Females and Their Diseases; A Series of Letters to His Class  

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Females and Their Diseases; A Series of Letters to His Class (1848) by Charles Delucena Meigs

Contents

Full text[1]

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FEMALES


AXD THEIR


DISEASES;


A SEniES OF


LETTERS TO HIS CLASS,



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PHILADELPHIA: LEA AND BLAN CHARD,

1848.


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FEMALES


AND THEIR


DISEASES


A SEHIKS OF


LETTERS TO HIS CLASS,



BY v_.

CHARLES D. MEIGS, M.D.,

Professor of Midwifery, and the Diseases of Women and Children, in the Jefferson Medical

College at Philadelphia; Member of the American Medical Association; of the

American Philosophical Society, and one of the Council; Fellow of the

College of Physicians of Philadelphia; one of the Physicians to

the I>ying-in Department of the Pennsylvania Hospital ;

&c. &c.


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PHILADELPHIA: LEA AND BLAN CHARD

1848.


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Entered according to the Act of Congress, in the year 1S47, by

LEA AND BLANCHARD,

in ilie Clerk's Office of the District Court for the Eastern District of Pennsylvania.


Philadelphia: t. k, 4xd r. g. collins, pkinteks.


TO THE

STUDENTS OF MY CLASS^

IJf THE

SESSION OF 1S40-7,

THIS VOLUME

IS RESPECTFU-LLY AND AFFECTIONATELY BY

THEIR GRATEFUL FRIEND,

THE AUTHOR.


l?.'=\OS


AN INTRODUCTORY LETTER TO A FRIEND.

Dear Sir :

I send you a new Medical book, which I beg you to accept as a testimonial of ray respect and affection. I have not dedicated it to you, because it belongs to the Gentlemen to whom I addressed the Letters of which the volume consists. I shall be obliged to you if you will look at it, and tell me wdiether you think I have committed an unpardonable breach of the forms of our Science, by writing with such a freedom and abandon as you shall here find.

Dr. Forbes, in his last article, in the British and Foreign Medical Review, tells us it is a lamentable truth that the eminent practitioners of England neither read nor buy medical books ; and I fear a chief reason of it is to be found in the dulness and jargon which characterize so many medical writings. I am sure that, excluding such as treat of the Physiology of Man, many are very tiresome and disgusting ; for, the Doctors seem not to have heeded the lines of Horace, where he says :

"Orane tulit punctum qui miscuit utile dulci, Lectorem delectando pariterque monendo."

I have endeavored, according to my poor ability, to tell the truth about our Science and Art, and in doing so, to avoid the dulness — and I thought the honestest way for a man to speak is, to speak Avhat he thinks, in his own tone and manner, and not to come before the public under a false disguise. The young gen- tlemen who composed my Class, were accustomed, all winter, to hear me say just whatever the occasion prompted me to say to them, without any reservation of mine, from distrust of them ; for I went into the Lecture room with'my heart in my hand ; and it is in the same fashion that I have sent them these Letters. In- deed, when I promised to write for them, I engaged to adopt the

1*


VI INTRODUCTORY LETTER TO A FRIEND.

most familiar style, saying, " I ^vill write in the same language I should address to any one of you, whom I might be instructing, in my library here at home."

You will see that I have kept my promise. Whether such a mode of writing may prove agreeable to the brethren, so as to meet their approbation, remains to be seen. If I have failed, let us hope that some one else will try some other method to get rid of our medical dulness, and our time-honored clergyableness; for, to judge of the medical student of the present day, by comparing my own student life with his, I cannot but think he must still find the books as tedious and uninteresting as they used to be when we were young men like them.

As to the doctrine and the precept of these Letters, I should suppose, I have a right, at this stage of my life, to be heard upon them — and having felt it an occasion of self-reproach, that I could never find time, in the winter curriculum, to fulfil my duties as Lecturer on Diseases of Females and Children, I have taken occasion to speak to my Class through the press. In doing so, I cannot but stand before the public.

Flaccus says, " Scribendi rede, sapere est et principium etfons.^ You will be able to judge whether I have said that which is naught as to the diseases treated of herein. Certainly, I have had much opportunity to see the things spoken of, and if the book turns out useless or disagreeable, mine is the fault. You, who have seen so much, may be my competent and dispassionate judge.

Let me tell you, though, my dear Hodge, that the whole of these 660 pages have been begun and finished since the month of May last. They have none of the nonum prematur in annum merit, therefore — and I wish you to understand, that, I have been obliged to do the whole of the work, in addition to my diurno-nocturnal task of visiting the sick. I cannot, under these circumstances, claim for it the same consideration as might be due to essays carefully revised and finished; and I have a just right to make this apology. But, shall people, who desire to make a contribution to the art that has absorbed their whole existence, refrain from doing so from a fear of offending in the matter of their manner? Would that be American-like? And shall they go out of the world making no sign? — Beaufort was asked but to hold up his hand, but "he died and made no sign."

I wish you would make a sign for us ; we all wish so.


INTRODUCTORY LETTER TO A FRIEND. Vll

I have made this apology to you, my dear Hodge, because I look upon you as a chief representative of Medicine, on this topic, in the United States: and, as I desired to say a few words to the brethren, in addition to all I have said in these Letters to my Students, I trust that in saying these things to you, in whom they have confidence, I am, quoad hoc, absolved as to apologies. As to my personal feelings towards you — did we not sit on the same benches at the lectures ? — and have we not interchangeably assisted us with counsel and with dexterity, in our vocation these thirty years? — What more!

I pray God to prosper you long ; and to allow the City, and the Country, to enjoy, for many years, the advantages of your skill, tlie honor of your well-earned reputation, and the benefit of your public instruction, as well as your private example as a minister of your philanthropic calling. Farewell, dear doctor, and believe me very faithfully

Your affectionate friend,

CHARLES D. MEIGS.

To Hugh L. Hodge, M. D.,

Professor of Midwifery and Diseases of

Women and Children, in the University of Pennsylvania.


CONTENTS.


DEDICATION, iii

LETTER TO A FRIEND, v

LETTER I. Motives for writing, - - ..... 17 — is

LETTER II.

General remarks on conduct — Embarrassments of practice — Sir Thomas Browne's opinion of the practice of medicine, ..... 18 — 29

LETTER III. Sex — The ovtim. — ^^^itellus — Tlie corpus luteum, - - . - 30 — 37

LETTER IV. The female — Her distinctive characteristics, .... 37 — 52

LETTER V.

Sexual organs — Mons — Relaxed symphyses — Seton in pubal pains — Vulva — Labia pudendorum — (Edema labiorum, ..... 53 — 63

LETTER VI.

Wounds and laceration of the labia — Labial thrombus, ... 64 — 68

LETTER VII. Ruptured labium — Ruptured labium and perineum — Uncured laceration of peri- neum with procidentia uteri — Labial cysts — Warts of the vulva — Dr. Brainerd's letter to J. F. Meigs — Pruritus of the vulva — Cicatrices, - - 68 — 79

LETTER VIII.

Nymphee — Cohesion of the nymi^hae, ..... 79 — S3

LETTER IX. Vagina — Its structure and relations — Absence of the vagina — Operation by Dr, Randolph for absence of vagina — Congenital narrowness of the vagina — Dilata- tion of the vagina as a cure — Im perforation or atresia — Cases — Cohesion of va- ginal walls after labor — Case of the same — Ulceration of the vagina — Vaginitis — Inversion of the vagina — Vaginal fistula — Vaginal rectocele — Vaginal entero- cele — Vaginal cystocele — Double vagina, .... 83 — 112


X CONTENTS.

PAGE

LETTER X.

Cohesion of labia and nymplice — Ulcerated nymphoc — Excision of nymplicp, by Mauriceau, .-...--. 113 — 117

LETTER XL

Clitoris — Hermaphrodism — Free Martin — Nymphomania — Inversion of the blad- der — Mr. Crosse's case, ...... US — 126

LETTER XIL

Displacements of the womb — Prolapsus uteri — Lamotte's account of it — Prolap- sus, with abdominal neuralgia. — Case — Levators ani in prolapsus — Diagnosis — Carus' curve — Dr. J. H. Bennet — Causes of prolapsus — Pessaries — Gynsecio- rum of Spach — Simulative prolapsus — Miss Helen Blanque's case, and dialogue with her, 127—163

LETTER XIIL

Diagnostics of prolapsus — Bad training of girls — Quevenne's metallic iron — Powers of medicines — Dr. Cerise on neurosity, ... 1G3 — 169

LETTER XIV.

Pessaries — Mr. Joseph Warner and his instruments — Dr. Physick's pessary — Suffita — Sachet — Sponge — Cork — Caoutchouc — Whalebone-ring — Blundell's pes- sary, 170—182

LETTER XV.

Prolapsus in the unmarried — Case — Immobility of the womb — Case — Cautions as to pessaries — Utero-abdominal supporters, ... 1S2 — 189

LETTER XVI.

Retroversion of the womb — Wood-cut of retroversion — Dr. Amussat's pamphlet — Wm. Hunter and Dr. Hall — Dialogue with a patient — Cases — Treatment — Chronic retroversion — Pregnancy as a cause of retroversion — Dr. Weir — Mr. Mayor's case — Instrument for the repositing of the womb, - 190 — 218

LETTER XVIL

Anteversion of the womb— Flexion of the womb, ... 219 — 226

LETTER XVIII.

Inversion of the womb — Mr. Crosse of Norwich, in England, - - 227 — 240

LETTER XIX.

Dr. Betton's case of inversion — Polypus of the womb — Dr. SafFord Lee cited — Anne Ryder's case — Dialogue with a patient — A case of polypus — Adherent polypus, ........ 241 — 259

LETTER XX.

Polypus — Hasty diagnostics — Nascent polypus, - - - 259 — 264


CONTENTS.


XI


LETTER XXI.

Fibrous tumors of the womb — M. Scrrcs' Anatomic Transccndente quoted, 264 — 278


Cancer of the womb, Physometra — Tympanitis, Hydrometra — Hydatids,


LETTER XXIL


LETTER XXIIL


LETTER XXIV.


LETTER XXV.

Ovarian disease — Ovariotomy — Dr. Lee's tabular results.


278—288


2 S 8— 296


206—299


299—323


LETTER XXVL

Diseases of tlie Fallopian tubes — Tubal pregnancy — Cases — Ovarian pregnancy — M. Pouchet's opinion, - - - - - - 324 — 331


LETTER XXVII.


Puberty,


331—374


LETTER XXVIII.

The menstrua — Periods of eruption — Climatic influences — Nature — Causes — Extract from Burdach — Germ-production in vegetables and in animals — Migra tion of animals, birds, and fishes, ..... 374 — 385

LETTER XXIX.

Periodicity of germ production, or oviilation — Secretions — Prof Huschke — Martin Barry and Gerber — Negrier, Gendrin, Lee, BischofT, and Pouchet — M. Pouchet's Theorie Positive — Rapid evolution^of a Graafian cell, - - 385 — 392

LETTER XXX.

Corpus luteum — Author's opinion — Opinion of authors, as Henle, Carpenter, Huschke, Flourens, Velpeau, Jacquemier, Chailly, Bernhardt, Von Baer, Bischoi! — Experiments: constitution, and uses of the corpus luteum, - 393 — 401

LETTER XXXI. Menstrua — Brierre de Boismont's tables — Analyses of menstrual fluid — Rachel — Roussel, ........ 401—415


Emmenagogues, Menorrhagia,


LETTER XXXII.


LETTER XXXIH.


416—423


424—434


XU CONTENTS.

PAGE

LETTER XXXIV. Dysmenonboea, - _....-- 434 — 443

LETTER XXXV.

Change of life, - - - - - - - - 444—454

LETTER XXXVL Hysteria, 455—471

LETTER XXXVn.

Disorders of pregnancy — Fecundation and conception — Early changes of the womb — Uterine intrusion — Ovum grows by vis insita — A ventre plat, enfant il y a — Sym- pathy whh uterus in the mammary glands, the stomach, &c. — Missing the return — Quickening — Rational signs and sensible signs — Some of the signs, as diseases of pregnancy — Sahvations and vomitings — Bruit de souffle uterin — Sounds of fffital heart — Dr. J. A. H. De Paul, of Paris, and his work on Auscul- tation — Early discoveries of foetal heart — Evory Kennedy and others — CEdema gravidarum — Constipation — Compression of the great vessels by womb — Dura- tion of gestation — Incipient phlebitis from varix, . . • 472 — 500

LETTER XXXVIII.

Disorders of pregnancy continued — Cost of pregnancy to the blood membrane — Anaemia — A case — Palpitation — Endocarditis — Dropsy of chest — Sprain of the symphyses — Dr. Moreau's case detailed, .... 501 — 519

LETTER XXXIX.

Abortion — Dr. Merriman's table of duration of pregnancy — Causes of atortion — Take care of the pregnancy ! — Hemorrhage — Prophylaxis, - - 519 — 548

LETTER XL.

Lying-in diseases — Fainting after delivery — Concealed hemorrhage — Turn out the clots — Binder and compress — Keep the head down — Ergot — Opium — After- pains — Rheumatismus uteri — Neuralgia of womb and abdon^en — Lochia — Dr. Lee of London — Asdrubali on bandaging the accouchee — Retention of urine — Medicines for the accouchee — Diet — Dies nondinse — Vaccination of pregnant women, -...--.- 548 — 575

LETTER XLI. Puerperal fever, ....... 570 — 624

LETTER XLII. Phlegmasia dolens, or crural phlebitis, .... 624 — 63 1

LETTER XLIII. Puerperal convulsions, .--..-- 631 — 643

LETTER XLIV. The female breast, ...---. 643 — 661


PITTSBURGH ACADEMY OF Iuu^i.y.u\i^

822 North Craig St.,

PITTSBURGH, PA.


FEMALES:


DISEASES AND EEMEDIES.


LETTER I.

MOTIVES FOR WRITING.

Gentlemen: — When I took leave of you, at the close of the session of our Lectures on the last of February, I engaged to address to you a series of letters, in which I should endeavor to lay before you my views upon some of the disorders of females ; and you may remember, I on that occasion, requested each one of you to consider these letters as addressed to himself. I felt that I had not fully discharged the obligations of my professor- ship as relates to disquisitions upon the sexual maladies ; and explained to you that the time allowed for a course of lectures, a period of only four months, is too short to permit any one fully to describe the many diseases to which females are liable.

I had taken advantage, it is true, of every open occasion to describe the phenomena and treatment of the disorders and acci- dents of the various structures which it w^as my province to demonstrate. Still there was much incumbent on me to say, w'hich the shortness of your sojourn here would not allow me leisure to say.

When I enjoyed the satisfaction of meeting you in the after- noons, I felt that my happiness was to be esteemed great, in the privilege of addressing so great a number of gentlemen, all pa- tiently and politely receiving the instruction I was able to con- vey upon very important points of a business, which is related 2


18 GENERAL REMARKS ON CONDUCT.

to some of the most delicate and hazardous periods of female existence ; I need not repeat the assurances I gave at parting with you, that I was filled with painful emotions in bidding you farewell, for I could not be insensible to the goodness you had so steadily manifested towards me, or to the admirable con- duct of the whole class, which reflects the highest credit upon them, as demonstrative of their fine sense of what is due both to themselves and to their teachers, whom they distinguish and ele- vate by such consistent and admirable deportment.

To address these letters to you now, seems to be a renewal of our late delightful intercourse, and should I be permitted in the course of them to assist you, and strengthen your hands in your great mission of usefulness and benevolence, I shall be thankful to Him by whose Providence I have been allowed these now many years, to observe and contemplate the affections of which I am about to treat. Farewell. C. D. M.


LETTER II.

GENERAL REMARKS ON CONDUCT.

The relations between the sexes are of so delicate a character, that the duties of a medical practitioner are necessarily more difficult when he comes to take charge of a patient laboring under any one of the great host of female complaints, than where he is called upon to treat the more general disorders, such as fevers, inflammations, the exanthemata, &c. So great, indeed, is the embarrassment arising from fastidiousness on the part either of the female herself, or of the practitioner, or both, that, I am per- suaded, much of the ill success of treatment maybe justly traced thereto.

It is to be confessed that a very general opinion exists, as to the difficulty of effectually curing many of the diseases of women ; and it is as mortifying as it is true, that we see the cases of these disorders going the whole round of the profession, in any vil- lage, town, or city, and falling, at last, into the hands of the quack; either ending in some surprising cure, or leading the


EMBARRASSMENTS IN THE PRACTICE. 19

victim, by gradual lapses of health and strength, down to the jrrave, the last refucre of the incurable, or rather the uncured: I say uncured, for it is a very clear and well known truth, that many of these cases are, in their beginning, of light or trifling importance — cases in which the constitution takes no part in affections of tissues or organs, which, when slightly modified by disease, may long continue to be so without provoking any dis- turbance as to the harmony of the other great organs : this for example, in the organs of the circulation, nutrition, respiration, and innervation. Yet, by neglecting such aflfections in their rise, on the one hand, or by imprudently treating them by violent and disturbing therapeutical or hygienical methods on the other, the whole constitution at length comes into sympathy with the de- ranged member of it; and the health, the usefulness, and so, the happiness or life of the mismanaged and misinformed female, are sacrificed.

All these evils of medical practice spring not, in the main, from any want of competency in medicines, or in medical men ; but from the delicacy of the relations existing between the sexes; and, in a good degree, from the want of information among the population in general, as to the import and meaning, and tend- ency of disorders, manifested by a certain train of symptoms.

It is, perhaps, best, upon the whole, that this great degree of modesty should exist even to the extent of putting a bar to researches, without which no very clear and understandable no- tions can be obtained of the sexual disorders. I confess I am proud to say, that, in this country generally, certainly in many parts of it, there are women who prefer to suffer the extremity of danger and pain rather than waive those scruples of delicacy which prevent their maladies from being fully explored. I say it is an evidence of the dominion of a fine morality in our society ; but, nevertheless, it is true that a greater candor on the part of the patient, and a more resolute and careful inquiry on that of the practitioner, would scarcely fail to bring to light, in their early stages, the curable maladies, which, by faults on both sides, are now misunderstood, because concealed, and, consequently, mismanaged and incurable. In fact, what is it, in the human body, that can become disordered so secretly as to elude the ex- ploratory powers of a well educated medical man, who is allowed to make the necessary inquiries?


20 EMBARRASSMENTS IN THE PRACTICE.

It is an interesting question, as to what can be done to obviate the perpetuity of such evils — evils that have existed for ages. Is there any recourse by means of which the amount of suffering endured by women affected with peculiar complaints, may be greatly lessened?

I am of opinion that the answer ought to be affirmative ; for I believe, that if a medical practitioner know how to obtain the entire confidence of the class of persons who habitually con- sult him ; if he be endowed with a clear perceptive power, a sound judgment, a real probity, and a proper degree of intelli- gence, and a familiarity with the doctrines of a good medical school, he will, as far as to the extent of his particular sphere of action, be found capable of greatly lessening the evils of which com- plaint is here made ; and if these qualities are generally attached to physicians, then it is in their power to abate the evil throughout the population in general.

Can there exist any reasonable doubt that the country is abundantly supplied with well informed physicians ; seeing that the land is filled with members of the profession, who have en- joyed the best possible opportunities of storing the mind with all the lines and precepts of medicine, delivered down through a succession of ages, continually productive of ameliorations in the doctrines and the arts of curing disease? But such persons as these are worthy of the public confidence, both as to their morals and their understanding. They are, in general, worthy repre- sentatives of the style and character of the gentleman, and, therefore, capable of attracting the confidence of such as are under suffering.

I have met to-day, April 9th, 1847, with a case which shows how far the fastidious delicacy existing in the relation betwixt the sexes may be carried to the part of the physician. A lady, 40 years of age, consulted me as to a painful menstruation she has had for twenty years. She experiences severe pain and dis- agreeable weight and pressure in the loins and hypogaster, and pain in the head for five or six entire days before each menstrual period ; all which symptoms disappear with the first gushings of the evacuation. She represents her health to be the same now as for twenty years past. Hence, I presume, there has occurred but little change in the physical condition of the parts, else there would be some change in the sensations arising from the malady.


EMBARRASSMENTS IN THE PRACTICE. 21

She has been repeatedly subjected to the taxis ; but no one ever examined the os uteri with the speculum until to-day. Well, that examination reveals a certain state of the cervix and os uteri, and glands of Naboth, &c., which it was indispensable to know, in order to found a rational treatment. The delicacy existed, not on the part of the lady, but on that of the medical advisers; for I have her assurance, that her sufferings, both bodily and mental, have been so great, that she should long ago have submitted to any means of 'even a probable cure; and was, indeed, always desirous to have everything done that was possible in her be- half. I doubt not this lady might have been cured long ago, had her malady been thoroughly understood.

I have mentioned this case to show that the physician is in fault when he does not do his whole duty; for it is incumbent on him to leave nothing undone that may aid and comfort his patient. But let us return to our remarks upon the qualities that ought to distinguish the medical man.

I think that, in order to be a physician, one ought to enjoy strong perceptive faculties ; he should be able to make nice dis- criminations ; quickly perceiving the slightest shades of difference in all material forms, superficies, colours, weights, and resistance. The faculty of judging between the relations and differences of things should be of the primest quality; not sudden, hasty, and impatient in its operations, but slow, dispassionate, and attentive.

The mind and heart of the practitioner ought to be the shrine of truth and probity ; his mind should not deceive itself, and his heart should not suffer itself to be deceived and misled, by any earthly temptation, from the narrow and rugged way of duty and conscientiousness.

His intelligence ought to be vast, as acquainted, very generally, with what is called knowledge and science by mankind. Par- ticularly should he be fully informed as to the nature of the Life- force, as displayed in the various tissues and organs of any ani- mal economy ; not in that of man alone, but in the whole zoo- logical series, as well as in the vegetable kingdom of nature.

There ought to be no function of the economy, or of its parts, whose healthy rate he could not estimate, as well as all its devia- tions in sickness. But this is not all — he ouofht to be able to discern, not the signs only of maladies, but the tendencies of these maladies; as whether they possess a certain tendency


22 EMBARRASSMENTS IN THE PRACTICE.

towards recovery, or a tendency towards destruction; so as to enable him to say, as he does of a vaccine inoculation, let it alone, it requires no remedy, it carries the cure in its own nature, it will have disappeared, with all its phenomena, on the eighteenth day. Or, on the other hand, take care of that headache ; she is pregnant, and near term ; know that such a headache is but a step removed from an eclampsia; and that an eclampsia is often the penultimate phenomenon of life. Let that case alone — cure this one.

Do you not perceive, young gentlemen, that such a physician is not of necessity a doser, a druggist ; and that in a great moiety of the cases in which he is consulted, the patient will escape all physic and be cured by wise counsel — and likewise, that when therapeutical interference is required, he will know what to do, what medicines are required, and w^hen, and how much ?

It is often dangerous to ask a physician the question, what shall we do? because habit, custom, routinism, almost always compel him to say take — take.

He ought to be famihar with the doctrines of a good Medical School ; by which I mean, not the doctrines of the University of Pennsylvania, or that of New York, or Maryland, or London, or Paris, nor the Jefferson College, but a school which has taught him a demonstrative anatomy, a real eclectic physiology, a sound and philosophical chemistry, &c. A school, in short, which has set before him, in full array, the results of man's achievements in medical investigation, experience, and art; leav- ing him, out of his own clear, sound, honest, and capacious intel- lect, to become capable of saying, as to any case of disorder pre- sented for his opinion, such is the malady, its tendencies are thus, or so, its treatment requires such and such methods. Let him judge the case by the case, and by no other law or evidence.

Let him not be a methodist — let him be a man of principles in medicine; principles, which, like the genii of the Persian fable, come at his bidding and do his bidding, for no one can be taught to cure diseases by a method. Method in medicine is beneath contempt ; because, owing to the infinite variety and differences existing among the living molecules that are the subjects of the vital forces, there never were, nor can be, two absolutely similar cases. Each instance is an integer, and should, in strictness, be so deemed, and studied, and understood, and managed upon a


EMBARRASSMENTS IN THE PRACTICE. 23

reference to it, and not to another integer. It is true that the patient who is under care to-day, may be like "him who died o' Wednesday," but is not him. Hence, you perceive that I am no admirer of statistics except for the government, where statisti- cal returns of agriculture, commerce, manufactures, crime, popula- tion, &c., are useful to the statesman for making his assessments, his calculations, and his levies ; but when I treat a case of pleu- risy, I do not care how you treated your case of pleurisy; I shall bleed my patient on account of his fever, pain, cough, dyspnoea, &c., and not because you bled your patient, who had similar symptoms, of the gravity of which I am no judge, not having been present to judge. So, if I treat a female with certain pain about the middle of the sacral bone, with dysuria, or retention of urine, &c., by methods calculated to take the strain otT from her ligamenta rotunda, and thus cure her of retroversio uteri, what is it to me that you adopted some other mode ? That which inte- rests me is, to be sure that a woman, who has ligamenta rotunda not more than two inches and a half long, cannot have her womb turned topsy-turvy. That is the principle w^hich I ought to ap- prehend, and I shall carry it out in my practice. Do you get some other principle, if you can, and come to prove my error by your statistics ; I should be strongly inclined to take after Mr. Dennis Balgruddery, in the play, w^ho, if bothered with statistics by his friend Bull, would have been sure to say, " To the divil I pitch you and your statistics, Mr. Bull !"

Let a man, therefore, make himself so thoroughly learned in medicine that he can detect the lesion of structure or function wherever it may hide, and then he is the sole judge of the action required in the case. Not because twenty other cases were, but because this case is.

But I stated that one great cause of unsuccess, is in the absence of information among the population generally. This absence of information is the fruitful source of Homoeopathy, Hydropathy, Thompsonianism, Panaceaisra, and all the Catholicons, Infallible worm destroying lozenges. Balms of Gilead, and that shocking absurdity — the Vegetable pill, which, like a sort of epidemic diar- rhoea, has tormented the intestinal canal of thousands and tens of thousands of our far-seeing compatriots, until the American popu- lation have become hardened in purgations. If Horace were


24 EMBARRASSMENTS IN THE PRACTICE.

here, he would not think the dura messorum ilia the toughest things in creation.

Do you suppose, my dear young gentlemen, that if the com- munity at large should be as well acquainted with physiology and therapeutics as you and I, the Ledger and the Gazette would occupy nearly one-half of their columns with those horrid descrip- tions and unblushing confessions of piles and itch, and other dreadful disorders, which the sufferers under them love to parade for the public gratification and improvement, under their own signs manual in the Gazette?

You, who know the skeleton humanum, and the attitude of the uterus within the pelvis, do you think that Mrs. A. to X. would, out of a missionary zeal, suffer her name to appear as one of the wonder-worked cures of a shameless procidentia, by what is, at our daily breakfast-table, brought up in the morning paper, to stare the ladies out of countenance, under the modest title of a utero-abdominal supporter. Who wants to know, or ought to know that the ladies have abdomens and wombs but us doctors ? When I was young a woman had no legs even, but only feet, and possibly ankles; now, forsooth, they have w^ero-abdominal support- ers, not in fact only, but in the very newspapers. They are, surely, not fit subjects for newspaper advertisements, nor would they be advertised but out of our own stupidity or remissness.

I say, confidently, out of our remissness, and here are my reasons for saying so.

This is a land and an age of common schools and common sense. This is a country of general knowledge among the population. It is impossible that any system of science or art can stand in this country, flooded as it is with intellectual light, sustained by any but real claims to the respect and confidence of the public. We doctors claim this confidence and respect; and we deserve it, doubtless; but we claim it imperiously and as a vested right, as a right descended to us by inheritance, from our avos et proavos, the founders of our order. But we ought to remember that our privileges, those we received in a commission proceeding from the Legislature, under the Great Seal of the Commonwealth, are not of the nature of the privilegium clericale, as the lawyers terra it. There are too many persons in this country that can read and write, to allow us to claim a clergyable exemption from the general practice here of explaining one's self. What is the right,


EMBARRASSMENTS IN THE PRACTICE. 25

therefore, by which we assume, in the present day, to clothe all our proceedings in mystery, and to expect our patients to kneel down while we, (not confess, but) cut them with bistouries and knives, or put arsenic and prussic acid down their gullets ? They will not submit to our clerical manners; and they say, that if we persist to hide our art under an impenetrable veil of mystery and jargon, they must continue incapable of discriminating betwixt the true physician and the quack-salver, since both agree upon one course, that of demanding an implicit faith and obedience without recourse to reasoning. Is not this representation a fair one ? Even your early and noviciate experience must, we think, have furnished you the materials for judging whether I speak fairly or not.

I say then, it is our stupidity and remissness that work evil to the people, and redound to our own hurt also; for there is no person, endowed with a good share of common sense, to whom you could not address, through that common sense, a reasonable and plain statement of the facts of his case, the probabilities as to its course, duration, and end ; with an enumeration of the safest, most convenient, and certain processes for its cure. Imagine such a person, well-informed, and you have the idea of a patient the most docile, the most exact in therapeutic and hygienic obe- dience; the most confiding in your skill, and the most grateful for your intervention in his behalf. Would that all our brethren in this land might adopt views like these. With their united force of intellect, of character, of beneficence, and of social station, it would be but a short time e'er the diminished head of charla- tanism, under w^hatever disguise, would be found only to lift itself up among the most ignorant and abject portions of the population, instead of riding, as it does to-day, with chariots and with horsemen, a shame to the intelligence of the age, and a per- petual eye-sore to the lover of truth, and contemner of every species of imposture. Let us explain ourselves then to the people.

I hope it will not be deemed impertinent in me to say to you, that I have enjoyed a large share of professional business for some years past, and that, in the main, I have had reason to sup- pose I received very unbounded confidence, and a general obedi- ence to my medical directions, from those persons and families who called me. This good fortune I have long attributed, in a


26 EMBARRASSMENTS IN THE PRACTICE.

considerable measure, to the entire frankness of ray explanations as to any diagnostic, prognostic, therapeutic, and hygienic views in my cases; as well as the pathology of them.

Some of the brethren, chiefly, I presume, those who have not very clear and concise views of their own on medical topics, are bitterly opposed to all explanation, on the ground that our princi- ples of science are too recondite for the vulgar to be able to appre- ciate either them or the facts on which they rest. I have occasion- ally met with difficulties, in consultation, from the opposition of some of the brethren to my desire to let the patient fully into my opinions. If a man really have any opinions, that are honest and clear, and well founded, why should he conceal them ? I confess my belief, that where a physician forms perfectly trans- parent views of his cases, there is no need for the powdered wig and the gold-headed cane, the mysterious nod, and all the appa- ratus of deception that we might look for rather in old Felix Plater, or Horace Augenius, than in a modern physician, who is, or ought to be, a modern gentleman and man of honor; and, as such, above all false pretences — open, candid, and manly.

Now, I sincerely believe, that where you desire to effect a cure, and you meet with obstruction through the timidity, the doubts, or apprehensions of the patient, you will only have to speak common sense, and to take out your pencil, and, on a sheet of paper, make a few well sketched diagrams of parts, organs, and rela- tions of parts and organs, in order to bring the recusant back to a truer and firmer faith than before, by convincing his judgment and winning his inclination. Yea, verily, you shall sustain the fainting hope and the dying faith of the sick girl, for days and for weeks, and through months of pain, if you speak the truth and explain the truth ; if you show the hope and have the hope ; if you explain the power and really possess it.

If you have not the confidence of your patients, it is because you either do not merit it by your science, your skill, and your temper; or because possessing all these, you are destitute of, what I beg you to excuse me for calling in a grave book by a slight term, gumption. Depend upon it, my dear young gentle- men, there are plenty of people, "plenty as blackberries," who are very learned and very shining, except when you come to rub them, and who lose all shining quality, because they have not and cannot take a real polish.


EMBARRASSMENTS IN THE PRACTICE. 27

The celebrated Dr. Clarke, of London, from whose lectures that capital little midwifery book, called the London Practice of Mid- wifery, w^as pirated, says, somewhere in its pages, that one Doc- tor, by his good sense, shall retain the entire confidence of the woman in labor through the most painful pTotractedness, while another would lose her confidence, in a very short time, of hope deferred; and that, not because he hath not ability as a pre- scriber equal to the other, but from some fault of manner, expres- sion, or conversation.

If you would be learned men, it is well ; but it is better to be wise men. A man may be wise without being learned; but it is not uncommon to be learned, and yet to be a perfect ass in all that relates to what I might term administration, or action. Let your light, therefore, shine among men, and do not conceal it under a bushel of gawkeyness ; or some stupid conceit of your personal dignity; or, what is still more asinine, the dignity of your calling. Dignity is you, not physic, nor the practice thereof. Did you never hear that

" Worth makes the man, the want of it the fellow, And all the rest is leather and prunella?"

I have seen dignified shoemakers, carters, butchers, and even a very dignified tailor, and I have known philosophers and very learned men without dignity. Believe me, there is true dignity in great virtue, great information, and great power to diflfuse, apply, and make that information useful to our fellow men. Such is the dignity you should strive to attain.

If I could give you the best piece of advice in my power, I think I should give you this advice; namely, in all your dealings wuth mankind as physicians, and in all your life-doings, strive, first, to increase the boundaries of your knowledge ; and, second, strive to make that knowledge as vulgar, as popular as possible. Be a reformer in this particular, and you will, should you suc- ceed, become the real founder of a Sect in medicine, and that sect you may baptize as the Young Physic that Dr. Forbes advo- cates. That will be the true young physic, which succeeds in bringing down Old Physic to the level of this common sense age.

I say again, therefore, wherever you place yourself, be sure to have no concealment, no mystery, no pretence ; but endeavor, in the clearest manner, not to assert, but to show your claims to


28 EMBARRASSMENTS IN THE PRACTICE.

superior powers in that great utilitarian avocation of curing the sick and the wounded ; an avocation which is almost, I say it with reverence, next in goodness to the mission of Christ, who went about clothed with power and authority, — cyiipsiv tovi vexpovi

In order fully to discharge the duties of this great mission, is it not indispensable that you should prepare yourselves for its offices by suitable preparation of the mind and person? Of the mind, by arming it with knowledge and wisdom, with prudence and pa- tience, with firmness to encounter all vexation and responsibility, with charity and liberality, and with all that armature of the soul which alone can render men worthy to be called sUvOcfioi, for none are so but those* whose condition has raised them above the grossness and sensuality of the corporeal nature, rendering the body the servant and the minister, not the tyrant of the soul and the heart, that ought to "sit lightly on Reason's throne;" not as crushing, but adorning the intellect with noble sentiments.

It is difficult to say how a man, in forming his manners, should proceed. Indeed, there is, probably, no art so great to form the manners as that which teaches us to keep the temper and the desires of the soul within the just bounds within which it is con- tained among all true followers of the Christ. To be a true and accomplished gentleman, one should "do justly, love mercy, and walk humbly before God." Any person, under such guidance, cannot fail to have manners acceptable in all forms and ranks of society, where business may present him.

A special regard to one's person is also a very indispensable means of success, not in making money, but in curing the sick. The sick are affected by the presence of the physician. One well dressed, of good manners, of agreeable conversation, neither too grave nor too gay, would, cceteris paribus, inspire more confi- dence, infuse larger courage, longer patience, and greater hope, and therein succeed more surely in curing his patient, than an- other of equal information on medical science, but careless and negligent of his behavior and appearance.

I cannot advise that you always should carry about with you an air, and, indeed, a habit of boasting, and an appearance of self-sufficiency, which, wherever they are observed, generally are taken to be signs of weakness. But that which you do know, I would have you conscious of knowing, so that you may be en-


SIR THOMAS Browne's opinion. 29

abled to speak, with due boldness and decision, on all proper occasions.

But, alas! gentlemen, I fear I am uselessly consuming your time and exhausting your patience. I shall close this letter, therefore, by recommending you to observe the rules of conduct laid down by your Professor of the Institutes on commencement day. Should you remember and follow out the plan he then pointed out, you will become what I desire ardently that you should become, useful and successful in your calling, which will redound not only to your own honor and profit, but to the credit of your Alma Mater.

Before I close this letter, pray allow me to cite for your perusal a passage from Sir Thomas Browne's Iteligio Medici, p. 139, who, if you imitate him in the sentiments and conduct here pointed out, will be your sufficient model.

"I feel not in me," says Sir Thomas Browne, "those sordid and unchristian desires of my profession ; I do not secretly im- plore and wish for plagues, rejoice at famines, revolve epheme- rides and almanacks, in expectation of malignant aspects, fatal conjunctions, and eclipses: I rejoice not at unwholesome springs, or unseasonable winters ; my prayer goes with the husbandman's; I desire everything in its proper season, that neither men nor the times be put out of temper. Let me be sick myself, if some- times the malady of my patient be not a disease unto me. I desire rather to cure his infirmities than my own necessities: where I do him no good methinks it is scarce honest gain ; though I confess it is but the worthy salary of our well intended endea- vors. I am not only ashamed, but heartily sorry, that besides death there are diseases incurable ; yet not for my own sake, or that they be beyond my art, but for the general cause and sake of humanity, whose common cause I apprehend as mine own." Farewell. C D. M.


30 SEX.


LETTER III.

SEX.

You may remember that in lectures at the college, I very fre- quently repeated that the ovary of the female gives to her the sexual character, and that as the interior and active tissue of the ovary, is the part which Ch. Ernest von Baer calls the lager or stroma, so that very lager or stroma is the Sex itself.

You might, perhaps, at first hearing this dogma, feel disposed to reject it as too concise an expression of the multitudinous and diversified characteristics of the sexual nature — but I hope a careful examination of the matter may induce you to coincide with me in opinion.

The sexual office is designed to reproduce the material forms and faculties of a genus or species; and this is not done save by the production of a germ, which at least, in all the Zoological series, is found within an ovum, which, in plain English, is an egg. Omne vivum ex ovo, is a true saying.

An ovum then is an egg — which is not to be considered as a germ, but as a thing containing a germ and the material or pabulum for the early stages of the development of that germ.

An egg is a yelk-ball — which in some instances is invested with a quantity of albumen or white, and in some cases is not accompanied with any deposit of that sort.

The yelk-ball is a vitellus — and consists of a multitude of cor- puscles and granules, and punctiform bodies and small globules of oil swimming in a clear delicate fluid, inclosed by a delicate anhistous membrane, the vitellary membrane. In most cases yelk is of a yellow hue, in some it is red or greenish, &c.

If you break open a yelk, whether of the humming bird or the ostrich, of the elephant or the mare, the rabbit or the earthworm, the shad, the minnow, or the whale, you will find it to consist of corpuscles, granules, and puncta, with oil globules and the clear fluid.

If the egg has not been subjected to fecundation, as it caryiot


SEX. 31

be within the ovary, there will be found within it at the centre of the ball, or near the surface of the vitellary membrane, a smaller spherule of a beautiful transparency, and which is denominated the germinal vesicle — within which, adhering to the wall of the vesicle, are a number of very minute microscopic granules, which by Rudolph Wagner, of Berlin, by whom they w^ere discovered, are called the macula germinativa or germinal spot — so that an egg is: 1, a vitellus ; 2, a germinal vesicle contained within a vitellus; 3, a germinal spot lodged upon the inner wall of the germinal vesicle.

Is it not to be believed that the germinal spot is the true germ- point, or germ itself, and that all the other constituents of the ovum are placed round about it, in order that by its changing and formative power, its metabolic and plastic force, it may convert their elements into its own corporeal elements, evolving by their consumption the rudiments of its own organs, as brain, veins, heart, blood, &c. &c., until, having acquired sufficient organic form and force, to make its mesenteric attachment to the living parts of the womb — it is ready to be conceived : conception being the formation of that mesenteric attachment, and nothing more nor nothing less.

Nature, all whose operations are preordained, as being guided and limited by the law of God, has provided fully and most liberally for the production of germs, and thereby secured the perpetuity of her kinds. She has, in order for this germ pro- duction, adopted various methods of arrangement. In certain animals she has devolved the germ-producing and the fecundat- ing powers upon the same creature — in others, she has provided two independent forms of being for the carrying on of the office.

In the lower orders of beings, as the earthworm, for example, both the germiferous and the fecundative attributes are com- prised within the same individual body. So that the creature can fecundate its own female constitution by the act of its male constitution ; and this simple but effectual mode of keeping up the genus or species, is admirably adapted to the inactive and aperceptive nature of the being itself.

In higher forms, two separate individuals are provided, one with the male, or fecundating nature, and the other w'ith the female, or germinating nature. "Male and female created he them," unto the end that they might increase and multiply, and fill


32 THE OVUM.

the earth with sentient beings, wonderfully endowed with life- faculties, and therefore with the means of enjoyment, in other words, of happiness. To procure happiness and establish it, must be regarded as one of the highest attributes of Divine power and beneficence.

The important, the indispensable ovum, could not be left with- out protection — it could not be developed without a machinery.

The ovum is, therefore, protected with an ovisac, or capsule, which is what is called a Graafian vesicle, or Graafian follicle or Graafian cell, from Regnier de Graaf, a Dutch physician, who, in his Treatise de Mulierum Organis Generationi Inservientibus, published in 1672, gave the first clear account of those small pellucid vesicles that you have so often seen in the ovaries I exhibited to you.

A Graafian vesicle consists of a double-coated capsule, of which the outer one lies in contact with the stroma, and contains the inner one within its own sphere; not loose and unattached, but connected to it by means probably of a very delicate lami- nated cellular tela.

This interposed and connecting cellular tela may become filled with secretions ; and as the outer one is, like a mineral in its gangue, pressed against the stroma, it is clear that any interstitial deposit must have two contrary results, one to enlarge the outer concentric and throw it back against the stroma, displacing and distending it, and the other to press the ovisac inwards towards its contents to compress them, and to render the inner aspect of the ovisac uneven, wrinkled, or convoluted ; and, in fact, I have shown you on several occasions both these different results.

I pray you call to mind, not only the human ovaries in which I showed you the convoluted or wrinkled appearance of the inner aspect of the ovisac, but the more striking samples of the same effect in the ovary of the cow. In this latter case the inter- stitial deposit was so enormous, that the outer coat of the ovisac had grown to a size nearly equal to half the mass of the whole ovary, and was of an orange hue, derived from the deposit of a vast quantity of vitellary matter betwixt the two laminae ; the outer one being greatly expanded or extended, and the inner one being crumpled, convoluted, or wrinkled. This great orange coloured mass was the corpus luteum.

Before the corpus luteum had begun to form, the ovary had been


VITELLUS, CORPUS LUTEUM.


occupied in furnishing vitellary matter for the constitution of the yelk-ball; but that ball, having become complete in all its parts, and incapable of any further accretion, as contrary to its generic law, the ovarian stroma, whose office it is to produce germs and vitellus, could not at once withhold its vitelliferous power, and the deposit went on upon the outside of the ovisac.

Hence, you perceive that in a perfectly mature Graafian folli- cle, there is a yelk-ball with its germinal vesicle and germinal spot inside of it ; some fluid of the ovisac filled with granules ; while on the outer surface of the ovisac, between it and the ex- ternal capsule or coat, is a yellow deposit, which begins to ap- pear there about the time when the yelk is quite ripe, and con- tinues to augment in quantity for some time after the yelk has been discharged. Let me repeat, that this yellow body is the famous corpus luteum, and that such a yellow mass is deposited with the maturation and discharge of every yelk. Sometimes, perhaps, in pregnancy, the corpus luteum is larger than at other times, but whether large or small, it is a real corpus luteum ; for there are not, as some writers pretend, true and false, but only true corpora lutea.

But this gradual evolution of the luteal deposit has the effect of lifting the germ, with its vesicle and its yelk-ball, nearer and nearer to the superficies of the stroma ; to press outwards the tunica albuginea; and, finally, to press it so forcibly, that absorp- tion commences at the weakest and most distended point of its surface, until, a pore being formed, the yelk and the fluid about it, escape from their imprisonment in the ovary, and fall into the belly, or are received within the infundibular orifice of the ovi- duct, which you call the Fallopian tube, and thence conveyed to the womb. Its mesenteric attachment to the womb, as I before said, constitutes a conception, which pregnancy follows.

I have made the foregoing observations in order to fortify my assertion, that for the female, stroma is sex.

Do you think that if a-creature should be born with the external genitalia perfectly well formed; with a perfect uterus, and vagina, and tubes ; but without the trace of any ovarium, such a creature could be a female ? Or, if she should have two perfect ovaria, and be born without womb, or vagina, or external organs, would she be anything else than a female? I am sure you will agree with me, that she would not, in the former case, be female, and 3


34 SEX.

that, in the latter, she would be truly female — because, though unhappily deprived of any gestative organ, or organ of copulation, she is endowed with the germiferous, through her vitelliferous faculty, which resides essentially and exclusively in the substance called stroma. No germ could she evolve in the spleen or liver, in the kidney or brain, in the heart or lungs, nor, indeed, any- where, save in the stroma, which is the true sexual concrete, and is, therefore, itself sex; for liver, heart, brain, lung, nor digestive canal, is not sex, but stroma is sex for the female — nothing else is sex.

But, after all, what is sex ? Methinks you ask the question, which is a very difficult one. Perhaps I should best answer it in a few words, by saying it is reproductive power, whether male power or female power. It is a matter of indifference whether the philologists derive the word from secus, aliter, otherwise, after another manner; or from secare, to cut, to divide one from another. We have, in physic, less to do with philology than with facts. I consider that we are hitherto unacquainted with any facts that give convincing proof of a sexual nature in the germ.

There is an embryonal stage of life in which it is utterly im- possible to determine the sex of the embryo ; and it is not known whether the female embryo proceeds from a germ originally female, or whether the germ, being in its inchoate state, neither male nor female, assumes the female nature in the progress of its evolution, or takes on the nature of the male, under some law as yet unknown to us.

It is very certain, however, that for the human race, the pro- portion of the sexes, as to their number on the globe, is main- tained from age to age. The law that ordains this equable rate of production, operates so as to bring into the world about 104 males to 100 females; a proportion which keeps the sexes nearly equal in number; it being supposed that the temperament and exposure of the male render him more liable to premature death than the female, on which account the excess of males is or- dained.

If we refer to what is known to occur as to the non-sexual nature of the larva of the bee, hereafter to be mentioned, we may find arguments for the opinion that the germ, originally, is non- sexual, but becomes male or female under some unknown law of development, in its earliest embryonal life.


SEX. 35

If such a sentiment may be rightfully entertained, you will, perhaps, agree with me that the sex is something superimposed upon the mere living nature of a creature; and you will more readily admit of it if you contemplate two children, one male and the other female, of the same stature, weight, and temperament, born at the same hour, and brought up at the same breast. You cannot report to the mother of what sex they be, without referring to the pelvic extremity of the trunk. They are pleased with the same rattle, tickled with the same straw. They play at the same toys, and are alike, in moral and physical attributes, until the sexual endowment comes to be granted to them. Upon that instant they divaricate; their whole physical, and intellectual, and moral forces become different, and they pursue, so to speak, a separate walk of life, until the exhaustion of the sexual attri- bute, in the one and in the other, causes their paths to converge again, until they are seen sleeping " thegither at the fooV of the hill of life, over which they had toiled in distinct tracks from the puberic until the critical age. What can be more like an old woman than an old man? or what can be more like a g-irl than a perfectly ingenuous boy? Where is the likeness of men and women ?

Is it not true, then, that the sexual nature is something super- added to the mere living corporeal nature, which, on being taken away, reduces them back again to their original sameness of life- nature ?

You have heard, I presume, of a circumstance that may tend to illustrate this view, in the history of the honey-bee. The com- munity requires a queen — which means a vitelliferous, and so a germiferous creature — and it also requires a considerable number of drones — males, or fecundating members of the society ; which being provided for the hive in question, nothing more is wanting but a sufficient number of mules, or working bees, or creatures capable, first, of enjoyment, and second, able to provide for the conservation of the species by collecting food — 1, for the germi- ferous; 2, for the fecundating; and 3, for the providing part of the species. Now, all these males and workers are alike in the ovular state ; but if the males die, by some epidemic, a battle, or accident, the community know how to convert the larva into males by administering to them certain sorts of food, or to leave them mere workers by withholding that kind of aliment. So


36 SEX.

that, in fact, you discover here that the mere corporeal life of the larva possesses no sexual nature, and that a sexual nature may be superadded by a certain economy of the hive, an economy that can cause the ovum so to develop itself, as to become fitly provided with the fecundating apparatus and material, or to become a queen bee, or germiferous bee ; for, when a queen dies, after having deposited many thousand eggs in the mule bee cell, the alarm and confusion in the hive are very extraordinary, but it subsides after the tumult of the first excitement, and the mules or workers select some one egg, for which they enlarge the cell by converting three common ones into a single royal cell ; and then, by feeding the grub with an aliment called royal jelly, they cause it to pass into the female state, and thus the lost queen is succeeded by a queen produced from the egg of a mule or worker-bee; an egg that could only have developed a non-sexual creature but for the special influences brought to bear upon it from a state necessity. I ask you again, if this be true, whether it does not show that the sexual nature is not an original nature, but a nature superimposed upon a mere animal or living nature. And, if true of the bee, does not that truth established, likewise establish the law for all possible animal and even vegetable existences ?

I see not how a better proof, or, at least, illustration, could be given of my idea, that the sexual nature is a climax ; it is a culminating life-force that evolves it.

It ought not to excite our astonishment that the female sexual nature gives to her physical, intellectual and moral attributes, a bias different from that of the male.

Her organs are different — they are subject to fluctuations as to the tide of life within them that those of the male are by no means exposed to. They require a different and more complex system of innervations, more expensive to the nerve centres than those of the male ; more delicate, sensitive, impressible than his. These are circumstances implying a dependence and physical debility as compared with him ; a reliance and trusting to his power; and, in fact, all the peculiarities that mark her as a crea- ture of the feminine and gentle sex.

I shall, in my next letter, occupy your attention with some remarks on the distinctive characteristics of the female, to which I shall beg to invite your attention, not with a view that you may


THF FEMALE, 37

learn of me what those distinctive characteristics are — for a vohinie would not suffice fully to relate them — but that I may, perhaps, be able to turn your attention in that direction, in the hope that your young and vigorous strength may be incited to a more con- sistent and energetic pursuit of whatever literature and science ought to be garnered up by a physician, as the ornaments and aids of his career of usefulness and dignity. Farewell.

C. D. M.


LETTER IV.

SEXUAL PECULIARITIES.

Gentlemen: — Before I proceed to the consideration of those topics which are to engage our attention in the main, I wish to take advantage of this occasion to say some words to you on the Distinctive Characteristics of the Female — or rather, I should say, on some of them — for to describe them all, w^ould require rather a series of letters than a single discourse. I shall, therefore, in the present letter, attempt to indicate only a few points of contrast betwixt the male and female, with a view to turn your attention that way. I could readily fill a volume upon the different texts that I am about to present to your consideration.

It is proper, I believe, that I should fulfill this design, for I have long thought, as I now do, that without some prefatory remarks in this direction, you might be less fully prepared to receive those views of the disorders to which the woman is subject, which it behooves you as medical men to acquire; and less capable to appreciate those modifications of therapeutical indication and process that are demanded by the moral, the intellectual, and the physical qualities of the female; for her mere human, or generic nature is modified by her sexual or female nature, to such a de- gree, that in certain of the great crises of her life, she demands a treatment adapted to the specialties of her own constitution, as a moral, a sexual, germiferous, gestative, and parturient creature.

I do not suppose you could acquire just views on these points in the dissecting-room, or the theatre of anatomy alone. Nor can


38


THE FEMALE.


I give them to you here in one letter; the time is too short. There, it is true, you might explore the items of her physical structure, in order to compare them with those of the hardier sex. You might there learn that though she be a part of mankind, a truer Zygozoaire than those of M. de Blainville's classification, she yet differs from men in her stature, which is lower; in her weight, which is less ; in her form, which is more gracile and beautiful ; in her reproductive organs, that are peculiar to her ; and in her intellectual and moral perceptivity and powers, which are feminine as her organs are.

Beyond all these, you shall have to explore the history of those wonderful functions and destinies which her sexual nature en- ables her to fulfil, and the strange and secret influences which her organs, by their nervous constitution, and her functions, by their relation to her whole life-force, whether in sickness or health, are capable of exerting, not on the body alone, but on the heart, the mind, and the very soul of woman.

The medical practitioner has, then, much to study, as to the female, that is not purely medical — but psychological and moral rather: such researches will be a future obligation lying heavily upon you, upon all of you.

Every well educated medical man ought to know something more of women than is contained in the volumes of a medical library. Her history and literature, in all ages and countries, ought to be gathered as the garlands with which to adorn his tri- umphant career as a physician ; but these insignia of his power he can only gather by the careful and tasteful study of his subject among the rich stores of learning that are gained. in the belles- lettres collections, whether archaiological, mediaeval, or modern.

The medical man, surely, of all men, ought to be best able to appreciate the influence of the sex in the social compact. But for the power of that influence, which one of you would doubt the rapid relapse of society into the violence and chaos of the earliest barbarism ?

Are you not aware that the elegance and the polish of the Christian nations are due to the presence of the Sex in society — not in the Zenana! Do you not perceive that Music, Poetry, Painting, all the arts of elegance: Luxury, Fashion, (that potent spell!) are of her, and through Aer, and to Aer? Versailles and Marli, and the Trianons, had never been built for men. The


THE FEMALE. 39

loom blends and sets forth the dyes that add richer reflections to her bloom ; the wheel flies for polishing the diamond that is to flash in impotent rivality above her eyes; sea and land are ran- sacked of their treasures for her; and the very air yields its egrets, and marabouts, and paradise-birds, that they may add piquancy to her style, and grace to her gesture. Even literature and the sciences are in a good measure due to her patronage and approbation, which is the motive power to all manly endeavor. This is true, since, but for her approving smile, and her reward- ing caress, what is there should stir man from the sole, the dire, unremitted compulsion to act that he may live ? With woman for his companion, he acts not only that he may live, but that he may live like a Christian and like a Gentleman.

" Blest as the immortal Gods is lie, The youth ■who fondly sits by thee, And hears and sees thee all the while, Softly speak, and sweetly smile!"

The great stage of the world, w^e are informed by the inspired writers, was prepared as the scene of a grand moral drama. The earth and all that it inherit is for man, his use, his delight, his trial! But, this mankind — this genus man — what is it? It is an imperishable unit — it commenced at the beginning — it touches the middle and the end of time. It is a vast wave rolling down the tide of time, ever rolling, ever descending. Its spray and its foam are lost in the sands or melted in air, or the fragments of its mortality are broken off and swallowed up in the grave ; but the unit is unbroken; the wave rolls onward, onward forever; per- durable ; and shall not be swallowed up till the last trump shall sound, and the last end be come. The sun himself "grows dim with years," but the unit, the Genus man, springs ever fresh in immortal youth and vigor, like Antaeus of old, foreshowing the immortality of that spiritual part to which Adrian the pagan ad- dressed his speech, as it was leaving the imperial possessor a mere dust-fragment of the vast, ever-living unit man.

Animula vagrila blandula Hospes coraesque corporis. Quae nunc, abibis in locis.

Ael. Spautianus. — Adrian. Ccesar.

Now are not these great considerations? and yet from what meanness do they spring, even the germiferous tissue of the


40 THE FEMALE.

female ! It is from her stroma that issues the generic as well as the genetic force! What a wondrous law! what a won- drous power is that which maintains each genus and species pure and unalloyed as when it issued from the Creator's hand! So strange, so powerful, that each of them is set, as it were, within a magic ring, out of whose charmed round it can never stray ; so that no wild and horrid passion, no brutal lust, no insane desire can break, much less change or abrogate the law that set forth the primordial models, "each after his kind," of the species of the globe. For notwithstanding the countless myriads of genera- tions that from the remotest ages have reproduced individuals more numerous than the sands of the shore or the stars in the firmament, each blade of grass still obedient to its generic law, still imitates exactly its primitive pattern; and every elephant or worm ; every eagle that soars to the sim, or sparrow that chirps in the hedge ; every man, and every woman go steadily, like the current of a river, down Time's flowdng stream, ever ending, ever beginning, always changing, yet immutably the same !

I repeat it, the generic power is launched from the ovarian stroma : that is the sole animal concrete that is capable of produc- ing yelk matter. Yelk matter is germinal or generic matter ; I should rather say reproductive matter. The male tissues are no- where endowed with the power of this yelk production, and the sole elaboration of the stroma of ovaries is germ-elaboration. See, then, in this unobvious, apparently vile lump of animal texture, in the inner court of the temple of the body, — the ark that con- tains the law^, which keeps the genera unmixed, from age to age. How can you study this subject sufficiently?

But let us pass to other views. Let us go to look upon wo- man in the phases of her intellectual nature. If w^e scan her position amidst the ornate circles of a Christian civilization, it is easy to perceive that her intellectual force is different from that of her master and lord. I say her master and lord ; and it is true to say so, since even in that society she is still in a manner in bonds ; and the manacles of custom, of politics, or of hienseance not yet struck from her hands. She has nowhere been admitted to the political rights, franchises and powers that man arrogates to men alone. The Crown, when it rests on the brow of a wo- man, is always a political accident, grievous and deprecable; and even then, where woman reigns, man governs.


THE FEMALE. 41

The great administrative faculties are not hers. She plans no sublime campaigns, leads no armies to battle, nor fleets to vic- tory. The Forum is no theatre for her silver voice, full of ten- derness and sensibility. She discerns not the courses of the planets. Orion with his belt, and Arcturus with his suns are naught to her but pretty baubles set up in the sky. She guides no ship through night and tempest across the trackless sea to some far-off haven half round the world. She composes no Iliad, no ^neid. The strength of Milton's poetic vision was far be- yond her fine and delicate perceptions. She would have been affrighted at the idea of that fiery sea on whose flaming billows Satan,

"With head uphft above the wave, and eyes

That sparkling blazed

extended long and large, Lay floating many a rood : in bulk as huge As whom the fables name of monstrous size ;

■ or that sea-beast

Leviatlian, which God of all his works Created hiigest that swim the ocean stream."

Do you think that a woman, who can produce a race and modify the whole fabric of society, could have developed, in the tender soil of her intellect, the strong idea of a Hamlet, or a Mac- beth. Could her voice, like the accents of Hortensius, or TuUy, or Chatham's, or Burke's, command the bent ear of listening senates, or move like a tornado the agitated masses of a peo- ple tossed in the tempest of its own vehemence; and then, like a gentle west wind, soothe and calm them down again by the influences of its reasoning and prayerful suasion .-'

" Ille regit dictis animos, et pectora mulcet.

.^NEID, I.

Such is not woman's province, nature, power, or mission. She reigns in the heart ; her seat and throne are by the hearth- stone. — The household altar is her place of worship and service. — The Forum is too angry for her. — The Curia is too grave and high, and the Commitia too boisterous and rude. — Home is her place, except when, like the star of day, she deigns to issue forth to the world, to exhibit her beauty and her grace, and to scatter her smiles upon all that are worthy to receive so rich a boon — and then she goes back to her home, like as the sun sinks in the


42 THE FEMALE,

west, and the memory of her presence is like the sun-light that lingers long behind a bright departed day.

Her voice is not for brawling. Its tender tones are for sooth- ings and caressings. The sweetest lute is in her vocal organs ; and with its music she stifles the passion, assuages the rage of her master, and reduces back to the gentlest flowing, the furious tide that boils in his veins. It is by the mere contrast of her gentleness, her docility, her submissiveness and patience, that she makes herself the queen and the arbitress of the fate of whom she loves, and whose best rewards for the pains, hazards and toils of existence, are ever to be found within the narrow circle of her domestic reign.

It is true, that we meet in the pages of History and Biography, the relations of strange phenomena in the lives and actions of certain women. There are Julias and Messalinas, that are mon- sters. There is even somewhat questionable in the nature of such ladies as Elizabeth, or Mary of Medici. — We have the male powers of a Dacier and a Stael. We find the gentle and femi- nine Hemans sometimes bursting forth with a wild, impetuous and martial enthusiasm. Yet these are exceptions, and not rules, that fill us with surprise, as of things out of, or beyond the com- mon course of nature.

The bibliographical lists are full of the prettynesses of the ladies. — No Mecanique Celeste — no Principia — no Treatise de Senec- tute — no annals of Tacitus ; but canzonetti, fairy tales, stories of the heart, Mysteries of Udolpho, and Coelebs in Search of a W^ife. Such are their works. So that it is easy, by a slight glance at history, and by the facts that surround us, to conclude that the intellectual and moral force of the female are different from those of the stronger or ruder sex.

Who could imagine such an intellectual fairy as Felicia He- mans joining a charging squadron of crusading chivalry, with Godfrey de Bouillon, or Cceur de Lion, and glorying in the com- mingling of the spears ? Yet, though timid herself, her very ten- derness gives her the keenest perception of the nature of courage, and the deepest sympathy with the feelings of her gallant knight.

See, gentlemen, in the following lines by Mrs. Hemans, her touching sympathy with a captive Crusader in some lofty Pagan tower, perched above a deep craggy wady in Palestine.

Worn and wearied with a long and lone captivity, his valiant


THE FEMALE. 43

heart, though broken, still pants, in its solitude and hopelessness, for the freedom and action of the field. Suddenly he starts at the wild scream of a bugle !

"Twas a trmnpet's pealing sound !

And the Knight look'd dovv-n from the Payiiim tower

As a Christian host, in its pride and power,

Through the pass beneath him wound.

Cease awhile, Clarion — Clarion loud and shrill —

Cease ; let them hear the Captive's voice. — Be still, be still.

I knew "twas a trumpets note ; And I see my brethren's lances gleam, And their pennons wave by the mountain stream, And their plumes on the glad wind float. Cease awhile, &c.

I am here in my heavy chain ! And I look on the torrent sweeping by. And an eagle rushing to the sky, And a host to its battle plain ! Cease awhile, &c.

Must I pine in my fetters here With the wild waves foam And the free-bird's flight, And the tall spears glancing in my sight. And the trumpet in my ear ? Cease awhile, Clarion, &c. &c.

Now, for my part, I cannot but see in these verses of that most sweet poetess, proofs of her liveliest sensibility to both the nature and the intenseness of those male passions, which, however they may be fitted to enkindle her admiration, and enslave her heart, as forming a perfect antithesis to her own gentle nature, would, as existing in her own breast, demoralize and deform it.

The military pennons and plumes floating on the glad wind, and the tall spears glancing in her mental sight, are not for her to wear or wield. But she may well glory in the hero who is both able to wield and to w^ear them.

As to the more strictly moral attributes and propensities of the female, what are the facts ? Is not her heart, in general, the seat of tenderer and gentler emotions than those of her mate ? Her susceptible soul is acutely alive to the human charities and trem- bling sympathies that spring spontaneously in the delicate inner- vations of her feminine constitution. She cannot unmoved look on scenes of w'oe.


44 THE FEMALE.

She melts at the spectacle of human distress — a maiden shelter- ing a wounded dove in her bosom is an eidolon of the sex.

Mungo Park in the Sahara, and Ledyard among the wildest Samoiedes, always received good, and not evil entreaty at the hands of women, whose husbands had hearts like the nether mill- stone.

Notwithstanding the poet has characterized her as being,

" in our hours of ease, Uncertain, coy, and hard to please. And variable as the shade By the light trembling aspen made,"'

she is faithful and true. She follows the fortunes of her mate, who has gained her affections. Yea, she adheres to the promise at the altar, which was for better for worse, for richer for poorer, in sickness and health — even unto death ; so that the same rhymer apostrophises her with

"When pain and anguish wring the brow A ministering angel thou !"'

What a beautiful picture is that engraving of the "Intem- perate!" which you see everywhere in the print shops? What touching, what immortal fidelity is depicted by the artist in the face of that woman! A face beautiful in its expression of resig- nation, and of pride in her own faithfulness and truthfulness, as she bears on her bosom the youngest child, while she leads a sick boy by the hand, and is clutched by a timid older girl, all of them barefooted, houseless, hopeless, homeless, for they leave behind in the distance, the pretty cottage where they were born, to pur- sue, along a rugged way, the uncertain, drunken footsteps of the husband and the father, who leads them miserable far away, deserting the homestead she had brought as her dower, in that blessed morn when in the village church she gave herself away for him. Now here is her reward! But she will cling to him until the' death of the drunkard shall have broken the bond ; and after that, go weep on his discreditable grave, and forgive him too. Such pictures are from life. There are thousands of such.

The female is naturally prone to be religious. Hers is a pious mind. Her confiding nature leads her more readily than men to accept the proffered grace of the Gospel. If an undevout astro- nomer is mad, what shall we say of an irreligious woman? See


THE FEMALE. 45

how the temples of the Christian worship are filled with women. They flock thither with their young children, and endeavor to implant in their souls the seeds of virtue and piety, to be reared in that pure soil and by their watchful nurture, into plants that shall blossom like the immortal amaranth among the stars. See then what and how great the influence that women exert on the morals of society, of whole nations, of the whole world : wherever there is a true civilization, woman reigns in society. It is not until she comes to sit beside him, in view of all the people, that man ceases to be barbarous; or semi-barbarous, and cruel, and ignorant.

She spreads abroad the light of civilization and improvement as soon as she issues from the prison of the Harem, or Zenana, to live with him in the world. Who made us human? Whose were the hands that led us to kneel down and whose the lips that taught our infant voices the earliest invocations to Heaven? Is it not so, that after the world and fortune have done their best, or their worst by us, we, in late years, and early, forget not those pious mothers, who so steadfastly strove to bias our young minds in favor of whatsoever is true, whatsoever is pure, whatsoever is of good report!! How can we forget the rewards we received at her hands for all our good, and the gentle, and sometimes tearful reproachings of our evil inclinations and practices ? She was not only our teacher and pattern, but our companion and playfellow, for, of a truth, she was of a child-like temper — and that was the secret of the bond that united us so long and so closely. Hear what an eloquent Frenchman says of her :

" Source feconde et sacree do la vie, la mere est la creature la plus respectable de la nature ; c"est d"elle que decoulcnt les generations sur la terrc ; c'est Eve ou I'etre vivifiant, qui nous rechauffe dans son sein, qui nous allaite de ses mam- melles, nous recueille entre ses bras et protege notre enfance dans le giron de son inepuisable tendresse. Femine ! mere ! hormeur de la creation ! quels hommages eteniels ne vo'us sent pas dus dans tout Funivers ?

ViRET. — La Femme.

The male is less versatile than the woman. His mission is more adventurous and dangerous. He enters on the path of am- bition, that dark and dangerous, or broad and shining road.

He pursues the devious track of politics with a resolute will ; reaching ever onwards to the possession of fame and patronage, and rank and wealth.


46 THE FEMALE.

She sits at home, to adorn the tent or the cottage with wreaths of flowers ; or to guide the tendrils that give shade to his bower. She plies the busy loom — and the sweet sounds of her singing — how often have I listened as they accompany the hum and buzz of her wheel, as she gracefully advances and retires by turns, forming the threads about to be woven into garments for her hus- band or child! Her nimble fingers, all day long, ply the shining needle, to fashion the robe for her spouse — or to arrange the more elegant embellishments of her person, that they may engage his admiration, and augment the flame of his love. For woman, man's love is the moving spring of all her actions. This is at the foundation even of her vanity. Lais herself is said to have sacri- ficed even her rage for wealth, at times, to the gratification of her vanity ; and the lioness tearing a ram to pieces, which was sculp- tured upon her tomb, was the emblem of her insatiable avarice. Yet Lais lived more for love than for gain.

What say you of the fortitude of woman? She bears the evils of life without repining or complaining against the providence of God. Is she evil entreated, prevented, injured? That which sets a man on fire with an insane rage, kindles in her bosom, perhaps, only a virtuous feeling of indignation. She bears the greater crosses. How beautifully does Shakspeare say so in the words,

" She never told her love, But let Concealment, like a worm i' the bud, Prey on her damask cheek ; And sate, like Patience on a monument. Smiling at grief."

She dies a willing martyr for religion, for country — for her children.

Who can number the Lucretias and Portias ? How many are like the charming Roland? Think of the calm features of Char- lotte Corday!

Women possess a peculiar trait — it is modesty — and is one of the most charming of their attributes ; springing probably from their natural timidity and sense of dependence. All rude, bois- terous, and immodest speech or action unsexes and disgraces her. This modesty is one of the strongest of her attractions ; and she sometimes, perhaps, affects to possess it for the purpose of riveting her chains on the conqueror man.


THE FEMALE. 47

^Tajo me CJnlatCtT petit, lasciva puclla, Et fugit ad salk'cs et sc cupit ante videri.

The attribute of modesty certainly lends the most powerful aid to the charms of a woman. It is one of the qualities given to her in order to be a strong fence for her children ; it binds her to the domestic altar — her children could not but endure damage and loss, should she leave them at home to plunge into the torrent of public affairs, or mingle freely with the distracting world ! Her modesty, gentleness and timidity assimilate her to the cha- racters of children, whose best playfellow, nurse, and instruc- tress she is. Come out from the world, and be separate from it, is peculiarly a command for her.

There is in the Museo Pio-Clementino, at Rome, an antique statue, which the learned Visconti asserts to be a statue of Mo- desty; and, as I am informed, is among the most beautiful of the works of ancient art now remaining in the world. It is com- pletely clothed from head to foot, and veiled. It seems to me that such a work is proof enough of the ancient admiration of the quality in question ; for the artist who could produce, and the people who could appreciate such an exquisite specimen of taste and right feeling, must have had a keen perception of the charm.

By her physical form and proportion, she is still more trench- antly divided from the male. Look at two statues, male and female. Take the Venus de Medici as the consummate expo- sition — the very eidolon of the female form, just as Praxiteles in the greatest verve, fervor and enthusiasm of his genius, and he alone of all mankind, could conceive the idea of the Queen of the Loves.

Compare her with the Apollo of the Belvidere — she has a head almost too small for intellect but just big enough for love. His magnificent forehead, calm as Heaven, and almost as high as it, rises above those eyes that are following the shaft he has sped with his clanging silver bow.

The front of Jove himself,

An eye like Mars, to threaten and command ;

A station, like a feathered Mercury, new-lighted on

Some Heaven-kissing hill.

Her thorax seems built as the sanctuary of that beautiful bosom, whence is destined to flow the sweet nutriment of the winged boy.


48 THE FEMALE.

His vast chest is for breathing, and for eloquence and com- mand. From its capacious stores of oxygen he draws the ele- ments of the most strenuous, the most protracted exertion. He breathes deep, that he may ascend the highest hills and the sharpest crags in pursuit of his game or his prey, and that his loud harmonious voice may command his armies in the midst of the conflict — or sway the forum with its tones. Like Virgil's wild horse — he is equal to the longest career — nothing can stay him in his race.

?'fon Scopuli, nipesque cavae, atqvie objecta retardant Flumina, conreptos unda torquentia monies. — Georg. III.

See his loins how" they are narrowed down, as they approach the hips, that he may balance himself, as it \vere, on the point of an inverted cone, ready for the promptest motion. His pelvis contains no variable organs, requiring ample space for extraor- dinary developments ; but its depth and solidity afford origin and insertion to the powerful muscles, by whose immense strength he can act w'ell in the wild, rude, and adventurous life to which he is ordained.

The cone, on the other hand, is reversed in the female. The apex is above, and the base is at the hips. It is within that bony cell that are hidden those miraculous organs, that out of nothing, can evolve the w^ondrous w^ork of reproduction. Her pelvis is broad and shallow, lighter in substance, its excavation ampler, and its pubic arch round or Roman ; while his is Gothic or lanceolate. From under this arch a child could not go; the other gives it easy utterance. The organs of the male are perma- nent — hers are mutable. The uterus — no bigger than my thumb — comes in gestation to be twelve inches high and nine in width. Its invisible vessels and nerves come to be great cords and tubes, and its uncognoscible muscles acquire a force to rend itself in pieces in its rage, and, what seems still more miraculous, to ex- pel a full-grown foetus from its parietes, against the enormous resistance of flesh and bone. She is a germiparous and vitelli- ferous creature. She — the female — possesses that strange com- pound or concrete which you call stroma, ovarian stroma, of which I already have spoken, but must again speak. Now that stroma lives by the blood it receives out of a common endangium, and yet it has a nerve which enables it to convert that blood into vitellus or yelk. The perpetuation of races and germs depends on


THE FEMALE. 49

the elimination of that matter. There is no animal germ without it — so that an organ so small, so iinobvious, is endued with the vast responsibility of keeping up the living scheme of the world — with its moralities — its lives — its actions — its trial — which, were it to cease, there would be left no flowers to bloom, no in- sects to sport in the evening beam, no choral song of birds, no lowing of cattle, no bleating of flocks, nor voices of men to thank and praise and acknowledge the author of every good and every perfect gifl:.

Think of that, gentlemen. Think of that great power — and ask your own judgments whether such an organ can be of little influence on the constitution of the woman ; whether she was not made, in order that it should be made, and whether it may not on occasion, become a disturbing radiator in her economy, and how much. You will answer yes, if you know that her ovary is her sex — and that she is peculiar because of, and in order that she might have this great, this dominant organ concealed within the recesses of her body.

Men cannot suffer the same pains as women. What do you call the pain of parturition ? There is no name for it but Agony.

Why does she love her child more than its father does. Why, he grew to her ; he was perhaps an acinus cast out of her stroma, and after drawing his blood from her own blood, he drank life at the living well of her bosom, and character from her monitions and example. What were Cornelia's jewels ? Who was Wash- ington's mother ?

What do we owe her? — life, peace, liberty, social order. She built up this great frame of society in civilization. It is to her we are indebted for our

" Placidam sub libertate qiiietein."

Christianity is propagated by her domestic influence. The loom is her work, and the tapestried walls are of her imagining. Were it not for her we were this day clothed in sheep skins and goat skins, and should lie down in dens and caves. It is for her that the looms of Cashmere, the silks of China, the gauzes of Hindustan, the mousselines of Lyons, the laces of Belgium and England are formed; the carpets of Ispahan and Dresden, Cor- nelius' blazing chandelier, all the riches displayed by Levy and 4


50 THE FEMALE.

Baily are for her. Everything that man is and hath, except his brute force and brutal inclinations — are of her, and for her.

See her gliding down the Cydnus in her stately barge, with its silken sails and costly equipage, and the great Triumvir at her feet, who thought the world well lost for her love, and gave up the world to lie there.

Look at her in the regal halls of Windsor, waving her golden sceptre around the globe over dominions of hers, on which the sun is never set for all. Drive her out, and all her sex with her, to the primitive rudeness of her nature, and leave man alone, and W'hat should move him afterwards to do more than is done by the lions and tigers, who follow their instinct, and who are less cruel than he by nature, since he reasons in his evil, while they are only instinctively monstrous !

Study the nature of woman, young gentlemen, follow out all the psychological and physical transformations which her sex produces. What is her erotic state? what the Protean manifest- ations of the Life-force developed by a reproductive irritation which you call Hysteria.

Take Martin Barry's microscope, and Bischoff's History of Development, and study the myriad germ points that are buried in the depths of her stroma.

I have already placed in your hands the key that unlocks all the secret details of her mensual phenomena, and not hers only, but those of all that reproduce, both of the animal and vegetable kingdoms of nature.

It were an endless task to undertake the protraiture of all the characteristics of the sex, as exhibited in their intellectual and moral aspects.

I have made the foregoing slight indications of them, with the purpose of turning your thoughts in that direction ; for I believe the contemplation of such subjects is extremely useful to the prac- titioner of physic, and especially so to those that have design to engage themselves in the business connected with the obstetric art and practice. I shall not deem it necessary now to do more than merely hint at the potent influence which must be exerted upon the pathological tendencies and states of the female, by the constitution of her organs, and, indeed, by the more delicate, gracile and impressionable nature of her whole economy. I say I shall merely hint at the subject in this letter; for as much as the


THE FEMALE. 51

whole series is relative to these effects, I shall treat of them herein in extenso.

Appreciating as I do, at the highest possible rate, the influence of the gentler sex upon the character and action of the male, I cannot but see in that influence the cause of a major part of the happiness now enjoyed by mankind in civilized, or, to speak more exactly, in Christian lands. It is true that, during the great glory of the Roman empire, manners, luxury, pomp, had attained to a high perfection ; but it is equally true, that the social and domestic position of the women was even there ele- vated, although not to a station so coequal as that to which she has attained in our own age. Petulanter facimus, si matrem- familias, secus, quam matronarum sanctitas postulat nominamus, — is the saying of Cicero.

When, upon the dismemberment of the Roman empire, and the darkness that was consequent to the descent of the barbarians into western and southern Europe, society seemed to have lost all its security ; and when brute personal force appeared to be at the foundation of all administration, as well as of all domestic security, the sex came forth again, and by troubadour and knight, whom she created and moved, brought her human- izing hand to bear upon, and to recompose the shattered frame of society. The virelay and the tale of the troubadour, and the scarf of the knight, were worthless but as sanctioned by her smile of approbation. The Tales of Boccacio, the old Romances, the illuminated missals and hours, led by degrees up to the search for a higher literature and a truer learning; so that at the breaking forth of the love of letters in Europe, the way was already pre- pared for their reception and just appreciation. Education, de- cency, what is understood by good breeding, laws of society, all these take much of their complexion and most of their beneficence from the sex, who thus, while disfranchised as it were, by the political constitution of the world, are yet, in fact, the secret promoters and moving powers by which it is made both pro- gressive and improving.

In speaking thus of the influence ofw^omen on society, I do not wish to disparage that of religion, of which they are justly to be viewed as the promoters ; nor would I lessen the sense of grati- tude due to the wise philosophers, the good legislators, the ardent philanthropists, to whom we owe an impayable debt of reverence


52 THE FEMALE.

and praise. I am far from desiring to look on woman as the race — I contend that though she is unlike man in her fleshly nature, and different from him in her intellectual nature, yet she is a great and predominant force in the world ; physically weaker, yet not less noble ; restrained of power, yet the cause and reward of his efforts — requiring his protection, his homage, his love, yet repaying him in the perpetual provocation she offers to noble endeavor; more than compensating him for support, in the rear- ing of his offspring, and by the humanizing, softening, meliorat- ing influence which she carries into his public as well as his domestic life.

But why should I attempt, or why should I have attempted a theme too great for a volume, and far beyond my abilities. You see how I have failed. It requires the eloquence of a Roussel and the learning of a Virey, to present even a sketch of a topic so vast, so interesting, so closely related to whatever may be called happiness, whether domestic, or social, or political.

I hope you will study this subject better than I have done, or can do.

I do not believe in a physician who knows only calomel and rhubarb. I would have you fill your souls with knowledge ; I would have you bathe in it as in an ocean. Were I young again, and could I appreciate as I now in some degree begin to do, the beauties of learning, I could not cast away, as I have done, a half century of time, but I would grow pale by the reflection of the midnight lamp, and I would never be satiated until my soul were satisfied with the fulness of knowledge. For what are we in the general but erring and curious inquirers ? and, does not the most highly cultivated intelligence to be found among men, leave thern at last, even the most gifted among them, blind, grop- ing, feeble worms of the dust? What should be our motto and our cry, from the lowness of the human nature in which we lie groveling? — Excelsior! Excelsior! C. D. M.


SEXUAL ORGANS. 53


LETTER V.

SEXUAL ORGANS.

Gentlemen : — In my Letters I have set before you some gene- ral ideas on the nature of sex in the female; and have also pointed out some of the more distinctive characteristics of that best half of our race. In this letter, I shall speak to you of the reproductive organs; begging you to accompany me in the disagreeable task of this investigation with minds purified by the love of truth, and by that decent self-respect, which ought to guard every physician when he comes to study, as a part of his professional obligations, this department of anatomy; a department we cannot omit to learn, without leaving ourselves incompetent to the safe discharge of many important medical and chirurgical duties; and which we cannot study without feeling that we are engaged in inquiries that ought not to be exposed to the public gaze.

Instead of treating in this letter, of the private parts in question, I might perhaps as well have referred you to the anatomical treat- ises already published ; but, by so doing I feel that I should leave this volume less complete than it ought to be.

In a recent report of testimony given before one of our courts of justice, where a person was in question for having published an obscene book, pretending to be a medical work, a witness characterized it as "fit to be seen only in a Doctor's shop."

Let us take a lesson from this undesigned reproof of the medi- cal faculty; and while we acknowledge that our ministry calls upon us to know all that can be learned as to the anatomy and physiology of the reproductive organs, let us admit also that it behoves us out of a feeling of self-respect, and respect to our calling, to treat these subjects with all decency, and wdth a just deference to our friends not of the profession; who, having no claims to acquire the knowledge we are compelled to obtain, must not be offended by any unavoidable indelicacy of expression in our writings. Such persons being to us entirely esoterical, ought not to suffer themselves to pry into those particular mysteries of


54 SEXUAL ORGANS.

the medical profession, which it is better for them not to learn than to know. If they look into our books and blush, they are like eaves-droppers, who generally hear no good of themselves. As for us, let us remember that the President of the Board of Trustees, who, in the name, and by authority of the State of Pennsylvania, admitted you to the rank and quality of Doctors in Medicine, declared you vested with the powers exercendi, docendi et scrihendi, uhi rite vocati fueritis ; and that this commission allows us a great privilege of discussion; which being needful for our art and the security of the people^ is decent and proper in our hands, but vile and contra bonos mores in the hands of other people. Fantoni, as cited by Dr. Asdrubali, in the Trattato Generale di Ostetricia, &c., p. 68, t. 1., says, " Honesta quantum potero, muliebria examinando; honeste, inquam si potero; nam fieri vix posse puto, ut honestis appellationibus res vulgo obscsenas de- signamus, quae facile pudicas aures offendunt. Sed vobis nuUus sit pudor integris auribus ea excipere quse divina sapientia creare non erubuit," &c.

The reproductive organs of the female are external, and inter- nal. The former being situated upon the outer face of the pelvis, and the latter concealed within its bony cavity.

A sense of modesty induced the ancients to give the denomina- tion of pudenda to the external or visible privities of the female ; and this word, which is a plural noun, applies to the whole of the external genitalia.

The pudenda, therefore, comprise the mons veneris ; the labia externa, also called labia majora ; the labia interna or minora, called also nymphse ; the clitoris ; the prasputium clitoridis ; the vestibulum; the os magnum; the carunculse; the hymen; the fossa navicularis; the fourchette, and the perineum.

The internal genitals are the vagina, or vulvo-uterine canal, as the Frenchmen call it ; the uterus or womb ; the Fallopian tubes; the ovaries; the round ligaments, and the broad ligaments.

The word vulva applies to the sexual fissure, rima, or sulcus, that is observed between the two opposite labia majora.

Now, as to the mons veneris {le Penil,) it is an elevated portion of skin, that is lifted above the general level of the lower part of the belly, partly because it is on the share-bone or os pubis, and partly because it is underlaid by a considerable quantity of adi- pose tissue filled with fat.


MONS VENERIS. 55

This part of the skin is of a darker color than that \Yhich is above and about it ; for it contains a portion of pigmentary mem- brane which deposits on the exterior surface of its corpus rauco- sum,the same sort of dark matter as is known to color the axilla, the aureole of the mamma, the perineum, &c. It is also covered abundantly with hair, which begins to make its appearance under the critical efforts of the constitution when those efforts are being employed to convert the creature from childhood to puberty ; — or, in other words, when she is about obtaining such a degree of development as may consist with the power of germ-production. It is not unworthy of your observation, that when the power of germ-production is lost at the change of life, that of producing the pudendal hair is diminished very sensibly, and in old age, not unfrequently goes to the extent of a complete depilation.

Women also, who from feebler health, cease to bear children, as they advance in age, but who have not wholly lost the faculty of germ-production, often find that the pudendal hairs are less- ened in abundance during the suspension of the child-bearing faculty ; and that the crop is greatly increased as soon as they find themselves again pregnant after many years have passed since any former gestation of theirs. This I have learned from several cases observed and inquired of in my clinical experience, for I have many times had charge of labors in women, who being as it is called getting old, and not bearing children for eight, ten or twelve years, were yet surprised and vexed to find themselves so wonderfully young again.

As to the disorders to which the structure called the mons veneris is liable ; you will be sensible that they must be of the nature of the exanthematic and phlegmonous inflammations, con- tusions, and wounds ; and that such affections have not and can- not have any special relation to what is properly called midwifery. Perhaps, indeed, we may except some rare samples of pain, neuralgia or inflammation of the textures connected with strains, or violence done to the symphysis pubis ; either by the protracted influence of continued pressure and weight on the pubes by a heavy womb ; or by injurious tension and even disruption of the symphysis or of the bone, under the transit of an overgrown foetus, or a badly managed forceps operation ; where great violence is sometimes done to the bony structures, either by the power of the womb in its expulsive efforts, forcing too large a child


56 RELAXED SYMPHYSIS PUBIS.

through too small a pelvis ; or where, by the additional power of the forceps, such a child is drawn through such a pelvis, the articulation of the pubis, which lies underneath the mons vene- ris, becoming so strained as to inflame after the labor is over : or the bone itself may be broken asunder, as in some instances related by Madame Lachapelle in her admirable Treatise on Mid- wifery.

In any such cases, where pain is felt in the lower part of the mons, as I have heard many persons complain, it appears obvi- ous that the same chirurgical treatment ought to be adopted as is known to be most suitable to the articular maladies in general.

Professor Miitter has doubtless taught you that, in the treat- ment of articular inflammations, rest is of the primest force; and that in the movable joints, when inflamed, the splint is the first and greatest of remedies. Hence, in the instances where your patients after childbirth, shall complain of pain in the mons, in walking, or in turning in bed, you ought to direct your attention to the condition of the symphysis of the pubis.

I have met with many instances wherein the ligaments that bind the ossa pubis together have become so relaxed, probably under the infiltrative influences of pressure and tension, continu- ally exerted by the gravid womb, as to allow of a very per- ceptible play of the opposite ends of the ossa pubis upon one another; the right pubis moving upwards when the woman stood upon the right foot, and the left one rising above it again as she stood upon the left foot. I leave you to imagine the pain, the discomfort, the uncertainty and the feebleness of gait, attending so large, or even the least motion of this important joint. You fully know that the pubal bones cannot pass and repass each other, without, in some degree, disturbing the repose of the sacro- iliac junctions ; and I have shown you what sort of a cartilage that is, that we used to study under the denomination of the auricular cartilage of the sacrum and ileum. A cartilage so firm and resisting as that, could not become the subject of motion without the greatest inconvenience. It could not be treated by means of internal medicines; nor could any counter-irritants, lini- ments, lotions, or plasters, or ointments, have a very useful effect in the treatment.

Hence, you perceive, my friends, that, for your patients com- plaining of such movableness of the joint, there is but one chi-


RELAXED SYMPHYSIS PUBIS. 57

rurgical principle ; and that is, the joint must be allowed to rest. She must not make it move by walking about — for she can never transfer the weight of her body from one foot to the other, without transferring it from one acetabulum to the other; and you remem- ber that the pubis owns one-fifth of the acetabulum, and you ought to know, that an inflamed joint is nearly as little apt to be cured while motion is allowed in it, as a broken bone. They equally demand the use of the splint. This is the treatment sug- gested and used for half a century by our illustrious compatriot Dr. Physic. In Europe, it is becoming understood within a few years past.

I have tried various bandages, springs, and compresses, to relieve certain of my patients thus affected ; but such bandages are intolerable, because they cannot be kept in adjustment. Some women have soon spontaneously recovered by means of rest, which permits the joint again to become firm ; while others have continued to suffer more or less through successive pregnancies. — Rest is the ewe.

I will not say, that where the disturbance of the joint has caused an attack of inflammatory congestion, rest alone is indi- cated — for, in such a state of things the patient might very rea- sonably expect that you should seek to relieve her, further, by means of leeches; by counter-irritant applications; by stupes and cataplasms, and by anodyne liniments ; for the selection of which remedies in particular, I must refer you to the indications of the special case and time — as well as to your memory, for what Pro- fessor Mutter has counselled on such topics. These remedies are not dependable. — Rest is the cure.

I hope you will come to the conclusion, that w^herever the symphyses of the pelvis are found loose and relaxed after gesta- tion, that effect has been produced by a maladive condition. I am fully of Dr. Dewees' opinion on this point, and he used to scout at the notion of the bones naturally yielding in order to let the child escape more easily.

Dr. Moreau of Paris, whose excellent work on midwifery is in the hands of many of you, seems to think that the relaxation of the ligaments of the pelvis is not an unusual orunhealthful occur- rence; his remarks on the subject are at page 46, tom. i. I should be glad if you would read attentively his relation of a case at page 47, as well as a most interesting one at page 51. The


58 THE SETON IN PUBAL PAINS.

perusal of them would serve to show you how to act under similar circumstances. My own experience has not given me any op- portunity to observe such great disorders as he describes in his patients.

When I was in the city of Brussels, in the month of June 1845, I paid a visit to the magnificent Hospital of St. John, in that city. The medical officer on duty that day, was Dr. Grauiex, whose name is pronounced Gro. While accompanying him through the wards, and observing his methods of diagnosis, and of therapeu- tical direction, we arrived at the bedside of a very fine looking young woman, about 22 years of age, who did not look at all in bad health. I found she had been for a considerable length of time under treatment for a catarrhus vesicae, and that she had made no progress towards a cure. The frequent micturition was painful and annoying. Dr. Grauiex, after carefully examining the region of the bladder by palpation, took out a seton-needle already armed, and in a moment he passed a very long seton from side to side, near the upper edge or limit of the mons veneris, to the great chagrin and vexation of the young girl. But Dr. Grauiex w^as master in the case, and she was obliged to submit. I told him it was the first example I had seen of such a treatment of the troublesome disorder in question, when he rejoined that he regarded it as the most efficacious he had known ; and that he had learned it at Paris, in the service of the illustrious surgeon the Baron Dapuytren. Dr. Grauiex seemed to me, to feel quite sure that his operation would cure the patient ; but, as I very soon afterwards left the city, I am not able to state the result. I should think, from the opportunity I had of seeing Dr. Grauiex, and conversing with him, that his opinions on any'chirurgical or medical subject are deserving of great respect.

I have related this case, in order that you may, if occasion should arise in your practice, resort to it for the treatment of some of the more rebellious forms of cystic irritation and inflammation, as well perhaps, as for that of certain conditions of uterine func- tion that do not yield to gentler modes ; and I can suppose that, where the symphysis pubis has been injured in gestation or labor, leaving a chronical inflammatory state of the junction, you could hardly adopt a safer or surer remedy than this of Dr. Grauiex. It may seem out of place in this letter, but I trust, that whether


VULVA LABIA PUDENDORUM. 59

apropos or not, you \vill find it apropos in the chronic maladies of the parts crowned by the mons veneris.

I am not aware that the seton has been thus employed in this quarter by any of my friends.

Let us now proceed with our inquiries as to the other portions of the pudenda; and we shall find that the next in order is tht- part called the labia, the labia externa, or labia majora. The} are called by Felix Plater, in his Treatise de Partibus Mulierum Generationi Dicatis, by the name of CoUes, seu monticuli. The Greeks called them x^^'^'^i- Krauss, in his Lexicon, says that the Latin labium or labrura, is probably from the Greek xa/3w. The German is schaamlefzen, the French grandeslevres, the Italian grandi labbra pudende.

In the young embryo, the whole body is open in front, and all the organs and viscera quite uncovered ; but, in the process of development, or embryogeny, the sides of the chest and belly, curving first forwards and then inwards, until their margins come into contact, they fuse, or unite or soldei", the one to the other, and thus the thorax and abdomen become at last converted into closed cavities.

In this process of union or fusion, a place is left for the entry and exit of the umbilical vessels ; the margin of the anus is left unfused; and the vulva, in like manner, refuses to allow the op- posing mucous surfaces of the labia to be soldered together. This open space then is the vulva, or the genital fissure, rima, sinus pudo- ris, &c., on the right of which is the right labium, and on the left, the left labium majus. The upper end of the fissure, where the derm is disparted, is the superior, and the lower one the inferior commissure of the vulva. The labia extend from the one to the other commissure. The exterior surface of the labia is skin, covered with hairs, that diminish in abundance from above down- wards. The interior aspect of the labia is a mucous tissue, which, in the young, is of a bright rose-color, but becomes of a darker and less sanguine hue, in persons of eighteen or twenty years old, and of a livid purpureous tint in the more aged.

In fat persons, the labia are plump, or even turgid; in the macilent they grow lean, and possess not the firmness and solidity observable in the former sort of persons. I have ex- amined many hundreds of various ages.

The structures contained within the dermal and the mucous


60 LABIA. CEDEMA LABIORUM.

laminse of the labia, is a cellular tela; and, as before remarked, is, in fat persons, filled with adipose cells. Of course, there is a good supply of blood-vessels and nerves and absorbents ; so that they are the not unfrequent seats of inflammations, that have a very great proneness to run into the suppurative termination.

Inasmuch as the labia are also rather exposed to violence in falls, and blows ; as by kicks ; by falling astride of sticks and bars, &c., they present to us cases for counsel and treatment not unfrequently.

These parts also are subjected to enormous elongation and pressure by the out-passing child, in parturition; so that they may be torn in the direction of their longitude, or fractured hori- zontally, or filled with vast deposits of blood, injected into their loose cellular laminse, from ruptures and wounds of the branches of the pudic vessel.

In anasarca, and in the oedema gravidarum, the textures within the labia become greatly infiltrated ; and the dropsy of the labium renders it, at times, as large as a man's arm ;• excessively tense, and exposed to attacks of erysipelatous inflammation, and to gangrene.

Here, therefore, you will find a fruitful source of trouble to the female, and of opportunities to display your qualities as surgeon, physician and gentleman ; for I need not say, that without a just combination of all these qualities, you will never b-e acceptable as the medical counsel of those females, who may be so unhappy as to find themselves compelled to sue to you for help in so great a time of need and mortification.

Whenever from an anasarcous condition, or from an cedema brought about by the pressure of the gravid womb on the ascend- ing currents of fluid, whether venous blood in the iliacs or cava, or of lymph in the absorbing vessels, you are complained to, of a painful or inconvenient tension of the labia externa, you will always, I suppose, feel it a duty to investigate the case for your own guidance, and not confide in any description that may be proffered by the patient or by her nurse.

There are many instances of swollen or rather infiltrated and distended labia, which require no special direction from you ; for, whenever, after an examination of the part, you can come to the conclusion that whatever fluid of infiltration it contains, can readily be pressed out of the cellular tela by the thrust of the


(EDEMA LABIORUM. 61

presentation against it, you \vill merely console your patient by assurance that no danger, and little inconvenience are to be ap- prehended from her situation.

But, in certain other cases, in which labor is going on, or near at hand, you may deem the packing of fluid into the tissue to be so great, as to expose the woman to risk of rupture or lacera- tion of the labium, by the escaping head or buttock. Where you have any reason to fear that the labor may be protracted by the undue resistance of the labia, you may readily obviate the em- barrassment by making a few punctures on the inner face of the organ, with a slender lancet, the point of which should be carried merely through the surface into the cellular meshes. From these punctures the fluid soon escapes, whereupon the labium collapses again, and is more flaccid than before the tension came on.

Dr. Dewees speaks of infiltration as occurring without cedema of the leg's. I have never met with such an instance ; nor do I well know how it could occur except from a blow, in like manner as occurs in the eyelid, which is not rarely infiltrated from blows upon the forehead. In case of any purely topical infiltration, it is to be expected that the water will immediately begin to flow oflf into the adjacent meshes; and, therefore, it will not require any medical prescription, beyond, perhaps, some cooling lotion, such as a dilute mixture of Goulard's extract, and water; or a weak solution of muriate of ammonia in vinegar and water, with the addition of tincture of ophim. Cloths wrung out of such a solu- tion should be applied to the swellings. Half an ounce of the salt, a gill of vinegar and a tablespoonful of laudanum, mixed with a tumbler and a half of water, is the mixture that I com- monly employ.

I have never found any inconvenience to result from fine punc- tures of the labia, as above recommended ; and I believe that it is best to make them, whenever the inducement is of sufficient weight. I made such punctures in a bad case under my care a few years ago, during the process of distending the genitalia externa by the child's head. I found that the packing of the cellular structure of the labium with water was so very firm, as to prevent the yielding of the parts. Very soon after I had made the open- ings, the water within began to exude ; whereupon, I delivered the woman with the forceps, without injuring her at all.

Now, you may very readily understand that where the oedema of


62 (EDEMA LABIORUM.

the lower limbs has gone to the greatest extent, and the cause of the production of it still continues in force, not the labia piidendorum only, but the belly and chest, and even the upper extremities and head, have their cellular membrane filled ; a sample by no means difficult to find in practice. I am sure I have seen a woman in- creased in weight at least thirty pounds, or more, by this infiltra- tion alone.

You will also understand, that such a great cedema gravidarum, must, to a certain degree, interfere with the health, and that the labor is likely, on that account alone, to be a bad one. But a bad labor sometimes requires you to resort to the aid of the forceps, while the head is still pretty high up in the pelvis. This being the case, you cannot adjust the forceps to the child's head, without carrying the lock very far backwards, and thrusting the anterior edge of the perineum far tow^ards the anus and the coccyx. This you will be incapable of doing if the perineum be much infiltrated, thickened and hardened, so as to resemble rather a piece of deal than the ductile material of which it naturally consists. I have been baffled in all attempts to get the blades of the forceps adjusted by this resistance of the infiltrated perineum, but, when I have let the infiltration flow off through my punctures, then I rendered the perineum ductile again, and so could push it backwards and get ray instrument in situ.

Dr. Dewees appears to have treated some of the cases by venesection, by saline cathartics, and by doses of nitrate of potash repeated thrice a day. I believe that but little well-founded ex- pectation of a cure of the oedema can be indulged until the ter- mination of the pregnancy ; when the mechanical pressure of the gravid uterus being withdrawn, there is no further effusion of serum into the cellular laminae ; and the fluid of infiltration being taken up by the absorbents, the dropsical appearances soon vanish. You ought to expect, however, and you should predict, that your patient, who has suffered the extreme of this cedema, will look pale, and be, in fact, feeble and ansemical for some time after the close of her gestation. As a general rule, she will demand the use of a nourishing diet, wine, and iron, as the most likely means to re-establish her ha^matosis.

In one of the worst cases of this oedema I have ever seen, Mrs.

, a case in which I was seriously concerned for the

safety of the lady, I found that the expulsion of the child was


ffiDEMA LABIORUM. 63

immediately followed by a very great diuresis, which removed within eighty hours the last vestiges of the vast and general in- filtration. It is rare, I think, to find the most hydropic leg con- taining any serum three days after the child is born.

In the course of your practice you will be often called on to advise, on the subject of oedema gravidarum. As it is extremely common for primiparous women to have swollen legs in the last six weeks, and sometimes earlier, of their gestation, you ought never to forget that such a woman is more exposed than another to the alarming attack of eclampsia, or puerperal convulsion. In fact, I have known but few other worn en to have convulsions in labor than those with swelled legs. The pressure of the gravid womb on the ascending blood and the absorbents, causes the effusion of serum; the same pressure, be it observed, is exerted on the aorta, impeding the descending current of blood, and of course directing a more abundant circulation in the trunks and branches of the subclavians and carotids ; the consequence of which is an augmented arterial determination to the head and upper extremi- ties. If you permit this morbid determination to continue unmiti- gated, the slow but sure foundation is laid for puerperal apoplexy and eclampsia. The woman should be bled and dieted in a prudent and careful way, and all massive obstructions arising from a surcharged state of the colon ought to be obviated by gentle laxatives.

I repeat that I do not think you can reasonably expect to cure a considerable oedema by venesection; yet that it may be mode- rated by the use of the lancet and kept within safe bounds I do not doubt.

I shall close this letter here, with the design of speaking to you in the next, of certain other disorders to which the labia are sub- ject; — and I am very truly your friend and servant,

C. D. M.


64 WOUNDED LABIUM.


LETTER VI.

WOUNDS, LACERATIONS OF LABIUM.

Gentlemen: — I design in this letter to say something as to certain very distressing injuries of the labia, suffered by partu- rient women, and which are caused by the extreme tension of the labia themselves, or by the tension of other parts, whose accidents or diseases, implicate these external textures.

You are acquainted with the origin of the pudic artery from the ischiadic, in some individuals, and in others from the internal iliac; and you are aware that this vessel runs upward on the inner face of the ramus of the ischium, and sends branches forth to supply the external organs. Now, it occasionally befalls a woman in labor, or one affected by a wound, to fracture this pudica interna artery, or a considerable branch of it; — and as the labium ex- ternum is full of loose cellular tela, it is easy to see how a rupture of the vessel may cause such a quantity of blood to be dashed into the distensible texture within the labium, as to give the ap- pearance of an enormous tumor, of a very livid or even black color ; and producing all the pain to be expected from laceration of the inward textures, and the stretching of the others not imme- diately broken, by quantities of congealed or fluid blood, with \vhich the organ becomes thoroughly soaked and filled.

The rupture of a vessel within the brain may suffice to tear the brain like a wooden wedge driven into it. So, in the spleen, a vessel giving way tears that organ to pieces — and, in like manner, a broken trunk or branch of the pudic artery, may demolish the internal texture of the labium majus.

I have seen examples of the accident of various degrees of se- verity. Some of them were discovered before the termination of the labor, and others not until many hours subsequent to the accouche- ment. In the cases where the mischief is not complained of until long after the child is born, we may infer that the vessel is an arteriole only, — some branch of the pudic; which had given way during the expanded state of the inner genitalia, and which could


LABIAL THROMBUS. 65

not bleed while they were so expanded ; but commenced to scatter the extravasation within them, as soon as the distending and com- pressing cause w^as withdrawn. Such cases are less likely, I think, to prove mischievous, than the other sort, in which the labium begins to swell before the child's head has descended so far as to push the labium aside. When the labium fills in this way, antecedently to the emergence of the presentation from the arch of the pubis, we must suppose it to arise from the rupture of a trunk, not an arteriole. It is, therefore, more dangerous.

The quantity of fluid thus extravasated is surprisingly great ; and doubtless the bloody infiltration will run backwards into the loose cellular laminae that are in relation with the sides of the vagina ; producing disorder and difficulties to an unknown extent within; in addition to the more visible and tangible marks of them on the front of the pelvis.

A lady in this city was in labor of her first child in , 1844,

and after long-continued eflforts to dilate a rigid os uteri, drove the head into the vagina, where it rested, on account of a com- plete cessation of the pains, from exhaustion of the supply of uterine innervation. Her medical attendant, intent on procuring the expulsion of the foetus, administered to her a portion of secale cornutum, the influence of which w^as soon manifested by the renewal of the labor contractions in great force. The ergotic spasm thus excited, gave way, after no very long interval, from a second exhaustion of the nervous energy directed into the womb ; — and it was found that the left side of the vagina, the parts about the left crus ischii, and the left labium, w^ere swollen, tense, and painful. Being called to a consultation upon the case, I observed a large protrusion of the left half of the perineum, occasioned by bloody extravasation, which had gone so far backwards, as to fill the cellular material in front and to the left of the rectum ; while the looser texture of the labium had been rendered by it as turgid and dark as possible.

It would have been impossible to extract the fcetus from such a canal as was thus prepared, and as the indication was to use the forceps, I prepared the way for their successful application by making an incision into the inner and lower surface of the labium, out of which I extracted by means of the finger, which passed far inwards, a great quantity of coagulated blood, besides much fluid blood and serum; which being done, I next adjusted the- forceps 5


66 iABIAL THROMBUS.

to the head, and painfully, slowly, and with much effort, extracted the child, which was dead.

The patient w^as sorely exhausted by such a dreadful labor. Her very bad pulse did not amend after the delivery; the injured parts were attacked with erysipelas, to which she fell a victim, in the course of a few days.

I have thus given an account of a case which I hope may set, in a clear point of view, the nature and dangers of these bloody infiltrations; and I wish the perusal of it may set you on guard against similar occurrences, of which you will perhaps become the interested spectators. I should think the foregoing remarks enough to show you that the mere filling up a labium is a matter of small consequence, in comparison with the inward mischief and demolition likely to accompany such accidents. I pray you, then, not to disregard the complaints of your patients in child-bed, as to the affections of the external genitals ; but the rather, that you should pay very great regard to them, nor suffer the fastidious- ness of a modest female, or your own sense of delicacy, to prevent a complete and early investigation.

Do you not think that if a patient under your care, in labor, should begin to have extravasation (thrombus) filling up the labium, it w'ould be charitable, and dutiful, and prudential to lay open the mucous surface by an incision conducted in the longi- tude of the organ, and deep enough to give issue to the infiltrating blood? Would not such an aperture, by allowing the hemorrhage to exhaust itself upon cloths or napkins, prevent it from tearing to pieces, or obstructing the lax textures outside of the vagina and inside of the pelvis? Be you the judges to decide upon any case presented in the course of your practice. I think, that where a labium is already filled with blood, before the distending power of the head begins to be exerted upon it, if you allow the injecting force of the hemorrhage to go on unchecked or unrestrained, you will have reason to dread the extending of the thrombus to very deep-seated textures; and hence I should much prefer to allow the fluid to escape through an incision made on the mucous face of the labium.

I pray you to consult Dr. Dewees' article on this subject, in the Treatise on Females; it is a very. good one, and you ought certainly to consult the writings of that celebrated man — the more especially as he was an American authority.


LABIAL THROMBUS. 67

I have said nothing of the after treatment of the accident. Of course, you will not expect to discharge from the thrombus all the blood contained in it, by an incision. You will get out all the coagula, very great in quantity, and pass out much fluid blood and serum of the coagulations. The discharge of the rest will take place, partly by outflowing under the textural contractility of the parts, and partly by the absorbents, which will carry it away. I am sure I have seen at least a pint of blood effused be- neath a man's skin, from a blow, taken up and carried away by the absorbents in about a fortnight. *

The most convenient treatment will consist in very emollient dressings, either of tepid water, mixed with a little red wine or vinegar, or of flaxseed tea, mucilage of slippery elm, applied as stupes or fomentations, or linseed or bread and milk poultices, or poultices composed of crumbs of bread mixed with the petals of chamomile. These dressings, when the tumefaction becomes sufficiently reduced, ought to be followed by cerate dressings ; whe- ther of simple cerate, basilicon, or Goulard's cerate. The selection will depend on your judgment as to the wants of the case.

When a woman has suffered from such an accident, it must be expected, if the injury be of a grave character, that she will have great pain and constitutional disturbance from it. I need not say, that you ought not to leave the nerve system to the un- mitigated perception of such painful impressions ; but that you ought to quell both its impressible and perceptive faculties, by keeping them within moderate bounds, by the use of anodyne medicines in some convenient form ; such as the Dover's pow- ders, which may be repeated in doses of four grains every two, four, or six hours, until the therapeutical end of its exhibition is attained.

Should much febrile heat, and sanguine exaltation attend the early stages, you might perhaps prefer a medicine like the follow- ing recipe.

Take of fresh lemon juice, 1 tablespoonful ; carb. of potash, 18 grains ; mix them and add, solution of sulphate of morphia, ^ of a grain to make a draught, to be taken every two, four, or six hours.

It will be obvious also, that where a full or tense pulse is found to accompany the accident, or to follow it as a consequence, it


68 LABIAL THROMBUS LACERATION.

may be needful to reduce the force of the sanguine circulation, by venesection, to a proper extent.

During the treatment, the bladder of urine should not become overfull, and the alvine dejection should be procured at least once in twenty-four hours. The most scrupulous cleanliness, as to the parts, ought to be insisted on — and all sour poultices, or remain- ders of dressings, carefully expunged. But all these precautions would be of little avail, without the most profound recumbent rest. She should not leave her couch until cured.

Watch such a patiefit vigilantly. She is always to be esteemed, until suppuration is established, in danger of erysipelas of the wounded parts. If attacked with erysipelas, she will scarcely escape death from peritoneal fever. I say then, watch such a patient well, through the dangerous five or six days ensuing the accouchement. If the disposition to erysipelas become manifest, you should apply the nitrate of silver pencil freely to all the inflaming skin, if not to the very margin or lips of the wound. The anti- phlogistic power of the nitrate, is probably the most dependable of your resources for such circumstances, and may be handled so as not to give any pain. C. D. M.


L E T T E R V 1 1 .

Besides the affections I have now treated of in the two former letters, the labia externa are subject to rupture or laceration, not attended with the terrible conjunction of concealed hemorrhage, last spoken of. Indeed, it would, a priori, be evident to you, that a fracture of the tissue, laying it open to the air, would not con- sist with the formation of a thrombus within its walls.

It is always a subject of regret, when the labium is torn in labor ; for I presume that no professional rank or station of the accoucheur, could preserve him from the maligning tongues that are so fond to wag against their betters. The more exalted your station, the more will you be liable to the assaults of the envious and the malignant ; who will not fail to spread abroad the bruit


RUPTURED LABIUM. 69

of the misfortune, accusing you of ignorance, inattention or rash- ness; and averring that youtore Jier dreadfully ; when they do not know, that your knowledge of Professor Carus' curve and the agents in the extension of the head, with your own probe and faithful regard to duty, could not, all combined, prevent the inno- cent head of the child from breaking in pieces an obstruction which it could not otherwise overcome.

I doubt not, my friends, after the repeated illustrations made in your presence, that you perfectly understand why it is the head of the child, which in vertex presentations enters the pelvis ob- liquely and in flexion — descends and rotates still in flexion, until the occiput, engaging under the crown of the pubal arch, is pressed upwards, as it emerges, along the exterior face of the symphysis, being compelled to move so, coincidently with Carus' curve, by the strongly resisting perineum, against which the sagittal suture is driven by the labor throes.

You may remember that I urged you not only to aid the peri- neum to compel the extension, but to aid it in compelling the head to move out in coincidence with Carus' curve; and that because, should it quit Carus' curve at a tangent, the perineum must give way, or a labium be broken off, or perhaps both of them be de- tached somewhere in their longitude ; a horrid accident, which I trust may never occur in the hands of any member of the class.

Only conceive of a rent commencing at the lower end of the labium, and running back through the whole thinned structure of the perineum, not thicker than this sheet of paper sometimes, so as to burst through into the rectum. Take care then, I pray you, of the women, who under faith of your diploma, or your acknow- ledged skill, commit such precious interests into your charge.

Let me warn you against the risk of cutting the perineum with the child's elbow. You will be very apt to allow the accident to happen whenever the child's hand, in a vertex presentation, descends, applied to its face or throat; for the ulna of the child lies in contact with the posterior wall of the vagina, and as it slides forth, and comes to press with its olecranon on the four- chette, that olecranon cuts the tissue like a sharp knife — whence, I beg you be careful to prevent the accident, which I have so often told you can only be prevented by supporting the perineum, knowing why, and how it is to be supported.

Such a laceration as I have now mentioned, is very difficult of


70 RUPTURED LABIUM AND PERINEUM.

cure, and will not be cured, provided any sloughing process should attend the inevitably consequent inflammation. If un- cured, the woman becomes converted into a monotreme, and is a pitiable object for the balance of her existence here. Take you, then, scrupulous heed to the tedious doctrines of the mechanism of the pelvis and head in labor, and never lose sight of them in con- ducting your cases, and especially your cases terminated with instruments. I have been for many years engaged in midwifery practice to a great extent of occupation, and I defy any one to point out the sample of a female who has suffered under any durable lesion or disability of the organs concerned in the trans- mission of the foetus, under my administration over labors. I confess I take pleasure in claiming the merit of such a success, not as impertinently arrogating any superiority of skill over my brethren, but as evidence of the good results that must ever attend a watchful care over those who are committed to our hands.

When a labium gives way in labor, it is because of some too sudden and violent an exertion of the expulsive force of the womb and the abdominal muscles in the last agonies of the labor throes. The tenesmic sensations and propensities of a female, whose perineum is frightfully extended by the presenting part, are so irresistible, that she cannot be prevented in some cases — I might say in many cases — from an involuntary and excessive effort to free herself from them ; and I have made it a rule to give due warning beforehand of strict obedience to the directions I should give as to not bearing down the pains ; and then, reflecting on the causes of the extension of the head, and the direction of the axis of the plane of the perineal strait, have safely guarded my patient against injury.

Do not, I pray you, accuse me of quitting my proper task here in order to talk to you again of a purely obstetric subject. I am well aware that my letter relates to the accidents that befall the labia and perineum; but I cannot forget the sound though homely adage — that prevention is better than cure ; and I deem my re- marks germain to the subject in hand ; and hope that they may serve, if not to eschew fractures of the labia in the whole, yet, at least, to render them less extensive and mischievous ; nor do I doubt of your success in eschewing them, if you should suffer yourselves to be governed by these views.

When the accident has occurred, there is but little reason to


RUPTURED LABIUM AND PERINEUM. 71

hope for union by the first intention, as the surgeons call it. How, indeed, could we expect such a union of parts not cut asunder by a sharp instrument, but torn by violence. The raw surfaces are surfaces of laceration, and can, in the general, only be reaccommodated by the process of granulation — a tedious process.

It will not be necessary to keep them in contact by sutures — plasters cannot repose upon surfaces continually bathed by the lochial, mucous, and purulent as well as urinary excretions. The suture only adds to the sum of the local injury, and is not unapt to generate an erysipelatous propensity in the parts. Sutures are not necessary to keep the surfaces approximated, and when that is done, the chirurgical indication is fulfilled. The stupes of warm wine and water, of mucilages, the poultices, and cerate dressings, together with a prohibition to abduct the thighs, are all that ought to be ordered, beyond the scrupulous regard to clean- liness that must be obvious to every one interested.

It is a good precaution to fit a garter to each leg, and to tie them by a tape, in such manner as to prevent any inconvenient abduction of the knees. Most of the cases of considerable lacera- tion, whether of the labia or perineum, may be expected to recover by the time the purification of the woman is complete — say within the month.

I have to state that I have met with cases of injury to the pe- rineum by laceration, where union had never taken place, and would never take place ; because, in fact, the anterior perineum being divided as far back as the rectum, laying that intestine quite open, the sides of the cut became each incarned and covered with a real mucous membrane, so that the woman, instead of having a vagina and rectum, had only a true cloaca, into which was discharged the products of the rectum, the uterus, and on some occasions parts of the urine ; for the posterior semi-circum- ference of the anus was now converted into the posterior commis- sure of the vulva. So that, in fact, the labium extended back to the inner wall of the anus on each side. Even in such a dread- ful case as this, the lady rarely is aflfected with any leakage from the gut; but discharges the alvus as regularly as any other per- son, save when attacked with diarrhoea. Her protection from the disgusting incommodity of non-retention of the faeces, is owing to the conservatism of some of the upper bands of the sphincter of


72 INJURED PERINEUM PROCIDENTIA.

the rectum, which I have found to close very completely the new formed anus, which was invisible, because concealed within the depths of the new accidental vulva or cloaca. Where all the fibres of the sphincter are lost, there must be a very constant drain of offensive matters from the intestine ; enough to render the creature an object of pity to others, and of aversion to her own conscious self. Life, to such an individual, is rather an insup- portable burden than a boon. How anxiously should you, there- fore, direct the resources of your information to obviate such a great disaster.

I may as well, in this connection, call your attention to another circumstance. It is this — the perineum being taken away, the vagina torn open very far upwards, and its strength thus reduced, — the unhappy female endures not a prolapsion only, but a true procidentia of the womb, which descending more and more with the progressive advance of age and debility of the parts, causes the patient to endure much pain, and to become subject to erosions and inflammations of the extrophied tissues. You cannot sustain them with a globe, a disc, or an elytroid pes- sary ; but you can always keep the prolapsed parts high up within the pelvis by that admissible stem-pessary of Dr. James Blun- dell, which I exhibited to you during our meetings in the lecture room. I am pleased to find myself able to assure you, that good hopes maybe entertained, therefore, as to the means of comforting those who become the subjects of these great obstetrical catastro- phes — for to be connected with the management of a case, that offers no hopes of a remedy during a long lifetime, is to be truly unhappy.

In addition to the affections of the labia above mentioned, you should make yourselves aware, that the textures within the mucous surface of the organ, are capable of developing cysts, and also more solid tumours. These cysts sometimes attain a considerable size.

Upon pinching such a cyst betwixt the thumb and finger, or upon pressing it with the palp of the forefinger, it is observed to be soft and fluctuating. There is little pain accompanying it necessarily ; but the presence and pressure of the sac may induce pain at last in the surrounding textures. There is some danger of making a mistake in the diagnosis, provided one be careless in his inquiries. For example, a lump, or tumour within the labium,


CYSTS — WARTS OF THE VULVA. 73

might consist of a hernia of a portion of the bladder ; and it is within the bounds of possibility, that the tumour should be formed by a descended knuckle of intestine. I am sure, however, that not one of you will ever be so imprudent, as to venture on discharging- the contents of any labial tumour, by means of the lancet, or bis- toury, without first taking care to ascertain the true nature of the case. The cyst itself will always be found perfectly circum- scribed, movable, fluctuating, and indolent.

The surgical method of treatment, consists in dissecting out the whole sac. If you merely open it, and allow the contents to escape, the organic apparatus, being undestroyed, you may ex- pect the sac to fill again. Perhaps, however, were you to fill the cavity wdth port and water, or with a solution of iodine, you might reasonably expect to produce granulating inflammation, which would obliterate the cavity ; or it is an easy and prudent step, to pass a seton through the centre of the sac — using for that purpose a very large, curved surgeon's needle with two or four strands of silken thread. Inflammation thus excited would, after withdraw- ing the seton in three or four days, in all probability cure the evil, by obliterating the special secretory membrane.

Women are sometimes plagued with a growth of verrucae or warts, that spring in dozens or hundreds from the whole surface of the sinus pudoris. They are in certain cases, so abundant as to dispart the labia, filling up the entire sulcus, and rising as a great convex mass of pale cauliflower looking tumour, quite convex above the general level. Upon pulling the labia further apart, so as to open the sinus pudoris, they are perceived to be small warty excrescences from the mucous body of the mucous membrane, and differ not from the warts on children's fingers, except by their greater softness, which depends on their being always bathed with the sort of milky humor of the labial membrane. They 'often bleed when touched, and when pinched off" with the finger nails, the broken surface trickles with blood, which soon ceases to flow. I have found that, when the entire labium right and left, has been quite incrusted with warts as above, I could with the probe separate them anywhere, for they are distinct from, though in lateral contact with one another. You will readily include a great number of them in a ligature, which being tightly tied, they drop off' after some hours.

The readiest way to remove them is to snip them off*, several at


74 DR. brainerd's case.

a time with scissors, curved on the flat. This being done, and the surface being lightly touched with the nitrate of silver pencil, or with a solution of sulphate of copper, the mucous tissue is not very likely to reproduce them. I doubt not they are hypertro- phied papillae of the corpus mucosum of the genito-urinary tissue.

There occurred a very singular case under the care of Professor Brainerd, of Chicago. I shall take the liberty of laying before you a copy of his letter, describing the case, for which I trust he will receive as my apology, the great interest inherent in such an occurrence, and the desire I have that you should all have the opportunity to follow his example of treatment, should you happen to meet with individuals similarly affected.

The letter is addressed to Dr. J. F. Meigs, of this city.

Chicago, February 20, 1847.

Dear Sir — Accompanying this you will receive a specimen of morbid growth, of whose nature I am very doubtful. Knowing the interest you take in the diseases of females, and the researches your father has made in relation to all classes of these affections, I have sent you this in the hope that, by his aid, you would be able to enlighten me in relation to its class and character.

The little girl from whom it was taken, is the daughter of healthy parents, residing in Du Puy Co., Illinois, is nineteen months old, and was first seen by me on the 29th of January, ult. On examination, the abdomen was found to be much enlarged, an oval tumor extending from the pubi^ to the umbilicus, which gave the sensation of fluctuation. From the vagina there pro- jected a substance having every appearance of a common gelati- nous polypus of the nostril, being about an inch in length, and two lines in thickness. The urine was constantly dribbling away, the bowels constipated, much emaciation, and derangement of the health.

The history of the case w^as as follows. Nine weeks previously there was noticed a discharge from the vagina, mucous at first, and afterwards occasionally bloody. When this had continued four weeks, small semi-gelatinous bodies of the size of peas were discharged with it from time to time. At length the gelatinous bodies began to protrude from the vulva, the protrusion being preceded and accompanied by pains and straining, which were compared by the mother to those of labor. When exposed to the


DR. brainerd's case. 75

air these bodies soon became red, then brown; shrunk, and sloughed, and were succeeded by others, which in turn fell off. The enlargement of the abdomen was more recent than the dis- charge. •

Judging from the fluctuation and the almost constant discharge of urine, that the abdominal tumor might depend upon retention of urine, I introduced a catheter, and found this to be the case ; about twenty-four ounces were discharged, and the tumor entirely disappeared. Directing my attention then to the growth pro- truding from the vulva, I introduced a nasal polypus forceps into the vagina, seized it, and, with but slight force, separated and brought it away. This was repeated several times, and each time a reddish body, resembling a gelatinous polypus of the nos- tril was extracted. Finding the vagina still full and distended with such growths, I desisted from further attempts, and, on the first of February, inst., made use of the double canula and liga- ture, as for uterine polypus, embracing as much as possible of the growth. On tightening the ligature, it readily divided the parts embraced, and the withdrawal of the canula was followed by the discharge of a great number of the same substances; but, by scarcely any hemorrhage.

This operation was repeated either w4th the ligature or forceps daily, for a week, and each time a large number of pieces were obtained, one dozen each day would be a low estimate; and every day they increased in number, but diminished in size. Finding this to be the course of things, I introduced a sponge tent for the purpose of dilating the orifice of the vagina, which had been al- ready to a great degree effected by the protruding bodies, and soon effected my object, so as to allow of the introduction of the finger very easily. The vagina was found dilated so as entirely to fill the pelvis, pressing upon the rectum and .urethra, and rising above the superior strait, its sides were invested by the same bodies which had been extracted in such quantities. They ad- hered firmly over the greater part of its surface. Scraping it with as much force as was safe with such a structure, the finger was withdrawn, and immediately from fifty to one hundred of the bodies of small size followed. This operation was repeated daily several times, until but few followed, and there only remained behind an indurated spot upon the posterior surface of the canal, which seemed a matrix for the whole, and which could not be


76 DR. brainerd's case.

detached by moderate force. Having found, by the number and rapid growth of these bodies, that they would undoubtedly be re- produced, the next point was to prevent this danger, and it oc- curred to me t]iat some substance capable of coagulating albumen promptly, without acting too energetically upon the animal tissues, would succeed. A strong solution of alum was chosen and in- jected, a compress being applied to retain it. This was followed by the discharge of much coagulated albumen, of which thick layers were every day removed from the indurated points of the walls, until they seemed natural. The injection of alum-water was continued for several days longer, simple warm water being also used for cleanliness. The discharge gradually diminished and ceased.

At the last examination, the vagina was contracted so as barely to admit the finger, and seemed perfectly natural. The os uteri, which had not been distinctly felt before, was perceived, in form of a small tubercle, the orifice just perceptible, showing the uterus to have been unaffected.

The urine required to be drawn for the first week, but since she has gradually re-acquired the power of discharging it ; gra- dually improving in health and appearance until the present time, when she may be said to be quite well.

Some of the bodies removed in this case are the specimens sent, and you have only to suppose them larger, softer, and semi-trans- lucent, and you w^ill form an opinion of what they resembled when first discharged. They are only changed by the effect of alcohol. They were distinctly vesicular. The largest were an inch and a half in length, and an inch broad; the smallest not more than a fiftieth part as large.

At first I supposed them to be polypi, but soon perceived that such was not the case, since they had been discharged and re- moved to the number of several hundreds in all, and were evi- dently attached one upon the other in some points. So that I know not what they may be, unless it is an animal growth, allied to the acephalocyst, of which there are, I believe, several kinds, found sometimes in animals, and of which this may be a rare or unknown variety. Will you present the case, with my respects, to your father, and inform me, if convenient, of the opinion he may form of it ? Very sincerely, your friend,

D. BRAINERD.


PRURITUS VULV^. 77

Dr. Brainerd sent several of these curious bodies. I found, on examining them with a good doublet, that they were not cysts, but solid bodies, more resembling a mere sarcode than anything else. They were without hooks or other apparent appa- ratus. I could not adopt Dr. B.'s supposition that they constitute a variety of the acephalocyst, and like Dr. B. I remained uncer- tain as to their nature ; but rather inclined to believe that they consisted of a morbid production of the corpus mucosum of the vaginal membrane.

I sent them to Mr. Milne Edwards, the zoologist, at Paris, and hope to have his decision as to their character. Should Mr. Ed- wards ascertain and state their real nature, I hope to communi- cate his opinion to you.

There are a great many women, who when pregnant, are an- noyed with a most distressing, and even intolerable pruritus of the vulva, affecting chiefly the inner face of the labia, mainly attack- ing the portions of them in a range with the nymphse, and not irritating so severely the parts nearer the posterior commissure. The malady is not confined to the gravid female alone, but I should suppose that ninety per cent, of the instances I have met with, have been in women enceinte.

Dr. Dewees appears, at times, to have found the mucous surface affected with aphthous inflammation. I have not seen such a case, though I have met with some that were to the last degree distressing cases, in which the pruritus was so intolerable, that the person could not resist the provocation to scratch, and even wound the surface with her nails. In such a state I have found the mucous body of the membrane red, of a Modena color, very dry and hot, but I have not observed aphthae. In certain other samples, the dryness and redness were wanting ; nor was there any sensible increase of the heat.

Should you be invited by your patients to give counsel on such a complaint, I advise you to make careful inquiries as to the presence or absence of redness, dryness and heat; and where they exist in a subject not demanding or admitting the use of the lancet, to recommend the application of a few% say eight or twelve leeches, within the labial surfaces. If the signs be absent, it may not be worth while to trouble your patient with the leeching.

Some cooling laxative will be indicated in case of torpor of the bowels ; and a conformable diet should be prescribed. In such a


iO PRURITUS CICATRIX ABSCESS.

patient, salted meats, gravies, spice, pepper, spirituous and vinous drinks, ought to be forbidden. The warm bath, or the hip bath, is a highly useful ordinance; and some proper lotion or application should be provided for the affected parts.

It seems obvious that this must be a case for the nitrate of silver to show its alterative powers ; for if there be any sample of disease that would be likely to yield to it, this would seem to be, most probably, the very one. Yet, I am constrained to say, I have not found it to answer the purpose. Nor does vinegar, nor mucilage, nor cold, nor tepid water, nor laudanum and water, nor alum cure it; but this is true, viz., that very few cases fail to be either cured or kept within very moderate bounds, by the following recipe :

Take of biborate of soda, half an ounce; distilled rose-water, six ounces; sulphate of morphia, six grains. Mix, and direct the lotion to be applied to the part affected many times a day.

Every man becomes probably more or less a routinist in his methods. It is with me a routine to order the above compound lotion; and I aver to you, that I believe, if you order it for your patients, you will have very little trouble in curing them. I am speaking here of the general run of cases. Should you use this compound, and find yourselves disappointed as to its curative powers, you ought to request an opportunity to examine, by in- spection, the peculiarities of the malady, in order to enable you to judge whether blood-letting, purging, emollients, nitrate of sil- ver, or astringents and tonics should be preferred.

Ancient injuries, by laceration, by ulcers, and by fevers, may have contracted the external parts so much as greatly to interfere with the dilatations required for the transmission of the child in labor. Patience can, perhaps, overcome even the contractions of old cicatrices; but when you are called on to give your opinion in such cases, you would do well to have at the call of your memory the views of Dr. Dewees, who taught us that the most resolute cicatrix may be rendered dilatable under the influence of bleeding, ad deliquium animi. I have met with no such cases myself.

The labia are frequently the seats of a phlegmonous inflamma- tion. The texture of the organ being very lax and distensible, the abscess formed within it generally points early, and always points on the mucous surface. I never yet met with one that did


THE NYMPHS. 79

not end in suppuration; not because suppuration could not be prevented, but because the woman will never call for counsel until it is too late to expect any other termination. It is a sim- ple matter, though a very vexatious and painful one.

You should open the abscess as soon as the fluctuation of the pus can be made out. The pain disappears with the cessation of the tension upon the escape of the pus. It is very common for a woman, who has had one labial abscess, to be troubled with several consecutive attacks of the same kind.

With these remarks, which appear to me sufficient to set the matters in question in a clear light, I have to conclude this letter with the assurance of my respectful consideration.

C. D. M.


LETTER VIII

Gentlemen : — There is another part of the system of organs contained within the pudenda, which deserves your professional attention, I mean the labia minora, or, as they are more generally denominated, the nymphae ; quasi custodes castitatis.

They are composed of an external or mucous membrane, within which there is an erectile spongy texture, which gives to them in the young, a certain degi^ee of firmness, or hardness, that is not to be observed in individuals reduced by disease, or those who are advanced in age.

In the young and healthy female, the labia minora are of a rosaceous hue, which for such as have borne children, gives place to a dark, or even brownish tint. They are also much changed by the repeated excitement of the sexual passions, and are often after labor, discovered to be permanently enlarged, or torn and ragged or jagged on their edges or sides, by the violence done to them during the extremest extension of the parts, by the out- passing child, or by the edges of instruments employed in its delivery.

Iq a young child newly born, it is usual to find the nymphae


80 THE NYMPH-E COHESION.

jutting out beyond the genital rima — but very early — say by the end of the 14th or 20th day, the development of the labia majora, which proceeds rapidly as soon as the fcetal circulation is cut off, comes to cover up and wholly conceal the nymphse ; which, in the virgin, are not found to jut beyond the rima; whereas, the woman who has borne children, and who has suffered lesion of this organ in parturition, generally protrudes one, or both of them above or beyond the rima.

The physiological uses of the nymphas are not agreed upon ; but it is strange to find that such a writer as Dr. Campbell, in his Introduction to the Study and Practice oj" Midwifery, p. 31, should say that " they are supposed to direct the urine from the urethra, and prevent its flowing over the external parts, and they contri- bute to enlarge the vagina during the exit of the foetus; for at this time they are quite obliterated."

Pray observe that, should the stream of urine touch the lower end of the nymphse, it would be sure to flow over and bathe the whole perineum; and you will not forget my assurances in the lecture-room, that I had very repeatedly found during the ex- tremest distension of the external genitalia, the nymphse hard and well marked along each side of the distending head of the child. You wall find that Dr. Murat, in the article JYymphes of the Diet, des Sci. Med., avers that they do serve to the amplification of the vaginal orifice. It is incorrect to say so, since they belong not to the vagina but are a sort of valvulse conniventes of the labia majora, to whose enlargement in labprs they contribute not, or if I am incorrect in saying not at all, at least I am surely cor- rect to say very little.

Fabricius ab Aquapendente, relates a case in which there was atresia of the vagina from imperforate hymen. The external part w^as protruded by the collection of the menstrua within. This dis- tension had so effaced the nymphse as to lead to the belief that the girl had none at all; but when the collection had been discharged and the external organs recovered their situs, the nymphse were found to be perfect. This example is relied on by Dr. Murat in support of his view. But I ask you to consider whether the slow protrusion and development caused by a gradual collection of blood within the womb and vagina, might not introduce changes in the character of the formation within the sinus pudoris, which


THE NYMPHS. 81

could not be brought about by the rapid and rushing distensions of a common labor.

If such an addition were necessary for such a purpose as is pretended, it is probable that it would be found in the other warm blooded animals ; but we have Mr, Lawrence's assurance, in his Comparative Anatomy, p. 452, that none of the mammalia possess nymphse, and there is, in general, merely a thin border of the integuments instead of labia pudendorum.

In the case of diseased clitoris, of which I gave an account at p. 83 of my edition of M. Colombat's work, I carefully sought for the labia minora, and you will see, by reference to the cut at p. 84, that, notwithstanding the enormous tumor of the clitoris, they still preserved their visible physical character.

What, then, is the use of the nymphse ? — what their physiolo- gical function? It is to increase the surface of contact, and to bring the clitoris into contact, for the end to augment the aphro- disiac orgasm. That orgasm is probably essential as an agent in the fecundation of the germ, as without its intervention, it is probable the tubes could not apply their fimbrise to the ovary, and thus the ovulum would be lost.

It belongs to all women to possess them.

Among the various tribes of dark-skinned savages of Southern Africa, there is one called Bosjesman or Boschisman. Their women, it is averred, are all endowed with an appendage to the external organs, which is called the Hottentot apron — le tablier des Hottentottes, though the Hottentot women are without it — the production belonging only to the Boschisman women. One of these women died in Paris in 1816, and was dissected at the Jardin des Plantes. The tablier was found to be only a hyper- trophied state of the two nymphse, but so long and loose, and flap-like, that they could be turned up like hound's ears, above the symphysis pubis. It is a very remarkable ethnographical feature, and so far as I can learn, belongs to only one tribe, and that a South African one. The tablier, to a certain extent, may be met with as an accidental hypertrophy among women, here and there, of all races ; but that it should become an ethnographi- cal peculiarity is fit to excite our surprise.

I find that our distinguished countryman, Horatio Hale, author of the Ethnographical and Philological results contained in the 7th volume of the United States Exploring Expedition, makes no 6


82 TORN NYMPHA.

mention of this structure as a feature of the numerous and diver- sified races in the South Seas.

Travellers in Abyssinia assert that it is a custom practised by the quasi Christians, under the government of Selahe Salassie, to circumcise the females at an early age, by the excision of a por- tion of the nymphGB, and it seems to have prevailed in that be- nighted land for centuries, probably from some misapprehension of the Mosaic injunction as to the rite for males.

These organs are endovi^ed with a very high degree of sensi- bility, and as they have a copious circulation within, are subject to attacks of inflammation, whether accidental or specific. I have often found them to be more or less lacerated in labors. In the general, such accidents happening to them have not required at my hands any special direction beyond that of keeping them as far as possible free from the irritating influence of sharp or acrid discharges. For the most part, the tissues within the sinus pudoris are maintained in an emollient state by the lochial excre- tion, and by the mucus which is yielded in great abundance by the genito-urinary mucous membrane. They do not, therefore, like a dermal and exposed surface, require lotions and emollient cataplasms, since they are buried within emollient surfaces.

I advise you, however, to think, that if a woman be so unfor- tunate as to have a nympha half torn oft", the monthly nurse ought to receive clear instruction as to keeping her patient very clean, by bathing the parts often enough with warm wine and water, or other convenient lotions, such as infusion of chamomile and lint- seed or slippery elm ; for there is a vulgar and disgusting notion that a woman must not change her napkin often lest she stop her discharge thereby; and some of them are so fully imbued with this prejudice that they will allow the accumulated out- pourings of the vagina and womb to putrefy on the napkins. Imagine the fetor that must accompany such a state of those putrescible materials hidden beneath warm bed-clothes, and with the patient perhaps at a fever heat of 101 degrees of Fahrenheit!

I hope that you will be able to exercise your proper authority as medical counsel, and help, within your sphere, to cast out of the popular mind not this only, but every error and vulgar prejudice that you may find to have descended from remote and barbarous ages. A young female, with whom I spoke about a week since on the subject of a sexual malady, assured me she had never


THE VAGINA. 83

been permitted to use any napkin during her catamenial periods. She had been early forbidden to do so by advice of the family physician, who insisted that the women who use some such re- ceiver are subject to a more abundant effusion ; and so the poor girl, for fear of a stoppage of her menses, was compelled for three days out of every twenty-eight to wear a soiled and bloody under- garment. What say you of such a counselor?

I have not, in any case, found it necessary to secure the appo- sition of the torn edges of a lacerated nympha. Should you, however, encounter a case where the organ is badly torn, it will perhaps be thought by you prudent to secure the apposition of the edges by means of a suture, either consisting of a single stitch, or of two interrupted ones.

I shall not fatigue you with any further remarks on the lacera- tions of the nymphse ; but shall defer to my next letter some remarks upon other affections of the parts under consideration. Meanwhile I remain, &c. &c. C. D. M.


LETTER IX.

THE VAGINA. — THE HYMEN.

Gentlemen :— The organ whoj^e maladies we are now about to study, is one of great interest to the obstetric practitioner, as well as to the physician, on account of the numerous and formidable maladies of which it is the subject. Connecting the external with the internal genitalia, and possessing relations to both, and to several other important structures, it will be well for you to give to the study of it considerable attention.

It is a membranous tube, about four and a half inches in length, and capable of being considerably extended, on account of its great ductility. The interior of this tube consists of mucous membrane, whose free surfaces are continually lubricated with mucus, to prevent cohesion, as they are in contact in the living female. The mucous surface or coat of the vagina rests upon a


84 STRUCTURE AND RELATIONS OF VAGINA.

pretty firm exterior basis, which is composed of a dense laminated celhilar tissue, containing many vessels, whether sanguine or lymphatic; with nerves that are in considerable numbers, and connected with distant and neighboring parts.

I do not regard the coat, or texture, on which the mucous body of the vagina reposes, as a fibrous one; — for I cannot rea- dily comprehend why a fibrous tissue, save a muscular one, should be devoted to purposes so extraordinary as those to w^hich it re- sponds. Is it not, indeed, manifest that a fibious organ could not become the subject of those enormous changes that are necessary to enable a vagina whose mucous surfaces are in contact, to be- come large enough to admit of the birth of a child of seven, and sometimes of twelve, or even of fourteen pounds w^eight?

I have, after careful investigation of the structure, come to the conclusion that it consists in a very compact cellular tela, a sub- stance well calculated to admit of the necessary expansibility; and elastic enough to cause it to regain its ordinary dimensions, not very long after the birth of the child. The submucous tissue, or laminse, contains a great number of mucous glandules, while a great abundance of mucous follicles or lacunae open on its free surface. Outside of the elastic or cellular coat, there exists a spongy texture, which is erectile to a certain extent. The lower or pelvic extremity is embraced by a quantity of muscular fibres, that seem to be continuations of the anterior portion of the sphinc- ter ani muscle, and constitute a true sphincter for this vulvo-ute- rine canal.

At its outer extremity it is attached to the os pubis, by its ante- rior and lateral margins, whereas its posterior and lateral margins are attached to the perineum and labia pudendorum. Its upper end embraces the cervix uteri, which, filling that end of the tube, makes there a cul-de-sac. In front, it is attached to the bladder and urethra; behind, it touches the rectum, and is soldered to that gut, by the recto-vaginal septum, for about its middle third part; its upper third part, resting on a peritoneal investment, and its lower third answering to that pyramidal perineal tissue that lies betwixt the anus and the posterior and exterior extremity of the tube. On each side, the vagina corresponds to the cellular tissue inclosed within the ligamenta lata.

If you carry, a curved trocar into the upper part of the vagina, close to the womb, and then turn its point forwards and upwards,


ABSENCE OF VAGINA ITS RELATIONS. 85

and thrust it through the part, the point will enter the bladder, and open it, — lower dow^n, and near the outer end, the point will wound the female urethra.

If you carry the point high up, and near the womb turn it back- wards, and thrust it, you will cut into the peritoneal sac; an inch and a half lower down, the rectum will be pierced; and still lower down, the tissue of the perineum will receive the point. Turn your trocar sideways, and push it towards the ischium, it might be possible to drive the trocar to the plane without wound- ing anything but cellular tela, and the levator ani.

Pray take care to keep these things in mind in all your operations here, whether with the bistoury, the crotchet, the forceps, or the cautery. They will guide you, both in diagnosis and in practice.

The vagina, like all living tissues, is subject to various mala- dive affections springing from all those causes that can produce inflammation, and its sequels; such as blows, wounds, contu- sions, over-distention, long pressure, foreign substances, and poi- sons, whether animal, or of other sorts. You will occasionally encounter cases in which, being consulted for your professional opinion, you discover that nature has failed to develop the vagina.

For example, I have now under my care a young woman, who, upon attaining the age of puberty, did not become regular, as her mother had reason to expect. Instead of perceiving the men- strual discharge, she was at stated intervals of about a month, attacked wdth severe pain in the hypogaster and loins, which, after tormenting her for several days, left her in pretty good health, to return again as usual, at the end of a month. The mother, when I was called, informed me that some sort of obstruction existed in the passage ; and I was accordingly permitted to ex- amine the parts by inspection. The girl was slender, weighing from ninety-five to a hundred pounds ; about sixteen years old, and well developed in every particular, save that there was a cul-de- sac of the vagina, terminating less than one inch from the os mag- num. There was a hard tumor to be felt jutting upwards, above the plane of the superior strait, like the womb of a woman at quickening ; but itw^ashard and solid — not soft and compressible.

No access of exploration of this tumor could be had by way of the vagina, which, as I said, was a shallow blind sac.

By introducing the finger into the rectum, the tumor could be felt.


86 ABSENCE OF VAGINA.

presenting the same characters of hardness as above the strait, and the whole tumor was of a pyriform shape, like a developed womb of four or five months. Introducing a sound into the bladder, and carrying the right indicator into the rectum, it was easy, by press- ing the point of the catheter against the finger, to explore the parts inclosed betwixt them ; and thus to ascertain that the vagina positively failed at the bottom of the cul-de-sac.

You might here ask how I know that the vagina failed in its development, and that there was not some fine and delicate aper- ture and canal leading up to the womb and connecting the womb with the outer genitals. I should reply that I think a cautious examiner could hardly be deceived by his senses as to the presence or absence of a vaginal tissue between the point of the finger and that of the sound ; and, as I could discover no such tissue, and as I know that cases of total failure are met with now and then, I have confidence in the certainty of my tactile perception.

But there was one great uncertainty in relation to the case. I mean the uncertainty as to the nature of the cause that rendered the virgin's womb as large as that of a woman at quickening- time. Of course, I could not but presume that it was distention, and that such distention could arise only from the collection within the womb, of the products of repeated menstruations having no way of escape.

I consulted, for the benefit of the patient, that distinguished surgeon Dr. Jacob Randolph, who, after a careful exploration of all the points of the case, agreed with me in opinion, that it might be possible that the uterine extremity of the vagina might not have failed ; and in such case, the pudendal could perhaps be con- nected with the uterine extremity of the canal by means of an incision.

Dr. Randolph introduced a strong sound into the bladder, and gave me the staff to hold firmly, while with the left indicator in the bowel, he drew the bowel as far off as possible towards the sacrum, in order to separate the bladder as widely as he could from the gut — for, please understand, that we both conceived there was no tissue of the nature of a vagina betwixt them.

Prepared in this way, the surgeon, by means of strokes with his bistoury, which he directed from side to side, while the labia were strongly diducted in order to expose the bottom of the cul- de-sac, succeeded in carrying a deep incision accurately between


ABSENCE OF VAGINA. 87

the bladder and the rectum — without wounding either ; of which there appeared great risk and probability. Dr. R., however, did not find any uterine portion of a vagina, although his incisions were so deep that he could nearly bury the whole fore finger within the wound. Seeing at length, that there was no hope of estab- lishing a communication with the mouth of the womb in this manner, he brought the operation to a close. Introducing a silver bougie of near three inches in length, and one in diameter, to the bottom of the incision, he maintained it for several weeks in the artificial vagina thus prepared. This w^as done in the hope that the blood, supposed to be contained within the enlarged womb, might, by some process of absorption of tissues, find its way into the artificial canal, which was a probable expectation. This expectation utterly failed, however.

After many weeks, the periodical sufferings of the young woman being not only renewed, but attended with augmented intense- ness, with Dr. Randolph's approbation, I pushed a moderately small curved trocar and canula quite into the central nucleus, if I may say so, of the womb. Upon withdrawing the style nothing came away through the canula, save a few drops of blood, so that I failed also, in this attempt. Yet I had the satisfaction to find that the wound made by the trocar was not followed by any disa- greeable consequences, nor was the operation painful.

You will find upon consulting that fine work of Mr. Thomas Safford Lee, " On Tumors of the Uterus and its Jlppendages,^ that Mr. Lee, at page 8, has the following paragraph :

" Tumors of the womb are insensible. This statement at first appears startling, when we are aware that sensibility is one of the surest tests of their presence, when projecting into the cavity of the womb; but this sensibility depends upon the covering of the uterine cavity, which it receives in its descent. The tissue of the tumor itself is entirely deprived of nerves : I have seen a sharp pointed probe introduced some inches into its substance, without the patient feeling anything beyond the first prick through the sensitive nervous membrane."

Do you ask me, then, what is the nature of this tumor ? — I have to answer, that I do not know. It has not sensibly increased in size for the last three years, the girl is still in pretty good health, though she still is the subject of periodical pain, which is kept within bounds by the proper use of anodynes. The artificial


bo CONGENITAL NARROWNESS OF VAGINA.

vagina has disappeared, and the parts have returned to their con- genital form.

I say the case is a mysterious one. I am sure it is not a case of distention, for I know that my trocar entered the very centre of the mass ; and that any collected menses it might have contained Avould have flowed out through the canula. I repeat, that I do not understand the nature of the tumor ; but I have reason to suppose it consists of a solid mass of tissue, essentially of the nature of womb-texture, but, in some respects, hypertrophied and heterologue.

You will readily concur with me in the supposition, that were it a tumor from distention by menstrua, the uterus must by this time have acquired an enormous size, — this not being the case, allows me to form only the conclusions above stated.

For another case of absence of the vagina, I beg to refer you to " ColombaPs Treatise on Diseases of Women,' in which you will find, at page 119, the account, by me, of a sample in which the vagina was wanting as well as the womb itself. I shall not quote it here. Mr. Colombat gives at page 107, many cases of absence of the vagina; and at 108 relates, with details, a case treated by Dr. Stolz, of Strasburg. I must also refer you for these cases, which I prefer to do, as Colombat's work is everywhere accessible, and, moreover, so complete as to fulfil all one's reason- able wants of information as to the surgery of these affections.

The instances of congenite absence of the vagina present per- haps but small grounds of hope as to the induction of a truly natural and healthy state of the organs by chirurgical means.

Not so, however, as regards the congenital narrowness or con- striction of the canal.

I have met with instances of females in labor, in whom the vagina was so narrow, as to admit only with force, the fore finger in the taxis. Such a case was that, which I have stated, in Colom- bat. I well remember my surprise at the difficulty of making examination of the labor in that lady's case, and I cannot now believe that the sexual act could have been properly consum- mated, notwithstanding she was pregnant, and in labor.

I have also consigned, in the same volume, the history of a case of narrow vagina that was presented for my opinion in the year 1843. This married lady, whose vagina was not larger than a common silver probe, was cured without risk, and with very


TO DILATE STRICTURE OF VAGINA. 89

little pain, by the simple process of gradually dilating the passage, in which she lost no drop of blood, and suffered no attack of in- flammation.

I wish that you would take the trouble to reflect carefully for a few moments, on the power we possess to overcome constrictions and narrownesses, by means of sponge tent, bougies, and other apparatus. You may perceive that a man with a urethra reduced for inches of its tractus to the size of a knitting needle, can in a few days of dextrous and gentle use of the bougie, have his ure- thra dilated to such a size as to admit the largest lithontriptor ; that the female urethra can be made to admit the index finger, the anus permit the whole hand to enter the rectum, and the va- gina give escape to a child of twelve pounds avoirdupois. Such reflections ought to convince you that the congenite narrownesses and constrictions of the vagina ought not to be treated with the knife, but with the dilater. You should also remember the rela- tions of the vagina on its sides and at its upper extremity, so as to reflect on the danger of wounding the peritoneum, or establish- ing in it a diathesis of inflammation, which, once begun, is not easily checked ; and which, in fact, has been not rarely found to follow operations on the vagina, which it has caused to end in the death of the victim.

My counsel herein, is that when you shall be consulted for these maladies, you clearly explain the nature of the case — the modes of cure — their differences, and the time probably required to effect that cure; so that no disappointment or vexation may arise to embarrass you, or prevent your success.

A linen bougie can always be made to take the place of a probe, and you can augment the size of your cereoles from day to day. Half a yard of fine linen dipped in very hot w^hite wax, and coated, furnishes cere-cloth, out of which you can cut pieces of suitable size to be rolled up into cylindrical or conical forms. In the cities there are always silversmiths who can manufacture for you light bougies of silver, from a quarter to two and a half inches in diameter, which being galvanically gilt, last for a long time, and are exceedingly convenient and portable; the smaller ones sliding inside of the larger ones, like a nest of pill boxes.

I must offer you one caution on this head. Take the example so often presented in labors, of the dilatation of the parts, not by one resolute and unintermitted thrust, but by successive and long in-


90 DILATATION OF THE CONTRACTED VAGINA.

termitted impulses. So, in the dilatation of the constringed vagina, keep in view the law'of its dilatation in labors, which is done by a succession of efforts, with very considerable pauses or rests between each effort; do not endeavor to hurry the operation, therefore, but be satisfied to get on, however slowly ; festina lente is the motto. If you go too fast, you will excite irritation or in- flammation, which must be cured before you can go on again. If you go on slowly and gently, there will be perhaps some sense of soreness left for a while after each dilatation, but it will not rise to the height of inflammation, but leave the parts soft, ductile and humid, well prepared for the next attempt.

How often will you repeat these attempts? Once a day; not oftener; and it will be better occasionally to allow two days to elapse, provided there be reason to dread an irritative or inflam- matory engorgement as the sequela of the last attempt.

Don't leave your patient imperfectly cured ; by so doing you expose her to danger of death in any labor that might follow the •cure of the stricture. Dr. Brainerd, Illinois Med. and Surg. Journ., May, 1844, states a case in which the woman lost her life in labor by rupture of the vagina, which gave way, rather than allow of the dilatation of a stricture which had succeeded the second of two antecedent labors.

I advise you to look to a case that w^as published in 1712, in PHistoire de VAcademie des Sciences, p. 35, and which I find quoted in Dr. D. D. Davis' great work on Obstetric Medicine, t. i. p. 102. The case was related by M. Antoine de Mery sur seine : the end of a goose-quill could scarcely be forced into the vagina. It was not until ten years of married life that she conceived, and bore a son without harm or danger. I am sure any one of you would, in such a case, by means of cereoles, save the patient such ten years of suffering.

Let me again refer to Colombat for an account of the method I used in curing a case of contraction, by means of two longitu- dinal segments of a cylinder, which, being introduced separately, were afterwards strained asunder, by means of wooden cylinders, the size of which, small at the first operation, was larger at the sub- sequent ones. I have given a drawing of those cylinders, and the segments at page 97 of Colombat on Diseases of Females.

I shall say no more here as to the congenital contractions of the vagina, under the belief that what I have already stated and re-


IMPERFORATION. 91

ferred to, is sufficient for awakening your attention to the nature and cure of the evil.

The tube is subject to closure by imperforation of the hymen; and by cohesion of its surfaces.

The most common of these atresias, is the case of cohesion of the sides of the vagina taking place in consequence of inflamma- tion brought on by labor : the imperforate state of the membrana hymen, is less frequently met with, at least I have had reason, dur- ing my professional life, to adopt this opinion from my own obser- vations.

The words imperforation, atretism, occlusion, obturation, and cohesion, express, in fact, the idea of a closure of the canal, though you apply the terms imperforation, obturation, and occlu- sion, chiefly to the cases connected with faulty development of the hymen.

It is very improbable that the state of imperforation of the hymen will be ascertained to exist, until the age (^puberty comes to expose the young woman to the consequences that follow the accumulations of menstrual excretions in the inner part of the vagina and womb.

The lateness of this discovery is a matter of some surprise, if we advert to the constant secretion of mucous fluid from the geni- tal mucous membranes; since it is difficult to conceive what be- comes of all that is formed from childhood up to the fourteenth or fifteenth year. It must, of course, be removed by the absorbents; yet it would a priori seem improbable that so considerable a pro- duction could be taken up by the absorbing vessels. Such is the fact, how^ever, that the imperforate girl is commonly not dis- covered to be so, until the menstrual age, and then she is affected with all the signs of menstruation, save the show.

Suppose the young woman should have thirteen menstruations in the course of the first year, and produce only three ounces each time, the sum of the several productions would amount to thirty-nine ounces or nearly two pounds and a half. Of course, the whole accumulation would not reach so high a figure, because the thinner parts being continually absorbed, the remainder is reduced in quantity and becomes thicker and more and more vis- cid, from the admixture of mucus and epithelium. But it must happen that at length, the vagina being overfull, the w^omb itself will enlarge or expand to receive the new monthly contribution.


92 IMPERFORATION.

Be not surprised, in such a case, to find the girl suspected of gravidity, nor be misled to confirm such a suspicion by discover- ing that the mammary glands sympathizing with the womb, are developed as in gestation, and that they even proceed so far as to secrete a portion of milk. The mammary gland may be regarded as a life dependent of the womb, participating in its varying states, whether in pregnancy or in disease. It is a fact that cannot be de- nied, that where the womb becomes augmented in volume, in the amount of its sanguine circulation, of its innervation, its absorp- tion, &c., the mammee sympathise with it, and they may form the milk, whether the change in the uterus proceeds from pregnancy, or from some other cause.

This is a case in which, from inexperience, you might be prone to run into error. Take heed, therefore, not to pronounce your opinion until, by all possible means of making it sure and clear, you feel enabled to speak with confidence on the case. Men ot the highest professional rank have been, through careless or hasty diagnostical conclusions, led into the greatest perplexity; and some have thus ruined forever the fairest prospects of fortune and reputation. It is always a cause of mortification and regret to the brethren, when any one of their class brings discredit upon all, by exhibiting his own incompetency, whether through igno- rance or want of circumspection. Be ever mindful, then, that your errors and misconceptions redound, not to the hurt of your patient alone, but to your own shame and defeat, and the lessening of the authority and happy influence of all the members of your body. Those are the truest friends of the profession,- who honor it by their intelligence and probity. Such persons render medicine an honorable pursuit.

I have had one invaluable rule of action for many years past, w^hich has served me so faithfully, that I shall tell you what it is. When a female comes to me to complain of failure of the cata- menia, I scan as rapidly as I can, the state of her great vital functions, in order to discover any lesions or implications of them in her malady. That is to say; I observe her respiration, her cir- culation, and her general innervation. In using these words I mean to express not only the idea of a certain number of respiratory acts per minute, or so many pulsations of the heart, or the vague and abstract idea of nervousness; but I mean all the physiological de- pendence and resultsof the oxygenating function of the lungs; the


-IMPERFORATION. 93

nutrient, calorific, and colorific action of tke circulation, and the equableness and spontaneousness of the nerve power, as evinced in the countenance, gesture, station, and motions of the patient. When I can thus discover no signs of ill-health, I am at once aroused to the suspicion of gestation. But, a man must be a fool, who, in such delicate concerns, should breathe his thought ; this is, of all cases, the case where one's left hand ought not to know what the right hand doeth.

Let us suppose now, that a young person who ought to men- struate, but has never yet changed, should call upon you for coun- sel on account of a swelling and pain, or uneasiness in the region of the pelvis, yet exhibiting no signs of disease beyond these now specified. What can you say, what do, what know? Is there any therapeutics for an unknown case ? You can do nothing, nor know nothing, and you ought not to say anything, except, that you do not understand the nature of the malady, which it is, more- over, impossible to know without the taxis.

Now, this is a terrible decision to come to, as far as the poor patient is concerned; but it is not your fault that she is unfortu- nate in being so situated. If she will suffer the proper inquiry to be made, there can be little doubt of the ability to procure the information, and you cannot undertake to cure until you know what is the matter. Let them call a midwife, whom you can in- struct as to the visit she is to make ; or if none such can be found, you can offer your own services for the occasion.

Suppose the people connected with the case, are persons of sense and discretion, I am very sure they will refer the matter to your judgment, and you will make the proper exploration your- self.

Instead of finding the os uteri, you discover a cul-de-sac, just within the os magnum; and probably, it will present an exterior convexity, with fluctuation behind it. You place your hand on the hypogaster while she lies on the back, and you discover with the palm or fingers, the hemispherical fundus of the womb jutting quite above the plane of the superior strait. If you press it downwards, the convex bottom of the cul-de-sac becomes more protuberant, and you cause a fluid to fluctuate betwixt the fingers of the right and left hands.

Still unsatisfied in your opinion, you press an index finger into the rectum, and then find the pelvis filled, or nearly filled, with


94 IMPERFORATION.

a vagina and uterus evidently turgid with fluid, contained within their walls.

Now you have a clear ground to speak. The case is one of imperforate hymen ; a case of atresia vaginas. The remedy is to destroy the obturating membrane, and that is to be done by thrust- ing a trocar through it, while a finger in the rectum gives you a clear notion of the direction to be given to the trocar, the bladder having been first evacuated by means of a catheter, in order to make sure of that organ being quite out of harm's way when the trocar is pushed through the membrane: the rectum should be also emptied by means of an aperient enema, so as to leave not the least reason to dread any injury to parts not intended to be wounded by the trocar. If I were about to perform such an ope- ration, and the patient should say, "I have just now made water freely," I could not feel justifiedto plunge the trocar into the sac upon such a representation. I should never deem any one a pru- dent surgeon, who should do so until the catheter had proved the matter beyond doubt.

Do not expect to find the membrane no thicker than the page you are reading. It is very thick and strong. I have seen one not far short of a quarter-inch in thickness. When your trocar is withdrawn, and the detained menstrual fluid evacuated, pass a narrow straight bistoury with a probe point, through the opened membrane, and cut it into four triangular flaps ; carrying the in- cision nearly down to the level of the vaginal walls; and once in two or three days, press through the opening thus made, a silver gilt bougie of proper size, so that, when the cut edges are healed, they may not leave a constriction of the vagina, to expose the patient to danger of laceration, should she ever be placed in cir- cumstances of labor.

You may be consulted for a case like this. A married lady, married five years, in beautiful bloom of health, suflTered periodical attacks of pain coinciding with her menstruations.

The menstrua flowed very slowly, and with difficulty and pain ; the discharges black, viscous, and stinking. They continued many days, but when they were over she was well again. I cannot say that her health, in any essential degree, had suffered from this state of things, for she was strong and exhibited a very perfect embonpoint.


IMPERFORATION. 95

Accompanied by her husband, she came to Philadelphia and placed herself under my care.

She assured me that, though she menstruated, she was many days going through with the elimination, and that all the menstrual blood .that escaped, was very dark, often granular, and always quite offensive.

In a strong light, the patient lying on the back, I found a shallow cul-de-sac, the bottom of which was the hymen, in which I in vain sought to find any opening. There was not even a pore to be dis- cerned, nor could a probe, that I pressed against every point of the hymen, detect the smallest opening in the surface. I was obliged to desist from further researches, advising her that at the next men- strual period, near at hand, I should probably be enabled to detect the orifice from which the flow might escape, and asking to be in- formed as soon as the appearance should present itself.

After a few days, I was invited to attend ; and upon placing the parts in a good light, and pressing against the bottom of the cul-de-sac a speculum with a large opening, so as to put the membrane strongly on the stretch, I again was for a long time baffled, fori could not observe any signs of the menstrua, though she repeated she was unwell, and in her usual manner.

I felt the whole superficies again with a probe ; at length, I observed a small dark jwint and supposed it might be caused by the menstrual fluid passing forth. I pushed the probe against it, but it would not admit it. I next took a very fine one, fit for the puncta lachrymalia, and it passed quite through the hymen into the vagina, and when I withdrew it, there followed a drop of blood of the menstrua.

Finding nov;, that I had obtained access to the upper cell of the vagina, I forced a larger probe and then a very fine pointed bougie, and so a larger one until I dilated the pore sufficiently to pass up a narrow probe pointed straight bistoury, with which, I cut the membrane into flaps, and then passed two fingers to the OS uteri. She discharged a good quantity of menstrual fluid.

The subsequent treatment consisted in the daily introduction, by her hand, of a metallic short bougie, until the passage was rendered complete.

I suppose that the hymen in this case was one-quarter inch in thickness, firm, and fleshy ; and yet you see, the lady had men-


96 COHESION OF VAGINAL WALLS.

struated all her life through a pore, not larger than the punctum lachryraale ; nay, not so large.

1 used all this care, because I found the resistance so great. In a complete case of imperforation, with accumulation of menstrua above, the membrane would have been convex and fluctuating, and I should have opened it at once with a trocar or bistoury; but here I thought it more prudent to explore the part as I did, before I should venture to cut upon it.

I have nothing further to say as to vaginal atresia, caused by imperforate hymen. The books are full of such cases, which present very little of interest, save that arising from the necessity of being careful in the diagnosis. There is no difficulty in the treatment, either by the trocar or bistoury or the point of the finger, where the membrane is thin.

There are great numbers of cases of this affection published in the books. Of these. Dr. Davis has made a collection, and printed the references in his first vol. pp. 108-9. The whole matter is so simple, and so easily understood, and readily treated, that I shall not cite them for you, but merely refer to the pages of the Obstetric Medicine in which they are found.

You are aware that the vagina may become occluded after labor, by the cohesion of its surfaces. This is a consequence of inflammation, and probably of traumatic or wound-formed inflam- mation.

The accident takes place in some persons through very violent and distressing attacks of inflammation, which may, or may not be attended with sloughing. Or on the other hand, a woman who has given birth to her child without any extraordinary delay or difficulty, shall suppose all to be well with her, until the month of purification being over, she discovers upon returning to her hus- band's bed, that an obturation exists rendering her imperforate.

Again, a woman shall be attacked with ulceration of the lip of the OS uteri ; which being neglected, invades the whole vaginal cervix of the womb, and descending upon the walls of the vagina, may become an ulcer nearly as large as the palm of the hand. I have seen one, which, examined by means of a speculum uteri, exhibited such dimensions. This is not a malignant ulcer; but it is very difficult to cure ; for when you have reduced it to be not larger than the face of a shilling, it shall, perhaps, in the course of two days, recover its ancient dimensions. In this ulcer, I have


COHESION OF VAGINAL WALLS. 97

picked off from the surface large patches of what appeared to be thickened epithelium or exudation membrane. Some of the patches that were brought away by a dressing forceps, were large as half a dollar. Now an ulcer of this kind will hardly ever be found to heal permanently, until it has contracted the tube to an exceedingly small diameter, and then, when the canal is almost obliterated, it heals — or what cures it as completely, the surfaces cohere, which puts an end to the ulceration. The cohesion is easily overcome.

A young woman gave birth to a large child, and got well with- out any trouble, or supposing that anything was wrong with re- gard to the genitalia. After the month was out, it was discovered that she was affected with total atresia, or vaginal imperforation, and this without having had the least reason to suppose that anything was wrong with her. Of course the obturation must have taken place at a late period in the month, since, had it happened early, the lochia must have accumulated above the coherent points.

When she came to me I found no aperture whatsoever in the shallow cul-de-sac at the bottom of the sinus pudoris.

It was evident, on inspection, that the orifice of the vagina was puckered or crimped, and quite closed by cohesive inflammation. I in vain endeavored, by diducting the opposite sides of the cul- de-sac, to bring into view any small aperture ; nor could I dis- cover any by means of a probe, which was pressed upon all the different parts of the surface. The atresia was complete.

I took a strong probe in my right hand, and stretching the points of union with the thumb and medius finger of the left, I drew the bulb of the probe along the line of the cohesion, and found that it gave way just as happens in .the same operation for cohesion of the labia, or prepuce and glans, in children. By means of successive strokes of the probe, upon the line of cohesion, I found that at last, the probe had passed through the obstruction into the upper cell of the vagina. I next dilated the constricted parts with the index finger, then with a cereole, and at last with a metallic bougie, and sent her home, without causing the loss of twenty drops of blood, and with very little pain or inconvenience of any sort, in the cure. I advise you, that whenever you may be able to restore parts to their natural form and state, without the use of a cutting instrument, you should prefer such method, since it is true, that every wound when healed, leaves the tissue 7


98 ULCERATION OF THE A'AGINA.

changed, whereas a part cured without a wound recovers its truly normal form and properties.

I attended a lady in her confinement in the month of April, 1845. She was subsequently attacked with metro-peritoneal fever, and after great sufferings and risks, was found to be in a convalescent state, save that she had a retroversion of the womb. For this, she was treated with pessaries: in 1846, she was often complaining of debility, and discharges per vaginam of an un- healthy character, for which she would by no means be prevailed upon to submit to a vaginal examination, on account of her fasti- dious delicacy. At length, in the autumn of 1846, she submit- ted to a more particular inquest into her condition.

She was frequently attacked with the most cruel pains in the interior of the pelvis; which, also, extended up as high as the umbilical region, producing the greatest intolerance of contact, and a dorsal decubitus, with great flexion of the lower extremi- ties, the least motion of which augmented the pelvic and abdo- minal pain to an insufferable degree. The pulse was frequent, and of a hectical character. The stomach was affected with almost incessant nausea, and frequent vomitings of glairy mucus. The bowels were constipated. The patient was much reduced in strength, and emaciated.

The taxis at first gave me great alarm, as the roughness and hardness of the upper portion of the vagina gave me reason to suspect a carcinomatous degeneration of the organ.

I learned, by inspection, with the speculum of Recamier, that the OS, and the vaginal cervix were covered with an ulcer which extended upon the vagina. The surface of this ulceration was overlaid with a thick and unattached pseudo-membranous deposit of lymph, that I could pick off in scales of an inch square with the dressing forceps. It was in all respects like the croup mem- brane, or other diphtheritic deposits, which you will find in the throat in scarlatina, in ptyalismus, &c. As the speculum was a pretty large one, I could by passing it to the upper extremity of the vagina, not only examine the ulcer there, but in slowly with- drawing it, I could observe the whole character and extent of the vaginal ulceration.

Now I am sure that the superficial extent of the ulcer could not have been less than six or seven square inches.

I had a great deal of trouble with it. It was soon reduced to a


ULCERATION OF THE VAGINA. 99

superficial size of one inch ; and then broke out again to its ori- ginal extent, in the course of a few days. I made use of injec- tions of honey of roses, containing fine extract of cicuta suspended in it. I painted the whole surface with a brush dipped in a solu- tion of nitrate of silver. I repeatedly whitened the whole surface with my nitrate of silver pencil. She took corros. chloride of mercury dissolved in compound syrup of sarsaparilla; and after- wards, hydriod. of potassa, in the same vehicle.

The ulcer was at last most tractable under delicate contacts of acid nitrate of mercury, and finally healed up entirely, leaving the lady free from pain, and in good health and spirits. But, it should be observed, that this dreadful ulcer did not heal without contracting the walls of the vagina, so that for the upper third of the tube, the quondam seat of the ulcer, there is now a cylindri- cal vagina, about the size of this quill with which I am writing.

Please observe that the contraction of the vagina w^as an eco- nomical process, inasmuch as the smaller it became, the smaller was the surface to be healed ; and I doubt much, whether it could have healed at all, had the surfaces been kept constantly extended. I am not sorry for the result, since I have, 1st, the consolation to find my patient cured of a dangerous and painful disease; and 2d, to know that, with the bougie and the cereole, I can very rea- dily cause the vagina to receive its pristine amplitude, without risk or pain. I should be the most imprudent of men, w^re I to attempt the dilatation until a considerable lapse of time shall have allowed every vestige of ulcerative propensity to disappear ; since, to dilate the contracted vagina at once, with the cereole or the metallic bougie, would be very apt to awaken the old malady again.

The sensation communicated to the finger by the examination of this case, was so similar to that produced by the taxis in car- cinomatous vagina and cervix, that I think I should have been misled, had I confided for my diagnosis to the sense of touch alone. I beg to advise you to resort to the speculum in all cases where your diagnosis is obscure.

I do not regard the vagina as a fibrous tissue, but rather, as a mere mucous membrane. That is to say, a true corpus mucosum, with papillae, and epithelial delimitary surface; with mucous fol- licles, and abundant provision of muciparous glands. Such is the structure ; but, this essential structure is surrounded and limited


100 VAGINITIS.

or backed by a condensed cellular sheath containing muscular fibres, arteries, veins, capillaries, nerves and absorbing vessels.

It seems very reasonable to suppose that such a compound tissue as this, should be the subject and seat of many various maladies arising from various causes and forms of inflammation, hypertrophy, infiltration, weakness, and utter relaxation.

Like the air passages it is liable to aphthous disease, and like them, to the various states of catarrh; like them, also, it may be attacked with diphtheritic inflammation or plastic inflammation ; or the whole structure, mucous, vascular, and cellular, may be the seats of the most painful inflammation, proceeding to a height transcending the power of recovery by effusion, by resolution, or by adhesion, and terminating consequently in gangrene and mor- tification.

You will feel, I am sure, no surprise to learn that labor is often followed by inflammation, not merely mucous ; but inflammation deserving to be called a true vaginitis, in which the whole organ is implicated.

It is equally obvious that the vast distension of the tube by the child, must, in certain instances, lay the foundations of vaginitis, in which not the tube only, but the bladder, the urethra and rec- tum are, to a certain extent, and sometimes to a dangerous extent, involved.

These post-partum inflammations are scarcely more apt to be formed after long and tedious, than after very rapid labors ; and it is reasonable to conclude, that, when a child is forced into the world by one or two labor pains, in a labor lasting not beyond five or ten minutes, the dilating tissues must suffer a greater and more unnatural violence, than where the slower and gentler yielding of the textures allows them time to unfold and dispart, without rupture or laceration. My own experience certainly leads to the conclusion, that a labor of ten minutes is more likely to be fol- lowed by vaginitis than one of twenty-four hours.

You ought also to take into consideration the effects of long continued pressure of the vagina against parts of the pelvis. For example, in a labor where the forehead of the child rests upon the top of the right ischial plane, whilst its vertex is jammed against the middle or lower portion of the left ischial plane, and continues to impinge for hours upon the same points under the throes of a powerful womb, it seems almost miraculous that the compressed


VAGINITIS. 101

tissues of the vagina do not invariably slough after the labor is ended. But the fact is, they not only escape sloughing, but they in a great majority of such cases do not even inflame ; or at least, not to such an extent as to excite complaint, or communication of complaint to the accoucheur.

The pressure of forceps; the jam of the exterior curve of crot- chets, and sometimes the ploughing up of the textures by the point, or nipture, are among the causes that excite vaginitis.

Again, vaginitis is often extremely painful when provoked by gonorrhcEa. In these instances, the extension of the inflammation behind and below the mucous tissue brings the whole vagina into a state of suffering, just as happens in the gonorrhoea of males, where, from intenseness of the inflammation, the corpus spongiosum urethrse becomes affected, producing painful chordee, which is a true urethritis.

Vaginitis is characterized by sensibility, pain, heat, discharge of mucus, or of sangui-mucous excretions; by thickening of the mucous membrane ; narrowing of the canal ; by inflammatory exudation on the mucous surface; a sense of weight in the pelvis; micturition; aching in the sacrum and loins, andatenesmic state. The color of the tube is heightened, and I have observed that the orifices of the mucous crypta are elevated and surrounded by bright areolae.

The case should be verified by the use of a small conical specu- lum of Recamier, the uterine extremity of which should be cut obliquely at about 45°. This speculum being oiled with olive oil, not lard, should be carried to the cervix, and then by withdraw- ing the cone, every superficial inch of the vagina can be examined as the speculum is slowly withdrawn. By this method, gentle- men, you can be perfectly sure of your diagnosis.

In an intense vaginitis, there will be constitutional disturbance ; as rigors, with febrile reaction, and all the phenomena presented by the constitution under provocation by an inflammation of so important a structure.

Where fever is present, and no circumstances of the general health absolutely forbid it, you ought certainly to commence the treatment by enjoining, first, absolute rest in bed, with the shoulders very low; and second, a free venesection; third, a mercurial or saline purgative dose ; fourth, frequent vaginal injection of tepid mucilages ; fifth, anodyne enemata of the rectum ; and sixth, as


102 VAGINITIS.

soon as the constitutional disorder is somewhat on the decline, to lave the inflamed surface with solution of nitrate of silver.

Ten grains of the salt dissolved in an ounce of water, or twenty grains if occasion be, should be prepared. A large camel hair brush, such as is called here a throat-brush, dipped in the solution, can be freely applied by the beveled speculum, rotated as above mentioned, to all the parts on which the contact is desirable.

This is the best plan, but, where your patient is fastidious and foolish, you can perhaps, though not so w^ell, attain the object, by using the salt in solution, injected by means of the new glass- vaginal-syringe.

In intense inflammation of the vagina, eight or ten American leeches may be applied directly to the surfaces, by the speculum.

I think there w^ill be found few samples of vaginitis to resist such a treatment, properly administered.

Where the cure, however, lingers, you should repeat the vene- section, and make persevering use of the mucilaginous injections of the vagina. Dover's powder in doses of three to five grains may be given every four or six hours, but not to the exclusion of the anodyne enema at night. At the close of the case, astringents will be called for; and they may consist of weak solutions of Goulard's extract of lead with watery solution of opium, or w'ith extract of cicuta suspended in the fluid of injection.

As to the contacts of nitrate of silver, I am of opinion they ought not to be repeated beyond once in every twenty-four hours, and I prefer the solution as above, to the nitrate pencil ; because, though less powerful, they are more manageable, and may be recurred to more frequently than the contacts of the solid salt.

I shall trouble you with no further remarks on vaginitis, except to say, that where your case of inflammation transcends the powder of recovery of the tissues, you must expect to find the sloughs coming slowly away, and that you should favor their separation and escape by means of injections of castile soap and water; by small bits of fine sponge soaked in soap-suds, and held in the speculum forceps, and applied through the speculum, handled most gently. In all such cases, pray beware to hinder the forma- tion of a perfect atresia of the tube, which you can do, by daily carrying the index finger, soaked in very warm water and lubri- cated with castile soap or with oil, quite up to the os tincse : you cannot find a more proper or less painful bougie. In the closing


INVERSION OF MUCOUS MEMBRANE. 103

of the ulcers, if any prove perverse, you should aid the cure by thus carefully cleansing them, and then dressing them with honey of roses containing extract of cicuta. For this purpose, soak a long narrow plumasseau of lint in the solution, introduce it in situ through the speculum, which being slowly withdrawn leaves the dressing in contact with the ulcerated surfaces.

The vaginal mucous membrane may become enormously thick- ened. In this case it protrudes beyond the vulva, and projecting more and more, comes at last to make a tumor as large as a stout man's arm ; at the bottom, or most salient extremity of which, is found an opening, circular in shape, through which you can thrust your index finger up to the os uteri, which you will find inside of, or above, the anterior plane of the perineal strait.

The exterior surface of this great mass is dry if it have been long down ; and it is surrounded by horizontal corrugations or rings like the rings of an annelide. In fact, I have seen the exterior surface assume very much the character of the derm or skin, in a woman seven months gone with child. It went easily up beyond the sinus pudoris by gentle pressure ; but came down again as soon as the pressure was removed. A globe pessary two and a quarter inches in diameter, would keep it up while the patient was in a horizontal posture. But, she found such a posture inconve- nient in her circumstances, and preferred the prolapsion of her vaginal mucous membrane to the pessary, — so she laid it aside. At length she fell into labor, during which the prolapsed mem- brane retired spontaneously, and the delivery w^as easy and safe. This was more than three years ago, since which she has had com- paratively but little trouble from her disorder.

At St. Bartholomew's Hospital, in London, I saw a similar case, in which a tumor nearly as large as the foetal head at term, had resisted many efforts at reduction. I was pleased to see Mr. Lawrence apply his hand to the reduction, which he accomplished, after some three minutes of effort. This was in May, 1845. Such reposition, I presume, is always possible. The difficulty lies chiefly in the want of knowledge as to the manner of doing it. But, one leading point in that matter, is to push it in the true direction. To thrust it against the pubis, would be to fail; so would it be to thrust it against the perineum. It should be returned coincidently with the axis- of the vagina.

I shall not, in this letter, speak of vaginal leucorrhopa. I


104


VAGINAL FISTULA.


purpose to treat of leucorrhcea under the general head of the uterine disorders, though I am aware that the vaginal and uterine discharges are very different from each other.

For the same reason, I shall not here speak of carcinoma of the vagina.

Of vesico-vaginal fistula, I have little to say. It is better that the account of that frightful accident given by M. Colombat should be referred to. In that account you will obtain all the requisite information, and as I have laid it before you in my trans- lation of his invaluable work, I shall hold myself here excused from entering on any discussion of so painful a subject, as well as that of the recto-vaginal fistula, which, though not so distress- ing as the urinary fistula, is yet a frequent source of disgust, and a constant one of disquiet and unhappiness. Pray read especially the extraordinary case described by Dr. J. Rhea Barton, which I there reprinted. That distinguished surgeon, by an operation altogether new, relieved and perfectly cured a most distressing case. It was originally published in the American Journal of tJie Medical Sciences, for August, 1840. I might have mentioned the case while I was speaking to you on the affections of the labia perhaps, but as it also appertains to the vaginal maladies I shall refer to it in this connection. You will find it in Colombat, p. 263.

Doubtless the successes obtained by the various methods of treating vesico-vaginal fistula, consigned in Colombat's volume, are cheering — but, I fear that where a considerable loss of sub- stance has taken place, there is little hope of a cure — and you will find on inquiry that Mad. Boivin and Dr. Duges are equally despondent as to the cure of any considerable apertures in the bladder itself. I cured a very small one, by touching the orifice with nitrate of silver — it was in the cul-de-sac of the vagina to the right of the vaginal portion of the cervix uteri.

There is less difficulty when the leak is in the urethra — and particularly do I think so, since I witnessed an admirable opera- tion by Professor Pancoast, about a year ago, for the restoration of the canal of the urethra, which had been opened by a slough, produced by the protracted pressure of the foetal head, in a lady from a distant state. In this case there was an incessant drib- bling of urine from the orifice of the fistula — it ceased not, day nor night.

The urethra, when examined by the touch, was about as large


VAGINAL FISTULA RECTOCELE. 105

as one's little finger. That part of it which led to the meatus urinarius was contracted par defaut d'extension, and required to be dilated wuth a bougie.

In order to make the vesical communicate again with the vulvar half of the urethra, Dr. P., with a small sharp pointed bis- toury, made a deep incision in the vesical half, which incision penetrated parallel to the canal of the urethra ; and laid the tissue open from the right, quite over to the left angle of the gap. He next pared off the mucous lining of the vulvar surface of the gap, and cutting it into a wedge-like shape, thrust this wedge betwixt the lips of the upper incision, dovetailing, as it were, the lower into the upper one. This pared wedge, being in contact w^ith the fresh surface of the incision or slit, and being maintained there by the skillful application of several stitches, while a catheter kept up the calibre, union was produced, and the lady left the city, dis- charging all the urine again through the true meatus urinarius. I did not think, at the time of her leaving Philadelphia for her home, that she had perfectly recovered the voluntary power over her bladder — which was owing probably to injury of its sphincter by the labor. She, however, no longer had the constant dribble of urine, and to a certain extent could control it, several ounces often collecting before she was compelled to yield to the urgent call to discharge it. If she failed so to yield, the urine escaped involun- tarily.

More than twenty years ago I was consulted by a lady who complained of what she supposed to be descent of the womb. She had a sensation, not very painful, of distention of the genital fissure, and of something pressing itself out from the labia, near the inferior commissure. Upon exploring the case by the taxis I discovered a roundish soft tumor which consisted of the posterior wall of the vagina, which was protruding like a knuckle of intestine in hernia, from the sinus pudoris. I told her it was a protrusion of the vagina and rectum, and that it was distended with gas. I advised that the bowels should be kept in a soluble state, and that great attention should be given to obviate costive- ness, and particularly accumulations of faeces in the rectum ; that the tumor was a vaginal rectocele, and that it would cure itself if she would be careful upon the points suggested. She was so, and has never had any trouble with it since. I have


106 VAGINAL RECTOCELE.

met with the case in several different individuals, since the one now mentioned.

You can have no difficulty in verifying the diagnosis, if you will condescend to introduce the index finger into the rectum, and bending it forwards, press it into the pouch-like cavity w^hich constitutes the vaginal tumor, behind which the finger wull ap- pear, having passed over and above the perineum in a forward direction.

In all cases, where you are called upon to make an examina- tion of the rectum, you can, by pressing the pulp of the finger towards the vagina, push it forwards towards the os magnum — thus producing a temporary vaginal rectocele, which vanishes upon withdrawing the finger. In the old chronic and neglected relaxations of the part, there is formed a true and permanent pouch, which does not wholly disappear, even when the rectum is completely evacuated.

M. Malgaigne, in the '^Manoires de l\/3cad. Roy. de Medecine,^^ 1838, states that he had met with the first sample of the accident eighteen months before, say in 1836, and appears disposed to claim, at page 487, all the credit of having discovered the novelty.

" It may seem strange," says he, " at the present brilliant epoch of surgery, to see quite a new malady take its place on the file of external disorders, and which, though not rarely met with, may be as easily understood by the examination of the practitioner as by the scalpel of the anatomist. I have been enabled to maintain a pretension to its discovery ; for among the numbers that usually spring up to contest such claims, there has not been a single claimant for this one. All the classical treatises ; all the collec- tions of cases published in France, from the days of Mauriceau down to the period of Madame Boivin and Dr. Duges, are silent on this subject. The same silence is maintained by Scarpa in Italy ; by Richter and Chelius in Germany ; and by Sir Astley Cooper and Mr. Samuel Cooper, in England. But after much research I have discovered some mention of the disorder in those authors, who seem not to have been as explicit in their descrip- tions as is desirable."

M. Malgaigne then cites a passage of Sabatier, from his memoir on displacements of the womb and vagina, in the 3d vol. Mem. Royal .dead, of Surgery, in which the protrusion of the pos-


VAGINAL RECTOCELE AND ENTEROCELE. 107

terior wall of the vagina is fully attributed to the relaxation in- duced by habits of costiveness.

Dr. Monteggia, of Italy, says he, confounds the accident with procidentia of the vagina, while Dr. Clarke, of London, supposes that the relaxation of the wall of the vagina permits it to fall downwards, drawing the rectum with it.

Now, I wish you to observe, that this vaginal recto cele is a true rectocele, that is, a disorder of the rectum, and not a disor- der of the vagina, for you cannot deny that, were the rectum to preserve all its natural strength, no such protrusion could possibly occur. Indeed, I have on several occasions had the opportunity to observe, that in what is called impacted rectum, there is no vaginal rectocele. In impacted rectum, we find the whole excavation of the pelvis filled with faces, as it is filled with the head or trunk of the child, in labor. The child in labor spreads out the vagina equably, towards the bony walls of the excavation of the pelvis; whereas, in impaction, the impacted fteces within the rectum in like manner spread out the rectum towards the bony walls of the pelvis, filling it and jamming it full, with many pounds weight of the residuum of digestions. Now, in these impactions of the rec- tum, we have no vaginal rectocele; because, though the rectum is enormously distended, it is equably distended while in the vaginal rectocele, only the anterior wall of the rectum gives way by re- laxation, pushing the feeble tube of the vagina before it. Hence, when you wish to cure vaginal rectocele, your indication is to cure the rectum, which being cured, the vagina will also be cured, or rather, restored to its natural form. The vagina is not in fault.

The vaginal rectocele is not a large tumor; it is as large as a walnut, or as large as an egg.

I repeat, that to cure it, the state of the rectum is to be chiefly regarded; it is to be prevented from becoming overloaded.

If the patient should be annoyed, however, by an extraordinary relaxation of the tissue, one so great as to allow the protrusion from a collection of mere flatus, you may expect all the disorder to disappear upon introducing into the vagina a conveniently pro- portioned pessary, whether a globular or elytroid one.

While I am on this subject, I beg to call your attention to a case of vaginal enterocele, of which I published a description in the Examiner, edited by Prof. Huston of the Jefferson College.

The case occurred September 26th, 1844, in a person in West


108 VAGINAL ENTEROCELE.

Philadelphia, who was in labor of her fifth child, under care of Dr. Bicknell. She had always had very easy rapid labors. I ar- rived at two o'clock, P. M. She was attacked at twelve o'clock, the night before ; and was now fourteen hours in labor. I found her in violent labor pains, and she also complained of intense pain and soreness at a point in the right iliac fossa.

I could not reach the child's head without keeping my finger close to the symphysis pubis, for my finger was pushed in that direction by an immense vaginal enterocele ; consisting of a great mass of intestinal convolutions, which, falling dow^n below the brim of the pelvis, so completely filled up the excavation, pushing the back wall of the vagina towards the bladder, that the child's head could not possibly engage in the strait. The tumor was soft, though to a certain degree tense. I had scarcely explored it before I recognized its true nature ; and waiting, therefore, until a labor pain had ceased, I kneaded it upwards with my fingers, after having first thrust the head upwards a little. It began to move, and following its ascent with my fingers, it fairly flew up into the cavity of the belly ; the next labor pain which immediately fol- lowed the escape of the prolapsed convolutions upwards, nearly brought the head through the superior strait ; the succeeding one pushed it into the excavation ; after which, two other pains com- pletely expelled the child, which was a large one and in good health. Now here is a case in which the posterior wall of the vagina was thrust over towards the pubis, by a double handful of intestine, nearly strangulated by the superincumbent pressure of the foetal head in labor; as soon as the pressure of the convolutions was taken away, the vagina was no longer disordered or displaced, and the same, I imagine, will be the case in the vaginal entero- cele, whenever you shall obviate or prevent the pressure of the rectum forwards.

It is not to be denied, that the posterior wall of the vagina, or rather its mucous coat, may be the subject of engorgement, infil- tration, and ultimately of such a degree of relaxation, as to allow it to prolapse even through the sinus pudoris; but that case is very different from the case of descent of the whole mucous tissue, which I have described in a subsequent part of this letter. It is not a vaginal rectocele.

You should be careful to observe, that in some desperate cases of retroversion of the womb, the posterior wall of the vagina may


VAGINAL CYSTOCELE. 109

be thrust forward even so far as to escape from the genital fissure, by the posterior face of the womb pushing it out into sight. I shall shortly cite a very celebrated case of the kind, that occurred at Lausanne, and was described by Dr. Maior.

Small, solid tumors, depending from an ovarium, or developed within the ligamenta lata, may also cause protrusions in the same iJirection.

The very antithesis of the vaginal rectocele, is the vaginal cys- tocele, or protrusion of the anterior wall of the vagina, by a pouch- like enlargement of the lower and posterior part of the bladder of urine. You will verify your diagnostic here by introduc- ing your catheter, or a sound into the bladder, and directing the point downwards into the tumor, where the point of the catheter is felt by the finger in taxis.

This is a fault of the bladder, and not of the vagina. This is clear, since the bladder contains the urine, and not the vagina. If the bladder gives way in relaxation, the whole vesico-vaginal septum must yield ; but it is a cystic malady, and not a vaginal malady.

The tumor is soft, and disappears upon emptying the bladder, as a general rule; yet you may well suppose that a case may have been so chronic, and so neglected, as to give rise to a permanent pouch, which will not disappear, even when every drop of urine has been withdrawn by the catheter.

It gives in general little pain, and is only annoying by the sense of distention, or that disparting feeling that arises upon the protrusion of the sacculus through the labia pudendorum.

The woman should be directed to discharge the urine frequent- ly; and if incapable of that, to make use of a catheter, which she can readily be taught to introduce with her own hand; a thing far less disagreeable than to submit to the catheterismby the hand of the surgeon.

I have made it a rule in all such cases, to introduce a globe pessary, of suitable diameter, w^hereupon all complaint has ceased. The tissues thus supported, recover their tone in the course of a short time, and then the pessary may be withdrawn.

It is necessary I should inform you, that vaginal cystocele — or at least a tumor temporarily deserving to be so denominated — occurs aow and then in labor, and interrupts or totally prevents the accomplishment of the delivery until it is removed. This is


V


110 CYSTOCELE DOUBLE VAGINA.

a case where, from unequal or non-courdinate action of the fibres of the urinary bladder, those of the bas-fond yielding to the dis- tending pressure of an accumulated urine, the anterior wall of the vao-inais thrust backwards against the posterior wall, and both of them pushed towards the hollow of the sacrum and the peri- neum, by the presenting part of the child.

In this case, the child's head cannot enter the excavation, whil| that excavation is filled with urine contained in the bas-fond of the bladder. It is the antithesis of the vaginal enterocele that I encountered at West Philadelphia.

To make the diagnosis and the cure at one and the same time, you have only to introduce your catheter, well curved, directing its point downwards and backwards, into the tumor. The point of the catheter may be felt by a finger in the vagina, and it will be found, that, as the urine escapes, the tumor is resolved and withdrawn, wdiereupon the child's head can enter the excavation of the pelvis.

I subjoin the account of three cases of double vagina, which I submit without additional remarks, taking them from the Medical Examiner of December, 1846, in which they were first published. The account serves sufficiently to explain to you the nature of such a conformation of the parts, and the degree of inconvenience likely to attend it.

On the — October, 1846, I was called to Mrs. , aged

20 years, in labor of her first child. She is a remarkably well formed and comely woman.

The pains were sharp and frequent, evidently of the kind called dolores prseparantes, or grinding pains. After some time, as they had become more violent, I examined the state of the os uteri, which was of the size of half a dollar, the head of the child pre- senting, and the ovum unruptured. In the course of an hour more, I examined again, and the os uteri was then nearly dilated. While pressing the palp of my index finger to the left side of the pelvis, it caught in a seeming bridle, which at the instant made me fear the cervix uteri had been broken, so as to detach a semicircular portion of the os uteri, for the pains had been exceeding sharp, and their returns had been announced by violent cries. It was but a moment that I indulged the idea of a rupture of the cervix, for upon pushing the index farther, and flexing the finger, I found I could draw the point of it outwards, pulUng along with it the


DOUBLE VAGIXA. Ill

bridle in question. Still I did not understand the case until, hav- injT withdrawn the indicator, I examined with it the structure of the external parts, and then learned that the lady was possessed of a double vagina. Supposing that such a revelation would not be agreeable to her, I kept my own counsel, hoping that the child's head would come down through the right or the left channel with- £)ut injuring the septum. But after the head escaped from the circle of the os uteri, the bridle or partition would not go defi- nitively to the left or to the right, although I thrust it first one way and then the other. The tie was so strong that the fleshy septum extending from the anterior to the posterior columna of the vagina, would not admit of the dilatation of the lower or outer third of the tube. And as the lady was very strong, and had powerful uterine pains, I began to perceive some danger of the vagina being ruptured by the vain efforts for expulsion.

I now explained to the monthly nurse, and to a relative of my patient, the cause of the delay and the necessity that had anisen. I therefore procured the requisite permission to expose the parts to an inspection. Upon this, the two orifices of the vagina were seen to be exactly alike, and the partition stretched across the head from front to rear of the passage, which by it was wholly preventing from dilating.

I now^ with a strong scissors divided the wall by a single stroke of the instrument, whereupon the child's head advanced, dilated the OS magnum, and was speedily delivered with safety to both the mother and her infant. She never complained afterwards relative to the operation, and within a month I met her on foot in the streets.

A week later, I was called to a lady in her 30th year, in labor of her first child. Upon examining the state of the os uteri, I found the circle not much bigger than a quarter dollar, with thin margin, and within it the penis of the child ; the scrotum being detected within the os uteri after the pain ceased. As it was night, I went to another apartment and slept an hour, w^hen being called, I found the os uteri very much dilated, and a buttock, near which was the right foot, presenting.

While inquiring into the state of the cervix, I hooked my finger into a bridle, just as I had done in the case above mentioned, and I confess that the same thought was obvious to me, viz., that she had broken off a half rino: of the circle of the os uteri, but T im-


112 DOUBLE VAGINA.

mediately afterwards discovered that I had another case of double vagina under management. In this case the partition was very firm and thick, extending from the os magnum almost up to the OS tincae. I inspected the external structures, and the two va- ginas were each perfect and alike, included within labia pudendi common to both.

I w^as glad to find that only one foot of the child would come down, being fearful that if both should descend, I might not rea- dily prevent one from entering the right and the other the left vagina.

I now disengaged the right foot and brought it down the right channel ; the left leg was flexed upon the belly and thorax of the foetus. With a little assistance the foot was delivered, and the buttock of the child coming downwards, thrust the vaginal wall to the left, and so the trunk was delivered. I had great difficulty to extricate the head of the child, which remained long in the va- gina ; the infant breathing from time to time the air that I admit- ted through the hollow of my hand and fingers to its mouth and nostrils. The child, a male, was alive, and is in good health; the mother is quite well recovered.

Some years ago I was called by the late venerable Dr. Ruan to consultation upon a ease of double vagina in a primiparous wo- man. I delivered the child with the forceps through the right canal, without difficulty or any injury, and had some five weeks later an inspection of the parts, which, as I remember, w^ere very similar to those described in my second case above.

Farewell, gentlemen; I shall adjourn to my next letter some remarks upon the nymphse. C. D. M.


COHERENT NYMPHS AND LABIA. 113


LETTER X.

LABIA AND N YM PH.E— COH E RE NT.

Gentlemen : — In my 8th letter, I laid before you some obser- vations upon the accidents that happen to the nymphse, after hav- ing spoken of their physiological nature. In the present commu- nication, I have to offer further remarks upon those tissues.

They are frequently found to cohere in very young children ; so as to cover up the small triangular superficies lying in front of the symphysis, and which you studied at the dissection, under the deno- mination of Vestibulum. This triangular space, you remember, is bounded above by the clitoris, on each side by the nymphae, and below, by the crown of the pubic arch ; or in other word^, by the upper semi-circumference of the os magnum : — near its lower edge is the meatus urina.

A young baby is usually clouted, or to use a gentler phrase, diapered. In case its mamma is not scrupulously nice, the diaper is often left too long unchanged, and the irritating salts of the urine come at last to irritate and vex, and finally to inflame the mucous surfaces that are too continually bathed with it.

A very gentle inflammatory diathesis being in this way acquired by the mucous tissue, whose opposing surfaces are kept in con- tact, union or fusion of surfaces is likely to take place ; and at length, the mother makes the discovery.

When this gentle adhesive inflammation sets in, as to the nymphse, it is also almost sure to be established as to the labia raajora; of which, after all, the nymphse are but folds, or rugse of the labia. I have many times found the labia coherent, without cohesion of the nymphae. Indeed, the latter are much less likely to become glued than the former, because, when the lower sec- tions of the labia become fused or soldered together, there is nothing to tear them asunder — whereas, at their upper section, there is the repeated issue of a stream of urine, which is of suf- ficient force to break up a commencing process of the sort ; and so it happens that, we do not find cohesion of the labia to extend above the level of the meatus urinarius as a common occurrence. 8


114 COHERENT NYMPHS AND LABIA.

M. Colombat speaks of a case in which the nymphse cohered in such a fashion as to cover up the orifice of the meatus and compel the urine to ascend behind the cohering apron, in order to escape, with difficulty, and dribbling, over the genital surfaces. They were separated by an incision, which relieved the child of her dysury.

Dr. Duges, also, in the introduction to a Prad. Treat, on the Dis. of the Uterus and Appendages, p. 30, gives you the account of a little girl, whose urine escaped by a narrow orifice near the cli- toris. The catheter could not be introduced into the bladder from this orifice, but went into the vagina, because the labia were also coherent. Pray do not, however, believe what M. Duges asserts in the same place ; viz., that cohesion of the nymphai necessarily accompanies that of the labia externa; I am sure you will find, in practice, it is not the case, except very rarely.

It is to be readily concluded that, if a child, suffering from an otclusion, by this cause, of the genital fissure, should by neglect, or from excess of fastidiousness, be suffered to grow up, the fusion of the surfaces might become complete, and thus effectu- ally prevent the fulfilment of her sexual destiny as a parturient creature — for, the longer the union continues, the more complete will it become, and the more absolute the loss or extinction of the mucous structure, whose opposing faces first came into soldering contact.

Whenever the fault is discovered — say up to the sixth or eighth year, and I have known it not to be detected earlier than the tenth year — the mucous membranes are not lost, but only coherent, and they maybe pulled apart, leaving the newly uncovered super- ficies true mucous superficies, and not fleshy ones.

The same sort of cohesion I have observed in the glans and preputium of a little boy.

In all the cases that have fallen under my care, I have adopted the following method of cure.

The child is held down on its back, on the nurse's lap ; who abducts the left knee with her left hand, while I abduct the right one with my right arm. Then, separating and stretching asunder, as far as I can, the labia with my left thumb on the right labium, and my index finger upon the left one, I draw the bulb of a common probe dipped in oil along the raphe, which it always opens and separates without bleeding ; or at least, without the loss of


COHERENT NYMPHS AND LABIA. 115

five drops of blood. The pressure of the probe appears to me to have the effect of pulling out a sort of villi, like a cylindrical epithelium, which had interlocked their floating extremities and become hypertrophied, like placentules in the sheep.

M. Colombat advises, as a measure of precaution, after the divi- sion, to touch one of the surfaces, either the right or the left one, with the nitrate of silver; not to touch both of them. His notion is, that by touching one surface only with the nitrate, we institute in that surface a stage or a rate of vital action different from that going on in the one left untouched ; and as there is then no parity of vital movement in the two superficies, they will not cohere when they are brought into contact.

I have not adopted his idea. But the idea is a very philoso- phical one, or rather a truly physiological one, founded on what is well known to be a fixed law in teratology. You would do well to study that beautiful law as it is laid down by M. Serres in his remarkable w^ork, " The Anatomie Transcendantale^^ a volume which contains the richest stores of fact and reasoning on the nature and operation of the development forces in man. But to return to my subject :

When I have completely destroyed the cohesion, I dip the minimus finger in oil, and draw it downwards to the four- chette, effectually separating the labia, and I then explain to the nurse the necessity of repeating this method once a week at least ; as the mere separation of the cohering surfaces does not cure the cohesive tendency ; w^hich, being in full force, will soon unite the surfaces again, and give other trouble, besides that o^ feeing the surgeon. The last motive is an aegis for the baby: if you do not set it fairly before her, you may soon be called again to make it cry ; whereupon I advise you not to forget such a prophylactic charm. The last thing the sick think of is the doctor's fee; tell them of it and they sometimes take care of their health.

While I was writing to you about the labia, I did not say any- thing as to their cohesion, because I wished to make my remarks on it in coincidence with those I should have to make on the same accident as to the nymphse, and now I have nothing more to offer on the subject worthy of your attention.

The nymphae are occasionally the seats of a very rebellious sort of ulceration. I have found them at times very difficult to cure.

In one example, the nymphse near their summit or angle, were


116 ULCERATED NYMPHS.

deeply eroded, and the ulcerated surfaces were hard from the induration of the base of ulceration. The young person, about sixteen years of age, was not uncleanly in her person ; nor was her health positively bad, as being affected by any sort of consti- tutional vice, that I could discover.

In this case I succeeded in effecting a cure by repeated con- tacts with strong solutions of sulphate of copper ; which, next to the nitrate of silver, appears to me to possess a great power to overcome ulcerative tendencies of the mucous membranes. It is reasonably to be suspected, in such cases as are not clearly to be traced to some constitutioual depravation, that the local irritation is maintained by vicious propensities to excite the parts by fric- tion. On this head I would gladly refer you to the monstrous proceedings of a scoundrel under the garb of a physician, in a case related by the late David D. Davis, the able Professor of Midwifery in the London University College : you will find it at page 58, vol. 1, of his magnificent quarto on obstetric medicine. It ought not to be reprinted in this book.

Should you encounter any cases that will not readily yield to contacts of your nitrate pencil or to a sharpened crystal of sul- phate of copper, you will scarcely fail to obtain healthy and healing granulations, if you should carefully, very carefully and delicately touch the ulcerated points with a small camel- hair-pencil, whose point shall have been dipped in some acid nitrate of mercury. This escharotic cuts everything down like a knife ; and is not very painful, — but it is so powerful that you ought not to let it touch anything but the very points you design to affect. A jet of solution of soda, or salt of tartar, or of lime- water, upon the part after the contact, will neutralize all the excess of the acid that you may have incautiously left, and save the patient from the cauterization of other parts which you desire not to burn. A sponge filled with soap suds answers the same end, by neutralizing the excess of the acid.

An enlargement of the nymphse to such an extent as to prove troublesome and offensive to the individual herself, might be safely diminished by the excision of a portion of the hypertro- phied mass. You will please to observe, however, as the tablier des Hottentottes is an ethnographical peculiarity, it does not neces- sarily follow that an unusual development of the organ must be the occasion of great trouble. The chief annoyance resulting


EXCISION OF THE NYMPHS. 117

from its great protrusion is likely to be an ulcerative tendency, obtained from the constant friction of it in walking, and against the dress of the female. Such a source of disorder is, however, not likely to prove lasting, since the mucous surfaces, when brought out and kept constantly exposed to the air and to attrition, become covered with a real cuticle, and gradually acquire the properties of the true dermal tissues.

As the nympha is a very vascular structure, it might be ex- pected that the vessels would bleed freely upon an excision ; yet no difficulty could arise as to the suppression of hemorrhage from a part which, like this, could be readily compressed, as lying close to the top of the pubal ramus.

Mauriceau gives, in his 174th case, an account of an operation on the nympha as follows :

"July 25, 1676, I operated for the excision of the nympha, on a woman who begged me to do it for her ; because, as she was obliged to be much on horseback, she was put in pain by the friction of the organs, and also because such an indecence was displeasing to herself as well as to her husband."

After cutting off both of the nympha with his scissors, Mauri- ceau remained near her for an hour, in order to observe whether hemorrhage might follow ; during all which time she lost only about four ounces. Finding her doing so well he left her, but was much surprised on returning in the evening to find that she had had repeated faintings ; and that she had lost between forty and fifty ounces of blood in the course of only five or six hours.

Mauriceau says she soon recovered, and was subsequently con- fined under his care. The labor was with a shoulder presenta- tion, for which he turned. No inconvenience attended it, as relative to the absence of the nymphse, which, says he, " n'etoit utile que pour la decoration^ What a curious old Frenchman!

In my next letter I propose to speak with you of the organ called clitoris, as the subject of disease, and am very truly your friend and servant. C. D. M.


118


CLITORIS.


LETTER XI.

THE CLITORIS.

Gentlemen. — Blumenbach, in his Comparative Anatomy, says that " the clitoris is found more invariably than any other item of the external genitals in the mammalia, that it exists even in the whole of them, and is probably wanting in no other instance than in the ornithorincus.

Kraus has a long article on its derivation from the Greek xx«*o^tj from x%(w, claudo, I close or shut.

It is a body lying upon the symphysis pubis, composed of two corpora cavernosa, similar to those of the male, but unprovided with any corpus spongiosum, or canal of the urethra. As it has no corpus spongiosum, it of course possesses no glans. It has, however, a prseputium, consisting of a preputial fold of the angle formed by the junction of the two nymphse at their upper extremi- ties; so that in fact, the clitoris is an organ that juts its point forth beneath the superior angle of the nymphse, and thus gets a hood, covering, or prepuce from them.

Being embraced above by the fold of the nymphse, it is clear that when the nympha^ are drawn by any cause downwards, the point of the clitoris is depressed and thus more readily brought to touch any such body.

It is endowed with the most intense erotic sensibility, and is probably the prime seat of that peculiar life power, although not the sole one. Burdach, Phys. vol. i, 224, says that the clitoris is in "some sort the organ of touch for the genital apparatus."

The erotic sensibility does not abandon it wholly when old age or the change of life has converted the ovarian stroma into a non- germiferous texture ; nor even where the ovaria are totally extir- pated, either in women, or domestic animals. It is true, that the aphrodisiac nature attends upon the ovaria, as its prime source and sustainer, and is most perfect when they are in their highest state of health and power; yet there is an unknown connection and relation of this power as resident in the ovaria, to the means


CLITORIS. 119

of exciting it as resident in the tentigo, myrtis, dulcedo amoris, or clitoris^ and its congenerous tissues.

The anatomical constitution of the clitoris shows it to be the analogue in the female, of the male parts; and it might well be referred to as justifying the idea, that in a certain stage of embryonal existence the future sex of the forming being is not ascertained; as it certainly is not ascertainable by any inspection.

Should you reflect for a moment on the nature of the corpus cavernosum and find it here ; on that of the corpus spongiosum and find it in the nymphse which cover the orifice at least of the urethra; on the prostata, shaped like a Spanish chestnut, which, according to De Graaf, you find again on the outside of the ure- thra, which, like the male urethra, runs through the prostate gland ; can you not believe that the uterus is itself a transmuted prostate, or the prostate an atrophied womb, and thus discover the analogies that are so strong betwixt the various portions of the reproductive organisms of both the sexes? Should you carry the comparison farther, would not you find the spermatic cords in the tubes of Fallopius, and the seminal glands in the ovaria, of which the tubes are in fact the efferent ducts? Lesser transformations than these take place in many of the organs during the embryonal life ; in proof of which I recall to your memory, my remarks in the lecture room on the morphological changes that take place in the develop- ment of the foetal heart.

Like all the organical forms, that of the clitoris is liable to betray the generic law which should produce only the small pimple-like body that we discover in the well and naturally formed pudenda. It may become enormously large, so as to equal in size the con- generous organ of the male. A specimen of this kind is usually the subject of much stupid wonderment; and it is soon noised abroad, as a sample of that impossible thing in any high zoological grade, a hermaphrodite.

The mistake is the more sure to be made, if peradventure the labia participate in the faulty excess of development force, and come to bear, as they do, a strong resemblance to the male scrotum; in which case Martial's epigram on the Tribad Bassa seems appli- cable.

" Mentiturque virum prodigiosa Venus."

There is a very curious and most interesting work, by Parent du


120 ENLARGED CLITORIS.

Chatelet, entitled De la Prostitution dans la ville de Paris, a work ■written in a truly laudable and missionary spirit. M. P. du C. devoted immense labor of research among the thousands of Pa- risian females abandoned to that wretched life, with a view to ascertain the measures best calculated to promote not only their own reform, but the advantage of public morals. In his re- searches he addressed himself to every practicable source of in- formation. He says, at p. 121,

"According to Mess. Jacquemin and Collineau, and the phy- sicians of the Dispensary, there is in the public women of Paris nothing remarkable as to the appearance and dimensions of the clitoris. There are found among them, as among all married women, certain varieties as to this part ; but nothing remarkable.

"As these women are regularly examined, agreeably to a rigor- ous police ordinance, at stated intervals, their condition is well known; and yet, out of the thousands who are kept under such constant surveillance, there were only three in whom the organ w^as possessed of a notable excess of size. In one of these three, the clitoris was three inches long, and of the size of the indicator finger.

" It was probable, not certain, that this girl had no uterus, as none could be ascertained to exist. She declared herself to be equally indifferent as to males and females ; and that she had abandoned herself to such a course of life, not from an excess of libidinous propensity, but solely as a means of escaping from the pangs of hunger."

Parent du Chatelet does not believe that the other two women were specially urged by libidinous desire to enter on their aban- doned course. He declares that all three of them were utterly free from any signs of beard, which he looks upon as a trenchant characteristic of the male. The one particularly specified above, had no appearance of mammary development.

M. Louyer Villermay, author of the article Nymphomanie, in Diet, des Sci. Med. Sub. Voce., relates a case from the Ephem. JVatur. Curios., in which the organ in question was equal in size to that of the male. The salacity of the individual had been ex- treme, from an infantile age. She died in child-bed, non dum satiata, like the Empress Messalina, or Cleopatra. The metro- maniac was the dominant force throughout her life.

o

I presume it is not requisite that I should take the trouble to


HERMAPHRODISM. 121

point out cases of supposed hermaphrodism, in order to convince you that the conjunction of the two sexual natures in any highly organized animal, is a zoological impossibility : wherever nature makes the attempt, she fails ; producing a horrible confusion of organs, from which no effective function can possibly proceed.

Mr. John Hunter's celebrated Observations on certain parts of the Animal Economy, contains a paper on the Free-Martin, from which you may learn that " when a cow brings forth twins, one a bullock, and the other to appearance a cow, the cow-calf is unfit for propagation, but the bull-calf grows up into a very proper bull. Such a cow is called in this country, (England,) a Free- Martin, and is commonly as well known among farmers as either a cow or a bull."

The Free-Martin offers no attractions to the male, who never takes the least notice of her. The Free-Martin never breeds, has the bellow of the ox, and as a stall-fed animal resembles the ox or spayed heifer; being readily fattened, and possessing a tender and fine-grained flesh.

Mr. Hunter having procured one of these animals, found the external genitalia in all respects feminine, perfectly formed. But the vagina terminated in a cul-de-sac, a little above the urethra, from whence the vagina and uterus were impervious. The re- motest extremity of the uterus terminated in two horns; at the termination of these horns (the Fallopian tubes), were placed the testicles, instead of ovaries. In another specimen, he found both the ovaria and the testes at the end of the cornua of the womb.

You might, perhaps, feel inclined to object to me that, if both testes and ovaria were found here, the animal was truly herma- phrodite. It is a dangerous thing to doubt John Hunter's ob- servation ; and it is a sort of daring I should scarcely venture upon ; — but, in the present instance, I think if you will look at his paper, you will agree with me that Mr. Hunter's observation is incomplete, and that he is himself obliged to argue the point in favor of his inference. At all events, I see nothing in the paper to shake my firm -reliance on the inevitable tendency of generic force; and hence, I can place no reliance on human, nor any other mammiferous hermaphrodism. The idea is a poem in itself; but the prayer of Salmacis, that her lover's body and her own might be resolved and combined into a single one, and which is the highest culmination of the sentiment of love, is a prayer to


122 ENLARGED CLITORIS.

be granted only by the fantastical and freak-loving gods of the mythological host; the Ruler of the world, whose laws are what we call Nature, never departs from that course in which there is no variableness, nor shadow of turning.

But let us consider what are the maladies likely to obtrude themselves upon our attention, as affecting the part under con- sideration. Ulceration, hypertrophy, and enlargement, and ex- cessive augmentation of the libidinous desire.

I deem it not necessary to offer any special remarks upon the management of its ulcerations, which should be treated upon the same same plan as similar ulcerations of the nymphee, which are always likely to accompany it.

The hypertrophy is most likely to be congenite. If it take place during a maturer period, it can be readily excised; probably the only remedy, and not called for, except when great inconve- niences attend it.

Dr. Merriman describes one that was amputated in Dublin ; — it equaled, in size, a child's head two years old. There is in St. Bartholomew's Hospital, a specimen preserved in the Museum, constituting a mass of two inches in diameter, composed of a firm, pale, obscurely fibrous substance, traversed by glistening bands. The interior contains a number of cavities or cysts, filled with groups of small bodies attached by pedicles to their walls. For the above, I am indebted to an interesting volume published in 1847, under the title, " On Tumors of the Uterus and its Jip- pendages, by Thomas Safibrd Lee, M. R. C. S. E. &c., 8vo., London, pp. 222. I hope to present you some further citations

of this very excellent writer's passages in the course of these letters.

I pray you to advert to the very curious case of disease of the clitoris, which I published in Colombat's work, and about which I spoke to you at some length last winter. In that instance, the tumor was a globular body appended to the superior part of the genital fissure, and consisted of a clitoris, which in a gradual progress of morphological transformation continued during fifteen years, had become equal to the cubic content of twenty-two ounces of fluid blood, or mensual excretion. I have often had my feelings of surprise renewed, upon reflecting on the possible conservation during so long a period, of a material like that in question; and I am confident that it must have participated in the nature of the


NYMPHOMANIA. ' 123

menstrua, and that no other organic material save a reproductive one could have preserved it so long unchanged. But as I have no intention to describe the case and its treatment a second time in this volume, I shall merely beg you to refer to my account of it, and to the print, which gives a correct idea of its appearance.

Probably, the most serious malady that can affect the clitoris, is that morbid sensibility of it which provokes to constant attention to the erotic stimulation. This is a malady, dangerous not to the health only, but to the morals of the sufferer; for the physical sense is, in some instances, able to overpower the moral sense, which it carries captive in its mad and brutal career of indul- gence. I think that nothing can be found more revolting, than the spectacle of a female under the full influence of a Nympho- mania.

I have met with a few samples of this terrible malady in the course of my long experience, and I am thankful to be able to say, but few; and those, not of the greatest intensity. In one of the cases, which occurred in a thin brunette, aged only nine years, I learned, to my astonishment, that for months she had been in the almost constant constant habit of irritating the erotomaniac sense, by various methods of provoking its exaltation, while at school, on the form, or standing up in class, at church, at table, in the dining parlor, and more than all, upon retiring to bed ; so that it appeared, she was very rarely without the sexual sense in a highly exalted perception of it. Her health had become feeble, and from the most ingenuous and gentle of children, she had grown cunning, deceitful, and wicked in disposition.

I made vain efforts, through moral treatment, to awaken the com- punctions of shame and conscience, and to set in array the dictates of common sense, and the love of life and health. The affair became so threatening that it was necessary to examine the parts, w^hich were natural in appearance ; I found nothing peculiar as to the sinus pudoris; no change in the appearance of the nymphae or clitoris.

I put the case under a severe course of purgative medicines, that were repeated for a long time, and rendered her thin and weak. I gave purgatives to the child in order to reduce her strength by diminishing the crasis of the blood, hoping that such a cooling operation might be followed by some diminution of the erotic excitement.


124 NYMPHOMANIA.

I also directed ten grains of nitrate of silver, dissolved in one ounce of water, to be procured. The solution was freely applied to the nymphse and clitoris for several successive days. The child declared she had abandoned her habit, grew fatter and stronger; but at length confessed she had always continued in secret to ex- cite her sexual sense.

She w^as finally sent to the country, when her health became strong, and I have reason to believe that she lost her frightful propensity upon the recovery of her health. What, indeed, is ever likely to render all the innervations natural and healthful, if a firm and solid health of all the other organs fail to conduct back to a normal state, an organ or tissue that has become disordered. Health, like mercy, is twice blessed, since it not only gives, which is blessing, but receives, which is blessing also. I am not, there- fore, surprised, when I learn that a case so distressing, recovered under the invigorating influence of fine air and exercise, which, by restoring the harmonious concurrence of the other innerva- tions, compelled those of the aphrodisiac tissues to come under the same law of harmony. It is probable that by reducing her strength by the course of purgative medicines, I did harm rather than good to my patient. And yet, it is possible, that by so re- ducing her before sending her to the country, she was enabled more speedily to recover under the more extensive assimilations that were required to bring her up again to her former weight.

There should be in your therapeutical and hygienical purposes, as to the disorder under consideration, I think, a constant purpose to build up, as early as possible, the shattered edifice of the nerv- ous system by good air, and a nourishing, but simple and not stimu- lating diet ; by exercise, carried to the extent of turning off every excess of nerve power in the direction and activation of the muscu- lar system; by an almost constant presence; by new, innocent, and attractive trains of occupation and thought ; and the employment of the ferruginous tonics and vegetable bitters, the shower-bath, cold hip-bath, sleeping under thin coverings, and doubtless, above all, the administration in the evening, of a full dose of opium by enema. I confess, I have had but little experience in the treat- ment of such maladies, and as those which I have encountered have gradually terminated by a restoration of the health, without other inconvenience than the suffering, the mortification, and the alarm of friends, I am inclined to hope that, with great prudence


INVERTED BLADDER. 125

and circumspection on your parts, you will always find in the resources of your education, those principles of medical prescrip- tion that may enable you to conduct your cases to a favorable end. As I, like you, have been officially admitted to the rights exercendi, docendi, et scribendi, quocunque rite vocatus fuerim, I am admonished by the condition rite, not to cite in these letters any of the numerous shocking cases that are, perhaps, too fully and unnecessarily set forth and detailed in the authors.

The orifice of the urethra, though not a sexual part in strict- ness, yet it is to be so regarded in the female. It is, not rarely, the seat of diseases demanding your counsel, or your surgical ministry.

Dr. John Green Crosse, of Norwich, England, whose works are well known and highly appreciated, sent me a small pamphlet lately, containing an account by him, of a case of inversion of the urinary bladder, w'hich came forth at the orifice of the urethra, and made there a " tumor about the size and shape of a walnut, projecting visibly, at the external labia pudendorum. It was of a blood-red color, and somewhat granulated upon its external sur- face, so as to resemble a large strawberry; and the surgeon en- tertained a notion that it was a vascular tumor, which might be removed by ligature, on which account he requested me to in- spect it,"

Now, gentlemen, you will please observe that this tumor existed in a girl between two and three years of age; and that the highly respectable physician, a colleague of Mr. Crosse, mistook it for a vascular tumor, that ought to be cured by extirpating it with a ligature. If he had put on the ligature himself, without consulting with Mr. C, he would have cut off the child's bladder of urine!! See, then, how dangerous it is in physic, to jump at a conclusion; and beware of the advice so often reiterated in the lecture room, never to give an opinion, until you have an opinion to give, nor to enter upon an action until you have learned where it may end. Even after Mr. Crosse's first examination, the girl was in the greatest danger of losing her bladder; for just as the surgeon was about to put on the ligature, Mr. C. discovered both of the urethral orifices, and he then pressed the tumor back into the vulva, and continuing to push it, it retired upwards, along an opening into •which, after the tumor had gone up, he could and did actually introduce his little finger, and carry it quite up inside of theblad-


126 EVERTED URETHRAL MEMBRANE.

der ; so largely was the urethra of the child dilated by the long- continued distending pressure of the inverted bladder on its v^alls.

If the ligature had been put on, the child must have died.

Mr. Crosse could never learn how long the inversion had lasted; he could only ascertain that it had lasted for a " considerable time."

There was no relapse of the inversion, so far as he had learned.

Dr. Murphy saw a similar case at Dublin, which was cured by reposition.

You will also meet with cases in which the mucous membrane of the urethra becomes hypertrophied and inflamed, producing a fiery-red tumor at the orifice of the urinary canal. This is attend- ed with much burning pain, and obstruction to the flow of the water. It may be cut off by passing a silver canulainto the blad- der, and excising all the out-hanging mucous tissue, by a bis- toury ; cutting on to the silver tube by a process like the first inci- sion in amputation. Or where the patient is afraid of the knife, it may be readily cut off by half a drop of acid nitrate of mercury, or a camel's-hair pencil, which destroys at contact.

I will not, however, close this letter, without cautioning you not to shut your eyes upon many samples you must be destined to meet with, of incomprehensible maladies — maladies, however, that become perfectly intelligible to us, if we study them in the light lent to us by investigation into the nature, extent, and great power of that aphrodisiac or reproductive instinct, which, however disastrous and shameful its excesses, must be admitted to control, to a certain extent, a very considerable part of the motives and actions of men, and without the incitations of which, the entire scene of living nature would soon be blotted out, leaving the earth a howling and desolate waste. Very sincerely yours,

C. D. M.


DISPLACEMENTS OF THE WOMB. 127


LETTER XII.

DISPLACEMENTS OF THE WOMB.

Gentlemen : — The uterus, as you well know, is situated be- tween the bladder and the rectum ; resting on the upper end of the tube of the vagina; attached in front, to the bas-fond of the bladder; held in situ by two ligamenta rotunda in front, which prevent it from turning over backwards in the direction towards the promontorium of the sacrum ; and, lastly, prevented from librating to the right or left, by the left and right ligamenta lata.

It is easy, now, to understand, one would think, that if the vagina preserves its natural length, and if the round ligaments are neither too short, nor too long, while the broad ligaments are also in a healthful state of tension, there can be no displacement of the womb — for the womb cannot settle downwards in the pelvis, unless the vagina also settles down, by growing shorter — nor can it be turned over backwards, while the round ligaments are only two and a-half or three inches in length. Nor can it librate, and become oblique to the right, while the left broad ligament pre- vents it, nor to the left, if the right broad ligament be not relaxed and elongated. This is clear — and if it be clear, then it seems to me, that it might hardly be worth while to give you any further trouble in the way of indoctrinating you as to the deviations of the womb. But I have some plain remarks to make, that may possibly assist you in obtaining such clear notions, as to put it out of the question for you to be embarrassed in the treatment of such cases, and these remarks will be numerous.

Prolapsion of the womb, commonly in the world spoken of as falling of the womb, and bearing down of the womb, is so frequent an occurrence in married women who bear children, and is attended with so much distress and vexation for many of them, that I am sure no man can long practice physic without being appealed to for counsel and relief in this form of disease. But, with just views of the pathology and the semeiology of the case, there are few samples of it that may not be made to yield to a


128 DISPLACEMENTS OF THE WOMB.

judicious treatment, based on correct views of the state of the affection.

Let us speak, first, of prolapsus uteri — or falling of the womb.

By this is understood a case in which the os tincee approaches too near the orifice of the vagina ; and the degree of the pro- lapsion might, perhaps, in strictness, be measured by the distance between the orificium vaginse and the orificium uteri. I say, in strictness, yet I wish you to understand, that the amount of pain, distress, or inconvenience, is by no means proportioned to such a measurement ; because you shall find that a woman, with but a slight descent, shall suffer vastly more therefrom, than another woman, whose womb has fallen twice as low down in the pelvis. Indeed, there are women who always find the mouth of the womb to peer out at the genital fissure when they are on their feet; and who appear to feel no pain from it; while others are observed to sufTer the most vexatious and even intolerable pain, from a very slight depression indeed.

That excellent old author, the Sieur de la Motte, sworn Sur- geon and Accoucheur, at Vallognes, in Normandy, and who de- serves for his good sense, prudence, and skill, ever to be grate- fully remembered, makes two divisions of the malady, one of which he calls relaxation, and the other, descent of the womb. It is very curious to see how, by the use of a few quaint expres- sions, he paints the picture of the case.

"L'on appelle relaxation de la matrice lorsque I'orifice inte- rieur de ce viscere descend a I'entree du vagin, et quelquefois jusques entre les grandes levres, qui se fait remarquer en y touchant avec le doigt, par un corps d'une consistance moyenne, entre le dur et le mou, qui retrograde a mesure qu'il le pousse, et qui revient aussitot qu'on a ote son doigt, et qui se retire ou reprend sa place d'elle meme lorsque la femme se couche sur le dos, et qu'elle a dans sa situation les reins un peu plus bas que le siege."

The descente is where the os uteri comes quite out of the sinus pudoris. You see that La Motte, by the few words above quoted, has given a perfectly graphic picture of the phenomena of our case.

Among the inconveniences connected with falling of the womb, are those depending on the disturbance of the utero-vesical and the vesico-vaginal septum, for the womb and vagina cannot settle


PROLAPSUS UTERI. 129

downwards in the pelvis, without dragging down with them the posterior part of the bladder of urine ; which being fretted and vexed with this pulling force, is frequently prompted to contract on its contents — and thus is set up a course of urinary tenesmus. But a urinary tenesmus is itself a disturbing force. Tenesmus relates to a pelvic sensation ; and when your patient has a con- tinual prompting to make water, she has also a continual forcing or bearing-down feeling, w^hich compromits the repose and com- fortable sensations of all the other pelvic contents. There is a sense of weight, ponderosity, or pressure, at the perineal strait, which excites pain in the hypogastric and sacral plexuses and their branches ; so that the poor patient not only has sensation where there ought to be no sensation, but it is absolute distress and pain. As the nerves of the womb, and vagina, and bladder, have a very extensive fibre connection with the whole of the splanchnic plexuses, and with the great sympathetic and the spinal nerves, — you may readily suppose that a displaced womb, like an aching tooth, may disturb the renal, the hypogastric and sacral plexuses, just as the tooth starts into existence the most frightful trifacial neuralgia ; and you will find on examination and reflection, that hundreds of poor creatures are bled and cupped, hydrargy- rised and blistered, and antimoniated, under a false accusation of hepatitis or nephritis, or spinal irritation, who really have com- mitted the small and venial fault only of letting their uterus fall downwards a meagre half inch perhaps. I hereby warn you against false diagnosis, for diagnosis is in practice like Captain Greatheart in Bunyan, encountering and overthrowing all ob- stacles, so that even Apollyon, who in words less polite was the devil himself, could by no means oppose a bar to his habit in his practice of succeeding always.

You have all learned what is meant by Professor Cams' curve; well — the womb, when in its proper position, coincides as to its long axis with the superior part of this curve ; and if from any degree of prolapsion it settles downwards, it follows the curved line of the great Saxon teacher in its fall. When at the top of that curve, the woman being in a standing position, the long axis of the womb is directed upwards and forwards, and downwards and backwards. Suppose the womb to fall half way down to the OS magnum, then it would be vertical in the pelvis of a woman 9


130 PROLAPSUS UTERI.

standing upon her feet : — if it were to lapse downwards, so as to show its lips jutting through the os magnum, the womb would necessarily lie in a position nearly horizontal ; its mouth looking forwards under the crown of the pubal arch, and its fundus point- ing backwards towards the lower third of the sacrum.

Imagine your patient situated as I have just described ; and I think you may readily understand why she has both vesical and rectal tenesmus ; pains in the sacral and lumbar regions ; pains in the groins from discomfort and traction as to the ligamenta rotunda; some uneasiness in the ligamenta lata; while the recto- vaginal septum is strained, and the fundus of the womb actually rests and is pressed upon the inferior parts of the rectum, irri- tating it like a mass of scybala lodged in it.

Nerves from the lower end of the spinal cord are distributed on the w^omb and vagina, and to the bladder and rectum, as you may perceive in good Professor Tiedemann's beautiful drawings of the uterine nerves, and in Robert Lee's Treatise on Midwifery, but they receive a considerable endowment of nerve filaments detached from the great sympathetic. They also, in the same manner, are allied to the renal plexuses, the solar plexus, and, in fact, to the whole organic innervative apparatus. What a great disturbing power does this impart to the reproductive organs when sick ! what an uncomfortable creature is a woman with a prolapsion ! have we any cause of surprise or wonder to hear her complain of her hypogaster, of her groins, of her thighs, of her loins — of the region of the kidney or liver — or, indeed, need we feel astonished if the whole interior of the belly become affected with the most intense and insupportable neuralgia.

I had been long accustomed to regard much of the distress expe- rienced by females with prolapsus, as belonging to the class of neuralgic disorders, and my opinion on this point has been, for many years, confirmed by the occurrence of singular cases, to which I had not seen any allusion in books, until I met with an account of similar cases in the recently published work of Mr. Maunsell, of Dublin, a work which, although small in size, is replete with sound doctrine, and rich in numerous and important practical details. I have now met with about thirty instances ; in which, the most cruel neuralgia of the whole belly, with sen- sibility equal to that of acute peritonitis, proceeded solely from a very sUght degree of uterine prolapsion. I say so, for when I


PROLAPSUS UTERI WITH ABDOMINAL NEURALGIA. 131

could not press the palps of my fingers ever so lightly on the ab- domen without giving great pain, I have found that, when I sup- ported the womb on my index finger, pushing it upwards less than half an inch, the woman could not only allow me to touch the abdomen, but even to touch and press it very violently with- out complaining. From all this I conclude that much of the pain of prolapsus uteri depends on the pi^lling or stretching of nerve fibrils, caused by the sinking downwards of the organ. The patient feels instantly well, if you push the womb up to its place, or, I should rather say, if you elongate and carry out to its usual dimensions the tube of the vagina: when the vagina is up, the womb cannot be down. These cases I have been, for seve- ral years past, in the habit of relating in my lectures, as will be easily recollected by any of my early pupils who may peruse this page. I have also spoken upon this subject before a numer- ous assemblage at the Philadelphia Medical Society, in the winter of 1833 and 1834, The cases to which I allude may be exem- plified by the ensuing statement.

On the fifth day of July, 1828, I was called to see

, a mulatto woman, in Water street, aged about thirty


years. She was lying upon her back ; the knees were drawn up, and she was supporting the bed-clothes with her hands, lest they should press upon the abdomen, which was so exquisitely tender and sore, that she could by no means endure their weight or pres- sure. She had been suflfering this pain for many hours, and had a short quick respiration, on account of the pain which any ex- tensive motion of her diaphragm communicated to the abdomen, and which made it necessary for her to restrain the respiratory movements as much as possible. Upon hearing her account of the symptoms, witnessing her distress, and observing her decubi- tus, I was at first convinced that she was laboring under intense inflammation of the peritoneal coat of the intestines. The slightest pressure of my hand on the abdomen was resisted with exclama- tions ; for the part was, to the greatest degree, quick and sensitive. Upon examining the state of the pulse, which I expected to find tense and corded, I was much surprised to discover that it was nearly natural, as respected its frequency, volume and hard- ness. The incongruity of the signs derived from the examination of the abdomen and of the pulse, led me to make further inquiries. She had borne several children, of which the youngest was now


132 PROLAPSUS WITH NEURALGIA.

about a year old. I became convinced that her pains were those of prolapsus — a neuralgic state of the abdomen, produced and maintained by a misplaced womb. In brief, I obtained permission to make an examination per vaginam ; and upon pushing up the womb, which I found very low down near the vulva, the abdo- minal pain suddenly ceased, and in a few minutes afterwards she could bear, and did l^ar, without shrinking, the rudest pressure of the hand on the abdomen. This was the second instance of this sort of disorder I had met with; the first one having occurred in a young unmarried woman, about two years before. Since that period I have seen more than twenty-five similar cases, all of which bore, with the exception of the state of the pulse, the most striking resemblance to acute peritonitis. I feel well assured that instances of disorder of the kind just pointed out, can only be properly denominated by the title of neuralgia with prolapsus uteri.

Let me advise you not to forget what I said a little while ago, as to the direction and the attitude of the womb. Do not make a mistake in your Diagnostic; amistake often made in practice by respectable authorities, who misconceive the case as a sample of hepatitis or nephritis, or retroversion, whereas, it is a simple prolapsion. The womb descends in a see-saw manner, the fundus falling lower and lower towards the sacrum, while the os tineas rises towards the pubal arch as the fundus descends. It is not a case of retroversion, but a simple falling of the organ, in which it tends to become hori- zontal in the pelvis, instead of vertical ; changing its place, how- ever, so as to carry its os tincse not merely nearer to the symphysis pubis, but even out of the pelvis entirely, below and in front of the arch of the symphysis. In a real retroversion, the mouth of the womb is not any lower, but it is rather higher than before ; in fact, the greatest difficulty in some cases of retroversion in the early stages of gestation is, that it is found impossible to get at the os tincse at all, so high above the pubis is it forced by the augmented length of the gravid retroverted organ.

I must call your attention to a consideration, important in all your reasonings and administerings, as to prolapsion, and that is to the use of the levator-ani muscles. This great fan-shaped membranous muscle arises, as you know, from the outer half of the inner margin of the pubis ; from the obturator membrane, and from the ischial plane, just below the brim; and sending its fibres


THE LEVATORS IN PROLAPSUS. 133

downwards and inwards, goes to mingle them with some of the fibres of the sphincter ani muscle, and sphincter vaginse, and insert them generally into the parts around the lower end of the rectum and vagina; so that when it contracts, the effect is, to pull the lower end of the gut upwards, towards the plane of the superior strait. This muscle is granted as the chief active antagonist of the dia- phragm and abdominal muscles, Avhich, in straining at stool, and at urine, as well as in labors, tend always to push the perineum more and more downwards. Now, in order to counteract this tendency to descent of the perineal planes, the levator is provided, in order to pull the perineum upwards again, and keep all things in situ naturali. This is an action familiar to all persons, but it is most strikingly perceived in the course of a labor, in which you shall observe that when the throes push the head of the child against the floor of the pelvis, and thrust it so far downwards as to drive it even lower than the planes of the perineal strait, making there the enormous perineal tumor, the whole head, immediately after the pain is off, by a few contractions, pulls or jerks of the levator is drawn back again within the pelvis, so as to make the patient ex- claim — "Oh! it's gone back again;" which is the fact; for of a truth, the head is driven down and pulled up again, in some labors, for several hours, by this mechanism. Now, in a case where this strife betwixt the tenesmic and the levator power has been long and fatiguing, it happens, not rarely, that the levator does not recover its tone and full force for months, and even for years after the labor, because of the debilitation produced in it by its suffering in the labor : but this want of relevative power leaves the woman with a perineal tissue lower than it was before she was in labor. But, if the woman be the subject of frequent child-birth, her perineum grows weaker and weaker at every suc- cessive trial, until at last it becomes convex ^outwards, instead of concave, as it is in the young and the vigorous. All healthy young people have the anus high up in the sulcus betwixt the nates; but all old and weak people allow it to sink downwards ; until at last, in the very aged and feeble, it is not a sulcus that we find at the perineal strait, but a broad soft convex tumor rather. See, then, how important is the office of the levator-ani. See how it may be overstrained and enfeebled by one or by many labors ; and how, when it does get into such feeble health, it allows the pelvic viscera to sink, or prolapse. Do you not, also, in this


134 THE LEVATORS IN PROLAPSUS.

view of the case, perceive how it may happen that habitual cos- tiveness of the rectum may weaken the levators, and depress not them only, but the whole perineum, and all the contents of the pelvis, which in a degree repose upon it, and depend upon it for their best support? It appears to me that a true prolapsus uteri can hardly take place while the levators are strong, and, that we cannot have a weakened and enervated levator in the female, without more or less of prolapsus, or tendency thereto.

Where the levators have thus become injured, there will be the sense of weakness, weight and bearing down in the pelvis; and this is one of the sources of those complaints that are made by the patjent.

This complaint of bearing- down, is, being interpreted — tenesmus uteri. Stephanus says, tenesmus, or more properly tenasmos, fEtratf/toj id est crebra et inanis voluntas egerendi ; a vain and fre- quent desire to evacuate ; which is Pliny's account of it. How can you have such a crebra et inanis voluntas, if your levator be strong! I am very sure if you had any art to give to a poor woman, with prolapsus of the womb, a great thick red levator muscle, she could no more have a prolapsus, than she could have a procidentia while the constrictor vaginse is closed with a spas- modic foice.

Levret says that but few women with descent of the womb are ever radically cured, by any treatment whatever, and are unable to dispense with the use of the pessary; and quand elles devien- nent assez heureuses pour n'en avoir plus besoin hors de la grossesse, ce n'est que lorsque de tres maigre elles sont devenues tres grasses, en faissant un usage constant du pessaire. — UJirt des Accouchemens, p. 433.

I think Mons. Levret cannot be borne out by facts in this dis- couraging statement, for I have certainly met with many women who have recovered, and yet have not grown fat. A lady long subject to prolapsus, who used a pessary for four years, told me to- day, May 13, that she is perfectly well : she is no fatter than she was before.

Let us now consider the foregoing observations, in order to ascertain what results we have come to.

1. The womb rests at the top of the »vagina, a membranous tube, attached partly, on its posterior face, to the rectum ; on its sides, to the cellular tela included between the lamineeof the liga-


DIFFICULTIES OF DIAGNOSIS, 135

menta lata ; and in front, to the bladder, to -which a part of the womb also adheres.

2. The natural position of the womb is one in which its long diameter coincides with the upper extremities of Prof. Cams' curve.

3. In descending, in prolapsion, it slides down Carus' curve, so that, at last, it becomes horizontal in the pelvis, from which, 4. in procidentia, it finally escapes.

5. As long as the vagina retains its dimensions, there can be no prolapsion.

6. In all prolapsions, when the vagina recovers its pristine longitude, the prolapsion ceases, and so in proportion.

7. There is always some complicity of a feebleness of the leva- tors, with a prolapsion of the womb.

8. Prolapsus uteri is not a disease of the womb, but only a dis- ease of the vagina.

9. The indication of cure in prolapsus is an indication to cure the vagina.

In this, as in most of the sexual maladies, the difficulty of effect- ing a cure is greatly enhanced by those sentiments of a fastidious delicacy which sever so trenchantly the two sexes from each other in the ordinary relations of social intercourse ; and to such a de- gree does this extend in this class of maladies, that the patient ordinarily conceals the fact, or the extent of her suffering, lest, upon betraying them, she should be compelled to make confession to the physician; so that our duty in the cure is greatly embar- rassed by the advanced stages at which the malady has arrived before it is placed under our care.

We are, in many instances, not permitted to institute the only in- quiries that would possibly reveal to us the precise nature and indication of the case. Even after we have been consulted, and where certain concessions are made, there often remains some degree of uncertainty, because we cannot, as we can in persons of bur own sex, freely employ every means of research in ex- ploring, and in repeating the explorations of their maladies.

This difficulty is probably greater in this country than it is in Europe. I am rejoiced at it ; because, however inconvenient, and however baffling in the, particular instances of suffering, it is an evidence of a high and worthy grade of moral feeling. And I hope the day is far distant when the spectacle shall be seen in our


136 DIFFICULTIES OF DIAGNOSIS.

hospitals, of troops of women, waiting, in succession, for a public examination of their genitalia, in presence of large classes of me- dical practitioners and students of medicine. I regard this public sentiment, as to the sanctity of the female modesty and chastity, as one of the strong safeguards of our spontaneous public polity; — for woman, and man's respect and love for her, are truly at the basis, and are the very corner-stone of civilization and order.

He is but the pander of vice who parades his thousands of ute- rine cases before the public gaze ; and is himself an unchaste man, who ruthlessly insists upon a vaginal taxis in all the cases of women's diseases that, however remotely, may seem to have any, the least connexion with disorders of their reproductive tissues.

While I say these things to you, my young friends, I am bound also to say, that it will be your painful, even your distressing duty, to condescend to the task of making such explorations sometimes. It will be your duty either to do so, or to desist from taking the responsibility of curing the patient, whose case you can by no other proceeding become acquainted with. Yet even in this offi- cial ministry it is possible so to demean yourself, to be so filled with respect and with compassion for the afflicted, as to discharge the obligation without wounding the self-esteem of the patient, or lowering yourself from the high station of a missionary of health, furnished, by the blessing of Providence, with the wisdom and the skill, not truly to raise the dead, and give sight to the blind, but yet to make truly alive again, driving away the dark-winged fiend who is hovering over his promised victim, and scattering roses where the lily only drooped before, and opening up in re- newed freshness and copiousness, the fountains and streams of life, and hope, and enjoyment that always gush at Hygeia's feet.

What need have I to speak further in this letter as to the signs by which the case of prolapsus uteri may be discriminated from all other affections? If you remember the manner in which Prof. Cams' curve is projected, you will also at once perceive what must be the attitude and direction of the womb in all the succes- sive stages of its descent to the bottom of the pelvis. But lest you should have forgotten that famous projection, let me describe it again. Bisect a dried pelvis from front to rear; set one leg of a compass on the symphysis pubis; open the compass two or two and a quarter inches, equal to the semi-diameter of the superior


CARUS' CURVE. BENNEt's VIEWS. 137

strait measured from pubis to sacrum ; then describe with the free leg an arc of a circle, commencing at the plane of the upper strait and terminating before and below the crown of the pubal arch. This is Carus' curve, or the curved axis of the excavation. This is the curve coincidently with which the centre of the fcetal encephalon moves in passing through the pelvis, in labor; and it is the curve down which the womb slides as it descends in pro- lapsion of the uterus ; so that, when the womb is high, the os tineas looks downwards and backwards; when half down, it looks down- wards; whereas, when quite down, it points forwards.

Please observe, however, that in the descent of the non-gravid uterus, there is no distension of the perineum like that which at- tends the advance of the foetal head. Consequently, the lower the womb sinks, the more horizontal does it become, since the peri- neum presses the escaping cervix uteri quite up to the crown of the arch. In fact, the cervix approaches the centre of Carus' circle as it falls, while the fundus departs from it at a tangent. This explanation is to help you to discriminate betwixt a true retroversion and a mere prolapsion of the uterus.

There is a new book lately put forth by Dr. James Henry Ben- net, of London. A Practical Treatise on Inflammatory Ulcera- tion and Induration of the JYeck of the Uterus. Lond : 8vo. pp. 212, 1845. Dr. B. informs you that he had long opportunities at Paris, in hospital practice, to witness the treatment of these cases, and to make very careful researches as to their true nature and cure. The result is that, in prolapsus, there is always swell- ing or engorgement of the neck of the womb ; which, by its weight, pulls the organ down, dragging the vagina with it. Such is Dr. Bennet's proposition ; and I now lay it before you in order to ask you what you think of its reasonableness. Please observe, that an engorgement and swelling of the vaginal cervix uteri weighs and pulls downwards the whole organ; and when you cure the engorgement, then the ponderosity being done away with, the womb rises again to its accustomed place. I quote from page 53. " The uterus is so slightly poised or suspended in the cavity of the pelvis, that the slightest modification in its volume gives rise to a change in its position. The inflammatory hypertrophy of the cervix increasing considerably the specific gravity of the inferior portion of the uterus, the entire organ descends, prolap- ses."


138 bennet's views.

Now here is a rationale which you are to accept, and accept- ing, you are to act upon it as a guiding principle in practice ; or you are to regard it as unsatisfactory in itself, and incompetent to control your therapeutical or chirurgical ministrations. Judge now: the weight of a non gravid womb seldom ever exceeds two ounces, and of that the vaginal cervix constitutes not more than one-fifth part. But the author says that the engorgement and swelling of this fifth part drags the womb and vagina down to the bottom of the pelvis, and of course tends to precipitate them both entirely outside the cavity. Is this a reasonable rationale? Does it comport with other and analogous facts? Does the womb tumble out of the genital fissure because it grows heavy with gravidity, or with heterologue development; and does not the weight and heft of a womb at three or four months of gestation, far exceed any imaginable augmentation of its weight in engorge- ment and swelling of the cervix uteri ? But, if a gravid womb of three months is not a fallen womb, why should an engorge- ment of the cervix, not amounting in increase of weight to one ounce for the whole organ, have such an eflfect ? I cannot think you will accept Dr. Bennet's rationale ; nor will you twit me with the so oft repeated French axiom "a ventre plat enfant il y a — "

You will meet with many cases of swollen and hardened — even indurated womb, in which that organ comes to weigh a pound or more, and yet it does not necessarily prolapse. I cer- tainly have had many such under my care, — and have not found them to prolapse — indeed, I am sure that one of the worst proci- dentias I ever saw, was that of a womb which would not, in the scale, weigh more than an ounce ; how, then, can I believe that prolapsus is the effect of increased weight of the cervix uteri only ?

Dr. Bennet's explanation, then, does not explain the cause of prolapsus. Yet Dr. B.'s work is very well worthy of your regard; for it contains many cases of uterine disorders that were prudently, sagaciously, and successfully treated. I should be very glad if you would all read his work, because he is a man of sense and conduct, who is well esteemed in London. Nevertheless, I can- not agree with him in his views of the cause of prolapsus uteri.

I should think that of a given number of cases, ninety per cent. will be observed in persons who have had children. Nay, I doubt whether ninety-five per cent, of the cases are not caused by ges-


CAUSES OF PROLAPSUS. 139

tation and labor; for of the cases supposed to be prolapsus, a very large number are not really of that class, but consist of dis- orders arising from faulty innervation of various tissues within the pelvis, and curable by other means than those that are indispen- sable for the successful treatment of prolapsus of the organ.

In the early months of pregnancy, the womb, whose fundus grows broad and expansive, is pressed downwards into the pelvis by the superincumbent weight of the bowels, and by the tenesmic force of the abdominal muscles. So that, the os uteri settles at a lower plane of the excavation, yet cannot be said to be prolapsed, but only pressed downwards, or weighed downwards ; for there is no real disease of the vagina. As pregnancy advances, and the uterus expands with the growing ovum, the excavation of the pelvis becomes too small to contain it, and it accordingly, at about four and a half months of gestation, rises above the plane of the superior strait. When it has thus gone up, at the period of quick- ening, the vagina is greatly elongated, so much so, indeed, that in making the examination by the taxis, the extremity of the indi- cator finger can, sometimes, scarcely be carried so high up as to touch the OS tincae.

' In most women pregnant beyond the fourth month, then, you •will expect to find the very contrary of the state of prolapsion, and be embarrassed in making the taxis. This is not always the case. For example, a woman shall have a very large and capacious upper strait; a strait of such dimensions as to offer no impediment to the escape of the head in labor. Of course, such a strait will not prevent the lower segment of the gravid womb from settling down on the very floor of the pelvis — a true prolapsus, which is a most disquieting thing for the woman, who is subject to a con- stant kneading, or tenesmic sensation, produced by the weight and pressure of the gravid uterus on the rectum, and its jamming effect on the bladder, which is thrust by it against the pubis, or the lower extremity of the linea alba.

You may well venture to anticipate for such a woman, the suf- ferings arising from a precipitation of the womb, after the termi- nation of her pregnancy — for the long habitual descent of the vagina thus brought about, establishes in that very vagina, a dis- position to remain in the same curtal state long after the cause is removed by the birth of the child.


140 CAUSES OF PROLAPSUS.

These remarks show you how proper it is to enumerate among the causes of prolapsion, an excessive amplitude of the pelvis.

Many women complain to us of having brought on a falling of the womb by some great and sudden effort that they have made ; such as lifting a heavy child, or raising some great weight, which caused the sensation of something giving way in the interior of the body. Many such explanations have been given tome of the causes of the prolapsus that my patient complained of. Others, again, have accused their monthly nurse of ruining their health by allowing them to sit up too early; as on the fifth day, or the fourth day. But while it is true that a woman getting out of bed for half an hour at that period of the lying-in, certainly does allow the womb to settle downwards from its own weight, it is equally true, that if it remains down, after she has gone to her couch again, it does so on account of a weakness of the vaginal walls, which weakness would allow it to go quite as far down at the first alvine dejection, or effort to pass the urine. When I remember how the womb is secured in the pelvis, I cannot believe that a sudden effort can make it suddenly prolapse, and stay so. For, I am very sure that the alvine dejection of a female who is slightly con- stipated, can never take place but at the expense of a tenesmic force sufficient to push the womb lower down than it does fall in eight out of ten of the real prolapsions. Hence when a patient tells me that she made her womb fall by straining herself sud- denly, or by getting out of bed for half an hour, I do not believe her, for I cannot understand how she could produce such an effect. I always am ready under such circumstances to suspect that she may have brought about a retroversion of the womb, but not a prolapsion. A retroversion may take place in an instant ; a pro- lapsion requires a long course of preparation, before it can be ac- complished.

But how is a man to know that the womb is prolapsed, taking his information solely from the statements of the patient ? He can- not discriminate between the many causes of the very same painful sensation ; that painful sensation being the expression of distress arising from a great variety of states of the parts in the pelvis. The only way to ascertain very clearly what is the fault, is to examine by the touch ; and even that is insufficient in a great many of the cases of complaint. I say insufficient, not to detect a prolapsion, but to disclose the whole nature of the malady.


PESSARIES. ' 141

There is but one course to take when the patient declines to have her serious case inquired into ; and that is to argue the point with her so as to convince her judgment, and obtain her consent; or to decline assuming the responsibility of curing her altogether. It is surely better to have nothing to do with the conduct of a case of disease, in which the absolutely needful information is withheld. A physician who acts without knowing why, is more mischievous often than a disease left to its own native tendencies. Now — to continue in the care of a case you cannot cure, because you do not understand it, is no profit, or honor. The greatest profit being always attendant on him who makes the best and promptest cures ; and the greatest honor too.

Dr. Heberden, in his Commentaries, chap, cii., says, " A pro- lapsus of the vagina or the womb, is only to be relieved by a pes- sary."

The pessary is older than the time of Hippocrates. The Trea- tise on Diseases of Women by the sage of Cos is full of directions for the confection and use of a great many kinds of pessaries; and some of them are still in use in the world. The pessaries of old were scarce looked on in a true light — for the pessa were medi- cated, and were applied for the most part not merely as chirurgi- cal but as medical, or rather as therapeutical agents.

It is true that many of those applications were futile, and even ridiculous. Yet among them are to be found remedies that were possessed of excellent virtues. Those old-time people who knew nothing of the circulation or absorption — who had no clear notions of the nervous system, and a scant histological information, could not possibly enjoy the same power of discrimination as to patho- logical conditions or therapeutical power, as the mere tyro of modern days. Nevertheless, they conducted many cases with pru- dence and success, not because they were possessed of vast eru- dition and skill, but because mankind had already acquired much practical knowledge of treatment; and those doctors knew and used that general or domestic medication. I shall not copy a list of the curious applications in the way of pessaries mentioned by the Father of Medicine ; nor the strange methods recommended by other ancient authors. I shall merely say that one old writer, Avenzoar, advises, that in an obstinate case of prolapsion, the woman should be laid down on the bed upon her back, and firmly held there by several persons sitting upon her, while a frog, li-


142 AVENZOAR. GYNiECIORUM.

zard, mouse, or some other such terrific creature should be thrown on her feet and legs, with which she shall be so frightened, and make such efforts to withdraw her feet out of the danger, that the \vomb will at the same time be drawn up in its place. But I will give you the passage out of the venerable Arabian, so that the good son of Islam may, though he be dead, yet speak in this dis- tant land, whose existence he wot not of, when he was alive.

"If the malady," says Avenzoar, "will yield to light treat- ment, it is well, si non, fac earn supinam jacere, et fac quod ali- quis sedeat super pectus suam, et alius super crura; et.fac earn terrere ponendo circa pedes ejus aliqua reptilia, sicut sunt mures vellacerta^ aut ranae, vel his-similia; ex quibus multum terrefiat, et velit fugere ab ipsis, trahendo pedes et crura ad se; et inde omnia membra, et corpus totum simul contrahantur ; et hac de causa matrix intus redibat ad locum suum ; et cum redierit matrix, fac elevare coxas ejus in altum, et ordina ut jaceat supinam, et prae- cipe ut non se moveat omnino aliqua de causa, etiam, si vellet assellare." — Avenzoar, Fol. 85.

I have, besides old Avenzoar, a vast deal of learning as to female complaints now 'lying before me, in a folio volume whose title, printed in alternate red and black lines, is as follows :

Gyn^ciorum, sive de Mulierum, tum Communibus tum Gra- vidarum, Parientium et Puerperarum Affectibus et Morbis; Libri GnEcorum, Arahum, et Latinorum, Veterum et Recentiura, Quotquot extant, &c. &c. Opera and studio Israelis Spachii, Med. Doc. et Profess. Argentinensis, 1597. Argentina?. [Strashurg,) Folio.

This celebrated work is very difficult to find ; I know of only two copies in this country; one of which is in the Loganian Library, and the other, an edition in three vols, quarto, in the library of Dr. J. Redman Coxe. I was unable to find it in London, Paris, Heidelberg, or Geneva, — and have in vain asked for it from Leip- sic. It was a great merit in Professor Spach to collect and pub- lish, in one volume, so many authors on the diseases of women ; and though the progress of knowledge in these latter days has rendered his labors little useful in the daily ministrations of our modern vocation, we ought all to thank him for his care in trans- mitting in so tangible a shape, the notions, whether sound or crude, of the fathers in our art. Dr. Spach's book contains the works of Felix Plater, of Moschion, emended by Gessner; of Cleopatra, Mos-


GYN^CIORUM. PESSARIES. 143

chion, Priscian, and an anonymous author; of Trotula, or rather of Eros; of Nicholas Roche; Louis Bonacioli, of Ferrara; Jacob Sil- vius ; John Ruff; Jerome Mercuriali ; J. Baptist Montana ; Victor Trincavelli ; Albert Bottoni ; John le Bon ; Ambrose Pare ; James Guillemeau ; Albucasis ; Francis Rousset ; Gordffius' account of a lithopffidion, or stone child ; Caspar Bauhin ; Maurice Cordseus' Commentary on Hippocrates' Treatise on Female Diseases ; Mar- tin Akakia's work on Diseases of Females, and Louis Mercati's four works, called Gynseciorum.

The first work is that of Felix Plater, of Basle; then follows a Greek copy of Moschion, peri gunaikeone Pathone ; after which, we have a '■'■ Harmony of Female Diseases,' Harmoniffi Gynseciorum; the third chapter of which treats of conception. I mention this, not to fatigue you but because I wish you to be aware that pessa- ries are very ancient remedies ; and that when weak people and quacks shall pretend to scorn them, you may not be disquieted on that account, and make yourself ridiculous also by scoffing at a necessary evil ; for you will find some, even among the Doctors, who think that a pessary is an incarnate demon, which ought to be laid in the Red Sea, with all its supporters and partisans. Well, this third chapter has an account of pessaries, described in different paragraphs, and severally designed for every variety of ill — I shall count them for you — and I find here fourteen differ- ent sorts of pessaries ; some to make a woman conceive, and some to make her not conceive, &c.

As to pessaries, you would be very much amused to see the mixture of good sense and nonsense contained in Hippocrates' book, "De Morh. Mulierum,^^ but I am sure you will not, like the Divine old man, tie a lady's feet up to the tester, in order to make her womb go up to its place ; for you know very well, that you can push it up to its place with your primus, and that it will stay up as well for your primus as for his barbarous methodus me- dendi. Old Sieur de la Motte, whose paragraph I quoted at the beginning of this letter, tells you that the womb goes up as soon as you push it with the finger, and comes back again as soon as you take away the support. The father of all the doctors, I mean the Sage of Cos, knew less of the nature of prolapsions than the honest French knight.

You may safely make up your minds that, if you are to have anything to do with the management of these cases, you will be


144 SIMULATIVE PROLAPUS.

obliged to condescend to the use of the pessary. A man might as well treat fractures without the splint, as these affections with- out soma mechanical stay and support. Remember what Heber- den said.

The result is, that pessaries are necessary evils, since I con- clude it is better for a woman to have a pessary, and feel comfort- able, than not to have one, and lie all the year lounging and losing her health, for want of air and exercise ; so that. Dr. Heberden is, though not right, yet almost right in his assertion above quoted.

I say Dr. Heberden is not right, but almost right ; and here are my reasons for saying so. I detest the pessary, as a disagreeable and disgusting thing, whether to order or to wear. I will never employ one except where a conscientious regard to the sanctity of the interests committed to my care seem to render it indispensable. It is not always indispensable to think even of the pessary, because a female has pain in the back and hypogas- trium, and a bearing down sensation and urinary tenesmus. When women complain of such annoyances, w' e are very apt to leap at once to the conchision, that she has some deviation. But, I do find a very considerable number of women complaining of uterine tenesmus, attended with the host of nervous pains and inabilities that follow in the train of uterine deviations and displacements, yet have none. There are a great many unmarried ladies who complain in this way; and who, in consequence of such sen- sations, lose their spirits, and give themselves over to a habit of moping and fretting, out of some prospect they set up before their fancy, of uselessness and worthlessness in the world. What, indeed, can be more discouraging and melancholy for a fine girl than the idea, that she lets into her brain like an idee dominante, as Esquirol calls it, that she is unfit to be married ; that she cannot have children; that she has some horrid malady of those private parts of her person, on whose health and perfection all her charms depend — because, she well knows that a woman with a uterine disease loses her bloom, her gayety and splendor. These are cases simulating the phenomenon of prolapsion — and, indeed, it may be that there is some slight descent of the organ, arising from laxity of fibres and a general debility dependent on a faulty haematosis. Such cases do not at all require that the lady should be subjected to the grief and vexation inseparable from a medical


SIMULATIVE PROLAPSUS. 145

exploration by taxis. And, in fact, the experience of the physi- cian should enable him, with a coup d^oeil, to determine the non- existence of phenomena demanding so painful a concession. Do not compel the young girl then to submit to the abasement of a vaginal examination except on a well-founded opinion of its ne- cessity for her — and for you. When it is necessary, it is not an abasement. She is a fool to refuse it ; and if you be a physician indeed and in truth, with the heart and the missionary sense of a physician, God's messenger, I say she is a fool to decline your proffered aid.

Remember that pelvic pain does not always imply deviation and displacement, — though the patient herself may imagine that it does, and is unhappy about it ; yea, even sick. I assure you I have encountered and do frequently meet with many young girls, and certain young married women also, who are thus afflicted with a thought, oppressed with a notion, and slowly assassinated by an idea. In encountering such a case I have often proceeded as fol- lows : and I beg you to pardon me, and I beg the pardon of all the critics, who perhaps will gibbet me to all the brethren for twenty years, should my name last that long, for daring to put such things in print. Things that they will say are below the dignity of com- position, and a complete innovation on the time-honored solemnity of the powdered wig, square-toed shoes and buckles, and gold- headed cane of the Medical Faculty. I say I beg pardon of the critics ; and hope they will overlook me, as I consider myself in the act of holding a plain conversation with each one of you in particular in my own library here at home, as I told you I should do, when I engaged before all the class to send you these familiar letters.

I was requested on the day of 184-, to visit Miss

Helen Blanque, at No. — Chestnut street, and when I called at 11 o'clock in the morning, I found her reposing in a luxurious ybw- teuil of the richest crewel work, arrayed in a beautiful negligee, with her slippered feet resting on a low ottoman. The apartment was richly furnished with mirrors, and chandeliers, and candela- bras, and carved sofas, with chairs of every form and hue. A fresh bouquet stood upon the little table near her, by half a dozen vol- umes, some of which were opened and lying on their faces, as if taken up and laid down in disgust ; her hair was in curls, but carelessly; and the tout ensemble of the young lady was expres- 10


146 SIMULATIVE PROLAPSUS.

sive of languor and indifference, if not of pain or distress. As she was an old acquaintance, I could speak to her very familiarly, and so I began the following conversation :

" Good morning, my dear Helen, I hope you are not very sick ; and indeed I must think you are not, if I may judge by your fair face and bright eyes. What can you possibly want with a Doctor? Don't you know it is a very dangerous thing to meddle with people who go about the world with their pockets full of lancets, blue pills, and iodine?"

" Oh dear me, doctor, I am very ill indeed ! and I desired to know if you could do anything that might enable me to get rid of the pain and weakness I have endured so long?"

"How long?"

"Why at least two years and a half I have been absolutely broken down with distress. I can't stand up nor kneel at church without misery ; I faint at Bailey & Kitchen's or at Levy's counter ; the opera kills me, — I cannot dance, much less waltz ; and if I am to live this way, I declare my opinion is fixed that life is no boon."

"Tilly vally, child! there is little the matter with you. You are not half as ill as you think for, as I shall soon show you."

" I didn't think that Dr. M. would make game of a lady's sufferings."

" No, indeed ! I shall make no game, no light matter of it ; so don't fret, my dear; but let us have a complete understanding with each other. I, that I may know what duty I have in relation to your .case; and you, that you may learn how far you ought to be obedient to my counsels. To begin, then, what is your age ?"

"I am just turned of two-and-twenty."

"Charming age! Have you ever had violent diseases, as fever, inflammation, scarlatina, rheumatism?"

" Never ; I have been very healthy up to the time of this ill- ness."

"Please! what was your age when you changed ?"

" I was not quite fourteen."

"Was you well before, during and for some time after that


occasion:


?"


"Perfectly."

"Have you been regularly periodical ever since ?"

"Exactly so."


SIMULATIVE PROLAPSUS. 147

"How many days?"

" Five days."

"How many changes from first to last ?"

"Twelve."

"Always a dozen, eh!"

"Yes, — perhaps sometimes ten, sometimes perhaps fourteen?"

"Is it still the case?"

"No, sir; I have for the last year not had more than six to eight. I do believe it's leaving me."

"Pshaw! Have you appetite?"

" Capricious — yes, I can dine pretty well ; and I like my cup of tea ; but I have no real pleasure in anything."

"How is the sleep ?"

"The sleep? why, not good — so, so — often waked — often dis- turbed by dreams."

" You must tell me something as to your digestive powers. — Have you acidity and flatulence ?"

"Yes, very much. I have the bouche pdteuse every morning, a horrid, vile taste in the mouth and throat — "

"And the daily evacuation — is that right, or are you a little constipated?"

" Oh, very much. I am always obliged to take Seidlitz, or rhubarb, or some other medicinal Aorrew/-."

"Well, that's enough now. As to exercise, pray, my dear, have you walked three hundred and sixty-five miles since this day a year ago ?"

"Three hundred and sixty-five miles! why, doctor, what are you thinking of? Three hundred and sixty-five miles, indeed ! What an idea!"

" But consider, if you have not walked three hundred and sixty - five miles in a year, you have not walked as far as from Front to Eleventh street once a day, and that, you know, is but just a mile. How can you expect to be w^ell and keep clear of the doctors un- less you do at least that much walking?"

"Why — bless your soul, doctor! I can't walk round a square without sufl[ering the most dreadful pain in my back and down my limbs ; and if I ever stand before the glass to put up my hair in the morning I feel as if I should drop ; in fact, I am now always obliged to sit down to dress my hair."

"Very good, child, I see how it is with you, and how it's like


148 SIMULATIVE PROLAPSUS.

to be, if you take your own counsel ; and that is, that you'll get to be bed-ridden, and come to what the farmers call lifting. But I shall provide against that ; for be assured I shall compel you to walk six miles every day of your life, rain or shine."

"You might as well talk of six hundred as six, sir; and, in fine, I see you have no idea of my state at all ; nay, the very reverse."

" Perhaps so, my darling; and if so, I ought to learn more par- ticularly what your real condition is. Will you suffer me to knock on your chest a little bit ? 1 wish to percuss it a little, merely to learn what kind of sounds it may yield when struck upon."

"Yes, sir, as you please."

And so I percuss her thorax all over with the most healthful resonance everywhere.

"Now put your fingers to your mouth and draw in your breath between them so as to make a hissing sound as the air rushes into the lungs. Do it slowly, and as long as you can. I wish to judge as to how many cubic inches of air you can inhale at each forced aspiration. Do it thus — so — ^just as -I show you how. Yes, that's well. Why, you imbibed at least fifty cubic inches, with one aspiration, and that is most admirable. Your lungs are as sound and as light as the last new sponge from Cephalonia or Corfu. Now, sit still and don't speak — I am to count your breath- ings. There, — you breathe fifteen times a minute, and that is just right; just nine hundred respirations to the hour, and very suffi- cient full ones they are. I must count your pulse — let's see — seventy-two beats to the minute! — regular in the intervals as the town-clock pendulum! But your face is rather pale, I see ; nay, you are by this better light, quite pale. Have you been so long?"

"Oh yes, sir, these two years; these two mortal years."

"No wonder! — nobody can have color, except out of the rouge saucer, who does not walk at least two thousand miles per annum in the open sun-light. What is your ordinary weight ?"

"Oh, doctor, I used to be exactly witches' weight, one hundred and seven, you know; but now I'm all gone, and am only ninety- six and three-quarters! Ain't it dreadful?"

"That is a pity! Let me feel your arm. Come, there's some- thing left of you yet, for your arm is not an absolute parallele- piped, though it's not as round as I could wish ; and I perceive that your muscles and tissues are soft, not solid like wood."


SIMULATIVE PROLAPSUS. 149

"Yes, indeed, I am in a most dreadful state!"

"Well, never mind your dreadful state — never mind that — wait a little till I cure you, and you shall, with the blessing, have two cheeks like the sunny side of an apple ; and those pale lips shall pout like twin cherries. But I have one more inquiry to make, and that is, as to your real ability to move about. Don't you find when you go up stairs that your heart throbs very much ?"

"Throbs! Doctor! why, it jumps up to the top of my throat! and I am so out of breath that I am obliged to stop on the stairs once or twice before I can get up to the top ; and my poor knees feel as if they would bend under me in spite of my will. In fact, doctor, my free-will over myself is nullified and abolished ; so you see if you cure me at all, you are to clear me of those two pests of the time, nullification and abolition."

"Very good, very good, dear, I take. That's very well. But let us try an experiment : I wish to count your pulse again. There ; — it beats while you are sitting on the sofa, just seventy-two times a minute, as before, which is right. Now, go out at the door, and walk to the top of the stair ; not in a hurry, but in a good pace, as if you were going up for your hat or shawl ; and as soon as you come to the second story, turn and come back to take your seat again, that I may feel your pulse after the exercise. I want to know how many additional pulsations you will require to carry you to the top of the stair — that's the object of my experiment."

Upon her return I found the pulse 140 per minute, (I have often counted it at 160 for such a trip,) and said to her, "See here now what an extraordinary thing. Your pulse, before you went out, was seventy-two — it was one hundred and forty upon your return; that is to say, to carry you up sixteen feet, the height of the ceiling, your heart was required to beat sixty-eight extra times, or one hundred and forty times per minute. Do you understand that, or is it all Greek and Hebrew to you?"

"Indeed, indeed, I hav'n't the least notion of it except that it tires me to death to go up, and makes my heart palpitate like the fluttering of a pigeon. It's very strange."

"No, indeed," I rejoined, "there's nothing strange in it; and I can make you understand it very clearly in a few minutes, if you are willing— and I should like very much to inform you ; because, if you could but understand what you really require in the way of a cure, I suppose it would be far easier to cure you."


150 SIMULATIVE PROLAPSUS.

" Oh, pray do, doctor, tell me all about it, for I'm dying to learn. I like reason and common sense above all things. I detest faith and obedience, except to the Gospel ; and I am a full believer in common sense and conviction. If you address my common sense, you will command my most implicit faith and obedience. Wo- men, who seem to be a sort of human Parias — who have lost caste, — are always flattered and soothed by being treated as if they were really reasoning beings ; for when so treated they seem to have regained their caste. Tell me, then, as clearly as you can, without any of your Latin and Greek technicalities, what it is that ails me, for I assure you I am most miserable, most unhappy."

"Well, open your ears — or rather, as Antony said to the mob, 'lend me your ears,' not that I may pour any 'leprous distilment' of Latin or Greek into their porches, but that I may fill them with some of the most enchanting truths of Biology, or Life-doctrine, which is the same thing. Do you know what Moses the prophet said about you, my dear? and he was a prophet."

"What did Moses say about meV

" Why, in speaking of you, he said ' the blood thereof is the life thereof which was equivalent to saying that where there is no blood, there is no life, or this other equivalent : where the blood is bad, there is a bad life, a life not strong — not healthful, hardly worth having as a gift! Miss Helen thinks so."

" Oh, my! Doctor! do you mean to say my blood is impure? what a horrid idea ! — how very dreadful — shocking!"

" Far from it, my dear; it's bad, because it's too pure — it's too delicate, too lady-like, too thin, too weak — too dilute. — It has not enough of consistency, which the doctors call.Crasis, to effect fully all the purposes for which it was given to you, except when you are sitting or lounging merely. But for any emergency, it is not strong enough ; for example, it is strong enough at seventy-two beats of your heart to let you sit on that fauteuil very comfortably ; but it must have 140 beats to walk you up one pair of stairs — and I am sure if it would be hurried by 200 pulsations, it is not strong enough to lift you to the top of the shot- tower down yonder by the Navy Yard!"

" Ah, doctor, you are using parables with me ; and I can't read them."

"To be sure you can't; I didn't expect you could; but you will by and by. See here ; — here is a very large vein on the


SIMULATIVE PROLAPSUS. 151

back of my hand — I suppose you know what a vein is, don't you?"

" Oh yes — that's a vein, and so is that."

" True ; but what's a vein for?"

"I'm sure I don't know; but I believe they are where people are bled, arn't they?"

"Yes — but if people are bled from their veins, it is because there is blood inside of them. But attend to what I say. You see here — here is a vein — and you are to understand that a vein is a blood-tube. This one on my hand, is about the size of a swan quill, is it not?"

"Yes, sir."

"But this tube, this swan quill has another tube inside of it — a quill inside of the barrel of the swan quill, and the two grow fast to each other, making a double tube ; do you understand that?"

"Perfectly. That's very clear."

"Very well; now you see I have many veins on the back of my hand ; for I am getting old, and they become more visible in the aged, than in such young things as you: look at your own hand — I see a small blue trace where the delicate vein tints through the translucent skin. How pretty it looks! But you see I have not one vein only, but a thousand — nay, perhaps many thousands — which are connected with certain still smaller tubes, that are called by us capillaries, because capillum is Latin for a hair, and because these capillaries are as small and fine as hairs. They are all blood-tubes. Do you see ?"

" Oh yes, very plainly."

"Well; these capillaries are millions and billions in number; but they are the fine extremities of arteries and beginnings of veins. Arteries are the tubes thati^eat ; we feel an artery to dis- cover its pulses, its pulsations. When a doctor puts his finger on your wrist, he does it in order that he may feel your arterial pulse. That pulse is caused by the action of the heart, which fills and empties itself by turns of blood, discharging it into the arteries. As it forces the blood out, it forces it with a pulsatory motion. If the pulse is big, hard, violent, — it is because the heart sends out much — violently — into a tube that strongly resists it ; and there- fore the tube feels hard, big, strong. So now you are to know that the arteries, the capillaries, and the veins, are all alike in

10*


152 SIMULATIVE PROLAPSUS.

consisting of double tubes, the end of one being the beginning of another ; or one interior tube contained in an outer tube or sheath."

" I understand you perfectly; — pray go on. Oh, how I should like to be a doctor."

" No you wouldn't ! For it is the most abominable vocation ever gentleman was engaged in, or woman either. But let us proceed.

" Now, how much blood do you suppose is in that little 96 pounds of a body of yours?"

" How should I know ?"

" Sure enough, how should you ? but it is variously estimated at 500 or 600 ounces — but, 500 ounces is 31 pounds; leaving you 65 other pounds of flesh, bones, and so forth. But all this blood is contained in those arteries, capillaries, or veins, we w^ere just now talking of. And the blood is not in contact with any part of your whole volume, save that inner tube, that inner quill within the swan quill ; but, that inner tube is the ' common membrane of the blood-vessels,' and it would be much more sensible of us, if we would never call it by any other name than the blood-membrane, or the blood-making membrane : and if I were not too well-bred to speak Greek in your ears — a sort of 'leprous distilment,' I might call it the Haematosic membrane, a Greek work that signifies blood- preparing, or blood-manufacturing membrane ; or perhaps I might call it the Endangium, which means the inner vessel, or inner tube, for that is the name that is preferred for it by the great German physiologist, the illustrious Burdach ; and a very pretty convenient name it is, which expresses the idea of an inner vessel.

"If all the blood in your body touches this membrane, this tissue, and nothing else, — then you have wit enough to perceive that, whatever be the cause gf the production of the blood, that cause must exist in this haematosic membrane ; I say exist in it, either originally resident therein, or at the least transmitted there- through. This membrane is the ultimate, or the penultimate tissue in the hematosis.

"Suppose that membrane to be all right — all well — perfectly healthy and active in the performance of its duty in making 'the blood thereof,' don't you see that 'the life thereof will be good and strong, and durable and pleasant. But, suppose, on the other hand, that the hsematosic membrane is pale, flaccid, sick — weakly


SIMULATIVE PROLAPSUS. 153

— good for nothing, can't you see that 'the blood thereof will be like 'the life thereof — good for little, or good for nothing!"

"Oh yes — certainly, how very curious, — and how vastly amusing!"

"Amusing! it's more than amusing, it's useful.

" But come, let's get on with our lecture. See here, now, here's a little shagreen box, with this brass tube in it, that I shall take out. This is one of Dr. Donne's microscopes, — it is composed of certain magnifying glasses so adjusted the one be- hind the other, that any object seen through it, is greatly mag- nified ; and, indeed, you can discover in it objects so small as to be far too minute to be seen by the naked eye. It's a very pretty instrument, and a very useful one, too, especially to us; who often have occasion to see things, that other people cannot see, — and we do see them, too, though the vulgar accuse us now and then, of pretending to see through a grindstone; lend me a needle."

"A needle, oh ! I haven't one."

"Not a needle! — what should a lady do without a needle? I thought a lady and a needle as inseparable as Chang and Eng. It's a bad sign, when a lady has no needle ! well, then, a pin — surely you have a pin! now, look! I prick my finger with the pin, and there is a minute tropfchen of blood, and now, I have put the little drop on this plate of glass; and there, it is adjusted under the object glass of the microscope — now, look through it ; what do you see ?"

"Good gracious! what a curious sight! — why I see a million of berries, or peas, or shots, or little balls; no, they are not balls; they look like little bits of biscuits ; or rather they are like new thick quarter dollars on the banker's counter."

" You are perfectly right, dear ; they do look like little thick quarter dollars, or small discuses. Those objects that you are gazing at, are magnified by the glasses, just 300 diameters, — and they consist of the particles of the blood, or corpuscles of the blood — they used to be called globules of the blood ; at the present day they are called blood-discs. Don't you see — they are floating in a kind of watery fluid? Well, that is the serum of the blood. — Was you ever bled?"

" Dear me, yes ! what American was never bled !"

"Sure enough! Well, w-hen you was bled, the blood divided itself into two parts, one red solid cake part, and the other a pale


154 SIMULATIVE PROLAPSUS.

yellowish fluid or watery part : you see those parts separate in the microscope. The discs are the red blood, and the other the serum or watery part. If you w^as bled for a pleurisy, you probably observed on the top of the red cake clot, a thickish or buff-looking colored matter, or crust — that was another portion called fibrin. The last portion to be named, you never saw — it is the albuminous portion, or albumen (which is very nearly pure in white of eggs), dissolved in that watery part of the blood in which you see the discs floating, so that though it is there, you don't see it — neither could you see a lump of sugar, when it is dissolved in your glass of eau sucree. Now come, we have analyzed the blood, and di- vided it into four parts, or kinds of things, 1, discs, 2, albumen, 3, fibrin, 4, water. When all these parts are justly mixed and proportioned, the blood is healthy, when otherwise, it is unhealthy ; yours is unhealthy."

" How is mine out of order, doctor.'"'

"It has too much water."

" How do you guess at that?"

" I don't guess at it ; I see it and Jeel it."

"You see it!"

"Yes, truly — I see it in your pale lip and cheek; I see it in your hurried breathing when you walk up stairs ; I feel it in your pulse at one hundred and forty for rising sixteen feet upwards, whereas while you sit still it is only seventy-two."

"Ah, doctor, you are in Greece, again."

" No, my dear, not at all. It's all plain Yankee-talk."

"It's Greek to me — nay, I fear it's gibberish."

" Stop a bit; let me tell you that those great men, Mr. Andral, Mr. Gavarret, Mr. Franz Simon and many others, have analyzed the blood over and over again, in all sorts of diseases, as well as in the healthy state ; and they pretty nearly agree in this conclu- sion — that in one thousand grains of healthy blood of man, there are of


Water


790 grains


Discs


127 "


Albumen


80 "


Fibrin


3 "


1000 grains. This is either the truth, or so near it, that it is safely to be


SIMULATIVE PROLAPSUS. 155

received as truth. But, if Moses is true, also, where he says, 'the blood thereof is the life thereof,' then when in your blood the figures for the analysis stand thus.

Water 840 grains,

Discs 71 "

Albumen 80 "

Fibrin 9 "


1000 grains — it must be clear that, in as far as the blood thereof is the life thereof, the life is weakened, for the blood is weakened, and that's the fact as to you, my darling Helen.

" Such things are scarce fit for ears polite — but for the sake of the illustration, permit me to say, that there was a famous English pugilist, or prize-fighter, named Thomas Crib. He was as bold as a lion, or perhaps as General Taylor. For the sake of an agreeable pass-time, his friends and he, too, laid large bets that he could, on a day fixed, beat an immense negro, called Molyneaux, in a pugilistic encounter; and so Tom was handed over to the celebrated Col. Barclay, of Uri, in Scot- land, for training for the fight. When he came under the colo- nel's guidance he was a great fatty sort of a fellow, who could not run a hundred yards without getting out of breath. He had drunk, I suppose, much beer and brandy, and lived rather a heedless sort of life, so that his blood was out of order and his flesh not so hard and solid as the Prince of Denmark's — w'hich, if you remember, would not melt, though his highness was so anxious for it. Tom Crib's would "melt, resolve, and thaw" into a dew^ ;" and if it would, he was not fit to encounter the gigantic black man. Well, Col. Barclay gave him some doses of medicine, made him perspire, regulated his diet by weight and measure, made him w^alk, pitch the bar, run, and so forth, according to a prescribed rule of training, and the end was, that in about ninety- days Tom could run a mile up a Highland hill and stand upon the top without drawing a long breath. In short, he was so thoroughly trained, that is to say, brought into such a condition of health and strength, that, with the greatest unconcern, he en- countered and easily overthrew^ his black-amoor adversary. Pierce Egan's account of it is very curious,

" The moral of this history is a very good moral indeed — it is that


156 SIMULATIVE PROLAPSUS.

you do not want a Doctor, and that you do want a Trainer ; and if you had one, it would not be long before you could go up stairs beginning at seventy-two and ending at seventy-three or seventy- five pulses instead of one hundred and forty."

"Well, doctor, can't you put me in a way of this training?"

"Yes, I can ; but I can't do it like Col. Barclay, I only wish that instead of having a Smithsonian Institution to buy old musty volumes with, we had a real Barclay College to save the health and lives of half the nice young ladies in the land. Talking of musty old books, what old book is this on the pier table?"

"Oh, I believe it is some horrid Latin thing that papa picked up at auction last night; and, would you believe it, he thinks he has got quite a treasure in it."

" So indeed he has. Why, its a Fifteener! a copy of Seneca, printed at Venice by Bernadine de Coris of Cremona, in 1492. Bless me, a real beautiful Fifteener ! Why, that prince of bi- bliomanes, the Rev. Dr. Thomas Frognall Dibdin himself, or even the Most Noble, the Earl of Althorpe, would feel lucky to get such a precious bibliographical morceau ; and what admira- ble preservation. Look, child! this ink is as black, and as delight- fully clean put on, as if Lea and Blanchard themselves had printed it with the Exploring Expedition press.

" See here, Miss Helen, here is Seneca's fifteenth letter of the second book to Lucilius, and I find it has a passage about you. But you will read it yourself, won't you?"

"What! I read such an old pagan as that, and in those horrid types, and that incomprehensible lingo, which, thank Heaven, I do not understand, nor don't wish to — nor Dutch neither."

" Well, then, Seneca, for I must tell you of it, is speaking in this letter to Lucilius about the necessity of health as a means of happiness and activity of the mind, as well as of accuracy in its operations. Seneca thinks, that to be wise is to be well ; for if, says he, we be not wise, the mind is sick, no matter what may be the amount of the bodily strength; for such strength is like that of a raving madman, governed by no fixed principle. Hence he says our chiefest design ought to be to keep the mind in health ; and the next object should be to keep the body in health, &c. Next Seneca goes on to say, that it is very foolish and ridiculous to act, as many persons of his time were used to do, — namely, pass their whole time in exercises calculated to strengthen the


SIMULATIVE PROLAPSUS. 157

arms, and neck and sides ; because, the very best school of gym- nastics will never be able to make a man either as strong or as heavy as an ox,"

"Why, doctor, what has all that to do with me?" "It has this to do with you, child! it serves to show, that in Seneca's time, people did devote some portion of the day to the conservation of the health. And the good old man finds fault with them for carrying their care over it too far. I am very sure myself, that the Romans and the Greeks before them, were much wiser than the English, the French, the Germans, or the Anglo-Ameri- cans, in respect to their care over their persons. They did devote much time, many of them, as Seneca says, too much, to the study and practice of those exercises, baths, dresses, modes of diet, &c., that kept them like Tom Crib, in constant training. And, in fact, the consequence was, that the Greek Phalanx was irresistible and irreversible ; and a Roman Legion thought no more of a cloud of Persian cavalry, or Uacian spear-men, than Rough and Ready did of the Peons of Mexico. The gymnastic usages and habits of the Romans, enabled them by strength and activity to conquer the world ; indeed, they were a set of complete Tom Cribs. To be sure, they got much glory and a great deal of money and lands to locate in as we say; but there's the other fact along side of it, that there's not a valley nor a hill, nor a river or marsh, from the Tanais to Gibraltar, from London to the falls of the Nile, that has not drunk their blood, and seen their skulls grinning at the cold moon, and their bones mouldering under the night dew. It makes me melancholy to think about those fme young farmer fellows, like Tityrus and Melibceus, dying for empty honor so far from home, leaving their Galateas and Lalages to weep in hopeless, hapless maidenhood, or wait for some other lover — for I am dis- posed to ask with old Jack in the play, can honor set a leg? No; or heal the grief of a wound? No." "How you do talk, doctor!"

"Well, my dear, I hope it's not disagreeable to you?" "Oh no, far from it. Yet I confess myself blind as to any con- cern I have with Tityrus or Melibceus, or Lalage and Galatea; what pretty names, though!"

"You have this concern, namely; that you live in the nine- teenth century, and they, before the year one — and yet you don't know half so well how to take care of your bodily health, as those


158 SIMULATIVE PROLAPSUS.

old-time people did ; for the world in some respects of useful knowledge has lost ground, not gained it. It makes rail-roads to break people's arms and legs with, and steam-boats to blow them up ; but society is not half so elegant and grand as it was in their great day. Now you who are listening to my voice, cannot run fifty yards upon a level without panting for breath, and beating your little heart like a pigeon's flutter; but Galatea could run or even fly ; does not Virgil say of her, fugit ad salices ? Nay, you can't go up stairs without making your pulse simulate that of a person in a scarlet fever. And it's your own fault, for you have not walked 365 miles in the entire year 1846. Why, bless your soul! a bee thinks nothing of going to farmer Robinson's buckwheat field, six miles off, and back again, half a dozen times a day for a little honey and wax. And Sukey, the cow, would starve to death in the richest grass lot were she to lie down or even stand still all day. Sukey must walk about to pick up the material for her cud. You lounge on the sofa, and your maid brings it to you on a silver sal- ver! Everything must move. I verily believe, that the mute cab- bages would die, if it were not for the exercise that the wind gives them; and surely, dear Helen, if there be a real pleasure in this world, it must be that of a corn-field, when the zephyrs dance down the wheat ears, and they courtesy and wave them along, bowing their heads upon their slender and graceful stems as they pass. Don't you think the bread is sweeter and whiter for every motion that the winds have communicated to the dancing grain? There's the poor potato ! see how sick it has got ! and all from being shut up, like Miss Helen, in one small hole for so many years. Are not our houses our holes, to which we retire like, the foxes in the Old Testament? You say you cannot walk, you cannot enjoy the church services to edification, because it hurts your back and sides, and limbs, and you are ready to drop. I was going to say, but shall not, hang your back ! forget your back, and your back will forget you. At all events, this I can most solemnly assure you of. 1st. That you are not ill; that you have a thin watery blood. 2d. That your membrana vasorum commune, which is your blood-membrane, your haematosic tissue, is feeble. 3d. That your pains are what we call nerve pain, neuralgia, not pains from inflammation ; and that they carry in them no element of death and ruin, &c. 4th. That when your blood shall stand at the figures 3, 80, 137, 790, your weakness will be gone; your nerve streams


SIMULATIVE PROLAPSUS. 159

will flow from the brain and spine-cord steadily, or at the com- mand of your Free will ; and that the apple shall bloom on your cheek, and the cherry pout on your lip, and the waltz and the cachuca not fatigue you, and all the ghastly clouds of blue imps that love to hover over and about you, will be dissipated by the radiance of a face beaming with health and hope, and happiness, as Tom Moore says, 'just as the sun licks up each sneaking star.' Don't you know what happens to the celery, my dear?"

"Why, what?"

" This happens to it ; it grows up a great green rank stock, hard enough to make a whip handle; very disagreeably tough and fibrous to the taste ; nobody likes it. It is too strong, too healthy, for it has been waved in the wind for its exercise, and shone on by the sun, which gave it color and strength. Now the gardener comes, and seeing the great brute of a celery stalk — he says, 'so Mr. Clodhopper, thou coarse fellow thou! — dost think thou art fit to be admitted to an aristocratic gourmand's salad-dish? Shade of Brillat! — no, sir — I shall soon make a veal of you. I shall weaken you, sir, and take that horrid green cheek out of you, sir,

and make you so delicate, sir, that even Miss Helen can

digest, and approve you, sir' — and so Mr. Gardener makes a deep trench, and piles the earth up about him almost to the top of his stalk, and effectually quiets all motion in him ; in fact, he splints him, as we say: and what's more, the sun's life-giving beams no longer reach his buried stem. He grows weak, pale, watery, tender, — and when he is blanched like you, he digs him up for your salad; and the whiter and w'eaker and tenderer he is, so much more does he ask for him, and so much more do you value him. A stock of blanched celery may be compared to Miss Helen. It has not walked its mile a day, and it has been shut up in its room devoid of the fresh breath of Heaven, and cut off from the life-giving beam of the glorious god of day. You are etiolated, dear patient; look in the pier-glass, and see your cheek! You are etiolated, and that is the reason you have pain. Your pain is from weakness, and nothing else."

" Can't you give me some medicine to cure my pain though, doctor?"

"Oh yes, certainly; nothing so easy; take laudanum."

" I hate laudanum."


160 SIMULATIVE PROLAPSUS.

  • 'I'm glad of it. So do I. But laudanum will put a stop to

the pain."

" Yes; but I fear it won't cure me."

"Certainly not. On the contrary, it will be sure to make you worse; so will almost all other kinds of physic. But if you will have physic to cure the pain, take that pernicious laudanum, and then you will be like a spendthrift who has not come to his estate, but wants money; so he pays the usurer two and a half per cent. a month, and when his grandmother dies, and leaves him all her property, it must be paid over to the shaver; for it comes exactly to the principal and interest of his borrowings. This is just a fair specification of what you will come to, if you will take opium to cure your painful sensations. But come, dear, I shall now be serious, and give you a prescription. Let's see; yes! Take —

" Take courage, and be well. Then believe what an experienced man says, who can have no interest to deceive you; believe that he knows what he says, when he tells you that a trained health is the health you should seek for.

" Don't regard the pain ; take the more courage, the greater the pain ; for you will have pain. Be well assured that you can, within three or six weeks be in the regular habit of walking six miles a day, which will exceed two thousand miles per annum ; and that when you shall have reached your six miles a day, you will be well again, for what health and strength shall a lady require beyond that which enables her to walk two thousand miles a year, in the beautiful sunlight, over this goodly earth that God has given her for her flower garden!"

"Yes, doctor, that's very fine — very fine, indeed ; and vastly poetical ; but to walk, I repeat, kills me, and I am afraid that my disease will be rendered incurable."

" Tilly-vally, tilly-vally, Miss Helen, you know nothing about it. I tell you that your hamatosic tissue is not in health, nor will you be in health, until it shall be re-established by the sun which is indispensable for life, by the oxygen of the air, without which everything dies ; by a frequent and strong induction of nerve-power into all your organs, your muscles, your lungs — your heart — your haematosic tissues — everywhere. These are the remedies for such maladies as yours. You must diet aright — you must dress aright, you must bathe aright, and move, and lastly you musttalce some pills not bigger than the head of a diaper-pin ; to be made of Monsieur


SIMULATIVE PROLAPSUS. 161

Quenesville's metallic iron. I shall give you this prescription, not as a drug or as a medicine, but as an element of your body ; with- out a certain abundance of which, neither you, nor any mammi- ferous creature, nor bird, nor creeping thing can live. I verily believe, that even a monas crepusculum would die but for his iron. You ought to have found the dose in your bread and butter, your rice, your salad, and your chicken, daily, these two and a half years past. It was there, but you did not get it. I shall give it to you, and shall present it daily to your organs, and you shall see what the effect will be. Here, give me a scrap of paper. I shall begin the prescription in German, and end it in English; and so you see my caption is

'^Mitlmelfe Gottes.

" Take of Quenesville's metallic iron, one hundred grains.

" Powdered gum Arab, and sugar, a sufficient quantity.

" Make a pilular mass to be divided into fifty pills, and direct, for Miss Helen Blanque. To take one pill for a dose immediately after each breakfast, dinner, and supper. C. D. M.

"Now you must take this iron regularly, and exactly, and for a long time. Eat plenty of bread and meat, and take one or two glasses of good Bordeaux wine at your dinner ; but it should be di- luted with water. Rise early, and go to bed early. Think, what is true, that you have made yourself sick by a silly indulgence upon some slight maladive sensation, which will disappear, when you shall again learn to act like a reasonable creature as to the care of your health ; and I will answer for it, that you will soon be found to make no more complaints.

"You have often heard of the general faith and belief in qui- nine as a cure of ague and fever, haven't you?"

" Oh, yes. I know that is what everybody takes, and wdiat all the world believe in."

" Very well; I believe in it, too, implicitly; but I have quite, as strong a belief in the power of this medicine to cure your hse- matosic membrane, to enrich your blood by bringing it up to its proper crasis, so that its figures shall stand respectively, at 790, 137, 80, 3. And that is all you want; for when you have that, and are totally destitute of any organic lesion whatsoever, your rich and valid blood shall disengage by its oxygen, a full nerve-power in the brain — which, exciting life motions in due intensity every- 11


162 SIMULATIVE PROLAPSUS.

where within your economy, you shall in vain try to find the point so big as a pin, that is not in consummate order and health and perfection ; and when that shall come to be the case, when the red tint of the butter pear shall glow on your . cheek again, and the cherry turn pale in comparison with your lips, you shall seem as charming as you really are, and I will say, after good old Am- brose Pare, 'I dressed, and God healed her.'

" And, now I rnust bid you good morning ; for it is time to visit some persons who are really sick, which, thank Heaven, you are not."

" Stop, stop, doctor, a word before you go. I assure you that for more than two years I have been most unhappy, most wretch- ed, in the contemplation of a present and prospective ill-health. Nothing has pleased me — nothing given me the hope of true en- joyment. I have been even sensible that I was daily losing a naturally good and placable temper ; and becoming what a lady should never become, unamiable, acdriatre, tracasseuse! I be- lieve that I have been in some sense like Lady Macbeth — not in the wickedness, I hope, but in the phantasy: there is a pretty Shakspeare on the table; do open it at Act V. Scene iv., and read it for me."

Macbeth. — How does your patient, doctor?

Doctor. Not so sick, my lord,

As she is troubled with thick-coming fancies, That keep her from her rest.

M. Cure her of that:

Canst thou not minister to a mind diseased ; Pluck from the memory a rooted sorrow ; Raze out the written troubles of the brain ; And, with some sweet oblivious antidote. Cleanse the stuff "d bosom of that perilous stuff, Which weighs upon the heart ?

D. Therein the patient

Must minister to himself

M. — Throw physic to the dogs, I'll none of it : — Come, put mine armor on. —

" There, Miss Helen — there is your quotation. I hope you will follow the last line, ' Come, put your armor on.' "

" Depend upon it, doctor. I shall try to follow your advice. I cannot say that the conversation I have had with you, has enabled me to understand as clearly as I think you do, what ails me, and what I require for the re-establishment of my lost health and


SIMULATIVE PROLAPSUS. 163

spirits. Perhaps, indeed, a long preliminary study is requisite to the understanding of those points, that you characterize by such very hard words, as en — en — end-angium, was it not ? and Hema- tosis ? yes, Hematosis, and other such gibberish. But, admitting that I have not learned anatomy and physiology from your dis- course, I at least have obtained some glimpses of the nature of my indisposition, and feel that from this hour forth, I shall be better, for I have found courage and confidence. I am convinced that the game is in my own hands. I know it will be a hard game to play, but I also know that ' lejeu vaut Men la chandelle,^ and be assured I am about to play it well. In fact you have cured me already by opening my eyes, and cleansing my bosom of that perilous stuff, I thank you heartily for this visit. My father, who is rich, will know how to send you a good fee for it, for he loves me, — you know I am his only child. I thank you the more heartily, because you have not even once made me poke out my tongue ; and because, though a doctor, you have neither cut me with a lancet, blistered me like a Miss Marsyas, nor poisoned me with that detestable calomel, and oh!-ugh! castor oil! So now good-bye, doctor ; come and see me again. I feel that I shall be soon well and happy."

Such was my conversation with Miss Helen Blanque. In twenty days, I met her as beautiful as a Houri; with a gait like Hygiea, and a cheek that might put Euphrosyne or Hebe to shame. C. D. M.


LETTER XIII.

Gentlemen : — In my twelfth letter, I spoke at large, and per- haps in rather a random manner, on the subject of prolapsions of the womb, and was led away by the train of ray thoughts, to con- template the state of a young woman complaining of aches and pains and inabilities, that are the usual accompaniments and simulations of the uterine displacements. I said that many pain- ful, inconvenient and annoying sensations are produced in the


164 DIAGNOSTICS OF PROLAPSUS, ETC.

female pelvis, from very different causes, which are, in their ope- ration on the sensitive system, the same, whatever may be the difference of their true causes. I also said that, for the diagnosis of many cases of such complaints, it is not indispensable to pro- ceed to the taxis as the sole means of coming at a sufficiently clear understanding of the disorder; and that, while I would rigorously insist upon the right of using all necessary and proper means to clear up the obscurities and difficulties that embarrass the decision and action of the practitioner, I should be held con- scientiously to abstain from any unnecessary inquiries or modes of inquiry. I think that a diagnosis by exclusion will in many diseases lead to the discovery of the truth — that is to say, a phy- sician ought to be able to judge the rate of all the accessible functions of the body, and by comparing their actual state with a standard of health that he knows how to erect in his mind, he ought to be able to say this and this and this are right ; and so through the great catalogue — excluding all the healthy ones — but this and that are wrong — and they are wrong — in this or that especial w^ay. Where he cannot decide in what especial way the deviation of the function takes place — then let him carry his explorations to the farthest proper extent. In my conversation with Miss Helen Blanque, and in the observations that I made, in regard to her gestures, her mode of sitting down, and of standing up; of walking; of the tone of her voice; her respi- ration, her complexion, her style of dressing, her physiognomical expression, her sentiments and trains of thought, &c. &c., I was quite convinced, that although she w^as affected with pains, aches, and inabilities, like those of the patient from prolapsus, I could very clearly trace them to faulty innervations, arising from defi- cient crasis of the blood ; and I concluded that, by exposing her to exercise; to the bath; by a better diet and drinks; by sending her into the air — the sunlight ; by insisting upon her effecting those modifications in development, that can be brought about by a course of training, I should cure her of her complaints, with- out resorting to the shocking ultima ratio — the exploratory taxis, or the still more detestable resort of the pessarium. I also or- dered for her a preparation of iron, which is probably the most efficacious of all the ferruginous articles, and has the additional good property of being quite destitute both of taste and odor. I cannot say that my hypothetical conversation with Miss Helen


BAD TRAINING. 165

was able to make her acquainted with my views of her hygienic and therapeutical w- ants ; but I flatter myself, it may have suc- ceeded in recalling to your memory some of the many arguments and rationales I had the honor to present to you last winter, and that they disclosed to you, if not to Miss H. herself, the precise views that actuate me in my professional ministry over many such cases. How many times have I spoken to you in that way!

Whether these views be just or not; whether I have been able fully to disclose my thoughts or not, this is very certain, namely, that I have many, many times, held conversations like that, with young people whom I found depressed, and indeed almost broken- hearted, under a painful idea that they were ruined in body, by a disease which, after tormenting them for a number of years, was destined to bring them to an untimely grave. It is a great matter, in the management of such a case, to clear the mind of the per- nicious impression, for everybody knows, (look again at my quo- tation from Seneca,) that the mens sana in corpore sano, is an indispensable condition of happiness and health. I intend not to deny that a good man may be calm under physical suffering, the most extreme. Nay! I have seen a fine fellow, dying on the rack of a traumatic tetanus, and rejoicing in his spasm and smiling forth from amidst the most horrible cramps, even of his face ; and glorying in an approaching death that was to enlarge his soul for its instant flight to Heaven. I have seen this, and more than this, for I have seen greater courage and peace amidst protracted and hope- less pain; hopeless at least, as to earthly hope; but it is true, nevertheless, that a thought can kill, and a conviction utterly de- stroy.

The morale of the patient has as much to do with his cure as the calomel, the senna, or the cinchona.

If a girl, in coming up to the age of puberty, is badly managed ; if her digestive organs are suffered to become permanently de- ranged, under a vicious course of feeding; her nervous system to be badly or imperfectly developed, by means of vicious habits of education, in exercise, in sleeping and waking, in unnatural atti- tudes, in the consumption of the nervous force in studies at school and at home ; it is reasonably to be expected that the whole future life will take a color of feebleness and impressionability from the character of the constitution acquired at the close, and true com- pletion of the puberic age.


166 BAD TRAINING, ETC.

Such a person could hardly be expected to execute the great and trying periodical functions included in the meaning of the word menstruation, without experiencing certain maladive sensa- tions, like those of Miss Helen, which, though simulative of, are wholly independent of prolapsus or other uterine deviation. Nor should a physician indulge the expectation of curing such a case, save by means of a treatment, adapted to the wants, not of the reproductive tissues alone, but of the entire constitution of the female, which has that vice in it that no alterative can cure, but which can be cast out wholly, by a change in the manner of one's life.

One may safely venture, in general, to rely upon the evidence of one's senses, and we have only to look about us, to discover the differences as to physical power, durability and perfection be- tween a languishing, impressionable city miss, lapped in luxury and indulgence, from the cradle upwards, and a buxom, rosy milkmaid, who drains the udder for a dozen cows at three A. M., drives her own horse and cart five or six miles to market, and returns to breakfast at home, after having distributed to the lazy citizens, the precious contents of her milk-pails.

But the languid, perceptive, exquisite citadine is, of a truth, the same creature as the country girl ; and you know very well, that to exchange positions, would in the course of a year, or more, be to exchange characters — the languor of the one for the active vigor of the other — to plant roses on the pale cheek of the elegante, while the lily would spring where the jocund health of the milk- maid was too boisterous for its white blossoms before. Is not this plain fact? and is it not common sense too? Yet, is it not also true, that we doctors frequently forget to look to nature in our queries? peeringonly into our books; following a theory instead of following only truth ; and imitating the painter, who, instead of forming his landscapes in the open fields, is condemned to imagine the waning distance, the winding river, the babbling brook, the umbrageous woods, and clear transparent air ; and the form, port and hues of men and animals, by the yellow light of a lamp in the dark narrow limits of a studio, instead of filling his artistical imagination with perfectionings, if that were possible, of the beau- ties and truth of nature as seen under the true lights and shadows of the open day. Truly, Dr. Forbes is right, when he invocates a Young Physic. We want a young Physic, a vigorous, active,


quenesville's iron. 167

healthful youth, born, indeed, of the ancient Gamaliels, but nursed and brought up in the lap of nature herself; the heir and suc- cessor, in this modern age, of the old time-worn Physic of our Torefathers.

T told Miss Helen that if any confidence might justly be had in the power of sulphate of quinine to cure an ague, I had equal trust in the power of chalybeates to cure the diseases of the blood, describable under the name of Anaemia; and I accordingly gave her portions of Quenesville's metallic iron.

Allow me to say a few words to you on this subject.

Quenesville is a Paris pharmacien. He places in a porcelain tube, a quantity of protoxyde of iron. The tube passes through a furnace heated to redness. He disengages hydrogen and con- ducts it into one end of the tube, the other being left open. The hydrogen unites with the oxygen of the iron and flies off as water ; leaving the metal revived, and existing in shining microscopic particles of pure iron, impalpably fine. This pure powder of the metal unites with any of the acids of the gastric solutions, and is the most efficient of the chalybeates that I have met with. I believe that two grains are enough, if taken on a full stomach, that is to say, immediately after each meal. When made into pills with gum, it is both tasteless and inodorous.

I conceive that w^e have not, and that we cannot ever reason- ably expect to have any very clear notions as to the methodus operandi, as it is called, of any medicine. Who can explain the cathartic power of jalap, as contradistinguished from the emetic force attendant upon the chemical constitution of the calicoca ipecacuanha, or the tart, of antimony and potash? We are well acquainted with the facts, the phenomena ; and we can count upon our power to make them manifest under our prescriptions ; yet to say why tartar emetic shall produce vomiting, w"hile sul- phate of magnesia shall have the effect of a purgative, is beyond the power of the human mind. There is something metaphysical, and not purely physical in the case, and we cannot seize upon the metaphysical element, because we cannot go up to the fountain head to know truly what Life is ; which can only be fully known to the All-wise mind. The differences in the two operations are differences of perceptivity in the organs ; but perceptivity is a metaphysical, arid not a purely physical force.

No man can know, then, more of the power of medicines than


168 medicines; their power.

the facts of their force made manifest in their operations. I do not pretend to know why it is that iron dissipates, like a coup de theatre, the whole train of evils concomitant on the state which I call Anaemia. But this I do know, or at least I think I know if, that when a person labouring under anasmia is submitted to my control, and who has no organic lesion that I can detect, of the great organisms of circulation, oxygenation, and gastro-intestinal digestion, I look forward with an undoubting confidence to the cure, which I expect to see begun within a few days, and com- pleted within some twenty-one days or thereabouts.

I do not consider myself as credulous in believing that iron has a special power to invigorate the tissues composing the haematosic membrane, the membrana vasorum commune ; certainly not more so than ten thousand American physicians, who confidently administer five or twenty grains of calomel with the utmost cer- tainty of exciting the liver into greater or more healthy activity ; squills to excite the mucous follicles of the bronchi ; nitre to arouse the kidney ; or belladonna to stimulate the skin ; and strychnia to wake up again the torpid muscle of a paralytic leg or arm. In methodus operandi of medicines, and drugs, all our cognitions are purely empirical — the results of the experience and observations made by mankind in a series of centuries, an innu- merabilis annorum series, et fuga temporum.

Do you ask a further explanation of the confident tone with which I speak of health to be restored by restoring the crasis of the blood ?

Why what else is health if that be not it which depends on perfect solids and perfect fluids ? What is the blood ? What its use, destination or design, in the body ? It is the chaire coulante (the fluid flesh) of Bordeu. When the chaire coulante comes to be fixed, it is the chaire solide — but the blood is more than that, it has a higher function still ; it is the direct agent in extricating the life-flash ; the nerve force ; the excito-motive power ; the life itself.

Dr. L. Cerise, in his prize paper, in the Mem. of the Royal Acad, of Med., on " The Excitation of the JVervous System,^^ says at page 294, vol. 9th, " Every instance of nervous-excitation is therefore a result of the concurrence of a sanguine with a nerv- ous element. Hence every sample of excitation may be repre- sented by a product formed by the contact of these two elements."


DR. CERISE. NEUROSITY. 169

Dr. Cerise proposes to denominate this product, this result, by the word neurosity. I cite Dr. Cerise's words, as I wish you to understand that I disagree with him in his opinion that the re- sult is the product of contacts of blood and nerve matter. For I adhere to the opinion I have so often expressed to you that the product is the result of the contact of oxygen (of the blood) and nerve-matter. Black blood, blood without oxygen, cannot pro- duce the result. There is no neurosity developed in true, com- plete asphyxia or cyanosis, though the brain is gorged full of blood.

The brain and nerve are the creature ; the animal ; the percep- tive being. It demands two conditions of existence, to wit : the substance of brain — the neurine — and the oxygen, whose contact and immiscence with it extricate the power. Give to the brain the oxygen, and the force is present ; diminish the oxygen, and the force is lessened ; take away the oxygen wholly, and force is gone — it is death.

But a watery and ana^mical blood cannot carry sufficient endow- ment of oxygen. None but a blood whose crasis is true, — ^just, — normal, — can carry to the neurine the true, just, normal amount of oxygen ; or extricate from the neurine by its action on it, the true, just, normal sum of innervative or excito-motive power. Such are my views. Such is my physiological explanation. Such are the motives that lead me in my walks to desire to cure the solids first, and then to find the fluids cured.

I am not a Solidist, nor a Humoralist, but I am Eclectic in pre- ferring the best and most rational theorems of both the schools. I shall make no further remarks in this letter, which, perhaps, you will consider as sufficiently visionary, on the theory of ansemical disorders, remarks into which I have been perhaps prematurely led by remembering the considerable number of persons who have recovered from symptoms and accusations of prolapsus, without recourse to the usual remedies of prolapsus. I shall in a future letter enter into fuller statements of the views I have long held on these topics, and which I have so often discussed in your hearing at the Lecture room. I beg you to understand that my hypothetical conversation detailed in the last letter, is not very different from many long conversations I have had with patients, situated as the imaginary patient Miss Helen Blanque was.

Farewell. C. D. M.


170 PROLAPSUS UTERI .


LETTER XIV.

Gentlemen : — I am still to treat of prolapsions ; I mean not the simulative descents of the womb, but those clearly decided cases of malady, proceeding from weakness and relaxation of the support- ing tissues, and involving the patient in distress and inconveni- ences arising from the traction and distortion of important nerves, and bundles, and filaments of nerves, and from pressure upon points unaccustomed to it, and unsuitable for it.

In these cases the remedy is mechanical ; it consists in adjust- ing beneath the descended womb an instrument which lifts it up to its proper height or level within the pelvis, and maintains it at that natural situation until the tone, the strength of the tissues can be restored by time and by remedies.

The comfort desirable from this method of support, is scarcely describable. A woman who for months had been unable to walk, or even to stand, without an ineffable sense of weakness and pain, moves freely and spontaneously after the adjustment ; and in short, is as greatly relieved as is the man who has his humerus reposited after a dislocation. To show you how great that relief is, let me tell you that I was called to a very pious citizen, who dislocated his humerus into the axilla, and who, when I arrived, was holding the right arm in an elevated position, by means of the left hand, with which he supported it; as the least descent of the elbow gave him exquisite pain; I took hold of the limb, made the extension in the proper direction, and then depressing the elbow, reposited the head of the bone in the glenoid cavity. As the orbicular head took its place, he ejacu- lated with the utmost unction, "Bless the Lord, oh my soul ! and all that is within me, bless and magnify his holy name!" He had occasion to ejaculate his thankfulness, for he passed from agony into perfect calm. It is true I have never heard a female make such an ejaculation upon a repositio uteri, — but I doubt not the relief has many times been almost as great in the one case as in the other.

Pessaries are as various as the ingenuity of the doctors, and


JOSEPH WARNER. — PESSARIES. 171

sometimes, of the patient herself. Most of those used here, are of blown glass, and consist of globes from an inch and a half to two and a half inches in diameter, or else of concavo-convex discs, about the same size.

The best of our pessaries, however, have been for many years constructed by Mr. Joseph Warner, gold and silver-smith, No. 16 Merchant Street, Philadelphia.

Mr. Warner is an admirable workman, and produces articles of this sort of the most perfect construction. The material is hammered silver ; grit, either by fire gilding, or by the galvanic process.

Silver is preferred in the manufacture, on account of its hard- ness, which enables it to be reduced to the thickness of letter paper, while retaining its firmness, which could not be expected of so thin a plate of gold. While it is lighter, it is also less costly than gold. A globe of two inches in diameter, thus formed, weighs not more than two scruples, and when polished and covered with a sufficient coating of gold, possesses properties pre- ferable in practice, to one of pure gold, inasmuch the lighter an instrument of this kind, the less objectionable is it. The same material is employed in the fabrication of the discus, the ring, the elytroid, and the horse-shoe pessary, as well as the olive of the stem pessary, from out of the whole great number and variety of which you can select, according to your opinion of the indication. Mr. Warner could readily supply your wants in his line, through the various express companies established here for parcels-deli- very. Should you have occasion, therefore, to use any of his instru- ments, your letters, with description of the kind of instrument required, would probably meet his prompt attention. It would be only necessary to order a globe pessary of one and three-quarter inch diameter, or two inches, or two and one-eighth, &c., or a flat pessary, or a ring, &c. There are few towns in the United States, that are not reached, almost with the rapidity of the mail, by the Express lines of Adams & Co., Harnden & Co., &c. &c.

The object to be gained in employing a pessary is the eleva- tion of the uterus to its proper level in the pelvis, and the maintain- ing of it in situ naturali. Many of my friends prefer the discus or the horse-shoe, the ring, &c. The late Dr. Dewees, invariably I believe, made use of the discus, commonly in this city called Dewees' pessary; and his deserved reputation as a practitioner.


172 DR. physick's pessary.

gives to the instrument of his choice a great vogue, so that multi- tudes of them are made and sold.

The equally distinguished Professor, the late Dr. Physick, who seemed to me, in his lifetime, almost never to be in error in any surgical or medical indication, as invariably preferred the globe, very generally known as Dr. Physick's globe pessary. In a con- versation I had with him, some years before his lamented death, (such men ever die too soon,) he told me, that while he was dress- er at Guy's Hospital, under John Hunter, he had charge of a female under prolapsus, who was treated by a discus pessary, having the usual perforation ; that a portion of the os uteri had slowly engaged itself, and become strangulated in the aperture ; so that he had difficulty in extricating it, an accident which I also have witnessed more than once. As he would not venture to expose the woman to a second strangfulation from the same ill-constructed pessary, and as an old billiard ball that had been some time in the ward was at hand, he adjusted it beneath the uterus. The new application succeeded so admirably in sustaining the organ, that the Doctor ordered globes to be constructed, and we are, I believe, truly indebted to him for the beautiful and valuable resources thus placed in our reach. Such is my understanding of the history of the globe pessary of Dr. Physick.

As to my own preferences in the matter of pessaries, I have only to say, that whatever may keep the womb at its due height without irritating it, or incommoding the other organs and textures implicated in the descent, is a good pessary ; but I deem the globe the most perfect and most suitable for the ordinary simple cases. An instrument of two inches, pressed upwards to the uterine ex- tremity of the vagina, lifts the womb high enough; higher in fact than the position occupied by it in eight out of ten of those w^omen who have had a child, and that is high enough. It is kept up -by the double and consentaneous actions of the sphincter vaginae muscle, and the levator ani. It has no angles, no sides; it can- not be displaced, save by being ejected. Its pressure is uniform over its whole superficies, save where its lower segment looks down the tube of the vagina. This cannot be so truly said of any other instrument, if we except, perhaps, the gum-elastic bottle, used and recommended by Dr. Hervez de Chegoin, in his paper in the Mem. de VAcad. Roy. de Med. The globe has a perfect polish, and an unoxydizable surface. It may be worn a year or


PROLAPSUS. PESSARY. 173

more without displacement, if required ; and it has no aperture to admit of the collection of putrescible materials within it. It does not prevent the escape of the mucus of the uterus and vagina, nor of the menstrua ; and in short, is the least uncomfortable and •most perfect of instruments. It is a true suspensory, as needful for the descended womb as the suspensor scroti for a hernia humoralis or orchitis. It is as neat and perfect in its kind, as Petit's tourniquet in its kind, and as indispensable for the cure. Dr. Physick used to tell us in his Lectures, that a man might as well attempt to improve the Bible as Petit's tourniquet, and I, after him, repeat, that you might as well attempt to improve Petit's tourniquet, as Physick's globe pessary. But you know I always have warned you to be Nullius addictus in verba jurare magistri, and so I say, judge of it for yourselves.

Can a man expect to cure a prolapsus by the use of the pessary? Yes, provided there be no loss of substance. A woman who in labor, has lost the perineum by the effect of laceration or slough- ing, may be held to have lost also, all useful function of her leva- tor ani, and there is no hope, therefore, of a permanent cure of the tendency in her to prolapsus; since, in fact, the perineum, the normal antagonist of the diaphragm and abdominal muscles, is taken away from her, giving to the antagonism alone, supreme and unresisted powder. Such a woman can expect to provide only an artificial antagonism, which you can always furnish her with, by means of the stem pessary, to be hereafter described.

Those females, however, who labor under prolapsion from the mere descent of the vagina, arising from its relaxation or loss of tonicity, can be cured by the pessary. I take it for granted, that every living tissue has an inherent tendency to contra^, and when that tendency is not carried out into execution, it is because something resists, antagonizes, prevents it from obeying its law. To support, then, a vagina at its normal elevation within the pelvis, is to take away the resisting antagonizing preventing cause, and to allow it, with time, to recover its normal density and solidity,

I mean not to say that this is always the sole thing needful to the cure ; but I do suppose that it is in many instances the only chirurgical or medical process demanded, since the freedom from pain or inconvenience that follows the timely application of a proper pessary sets the woman free from the bonds of her symp- toms, and enables her to take advantage of the restorative power


174 • PROLAPSUS. CURE.

of diet, air, exercise, bathing, traveling, and other hygienic methods, the wise and prudent employment of which may be expected to repair the mischief of debility and relaxation not as to the vagina alone, but as to every part and parcel of her living system.

Where the woman's general health, however, is broken, and her great alimentary, respiratory and circulatory functions overthrown, we should gather by careful inquiry and observation the indica- tions of treatment, and pursue them to a subduction of the special evil or evils. A woman may have bad health from deranged action of the chylopoietic organs, requiring the exhibition of blue pill, taraxacum, alkalies, nitro-muriatic acid, eccoprotics, or even purgatives. She may have neuralgic or neuropathic affections springing from a vice in the hsematosic tissues, from exaggerated vital sensibility of the heart, &c. In all these varieties of com- plaints, whose name is legion, let the especial sin be found out and eradicated.

The bitter tonics, bark, wine ; the chalybeates ; a trained health ; the exact indication of the diet as to quality and quan- tity ; the amount of wine, malt liquor, &c. : these are the pro- blems you are to solve, and upon their correct solution depends the question whether you are to have the great satisfaction of seeing your patient restored to health ; or whether she, by a dawdling, indeterminate course of counsel and prescription, is to be left to drag out the weary years of broken health, lapsing from one evil to another, until, under the first serious attack of disease, she falls the victim of what is truly denominated a broken consti- tution. Who broke that constitution ? The disease, by its vio- lence, QT the Doctor, by his want of foresight, zeal, and intelli- gence ?

The pessary, then, is to be regarded as the suspensory, as the splint, as the bandage — and, in truth, as happens in many other cases in surgery, these are the only indications. But, as in sur- gery, you would not, perhaps, treat an orchitis solely by the sus- pensory, but would make certain prescriptions, with a view to abate constitutional or local derangements of the circulation, the absorption, or the innervations of a part, so in the management of the prolapsions, you might not rest content with the curative power of the pessary alone, but provide the other juvantia of which I have already made mention.


PROLAPSUS. PESSARIES. 175

How long shall a woman wear the pessary? An important question, that cannot be solved but upon experiment. Several months will in general be required in any case, because the fastidious delicacy of a female will always prevent her from dis- closing to you her distress in its early stages, and you know that chronical disorders are more difficult of cure than recent or acute ones. Hence I repeat that the cases that may come under your care, are very likely to prove tedious and protracted. They will be mostly chronical.

It will be a part of your duty to keep up a strict surveillance of the patient under treatment. It will be a duty to receive her report from time to time as to the operation of the instrument. You may become convinced that a larger or a smaller one is indi- cated ; and always, where you can believe that a reduction of the diameter of the instrument is admissible, that ought to be done, on account of the less inconvenience to be suffered by the tissues under a less degree of distention and pressure. I esteem it a very great fault on the part of the medical man, to adjust a pessary for a female, and to send her away without very plenary instructions as to the conduct of the subsequent steps of the cure. Women sometimes have wholly forgotten them, and allowed them to remain for a series of years, until the instruments, having become spoiled by age, or the action of the acids of the parts, have rusted, opened, and admitted into their cavities the most shocking collec- tion of putrid humors. Ihave removed several such for persons, who had neglected themselves for years, and thus become exposed to the danger of putrid infection from materials kept in a state of decomposition in the interior of their bodies. Pray turn to the 145th page of Colombat, and read the foot note, for the case of the Baroness de Carl . . . , who was supposed to be laboring under a cancer of the womb. This lady was suffering from a pessary that had been introduced thirty years before. It was thickly covered with calcareous incrustations that could not but irritate all the parts touched by them. I am acquainted with a lady who suffered under uterine and vaginal hemorrhage, with a frightful, stinking leucorrhcea. The surgeon who had adjusted the instrument ten years before, as well as the lady herself, had forgotten it. The treatment was all in vain, until, upon making his taxis, he discovered the cause of the malady. Its removal was the indication. The indication being fulfilled, the disorder dis-


176 PROLAPSUS. PESSARIES.

appeared, after having reduced the fine woman very near to the grave.

There is another reason why you should overlook the operation of your pessaries; and that is, that their pressure, in some in- stances, is followed by absorption and ulceration of the parts com- pressed. There are plenty of samples in the records, of pessaries that, by neglect, have forced their way into the rectum, compelling, by long pressure, the absorbents to remove the recto- vaginal sep- tum ; so that, a part of the instrument resting in the vagina, an- other part of it forced its way into the bowel, establishing thus a recto-vaginal fistula. The same catastrophe may happen as to pressure in another direction. The bladder may be opened, and even bladder, vagina, and rectum may be and have been made to communicate with each other, by the ignorant or careless em- ployment of these excellent instruments. I am very sure that such distressing occurrences will never follow your ministration in this line, since I indulge the hope that you will never fail to do your whole duty, which is, after adjusting the apparatus, to make the woman clearly understand what she has a right to ex- pect, and what she ought to do, in reference to the remedy.

You would not be apt to suppose that a woman, who had long suffered the pains, &c., of prolapsus, and who should be completely relieved of them by wearing a pessary for three, six, or twelve months, could dispense, at once, with the suspensory instrument, without finding reproduced some of the annoying sensations which its presence had rendered impossible. Therefore, whenever you conclude to remove the support, she ought to be informed that she will experience some return of the strange feelings, and thus be led to fear she is not cured. The fear of this, is the motive for advising you to substitute a smaller for a larger instrument^ and so on at each consecutive change, until the patient is quite able to do without them altogether. Or, if you be prompted by any motive to desist from the further employment of the support, you cer- tainly ought not to do so, until, by a proper aperient dose, you have cleansed the alimentary passages of their contents ; and then, taking away the pessary, command that the patient should keep her bed for a few days, in order to obviate the pressure and descent of the pelvic contents likely to take place upon the sudden withdrawal of all antagonism — the patient being not only on her feet, but en- gaged, perhaps, in occupations of a Mborious or fatiguing kind.


SUFFITA. — SACHETS. 177

I verily believe, my young friends, that you have now not the intelligence only, but the means, apparatus, and authority required to enable you to effect a certain and durable cure. If you do not effect that cure, the fault will lay at the door, not of the malady, but at your door for carelessness, or at the woman's, for obstinacy and folly.

The ancients were in the habit of employing for these maladies many medicated pessaries, which though really pessaries, were also deemed to be suffita or fumigations. It is probable, that among the host of old methods, were some very effective ones, now become wholly obsolete in the elegant practice of the metro- politan physicians. I think I have in my lecture room, advised you not to omit in your armamenturium, the sachet or little bag, recommended by Levret, and, indeed, by Hippocrates and his descendents down to this very writing.

When your patient shall have discarded her pessarium, let her construct half a dozen small cylindrical bags as big as the thumb. They should be made of good linen, and should be packed full, very full of finely grained, not pulverized Aleppo galls, to which may be added a few grains of sulphate of quinia and alum. The bag may have a short bit of tape or a Ihtle loop of tape secured to its lower end. If soaked, for an hour or more, in some common rough claret or weak port, then pressed and dried in a napkin, and dipped in sweet oil, it can readily be introduced into the vagina as a medicated elylroid pessary. It does not inconve- niently distend the vaginal walls, which it tends to strengthen, enhancing their tonicity by the medicinal articles contained, while it elongates, or produces the vagina, and" thus supports the womb in situ.

A sachet adjusted in the morning will not escape, if the patient wears her napkin ; and it might very safely be allowed to retain its place for four or six consecutive hours, more or less, daily, for an inde.erminate period.

These medicated sachets are of very great value in the treat- ment, not only of the relaxation and fall of the vagina, but also, as agents for suppressing the too abundant excretions of the follicles and glandules of the mucous membrane. I am surprised that they are not more commonly resorted to in the United States. In addition to the materials I spoke of, they can be compounded, with proper proportions of cubebs, opium, kino, krameria, oak 12


178 SPONGE. CORK. CAOUTCHOUC.

bark, &c. &c. If you will take my advice, you will not reject them from among the resources of your art.

Half a dozen of them, prepared by the patient herself, who is supposed to be never disjunct from the needle and scissors, would last as many days.

I am hardly willing to burthen these letters with descriptions of the other sorts of pessaries. Yet I ought, perhaps, to protest against the sponge, most particularly against the sponge. It is a tampon. I have, in my long lifetime, had too many occasions to use the tampon, not to have learned what a foul and fetid thing it is after having passed only twelve hours, bathed in animal fluids at a temperature of 95° or 96°. I protest against its employment as a pessary, not only on account of its irremissible fault of un- cleanness, but for the additional objection of its irritating nature; the points of the sponge could not fail to vex and fret the mucous tissue of the vagina.

Pessaries are also made of pieces of cork cut into oval or cir- cular discs, and dipped repeatedly in melted wax, until a sufficient coating of the wax being imposed, they are adjusted beneath the uterus to retain it at its due height in the pelvis. Similar instru- ments are also prepared by coating a tissue with varnish consist- ing of boiled linseed oil, after the manner of the French bougie or catheter. They are also objectionable as liable to change, and to infiltration. The wax coming off from the cork, leaves its scab- rous surface in contact with the living tissue of the womb or vagina, to their great damage or ruin, while the accumulation of putresci- ble fluids about them might well serve to provoke the attack of dangerous fever.

You will find a capital, cheap, and commodious pessary in one of the little caoutchouc bottles that you can buy for ten or twelve cents at any of the apothecaries. This is the pessary recom- mended by Dr. Hervez de Chegoin, in a paper on retroversion, read at the Royal Academy of Medicine, and which I have already spoken of.

Procure such a gum-elastic bottle, about two inches in diameter, and without cutting off the neck, pack it full of finely-carded wool. Take care merely to distend it well, not too much, for it is desira- ble to have it very soft and elastic. After filling it so as to give it permanently the requisite form and size, be very careful to tie up the neck of the bottle so securely as to remove all danger of


CAOUTCHOUC. WHALEBONE RING. 179

the wool being penetrated by the excretions of the vagina. If you allow those fluids to get inside of the bottle, they will suffer a horrible putrefaction. Leaving the neck sufficiently long, the pessary will maintain its position, because the cylindrical neck being directed towards the os magnum, will keep the instrument steadily in situ. You can cut a solid piece of caoutchouc into the shape of a phial-cork, and stopping the neck of the bottle with it, secure it there with gum-elastic cement, which seals it her- metically. I prefer the stuffed one to the inflated one of Doctor Hervez.

It may be worn long without changing. It is soft, light, elastic ; and, therefore, suitable for some cases in which the metallic resist- ance of the globe or ring, or elytra, would be painful. For the poor it is cheap — and perhaps it is, on the whole, nearly as good an instrument as a silver-gilt one. These bottles have a neck from half an inch to three-quarters of an inch in length. If you should prefer one of them, after you have filled the bottle with carded wool, which you can press into it so as to give it any shape you may prefer, should you have no gum-elastic cement at hand, you might put a short velvet cork in the neck of the bottle, and draw- ing the gum-elastic over the cork, tie it so as completely to ex- clude the air and to prevent the entrance of any of the fluids of the vagina within the bottle. The neck of the bottle being directed towards the vulva, there is no risk of the instrument changing its position.

I had some time charge of the health of an old lady here. She was 85 years of age, and had long endured the inconvenience of a procidentia. The perineum and the levators were without tonicity, and no globe nor disc could she wear, as they instantly escaped on account of the relaxation of all the parts. She was for years of her decline made comfortable, as to her prolapsus, by means of a ring pessary.

She took a long slender whalebone, bent it into a ring of near three inches in diameter ; then wrapped it, or as the sailors say, served it with bobbin, so as to give it proper size and firmness. She then dipped it in melted wax again and again, until it was completely and sufficiently coated with the wax. This ring she adjusted within the vagina, and maintained by its aid the womb in the pelvis.

Another woman employed a common umbrella ring for her


180 DIAGNOSIS.

prolapsion, and wore it for years a Vinsgu de son mari. It might happily have been denominated the Gyges pessary.

Pessaries are never to be introduced except after a careful in- quiry with a view to ascertain the state and wants of the tissues affected. A gentleman informed me, in the street, that he had a very singular case of prolapsus uteri — that the vaginal cervix was enormously swollen, and that he had in vain tried repeatedly to discover the os uteri. He feared that some very extraordinary state of things must be present to alter so completely the form of the parts.

" What are you doing for your patient ?" said I to him. " Why, I have tried the pessary, but without any success. She cannot retain it at all; it comes away, and, moreover, gives her great pain."

How are her strength and health?"

"Oh, very weak; she has the most violent menorrhagia, and has become, in consequence of it, much reduced and perfectly blanched."

"Go," said I, "to your patient again, and make a careful ex- amination. You shall find that your enormous cervix uteri is not a cervix, but a polypus that fills up the vagina — that bleeds, and that has no os uteri."

He took my counsel, repeated his diagnostic exploration, and came to say that it was truly a polypus. Upon the extirpation of the tumor by means of Gooch's double canula, the hemorrhages ceased, and the lady recovered good health without any prolap- sion.

I relate this case for your warning ; because the gentleman who made the mistake, is a person of the most elaborate medical education, both theoretical and clinical. You, who are young and inexperienced, will be vastly more likely to make such bevues than he. And indeed ! it is curious to think how many strange, ridiculous misapprehensions one meets with among the brethren in regard to women's maladies. It seems to me that the delicacy of the relations existing between the sexes must have the effect of blinding some persons to the plainest and the most diaphanous truths and facts.

There is a kind of pessary, called the pessary en bilboquet by the French, but which is properly, in English, denominated the stem-pessary. Such an instrument is indispensable for the com-


DR. blundell's pessary. 181

fort of those who, having lost all sphinctorian, elevative, and peri- neal force, can not retain within the walls of the pelvis, either the reproductive organs, or the fine instruments introduced to serve the purpose of an obturator or diaphragm.

Dr. James Blundell, of London, furnished such an instrument to a patient of mine, who had long suffered with prolapsus and retroversion.

It consisted of a gilt pear-shaped pessary, about one and a half, by three-fourths of an inch in diameter, screwed on a small gilt cylinder, the size of a writing quill, and three and a half inches long. This was the pessary. Now the frame on which the pes- sary was supported, was a hard silver wire, twelve or thirteen inches in length, bent so as to bring its extremities together, which were secured with hard solder. The wire ring thus made was reduced to the form of an open parallelogram, the angles being left rounded, and a cross piece of silver being adjusted across the middle of the wires, constituted a bed into which the free extremity of the pessary stem was screwed. The flat bar was three-fourths of an inch long, by one-fourth in width. The wire frame was bent so as to make it fit the curve of the inferior part of the trunk of the body ; more or less, according to the em- bonpoint of the patient. A girdle of suspender-web was fastened round the hips just below the cristge of the ileum, and straps of leather attached to each extremity of the wire frame, were fastened by the hook and eye to the girdle.

Such an apparatus can be worn with little inconvenience, after a day or two of habituation ; and the vagina can be extended, car- rying the uterus before it to any desirable length. Patients who have employed it, have been relieved of uterine deviations that would not yield to the globe, the discus, or any other treatment. The greatest objection to this instrument is its costliness, for Mr. John Rorer, of North Sixth street, who has prepared several at my request, informs me they cannot be sold at a price under fif- teen dollars each.

There is another pessary in use here, fashioned somewhat like a horse-shoe, either furnished with the corks, that is, by bending the heel of the shoe, or without the corks ; I have never used this instrument, nor shall I employ it, since I cannot deem it safe to allow the points of the horse-shoe to be the points of resistance to the whole tenesmic or bearing down power. Such a point of


182 PROLAPSUS IN THE UNMARRIED.

pressure is too small. Indentation is followed by absorption ; upon the same principle as that which causes what is called the bed- sore ; and ulceration of the compressed points gives insufferable pain.

Having now said all that it is obvious for me in this letter to say on the subject of simple prolapsus, and the use of pessaries, and their kinds, I shall proceed now to recapitulate my views on the disorder —

1. Prolapsus uteri is a disease of the vagina, not of the womb.

2. To cure prolapsus uteri, you are to seek to cure the vagina, and when you have done that, the womb will be found cured also.

3. The pessary is a suspensory, which in the cure of prolap- sus, is as necessary as a suspensory is for an orchitis.

4. I prefer, as a general proposition, the globe, to all other forms, and Dr. Physick's globe pessary to any other.

5. If you apply the pessary in cases not suitable, you will do mischief. There ought to be no inflammation nor ulceration either of the vagina or the womb.

But I defer to my next, some further remarks on the use of the pessary. C. D. M.


LETTER XV.

PROLAPSUS UTERI.

There are certain other circumstances connected with prolap- sus uteri, that I ought to notice, as supplementary to the observa- tions contained in my last letter.

The question arises as to the treatment of prolapsus in the unmarried female, and I may observe, that I have been many times asked by my friends of the profession here, whether I had met with prolapsus in young unmarried women, and if so, how I had proceeded in the treatment of them.


PROLAPSUS IN THE UNMARRIED. 183

Now you will have observed, that in the former letter, I have averred that prolapsus uteri is an affection of the vagina, and not of the womb itself, and that to cure prolapsus uteri, you should direct the resources of your skill to the curing of the canal, and curing that, you would find the womb, ipso facto, cured also.

I do not entertain any doubt as to the correctness of this opin- ion, and often I have, in an otherwise healthy, strong, and well developed female, still a virgin, found the os uteri so depressed, as to touch the posterior surface of the membrana hymen.

The effect of long-continued tenesmus, connected in its origin with a costive condition of the rectum, and the accompanying urinary tenesmus, might well be deemed enough to shorten by degrees the vaginal tube, and thus allow the womb to settle down to the very hymen itself, as in the cases referred to. Long-con- tinued irritation from hemorrhoidal disease and from catarrhus vesicae — from an habitual pruritus vaginae — a sedentary life — might reasonably be expected to produce the same state of things as to the vagina.

In the conduct of such a case, I should not deem a medical man warranted upon a mere suspicion, that the distress com- plained of, had its origin in a uterine descent, to institute a vagi- nal taxis. On the contrary, he ought to endeavor, by therapeuti- cal measures, to obviate the distress. Fortunately these measures are sufficiently numerous and prolific, if well chosen. They are 1, a free venesection ; 2, the operation of a few doses of some safe, but active purgative medicine, such as the compound powder of jalap and cream of tartar, repeated on alternate days for four or five doses; 3, an enema of forty-five drops of laudanum in a fluid- ounce of starch water nightly, upon going to bed ; 4, rest in a re- cumbent position for a week or ten days; 5, the warm bath repeated nightly, before sleeping, and used during two or three weeks ; 6, great care taken to avoid accumulation of considerable portions of urine in the bladder, which can be accomplished nearly at will by the patient, under proper instruction.

There is good reason to expect that such a course of advice and consequent action, will be followed by relief from the distress- ing symptoms of the malady ; and that when thus in a measure, relieved, the young woman will be able, under a judicious treat- ment as to sleep, exercise, and food, to recover her health. It is very clear to me, that I have seen several, nay, many of them,


184 CASE OF PROLAPSUS,

get well under such a course. But, to recover thus, is far better than to recover after having been subjected to the mortification of the touch. I assure you, that I have allowed a young lady to lapse from bad to worse until her situation had become dangerous and to the last degree alarming to her friends, rather than expose her to such vexation. I shall report to you a case of this sort when I come to speak of menorrhagia.

In one person, aged about thirty-five, who had been long ren- dered miserable and inefficient in the performance of her duties, consisting in earning her own support and that of her mother, I found the os tincae jammed against a strong hymen. As the Sieur de la Motte informs you in the extract at page 128, I could readily push the os uteri away from the membrane on pressing my index finger through the opening ; but as soon as I withdrew it again it came back to its old place where it had long rested, in consequence, I suppose, of her sedentary habits, and the torpor of the rectum attendant on such habits. It was necessary to cure her of a disabling pain. I therefore pushed the uterus out of the way as far as I could ; that is to say, I made the vagina as long as I could make it by pressing the point of my finger on the OS uteri, and thrusting it slowly as far as I could reach ; but this operation could not cure the patient, for, as the knight of Valognes saith, "il revient aussitot qu'on a ote son doigt."

I had no other recourse, therefore, than to the employment of a suspensory apparatus. The suspensory that I chose, was Dr. Physick's globe pessary. I do not remember the size of it, but I presume it might have been one of an inch and seven-eighths in diameter. This globe, being slowly and gently pressed into the os magnum, after being dipped in a cup of olive-oil, ascended in the vagina to a sufficient height to produce that organ, and restore its long diameter. You should observe that such an instrument does not rest at the lower end of the canal ; for in fact, it is pressed up- wards, by the contraction of the muscular fibres that serve as sphincter, and which in some women are so strong as to possess a truly spasmodic force. I repeat the words, spasmodic force; and I say so because I have met with more than one example of that spasm existing as a tonic spasm and giving rise to great pain like the pain of cramp; and even preventing the accomplishment of the union of the sexes until overcome by treatment : and this in several persons of 40 and of 45 years of age, who had borne


IMMOBILITY OF THE WOMB. 185

children. I regard such cases as being forms of rheumatism. In one case here, the sphincter fibres were divided as in some of the tenotomy operations — the woman afterwards bearing children. This operation was done by your Professor of Anatomy, Dr. Pan- coast, who related the circumstance to me within a few days.

I have only to remark as to my patient, that she was relieved of her distress. I have lost sight of her now, and am unable to represent to you the actual state of her health.

In other samples of young and unmarried ladies, I have been compelled to adopt the use of the pessary ; but I have had less re- luctance in so doing where I have found the hymen wanting. Not that I mean to cast any reflections upon those in whom I have not observed signs of virginity ; for I am speaking of persons against whose honor and purity no breath, nor the slightest whisper of imputation could possibly be breathed. There are many, many young virgins, in whom the membrane never existed ; and I have a right to say so equal to the right of any other medical man of my age. As I have permitted myself to go so far in a discursive way, allow me to add, that I hope you will not be so stupid, when being engaged in practice, as to accuse of impurity and unchaste- ness, any female, otherwise worthy of your respect, because you may happen not to meet with this membrane. I can assure you that I know several persons, long married, in whom it has never been broken ; and among them, some whom I have delivered of several children, and in whom the mark of virginity is still in its place. Hence, the hymen is not proof of virginity, nor is its absence a sign of defloration.

There is a sort of prolapsus that has this peculiarity: viz., that when you attempt to push the womb up to its place, you cannot make it recede, for it seems to be immovably fixed ; and this is the case described as immobility of the uterus. But please observe that this immovable womb is not, indeed, immovable.

There came to me a few years since, from the State of Rhode Island, a gentleman, bringing his wife for my counsel as to her case. They had been married for some time, I think over two years, and had had no children. The lady suffered with constant pelvic pain ; also great pain in the back and hypogaster. She was reduced in flesh ; could take no exercise ; had a poor appetite ; was costive ; and had been confined to her house for many weeks before leaving home in the steamer for the journey. The gentle-


186 CASE OF IMMOBILITY.

man was in the habit of carrying her in his arms up and down stairs, in consequence of her weakness and her pelvic pain.

Upon making the vaginal taxis, I found the os tincaj just at the OS magnum, and that it would recede but very little upon my pushing it with the palp of the finger. It was as firmly fixed as if it had grown fast there.

As I concluded that all her pelvic distress was reasonably to be attributed to a prolapsed condition of the womb, I resolved to get it out of the way, and I was sure to accomplish my object ; for I had many times before met with this so-called immobility of the womb, which I had proved to my own conviction not to be im- movable.

I procured, therefore, a small globe pessary, the diameter of which did not exceed an inch and a quarter. This pessary I slowly pressed through the os magnum, allowing time enough to permit the vagina to yield in the direction of its axis. I was a long time engaged in pressing the globulus into its position, and I did fail to adjust it to my mind's contentment ; for I was com- pelled to cease any further prosecution of the attempt, and leave it so far immerged that the equator of the ball w^as within the grasp of the vagina, yet leaving a small segment of the sphere projecting betwixt the labia pudendorum, that were slightly disparted by it, rendering it easily tangible externally. I now caused her to be drawn up into her place in bed, lying on the back, with an urgent request that she would tolerate any pain or strangury that might come on during the night, and holding out the expectation that the protracted and gentle pressure to be exercised by the con- tractility of the tissues, would by the next morning carry the ball high up into the pelvis, though it was now just under and perhaps, a little in the rear of the crown of the pubal arch.

And so it happened. In the morning I found the globulus had been pressed completely into the more lax segment of the vagina, by the contractions of the sphincter and the contractility of the non-muscular tissues.

In short — she began to go about the city; soon afterwards re- turned to her own home, and within about six months I had a letter asking my advice, as to the continued employment of the pessary, in her then condition ; as she was in the fourth month of her pregnancy. Of course, I advised the removal of the instru- ment, since which I have had no intelligence from her.


PRECAUTIONS AS TO PESSARIES. 187

Byway of parenthesis, let me inform you that the pessary does not put a bar either to gestation, or to conception. I say this, being founded on repeated observations ; one of which, but yester- day, May 22d ; the woman having told me she had never removed the globe, though she is now enceinte.

Why should you, then, feel any anxiety as to the escape of the mucous and mensual excretions ? The globe and the disc are alike incapable of preventing the due discharge of all the products of secretion, the hemorrhages, &c., that may appear beyond it.

You would reasonably expect that the pressure, and even the presence of any foreign body in the vagina, and touching the womb, might excite an increased mucous discharge. This is a general consequence of the first use of such methods, but these newly excited discharges soon disappear. Take heed though, and take good heed too, that the patient shall inform you of any such discharges coming on at a later period of the treatment ; and par- ticularly if such discharge should have any, the smallest trace of blood mixed with it. Such an occurrence would lead strongly to the inference that the instrument had excited ulcerative inflam- mation, with purulent discharge. It is of the highest moment in any such case, to take away the support and carefully examine the parts by the speculum uteri. If the os tincse, or either of its lips should be found red, with visibly enlarged venules and capillaries ; or if any abrasion or granulations should be detected; touch them with sulphate of copper in solution held in a camel-hair pencil ; or with Goulard's extract of lead; or with acetate of zinc and wine of opium; or with nitrate of silver. Ten grains sulphate of copper, to half an ounce of water will do; Goulard's extract and water, equal parts ; ten grains acetate of zinc, forty drops wine of opium, and half an ounce of rose water ; ten grains, or twenty grains of nitrate of silver, to the ounce of water. These formulae are perhaps sufficient.

If the vaginal cervix is turgid, red and sensitive, eight or ten leeches dropped into the speculum of Recamier, will, in twenty-five to thirty minutes, have drawn from the cervix caught in the uterine extremity of the speculum, a quantity of blood, sufficient to lessen the turgescence of the cervical circulation.

Surely such a patient should keep her bed or her couch until cured of the abrasion and inflammation.

As to the use of the pessary. I recommend that you adopt as


188 UTERO-ABDOMINAL SUPPORTERS.

an invariable rule of practice, that you will not prescribe, nor even sanction its employment, until convinced by actual know- ledge, that the indication for it is there. I say so, because every- body knows something, however imperfect, about the pessary ; and every woman who has a pelvic misery, will naturally be dis- posed to play the quack as to her own case. If the case be one likely to be benefited by it, you ought to allow and recommend it ; but that you cannot know by instinct. Inquire, examine for yourself, and if there be sensibility, discharges, — and especially discharges of a bad color, — away with a pernicious instrument, which can only make the sick woman more ill, and bring into dis- credit a means of relief commended by the united voices of twenty centuries.

And now, what shall I say of those utero-abdominal supporters, that you see paraded in the newspapers, and forced into vogue by the certificates of physicians, and proh pudor ! of Professors in the Schools of Medicine !

What shall I say of them? Have you a skeleton in your office.^ I pray you open the door where the grim and ghastly representa- tive of our poor mortality stands, as the mocker of all human pride and ambition. Don't you see that if you draw a line from the pubis to the xyphoid cartilage, it will represent the linea alba of the grim horror? Look again, and observe the place where the mesentery was attached, and the root of the mesocolon too. Look down through the plane of the superior strait to see where the uterus was, and where grew the vagina that supported it.

Now take a utero-abdominal supporter, and adjust it as the mesmerized do, mentally, upon the skeleton, and you will see that it can have no effect to hold up the bowels: that it can only push your fancied tractus of the linea alba backwards against the spinal column; and with what effect, pray? Surely, with none other than one of encroachment on the capacity of the abdomen. Do you not see, that the belly of a living man or woman, is a vacuum plenum. How can you hold up the bowels by a pad? If you could thrust them upwards in the vacuum plenum, which you can- not do, you would only thrust them towards the concave of the diaphragm. But the diaphragm must come down, or the woman will die. She can't breathe but by the descent of her diaphragm. Her diaphragm is her respiratory piston, and the trunk of the body is the cylinder in which this piston moves downwards in the aspi-


UTERO-ABDOMINAL SUPPORTERS. 189

ration, and upwards in the expiration of the air of the atmo- sphere. But your utero-abdominal Supporter knows better than the Providence that made this great machine; and he is about to make the piston work half strokes in breathing; like an engine that one is afraid of. No, young gentlemen! the utero-abdominal supporter cannot hold up the bowels ; it can make the belly too small to contain them, and they will make haste to get out of the squeeze by falling down into the pelvis, where they were not before, and ought never to be.

How could the surgeons of the United States and England, put their names, like so many notes of admiration, to such' an anti-chi- rurgical and anfi-physiological nonsense! Did they not forget that one-fifteenth of the human family is asserted to labor under hernia in some shape? And why? Because the belly is too small for its contents in one out of every fifteen of us, and they force their way of escape by the umbilical ring, by the abdominal canal, under Gimbernat's ligament, and elsewhere, wherever the pressure can force them out: yet these recommenders of an unblushing ad- vertisement come to put on utero-abdominal supporters, forsooth. I am ashamed for my cloth, when I see their names so wrongfully appended to a quack advertisement. I thank Heaven you do not see my friend Dr. Hodge's name there; and you may take my word, that mine shall suffer from no such use of it.

You perceive I am not quoting in these letters a hundred authors to sustain me, in my instructions to the cherished members of my class. I promised you to make for you a book out of my own brains, and that I shall try to do, avoiding useless citations. It would be far easier to take my scissors and cut these letters, paragraph by paragraph, out of the volumes in my library. I hope you will not be inclined to say it would be better had I done so, as the letters would have been better letters. There, however, are the volumes; too many of which, like all the early literature of our calling, have been made by the scissors, being the lazy repetitions of what has been said a thousand times. I hope, though, you will take every opportunity of reading what those books con- tain on all these topics. There is no danger of your reading too much. The more you read, the better will you be prepared to judge, whether what I say here and in the lecture room, be just and reasonable or not. Farewell. C. D. M.


190 RETROVERSION.


LETTER XVI.

RETROVERSIO UTERI.

Gentlemen : — My purpose as to this letter, is to put down in it the opinions I have formed, as to a very common malady, which, though it has been the subject of frequent publications, and of much discussion, seems to me not to have been placed in that clear open light, that the simplicity of its causes, ought to have enabled authors to shed upon it, in their printed communications.

Retroversion of the womb, or the state wherein the womb is turned over backwards, is one of the most common of the devia- tions of the organ met with in practice : it appears to rne to be a case whose principles, as well as the methods of cure, ought to be easily understood ; yet I have been much surprised to find many women come to this city from remote districts and states, in order to be treated for some uterine disorder, which had never been fully investigated by their physicians at home ; cases of which the outward signs were in general, sufficiently clear to warrant one, if not to pronounce this diagnosis, yet at least sufficiently to point out the necessity of completing this diagnosis by touching.

Before we proceed farther, let me beg you to stop for a moment, in order to reflect upon the situation of the womb within the pelvis, and its relations and connections with the various parts by which it is environed ; to regard it as placed betwixt the bladder and the rectum, being largely attached to the bladder at the utero- vesical, and vesico-vaginal septum ; to the vagina, upon whose top it is invaginated, and subject, therefore, to be alternately moved backwards towards the sacrum, or forwards towards the pubes, by the varying conditions of the bladder of urine, as filled or empty.

Whenever the urine is evacuated, the bladder is collapsed, or rather contracted; and the womb is brought nearer the pelvis, — when the bladder is full, it pushes the womb towards the sacrum. "What is the limit of this retreat of the womb ? Is there no appa- ratus to prevent it from being carried beyond due measure back-


RETROVERSION. 191

wards? — oris it liable to be pushed bodily against the face of the OS sacrum ?

What other office could you assign to the ligamenta rotunda than that of preventing the womb from going too far in a backward direction? Be assured that the sole use, destiny, or office of the round ligaments, is to oppose the retreat of the uterus beyond due measure backwards ; and that, like the forestay of a ship's mast, each ligament is charged with the duty of retaining the organ in sufficient propinquity to the anterior semi-circumference of the pelvis, and of retaining it erect nearly in the middle, not too far back, and not too nigh the pelvis, where its presence might interfere with the office of the bladder of urine.

Suppose a woman could, by any accident, or by any surgical operation, have her round ligaments cut off! You perceive the inevitable consequence would be, that the womb would turn over backwards, and rest against the sacrum ; or even dive backwards, carrying its head deep down into the peritcineal cul-de-sac be- twixt the vagina and the rectum, while its os uteri would point upwards towards the bladder, behind and above the crown of the pubal arch. This would be a true retroversion ; but if, by any art, the cut ends of the round ligaments could be made to unite again, the retroversion would be at once cured ; for there can be no retroversion with round ligaments only two and a half inches long. How could there be? — since the plane of the superior strait is four and a half inches over, from front to rear. Certainly, two and a half inches of round ligament cannot stretch across the plane, which is four and a half inches long.

Retroversion of the womb, then, is a case in which the fault, the maladive or pathological fault, is in the round ligaments ; and not in the womb itself. Hence, if you intend to cure a woman of retroversion, your intention should have reference, rather to the ligamenta rotunda, than to the womb. Cut off the round liga- ments, and you will have retroversion ; heal the wound, and the ligament being united again at the wounded point, the womb will be held up, and there can be no retroversion. Relax, stretch, elongate the ligamenta rotunda, and the womb retroverts; — strengthen, shorten, cease to elongate the same ligaments, and the patient is cured. This is the doctrine.

As to the persons subject to this accident, it must be admitted that the virgin and the wife, the sterile and the child-bearing are


192 RETROVERSION.

all liable to it, because they are all liable to the operation of causes that over-strain, and elongate the round ligaments.

Yet doubtless it is of more frequent occurrence in child-bearers than in other women ; since such are the persons in whom the round ligaments are most frequently put on the stretch, elon- gated, and weakened. Nevertheless, it is true that a great many women, who have never conceived, are troubled with the affection. I speak very confidently as to the liability of the virgin to the dis- order, since I have treated it in such persons.

I said that the malady is essentially a malady of the round ligaments, though the womb be the apparently suffering organ. I do not mean to say to you, that it is a matter of little moment that the womb should be reversed, and that the matter of great moment has relation to the round ligaments only; for I am not so inaccessible to reason and observation, as not to know, and admit, that a distorted, and so to speak, dislocated condition of the uterus, particularly in pregnancy, is a matter of serious moment; nay, a state of imminent danger, and of great pain. In all such cases you should make haste to relieve the womb from its false and dangerous position — remembering, though, all the while, that it is not the fault of the womb, but of the round ligament;— r that your intention should be to disembarrass the womb, by taking it out of the false position, in which it has fallen, not through any fault or disease of its own, but through fault and disease of the round ligament, which ought to have sustained and maintained it in its true normal attitude, but did not.

Let me repeat, that a healthy round ligament will not reach across the plane of the pelvis from front to rear — but a weakened, or relaxed, or overstretched one may be so very long, that it may reach not only across the whole plane, but even down almost to the point of the coccyx. And now, I think I have defined my opinion, and that we cannot misunderstand each other in the sequel.

Here is a drawing copied from the specimen that I showed you last winter ; and which represents it very correctly. The figure is a half female-pelvis, with its contents, but exhibiting the womb retro- verted. Look how the posterior face of the womb has become, by the retroversion, the anterior surface; and see how the os uteri is directed upwards, instead of downwards. This womb is quite topsy-turvy. The fundus of the womb impresses itself into


RETROVERSION.


193


Fig. 1.


the texture of the rectum ; and the bladder of urine is distorted by the dislocation of its neighboring organ.

The artist has made a dotted line ending at (6), which shows you how much the round ligament must have been stretched, to let it reach thus to the bottom of the pelvis. The other dotted line, marked (a), shows how long, and where, the unstretched round ligament ought to be, and was, before the re- troversion took place. If you push the index into the vagina, you will press it on the fundus and corpus ute- ri, down near to the sacrum, while the os is high up near the pubis. I think the drawing may explain the state of the case better than all the balance of this sheet.

In looking through the books again to find what the writers think on this subject, which, as you may remember, I have often presented in this light at our meetings in the lecture-room, I discover them not to be so clear and concise in their apprehen- sions of the true nature of the case, as I think you will be, if you adopt the opinions above expressed and set forth. They all know that retroversion is retroversion — but they seem not to know why. The famous Dr. Deleurye, in his Traite des Accouchemens, Par. 127, says of the round ligaments, " Hors le temps de la grossesse, les ligamens ne sont d^aiccun usage a la matrice; pendant la grossesse, ils peuvent lui servir, etant tendus et droits." So that Mons. Deleurye appears to regard them as provisions against a 13



194 RETROVERSION.

gestative want. Most of the authors, I believe, equally overlook the ligaments, as allowing by their failure the occurrence of a retroversion, except Velpeau, who, at p. 94, 2d edition, Paris, 1835, says, "but for them the womb would every moment be turned over backwards by the bladder, which is distended several times every day, with urine." They have escaped the attention of Robt. Lee, whom nothing escapes. Cazeaux passes them by with scarcely a remark; nor does Churchill seem to deem them worthy of notice. Even MM. Desormeau and Paul Dubois, authors of the article in the JVouveau Diet, de Medecine, pass over these organs without due regard, while Dr. Jacquemier's new Manual of Midwifery, which is the last novelty in our line, seems also to attribute this pathological condition to any tissue save the one really in fault. Authors say it is a full bladder that causes retroversion, or that retroversion causes the bladder to be over- filled.

For example, — here is a brochure entitled Memoire sur la Re- troversion de la Matrice dans Vetat de la Grossesse, 76 pages, 8vo., 1843, by the distinguished Dr. Amussat, of Paris. I shall translate a whole paragraph from p. 22. It is in the following words : " A retention of the urine has been indicated as one of the causes of retroversion of the womb. In my opinion the effect has been mistaken for the cause; a retention of urine being an inevi- table consequence of the displacement ; since the cervix, provided it have not been really bent, must immediately press upon the urethra and obstruct the escape of the urine. Certainly where the retention of urine produced in this way is misunderstood, the distention of the bladder will tend to increase the displacement, and the use of the catheter, by drawing off the urine, might partly cause the organ to rise again above the promontory of the sacrum. But, it is incorrect to say that a retention of urine may produce a retroversion of the womb ; it can only increase it — perpetuate it. However, I admit that where the bladder is habitually distended by a great quantity of water, and where this distention is a conse- quence of disease of the bladder or the urethra, there might in the long run follow a depression of the fundus from the weight of the bladder, and so, a tendency to a retroversion."

There, what say you as to Dr. Amussat's view of the case ? In his whole pamphlet there is not one word of the round ligaments —


RETROVERSION. 195

and a man who teaches you the doctrines of retroversion without mentioning them, is like a surgeon who should teach you the whole doctrine of dislocation of the hip-joint without the least allusion to the orbicular ligament or the capsule. You might ask such a teacher, can a hip-joint be dislocated without troubling the orbicu- lar and capsular ligaments ? — and you might ask M. Amussat if he thinks a womb could be retroverted with a pair of ligamenta rotunda not over two inches and a half long!

Dr. Samuel Merriman's " Dissertation on Retroversion of the Womb, including some Observations on Extra-uterine Gestation,^ is equally devoid of concision in the exposition of the causes of the accident, for his whole book from beginning to end has not one word on the subject of the ligaments.

Dr. John Burns, of Glasgow, whose work, with notes by the late Professor James, was so long a text-book of the University of Pennsylvania, has not an item on the subject of the round liga- ments in the whole of his article, which you will find in vol. i. p. 186, of Burns Midwifery. Dr. Robert Lee, of London, who in my opinion is one of the ablest men in his department now alive, does not hint at the existence of ligamenta rotunda in his article on retroversion, which is at page 207 of his " Lectures on the Theory and Practice of Midwifery, delivered in the Theatre of St. George's Hospital. London, 1842, 8vo." Nor does Dr. William Hunter, the father of all retroversion authors, say any- thing about them.

I think, that as retroversion is an accident very common, and in pregnancy, very dangerous, it is important that you should not only be well aware of the state of the womb under it, but of the implications it may introduce as to other tissues ; and it is exi- gent, not only to know these things, but why they do happen, so as to enable you to direct aright your intentions and method of cure.

Can you entertain any scruples in regard to my explanation of it ? Let us try conclusions then.

The bladder, when it fills from the perpetual stillicidium of the two ureters, always fills first in a direction backwards, towards the sacrum ; and when it cannot distend any farther, in that direction, its fundus mounts upwards towards the umbilicus. In Dr. Hun- ter's case, figured in his anatomical tables of the gravid womb, it


196 RETROVERSION.

went up halfway between the navel and pit of the stomach. Now, in a healthy strong woman, the bladder, in filling, cannot go back to the sacrum, pushing the womb before it, because, as soon as the round ligaments are put on the stretch, they cease to yield, and compel the bladder to develop its walls in an upward direc- tion towards the navel. The womb is therefore safe ; it repels the intrusion of the bladder, and makes it rise upward, in the belly, agreeably to the explanation of M. Velpeau, in his Midwifery. But, there are certain women, who, from insensibility of their ner- vous system, or from their situation in the world, habitually allow the bladder to become enormously distended, before they yield to the urgent call of nature. Such a habit must, inevitably, gene- rate a laxity of the round ligaments, which being daily over- strained, yield more and more to the antagonizing force of the distended bladder, until they end, by becoming too long to hold the womb in due propinquity to the pubis; wherefore, it must fall backwards to the sacrum, since there is nothing devised for holding it forward, except these round ligaments, that can now no longer do their office. This slow, gradual elongation of the round liga- ments, will explain to you the reasonableness of those writers who say, that retroversion may, in some women, come on gradu- ally, and by small degrees, until it is at length completed. I have myself, no doubt, that the cases of retroversion in the unmarried, are mostly brought on in this slow chronical way; though, it is true, when the woman is prepared for it by this process, some sudden exertion or succussion of the body, may complete it in an instant. Suppose the round ligaments to have become habitually overstretched, until they have become four and one-fourth inches long. Do you not perceive, that a full bladder, suddenly jammed downwards in a fit of vomiting, or coughing, or straining, or jump- ing, might press the head of the womb down beneath the sacro- vertebral angle, whence it would not be likely soon to be pulled up again by the said ligaments.

Any pressure upon the rectum, whether from within, or without the cavity of the gut ; any inflammation of it, or any irritation act- ing upon it or the bladder, excites what is called tenesmus or a bearing-down. In tenesmus, all the parts contained within the pelvis, are pushed downwards towards the perineal strait, and, as the tenesmic feeling becomes more and more intense, it must hap-


RETROVERSION. 197

pen that the overturned organ shall be pushed down into the peri- toneal cul-de-sac, betwixt the bowel and the vagina. The womb cannot come into this situation, without greatly augmenting the tenesmic feeling, and bringing on other complaints, such as stran- gury, or dysury, urinary tenesmus, rectal tenesmus, pain in the middle of the sacrum, in the ligamenta rotunda, sciatic pains, and pains along the distributive places of the obturator nerves in the groins and thighs, and a great disturbance of the entire splanchnic system of innervations.

You may very readily conceive of the disturbing influences, as to the general health, bodily and mental, of such a state of things ; and in making up your notions of the modality of such disturbing operations, you will not leave out of the computation, that vast and dominant force, which the reproductive organs of the female ever exert upon her entire physical nature. How much greater that force when the womb and the ovaries, and the whole repro- ductive apparatus, indeed, is advanced in power by the sanguine affluctions, and nervous determinations to which they are subject under such circumstances. You should not be surprised to witness the wildest hysterical phenomena; nor, indeed, the whole protean genus of hysteria.

I have been accustomed to observe these influences for many years past, and have seen them carried to the extent of producing a temporary insanity and the various modifications of the nervous manifestation below that which constitutes insanity.

The disordered womb can, by its nervous connections with the spinal and sympathetic nerves, disturb and vex any and every organ in the body, from the brain to the massa carnea on the sole of the foot. It can vex the pharynx and oesophagus with spasm or globus — close the jaws through the masseters or temporals, jaundice the blood by its influence on the liver, cause ischuria or diabetes in a moment, bring on constipation or diarrhoea, simulate apoplexy and eclampsia, set the hemispheres in a rage of in- sanity, or excite the cerebellum to the manifesting of chorea, or abolish the sensorial and motor chords of the spinal marrow ; but, if, in the non-gravid condition, the retroverted deviation of the uterus can cause such great derangements, what must be those that attend some of the terrible consequences of retroversion of the gravid womb. They are truly appalling. They consist in all the


198 EETROVERSION.

fruits of complete compression and obstruction of the contents of the pelvis, by the growing womb. Dr. Wm. Hunter describes a case, the first one perhaps, which was clearly understood, wherein, after the death of the patient, it was found that the womb had continued to expand under the development forces of the ovum, until it so completely jammed and impacted the uterus into every anfractuosity of the pelvis — arresting the flow of the urine, and the course of the rectum — that the uterine mass could not be ex- tracted through the superior strait, until the ossa pubis were sepa- rated by the saw.

This case of Dr. Hunter's was under the care of Dr. Walter Wall, who had studied in Paris, where he had received the in- struction of Gregoire. Persevering attempts were made to restore the womb to its natural position ; but the magnitude of the ovum, at four months, rendered it impossible to get the fundus above the linea ileo-pectinea. The bladder was filled, so that its fundus was half way between the umbilicus and the scrobiculus cordis, and she died shortly after Dr. Hunter saw her. Dr. Hunter gives very beautiful drawings of the specimen, in his great Tables of the gravid uterus. Before the examination of the body, he in- vited many physicians to be present, and gave a lecture on the subject. It was Dr. Hunter who applied the name of retroversion, which is now adopted universally. Many physicians had seen the malady before his time, but I think him entitled to the credit of describing it, and making it first clearly understood.

As to the several signs by which the accident may be made known, they are pain and obstruction or irritation within the pel- vis. You rejoin, perhaps, that other affections are manifested by the same symptoms ; and it is very true that simple prolapsion gives pain in the pelvis, and in the back; and troubles the course of the urine, &c. ; — but, in forming your inference as to the ex- istence of a retroversion, upon representations of pain made by the patient, you will address your inquiries in such a manner, as to deduce from the history of the attack, a judgment as to its seat, causes and nature.

For example. I was called some time since to a young woman residing in Ninth street.

When I presented myself to her, I found her lying upon the bed, apparently in pain. It was afternoon.


RETROVERSION. 199

" Will you please inform me what it is that has induced you to call for me, madam?"

" I am in great pain, sir."

" Where is the pain situated ?"

"In the lower part of the stomach and back."

" You mean in the lower part of the abdomen, I presume ; near the shear-bone, or bar-bone."

" Yes, sir."

" How long have you suffered from it ?"

" Since the early morning."

"Are you married?"

" Yes, sir, these six weeks."

" What bfought the pain on you?"

  • ' I do not know, sir. It came on in the car, as I was return-

ing from New York."

" Have you any difficulty in making water?"

" I cannot make a drop ; or at least, only a few drops pass, with the most violent efforts — and the urgency never ceases ; I am suffering dreadfully, indeed."

"Had you ever such an attack before?"

" Never."

" What's your age ?"

" Twenty-two, sir."

" Are you regular?"

"No, sir."

"Do you suppose you are enceinteV^

"Yes, sir."

"How long?"

" About five weeks." '

" And you never felt this disorder before?"

" I never felt anything of the sort till to-day,"

"Have you pain in the back, did you say, too?"

"Yes, dreadful."

" Is that pain chiefly felt about three inches above the lower end of the back bone?"

" Exactly there."

"You have a retroverted womb, madam; with retention of urine, caused by it."

"I do not know what you mean, sir."


200 RETROVERSION.

" I mean that, as you are pregnant some five weeks, the womb is become much larger than it was before you were married ; and it is now turned over backwards ; — in fact, it is topsy-turvy. The pressure of the top of your womb against the lower part of the bowel and the back bone, gives you pain in that situation ; while the bottom, or rather the point of the womb, is pressed with force against the bladder of urine, vexing and paining it, and stopping the course of the water, which can only escape drop by drop, while your bladder becomes continually fuller and fuller. It is very full now."

" Why, what in the world is to be done?"

" You are to allow me to remedy the difficulty."

"How?"

"By replacing the womb in its natural position."

" But how can you do that ?"

"With my hand."

" I can't think of such a thing."

"Very well, madam, I shall have to bid you a good afternoon, for I can't think of anything else. In fact, there's nothing else to be done for you."

"Why, I'd rather die."

" As you please, madam; you are the mistress; ce que femme veut, Dieu le veut ; but I hope you will permit me to say it would be very silly of you to die, for want of the power to make water, when there's a physician at hand, can put you so easily in the way to do it easily."

And she resorted to the ladies' resort — tears. After she had comforted herself a little in this way, and had come to her calmer reason again —

"Will it hurt me, sir?"

"Oh no, not a bit."

" What am I to do, then, if I must ?"

" You are to lie on your left side, in bed. Covered up head and ears, with the bed-clothes. You are to draw up your knees very high, and I will cure you in a moment."

I washed my hands ; I always do that first. I dipped the index finger of the right hand in oil. With its point I felt the gravid bas-fond of the womb looking downwards and forwards in the pelvis, while the ostincse was cocked up against the urethra above the arch. Look again at the wood-cut.


RETROVERSION. 201

" Don't bear down now, child ! don't resist the pressure of my hand! I shall not hurt you at all, not in the least !" and so by a gentle, steady, augmented pressure against the bas-fond, press- ing it upwards and backwards, I followed the ascending fundus until it suddenly escaped above the promontory, upon which the OS uteri looked downwards again, and the organ w^as reposited."

" Now, how do you feel ?"

" Oh, greatly relieved."

" Set up, and try to make water. I shall retire from your cham- ber. Call me when you are done. Is there a wash-stand in the next chamber?"

In a few minutes she called me back; thankfully telling me she had made a large quantity of water, and was quite well again.

" Is not this, bad as it is, better than dying?"

" Oh yes, sir, thank you!"

" I think it is. Farewell, madam. Let me tell you though, before I go, that if you had made water freely, before you started from New York this morning, you would not have had your womb turned over, for nothing did it but the bladder. Your bladder was full when you got up in the morning; you was hurried to the steamer, and it became fuller, because you could not relieve your- self in company. There was not room enough left for both the bladder, and the womb in their usual places. So the bladder thrust the womb downwards and backwards, until it was over- set. The round ligaments could not hold it up, they had to give way. See here, I have made a drawing of the situation of things. This is the womb overturned backwards. These are the round ligaments, stretched almost to breaking. That's the mouth of the womb turned up here, and compressing this neck of the bladder, which you see is horribly distended wuth water, that gave you so much pain. As soon as I pushed the womb up to this point, the mouth of it turned down to this place, its natural situation, and the pressure being taken off from the neck of the bladder, you could easily make water. Do you understand it now ?"

" Oh yes, perfectly."

" Take care then, not to let it get so full again, or it will serve you the same trick a second time."

"Yes, sir."

"Farewell, madam."


202 RETROVERSION.

. " Good-bye, sir."

I have given you the foregoing dialogue, as an example of many conversations I have held on such subjects, with the sufferers from an accident.

What inference, other than that I did draw, could I possibly deduce from her relation ? Think over, for a moment, the ana- tomy of the parts within the pelvis, and you will see that I could not well obtain any other inference than that of an overset of the uterus.

If the patient had replied to my questions, that she had long suffered with backache, and dysury, &c., I might have supposed some other cause than retroverted gravid womb ; but as she was young and strong, how could I imagine that anything else could have happened to her pregnant uterus, except that which had really happened to it. There was nothing else to be deemed of it, and so I could confidently say to her — your womb is retro- verted.

You will not expect always to relieve the patient so promptly, nor will your diagnostic always be so correct. This at least, I have many times found to be the case, as to my own patients ; for I have very confidently expected to find retroversion, where there was only prolapsus: and sometimes, where a true anteversion of the organ existed. There are other cases, again, in which the splanchnic neuralgia that I described in Letter XII. p. 131, has depended upon retroversion, while I expected to discover a simple uterine descent. For the most part, however, you may venture to speak with boldness, upon a clear history of a sudden case, in a healthy pregnant woman. You may also entertain a very con- fident reliance in the diagnosis, even in the chronic forms, but, a fortiori, in the instances of the accident connected with preg- nancy.

If you should have reason to speak very confidently on the diag- nosis, from this mere external or rational evidence, you would of course verify the opinion by the touch, should you continue in charge of the case. The touch should be effected in the usual way ; the woman being on her left side, in a flexed position. In retroversion, the os uteri is behind the symphysis, looking more or less obliquely upwards, according as the fundus is more or less completely forced behind the vagina, while the os tincae is found


CASE OF RETROVERSION. 203

up near the symphysis. The fundus is felt in the non-gravid, as a firm, solid, hemispherical mass, lying against the exterior surface of the posterior wall of the vagina, which is pushed more or less near to the os externum, according to the degree of the overset. In M. Mayer's case, it was pushed through that wall, which it ruptured, and turning quite upside down, came out through the vulva.

It is true you might commit an error in the diagnosis — mistak- ing some tumor formed in, or fallen into the pelvic cul-de-sac of peritoneum, for the overturned fundus; but I apprehend but little likelihood of such a mistake, should you trace the cervix from the OS uteri to the corpus; and so to the fundus of the organ; the more particularly, as in all cases not perfectly clear, you would resort to the exploration by the rectum.

I said you will not always be able to relieve the patient so rea- dily.

A lady called upon me many years ago, on account of a retention of urine. I found her pregnant at more than three months, and the bladder making a large painful tumor in the hy- pogastrium. When I informed her of the probable cause of her distress, she very readily accepted my offer to attempt to relieve her of the difficulty.

As the uterus at three months is already very large, I did not make any attempt to reposit the womb, while the bladder was still filled with a great quantity of water; for, when the bladder is so dis- tended, I presume it will effectually prevent success in any attempt at reposition, particularly, the womb itself being also very full. If the rectum be overloaded, that part of the gut that lies above the overset uterus, will be so distended with feces, as to aid very mate- rially in keeping the uterus down. The bowel should be tho- roughly emptied by an enema of salt and water, before anything else is done. In the case now under consideration, it was not necessary to resort to this aid. Instead, therefore, of uselessly worrying my patient, I commenced, by drawing off the water with a catheter : — and I found it necessary to carry the female catheter almost up to the ring, before I could introduce the point into the cavity of the bladder ; so much was the urethra stretched by the complete see-saw of the womb. By way of parenthesis, I must here warn you that, in these distortions of the organs, you may find yourself disappointed in attempts to draw the urine by


204 CASE OF RETROVERSION.

a female sound, owing to the great lengthening of the canal ; in any such case, you would have no difficulty in reaching the de- posit, should you employ a male catheter. I mean a French one.

When I had evacuated the bladder, I proceeded to attempt the reposition of the organ; but I found, on thrusting against it with two fingers of the right hand, I could not make it ascend, — but that my fingers indented the womb so much, as to expose me to the risk of disturbing the connection of the ovum to the uterine walls, and so causing an abortion to take place. This reflection induced me to pause.

Here, said I, is a woman pregnant at three months, past ; who has suddenly suffered a retroversion, probably brought on by a dis- tended bladder ; which, pushing the womb backwards and down- wards, has, upon some sudden succussion, shock, or straining by the abdominal muscles, thrust the fundus fairly down below the promontory of the sacrum, which holds it there. But now, that I have removed the pressure from the bladder, by emptying it; if I persist in attempts to push the womb up again, I shall perhaps break or detach the membranes, or possibly separate a part of the placenta. I shall, therefore, do no such thing ; I shall hope and trust, that the round ligaments have strength enough to pull the womb up from out of its new bed, and set it on end again — the more likely, as I have no reason to suppose they are chronically weakened and elongated. Many samples have been met with of the womb restored by taking off the pressure of the bladder. Dr. Ingleby, in his Obstetric Medicine, p. 65, describes a case in which the " womb rectified its position almost instantly after the bladder was emptied." He relates a good success, also, at p. 67, in which the womb remained retroverted at the fourth month of pregnancy, notwithstanding the daily introduction of the catheter for many days; Dr. Ingleby advised that it should be introduced every four hours. In this instance, notwithstanding the fundus was almost down to the anus, and the os uteri was just above the brim — on the third day of repeating the catheterism every four hours, it was restored to its natural position. I therefore explained to the patient the views which led me to desist from troubling her for the present, and promised to observe the case.

Upon calling many hours afterwards, she had made no water; the bladder was again to be felt, full, above the symphysis pubis, whereupon I used the catheter again; and then renewed my


»#■


TREATMENT OF RETROVERSION. 205

attempts to get the womb up, in vain. The attempt to press the organ upwards, was resisted by two causes; 1st, the fixed state of the mass extending quite across the pelvis, and, 2d, the bear- ing-down, or tenesmic effort, which was excited by the pressure of the fingers.

A person who is on the knees, with the top of the sternum rest- ing on the same plane as the knees, cannot bear down. The tenesmic power is either wholly annulled, or so weakened, that it is nearly nullified by that attitude. Dr. Hunter's patient was placed in this position, but she was too far gone to enable him to succeed.

I directed my patient to turn on her face in bed; — then to draw her knees upwards, until the thighs should be vertical ; and to keep the top of her breast upon the matrass, so as to have the pelvis elevated to the highest point.

Introducing two fingers into the vagina, and conducting them along the curve of the sacrum, I found I could disengage the womb from its jammed position ; and following it as it moved, I had the pleasure to find it escaping towards the plane of the superior strait, while the os tincse see-sawed down into its proper place in the vagina; and she was relieved. Her retention of urine returned no more ; and I attended her at the birth of the child, at term.

It is worthy of remark, that two years later, I had to repeat the same process for the same lady, in a succeeding pregnancy, and with equally fortunate results. Dr. Amussat, in his work on retroversion, describes a similar case, in which the accident oc ■ curred in two successive pregnancies.

In neither of these cases did I resort to venesection, ■(v'hich Dr. Dewees justly commends as a most important item in the treatment of the rebellious cases.

Our celebrated countryman was a bold bleeder, and was ac- customed to overcome all obstacles of soft resistance, by copious abstractions of blood. I have heard him highly recommend the lancet, as a means of subduing the tenesmic resistance that is awakened by the hand of the surgeon, disturbing the tumor. But having found the position above recommended, amply pow- erful for the subduction of the tenesmic force, I with confidence recommend it to you, as preferable to large abstractions of blood ;


206 CHRONIC RETROVERSION.

which are not indifferent in their prospective influence upon the health.

Should you, however, in any such case, have reason to suppose that the engorgement and irritation are about passing, or already passed into the stage of inflammatory action, I trust you would not hesitate to resort in the freest manner, to the curative and conserv- ative efficiency of venesection.

I hope you will see, my young friends, that in taking the above method of laying before you my views upon retroversion, I supposed that a concise account of the symptoms, state, and cure of some cases would be more efficacious to clear the matter in your minds than the longest didactic and stately detail. These cases might perhaps suffice for the end I have in view, since ex uno disce omnes is nearly true. Yet I shall beg to say that, you will probably meet with some specimens of the accident that you cannot remedy by any means, and that it would be very dangerous to persist in curing them. Let me speak of them, therefore.

The chronic duration of a retroversion of the womb can scarcely be regarded as consistent with a healthful state of that organ. The distortion, the pressure, the firm and continued contact of parts not designed in nature to be brought into fixed apposition, develop an adhesive inflammation, and such inflammation is at an end when it has finished its mission of uniting two parts into one, by a bond of union common to both. Doubtless, many are the cases of retroversion that are thus rendered incurable, and these are the samples against which you should be warned, lest in your zealous attempts to succeed in restoring the womb to its normal attitude, you should effect some disruption. of tissues, the laceration or even the tension of which might endanger the life of the patient. Hamlet is very right where, in his soliloquy, he resolves it is

" Better to bear the ills we have, Than fly to others that we know not of."

I speak very confidently as to the confinement of the fundus in the back part of the pelvis by adhesions, not from any opportunity I have had of proving the fact by a necroscopic test, but by the circumstances of a case that came under my charge six or seven years since. It was that of a married lady from one of the West- ern States. In this case all the usual phenomena of the malady were present. The os uteri was directed strongly towards the


■ < RETROVERSION. 207

symphysis pubis, and the rounded fundus of the womb was clearly distinguishable on examination, both by the vagina and the rec- tum. During several consecutive months, I made various attempts with the hand, in both ways, to push the fundus upwards ; and I also introduced a large globe-pessary, in the hope, that, by its protracted pressure in an upward direction, it might gradually loosen the ancient attachments of the womb, and thus allow it to recover. I did not succeed to any great extent in repositing the deviated organ ; but the patient left this quarter of the country in improved health, and with the organ less impacted and less im- movable than when I took charge of the case. I concluded it to be not possible to disengage it wholly from the ties by which it was bound down.

Amussat, Mem. sur la Retroversion, &c., p. 27, says, " I have two drawings representing cases of retroversion of the non-gravid womb ; in one of them the subject was an adult, and there was adhesion to the rectum ; the other case was that of a new-born child; and at page 29 he continues thus:

" The consequences of reposition of the retroverted womb are far from being so simple and fortunate, as might be supposed, to judge from the three cases under my care. Indeed, in some in- stances the manoeuvres, even careful ones performed with the fingers introduced into the vagina, have brought on abortion, and in some cases this accident itself has been followed by fatal metro-peritonitis.

"If a female have been the subject of a puerperal or other peritonitis, she may have recovered with adhesions of the womb to the peritoneum behind it. Such a state would not necessarily vitiate her power to conceive. She might even develop the child in a uterus partially retained by adhesive connection within the pelvis, but would be more likely to miscarry as soon as the trac- tions should become intolerable to the uterus. We have examples of adherent uterus causing death by hemorrhages."

I pray you allow me, at the risk of iteration, to call your atten- tion to the remarks I made in a former letter, p. 129, as to the mode in which the womb changes its position in all the prolap- sions. I said the womb falls down along a curved line — Cams' curve — and that, when the os tincee presents itself at the os mag- num, the uterus is lying in a horizontal position across the pelvis. If you do not keep this fact in mind, you will be very apt to


208 RETROVERSION.

mistake a simple prolapsus uteri for a retroversion of the organ — but the cases are very different. In retroversion always expect to find the os uteri above the crown of the pubal arch, and not beneath it. If I am correct in this view, I differ from M. Colom- bat, who seems to approve of the opinion stated in the following sentence from page 154 of his work. " The terms anteversion and retroversion have been applied to those cases in which the longitudinal axis of the uterus has been found placed in a hori- zontal position." If M. Colombat, who is generally a very relia- ble authority, is right in these words, then there can be no differ- ence between retroversion and prolapsus — since in each case, the womb is horizontal in the pelvis. According to my view, you shall always insist in retroversion, on finding the vaginal cervix higher than the crown of the pubic arch — for where it is at a lower level than that, the case can claim to be only a true prolapsus. I am quite confident that many mistakes are made as to this diag- nosis.

Such mistakes are the more easily made, where what is called im- mobility of the womb exists ; a case in which the organ refuses to retreat upwards in the pelvis, for any allowable degree of pressure, except the slow pressure of a pessary ; which I have proved capa- ble in the course of twenty-four to forty-eight hours, to lift quite high up in the pelvis, a womb that I could not venture to start in that direction, by any short-lived pressure I could make with the index and medius.

I have not made any remarks as to the manner in which preg- nancy operates to produce the disorder in question. I am not at all inclined to admit the theory, that the womb goes over back- wards, because the posterior half of the organ yields to the growing ovum, faster than the anterior half. I have explained how a full bladder may cause the slow gradual occurrence of our disease. But it is more frequently seen to arise in married than in single women ; why is this the case ?

You should reflect that the round ligament is from two and a half to three inches long, and that arising from the angle of the womb, it runs to be inserted on the tissues exterior to the os pubis. The non-gravid womb is two to two and a half inches long, from top to bottom; when a woman becomes enceinte, the growing ovum compels, by its antagonistic expansion, the uterus to expand, in order to yield and furnish the admirable nidus of the ovum.


PREGNANCY AS CAUSE OF RETROVERSION. 209

The process of expansion continues for nine months, at the end of which time, the summit of the womb is at the scrobiculus cordis, and distant some twelve inches from its os tincae. During the whole of this growing state, the ligamenta rotunda continue to exercise their office of forestay of the womb, holding it, or assist- ing to hold it forward. But, by the end of the pregnancy, your three inches of round ligament have become five or six, or more inches in length. Now comes the labor, which, in some women, requires half an hour only to complete it, and the average of all labors is but four hours. The womb in two or four hours goes down, far towards the plane of the superior strait, and continues to condense its tissue, so that in twenty days, it is not larger than the non-gravid womb. But if the round ligaments do not con- dense themselves equably with the uterus itself, what guaranty have we, that the womb shall not tumble over backwards, as soon as it has become small enough to allow its fundus to subside below the promontory ; seeing especially that its round ligaments are left relaxed, elongated, stretched, and offering no opposition to the fall.

You should take into consideration, that though the round liga- ments spring from the uterus, and are uterine intextural nature or at least partially so, and therefore muscular, they have not power of contraction so active and quick as those appertaining to the womb proper, and then you will recognize the cause of those fre- quently observed retroversions, that occur in women, pale, thin, watery and relaxed, who, offering no considerable resistance to the escape of the child, are delivered in a pain or two, before the doctor can come.

I do not like to see a woman delivered of her child too easily, for it indicates a feeble resistance, and is more frequently followed by disorders, especially such as that under consideration, than where a solid and stern resistance can only be overcome by a stout and good long labor, evincing the power of the constitution, not only to bear the child, but to get the women well out of the lying- in chamber. You will find such weak pale women, complaining of pains and obstructions after delivery, that make you infer a de- viated womb. I think in such case, a physician is in duty bound, even where the signs are doubtful, to ask for the examination, and, if requisite, to assign his motives for such a request. I have a patient whose uterus was retroverted a few years ago, after her con- 14


210 PREGNANCY CAUSES RETROVERSION.

finement, since which time, she has had two children. She has had it turned over so many times since, that she now knows perfectly well, when the accident takes place, and sends me word. If I ask her if it is retroversion again, she replies in the affirmative, and asks to be relieved. I am sure I have reposited it more than a dozen times. I have never known her to have it in pregnancy, however. She is now enceinte about three months, and the organ is in a proper position. I expect, after the birth of the child, that the round ligaments will again be found relaxed, and then the womb will again let its fundus fall down.

When you shall have charge of a retroversion in a pregnant woman, lay it to heart, that a most solemn obligation is u})on you, to treat the case with a conscientious regard to her safety, as well as that of the unborn embryo. Such a case is always dangerous. For, to say the least, it endangers the life of the foetus, and if un- cured, will probably, if not assuredly, cost the life of both parties. This is a solemn consideration, a consideration that becomes ex- aggerated by the prospect of the most dreadful and hopeless suf- fering for the patient, if she be badly treated.

To suffer an abortion is always a risk, but to suffer an abortion brought about by so strained and unnatural a posture and con- finement of the womb, must enhance the risk immensely, though, it is true, that when the uterus cannot be reposited, while the gra- vidity continues, we are authorized, and even commanded, by a sense of duty, to bring on the abortion, in order to enable us to save the woman's life, by arresting the further development of the child-bearing organ. One may take comfort to himself, however, in the instances of advanced pregnancy in retroversion, by con- sulting some of the wonderful escapes that are recorded in the books. And I am going to give you the account of one of them by Dr. Weir, which I quote from Ingleby's Obstetric Medicine, p. 12.

"We are indebted to Dr. Weir, of Glasgow, for one of the most important cases of this nature hitherto recorded. See Glasgow Med. Journal, vol. i. No. 3, p. 262. This patient had taken strong purgatives with the view of procuring abortion. For some days prior to Dr. Weir's attendance, the urine had dropped away involuntarily, and now the abdomen was swollen by a firm tumor, painful on pressure, and occupying the sub-pubic region. The vagina was filled by a tumor regarded as the uterus in a state of retroversion, although the uterine orifice could not be reached.


DR. weir's case. 211

This tumor not only pressed upon the bladder, and prevented the free discharge of urine, but nearly obliterated the rectum also, yet the bowels responded to the action of medicine. Urine was drawn off repeatedly by the catheter, varying in amount from two to four pounds in the twenty-four hours, and yet the sub-pubic tumor was only partially lessened. The lower extremities as well as the ab- domen became oedematous ; the tumor in the vagina approached nearer and nearer its orifice ; every distressing symptom was in- creased, and it was now impracticable to pass any description of catheter the requisite distance into the bladderr A smaller quan- tity of urine was each time drawn away, and the bladder reached considerably above the umbilicus, whilst the fundus uteri was progressively descending, the uterus being ultimately turned al- most upside down. About the tenth day from commencement of the severe symptoms, pains ensued resembling the pains of labor, and owing to the strong action of the abdominal muscles forcing the uterus still lower, the introduction of the fingers into the va- gina proved exceedingly difficult. The condition of the patient had now become desperate, and it was essential to attempt her relief almost at any risk. The puncture of the bladder, (previously contemplated,) was abandoned under a well-fourided conviction that such a measure would have little or no effect in bringing down the uterine orifice. The puncture of the fundus uteH was also suggested, but prior to its adoption, it was determined to make a last effort to reach the orifice. ' After much difficulty, and a great degree of force, and in opposition to the strong and powerful exertions of the patient, I succeeded in getting my hand into the vagina, forced up my finger above the pubes, and reached the mouth of the womb. An assistant at the same time got his hand into the rectum, and we had thus the perfect command of the patient. By steadily pushing upwards the fundus, and cau- tiously pulling the neck and mouth of the womb downwards, the tumor was gradually raised above the promontory of the sacrum, and the uterus reduced to its proper position.' A considerable quantity of urine was discharged during this proceeding; the pu- bic tumor disappeared ; labor progressed, and a four months fcetus, putrid, was extracted about twenty-four hours after the uterus had been replaced. Severe abdominal inflammation ensued, which demanded vigorous depletion ere the patient was safe. She per- fectly recovered."


212 M. mayor's case.

Here is another case taken from the 1st vol. p. 217, of Dr. Moreau's Traite Pratique des Accouchemens . It was communi- cated to Dr. Paul Dubois, of Paris, by Dr. Mayor, of Lausanne.

"S. G., an ignorant peasant woman, set. 32, who had borne three children, being assisted in her last two by her mother-in-law, ignorant as herself, was three and a-half months pregnant, when, on the 7th Nov. 1836, she was attacked with wandering pains; though the pain did not prevent her going out about her affairs: she said, in her trouble, it might he that she would die the next day.

"Upon coming home about 8 P. M., she went to bed, and was soon seized with sharp pains in the belly and loins, that made her cry out aloud, and which the mother-in-law supposed were fore- runners of a miscarriage; this was at 9|- P. M. At 10| the husband, who was assisting her for some purpose, discovered a large substance escaping at the genitals: being alarmed by this and the hemorrhage and pain together, they began to think of calling in a physician. The husband went to the midwife of

M , a neighboring village, who, reaching her at one o'clock,

found an enormous tumor outside of the vulva, attended with anomalies so extraordinary, that she insisted on having the opinion of an experienced accoucheur. The husband ran to Mr. C, who arrived at 3^ A. M.

" After some inquiries into the nature of the tumor, the surgeon ascertained that it was the womb in a complete state of retrover- sion, and he succeeded in pushing it back and restoring it to its natural position. But the woman, who was already in the most deplorable condition, expired at half past four A..M., very soon after the reduction of the organ."

The patient's death would have passed without remark, as one of the events that sometimes occur in abortion or hemorrhage, had not rumor attributed it to criminal designs.

The authorities, therefore, ordered the autopsy for three o'clock on the 10th, fifty-seven hours after the decease ; and Messrs. M. &. C, two well informed and well known surgeons and accouch- eurs, were appointed for the purpose. Their proces-verbal con- tains the following account :

"The external genitals exhibit nothing peculiar; but when slightly separated, they exhibit at the depth of one-eighth of an inch, towards the fourchette, a ragged wound. The vagina is smooth


M. mayor's case. 213

to the touch and the neck of the uterus, firm and unengorged, is found resting upon the symphysis pubis. The vagina is very re- laxed, and the body of the womb, when raised, is very movable,

" We opened the abdomen, and sawed asunder the ossa pubis in order to obtain a better view of the organs, contained in the cavity of the pelvis. The bladder, which was very large and flac- cid, containing no urine, was raised above the pubis, and appeared to have been distended ; in other respects it was unaltered, and partially concealed the body of the womb. This organ, pyramidal in shape, was six inches in length by five in breadth. It was soft, flaccid, reddish, and showed several ecchymoses, and small semi- circular lacerations, as if cut with the finger nails. Discovering in froilt of the sacrum, in the peritoneal lining of the pelvis, a trans- verse wound, we found the womb communicated with the posterior inferior part of the vagina, so that the vagina communicated with the abdominal cavity. Here, then, was an accidental canal, whose upper orifice was formed by a rupture of the peritoneum, its lower by a laceration of the vagina, and of which the middle portion occupied the lacerated recto-vaginal septum."

" Upon pushing the body of the womb into this opening, we found that it passed without difficulty through the inferior opening near the fourchette ; and thus we observed the position of the womb when it was seen by M. C , during the woman's life,"

I shall not cite any of the remaining passages of this case, pre- sented by Dr. Moreau. They consist of stupid interrogatories of the lawyers who were concerned in the trial of the accused. The foregoing are enough to show how great is the power to bear down, (tiivarjfio?,) in a strong woman like this peasant, who, under the irritation of her tenesmus, actually drove the body of her re- troverted womb through the posterior strong wall of the vagina, and fairly pushed the whole organ out of the genitalia, the fundus hanging down betwixt her thighs, and the os tincse looking up- wards into the pelvis. It is truly an extraordinary case, and one well calculated particularly to impress your minds not only with just ideas of the serious importance of the malady, but to show how powerful is the resistance a strong woman is able to make to your attempts to reposit, when her tenesmic force is excited, and beyond the control of her will.

It sometimes happens that the surgeon cannot succeed with the two fingers of the right hand, in carrying the retroverted womb so


214


RETROVERSION.


Fijr. 2.



far upwards, along the curve of the sacrum, as to compel it to rise above the promontory of the bone, and thus be set at liberty from its imprisonment in the lower basin of the pelvis. In order to effect this, the fingers are required to be longer than the usual length.

By means of the little instrument, of which the ad- joining figure is a representation, you will be enabled to carry it much farther than with the fingers. The instrument is made of steel, and it is conveniently curved to suit the form of the back part of the excava- tion. Conducted along the Jeft indicator finger, to the cul-de-sac, behind the vaginal cervix, it may be pressed against the overset womb, which is readily pushed upwards by it. It is also a convenient instru- ment for drawing do\vn the cervix from near the pubis ; — that part of the organ being taken hold of by the ring. The whole instrument, from the top of the ring to the end of the handle, is just eleven inches in length.

It is made by Mr. John Rorer, and also by Mr. Schively, of Philadelphia.

As I have found it a most convenient and useful apparatus in the management of retroversion, I heartily recommend it to you.

I beg you to be careful in your diagnosis; always be very careful. If you love your profession, and would keep up its dignity, and your own, do not make mistakes. Do not suppose you have a re- troversion, when, instead of that, you are called to a case in which an enlarged ovary has fallen down in the pelvis. Such a tumor might fill up the whole of the space betwixt the sacrum and the bladder, lifting the womb up and jamming its cervix against the pubis. In such a state of things, should you seek for the os uteri, and find it up at the pubis, and also find a rounded mass thrust- ing the posterior vaginal wall forwards, you would be in great


danger of making a false diagnostic.


The pathognomonic mark of a retroversion is the os uteri not beneath, but above the crown of the pubal arch, while the cervix can be traced with the finger backwards to the body, which presses the posterior wall of the vagina forwards and downwards, giving


RETROVERSION. 215

the sensation of a mass or tumor, which is hard or jBrm in the non- gravid, and softer, or yielding in the gravid womb. If you should, in your early career, meet with a retroverted gravid womb, and make prudent attempts at reposition, after all the preliminary- measures have been fully attended to, you might prefer to obviate the inflammatory engorgement by venesection, the bath, emollient cataplasms, anodyne enemata, or doses of anodyne medicines, and very scrupulously attend to the evacuation of the bladder, in hope of meeting with such success as Dr. Ingleby justly boasts of ob- taining in the case I quoted from him.

But when, after consistent attempts, you shall have ascertained your failure, you ought, if possible, to introduce a sound into the OS uteri to rupture the ovum, and discharge the liquor amnii. After which you might expect to succeed in your manipulation by the vagina, or by the rectum. But as it will in some instances be found impracticable to get the sound into the os uteri, you have the last resource of puncturing the membranes, by means of a curved small trocar, carried into the uterus itself. This is a dangerous operation, because, as the peritoneum descends be- hind the womb, on the vagina, you must necessarily make two wounds in it; and thus expose the patient to the danger of a wounded serous membrane, besides that of a wounded uterus. A statement of the circumstances and motives would always, however, leave your skirts clean, provided the circumstances and motives have both been well weighed, and perfectly apprehended by you.

Your writers will tell you, that when the womb is reduced or reposited, the woman should lie on a bed with her hips elevated, or some of them advise her to lie as long as possible on the face. As to this piece of counsel, you ought to judge from the circum- stances. If the case be one of non-gravid retroversion, the best position for renewing the diflBculty would, I think, be the dorsal decubitus ; and I should much prefer to lay the patient on the hip, slightly inclined forwards. In the gravid case, if the pregnancy have proceeded as far as the second month, and a fortiori, if to the third month or more, it is extremely improbable the accident will be repeated if the urine be regularly drawn off, for the uterus is too long to fall over without reluctance and force.

If you deem the case one not unlikely to relapse, you should, if not living near enough to render aid yourself, at the proper seasons,


216 RETROVERSION.

give the patient directions as to the use of the catheter, and in- struct her to introduce it every four or six hours, so as to make sure that no bladder-tension shall overthrow the womb again during your absence.

"When you can venture to employ a pessary, which you cannot well do in the pregnant female, you should adjust one of suffi- cient magnitude to produce or extend the vagina. I say extend the vagina, and I say so, because there will be scarcely a relapse if you keep the vagina stretched to its full length. When it is so stretched, it carries the uterus upwards, and makes it move up- wards coincidently with the curve of Dr. Carus. In order to a first retroversion, I esteem it indispensable that the whole womb should descend, see-sawing backwards; for I cannot imagine a retroversion, as taking place with a vagina four and a half or five inches long. Try the case in your own judgment ; think how a womb could be retroverted, while it stands so high up in the pelvis. If you perpend the question carefully, I believe you will decide that it cannot be turned over by the bladder, without first descending along Carus' curve, so as to enable the fundus to get down lower than the promontorium, and when once down there, the tenesmus will complete the oversetting of it.

I have many times reposited a non-gravid womb, that had long been retroverted, and placed beneath it one of Dr. Physick's globe pessaries, of two and a half inches diameter. Such a pessary will keep the womb in its place pretty well ; but, if the round ligaments have lost all their tone, a full bladder, aided by a fit of sneezing, laughing, or in straining at stool, will readily overset it again. I speak of the non-gravid womb, which, you know, is about two inches long, more or less.

You might well imagine that, when the womb is supported by such a pessary as I have just mentioned, the retroversion might take place upon the emptying of the bladder, — because, as the posterior wall of the bladder comes nearer the pubis, the less the water within it ; so the anterior face of the womb, which is attached to it, must also approach the pubis ; and being only two inches in length, and without support from its ligamenta rotunda, would rea- dily tumble over backwards. I say that this is, to my knowledge, the case; and I say so, being grounded upon observations made, over and over again, especially in three individuals, whose names I have no right to make public. In all these women, I have repo-


RETROVERSION. 217

sited the uterus completely, and it has fallen over again imme- diately. I have reinstated it, and again it has become displaced : nor could I get it to stay in situ, until I had supported it at a great height, by means of Dr. Blundell's stem-pessary.

I have, in fact, come at last to the conclusion, that in one of those exceedingly relaxed cases of round ligament, where the womb falls over as soon as you put it up, it is pretty much a hopeless task, the attempting to sustain it by any other than the stem- pessary. Yet, in a case where the uterus does not at once turn over again, after being reposited, I conceive the globe the least inconvenient, safest, and surest of all remedies.

If you prefer to make use of Dr. Dewees' disc, you can do so ; but I apprehend a careful inquiry into the relative power of eleva- tion of the two sorts of pessaries, will bring you to the conclusion that a two inch globe will lift and hold the womb much higher than a three inch disc-shaped instrument. As for the sponges and other horrid conceits of the sort, they are too detestable to be thought of. I disapprove of the glass ones — when strong, they are too heavy, when light, too frangible. A cork pessary is bad, because the wax that covers it comes off, and leaves the rough cork in contact with the parts. Such contact is dangerous — it is ulcera- tive.

Do you expect I should say something more of those utero-abdo- minal supporters ? I deem them abominable. I have never used, and never shall use one of them. To think of curing a retroversion or prolapsus with them, is an anatomical absurdity. But I shall not dwell on them, because you will not forget w'hat I said of them in my lectures.

I have w'ritten you a very long letter on retroversion, perhaps too long ; and yet there remain many things I could say. Let us recapitulate before I close, some of the opinions expressed in this letter.

1. Retroversion consists in the turning of the top of the womb over towards the sacrum. The fundus uteri dips down into the hollow of the sacrum, and the posterior surface of it comes into contact with the posterior surface of the vagina, which it presses forwards and downwards towards the os externum, making a tumor there. The os uteri is directed up against the bladder, which it pushes against the symphysis pubis.

2. It causes dysuria, or retention of urine ; or at least, mictu-


218 RETROVERSION.

rition. It also gives rise to pain in the course of the round lio-a- ments, and the ligamenta lata. It is attended with pain in the region of the sacrum, loins and kidneys, and there is a sense of weight, pressure, or bearing-down, in the hypogastrium and pelvis.

3. When it occurs in the pregnant woman, it is fraught with danger both to the mother and child. If uncured, the mother is likely to be the victim of a dreadful death, from pain, inflamma- tion, and from total obstruction of the pelvis.

4. The more advanced the pregnancy, the more dangerous the accident.

5. It is a diseased or debilitated state of the round lijiaments that gives rise to the disorder. The cure consists in the restora- tion of the health and tone of those ligaments.

6. It is in some cases incurable, from adhesions tying the womb down in the excavation.

7. It should be treated — 1st, by evacuating the bowel; 2d, by drawing off the urine ; 3d, by repositing the womb; 4th, by sup- porting the reposited womb with a pessary; 5th, by carefully en- joining an attention to the state of the bladder, which should never be allowed to get too full.

8. Lastly, I ask you why a pessary should be able to cure the round ligaments? I am sure of your answer. It is this: every tissue of living beings that is not compelled to extend, has a tendency to condense or contract itself. This is true, whether of muscle, cellular tela, lung, skin, and all the rest. While the round ligaments are extended by an overturned womb, they can- not become shorter, they cannot exert their natural tendency to condensation. To lift up the womb, and keep it up, to empty the bladder, and prevent it from being overfull again, is to give to the round ligaments an opportunity to act out their nature — that is, to regain their natural length, strength, and tension — which is effected by time, by tonics, by wholesome food, and by whatever tends to consummate the state which you call health. Take care that when they do recover, they go not beyond the state of reco- very, and contracting too much, bring on the very antithesis of retroversion, I mean an anteversion of the womb, which shall be the subject of my next letter. Farewell.

C. D. M.


ANTEVERSION. 219


LETTER XVII.

ANTEVERSION OF THE UTERUS.

Gentlemen : — The state of the uterus described in my last letter, under the title of retroversion, is much more common than its op- posite, the anteversion of the organ, a case in which the fundus is drawn or pressed towards the bladder of urine, and permanently maintained in that position. In such circumstances, the external signs are perhaps not different from those that attend upon the retroverted state; and they consist chiefly of pelvic pain, misery, bearing-bow^n sensation,' micturition, and pain and w^eakness of the lumbar and sacral region, which are increased by exercise, and by the standing position. I do not think that I should be able, from any complaint, or relation proceeding from the patient, to discriminate between the affection attendant upon the ante- verted and the retroverted state of the organ ; nor do I suppose that any physician could correctly and confidently make such a discrimination, except upon information acquired by means of the

TOUCH.

I said that the anteverted is not so frequently met with, as the retroverted deviation. I am, indeed, of opinion that it is a rare malady, for, in more than thirty years, I have had few opportu- nities of observing it, whereas, I have met with a very consider- able number of the contrary sort ; a number so great, that I think it not very much disproportioned to simple prolapsus, as to fre- quency of occurrence.

The anterior face of the non-gravid womb, as high up as the middle of the corpus uteri, is in contact with the bladder; which, as I remarked in my former letter, pushes the womb backwards when filling, and draws it forw^ards towards the symphysis pubis as it becomes emptied; the round ligaments being put upon the stretch in the former, and completely relaxed in the latter pro- cess.

The only natural anatomical power that can draw the fundus uteri to the pubis, is to be found in the bladder of urine ; — for the


220 ANTEVERSION.

round ligaments do not, as a physiological act, draw the womb nearer to the pubis than the middle of the pelvis, where it ought to be coincident, as to the direction of its axis, with the curve of Carus; whence it appears to me, that in all cases where the fun- dus uteri is permanently drawn against the bladder, and near the pubal bone, we must resort to one of two modes of explanation of the occurrence, one being, that it is pushed there by some body lying upon and behind it ; and the other, that it is drawn or pulled in that direction by the ligamenta rotunda, which have become so short as to prevent the womb from retracting towards the sacrum when the bladder, being full, tends to send it off in that direction. Here, then, are two possible causes of anteversion ; one, pressure from above or behind; and the other, traction or drawing from before.

Now, the causes that might act on the organ from above and behind it, are tumors fallen down into the pelvis, or developed in its superior parts; which, by their weight or volume, compel the uterus to assume a sort of horizontal attitude, pointing the os uteri backwards, and the fundus forwards ; — or, the compressing cause may consist in a tumor, or tumors developed on the supe- rior and posterior parts of the corpus and fundus uteri, extending backwards in their growth, until meeting with a point dappui on the back part of the pelvis, and unable to extend farther in that line, continue to grow, but always finding space by thrusting the organ from which they spring towards the bas-fond of the blad- der.

Doubtless such may be the true rationale of some of the cases, yet admitting this to be true, it is still clear to nie, that a con- traction of the ligamenta rotunda is much more generally the cause of anteversion. I can form no other conclusion from my own observations, and, on several occasions, I have had opportu- nities to test the thing yi my practice ; I having, in some of the samples, in vain tried to push the fundus off from the vicinity of the pubal symphysis, with one, or with two fingers, introduced far upwards behind the shear-bone. Upon making such attempts, having failed to move it out of its fixed position, I have been obliged to adopt the opinion, that the womb was tied down by a contraction or condensation of the tissue of the ligaments, so often named. What other opinion, indeed, could, or can be reasonably adopted in a case where the most careful exterior palpation clearly


ANTEVERSION. 221

proved that no tumor, fallen from above, or developed behind the womb, had pressed it against the front bone of the pelvic cavity. I saw to-day, June 10th, a case in which the womb was jammed hard against the pubis, by a tumor in the pelvis.

It is pretended that the front, or the posterior half of the womb, may, by some vicious condition of the development force, grow to so great a size as to overthrow the womb, either in a backward or in a forward direction.

I have not had any opportunities of seeing such samples, and cannot, therefore, speak from experience, as to such causes of ante- version. I may, however, say that I have met with several cases of unequal lateral development of the uterus, giving to the organ a tendency to fall or become oblique, to the right or the left side, according as the right or as the left symmetrical half of the womb was the largest.

Dr. Tiedemann showed me two or three such specimens, in the Anatomical Museum at Heidelberg, in 1845, and I have had two such in my own collection. It should be observed, that as the uterus originally consists of two symmetrical lateral halves, we might reasonably expect to meet with such unequal developments occasionally. It is probable the other sort, or that wherein the anterior and posterior halves are so unequally developed, must be from the nature of the embryogenic development law, much more rarely observable.

Allow me to repeat, that I have not met with a great many in- stances of anteversion. In all that I have met with, how'ever, there has been left upon my mind, after careful exploration, no doubt as to the shortening of the round ligaments; and why not? The round ligaments are very subject to disease, being often in- flamed after parturition; so much so, as to constitute a cord as large as the fore-linger of a man, or even as large as a thumb, very painful upon pressure, and traceable in its course not only through the abdominal canal, but backwards towards the angle of the womb, through the thin integuments of a scrawney woman. I have met with several samples of this sort, that I have been obliged to treat by leechings, fomentations, cataplasms, and by small doses of tartar of antimony and potash.

Morgagni, in his forty-fifth epistle, tells us, that he found them so in his dissections. He regards them as constituted chiefly of blood-vessels; but Velpeau considers them as endow'ed with a


222 ANTEVERSION.

considerable portion of muscular fibres. I deem it quite reason- able in M. Velpeau, to hold such an opinion, since, as they spring directly from the womb, and proceed to be inserted upon the ex- terior of the pelvis, they could not but carry with them a structure like that of the womb, as well as like that of the Fallopian tubes, of whose muscularity no doubt can be entertained.

Seeing, then, that the womb naturally rests on the top of the vagina; that it is wholly without attachments on its posterior face; that it has none but those of the two ligamenta lata on its sides, and that its only connection in front is a partial one to the blad- der, and its sustentation by its round ligaments, we cannot doubt, when we find it held firmly against the pubis, of its being held there by means of some tumor behind or above it, or by a pair of contracted ligamenta rotunda; contracted, I say, either by a simple process of hypertrophy, by the consequences of inflamma- tion, or by some spasmodic innervation of its muscular fibres.

To cure it, we must push the top of the womb off from the vi- cinity of the pubis, or we must cure the ligaments of their hyper- trophic or inflammatory vice.

It is possible that Dr. Grauiex's seton, mentioned at page 58, Letter V., might profitably be applied to the subduction of the morbid activity of the ligaments, and in any case where the pes- sary and other means of countervailing pressure should be deemed inadmissible, I hope you would take into consideration the ques- tion of this especial seton. You are aware that the seton, in a cure, is like money in the funds, it works while you are asleep, it works day and night, for weeks, and months, and in general, only well, only with beneficence. I advise you to think of the seton, therefore. I confess I have not met with the case that I have deemed suitable for its trial, but I should certainly recom- mend it to a patient of mine, whom I should deem likely to be benefited by it.

The pessary, after all, is the most probable and most convenient remedy.

A globe of two and a half inches, will lift the uterus very high upwards in the pelvis. Its action must be to push the womb up- wards and backwards, and therefore to resist the contractility of the round ligaments. But, by resisting it steadily, gently, and protractedly, it will at length draw them out, elongate, stretch, or restore them to their due and normal length; which, being done,


FLEXION OF THE WOMB. 223

the globe maybe removed, and the filling of the bladder entrusted with the business of maintaining them at their proper longitude, for the rest of the patient's life. Such a patient, even while under treatment by the pessariuro, should be advised to keep her bladder pretty full. A bladder of urine, containing sixteen or twenty ounces of fluid, would be a very powerful antagonist of the con- traction of the lio^amenta rotunda. This is one of the cases in which a mere verbal order, or talking explanation will not answer your purpose. You ought to take out your pencil, and making an intelligible sketch of the parts interested in producing the incon- venience, show to the woman, and convince her of it, that if she will not carefully push the womb away from the pubis, by filling her bladder quite full every day, and more than once a day, she need not very confidently expect to remain cured, even if you should cure her.

Before I close this letter, I must take occasion to say, that Mr. Warner, whose name I mentioned before, makes for me an egg- shaped pessary, larger than a hen's egg. He can make them for you of any ordered size. I have found this ovi-form pessariura very useful in anteversions. I adjust it with the lesser pole of the egg directed to the os tinca^. The greater pole is in the lower part of the vagina, just above the grasp of the sphincter. I think such a shaped instrument serves to stretch the ligaments more effectually than any other.

There is a state of the womb called flexion of the womb, which may be either a retroflexion, or an anteflexion. In this condition the organ is bent, either forwards or backwards, and the bend, or angle is found in the neck.

Madame Boivin says the flexion is found at the junction of the cervix and corpus ; and she is of great authority. I have seen, and I possess one such specimen; but this is the only one I have seen; whereas I have met with a considerable number of in- stances in which the bend took place in the true cervix, far be- low the corpus, and sometimes in the vaginal cervix itself. I have now under treatment a young married lady, in whom the vaginal cervix is bent very nearly at a right angle to the long diameter of the womb ; whose fundus is strongly held by a con- tracted state of the round ligaments, close against the pubis. In those cases of diseased uterus wherein we find the womb grown solid, and as large as the healthy uterus, at four or five months


224 FLEXION OF THE WOMB.

of pregnancy, we rarely fail to find the cervix bent like a retort neck.

I do not know any general signs by which flexions of the womb can be diagnosed, save those discoverable by the touch, and they are so clear as hardly to be worthy of description. Everybody knows that the womb is straight ; and where it is found bent into a curved, or an angular form, it is a case of flexion ; anteflexion if the re-entering angle is forward, and retroflexion, if the salient angle is turned towards the front of the excavation.

Many women have the cervix uteri very slender; some of them are not bigger than the little finger. Now, if a woman with such a slender, flexible, and weak cervix, should have some degree of descent of the womb, it might happen that the long slender cer- vix, being driven, or having descended far enough to rest, upon the posterior part of the pelvis, or even on the posterior wall of the vagina, should bend with its own weight and any superadded weight, so that the cervix would cease to be straight ; but, become curved or angular ; and after being kept so for many months, would acquire such a form, as its permanent character.

I deny not that other causes besides direct pressure, might give to the cervix uteri this distorted appearance ; such causes might be intrinsical ones, depending on some development of the pos- terior or anterior half of the cervix, causing the anterior, or the posterior half to be too short. Such an unequal development would certainly bend it. There can be no doubt that such is the case as to those lateral curves that I spoke of in a former part of this letter as having been shown to me by the good Professor Tiedemann, at Heidelberg.

I do not know that these curved or angrular conditions of the cervix are, in themselves considered, to be esteemed as matters of any very great consequence. I have not any reason to sup- pose that they cause the patient to experience any pain, or any distress. My opinion is that they are chiefly to be regarded as signs and accidents of a displacement of the womb, and that the indication is to support the womb, which being done, the curve will disappear. However, it should be observed that if the curve is a development fault, no lifting up of the uterus will be likely to do any good, as far as the curvature is concerned.

It is probable that where this curve or angle of the cervix uteri exists, there will be little probability of the womb ever becoming


FLEXION OF THE WOMB. 225

fruitful. To cure it, will be perhaps to remove the barrenness. I say this, though I am aware it has been asserted that curvatures are met with, even in the pregnant female. I deny not that Bau- delocque may have met with curvatures in the gravid womb, but I do contend that any such curvature is avery different thing from the angularities we are speaking about.

You may see in the plate 11, figures 15, 16, 20 and 21, of Wigand's Geburt des Menschen, 2d edit, by Dr. Froriep, samples of this distortion in the gravid uterus, but they are all lateral curves; and I pray you to remember that symmetrical halves are governed by laws quite different from those that rule over opposite halves, at least in all the true Zygozoars. Wigand says of these unequal sides: "Die pradisponirende Ursache dieser s'ich so allmalig und erst wahrend der Geburt, und selbst bei der normalsten Kopf-oder Steifslage entwickelnden schlecten Configu- ration des Uterus, scheint auf einer gewissen abnormen ange- bornen structur-oder Entwickelung der Bewegungsfasern der Gebarmutter, und einer daher ruhrenden krankhaften Neigung derselben zu partiellen, unregelmassigen Contractionem zu be- ruhen." — Geburt des Menschen, p. 75.

The predisposing causes are, in Wigand's opinion, to be sought for in a certain original deviation in the structure or deve- lopment of the muscular fibres of the uterus, and a consequent tendency to partial and non-coordinate contractions in labors.

But, after all, I deem there is but little profit in so much dis- cussion; the gist of the matter being essentially the cure. But how to cure it! Some have proposed to pass up a small spatula of wood (it might be well denominated a peg), into the canal of the cervix, to straighten the bent cervix, by leaving it in situ. Such a process of spitting or skewering the w^omb, appears to me ridiculous. The more especially, as I have always found that when I had straightened the cervix with the pressure of my fingers, it would always immediately recover its curvature wuth a spring, as if made of caoutchouc.

To wear such a skewer or peg as has been proposed, would be merely to hurt the woman, not to cure her womb ; pray don't try it.

But, how to cure it! that's the question. I do not know any other method than lifting the womb up. If it be a case of ante- flexion, lift up the womb to stretch off the ligamenta rotunda; if 15


226 FLEXION OF THE WOMB.

a retroflexion, raise up the womb to let the ligamenta rotunda contract, and condense themselves. You see that the pessarium is in this case, in the same predicament as the Satyr's guest on the mountain, who blew his fingers to warm them, very reasona- bly, and then blew his porridge to cool it, which was also quite a reasonable action. Don't you, like the Satyr, turn him out for blowing hot and cold with the same breath. That Satyr was but a Satyr at best. What reason, then, had Father Msop to expect philosophy in such a beast, or to set him up as an example of wisdom and justice? If it be a retroflexion, use a large globe; if it be an anteflexion, take an oviform pessary of silver gilt, and choose one as large as a Normandy hen's egg; adjust it, so that the lesser pole of the egg shall look towards the uterus, while the larger pole shall lie in the lower segment of the vagina. I have found such an one efficacious in pushing oft' the uterus from the bladder, and at the same time in producingor elongating the tube of the vagina.

I said, in a note to Colombat, p. 150, that I had met with but one sample of the true anteversion of the womb up to the date of that writing, which was nearly three years ago. Since that I have met with several cases of anteversion.

I had seen many instances in which the vaginal cervix was angular, either in the anteflected or retroflected form, but they were instances derived evidently from the pressure of the flexible cervix, against the posterior wall of the vagina, and did not in- terest the principal portion of the long axis of the uterus ; proba- bly such cases scarcely deserve to be classed among the true ante- flexions of the organ.

I shall say nothing in this letter as to the lateral obliquities of the womb, I shall probably advert to them when I come to speak with you on the disorders and accidents of pregnancy. In my next, I shall offer you some observations upon inversion of the womb, several samples of which have fallen under my notice.

I am, &c., C. D. M.


INVERSION. 227


LETTER XVIII.

INVERSIO UTERI.

Gentlemen : — The term Inversion of the womb, is applied to express that state in which the uterus is turned inside out; as a stocking or a glove is turned inside out by drawing it off the foot or the hand.

Dr. John Green Crosse, of Norwich, in England, published in 1845, an 8vo. volume. Part I., entitled An Essay Literary and Practical^ on Inversio Uteri, which is so fu]l of learning, research, and that practical good sense that distinguishes all the writings of that able gentleman, that I am under no little temptation to give you the whole of it as a letter; but I should, in that case, violate the rule laid down, to render this volume as nearly as possible an original one. I shall only, therefore, advise you to take the firt.t opportunity to read Mr. Crosse on the subject in question. Doing so, you will learn that he says at p. 8,

"Inversion signifies not only a turning inwards of the uterinr walls, but a turning inside out of the whole organ, by its passing successively through the os tincse, converting the lining mucous membrane into an exterior covering of the uterus, and creating a new cavity, which is lined with peritoneum, and communicates superiorly with the cavity of the abdomen."

Mr. Crosse, in another paragraph, says, "inversion of the uterus is either partial or total; the latter can exist only in one degree, and admits of no subdivision. Partial inversion, on the contrary, comprises very many degrees, and there are both physiological and practical reasons for noticing and describing three, by way of classification, namely, depression, introversion, and perversion.

Such are the divisions of our malady proposed by Mr. Crosse, and he next goes on to show, that depression, which is the slight- est degree of partial inversion, is present when any portion of the entire thickness of the walls becomes convex towards the cavity of the uterus. Introversion is the case where the depression has gone so deep, as to bring a part of the fundus within the grasp of


228 INVERSION.

the portion of the uterus into which it i« received. Perversion is when a portion of the fundus projects through the os tincae.

This, then, is Mr. Crosse's classification, which, as you per- ceive, furnishes easy terms of communication, whenever in con- versation or in writing, you desire to treat of the several degrees of the accident in question. It serves, also, to keep in the re- membrance the fact, that where the womb is in danger of inver- sion, that danger may be greater or less, according as the accident has proceeded to a greater or less degree.

You may know that the womb is inverted by several signs; which are, pain, hemorrhage with its attendant phenomena, ab- sence of the uterus from its usual place, a tumor in the vagina, or in the womb, or depending outside of the vulva, also by a concavity felt in the fundus of the womb, instead of its natural convexity ascertainable by palpation of the hypogastrium.

The causes of inversion are chiefly to be found in improper or accidental tractions on the cord in child-bed. They are improper whenever an ignorant person takes hold of the umbilical cord, to pull forth the after-birth, without first ascertaining that the womb is contracted ; the accidental causes are where too short a cord inverts the womb which has just forced the child into the world, aided in its contraction by the contraction of the abdominal mus- cles. A woman is sometimes suddenly delivered while standing upon her feet, or in rising from the close stool ; in such a case, the fall of the child towards the floor, is apt either to break asunder the cord, or if the uterus become suddenly relaxed, it may draw the adherent placenta still attached, and the whole fundus and body out at the genital orifice.

A womb may also be inverted, by rudely pressing or kneading the hypogaster with the hand in order to enforce its contractility. To press rudely, in this way, upon the top of the fundus, and im- mediately expect the woman to bear down, is not very safe, since if a depressioTiy as Mr. Crosse calls it, should have been produced by your palpation, and the woman should at once begin to bear down, she would probably convert the depression into an intro- version, then into a perversion, and so at length, into a complete inversion. Even the act of straining at stool, or at urine, after the delivery of the placenta is completed, might suffice to cause an inversion, provided it should be done at a moment, when the womb is lying within the belly flaccid, and loose as a wet bladder.


INVERSION. 229

I have found the womb to fall down as it were spontaneously, seemingly because it was destitute of any solidity capable of resist- ing the ordinary pressure of the abdomen, even when not under a tenesmic irritation.

A polypus, or other tumor, growing within the cavity of the womb, comes to be so large in the course of time, that it passes out of the circle of the os uteri, and takes possession of the vagina. Here is naturally set up a powerful uterine tenesmus; the depres- sion makes its appearance, the introversion follows, and so from step to step, the patient lapses into true complete inversio uteri.

The diagnosis of inversion in its different stages, is not without great difficulty in some of the cases. It is so in reference to the similarity of the appearances presented by some of the fibrous, and even by some of the cellular polypi, with those exhibited by the inverted womb, and as this special diagnosis is not only a very difficult but a very important one, I beg that you will always very seriously incline yourselves to great cautiousness and slow- ness, before you make, and especially before you announce your opinion of any case.

Where you are called in to witness, and give counsel or aid, in an inversio uteri that has just taken place, you can have no diffi- culty in making a correct opinion. But in those that have hap- pened long before, and in which the womb, though inverted, has re- covered nearly its non-gravid size; take, I beseech you, very great care not to make a mistake ; don't think you are dealing with a uterine polypus, when you in fact are dealing with the womb itself; because, when people deal with a polypus they cut it off, when they deal with the womb, they let it alone, which is a very great and a very important difference.

I repeat, that it is difficult in some of the instances, to discrimi- nate between the inverted uterus, and the polypus uteri. In neither is there an os uteri to be felt ; they are both reddish look- ing, softish, bleeding, rather insensible masses, about as large as the larger end of an egg, save when the polypus is larger; I mean in the chronic forms.

In passing the finger or two fingers upwards in the vagina, a ring like what the French call a bourrelet, is felt through which the tumor passes outward, into the cavity of the vagina. If you look at them through a speculum uteri, you will scarcely be able from the light to discriminate betwixt them.


•230 INVERSION.

You must carefully gather the whole history of the case, as for example by the following method.

"What's your name?"

"A. X."

"How old are you?"

"Twenty-six."

"Are you married?"

"Yes, these eight years."

"Had any children?"

"Three."

"When was the last one born?"

" Six months ago."

"Any trouble or difficulty at the birth?"

"Oh yes, I flooded dreadfully."

"Who attended you?"

"Mrs. Lucina."

"How was it with the after-birth? Did it come away soon?"

"No, sir, it was a long time coming."

"Did it hurt you?"

"I guess it did, indeed; she pulled me so hard, I screamed till you could have heard me a square off."

"Well, what happened next?"

"I don't know, for I fainted away and was a long time so weak, that I cannot tell what happened."

"Did you flood very much?"

"Flood! why I was fairly covered with blood."

"How long before the discharges stopped?"

"Why, it's never stopped in fact, for I am more or less unwell every day, especially if I do any hard work."

"You look very pale."

"Bless your heart, I used to be as red as a rose."

"Have you any appetite?"

"Yes, pretty good, thank you."

"How are the bowels, regular?"

" Oh, no, quite costive."

"Any trouble of making water?" »

"Very much; often obliged to go, and to get up at nights. It's a great trouble to me."

"You must let me examine the case; I can't tell what it is ex- cept you allow that."


INVERSION. 231

"Well, I suppose if I must I must. But don't hurt me."

"Not in the least, not at all."

Now let the patient lie down on her left side, with her buttock near the edge or foot of the bed, her thighs at right angles to the trunk, and the legs flexed ; a pillow betwixt the knees ; wash your hands with soap and warm water; 1st, to cleanse them; •2d, to soften them; 3d, to increase their tactile sense, for you ought to have that sense in its highest perfection. Anoint the index with oil, and Touch the patient.

The tumor is as large as an egg, and contained within the va- gina. It is pyriform or ovoidal, and gives no pain. Push your index up along the root of the tumor to a sort of circle or cul-de- sac, which prevents the further advance of the finger. Touch it all round the tumor, in front, behind, and on the right and left. Introduce a Sedillot's catheter, and push the end upwards through the encircling bourrelet, to ascertain how high it will go, and whether it will go equally high all round the neck of the tumor. If it will go high on one side and not near so far on the other, the inference is, that you have not under care an inversio uteri, but a polypus uteri. If it go equally high all round, and not very high anywhere, the inference is strong in favor of an inversion.

Now insert your Sedillot into the urinary bladder, after having put a cork into the outer end of the silver tube to prevent the urine from escaping. Keep it there while you pass the indicator of the left hand into the rectum, very far upwards. Then, tak- ing the catheter in your right, turn the concavity towards the sacrum, and with your finger bent forwards towards the pubis, try to meet the point of the sound ; surely, if you will do this, you cannot fail to ascertain that no womb is to be found betw^een the points of the finger and catheter, and therefore, the tumor in the vagina is the womb inverted.

It was inverted at the time of her confinement, six months ago. Mrs. Lucina inverted it by pulling at the cord before the placenta was detached, and either did, or did not know what she had done. The hemorrhage was terrible. The woman ceased to bleed, and did not die, because she fainted so badly, that the vascular injec- tion by the heart was too feeble to kill her by hemorrhage. She slowly recovered in a measure, but bleeds still upon the smallest excess of exercise or labor.

Well, now, my young friend, you have made your diagnostic ;


232 INVERSION.

what are you to do for the patient? Will you reposit or reinstate this womb? You can't. You might as well try to invert one of the non-gravid uteri on my lecture-room table as to reposit this one. The time is gone by. You have no art or skill, nor no power equal to the performance of such a miracle of surgery as that.

I can with difficulty, conceive of a more dreadful condition for lying-in woman, than that in which she is placed by a total inver- sion of the womb in labor. For example — here is a case that I have already published, in my Practice of Midwifery ; but which I think it right to republish in this letter. It is the case of Mrs. S., in S. 7th street, which occurred in June, 1831.

It seems that having on both the preceding occasions suffisred severely from the method adopted by the physician in removing the afterbirth, and supposing that a midwife would deal more gently with her, she engaged an old woman much accustomed, as it was said, to the care of women in labor, to attend upon her in this confinement. The child was born by a very easy labor, but the afterbirth not coming away so promptly as was desirable, trac- tions were made upon the cord which caused the afterbirth to come into the vagina. This gave the patient exquisite pain. The mid- wife, who could not understand why the woman should suffer so severely, made haste to draw the placenta forth by the cord, which made her cry out so loud that it was said her voice was heard in the street. When the mass came away, the good woman found it still adhering to something: she could not take it up and put it into a basin. She therefore continued to pull at it with great force, not knowing that she held in her hands the afterbirth still adhering to the fundus of the womb, which was now completely drawn forth and turned inside out. The hemorrhage was enor- mous, and the patient soon sunk into the extremest weakness and exhaustion. Half an hour elapsed before she thought proper to confess her incompetency to manage the case. I was sent for, after she had acknowledged her ignorance of the method of pro- ceeding, and when I arrived the patient was without pulse, very cold, suffering the extremest distress, with constant jactitation, and a thirst that was unappeasable. To all appearance the wo- man was in the agonies of death. I found the globe of the womb hanging down full half way to the knees, and still invested with the placenta and membranes, except where they had been torn


INVERSION. 233

and broken by the attempts of the midwife to pull the entire mass away, uterus and all.

I endeavored to push the whole womb and placenta back into their natural position, but finding I could not succeed I sent for my venerable friend Dr. James, who speedily arrived. Dr. James now made an attempt to reposit the womb, but he also failed. By his advice I now removed the placenta, but could not force the uterus up into the pelvis.

In making the attempt to restore it to its place, I followed the method recofnmended in the books, that is, I compressed the or- gan in both the hands in order to reduce its size. At last I ob- served that the more I handled it, the firmer and harder it became ; in short, that I excited in it the after-pains, just as we excite them by frictions on the hypogastrium after the child's birth. I therefore inferred that the proper way of proceeding would be to let it rest ; and as soon as the relaxation of the organ should be complete, as it is in the intervals between the ordinary after-pains, to endeavor to indent its fundus, like the bottom of a bottle, and then carry it upwards. I found, upon observing it, that the womb repeatedly expanded or relaxed, and then contracted again, being soft in the former and hard in the latter state. Taking, therefore, the moment of the completest relaxation, I indented the fundus with one fin- ger, and as it became more and more concave, I applied each of the fingers in succession, until I found that its further progress was impeded by the os uteri, which, although it was completely inverted, yet resisted for some time the attempt at reposition. By a resolute perseverance, I finally had the pleasure to overcome the resistance, and the peritoneal surface of the fundus was pushed upwards beyond its os uteri, and at last the womb was found to be completely restored to its natural position, but still containing my hand, which was now up as high as a little above the umbili- cus. As no contraction came on immediately, I retained posses- sion of the cavity of the womb, which I gently excited by moving my fingers within it, and finally a contraction came on which I suffered to push my hand out into the vagina. Upon withdrawing the right hand, I felt with the other the womb very firmly con- tracted in the lower belly, and enjoyed the satisfaction of com- plete success in this distressing case.

I have said nothing of the brandy and volatile alkali that were given to the woman to keep her from dying. She took a very


234 INVERSION.

large quantity of these articles, besides laudanum, before I left her, which I was obliged to do in order to attend to another patient; and I feel under great obligations to my friend Dr. George Fox, who came at my request and took charge of Mrs. S., for the re- mainder of the time that she continued ill. Her situation when I gave her up to his care was nearly desperate, from anemia; nevertheless, by the administration of proper restoratives and the judicious exhibition of stimulants during several hours, she, under his good and wise care, rallied, and, in no very long time, reco- vered a good share of health.

From that period she was, for a long time, not quite regular as to the catamenia, which appeared at uncertain periods, and less abundantly than before her dreadful accident.

Since the above period Mrs. S, has been twice safely delivered of healthy children by my friend Dr. Bache. It is worthy of re- mark, that the placenta was adherent in these cases also ; and that Dr. B. was not able to effect the delivery of the afterbirth until he had separated it from the womb by the introduction of the hand into its cavity.

I cannot refrain from mentioning here, the case related by Mr. Charles White, of Manchester, in which he succeeded in restoring an inverted womb to its natural state by compressing it, and then pushing it up. In his case I am not very sure that the inversion was complete, since, although he represents the inverted uterus to have been as large as a child's head, it was never expelled through the external organs, and it is improbable that if fully in- verted, it could be retained in the excavation. Mr. W. regards his method as of the very highest importance, and thinks he should never have succeeded but for the compression of the womb in the hands.

I am ready to admit that it might happen that a tonic contrac- tion of an inverted uterus should come on at once, and last so long as to prevent the employment of the plan that I suggest ; but I think it probable that it would always be practicable to return it, in any case where it had not been inverted more than four or five hours, by waiting for the moment of its greatest relaxation, and then first indenting the fundus, and afterwards pushing it steadily upwards through the os uteri, and so into the abdomen again.

M. Colombat, at p. 185, advises that the whole mass should be pushed back within the vagina, which is a bad advice, and which


INVERSION. 235

I hope you will not follow, but rather follow mine. I made the following remarks on Colombat's advice at his 186th page.

I cannot think that M. Colorabat gives the best counsel as to the method of proceeding for this reduction. It is hardly neces- sary to say that the state of inversion does not deprive the womb of its muscularity, and consequently of its ability to suffer what are called after-pains. It is also well known that frictions upon the sur-pubal region, and irritations applied to the mouth of the womb, or the internal surface of the organ, are constantly re- sorted to as means of exciting its muscular power. It cannot be, then, that by M. Colombat's method of grasping the neck of the tumor and shoving it upwards, we could fail to excite or irritate the organ into a violent exercise of its muscular force, which could not exist without hardening the tumor and rendering it stiff and inflexible. But if we render it stiff, hard, and inflexible, how shall we expect to return it through its hard and rigidly contracted OS uteri? It is manifest we cannot expect success by so unrea- sonable a method of operating. As the ancients used to say, non cuivis contigit adire Corinthum, so I may say it does not happen to every practitioner to have reduced a completely inverted womb ; and the late Prof. Dewees says, at p. 512 of his System of Mid- wifery, 2d edit., that "we may justly entertain doubts" of the uterus having been reinstated after complete inversion. I have already spoken of the case which I saw with the late Prof. James and Dr. Geo. Fox, in which the womb was not only com- pletely inverted, but had been strongly pulled by the midwife. Now in that case, I used the method recommended by Dewees and other authors, of grasping the globe firmly with the hands, in the view of pushing it back bodily into the pelvis — for it was of enormous size, reaching near half way to the knees — but I w^as unable to meet with the least success, until I had taken off the placenta, which still adhered, though detached in certain parts of the surface and much torn. And after I had removed the afterbirth, I found that the organ became alternately soft and rigid, just as happens after delivery in an ordinary labor ; and I further observed that to handle it w^as to irritate its contractility and to harden it, which rendered it obdurate against every attempt at reduction. I was compelled, therefore, to do what M, Colombat so pointedly condemns: i. e., to wait until it became relaxed, and then to in- dent the fundus and to drive that cone through the centre of the


236 INVERSION.

globe, and up through the cervix and os uteri, until I had carried my hand so high that the external organs contained my arm not more than four inches below the elbow. I feel very confident that if, in any case, I could succeed in indenting a fundus uteri, and in bringing the cone up to the os uteri, I could always per- fect the operation by gently pressing that cone against the ostium uteri, which, under a persevering maintenance of the pressure, would yield as readily as it does to a labor pain, or to the cone of the hand, when introduced in cases of hourglass contraction or spasm of the cervix under encysted or retained placenta. I dare recommend to the reader, therefore, to disregard Colombat's injunction and to adopt the method which I found successful.

In any case of irreducible inversion, I suppose all that can be done is to have patience, and to hope for the best.

You should advise the woman to lead the quietest life she can afford to lead, avoiding all hard work and all fatiguing and pro- tracted effort ; advise her to live in hope, inasmuch as though a doctor cannot cure the malady, nature can, and sometimes does ; and as this is one of the greatest occasions for a woman to cry out in the language of Terence's Andrian,

" Juno Lucina, serva me obsecro."

You will be hard pressed to say what are the powers that can be employed to bring back to its natural form a womb long in- verted.

In every such case the organ or appendages that are connected with the fundus, must be drawn down into the vortex made by the total descent of the fundus, and its escape from the circle of the OS uteri ; that is to say, a good part of each broad ligament, of each Fallopian tube, and of each round ligament. Nor, indeed, can it be, that a part of the bladder is not also pulled into the vortex.

When you reflect that the womb inverted, nearly recovers in process of time its non-gravid size; and if so, becomes hard and elastic, not ductile, it is exceeding difficult to account for the spontaneous reposition. But the law of life, the generic law, is so powerful, that the inverted organ must exist under a constant tendency at least, to recover its form. At all events, the history of our art is sufficiently replete with cases to prove the possibility of a spontaneous recovery. I have the less hesitation then in


INVERSION. 237

laying before you the following cases, which, I have no doubt, are examples of the spontaneous recovery of the inverted womb. I take them from Colombat, page 183, where I published them as a note in my translation of his valuable work.

I saw, a few years since, a female in this city, who had been the subject of an inversion of the womb for about two years. This inversion took place at the time of her confinement, when she had a very profuse hemorrhage, so as to be supposed to be in danger of a fatal result. Her health gradually improved, but she remained subject to frequent attacks of hemorrhage, by which her strength became again much reduced. At length, a physician, who was called in, detected the existence of inversion of the womb, and invited me to examine the case and verify the diagnosis. I found the womb projecting into the vagina, and I believe it to have been, at the time, completely inverted. It w^as not much larger than the non-gravid womb, bled readily from pressure at the time, and was not very sensible to touch, as indeed the healthy uterus is not.

In this case I made the most careful attempt to discriminate between polypus and inversio uteri, and I remained under the absolute conviction, as did the physician. Dr. Moehring, a highly capable practitioner, that the case was one not of polypus, but of inversion. I gave such a prognosis as I deemed reasonable, but added to it the opinion that she would never again be subject to conception. This female was subsequently examined with care by Professor Hodge, of the University of Pennsylvania, with the same diagnostic result ; and later by Dr. Warrington, of this city, well known as a Teacher and practitioner of Obstetrics. These gentlemen all agree that the case was one of inversion, and the at- tempts made by myself and by them, to reposit the organ were with- out the least success. Nevertheless, about some four years poste- rior to the period of my visit to her, she became pregnant, and miscarried of an embryo of more than three months, under the care of Dr. Warrington, who received the embryo, and who feels as much surprised as I do at the circumstance. I may take the occasion to say that Dr. Hodge and Dr. Warrington have assured me of their convictions of the correctness of their diagnosis in the case, and I may add, that I have not the least doubt of its correct- ness, for I do not think I or Dr. Mcehring could make so gross a mistake where our careful attention had been given to the forma-


238 INVERSION.

tion of a correct opinion. Far less can I suppose that the other gentlemen could be equally mistaken.

May 5th, 1841. — I saw in company with Dr. Levis, of the city, Mrs. S., aged twenty-seven years. She has two children, the youngest born five weeks ago. Dr. L. informed me that the child was expelled before he reached her dwelling. Upon arriving there, he found her lying upon her back, near the edge of the bed, the feet resting upon chairs, as if she had hardly found time to get upon the bed before the escape of the foetus, which an attendant was then holding up in her hands, in order to keep it out of the great pool of blood collected about the hips of the patient. The child's head, indeed, was quite born before tj;ie lady could rise from the pot-de-chambre, on which she had placed herself. Dr. L. removed the placenta from the vagina, having found the womb contracted.

After the delivery, she flooded a good deal, but, in a fortnight, was much recovered. Subsequently to this period, she was again seized with flooding of a severe character, since which she has not been free from bloody discharges, which are occasionally quite copious. Two days ago, the doctor examined his patient, and found a tumor projecting from the os uteri, which he suspected to depend upon inversion of the organ. She is now very feeble, is bleeding, and has frequent fits of hysterical delirium.

Upon Touching per vaginam, and upon inquiry made by means of the speculum, and even by disparting the labia with two fin- gers of each hand, it was easy to discover a tumor which bore so great a resemblance to an uterine polypus, that it was difficult, viewing its size, form, color and resistance, to believe that it was not a polypus which had existed throughout the gestation; an idea which yet could not be very reasonably indulged, seeing she had gone through a healthful pregnancy to full term ; though I admit its possibility in certain cases. As the parts, as well as her whole frame, were very much relaxed, I introduced half of my right hand into the vagina, behind the tumor, so as to enable me to carry two fingers quite far up into the cul-de-sac, behind the cervix uteri, which was not inverted. Having thus possession of the canal, I carried the two fingers forcibly upwards and forwards, so near to the margin of the superior strait, just behind the sym- physis pubis, that the fingers of my left hand, pressed forcibly upon the lower part of the hypogastrium, were but a very small


INVERSION. 239

distance from those of the right hand within the vagina. The ends of my fingers approached so near to each other that I remained per- fectly convinced that no womb was interposed betwixt them, and that the tumor within the vagina consisted of the inverted womb, and nothing else. She remained for some time feeble, and subject to hemorrhage, which gradually disappeared. She made a journey to one of the Western States, and returned to the city : since which she became pregnant and gave birth to a child.

Now, in these two cases, I am very confident of my diagnosis ; and, as both these women have since been the subjects of concep- tion and pregnancy, without artificial reposition of the organ, I rest convinced that the inverted womb, where the accident does not prove suddenly mortal by hemorrhage, nor slowly fatal from ex- haustion by inflammation and gangrene, or discharges, may re- posit itself in some rare instances. I made a statement of these cases to Dr. J. Greene Crosse, of Norwich, England, to whom the profession is about to be indebted for a second part of his work upon inversion of the womb, which I impatiently expect. I draw from my experience in these cases, and from what is .stated by M. Colombat, much consolation for those women who are so unhappy as to be affected with inversion of the womb, irreducible by manual aid.

I think these cases are well calculated to encourage and strengthen your hands in the administration of your art, for those persons wdio, having suflfered inversio uteri, cannot be relieved by the chirurgical reposition of the womb. They hold out consider- able encouragement for cases otherwise hopeless perhaps. As to the losses of blood that ensue immediately after the accident of inversion, you will have little to fear, provided your patient es- capes the foudroyant hemorrhage, and be allowed to live long enough to get her -womb once well reduced to near the non-gravid dimensions. By rest, by styptics, by position, &c., you will be enabled to bring her into a state of comparetive security and com- fort ; and if you keep the inverted womb quite high up within the pelvis, she will always have the hope, at least, of one of those spontaneous recoveries. Surely, you would not indulge the hope of such a recovery, should you allow the inverted globe to pass forth and remain outside of the genital fissure.

If in such a case, you should be unable to make the woman bear a pessary, you could, at least, invent a pad and T bandage,


240 INVERSION.

•which, compressing the labia together, would effectually obviate the procidentia of the ruined womb.

I confess, ray young friends, that I am deeply interested in the question, as to whether an inverted uterus can be reposited by an intrinsic force of the body. I was, upon first publishing the above cases of spontaneous recovery, much concerned lest the brethren who should read the account of them, might accuse me of credu- lousness in supposing such a thing possible. But the records of the science are not without strong proofs of the possibility of such spontaneous recovery.

Daillez, who published certain lectures of his master, the great Baudelocque, gives accounts of two such cases seen by that illus- trious physician, I am not able to quote from Daillez himself, whose essay was published in the Theses des Paris, which I have not been able to procure. It is cited by Mr. Crosse ; and also by Messrs. Paul Dubois and Desormeau, in their article in the 30th vol. of the Diet, de Medecine, p. 358. These are their words :

"The womb, after having been long inverted, has been found spontaneously to recover its natural state, in consequence of some violent accidental shock suffered by the woman. It seems that the spontaneous reduction of the uterus took place after two months' duration of the accident in one of the cases reported by Leroux, as appears from a letter to Louis, mentioned in Daillez's Dissertation, before-mentioned. The same dissertation also con- tains two cases, one by a surgeon named Barre, and the other by Baudelocque ; in the first, the reduction occurred at eight months, and in the second, after the lapse of eight years. In cases of in- version caused by uterine polypus, there is no special indication of treatment, since the womb recovers its proper form as soon as it is freed from the weight that has dragged it down." Such is the statement by Dubois and Desormeau.

As to the operations for the removal of the incurable and in- supportable inversio uteri, I refer you to Mr. Crosse, and to Colombat.

I am very truly your obedient servant, C. D. M.


POLYPUS. 241


LETTER XIX.

POLYPUS UTERI.

Gentlemen : — Before proceeding to my remarks on polypus, allow me to premise an account of a case of Inversion, that of right belongs to the last letter, but which, having been accidentally omitted, I shall relate here. It is a case of inversion of the womb, related by Dr. Thos. F. Betton, of Germantown. I desire you carefully to read it, in order that you may more fully appreciate the danger to which a woman is exposed by such an accident. You will see that Dr. Betton took, upon his arrival, all the pos- sible precautions against the danger; but the loss of eighty ounces of blood had so exhausted the vessels of the unfortunate woman, that it was impossible, even by Dr. B.'s judicious, prompt, and scientific course, to rescue her from the conse- quences of the accident. The case was originally published in the Jim. Journ. of the Med. Sci., for 1836, vol. 19.

Dr. Betton says, " On the evening of the 4th of August, 1836,

I was called to see the wife of S. B , living at the Rising Sun

Village, about three miles distant. On reaching the house, I found a woman of about 18 years of age, in extremis. The mid- wife gave me the following history. The patient had had an easy delivery: the midwife placed her hand upon the abdomen, to feel if the uterus were contracted, but could not perceive it. A violent pain followed immediately, and the placenta, with something adhering to it she did not understand, was forcibly expelled. This, I found on examination, to be the uterus, com- pletely inverted and prolapsed, lying like a gum elastic bottle, between the thighs. I immediately separated the placenta, and endeavored to restore the uterus, which endeavor was successful in two or three minutes. The woman was pulseless, from loss of blood; the carotids could not be felt, and the action of the heart was extremely feeble ; jactitation extreme; mind wander- ing. About twenty ounces of blood had coagulated around the uterus, and between it and the placenta, which was partially 16


242 POLYPUS.

separated. From the distance at which she lived, I did not see her for at least one hour after the occurrence of the accident, and she had lost full eighty ounces of blood before my arrival. She did not lose more than two or three ounces after the reduction of the uterus, but in her exhausted state, that was too much. I gave her immediately a large dose of the vin. sec. corn., but it failed in producing any effect. Brandy, and wine and water, were freely administered, but in three-quarters of an hour after my first seeing her, she expired.

"My own conviction always has been, although the midwife denied it at the time, that she had produced the inversion and pro- lapsus, by pulling too strongly at the cord."

Let us now proceed to our inquiries upon polypus of the womb ; and I ask, is it not obvious that all the tissues of a living body are undergoing a perpetual accretion and waste ? that the perfect balance between this deposit and absorption, maintains all the organs and the parts, and the whole body in one even tenor of health, of weight, and dimensions, for months and years of time; and that the loss of such a balance or equableness of the waste and deposit, changes the weight and dimensions, as well as the health of the body, or of any of the parts or organs of it? But, w^hen the accretions of a part become excessive, then we have either a hypertrophy or a tumor.

It is one of the standing miracles of nature, that the bodies of creatures are maintained at one even tenor, not only through the lifetime of the particular individual, but from age to age. Thus a single herring shall develop 300,000 eggs, from each of which shall be evolved a herring, whose weight in no instance, perhaps, in the countless myriads of that tribe, will ever be found to ex- ceed by 200 per cent., the weight of a perfect fish of its genus Clupea.

On the other hand, an army of wild pigeons so numerous as to darken the air for days and days of its migratory flight, will not contain a single bird as large as the barn-door fowl; because each genus of creatures, by its miraculous generic law, is limited to a certain stature, weight, and dimensions.

The same thing is true of the vegetable tribes. You shall never expect to see an arbutus rival the forest oak, nor a violet to grow on the branches of a trunk as tall as the plane tree. You wonder not, nor become amazed at this miraculous order; but


POLYPUS. 243

you and all your County would turn out in crowds to see an ear of Indian corn growing on a wheat stalk, or a magnolia grandiflora blossoming on the tender vine of a cucumber. You are, there- fore, not surprised at the daily miracle set before your eyes in the order and regularity of Nature's operations ; but you are startled, and lift up your hands in a gesture of wonderment, when she errs, and in her errors gives rise to some unnatural form or con- junction ; some Saeculum Py*rrhae, nova monstra quaestse. Do you not perceive in this statement reasons to be far more surprised, when you observe that men and women too, are found to live out their threescore years and ten, and even longer, without having experienced during their whole life, a single deviation from the natural forms and weights of their organs, or of their external configuration ?

There can never be deposited in an organ, any atom or mole- culus of its constituent tissue, but by an act of a blood-vessel; which puts it down in its place, and puts down the true chemical elements in the right place. But the blood-vessel that carries and deposits the moleculus, can only deposit it under the indicating and controlling force of the accompanying nerve. You are very well aware that each organ has its own nutritious artery to con- vey to it the materials for its daily accretion ; that it has its lym- phatic absorbent, to remove the daily detritus of the life of the organ ; and also its generic nerve which indicates and controls by its force, the kind, as well as the amount of the daily deposit, and the kind and amount of the daily absorption.

You do not doubt if the generic nerve becomes compressed, or is tied or cut off — or softened, that the organ will waste away, or become atrophied, however sound and perfect the artery may re- main ; or if too energetic in its indication and compulsion of the daily deposit, that the organ may become hypertrophied, from a faulty rate of action of the generic nerve.

In the womb, for example, the daily detritus and accretions of life will maintain the form, consistence, and weight of that body in one even tenor, for a lifetime, if it continue obedient to the generic law of its development — for that law which tends to keep it always two inches long, and of the weight of two ounces, and of a certain form, is as truly a generic law for the womb, as is the law that commands the genus Bos, or Equus for those genera. But, if it disobey its generic law! What then?


244 POLYPUS.

Now in the code of morals — the Decalogue — we have plainly set down for our guidance, certain rules, or laws of action, to be obedient to which, or to be disobedient to which, constitutes us good or bad men, righteous or sinners.

So, in the physical nature of living beings, there is a law which they ought to obey, and be bound by ; if they disobey ! if they fail to be governed by the provisions ordained for their just maintenance! then they maybe likened to sinners against the moral law. They, in fact, do sin, rebel against, or contemn the law ordained for their government, their protection, and security. In this physical disobedience, I can perceive a close analogy with moral disobedience. In each, it is the first step that is fatal — c^est le premier pas qui coute. In the moral law, the first sin, or corruption, leads to still renewed wickedness, until the whole moral constitution of the man is subverted, changed and ruined, and becomes a mass of moral pollution. So, in the physical, or organic sin ; the first error is followed by the second, until the en- tire constitution of the organ is subverted and ruined so completely, so completely changed, that the most expert anatomist can no longer detect its old familiar features in the depraved and hetero- logue mass that lies under his scalpel and his doublet.

In the hopeless wreck of the moral creature, brought about by vicious indulgence, the voice of conscience is raised in vain, the appeal of reason is powerless; the invitation of the minister of the Gospel is like the idle wind, and suasion and argument equally fail to recall him to the path of duty and safety. Just so is it in the physical sin of the organs ; when they have fairly broken the generic law, they continue free from all future bonds, and go, like the idle wind, where they list, and no one knows whither. It is in vain that you apply the restraints of your hygienic and thera- peutic forces. The heterologue mass has no generic law, and the cry of the rest of the organs that suffer for its rebellion, like the cry of society against the breaker of the law, is raised for ears that are deaf. Such an organ is become like a wild horse in a bound- less plain, that scorns the caress; and, fleeter than the winds, will not bend his neck to the accustomed rein.

I have been led into these reflections, by having witnessed to- day, June 10th, the dissection of a preparation brought into the city, by two medical gentlemen from a distant county. Prof. Horner made the examination. The whole mass weighed thirty


POLYPUS. 245

pounds, and consisted of a womb, very much thinned and at- tenuated, which, upon being laid open by an incision from the fundus to the os uteri, disclosed a solid tumor, whose weight could not have been less than twenty-nine pounds avoirdupois. This solid mass w^as ^ fibrous polypus^ springing apparently from the side, not the fundus of the uterus; and attached here and there by strong exudation or accidental attachments — the results of pressure and inflammation long endured.

Now, this vast mass probably sprung, at the beginning, from the very slightest aberration of the development force. The offence was small, and then became greater, until, in the end, you see how "rank" it was. What therapeutical power could you bring to bear as a control upon such a heterologue mass as this polypus of twenty-nine pounds avoirdupois; a polypus, whose sole connection with the living constitution of the poor victim it destroyed, may have been by a root, neck, or pedicel, not bigger than your thumb ?

Don't you see what a physical sinner it was, and how small was its first offence? It had broken its generic law, and you perceive the end.

Let us take good heed, that in our small and venial offences, we do not come to say with the king, "Oh, my offence is rank; it smells to heaven!"

This parallel between the moral and physical states of disobe- dience to the laws that ought to govern both, I have run in order that I might haply impress your minds, and my own also, with clearer perceptions of what we have to hope, and what we have to fear, in the conduct of those maladies that are, in the strictest sense of the term, chirurgical. I also hope that the ana- logy I have set forth, may be not without some advantage in its moral, since from it we may lay to heart the equal necessity in morals and physics, of opposing the very beginnings of evil; and since we ought, like Jacques in the forest, to be able to find "sermons in stones, books in the running brooks, and good in everything."

But let us leave moralizing, and return to our physic; all the cavities of the living body, as the cavity of the nostrils, the ventricles of the brain, the womb, and even some of the solid parts are liable to become the seats of excrescence or growths, some of which take the name of polypus, which is a tumor grow-


246 POLYPUS.

ing by a narrow neck, or root, out of any superficies, and extend- ing itself in length and breadth, to an extent limited only by the duration of the life of the patient, and by accidental strangulation, or death taking place in the tumor itself.

Such a tumor is a polypus, which may be either hard or soft, being called in the former case a fibrous, and in the latter a cel- lular or cellulo-vascular polypus. Such a tumor possesses a low organic life. It has a very traceable interior circulation, while its superficial circulation is in many cases active enough to give rise to profuse hemorrhage : without some internal circulation it would be subject to decomposition ; without an active superficial circula- tion, it would not grow. Its growth is supposed to be peripheral.

A polypus of the womb is far from being a rare chirurgical malady. A polypus growing from the interior of the uterus, may be supposed to be, in its earliest state, a small excrescence like a papula, which, rising higher and becoming broader at the base for a certain space of time, ceases at length to grow at the base in breadth, but elongates itself, spreads out into an utero-morphous shape, filling the cavity of the organ more and more as it grows larger and larger, sometimes distending the uterus enormously, as in the instance above mentioned, and in other instances pressing itself into the canal of the cervix uteri, and so dilating it as to find its way at last through the os tineas, whence it slowly advances into the vagina, expanding in a lateral direction, so as, at length greatly to distend that organ.

A polypus, then, is a tumor either fibrous or cellular, that is, either hard or soft, springing by a narrow neck or stalk from the womb, and increasing in size daily, so as to distend and fill up the womb to a considerable size: or otherwise, it may dilate the neck and mouth of the womb, so as soon to come forth into the vagina, or even to project beyond the ostium vaginae.

A polypus will not, in all cases, come out of the womb ; espe- cially will it not come forth to disclose its true nature, in those cases where accidental adhesions have taken place between it and the womb. In such a case of adhesions, it would be in vain that the womb should make efforts to cast out the incumbrance; no pain nor contraction could get it forth from a cavity to which it has become bound in consequence of adhesive inflammation. In all cases, however, where the sole connection of the polypus and womb is to be found at the root or neck of the polypus, we have


POLYPUS. 247

reason to expect, in the long run, that the uterus will become irritated into contractile or labor-pains, and cast it out, just as it does cast out a dead ovum or embryo that has perished in the early months of pregnancy.

It is very possible, that the earliest beginnings of a uterine polypus may consist merely in a hypertrophy of some superficial layer of the womb, and that the tumor, in this sense, is a part, and a real part of the womb itself, partaking of the true nature of the uterine tissue : but, if the growth proceeds, so as to make it come to be either a fibrous or a cellular polypus, it cannot be sup- posed that it will go very far, before the new accretion will be- come really heterologue, and thus give rise to a mass growing from the uterine surface, nourished by branches of the uterine or spermatic artery, and yet retaining, in its histological character, no true features of the womb from whence it derived its origin.

Such a tumor has no generical limit ; it might grow to the weight of a ton, could it be supposed to continue in the reception of its pabulum from the uterine branches to which it owes its ex- istence. It has no generic delimitary term ; and it can have none ; seeing that it carries with it no special absorbing apparatus to counteract the accretive power which it receives from the vessel that makes the deposit and from its nerve. It is probable, as I before said, that most of the increase which it receives is derived from the exterior surface of the tumor, which, even in the most enormous tumors of the womb, it is said, may be successfully injected upon the more superficial portions. Dr. Th. Saflford Lee tells you at p. 8 of his book on Tumors of the Uterus, that an injection may be made to penetrate " the morbid mass," and that 2268, 2270, and 2266, in Guy's Hospital, are cases in which the injegtion has been made; but surely Dr. L. would not suppose that such a tumor as he has beautifully figured in fig. 2 of his plate, could possibly be injected by the anatomist; at least not the w^hole of it.

Such a tumor carries with it in its augmentation, delicate pro- longations of the arterioles and capillaries, from which it draws the material of its daily accretions. It probably aTSb carries with it a certain amount or form of nerve fibrils, without the presence of which it would be subject to putrefaction; but those nerve fibrils may reasonably be deemed to be imperfect in their action, and as serving merely to retain the growing mass in vital relation


248 POLYPUS.

to the body of the woman, yet unable to control or modify the ac- cretions as they can and do in a healthy normal function of the development forces. I deem that there cannot be truly any life where there is no cerebral or nerve matter ; but I can well conceive that, in the case of the most extreme deviations as to form, magni- tude, and consistence of organs or parts, by their conversion into tumors, there must accompany them portions of nerve matter, de- riving a source from the nervous system of the patient, yet so imperfectly connected with it by constitution or power, as to lose the faculty of controlling the development of such said organ or parts.

If this view of the case be just, it would be idle to attempt to modify or control the growth of such a tumor, by means of drugs and medicines administered internally. Since, however power- fully such drugs and medicines might be able to modify the actions of the woman's constitution under its natural physio- logical laws, they could not reach in their influence, nor in any degree control the accretion forces employed in the production of the polypus, which, being heterologue, Avill not, neither indeed can, come under obedience to the physiological law of the woman's life ; a law with which it has no longer any lot or part, beyond that of living as long as she lives, preying as a parasite upon her ma- terials, and sending back no answering organic influences to serve in maintaining that beautiful harmony of the organisms, whose concert of action is life. Such a growth is not a part or parcel of the economy; it is not like one of the members of a family or a flock, but is like a stranger or a thief and a robber, that has entered in by guile or by violence, to dwell among them and to disturb and destroy them.

Hence you see, that such tumors are to be treated chirurgically and not medically. They may be extirpated, they cannot be cured. Save yourselves and your patients, therefore, the trouble and loss of using physic or drugs.

In a womb that becomes the seat of a polypus, it is natural to expect the signs of uterine irritation. Therefore, as soon as the excrescence begins to acquire a certain volume, and to press upon and dispart the cavity of the organ, we may expect to find the fruits of such irritation, in diseased sensations, as pain, weight, tension, modification of the menstrua, white and sanguine discharges, &c. It is true, that we shall not be able in the early stages, to make the


POLYPUS. 249

diagnosis of such a tumor, because, when it inhabits the cavity of the womb, and expands that portion of the organ only, it may not in the least decree change the form and dimensions or resistance of the cervix. We have no art and no skill, under such a state of things, to pronounce confidently as to the existence of a tumor; though we may be induced to infer it from the total absence of signs of other malady. It is inaccessible to our touch or sense.

A woman otherwise in good health, shall at irregular periods be attacked with uterine hemorrhage, whether moderate or violent, and you come to make your diagnosis and can by no means dis- cover that there is any inflammation, ulceration, deviation, hyper- trophy, plethora, &c., on which to rely as suflicient cause for the irregular and alarming attacks of flooding.

You are fully resolved that it is not a menstrual hemorrhage, for the causes of menstruation are not so irregular in their operation, as to allow you to call it mensual hemorrhage : what course will you take to clear up the difficulty? I see not what other recourse there is, besides that of accusing a polypus of the womb. The womb-sound or womb-probe, w^ill not, I think, throw any very clear light upon the case for you. The vaginal taxis and the hy- pogastric exploration, cannot clear up your difficulty. It is a process of ratiocination that leads you to the one and only possi- ble conclusion. The case is one of a polypus, because it could be nothing else.

I have not been afraid to make such a diagnosis. I had for ten years the care of a female, who at the age of about thirty years, was repeatedly attacked with the most alarming uterine hemor- rhage, accompanied with severe pelvic and hypogastric pains. I do not suppose I have ever met with more violent hemorrhages of the womb than in the person alluded to. It seemed scarcely credible that she could survive the attacks. She was very thin, and feeble, and pale and rachitic. I never could detect any aug- mentation of the size of the fundus and body of the womb by the Touch, or by external palpation, and yet so free was she from all the symptoms of other disorders of the interior of the womb, that I ventured to tell her she had polypus, which at some future day would surely disclose itself.

I was called in the course of consecutive years, many times to this person, on account of the frightful hemorrhage and pain with which she was attacked; and I repeatedly explored the case by


250 POLYPUS.

the vaginal and rectal Touch and the hypogastric palpation. I could never detect any certain physical signs of the malady, but rested convinced that the polypus was concealed within the womb. At length, amidst the severest pelvic pain and a great flooding, the polypus was expelled into the vagina, and I removed it with Dr. Gooch's double canula. After which she had no more re- turn of the hemorrhage. But she died two years later, with pul- monary consumption, connected with a distressing rachitis, and precipitated, I suppose, by the extreme debility brought on by ten years of repeated hemorrhages. Life had become a burden to her, and she died with a countenance beaming with smiles, as she faintly repeated, in broken and scarce audible whispers, the beautiful verses —

Vital spark of heavenly flame ! Quit, oh! quit, this mortal frame; Trembling, hoi:)ing, lingering, flying, Oh, the pain, the bliss of dying ; Cease, fond nature, cease thy strife, And let me languish into life.

Do you ask me why, in a letter on Diseases of Females, I cite these mal-a-propos memoranda of a death-bed ; and which have nothing to do with our subject . I answer that my letters are about females, as well as their diseases and remedies. I would not forego this. opportunity connected with her case, to make mention of one unknown, humble, truly pious, whose gracious manners, whose noble sentiments, and heaven-tempered spirit, as well as her willing submission to an inevitable and painful fate, filled me with admiration of the characteristics of woman. ■ I have seen a man die with the dignity of a Christian and a gentleman; none but a woman could die with such gentle and feminine grace and beauty as poor Anne Ryder. In her, her nature was wholly un- changed, until the last dull clogs of her mortality were already cast oJET.

There is nothing so difficult, my dear young friends, as to be- come a physician from the reading of mere descriptions of disease in the books. To read those descriptions is well, is indispensable. But to understand them, one must see the cases, and compare them with the book description. I can hardly flatter myself, that I shall be peculiarly successful in teaching you how to discrimi- nate between the different maladies that are often characterized by the same outward signs. Let me hope, however, that I can


POLYPUS. 251

describe a case and a conversation that I had some time ago, with a patient; and we shall see whether I can give you a clearer view than you now have, of the method of proceeding, and of the ration- ale of an opinion, that you may readily form without greatly vex- ing your patient.

The person in question was a very tall, slender woman, a widow, who lived in Sugar alley, near Seventh street; she may have been some thirty-eight years of age, and had children.

When I went to her chamber, she sat at an open window sew- ing the leather binding on a truss, which was her Trade or occu- pation. The room was about fifteen feet square ; and I seated myself near the door, while she sat at the window, say, fifteen or sixteen feet off. She was a stranger to me, and I said,

"You wished to see me as to your health?"

"Yes, doctor, I have been long sick, and knowing that you at- tend many women, I was in hopes you could tell me what's the matter."

"Why, you look very pale; too pale and weak to work, I should say. Pray how long have you been so?"

"Oh, a long time, sir."

"What makes you so pale, though?"

"I am all the time unwell.'

"I should think so. How long have you been unwellV

"Six years and a half."

"Six years and a half! Do you mean really to say six years and a half?"

"Yes, sir. I have not been free from my courses for six years and a half."

"What! not one day?"

" No; not one day."

" Tell me; are you serious, when you say that for six years and a half you have not been a single day without an issue of blood?"

" Yes, sir, perfectly serious ; I have not passed a day without a show, and sometimes a flooding, for six years and a half."

" But that is enormous ; yet to look at your face and hands, and to see how pale you are, one might well believe it."

" It is perfectly true."

" Have you any pain ?"

"No, only weakness."

" No pain in your back, or in the lower part of the bowels ; or thighs?"


252 POLYPUS.

" Not the least; only weak."

" No offensive discharge?"

"No, sir."

"No burning sensation, no shooting pain within, and between the two hips ?"

"Not the least."

" Are you much unioell still?"

" Sometimes very much — sometimes not much — but I'm never without it."

"Any trouble about making water?"

"No, sir."

" No pain at the stool? no difficulty?"

"Never."

"And you have no offensive discharges?"

"None."

" Then you have a polypus of the womb."

"What Is that?"

" It is a tumor, or lump that grows in the womb ; it has a nar- row neck, which lets it hang out of the womb into the passage ; it has blood-vessels, that always bleed."

"What causes it?"

" I'm sure I don't know. Nobody knows ; it comes without any ascertainable cause ; it comes in women who bear children, and in those that have never had any, as well as in unmarried women."

"What can be done for it?"

"It can be removed with a ligature; that is, by tying a string round its neck, whereupon it will fall off, and then you will bleed no more ; but, if you do not lose your blood, you will grow strong and healthy again."

" But I cannot let you do it."

"You ought to have it done ; at least you ought to have it ex- amined, for, though I am very sure of finding the polypus, I have never yet had any sensible sign of it. I only judge it to be there."

"I cannot."

" Very well, madam. You have bled six years and a half; you are greatly reduced; your blood is thin as water, and if you go on much longer, there is fear you will have a dropsy, and then lose your life. Would that be wise, or foolish ?"


POLYPUS. 253

"I can't help it; I cannot think of being examined."

" Very well; it is your affair, not mine. I have no other ad- vice for the present, than that you should carefully revolve the prospect before you, and if you should change your mind, you can let me know, if you should desire to see me."

And so I left her to her reflections. On the next day she begged me to return. I went to her, taking my Gooch's canula with me, and found a soft polypus, large as an egg, on the neck of which I threw Gooch's ligature, and the tumor fell off in less than twenty-four hours ; after which she had no more hemorrhage, but recovered her health and strength.

Now the above is, I think, very near literally the conversation

I had with Mrs. , and since you have read it, I ask you what

other opinion I could possibly take up as to her case ?

She had no pain; therefore she could have no carcinoma; she had no disagreeable odor of the discharge ; a fortiori, she could not have cancer; she had been unwell six years and a half with- out a day's intermission; but that was not the character of a men- orrhagia. It must be that she had some insensible tumor that would bleed always, and yet never give her any pain ; what in- sensible tumor? There is none other than polypus uteri. Had I not, therefore, a just ground to make the inferential diagnosis of polypus uteri, and to indicate the proper treatment?

What a shameful mistake to have said — it is change of life — it " is weakness — it is irritation — it is this, or it is that, and so compel the woman to swallow drugs, usque ad nauseam, and at last find one's diagnosis proved erroneous to the discredit of Medicine, which is always discredited by the mistakes of physicians.

A polypus of the womb, I have said, cannot come out from its nidus, provided it have become attached at various points to the uterine walls, by inflammatory adhesion. You are not to be sur- prised that such adhesions do occur, for as the superficies of the polypus is quite vascular, and covered by a smooth membrane, which is probably of the nature of mucous membrane, adhesions would be very likely to ensue upon the escape of exudation par- ticles from the uterine, or from the polypous surface.

I have no hope to offer for such cases. It seems to me in vain that any one should attempt to extirpate, and I have no faith in the curative power of drugs for them.

I am unable to state what is the difference of the causes that on


254 POLYPUS.

the one hand produce fibrous, and on the other cellular, or soft polypus. I believe they are equally curable by the ligature ; at least, I have not met with any instance in which, after the remo- val by the ligature, the tumor has again proved troublesome by renewed development from the root ; which is not a little wonder- ful, seeing that, whenever we destroy one by the ligature, we must leave the base or root from which spring all the vessels and other apparatus concerned in the nutrition and development of the tumor ; and that might well grow again.

I have met with no case in which I could accuse the polypus of malignant degeneration, except one that I saw in the Lying-in w^ard of the Penna. Hospital ; and that, perhaps, was not a true polypus in its origin. It was the case of a stout, short woman, about fifty years of age, who had long had putrid sanious dis- charge from the womb, and in whom, after a long time, the os uteri opened sufficiently to admit of the introduction of two fin- gers, by which a mass occupying the cavity of the organ could be felt. I in vain attempted to pass an instrument containing a ligature, and was obliged at length to break the mass with the fingers, by means of which I got away a large handful of hetero- logue material, half fibrous, half cerebriform, to the considerable relief of the patient, who at subsequent times was relieved in the same way, of considerable portions of the same kind, as the con- tractions of the womb forced them down within the reach of the fingers. But, although a considerable quantity of it was brought away, the production of it continued. The woman left the ward at length a good deal relieved, as it was thought, but it proved otherwise in the end. Her sufferings became very great, with all the marks of malignant degeneration of the uterus.

I know that Dr. Dewees attended a lady here many years ago, affected with polypus uteri : he removed the polypus, as he in- formed me, and unmasked a cancer of the cervix, which soon afterwards destroyed the patient.

You will find in your studies, that it is conceded the presence of a uterine polypus may lead to malignant disease of the womb. The same thing happens in polypus of the nose, or antrum. The distending pressure of the tumor alters all the tissues that are in contact with it. The same might be true of the uterus and vagina.


POLYPUS. 255

There are various instruments for putting the ligature on the neck of a polypus.

I prefer Gooch's to all of them ; and I think the ligature is to be preferred to all other modes of extirpation. It is not in every case to be effected without hemorrhage. I know of two cases here, in which the hemorrhage was terrible ; but there is less danger from hemorrhage by this process, than by that of twisting or avulsion of the tumor.

Whenever you are called to a case of polypus uteri, in which the neck of the tumor can be secured by a ligature, it will be your duty to put it on. You might be able to put it on in certain of the cases even where the tumor is still contained wholly in the womb ; but, in order to such a great success, it will be indispensable that the os and cervix uteri shall be both dilated and dilatable ; and the polypus ought not to be a very large one. "Where the polypus is of vast size, an instrument used to conduct the ligature upon its neck, should be so curved, as to fit the convexity of the tumor, and the coincident concavity of the womb. It must be a very difficult task to arrange the curve in a proper way ; and if it be not so arranged, the pressure of the instrument could not but be very dangerous; since the inner wall of the uterus is ill calcu- lated to suffer the forcible contact of any foreign body long con- tinued. Upon the whole, then, I am disposed to advise you, where the polypus is still within the uterine cavity, to wait until it is forced into the vagina, where there is little difficulty, and per- haps no danger attending the operation of tying it.

Dr. Lee, On Tumors of the Uterus, p. 69, says, in speaking of the treatment of polypus, "Supposing it to be placed within the cavity of the uterus and the os uteri closed, it would be folly to attempt its removal ; we must suppress the bleedings by plugging the vagina, rest, an elevated position of the pelvis, and local cold, wuth some refrigerant drink."

I am glad to be able to quote so sensible a writer in behalf of so sensible an injunction ; for there are cases of persevering en- deavors to extract large polypi from the womb, that bespeak more obstinacy than prudence on the part of the practitioner.

The rule is a good one, not to attempt the extraction until the tumor has passed into the vagina. I do not mean by this to say it is not to be done until the whole tumor has come down, but only that we should wait until it is so far descended that the uterine cavity


256 POLYPUS.

which still contains a part of the mass shall have become a cylin- drical, and not a globular or pyriform cavity; whenever it has become cylindrical, which will be the case where the major part of the polypus is pushed out, no objection can exist against the casting of the ligature upon it.

To adjust the ligature upon the polypus even in the vagina, is often a vexatious and difficult task. Take patience for the work, and be not in a hurry to get it done. If the vaginal walls are tense, you will require some time.

Let the patient lie upon her back; the hips to the very edge of the bed ; the feet resting on the backs of two chairs, well sepa- rated.

Let the Gooch canula be of a good length — most of them are inconveniently short. See that the ligature is long enough not to annoy you with the tubes interfering with your hands. See that the ligature be well oiled, so that it may run freely; strong enough not to cut or break; and small enough to move freely in the canula.

Arrange the canulse so as to have them parallel in the right hand, introduce them parallel, to the greatest depth ; and then taking one in the left hand, while the other is held in the right, carry either the right or the left hand one round the tumor, until you bring it parallel again with its fellow. In this way you will have cast the ligature round the neck of the tumor ; next, you are to slip the canulse each into its ring at the end of the staff, and slide that ring to the top, securing the foot of each canula in its cannon. If great care be not taken in doing this, the ligature will be apt to fall off. You will know whether you have succeeded, upon gradu- ally tightening the cord. If it has taken proper hold, it will pull the polypus downwards when you draw with it. Take great care to slide the ends up as far as possible, so as to get as much as you can of the base or neck of the tumor in the loop, and then draw it as tight as possible, so as effectually to strangulate the mass. If the polypus be a cellular one, you may expect it to fall off in twenty-four or forty-eight hours; if it be a hard fibrous one, it sometimes requires seven or eight days to cut through.

The woman ought to be put to bed, and commanded to keep her bed, until the canula comes away.

Once a day the ligature should be tightened, as the compres- sion is lessened by the daily shrinking of the mass.


POLYPUS. 257

As soon a's the mass dies, a most foul and offensive discharge comes on, which requires all the cares of cleanliness. Sometimes, when the apartment is warm, copious injections of soap and water should be made with a syringe having a gum elastic tube adapted to the metallic fistula.

If the polypus is very large, you can pull it away with a Mu- zeux forceps, or with- a sharp crotchet, or even with the obstetric forceps.

In some cases, the tumor has been so large as to require to be divided before it could be got away, by a polypotomy operation, as one might call it.

The extirpation of a uterine polypus is a very beneficent ope- ration, as it relieves the patient from w'asting hemorrhage, and from mental anxiety and physical pain: she soon recovers her health and spirits, and is in general grateful for the relief, as much so, probably, as for any surgical operation whatever; but you cannot always do the operation. For example — some months ago, a lady came to me from New Jersey. She had been for some years laboring under a uterine disease, accompanied with violent and exhausting floodings. Upon arriving here, she w^as wholly unable to walk or to sit up in her chair. I discovered a hard polypus, whose apex was lying just within the os uteri, which was a circular opening as large as a half dollar. This os uteri was pretty low down in the pelvis ; it was very hard and completely undilatable. The fundus uteri was half way up to the umbilicus, and the uterus hard and solid, so as to allow me to trace its out- lines very clearly in my hypogastric palpation. I assure you, I have rarely met with a more extreme case of anaemia than in this person. This anaemia was evinced not only in the pallor of her surface and its flabbiness, and in her irregular breathing, the fre- quent palpitation of the heart, and the ansemical throb of her pulses, but in the state of all her innervations, which were most miserable indeed, except when lying profoundly still in a low recumbency.

After a few days of refreshment from the journey, I attempted to do what I thought I should fail to do ; namely, to get a ligature on the tumor. But I soon found how vain was such an attempt, for I never found the uterus a moment relaxed, nor to open beyond the size of a half dollar. My attempt caused an attack of hemor- rhage to come on that I was glad to suppress, by cold, by rest, and by opium. 17


258 POLYPUS.

I kept her here many months, in hopes of seeing the uterus enter into powerful contractions to throw off the morbid mass. I gave her large doses of ergot. I thought the ergotism that was produced, might expel the polypus, but I was disappointed, and subsequently had reason to believe the tumor had formed strong attachments to the inside of the uterine walls, so low down, that I could reach them with my finger, but could not break them up. During her residence here, I thought to see her bleed to death before my eyes ; her life was hardly saved by the tampon, so perverse was the hemorrhage. At length I sent her home, with directions as to her health, and a request to be informed if the tu- mor should descend into the vagina. It will never descend into the vagina, if the adhesions I supposed to exist are truly there.

I have mentioned this case to you, in order to show you in the first place, that I could by no means cause that os uteri to dilate ; neither by manipulations nor by force of the ergotic spasm ; and in the second place, and chiefly, in order that I might tell you •what happened in the course of my treatment of it. It is this: she came here most deplorably ansemical. She continued here many months, during which time she always had some show, and suffered several severe floodings, one of which, as I have stated, was well nigh fatal. But except when reduced by copious flood- ings, she was raised, I was going to say, as by magic, into a state of ruddy health, by the daily use of Quenesville's metallic iron, in doses of two grains after each daily meal.

I pray you do not accuse me of being credulous, and as argu- ing a propter hoc, in a post hoc case. The phenomena were so striking and rapid, as to convince any one that. they ought to be attributed to the power of that article over the blood membrane, the membrana vasorum communis.

The greatest waste of her blood was followed by a rapid repro- duction of it, under the tonic power of the article. Do not say that it was her constitutional force that restored her; since, for years, she had been pale, palpitating, and exsanguious; whereas, under the use of the remedy, she rapidly regained all she had lost by the attacks. At all events, I pray you, when such a case shall present itself, and where you cannot get the offending tumor away, I pray you to test the power of microscopic particles of iron over the blood-making faculty, which, as I have so often repeated in your ears, I suppose to reside essentially in the endangium, a tis- sue which I deem to be as obedient to the therapeutical influences


POLYPUS. 259

of iron, as the alimentary canal is to rhubarb or the uterus to secale cornutum. You see I speak very confidently on this topic. I confess, men suffer themselves to be readily deceived by what they deem experience. But, at least, I conceive that my expe- rience warrants me in this confident belief, a confidence which, while it is confirmed by my diurnal observations, is also enforced by the authority of such a writer as Raciborski, not to mention numerous authorities who give opinions, if not so approving as mine, yet at least such as to recommend the medicine to your careful study, as to its therapeutical powers.

Upon reviewing this letter, I find that I have been less exact, and less full in my account of polypus than I intended to be. I shall not rewrite it, at least for the present; in fact, the question as to polypus, resolves itself principally into this, viz. : to disco- ver it, and to remove it by the ligature. That is to say, to re- move it when you can, not when you cannot ; but, you cannot, in cases where it is shut up within a contracted womb. Physic and drugs are useless in the view of counteracting or retarding the growth of such tumors. Physic cannot hurt the polypus ; but it can, and will hurt the patient. If, however, the patient bleeds too much, you must check or repress the flow. If the polypus is oflfensive, you must give such directions as may keep it free from that odious quality. If it gives pain, you must lessen the pain. I do not think you will get any advantage from caustics or cau- teries ; whenever such things are applicable, the ligature is appli- cable, and that will eradicate the evil. I beg you to receive this letter, imperfect as it is, with the assurances of that respectful regard, with which I am yours very faithfully. C. D. M.


LETTER XX.

Gentlemen : — In my last letter, which, as you may remember, I begged you to receive, notwithstanding I had prepared it with less care than I ought; but which I concluded to send you notwith- standing my dissatisfaction wdth it, I did not say anything as to


260 POLYPUS.

those polypes that arise from the lip of the os uteri, from the canal of the cervix, or from the surface of the vaginal tself; nor, indeed, can I think it very much a matter of consequence to say anything of this sort of cases ; for as much as, the chirurgical na- ture and quality of these tumors being once established, nothing remains except to determine their existence ; and then to apply the proper remedy, to wit, the ligature. This task is compara- tively easy in these cases of polypus, because they are readily accessible, and may be subjected to strangulation upon their de- tection.

Allow me, how^ever, to put you upon your guard against a mis- take that you would be liable to fall into in certain of these cases. I mean the instances in which the polypus is so small, that you can with difficulty detect it by the touch; and are even liable to mistake it when you do touch it, for a coagulum.

I have seen one of these excrescences not so big as a grain of corn, and I lately removed one, not much larger than a grain of corn, for a patient who had suffered a constant wasting hemor- rhage from it for more than a year, to so great a degree, indeed, that she was rendered thoroughly anaemical by it, and suffered all the miserable effects of an anamical innervation.

I confess, I was surprised myself, upon discovering the polypus to be so very small; having expected to find one as large as a small pear at least. I was in doubt for a while, whether so great a waste could have depended on the effusion of blood from so small an excrescence ; but when I had taken it off, the waste immediately ceased, and the lady recovered her health and strength; from which, I imagine, I have good reason to believe that the hemorrhage did, indeed, proceed from the polypus.

I sliall in a subsequent page inform you, that I cured a lady by means of the caustic acid nitrate of mercury, of a polypus spring- ing from the os tincse, and which was so small as not to be de- tected, save by inspection with the speculum uteri.

Pray, then, remember, that when you have perverse hemorrhages of the womb, not justly attributable to a menorrhagic cause, or to a large polypus, you may, perhaps, by careful exploration by the iouch, or by the speculum uteri, make a good diagnostic so as to finable you to cure the patient, whom you could not cure should you happen to overlook the true organic cause of the trouble.

I am afraid that I may in my letters, now and then, lead you into


HASTY DIAGNOSIS. 261

the error of jumping at a conclusion. You ought never to do that : you ought to arrive at all your conclusions in medicine, by a regular process of perception and of reasoning. Let me tell you a story about leaping at conclusions, which may serve better to put you on your guard, than ten pages of mere homily about pru- dence and cautiousness.

A gentleman here, for whose medical judgment and chirurgical skill I have the very highest respect, called on me some time ago to request I would be present at the removal of a polypus uteri, for which he proposed to operate the next morning. He said, the polypus was already partially descended into the vagina; but the patient had been much annoyed by it, both as giving pain, and causing the loss of a good deal of blood. He had carefully made out the diagnostic of the case, and should be provided with a Gooch canula for adjusting the ligature.

Upon reaching the rendezvous next day, I found a good many of the lady's friends assembled on account of the operation ; and of course no little anxiety was visible in their inquiring faces, for notwithstanding such an operation is a trifling matter in fact, the women will not so deem of it.

My good friend informed me he had repeated his diagnosis, which was satisfactory; whereupon I was requested to examine the tumor, in order to found my own opinion. When we had re- tired to another apartment, I said,

"Are you sure, my dear doctor, that your diagnosis is correct in the case?"

"Oh, yes, certainly, I made it very carefully."

"I am afraid you have made a mistake."

"How?"

"Why, I do not take it to be certainly a polypus."

"What do you take it to be, then?"

"I think it is a compressed ovum that she has been long cast- ing off, and that is now ready to come away from the canal of the cervix."

" Oh no, sir, not at all ; I assure you I have most carefully ex- amined it, and I am sure it is a polypus. Did not you observe its pear-shape, its smooth and polished surface, its resistance? It is clearly a polypus uteri."

"Certainly, I do not like to differ from you in opinion on the case; I may be mistaken myself, but I shall be greatly obhged if


262 HASTY DIAGNOSIS.

you will do me the favor to repeat your examination, carefully noting the diagnostic differences of polypus, and the case I sup- posed. I am far from presuming on my own judgment, but I must doubt you will come to my way of thinking as to this matter."

So he went to the patient's room, and soon came back, assuring me most confidently, that I had been mistaken, and that the case was a case of polypus uteri, pointing out to me all the infallible signs of that diagnostic.

"Very well, doctor, it may be that I have made a strange mis- take, but you know that a man's perceptions are his percep- tions, and they are what he is to go by. I hope you will allow me, before the operation is performed, to correct myself by a new exploration."

"Oh, certainly, I wish that you should do so, for I am quite sure you will find it as I have said."

We went to the chamber; I passed the right index finger along the tumor into the canal of the cervix, which was considerably dilated by the ovum, and having carried it as high up as I could, I bent the last joint, indented the mass with the finger-nail so as to make it serve as a crotchet, and then exhorting the woman urgently, to bear down, — to strain, — hard, — harder, — the dead ovum slipped into my palm.

I called for a basin of water, to put it in, and taking it to the window, I showed him the dead compressed ovum, of which the chorion and amnion were the irrefragable evidences.

"What is it, doctor?"

"It is an ovum."

"I told you so."

"Yes, but it is very strange ! Do you know that I have attended a thousand labors? How could I make such a mistake!"

Now, do you, my friends, ask why I- make all this detail of so simple an affair? All medical practice is a simple affair; it only requires, 1st, that you should be well informed as to the na- ture of your duties; and, 2d, that you should reflect upon those duties, in order to perceive what they be. The gentle- man in question is a man of talents, very superior to hundreds or thousands of our brethren. But you see what a mistake ! I make all this detail, in hopes of warning you not to frighten a whole household, by discovering that the mother of it has a polypus uteri, when she has no such thing. In fact, I make


NASCENT POLYPUS. 263

it to prevent you from jumping at a conclusion. How jump at a conclusion, say you? "Why! certainly my friend did so; and in this way. " The woman bleeds. She has a polypoid mass in the vagina, wdth certain uneasiness and pain ; ergo, it is poly- pus, ergo, it must be extirpated." He ought to have reasoned differently. He should have said, " The woman bleeds; she has bled not many days ; she has young children ; she is a breeding woman ; she has a polypoid mass in the cervix and vagina ; but a polypus requires a long time for its development ; ergo, 'though polypoid, this mass is not polypous, it is an ovum, compressed, and which is grasped by the cervix ; I shall pick it away with my finger; and when it is done, I shall say, you are well, now, madam; the miscarriage is over, for I have the whole product of the pregnancy in my hand."

I have no further remarks to make upon the subject of con- cluding too suddenly an opinion on such a case. If you will per- pend the circumstances I have just related, the facts, for they are facts, ought to serve to arouse your attention ; but, if you be really attentive to the business before you, how can you fail to make just and right conclusions ?

Let me relate another case to you, which is that of a lady about six-and-twenty years of age, the mother of a child about two years old.

Having for some time complained of pain apparently situated in the womb, and of vaginal discharge, and aching of the loins, and, indeed, of the pelvis generally, with increasing general de- bility, she was prevailed on to submit to an examination by the Touch. The os tincae was low down in the pelvis, and painfully sensitive ; but I could not discover any marks of swelling of the vaginal cervix, nor of engorgement of the whole uterus.

By means of the speculum, I found that the os uteri as to the left half of its anterior lip was red, injected — the venules and arterioles being visibly enlarged. The color was that of the brightest and healthiest lip of a young person. The rest of the OS tincae was of the natural pale whitish hue.

I advised rest ; recumbency during part of the day, and all night; a regulated diet; and as for the localturgescence, I treated it with contacts of the nitrate of silver pencil. But I did not make any progress towards a cure. As soon as the effect of the caustic was done away, the redness was found to be more intense,


264 NASCENT POLYPUS.

and occupying a larger base. The substance of the inner aspect of the said lip, and as far up the canal of the cervix as I could trace it by sight, was red and swollen, and vascular. This vas- cularity augmented, and the mass became a small tumor, which began to hang outside of the os uteri, so that I could lift it, and move it about from side to side, and up and down, with the points of the speculum forceps ; and, in short, it had converted itself by degrees into a cellulo-vascular polypus ; very small, it is true, but a real polypus. I cut it down to the level of the surface from which it sprung, with acid nitrate of mercury; but it sprung again, and again I cauterized it ; and so for several repetitions, until at last the tendency of the part to develope a polypus was abolished, and now I consider the patient as cured.

Have I not cured this patient of a nascent cellulo-vascular poly- pus of the OS uteri ? I believe that I have, and the case is on that account rare, and w^orthy of your attention. The little tumor always carried with it an epithelial covering, which was so tender, that on some occasions it would give way and bleed, upon being touched very gently, with a plumasseau of lint. Perhaps some of you may think it was a mere vivace that I cured ; but I cannot but suppose that had I let it alone, it would soon have become a bleeding polypus, like the small one that I mentioned in a former part of this letter, and which caused so long and exhausting a hemorrhage from the lady. I am, &c. C. D. M.


LETTER XXI.

Gentlemen : — I showed you on several difTerent occasions last winter, samples of uteri containing one or more hard nodular looking tumors, and also specimens, in which the entire mass of the womb had by disease, been converted into a tumor. .You may remember that of the smaller tumors, some rose to a considerable height above the general level of the peritoneal surface; some of them being mere knots, and others having the appearance of being attached by necks or peduncles to the superficies of the organ


FIBROUS TUMORS. 265

from whence, and through a faulty operation of the development force, they had sprung.

You shall find cases in which a womb shall be covered with such botryoidal prominences. They are to be met with as large as a child's head, and of every intermediate size, down to that of a filbert or a pea. They are, doubtless, all of them poly- pes, and they differ from the other sort, of which we have been before speaking, only in this, that they grow in a direction to- w^ards the serous, instead of in a direction towards the mucous paries of the uterus. The same principle is employed in causing the growth of either sort. There are some of them that appear to have pressed themselves, or rather to have been pressed down into the substance of the uterine walls, and sit, as it were, like an acorn in its cup, but attached at the bottom of the cup by a root, neck, or peduncle.

These tumors are not in themselves painful. They may give rise, however, to pain, by irritating the organ from which they grow, and yet they are not unfrequently met with in considerable numbers, in the uteri of patients who, having perished with other maladies, had never any suspicion of being aflfected in this way. In the long run they may fee expected, however, to bring on dis- orders by disturbing the womb, which you know is eminently a disturbing organ, when it is itself disturbed. Upon attaining a certain size, they are likely also to introduce a bad state of health by their intrusion on the places of other organs and parts, whose circulation, absorption, nutrition, and innervation, they directly oppress and contravene by their mechanical displacement and pressure.

People talk of taking medicines for such tumors, and they even take homoeopathic pellets in decillionths of grains! Leaving out of question the unspeakable nonsense of the homoeopathic dosings, I see no! on what ground they should take even real physic for such complaints, since drugs cannot, and were never designed to heal such tumors and make them return under obedience to the natural development laws of the organ, and restore its outline and contexture to a normal form and dimensions.

Don't you see that these are really chirurgical maladies, — that is to say, they w^ould be subjects for chirurgical manipulation and operation, provided they could become accessible to the fingers, or


266 FIBROUS TUMORS.

bistoury, or ligature, &c.? True, Mr. Lisfranc has proposed to enucleate them, and possibly, when one of them happens to spring from the vaginal cervix, it might be turned out with the handle of a scalpel, or dug out with the fmger nails. If you like such surgery, it may be well, but I confess I am not of that class of people. As to doing anything with those that grow outwards to- wards the peritoneum, I look upon it as hopeless. I detest all abdominal surgery, save that which is clearly warranted by the otherwise imminent death of the patient. I say imminent death, not inevitable death, for death is ordained for us all.

It does not, however, follow, that because you have come to the conclusion, that nothing can be done in the way of curing a fibrous tumor of the womb looking towards its serous surface, you are to do nothing for the patient herself.

Much may be done in a way of wise counsel and prudent pre- scription as to her conservation; as to putting off the evil day; as to obviating and combating all the provocatives to an unneces- sary increase of the malady; and as to counteracting the effects of pressure and intrusion, the natural accompaniments of the tu- mor. She maybe confined, by your orders, to the house, the sofa, or the bed, whenever the disturbance ajjises to a height rendering such intervention of yours desirable. If obstruction of the pelvis attend the complaint, the" enema, the aperient, the strong pur- gative, are at hand, under your direction. Her diet and clothing may be regulated wisely and usefully. If inflammation and pain be threatened, or actually make the attack, you will save the perilous organs by your venesection, your leechings, cuppings, counter-irritants, stupes, and cataplasms; by your tartar of anti- mony and potash, your calomel, and your opium. So that when you cannot cure the fibrous tumor, you see I do not advise you to turn your back on the patient, leaving her to an inevitable fate, rendered tenfold intolerable by unwise treatment, or by no manner of treatment. For I deem those who are doomed to an inevitable and not distant death from incurable disease, to have no less need of the physician than those who are certainly curable; and I think no higher exercise of the medical functions can ever be found than in those euthanasial benefactions that can smooth the way of the dying, and through composure, and comfortable counsels, and charitableness, and "sweet oblivious antidotes,"


SERRES' VIEWS. 267

divest of some portion of their terror and pain, the last fast fleeting hours of men.

I am, my dear friends, in no little danger of making a ram- bling sort of letter of this, as well as the last one ; for I find myself disposed very strongly to come back again in this* one to the con- templation of principles that I find I have partially discussed in the former. I hope, however, that as I am writing letters, and not a regular book, you will pardon me if I depart from the regu- lar epopoeia form of book-making, and preserve in this series of communications the liberty and latitude which would be unbe- coming in a regular gradus operis. In fact, I am very desirous to lay before you a translation of part of Article XVII. of M. Serres' Anatomie Transcendante, which is at page 130 of that admirable work; and I do this, because I feel very sure that no one is likely to republish the work in this country, and that you will probably not have an opportunity to seethe passages in ques- tion, unless I give them to you here. You will judge whether the citation be german or not, to the matter in hand, to wit, the abnormal developments to which the womb is liable.

Mr. S. says, " The structure, as well as the form of organs, is subject to various metamorphoses. An organ passes through va- rious phases or gradations, before it reaches the condition in which it is destined to remain throughout the rest of its exist- ence. An aberration of its form produces monstrosity ; an aber- ration of its structure produces disease. Both these aberrations are subject to certain rules, and very nearly to the same rules.

"In order to conceive just ideas of an aberration of form, we must follow the successive evolutions of such form from the mo- ment of its first manifestation, up to the period of its complete development.

" To conceive of aberrations of structure, we must adopt the same plan. But, inasmuch as a case of monstrosity is nothing more than the retrocession of an organ towards«»another and more simple condition of such organ, or its arrest at one of its embryo- nal and primitive conditions ; in the same sense, an organic dis- ease is often nothing else than a return of an organic tissue towards a textural condition, which it naturally possessed at some one period of its embryonal life.

"Diseases consisting in retrocession of tissues, correspond to cases of monstrosity by default; and monstrosities from excess


268 SERRES' VIEWS.

approach, in their nature, those morbid conditions in which there is a new organic production. Now, as a monstrosity by excess is but the repetition of an already acquired organization, so, produc- tive maladies can never give rise to any other than already exist- ing tissues. They reproduce tissues, as monstrosity reproduces organs; and these tissues as well as these organs almost always have their analogues in the normal and regular organization.

"Thus, the reproduction consists in a cellular tissue — in a membrane, the basis of which is cellular tela, or albumen ; or it is a cellular part, becoming a fibrous part; and the latter passing into the osseous, or cartilaginous state ; or, the product consists in natural cartilages, in which ossific matter is deposited; in strange muscular fibres that exhibit themselves ; in organs of secre- tion that are formed, either in the state of cysts or of crypts, whose analogues already exist in the economy ; or there are blood-ves- sels rising up spontaneously in newly-formed tissues, and, in fine, the nervous system itself may come to add itself to these acci- dental products.

" Notwithstanding they are formed in the midst of disease, these productions are subject to certain laws. The first law is this ; and it confirms one of the laws both of physics and chemistry, viz., that as a slow action is necessary for the operation of a regu- lar crystallization, so a slow action is indispensable for the ac- complishment of these formations. A rapid action would pro- duce either the destruction of the organs, or a hemorrhage, or collections of sanguine, or serous matters, or even purulent depo- sits, in which no organic movement is discernible.

" The second law is a consequence of the former; and it is that the growth of these products is effected by means of juxtaposition. The membranous layers superimpose themselves, one above the other where the membrane is plane ; if, on the other hand, it is bent or curved, so as to form a cyst, the addition is made upon the interior, in a (^ncentric manner. The exterior in this man- ner becomes the internal membrane of the cyst, which is nothing more than the membrane rolled up. This difference in form, slight as it is, produces a very great difference in the result ; for, whereas the membrane can acquire nothing beyond an individual existence, limited, at most, to the mere production of the sangui- ferous apparatus, the cyst frequently becomes a real organ, the interior of which deposits fluids of various nature and consistence.


SERRES' VIEWS. 269

■It may even constitute a heing, self- existing, and become a first degree of animality. The third law relates to histogeny, pro- perly so called.

"It was, no doubt, an error of the ancient anatomists to perse- vere as they did, in the search after an elementary tissue or fibre, the origin of all other tissues or fibres. Yet, underneath this idea lay concealed the profound and true notion that tissues apparently very different have, in fact, the very same origin; and consist but of the same element subjected by the powers of nature to diverse modifications.

"Thus, the cellular element, when disposed in areolae, or in fibres, constitutes the system to which it gives name : in bundles, it is the fibrous system ; rolled up so as to form a closed sac, it be- comes the serous system, &c. These various systems are nothing but natural and normal transformations of one common element. But, if it be in nature to undergo these transformations, we may perceive how a cellular part in man may, like the posterior cervical ligament, become fibrous in certain animals ; how a ligamentous part such as the stylo-hyoid ligament, may be transformed into an osseous chain ; how cellular parts may become serous membrane, while the serous membranes of the last order may become re- placed by cellular tissue, &c.

" We may also conceive that diseases, by modifying this common element, as nature modifies it in a normal state, shall cause cellular to become fibrous, cartilaginous, osseous, and serous parts, &c. All these modifications of a common element, may be converted one into another, while still circumscribed within their proper limits. The same will be the case as to the nervous and muscular elements, each of them forming systems analogous to themselves, although differing among themselves. In fine, the vascular, or sanguiferous element, intervenes in all these diverse systems, as a condition of all, in a somewhat ad- vanced formation.

" These analogous systems transform themselves each into the other, without, nevertheless, overleaping their respective limits. The cellular, will never, under any circumstances, clothe itself with those characters that are proper to the nervous or the fnus- cular element, nor will the nervous or the muscular elements ever exhibit the evident conditions of the cellular. However varied


270 SERREs' VIEWS.

may be such accidental products, you will ever find them cir- cumscribed by their true special nature.

" The very contrary of these statements is to be found in most of the treatises on pathological anatomy, wherein you are told that all the tissues, commencing as cellular, may again take upon themselves this transformation. In those treatises you find ac- counts of cellular, fibrous, cartilaginous, and even osseous trans- formations of the nervous system and of the muscular system. The fact is true ; its explanation is not true : the nervous system is never, in any phasis of its development, cellular. According to our views, therefore, it cannot, under any circumstances, manifest the transformations that are peculiar to the cellular ele- ment. But, incontestably, these metamorphoses are observed in it: then, it must be because the cellular element intervenes. How should it intervene? Always by accident. A solution of continuity suddenly separates portions of the nervous matter of the encephalon or spinal cord and nerves, a cicatrix repairs the injury. Such cicatrix, at first cellular, may become mucous, provided it fills with pus; it may become fibrous, cartilaginous, and even osseous; I have met with, and reported cases of each sort. But we see that in these cases, which I have analyzed with the greatest care, the nervous element remains entirely a stranger to these transformations. It is the cellular tissue, which, supervening pathologically in the nerve-matter, becomes the basis and the seat of these metamorphoses. Here, as everywhere else, it undergoes the evolutions peculiar to it, and to itself only.

" The practical consequences of these principles are so easily deducible, that, for the present, I shall refrain from deducing them. I will, however, remark that these new formed tissues never do attain the full degree of development, of the normal tissues to which they approximate. Thus, the osseous transformation may produce laminae, or granules, but never anything comparable to a bone. The cellular transformation of cicatrices is very far re- moved from the natural disposition of that tissue; a serous cyst can never produce a pericardium or a pleura ; nor, will the acci- dental mucous membranes ever rise to the height of that rich organization which we observe, for example, in the intestinal mucous membrane. Disease produces an abortion of tissue, just as monstrosity produces an abortion of organs."

There, gentlemen, I know not what you will say, or what you


FIBROUS TUMORS. 271

will think of such a long extract in this letter, but I know what you ought to think, and that is, that you ought to think yourselves much obliged to me, for giving you an opportunity to read the above beautiful and philosophic exposition. I advise you, before you go any farther, to turn back and read M. Serres' remarks over again. It will do you good to read them again, and it will do your patient good, for they are replete with the wholesomest doctrine constantly applicable to clinical ministrations, and perhaps, indis- pensable to a correct understanding of the diseased morphology of the uterus, which is the special subject of this letter. I did not intend to make so copious an excerpt from any body, but I could not resist the temptation to present this one from that admirable philosopher. And I am sure there is not an ingenuous and intel- ligent young man among you who will not concur with me in thanking M. Serres for even this much of his profoundest thoughts. Having now laid before you M. Serres' observations as above, let us proceed with the more direct object of this letter.

What was the real nature of that immense and very firm mass of polypus that I mentioned in the beginning of this communication? I said itw^as fibrous, and I suppose that that fibrous matter, though not truly a mass of uterine matter, must have nevertheless been deposited under a development or accretion law, identical with that which originally developed the fibrous matter of the womb itself, though modified in its operation by disease in this instance. Uterine polypus may be cellular or cellulo-vascular. In such cases, the vascular and cellular elements become the subjects of diseased deposit ; in the former, the muscular or fibrous portions are chiefly the subjects of it.

But you saw specimens last winter, in which the entire mass of the womb became altered, having grown to a vast size, and retaining in its augmentation very few of the characteristic features of its normal fabric. It, in fact, is become under such circum- stances, a heterologue organ, or rather, is converted into a tumor. Those cases wherein the whole womb is converted into a tumor, are very different from the mere hypertrophic modifications of its volume and weight, and the tumor is different in different samples, according as one or as another of its normal elements has been the chief subject of the morphological transformation, and the de- parture may be greater or less in different specimens, some retain- ing, and others losing every trace of the original character.


272 FIBROUS TUMORS.

In regard to all the possible forms into which the material ele- ments of the womb may become converted under the wild hetero- logue operation of its development force, w^here it has abandoned its generical law, it seems to me nearly bootless to inquire.

Some of the writers on these strange appearances have endea- vored to classify them and reduce their arrangement to a scien- tific scale. For my part, it seems to me enough to know that the elements may, each of them, undergo changes by a morbid act of deposit, and I am not, therefore, surprised to find a hygroma, a hsematoma, a lipoma, a cancer, &c., formed upon the basis of the uterine textures. If the morbid development deposits in the uterus a mass of cartilaginous structure, there is no reason for surprise when that cartilage passes into bone, since it is one of the functions of cartilage to do so. All such cartilage deposits are effected through the agency of cells, and Thomas Schwann has shown, in his '■^Comparison of the Development of Animals and Plants,'^ that in each of those kingdoms, the cell life force is the agent of nature in the work of evolving her living forms.

You will readily admit, that this cell force moves in a true generic line partly in virtue of an original nature or bias with which it is endowed, and partly in virtue of certain chemical at- tractions that concur with it; for example, the cells of the chorda dorsalis of a tadpole, are probably very different in their original life endowment from the cells of the pollen tube of a cactus or a lily; yet even if you presume them to be not different in the essential nature of their nucleated nucleoles, they are very differ- ent as to the circumstances in which they are placed ; for the chorda dorsalis cells could not possibly be developed in such a cytoblastem as that which is provided for the pollen cells in the stigma or style of a vegetable, and vice versa, for the pollen cells could find no proper elements in the albuminous fluid of the spinal marrow.

Now, as to the morbid tumors of which we have been speaking, the cell — the mother-cell — finds a new cytoblastema in a morbid deposit, and it appropriates it to form a tissue, a morbid one, but still a tissue, which is heterologue, and to such a degree, that it will be difficult in many samples to ascertain which is the devi- ated element in the case.

If you examine the cells of a malignant tumor, you shall often find no appreciable difference between their appearance and those


FIBROUS TUMORS. 273

of the healthiest young growing part, as for example, the cells of the chorda dorsalis, those of cartilage in very early embryos, or those discovered by compressing the pollen grains of a flower, or the plumule of a bean.

The caudate cells of some of the cancerous tumors, the acicular crystals, the granules and laminae of earthy phosphates and car- bonates that we find in these masses, ought not to excite our surprise, though they may well overwhelm us with grief, if like the good Sir Thomas Brow^ne, whom I have already quoted, w^e be not only grieved, but thoroughly ashamed, that there is in the world, not only the greatest of evils, death, but that other great evil of diseases incurable.

I do not imagine, my young friends, you will make any very great progress in real knowledge, by burdening your memories with all the varieties of nomenclatural distinctions, that are in the books concerning tumors of the womb.

Dr. Hooper's costly and beautiful volume, *' The Morbid Anato- my of the Uterus and its Appendages,' is one of the clearest of them, but I think you will find in it too elaborate a systemization of these vagaries of the development forces, an attempt to classify what need not, and indeed cannot be classified, videlicet the freaks of nature, aicting without generic law, or end, or aim. It is far better to study M. Serres' beautiful doctrine, that I have quoted for you from his Anatomie Transcendantey in w'hich is explained the true philosophy of such extraordinary operations.

You shall probably meet, in the course of your long experience, with cases where the womb, that weighs in its natural state only- two ounces, has become as large as a man's head, and weighs many pounds. The texture here is not uterine texture ; it is a mixture of fibrous and cellular material, with greatly diminished proportions of vessel, nerve and absorbent. It seems to me that the process of production for this abnormal uterine matter is one that has no natural term; it is limited only by the life of the pa- tient, and there is no power to recall it. It is, therefore, useless to give drugs with that view. It is true, I have met with several examples of enlarged and heterologue uteri, that have ceased to grow, and I can well imagine that now and then in the pro- cess of extension, there will be attained a final term of the deve- loprL.ent force. That is to say» the uterine and spermatic arte- 18


274 FIBROUS TUMORS.

ries that serve under the registry of the accompanying nerves, may convey material sufficient to carry out the morbid formation to a certain extent, but cannot transcend that certain extent, because the calibre of the vessels will not admit of a sufficient quantity of blood to pass to effect any further accretions, or haply the accompanying nerves will lose, by their extension, their indi- cating or controlling vital power over the morbid organic acts of accretion.

Such an effect as I have just spoken of, would doubtless follow the tying of both the uterine arteries ; or, perhaps even of one of them; and in any case where a uterus should be known to be about to convert itself into a solid tumor, it seems to me not an impracticable surgery to secure the uterine arteries, with a view to suppress the further development.

Suppose, in any such case, Robt. Lee's ganglions of the cervix uteri could be carried off by a dextrous operation, would not the further development of the tumor certainly be arrested ?

I repeat that I have seen some cases of morbid augmentation of the womb carried to such an extent as nearly to fill the whole of the excavation of the pelvis ; so much so, indeed, as greatly to impede the functions of defecation and urination, and wherein the patients, after years of great suffering, have recovered their activity and good health.

In such samples there has been, however, a loss of appetite, or a regulation of the diet amounting almost to the diete absolue: and there is reason to suppose that the cessation of development has arisen from the extreme reduction of the development force, partly by feeble health, and partly from the diminution of the sources of supply under a rigorous diet.

I saw a cancerous mamma, as hard as cartilage, ulcerated, and firmly adherent, that was totally removed by absorption, in a long paraplegia.

Many of these great tumors of the whole womb are accompa- nied with dreadful hemorrhages. After death, you find a uterine cavity longer than natural, but not much more spacious. The walls of the cavity, however, are many inches in thickness.

I attended, for a long time, a lady with a vast tumor of the whole uterus. She had enormous uterine hemorrhages. The uterus weighed many pounds; its cavity was not much larger than the normal size; in the right ovary, which was as large as


FIBROUS TUMORS. 275

the fist, was found a quantity of human hair. Probably, the fatal development of the womb was provoked by the irremissible irri- tation communicated by the ovary to the uterus.

In case the womb begins to develope itself as a uterine tumor, it will in the stages be sure to sink low down in the excavation of the pelvis; and as it developes its magnitude more and more, it more and more interferes with the parts upon which it presses. If you touch such a mass, you scarcely shall fail to find it firmly packed, or jammed in the pelvis, putting you in mind of those cases of immobility of the womb that I spoke of in my XVth Letter. If you let the uterus go on increasing in size and weight while inhabiting the excavation, you will be sure to have much trouble from complaints of urinary and intestinal tenesmus, that must inevitably accompany such pressure and intrusion. Reflect for a moment on the facts, and you will perceive that though apparently immovable, the mass is not really so; and that it is only apparently so from the condensation of the tissue of the vagina, and from its weight. If you could get the tumor well raised upwards, so as to carry the mass of it above the superior strait, you w^ould do the woman a great service, by relieving her of all the painful and annoying accidence of the malady. But, when you try, with your hand to raise it, it will not go! Don't be disheartened; make it go. How? Place a globe-pessary in the vagina, a small one; one of an inch and a half, or an inch and three-quarters ; leave it in situ for a week, more or less ; then adjust one of two inches, and next one of two and a quarter inches. In this way you may very confidently expect to raise the tumor out of its narrow bony chamber in the excavation, which is too small for its accommodation, and get it up into the free and large space of the abdomen, where its pressure is scarcely inconvenient. But, think, gentlemen, if you take away by this means, a constant and irritating tenesmus, you turn aside in that very act, a strong and perpetual provocation of the sanguine and nervous systems to excessive activity, and thus diminish the tend- ency to rapid growth of the tumor. Nay, might it not be that the growth should find itself completely arrested in this way? I am convinced that the abolition of a constant and vexatious tenes- mus would be far more efficacious in diminishing the tendency to morbid nutrition and development of the womb, than half a dozen leechings, cuppings, or blisterings, to which you would resort as


276 FIBROUS TUMORS.

your chief therapeutical armamentaria medico-therapeutica. But in this, I speak not as one theorising only ; I speak from what I regard as well-observed clinical experience of my own.

One is greatly tempted, under such circumstances, to pre- scribe ; and, if we must prescribe, let us allow the woman to test the power of the deobstruents, as they are called. Such is the iodine.

I have no clear rationale to offer you as to the therapeutic action of iodine. Its probable efficacy, as combined in the spongia usta, in the cure of bronchocele, led it into a great vogue as a means of promoting the actions of the absorbent system ; and there can be no reasonable doubt as to the disappearance of swellings of glands after its exhibition ; of the disappearance of various cuta- neous eruptions ; and also of certain engorgements of organs. But, whether tumors are obedient to its power, is a question not yet settled ; for a tumor is a new material, and not simply an old one modified as to size, sensibility, and resistance. Nevertheless, you would probably give the patient iodine. Let her take it for along time. Let her take it in combination with some of the diet drinks; as Zittmann's decoct., or decoction of the woods; or simple infusion of sarsaparilla ; or, what is the least inconvenient of all, the compound syrup of sarsaparilla. Let her have five drops of Lugol's solution of iodine, with half a fluidounce of syrup of sarsaparilla, twice or thrice a day. One good effect of such a drug may be counted upon ; and that is an improvement in the state of the skin, w^hich becomes warmer, more humid, and better colored under its use, and if so, then the internal determination is in so far lessened, which is a great point gained.

The use of the bath at 96° or 98° of Fahrenheit, will conduce favorably to the same end. If repeated too frequently, it will be found exhausting. I advise you to order the bath about three times a w^eek, and that the patient go from the bath to bed at night.

Seeing that the womb is subject to a monthly hemorrhage, in consequence of the periodical ovi-posit by the ovary, and that this mensual hemorrhage absolutely depends on a periodical hemor- rhagic engorgement and nisus of the internal reproductive organs, it is a clear duty to regulate the patient so as to cause the monthly periods to pass by with the least possible injury to the womb.

If the woman whose womb is about converting itself into a


FIBROUS TUMORS. 277

tumor should be careless of her menstrua; if she allow them to be checked or prevented, and the vessels and the nerves of the organ to remain too long, or too considerably under the influence of the mensual nisus, the tumor will be surely aggravated by that protracted or too violent sanguine and nervous determina- tion. Let her, therefore, be advised to stay at home ; to keep her feet from cold pavements, or grass, or earth ; to maintain a solu- ble state of bowels; to diminish her rations; to be calm, and gentle in all her movements, and in all the affections of the mind during the existence of the mensual crisis.

It will be advisable also to abstract her constitution from the too considerable irritation communicated by the tumor, acting upon and vexing that constitution day by day, and nightly, for weeks and for months. Small doses of opium in the form of Dover's powder at night, alternating them from time to time with enemata of black drop, or laudanum, will be the most pow- erful means within your control for such ends. But, as you will have a long case before you, you should be careful to avoid op- pressing the nervous system by a profligate use of such narcotic remedies. The nervous system is more apt to be debauched than saved by the intemperate use of such drugs. Let your doses, therefore, be the smallest possible ones consistent with the pro- duction of a moderate therapeutical result.

I cannot close this letter, without again saying to you that women, in whom the whole mass of the womb becomes converted or metamorphosed, are very liable to uterine hemorrhages. The change in the constitution of the uterus, does not of necessity implicate the healthful vitelliferous and germiparous operations of the ovaries; but the ovaries, and not the womb, contain the cause of the menstrua. Hence, the menstrual action goes on in some of the specimens with very great regularity. It is to be noted, however, that the new condition of the uterus itself, com- monly renders it hemorrhagic, and the same causes and influ- ences, therefore, which produce the healthful mensual elimination in the healthy uterus, operate to cause an excessive discharge of the menses, in some of these altered uteri. As to two females, in each of whom the womb was as large as a man's head, the waste was very great.

To combat such wasting discharges, you have at your com- mand the usual resources of local cold, of recumbent rest, of


278 FIBROUS TUMORS. CANCER.

opium, of saccharum saturni, of alum, of krameria, kino, &c, &c. But, I have seen all these fail, and yet the hemorrhage held in check, by doses of a decoction of dewberry root, and black currant root, taken in half-teacupfuls at a time, and re- peated pro re natd. I mention it here, as an article worthy of your attention, especially in the examples of hemorrhages in which you find yourselves baffled. The ultima ratio, the tampon, will, of course, ever supply your wants in the instances wherein it may be indicated.

Lastly, never despair; never give up the patient; never pro- nounce the case hopeless, even when it is to all appearance hope- less. Not that I advise you to deceive the sick, or their friends, which is cruel and useless ; but you should remember, that men and women and children, have recovered from even apparent death. In these cases of enlarged womb, you have the hope that the growth will cease, and you have the example that they sometimes diminish again. It is time enough to pronounce that there is no more hope, when the life has left the body. I have seen the life resumed, even when I had regarded the signs of death as complete.

I wish, my friends, I had more comfortable prospects to hold out for you than those which, as to tumors of the womb, are con- tained in this letter. Medicine is always making progress, how- ever, and let it be your duty so to study, to observe, and to reflect upon these mighty disorders, as to enable you in the next half century, to leave more consolatory counsels to your pupils, than I can to mine. C. D. M.


LETTER XXII.

Gentlemen: — There is a frightful malady to which women, the subjects of these letters, are very much exposed; I mean car- cinoma, or malignant degeneration of the womb.

I have little to say on this subject, and, I might add, there is little to be done for those who are attacked with it ; I mean little


CANCER OF THE WOMB. 279

to be done under prospects of curing the persons so attacked, or restoring their health.

It is enough to make a physician's heart sink within him to make the diagnostic of cancer uteri, for such a diagnostic is ipso facto a prognostic of death ; and when the physician has made it, and is brought to the point of giving true expression to his opi- nion, he might be supposed to be as painfully situated as an Eng- lish judge, when he puts on the black cap before the final an- nouncement of the judgment unto death.

It is probable that the double functions of the uterus, as a men- struating and a child-bearing organ, render it more liable to the attack of this atrocious malady, and that its structure, also, which in the healthful state is solid, hard, and elastic, without excessive abundance of circulation or nerves, exposes it more constantly to the causes of carcinomatous change.

What is that condition, that carcinomatous condition which re- sults in ulceration or open carcinoma of the womb ? and how is it originally established and set up in the texture of the cervix ? Do you say it is cell-life begun and carried on there ab initio? How is the cell-life begun? — what gives origin to it? — when does the cell development begin ? — is cancer always an inoculation, and whence the inoculation ? — can the healthy actions o§ the womb deposit mother cells in a healthy texture, and furnish them with the indispensable cytoblastem, without which they would die ? These are questions more easy to propound than to answer, be- cause physicians, very rarely enjoying opportunities of inquiring into the rise and progress of these disorders, do not begin to ob- serve them until they have reached a stage of development so advanced as to leave little ground to expect any advantage from treatment, beyond the mere benefits arising from cleanliness, and some suppression, perhaps, of the progress as well as of the pain and irritation. Such cases cannot be studied ab initio. A mere schirrus of the cervix does not give pain, and the woman herself will not ask our aid or our opinion on a case of whose existence she is not aware. I say, then, we cannot study these carcinomas ab initio. They can be reasoned of, however.

I have never been able to bring myself to a consent that these diseases are the results of anything but inflammation. I have always regarded the transformed materials of a carcinomatous cervix, as the transformations of deposit brought about by inflam-


280 CANCER OF THE WOMB.

matory action. And, if you will keep in view the remarks of M. Serres as to the gentle and slow progress of those actions that re- sult in morphological changes, you will not find it difficult to agree with me that a carcinoma is an inflammatory result; for the slowness of the process, of which M. Serres speaks, is an attri- bute of those chronical inflammatory movements which produce, not hemorrhage, not secretions, not pus, not sphacelus, but new textures. But a carcinoma is a new and a changed texture. It is an imperfect texture. It is a texture whose combination of vessels, absorbents, and nerves is a perishing and unpermanent one; one that, from the very nature of the proportions of these in- struments and agents of life, cannot exist long in one tenor of life, but must change and decay from the very fault of their crasis or composition. In a healthy cervix, the accretion and waste are duly balanced, because the absorbent and the nerve are there to regulate them ; but when, in consequence of a slow, a chronic inflammation of the cervix, the interstitial textures become filled with laminae, or fibres, or bands, or granules of coagulating lymph, or fibrine of the blood, it is manifest that the vessels are to be collapsed or compressed and closed by these deposits outside of them, as is clearly shown by Pujol, in his admirable doctrine of inflammation ; and that the absorbents are sealed or compressed so effectually, and the nerves so absolutely destroyed, that the quasi organization of the carcinomatous cervix has come to its end, its term, and no longer, in truth, exists as to the sura of the particles of the cervix ; and then commences a process of absorptions, and sloughings, and suppurations, and hemorrhages, and macerations, and sanious putrid excretions, which proceed until the constitu- tion of the victim being entirely exhausted or overthrown, she sinks into the grave, her only and her last best refuge.

In the progress of this half erosion or maceration, and half phagedenic ulceration of the parts, the mother cell makes its be- ginning; and once begun, the parts once inoculated with this new and wild, unconstrained, uncontrolled form of life, the de- struction goes on with rapidity ; nothing stays, nothing arrests it, and the sole resource of our art consists in the exhibition of opium in some one of its forms, for the subduction of the distress.

The principal matter, however, is to make a correct diagnosis. There is danger of an incorrect one in this, that if you come to the clear conviction that the case is one of veritable carcinoma or


CANCER OF THE WOMB. 281

cancer, you will be paralyzed by that conviction; and, like every- body else, will settle down in the conclusion that nothing is to be done beyond the administration of those palliatives, which, though they cannot cure, yet can console and cotofort the patient.

I have certainly met, in the course of thirty years, with several cases of diseased uterus, which I had the greatest reason to sup- pose cancerous, but which yielded to persevering treatment, and ended in the perfect recovery of health.

Far be from me the intention to proclaim that I have been more fortunate than my brethren, and that I have cured cancer of the womb. My desire is to say that I was mistaken in my diagnosis, and that I treated a curable and not an incurable malady. I am of the opinion that everybody holds on the subject of this terrible evil, viz., that it is one of the opprohria medicorum, and that it cannot be cured. No, not even by the excision of the part affected. I speak of the true cancer.

Dr. Muller,in his work on the Nature and Structural Characteris- tics of Cancer, &c., combats the opinion of Wenzel, that scirrhus and carcinoma are mere inflammatory induration, followed by ulcerative action. Yet, notwithstanding my ready assent to the doctrine of cells, as the agents of vital development, I confess myself to be quite in favor of the doctrine of Wenzel, and of those who, while they deny not the destructive activity of the de- veloping cells, which are so readily detected in various forms of ulcerated carcinoma, and of fungoid disorders, yet regard the antecedents of cancer as caused by inflammation. Perhaps you, my friends, may be in favor of Prof. Muller's views, and I ac- knowledge his arguments are very powerful, and that his citations of examples and varieties in the forms of cancerous degenerations, add to the force of his reasoning. But I cannot bring myself to believe that cancer ever commences anywhere, as a punctum saliens of disease. There is always an antecedent state of alteration of tissue ; a state which lays the foundation for the wild evolution and increase of cells, out of and beyond the control of the accre- tion and waste laws of the part or organ.

When a part has once become changed by a certain form of indu- ration, the control of the generic nerves is abolished in it; and a cell deposited within it, or inoculated from without it, might live and multiply upon its morbid cytoblastema, so as to result at last in the strangest modifications of the texture ; becoming carcinoma


282 CANCER OF THE WOMB.

reticulare, alveolare, fasciculatum, melanodes, or medullare. These several forms of degeneration depend on the loss or re- tention of more or less of the nerve-power of the part, by which one or another of the constituent elements of a fabric may be held in check, or allowed to run into riot and ruin, under the action of the disease.

But it is not my purpose, and I confess I have not sufficient information upon these points, to enter into a useful discussion of the microscopic characteristics of the various forms of cancer. There seems little profit in such discussions, beyond that which enures to the enrichment of our possessions in biology. They will probably have but little influence in a utilitarian sense, since they add not to the power of the therapeutist, nor to the success of the surgeon. I cheerfully refer you, therefore, to Prof. Muller's beautiful work, hoping, however, that you will always endeavor to exercise an independent judgment on all matters of science; not without that due respect to the superior knowledge and oppor- tunities of such men as John Muller, whose great learning and noble devotion to the enlargement of the boundaries of medical science, have earned for him so distinguished a name. I shall refer you to Colombat for a fuller description of the phenomena of scirrhus and cancer of the womb ; merely saying here that, when the OS tincse becomes covered with hard lumps, that feel like shot lodged under the epithelium, that give sharp pain when pressed with the finger; that deform the os uteri, by causing it to swell unequably; by unnatural discharges; you will have a right to suspect scirrhus. If it have gone so far as to bleed for a touch, and to give rise to sanious discharge, with a peculiar odor, not very difl[erent from that of carious ulcer, it is ulcerated cancer, and the patient will die.

You will find that many of the European surgeons have treated cancer of the cervix, by cutting off the diseased part, and that they assert the patients to have been sometimes cured by the ope- ration. I think the remark made to me by an eminent Philadel- phia surgeon some time since, is worthy of being repeated. "If the cervix was cut off," said he, " and the woman recovered, it affords the most incontestable proof that the operation was unne- cessary." It is probable that the course of your future expe- rience, in recovering certain forms of enlargement, induration, and ulceration of the cervix uteri, will bring you, in the end.


CANCER OF THE WOMB, 283

to a similar conclusion. In fact, there have been so many cases of excision of the cervix, within thirty years past, with so little happy result, that the operation is understood to be nearly aban- doned by the German and the French surgeons. T. S. Lee says, " I have seen but one case of this kind, (excision of the cervix :) • the neck of the womb was entirely removed, leaving an open cavity in the womb. After the operation, the patient remained in the hospital some long time, until the ulcer caused by the ope- ration had entirely healed ; but, after her dismissal, she shortly had a return of the deep-seated pain in the pelvis, the dragging at the groins, inability to walk far, and many of the same symp- toms of which she complained before the operation. M. Lisfranc states that the success of this operation is very great in his hands; but he can hardly be relied on. It is an operation not much prac- tised by our own surgeons, on account of the liability of the dis- ease to return. Caustic is our only resource when the granula- tions become too luxuriant; but I have never seen it do much permanent good. Opiates are constantly necessary to allay the deep-seated and other pain which disturb the rest and break up the constitution. Coniura and hyoscyamus are the best; they affect the head less, but frequently are not sufficiently powerful ; then opium, in some form, must be had recourse to. The bowels are to be kept gently open: but, diarrhoea is to be avoided."

What more? I am out of heart, and ashamed to name cancer of the w^omb ; and yet, what is the miserable victim to do without the aid of the physician ? You must aid her. You must wash away the foul and putrid collections that actually sometimes g^^sA from the diseased surfaces.

If you treat such cases, you may add greatly to the comfort of the woman by the upward douche. You can suspend a glissoir and conduct into it a pailful of water, at such temperature as you please to indicate ; the lower end of the glissoir, if provided with a gum-elastic tube, may be carefully introduced into the parts while the patient reclines in a bath-tub, or sits on a bench over a wash-tub, so that the douche may be directed to the affected parts with the effect of lessening the accidental epiphenomenal inflam- mation, and carrying away all the detestable odour of the sanies. Or the patient may go daily into a sitz-bath, and cleanse herself of the odious exhalations of her malady. What a comfort for a woman!


284 CANCER OF THE WOMB.

Dr. Lee says that caustic is the only recourse. Take a small phial containing acid nitrate of mercury, a camel-hair brush with a long handle, a speculum of ivory and a speculum forceps, a small sponge, some honey of roses containing wine of opium or black drop, or extract of conium, or extract of hyoscyamus, -

Let the patient lie across the bed, her head, not the shoulders, on one single pillow ; her hips at the very edge ; her feet on the upper bars of the backs of two chairs ; her knees widely separated, covered with a sheet.

Introduce the cylindrical or conical speculum, not too far, wrap the edge of the sheet all round the tube, so as completely to con- ceal the person, leaving only the projecting portion of the tube to be seen. Press the speculum down slowly and gently until you disclose the diseased part. You will be sure almost to find some of it upon the vaginal walls. DonH burst them, nor hurt them by jamming your tube into them. When they come into sight, take your bit of round, soft sponge filled with Castile soap, dip it in tepid water, thrust it into the mouth of the speculum, and then holding it in the forceps, carry it to the bottom of the speculum and wash the ulcer clean. A soft sponge, well filled with fine Castile soap, is as soft as the mucous membranes themselves, and may be freely but gently turned round and round over the granu- lations and shreds, without inducing hemorrhage or the least pain. On the contrary, the patient is greatly comforted and consoled by the process, both physically and morally, for her pain is diminished and she feels herself to be less an object of aversion and disgust when the frightful foetor of her cancer is even tempo- rarily taken away.

Having cleansed the surfaces and dried them with soft dossils of charpie or linen cambric, if the indication calls for it, dip the camel-hair pencil in the acid nitrate, and carefully conducting it to the granulating surfaces, touch them with the solution ; where- upon they immediately assume a gray or ash color ; and the se- cretions are, for the while, suspended by the coagulation and caiiterization of the orifices and surfaces of exhalation. When you have made the contact of the caustic, carry your sponge, filled with warm or tepid soapsuds, to the bottom of the speculum, in order to neutralize any excess of the acid that might flow off upon surfaces you do not wish to act upon; and then having dried the sore again, dip a small bundle of charpie or soft linen cambric


CANCER OF THE WOMB, 285

in the mixture of honey of roses, attaching a strong thread to the bundle; place it in contact with the ulcers and keep it there with your forceps, until, by gently withdrawing the speculum, you observe that the collapse of the vaginal walls will hold it in situ. The patient may withdraw the pledget or plumasseau in the course of four, six, or ten hours, according to the heat of the apart- ment and the heat of her body. The thread serves to draw it away.

Dr. Lee tells you to use conium or hyoscyamus as your ano- dyne ; but he also says they are not very reliable resources, and that you must come to the opiates at last. In the matter of opiates you should reflect that in addition to the debauching influences of opium on the nervous constitution, and on all the secretory acts, there is a directly pernicious impression on the primse viye. But you should save the digestive power as far as you can. Use the laudanum, therefore, as enema, and use it wisely. Teach the poor creature not to waste so great a blessing as that which God, in the midst of his chastisements, has vouchsafed to her. If she uses her anodyne too much, like a spendthrift, its power will soon be gone.

Let her, then, in the beginning, learn to quell not to crush the pain, for it will rise again. She should be provided with a proper syringe, one that will hold two fluidounces, and no more; and the fistula plumbea should be of a good size and sufficient length. Let her add to two tablespoonfuls of clear starch, twenty- five to forty-five drops of laudanum, or eighteen to thirty drops of black drop, or two to four teaspoonfuls of solution of morphia, to make the injection into the rectum — an injection that may be repeated once or twice, or thrice in twenty-four hours. She should be clearly informed that the progress of her malady will surely require larger doses, and the larger the doses the worse the influence upon the digestive and nervous power. Teach her, then, not to be profuse in the expenditure of that treasure of com- fort which she possesses.

Where you have under your care cases that are attended with wasting discharges of blood or sanies, from cancerous tumors of the cervix proper, that sometimes are tuberous in form and of a large size, I presume you will as readily counteract the bursting tendency of the tumor, or its tendency rapidly to pullulate like the granulations in what is commonly called proud-flesh, by using the


286 CANCER OF THE WOMB.

acid nitrate. You may, perhaps, prefer the caustic potash. But- the most efficacious and sudden of these powers, is that you pos- sess in the actual cautery. The greatest objection to it in this country is the terror and the talk it would excite. But it does not give pain nor cause sensation, and the death of the points touched by the hot iron is so complete and so deep, that it is more efficacious than any potential cautery, and leaves a better base after the fall of the slough.

It is very easily applied through an ivory or horn speculum. You ought not to employ a silver, or metallic speculum for this operation, because, in using the actual cautery, you must have the iron intensely hot; if it be merely cherry-red, it will adhere to the surfaces that you touch with it, and you will tear them in removing it. Your houton should be white-hot ; when, indeed, it burns before the actual contact, and does not adhere to, but rather repels the surfaces. Now, if you pass a white-hot cautery down the whole length of the metallic tube, you will heat the tube, and burn the whole vagina, whereas, if you pass it down an ivory or horn cylinder, which is a non-conductor, you will give her no pain at all.

Many of you, living in remote country places, will, perhaps, not find it convenient to procure the beautifully turned ivory specu- lum ; but there is everywhere to be got a cow's-horn. Cut one to the length of six inches ; drill or reame out the interior to the dia- meter of one and three-quarter inches at top, by one and a half inches at the lower end; shave it thin and polish it, and you will have as good a speculum as if Charriere himself had made it. You would do well to have several, of different sizes, for in some of the carcinomata of the uterus and vagina, you will want a very small cylinder, inasmuch as a full sized one would give pain and even endanger the laceration of the vagina.

M. Jobert de Lamballe, one of the surgeons of St. Louis, at Paris, is very famous in Europe, for the common use he makes of the actual cautery, in the treatment of diseases of the os tincse. It is, in fact, for him a great specialty. M. Jobert, in a publication, has supposed the cervix to be nearly destitute of nervous sensi- bility. He treats a great variety of disorders of the cervix, by this means, and asserts that many of his patients are completely cured by it.

I have seen him apply the cautery to many women who came


CANCER OF THE WOMB. 287

in succession, to place themselves on the bed arranged in his lecture room. The iron was always brought to him by an aid, as soon as the speculum was properly adjusted. The hiss of the burn was distinctly audible, but the women were never sensible of the contact, as I was assured, both by carefully observing their expression of countenance, and by their own avowal ; for they assured me they felt nothing, though, in the course of a little time afterwards, there was heat and pain, which soon passed away. M. Jobert himself is very confident in the vast benefit of this pro- cess ; but the English on the opposite side of the channel, detest his process, and condemn it. There is no objection, however, to your making use of it, for the suppression of otherwise irre- pressible fungoid growths, or perverse hemorrhagic discharges.

So much I have said as to cancer. I sincerely wish it were in my power to say more ; but I can find no encouragement in my own melancholy experience, nor in the writings of Recamier nor Lisfranc, or Duges and Boivin.

But, for the cases that simulate it; that present hardened and patulous OS uteri, with granulations that bleed for a touch, and that sit on a hard and swollen base; if the patient be not already reduced in strength and flesh, bleed her from the arm, purge her every alternate day, with compound powder of jalap and cream of tartar, until she has taken four, six, or eight doses. Touch the granulations with the nitrate pencil ; keep the woman in bed ; direct the frequent use of the bidet ; let her have a tepid-bath three or four times a week; give her a diet, in which she shall have some meat every alternate day at dinner, and only then. Dissolve a grain of corros. chloride of mercury in a pint of com- pound syrup of sarsaparilla, and direct a tablespoonful for a dose, twice a day, to commence after the close of the course of purga- tives. An anodyne enema at night will not only procure sleep, but procure that sort of hebetude as to constitutional impression, that is highly conservative under these circumstances.

Such a diet as T have advised above, I have for many years been in the habit of recommending in long cases, and I have pre- ferred it to a continued abstinence from animal food, because the digestion is less apt to give way under it, than in a diet of lavage or mere vegetable matters, and moreover, the patient submits with greater cheerfulness to a restriction that is not absolute. In such a course of diet, the patient in thirty days will have taken only


288 PHYSOMETRA.

vegetable matters on fifteen of those days, or thirty days in sixty, which, for many cases, will be found a sufficient degree of absti- nence.

Certainly, I have cured some very unpromising forms of dis- eased OS and cervix uteri, by such a course. And now I shall desist from further remarks on this painful subject, referring you to the publications already mentioned, where you may find greater details, but little more encouragement ; and I am very truly, &c.

C. D. M.


LETTER XXIII.

Gentlemen : — If you will look into the books, or listen to the relations of your patients, you will, perhaps, be led to believe that the womb is occasionally to be found distended with air, which, after having caused it to expand, until -it attains the size of a womb six months gone with child, more or less, suddenly escapes; whereupon the signs of the woman's pregnancy disappear to the great astonishment of the hopeful patient, as was the case in the celebrated instance of Mrs. Commodore Trunnion, of whose baby the author said, " tenues in auras evadit.' These ventose pregnancies are nonsense, and no thoroughly-bred and close thinking physician ought to be for a moment misled by such a story. It is against physiology; it is against pathology, and it flies in the face of common sense, to talk of collections of wind distending a material like the womb, a material which creaks under the edge of the bistoury, and expanding it like a normal ovum, whose gentle slowness of growth is the sole reason for the deployment of the gravid uterus.

Air is too subtle to remain quietly locked up in a bottle that has no cork in it ; and you all know very well, there is no womb into whose cavity you could not thrust a large quill, or male catheter; how, then, is air to remain in the womb, and blow it up like a Freshman's football, not only against the resistance of the womb itself, but against all the succussions of the abdo-


PHYSOMETRA. 289

minal muscles and diaphragm, and the resistance of the skin of the trunk of the body to boot! It is an idle conceit.

What ! is there no such thing, then, as physometra and tympa- nites uteri ; or a discharge of wind from the womb ? Has it never been heard? Yes, I have heard it many times, both in child-bed w^omen, and in others. Yet I repeat, that inflation and distention of the womb with gas, the ventose pregnancy, the pet vaginal are not diseases, but pure accidents. Madame Boivin and Duges, at page 134, say, " We have never known the existence of an aeriform body in the uterus, except in obstetric cases, as in reten- tion of the membranes, or of portions of the dead foetus, or of putrid coagula, causing gaseous exhalations, found in the uterus after death, or escaping per vaginam during life."

Let me explain this matter to you, for I cannot patiently endure to think that a pupil of mine, be he settled in Maine or Wiscon- sin, at the Sault St. Marie, or Monterey, should admit to a patient that the womb can become filled and distended with gas, as a result of diseased secretion, for such secretion is impossible, and to admit it ridiculous.

I have often been present at the discharge of large quantities of gas from the genitalia. A woman shall be seized with her last labor-pain, and bearing down with great violence, thrust not the child only, but the placenta also forth upon the bed; and, in bearing down with the violent force of the labor-tenesmus, she pushes the very womb itself to the bottom of the pelvis, shorten- ing the vagina in so doing, wrinkling and crushing it down to the OS magnum. As soon as the tenesmus is over, the resiliency or elasticity of the tissues recovering its power, the w^omb rises again to a certain height within the excavation of the pelvis ; but, as it is a cul-de-sac that rises, it is natural for air to follow it, and the vagina, and the womb itself, may thus contain air that has been drawn up within them, upon the same principle as that which makes it follow the movement of a piston in a cylinder. Then comes a new pain — an after-pain ; or else I apply my hand to the hypogastrium to make sure of a good contraction of the womb. If I compress the womb with my hand, and particularly if I push it downwards in the pelvis, I am very apt to cause a quantity of air to rush out at the ostium vaginre, with consider- able noise. This I have heard a great many times. So, in making 19


290 PHYSOMETRA.

the examination per vaginam, when the uterus is very low down, or when in making use of the speculum I push the os tincai far away from the os magnum, air enters the passage, and follows the retreating womb. If it be left there, and the woman is seized with a fit of coughing, or if she moves quickly, or changes her posi- tion, the air is pressed out with the sound of the pet-vaginal. And there is no other way to account for it, that is reasonable. So, also, a woman has a heavy womb, with a large loose vagina ; she lies on the couch or bed ; and the uterus retreats, as La Motte says, drawing air after it; but she rises, or coughs, or turns, and the air is expelled. These occurrences give you no colorable ground to suppose that she secretes air from her genital mucous membrane; did you ever hear of air being secreted by the blad- der of urine? Never. Air is not secreted. The bubbles of it that you see upon the skin, are not bubbles of secreted air; ihey arise from the vaporization, or from the transformation of fluid products on the skin.

A fish even does not secrete the air of his swimming bladder. He comes to the surface for it.

If a woman sends for you, with a distended abdomen, with suppression of her catamenia and other signs of pregnancy, and complaining also of the pet-vaginal, I pray you be not so thought- less as to tell her that her womb is distended with air, for it is not. Auscult the patient, and percuss the abdomen, and explore it by means of palpation, and if she be not pregnant, you may say she has a tympany, or ascites, &c.; but do not say she has a flatulent womb. I would as lief hear you had told her she has a flatulent right ventricle of the heart or ventricle of the brain.

If, as Madame Boivin says, there be a putrid placenta corrupt- ing and rotting within a lately delivered womb, or lying in the vagina like a huge putrescent tampon, you would not be surprised, upon taking it away, to find it followed by a gush of foul air, which, it is said, has even been found to be inflammable. In ex- tracting the putrid placenta, I have not only had to submit to the horrible offence of this putrid blast from the womb, but I have found the decaying mass of the after-birth crepitating under my hand like a putrid })iece of emphysematous lung.

But in these cases the passage has been closed by the decay- ing mass; and you might suppose that a very firm clot or a quan- tity of chorion and amnion left in the womb after labor, could so


PHYSOMETRA. 291

shut up and close the orifice as to detain within the globe the putrid or other gases formed or extricated within.

It might even happen that an ulceration of the canal of the cer- vix with luxuriant granulations, should shut up the mouth of the womb ; and that some of the fluids detained above the obturation might extricate gases : but that they could expand the uterus so as to make it large as the womb at five months, is what I cannot conceive of, and if I should, like Frank, meet with such a case, I would not believe it. I would rather believe I had made a mis- take in my diagnostic.

A woman might well have an escape of air from the os uteri, who had had a utero-rectal fistula, a thing quite possible after ad- hesion of the utero-rectal peritoneal cul-de-sac.

Well, then, as I do not believe in a physometra as a disease, but only as an obstetric accident, I have nothing more to say about it, except that when your patient complains of it to you, and is disquieted and alarmed about it, I hope you will make her understand that she is not the subject of any sickness, but only of an accident.

Although I have nothing more to say about physometra, I have something to observe about those supposed pregnancies that consist merely of wind — wind in the bowels.

Certain nervous women, of child-bearing age, and certain wo- men about the change of life, are liable to suppose themselves pregnant because the abdomen is enlarged and the catarneniahave not returned.

A young lady of my acquaintance was married, and went to another city to reside with her husband ; there she became preg- nant, as she supposed, and when about seven months gone, came to see her family. Her physician, who had seen her in her new residence, had pronounced her pregnant, and all the charming prospects and tender sentimentalities connected with these new scenes for the newly married, were hers.

Soon after her arrival here, I was hastily called on account of a threatened premature labor, as she had a considerable show. Upon reaching the apartment, the scene of much anxiety, and after making inquiries as to the stage of the gestation, the amount of the hemorrhage, &c., I placed my hand upon the abdomen to discover whether the womb was condensed, and found the belly so uniformly distended up to the scrobicle, and so soft and so


292 PHYSOMETRA TYMPANITIS.

free from any hard uterine outline or delimitation, that I pushed the bunch of my fingers gently down to the plane of the superior strait, and could almost carry them to the promontorium without encountering any obstruction from womb or child. Next I ob- tained permission to examine by the Touch, and discovered the uterus to be non-gravid. What did I do next ? — or what do you think I ought to have done? My patient was already sufficiently agitated and nervous with all these palpations and explorations. If I had at once communicated to her the result of my researches, I should have had a scene. I reassured her — I told her there was no danger ; and then, in another apartment, I communicated to her mother the disappointing intelligence, warning her to break it gently to the young lady, which was judiciously effected.

My patient, after having some treatment adapted to the morbid innervations of her alimentary canal, recovered, and returned to her home. The symptoms, after a few months, returned, and at six or seven months of the gestation, the medical man, who de- clared on this occasion that she was not pregnant, resolved to bring her doubts to a final term ; whereupon he gave her a strong dose of physic, which brought away a young dead foetus. The same patient crossed the Atlantic, and became pregnant in Eu- rope. Her medical men permitted her to embark for the United States at an advanced period of gestation, and she reached her native place in safety. When she came here I discovered it to be another attack of tympany. After this, her health being better, she again conceived, and had an abortion of about two months' gestation.

Now these were not examples of physometra,"but of tympanitis.

A lady twenty miles from town was pregnant — her physician agreed that she was ; — her monthly nurse was engaged here, and near the term was conveyed to the country residence to be in readiness for the accouchement. The accouchement came not: the nurse remained six weeks in waiting. The physician at length wrote me a letter giving an account of the case, and sent the lady to town. I percussed the abdomen with flatulent resonance on the whole superficies of the belly, which was a uniform tympa- nitic tumour, and not a uterine tumour. "You are not pregnant," said I; " you are resonant upon the whole abdomen, down to the very hypogastrium, and there is no click of the foetal heart. The motions you have felt and the distention you have suffered were


PHYSOMETRA TYMPANITIS. 293

motions of borborygmi and the inflation by gases in the intestines. Take these doses of physic : buy a yard of fine flannel ; tear it into strips, four inches wide, to make a swathing bandage ; wrap the long bandage round the abdomen, round and round, as tight as you can bear it without inconvenience, and reapply it daily. Com- press the bowels and they will not yield to the lateral distending pressure of the gases developed within their tubes: your abdomen will become as small as ever." And so it was. She took her physic ; she wore her bandage ; she recovered her digestive health, and her physometra or wind pregnancy disappeared. She after- wards became really pregnant, and I delivered her here.

I had a lady about 48 years of age under my care. She was anxious to have a child: had been long married, but there was no blessing. At length I was apprised of the approaching good fortune. I percussed the abdomen, and I detected the denying resonance everywhere. I ausculted in vain : there was no click of the heart, and I announced my diagnostic. My flannel roller on the abdomen, some aperients and tonics cured the physometra. How many cases of this gestatio-ventosus have I seen! I have assuredly never, no, not in a single instance, announced or ad- mitted a pregnancy in such circumstances; nor will I ever do so; because I will never say to any woman, "you are pregnant," until I know it.

The faults in these cases of chronic tympany — I mean those samples of it that are unattended with any severe or violent and dangerous local disorders, such as ulcers of the bowels, &c., are readily curable with a roller of flannel, about four inches wide and three or four yards long, which should be turned round and round the belly, covering the half of the last turn with the suc- ceeding one, and securing them all neatly with strong pins or a needle and thread.

Nobody could have chronically inflated bowels but from debility or insensibility of the circular muscles of the alimentary tube. Now, that debility or want of action may arise from a faulty in- nervation, begotten in general debility, sedentariness, certain affections of the mind, and in many examples, symptomatically or sympathetically by the reproductive disorders: — a woman, for example, ought to menstruate regularly; she stops menstruating — nobody can tell why — she has not very visibly lost her embon- point, nor has she taken cold, or met with any moral or constitu-


294 PHYSOMETRA tympa:nitis.

tional shock, and yet she does not see ; who can tell whether she produces germs or not ? It is very possible that her ovi-posit goes on as regularly and perfectly as ever it did, but that the consenta- neous irritation and excitement, instead of being propagated to the womb, is propagated by the various plexus-connections to the splanchnic system of the belly, and betrays itself in these false or wind pregnancies. I do not know that it is so, but if any one should suddenly die, or be killed while so affected, and a recent cicatricula ovi-positionis should be detected in the ovary, I would hold it a strong evidence of the above rationale, and of course I would say that the tympanitis had been an hysterical manifest- ation.

Tympanitis is often a hysterical manifestation ; for a woman in an attack of hysteria generally has copious eructations at the close of the fit.

I was called into a jail, in the State of Georgia, thirty-two or thirty-three years ago, to see a young girl who was seized there with an alarming attack of hysterical convulsions. I well remember to have been sitting by her bed-side as her convulsions went off, and seeing her abdomen rise and rise and rise, to such a vast size of distention, and that visibly, as to its progress, that not I only, but all the persons about her, feared the belly would burst like a shell. I have never seen such an example since. It required but a few minutes for the abdomen of the girl to become as large as that of a woman at term.

Now, pray take notice that these distentions could never take place, but as being permitted to occur, by the yielding of the circu- lar peristaltic muscles : wherever these peristaltic muscles do their physiological duty, they do it by compressing the contents of the bowels, whether solid, fluid, or gaseous, while those contents are compelled to move along the intestinal tractus, in the direction of or in a line with the peristaltic motion. If you discover, therefore, that your patient has lost this power of compressing the intestinal contents, you will reason about it, and you will say, "I can re-ex- cite this lost power. How? By giving the patient a purgative or an aperient, or eccoprotic dose, for that is the meaning and in- tent of such a dose. I shall give some rhubarb, senna, or pur- gative drug, and I will cause all this gas to be expelled."

It is very well for you to reason in this way, but you will be disappointed upon the trial, for your purgative will purge the pa-


TYMPANITIS. 295

tient, and the bowel will discharge all its stercoraceous contents, and much liquid and mucous matter, but the gas will stay in, and the belly be as big after, as before the operation. You cannot get along, however, without your purgative, or aperients ; and when you choose them, pray take my advice, and use one of Dr. Brown's formulas. I have used it for many years, and if it was not unprofessional to do so, I would imitate the epigraph I have seen in many old ladies' family recipe-books, and write over it probatum est.

Dr. Brown was a famous physician who lived at Port To- bacco, in Maryland, many years ago. He was one of three bro- thers, all of whom obtained considerable eminence in medicine, in their owm districts and States. He was the Dr. Brown who was called in consultation with Dr. Dick and Dr. Craik, at the last illness of Gen. Washington. My master, Dr. Thomas Han- son Marshall Feudal, of Georgia, was his pupil, and he told me, thirty-eight years ago, that this was one of Brown's formulas. Dr. F. used it in almost all severe cases of tympanitic disorder, and I have used it ever since, and ever shall.

Take one ounce of manna;

One drachm of anise seed ; Eight ounces of boiling water. Mix them, and let the mixture rest for half an hour, then strain the liquor.

To the strained liquor add three drachms or four drachms of carbonate of magnesia, so as to make a perfect mixture.

A wineglassful may be given for the dose, to be repeated every two hours, or three hours, until it operates. This is Dr. Brown's carminative cathartic, and if a man may venture to speak on •an experience of thirty-eight years, I am willing to say that I have all that time found it the most dependible carminative physic that I know of; and I heartily recommend Dr. Brown's formula to you.

I do not pretend to know why it is the most efficacious dose in tympanitis ; nobody knows why one medicine acts thus, and another so ; it is enough to know that ipecac, makes you vomit, and that jalap purges you. The why, is a metaphysical, if not a psychological proponendum.

If, in the treatment of these wind pregnancies, or tympanies,


^'


296 TYMPANITIS. HYDROMETRA.

you can get the bowels once to discharge the flatus which seems to stay, in some instances, for weeks and months, in one even tenor of tension, you will gain an important point. If you can do it, then pray tighten the flannel roller, and keep all the advantage you have gained by aiding the weakened intestinal muscles to compress the intestinal contents. Keep up the activity of the muscles of the bowels, by means of an aloetic, such as Lady Webster's pill, or by draughts of infusion of rhubarb, quickened with some compound tinct. of rhubarb or senna.

Let her drink brandy and water with her dinner, and a hot glass of punch at bed-time ; have a good index expurgatorius of eatables, in which you should carefully set down sour-krout, pork, veal, duck, goose, beans, beets, corn, and id genus omne of the wind-begetting vegetables, that are fitteT for the dura messorum ilia, than for the tender intestinal constitution of hysterical ladies.

Some of the doctors will tell you, for they still do insist on it with me, that these wind-swellings, these tympanites are produced by collections of gas secreted in the peritoneal sac.

I should be astonished at any one of you, could I hear him say he had a caseof tympanitis of the pericardium, arising from secre- tion of gas by that serous sac. I should be equally astonished to hear any one of you attribute an ordinary tympany of the belly to such a cause. The air in tympany is always in the bowel ; never outside of it. Farewell. C. D. M.


';-/.


LETTER XXIV.

Gentlemen: — The womb is sometimes distended with water, which, after having enlarged it to a certain size, suddenly gushes forth, leaving the organ to return to its non-gravid size. This state is called hydrometra, or dropsy of the w^omb.

Now, as to hydrometra, I do not believe in it. It is indifferent !o me who has seen it, or w^ho has heard of it. I repeat, I do not believe in such a malady, and therefore I had serious intentions of passing over it in silence. The womb is a cul-de-sac, which


HYDROMETRA HYDATIDS. 297

can hold no water, except when the mouth of the cul-de-sac is turned upwards, in which I admit it would be possible for it to hold a little water; but, when the mouth of the cul-de-sac is turned downwards, the water would run out of it, as surely as it would fall out of a teacup or tumbler, that you should turn upside down.

Still, they say the womb fills with water, and becomes as large as the gravid womb at seven months. There is no doubt of it ; I have seen it; but that does not make a dropsy of the womb; it is only a case of a womb expanded by a body growing or en- larging within its cavity.

It is said an acephalocyst, or rather a half million of acephalo- cysts, might develop themselves in the womb. These acephalo- cysts, or bladder- worms, fill with water by some process of absorp- tion, or endosmosis, and as they expand, the womb which does not know it is not pregnant, yields to the delusion, and gives way to the internal pressure, just as it does under the pressure of a growing healthy ovum. The acephalocysts fill more and more, until at last, the womb will no longer tolerate the incumbrance, and beginning to contract, soon expels the intruding masses by a regular process of labor-pains.

When the mass is expelled, it is found sometimes to be in quan- tity sufficient to fill a wash-hand basin, and you call it a mass of hydatids. These hydatids look like bunches of grapes ; like the finest Malaga grapes, and are of various sizes, from an inch in diameter, to that of a small pth-head. Each one is attached to a mass of partially organized matter, consisting mainly in laminar cellular tela, with blood-vessels creeping among the grapes.

I have seen them come off with very great hemorrhage, even to fainting.

I said they are called acephalocysts. I ask you whether that is likely; and whether each one of the grapes of a bunch of hyda- tids, is to be esteemed an independent ens?

I have never heard of hydatids in the virgin, nor do I believe that a virgin could have an hydatid or anything like it developed in her womb. I have met with them only in married women. I do not regard them as hydatids, or acephalocysts; but I think they are morbid products of conception.

A woman shall conceive healthfully, and carry on the gestation for a few weeks, when the embryo dying, she ought to throw off


298 HYDROMETRA HYDATIDS.

the ovum by an act of abortion; but she does not do so. The ovum having formed its mesenteric attachment, keeps up a sort of life within its textures, and the floating extremities of the villi of the chorion imbibe, by means of the endosmosis, the transpa- rent fluid which you see in the bunches of hydatids. They are not animals, they are dilated and hypertrophied villi of the cho- rion. A bunch of hydatids is a dropsical placenta, and a drop- sical placenta is the dropsy of the womb, or hydrometra, of which you have heard. To have a true dropsy of the womb, you must imagine the os uteri hermetically sealed, and the cavity of the organ filled, and distended with serum. That would be a dropsy.

It is said that a single acephalocyst, or living hydatid animal, has filled the womb to a great size, and suddenly bursting, has dis- charged its whole fluid contents, at a gush. I have never seen such a case, but I have seen many times a pool of water on the flow, from rupture of the ovum, where I know the ovum was not rup- tured. Such pools of water were hysterical discharges of urine. And, as I cannot conceive of a cysticercus, or acephalocyst, large as a child's head, I prefer to suppose that the doctor and the patient have both been deceived, than that so improbable a magnitude should ever be attained by an animalculus.

In true pregnancy, the womb is occupied by the ovum, whose growth causes the womb to grow pari passu. The ovum in preg- nancy, consists of the embryo or foetus, the cord, the placenta, the amnion, and the chorion. The ovum is a living, independent, self-supported creature. It may well be likened to an acephalo- cyst, and yet its head might be stated to be the placenta, which attaches itself to the uterine walls, and sucks or draws from thence the materials for the development of itself, and its depend- encies. Its dependencies Isay; and by that word, I mean to imply the child, and all its parts. The child may be regarded as one of the complex organs of the acephalocyst, which perishes at the end of a prescribed term, leaving the organ it has deve- loped, a complete and self-existent creature, as it had itself been before it. This is the only true single acephalocyst that I can conceive of, as filling and distending the womb to a great size. And this acephalocyst may become morbid, that is to say, it may become enormously overgrown, so as to distend the womb beyond measure, and greatly interfere with the woman's health, by the distention and intrusion. The womb itself may be injured, or


HYDROMETRA. 299

weakened, by the extension; and the constitution may suffer from pressure of an overcharged womb on the vessels and nerves, and other organs in the belly.

A womb, in this sense, might be said to be dropsical ; but, rather, it would be truer to say the ovum is become dropsical.

In general, there is no remedy for this dropsical state of the womb, of which I now speak. Not that you could not readily bring it to an end ; for nothing could be easier than to do so, by pushing a catheter through the os uteri, and through the chorion and amnion, to let off the water. The escape of the water would end the dropsy, but I hope you will not think of resorting to such a treatment for any degree of inconvenience that might arise from the over-distention, short of one involving the woman manifestly in danger. You have no right to bring on anybody's labor, but upon the strongest and most clearly understood motives of necessity, and of indispensable necessity, to do so. It should always be determined on in a formal Consultation with persons of ripe judgment, and enlarged clinical experience and knowledge. Where the necessity for removing the accumulation exists, it is, I repeat, easy to effect the removal. But I find I am lapsing in- sensibly into an obstetrical topic, and shall, therefore, cease to discuss it here, in hopes of presenting it at fuller detail, in my work on Midwifery ; and as I have now treated, tant bien que mal, on all the particular maladies of the womb, I shall close this letter, in order to take up some of the questions as to diseases of the uterine appendages, as they are called. It would be far truer to call them the reproductive organs, for I am always of the opinion announced in an early letter of this series, that the stroma of ova- ries is the true sexual tissue of females; in fact, that stroma is sex for them. C. D. M.


L E T T ER XX V.

Gentlemen: — I have now to offer you some remarks upon the diseases of the ovaries; and I wish that in doing so I could feel that the study and treatment of such affections had enabled us to


300 OVARIAN DISEASE.

give to the medical student clearer views as to the origin and early detection and control of such maladies, than those which the labors of the numerous writers have opened up . to us on these subjects. I am persuaded, however, that our knowledge of the disorders of these most important organs is vague, and that the most serious of their maladies are of a nature so insidious, as to allow them to become considerably advanced and firmly estab- lished, long before they are detected by the pain or inconvenience or interrupted function to which they give rise.

The ovaries are the reproductive organs, and they are endowed with a life-power that is variable in its operation, alternately tor- pid or quiescent, and most highly excited ; pale, oligsemic, or red and hypersemic ; so that the life-power does not act steadily and continuously, or in one even tenor, but is diminished and aug- mented by turns, exposing the texture to the multitudinous acci- dents that are ever ready to happen in tissues or organs of an unequable rate of vital function.

One or other of the ovaries matures an ovule in the Graafian follicle every twenty-eight days, and discharges the egglet, either into the fimbria of the Fallopian tube, or into the peritoneal sac ; and this, with the greatest regularity in all healthy women that menstruate. Each of the ovaries contains fifteen or twenty of these Graafian follicles, of various sizes, from the bigness of a mustard seed to that of a pea. The smallest ones are generally to be found buried deep in the substance of the stroma; while the larger and more mature ones are to be seen nearer the surface of the organ, and even rising above its surface in segments of spheres more or less considerable, as the cell is more or less prepared for the act of ovi-posit.

Seeing that only one of the Graafian cells is matured at once, as a general rule, and that the later days of its ripening process are those in which the process goes on most rapidly, we may well conceive that such greater celerity of development takes place in consequence of a greater activity of the vital processes concerned in it. In fact, if we examine such a rapidly developing cell and germ in the body of a person who has perished during such act, we find the necrologic proofs of that extraordinary excitement. These proofs are seen in the highly injected state of the portion of the ovary immediately in contact wdth and circumjacent to the swelling follicle, where numerous arterioles and venules may be


OVARIAN DISEASE. 301

observed with the naked eye, and more plainly with a lens, sur- rounding and burying the growing cellule among a mass of blood- vessels.

It is also presumable that the nerves of a part bathed in this manner with a luxuriant circulation, will be in like manner in a hyperaesthesic state; and hence that the life-force in the said part is in a highly exalted condition.

Whenever you shall examine an ovary, under these circum- stances, I doubt not you will find the state of the case as I have represented it, and I can but perceive in it a close analogy to what happens during the last stages of dentition, as to the gum over a growing tooth. The gum in such state becomes swollen, suc- culent, sensitive, and painful. In like manner, I suppose, the stroma of the entire ovary may become engorged, swollen, red, and, in some instances, sensitive and painful. But the Graafian cell having become perfectly mature, opens by a sort of hila or rather porule, in order to allow the yelk to escape, and the crypt left upon its escape, fills with coagulated blood, while the edge of the pore is granulating and bloody, and at last heals over. In process of time the coagulum left within the crypt, and the vitel- lary matter secreted on the exterior surface of the inner concentric spherule of the cyst to constitute the corpus luteum, are both ab- sorbed, leaving the surface of the ovary indented with its puckered cicatrix, the mark of the last menstruation. If an advancing tooth may excite such maladies as are attributed to dentition in chil- dren, what must be the extent and power of complication of the ovary in the monthly act of eliminating the ovulum!

A monthly, or bi-mensual repetition of this process, continued for years, is in some women followed by diseased or morbid life in the ovarium ; and we have no cause to wonder if a delicate and important organ should be found to succumb to such violent revulsions of its physiological action, repeated for months and years in succession. I should think we have greater reason for surprise at the rarity than at the frequency of the rise of ovarian diseases under this view of the condition of those organs.

Besides the above-mentioned causes of liability to the superin- duction of morbid states of ovarian health, we ought to take into consideration the state of the ovaries in gestation, a state in which both their innervation and circulation may be supposed to be sub- jects of considerable modifications. Labor, too, and the lying-in


302 OVARIAN DISEASE.

state may be supposed to bring them into no little hazard of a change in their life-action.

There are certainly many women to be met with who complain of ovaric pain during the menstrua — as they are frequently found to indicate, not the uterus, but the left or the right ovarium, as the seat of the distressing sensations of painful menstruation.

The ovaria are occasionally the seats of ovaritis in an acute form, betrayed by pain in the region of the organ, and demon- strated by purulent disorganization after death; and inferentially, by collections of pus which discharge themselves at the groin or above it, u'ith recovery of the patient.

It is probable, as Madame Boivin states, that acute inflamma- tion of the ovary, in the non-gravid state, has rarely been observed, or rather, has rarely been with clearness made out; and yet, as I have met with many samples of very distressing pain and ten- derness in the region of the organ, connected with painful and hysterical menstruations, I deem I had good cause to suppose the ovaries were actually in a state fit to be called ovaritis. Very cer- tainly, many of the cases of puerperal metritis and peritonitis commence with pain in the iliac regions; and, where the case has proved fatal, dissection has revealed greater ravages in the ovary than elsewhere; and it is by no means rare to find the organ filled with pus, or converted by the inflammation into a mass of softened tissue, which had undergone the process of ramollisse- ment, one of the results of inflammation in this special tissue. I regard the following case as one arising from acute ovaritis.

I had for a long time charge of the health of a lady here, who at her mensual periods suffered the most terrible paroxysms of hysteria, during which she experienced such distress in the regions of the ovaria, as to cause her to scream and to make the most violent complaints. She recovered of her dysmenorrhcea and gave birth to two children, the second one about two years after the eldest. Subsequently to the second confinement, she disco- vered a small floating tumor in the left flank, which I ascertained to be an enlarged ovary. That tumor may have been three and a half by two inches in diameter, and for the last four years has not sensibly increased in size. The catamenia are regular and no longer painful, and she uses great precautions as to exercise, diet, dress, &c,, at the mensual periods, which have thus passed over her without seeming to aggravate the tendency of the ovary to grow.


OVARIAN DISEASE, 303

When an ovary has become the seat of a hypertrophic, or of a heterologue development, it probably ceases to produce and evolve germs, but it is still liable to the periodical augmentation of the life-action, as propagated from the healthy ovary to the womb, and from the womb to the diseased ovary. If this be so, then the most hazardous period for the female with a diseased ovary, especially in the early stages of such diseases, ought to be esteemed the menstrual period ; hazardous, I say, as to the danger of increasing the propensity to morbid development, not hazard- ous as imminently dangerous to the life of the woman. I trust that you will reflect upon views of this sort, when you come to give advice under such circumstances, and institute such a course of treatment and management of the health as may enable the woman more safely to pass these mensual crises.

In a case of acute ovaritis, attended with constitutional disturb- ance in the form of fever, and with pain in the region of the ova- rium, you would resort to venesection and leeches, or cups to the iliac region, to stupes or cataplasms, to the obtaining a soluble state of the bowels, and the use of tartar of antimony and potash, or Dover's powder wiih recumbent rest.

A few years ago, I opened the body of an elderly woman, who died with an immense collection of water in the abdomen. The fluid amounted to several gallons, and after it had been removed, I continued the incision from the sternum to the pubis, and when I had finished the incision, and, with the medical friend who was with me, looked into the cavity, we were both for some time very much astonished to behold only a smooth muco-serous surface in the cavity, and we looked for some time in vain to find any liver, or stomach, or alimentary canal. It seemed that we were exa- mining an abdomen from which all the viscera had been care- fully removed. I was greatly astonished, and quite at a loss what to think of the case, or imagine what had become of the abdominal viscera, since the line of the spinal column was strongly drawn at the back of the cavity we were inspecting, and we seemed to look quite up into the empty concave of the dia- phragm. At length, in examining the cut edge of the incision, I saw that we were looking into an empty cyst, whose edge was there to be seen, and the outer superficies of which was adherent to the peritoneum. The cyst adhered pretty firmly everywhere, but it was cleavable, and I detached it completely, discovering the atrophied organs behind and below it, firmly compressed against


304 OVARIAN DISEASE.

the back part of the abdomen. I have no doubt, this cyst held more than a thousand ounces of serum, probably twelve hundred. There was at the lower part of it a small solid or hardened por- tion, which was the altered remnant of the left ovary, all the rest of the cyst having been developed out of that body. I gave the specimen to Dr. Horner, who preserves it still, I believe, in the Museum of the University of Pennsylvania. It was the largest single cyst I have ever met with.

Now, gentlemen, what was this cyst? It was certainly no longer an ovary, but a new tissue, heterologue, formed on the generic basis of a true ovary, and commencing, perhaps, as a Graafian cell, which, instead of bursting to discharge its ovulum, continued to fill and to strengthen itself, appropriating to the ex- tension of its heterologue walls all the nutritive results of the ova- ric circulation and innervation.

It was a case of encysted dropsy of the belly. The cyst was an altered ovary. It was a single cyst.

It does not always happen that the ovary, in developing itself out of, and beyond its generic form, assumes the nature of a single cyst, like the one above mentioned. It more commonly, I think, consists of much- solid interstitial material, containing within it cells of various sizes, from the magnitude of a walnut to that of a child's head, and in these instances the fluid is ropy or albuminous, and sometimes almost as thick as melted calves'-foot jelly or glue.

In some of the samples there is a great bunch of solid material lying partly within and partly above the plane of the superior strait, with one vast cyst holding 800 or 1000" ounces of fluid, that fill out and distend the belly as a fluctuating mass, like a common ascites.

If you do not see the patient from an early stage of the disor- der, nor until the abdomen has become very tense from the vast- ness of the collection, you will scarcely be able to make a good diagnosis of the tumor, since the hardness and resistance of the belly will not admit of your fingers indenting it sufficiently far or deep to make out the existence, much less the size and form of the more solid masses or portions of the altered ovarium. It is not until the woman has been tapped that the relaxation of the ab- dominal walls permits the palps of the fingers to estimate the ex- istence, and size, and forms of the solid portions of such tumors. Hence, when you shall be invited to give your opinion in a case


OVARIAN DISEASE. 305

of the sort, as to its nature, as being, ascitic or cystiform, you will be unable to answer positively the question ; or, if you do answer positively, you will do so at the risk of compromising your own reputation, and injuring that of your brethren. You have no occasion to hesitate in such a case. If the means of discrimina- tion are not at your command, why should you not say so. If you owe a thousand dollars and have not the money, you would say so. If you cannot tell what is the nature of a tumor or a col- lection, are you afraid somebody else will know better, and thus discredit you? Let him know better if he can; but he cannot. If you cannot touch the altered and solid masses, either by the vaginal or the external exploration, how can he do it? — If you cannot extract a clear history of the formative stages, how can he do it? If you can estimate the fluctuation, what can he do more ? Let him make his declaration — he does it at his peril, not yours. There are some that will be ready to make it, hit or miss — with all my heart, let them hit or miss. If they hit, they are like rockets that go up with a whiz and a great light — if they miss, they are like the rocket stick, which falls, not sweet, to the ground. There are two ways to hurt the profession which any one may perpend. One is to act immorally and unconscientiously, and the other is to make mistakes in diagnosis, treatment, and prognosis; both serve with equal force to bring physicians, as a body, into disgrace. The whole herd of quack doctors and char- latans, who perform such inexpressible wonders of folly in diag- nosis, treatment, and prognosis, are sustained upon the shoul- ders of medicine; for they could not exist in an enlightened community but upon the force of that confidence which mankind cannot withhold from medical science ; but which is so far pecu- liar, and, therein beyond the reach of the esoteric classes, that they cannot discriminate between the true physician and the un- learned and bold pretender to medical science. Hence we, that is the physicians, who are the conservators of medicine, and her representatives in the world, bear all the odium of every vile quackery and charlatanism.

These encysted dropsies are often very chronical in their move- ments. I know a lady who has worn one for more than twenty years — it has never been tapped, and is not larger now than it was fifteen years ago. Another lady here, with a very large en- cysted dropsy, gave birth to several of her children after the cyst 20


306 OVARIAN DISEASE.

had become very large indeed. She ceased to bear children, after having been swollen for fifteen years; and at length, the weight and tension becoming insupportable, she was tapped with great relief, and without any inflammatory result or any inconvenience. In about five years the sac was insufferably full again, and she was tapped a second time, discharging a vast quantity of fluid. She recovered apparently, but about twelve days afterwards rode twenty miles to a funeral. Soon after reaching the country place, she was seized with symptoms of peritoneal fever, from which she barely escaped. The sac has again filled. You see how chronic the case is. She has not been tapped for near six years.

A lady here had a very enormous encysted dropsy. She was never tapped. After wearing it for many years, the size of the abdomen diminished, and more and more rapidly, until every ves- tige of the malady had vanished, and she now enjoys good health.

I saw a patient in the Pennsylvania Hospital with ovarian dropsy. The tumour gradually disappeared and was followed by crural phlebitis of the left leg, or milk leg.

Now the question arises as to the quo-modo of these dispari- tions of ovaric dropsy. You will not, I presume, imagine it to be possible that the collection within the cyst, a collection that has existed within it for a series of years, could be taken up by the absorbents of the sac, and carried off as in ordinary cases of ab- sorption. You should recollect that the sac is only like a true organ, not a true one; it is not in truth a human tissue, or a tissue of a mammiferous creature; it is something different from any of the organic materials that enter into the composition of such a being; it is a monstrosity by excess, a case in Teratology. Such a cyst, though it has arteries, and capillaries, and veins, and nerves, has them in a new and ungeneric way. It cannot be supposed to possess the just proportion of absorbing apparatus; and it cannot, therefore, absorb the products of its exhalent or secretory elements. But still, such tumors do disappear now and then.

Without pretending to dogmatise on the subject, I may be allowed, I hope, to say, that in all such cases of disparition of the collection, I have supposed that an aperture being made in the cyst, the fluid has passed into the natural sac of the peritoneum, and being there subject to the action of a true natural absorbent apparatus, has been taken up and carried away, leaving the sac


OVARIAN DISEASE. 307

itself to collapse and shrivel, and sink back towards the pelvis, where it might exist during a long lifetime, an innocuous mass that never fills again, and whose inner parietes perhaps become coherent from long quiet contact. In the case of adhesion of the cyst to the peritoneum, in the elderly woman that I mentioned a little while ago, the cohesion was equal in force to that of a full developed placenta to the uterine paries, or equal to the cohesion of the skin of a ripe orange to the fruit.

That such apertures and leakages of the ovarian cyst into the peritoneal sac do take place, has been proved by Dr. Bennet, in his account of a case referred to by Prof. Simpson in his pamphlet on Ovariotomy, p. 9. Such a leakage, to a greater or less ex- tent, must, I think, always follow the tapping of an ovarian cyst, when the cyst does not adhere. It is not improbable that the danger of the operation of tapping, in these encysted dropsies, arises in the main from the irritating influence of the contents of the cyst effused suddenly into the peritoneal cavity, upon with- drawing the canula. When the cyst opens spontaneously, and the leakage is small and gradual, probably the inflaming tend- ency is less. Possibly the tension hinders inflammation. This, however, is mere hypothesis, although it is certain that a great many of those persons speedily perish who are for the first time subjected to the paracentesis. If my hypothesis is correctly founded, it would seem to be less dangerous to tap in the com- pound dropsy of ascites and encysted collections, than where the sac is still unbroken ; as the peritoneum that had learned to tole- rate the leakage, would not suffer from a leakage made by the trocar. Certain I am, that where a female has been once tapped for an encysted collection, and escaped death, she is but little liable to perish from subsequent operations ; such at least has been the result of all my experience on this head.

Dr. Lee, *' Tumors of the Uterus,^ p. 175, has furnished some highly interesting information on the subject of tapping these cysts. He avers, that where the collection exists in a single sac or unilocular cyst, the danger is much less than in the cases where the collection is contained in many different cells, or cham- bers of the tumour — and this I think is to be expected; inas- much as the multilocular cysts are always of a more massive and solid material, and afford greater basis for inflammation and its pro- ducts ; whereas the unilocular cyst is like a vast bladder, possessed


308 OVARIAN DISEASE.

of scarcely an organization, and not so readily obedient to the provocatives to inflammation ; or if inflamed, not admitting of such vast masses of inflamed material.

Dr. Lee has made some curious, interesting, and valuable researches on the effects of these tappings. He has collected forty-six cases wherein the effects were observed, eight of them by himself, five by Dr. Ashwell, five by Dr. C. Smith, six by a London surgeon of high standing, and the remaining twenty- two taken from journals. Of these forty-six patients thirty- seven died, and nine recovered. Of the thirty-seven who died fifteen died within one month after the operation, at various periods from a few hours to the end of a month. Seventeen died by the expiration of two years, and five died in from three to fifteen years. Eighteen of the thirty-seven were tapped but once, the others more than once, say from twice to seventy-eight times. Dr. Lee furnishes also a table of twenty cases from Mr. Southam, from the Lond. Med. Gaz., Nov. 24, 1843, Of these twenty cases fourteen died within nine months, two within eighteen months, and the remaining four in several years, from four to nine. Dr. Lee gives, at page 180, another table, showing that of fifty-seven patients, from his own tables and Dr. Southam's combined, who died, twenty-four died after the first tapping, and all of the twenty-four within a period ranging from a few hours to eight months.

I have made the above citations from Dr. Lee's work for you; I should much prefer that you consult the book for yourselves. I think the statements of the author highly useful, and am sure that they agree very nearly with my own observations. As to cure of dropsy of the cavities, or of ovarian dropsy by tapping, or after tapping, I have never met with an instance of such success.

I trust that what has now been said, may serve to put you on your guard against an opinion, very prevalent in our profession, that paracentesis abdominis is a slight operation, that may be performed with safety to the patient. I have assuredly not ob- served it to be so, since I am under the impression, that of first tappings, of which I have been a witness, well nigh one-half have been speedily followed by the death of the subject from peritonitis, developed soon after the performance of it, and all ended fatally sooner or later, save the case above-mentioned.

These encysted dropsies occur in young and unmarried females.


OVARIAN DISEASE. 309

I now remember seven cases of this kind that have fallen under my immediate notice. I have certainly seen a much larger num- ber of them, and a great many in married women.

You will in vain attempt to cure them by diuretics. Diuretics and hydragogues can not enter into competition with the powers concerned in making and augmenting the fluid contents of the sac. It is wrong, therefore, to assist the disease in uprooting the foundations of the constitution by acting on it with drugs, most of which are exceedingly enervating in their influence on the stomach and bowels. In the conduct of all such chronical, long continuing maladies, you ought never to lose sight of the liability of those important organs, to be injuriously deranged by the pro- tracted employment of remedies addressed either directly to them or through them to the whole constitution of the patient.

We have hitherto spoken chiefly of the unilocular cyst con- structed out of the ovarium. It is necessary to observe that some of the ovarian tumors are solid degenerations of ovaric tissue, enormously increased in size and totally destitute of the anatomical characters and physiological powers of the stroma. Such a tumor when felt, through the abdominal parietes, is found to be hard, resisting, presenting a defined outline of an irregular figure ; be- cause the surface of the tumor is broken by large lumps or pro- tuberances divided by sulci of various length and depth. Some of these tumors, when cut open, present a sort of haematomous or cere- briform appearance as to color. Others are filled with numerous cells or loculi, containing viscous or serous effusions, and sometimes pus or puriform excretions. The loculi are of various sizes and shapes, some communicating together, and others entirely isolated. The tumors are found of a size to fill up the cavity of the belly, so as to make it as large as that of a woman in an advanced stage of gestation. In many of the samples, adhesions of the peritoneal surfaces of the tumor to that of the intestines, or abdominal walls, are observed, the results of ancient or recent, or of repeated attacks of peritonitis. But why describe the peculiar forms and aspects of tumors which embrace within their precincts, the possible modifications of the cellular, vascular or fibrous elements of the altered organ ; modifications so infinitely varied and mixed, that the usual and clearest description given of them in a necrological account is a "mass of disease?"

Tumors of this fashion, large as a man's head or larger, draw


310 OVARIAN DISEASE.

nearly the whole of their support from one ovaric artery running off from the aorta, or emulgent, and reaching the points of distri- bution after a long tractus, while its strange vitality and econo- mic connection are maintained chiefly by the accompanying spermatic nerve. It is clearly a case of physical sin and abso- lute rebellion against the authority and laws of the economy, so that it can neither be recovered nor subdued. What idleness, if not what folly, to give medicines! Medicines for a tumor! Give medicines for a swelling, for a disease, but not for a tumor. "What, then! Shall w^e not treat such cases?" Yes, surely; they require treatment ; they admit of it ; and the patient is bene- fitted and even preserved by it ; but the tumor is unaffected, it pursues the even tenor of its way indifferent to the condition of the woman upon whose person it has attached itself and on whom it preys. I have before said, that you cannot make a very certain prognosis of it, for you cannot know whether it will grow con- tinuously larger, or whether, becoming the seat of a disorganizing activity, it softens and deliquesces, or suppurates within the ab- domen, pouring its fatal products into the peritoneal sac ; or whe- ther, preserving for years its quasi organization, and losing the power of increase from atrophy of the most distal and attenuated branches of its vessel and nerve of supply, it stops at a term, and continues there for years without apparent change. For exam- ple, there is a lady here of whose health I have had principally the charge for about eighteen years. She is at present near sixty years of age. For eight years before I became acquainted with her, she had suffered from an enlargement of the right ovarium. The tension and pressure, and intrusion, gave her at times much pain in the right inferior portion of the abdomen ; and at different times since my being first called to her, she has had attacks which I regard as peritonitis, brought on by the pressure and friction of the mass. These attacks have pretty readily yielded to the appropriate antiphlogistic treatment, consisting mainly in copious depletion and recumbent rest. I have lately examined the state of the tumor, which I find scarcely changed in the course of eighteen years, except, perhaps, in a slight increase of its magnitude. It has never exerted the least influence on the nutri- tion of my patient, who is a robust, ruddy faced, even fat woman, who walks freely in the streets on affairs of business or amuse- ment; and there is good reason to suppose, from her present state,


OVARIAN DISEASE. 311

that she will attain to an age not the least curtailed by a tumor of the ovary as large as a man's head, and so firm in its resistance, as to yield not at all to pressure, and afford no reason to suspect the presence of fluid within it. In all these eighteen years I have never given my patient any medicine with a view to act upon the tumor. I have bled her many times for the accidents arising from its pressure, and administered many doses of medicine with a view to obviate the effects of those accidents. Had I been occu- pied always with the preposterous idea of curing her tumor, she would have taken physic enough to establish a Chestnut street apothecary, and cui bono, I pray, save to the apothecary?

These solid tumors nobody, in his senses, would propose to tap ; and, you see, I insist there is no medicine can do them good. "What then is to be done? Can ovarian tumors be cut out? Yes, they have been cut out, and the patients, in certain instances, have recovered.

As to the question of cutting out the ovarian tumor, it is a question in surgery which, as an Accoucheur and a Practitioner of medicine, it may be supposed that I have no special claim to speak to. Nevertheless, I have an undeniable right to lay before you a statement of the motives that should govern me in any question as to the performance of this operation on a patient of mine ; and, I trust, that in entertaining the opinions I do on this topic, I maybe held to do so not without due respect to the enter- prising and courageous surgeons who have advocated the extir- pation of the diseased ovary.

As to surgical operations in general, I hold to the sentiment that prevails very generally in this quarter among surgical gen- tlemen of the highest standing, that it is a dire necessity that compels a resort to the bistoury, and that the fact of a surgical operation being necessary in any case, is a reproach to medicine. This is a noble sentiment, and one that deserves to be upheld and propagated far and wide by all the true lovers of our divine art. It has, in a prime degree, governed the conduct of the surgeons of the Pennsylvania Hospital these many years, and is one of the titles to that general confidence that has been given so steadily to that admirable establishment.

Doubtless, in the history of surgery, many cases are to be found of operations performed without necessity. That this is the case no one can deny, who will refer to the examples of the Cesarian


312 OVARIAN DISEASE.

and Sigaultian sections, not to allude to many others that are on the files of cases. But as "life is short, while art is long, occasion fleeting, and judgment difficult," to use the language of the first aphorism, there must have been, and must still exist many cases where the actual circumstances cannot admit of the exercise of a perfect judgment, so that operations are performed under the spur of a seeming necessity. Many a limb, for example, is sacri- ficed by the catlin and saw that might be saved by the use of a more sober and cautious judgment.

In regard to the Cesarian section, which is, perhaps, the most important of surgical operations, much is to be left to the judgment and conscience of the surgeon and the gentlemen of the consulta- tion, since even at the present day, it is not determined what pre- cise degree of reduction of the pelvic diameters makes the opera- tion not lawful only, but indispensable as an act of professional duty and charity.

For a medical man called to and placed in charge of a labor with deformed pelvis, there is a most solemn obligation resting on him to protect the lives of both the mother and the child, and if he be truly competent to the exercise of that wise discrimination and judgment that alone are suitable to such great and trying occa- sions, I can clearly perceive that, with the calmest and most un- troubled conscience, he may recommend and perform the Cesarian operation, w^hich he knows will result in the death of the mother in about one-half of the cases in which it is performed ; and I deem that where he has both counseled and performed the operation, he might look with an undisturbed aspect upon the body of the vic- tim he vainly strove to save. Such a person being in charge of the case, cannot escape from the stringent necessity of acting in it. He cannot go out of the lying-in chamber saying that there is a chance for recovery by the Cesarian section, but declining to do it.

Not so in any tumor or other malady developed by diseased ac- tion. For example, in a cancerous breast, a man may refuse or consent to perform the operation for its ablation ; but he cannot refuse the operation of lithotripsy, or that of cutting for the stone in the bladder in a case proper for it; in the case of the cancer- ous breast he may decline or consent, according to his opinion of the risk from the operation or of a return of the disease. In the case of the stone he cannot refuse, on account of the urgent dis- tress that appeals to him for relief.


OVARIAN DISEASE. 313

In forceps operations, and embryotomy operations in midwifery, I do not understand how any one can have the right to decline in- terfering where the safety of the mother or that of the child clearly requires his intervention. In such cases as stone in the bladder, in amputations for railroad accidents, for white swellings, &c. &c., the requirements are instant and pressing, and the exigency admits of no refusal nor delay. It is a hard and dire necessity then that makes the act of the surgeon not only excusable, but charitable, and even noble. Any surgical operation founded on other prin- ciples, — on some cold and calculating computation of benefits pos- sible, I regard as of doubtful propriety ; and I believe that no surgeon ought to operate where he can escape the duress that binds him to do his cruel kindness.

I will add, that in the Cesarian operation, there is but one rule for the conscience of the physician, and that rule has reference to the mother. The Cesarian operation is never to be performed for the sake of the child. If a man perform the operation for the sake of the child's safety, and the mother perishes, who might have been saved by some other method, I see not how his conscience can ever recover its composure and complacency. No! Whenever you are tempted to perform the Cesarian operation, let it be done from a conviction, and a clear one, too, that to deliver ^gr vias is equally hazardous with the section. When you can come to this intelligent conviction, then you can enjoy the high gratification of hoping to save both the mother and her offspring.

Having said so much, it is clear that I am opposed to the ope- ration for extirpating the diseased ovary. The ground of my ob- jection lies in that principle of surgery, which I hold to be one of its highest principles, that there can be no duress, no binding obligation to perform it, and that the surgeon's conscience may be at peace, though he refuse and the patient perish by the pro- gress of the malady.

I have read with great pleasure Professor Simpson's remarks in favor of ovariotomy, in a pamphlet, for a copy of which I am indebted to his politeness. I admit the considerable force of many of the arguments arrayed in Professor Simpson's publication, but I see no parity in the duress of the surgeon who decides upon an ovariotomy, and that of the surgeon who performs the operation for the stone, or an amputation, or the ligature of an important vessel, &c., which he dare not refuse to perform, whereas no


314 OVARIAN DISEASE.

such urgent, imminent, aiid definite necessity can ever be sup- posed of an ovariotomy operation.

In the one case, the surgeon resorts to the operation under compulsion of an imminent and pressing danger; in the other, he takes his instrument in his hand under the dictation of a cold calculation of chances as to a human life. Now, who, I pray, has the right to calculate as to the value of a man's life, even for an hour, much more for a week, a month, a year, or a quarter of of a century !

I am opposed then to the operation of ovariotomy, and I am opposed to it on the grounds of objection I consider valid against all surgery that is not unavoidable.

The ovariotomy operations are not unavoidable, since no one, I presume, would think of operating for a patient not remote from dissolution, and since in any case not menacing a speedy termi- nation of the life of the patient, the unavoidable necessity has not arrived.

In a note that I added at the 415th page of the American edi- tion of ColomhaVs Treatise on Diseases of Females, I stated that I fully concurred in opinion with M. Colombat, who disapproves of the ovariotomy operation, and that I look upon operations for the extirpation of diseased ovary, as not to be justified by any amount of success. There are certain medical facts that belong not to us as a body of physicians alone, but which enter into the common treasury of human knowledge, and no array of statistical results can ever, I imagine, change the nature of things. It is in the nature of things, that wounds, even small ones, of the great cavities are dangerous wounds, and a fortiori, wounds of vast dimensions, and wounds, too, requiring that other deep-seated parts should be cut away and vessels tied within those cavities, are so dangerous, by the common voice and consent of man- kind, that I should in vain endeavor to reconcile it to myself that I am bound to do such things, except under the duress and stringent necessity laid upon me by my position as physician or accoucheur.

I have already shown you from Dr. Lee's work, how dangerous is the simple operation of a first tapping in ovarian tumors. The same valuable work contains a table of 118 operations for the removal of the ovary with the results; but Dr. Lee shows that the unsuccessful cases have not all been made known to the public,


OVARIAN DISEASE. 315

for Mr. Phillips informs him that he was aware of five other cases of which, at least, three were unsuccessful, and D. F. Bird men- tions several not made public, that would go to swell the list of fatalities. I shall not fatigue your patience by following the com- parative estimates of mortality in ovariotomy and other grave operations in surgery. What I have already stated as to my opinion, on the binding nature of the chirurgical duty in serious operations, may excuse me from giving you such trouble, for I hope I need take no further pains to show you that what you must do, and what you md^j prefer to do in the way of surgery, are categories wholly different from each other.

Facts are the things that teach — and I shall close this letter by laying before you the Tabular View presented by Dr. T. S. Lee, who, I am sure, will not object to my using so great a liberty v/ith his work, the more especially as it may assist in spreading further and wider the knowledge he has been at so great pains to collect, and make it both more public and useful at once.

C. D. M.


316


DR. LEE'S TABLE










TABLE, by


Dr. Lee


Ji Table of all the known Operatio



= ■2



Length


Adhesions


Error of


Complica-


Character of the



No.


a « i Operator.


to


of


or


Diagnosis


tion with


tumor.


Cause of de



5 S



<


incision.


not.


or not.


other dis- eases.


cystic or not.



1


L'Aumonier



4 in.





Aliscess of the

OTary after delivery

cyst.



a2


1809


Dr. M'Dowal



9 in.


None




Cysts



3



Do




Adhesions


Not re- moved.


Both ova- ries affect- ed.


Cysts



4


1816


Do




None




Scirrhus ovary



5|1817


Do




. None




Scirrhus ovary



6


1819


Do




Adhesions




Cysts with bone and hair.


Peritonit


67



Dr. Chrismar, or



Long







8



Chrysmer



Long







9


1819


bo


47


Long


Adhesions




Cartilaginous

& cardaceous

tumor.


Gangrene Intestine


10


1820


Do


38



Adhesions




Fibrous & cel- lular tumor.



11


1820


Do


38



Adhesions



Tubercular

lirer, scii-rhus

mesenteric

glands.


Lardaceous & cysts.


Peritonitis Gangren


12


1821


Dr. N. Smith, (Connecticut)


33


3 in.


Adhesions




Cystic.



13



Do



Unknown



Not re- moved.


Disease of the uterus.


Uterine tumor.



14



Do



Unknown


Adhesions


Not re- moved.



Cyst.



15


1823


Dr. A. G. Smith


30


Long





Cyst.



16



Do



Unknown







17



Do



Unknown






Secondar haemorrha


18



Do & M. M'Dovv^a!



Long



No tumor.



Conglomerat. Intestines.



19


1823


Mr. Lizars


27


Long



No tumor.





20


1825


Do


36



None



The other o- vary diseased.


Ovarian tumor.



21


1825


Do


25



Adhesions




Ovarian tumor.


Gangrene < the perito


22



Do


34




Not re- moved.



Solid and vas- cular tumor.


neum.


23



M. Dzondi



Unknown







24



Galenzowski


27


Long, 5 in.


Adhesions


Not re- moved.



Multilocular cyst.



25



Dr. Quittenbaum



Long







OF OVARIOTOMY.

Tumors of the Uterus, pp. 264-71.


317


if Ovariotomy, from 1809 to 1846.


!"ime of





death


Result.


Remarks.


References.


after





jeration.






Recovered.



Edin. Med. Surg. Jour. vol. xviii. p. 532.



Recovered.


Cyst opened, dirty gelatinous fluid withdrawn,


American Jour, of Med. Sciences,




and sac removed. Wound 3 in. to the left of


from Eclectic Repertory, p. 261.




rectus muscle.


Jan. 1845.



Recovered.


Both ovaries affected, cysts opened, bloody and gelatinous matter escaped, adhesions to blad- der and uterus, incision in the same place. See note.


Ibid.



Recovered.


Incision in linea alba.


Ibid.



Recovered.


Profuse hcEmcrrhage.


Ibid.


3d day


Died.


Incision on the left side.


Ibid.



Recovered.



Monthly Jour, of For. Med. vol. iii.



Died.



p. 440. Phila. 1829.


3 hours.


Died.


Extensive adhesions to colon, stomach, and pe- ritoneum ; one gallon of yellowish-green se- rum in the abdominal cavity.


Ibid.



Recovered.


Afterwards became pregnant, 8 years after the operation.


Ibid.


5 hours.


Died.


Diseased and deformed from infancy, tumor varicose, pedicle 4 inches in thickness. As- cites.


Ibid.



Recovered.


Emptied the cyst and removed it; it weighed


Edin.Med.& Surg. Jour. vol. xviii. p.




two or three ounces.


532. (Amer.Med.Rec. vol.v.p. 124.




alsoDub.Jour. vol.xxv. 1844. p. 382.)



Recovered.


Uterus was the most voluminous part of tumor. Med. & Surg. Memoirs, by N. Smith,

1 edited by N. R. Smith, p'. 231.



Recovered.


Sac emptied, but too adherent to be removed. Ibid.




slight peritonitis, sac and abdomen again





filled.




Recovered.


Emptied the cyst, drew out the sac, tied its


North Amer. Med. Jour. Jan. 1826.




pedicle, and removed it. New York Jour, of Med. Sept. 1843, |





p. 169.



Recovered.





Died.


The animal ligature used, gave way prema- turely.


Ibid.


2d day


Died.


The patient tapped herself 90 times.


Ibid.



Recovered.


Deceived by great obesity and distended ful- ness of bowels.


Lizars on Extraction of Ovary.



Recovered.


Some ha3morrhage, other ovary diseased, but

left. Tumor weighed 7 lbs.


Ibid.


2 or 3


Died.


Ibid.


days






Recovered.



Ibid.



Recovered.


By incision, the use of tents, and subsequent


North Amer. Jour, of Med. Science,




extirpation of the mortified cyst.


vol. XXXV. 1845. Atlee's Table.



Recovered.


Opened the tumor, tore up the cells, fixed it


Jeaffreson's Essay, Lond. Med Gaz.




by ligature to the wound, and obtained a per-


1844-5, p. 81.




fect cure.




Recovered.



Philips' Tables, Med.-Chir. Trans.





vol. xxvii. p. 672.


318


DR. LEE S TABLE



, si

0-2




Length


Adhesions


Error of Complica-


Character of tlie



No.



Operator.


bo


of


or


Diagnosis! lion v^^ith


tumor,


Cause of de



5 u



<


incision.


not.


or not.


other dis-


cystic or not.




^o"







eases.




26


1826


Dr. Granville



Long,9i in.


Adhesions


Not re- moved.



Cyst.



27


1827


Do


30 40


Long, 9 in.







28


1826


Dr. Martini


24


Long, 9 in.


Adhesions


Not re- moved.



Cartilaginous tu- mor, with cysts.


Haemorrh


29


1828


Dr. Dieffenbach


40


Long


Adhesions


Not re- moved.



Tumor highly vascular.



30


1829


Dr. D. L. Rogers


20


Long


Adhesions




Cyst.



c31



A case in Frori- ep's Notizen. Anonymous.


48


Long


Adhesions


Not re- moved.



Cyst.



32



Dr. Ritter


31


Long


None




Cyst.



33


1830


T. C. Warren


40


Long


None




Scirrhous tumor.


Hsemorrh


34


1833


Mr. Jeaffreson


40


Minor U in. Long,


None




Cyst.



35


1834


Mr. King


40



No tumor









7 or 8 In.







36


1836


Do


37


Minor


None




Cyst.



37



Do



Minor



Not rem.



Omental tumor.



38


1836


M. Dolhoff


23


Long





Cyst.


Peritoni


39



Do


27


Long


None Adhesions


Not re- moved.



Solid tumor.



40



Do


28


Long



Notumor





41


1836


Mr. West


45


Short, 2 in.


None




Cyst.



42



Do


23


Short





Cyst.



43



Do


24


Short




Shattered constituti'n


Cyst.


Sunk aft operatio


44



Do


40


Short


Adhesions


Not re- moved.



Cyst.



45



Mr. Hargraves


40


Short


Adhesions


Not rem.



Multilocularcyst



46


1840


Mr. B. Phillips


21


Short


None



Ulceration of the bowels of long standing-


Cyst.


Inflammatic

niuruus coa

the bowe


47


1841


Dr. Stilling


22


Long, 6 in.


None





Haimorrh


d48


1842


Dr. C. Clay


46


Long


Adhesions




Solid & fluid.



49


1842


Do


57


Long, 14 in.


Ext.Adhes.




Cysts.



50


1842


Do


39


Long, 28 in.


do




Cysts.



51


1843


Do


47


Long, 16 in.


do


Not rem.



Anomalous.


Inflamma


c52


1843


Do


45


Long, 14 in.




Disease of

the uterus.


Fleshy tumor of uterus.


Haemorrh


53


1843


Do


40


Long, 14 in.


Ext.Adhes.




Cyst.


Flasmorrh


54


1843


Do


22


Long, 14 in.


Adhesions




Cysts.



55 1843


Do


40


Long, 14 in.


None




Cysts.


Inflammal


56


1843


Do


43


Long,14in.


Ext.Aiihes




Cysts.



57


1843


Do


59


Long, 16 in.


E-xt-Adhes.




Cysts.


Exhaust!


58


1843


Do


45


Long, 14 in.





Hydatid.



59


1843


Do


58


Long, 8 in.





Pelvic tumor.



60


1843


Do



Long,16in.


Ext.Adhes.




Tumor.



c61


1844


Do


49


Long




Disease of uterus.


Uterine tumor.



62


1845


Do


35


Long, 14 in.


None




Cystic with solid matter.



63


1846


Do


51


Long


None




Cystic.



OF OVARIOTOMY.


319


ime of





death after eration.


Result.


Remarks.


References.






Recovered.


Very adherent, incised largely and carefully


Churchill's Notes. Dubl. Jour. vol.




emptied.


XXV. 1844, p. 383.


3daya


Died.


Death attributed to venesection, under the false alarm of peritonitis.


Ibid. & Med. Gaz. Jan. 13, 1843.


hours


Died.


Inseparably connected with the brim of the pel- vis ; removed a sacculated portion of it.


Churchill's Notes. Rust's Magazine.



Recovered.


Startled at the size of the base of the tumor,


Amer. Jour, of Med. Science, vol. v.




and flow of blood on puncturing it. Opera-


1829-30. Rust's Mag.




tion abandoned on account of adhesions.




Recovered. Cyst unintentionally opened, emptied, relieved


New York Med. & Phy. Jour. Jan.




of very extensive adhesions, and removed.


1830, p. 285. Amer. Journ.ofMed. Science, vol. v. 1829-30, p. 549.


th day


Died.


Had been tapped 5 times in 6 mionths, had a


Churchill's Essay. From Froriep's




broad base, and not removable from the os


Notizen.




innominatum.




Recovered.


First tapped, and two weeks after removed the ovary.


Churchill's Essay.


)n the


Died.


Ligature slipped.


Surg. Obs. on Tumors, by T. C. War-


table




ren, p. 590.



Recovered.


Cyst emptied of 27 pints, drawn out and re- moved.


Trans. Prov. Med. Assoc.vol.v.p.239.



Recovered.



Churchill's Essay.



Recovered.


Cyst, with a solid base, 27 pints of fluid evacu- ated, sac drawn out and excised below the ligature.


Lancet, Jan. 21, 1837, p. 586.



Recovered.



Med.-Chir. Trans, vol. xxvii. p. 473.


days


Died.


Cyst emptied of 1.5 pints and removed.


Trans. Prov. Med.Assoc.vol.v.p.245.


houra


Died.


Declined removing it, being solid and fixed in the pelvis by adhesions.


Churchill's Essay.



Recovered.



Ibid.



Recovered.


Cyst emptied of20 pints, drawn out and removed. Simple cyst. Prep, in St. Bartholomew's Mu- seum.


Lancet, Nov. 25, 1837, p. 307.



Recovered.


Cyst emptied of 24 pints and removed.


Lancet, Oct. 14, 1839.



Died.



Ibid.



Recovered.


Not removed on account of adhesions, had to be tapped afterwards.


Lond. Med. Gaz. 1844-5, p. 86.



Recovered.


N^ot removed on account of adhesions.


Ibid.


th day


Died.


Died of the disease, not the operation.


Ibid. Oct. 9, 1840.



Died.



Brit. & For. Rev. Churchill's Essay.



Recovered.


Incision 27 inches, tumor 2S lbs.


Mediciil Times, No. 160.



Recovered.


Extensive adhesions, tumor 24 lbs.


Ilnd. No. 161.



Recovered.


Tumor 73 lbs., very extensive adhesions.


Ibid. No. 162.


th day


Died.



Ibid. No. 163.


imedi-


Died.


Tumor and entire uterus, except the cervix, re-


Ibid. No. 164.


itely.



moved.



hours


Died.


Ovarian tumor 26 lbs.


Churchill's Essay.



Recovered.


Tumor 26 lbs.


Ibid.


hours


Died.



Ibid.



Recovered.


Tumor 31 lbs.


Ibid.


hours


Died.


I umor 54 lbs.


Ibid.



Recovered.



Ibid.


th day


Died.


Dr. Clay says she recovered from the operation. Ibid. |



Recovered.


Tumor weighed 26 lbs.


Ibid.


ivceks


Died.


Uterus and ovaries were removed.


Ibid.



Recovered.


Solid tumor 9 lbs., fluid and solid .53 lbs., evacu- ated the cysts before extraction, patient re-


Med. Times, No, 282, Feb. 15, 1845.




turned into Wales 1-5 days afterwards, subject |




to the disease 10 or 12 years.




Recovered.


Well 17 days after the operation.


Med. Times, No. 333, Feb. 14, 1846.


320


DR. LEE S TABLE



o.e



j;


Length


Adhesions Error of


Complica-


Character of the



No.


S 5


Operator.


bcl


of


or Diagnosis


tion with


tuiTior, Cause of de



O



<


incision.


not. or not.


other dis- eases.


cystic or not.



64



Dr. C. Clay



Large






65



Do



Large







66


1842


Mr. Walne


58


Long


None




Cysts, with solid tumor.



67


1843


Do


57


Long


None




Cysts.



68


1843


Do


20


Long


None




Cysts.



69


1843


Do


54


Long


Ext.Adhes.lNot rem.



Cyst.



70


1844


Do


45


Long


None



Uterine disease


Cvsts solid and 'fluid.


Tomor of nt

resting aga incision.


/71



Mr. W.,

(B-k-s-w)



Long


None



Exhaustion before ope- ration.



Peritonitis . haustiun a 3il day. G tynipaniti


72



Chrismann



Large


None






73



Mr. Crisp



Unknown





Cyst.



g74


1843iMr. Morris,



Large









(Rochdale)









hl5


1843


Mr. Southam


37


Long


None




Cystic sarcoma.



76


1845


Do


38


Larpe, 6 or 7 in.


None




Cystic.



i77


1843


Dr.F. Bird


35


Small, 4iin.


None




Cysts.



78


1843


Do


21


Small, 5 in.


None




Cysts and solid matter.



79


1844


Do


35


Large, 8 in.


Strong




Cysts and col- loid disease.



80


1844


Do


21


Small, 3 in.


None




Cysts.



81



Do


21


Small, 5 in.


Adhesions strong




Multilocular thick cyst.



82


1846


Do


52


Short, 5 in.


Strong pelvic adhesions




Cystic vpry tliick, and filled witli cliolestei'ine.



83


1843


Dr. T. L. Atlee


2!:;


Long


Adhesions




Cysts and hydatids.



84


1844


Do


4ii


Long


Adhesions



Disease of uterus.


Fibrous tumor of uterus.


Haemorrb


85


1843


Mr. Heath


40


Long




Disease of uterus.


Fibrous tumor of uterus.


Hsemorrl


A;86


1843


Mr. Lane


28


Short, 5 in.





Cyst.



87


1843


Do


45


Large, 8 in.


Adhesions




Cysts and solid.



88


1844


Do


38


Large, 7 in.


Adhesions




Multilocular cyst.



89



Do



Large, 7 in.


Adhesions






90



Do



Small


None




Multilocular cyst.



91



Do



Large


Extension




Multilocular cyst.


Periton


92


1843


Mr. Key


19


Long


None




Multilocular cyst.


Periton


93


1843


Mr. Greenhow


29


Long


Adhesions



Disease of stomach.


Cyst.wilh a dense TiisruloceUular tumor.


Periton


94


1843


Mr. B. Cooper


32


Long


Adhesions


i


MaUgnant dis- ease of ute-


Solid and cysts.


Periton


95


1844


Dr.W. L. Atlee


61


Long


None



rus.


Bilocular cyst.


Insidious ritonitis


96


1S44


Do


24


Long


None



Uterus dis- eased.


Fibrous tumor of uterus.



97



Ehrhartstein


36


Large


None




Solid and cysts.



DR. LEE'S TABLES.


321


rime of death after leration.


Result.


Remarks.


References.


3 days


5th day 17 hours


9th day

7th day

6th day


Recovered. Recovered,

Recovered.

Recovered. Recovered, Recovered. Died.


Died.

Recovered,

Recovered. Recovered.

Recovered.

Recovered.

Recovered.

Recovered.

Recovered.

Recovered, Recovered,

Recovered.


Recovered, Died.


Died.

Recovered Recovered Recovered


Narrow escape, followed by phlegmasia dolens. Tumor 28 lbs.

Fibrous tumor of uterus, resting against incision, was supposed to have produced inflammation, and death.


Tumor 8 lbs. Recovered in 6 weeks. After- wards pregnant.


Ligature drawn into the abdomen, but incision entirely healed.

The ligature came away on the 49th day. Left ovaries tapped and extracted.

Sac punctured, drawn out, the pedicle tied, sac removed.

Incision 5 inches, cyst emptied, withdrawn, and excised, no pedicle.

Many adhesions, sac emptied of a firm gelati- nous matter, excised tumor 35 lbs.

Followed by slight peritonitis.

Case not published, but given to me by Dr. F. Bird.

Cyst tapped and extracted : there was no pedi- cle ; and a small section of the uterus was re- moved with it.

Both ovaries removed.

4 uterine tubercles, with thick vascular pedicles, extensive adhesion, hemorrhage from slipping of ligature.

The uterus and all were removed.

Phlegmasia dolens followed the operation.

Two cysts emptied before removal.

Cysts emptied before removal, the cyst sessile,

and firmly attached to the fundus and neck of

the uterus.


Recovered. Recovered,

Died.

Died.

Died.

Died.

Died. Recovered Recovered.


Adhesion to liver, suprazenal capsule. Ascend- ing vena cava. Kidney and intestines poste- riorly. No adhesions anteriorly.

Large vessels on tumor.

For 4 years previously had uterine hemor- rhage.

A portion of the omentum was included in the ligature.

Colon involved in abroad pedicle: both ovaries diseased.

Thick fleshy pedicle, followed by violent peri tonitis : intestines troublesome.

Tumor tapped before extracted.


The particulars of both these unpub lished cases were kindly given me by Dr. Clay.

Churchill's Essay, and Med. Gaz., Aug. 11, 1843, p. 699.

Ibid. Oct. 13, 1843, p. 47. Ibid. Feb. 23, 1844, p. 686. Ibid. March 10, 1844, p. 783.


Unpublished.


Psaffs Journ. vol. xii. part i.

Lancet, Dec.

Churchill's Essay, from the Manches- ter Courier. See note. Med. Gaz. 1843.

Prov. Med. & Surg. Journ. Sept. 10, 1845. Med. Gaz. May 26, 1846.

Lond. Med. Gaz. March 22, 1844, p 832.

Ibid. Dec. 29, 1843, p. 409.

Ibid. Aug. 18, 1843, p. 732.

Ibid. Dec. 8, 1843. Not published.

Not published, but particulars given me by Dr. F. Bird.

Am. Med. Journ. Jan. 1846, p. 44, Ibid. vol. XXXV. 1845, p. 335, Atlee's table.

Med. Gaz, Dec. 8, 1843, p. 309.

Ibid. 1844-45, p. 84.

Med. Gaz. 1844-5, p. 84. Jeaffreson's table.

Philips' table. Not published.

Unpublished. The particulars of both these operations were kindly given me by Mr. Lane.

Guy's Hospital Reports, Oct. 1843, p 473.

Med.-Chir. Trans, vol. xxvii. p. 88.

Ibid. vol. xxvii. p. 76.

American Med. Journal, July 1844, p. 43. Ibid. April 1845, p. 309.

Med.-Chir. Trans, vol. xxvii. p. 473 Philips's table.


21


322


DR. LEE'S TABLES.


No.


O


98

99

100

101

1102

103

104

105

106

107

1

109


1844 1844


»110 111


112 113

114 nll5


0116


117 pll8


1845 1845


1846 1846

1846 1846


1846


1846 1846


Operator.


Dr. Hopser Do Macdonald Groth

Morgan

A. B. C. D. E. F. G. H.

Case in Gooch Dr. Bowles Prof. Webster


W. B. Page John Dicken


Dr. Handyside

Mr. Solly


Dr. Protheroe

Smith Mr. Arrowsmith (Shrewsbury)


H. E. Burd

(Shrewsbury)


Mr. W. Caesar Hawkins


Length

of

Incision.


22


Large Large Large Large

Small, Hin

Long Small Large Large 6 inch. Long Long


33jSman,4in 18 LargCjHin


26


18


Large Short, 4 in- Large Short


Long


Long Small, 3 in.


Adhesions


Adhesions

Adhesions

None


Adhesions Adhesions Adhesions


Adhesions Adhesions


None

Extensive, but cavity broken down.


None


None

Very ex- tensive.


None


None


Error of

Diagnosis

or not.


Not re- moved. Not rem, No tumor


No tumor


Not re- moved.


Not re- moved.


Complica- tion with other dis- eases.


Chronic peritonitis.


Character of the

tumor,

cystic or not.


Solid tumor. Solid tumor.

Cysts.


Solid tumor. Cyst.


Cysts. Multilocular cyst.

Cyst.

Unilocular cyst of right ovary,

Multilocular.

Multilocular.


Multilocular.


Unilocular.


Cause of de


Haemorrha


slipping of ligature.


Shock of C ration.


a Case 1. From the American Journal of Med. Science, vol. xxxv. 184.5, p. 262. Still continues to enjoy good heal

Case 2. Dr. M'Dowall states, that he thought his patient well of her disease: "but she informed me a short t since that it had been growing for the last 12 or IS months, and says it is now about the size it was when 1 opened six years ago.

Case 4. "She recovered happily, bull am told her health is not good; the account I had of her was awkwardly gii from what I could learn, her complaint is hysterical."

b I have been unable to obtain the Monthly Journal of Foreign Medicine, vol. iii. p- 440, Phil. 1829, but presume tl: five operations to be correct, having extracted them from Dr. Atlee's Table. Amer. Jour. Med. Science, April, lS45,p.

c The anonymous of Dr. W. L. Atlee's Table.

d I feel greatly indebted to the politeness of Dr. Clay in giving me a corrected list of the operations he has aire performed. I am also authorized to mention, that Dr. Clay says in a note to me : "I took a survey of the state of all successful cases for my particular friend. Prof. Simpson of Edinburgh, and found them all in the enjoyment of be health (since the operation) than for many years previously."

e Cases 52 and 61. These cases, I have authority for stating, were not operated on "as ovarian." "This was the plication of the same operation to disease of the uterus, which, though not successful, ought not to be included in statistics of Ovarian operations." Dr. Clay's note.

/ Case 71. This case has not been published, but was related to me by the nurse who was present at the operat: Also at the OlTice for the Register of Deaths.

g- Case 73 has been disputed, on account of the authority it was originally taken from, viz., the Manchester Cour but I have authority to state, that Mr. Morris did operate on a patient, and was successful.

h Case 75. "On referring to the report of my former patient," says Mr. Southam, "it will be found that the tympan and obstinate vomiting which supervened on the operation, caused the ends of the ligatures to be drawn within the


DR. LEE'S TABLES.


323


'ime of death after eration


Result.


Remarks.


References.


I hours hours


) days hours


hours


Died. Recovered Recovered

Death.

Death.

Died. Recovered Recovered

Death. Recovered Recovered Recovered,


Recovered Recovered


Died.


Died.


Died. Recovered,


Recovered.


Recovered Recovered


Ascites.

Malignant tumor. Tumor 22 lbs.

A portion of fluid removed before extraction : 2^1bs. of blood found in the pelvis.


Not removed on account of adhesion. The patient rapidly recovered from the operation, after the peritoneal cavity had been exposed for two hours ; but the disease progressed, and she died from it in about 2 months.

Tapped and extracted.

The ligature came away in 3 weeks. Each ar- tery was tied separately. The whole pedicle was not included. Left ovary healthy.

Both ovaries diseased and extracted.

A portion of the pedicle, containing the Fall, tube, slipped from the ligature, and gave rise to hemorrhage ; left ovary diseased.

Tumor weighed 20 lbs.; fluid 10 lbs.

An exploratory incision was made of a few inches in extent, but the adhesions were found to be so strong and extensive that the operation was considered unjustifiable.

The patient recovered without any untoward symptom.

The weight of the tumor, with its fluid and solid portions, 50 lbs. The patient was preg- nant of about 3 or 4 months' standing, and aborted forty hours after the operation.

Ligatures came away from the 22d to the 25th day : the wound entirely healed on the 29th day.


Med.-Chir. Trans, vol. xxvii. p. 473

Ibid. [Philips' table.

Ibid.

Ibid. PsaSs Journal.

Philips' table ; and from Dr. F. Bird, who saw the operation. Philips' table. Ibid. Ibid. Ibid. A case unpublished.

Western Lancet, Oct. 1846.

Not reported. American Journal of

Medical Science. Atiee's table,

vol. Iv. p. 335, 1845.


Lancet, April 5, 1845, p. 397. Provincial Med. & Surgical Journal for Oct. 7, 1845.

Edinb. Med. & Surg. Journ. 1846.

Chemical Lecture. Lond.Med. Gaz July 10, 1846.

Unpublished, but at which I waf present.

Unpublished ; and the particulars given to me by T. Y. Arrowsmith, Shrewsbury.


Unpublished ; and the particulars given to me by H. E. Burd, Shrews- bury.

Unpublished.

The particulars kindly given to me by Mr. Caesar Hawkins of St. George's Hospital. Med. Gaz. Oct. 30, 1846.


minal cavity ; the wound had perfectly healed, and the patient was restored to health, whilst they were still in the 3omen. After several weeks had elapsed, a small abscess appeared at the lower part of the cicatrix, an opening

which gave exit to a quantity of healthy pus and the ligatures. A free discharge was promoted by poultices for ew days, and at the end of the week the wound closed. No constitutional disturbance occurred, and there has not 3n the slightest interruption to the most perfect state of health since the termination of the report. The catamenia peared with the greatest regularity, and in the same quantity as previously to the commencement of the disease, ere is a tendency to corpulency, which is in a great measure checked by her active habits." Provincial Med. & rg. Journ., Sept. 10, 1*^45. i All Dr. F. Bird's cases are doing well.

b All Mr. Lane's patients are doing well; he gave me the account of the two unpublished cases.

Case 102. This case was operated upon by Mr. Morgan of Guy's Hospital, and is the same as the one reported as by . Ashwell, and Guy's Hospital," in Dr. W. L. Atiee's Table. Am. Jour, of Med. Science, vol. xxxv. It45, p. 333. n "I may take this opportunity of mentioning, that the woman from whom I removed an ovarian tumorin August, 14, was, when [ last heard of her, some months since, hi good health, and following her usual occupation, that of

itinerant dealer in pens and paper, in the neighborhood of Edinburgh." Mr. W. B. Page has again performed ! abdominal section ; the particulars of the case are given in the Lancet for Dec. 1'2, 1S46, whence the above remarks i taken.

1 Case 115. I here beg publicly to thank T. Y. Arrowsmith, Esq., and H. E. Burd, Esq., both of Shrewsbury, for sir great politeness in giving me the particulars of their cases, 115, 116.

) Case 116. Mr. Burd states in a note, that "on this, the seventeenth day from the operation, the patient isdoingwell,

d gives fair hopes of recovery."

5 These last four cases occurred after this work was in the press, and therefore are not included in the statistical

suits.


324 THE FALLOPIAN TUBES.


LETTER XXVI.

Gentlemen : — The Fallopian tubes, like the ovaries and other generative tissues, are liable to disease ; but it unfortunately hap- pens that the Fallopian tubes being hidden within the bony cavity of the pelvis, and not approachable either by the vaginal touch or the hypogastric palpation, may be the seats of disease, pro- ceeding to the most inconvenient or even dangerous extent, with- out our being enabled to detect its existence by any process having the clearness of demonstration. I presume, indeed, that for the most part. Fallopian disorders will scarcely be clearly made out until a necrological examination may serve to reveal them. This opinion, I think, is well founded, except, perhaps, as to some samples of tubal pregnancy, of which the signs, too late discovered, are sufficiently clear to admit of our pronounc- ing boldly upon the case.

Affections of the Fallopian tubes may serve to condemn a female to incurable barrenness. Thus, if a female, in early life or later, should experience an attack of acute peritonitis, marked with the characters of adhesive inflammation, the Fallopian tubes, one or both of them, might become attached by adhesive bands to the broad ligament, or to the bladder, so as effectually to prevent a tube ever afterwards from serving as a conductor of the ovulum to the womb. In such an instance, it would be impossible for fecundation to take place, and equally impossible to make the diagnosis of the accident during the person's lifetime.

An adhesion of a Fallopian tube to the broad ligament, leaving the other one free to fulfil its office of excretory duct to the ova- rium, would not, however, at all interfere with the reproductive power of the woman, since one ovary might produce germs for the fecundative conflict. Neither would such an adhesion ex- pose her to any danger of suffering from violent traction and disruption of the adhesion in case she should become pregnant, when the womb must rise upwards to the height of the scrobi- culus cordis ; because, the broad ligament itself equally yields to the distending force of the growing womb, and thus carries the


DISEASES OF THE FALLOPIAN TUBE. 325

adherent tube upwards along with itself. No great inconvenience, therefore, is to be apprehended from an adhesion of one tube. When both are adherent, so as to prevent the fimbriae from reach- ing the ovary, barrenness is inevitable.

A Fallopian tube may become the seat of inflammation at its fimbria resulting in the closure of that extremity of the organ, while the uterine orifice of it also becomes closed. In this situa- tion it sometimes is found to be filled and greatly distended with water. A beautiful drawing representing this condition of the Fallopian tube is given by Dr. Hooper, at p. 61 of his Morbid JJnaf. of the Uterus, &c.

M. Duges supposes that pain and inflammation in the region of the Fallopian tube, unaccompanied with swelling or hardness there, may be held as signs of inflamed Fallopian tube ; but I do not discern how such signs can be taken as evidence of that par- ticular malady, since they may be as well marks of disease attacking the round or broad ligaments, and I should place very little reliance on the diagnostic skill of any one for the particular diagnosis in question. All such maladies are and must, during their course, remain obscure and unknown, except as far as they introduce constitutional disturbance.

The Fallopian tube has been found full of blood, probably menstrual blood.

I am not aware that any one has perished from the escape of a quantity of menstrual fluid from the uterus, in atresia of the vagina or womb ; and yet it seems wonderful that where the uterus is ex- panded to the cubic content of twenty or thirty ounces of men- strual excretion, the uterine orifice of the tube should never suffer it to flow off' into the peritoneal sac. The surprise is increased upon remembering that the tube is so expansible as we see it in some morbid specimens.

For example. I attended a lady in her accouchement in June, 1841. She had a favorable labor, and all the usual circumstances

of a lying-in woman attended her for a period of hours,

when she complained of heavy and distressing pain in the region of the right Fallopian tube. The pain, and the complaint of it were great. Of a sudden the pain began to spread over the lower belly, and the constitution evinced its participation. The pulse became alarmingly excited and accelerated, and she was soon seen to be far gone in a puerperal peritonitis. As she had com-


326 DISEASE OF THE FALLOPIAN TUBE.

plained of pain in the right side for some time before the ac- couchement, I feared that some local malady, suddenly aggravated, was at the foundation of the danger. She died; and upon in- specting the abdominal cavity, much pus and sero-pus were observed. But what most particularly struck me, was the state of the Fallopian tube, which was much larger than a stout man's thumb ; and its cavity, which would freely admit of the introduc- tion of a finger into the tube, had been filled with pus. I have little doubt, that acute inflammation of the tube, sealing the ovaric extremity of it, and afterwards filling and greatly distending its calibre with pus, discharged at length into the belly, is the true rationale of this fatal attack.

As the Fallopian tube conveys the ovulum from the ovarium to the womb, it is occasionally liable to destruction from an arrest of the fecundated ovulum in some portion of the tractus. An ovulum, when fecundated, whether it be arrested in the tube or whether it be arrested in the uterus, makes its mesenteric attach- ment to whatever vital surface it is confined. No doubt is enter- tained as to tubal gestation. No doubt, therefore, can be had, that, in all such instances, the ovulum was fecundated before it had passed down the whole length of the tube.

When such a tubal conception hath taken place, the woman will probably deem herself pregnant, since the rational signs of conception, such as nausea, deeper tinted aureoles, and even failure to menstruate may attend the misfortune.

No suspicion of the dreadful fate that impends the victim is aroused until the tube has attained the utmost degree possible of its expansibility. That degree will rarely allow her .to go beyond the third month, before the tissue gives way, and the ovum burst- ing, pours its contents into the peritoneum, followed by torrents of blood effused from the ruptured arterioles and venules of the tube.

If the patient complains, for some days before the accident, of pain in the region of the ovary, it is probable the pain will be attributed to some other than the true cause, and the first symp- tom of the rupture is characterized by an instant burst of distress and a rapidly developing inflammation, attended by the evidences of a simultaneous hemorrhagic exhaustion, and the speedy evi- dences of approaching death, seen in mortal pallor of the face, coldness and clamminess of the limbs, shortening respiration, and a vanishing pulse, repeated with inappreciable rapidity.


FALLOPIAN PREGNANCY. 327

Suppose you should be spoken to on the subject of a preg- nancy just commenced, for your counsel as to the conduct of the patient. If, after the lapse of six weeks or twelve weeks, you are hastily called to her, and find her in the condition above de- scribed, what other diagnosis have you to offer than that of a ruptured Fallopian tube? You see very clearly that such pheno- mena could by no means attend a sudden internal strangulation of a bowel ; and the antecedent health of the woman would not allow you to attribute her symptoms to a perforation of an intes- tine. You have no other diagnosis to offer, and, unhappily, the only consolation for you, under such circumstances, consists in your ability clearly to point out the nature of the causes, and pre- dict the verification of your decision after the death of the victim, which may be pronounced unavoidable.

I was the distressed witness of a case of this kind, a few years since, in a fine young woman, who had been several years mar- ried without offspring, when she came at last to tell me, with un- feigned pleasure, that she was pregnant, and to take my advice as to her hygienic management. When her pregnancy had pro- ceeded a little beyond the second month, she arose from her bed in good health and spirits. She took a broom and began to sweep some part of her apartment, when, in an instant, she felt violent pain in the region of the ovary, became suddenly of a mortal paleness and coldness, and by the time I reached her apartment, was already sinking from the peritoneal hemorrhage.

Here is another case that fell under my notice.

Mrs. , aged thirty-two, a healthy woman, mother of four

children, was in excellent health on Sunday, October 7th, 18 — . At six o'clock in the morning, she was gayly singing and playing with her young children at her country seat, about two miles from town. At seven o'clock, an hour later, her husband, who was sick in his chamber, heard her slowly ascending the stairs, and groaning heavily. Upon her entering his chamber he perceived her to be alarmingly ill. Her physician. Dr. , was imme- diately sent for. He found her with a pulse at 140, and com- plaining of violent pains extending from the top of the thorax, on the right side, quite down to the iliac region. He attended her all day, applied a blister to the right side of the belly, and gave her a cathartic, &c. She passed a dreadful night, but was easier the next morning at 8 o'clock, when the pulse was but 120 per


328 FALLOPIAN PREGNANCY.

minute. He left her for a short time, but found her symptoms aggravated upon his return. I was invited to see her with him, and met him at half past 2 o'clock, when she appeared to be dying.

As she had vomited very much, and labored under excessive tympanitis, with violent pain in the whole belly, she got an ene- ma, which brought off a great deal of stercoraceous matter, but without any relief of pain. In half an hour she said "raise me up, my breath is leaving me," and she was slightly elevated on a pillow, when she immediately swooned, and died.

Twenty hours after her death I inspected the abdominal cavity, \vhich contained about thirty ounces of blood and bloody serum. The pelvis was filled with coagula, and much blood was lying among the intestinal convolutions.

This blood escaped from a rupture in the left Fallopian tube, which contained a foetus of six or seven weeks. The ovary was somewhat enlarged. The womb contained a deciduous lining, and the canal of the cervix contained a claret-colored mucus or lymph. The womb was larger than a non-gravid womb, though not much larger.

There is a lithographic print which very faithfully represents the appearance of the specimen, which you may see at page 107 of my ^^Philadelphia Pract. of Mid.,' 2d edition.

What, alas ! can we do in these cases ? We could make an incision in the abdomen and clear away the coagula and the se- rum. But who is he bold enough to do so ? Who is he astute enough to discriminate betwixt all the possible causes of such phenomena, with so much clearness as to warrant him in the per- formance of a gastrotomy for Fallopian pregnancy? There is no such wise and bold surgeon; and, therefore, nothing remains for us but to extend all the relief within the narrow boundaries of our power, and calmly await and submit to the inevitable end. Such are painful scenes to the sensitive mind. They cast a co- lor of gloom over the pathway of the medical man, whose whole walk, indeed, is among those who are in pain, in weakness, in fear, or in the valley of the shadow of death. A physician may be calm, and even cheerful, but a merry doctor is a very singular phenomenon.

The diseases of the Fallopian tube then, you perceive, are ob- scure, and very unmanageable where they become serious.


OVARIAN PREGNANCY. 329

Doubtless they are many times unsuspected, while thiey are the true causes of disorders treated under another name, and doubt- less their inflammations, spasms, neuralgias, and engorgements, may yield to constitutional and local remedies addressed to symp- toms supposed to depend on modifications of other tissues.

I did not say anything as to ovarian pregnancy when I wrote to you my meagre letter on the ovaries, because I intended to say what I have now said on tubal pregnancy, and preferred to reserve ray remarks on ovarian gestation for this connection.

You know, for I have many times spoken with you of it, M. Pouchet's opinion that ovarian pregnancy cannot exist. M. Pouchet says, at p. 421, Theorie positive de V Ovulation spontanee, &.C. : "I formally deny the existence of ovarian pregnancy. I admit, indeed, that the e^g in the act of escaping from its cap- sule, may become fecundated by the sperm brought into contact by means of the fimbria, and that it may subsequently be devel- oped at the surface of the ovarium in consequence of adhesions contracted with that organ. But I have no idea of an ovarian preg- nancy as understood by writers, that is to say, a development of an ovulum still contained within its Graafian vesicle, and which by its development engenders a foetus enclosed within the very ovary itself.^

M. Pouchet, to whom we are indebted for the fruits of very great labor and research on this subject, can hardly, we would think, escape from the necessity of admitting a true ovarian preg- nancy, if he will consult Dr. Granville's account of the case pub- lished by him in the Lond. Phil. Trans., Part 1, 1820. In July, 1845, I had the honor of an interview with M. Pouchet, at his house at Rouen, and a conversation took place, among other topics, upon this very one of the ovarian pregnancy. I stated my own conviction, that it is impossible to deny the existence of the ovaric gestation, and that the embryo might well be developed in the Graafian follicle, which I see M. Pouchet, in the above sentence published in 1847, does not admit — he adhering to the opinion that the development can occur only at the surface of the organ.

It seems to me, gentlemen, that if you assert the mutual pre- sence and contact of the generative elements to be necessary to fecundation, you have no occasion to doubt the presence of the male element in the tube, in all cases of tubal pregnancy at least, and M. P, himself says, that it may be possible for fecundation


330 OVARIAN PREGNANCY.

to take place on the surface of the ovary, by the contact of the germ with sperm brought into the fimbria.

My opinion at Rouen was, and is still, that the porule being formed for the escape of the ovule, which being retained within the capsule by the granular retinacula, it might be the subject of impregnation by sperm brought to it in the fimbria of the tube.

Let us suppose the impregnation to have been effected — then some change of position covering the porule with a peritoneal superficies allowing of adhesion, the ovulum w^ould be necessarily shut up in the crypt or cell, which having now become again a shut sac, development of the germ would go on absolutely in the interior of the ovulum, and Granville's fact, for facts are stub- born things, would be explained without at all shaking the con- clusions as to the oviponte.

I cannot predict what may be the opinion you shall adopt on this point. I presume, however, there is not one among you to believe that the macula germinativa, w^hich is on the inner wall of the germinal vesicle, which is buried among the vitellary corpus- cles of the egg, which itself is in the centre of the granular masses contained within the inner concentric of the Graafian fol- licle, hid below the tunica albuginea and indusium of the ovary, can be exposed to the sexual presence and contact by any pro- cess other than the spontaneous ovi-posit, which M. Pouchet describes. For my own part, I cannot imagine any other w^ay in which the mutual influences of the generative elements can be brought into effectual activity.

I do not, then, believe that in the ovaric pregnancies the fecun- dation has been effected, except through an opened Graafian cell, which being subsequently closed by adhesive inflammation at the edge of the porule, has allowed the pregnancy to go on in the ovary itself.

The womb is so constituted as to admit of a development con- tinued throughout the nine allotted months of a gestation ; its pro- vision of materials being ample for that purpose. No such provi- sion has been made for ovaric or tubal gestation : hence, within three months, probably, in most cases earlier, the fatal rupture of the containing walls will take place, and the patient lose her Hfe.

I have now treated in succession of the maladies and accidents of the external and internal genitalia. There are many points


PUBERTY. 331

which I have passed over in silence, because I have wished to avoid expressing an opinion upon subjects, on which I have had no practical or clinical knowledge. Others I have postponed to a future page, in order that I might not be compelled, on the one hand, to anticipate, nor, on the other, to separate subjects that have a sort of natural alliance. For example, ruptures or lacera- tions of the womb and vagina, it appeared to me, might better be arranged under the head of those diseases and accidents of preg- nancy of which it is my intention to treat. It will be my duty to say much upon the subject of the menstrua, an important item in the history of the female, and one whose modifications and dis- orders exert a mighty influence on her health and happiness. In order to approach this subject properly, I ought to make remarks on that important and interesting crisis, which is called puberty in the female, and, therefore, my next letter shall be on the sub- ject of puberty, or the puberic age. C. D. M.


LETTER XXVII.

Gentlemen: — I know not whether I shall in this letter succeed in setting forth with clearness, the views I have long entertained, or rather those which I have supposed myself to entertain on the subject of puberty in girls; I fear I shall not. A man may think he has clear views on points in physiology, or in general philoso- phy, and particularly in any metaphysical contemplation, while, in fact, his notions are not clear, but confused, indefinite, dim, and not readily explainable in words. In such a state of his mind, a man will be found unable to set forth a lucidus ordo of thoughts, for there is no such characteristic order in his opinions on the special topic ; and if a writer doth in this way fail, you have fair inference that he fails to be distinct and clear and coherent in his exposition because he is himself indistinct, confused, and incoherent in his appreciation of the subject in discussion.

If you had happened to be eye witnesses of a certain historical event, you would, doubtless, expect to be able to relate all the


332 PUBERTY.

successive incidents thereof in a regular order, as they occurred ; but should you not be able to do so, it Would be because you had observed badly, and kept no memorials or records worthy to be depended upon ; in fact you would not know or understand the events of which you had been eye witnesses, and which you sup- posed yourself to understand and remember perfectly well. We see constant examples of this uncertainty and imprecision of knowledge in testimony daily given to our courts and juries by witnesses called in the case. The truth is elicited only by cross- examination.

Now, when in this letter I come to speak to you on the subject of puberty in girls, I consider myself as having been an eye wit- ness in the cases to be taken up, as to the events and circumstances that attend upon the puberic age ; for, the major part of along pro- fessional life has been past amidst such scenes and histories. During many years, I have frequently been charged with the con- duct of the health of young females entering upon, passing through, or already gone beyond the puberic age ; yet, notwithstanding I have witnessed so many cases requiring medical interposition, I confess that to write you a letter on the subject of puberty ap- pears to me a most difficult task. Certainly it is one I should prefer to avoid, both because of the doubts existing in my owm mind as to the peculiar nature of the puberic affections, and of the jejune and little practical notions upon it that I find in the authorities, which I take to be a proof of the difficult nature of the subject. I must pray you, therefore, beforehand, to scan very closely the sentiments that I shall express in this letter, and if you find them to coincide with what is true, or probably true, to adopt and apply them ; whereas, if they should prove to be hypo- thetical and unfounded in truth, you ought to reject and condemn them. I desire only that they should be useful, not merely that they should be acceptable.

The writing a letter upon puberty would not be a difficult undertaking, were one to confine himself to pointing out in the usual manner the period and general phenomena of the change from the girlish to the womanly estate. Nothing is easier than to say that at the age of fourteen or fifteen years the pelvis becomes expanded and consolidated, that the internal and ex- ternal genitalia and the lactiferous apparatus become completed, &c. &c. But such statements, that are to be found in all the books


PUBERTY. 333

on these matters, serve to throw but very little light on the abstruse subject of puberic disorders.

I shall endeavor, then, to relate to you what are the opinions I entertain on the subject, and point out to you the indications of treatment for those young people, who approach dangerously and pass with risk through the great and important crisis of the pu- beric age. What is meant by the word puberty ?

Stephens, in his Thesaurus, says: " Pubertas. Aetas in mari- bus qui est annus xiv., in foeminis xii. Pubertas plena xviii. annus est. Pubertas est emissio pubis, a qua anni pubertatis dicti sunt. Pubertas, generandi vis.

Dr. Noah Webster, in his Dictionary, says, "Puberty. The age at which persons are capable of procreating and bearing children. This age is different in different climates ; but is with us considered to be at fourteen years in the males, and twelve in females."

You see that Stephanus and Webster, I shall not take the trouble to examine any others, agree that puberty in females is the age of reproductive power just begun, and that that power is acquired at twelve years of age ; Stephanus says, plena at eighteen ; but you, even as young students of medicine, know that neither of these Dictionaries speaks truly, for the reproductive power is not attained at twelve years in the average of cases, nor does the average come at all near to twelve years — it is beyond fourteen years in this country. The first true and veritable eruption of the menses may be taken as the evidence of the girl having reached her puberic age, for that eruption is the evidence of germ evolution in the ovary, and even of the ovi-posit. This occurs be- tween fourteen and fifteen years of age.

Instead of limiting the application of the word puberty to the state of the girl at the first mensual manifestation, I prefer to use it as referring to a long stage of preparation for the menstrual office, and to a stage, also, which extends far beyond the date of the first show, into the period when the function has become re- gularly established ; so regularly and firmly, I mean, as to leave no doubt on the mind as to the permanent and normal acquisition of the power; a pubertas plena. The fact is, that many persons are to be met with, in whom it has never been perfectly esta- blished; persons in whom the power to menstruate exists, but


334 PUBERTY.

exists feebly, morbidly, interruptedly. All such persons have failed to pass through the crisis of puberty.

A girl may have a sanguine discharge from her genitalia with- out having any pretension to be menstrual. I have observed such discharges in children at birth, in the month, and in little children under six years of age. When I have been consulted about these cases as extraordinary samples of precocious menstruation, I have been far from joining in such a preposterous notion.

The young child is but the sketch, the ebauche, the mould in which are to be formed the organs of the woman. She employs some fourteen years of her life in consolidating and forming her body, in order to fit it for its high destiny as a reproducing agent : but the apparatus and the force necessary for the fulfilment of that destiny are not added, except as the last and crowning power of her constitution. Her weak and tender tissues, in the early years of life, could not possess the strength and solidity, nor could they furnish the materials, for the evolution and perfecting of the new being, which is for a series of following years to represent its parent, as one of the integers of the immortal genus, man.

The earliest years of her life are occupied, then, in bringing her up to that point of perfect development of her alimentary, re- spiratory, innervative, and circulatory life, that may fit her for taking on the last great reproductive force. The time for taking up that force is the time of puberty. Puberty is the term of pre- paration to produce and mature ovarian ovules or germs, and discharge them from their capsules in the ovary.

Having duly acquired this power and faculty, she has passed through the crisis of her puberty. She has transcended the pu- beric age, and has become a woman. She has become possessed of a faculty that she is destined to enjoy for nearly half of her life- time, and then, losing it again, she turns on the reverse of the path of life, and begins to descend to the bosom of the dust from whence she originally emerged.

It might be true to say that the whole menstrual period of life, extending from fifteen to forty-five years of age, is a continual crisis for the female; yet, when once fully formed and estab- lished in the economy, it is become a nature and a habit, and ceases to have that character of crisis which more truly applies to the stage of preparation or inception of this great power, and its positive and firm establishment as a part of her life-offices.


PUBERTY. 335

A girl grows up from infancy, and from childhood, continually developing, confirming, and consolidating her tissues and organs appropriate in their magnitude and their density to the particular stage of existence through which she is passing. In weight, stature, proportion, vigor, and intelligence, there is a continual conformable progress — not a non-conformable progress. The last faculty she acquires is the reproductive, the crown and glory of them all — it would be an unconformable progress in development, should its acquisition be either greatly anticipated or postponed in point of time.

In growing up from the infantile to the womanly estate, she passes through many crises, great and important ones ; but the greatest and most important of all is the puberic crisis.

In the beginning is the crisis of establishing the new aliment- ary, and respiratory, and circulatory life, at birth. This being effected safely, and it often fails, she passes through another criti- cal stage at the eruption of the infant or milk teeth, which are brought forward by a series of vital paroxysms, if I make not use of too strong an expression. There is a stage of excitement, often diseased, at the eruption of the incisors ; a second one at the bring- ing forward of the molars ; a third, attendant on the cutting of the cuspidate teeth, and another with the second molar eruption.

Thousands, and tens of thousands, nay, millions of young children fail to escape the dangers of the age of their first denti- tion ; and the bills of mortality are swelled with the returns of death in children. The first, or milk set, having served their turn, the child incurs great hazard at the quasi paroxysm that waits upon the second dentition. Many children now lose their appetite, their embonpoint, their gayety; they cease to play, and utter the glad voice among their shouting and laughing compa- nions. The pulse becomes compressible and frequent, and, upon the slightest motion, the heart beats with redoubled haste, and soon subsides again into a habitual languor of action. Fretfulness of temper, and frequent crying for any slight cause, or for no per- ceptible cause, mark what is very commonly, in families, known as the "cry-baby" age of children in their second dentition.

Children suffer frequent distressing pains in the decaying and loosening out of their first teeth ; and a strange erethism of the parts about the mouth attends the tension of the gums coincident with the bringing forward of the permanent set. I have had


336 PUBERTY.

many patients under my care, whose health had been rendered wretched by these causes. Such patients have had convulsions, deranged bowels, palpitations, and hypertrophic throb of the heart, loss of appetite, cephalalgia, and other disorders, attributable to the difficulty experienced in forcing them through this especial crisis of life.

Under circumstances of a crude, imperfect, saburral digestion, thus brought about, the growth is sometimes arrested for a time. Thousands of children attacked at this period by disease, are hur- ried to the grave. Measles, scarlatina, pertussis, &c., attack them, and they cannot resist the combined influences of a severe malady and a dental crisis, either of which encountered alone, would probably be far less dangerous. In the progress thus far, also, many of the organs and parts of the child are found to be unequally developed. The heart, for example, which in its evo- lution of substance and power ought to move pari passu with the entire economy of the child, is not rarely found to get ahead of the other organs, and we observe by auscultation and other modes of inquiry, that the child of six or eight, has a heart suitable for a child of eight or ten years of age ; and that the non-conform- able power of this prime agent of the circulation exposes the pa- tient to danger of excessive determination of the. blood to the head, to the lungs, to the liver, the spleen, &c. &c., afflicting it with epileptiform convulsion, pulmonary engorgements, hepatic obstructions, &c., according as the excessive momentum of the circulation happens to be determined.

Nothing is more common than to observe the excessive and non- conformable growth of the head in young persons, by which they are exposed to great risks, but which is corrected, at a later date, by the rest of the system recovering its due proportion to the encephalon. If the child, even after difficulties encountered, gets well and safely through this period, it is safe for a terra of years.

In like manner, the girl approaches the greatest of all her criti- cal stages of existence. She has concluded all the preparatory stages, and if they have all been perfect and complete, she turns over from the childish or girlish to the womanly condition, with- out stay, let or hindrance. She glides onward, and is found to be a woman, and that without the least inconvenience or disorder of health.


PUBERTY. 337

The epiphyses of the bones, and all the individual pieces of which they are constituted, have become solidified and compacted. The coxal bones and the several portions of the os sacrum have each acquired the due firmness and solidity. The pubes are covered with the marks of womanhood, the external genitalia ac- quire larger proportions. The transverse and antero-posterior diameters of the pelvis have suddenly and visibly increased ; the mammary glands and the aureole and the nipple are augmented in size. A growth of fine downy hair is observed on the upper lip, near the angle of the mouth ; a more considerable deposit of fat lends roundness to the limbs and grace to the contours of the young maiden. A new and different lustre sparkles in her eyes, which more promptly veil their brightness by downcast glances, or the continual dreamy and thoughtful drooping of the lids above them. Heightened colour in the cheek and lips, show the greater intenseness of the glow with which the fires of life are burning within. It seems as if the forces which had been employed to perfect the beautiful machine, by arranging and completing all its organisms, were now occupied with a sort of paroxysmal in- tensity in adorning it with all its graces and attractions, and setting upon it the seal of perfection. She is perfect ; in a few months she is" habitually, naturally perfect — the crisis is over — inveni portum, spes etfortuna valete.

Let us suppose, on the other hand, that all these acts of prepa- ration have been duly effected, yet the girl is not ready. Why is she not ready? She is seemingly ready for the great change; what lets its accomplishment? She marches up to the critical age and it flees before her. In vain the progress of weeks and of months urges her towards the goal of change ; but she changes not. Insensibly and by the slowest degrees the conformable re- lations of her organs are found to be dissolved. Her nutrition gives place to marcor and atrophy ; her brilliant hues are replaced by sallow tints. The bright laughing eye is grown dim and sunken, her heart beats hurriedly, especially upon exercise. Her appetite fails, or some craving pica or malacia takes place of the normal desire for food; debility, exhaustion, mucous diseases, diarrhoea, or constipation, make daily inroads upon her already feeble life-domain, and, while everybody knows that she would be well if she could become a menstrual creature, few deem that to make her so it is only required to cure her of a disease of the 22


338 PUBERTY.

endajigium, a disease whose existence is incompatible with the exercise of that great function.

There is no reason to hope, under these circumstances, that the great transformation will be effected. Such nutrition, circulation, respiration, and innervation as hers, will not admit of it. It is far more probable that one system of functions after another being perverted, prostrated, and overthrown, she will become more and more diseased, feeble, and exanimate, until some local inflamma- tion finds her an easy and rapid conquest. You have no reason to expect to cure her of her emansio-mensium, until you cure her of her puberic malady. What is that malady ? — how will you pre- scribe for it ? — what is the indication ? — is it that everlasting calo- mel'? — is it snake-root, senna, rhubarb, quinine? — what is it? — what ails the patient ? She is impuberic, though advanced far in the puberic age.

Look at her — measure and weigh her — compare her with her former self. Don't you see what enormous efforts her constitution has made to transform her as it has done, from the condition of a child to that of a woman? Her great haunches are no more like those of the boyish pelvis she had ten months ago than her bust is like that of a boy. Her wide womanly pelvis, and the vast glutei, the expansive levatores, the iliacse and psoee, have been almost created as by a coup de theatre ; and all this at the ex- pense of effort by the iliac arteries and their branches, and accom- panying nerves. The same apparatus has been laboring with a surplus of activity to develop the uterus, the tubes, the vagina, and the external genitals, and all these parts are, perhaps, perfectly formed; but the sexual concrete, the vitelliferous tissue, the stroma of the ovary is incomplete. No yelk matter can it pro- duce ; there is no germinal spot yet, no germinal vesicle, no vitellus, no Graafian follicle, and, of course, no menstrua.

She has lost her health ; she has fallen sick. She is useless in her present state and prospects as a reproductive agent ; and the reproductive vitellary element is withheld from her. Cure her health, re-establish the conformable relations of her organisms. Let her innervations become equable and universal for her micro- cosm, and she will give you the proof of her restored health in the assumption of her catamenial power.

Open your books of therapeutics and materia medica. You find in them a great catalogue of plants, and minerals, and ani-


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mal substances, under the head of raenagoga, or emmenagogues. Does the young lady want an emmenagogue? — and what em- menagogue ? Is it tansy, is it hellebore, is it madder, that shall cure the puberic disease under which she labors? I ask you again to perpend the question — what ails her ? Let us try if we can learn what really ails the patient.

If you will advert to the state of the creature in the earliest em- bryogenic period, you will remember that it passes first from the embryonal into the state of a foetus, and then into that of the child, the girl, and the woman; and that all these mutations are effect- ed by, and solely dependent on, the power of accretion, or nutri- tion of the parts. This accretion takes place at the expense of the blood, which is the pabulum, or the magazine, out of which all the new molecules are taken, and deposited under the indicating and controlling force communicated by the accompanying nerve. In fact, all life is but a continued scene of development; and but for the waste and detritus of the organs, no limit could be as- signed to the extension of the body. It is this generic nature, or rather law, which compels all animal forms and parts to remain within certain boundaries, according to a pre-existing idea of suchgenus, or such species. Without such generic delimitations, it is plain that the whole zoological series, as well as all the vege- table forms would be lost in the progress of a few generations ; whereas they have been kept until now, the exact copies of those archetypes which, in the Garden of Eden, were commanded to go forth and fill the earth, each after its own kind. It is the greatest miracle of all.

Have we then any reason to be surprised, when we find that this long development of the foetus, the infant, the child, and the girl, sometimes exhausts the powers concerned in its effectuation? For example, the child grows too fast and falls sick, are you surprised at such an event? If the waste of the forces and materials of the blood is rapid and great under the double necessity of both maintaining the existing stage, and also of adding thereto, in order to rise to a higher stage of development, what wonder have we to perceive that the child that grows rapidly tall, also grows thin and weak, and pale, and sickly? or to hear its mother say it is sick for growing too fast ?

I assure you I think it must oflen happen that you shall be called to give your opinion on cases of the sort, in which you will


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have occasion to observe that, when nature, after a violent effort and crisis of development power, shall have ceased to develop the child in stature, it will be found to augment in breadth ; and when that process is fairly instituted, it wnll cease to be lanky and thin ; for, in fact, in the growing up of children, you shall almost always find that they grow alternately tall and bulky. When the elon- gating crisis comes on, they grow thin towards the end of it, and are said by the vulgar, very truly, too, to " outgrow their strength." As soon as this weakness comes on, they cease to grow in longi- tude, and then commences the development or growth in latitude. So that the child becomes stout again, and so on it goes, growing by turns, first taller, then stouter, then taller again, and next stouter, until at last it shall have acquired its true generical limits and form.

A child, I said, grows from the appropriation of materials taken out of the mass of the blood, which is the pabulum nutritionis. There is then a constant and wasteful call for supply. But whence the supply, gentlemen, and shall we not expect sometimes to find that the organs of supply become wearied and exhausted of functional power by the sheer excessive exercise thereof?

And now, we come to the gist of the matter; what is it that makes the blood? what is the hsematosic tissue? That is the true question ; and if we can settle that question, w^e shall succeed in setting forth in a clear and lucid order our doctrine as to the principal maladies of the puberic age in the female.

An army of 100,000 men can be manoeuvred and marched according to the will of the general-in-chief, upon one condition, and that is the condition that its rations shall be supplied ; for no courage, no discipline, no conduct on the part of the officers or men, can keep it afoot without the aid of the commissariat. The 100,000 men would fall faster by famine, than by the bullet or the sword. The daily rations which keep the army up to the faculty of the highest activity and courage, are essential to supply the daily waste, consumption, or detritus of the life actions of the soldiers. The ration is converted to chyme, it next becomes chyle in the thoracic duct, and it is poured as chyle into the mass of the blood, when it is precipitated into the auricle of the heart. The churn- ing power of the chordae tendinis mixes the new material with the sanguine mass, and it is hurried off into the system of arteries, capillaries, and veins, and after a few revolutions it is — what? —


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blood. How has it become blood? If you answer, by the un- known force of the cell-life, I reply that a condition of the exercise of that cell-life force is this, namely, that it should be in contact with a livinof solid — and w^hat solid ? It must be in contact with the membrane commune of the vascular cyst, the membrana vasorum commune, the endangium, as Burdach calls it. Even in the very earliest manifestations of the presence of blood in the punctum saliensof the incubated egg, where the blood disc seems most like an independent self-creating physical ens, which makes its own vascular tractus, we cannot deny that the power to form itself is a transmitted power-^transmitted from the living elements of the ovum itself, by which it is surrounded, and by which it has its being. The sanguine body could not become blood in the stomach, the duodenum, or jejunum, nor in the lacteal tube, nor the thoracic duct; but it can become blood while in contact with the interior lining of the vessels and nowhere else. Hence I infer that the membrane which lines the interior of the heart, the aorta, and all its branches, the capillary vessels, and all the veins, is a blood making surface, and that there is not and cannot be found any other blood making tissue in the economy. When this tissue, this membrana communis, is in perfect health, and the supply of chyle passed into it is perfect, we have perfect blood ; when the tissue becomes diseased, we have diseased blood, or at least it acquires a dyscrasy that prevents it from exercising its due influ- ence on the organs and tissues.

So little is as yet known concerning the true nature and powers of the common membrane, that I dare not trust myself to speak of it without much hesitation and doubt of my correctness as to its diseases. But at least w^e do know that the membrane is liable to simple inflammation, to diphtheritis, to inflammatory exu- dation, to pyogenic inflammation, to adhesive and to destructive inflammation, and ossific degeneration, and that is enough to show us that it is also liable to debility, and to imperfect and unequal exercise of its functional office.

Where it becomes the seat of a pyogenic inflammation, it car- ries death in its function, for it produces innumerable pus corpus- cles, which, being washed away into the circulation, poison the whole mass of the blood, and curtail the existence by purulent infection of the blood.

When, again, it is endowed with a preternatural activity and


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force, it, the blood membrane, fills the vascular cyst to overflow- ing with a rich and excessive blood, so that the patient labors uiider all the symptoms of plethora ; and when it has lost its tone, or has exhausted its force by excessive exertion of it, we have the appearances that appertain to the anaemic state.

Allow me to lay before you some remarks made on this mem- brane by Dr. Burdach, for which I refer you to the French copy, vol. vi. p. 194, of his Physiology, whence I have taken the fol- lowing extract, and which relates to a point in this discussion of the greatest interest.

" § 698. A vessel is the special delimitation of the vital fluid, which constitutes a liquid, apart and distinct from all the other humors; that is to say, the blood. It traces out the career which that liquid is to run, and marks out the direction it is to follow ; it may be considered as the expression of the blood in space, for it was formed by its current, and makes but one with it.

"Hence it follows that the most essential part of the vessel must be in direct contact with the blood, and be the internal layer of its walls. This internal membrane {membrana vasorum commune, endangium) extends uninterruptedly in the heart, the arteries, the capillary vessels, and the veins. It is an elementary tissue, of a special nature, and cannot be referred to any one class of the membranes. According to Meckel, it possesses greater analogy to the serous membranes than to any others; and it is so by its structure, its vital properties, its tendency to adhesion, to inflammation, and ossification. It appears to me that it ap- proaches in character nearest to the character of the epidermis, seeing that it separates the blood from the rest of the organism, as the epidermis separates the whole body from the external world, and as its essential properties much resemble those of the epidermis. In fact, it is a uniform, thin, transparent, whitish coagulum, v.ithout anything special in its structure; and the mi- croscope reveals in it neither globules, nor fibres, nor interstices, nor pores. It is true that Geri pretends to have discovered longi- tudinal fibres in it after macerating and drying it; but such an appearance manifested by a body in a state of putrefaction, cannot be alleged as proof of the existence of organic fibres. The in- ternal vascular membrane has neither vessels nor nerves. Ribes states that he has seen vessels in it when inflamed; but every- thing tends to the belief that they were the vessels of the fibrous


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coat seen through its transparent tissue. It is fragile, as it readily breaks when a ligature is drawn round a vessel; but it heals readily, and is reproduced."

I cannot see how M. Burdach can dispose of the difficulty that surrounds his view of the membrane — a tissue, possessed of vital properties, capable of the adhesive inflammation, of healing pro- cesses, of being reproduced, &c., while he asserts it to be anhis- tous or without organization, a mere coagulum. I leave it to you to decide for yourself as to the probable correctness of his view of the case ; but, I advise you to read on this head a work by Raci- borski, on the veins; a work in which he examines very much at large the history of their nature, uses, and maladies. Raciborski, you wall find, holds that the veins, in penetrating into the most inte- rior structure of organs, carry with them only the endangium, the membrana commune, which, if that idea be well founded, is equi- valent to asserting that this inner membrane is the essential organ or agent, and that the fibrous and elastic, and other materials of the structure of blood-vessels, are merely the protective invest- ments of the blood-making organ. As for me, I shall continue in the belief that I have long entertained, that it is not only an organ, and a living one, but that it is one of the most susceptible to morbific impressions, and one whose modifications of health or disease exert the most important and diversified influences on the state of the entire economy.

This blood-membrane, this hemapoietic organ, is interested in all the blood diseases. I doubt not it is one of the prime seats of the pathological lesions in erysipelas and scarlatina. It suffers in all the protracted intermittents, it becomes diseased in multitudes of pregnant women, in women during lactation, in men over-fatigued and exhausted with vigils, in the badly fed and badly clothed, in the intemperate, in the broken-hearted, and in all those who are long deprived of solar light in dungeons and mines. It is the sole pathological organ in many samples of frequent deliquium, in many cases of supposed dilatation of the heart, or the large arteries, in neuralgia, and other neuropathic maladies. It is constantly affected in children during dentition, and very often in girls ap- proaching or passing through the puberic crisis, and in such as do not regularly menstruate. Disease, or debility of this mem- brane, is, in most cases, the puberic malady in girls.

It is the chief seat of the pathological deviations in all the cases


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of what the French csill pales couleurs, and which we term green- sickness, or chlorosis. Its continuance is continuance of the malady, its cure is the cure of the patient.

You may remember the occasion on which I spoke at consider- able length to the Clinical class, in Nov., 1846, on the case of a pale young woman, who came into the Clinic on account of a goi- tre ; and I beg you to allow me here to make for you a memo- randum of what was said by me in the clinique on that occasion, and an explanation of the motives that led me to recommend a particular therapeutical course for her. I think I counted her pulse for you, and found the beats were 75 per minute ; her re- spiration was equable and natural as to its frequency and com- pleteness. Her face of a dead-white or blanc-mate hue. She was not emaciated ; her cataraenia were suspended.

This was the state of the patient while sitting at ease on a chair. But I wished to learn what would be the effect of a slight muscu- lar exertion upon one, who, with perfectly sound lungs, ought to be able to make a considerable effort without adding considerably to the number of respirations or of the pulsations. For, in order that a muscle should contract, there must be sent into it a stream of nerve-power — call it excito-motor if you prefer. But that stream is developed in the brain or spinal cord, and the stream will not flow if the source be not supplied. In a sitting posture the supply was abundantly equal to the demand. But let us see whether she can obtain the supply under strong effort, with the heart and lungs acting at their present rate. I presume she can- not ; and my reason for so thinking is this : I find her pulse soft, compressible, large ; her skin pale, the rosy tinted mucous mem- branes of the mouth and throat whitish, bleached. Her lungs, on percussion and auscultation, perfectly healthy, and, in fact, while she sits here and has nothing to do, she is well enough. Because, with the present rate of her circulation and respiration, there is generated a sufficient amount of nerve-force to innervate all her muscles, and, indeed, all her organs. Were she lying down, the necessity for all muscular exertion being suspended, the supply of innervative power is superabundant, perhaps. How is this nerve-stream produced ? Is it not evolved by the action of the blood upon the matter of the brain ? I mean, in strictness, the action of oxygen on the matter of the brain. Can black blood,


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venous blood, determine in the brain the evolution or extrication of the nerve-force, the nerve-stream? If you enrich the blood by good diet, if you highly oxygenate it by exercise in the air, if you increase the impetus of it by motion, by champaigne, by nitrous oxide gas, by the exciting passions of the mind, do you not in- crease the energy of the innervative force, by sending into the brain larger supplies of oxygen in its vehiculum the blood ? But in the present case, if I am correct in supposing this girl's blood to be thin, watery, aqueous, how can she upon any considerable necessity for extraordinary evolution of nerve-power — how can she get at that evolution, sending, as she now does, a dilute, aque- ous, anemical fluid, instead of the rich stream which circulates in your vascular system.

If she must make the effort, she must supply the material, she must inject the oxygen into the brain; and how ? By increas- ing the rapidity of the injection; how? By doubling or trebling the number of pulsations, and increasing their force.

That immortal physiologist, Xavier Bichat, has set this matter in the clearest light for us. He has shown us that life in the mammal consists in a trinitarian power of the brain, the heart, and the lungs. When once endowed with the gift of life, we cannot put it off but at one of the angles of this trianHe.

The blood is oxygenated in the lungs, the heart injects it into the brain ; the brain touched by the oxygen is compelled to send forth the stream of innervative force to all the organs. If the lung dies, no more oxygen, no more nerve-stream, and the cessa- tion of all motion, which is the consequence, is death. Again, if the heart dies, no more oxygen reaches the brain, whence flows no more the nerve-stream to the lungs ; if the brain dies, no more motion, no oxygenation of blood in the lungs, and no motion of the heart to inject it to the brain.

This is Bichat's view. But do you not, under this aspect, per- ceive that if the blood in the lungs is not healthful, the oxygenat- ing power will be incompetent to a certain extent, and the brain to a certain extent will fail to radiate its nerve-force to the organs, and so, as to all the consequences of such a dyscrasy of the blood? The pale girl near us has blood incompetent to be en- dowed perfectly with oxygen. But so much oxygen so much nerve-force, — so little oxygen so little nerve-force.

In the healthy individual, fourteen or sixteen respirations per


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minute suffice to oxygenate the blood perfectly ; in the unhealthy, there may be required twenty-eight or thirty-two respiratory acts per minute. It is not rare to see the respiration rise to sixty ; for without oxygen we die, and if fifteen breathings will not endow us with enough, we must breathe fifty, sixty, or 120 times per minute. Suppose the blood of this patient be represented by corpuscles fifty, albumen eighty, fibrine ten, then the water must be 860 ; but it ought to be 790. Do you think that blood, whose water stands at the figure 860, can carry so much oxygen to the brain as that whose figure is normal, at 790 ? And, if there be demand for considerable nerve-force, can it be yielded without increase of the pulsations, and the respirations to the reflex innerva- tions, or to the voluntary ones ? Do you not know that when the ordinary rate of the respiration becomes insufficient, the free will of the patient comes to add the force of its innervative power to the ordinary respiratory innervations ? and that an instinctive feel- ing of the necessity of air compels all the nerves connected with the act of breathing, to lend their aid in carrying on that functional act? The medulla oblongata knows the system will die if it re- double not its power and influence.

Let us try the experiment in this case.

Accordingly she descended the stair-case to a lower floor, some twelve or fifteen feet, and then returning on the ascending stairs, came to take her seat again in your presence. Her pulse when she left the amphitheatre was at 75, and when she had come up the stairs, after an absence of two minutes, it w^as 150. The respira- tions at 18, became six and thirty. She was out of breath and the heart in a state truly deserving to be called palpitation.

As I am desirous to be understood I am sure you will allow me to give a rationale of this change.

The act of descending the stair was, probably, not accompa- nied with any, or, if any, with slight augmentation of the heart's frequency, because little muscular effort is required to descend, but the labor of lifting a body in opposition to gravitation is great — hie labor, hoc opus est — and the brain could not supply the nerve force when stimulated to do so by an anaemic blood in- jected at a moderate rate. The first step in ascension is therefore caused by a great effort of the free will, which is itself a FORCE, which determines the muscular innervation, but such an exer- tion of the Free will is consentaneous with augmented evolution


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of the excito-motory force determined to the heart. The mere intenseness of the effort to rise upon the first step is sufficient to determine an increased activity of the heart's motion, perhaps upon the principle of the physiological reactions. M. Dessaus- sure, in his ascent of Mont Blanc, found that at the height of ten or eleven thousand feet, none of his party could move more than a few feet without panting for breath, and being compelled to rest a few moments before renewing the attempts to ascend. Des- saussure and all his men were, though in good health a few hun- dred feet lower down the mountain, actually in the state as to respiratory power in which the ansemic girl is found at the level of the base. That is, the blood, though its crasis was not different on the mountain, could not convey to the brain the necessary quantity of oxygen; for with the barometer at 16 or 18 inches, so great is the rarity of the atmosphere that two or three ordinary aspirations of air could not impart so great a quantity of oxygen to the blood as one moderate one would endow it with at the sea-level. My pa- tient coming from the lower floor is compelled to breathe fast and redouble the systolic effects, and thus you see is set on foot a train of innervations of the locomotive muscles and of the heart's mus- cles commensurate with each other and commensurate with the wants of the occasion. Her state at this level is precisely like that of Dessaussure at 11,000 feet on Mont Blanc.

By the time the young woman had regained her seat, the heart, the brain and the lungs were all in a fury of excitement, which soon subsided, as it always does, upon a cessation of the effort. Here, then, is a case in which the organs are imperfectly inner- vated, while the patient is in the act of taking exercise, from want of power to supply the brain wdth the normal quantity of oxygenated blood. The Dessaussure party presented the same phenomena, be- cause they were breathing a rarefied air. They were not diseased. The girl who manifests the same phenomena is diseased, she has too little oxygen, and the disease is debility of her endangium. I do not say, endangitis or phlebitis, but loss of tone of her blood- membrane. What is the indication? To restore the tone to her blood-membrane. If you can effect that — her cerebro-spinal axis will innervate all her organs healthfully — and she will be restored to health.

I hope that you now understand my meaning on this subject ; if you do understand me, it is because I have been enabled to explain a meaning that I myself understand; if you do not, I


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have reason to fear that my own views are confused, unclear, in- determinate. Be that as it may, it is very certain that for some years past I have acted under these views, in my therapeutical pre- scriptions, for a great number of such cases ; and that with a result so satisfactory, both to the patient and to myself, as to confirm me in the validity of the theory, or rationale under which I make choice of the remedies for the case. The prime indication being to cure the membrana vasorum interna, the endangium, the lining membrane of the blood-vessel — the blood-membrane.

Let us now return to the consideration of the girl approaching to her puberic age.

She is turning from childhood into the new paths opened for her career. Her bones are to become solidified and expanded in their dimensions. The little hipless creature that you leave at home in January, as a child, is found when you return in November to have chanofed into a woman. The s;reat broad haunch bones are already formed, and that in so short a time. The epiphyses are consolidated and indissolubly attached; the marks and traces of distinction in the pieces of the sacrum and the coxalia are all gone ; for the pelvis has been prepared during your absence to bear the weight and the strain of gestation and labor. The or- gans within have acquired the consistency, and the forms, and the capacities requisite to enable them to fulfil their great destiny and office. The stature has increased; the round and swelling limbs and the panting bosom have taken the place of that angular, and lean and awkward form that you left behind at your departure, and the whole creature, as to her physique and her morale, has been transmuted as by the stroke of a magician's wand. Does this cost nothing of life-force, life-effort, life-expenditure? Is not this great and sudden transformation, and loss, a stage of crisis and danger? Do you not perceive how needful it is to watch over and provide against the assaults of disease for the young girl : how her alimentation should be sustained by food, by the stimula- tion of insolation, of the open air, and the habituation of exercise, which is the absolute requisite of a perfect nervous induction.

Suppose she be badly managed, and feeling badly, as often she does, she is indulged in a lounging life at home, with the imagi- nation on the rack of some passionate novel, and the digestion on the rack with cates and comfits, and every trashy aliment which her pica and malacia could prompt her to indulge in. But this


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is not all: the young lady must be educated; she must learn astronomy, God wot! and algebra! she must speak French and Italian, at least ; it is imperative for her to have studied Latin, and geography, and rhetoric, and history, and natural history, and chemistry, and music of the piano, the harp and the guitar, and drawing, and embroidery, and dancing; but she cannot make pud- dings, nor milk the cows, nor confect an apple pie, nor sew, nor knit, nor spin, for her destiny is to rival the lilies of the valley. Behold them ! They toil not — neither do they spin — yet Solomon, in all his glory, is not arrayed like one of them.

If a girl grow up like a pine knot she can't be hurt — you may do what you please — she is too tough and strong to be hurt by any educational process. But if she be truly a lily — lily white in her complexion — tender and nodding in her feebleness, like the flower on its stem — what hope have you to be able in the binary consumption of the thought-power and the development-power (both coming from the same encephalon) to carry her securely through the dangerous way in which her puberic age must walk?

The girl has need to grow and become of fall size and strength; but, if you send her to the boarding-school, and place her on the form, and put before her some dull and unintelligible gallimatias of grammar or mathematics, if you compel her to commit to me- mory mille versus stans uno in pede, how can she be expected to preserve her health and attain to those important developments?

There is a passage in Raciborski's pretty work, " De la Puberte,^^ &c., at page 44, which concurs w'ith my own observation and ex- perience as to the influence of studies on the young girl.

" I learn from a physician attached to one of the largest board- ing-schools in Paris, that the young ladies of the establishment are, for the most part, very tardy in making their change ; and that, when they have become catamenial, the menstrua are often very irregular." M. Raciborski adds, that "the physician could not well account for this peculiarity otherwise than by referring it to the nature of the diet, which, he thinks, is not sufficiently tonic. When these young ladies go home to their parents during the va- cations, and remain there a short time, the catamenia become very regular, but are deranged again soon after their return to school."

I have attended at different times in some of the boarding- schools in Philadelphia, and I have never attributed the failure of


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menstruation to any dietetic cause, because young ladies are well fed in those establishments.

I assure you that it is very common for me to fmd young women who have grown up admirably, and who have turned through the straits of the puberic age in perfect safety and with complete success, to lose, in five or six weeks, the habit of menstruation upon being brought to town and set on the school form and com- pelled to undergo the fatiguing labor of the mental and educa- tional discipline and culture. Such a patient is too busy with the mind to attend to the body — the confinement, the study, the de- votion of innervative power to thinking in one train of thought, prevents the healthful innervation of the muscles, the skin, the alimentary apparatus — the biliary organs give way, the kidneys fail to cast out the nitrogenous surplusage of the economy, and the whole mass of the blood loses its fine and delicate crasis, and the endangium itself loses the power to keep up the constitution of the blood to its normal standard.

In this condition of the whole system, where the organs have lost that harmony of life that is essential to the well performance of all the functions of life, there is no need for us to be surprised if certain of the offices of the economy, those exquisite deuto- biological offices, that rest like the topmost stone at the summit of the pyramid, should first fail to be manifested, or that they should be among the first to disappear where they have been once already made manifest.

Indeed, almost the first perceptible change in the health of the female is the disappearance of the catamenial force.

Do you not remember that while I was discussing this subject in the lecture-room, I said, that life in the general might be likened to a rocket? The flashing train rises out of the thick darkness of night, and glowing more and more the higher it rises towards the heavens — gives out, at length, when at its highest point of ascension, the last brilliant flash that fills the whole air with sparkling diamonds of light — the most perfect part of the exhibition — so in the female — the life has reached its high ascen- sion when at its culminating point, these sur-vital manifestations are beheld.

But a woman in health will menstruate : therefore, when a woman does not suffijr her regular monthly evacuation, it is because she is not in health. There is want of harmony somewhere in the play


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of the organs. She in general does not become sick because she does not menstruate, but she ceases to menstruate because she has fallen sick. To make her become regular again it is only necessary to restore her health — for she is a menstruous creature, and will always fulfil her natural law if something does not pre- vent her, which, by acting upon her constitutional health inju- riously, prevents that constitutional force from developing all the antecedents of the visible signs of the mensual office.

This is true in the general, but I deny not that the first blow may be struck at her health by suppressing her catamenia. Yet, I think, this is a rare case. Certainly it is a rare case ; as far as my opportunity for observation has enabled me to judge of it.

For example, I have known many to lose their catamenia by severe application of the mind to studies. Many to lose it in consequence of catarrhs, fevers, consumptions, &c. &c. It is true, also, that I have many times been consulted on account of a sup- pression of the evacuation from cold, and from other slight causes. Yet, out of the vast majority of these cases, there have been very few who had any lasting trouble from the suppression; inasmuch as the next operation of the periodical cause being perfect, the evacuation has been regularly restored.

It is easy for you to understand, however, why it happens that a sudden suppression of the menstrual flow, in mild cases, or at the very commencement, or in the case when a suppressing cause has been apphed just before the apparition, should lead to a long train of morbid actions.

A young lady, in consummate health, wished to go to a ball. But, unfortunately, in the afternoon, before the time for dressing arrived, she was seized with her courses, which were generally profuse ; and she began to fret at the occurrence, as she was afraid to appear at the gay scene of the dance, situated as she was. Her nurse, an old and confidential servant, much attached to her, said, in order to quiet her grief — My dear, if you won't tell on me, I will arrange it so that you shall go to the ball." "Oh! dear nurse, do, and I'll love you for ever." The nurse brought a large tub full of fresh cold water, and bade the blooming girl sit in it. She did so: the menstrua disappeared. ^]\e went \.o the ball: came home before the end with a blinding headache, was attacked with a brain fever, lost her bloom, and her embon- point ; and now, at the age of near fifty years, still feels the mise-


352 PUBERTY.

rable effects of such a scandalous dereliction on the part of the favorite and confidential servant.

The uterus and the ovaria, and all the branches of the hypo- gastric, the sciatic and the ovaric arteries, were full — it was full tide with all that system of vessels — the accompanying nerves were all ripe and rife with the periodical excitement. The cold hip-bath produced instantly a spasmodic closure of the excreting orifices in the womb, and the uterus and ovaria became instantly the seats, not of an out-flowing aflEluxion, but of intense engorgement, which, reacting as a disturbing force upon the cerebro-spinal sys- tem, laid at once the train for years of ill health. That lady's whole life was rendered a scene of bitterness — of vapours and caprices by that single hip-bath. It shocked her nervous system ruinously.

Many women, who were in the full flow, have sent for me, to say, the flow had suddenly ceased, from wet feet, from cold drink, from cold bathing, from pathema mentis, &c. &c. I have found them in agonizing headache, neckache, backache, nausea, courbatisme, throbbing pulses, and the most exaggerated calorific power.

Such cases do not excite in my mind any solicitude for the safety of the patient. A venesection, an aperient emollient enema, a dose of castor oil, some camphor and opium, made into pills; these are usually followed by remission of the distress. The constitution is again brought into obedience to the laws of healthy innervation. The next Graafian follicle fills, rises to the surface, bursts, and the mensual hemorrhage goes on, at the due point of time, as if nothing had interrupted for a moment the regular play of the functions. So often have I found this repre- sentation of the case to be carried out in the action of the organ- isms, that I fear not to allay the alarms and misgivings that arise in the mind of the patient, or her friends, with assurances that nothing is to be apprehended from such incidents in the health.

Nevertheless, interruptions of the monthly efflux, produced suddenly, as above supposed, may leave the whole reproductive apparatus engorged, and even subacutely inflamed. The cur- rents introduced into them by the spermatic and uterine arteries, and the branches of the ischiatic ; and the nerve streams that ac- company all these vessels as their regents and moderators, — these are disordered in their very structure, crasis, and chemical con-


PUBERTY. 353

stitution, and the next period of elimination may fail, because the ovarian stroma is become unhealthy. But this ovarian stroma — this vitelliferous, and therein germiferous organ, whose import- ance I proclaimed in my second letter, has now become a disturber of the constitution. Its nervous connection and rela- tion to all the plexuses and nerves of the whole splanchnic sys- tem, enable it to call them into sympathizing disturbance, and the health is overthrown. The emulgent artery, the cceliac, the mesenteries, and all the concomitant cortege of nerves are dis- ordered, and now we have disordered renal action. The vast por- tal system no longer plays its healthful part in the eliminations for which it is provided and appointed. Emaciation, opaque skin, dyscrasia of the blood, palpitation and irregular action of the heart, with consequent morbid states of the innervations proceed from bad to worse, and w^e behold the victim of a checked men- struation laboring under all the complications expressed in the term chlorosis, or green sickness. But if all this may come from a check of an established menstrua, a fortiori, it may spring from a hindered, or prevented one.

If the mass of the blood becomes affected with dyscrasia, from whatever cause, we have at once a diminished power of the ner- vous system, whose force, whose product, (the neurosity,) is the re- sult of the contact of oxygen with the matter of the brain. I have not forgotten, that though neurine and oxygen give out neurosity, there may be qualitative differences in the neurine, and quantita- tive differences in the oxygen. That a brain and nervous system may be good or bad, healthy or sickly, vigorous or feeble, but all these differences may, to a certain extent, depend upon the qualities of the blood, its capacity for oxygen, or for heat, its pres- sure, its momentum. The nervous system, though it be the essential Ens, is produced from the blood, out of which all the solids of the body are made and constituted into organs.

I have no doubt the brain itself is frequently altered in its density, in its perceptivity, and its power to extricate neurosity for the innervative acts of the economy ; in some cases acquiring a double portion of such faculties, and in others nearly losing them; when lost, it is death. There is a hyperneuric as well as a hyponeuric health, as stated by Dr. Cerise.

Since the introduction of the process of etherization, in surgery, we see abundant examples of the modification of the powers of 23


354 PUBERTY.

the brain and nervous system made by that agent. M. Flourens has shown that inhalation of ether, to a certain amount, suspends first, the action of the hemispheres, next that of the spinal marrow, next the quadrigeminal tubercles, then the cerebellar lobes, and, lastly, the medulla oblongata, which last he regards as the nceud-vital. As long as the ncpud-vital remains unaffected by the ether, respiration goes on, and the other parts of the brain may recover, because the noeud-vital being the seat of the respiratory power, it can compel the oxygen of the air to enter into the blood, and arouse the rest of the cerebro-spinal axis from the insensibility into which the ether had plunged it. If the nceud-vital becomes engourdi, respiration, or oxygenation of the brain ceases, and the animal is dead. You see then that you can in a moment render the brain hyponeuric by ether, as you can also render it hyper- neuric by champagne or nitrous oxide.

I have no inclination, and, indeed, it would be out of place in this letter, to enter largely into explanation of the state of the system in chlorosis. Chlorosis is often' something more than anaemia; it is often glandular disease — and is connected with va- rious states of hepatic and intestinal disease. What I have said, I have said with the design of inviting you to reflect upon this important question, viz.: What are the evils to be feared from a puberty imperfectly effected and ignorantly conducted ? My repre- sentations above, ought, I think, to show you that the puberic age is one that deserves to be carefully watched and wisely treated. But certainly, in this country, at least, too little regard is paid to the dangers of the crisis, and when the threatening conse- quences of mismanagement or misapprehension have become startling, those fatal mutations are attributed to some trivial cause, and the victim passes away to the sound of the passing bell, and no increase of knowledge, acquired by such a mournful expe- rience, stands in the way of the next victim to a management as unwise and as thoughtless.

I find that I have, in my letter on puberty in girls, lapsed into a discussion of some points of the doctrine of menstrua- tion, in which I have anticipated observations more appropriate, perhaps, to that special topic — but puberty in girls, after all, has reference chiefly to the establishment of the menstrual ofl^ce, and I could not well avoid falling into such a train of thought. I wished to show you that if you do not take wise care of the health


PUBERTY. 355

of the growing females of a family committed to your care, as physicians, you will have the pain to witness their early subjection to dangerous and fatal disorders, or else to see them, even after the puberic phenomena shall have been all made manifest, and the age of puberty indeed past, suffering those derangements of the health which serve to render them useless to their friends, ineffi- cient as the heads of families, and unfit to encounter and discharge the stern obligations and duties of life. Many are the examples I could cite from my memory of the persons who, even after being married for years, and after having been regularly menstrual, still continued to labor under the effects of a badly passed puberty; showing these effects in an over excitable circulation, excessive nervous susceptibility, dysmenorrhcea — though regularly men- strual — sterility, and the impatience and discontent that neces- sarily wait on feeble health and disappointed expectations ; some recovering completely under a careful treatment, and others falling into weakness, becoming, at last, victims of consumption, menor- rhagia, or other disorders of which the foundations had been laid in an improperly conducted physical and moral education.

As to our own fair countrywomen I think it is true, that, as a general rule, the women of the United States break very early. I appeal to your own observation for support of this assertion. A lady here with two or three children is generally without color — pale — and fatigued, attenuated. Perhaps this early break-up of the constitutional force of females may be, in part, attributed to the nature of our climate, which, from the violent and rapid re- vulsions of its temperature, moisture and pressure, as well as from the intense force of its light in summer, is more exhausting to the life-powers than the cooler and more steady skies of Europe, where the women certainly preserve their youthful appearance to a later period than here. Those of you who reside in the south- ern States will have observed the very striking difference in the appearance of persons who have spent the summer in the North and those who have waited during the hot months, in Georgia, Alabama, and the other southerly regions of the United States. Having spent the early part of my life in the South, I was accus- tomed to see my friends and acquaintances return from the North at the close of the hot season looking ruddy and healthy in com- parison with the fatigued and exhausted aspect of those who had drawn out the long summer season at home — and I am sure that


356 PUBERTY.

no one can arrive in our ports, in August and September, from a trip across the Atlantic, without being struck, and even painfully struck, with the air of ill health that is visible in the faces of the crowds on the wharves and streets of places so far to the north as New York, and even Boston. The cold w^eather of winter and spring restores to them the hues of ruddy health, in order that by the close of the ensuing hot season every body may be again pulled down, to use an expression much in vogue.

The western coasts of Europe do not possess such brilliant skies as ours. The veil of mist or cloud from the Atlantic, that is almost always spread above their heads, prevents the excessive radiation of solar light and heat, and the powers of the body are, consequently, not so exhausted by over-stimulation from these causes, as exhibited in the hurried pulse, the profuse diaphoresis, and the almost universal bilious or sallow hue, acquired by the complexion on this side.

If I am not incorrect in attributing to the brilliant skies of the United States morbific powers of a most inconvenient kind, then I am surely correct in the opinion that young girls approaching and passing through the puberic crisis, ought not to be incau- tiously exposed to those influences. I speak only of those whose condition may seem to require your counsel, and not at all of those (the infinite majority) hardy and healthful people, who never give cause for apprehension as to their sanatary condition.

Your delicate patient requires light as one of the conditions of health, but not too much light. I have already, in ray putative conversation with Miss Helen Blanque, in my XII. Letter, ex- pressed my opinions as to the necessity of light as a condition of healthful life, and I have no reason to distrust the sentiments therein expressed.

But an incautious exposure during the summer heats, is ex- ceedingly enervating. Such exposure excites the movement of the blood, and augments too considerably the calorific power of the lungs. It produces a quasi feverish state of the body, which is only kept down by copious perspirations, that exhaust the activity of the cutaneous capillaries and nerves, and introduce derangements of the secretions depending on the termini of the great splanchnic or digestive vessels of the abdomen. All those secretions are effected at the expense of the coeliac and the two mesenteric arteries and their termini, and it is undeniable that


PUBERTY. 357

the sanguine circulation in those vessels and the portce, has a close connection with and dependence on the cutaneous organ.

Do I recommend that the young girl at the season of puberty should lead an idle and inactive life ? Far from me the thouofht. I repeat, that I think every such person should be exercising in the open air, to the extent of walking many miles daily. But from the 20th May until the autumnal equinox, that exercise can- not be well taken later than nine o'clock in the morning, and at hours when the sun has descended so near the horizon as to lose the power of a too violent radiation.

There are a freshness, and humidity, and coolness in the early morning air, that impart greater vigor to the constitution than that of later hours. Early rising and early walking, then, ought to be recommended to all such persons as are directed in a course of training for health.

But early rising is unendurable, except for those who retire early to rest. They go hand in hand with each other.

The young girl should be at rest before ten o'clock at night, then at five o'clock in the morning she will be fitted for a walk of two or three miles ; it is easy to walk three and a half to four miles an hour. Such a walk in the early morning air, after eat- ing a biscuit and drinking a glass of water, would give appetite for breakfast and power for its digestion. A walk of three or four miles in the evening, before and after sunset, would furnish the requisite amount of out-door exercise, say seven or eight miles a day. An amount far, I fear, beyond that taken habitually by the young portion of the sex in the United States.

I am much accustomed to make inquiries on this head ; and I lament to learn, as I often do, that young persons of the class un- der consideration, frequently pass many consecutive days without walking a mile per diem in the streets, or roads, and paths in the country, and even without going out of the house.

Physicians are the health officers of society. I would that phy- sicians, as a body, were awake to the importance of so guiding the public mind in all topics connected with the conservation of health, as to exert the whole influence of the profession, a great influence, in impressing upon the public mind clear and sound notions in regard to those hygienic uses and appliances which the public either know not, or overlook, perhaps, in the hurry and


358 PUBERTY.

cares and embarrassments of the business and occupations of the world.

It appears to me that common sense and daily observation ought to teach the necessity of exercise as a means of preserving the health. The social condition of man has, in some degree, changed his nature, for by nature he was doomed in the sweat of his brow to eat his bread. Society has enabled him to eat bread without perspiring for it, and the luxurious and effeminate man- ners of the times seem likely to grow more and more Sybaritic under the labor-saving results of the improved machinery of these modern times.

A physician ought to exert the intellectual power, which, by his position in society he is presumed to possess, in protecting society against the evils of ignorance on hygienic subjects.

Forty-thousand medical men in the United States should not allow their day and generation to pass away without leaving some signs of progress, some amelioration of the condition of society, beyond the mere restorative results of their therapeutical prescrip- tions. I fear that so much intelligence, so much power is nearly restricted in its beneficence to the cure of the sick alone, whereas it ought to be capable, if not of preventing the onset of disease, at least greatly to lessen the number and violence of the cases.

In the conduct of those cases where doubts as to the successful effectuation of the change into menstrual life cause you to be con- sulted, I trust that you will never confine your intentions to the mere point of compelling the young person to have a show. In- deed, if you take up just views of the nature of the catamenial office, I am persuaded you will not do so ; since you will know, that, if she produces and evolves germs she will menstruate ; while, if she does not produce them, you cannot cause her to menstruate. You can make her bleed, perhaps; nay, you can, very certainly, make her bleed by leeches, with cups, or wit^h the lancet; but every tyro knows, that to bleed a woman every twenty-eighth day, is not to satisfy the physiological demands of nature in menstrua- tion ; because nature does not require merely the loss of so many drachms or ounces of blood, but she does require that the impor- tant organs should all enjoy the power of exercising the functions appurtenant to their several natures ; when they do so, the economy is healthy, when they fail therein, it is sickly.

The prime interest in the conduct of the case is first, to explore


PUBERTY. 359

and understand its nature and all its peculiarities and wants. This seems to me by no means a difficult task, provided one goes the right way about it. For example, suppose a young person pre- sented to you for examination, and that you proceed in manner as follows :

"What is your age, child?"

"Fourteen years, sir."

"Are you sick?"

"No, sir. They say I'm sick, but I don't feel so!"

"Have you ever been sick?"

"Yes, I had measles, and scarlet fever, and whooping cough, but that was a long time ago. I have also had some bad colds, occa- sionally."

"Do you feel strong and healthy?"

"No, not very; but I'm not sick though."

" Are you as fat as ever you were, or are you thinner than you used to be?"

" Why, I am thinner, I suppose, but not much."

"Do you go to school?"

"Oh, yes, I go to 's school."

"When does school let in?"

"EigRt o'clock in the morning."

"How long before it lets out?"

".Half past one."

"That's five hours — a long session! but what do you do all that time?"

"I am studying my lessons and reciting them."

" What lessons ? What is your daily work in school ? Tell me all about it? Tell me the whole course of a day's schooling?"

" Why, when we assemble, we have prayers, then a chapter in the Bible, then a hymn, and close with a short prayer ; after which I recite my lesson in spelling, then English grammar, and next, one in geography."

"Why, when do you get all these lessons?"

"In the evenings, at home."

"Do they keep you late up?"

  • ' Until nine or ten o'clock, only."

"Well, what comes after geography?"

" Oh ! I write copies, and then study my Latin grammar. When


360 PUBERTY.

I've got the lesson I conjugate the verb, and decline a few nouns and recite some rules."

"What next?"

" I study fifteen or twenty lines in Virgil, which I construe for the teacher."

"Does he make you parse it and scan it ?"

"Oh, yes sir, to be sure, always."

"Have you any other studies?"

"Yes, sir, French."

" And you commit to memory in French, too?

"Yes, and read, and translate, and write exercises."

" Anything more ?"

"Algebra."

"What, algebra? Oh!"

" Oh, yes sir. And then we have lessons in drawing."

" What do you draw ?"

" Landscapes, maps, &c. &c., as figures, flowers, and what not."

" Any music?"

"I have a lesson on the piano three times a week; but mother makes me practise two hours every day, one before I go to school and one in the evening."

"My poor child, I am sorry for you."

" Why are you sorry for me, doctor ?"

"I am sorry to find that you work so hard."

"Oh no, sir, I am delighted with it."

" No doubt! no doubt! but it will ruin your health. I don't be- lieve there is anything the matter with you now but schooling. Bless your dear little heart, you ought to be chasing butterflies, or training flowers, or weaving them into pretty coronals, such as white morning glories, pale as yourself; or you should be dressing dolls, or galloping the pony, or dancing, or dawdling. You must not do so much work at school, and you shall not, if I can prevent it. But come, tell me about your health. Do you walk out to Schuylkill every day? or as far as the College?"

" Oh, no, I've no time! Didn't I tell you I go to school at eight o'clock and come out at one ? and then I have two hours in school afternoons."

"The d—1 you have!"

" What did you say, doctor?"


PUBERTY. 361

" Nothing, only an ejaculation; an extorted one. When do you get to bed, my dear?"

" About ten o'clock, or soon after ten."

"Do you sleep soundly?"

" Not always, I often get frightened in my sleep with what they call nightmare."

"Not to be wondered at. I should think your poor little head would be too tired to sleep soundly, and that you w^ould have a nightmare in the shape of a monstrous folio grammar, or diction- ary with a pair of spectacles as big as two moons on its nose, staring at you from a pair of dead looking eyes. Do you eat hearty breakfasts?"

" No, doctor, I have but little appetite for breakfast. I take some cold water and a slice of bread and butter, and make haste to school after my piano practice, for I am so tired in the morning that I can hardly get up, and that keeps me late."

"How's your dinner?"

"Oh, I like pies and preserves, but I can't bear meat, and as for soup, I hate it."

"Oh, dear! poor child ! Alas for you! Come here, sit by me, and let me feel your pulse. Don't be frightened. There, now. Your pulse beats eighty times a minute ; and you are fourteen years old you said. You are breathing twenty times a minute. Are you oppressed in breathing?"

"What do you mean, doctor?"

" I mean to ask if you can draw a great long breath. So — try it now."

"Why, it hurts me."

" Where does it hurt you?"

"Nowhere in particular; it is rather disagreeable than painful. It seems like weakness and a tired feeling."

"It does not make you cough, does it?"

"No, doctor."

"Have you headache often?"

" Oh, yes, my head always aches when I wake in the morning; and if I run, or skip the rope, it aches, and swims, and beats dreadfully."

"I should think so. When a body is pale like you, any exercise makes the head beat and ache. Do you remember ever to have had red cheeks?"


362 PUBERTY.

"Oh yes, doctor. My cheeks, when I was ten years old, were red as the inside of a conch shell."

"Have you grown much of late?"

"Oh, monstrously; I have grown half a head taller in eighteen months."

"Where's your mamma?"

"She's up stairs."

"Go, call her to me. You need not come back yourself. I shall send for you when I want you."

" Pray, madam," said I to Mrs. , " what do you suppose ails

Miss Mary?"

" I can't imagine what it is that has changed her so, doctor. She used to be the healthiest child in the house, merry as a grig, always singing and dancing ; but now she is dull and moping, and has grown pale and thin, and has no natural relish for food. I suppose it is a change working in her. Don't you think so, doctor? She is fourteen !"

"I cannot tell. It is probable that her constitution is making an effort in that way; but I wished to ask you some questions that I did not like to address to the child herself. Can you tell me what is the state of her digestion?"

" As to that, she is very irregular, sometimes costive and then again very much the reverse, and that without any evident cause for it. I suppose it may be owing to her living, for I can't get her to eat any good food. She likes nothing but cakes and sweet- meats, candies, and all such trashy food."

"Is there any change in her temper?"

"Yes, doctor. She is more irritable and cross than is her nature to be, and she is easily put out ; the least thing makes her cry. Indeed, we find her very much changed of late."

" She has never been unwell yet, has she?"

" Once, about four months ago, her nurse told me she had seen a very slight mark of change, but it was merely pour marquer, not anything of consequence, and has not returned since. We are very much concerned about her, for we find she is growing pale, thin, and lounging, and cannot be persuaded to walk out, nor does she like to go out in the carriage. Nothing pleases her so much as books. If you give her a book and a sofa she is perfectly satisfied. But I fear she reads too much, and that her lessons are exhausting her."


PUBERTY. 363

"My dear madam, I think if I might venture to speak Latin, I should say rem acu tetigisti — you have hit the nail on the head ; and I am much afraid you will destroy her health unless you make some change in her mode of education."

"But, doctor, that is very difficult. You know that schools are managed by classes, and that we must educate our daughters ; they must be with their classes, you know. They cannot be always put back ; it disheartens them. "What is one to do in such a case ? You wouldn't have her brought up in ignorance, w^ould you?"

" No, certainly, not in ignorance, but I should much prefer to have a daughter healthy, sweet tempered, sensible, and beautiful, without Latin and algebra, and grammar, than to have one ever so advanced in her humanities, with her health ruined, or, perhaps, lying under a marble urn at Laurel Hill."

"Why, doctor, you shock me."

" I intend to shock you, madam! I know what love you bear to this dear child. I am aware that her great beauty and intelli- gence, and sweetness of temper render her not only your admira- tion, but that also, of all your friends, and I am grieved to see that, in the impetuous hurry and press of her intellectual and moral education, you have wholly lost sight of a part of her edu- cation, without which the others are of no value, of no effect, but rather poisons, that destroy. I wish to shock you; I wish you to learn that unless you change the treatment, you will lose her. She will die, madam!"

"Are you serious, sir?"

"Serious, dear madam? Serious! I am more than serious, I am grieved. I saw a sweet creature within a year, an only daughter, an only child, indeed, worth to her parents more than a chrysolite as big as herself, done to death by mere schooling. Why, can you not perceive that if this child of yours had nothing to do but grow and enjoy herself, she would be as beautiful as a houri, instead of breaking one's heart, as she does now, with that painful conviction of uncertain health, that is inseparable from a look at her."

"What are we to do, then, sir?"

"Do! dear madam? What are you to do? Educate her as a sensible woman would educate her daughter."

"But every body insists on her learning all these things! All the girls learn Latin now."


if


364 PUBERTY.

"I tell you that to rack her little brain learning Latin is non- sense. She can't learn it, in the first place. She can only try till it makes her sick, and then she'll give it up. Tell me, now, who of all the women in America or England have learned Latin! Nobody. Madam Dacier learned Latin I grant you, but she would have been much better employed learning to make pud- dings and to keep house."

"Ah, doctor! that's the way you men all talk ; you think that women are inferior creatures, and that they cannot learn what is very essential to the education of every gentleman."

" Far from it. Instead of thinking that women are inferior crea- tures, I for one look upon them as infinitely superior in many respects of their understanding, and altogether in morals, to men. But their lot is cast for them; men did not make it ; God made it. They cannot, in the present state of the world, and probably never will, participate in the affairs of nations or municipalities, be- cause, by the very nature of their moral and physical constitution, they are bound to the horns of the family altar; if they let go, they soon become captive to some tipstaff of an Asmodeus or other evil spirit, who, like constables and tipstaves from the lower w^orld, are wandering up and down in the earth, seeking whom they may devour among unemployed ladies. I do not believe that women are inferior beings. I regard them on the contrary as the ministering angels of the race; as the source of happiness and virtue, as well as its reward. But in order to be educated it is surely not necessary to have a smattering of Latin and Greek. What is it to Mary that Horace or Virgil wrote their verses, or Tacitus his annals, or Terence his Comedies ? She can read Pliny's letters better in Melmoth than in Pliny, for Melmoth is a better writer than his author; and as for Tacitus and Virgil, Davidson and Murphy will not rack her brain like the Arma vi- rumque cano, or the Urbem Romam a principio reges habuere. Mary wants to grow — she wants to grow up to be a woman — not to peer into the amatory elegies of Tibullus and Catullus, or pry into the detestable stories of Apuleius the Madauran. What does she want with algebra? Shall she rival Leverrier or Arago ? The only arithmetical calculation she requires is the re- lation between one dozen eggs at twelve and a half cents, and three dozen eggs at the same rate ; and the unknown quantity she ought to look for is, the proper gentleman whom the fates


PUBERTY. 365

and sisters three have in store for her as her future lover. Ah, madam, the ancient literature was much of it lost at Alexan- dria, and if that blessed St. Omar, who burned it nearly all up, had been lucky enough to get all the Latin school books into the bargain under the baths, — I can't say I should be glad for my own particular sake, for I should not ; but I am very sure the whole rising generation would be glad to contribute all their coppers and ten cent pieces to make a statue for the shrewd Caliph. The labor of life is a great labor and a long one, but there is no toil like that of an over-tasked schoolboy or schoolgirl. As for your child it is true she ought to be educated, but let her education fit her for her duties in life, not destroy her health and beauty. Lady Jane Grey and Queen Elizabeth could read Latin, but they had a different destiny from that of a republican's daughter. Let those who are likely to use to advantage the more elaborate parts of early instruction, let them have it, but do not kill them to get it. Igno- rance is always to be eschewed — but if I v/as destined to be a doctor, what use was there in making me study logarithms or lunar distances, or compute the orbit of a comet ? I was brought up to my trade — let Mary be brought up to her trade. What is that? It is taking care of a family — wisely, happily, elegantly; to do that, let her learn the world and the ways of it — not too much, though. Educate her in truth and the love of it — in piety which is the best ffrace of the sex. Teach her administration — domestic administration. Teach her to have a place for every- thing — and to put everything in its place. Make her an econo- mist — not a miser. Teach her to be saving. Do not impress upon her the scoundrel maxim, as Thomson calls it,

" A penny saved is a penny got; Till from her board it drive both plate and pot."

Teach her the great virtue cleanliness and tidiness ; improve her natural propensity to adorn her person under subjection to the simplex munditiis rule. Let her make herself beautiful and pleasing. Of all things let her be charitable and kind — for charity overcometh all things. Mr. Clay, Mr. Webster, Colonel Benton and Mr. Calhoun will take care of the politics : General Scott and General Taylor will take care of the soldiers ; let the daughters take care of the children, and learn to be bright at


366 PUBERTY.

the breakfast table, elegant at dinner, enchanting as pourers out of tea, and the ornaments and grace of the saloon."

"Ah, doctor! I see how it is ; you pretend to be a great admirer of the sex — but, like all the rest, you would condemn them to an inferior place."

"I! — I condemn them to a lower grade of rank in the body social? Not I. I am a convert to Burdach's views. I see in them the race, and we men but the supplements. They are the queens in the hive — we but a sort of mixed medley of drones and workers. It is far more noble, in my opinion, and far more elevated, to shed the benign influences that ever flow from the reign and dominion of a fine woman over the family and through- out the circle of society to which they extend, than to shatter men, women and children, and churches by shelling the enemy out of Vera Cruz, or giving them ' a little more grape' at Buena Vista. No, madam, I do not disparage the sex by confining them to the domestic duties, but I rather magnify them and make them honor- able. But let us change the subject, or rather let us return to our subject, which is Miss Mary's health and the conduct of it."

"Well, what must we do, doctor?"

"It is now the end of June. The heats of summer are come, and the dog-days will soon be here. It ought to be a general holiday. Take Mary to the mountains or to the shore. If you take her to the mountains it is well, if to the shore it is perhaps as well. Among the mountains she will walk on uneven places, up hill and down. The air is pure, the streams clear and rapid, and there is no malaria; walking among hills is admirable exercise; it compels the blood to reach the most distant points of the cir- culation, and drives it from the deepest recesses of the body. It augments the development power pari passu with the invigo- ration of the appetite and digestion. There is shade in the deep valleys and dark ravines, and to walk by the side of running waters, and listen to the plash of their falls, imparts a delicious calm to the soul, while the physical powers, as in a sort of waking sleep, seize the opportunity to renew and restore their wasted strength.

" Take her to the shore. There you have the benefit of the breeze from the sea, and the ever varying spectacle of the ocean's surface presenting ever new and pleasing sources of sensation. The sounding strand, the leap of the breaker, the ebbing and


PUBERTY. 367

flowing roll of the waves on the sands; ships heaving in sight and slowly disappearing ; company, conversation, music, the dance, and above all the bathing in the animating surf, present combined means of increasing the health and spirits, that are, perhaps, not certainly, equal to those derived from a visit to the mountains.

"If you take her to the hills, let her walk, as much as you dare — at least six miles daily, and if the country is very hilly, that is more than equivalent to a walk of eight or ten miles on level roads.

" If she goes to the shore, be careful not to allow her to bathe too much, surely not more than once a day ; nor too long, not more than fifteen or twenty minutes each time. I am quite con- fident that those who stay very long in the water are weakened by it. They generally come away from the coast thinner, and shrunken, and lighter than when they go there.

" The sea bath has great power on the body by its saline nature, which is stimulating to the whole skin ; by the motion and effort that those use who bathe in a strong surf ; by the delight which the dash of the wave communicates, and by the gayety and joyous feeling engendered by the company of the bathers.

"If she remain very long in the water, her hands and feet will be shriveled or puckered when she comes out, and it will be after a long time and with considerable effort that the blood will again reach to, and distend the tissues on the surface, and the most dis- tant parts of the limbs. In order to receive any benefit from the bath, there ought to be some degree of such a reaction, but it is well nigh morbid, when it comes too slowly. A person coming from the bath and remaining cold, or even quite cool, for half an hour, has been in it too long. Many persons suffer from the bath such a concentration of the blood in the great cavities, as the chest, and head, that they find themselves oppressed in breathing, or giddy and affected with headache, upon leaving the water. I have seen many such coming from the bath unable to see, and with intense cephalalgia, and only relieved by the act of vomiting; all which was dependent on the rushing of the blood to the brain, w^here it had been driven by the cold water from the extremities and the skin.

" Take care of Mary's diet.

"Let her eat beef, mutton, or poultry, once a day; don't give her the sort of vegetables so correctly denominated in this couu-


'Hp^


368 PUBERTY.

try, trash. Indeed you ought to give her her eatables with one sole view — that is, to nourish her, to make her grow, — to make her stronger and healthier. Don't allow her to swallow a morsel, merely because it tastes good. It would not be amiss in educat- ing her, to educate her palate. I wish yoii would buy her a copy of Brillat Savarin's Physiologie du Gout ; it would do her more good, and make a better woman and wife of her than Massillon, or even Telemaque, or Paul and Virginia, for it would teach her what every woman ought to be taught, the difference between an elegant gastronomic taste, and that horror of horrors, foul-feeding in a lady. Only think! only think of a lady eating tripe — or de- vouring fried haslet ! ! It is surely but one step above the dinners of the Bosjesman's. Take care of her dress; when the weather is hot, don't heat her; when it is cool, or cold, don't let her be chilly for want of a flannel petticoat, or a mousseline de laine, instead of a gingham, or fine print.

" No body is well who has not a proper state of the bowels. The upper bowels are well enough for most people. It is the large intestine that is the seat of costiveness. You must avoid that. How? By regulating her diet. Bran bread regulates the bowels, keeping them soluble. So do mush and milk, baked apples and milk, ripe sweet fruits, food not too much salted. We eat too much salt, in this country, it heats the blood and over stimu- lates the dio^estive organs. I believe half the charm of the French

o o

cuisine lies in the perfect apportionment of the salt. No spices. Not too much drink. Every body drinks too much. In the cities they drink too much iced water. Half a tumbler of spring water slakes thirst more than a tumblerful iced down (o 45°. If her bowels are slow, you can make her take a pill of aloes and soap, or a pill of aloes and rhubarb ; one grain of aloes to two grains of rhubarb. Such a pill taken daily early in the morning, or on going to bed, will keep the bowels regular enough.

"Perhaps there is no pill to be found that is preferable to Lady Webster's pill, called also Lady Crespigny's pill, and the Dinner- pill. It is made after the following formula : R. — Aloes, 3vj.

Mastiches, 3ij.

Ros. rub. .5ij.

Syrup absinthii, q. s. M. ft. massa in pilul. no. cc. divi- dend.


PtTBERTY. 369

" One or two of these pills, taken from half an hour to an hour after dinner, will rarely fail .to procure an evacuation without purging.

"Don't suffer her to be violently excited ; take every precaution to keep the mind not stupefied, certainly, but in a calm and com- placent mood — rather gay than grave.

" Examine her books before you let her read them. Keep out of her hands the Paul Cliffords and Ernest Maltravers, and all that sort of passionate novel reading. Walter Scott will never do her any harm. On the contrary, he is always on the side of virtue, decency, and order ; his passions are not very passionate, except perhaps, Dirck Hatteraick's case, and he was a mere brute. But as a general rule, works of fiction are of little value in the moral education of the young ; they spoil the taste for more useful studies ; and are for the most part dull and uninviting, except they be sea- soned with the wild, the terrible, or the passionate, in revenge, in mysticism, or in love.

"It is surely practicable, while her mind is evolving itself, to educate it and cause it to develope itself in a particular direction. You do not deny that she might be educated to become a devoted sister of charity, a calm, unimpassioned country girl, or a fantastic, uncontrolled opera dancer.

" If you educate her for the persistent zeal of the conventual life, for the dull complacency of the farm life, or the excitement and passion of the spectacle, do you not modify her whole nervous system by these several modes of education. Is it not true, in morals as in gardening, that 'just as the twig is bent the tree's in- clined,' and is there the shadow of a doubt, that you could so edu- cate your daughter as to make her a pattern for a nun, a milk- maid, or a prima donna?

"If there be no doubt as to the power of the moral educational processes, to give such or such a bias and propensities to the mind, then you ought to consider what is the bias it is for her in- terest and your own that she should take.

"If you wish her to be beautiful, steady, sensible, useful, and therein admirable, you should take heed to give her all the habits that may conduce to such an end of her physical and moral educa- tion. Let her know the history of her race ; teach her the lives that she may imitate the example of the most illustrious women, illus- trious I mean for virtue ; give her a good foundation of geographical 24


370 PUBERTY.

and chorographical knowledge. Let her learn the uses of figures. Give her a competent view of chemistry, that she may understand the true nature of the physical things of the globe ; a sketch of natural history, I mean not only zoology, but botany ought to be clearly understood by her ; the purest and best poets, and writers of criticism. The use of one or more foreign languages, chiefly French or German, ought to enter into the plan of a lady's edu- cation. If she have a positive talent for music, let her be taught the use of some instrument and of her voice ; if not, pray don't make her ridiculous by a pretension to musical power she can never possess. Don't teach her the art of squalling. To draw is always a useful accomplishment. But do not let her learn that art by halves ; nor not at all if she is without the taste and in- clination that alone can give her real success. There is scarcely a more useful point in the ornamental part of education, than the talent of drawing ; it serves pre-eminently to render one's ideas of form, dimensions, and distances more perfect.

" As to the religious part of her education, I have no other words to say of it, than that a woman who is impious, is impious indeed.

" I think in this country a woman is not properly marriage- ble until she is eighteen, and better so at twenty. If, therefore, you commence the literary education in earnest as early as nine or ten years, you have eight or nine years of applicable time to give to the daughter the elements of her education — to give her her school education — by which I mean, the acquisition of a love for letters in a proper direction. To think of any one being educated at eighteen is preposterous. All life ought to be a continued scene of education, and the longest life is too short to allow us to do more than 'just to look about us and to die.'

" As to the medical management of the child, I believe that to be a very simple matter. It consists in a wise regulation of her diet, and dress, and in a careful attention to the state of her di- gestive organs.

" If you can provide for the regular evacuation of her bowels, "without tormenting them with drugs, they will take care of the rest of it. Do not allow her to be costive. As for the rest she requires to be sustained, not reduced. If in the country she should acquire a good appetite, it is probable that the bowels will be ipso facto regulated by a proper and full allowance of food ; if not, give her some rhubarb ; rhubarb pills, or some elixir-pro, or


PUBERTY. 371

some tincture of hiera-picra, very little, however ; the smallest quantity that will answer the purpose is the best quantity.

" She is weak at present. She has grown very rapidly during more than a year, and has outgrown her strength. Under such circumstances you would not do wrong to give her a small glass of sherry or port at dinner, diluted with water, though. There are a great many bitters that are useful in supporting the digestive or- gans, such as wild cherry bark, quassia, infusion of gentian and cascarilla, or bark and cascarilla, or sulphate of quinine, the latter is probably the best of them all. But all these bitters are more or less disagreeable to young people, and they grow tired of them and give them up. If you please you can compel her to take them.

"While it is true that the vegetable tonics are endowed with great medicinal power, it is equally true that the mineral articles are also capable of increasing the tone of the solids of the body, by augmenting the development force resident in the sanguiferous apparatus, and its nerves.

" Among these tonics, the safest and not the least efficacious, are those derived from iron. The chalybeates may be taken for an indefinite period, and they neither fatigue, nor disgust, nor poison the patient.

" There is a large and free selection to be made out of the n\i- merous preparations into which iron has been converted for medi- cinal uses. It is probable that they all partake more or less in the tonic properties of the chalybeate. M. Raciborski, in his Treatise de la Puberte, &c., seems to think the most powerful and preferable of them, is the article proposed by MM. Quevenne and Miquelard, the impalpable powder of metallic iron, procured by passing hydrogen on an oxide of iron heated to redness in a porcelain tube, which reduces the metal, and leaves it in micro- scopic shining particles. This powder of pure iron unites with the acids of the digestion, and exerts its peculiar influences, whatever they are, with very great certainty.

"Two grains taken for the dose, and swallowed soon after each daily meal, serve in a pure, unmixed ansemia, to restore the crasis of the blood in a fortnight or three weeks. Made into pills with sugar and gum, they are supposed to keep perfectly well, and they are both inodorous, and without taste, provided they be not chewed in taking them.


372 PUBERTY.

"Procure 200 or 300 such pills, and you shall see what a power they have to steady the circulation, to render it powerful, and hence to give steadiness, firmness, and precision to the actions of the nervous system. I should advise you to give the medicine daily for many months. It is not very rare to take it for more than a year. I have very good reason, from my observation of cases, to believe that if a person, under these circumstances, re- covers a good appearance of health and vigor under the use of iron, and then at once leaves it off, there is a propensity to re- lapse. Hence I insist upon a protracted use of it; and I have the less hesitation to do so, inasmuch as I do not regard it so much a drug that I administer, as one of the regular elements of the bodily constitution.

" Open your senses to the truth, you shall see with your eyes, and hear with your ears, the sound that comes up out of the bosom of nature, proclaiming aloud that every violation of the laws of na- ture is a wrong. Anybody can perceive that, in a highly polished state of society, there are innumerable violations of the dictates of nature, which speak to us constantly, and cry out to us aloud. Nu- merous diseases are engendered by the constraints and the indulg- ences of the bienseance. Make your child, therefore, as natural a creature as possible in society ; that is the way to secure her physi- cal health. Make her also — wise — wise unto the end and destiny of her being. I grant you, that being at Rome, we must, in some degree, behave like the Romans ; not wholly so; for we may live in society, and even be regarded as presentable people without becoming victimized, and wholly converted from a natural into an artificial condition, either as to temper, manners, or the tone and practice of truth and sincerity.

"As to rest and labor, as to dieting and dressing, as to amuse- ments and studies, there is a degree and a time which common sense makes clearly known to any one who will reflect.

" The health, the beauty, and the happiness may be impaired or perverted, and even destroyed by educational processes wrongly conducted. There is no Procrustean rule by which all capacities are to be measured, and it is the business, and it ought to be the sagacity and the skill of the directors of education to discrimi- nate among the talents, and propensities, and abilities of those who are to be brought up. I shall relieve you from this long homily by repeating the words that I heard in the spring of the


PUBERTY. 373

year 1813, from the lips of our venerable and illustrious medical professor at the University of Pennsylvania, Dr. Rush. Those words were spoken in the ears of several hundreds of his pupils. He rose from his seat, for his age was great, and his hair white as snow. He arose and stood up, and casting his eyes over the large hall, looking to the left, and then to the right, and then to those in front of him, he said, 'I rise from my seat in order to pronounce two words in your hearing; and that you may remember them long, and apply them wisely :

OBSTA PRINCIPIIS OBSTA PRINCIPIIS.

Oppose the very beginnings of disease.' And now I repeat them to you, madam, obsta principiis ; oppose the beginnings of disease in the child ; watch over her health, and when you see that it is deranged, call the physician, and he will tell you whether you are to do something or nothing. Do not allow her to become slowly and insidiously, and deeply disordered, before you take prudent measures with her."

Gentlemen, I have written you a very long letter about puberty in girls. Upon looking over it, I fear it will merit the character of a letter de quibusdam rebus et de omnibus aliis. Have I suc- ceeded in my intention and design? That design and intention was to say why I regard the puberic malady as a malady of the blood, arising from a pathological state of the endangium, the

BLOOD-MEMBRANE.

If you look through the volumes in your libraries, I apprehend you will not find in any of them so concise an opinion, as that which I have herein expressed ; and I beg to assure you that so far from expecting that such opinion will be accepted by my brethren, who may chance to do me the honor to look over these pages, I even expect to be condemned as hypothetical and vision- ary in my notions on this particular point. To any such reader, I would gladly be allowed to submit, that after many years of reflection and observation, which happen to have accumulated, as to this particular malady, I have been unable to come to any other conclusion. I hope there is no person of sensibility, who would be indifferent to the opinions of his peers, or his superiors, in any walk of life. I freely confess that I am very remote from any such indifference, and that I should seriously regret the put- ting forth of opinions in medicine, that might be supposed to in-


374 THE MENSTRUA.

juriously mislead the young and inexperienced. I have, there- fore, to express my hope that, if upon a perusal of this letter, it may appear to any of my brethren I am obviously in error as to my notion of the endangial disorder, as a cause of the puberic malady, such brethren would do me but bare justice, by inquiring how it is possible to explain that affection by any other hypothesis, seeing, that it is purely a want of innervative force for extraordi- nary efforts, while that- force is fully and absolutely adequate to all the functions of health, while the body is in repose ; all I say, sav- ing and excepting the last climax of development force as exhi- bited in the production and evolution of ovarian ovules.

My suppositious conversation with the patient and her mother, I thought might serve to lay before you, my young friends and pupils, less tediously, not less didactically, a manner of talking to my patients, that I have long used.

I have nowhere asserted that other maladies may not enter into the category of the puberic maladies. I now say that when they do so, they are pleuritis, rheumatism, hepatitis, gastro-intestinal diseases, and, in a word, all the various forms of diseased action that may serve to contravene the menstrual power and offices. But when they do so come, we are to treat pleuritis, hepatitis, rheumatism, &c., and not the puberic malady. That is an en- dangial disorder. Farewell. C. D. M.


LETTER XXVIII.

THE MENSTRUA.

Gentlemen : — It is universally known that the female is dis- tinguished from the male, not more by the peculiarities of her struc- ture, than by those of certain functions, such as child-bearing, giving suck, and by the regular elimination at stated periods of a quantity of sanguineous or bloody fluid. The functions of men- struation, of bearing children, and of providing the aliment for them in the mammary glands, are then the three distinguishing


THE MENSTRUA. 375

functions of the sex. Yet, though differing from each other so manifestly, they are to be considered as intimately allied to each other, the one not being possible, as a general rule, without the existence of the other two.

You know already, that the sexual functions are not assumed in this country until the fourteenth or fifteenth year, and that when they happen to be assumed earlier than the fourteenth, or later than the sixteenth year, they are to be deemed precocious in the one case and in the other tardy. That individual is to be regarded as most fortunate, in whom this occurrence is first noted between the age of fourteen and fifteen years. A prema- ture eruption of the menstrua is always to be deprecated, be- cause it is the evidence of a precipitate development of certain parts or structures, while others, not less important in the same category are delayed and incomplete. The individual who passes at a usual and healthy rate through all the stages of growth and development, from infancy up to maturity, is most likely to enjoy a healthy and happy life, free from weakness, pain, and the dan- ger of premature death. Death loves a shining mark, it is said, and those children and youths who astonish us by the early per- fection of their structures or their intellectual forces, are snatch- ed soon from the world, as the earliest blossoms are ever most ex- posed to the chilling frosts of spring. On the other hand, a late and procrastinated first eruption of the menstrua, is to be regarded as the sign of some weakness or disorder, preventing the mani- festation at the average period of life, and always excites painful apprehensions as to the security and perfectness of the individual in whom it is observed.

Diflferences of climate, situation, and condition introduce differ- ences in the period of the assumption of these powers. There is no doubt that the women of Lapland, the arctic highlanders, the women who are brought up roughly to laborious employ- ments, and on coarse food, are later in the manifestation, than those who reside in temperate or hot latitudes, those who are brought up luxuriously, and in whom the susceptibilities of the nervous system are exaggerated by their moral and physical training and education. Such is the report made by those who have collected statistics on these subjects — for which I shall refer you to the authorities, among whom no one appears to have taken greater pains to collect numerous statistical returns than M. Bri-


376 THE MENSTRUA.

erre de Boismont, in his Treatise on Menstruation. For my present purpose it suffices to say, that in our country girls become regular between fourteen and fifteen years of age. Nevertheless, many do not see until advanced in their sixteenth year, while a great number are changed at thirteen and a half, at thirteen, and even before they have completed their thirteenth year. I have known a great number of such, but I always learn it with regret. I say with regret, for I am assured that if the pelvis of a girl, who had become regular at thirteen, should be long macerated or subjected to ebullition in water, the several portions of her ossa coxalia would separate into ilium, ischium and pubis, and the epiphyses and apophyses would also be found unconfirmed in their union. Here then is a proof of want of conformableness in the development of the machine — for to menstruate is to be fit for conception, gestation and labor; but to have unconfirmed union of the pelvic pieces is to be unfit for those offices. But all want of conformableness in development is disorder, not health. This is the argument that ought to be regarded as unanswerable against early marriages, which are sacrifices; nothing less.

The menstrua, the catamenia, menses, courses, terms, periods, monthlies, monthly periods, purifications, and other names, con- sist of the periodical discharge of blood mixed with mucus and epithelium. In women in good health they return once in twenty- eight days, and continue during three, five or seven days, less or more, according to the particular constitution of the w^oman, and she eliminates an amount that greatly varies in different women, and even in the same individual at different times and ages.

These monthly discharges return with great regularity from the fifteenth to the forty-fifth year, except when interrupted by preg- nancy or by giving suck. At the age of forty-five they cease to return, and thenceforth the female is no more capable of con- ceiving, as she was equally incapable previously to its first erup- tion. It has, therefore, a clear connection with the power of re- production.

For more than twenty centuries there has been a constant inquiry among the learned, as to what should be the cause of a regular menstruation in women ; a phenomenon that is common to them in all nations, climates and ages of the world. It is not wonderful that an anxious curiosity should have existed on this subject, seeing that the regular and healthy performance of the


THE MENSTRUA. 377

office is related to the health, beauty, perfection and security of the female, and this among all people of every age of the world. Nor should we be surprised to learn that many superstitious opinions, rules and observances in relation to it, have existed in ancient times, and yet linger among the better educated classes of society. Notwithstanding this great anxiety to learn the truth as to menstruation, and in despite of the researches, observations and conjectures of so many enlightened philosophers and physi- cians, no certain or even probable conclusion was reached until very lately, that several illustrious medical men in Europe have had the happiness, through a succession of fortunate discove- ries, all tending to the ultimate conclusion, to place the matter in what seems to be a clear and perfect light. So that I am of opinion, that ere long there will be no difference of sentiment as to the causes and nature of this function. I believe that they have arrived at the truth of this doctrine. Truth is always precious, and never more so than when its rays, like a bright sunbeam fall- ing into a darkened chamber, make manifest an object never clearly seen or understood before. The discovery of the truth upon this important subject, makes many things plain to physi- cians, as to counsel and action, that were obscure and uncertain before ; whence they are now enabled to do much good they could not previously effect, and avoid much evil, which their io-norance of the real nature of the catamenia led them unavoid- ably to commit. The discovery in question should, therefore, be hailed as one of signal importance in the practice of our art, and it is proper that I should devote some portion of this letter to the object of explaining it to you, adding such reflections of my own as may arise in my mind in the course of writing this letter to you. Before I come properly to the particular subject, I ought to pre- mise that great confusion and error have existed in the opinions heretofore formed concerning the w^onderful periodicity and regu- larity of the catamenia, and the wonder has been the greater, because the intervals between the returns are so long. In very regular women it returns on a day that they can count upon for months before hand. To take a single example. January 3d, 1843. — Mrs. • told me this evening, that she became regu- lar at thirteen years of age. During her whole menstrual life, now probably closed, she was six days unwell, and her returns were always on the twenty-eighth day from the day of the last


378 THE MENSTRUA.

attack. The returns never had reference to the phase of the moon, or the day of the month, nor had she ever any diseased or painful sensation relative to her menstrua. She had four children.

There are many women who menstruate earlier than the twenty- eighth day, while others experience the returns only every thirtieth or thirty-fifth day, or after a still longer interval.

The recurrence once in twenty-eight days, or once in each lunar month, led to the general conviction that a lunar influence rules the return. This notion has been for ages deeply impressed in the public mind ; notwithstanding millions of persons could daily testify to the contrary, seeing that everywhere in the same meridian, women are unaffected by any such influence, for there is probably not a moment of any day in which some women are not in the beginning, middle, or end of the term. If the influence of the moon could be justly supposed to have anything to do with it, it ought to be felt by the mass of the female population on the meridian and not upon one of a hundred.

Another hypothesis is, that the courses are caused by a state of general plethora or vascular fulness, occurring regularly in the female, and rendered necessary to her as a reproductive or child- bearing creature. Her liability to pregnancy, it was thought, re- quired that she should habitually produce an excess of bjood, so that, when a surplus beyond the requirements of her own consti- tution should be demanded by the growing embryo, that surplus might be at hand. But such a plethora would be inconvenient, unless it was reduced by menstruation, or gestation, or lactation; hence out of the necessity of the case she menstruates.

To say, however, that the woman menstruates from a necessity to eliminate a certain quantity of blood, once a month, is merely to present the proposition in another form ; it is equivalent to saying that she menstruates because she menstruates.

The fact is that all sorts of women are regular, whether ple- thoric or not. There are even some of them who menstruate, though quite ansmical, or to a certain extent bloodless.

You do not prevent a female from having her returns next Monday because you take fifteen ounces of blood from her arm to-day, Satur- day, but you certainly do remove her hyperaemia by so doing. I have bled many women just before the return of the courses, without checking or at all hindering their regularity. The phy- siological laws of menstruation are not to be broken or prevented


THE MENSTRUA. 379

by any act of reducing the mass of the woman's blood. Besides, there are many thin, scrawney women, who lose much greater quantities at the time of being unwell, than the robust, and fat, and florid people whom you would suppose to yield a vast quantity. There are even women, while laboring under severe chronical disorders, such as shall at last bring them to the grave, who nevertheless menstruate quite regularly and plentifully, until a late period of their decline. I say this of some women, not of the generality, for so delicate are the machinery and working of this catamenial office, that, in multitudes of the sex, the slightest thing that can touch the health to disturb it, puts to instant flight all this power of life.

Do you imagine then that a state of general plethora can be assumed as the cause of menstruation ? I should think not.

The next idea was, that a local plethora, or turgescence of the vascular apparatus of the reproductive organs, is the cause of the menstrua; and that some unknown necessity, some unknown force caused this local plethora to rise to such a height, as to pro- duce the outward sign of the menstrual act, in the visible flow of blood from the genitalia.

Now, this is a true doctrine, as far as it states the fact, viz., that a local plethora, or hypersemia occurring at stated periods, is the cause of the mensual hemorrhage ; but what is this unknow^n force? what this power that recuperates itself for every lunar period? The solution of this question, is the solution of the long difficulty, and I shall proceed to lay it before you, with certain premises, however, because I wish to instruct you, not to dogma- tize with you. If I should say in a few w^ords, that the local plethora is the result of the physiological function of ovulation which is a vital paroxysm, common to all reproducing creatures, whether animal or vegetable, I should merely dogmatize for you ; if I can lay before you the arguments by which I have been con- vinced, I shall be more likely to lead you to the conviction of what I deem a most essential truth.

If you should pick up a pebble on the shore, or a handful of sand ; if you should break off a bit of stone from one of the great rocky strata of the earth ; or if you take in your hand some salt, or a piece of glass, or a bar of iron, or ingot of silver or gold, and carefully examine them, and inquire into the laws of their pro- duction and continuance in a present condition, it will be easy to


380 THE MENSTRUA.

arrive at the conviction that they are destitute of life, of sensibility, or appetency, and incapable of producing or generating their like, and altogether without organization, and that they are, in short, inorganic bodies, controlled only by the laws of the cohesive, elec- tive, and gravitating attractions. If now you take into your hand a butterfly, or the smallest creeping thing, or infusorial creature, or any plant, blossom, or seed, or whatsoever thing that is en- dowed with life — with life-force, you will perceive at once the difference between it and the inorganic masses, that possess only the brute force of matter; but if you attempt to set down in plain words the differences betwixt inorganic and living organic mat- ters, you will be surprised to find how difficult is the task. In- deed, it is in some instances impossible for the naturalist to decide at what point in a series, the organic ceases, and the inorganic nature begins; and there are certain bodies, whose place has not as yet been ascertained, as whether belonging to the mineral, or to the vegetable kingdom.

Burdach, at p. 128, vol. 4th of the Physiology, says, " when a mass which is homogeneous as to its substance, develops antago- nistic forces throughout its extent, and flows, and becomes fixed in certain determinate directions, the result of such motion is crystallization, or the acquisition of a regular form, which is de- termined by the nature of the mixture, and accomplished by means of the proper motions. The crystal is, therefore, the permanent expression of the moving forces; in it, motion has become rest and permanent extension : activity is metamorphosed into a cor- responding existence ; it is extinguished as motion, and is now only manifested as cohesion," &c.

Neither Mr. Burdach's views, as above set forth, nor the opin- ion that organic matter is characterized by the binary combina- tion of its elements, while a ternary, or quaternary combination produces animal or organic matter, can be considered as remov- ing the difficulty in deciding where, in matter, organic and inor- ganic nature are to be trenchantly divided ; but we are left to the conclusion that there is not actually a hiatus, or a limitrophic dis- tinction, but rather that they mutually pass into each other upon the confines of both. The philosophic poet Lucretius stumbled over the same difficulty that lies in our way at the present moment.

Ignoratur enira quss sit natura animai, Nata sit, an contra nascentibus insinuetur.


THE MENSTRUA. 381

It appears to me that the reproductive force is the eminently discriminating and characterizing force as betwixt the organic and the inorganic bodies, since it is clear that the ponderable bodies, as the metals, alkalies, earths, and gases, are incapable of reproduction, whereas all living, or organized bodies, are but the repetitions, or reproductions, of forms and forces with which their archetypes were endowed, from the commencement of the present cosmic order and arrangement.

Mr. Burdach's extract above given, would seem to warrant the opinion that there is this difference: viz., that in the inorganic bodies, the cessation of molecular motions gives them permanency and stability, cotemporary with the globe ; while in the organic matters, the cessation of motions is the signal for the final dissi- pation of their elementary materials. The one being permanent as the world, and the other unstable, transitory, vanishing like the morning dew, perishable as the new-mown grass, or like the flower that comes up, and is cut down.

You ought, however, to remark that the Divine Author of the world has so ordered his laws, that the fleeting and evanescent form of living beings, is, after all, as permanent as creation itself, and that while we are in our own persons such perishing creatures, we are permanent, I had almost said immortal, as a genus, or a kind ; who have been present here since the begin- ning, and destined to exist as long as the inorganic materials upon which we tread. Does it not seem, then, that God has im- pressed upon our natures a great Force, a great principle of ex- tension in time, and in space, and which insures our permanency? Judge, then, what must be the amazing power and necessity of that law, or that Force upon which the conservation here, and the permanency of the genus depend, and alone depend !

But if the Creator has fenced his genera about with such strong bonds as these, then it cannot be but that those bonds and laws are worthy of the close contemplation of the medical student, since all the deviations, w^hether as exaggerated in intensity, or whether as feeble and imperfect in action, must exert a potent in- fluence on the health and security of the individual. But if the physician should be able to know and understand these laws, he would be better prepared to provide the remedies for all the results of this disordered or interrupted action.

Take further into consideration the thought, that if these laws


382 THE MENSTRUA.

are really so potent as to keep us forever here upon the earth as mankind, so that the earth cannot become again a wilderness, the abode only of inferior creatures, must it not be that similar laws and sanctions are provided for the conservation of all other forms of existence ? Do you not, therefore, perceive that each blade of glass, each tender blossom, or branching oak, or lofty pine, or trailing vine, repeats itself by means of the same Force, from age to age, so that the modest violet peeping with its blue petals and yellow anthers from its shelter of dewy leaves, is in fact as dura- ble as time itself, and that its perpetuity is secured by the same force that perpetuates us and all creatures besides. Every grain of wheat, every kernel, every seed contains a germ, every egg of the smallest aphis, the tiniest sparrow, the tallest ostrich, has a germ within it. All the spawn of fishes contains in each granule a germ. If you put a quart of distilled water in an open vessel upon your window-sill, it will soon be teeming with living infu- sorials, whose invisible germs float on every breeze through the air, and when deposited in the vase evolve themselves and be- come instinct with life and motion. All the mammalia ar^ like- wise reproduced from germs contained within true vitellary bodies or eggs. The egg of a barn-door fowl is not more perfectly an egg than is the microscopic egglet you find in the Graafian follicle of a cow, a mare, a sheep, a dog, or a whale. Each egg contains not only its germ, but its yolk. The viviparous creatures require but a small quantity of yolk about the germ, as the embryo at- taches itself to the living solid of the mother, the oviparous crea- tures require a large amount of vitellary matter, for the embryo- trophic wants of the germ are great, and the amount of yolk is conformable to the wants of the embryo. The germ in the egg of a humming bird is as large probably, as that in a cassowary's egg, but the humming bird at leaving its shell is incomparably smaller than the young of the cassowary or ostrich. Hence the embryotrophic wants of the latter are supplied by a vast quantity of materials, and the former by a few grains only of the same sort of reproductive matter.

The germ of a whale of eighty feet in length is not larger, probably, than that of a perch. But the placental life of the balsena enables it to evolve its young of the length of twenty feet or more, while the spawn of the perch or salmon is not larger than the head of a pin, and its embryo of a conformable magnitude.


THE MENSTRUA. 383

I have now to ask you to inquire whether these ova, in all the living tribes, whether of an animal or vegetable kind, are produced continuously, or at stated times. But why should I ask you to make this inquiry, since I know that you have already made it, and are well informed upon the point.

You know when you go into the gardens, in the early spring, to soften the soil and prepare it for planting. You know when the farmer mows, and when he reaps his harvest. You know when the lambs of the flock are yeaned, when the roses and tulips, when the migratory birds and fishes produce their young. How often does the germ production take place? Once a year. The flight of the pigeon, the migration of the swallow, the annual arrival on our coasts of the shad, the herring, and the salmon, and cod; the bursting of the leaf-buds of the forest, the springing up of the grasses and flowers in the vernal season, are facts known to you, and which have taught you that germ production is not con- tinuous and progressive, but paroxysmal, and periodical. But, if throughout all nature we find that germ production is a periodi- cal occasion, a vital paroxysm, why do we hesitate to believe that we also, are under the same universal sole law of reproduction ? As well suppose half a dozen different principles of gravitation, or of cohesive, or elective attraction, as a variety of reproductive prin- ciples ; there is but one, which is omne vivum ex ovo, and the ovum is produced not continuously but paroxysmally.

As I am considering the subject of the periodicity of germ pro- duction, I shall take occasion to call your attention more particu- larly to a wonderful scene, that is annually presented in the United States. I allude to the annual rush into the American rivers of the different tribes of migratory fishes that force their way from the ocean into the mouths of our rivers, and ascending as near as they may towards the head waters, find at length the suitable places for depositing their spawn, or in plain English for laying their eggs, each one of which contains a germ. The fishermen of the Potomac and of the rivers in North Carolina, not unfrequently catch at a single haul as many as fifty thousand herrings, while vast quantities of shad are also captured in all the rivers of the Atlantic American coast. In the spawning season the salmon in the Oregon rivers, are so abundant, as actually to check in a de- gree the current of the streams, as we learn from the traveler Mackenzie, as well as from Messrs. Lewis and Clark. The an-


384 THE MENSTRUA.

nual visitation of the shad takes place in the United States in the spring of the year. They, perhaps, come up from the antarctic ice and strike our coast north of Carnaveral, entering first the rivers of Georgia, where they are seen sometimes about the 20th of January. They next and in succession explore the waters of the Carolinas, Virginia, Maryland, and Delaware, entering the streams of Pennsylvania, New Jersey, and New York, and so on at later and still later times of arriving until the migration is over; millions are consumed as fresh food and an immense number put up as salt fish for later consumption and for exportation. It is rare to find one of them in the waters that run into the Gulf of Mexico. Thousands of millions of herrings annually pursue the same course. The herring are said to come from the shores of Spitzbergen and the Greenland ice. They divide into two immense streams, one of which proceeds downwards near the coasts of Europe, and the other by way of Labrador, and so south, until their instinct teaches them the time is at hand for securing the reproductive product. Now this vast migration through many hundred leagues of trackless ocean, is compelled by an in- stinctive Force, which is a part of, or at least attached to the re- productive Force, just as the commencement of the nest for the mocking bird, or the darkening of the aureole for the impregnated woman is a part of that force. That instinctive force it is which causes them to ascend to the shallows where the sun's vivifying light and where the lessened temperature of the waters, at the proper season, may perfect the evolution and exclusion of the embryo fishes.

In all the bony fishes, the male is destitute of any copulative apparatus ; and hence his only function is to follow the female, in order to shed his fecundating secretion over the places where her germs are deposited, and his voyage of hundreds of leagues, is a compulsory one, under the stimulation of that great reproductive Life-Force. Once a year he returns from his distant feeding- ground "in number numberless," to perform this great act for the conservation of the genus. It is in a staccato, not a sostenuto mode that this great hymn of nature is performed. Could I pos- sibly cite a stronger case to show the periodical, paroxysmal, puls- atory nature of the great reproductive function?

In like manner, the herds of the Buffalo, on the great western prairies, 10,000 in a herd, wander from the Internal Provinces, to


PERIODICITY OF OVULATION. 385

the banks of the Saskatchawan, annually repeating the same scene, and so it is with the moose, the elk, the deer, bear, wolf, fox, and martin ; it is so with the saurians, the chelonians, the ophidians; with every animal, and every vegetable; why should it not be thus with the woman ? It is thus. Her term is mensual, not annual ; she has the reproductive paroxysm every 28th day. Some of the domestic animals have it every 45th day; and the vibration is longer or shorter, according to the nature and con- dition of the subject of it.

A healthy woman matures, and deposits an ovum every 28th day, from the age of 15 to that of 45 years, failing only in case of pregnancy and lactation, and sometimes not even then. She sometimes suffers an arrest of the force during lactation, yet in the majority even that arrest is but of short duration, and in many it does not take place at all. The closing stage of the process of maturing and depositing, or discharging the ovum, is attended with a discharge of bloody fluid from the genitalia, which is called menstruation, because it takes place once a month.

Such is the opinion I entertain ; such is the opinion I desire that you should hold. It is founded on evidence too strong to be resisted, for the gentlemen who have been concerned in establish- ing it, have left no peg to hang a doubt upon, so thorough and so diligent has been the care to fence it about by both reasoning and facts. C. D. M.


LETTER XXIX.

Gentlemen: — I hope you are not already fatigued with the discursive method in which I have spoken of the periodicity of germ production and deposit, throughout the two kingdoms of nature, vegetable and animal. I deemed it necessary to speak so, since this very periodicity has for 2500 years been a stumbling- block to the seekers in this path of inquiry ; and since, if it be truly observable in all creatures besides, it ought to be considered as established for our race, as well as for them. I shall now pro- 25


386 PERIODICITY OF OVULATION.

ceed to state that, in the economy of the human female, as in all the other creatures, there is provided an organ for the evolution of germs, and that these germs cannot be produced by means of any other of the tissues or organs, of which any animal or vegetable consists. This organ is the ovary. In the woman there are two ovaries, oval-compressed bodies, each about an inch in length, by half an inch in depth, and a third of an inch in thickness. But the size of the ovary differs in different women, being in some larger, and in others smaller than the above-mentioned average. Each ovary is attached to an angle of the womb, by means of the ligament of the ovary, which is a cylindrical cord, about an inch and a half in length, more or less, and as large as a small quill. Each ovary lies behind the Fallopian tube and round ligament, and is inclosed within the peritoneal or broad ligament, which gives it its covering, or indusium. Inside of this indusium, or peritoneal covering, is found the fibrous strong coat, or delimi- tary membrane of the ovary, which being taken off", nothing is left save the stroma, or ovarian substance, containing the Graafian vesicles, or Graafian follicles, or Graafian cells, as they are indis- criminately called.

The stroma of the ovary is produced by the ovaric artery and nerve. I say produced by them, for it was originally evolved by them, and is constantly fed and maintained in its rate of size, w^eight, and functional power by them, as the source whence are derived all the accretions required by the momentary waste, detritus, or life-combustion of its molecules. What a curious speculation it is, that this long, wandering ovaric artery, and sper- matic nerve, should be the only artery, and only nerve in the whole economy capable of producing vitellus or yelk matter; for after all that can be said, they do produce it, and they, alone.

Nullam rem e nihilo gigni divinitus unquam, is a dogma much older than Lucretius. The ovary being endowed with the power of producing vitellus, as in the ostrich, where a vast quantity is evolved, and in the female of our race, where the quantity is so small, that a good doublet is necessary to find, and a good micro- scope to observe it afterwards, it is also endowed with the power of producing germs, of which vitellus or yelk is the sustaining prin- ciple, or aliment, or cytoblastema. For, even if the true germ be indeed Rudolph Wagner's germinal spot, [macula germinativa,) and is to be regarded as the nucleole of the cell, while the germinal


PERIODICITY OF OVULATION. 387

vesicle is the nucleus, and the vitellary membrane of the yelk the cell itself, still it holds good that the whole product, macula, vesicle, and vitellus, are products of the ovarian stroma, and that nothing of the nature of an animal concrete, save the stroma, could pro- duce it. Hence the stroma is truly the germ.iferous or germipa- rous organ; and hence, also, the dogma that I deem true, stroma is the sexual tissue, nay it is sex, as I said in one of my former letters.

The origin of germs is a subject that might well fill the mind with amazement. It is so difficult to come at, that the stransrest hypotheses have been forced into the service of its explanation. Lucretius says, "Semper enim partus duplici de semine con- stat." Lib. 4th. But this epigenetic notion could not satisfy the demands of reason, and hence the doctrine of ova, or germs, must be resorted to, and the dogma of omne vivum ex ovo, must be brought in to take its place.

Supposing it true, and established as truth, that all life pro- ceeds from germs, or ova, still the aching void of an unsatisfied rea- son remained unfilled. Wherefore, it was averred that all germs, or ova, were originally created — each thing living at this hour, having proceeded from a germ which was included within the germ of its antecedent, back to the original creation; so that the ova in the ovary of Eve contained the ova or germs of the whole human race down to the present day, as well as all that shall hereafter exist, and so of all descent, or generation. This evolution doc- trine was opposed by the Pythagorean idea of a palingenesis, or metempsychosis, under which notion you are to suppose that the animating principle that has heretofore animated the bodies of the living, seeks a new union with organizable matter, upon the dis- solution of its last tabernacle, and carries on the new evolution until again displaced, and set free to make new combinations.

M. Huschke, by way of satisfying the insatiable hunger and thirst after knowledge on this point, proposes what seems a very inge- nious opinion. It is extremely difficult, certainly, to conceive how the plastic and metabolic forces of the cell, or the nucleus, or germ, could first be imparted to the germinal spot, {macula germinativa.) To do so, the mind must accept the idea of a new creative force, a force to create the germ, and launch it on its career of development and power. Such a metaphysical


388 PERIODICITY OF OVULATION.

stumbling-block is always in the way here. We have little diffi- culty in accepting the doctrine of reproduction by gemmation, and by scission, for we can readily follow out Trembley's experi- ments on the fresh water hydra, or polype, and comprehend to the full satisfaction of the reason and judgment, how a hydra can be reproduced by scission, by gemmation, or by evolution; at least there is a much smaller caret, or hiatus in the facts and the ration- ale. Now, M. Huschke supposes what I do not know that he has a histological right to suppose, videlicet, that the ovarian stroma contains, and essentially consists of acini, and that an acinus being, by a physiological process, cast out of its gangue in the ovary, carries away with it the plastic and metabolic forces that enable it to become a new ovule; just as a bud from a plum, or cherry tree, may carry away with it to another tree on which it is engrafted, all the peculiar forces that enable it to bear plums or cherries, on a new and different stock.

By this method of M. Huschke's, you see, we are absolved from the whole difficulty of the discussion, for under such a view of the case, there is no necessity to imagine a new creation, an epigenesis or a palingenesis, but we have a series of successive evolutions, or rather extensions, or propagations, or productions of living matter, extending downwards in time from the acinus in the ovary of our common mother Eve, to that which exists in every female now living, or that shall hereafter live on the globe. Under this view, farther, we might conceive that Eve is not yet dead, but that by her acini she still lives by extension, after having evolved , in the six thousand years, all the bodies of her descendants.

Such is the inference from the theory that the stroma is acini- ferous. I do not know that it is aciniferous. I have many times observed, in the microscope, the myriads of granular bodies which both Martin Barry and Gerber describe as visible in a par- ticle of stroma. Still I do not know wdiether those puncta be really acini or not — if they be not acini, of course M. Huschke's theory falls to the ground. Certainly, however, it is a very pleas- ant hypothesis, since it saves us from the rude difficulty of imag- ining a germ created by common physiological law and without miracle. If you should plant a Lombardy poplar, or vine, or willow, your son who should plant a slip cut from it might pro- pagate his vine, and so on with his son, and to the millionth generation of your children. It is no wonder to see the cuttings


PERIODICITY OF OVULATION. 389

grow, but to make a creature, de novo, that is the hardest thing in reason or philosophy. Hence M. Buschke's hypothesis is a very agreeable one. I have thought it proper to lay the doctrine before you, and shall leave you to your own reflections upon it, begging you to arrive at your own conclusions.

At different times I have exhibited to you, and great numbers of the class have come down into the rotunda to look at it, the yelk taken from the ovary of the cow, as well as that from the ewe. You remember that the ovarian vesicle was punctured with a lancet, and the drop of liquid wdiich spirted from the in- cision being collected on a lamina of glass and placed under the microscope, the yelk containing its germinal vesicle and macula were shown you in one of Chevalier's microscopes. This yelk ball was contained within Graaff's vesicle. Graaff's vesicle has two coats, an inner one, and an outer one which contains the inner one, sphere within sphere ; but the spheres are buried be- neath the fibrous coat or albuginea of the ovary. The albuginea is contained beneath the indusiurn or the peritoneal coat.

This statement, taken in connection with the fact, that the ova of birds and fishes, and frogs, &c., are discharged without the intervention of the male, or any antecedent sexual conflict, ought to convince anyone that the fecundation of the ova does not take place within, but outside of the ovaria, and, therefore, the ova must escape from the ovaria previous to the impregnating act. In other words, there is a physiological function of the ovary to mature and discharge its ova, in order that they may be after- wards haply fecundated. If you admit that this statement is a correct one, then you accept the doctrine of the spontaneous ex- pulsion of ova, or the ovi-posit. Admitting the ovi-posit as a law of the reproductive force, then the question arises again, is this an irregular or a regular and periodical function? I have shown that throughout all living nature it is periodical, not continual, not irregular, not accidental. I see no bar to the conclusion that it is so in women.

M. Negrier, of Angers, M. Gendrin, Dr. Robert Lee, M. Bis- choff, and more than everybody else, Dr. Pouchet, of Rouen, have taken pains to observe the state of the ovaria in women who have died during or soon after the act of menstruation. They have all found that at that crisis the ovary exhibits a mark on its surface, • a bloody spot, a hole, a pore — into which can be pressed the


390 PERIODICITY OF OVULATION.

point of a probe. This hole, this pore, leads to an expanded crypt, filled with a minute clot of blood ; if the ovary be split with a scalpel conducting the incision so as to cut through the pore, it will be found to lay open a Graafian follicle, from which the egg has escaped through its pore-like hila, as happens in the ovary of the bird. These appearances are seen whenever an ovary is examined during or shortly after a menstruation. You may remember that I showed you such an one in the ovary of a young woman who died shortly after her menstrua, and what is more, I showed you the trace or cicatrix of the menses that preceded the last one, and I laid it open and showed you its crypt not yet closed up within, though healed on the surface, and a specimen is now in the museum, which contains the uterus of a young person who died suddenly while the menstrua were present: the uterus still contained the fluid, and the pore was bloody. My own opinion is, that you will never examine the internal genitalia under such circumstances without finding the fresh spot, and that you will not find it under any other circumstances. All this has been so clearly made out by M. Negrier, and particularly by M. Pouchet, that it is a loss of time to talk about it by way of proof or corroboration ; and I really suppose that he who does not see and admit the doctrine of a spontaneous ovi-posit coincident with menstruation, must close his eyes to the light, and deny the most irrefragable demonstration.

M. Pouchet has recently, 1847, put forth an enlarged edition of his treatise, under the title of Theorie Positive de Povulation spontanee, et de la Fecondation des Mammiferes et de Pespece hu- miine, basee sur P observation de toute la serie ammale. This superb work is accompanied with an atlas, in quarto, containing twenty most exquisite engravings, colored after nature, and exhi- biting the appearances in the most faithful manner. The plates are twenty in number, with many drawings on each one. M. Pouchet shows in Plate XII. and Plate XIII. , the microscopic appearances of the vaginal discharges in the menstrual and inter- menstrual periods of the female; discharges that consist of blood- discs, mucus and epithelium. Plates XIV. and XV. exhibit the menstrua of the sow, and the rabbit, showing that the sow and the rabbit, at the time of their erotic excitement, which is regu- larly periodical, also discharge a fluid consisting of mucus, blood- corpuscles, and pavimented epithelium. I regret much that it is


PERIODICITY OF OVULATION. 391

not in my power to furnish you in this letter, with a faithful copy of these beautiful engravings, and still more, that the whole phi- losophical and admirable treatise is not in the hands of each one of you.

M. Pouchet assures us, at p. 262 of his fine work, that the sow, during its menstruation, "exhibits in the vagina, a rose tint, and a small quantity of mucus; the microscope shows that this discharge is composed of fragments of epithelium, whether pavi- mented or cylindrical, globules of mucus, and also a very small proportion of blood-corpuscles." His figures representing these appearances in the rabbit and the sow, do not differ from those representing the catamenial discharges in the human female, ex- cept in the proportion of the blood discs, which in the latter are vastly more abundant. He declares that the womb before the bifurcation is highly red and injected, as well as the cornua. M. Pouchet has observed similar appearances, at the period of the ovi- posit, in many other mammals. He insists that, as it is more than sufficiently proved that the period of ovulation in the mam- mifers coincides with that of the periodical excitement, it is equally evident that similar phenomena rule the physiology of the female at the ovi-posit in the human being, p. 267.

I deem it scarcely necessary to do more than refer to the ob- servations of Dr. Robert Lee, of London, M. Gendrin and M. Negrier and M. Raciborski, in France, on the subject of a spon- taneous ovulation and deposit in the human female. All these waiters, however valuable their contributions on this point of human physiology, have but sketched and hinted at the subject, in comparison with the laborious researches and fine suite of rea- sonings of M. Pouchet as to this great physiological act. It is to him that we are most deeply indebted for clear views ; yet the name of M. Negrier, of Angers, is also to be held up and honored by all physicians for his most valuable work, which, though it be less full and complete than M. Pouchet's, yet is highly meritorious, since it is to him we owe much of the early light thrown upon our path.

I conceive that enough has been said to convince you that the ovulation and spontaneous deposit of ova is completely independ- ent of the sexual congress ; and you ought to add, completely independent of, and disconnected with any sexual sense or senti- ment, in the human being, though it is far otherwise in the lower


392 PERIODICITY OF OVULATION.

mammals, &c. The reason of this difference is to be found in the high morals of reasoning creatures, as distinct from those beings that are governed by instinctive sense, and not by reason.

If you accept the doctrine of the spontaneous periodical depo- sit of ova, then I think you have little difficulty to account for the mensual engorgement of the reproductive organs, or the monthly local plethora or turgescence or hypersemia, which is relieved so regularly and completely by the catamenial or mensual hemor- rhage.

The evolution of a Graafian cell is more and more rapidly effected, as it approaches nearer and nearer to its completion. The largest and most mature follicle is now enveloped, so to speak, in a mass of injected and engorged and hypersemic tissues redolent with life ; it is surrounded with red vessels carrying on in it the development offices. The cell, like a growing tooth, is magnified and raised up so rapidly, that, like the gum over the tooth, the stroma around the cell becomes turgid, succulent — almost in- flamed, we might say. Under such circumstances, what wonder have you to find the whole ovary swollen and turgid, or the womb itself affected in the same way ? w^hat w^onder to find the w^oman complaining of pain in the ovaric region, and in the womb — with aching, with heat, with sense of weight and dragging in the pel- vis ; and to find, on examination, that the uterus is larger, heavier, and more colored than in the inter-menstrual periods ?

In fact, the womb, previous to the disengorging out-flow of the menstrual blood, is redder and heavier, and more succulent, than when it has been fully acquitted by the discharge. It is proved to be so upon examination in life, and the necroscopic examina- tion confirms it to be so; what more! It is bootless to talk about it any further, and I shall, therefore, desist from any further re- marks for the present. Farewell. C. D. M.


THE CORPUS LUTEUM. 393


LETTER XXX.

Gentlemen: — I concluded my last letter with remarks on the periodical turgescence or hyperemia of the reproductive organs, caused by the rapid march of development in the last days of the maturation of the ovulum.

It is quite necessary that I should, in this present communica- tion, explain the causes of the rise of the yelk from the centre of the stroma to the surface, whence it is ultimately destined to escape ; and in making this explanation I cannot avoid speaking of the corpus luteum, a yellow body which is discoverable in the menstruating ovary and more sensibly in the ovary of the gravid animal.

I have to beg you to remember that the title of this volume, which treats of females, their diseases and remedies, gives me a very general warrant as to the choice of topics, so I but keep within the real boundaries of my subject ; and I believe I shall not go beyond those bounds if I now address you on the subject of the corpus luteum. I deem it, also, a matter properly related to the doctrines of menstruation, and one which it is requisite that you should take into consideration in your study of that im- portant physiological function. Hence, I beg you not to consider me as abandoning the consideration of the menstrua, while I am treating of the nature of the corpus luteum, my design being to continue my remarks on the menstrua after I shall have laid before you the following observations on the corpus luteum. It is proper to say that I lately read before the American Philoso- phical Society, a memoir on the subject, which the society has ordered for publication in their transactions. The substance of that memoir will be found in the present letter.

While I was engaged last winter in my lectures at the College, and during my preparations for the lectures on this point, I be- came convinced that the views heretofore entertained as to the nature of the corpus luteum were unsatisfactory, at least to my own mind, and made some experiments which led to the inference that the corpus luteum is a vitellary body.


394 THE CORPUS LUTEUM.

Since the date of those lectures, I have carefully made researches both by means of the Chevallier micros'cope and other methods, as to the comparative appearances presented by fresh vitellary matter taken from the hen's egg and matter collected from fresh corpora lute a.

These researches suffice to convince me that the yelk of eggs, and the yellow matter from a corpus luteum are of the same ap- parent constitution, form, color, odor, coagulability, refractive power, and microscopic appearance.

Having placed a small quantity of yelk on the platine, I have been struck with the appearance of a yellow light filling the whole tube of the microscope, just before the object is brought into the focus of the instrument.

Whenever, in like manner, I have placed a bit of fresh corpus luteum of the cow or sheep on the compressor, and have crushed it by turning the screw, I have found the tube filled wdth the same tinted light before obtaining the focus.

A portion of yelk placed beneath the objective, and examined with a strong power, exhibits numerous granules, corpuscles con- taining a yellow fluid, oil globules, and a quantity of punctiform bodies, floating in a transparent liquor.

Upon turning the screw of the compressor upon a mass of corpus luteum, carefully dissected out from the ovary, there is seen to escape from the crushed object a quantity of granules, corpuscles filled with yellow fluid, oil globules, and punctiform bodies, swimming in a pellucid liquor.

The appearances observed upon examining a portion of yelk, and a portion of corpus luteum, are so similar that it would be difficult to discriminate between them, but for the exception that along with the granules and corpuscles, oil globules and puncta of the corpus luteum, there will be found flocks of laminated cellular tela, blood discs, and other detritus of the organ destroyed by the compressor.

The transparent corpuscles transmit a yellow light, whether observed singly, or in clusters or acervuli.

The same is true of the corpuscles of the yelk.

Upon crushing a bit of corpus luteum in the compressor, there escapes much granular matter, that accurately resembles the granules of the granular membrane, the retinacula, or the pro- liferous disc of the Graafian follicle. This is the case where the


THE CORPUS LUTEUM. 395

very greatest care has been taken to procure the bit from the outer portion of the yellow body, so that no portion of the crypt could be invaded. All the portion used was from the substance of the corpus luteum.

The similarity of appearance leads me to infer a similarity or even identity of nature and origin. I think no person, accus- tomed to the use of the microscope, could detect any difference between the molecules pressed out of the bit of corpus luteum and those that escape from a ruptured mammiferous ovulum (as of the cow or sheep), or those that are seen in common yelk of egg, ex- cepting the debris or detritus before mentioned, should signalize the difference.

I have so many times examined the mammiferous ovulum, that I suppose myself to be quite competent to compare its contents with those of the corpus luteum, and with that of the bird's egg, and I feel that I am entitled to say with confidence that, the chief constituent bulk of a corpus luteum is a true vitellary matter, deposited outside of the inner concentric spherule or ovisac of the Graafian vesicle ; that is to say, the vitellary matter of the corpus luteum is deposited betwixt the inner and the outer sacculus of the follicle.

As to the correctness of this opinion, I must refer to the future observations of the micrographers, who will be able to confute or to confirm my statement and opinions.

I do not know that any author has expressed a similar opinion as to the constitution of the corpus luteum, though that substance has been the fruitful topic of elaborate discussions, and of re- searches, and hypotheses, for many years among the learned, in consequence of the importance of the subject, both in a physiologi- cal relation and in a medico-legal application.

It is surprising to observe how much has been said about it, with- out coming to any reasonable conclusions. You ought to know that previous to the year 1825, nothing was in fact clearly under- stood about it. But in that year, John Evangelist Purkinje, of Breslau, in Silesia, discovered the germinal vesicle in the unfe- cundated egg of the barn door fowl. In 1827, Ch. Ernest Von Baer detected the mammal ovulum with its germinal vesicle. In 1830, Rudolph Wagner ascertained the macula germinativa or germinal spot. You may therefore safely venture to say, that antecedently to these epochs, viz., 1825, 1827, 1830, all talk, all


396 THE CORPUS LUTEUM.

discussion, and opinion on the mammal ovum was naught. Hence, I should think it bootless here to ask what the writers, previous to 1825, may have said or supposed about it.

Of those who have written concerning the corpus luteum, since the above dates, I have to say as to the constitution of the yellow body, that Drs. Carpenter, J. Miiller, Thomas Schwann, Henle, Huschke, have not hinted as to its vitellary nature. Dr. Henle, in his Algemeine Anatomie, says, " So weiss man namentlich, wie die Graafschen Bliischen, in Folge der Congestion, welche dem fruchtbaren Beischlaf folgt, zuerst anschwellen und denn platzen, wahrend sie zugleich von Blut angefiillt werden, w^elches sie allmahlig entfarbt, organisirt und in eine Narbensubstanz ver- wandelt, die zuletzt verschwindet" — p. 894.

In the passage here quoted, Dr. Henle attributes the swelling and the bursting of the Graafian follicle to the congestion attend- ing a fecundative union of the sexes. He says the ruptured cell is filled with blood which colors it, becomes organized, con- verted into a scar-like substance (narbensubstanz) and after some time disappears.

Dr. Huschke, in his Treatise on Splanchnology, elaborately details the opinions of authors on the corpus luteum, but nowhere alludes to the vitellary nature of that substance.

Messrs. Gendrin, Negrier, Robert Lee, Wharton Jones, Raci- borski, Ollivier d'Angers, and Pouchet, make no such allusion; they all enter into details.

Dr. Montgomery, Dr. Swan, M. Flourens, MM. Velpeau, Mo- reau, Jacquemier, Cazeaux, and Chailly are silent as to the vitel- lary constitution of the yellow body.

Bernhardt, who was assisted in the preparation of his Symholce ad ovi Mammalium HistoriaTn ante Prcegnationem, by Dr. Valen- tin, and in which admired work you may find a complete deduc- tion of the whole literature of the corpus luteum, alludes not to its vitellary nature.

The celebrated letter of Professor Von Baer, de Ovi Mammalium et Hominis Genesi, says of the corpus luteum, at page 20, "Me judice minime corpus novum est, sed stratum internum thecse majus evolutum," which sets forth with sufficient clearness and great conciseness the opinions entertained in the rest of the para- graph.

Dr. Bischoff, of Heidelberg formerly, but now of the University


THE CORPUS LUTEUM. 397

of Giessen, in his Entwickelungsgeschichte der Sdugethiere und der Menschen, says, at page 33, " Wenn man die erste Entwickel- ung des gelben Korpers unraittelbar nach Austritt des Eies bei Thieren beobachtet hat, so kann man dariiber nicht in Zweifel sein, dass die Bildung seiner Masse von der innern Flache des Graafschens Blaschens ausgeht. Da sich nun hier die aus Zellen gebildete membrana granulosa befindet, und dieselbe als gelber Korper erkennbare Masse gleichfalls aus Zellen besteht, so ist es wohl gewiss, dass von einer starkeren Entwickelung dieser Zellen der memhrana granulosa, die ich auch in der Periphiirie des Eies noch nachweisen werde, die Bildung des gelben Korpers aus- geht."

From the above passage, it appears that M. Bischoff was not far from discovering what I suppose myself to have discovered, I mean the vitellary nature of the corpus luteum ; since, he says it is composed of cells, and proceeds from the inner membrane of the Graafian vesicle.

I shall make for you no further citation of authoritative opinions here.

I pray you suffer me to remark, that if the inner concave super- ficies of the true ovisac, or inner concentric spherule, is charged with the function of producing or excreting the corpuscles of the vitellus of the ovulum, or the materials of them, which cannot be denied, there is no difficulty to conceive that the convex or ex- terior surface of the membrane may exercise the same function, as dominant of the elective affinities, which must be supposed of this as of every other vital excrete. Such a supposition is not a wresting of physiology, and it finds abundant support in the analogy of the organs, as for example in the periosteal and medullary membranes of bone, which, under certain circum- stances, are known to alternate their functional forces. The medullary membrane, in the cases alluded to, comes to be a de- positor of phosphate of lime, instead of a renfover, its natural office ; whereas the periosteum in turn, becomes a remover instead of a depositor, its normal function. This mutation and interchange of powers as to the inner and outer membranes of bone, have been too clearly exhibited and demonstrated by M. Flourens, in his admirable paper on the reproduction of bones and teeth, to ad- mit of any doubt or cavil. But I am very far from claiming this illustration as proof in favor of my views, strong as I might deem


398 THE CORPUS LUTEUM.

it to be. It seems to me sufficient to know this, namely, that vitellary matter is germinal matter, germinal cyto-blastem, and that it is the office of an ovary to produce it, and that nothing else in nature can do so.

It is with deference to the opinions of persons more learned than I, and far more versed in the use of the microscope, that I make public these opinions, which I am well aware cannot stand upon my single testimony. I therefore readily confide in the opinions to be hereafter formed as to these views, by the micro- graphers, and I doubt not MM. Pouchet, Bischoff, Wharton Jones or others, will confirm or reject these views according to their own more able observations to be hereafter made.

As to some points of resemblance not yet mentioned, I have to observe that boiled corpus luteum, becomes like boiled yelk of egg, very hard, and in like manner friable and granular; leaving a yellow stain upon the fingers or on white paper, when rubbed on them. Dr. Thomas Schwann says he found the corpus luteum to become hard, coagulated, granular, and friable, upon being boiled.

I threw a portion of fresh corpus luteum on a live coal; it gave out the odor of roasted egg.

Hence, in coagulability, in friableness, in staining yellow, in becoming granular, and in yielding when burned the odor of roasted eggs, the corpus luteum resembles vitellus, as much as it resembles it in its microscopic characters.

I think that these circumstances warrant me in forming the opinion that the corpus luteum is a vitellary body.

In reflecting upon this subject, the question arises, are the granules and corpuscles of the corpus luteum cytoblasts and cells?

I endeavored with a very high power to make out the nuclei of the corpuscles, but could not succeed in doing so ; nevertheless, I cannot suppos'e that the invisibility of a nucleus is to deprive a body of the character of the cell. Even Dr. Schwann himself, at page 204 of that wonderful work, the Mikroscopische Untersu- chungen, says, "Die kerhlose Zellen, oder richtiger ausgedruckt die Zellen in denen bis jetzt noch keine Kerne beobachtet worden sind, kommen nur bei niedere Pflanzen vor, und sind auch bei Thieren selten;" and he cites as samples of the non-nucleated


THE CORPUS LUTEUM. 399

cell the young cells within the old cells of the chorda dorsalis, the cells of the yelk of the bird's egg, &c.

Whether the non-nucleated vesicle be a cell or not, it is very certain that the milk corpuscle, and probably, the chyle corpuscle are of that nature, and no one can contemplate the evolution progress of a corpuscle or spore of saccharomyces cerevisise, with- out admitting for it at all the qualities and development forces of the mother cell: it is to the last degree reproductive; while the filiform fungi, the muscardine, and many other sporiferous bodies claim to possess the same metabolic and formative powers.

Supposing that my view is sound as to the vitellary nature of the corpus luteum, then you will observe how beautifully simple and concise is the machinery or apparatus by which the ovulum is brought to the surface and deposited ready for fecundation, on the ovarian indusium or within the fimbria of the Fallopian tube.

In the bird's egg, which, as in the ostrich and the cassowarj'", contains a gigantic yelk, the simple augmented tension of the membranous sacculus of the ovary suffices to open the ovisac upon its hila. The same happens in the immense yelk of the larger ophidians, as the coluber Boasformis, figured by Dr. Swan, and indeed in all the membranous ovaria.

But, in the dense tissues of the mammal ovarium a special pro- vision for the opening of the porule or hila, for the escape of the ovulum, was required.

How has it been effected ? Is it not as follows ?

The function of stroma is to produce germs and vitellus. When the production of the germ on the inner face of the vesicle buried within the vitellus is complete, the ovulum is ripe; it has attained its generical magnitude and weight; but the stroma continues to supply the vitellary matter; it deposits it betwixt the two concen- tric spherules of the follicle. The inner spherule yields to the pressure of the increasing mass and becomes convoluted as it is crushed inwards towards the yelk ball. The outer spherule is driven outwards against the gangue of the ovarian stroma, and the deposit goes on, particularly in the cow and the swine, to a vast extent, making, in some instances, a mass of corpus luteum equal to half the volume of the ovary.

At the same time the inner concentric, growing smaller and smaller from the pressure towards its centre, lifts the yolk ball to the albuginea and indusium where the resistance is weakest. The


400 THE CORPUS LUTEUM.

cavity of the follicle becomes reduced nearly to nothing, as the pressure augments, until at last the porule, being established by the absorbents or by rupture, the yolk ball escapes, along with its granular membrane, in fragments, leaving a crypt which becomes filled with coagulated blood, the crypt being contained within a yellow mass of vitellus called the corpus luteum, which at some stage, as yet unascertained, begins to be absorbed as the vitelli- ferous forces of the stroma become determined towards the de- velopment of another follicle. It would be unreasonable to sup- pose that upon the escape of the ovulum, the yelk-producing force and activity should be immediately suspended. It is even pro- bable that the corpus luteum may continue to augment for a certain but unknown short period.

It is a periodical exacerbative or paroxysmal force, that develops the ovulum. It is employed first upon one and next upon another germ point, and so on throughout the reproductive life of the woman or the animal, at the pairing season of birds, the rut of the mammals, the reproductive periods of the reptiles, fishes, insects.

I am surprised to find that some able and distinguished writers still cling to the antiquated notion of ovarian fecundation. But I presume that M. Pouchet's illustrated w^ork on ovulation will put to flight all cavils on that point.

No woman can menstruate but in coincidence wdth the sponta- neous ovi-posit. Every ovi-posit is followed by a corpus luteum, except where a failure of development may possibly, as a disease, prevent it. The corpora lutea are of various sizes. Many wo- men have scarcely discernible ones after conception. I recall to your memory the gravid uterus with its young seven months' foetus, in my collection, in which no trace of a corpus luteum is dis- coverable.

The true and false corpora lutea of Dr. Montgomery are all equally true corpora lutea ; and though different in size, are not essentially different in nature.

My letter would be far more satisfactory to me, were it in my power to accompany these pages with copies of M. Pouchet's ex- quisite colored drawings of these objects, but it is not in my power to do so. I warmly recommend them to your attentive and careful study.

And now, gentlemen, do you ask me what is the use of all these remarks on the corpus luteum? I answer, that ray letters


MENSTRUA. 401

are oi females, their diseases, and remedies. You would not un- derstand the nature of women if you should not study their corpora lutea.

In studying their nature and offices, you may find a key to much admirable pathology. In my own mind there has long existed not the least doubt as to the power of these bodies to develop the very beginning of lying-in diseases, and others.

If, in a court of justice, you come to stand as a witness, subject to the interrogations and cross-questionings of a lawyer, you would be thankful for the whole history of these bodies, as given by Bernhardt, and, a fortiori, you would be happy to save some person accused, from the gross misjudgments of lawyers, judges, and juries, who might condemn an innocent person, out of their igno- rance of the true laws of the ovulation and spontaneous ovi-posit in the human female.

I therefore again recommend this point to your careful contem- plation, and shall now bid you farewell with the intention to re- sume my remarks on the menstrua, which have been, seemingly, not really, interrupted by the "present episode on the yellow bodies of the ovaria. C D. M.


LETTER XXXI.

Gentlemen: — My last letter, No. XXX, was occupied with an account I desired to lay before you of my views relative to the corpora lutea, one which I considered it proper to introduce into the series of remarks on menstruation. I know not what you or others may think of the idea set forth therein as to the vitellary nature of that body, — but, I hope that, whatever may be your opinion on that point, you will, at least, agree with me in con- sidering those bodies as a part of the normal results of the men- sual ovulation, for that is the main point ; and that is the point of interest in any medico-legal discussion or testimony you may hereafter happen to be engaged in.

Having said what I wished to say to you on the corpus luteum, 26


402 MENSTRUA.

we shall now, if you please, proceed with our observations on the menstrua.

From what has already been remarked, I presume you have perceived that, in contemplating the nature and laws of the cata- menia, I adopt the notion that the act of menstruation, rigorously construed, consists in the periodical maturation and deposit of an ovulum ; of which act the flowing of the menstrual blood is but the outward and visible sign — so that, in fact, a woman may menstruate very regularly and exactly, without having the least hemorrhagic sign of that menstruation. Doubtless many women are perfectly regular who give no outward sign of it. Do you doubt the truth of this proposition? If you do, then I ask you if it be not proved by the fact that a great many women who give suck, do not have their courses until they wean the child? It is true that, a great many women, during their lactation, find themselves to become regularly unwell from the seventh month ; and it is also usual to observe that a woman lying-in, has a return of the courses six weeks after the birth of the child. This is so generally the case, that I always expect my patient to be unwell again at the sixth week; and to be regularly menstruous from the seventh month. This is the rule — the exceptions are in those women who never see until they wean the child, of which class the number is large.

Mpril 21th, 1847.— Mrs. d told me this day that she

never saw her menstrua while nursing, nor until three months after she had weaned the child. This is her fourth child; she is a small and very delicate person. One of her children was suckled for thirteen months.

Brierre de Boismont says, at page 159, that he inquired as to the return of the menses in eighty-two women who had been con- fined.

the menses returned immediately after the labor ! " " in 8 days!

u u in 15 "


In


1


In


1


In


2


In


4


In


9


In 38


In


7


In


7


In


6


m


6 weeks.


in


1 month.


in


6 weeks.


in


5 to 6 weeks


in


2 months.


in


3 months.


MENSTRUA. 403

In 2 " " in 4 months.

In 3 " " in 5 to 6 months.

In 2 " " in 7 to 8 months.

M. de Boismont's statistical return ought not, I think, to influ- ence you in your opinion. I feel very sure that a much truer statistics than the above, is the one in which I told you that your patient may expect it to return in six weeks ; and then become re- gular and continue so from and after the seventh month. But sta- tistics often fly in the face of opinions as w-ell as of the truth as ac- knowledged in the world, or by the public whom it may concern.

You ought farther, to learn that, some women do not see from the time of their first conception until they have borne a con- siderable number of children, because, becoming fecundated while they are nursing, they carry out the pregnancy to term, become again enceinte, and so on, never seeing their courses as I said, until, being no longer impregnated, the ovulation is marked by a natural return of the mensual hemorrhage. I have met with several samples of this kind; and they are so abundantly re- corded in our books that there is no need to cite the cases; you may set it down as a fact, that it is so, with not a few women. How could it be otherwise with those women who have a child every year, or eleven months. I have seen a child born at ten months after its antecedent.

Now, supposing the ovulation and spontaneous deposit of the ovule to be the true doctrine, do you not see that these suckling women, in question, did really produce ovules for fecundation, though they did not have the menstrual discharge ? I deem it no matter of surprise that they had not the menstrual discharge, be- cause I can perceive in the function of lactation, an action de- rivative from the internal genitalia to the mammary glands, of strength sufficient to turn aside the determinations, whether san- guine or nervous, of the constitution, from the genitalia to the lactiferous apparatus. Many other things turn it aside in the same way. There are many women who may be presumed to have the inward menstruation, videlicet, the ovulation, without any bleeding; a case that may take place without the least shock to the woman's health. A young w^oman, for example, may have reached the proper age for menstruation without having seen the sign, or show. She may be married, conceive, and bear a child — suckle it, and at the end of seven months have her first men-


404 MENSTRUA,

struation. This has been observed to happen more than once. Who can doubt that she matured and deposited her germs, which were fecundated after her marriage? Or will you go back to the idols, and embrace the old doctrine that the germs were fecun- dated in the ovaria? If you will go back to such idols, I have nothing to do but "let you alone."

You might well suppose that pregnancy will put a stop to the ovulation — and perhaps, in a majority of cases, it is true that when the womb has once fairly begun its career of gravid de- velopment, the sanguine and nervous forces of the reproductive organs are so completely absorbed in the business of gestation, that the ovarian function is suspended, or proceeds but slowly and feebly at most. Yet there are pregnant women, not a few, who have regular mensual returns for three or even four months. I had a patient here who was regularly unwell up to the eighth month, when I attended her. She went out her time, and was laid at the ninth month.

Moreover, some women have the most insuperable tendency to miscarry, and those miscarriages are found to take place at the period of their usual menstruation — in fact, the major part of the abortions and threats of abortion, you are hereafter to meet with, coincide with the woman's catamenial period ; a fact very im- portant for you to know, because, you ought to take measures to obviate the danger at the time — and when the time is passed re- lieve the patient from the onus of an unnecessary treatment.

All the foregoing may suffice to show you that you are not to take in hand every female who does not have the show just at the time it is expected, and that you will be at liberty to suppose that her constitution does not suffer the least injury; because, while she does not seem to be regular, she is, in fact, perfectly regular; that is to say, she regularly matures, and deposits her germs, — for that is the physiological act of menstruation, and nothing else is. That is what her constitution requires her to do. If she bleeds, it is well ; but she is often found to be well even if she does not bleed a drop. Is it not so with the suckling woman? I am glad to have an opportunity to tell you these things, for I hope they may have the effect to make you keep clear sometimes of the drugging process which is too apt to be set on foot the mo- ment a lady complains of amenorrhoea.

In a former letter I said I had often seen young women lose


MENSTRUA. 405

their courses when brought to town, and set on the school-form, yet retaining all the outward appearances of valid health. When- ever I have been consulted as to such a one, I have made a very careful exploration of the rate and degree of the various functions ; and when I have found that the intellection, the respiration, circu- lation, innervation, calorification, digestion, secretions, &c., are all normal, and that nothing is wanting save the raenstruous show, I have let the patient alone, merely directing a close surveillance of her health, and proposing to interfere only in case some further signs of disorder should present themselves. The deviation in such cases I have attributed to the consumption of the nerve force, the neurosity, by the hemispheres, in the too constant operation of the powers of the intelligence. A holiday, or a return to their homes, cures them better than drugs. Do not, I pray, let me mis- lead you here. On the contrary, I repeat that the state of the whole constitution should be carefully explored, and when thera- peutical treatment is evidently demanded, see to it that the true indications be fulfilled.

I have now another topic to speak of, and that is a case where you are called to a person who complains of a retention of the menses, appealing to you for relief.

The stupidest thing a physician can do, is to be misled by such complaints to the administering of drugs and medicines, which may bring on, not the menses, but an abortion, or a premature labor. How can a man look more like a fool than he who suffers himself to be entrapped to the commission of such a wrong .

If a woman comes to your office, or if you be called to her dwelling to speak with her on such a subject, you may perceive at a glance that she is sick ; but you may as readily also discover by a single look that she presents all the signs of the most con- summate health. How can a woman exhibit all the signs of ro- bust health, and yet fail of her menstruation, when she has always before been perfectly regular, and when neither disease nor stu- dies, nor misfortunes can be supposedto have had power to inter- rupt the course of a function always sure to be exercised when nothing stands in the way of its exercise ?

I am far from advising you to be constantly on the look out for sin, and smelling out every possible iniquity. But I do advise you so to demean yourselves that you shall bring no discredit on yourself, or on your profession. Our profession, alas ! has a vast


406 MENSTRUA.

weight of incompetency among its own asseclse, and an immense onus of charlatanry among the whole race of quacks and pre- tenders to bear upon its ample shoulders. You will be in the good path if you determine early to give no occasion for additional scandal by your conduct as physicians. It will be your duty, then, in all these cases, not to suffer yourselves to be misled and imposed upon.

I was sent for to see a young woman. Upon reaching the house

her married sister said that she wished me to visit , as

she was quite out of health.

"What ails her?"

"I suppose it is her courses; she has not been right for several months. Go up stairs, and you will find her in the chamber."

" Does she appear to be ill ?"

"No, not at all."

She was sitting in a chair, bending over a tambor-frame, where she seemed to be most diligently employed passing the needle in and out of the stuff at which she was working.

I observed that she blushed as I entered the apartment, and seemed agitated, whether from a modest timidity, or from a con- sciousness of impending disclosure. Her face was radiant with health and bloom, and her embonpoint was visible on her shoul- ders and arms.

She told me, in answer to my inquiries, that she had seen no- thing for near seven months, but was very much swollen — was fearful of a dropsy — had no pain — good appetite, sleep, digestion, and strength. The pulse was normal, except the slight precipi- tation, ci pathemate mentis. She very reluctantly allowed me to place my hand on the abdomen, stooping the while over her tam- bor-frame. I held the hand there a long time, but could not dis- cover any spontaneous motion, nor did I hint at the object I had in view — which was to discover the movement of a child. After some conversation, she allowed me to auscult the abdomen, which was as large, and as regularly developed as in a gestation of seven months ; upon adjusting the ear I heard the click of the infant's heart.

When I informed her of my discovery, she most indignantly de- nied it, and was angry with me for the liberty I took to say, that she, an unmarried woman, was in the family way ; but at length


MENSTRUA. 407

gave in and made her arrangements for the accouchement — which was very happily effected at the due time. The child w^as taken kind care of, and is well. She refused to marry her seducer — but two years later married a worthy man, after informing him of her mishap. They live prosperously together, and are raising their hopeful children.

I am aware it would not be well to fill up this book with cases of this kind, of which I have met with a great number, some of them very curious ones. I have only recited the above to show

you how easy it would be to have taken 's word as to her

case, to give her a violent emeto-cathartic, some savine, ergot, or what not, and bring on a premature labor at the risk of her life, and to the discredit of our divine art. You never will make such a mistake if you will make a good rule and follow it religiously. Let that rule be, not to speak until you know. If you will conjec- ture, if you will guess, let it be a conjecture, a guess, or a sur- mise; but when you know, then you can speak.

I need not again advert to the case of non-appearance of the menses, depending upon atresia of the organs, having already spoken of that accident in a former letter.

As to the quantity and duration of the mensual discharge, I have to say, that each woman, in good health, has a rate of her own. Some discharge one ounce of blood, and some twenty ounces at each period. The quantity a woman loses, depends upon some peculiarity of her constitution. In like manner the quantity a woman loses in her labor depends on some such peculiarity. Many women bring the child into the world without staining the napkins and cloths about them, and I have many times taken away the placenta without a red spot on my hands ; the woman afterwards having only a moderate lochia, not so considerable as the ordinary menstrua of other women. On the other hand you will meet with patients who discharge a great deal of blood with the child, and always do so — while the post-partum discharge is also so considerable as invariably to reduce the strength.

The great matter in diagnosis, then, is to learn the amount, and to ascertain the constitutional wants or demands and habit of the patient herself.

One may be well enough able to judge of the quantity imbibed by a napkin; from one to two tablespoonfuls would render it uncomfortable. But a tablespoonful is half a fluidounce, then


408 MENSTRUA.

twenty-four napkins would, by estimate, be twelve fluid ounces. But it is often much more than that — for on some of the napkins there will be found from an ounce to an ounce and a half.

Haller, in lib. xxviii,, sec. iii., says, "The quantity of blood discharged is various; it is greater in warm climates, being as much as a pound or even more — or it may be equal to ten ounces ; or it may go to the extent of producing deliquium animi, and even death itself. In cold climates the discharge may be six ounces, five, four, or it may be as low as three ounces," &c. He speaks of the effects of diet, showing that those who live well are more free in their menstrua than those who are com- pelled to subsist on spare, and poor rations.

There is an observation as to the quantity of menstrual fluid pro- duced in a given time, that is unique, so far as I know: it was made by M. Brierre de Boismont, and is found in his work on Men- struation, p. 172. He says, that one of his patients had the com- plaisance to lend herself for the experiment, which was performed by adjusting a speculumto the vaginal cervix which it exactly fitted. The cervix remained like a plug in the speculum for ten hours. By this means the product was collected, and must have been free from any admixture with the excretions of the vagina. The quantity of fluid that escaped from the womb was twenty-two grammes, which is a little more than an ounce. At this rate twenty-four hours would have produced nearly two and a half ounces. This person had had several children. She was thirty- five years of age. She was of a delicate constitution — her menses usually lasted eight days — probably she would usually lose ten to twelve ounces, therefore, at each menstruation.

When people consult me on these points, I am accustomed to in- quire how many changes they have been in the habit of making dur- ing the whole menstruation. Now, many individuals have assured me they always use eighteen, twenty, twenty-five, and some of them thirty changes, in each mensual period. Others have em- ployed only six — some three, and now and then I have met with a person who never used any in her whole menstrual life. Hence, it is easy to perceive what great differences there are among females as to the amount eliminated.

I am but little inclined, gentlemen, to enter upon any further discussion as to the nature of the menstrual fluid, as to whether it be a secretion from the arteries or the veins. Such discussions


MENSTRUA. 409

are of little profit. At least I am so fixed in the belief that I am correct in calling it the mensual hemorrhage, that I shall proba- bly never adopt any other view of it ; and it therefore appears to me idle to endeavor to reason one into the belief that it is a secre- tion — in the same sense that bile, or saliva, or milk, are secretions. The menstrual fluid is blood. All writers and authorities are not agreed upon this point. Among others I may mention that Mr. Hunter regarded it as differing from blood, on account of its not coagulating. Dr. Burns, the author of a system of Midwifery, was of the same opinion, as is also Professor Chapman, of the University of Pennsylvania, (see his note at p. 106 of James' Burns.) The late Professor Dewees, in his Treatise on Diseases of Females, at p. 87, observes, "I adopt the opinion that the men- strual discharge is a genuine secretion," &c. It is unnecessary to cite a great number of persons of the same way of thinking. I merely cite the above to show you that the opinion is held.

I have had pretty numerous opportunities of inspecting the menstrual product, and I remain convinced that it is blood — but I am ready to pin my faith in this matter to the sleeve of a person better qualified to judge of it than you or I. I mean the late Madame Boivin, author of the \Memonal sur VArt des Jiccouclie- mens — long Sage Femme en chef of the Maison des Accouchemens at Paris, and author of the admirable Treatise on the Diseases of Women, &c. Her writings prove her to have been a most learned physician, and as she enjoyed a very large practice, her science and her great clinical experience, as well as her own personal knowledge, are more to be relied on than that of all the male phy- sicians together. She says, " The blood of the menses is just like that which is taken away from a vein."

I say, I rely more upon Madame Boivin, than upon anybody else. I do not see what particular privilege we men have to know best what the discharge consists of. I do know very well, that women have a sensibility, a shame-facedness about it that makes them very reluctant even to talk about their courses, and they are very far from exhibiting the material. A woman will get drunk, she will prostitute herself for a shilling, she will walk in the public streets, in rags and filth, she will curse and brawl, and be- come in all respects utterly, thoroughly profligate and debauched, but she will not show her napkin if she can avoid doing so. She conceals her menses from all eyes but her own, insomuch, that


410 MENSTRUA.

even where her moral faculty has become a hopeless, cureless ruin ; where decency, and the last remainder of womanly modesty are clean gone, she still clings to the inherent respect and shame that she feels on account of this strange function of her body. She always dislikes to talk of it, and abhors the open exhibition of it. It was unclean in the sight of all Israel. How then-are we doctors to become the best judges of it ? We may practice physic for half a century and have a few rare occasions to inspect it, and those only when it is morbid. I say it again, I consider Madame Boivin's declaration worth more than the contrary opinion of a Consistory of Physicians.

MM. Andral and Gavarret, in their frequent analyses of human blood, settled down to the conclusion that healthy blood, say 1000 grains, contains of

Water 790 grains.

Globules 127 "

Albumen 80 "

Fibrin 3 "

The analysis by Becquerel and Rodier, of blood of eleven men, gives the following mean result on 1000 grains — Water 799-0

Solid constituents 201 '0

Fibrin 2-2

Fat 3-2

Albumen ■ 69-4

Globules 141-1

Extractive matter and salts 6*8 I have quoted the above stated analyses of blood in order that you may be able to compare them wdth the following analyses of the menstrual fluid.

M. Brierre de Boismont, in his w^ork on Menstruation, gives at p. 172, this analysis by Denis, of the menstrual fluid of a healthy woman aged twenty-seven years. It appeared to him to be a mixture of blood with mucus, and consisted of

Water 825-00

Globules 64-40

Albumen 48-30

Extractive matter 1-10

Fatty " 3-90

Saline " 12-00

Mucus " 45-30


MENSTRUA. 411

The patient of B. de B., who has been already mentioned, agreed to allow a portion of menstrual fluid to be collected in such a manner as to prevent any admixture of vaginal mucus. This was done, as I said, by adjusting the mouth of a speculum uteri upon the cylinder of the cervix. The fluid passing through the tube was collected from the other end. It yielded to the one hundred parts of

Water 90-08

Fixed matter 6-92

The fixed matter was composed of

Fibrin, Albumen and coloring matter 15'27 Extractive matter 1*42

Fatty " 2-21

Saks 5-31

Mucus 10-79

Rindskopf (vide Simon's Chemistry of Man, 337), found the menstrual fluid acid, and it contained

Water ' 820-830

Solid residuum 179-170

Salts 10-150

In a second analysis, he found

Water 822-892

Albumen and haemato-globulin 156-457

Extractive matter and salts 20-651

Simon's Analysis.

Water 785-000

Solid constituents 215-000

Fat 2-580

Albumen 76-540

Haemato-globulin 120-400

Extractive and salts 8-600

Dr. Letheby, Lancet, May 2, 1845, analyzed menstrual fluid

delivered from an imperforate hymen. It contained

Water 857-4

Solid constituents 142*6

Fat 5-3

Albumen 69-4

Globules 49-1

Heematin 2-9

Salts 8-0

Extractive 6-7


412 MENSTRUA.

Now that I have laid before you these statements of analysis both of pure blood, and of the fluid of the catamenia, I leave you to judge whether the menstrual discharge is a mensual hemor- rhage or a menstrual secretion. I presume you will feel inclined to look upon it as a periodical hemorrhage, like a periodical epis- taxis, exhibiting modified appearances according to the quantity of epithelial scales and mucus that happens to be combined with it. For my part, I follow Madame Boivin, and I prefer her au- thority even to that of the chemists and micrographers. I beg leave to repeat that although, in the course of a long practice, a physician does meet with occasions, where, upon some difficult diag- nosis, he must ask the privilege to examine the napkin, it remains true that a woman in health never calls in the doctor upon that point at least, and that when he does find a necessity to examine it, there is disorder or suspicion of disorder. Wherever you shall see it, you are to suspect its quality to be abnormal.

Now that I have laid before you the analysis, and shown you what the material is, and hinted at the difficulty of examining it, I hope you will allow me to say a few words that are germain to those hints, and will not much interrupt the regular course of our studies of the subject. I wish you again to consider how difficult it is for us to be sure that such portions as we see are not diseased, or at least abnormal specimens. Let me beg you, in order to show how modest women are upon this subject — to remark, that while in this populous city, of more than 250,000 souls, half of whom are females, multitudes of them thronging the streets and the mar- kets, you never saw one of them, no, not one, who allowed a single drop to stain her stocking, or spot the thin .dress that she wore. You never met with such an horreur at the cotillon party, nor with those who waltz or move in the Polka or Cachuca. I know not how I could give you a more striking proof of the re- gard, the respect, I was going to say the superstitious veneration, with which the sex observe all the obligations of a perfect conve- nance on this subject. The fact is, that the sex have learned by a time-honored tradition handed down through the mass of mind from age to age, that their life, health, comfort, fruitfulness, and beauty, have a strong alliance with, and dependence upon this office. It has become, therefore, a public sentiment — a female vox populi — vox dei, that commands it to be respected. Take good heed, then, that you always treat it with respect in your con-


MENSTRUA. 413

versations, inquiries and directions addressed to your patients and their friends and nurses.

If I had time, I could give you an account of many supersti- tious observances and opinions relative to the catamenia that still linger even among some of the better informed people. To show you how ancient is the respect with which it is still regarded, you should advert to the story of Jacob and Laban. You remem- ber that when Jacob fled with his beloved Rachel, they carried off a part of the worthy father-in-law's images.

In the 31st chapter of Genesis, the story is told in the follow- ing words: — "And it was told Laban on the third day that Jacob was fled. And he took his brethren with him, and pursued after him seven days' journey; and they overtook him in the Mount of Gilead. Now Jacob had pitched his tent in the Mount, and Laban with his brethren pitched in the Mount of Gilead. And Laban said to Jacob, what hast thou done, &c., &c. — yet wherefore hast thou stolen my gods? And Laban went into Jacob's tent, and into the two maid servants' tent, but he found them not. Then went he out of Leah's tent and entered into Rachel's tent. Now Rachel had taken the images and put them in the camel's furni- ture and sat upon them. And Laban searched all the tent but found them not. And she said unto her father, let it not displease my lord that I cannot rise up before thee; for the custom of women is upon me," &c. Here you see at how ancient a period it was a custom of women to be unwell — and what is more, you see a man who, with an armed force, had pursued his runaway family for seven days' journey, manifestly with the most violent anger, and eagerness to recover his idols. Yet, for the simple words, custom of women, he went out of the tent without making the lady violate the convenances belonging to her sexual custom. If she had not made this pretence, do you doubt that he would have dragged her from her seat to find the precious gods in whom he put his trust !

The Hebrew Lawgiver doomed every Israelitish man to death that should lie with a woman at such conjuncture.

The 15th chapter of the 7th book of Pliny, contains the follow- ing passage, showing what impression existed as to this discharge among a polished people. " But woman is the only menstrual animal; {solum animal menstruale,) and therefore the only one whose womb produces what is called a mole. A mole is an


414 CATAMENIA.

amorphous mass of inanimate flesh, which can neither be cut with the edge, nor pierced with the point of a knife."

"There is, perhaps, nothing in the world more monstrous than the menstrual fluid. Wine turns sour in its presence ; seeds, when touched with it, lose their germinative power ; hedges die ; and seeds planted in a garden where it falls are burned up in the ground. If a woman with the menses sits upon a tree, its fruit falls. Mirrors lose their polish, knives their edge, and ivory its bright- ness by its contact. Bees perish in their hives, and brass and iron are seized with sudden rust, and acquire a horrid odor if touched with the fluid. A dog that tastes it goes mad, and his bite is mortal," &c. The 7th chapter of his 28th book contains very copious details of the superstitious notions held concerning the menstrua centuries ago.

The periodical discharge is an indispensable attribute of the sex — I mean the healthful part of them ; and no faith is to be given to the idle reports of travelers, who pretend that certain na- tions or tribes in the interior regions of South America are devoid of it. Nor is greater regard due to the oft-quoted notion of Roussel, that the habit of this discharge is not a natural one, but one ac- quired in past ages, and now become a settled and regular attri- bute. Roussel is celebrated chiefly for his small volume, entitled, Systeme Physique et Morale de la Femme, a work praised greatly beyond its deserts, although it must be admitted to be written in a very pleasing style. In Chap. II., of the second part, where he alludes to the hemorrhagies, by means of which men escape from the evils with which they are menaced in the shape of rheuma- tism, hypochondriasm, gout, and apoplexy, &c., he proceeds as follows : —

"Women, from their sedentary and inactive mode of life, are less able to avoid them : the nature of their occupations favors the superabundance of humors which they possess in common with the male, instead of diminishing them, as is the case with the avoca- tions of men ; but then they have an excretory organ, by means of which they can be freed from the superabundant, and thereby hurtful humors. Animals that are not withdrawn from the empire of nature's laws, and who act under the guidance of instinct, have no need of this resource ; they are not, like men, liable to hemor- rhagies, nor, in consequence of such liability, to the morbific affec- tions which they serve to introduce. These hemorrhagies have


CATAMENIA. 415

become a necessary function, intimately connected with the hu- man constitution ; so that, in the present state of things, a woman is born with a tendency to have her menses at a certain age, as she is born with a tendency to take the small-pox ; for we can contract a new necessity as we can contract a new malady. Were it possible to review all the changes through which the human race have passed since their origin, we should, perhaps, discover that they have not been always the subjects of the same necessi- ties, the same functions, and the same diseases as at the present day. Having once contracted some vice of the constitution, or some new disease, which, beyond doubt, happens in all the species of animals, such vice, or such diseases, are transmitted from gene- ration to generation, and are perpetuated until some contrary cause arises to destroy them. This is the reason why races dege- nerate, and become changed in the lapse of ages. Thus the men- strual evacuation, being once introduced into the species, is com- municated by an uninterrupted filiation, so that we might say that a woman has her courses at the present era solely because her mother had them, just as she, would have been consumptive if her mother had been so. And further, she may be subject to the menstrua even though the primitive cause that established this necessity of the female no longer subsists in her constitution. In fact, many women are regular who are not subject to plethora, nor a surcharge of humors. In these women the menstrual flow depends solely upon the habitual direction of nature's movements, like the periodical hemorrhagies that occur in men whose consti- tutions are already exhausted."

Such are the views of the celebrated Roussel. You will readily perceive that if such modifications of the human nature, as he therein supposes to be possible, can actually take effect, there are no bounds to be set to the range of modifications possible ; and that, if Roussel's views are just, then the doctrines of the "Vestiges of Creation" are equally true, as to the gradual evolution of new specific and generic forms of creatures.

It is not to be believed that Roussel would have entertained the opinion if he could have been acquainted with the functions of the ovaries, and the history of the early stages of the reproductive act.

Having already drawn out this letter to a considerable length, I shall adjourn to the next a further consideration of the subject.

I am, &c., C. D. M.


416 EMMENAGOGUES.


LETTER XXXII.

Gentlemen : — The distinguished Professor of the Theory and Practice of Physic, in the University of Pennsylvania, Dr. Chap- man, begins, at p. 37, vol. 2, of his Discourses on Therap. and Mat. Med., an enumeration of the names and the qualities of the Menagoga, or Emmenagogues. The entire suite of his articles is

1. Polygala senega.

2. Juniperus sabina.

3. Rubia tinctorum.

4. Rosmarinus officinalis.

5. Mentha pulegium.

6. Secale cornutum.

7. Helleborus nio^er.

8. Cantharides, (perhaps.)

9. Terebinthinous preparations.

10. Phosphorus.

11. Cold bath.

12. Exercise.

13. Change of air.

14. Generous diet.

15. Bark.

16. The ferruginous articles.

17. Fetid gums.

18. Castor.

19. Musk.

20. Venesection.

21. Aloes.

22. Blisters.

There, you have Dr. Chapman's list; look at it, study it, and when you have done so, ask yourself the question— is there an emmenagogue? No. Look at Murray's list, in his system of Mat. Med. and Pharm., at p. 284, vol. 1. Read over Cullen's list, with Professor Barton's additions; indeed, without reading anybody's list, reflect upon the causes of menstruation, and see


EMMENAGOGUES. 417

whether any animal, mineral, or vegetable thing is likely to make a woman menstruate. Cullen, after a long experience and prac- tice, with careful attention to collect results of this therapy, comes to the melancholy conclusion, that they are the most unfaithful of medicines, not answering to the hopes awakened by their repu- tation.

I have long since arrived at the same conclusion; and you will, I suppose, remember how often I have expressed this disbelief in their powers, while lecturing upon the emmenagogues at the Col- lege.

What then ! is there nothing to be done for a retention of the menses ? Are we to say to the sick, there is no medicine for your case? Far from it; the sick require to be cured, and they may as often be cured of an amenorrhoea as of a rheumatism, or colic ; but emmenagogues will not cure them. Dr. Cullen, as I have said, placed no confidence in them.

Upon a review of Dr. Chapman's list and remarks, you will readily perceive that he has little confidence in them, as little, perhaps, as Cullen himself; and yet you find that what with the lancet, the baths, the aloes, the blisters, the martial preparations, &c., he arrays a really powerful armament for the combat against the causes of obstruction.

Yet the very array shows that Dr. Chapman seeks rather to cure the disorder which prevents the menstruation, in order that men- struation may occur naturally, as it will do in a healthy woman, than to compel the woman to menstruate first, in order that thereby she may be cured.

Perhaps you would prefer to call a foot-bath, or a suffumigation, by the name emmenagogue! A woman of a very susceptible and delicate constitution, who should get her shoes and stockings wet in a sudden shower, is liable to have her courses stopped, with pain in the pelvis, headache, and general soreness; and even some de- gree of fever. If she afterwards sit with her feet in a mustard or salt bath, for fifteen minutes — or, if she sit over the vapor of boil- ing water for half an hour — it is very likely the flow may return ; or, if she will place herself in a sitz-bath, or go into a plunge- bath at 100°, for twenty or thirty minutes, it is probable that her menses will return ; or, if she will take a large warm emollient in- jection, perhaps'the flow will recommence; but if it does, will the effect entitle you to say that these remedies are emmenagogues? I 27


418' EMMENAGOGUES.

think not ; for they do not compel, they do not lead, they do not draw forth. Such remedies serve, by removing causes of obstruc- tion, or delay, to allow of the effectuation of the function. To break down a door, is a very different thing from unlocking it, and setting it wide open. These medicines, perhaps, may serve in this sense to set open the door; they do not break open, and thrust through, which is the idea and modus of a true emmenagogue.

There are a great many cases of difficult, or suspended men- struation, that depend upon a rheumatic state of the womb. The pathological state of the organ preoccupies it, and brings it into a condition of sensivity and irritability incompatible with the per- formance of the mensual act. I am well persuaded that much of the dysmenorrhcEa we encounter, is rheumatic disorder. It is characterized by all the pains and fullness, and heat and pressure within the pelvis, of which we hear women complain, while they appear, in other regards, to enjoy very good health. The uterus becomes sensible upon pressure with the index finger ; a pessary in contact with it produces a sense of hot or burning pain, and yet the Touch reveals no change in the form, dimensions, or re- sistance of the vaginal cervix. I presume it is in many ex- amples, identical with what has been called irritable, or neuralgic uterus. It may last very long without change, and without in- ducing any cognizable change in the part.

These are the cases that sometimes yield to the anti-rheumatic treatment. Is it not fair to presume that Dr. Dewees' vol. tinct. of guaiacum, w^hen it has done good in the dysmenorrhceas and suspended menstruations, has effected that good by virtue of its anti-rheumatic properties? I do not apprehend why the guaiac should possess any power to bring on menstruation, save that it has it in virtue of its anti-rheumatic therapeutical force.

I advise you to study with care, in all your clinical cases that may be probably attributed to rheumatism of the reproductive organs, particularly the womb, the phenomena that may present themselves. You should carefully note, not only the signs given out by pain, and by suspended or altered function, but the influ- ence of remedies, for you may rest well assured that a great many cases of rheumatism of the womb have long been, and still are, commonly mistaken for prolapsions and other afi'ections; a false diagnosis that leads to a false and unsuccessful mode of cure. Rheumatism of the womb is becoming a more frequent


EMMENAGOGUES. 419

object of inquiry than it used to be, and I am sure the subject is worthy of your special study and exploration.

The gravid uterus is the frequent subject of rheumatic attacks, and it will be my duty to speak of it under the proper head.

Meanwhile — if you find a patient complaining of pelvic pains, heat, weight, tenesmus, dysmenorrhcea, you would not be apt to make a mistake as to the true nature of the malady, should you, after due examination, come to the conclusion that you have a rheumatism to treat. Suppose you have made an examination, by the touch, and by external palpation, that you find the womb not displaced, nor at all disordered, nor swollen, and in addition to all this, learn that the patient has been subject to rheumatic pains, that she has accustomed herself to the use of the cold bath, that she is careless as to wet or damp cold feet, and that she wears no drawers, I see not what inference you could draw, save that she is rheumatic as to the uterus.

If you cure the rheumatism the patient is cured, all the signs of a uterine disorder vanishing with the disappearance of the pain. But a local rheumatism may often be cured by a bath, or you may obtain great relief by the w^earing of flannels. A wo- man with a rheumatic uterus should assuredly be directed to wear drawers of flannel, with a view to keep the pelvis, and loins, and thighs well covered and protected against the per- nicious influences of cold and damp. Such a patient should have a soluble state of the bowels, which may be obtained by any gentle aperient. If she have complained long and much, previously to your first interview ; if she be of a costive habit, and leave you to infer that some considerable accumulation of faeces has taken place in the colon, she should be purged, and well purged, as a preliminary treatment. There is scarcely to be found a safer or preferable compound for this purpose than the mixture of jalap and cream of tartar with oil of anise. Twenty, or twenty-five grains of jalap, forty grains of cream of tartar, and five drops of oil of anise, made into a powder, should be given for a dose, at an early morning hour. It may be expected that the dose shall operate five or six times. Two days later the dose may be repeated, and again in two days, which will probably suflSce. After this let the patient take at bed-time an anodyne enema of forty-five drops of laudanum, with the view to abate the neuralgic sensibility of the parts within the pelvis. Let


420 EMMENAGOGUES.

her have a bath at 98° three times a week, before going to bed ; let her keep herself warm as to her clothing; let her take sul- phate of quinine, or quinine and iron — and the disease can hardly resist the treatment. In fine weather it will be proper for her to exercise in the open air. The diet should be plain, but nutritious, and the treatment directed to build up the strength of the whole constitution.

There are such things in medicine as sanguine determinations, as they are called. A sanguine determination to the head may exist, giving occasion to cephalalgia ; to flushings of the face ; to buzzing, or droning in the ears; to hemicrania; to sopor; to apo- plexy, or to coma.

There are such things as loss of determination of blood to a part. All those people who complain of cold feet and hands, suffer from loss of determination to these points ; and they suffer so for months and for years. Now there is a great difference between the cases of excessive determinations to a part, and loss of determinations to a part. The former tends to procure exces- sive development; and the latter leads to debility, and even atrophy of the part. Well! a female may have an excessive san- guine determination to the pelvic extremity of the trunk, or she may suffer loss of such determination; if the former exist, she will be liable to excessive menstruation; if the latter, to amenor- rhoea. Suppose a woman to have an amenorrhcea from the latter cause; then you will increase the pelvic determination by hot pediluvia; by the hip-bath; by the use of frictions to the lower extremities; by tight garters, or bandages on the legs ; by warm flannel drawers and stockings; by exercise on foot,- which deve- lops the lower circulation ; by galloping on horseback, which pow- erfully develops it ; by the dance ; and, lastly, by any medicines that tend to excite and stimulate the life forces of the pelvic ex- tremity of the trunk of the body.

If a woman have a violent strangury, or a violent tenesmus, she will ipso facto have an augmented sanguine determination to the pelvis, its veins, and arteries, and capillaries. But there are medicines that give rise to these phenomena. The resins ; the balsams; spts. turpentine; cantharides; aloes. Such are the articles you would select. The tinctura sacra, spirits of turpen- tine, aloes, and assafetida ; Lady Webster's pills, oil of Juniper berries; Dewees' tinct. of guaiac, and tinct. of black hellebore;


EHHMENAGOGUES. 421

all these articles tend to fulfil the indication, which is to augment the pelvic determination. If they do fulfil the indication, then, the forces of life and development in the ovary being remodified and reinstalled, the germ production will recommence, the ovula- tion and oviposit will be re-established, with monthly exactness, and the patient will have become regular again.

A woman may miss of her monthly courses from debility; what debility ! She may have been weakened by excessive menstrua- tions. She may have lost twenty ounces a month, for many months, so that she has at last become really ansemical. Or she may have had a constant drain of blood from some hemorrhoidal marisca, or other excrescence ; or she may have been reduced by malarious fever, which has engendered an ague cake in her left hypochondrium. Her blood is reduced in its crasis by any of these, or by whatever cause. To cure such a case, bark and iron and wine and meats, and air and exercise, are the indications to be fulfilled by your authoritative prescription.

I refer you again to the so often proposed dogma, or rather truth, that Biotic power is the result of the contact of oxygenated blood with the substance of brain. None of the innervations of your patient will be perfect and powerful, unless there be a just proportion between the dose of oxygen in the blood, and the Biotic power to be evolved. Your thin, pale oligcemic patient cannot take up enough oxygen out of the air she breathes, tomake her strong. Let your business be, nay, let it be your sole busi- ness, to thicken, to enrich, to ensanguine her blood, in order that that rich and perfect compound, may be enabled to absorb, and take out of the circumambient air, the just and requisite amount of oxygen, wherewith to deflagrate, if I may so speak, in the brain, and evolve the Biotic, the life-force, the Lebens-kraft as the Germans call it. Meat and wine, and air and exercise, — bark and iron, the sea-bath, and mountain air, a cheerful spirit, an attention to the dress, soluble bowels, frictions of the skin — why need I enumerate all the thino-s that mio;ht concur in the great end of improving the general health, which, being renewed, the menstruation follows, as light follows the uprising of the morning


sun


Examine your patient carefully, to learn whether the uterus may haply have become the seat of a chronic inflammatory en- gorgement that tends to produce an hypertrophic state of the organ


422 EMMENAGOGUES.

which might render it disobedient to the normal influences that lead to the sensible signs of menstruation. In that case, should the state of the general health not forbid it, you would do wisely and well for the patient, should you take from the arm several ounces of blood, say from eight to sixteen ounces, in order to check, by such abstraction, the excessive vascular momentum directed upon the organ. I pray you be not afraid of the lancet; very few persons are hurt by the -use of that fine therapeutical agent, whereas hundreds and thousands are permitted to lapse in health, and fall into a premature decay and death, from the want of its curative power. I implore you to study carefully the nature of the therapeutical effects of blood-letting ; endeavor to estimate its power over the Biotic forces ; try to comprehend how and why it is, that the abstraction of blood modifies the general innervative forces, and, so, modifies the life-force in a diseased part, and you may safely be trusted in the world with the lancet in your hand, which you will never, or rarely apply to the hurt, or the smallest injury of your patient, while on the other hand, you will permit many to perish, or fall into chronic ailments, worse than death, if you are timid, or ignorant as to the use of a remedy, which in all ages of the world has been, and in all future ages is likely to be one of the prime resources of our art, against a host of mala- dies that are indeed not to be successfully controlled by other means.

I have heard that illustrious man, our countryman, Dr. Phy- sick, say — '* it may be that, in some few instances, I have had occasion to think I have carried the use of the lancet too far; but I have to lament very numerous instances in which my timidity has prevented me from using it with sufficient boldness to save my patient from death." Such a saying, of such a man as Dr. Physick, is worthy of your hearing, and your heeding, for he was, take him all in all, a man of matchless wisdom and skill as a physician.

In the further treatment of these cases of engorged uterus, with a tendency to hypertrophy, I advise you to make occasional ap- plications of leeches to the collum uteri. They are very readily applied by means of a Recamier speculum, to which is adapted a cylindrical cup, that fits into the larger end of the tube. This cup, being filled with the required number of leeches, should be inverted into the speculum tube, after that has been so adjusted


EMMENAGOGUES. 423

as to receive into its uterine extremity the whole vaginal cervix or collum uteri. The leeches generally fill within thirty-five minutes, and often in twenty-five minutes, when they may be withdrawn together with the tube.

In applying leeches to the uterus in this way, you should not use more than a dozen at a time, and I confess I have seen very copious bleeding produced by only one dozen American leeches. I have seen the hemorrhage go to the extent of causing most alarming deliquium, restrainable only by the tampon. Such accidents are, however, very rare, and only accountable for, by supposing that some considerable branch of the rete vasculosum of the vagina had been opened by the leeches. No danger need ever be apprehended from such an accident, provided you are at hand to obviate it, and that you can always do, as above said, by the use of a tampon.

By means, then, of general bleeding, and the topical abstrac- tion of blood by leeches, you will probably in most cases succeed in reducing the vascular engorgement of the womb, and overcom- ing the sanguine determination on which it may have depended. Yet it is proper to secure the good end, by rest in a recumbent posture, and by the employment of purgative doses, particularly the hydragogue dose of jalap and cream of tartar, repeated on alternate days, for several days. These purgative doses, with the anodyne enemata at night, will restore the balance of the cir- culation, taking aw^ay the pain, heat, and pressure; after which, a regulated diet, and proper exercise and clothing, with the adju- vant power of bitters, or ferruginous tonics, will bring the patient up from the lowness brought on by the disease, and by the treat- ment, after which she may be expected to menstruate again. I shall here close this letter, with the assurance of the respect and esteem with which I am your faithful servant,

C. D. M.


424 MENORRHAGIA.


LETTER XXXIII.

Gentlemen: — The word Menorrhagia means immoderate flow of the menses ; which flow consists of a purer blood than that of the regular catamenial evacuation. The blood is purer, because the impetuous haste of the discharge causes it to come ofl'less mixed with cervical and vaginal mucus and epithelium, than in the more moderate or normal mensual hemorrhage ; — and this, I believe, is the only difference between them. As the blood in menorrhagia is less mixed and combined with foreign matters, you would naturally expect to find it to coagulate more readily; while this is quite true, it is not the less true that the real normal menstru- ous excretion does, in many women, coagulate, without any sus- picion of menorrhagia ; and it is reasonable a priori, to suppose so, since one woman may be seven days getting rid of her six ounces of fluid, whereas another woman will part with ten or twelve ounces, in three or five days. She who discharges the menses ple7io rivo, will be sure to find some coagula; she who passes it slowly away, will find it to sink into her napkins with- out a clot, — for her blood has time to be much combined with mucus and epithelium.

I should think you would not be surprised to learn that a woman may be now and then menorrhagic, because you would reflect upon the highly hemorrhagic nature of the womb — ^a very small organ supplied by two very considerable uterine arteries, and over and above that source, deriving into its sanguine circulation no small quantity from the inosculations of the ovarian arteries. Under such circumstances, and with the propensity to eflfuse blood established by the regular monthly habit of bleeding, women should be esteemed always liable to excessive menstruation, though the vast majority of them do escape any such inconvenience.

In the case of epistaxis, one may readily acquire a sort of habit of bleeding at the nose, and the discharge in that case, differs not at all from that of the menstrua, except in respect to the nature of the epithelial desquamation, and, probably, also, some modified state of the admixed mucus. A patient shall bleed at the nose to the


MENORRHAGIA. 425

extent of losing an ounce of blood on one occasion, whereas on some subsequent one, he may lose a wash-basin full in a continu- ous rill; just so is it with the menstruating woman. When she bleeds just enough, just her accustomed quantity, it is all right with her; when she flows in excess, she is menorrhagic, she has menor- rhagia. The word is derived from the Greek i.ir,v month, and pjjyi'Vfti to breakout. It is a true case of true uterine hemorrhage, though we are accustomed to call it menorrhagia, in order to indicate the opinion that it is connected with the mensual hemorrhage, and is not an accidental one. Hence, I advise you, when speaking of he- morrhages connected with the causes of menstruation, to call them menorrhagias, a word that expresses a whole phrase. It is a word that may be thus paraphrased. The woman is bleeding excess- ively, because the ovi-posit, in her case, has induced an excessive nisus hemorrhagicus, instead of the usual moderate and natural .pne; but when a woman bleeds because she has a phagedenic ulcer of the womb, or a detached ovum, or a polypus, or a bunch of hydatids, or a wound, then it is uterine hemorrhage. In this way you will speak with precision; and if all our brethren would be equally precise, there would be a better understanding of the meaning and value of the words menorrhagia and uterine hemor- rhage.

Now the question comes up as to what can be the cause of a menorrhagia, and it is a question difficult, in many individual cases to answer. I say it is difficult to answer the question for a good many cases; in others it is not difficult.

There are some women who have a very powerful systemic ven- tricle, giving a large, full, hard pulse, like the pulse of a synochus fortis. In such people, the blood driven forward by every stroke of the ventricle with a great momentum, reaches the distal parts of the circulation, with such a force of movement, that we need feel no surprise to find the hemorrhagic surfaces, once begun to bleed, continuing for a long time, and abundantly to discharge the sanguine fluid.

Such hemorrhages are the common incidents of those persons who have hypertrophy of the left ventricle. In men, these hemor- rhages go to the lungs — the nose, the stomach, the hemorrhoidal vessels, or the brain ; and are called hemoptoe, epistaxis, heraa- temesis, apoplexy, &c. In women, the same dangerous tendencies exist, but the habit of yielding to the force of the sanguine injec-


426 MENORRHAGIA.

tion of the uterine and spermatic arteries, causes them to be more frequently attacked with menorrhagia. In such a state of the arte- rial pulse, a menorrhagic attack is readily explainable by reference to the enormous force of the heart.

It has been asserted that within two hundred years past whales have been captured of the length of three hundred feet, though it is at the present day rare to meet with a whale of seventy or eighty feet in length. The animal is so much sought for in the whale fisheries, that the large and aged ones have been in a good mea- sure destroyed, the captures amounting probably to ten thousand a year. But a whale of three hundred feet in length had an aorta of twelve inches in diameter, the blood of wdiich was impelled like a torrent by an enormous systemic ventricle. The power of that ventricle no dynamometer could estimate; it must be enor- mous. My design in mentioning it is merely to suggest by it to your mind a reflection on the power of the systemic ventricle in all animals. That power in all the species should be conformable to the power of the tissues that receive the sanguine injection. Now, you can perceive, that in our case of menorrhagia the injecting force may far transcend the resisting power of the tis- sues, and the consequence might be, a menorrhagia lasting until the abnormal energy of the injection-power comes back to a con- formable degree.

But there are some weak and very susceptible people, on the other hand, whose hearts are soft and gentle in motion, who nevertheless suffer from menorrhagia. For such people you can- not bring the excessive development of the heart to the solution of the problem. It is better, and more consonant to reason, to suppose that such patients suffer the excessive losses in conse- quence of an adynamic state of the womb itself, a state which enables a moderate force of arterial and capillary injection to overcome the barriers to hemorrhage that ought to be set up in the distal extremities of the vessels — vessels that ought to be strong enough to resist the hemorrhagic force, but are not, so that you have come to the conclusion that a menorrhagia may depend upon either an excessive power of the sources of the circulation, or upon an adynamic state of the organs upon which that circu- lation is directed.

This last supposed case may be dependent upon some faulty action of the entire nerve system of the reproductive organs — a


MENORRHAGIA. 427

faulty state brought about by frequent pregnancies and abortions or labor — by indulgences in unlawful contacts — by excessive libidinous sensations — and lastly in the wretched class of public women, by the habits which ruin and degrade them both physi- cally and morally.

Again, you may encounter cases of menorrhagia dependent on malignant disease, on typhus, on small-pox, on scarlatina, on cancerous vice — for all these maladies vitiate the blood, and pro- duce a state of the solids so utterly atonic, and of the blood so completely aplastic that it flows away passively, and soaks, so to speak, through living tissues that are already half dead.

A woman may have a menorrhagia because she has a polypus growing within the womb ; I say a menorrhagia, for the polypus may be a firm fibrous tumor, very sparingly supplied with cir- culation in its own substance, and without any abrasion of its superficies that might cause it to bleed : and in this very case the womb shall be so vexed and so irritated by its presence and pres- sure, as to be the subject of a hemorrhagic nisus of the greatest intenseness, arising from the presence, the pressure, and the irri- tation excited by the tumor, and not from the tumor itself, so that the flooding is flooding of the womb, and not of the polypus. You should note this distinction, for you may meet with many polypes that bleed themselves, but which do not make the womb bleed.

A sample of this sort was the case I mentioned at page 249, of my XlXth Letter, and I have seen many such.

I fear, my young friends, that, like some older persons, you will not be so careful as you ought to be in making the diagnosis of our case. I will not say that it is always possible to make that diagnosis with absolute assurance, but I presume that where a perfect periodicity of the bleeding, I mean a catamenial periodicity, is observable, you will be pretty correct in resolving that it is a menorrhagic and not a hemorrhagic flooding. Indeed, it will, with such periodicity, be truly menorrhagic, even if the causa ipsissima be a polypus, a carcinoma, a gestation, &c. &c. If the case be not characterized by this periodicity it will not be men- orrhagic, but will, far more likely, on the face of it, wear the imprint of polypus, of ulcer, of vegetations, &c. &c. &c. The appearance, and the abundance of the discharge furnish no means of discrimination.


428 MENORRHAGIA.

In order to explain myself more fully, let me say that a hemor- rhao-ic nisus once set on foot does not, in some cases, exhaust itself for days, for weeks, or even for months, and yet the case is a case of simple menorrhagia. For example, I was, some time last winter, invited to give counsel to a lady, unmarried, aged about 28, very fat, and even ruddy in complexion, and strong. She had not been one day w^ithout copious bloody flowing, for full six weeks, or forty-two days. I found her pulse not preternaturally full, but the rather, I found it to be quite conformable to the state of her general constitution. Still she kept on bleeding, as I said, for forty-two days, without a moment of intermission. My im- pression was, that the texture of the womb had, from some un- known cause, become relaxed so as to produce an hypersmic state of the organ, which all the discharge was as yet unable to reduce. I asked myself this question. — What does the lady re- quire for her cure — not what drug, but what change in any of her organs? Does the heart want any change? No; it beats well and temperately as I could desire. Is there any extraordinary excitability or sur-excitation of the nervous system in general? I can discover none. All the secretions are healthy; this issue of blood, wdiich is completely blood, is the only fault. What is most likely to cure it? Anything that may condense the tissue of the womb, that may serve to make the womb smaller, harder, more solid, stronger — for the womb is composed of uterine tissue, with its vessels, nerves, absorbents, and cellular tela. What can I do to bring about this state of advantageous condensation of the womb? I can or.der cold baths, astringents, rest in a recumbent position, cool air, cold acidulated drinks, cold enemata — but, of all remedies, the most clearly indicated one is the secale cor- nutum — because, if that should have any effect whatever upon the womb, it would be the effect of condensing the uterine solids. I gave some vinum secale cornuti. She took a teaspoonful, which was repeated three times a day, and in two days her menorrhagia was gone and returned no more — vel post hoc, vel propter hoc. I say, vel post hoc, vel propter hoc. At about the same time I visited a maiden lady, 40 years of age, who had long led a very sedentary life. She complained of a constant discharge of her courses, as she said; and had not been free from a sanguine effusion for more than three months, nearly one hundred days. As the effusion was the sole symptom, save the accompanying


MENORRHAGIA, 429

debility, I felt that I had a right to regard it as a case in which, if the womb could be made to acquire an additional and normal degree of tonicity, the complaint would cease. I said, if secale cornutum has the same power to excite the muscular innervation of the non- gravid as of the gravid womb, it will probably fulfd the indication ; for, if the womb, in its substance, shall become condensed, all its parts will receive of the benefits of that condensation. I gave her vin. secal. cornut., a teaspoonful three times a day, and she told me after three days that her trouble disappeared, since which she has enjoyed her usual degree of health. Kow, for my own part, I do not at all doubt the wine cured her, for here are two clearly marked cases of the therapeutic effect of the drug speedily manifested ; and for a great many years past I have occasionally found patients complaining in the same way, who have been in like manner cured. Pray, take notice of what I suppose to be the rationale of this cure, for it is for the sake of the rationale that I relate the cases. I wish you to understand, not so much that I cured these people, as the principles upon which I relied for their cure. I wished you to understand that a woman may have a menorrhagia because she has a flaccid, feeble, engorged, adynamic womb, just as an accouchee may have a post-partum hemorrhage because her womb will not condense itself; in the accouchee you will compel it to condense itself by various means, among which not the least nor last, will be the secale.

Sometimes the secale fails to evince the slightest power over the non-gravid womb, even over the post-partum flaccid womb ; and in such cases, being disappointed of the condensing force of the secale, you must seek for other means of cure, requiring longer processes, such as styptics, tonics, cold, wine, and the best of the resources, as to certainty of operation — videlicet, the Tampon.

Very young girls are, some of them, subject to menorrhagia. I have seen a girl under 18, using sixty napkins at every menstrua- tion. This young lady died about a year afterwards, with some physical alteration of the uterus, or ovary, I know not which, since she lost her life in a distant city.

You will be very undutiful as physicians, if you do not attend to the greatest of all points of duty, I mean the establishing a sound and true diagnosis. Remember the heart of the Balsena raysticetus, and its artery a foot in diameter. If your patient's pulse and heart's throb, put you in mind of the Balsena, you would


430 MENORRHAGIA.

bleed her, I should think; you would lay her in bed ; you would exclude all stimulants, all conversation, lights, rich food, &c; you would weaken her heart's injecting force by the lancet; and you would give her tartar emetic in small doses ; and digitalis, and cold acidulous and styptic, or hsem astatic drinks. Or, on the other hand, you w^ould find her circulating power to be normal, and in that case you would not proceed as above, but you would apply styptics, cold, rest, opium, secale, &c. &c.

As a general rule, I suppose that were a young person to send for you on account of a profuse menorrhagia, you would tell her nurse to put her to bed; to cover her lightly with bed-clothes; give her cold drinks, feed her sparingly ; apply some cloths wrung out of vinegar and water, to the hypogaster, and tell her there is nothing to be feared. Such a counsel would, in most cases, com- prise nearly all you ought to do, or direct; but now and then you must go farther than this.

I had a very extraordinary case under my care last winter, which I shall relate to you ; and I hope you will not find fault wuth my conduct in the case.

A very delicate young lady, brought up in the lap of luxury and indulgence, and having at command all the advantages of fortune — possessed, of course, that nervous sur-excitability, that accompanies the higher advantages of the social state. Her age was eighteen or nineteen — an only daughter. Her weight about 88 or 90 pounds. She had had a two months' amenorrhcea, which was followed by a rather profuse menstruation, which was succeeded by a three months' retention, during which she had no occasion to complain of ill-health, beyond the mere fact of the amenorrhcea. At the end of the said three months, she had in the morning a very slight show, which she was glad to discover; and, upon consultation with the mother, went out to take a walk, hoping in that way to secure a good elimination, by setting the blood in motion. She did not go very far, and upon returning to the house was considerably more unwell. Early in the afternoon • her mother sent me an urgent message. I learned that the dis- charge was excessive, with coagulations; but deeming it not at all alarming, I ordered her to be kept very quiet, in a low, recumbent position in bed. I gave her some powders made as follows : — Take a drachm of alum and a scruple of nutmeg; make a pow- der, to be divided into twelve parcels, of which one parcel is to


MENORRHAGIA. 431

be taken every hour, or every two hours, according as the flow is greater or less. She was allowed cold lemonade.

At 10 o'clock at night I was recalled and found a great alarm; a night-vase was filled with napkins deeply stained, and with many clots. The pulse was weakened, the face pale, but the patient not at all disconcerted. There seemed to be no hemor- rhagic nisus discernible in the action of the pulse. There was no pain.

The parents were deeply concerned, and asked me many ques- tions as to the danger, and the means to obviate it. I told the mother that the arrest was in my power at any moment. " Well, sir, why not use at once the means that may put a stop to so fright- ful a discharge?"

In reply I stated that I did not deem it necessary now to act ; for, there was reason to expect that the hemorrhagic propensity would soon be exhausted — that there were many therapeutical remedies of considerable force, and that I preferred not to resort to a chirurgical measure until compelled by the stress of circum- stances; for I should deeply regret to subject so young a lady unnecessarily to the Touch, without which the remedy in question was not to be applied.

You will think it strange that I passed the whole night, until daybreak, in that apartment, and that I suffered the child to faint again and again ; opening the windows, using the fan, applying iced vinegar cloths to the hypogastrium and thighs, administering opium, sulphuric acid, and rose-infusion, taking the pillows occa- sionally from under her head, and vainly endeavoring to reassure the mother, who repeatedly entreated me to use the tampon, but I would not. Towards morning a remission occurred, and I went to my home. She was calm until after breakfast, when, upon my return to her chamber, she began again to flood and to faint, so that I was compelled to say to the mother that the time was now come to put a definitive stop to the hemorrhage, whose longer continuance would compromise the young lady. This informa- tion she joyfully received.

When she had provided me with a bundle of old linen, and cut it into squares of four inches, many of them, I pushed them one by one, to the bottom of the vagina, out of which I first turned a handful of coagula. As soon as I had filled the vagina with the squares, I applied a napkin, folded up thick, in shape a


432 MENORRHAGIA.

parallelogram, that was carefully adjusted to the genitalia; and having secured the compress by the usual bandage very firmly drawn, the hemorrhage ceased. In twelve hours I withdrew the tampon; no flooding came on. In a few days the discharge ceased completely. I gave her broths and meats, and wine and iron, and she has been ever since in excellent health.

There, gentlemen, is the unexaggerated history of the conduct of a case of menorrhagia in a virgin. I am ready now to say, that if I had such a case at this moment, I should treat it in the same way, as far as to the chirurgical part of the treatment. I do not regret that I allowed her to bleed so much and so long. I would permit another young lady to do the same thing, because, having confidence in the power of the tampon to suppress such a flooding, I would let her go very far towards a dangerous state rather than subject her to the mortification of the surgical inter- vention.

As to the mortification which overtook' her at last, you ought to reflect that it was sunk in the hazard. There was not, and there cannot be, any mortification for the mind when the consciousness of extreme distress or peril becomes the paramount sentiment. I have no doubt that the very perilous condition into which I al- lowed her to fall, had the effect of removing wholly the shock, and the vexation, and the shame, that would have wounded her had I, like a remorseless barbarian, subjected her unnecessarily to the Touch.

I hope you will read this case with care. I say wuth care, and I mean to urge you, on the one hand, not to be too hasty with Your chirurgery, and on the other hand, not to let your patient sink so low as to make it out of the question to restore her. You ought, in the beginning of your career to be ever thoughtful, ever circumspect, never in a hurry to decide — always allowing your- self time to study the state of the case, in all its bearings both present and prospective. A young man is as capable of doing this as an old one; the only difference is, that the old man has learned to look about him, while the young man will not, in his hot and hasty temper, take time to think, but snaps at his con- clusions like a duck at a June-bug, as we used to say when I was a boy — excuse the homeliness of my simile ; many of you have known it to be a common j^arlance, especially at the south; at least it was so forty years ago.


MENORRHAGIA. 4^3

Styptics, in uterine hemorrhage, are not of very great power. The mineral acids are about as good as any of them ; ten to fifteen drops of elixir of vitriol, diluted with a wineglassful of infusion of roses, makes a very good dose that may be repeated every hour or two. Five grains of powdered alum, with two grains of nutmeg, made into a powder and mixed in syrup, is a good dose, to be repeated hourly. I think, upon the whole, this is one of the best of the styptics. It is a very safe one. If you should make use of it in some bad case, and should find the flowing to continue notwithstanding your administration, take my word for it that you ought to make the patient swallow a large teaspoonful of the alum for a dose, and repeat it several times. It readily excites vomiting; indeed, there is hardly to be found a more powerful emetic. But, an emetic is a good therapeutic against a hemorrhage or menorrhagia, because the state of nausea, and the emulging influence of the act of vomiting, are capable of changing the determination of the blood, whilst it powerfully modifies the rate, not only of the heart's action, but also the rate and distribution of the innervative or Biotic force.

Take, therefore, into your practice, the assurance that alum is one of your best medicines. See a paper on Croup, by my son. Dr. I. F. Meigs, in the Amer. Journal for 1847, for an account of the uses of alum as a remedy.

Again, you have in opium a powerful modifier of the circu- lation. Opium always modifies the pulse ; it checks the hemor- rhagic nisus of the womb very effectually; think, therefore, of the resources you have in your hands through this drug.

Sugar of lead is thought to be a very powerful article in the treat- ment of these hemorrhages. I do not like it, nor do I believe much in it; perhaps I have not dared to give it in excessive quantities, and having very rarely exhibited more than three grains in com- bination with opium for the dose, I am not sensible that I have ever been much struck with its haemostatic power, though I have made use of it many times, yet less frequently of late than in former years.

The secale cornutum is a good and safe remedy ; I know of no objection to its use in menorrhagia; I ought, however, to say that if you make a false diagnostic, and give the patient secale when she is pregnant, while you deem her only menorrhagic, you will kill her child by making her miscarry. This you ought not 28


434 DYSMENORRHCEA.

to do, for it is discreditable to you and to your art to make such a mistake. But having on a former page presented you my views on the use of secale, I shall not here iterate them.

When a patient has recovered of the actual menorrhagia, you should give judicious orders as to her exercise, dress, food, and medicines, and take care, on the one hand, that the cardiac forces of the circulation become not again predominant in their power, and on the other, that the density or tone of the tissues of the body may be restored to a normal condition by those hygienic and therapeutic remedies and conduct that are suitable in the case. In all anemias, pure anemias, iron is the best of the the- rapeutic remedies — the wine, meats, baths, &c., are of the great- est importance in the way of the adjuvant ordinances. Farewell.

C. D. M.


LETTER XXXIV.

ON DYSMENORRHCEA,

Gentlemen: — The Greek words Sd? fir;v pjw mean — first, difficult ; second, month; and third, I flow; so that out of SvifiT^vpsu it was easy to make the word dysmenorrhoea, which might be translated absolutely, a difficult monthly flow.

Dysmenorrhoea is a more or less painful disease ; sometimes not very much so, but not unfrequently so much so as to give a color of distress and affliction to the whole life of the patient. A lady said to me, some time ago, "Doctor, I have for fifteen years suf- fered invariably at my periods, such intense distress, that I can scarce think of anything else than that on a given day my pain is to be repeated; language is incapable of expressing the degree of torture which I suflTer under the pain, the approach of which fills me with horror."

A woman who suffers dysmenorrhoea, is, ipso facto, unhealthy, as to the womb, and very likely to be unfruitful in the marriage- bed. It is true, that dysmenorrhoea may last for many years, in


DYSMENORRHCEA. 435

certain persons, without bringing about any visible change in the health of the constitution, which remains vigorous and retains the normal powers of development, notwithstanding the invariable return of the pain at the mensual term.

You are not, however, from this statement advised to take up the notion that dysmenorrhoea is an indifferent matter viewed in the aspect of its influence on the health and security of the pa- tient.

The pain, the irritation, the imperfect performance of the func- tion, and the state of the tissues producing it, are, all of them, cir- cumstances well calculated to excite the solicitude both of the patient and the physician, because it remains everlastingly true, that the disturbance of the health of the reproductive tissues is very likely to exercise a disturbing influence upon the soundness and healthfulness of the entire rest of the constitution.

The pain of dysmenorrhcea, is a pain felt in the hypogastric region, in either or both of the iliac regions, in the tractus of the ligaraenta rotunda, in the sacral region, in the thighs, and very frequently in the course of the distribution of the obturator nerves. This pain, not unfrequently, extends to the whole belly, and is at times insupportable, from its violence; compelling the patient to lie down in the bed, or on the couch; forcing from her both tears and groans, and producing so great a degree of restlessness, that she seems to writhe like a crushed worm.

As a general rule, it maybe stated that, the pain is over in six or eight hours, and that it is rarely intense during more than twelve hours, while the painful sensations, however, may con- tinue one, two, or three days, and in some women through the entire progress of the catamenial act. A person who is subject to dysmenorrhoea, for the most part, finds herself relieved in the course of the first day, or as soon as the flow of blood becomes fully and freely established; and regards herself not subject to considerable pain or inconvenience, until the cycle shall have brouofht back to her the hour of her affliction.

There are hundreds and thousands of women, to whom the menses never bring any the least trouble or inconvenience; there are vast numbers of females, also, -who are notified of the approach of their terms, by some sense of fullness and weight, or dragging, in the region of the pelvis; symptoms which disappear as soon as the nisus hemorrhagicus has effected the opening of the mouths


436 DYSMENORRHCEA.

of the vessels, and begun to relieve the polygsemia of the repro- ductive tissues.

The woman's womb aches until nature bleeds her, as the pleu- ritic man's stitch torments him until his physician opens a vein in his arm. If the menstrual flow succeeds in relieving the turges- cence of the vessels of the womb, it will, pari passu, have relieved the nerves of the organ of their hypersesthesia. The pain is of the nerve, and, I suppose, might be fairly attributed to the sort of compression which the distal extremities of the reproductive nerves must suffer in any case where an organ so solid in its tissue, so firm and elastic, as is the uterine texture, becomes the subject of a very decided polygsemia.

I have already said that the uterus, or rather the reproductive, apparatus of the female, is extremely liable to that form of disor- der which is called rheumatism, a circumstance not to be won- dered at, in view of the manners and customs, modes of dress, and habits of the females living in the various latitudes in which miost of the people of Christendom reside. In those latitudes women are rarely clothed as warmly as they ought to be, custom, bienseance, the power of fashion, cause them to clothe the pelvic region of the body and thighs too lightly ; and the women who live in what are called the better classes of society, are constantly exposed to the morbific influences of cold and damp, applied to the lower extremities.

The menstrual alternations of the life-force of the reproductive organs, which allows them never to continue in one even tenor of action, probably exposes them more peculiarly than other or- gans to the morbific, repercussive influence of cold and damp, which are admitted to be the most considerable provocatives to rheumatic disorders.

Well, then, do you not perceive that a rheumatic womb is likely to be a painful womb during the menstrual act, and that much of the dysmenorrhcea which it will be your destiny to en- counter in your future career as practitioners, will be justly re- garded by you as a form of rheumatism? Dr. Dewees was fully convinced on this point.

I am desirous to impress this notion upon your minds, my young friends, because if the notion be well founded, which I be- lieve it to be, I am sure that it will teach you in your therapeuti- cal prescriptions, and in your hygienical recommendations and


DYSMENORRHCEA- 437

ordinances, to take such precautions, as may tend to free the patient from the essential element of her maladive condition, which is rheumatism.

But there are many causes besides rheumatic vice, which may give rise to pains in menstruation ; doubtless the womb may be like any of the other tissues, the seat of a pure neuralgia, by which word, I mean a preternatural sensibility of the nerves of the tissues. Such a neuropathic condition would not fail to be aggravated, at the inception of that vascular engorgement which, under every theory of the function, is assigned as the antecedent or attendant of the monthly flow; and it is quite reasonable to believe, that the full establishment of the evacuation might be expected to relieve the woman from her neuropathic state. It may well happen, too, that the patient may suffer tpains at the menstrual crisis, dependent upon the temporary aggravation of evils, derived from the presence of tubercles, and of various hete- rologue formations, to which the womb is not unfrequently found to be subject.

A displaced or a deviated womb, is truly a dislocated womb ; but a dislocated organ cannot be supposed to have a healthfid ex- istence, since such dislocation cannot fail to produce distortion and traction of the nervous tractus, which renders the organ liable to sufTering, under changes of its sanguine circulation, and its innervation.

A womb that is m.aintained at its proper height and in its pro- per attitude in the pelvis, will be, C2eteris paribus, less likely to be the subject of dysmenorrhoea, than a displaced or deviated one. A uterus that is retroverted will scarcely fail to be a dysmenor- rhoeal uterus ; a uterus that is far prolapsed will rest with the os uteri upon the floor of the pelvis, and resting there for a long time, the neck of the womb is likely to become bent at an angle ap- proaching more or less to a right angle. But, if the cervix uteri is bent at a right angle, don't you perceive that the canal of the cervix uteri is, by that very fact, placed in the condition of a strictured canal ? But, if you have a strictured canal of the cervix uteri, will not irritation in the body and fundus of the uterus, supervene from the difhculty which must necessarily ensue in the evacuation? Don't you know that a stricture of the urethra pro- duces irritation of the bladder, of the ureters, and even of the kid- neys, and will you find it difficult to suppose that a stricture of


438 DYSMENORRH(EA.

the canal of the cervix uteri, may, in the long run, lay the founda- tion for such irritation of the womb itself, as shall result in the establishment of a true dysmenorrhoea ?

I don't pretend to say, that all the cases of stricture of the cervix uteri, are to be attributed to anteflexion or retroflexion of the neck of the womb, although those flexions are among the fre- quent causes. It is very certain, that some of the strictures of the cervix uteri are congenital ; you will admit that this is the case, because you already know, that congenital atretism of that canal, is one of the possible circumstances hereafter to attract your attention and call forth your skill. I have had several samples of great contraction among the anatomical specimens in my collection, and I have seen similar ones in some of the mu- seums of Europe. It was upon the observation of this constriction of the canal of the cervix uteri, constriction so great, as to make it not a little diflicult to introduce a common pocket probe to the fundus uteri, that that most ingenious physician Dr. Mackintosh, author of the Practice of Physic, founded his successful treat- ment of cases of dysmenorrhoea.

Dr. Mackintosh has given numerous cases of females, in which he observed that the orifice of the canal of the cervix was exceedingly small; so small as scarcely to be perceptible to the touch : on pressing into that orifice a small bougie, which he car- ried up through the whole canal to the cavity of the body and fundus, he gently dilated the passage, which he fully dilated by successive operations, in which he employed larger, and still larger bougies, until the calibre of the passage was perfectly restored.

The effect of these operations was to cure his patients of the most distressing and long-continued dysmenorrhoea, which serves conclusively, I think, to establish the theory which I am laying before you, namely, that stricture of the canal of the os uteri may be a cause of dysmenorrhoea.

Dr. Mackintosh's practice has been used everywhere, and with undoubted success in cases proper for it. Some of the brethren have preferred to Mackintosh's method, the use of a concealed bistoury, which, being introduced to the upper extremity of the canal, is slightly disclosed by a spring, and then being with- drawn entirely from the os uteri, has divided the lining mem- brane of the canal, allowing of a complete dilatation of it. When I was in London, in eighteen hundred and forty-five, Dr. Locock


DYSMENORRHCEA. 439

showed me one of these instruments with the effects of which he appeared to have been much pleased in his practice.

If you have read this book, you must have observed in a former letter, that I strenuously opposed the use of all cutting instruments in the procuring of a requisite dilatation, upon the ground, that every division must be followed by a cicatrix, which is, essen- tially, a morbid existence; whereas all necessary dilatation can, I am convinced, be as readily and perfectly brought about by a dis- tending pressure, leaving the part, when the part has been thus cured, without a wound, and in a perfectly healthful and normal state. I repeat it, that a cicatrix is not a normal state ; it is always insecure, ahvays dangerous. I, therefore, profess my adhesion to Mackintosh's practice. My own experience in the use of the bou- gie, has been to a certain extent satisfactory to me ; satisfactory to this extent, that it has not only, in some cases, relieved the woman from distress, pain, and other disorders of menstruation, but that it has cured her of a preexisting sterility. A woman is likely to be sterile w^hen her uterus is unhealthy, and particularly when it is unhealthy from narrowness of its canal.

Within two months, there came to me from a distant state, after a correspondence which I had had wath her physician rela- tive to her case, a lady complaining of dysmenorrhoea. She had been for fifteen years, perfectly regular; she never failed in her menses; she could not remember a single instance of her cata- menia in which she had not suffered the most direful distress; her general health was excellent ; she had a lively, brilliant, com- plexion, a charming degree of embonpoint, but she had been many years married, and had had no children. After conversa- tion with her, she was willing to submit to an examination by the Touch, and afterwards by inspection by the speculum. I found, upon the Touch, that the os tincse rested upon the floor of the pelvis, where it had long rested; and I supposed that the weight of the uterus and the superincumbent pressure, had produced an ante- flexion of the cervix, bending it at about an angle of 110°. The opening of the os tincse was very small. Exposing that orifice by catching the collum uteri in the uterine extremity of a Recamier speculum, I pressed into it a linen bougie, which I conducted as far as the cavity of the womb. On the following day I repeated the operation, succeeding with a larger bougie, and the operations were repeated four times only, wdien I desisted from further attempts,


440 DYSMENORRHCEA.

because her catamenial hour was nigh at hand. On the fourth day after the last operation, her courses appeared in due time ; they flowed freely, abundantly, and normally, and for the first time in her menstrual life, which, as I before said, had now continued for fifteen years, she passed through her menstrual crisis with- out the least uneasiness or distress, to her great satisfaction and that of her anxious husband. She soon afterward returned to her own state, promising me to keep me informed of the progress of the cure, since which I have had no tidings from her.

I will not cram this volume with cases of an analogous kind, and in the treatment of which I have sometimes been so happy as to be very successful, while at other times my patient has not derived the least advantage from the process, probably because in the unsuccessful cases the remedy was not the one which I ought to have adopted.

Dr. Mackintosh, at p. 655, Washington ed., informs us that he has treated twenty-two cases of dysmenorrhoea by dilatation of the OS uteri, of which eighteen were permanently cured. " Ten of these were married and living with their husbands; of these ten, seven subsequently fell with child."

I have already asserted my belief that the uterus is the fre- quent subject of rheumatic disease. In the cases in which you may have reason to suppose that the malady is derived from a rheumatic vice, it will be reasonable for you to employ Dr. Dewees' celebrated volatile tincture of guaiac, on which, you know, he placed so great a reliance, but which, in my hands, I am sorry to say, has not fulfilled the high expectations which were derived from Dr. Dewees' lectures and publications.

I think you will find advantage in using, a few days previous to the attack of dysmenorrhcea, moderate doses of the golden sulphuret of antimony, combined with camphor and small por- tions of opium or morphia ; you will scarcely find an article possessing greater deobstruent powers, when an inflammatory excitement may be supposed to exist, than this special combina- tion, which not only has efficacy to soften the pulse, to increase the perspirability of the skin, and promote the secretions, but is also an efficacious agent in the subduction of the nervous excite- ment or erethism, which must be supposed in such cases. In any instance clearly traceable to a rheumatic condition of the fibrous texture of the uterus, and, in which you can indulge in a


DYSMENORRHCEA. 441

hope of doing good by purgatives, allow me to suggest to you, the employment of Scudamore's mixture of acetous tincture of colchicum, magnesia, and sulphate of magnesia combined with some aromatic distilled water; you should for this purpose, com- bine three drachms of acetous tincture of colchicum, one drachm of magnesia, and three drachms of sulphate of magnesia, with four ounces of any aromatic distilled water, as that of mint, cin- namon, or what you will. The dose should be preceded by a moderate portion of blue pill, or calomel, to be taken at bed-time, while the colchicum mixture should be administered the following morning, in wineglassful doses, repeated every second or third hour until the operation is sufficient.

It is important in all those cases where you wish to clear the reproductive organs of any accidental disturbing influence that may arise from irritation of the rectum, dependent upon accu- mulation of feces or improper excretions there, to move the ali- mentary passages as preliminary to some more direct treatment. The mere removal of the heat and excitement dependent upon irritation seated in the lovver bowel, may be sufficient to set the womb at liberty to perform its menstrual act without pain, or the least distress.

I have already expressed to you my little belief in the power of emmenagogue medicines, without withholding my assent to the opinion that certain medicaments are endowed with the faculty of increasing the determination of the blood, and of the nervous force, toward the pelvic extremity of the body. I have found it safe, convenient and efficacious with this view, to administer for a long series of days, weeks, and even months, portions of the common tincture of Melampodium or black hellebore, and I confidently be- lieve that for different individuals to whom I have prescribed such medicaments, the result has been most fortunate. I have prescribed from fifty to sixty drops of the tincture to be taken thrice daily, with an infusion of some garden herb, as pennyroyal, and, either post hoc vel propter hoc, the patient, who had suffered the greatest distress from dysmenorrhoea, has been in different instances en- tirely relieved of her sufferings. This result I have obtained so many times, that it has become habitual with me to make the prescription where some other indication has not had the pre- cedence of it; such as venesection, purging, leeching, the bou- gie, etc.


442 DYSMENORRHCEA.

I further believe, that the use of the ferruginous tonics in the cases where the crasis of the blood is so reduced as to warrant them, ought not to be omitted, and, that in a person laboring under dysmenorrhoea, and in whom it is right to prescribe the tincture of black hellebore, it will be, in general, right to prescribe Dr. Blaud's pill, of which one may be taken three times a day; or a pill composed of two or three grains of Vallet's mass, thrice daily, or, what, perhaps, is preferable to all the rest, two grains of Quevenne and Micquelard's metallic powder of iron. The patient, under these circumstances, in all the variable and cold seasons, should be compelled, as far as the authority of the physician will go, to wear drawers of woolen flannel.

In the cases of dysmenorrhoea, in which there is pain in the uterine region during the intermenstrual period, and which is greatly aggra- vated during the menstrual epoch, an examination by the Touch might convince you that the organ is left in a subacutely inflamed state. In your treatment of an obstinate and serious malady of this sort, I should think you would deem it your duty to solicit an opportunity of inspecting the coUum uteri, by means of the Re- camier speculum. It is not rare to find the interior aspect of the lips, and, indeed, the whole os tincse, red, turgid, and injected to such a degree, as to render the arterioles et venules visible, as you find them often in the chronic diphtheritis of the pharynx. A general bleeding, or a topical abstraction of blood, by means of leeches, are among the likeliest means to counteract this morbid state of the circulation of the parts, which, as long as it is allowed to persist, might effectually contravene your merely therapeutical efforts. To obtain a cure, bear in mind, also, I- pray you, this solid therapeutical truth, namely, the nitrate of silver applied to a superficies, is among the most powerful, and least painful, of the antiphlogistic remedies in your power; and that, in aiding to cure the topical affections of which the uterus complains, it will aid you to rid the patient of constitutional disturbances arising from those lesions.

Many of these dysmenorrhceal patients complain of the dis- charge of shreds of an organized membranous material, which is doubtless the caducous coat of the uterus. If you don't like this term, caducous coat of the uterus, then, I beg you to say that when such a membrane is discharged in dysmenorrhoea, the half organized mass is not, and cannot be the result of coagulation.


DYSMENORRHCEA. 443

but must be a plastic deposit, like the plastic deposit in croup, and like that in phlebitis, in pleuritis, peritonitis, &c., and ipso Jacto, proves the existence of an inflammatory state, because plastic deposits are not found, except in a condition which de- serves to be called an inflammatory condition.

Dr. Dewees regards this excretion as derived from a rheumatic condition of the uterus ; you will see his reasoning on the sub- ject, at page 106 of his essays on various subjects, Phil. 1803, and you will find that he was led from a priori reasoning to make use of the guaiac in the cure of the complaint. At page 110 is his formula for the preparation of his celebrated tincture, which is in the following terms: —

B. — Pulv. gum. guaiac: 5viii;

Carb. sodse vel potass : 3iij ;

Pulv. pimentse liij ;

Alcohol dilut. ffiij.

The volatile spirits of sal ammoniac is to be added, pro re natd, in the proportion of from one to two drachms, less or more, agreeably to the state of the system.

Dr. Dewees is justly to be regarded as one of the most emi- nent practitioners of midwifery in his day, and no American phy- sician has acquired a wider-spread reputation, either at home or abroad, than he. His opinions are entitled to respect, and I refer you to his article on dysmenorrhoea, which every student ought to read ; in that article you will find his directions for the admi- nistration of the volatile tincture of guaiac, with an account of the flattering results obtained from its employment.

I do not consider myself as treating his memory with any dis- respect, when I suggest to you that it is rarely the nature of rheu- matism to produce plastic secretions upon surfaces, and that in none but the most violent examples of rheumatic inflammation, do we find plastic secretions, even about the articulations.

Be careful, in all cases, about your patient's diet, about her occupations, and about her whole conduct; think always what you have to do, and how it is best to be done.

I think, gentlemen, I shall have nothing further to say to you at present, of dysmenorrhoea. I am

Very truly,

Your obedient servant, C. D. M.


444 CHANGE OF LIFE.


LETTER XXXV.

Gentlemen : — In this letter I shall speak to you on the " change of life," as it is commonly called, or that state of the female in which she finally loses the power of menstruation, ceasing from that time forth to be subject to the mensual evacuation of blood.

If I have been correct in the opinion I have entertained, and which in former letters I have expressed, as to the causes of men- struation, then I shall have little to do in making you acquainted with the causes of the cessation of the menstrua, or change of life. For it is obvious, that if women menstruate because of the month- ly ovulation and deposit, they cease to menstruate because the monthly ovulation has ceased to be a Biotic function.

I have all along insisted that the power of germ production is a climax of life-force — one that is only attained when the body has attained its full and mature development, maintained as long as that body retains its healthful vigor and force, and lost often upon the smallest change of the health, and given up definitively when the powers of life, having been exerted during the prime and ma- turity of the forces, begin to fail, and the possessor to decline to- wards the last term of existence, which is stated to be at three score and ten years.

There is something melancholy in the conviction that must at- tend the final cessation of the menses, of a decadence of the con- stitution. The subject of such a conviction is compelled to admit that that she has now become — what? an old woman. Hence- forth, what has she to expect save gray hairs, wrinkles, the gradual decay of those physical or personal attractions, which heretofore have commanded the flattering homage of society — the slow aug- mentation of the burdens of existence — when the grasshopper becomes a burden — when the keepers of the house shall tremble, and they that look out of the windows shall become dim. The pearls of the mouth are become tarnished — the hay-like odor of the breath is gone — the rose has vanished from the cheek, and the lily is no longer the vain rival of the forehead or the neck. The dance is preposterous, and the throat no longer emulates the voice


CHANGE OF LIFE. 445

of the nightingale. All these are melancholy convictions, and not even the fine arguments of Tally, in his Treatise on Old Age, can drive away the painful truth or make the wrong the better reason. To be sure, religion can bring its consolations, its hopes, and its triumphs ; — for religion can make us triumph over death and the grave, robbing them of their sting and their victory. Still, human we are, and we shall be human while the clogs of mor- tality still hinder and bind us.

What hope, then, has the woman who has come to the period of the change of life? Have you any comfort for her? Yes! She is no longer exposed to the direful risk and pain of child- bearing. She thanks God for that, and takes comfort in the thought. She is no longer to be the subject of the monthly trou- ble, which, while it lasted, and still held up her claim to be num- bered amongst the young, yet was often connected with sensations of ill health — which annoyed her by its failure — its procrastina- tion — its anticipation — its violence — its protractedness, and its pain. She has become fatigued with it, and tired of it. She had lost her color, and grown thin, for it exhausted and irritated her, but now that she has laid it aside for ever, her constitution no longer teased and taxed with the necessity, takes a new start of life and vigor; she begins to acquire a certain embonpoint, and, as Colombat beautifully depicts it, she seems to recover somewhat of the beauty, and grace, and attractions of an earlier date. Many women, in fact, do find that the health is greatly improved by the dispensation. The complexion recovers its former tint, and new deposits of fat give roundness to the limbs, and efface the wrinkled traces impressed upon the features by care, and watching, and exhaustion ; so that, though the loss of the catame- nia brings with it the melancholy conviction that she is becoming old, there is a compensating conviction in the apparently renewed health and comfort that follows the change. A few short years, however, renew, but in a gradual manner, the evidences of the decline of life.

But the sort of moral impressions of which I have spoken, and which, doubtless, are painful, are not the only evils to which the female is exposed at the change of life. I am sure that you will have no difficulty to conceive, that an organ, or rather a collec- tion of organs, that have been for thirty years concerned in the production of germs and in the performance of the great offices of


446 CHANGE OF LIFE.

menstruation, could not wholly cease from, and lay aside, those operations, on which have depended her health and security, without hazard, at least, or, perhaps, without some fatal lesion of her health; and you should take into consideration, that during thirty years of menstruating and gestative life, the uterine arteries and nerves, as well as the spermatic nerves and arteries, have been subject to constant alternations of activity and repose.

Should we not then be prepared to expect that, on the com- mencement of this long repose, these organs should become the subject of some unhealthy action of their innervative and circula- tive forces, laying the slow, insidious, but disastrous foundations of disease, which, too often, is not discovered or ascertained to exist, until it has passed beyond the curative stages? Such re- flections as these, it seems to me, ought to tend to render you extremely cautious in inquiring into the causes of those com- plaints which women at the change of life often make, and which, I am sorry to say, are as often hushed with the unsatisfactory reply, that such complaints are owing to the " change of life," and are likely to cease whenever that change shall become complete. A physician has no moral right, by his opinion, to put to sleep the anxieties of his patient, and to save himself the trouble of think- ing by so concise and unphilosophical mode of proceeding. Whenever, therefore, a female at this period, which is universally admitted to be a critical and dangerous time for her, comes to you to complain of symptoms, referable to some morbid condition of the reproductive tissues, do you not perceive, that it would be most clearly your duty, to give a considerate attention to her relation, and not dismiss her until your judgment should be fully satisfied as to the therapeutical or hygienical indica- tions of the case ? It will not be necessary, in all instances of complaints made to you of uneasy sensations in the pelvic region, to subject the female to the pain and mortification of the vaginal Touch, but whenever the complaints are so considerable as to give you just reason to suppose that some congestive, or inflammatory modification of the reproductive tissues has taken place, it will be your duty to insist upon a full exploration of the state of the reproductive organs. Such an exploration, made in the manner already pointed out in former letters, will enable you to be per- fectly satisfied as to the existence of disease in those organs likely to affect the health of the patient. If, upon such an exploration,


CHANGE OF LIFE. 447

you should discover no reason to suppose that the organs within the pelvis are the seat of any morbid action; then it will remain to you to inquire into the state of the whole constitution of the patient. I have so often, in my lectures at the College and in this series of letters, pointed out to you the mode of making a diagnosis by the successive exclusion of all the organs and func- tions that you are enabled to pronounce to be in a healthful con- dition, that I need not here iterate the directions for making such a diagnosis.

It might well happen, one would think, that a female, who, for thirty years, had been perfectly regular in her menstrual function, and who had, in a healthful manner, borne and nursed her chil- dren, might feel, upon the change of life, the loss of her accus- tomed evacuations. It is very certain that the habit of producing blood in quantities sufficient to carry on, in a healthful manner, all the ordinary life functions, besides yielding an abundant mate- rial for the monthly waste, is likely, upon the subduction of that waste, to be followed by disorders in the state of the sanguine mass. You remember the opinion so frequently expressed herein, that the blood owes its existence to the activity of the Endangium, or blood-membrane, as I have called it ; but disorders affecting that Endangium, modify the condition of the whole health.

Under these circumstances, the health will be modified by a condition of the Endangium tending to produce, on the one hand, plethora, on the other, anemia. Now, you will find many of your patients complaining of ill health, and in whom it will be impossible to say that it is the brain, the lungs, the liver, the spleen, the pancreas, the alimentary tube, the great articulations, that are the seats of special malady, while the ill health is really due to a change in the crasis of the blood. But if the doctrine be true, that the Biotic force is a product of the contact or immis- cence of arterial blood with the substance of the neurine, then it follows that you will have to discover the remedies, or the treat- ment that may serve to bring the blood back to an absolutely normal condition, which, when it shall have been effected, may serve to restore to the whole constitution, the salutary influences of a steady, perfect, equable innervation, which will be health.

I beg you to consider that shock to the health which is the result of the change of life, and, acting upon the principles which I have just expressed, endeavor to bring about some modification


448 CHANGE OF LIFE.

in the alimentary apparatus, that may exert the proper force in the direction of the assimilation, and the hsematosis.

This apparatus, in fact, may be said to stand at the very portals of existence, and any threatened invasion of the health is as likely or more so, to fall upon this point, as upon any other. Thus, in instituting inquiries into the state of the system in persons com- plaining of the change of life, it will be expedient for you to make inquiry into the wants of these alimentary organs. The peculiarity of their innervation and circulation, exposes them constantly to attacks of disease ; this peculiarity consists in this, that, the whole of the blood of the digestive arteries, — which you may remember are the cceliac and the two mesenteric, — is carried back to the black circulation by the vena portse, which trunk itself, is obliged to divide itself into a new series of venous capillaries, again to be assembled in the three hepatic veins, be- before it is finally returned to the right side of the heart.

Do you not readily perceive that so complex a condition of cir- culation in those vessels, exposes them to constant engorgement and obstruction, interfering with the great restoring and replenish- ing power of digestion?

Such disorders are frequently and carelessly expressed under the terms, biliousness, indigestion, flatulency, acidity, diarrhcea, costiveness, and it is not reasonable to expect, that they are to be instantly and promptly removed by the administration of one or two doses of some trifling aperient, or by the exhibition of the so much vaunted blue pill or calomel.

The administration of a drug can never set aside the necessity for the observance of the reasonable rules of a hygienic method. Don't expect, therefore, to cure your patient, without a careful prescription as to her whole conduct in relation to her diet, to her dress, her baths, her sleep and waking, her exercise, and a pro- per attention to the state of the alimentary organs.

By means of the exhibition of portions of blue mass, of calo- mel, of rhubarb, of the compound aloetic pill, and in weakly and cold persons, of some warm aperient tincture, such, for example, as a combination of the compound tincture of cinchona and tincture of rhubarb, in moderate doses, with wise prescriptions as to the nature of the aliment to be taken, you may hope to bring the digestive tube to a state of perfect health ; which, once effected, opens up the way to the removal of all the other difficulties that


CHANGE OF LIFE. 449

may have been connected with the development of the constitu- tional, or local maladies of the case.

It will become easy for you to ascertain whether or ho, the digestive functions are restored to a healthy condition. The signs of such a condition are found by making inquiry as to the state of the appetite, digestion, defecation, and the sensations of the patient as regards the abdomen and the health generally.

Reference should be had to the condition of the strength, the color of the skin, its perspirability, its elasticity, its temperature ; the condition of the tongue, the state of the lining membrane of the mouth and fauces, as ascertained by inspection, and the odor of the breath ; the nature of the urine, as to quantity, as to color, as to solidity; the respiration, and the action of the heart, the great source of circulation, to be ascertained by direct auscultation, and by an examination of the pulse ; all these inquiries will give to you an answer to your question, — "how is the patient?" — and you will not lose sight of her, I trust, until the answer is entirely satisfactory to your mind.

But there are circumstances, gentlemen, connected with the change of life, which often render it necessary for you to insist upon a direct examination by the touch as to the state of the repro- ductive organs.

It will be rare for you to find, at this age, signs of leucorrhoea, or any follicular malady of these parts: such affections, I think, appertain to an earlier period of life.

You will meet with some cases of great relaxation of the va- gina, which permits the uterus to fall down actually upon the plane of the perineal strait, or even, to take the position properly called procidentia. See Horace's Epodes, Ode viii. lines v. and vi.

The uterus, fallen so far out of its proper position, becomes a dis- turbing force to the economy. I have already told you, again and again, that the nervous system of the womb and reproductive organs allies itself intimately to the system of voluntary and ganglionic innervation of the economy ; and it is as easy to sup- pose that a female should feel perfectly well and comfortable with a dislocated humerus, as with a dislocated uterus ; for I deem it perfectly true to say, that a uterus fallen from its just level in the pelvis, is a dislocated uterus, a term which expresses the idea of 29


450 CHANGE OF LIFE.

the case more completely and more trenchantly than the softer terms, uterine deviations and uterine displacements.

I can't pretend to say, that if you would push the uterus back to its own level with your finger, and keep it there for a short time, your patient would be restored by that act to consum- mate health; but I repeat that a dislocated uterus is a disturbing force in the economy, and that whatever you may do or direct for the rest of her health, you will not be likely to have a perfect suc- cess, while you permit the unmitigated operation of that disturb- ing force. Therefore, in your plan of treatment, there should enter some means of placing the uterus in its natural position and retaining it so. The mode of effecting this desirable object, it is not necessary for me to dwell upon again in this letter ; therefore, I refer you to my letter on prolapsus, and the use of the pessary.

If, in the case, instead of finding simply relaxation and dis- placement of the womb, you discover upon its hallottement that the uterus is heavier, larger, more solid, than it ought to be, you wall at once inquire whether the state of the general circulation as to its force and vigor will warrant you in prescribing a blood- letting, or whether you might deem it more prudent to let blood by means of half a dozen or a dozen American leeches, applied to the collum uteri by means of a Recamier speculum, or whe- ther it might be deemed more advisable to take blood by means of cups applied upon the sacral region, or whether you will rely upon the resolvent influences of the warm bath, or of the applica- tion of some of the finer narcotic extracts to the interior of the vagina or the neck of the womb; such as injections of infusions of cicuta, — or extract of belladonna, or injections of laudanum into the rectum, — in the hope of effecting a complete subduction of nervous excitement and pain.

Twenty grains of the extract of belladonna, mixed with two ounces of mucilage of gum, will furnish you a compound, of w^hich, a tablespoonful may be injected into the vagina once or twice a day.

Half an ounce of cicuta leaves may be boiled in half a pint of milk, which, when cold, should be strained, furnishing a liquor, of which half an ounce or an ounce should be injected into the vagina two or three times a day.

If you prefer it, you may make use of an anodyne injection,


CHANGE OF LIFE. 451

made of forty drops of laudanum, mixed in half a fluidounce of boiled starch, to be employed as an injection, every night, and if necessary, every morning, of which you are to be the judge.

As to exercise, and as to rest, under these circumstances, it is impossible for me to give you explicit directions, for these are momentous questions, which can only be decided in the presence of the patient, and upon a good acquaintance with her real wants as to those points.

It is very certain, that a long recumbency in bed, or upon the couch, is frequently found to exert a salutary influence upon the congestive and inflammatory conditions of the uterus, doubt- less, in consequence of the beneficent influence of w'hat is in sur- gery called position, upon the circulation of the blood in these low, dependent organs.

I beg leave, however, to suggest to you a caution, as to the too long continuance of a confinement to the bed, or to the couch, which is dangerous to the health, since some exercise, some mo- tion of the body, some breathing of the fresh air of the open day, some relaxation from the perfect conviction of ill-health, only to be had in the conscious power of motion, is necessary to re- store the spirits of the patient, suffering under long chronical ail- ments.

Instead of meeting with these relaxations of the vagina, and descents of the uterus, you will, about the change of life, meet with some cases of extreme constriction and condensation of these tissues. It has been my lot to encounter several examples, in which the greatest alarm and distress were, as I thought, trace- able to vaginal contraction and stricture.

I need not dwell on the disordered mental impressions of the patient, connected with the reduction of the calibre of the vagina, amounting almost to a state of atretism. I am strongly inclined to believe that a case of melancholy, which led to suicidal pro- pensities and attempts, w^as justly attributable to such a convic- tion. Therefore, upon making such a discovery, I presume you would not fail to institute a treatment calculated to obviate such contractions, and I refer you to my letter No. IX., pages 88 to 90, for some directions as to the method of proceeding.

Among the most frequent and dangerous accidents to which women who do suffer at this critical period of life are liable, is the laying the foundation of carcinomatous disease. You will


452 CHANGE OF LIFE.

remember that I have already expressed the opinion, that these frightful affections are the results, not of a direct inoculation of reproductive cells, but of slow changes of structure, brought about by unsuspected and unknown inflammations, which become, so to speak, the proper nidus, furnishing the requisite cytoblas- tema on which these cells depend for their development and in- definite increase.

If, therefore, upon making your vaginal exploration and taxis, you discover some suspicious degree of hardening of the collum uteri, and especially of the os tinea ; if you find some change of the form of the mouth of the womb, altering its oblong, or its dimpled shape, rendering it irregular in circumference, and im- parting to the sense of touch the idea of botryoidal excrescences, or granules; then you will have just reason to fear that the fatal foundations are already laid; but, thank God, that as it is true, every swallow does not make a summer, so every suspicion of the commencement of carcinoma will not warrant the conviction that carcinoma is come.

You will wholly fail of your duty, under such circumstances, if you omit to examine, by means of the speculum, the actual con- dition of the parts in question.

For a woman who has a true carcinoma of the cervix, I believe there is no hope to be entertained ; but, be sure of the diagnostic ; and if you can flatter yourself, or convince yourself that the malady has not gone to the extent of clothing itself with the dire- ful characteristics of carcinoma, then there remains good hope of a cure, by a wise and careful treatment.

If it is not carcinoma, what will you call it? Is there any other name by which it can be named, than the name of inflam- mation, whether you deem it acute or chronical? But, if it be inflammation, what remedies have you ? Have you not purga- tives? Can you not appeal to the aplastic powers of mercury, to the deobstruent therapeutical powers of the narcotics, to the anti- phlogistic uses of the lancet, the leech, the cupping-glass, the bath, emollient injections into the vagina, anodyne injections into the rec- tum, dietetic rules, and rest and reassurance of the patient? Have you not at hand the almost miraculously antiphlogistic endowment of the nitrate of silver ? I assure you that on many various occa- sions, in which, in persons approaching the change of life, I have on the first exploration been shocked by the conviction that the


CHANGE OF LIFE. 453

patient was attacked by carcinomatous degeneration of the ute- rus, I have, on further exploration and diagnosis, been led to the institution of attempts to cure, which have been entirely suc- cessful.

I repeat to you here what I have said in a former letter, that I do not boast of curing cancer, but in the course of many years of clinical experience, I have met with many extraordinary es- capes from what I believed to be carcinoma, but in .which I had doubtless made a false diagnostic.

I shall not trouble you with further observations in this letter on the precise treatment of these cases, but refer you to the ear- lier letters of this volume for the principles and the treatment which you should adopt in their management — it would be but useless iteration to speak of them again here.

And now, my young friends, comes the question, as to the time when the change of life takes place. As a general rule, it is safe to adopt a public opinion, though it may not be absolutely true that vox populi is vox Dei.

That public opinion holds that the change of life takes place at forty-five years, and all our women look for the change at that time ; but all our women do not change at that time ; some women definitively lose their menstrua at thirty, and some even earlier. A lady with whom I conversed in March, 1844, told me that she became perfectly regular when she was twelve and a half years old ; she bore twelve children ; at thirty-five she definitively ceased to menstruate, and in her whole life never had the least trouble with her menstrua; she was as well at its cessation and since as she ever was. She was upwards of 40 years of age.

I have a patient now under my care, who at the age of 73 years, is as regular as a young girl, and has been so since an early age. Allow me to cite for you a passage from M. Brierre de Boismont, p. 209.

" It has been said in a general way, that the cessation of the menstrua takes place about the forty-fifth year in this country, — a little sooner or a little later: — the fact is true, but we believe that a better appreciation would be made by presenting a table indicating the different periods of the critical age ; we have here collected one hundred and eighty-one cases of women indicating the age at which they had ceased to see, and here are the results.


51 —


4


52 —


8


53 —


2


54 —


5


55 —


2


56 —


2


57 —


2


60 —


1


454 CHANGE OF LIFE.

At 21 — 2 At 34 — 4 At 42 — 7 At 50 — 12

24—1 35—6 43—4

26 — 36—7 44 — 13

27—1 37—4 45 — 13

28 — 1 38—7 46—9

29 — 1 39—1 47—13

30 — 3 40 — 18 48—8 32 — 2 41 — 10 49—7

Making a total of 181.

This informs us that the cessation of menstruation may take place at very different periods of life, since here we have cases showing that it may take place in years, varying from sixty to twenty-one. But the proportions at which it occurs at these several ages are very different, for, while it rarely happens in the young, it happens very frequently about the fortieth year, is very common about the age of fifty, at which time it sensibly diminishes, and in the last years of the table it follows the proportions observed in the early years.

I will not trouble you with any further statistical details on this point, which I consider as useless, preferring to refer you to the voice of {lublic opinion, which, you perceive by this table, coin- cides with the truth.

You should be careful, in your early wants as to clinical expe- rience, not to take every assertion as the truth. A young Doctor would do well to adopt as his motto, the new-fangled French word Panoptisniy which, to translate in an expression very common in America, would be set down in the words "wide awake." You are not to take it for granted, because a woman thinks that she has arrived at a critical age, that she is at the crisis ; you and not the patient, are to be the judge. If she be in the crisis, it is well, and you will act accordingly; you will not pester her with your vain emmenagogue treatment; if she be not in the crisis, you will provide such ordinances as may seem to be conformable to the requirements of the case. C. D. M.


HYSTERIA. LETTER XXXVI.

Gentlemen: — There is a disease called the Protean malady, because it simulates so many other disorders, that, like the fabled Proteus, it is assumed to be capable of taking on all forms. In common language, it is called Hysteria, from vatf/jo, the womb. The ancients used to call it suffocation of the womb, suffocatio matricis, and praefocatio matricis. It has been called rtn^ vatepixr;, and also artvovj artrota; the rising of the mother; and an Irish girl who came to our clinique, in 1843, as some of you may remember, replied, in answer to my question as to what ailed her, "The winding arrow, sir." "The what?" said I, "The winding arrow," rejoined her mother. "The winding arrow? I don't understand you," said I. " Why, it begins at the bottom of her stomach, sir, and it goes winding up along the course of her bowels until it gets to her throat, and then it chokes her, and she has a fit." So, we'll put down among other titles of hysteria, if you please, Irlandice, the winding arrow.

The question that first presents itself, after pronouncing the word hysteria, and when a person has already some knowledge of the phenomena of the disease, is this, videlicet, is it hysteria ? that is to say, has the womb anything to do with it ? and if the womb has anything to do with it, can a man, who has no womb at all, have hysteria ? This is a question which has long divided the profession. Many authors of rare merit, and great powers of discrimination, averring, that it is a hysterical, that is to say, a womb malady ; while others declare that it is wholly independent of the womb, and that males may have it as well as females. To reason this way, may be said to be a reasoning after the Baconian or inductive method, which is not always the best way to reason, since a rational method may, in many circumstances, lead to results as perfect, as clear, and as stable as those obtained by the most careful induction.

If hysteria depend upon the womb, then a man, who has no womb, cannot have hysteria; then, hysteria, you will say, cannot depend upon a disturbing force emanating from the womb alone.


456 HYSTERIA.

We seem to have come to a term in speaking in this way ; but we have not spoken the whole truth, because while hysteria may, in fact, proceed from the uterus, hysteria may, in fact, likewise attack the male. As to this point, I think there can be no doubt, since the medical records are full of testimony bearing upon it.

The medical writers who have asserted that hysteria proceeds from the womb or the reproductive organs, — for which the word womb should be taken as a general expression, — have probably not understood themselves; doubtless they have intended to assert that, modifications of the reproductive power of creatures, which might be characterized as the aphrodisiac sense, or, if you will have it, the aphrodisiac force, are the causes of the protean, or the hysteric malady. I say they could not really mean to say that the uterus alone, disengaged from, and unconnected with, the other reproductive organs, is, by its disturbing force, the cause of the hysterical malady, for that organ itself is probably far less immediately connected with the development of the aphrodisiac force, in the economy of creatures, than certain other parts, as the ovaria or clitoris, for example. But, as the constitutional aphrodisiac force is an appurtenance of both sexes, then, if modifications of that force can produce that malady, they maybe deemed equally capa- ble of causing manifestations of the same phenomena in the male and in the female. To say, then, that an affection of the womb, as an organ, is capable of causing all the strange modifications of the innervative power, which are witnessed in hysteria, would be saying too much; but, the aphrodisiac power is, in some in- cognoscible manner, connected with a modality of -the reproduct- ive apparatus as a whole, it would not be traveling beyond the record to say so.

That force, you will not deny, is capable of influencing the whole physical, intellectual, and psychological nature of the sub- ject of it; and, if even the conscience and the free-will must be admitted to be subject to morbid modifications, what hardness do you find in admitting, likewise, that morbid modifications of a power, so intense, so universal, so determinative of the whole con- stitution, might be capable of exhibiting itself in any or all the parts of the constitution in the strange and, so called, incompre- hensible phenomena of the hysterical paroxysm?

I have already told you, in former letters, that very slight


HYSTERIA. 457

modifications of the state of the womb, as to its level or its direc- tion in the pelvis, may exert a disturbing force upon the economy of the female, and it has been the custom, for two or three cen- turies past, to assign to the uterus the power of dispensing an aura, — which might be translated a vapor, or a halitus, — which, pervading different organs of the body, draws them into diseased sympathy with the distressed womb itself. This term, aura, is probably at the foundation of the word so commonly used in speaking of the maladies of females, I mean the word vapors, for a nervous, fitful, wayward woman is said to have vapors, — which I have regarded as synonymous with hysteria,' — so that a woman with vapors is a woman who suffers from an aura hysterica, an exhalation, a halitus from the womb; but we have got too deep into the nineteenth century, to entertain any further faith in the theory of vaporous exhalations from the organs, affecting other and distant organs.

Nevertheless, this word, aura, may be admitted to have some usefulness, as it has an important signification in medicine, and is a common parlance, for it refers to the sensible progress of an irritation from some ascertained point of the body, to some other point, as from the womb to the throat, where it produces a phe- nomenon, called globus, or, from a distant point on a nerve in the leg or arm to the brain, resulting in epilepsy, from the os uteri to the pylorus, or the breast, exciting vomiting, in the one case, and tumefaction or pain in the other; and, so from one organ to some other organ, calling its powers into sympathy with its own.

The dilatation of the cervix uteri in labor, is, by many persons, supposed to be the not unfrequent exciting cause of eclampsia, which it produces by disturbing the brain, excited beyond all tolerance by the pangs of the dilatation, which you might take as a strong example of the power of the aura hysterica.

Let me repeat that the rigorous meaning of the term aura, as aura epileptica, aura hysterica, etc., was, that a vapor, a halitus, or an exhalation, arising from an organ, and proceeding to in- volve another organ within the scope of its influence, is the absolute cause of the morbid phenomena in the organ which is secondarily affected. Now this term does express the fact that the suffering condition of one part of the body is capable of call- ing into sympathy other and very distant parts. It might be better, perhaps, and more precise, to use the word sympathy to


458 HYSTERIA.

express the idea attached to the word aura, and yet it is true, that in the case of what has been called aura, there is often a sensible tractus of irritation, or diseased perception, extending from some known leased point, as in the before cited case ; there are pecu- liar sensations experienced, from time to time, when an aura, passing either slowly or rapidly, the whole length of a leg or arm, and rising to the whole height of the head, explodes — so to speak — in the frightful manifestation of an epileptic paroxysm.

There is a most singular and most extraordinary exemplifica- tion of the influence of an excited condition of the aphrodisiac force, which you will find in the article Medication Antispasmo- dique, of Trousseau and Pidoux's Therapeutics. I will not cite it for you, but I advise you to take the first opportunity of read- ing it.

You may remember that in the course of my lectures last win- ter, I cited to you as a proof of the most intense hysterical modi- fication, the condition of a woman in the last moments of the conflict of labor, and, indeed, I think that if you will revolve the whole scene of a labor in your mind, commencing with the first phenomena, and observing the progress and extension of the complication it introduces in the action of the various organs, you will perceive the most perfect example of the power of the repro- ductive system of organs, when excited, to call other portions of the economy into sympathy with itself. At the commencement of a labor all is calm. The first pain is felt in the cervix uteri, which is strained a little by the positive contraction of the fundus and corpus uteri, which strain, it, the cervix, simultaneously resists by its own contraction. From this point of the labor, through the whole series of influences exerted on the brain, the heart, the lungs, the exhalants, the temper, the intelligence, I shall not fol- low the changes ; but I venture to say that should you practise midwifery, you will have many occasions to compare all these modifications with those of the most exquisitely marked hysteria — and be ready to regard them as proceeding from the same cause, videlicet, a modality of the reproductive apparatus, extend- ing its organismal influence beyond its own boundaries, and into the domain of other organs with which it has no direct anato- mical connection.

I presume there are few practitioners of some years' standing, who have not met with examples in males, of disorder, so closely


HYSTERIA. 459

allied to the nature of hysteria, as to be with difficulty distin- guished from some of the forms of that affection.

Dr. Marshall Hall, in his Principles of Diagnosis, p. 101, vol. i., has these words, in relation to hysteria: "It is almost pecu- liar to the female state." I have only to ask to what other sex it could be almost peculiar, and, if it be almost peculiar to the fe- male sex, does not Dr. Marshall Hall admit that it belongs also, in some degree, to the male sex?

I saw within five years, a gentleman thirty-five years of age, who was married, and who had symptoms of insanity. When I was called to him, I found him insane with extraordinary halluci- nation. In consideration of his pulse, temperature, and intellec- tual disturbance, he was treated by bleeding, leeches, purgation; which, together wdth a rigorous diet, with rest in bed, restored him. The pulse, which was at first feverish and hard, became soft and natural ; he recognized his situation and place, acknow- ledged the hallucinations with which he had been affected, and was soon after allowed to leave his room ; he rode out ; he walked out too much ; and having eaten immoderately, the fever was re- newed, and the same extraordinary hallucinations along with it. The excitement was so great, that it was found necessary to bleed, purge and confine him again to his bed. For the last three

days ( ), after taking a good many doses of laudanum

in ten drop doses, amounting to one hundred and forty drops in all, he was seized with a paroxysm, which I could characterize .by no other name than that of hysteria. He had globus most ex- quisitely marked ; he had rhythmical beating of his breast with his right hand, frequent appearance of strangulation, and clutch- ing at his throat. These symptoms alternated with the most un- controllable laughter, followed by floods of tears, succeeded with laughter again, palpitation of the heart, and cold feet and hands, all of which continued to trouble him for nearly three days. The paroxysms were relieved after my visit, by a few ten drop doses of laudanum.

In my note of the case, I found these words: — These phe- nomena are identical with those of hysteria in the female ; he says he has pain about the throat, the region of the occipital bone, and in the nucha ; and he has a general uneasiness in the pelvis, strange sensations affecting the perineum, and this ac-


460 HYSTERIA.

companied with frequent erections. I suppose I have never seen a more manifest example of hysteria in the male.

In conversation with him, I find that one of his hallucinations consists in a supposition, that all his late attacks of insanity were the effects of a violent attachment which he had formed for a very young lady, with whom, I believe, he is not acquainted personally, and with whom, I know, he has never spoken, though he thinks he has had this love for her for many years.

I have reason from the above to suppose, that in this case, there is an aphrodisiac element of morbidity, which, if it be not wholly causative of his disorder, yet exerts upon it a modifying power.

The tremor of his lip in speaking, and the childish tendency to cry, remind me of the case mentioned by Sydenham, in his letter to Dr^'Cole, on hysteria. The case of hysteria mentioned by Sy- denham, is found at the 320th page of Rush's Sydenham, Phila- delphia, 1815. It is in these words : —

" And by the way I must observe that men are sometimes sub- ject to such crying fits, though rarely. I was called not long since to an ingenious gentleman, who had recovered of a fever but a few days before ; he employed another physician, who had blooded and purged him thrice, and forbid him the use of flesh. When I came and found him up, and heard him talk sensibly on some subjects, I asked why I was sent for, to which one of his friends replied, if I would have a little patience, I should be satis- fied. Accordingly, sitting down, and entering into discourse with the patient, I immediately perceived that his under lip was thrust outward and in constant motion (as it happens to fretful children, who pout before they cry), which was succeeded by the most violent fit of crying I had ever seen, attended with deep and almost convulsive sighs ; but it soon went off. I conceived that this disorder proceeded from an irregular motion of the spirits, occasioned in part by the long continuance of the disease, and partly by the evacuations that are required in order to the cure; partly also by emptiness, and the abstinence from flesh, which the physician had ordered to be continued for some days after his recovery, to prevent a relapse. I maintained that he was in no danger of a fever, and that his disorder proceeded wnolly from emptiness ; and therefore ordered him a roast chicken for dinner, and advised him to drink wine moderately, at his meals; which


HYSTERIA. 461

being complied with, and he continuing to eat flesh sparingly, his disorder left him."

Dr. Sydenham, from whom I have made the quotation, does not appear to suppose that hysteria is a disorder proceeding from the reproductive organs ; on the contrary, he says : —

"Disorders, which we term hysteric in women, and hypochon- driac in men, arise from irregular motions of the animal spirits, whence they are hurried with violence, and too copiously to a particular part, occasioning convulsions and pain when they exert their force upon parts of delicate sensation ; and destroying the functions of the respective organs which they enter into, and of those also whence they come ; both being highly injured by this unequal distribution, which quite perverts the economy of nature.

" The origin and antecedent cause of those irregular motions of the spirits, proceed from the weakness of their texture, whether it be natural or adventitious, whence they are easily dissipated upon the least accident, and their office perverted, for as the body is composed of parts which are manifest to the senses, so doubtless the mind consists in a regular frame or make of the spirits, which is the object of reason only. And this being so intimately united with the temperament of the body, is more or less disordered, ac- cording as the constituent parts thereof, given us by nature, are more or less firm. Hence women are more frequently affected with this disease than men, because kind nature has given them a finer and more delicate constitution of body, being designed for an easier life, and the pleasure of men, who are made robust that they might cultivate the earth, hunt and kill wild beasts for food, and the like."

Among the samples of hysteria in the male, one of the most complete and perfect is by M. Louyer Villermay, in the Diction- naire des Sciences Medicales sub voce.

The question resolves itself into this narrow compass; is hys- teria a disorder proceeding from a status of the reproductive system, by which I mean the reproductive force ? If it be not, then there can be no reason alleged why males should not be equally ob- noxious to it with females. Males are equally with females liable to apoplexy, to pleurisy, to bilious, typhous, and typhoid fevers, and to all the exanthemata; and, if our disorder is not a sexual, it is a non-sexual disease, and applicable to the race, the genus, and not to male or female. If you argue that the malady is really


462 HYSTERIA.

sexual or reproductive in its essence, then I don't see why you' should not admit that though it be far more frequent, and far more intense in the female on account of the far greater development, alliance and importance of her reproductive system, it might be reasonably expected, that, the reproductive system of the male should also manifest its power occasionally to disturb in a slighter, or less intense degree, since the relations of his repro- ductive apparatus are less extensive, and less impressive upon his organisms, than is the case with the female. He possesses neither the gerraiferoiis, the gestative, nor the lactative powers; nor has he any analogy to the great catamenial office of the fe- male. But, as I have already remarked, those great powers and functions cannot but have a vast influence over the whole of the organisms which, in their very creation, must have been en- dowed with a proper adaptability to the varying exercise of the general system of forces.

It is impossible to reflect for a short time, one would think, upon the nature of the aphrodisiac infusion in the sum of the vital powers, without admitting that aphrodisiac power to be one of the most essential for the conservation of the species; that it is a great modifying principle, both of the physical and moral character of the species; and as such, has been recognized from remote ages. We control it in the domestic animals, by the various operations in which we quell it for the purpose of reducing them to a more perfect obedience, as w^ell as for the purpose of modifying the nature of their flesh, and rendering it more valuable in the mar- ket. Hear how beautifully Virgil descants upon its powers in his third Georgic.

Omne adeo genus in terris hominumque ferrarumque, Et genus Eequorcum, pecudes, picta-qua; volucres, In furias ignemque, ruunt: amor omnibus idem. Tempore not alio catulorum oblita leaena Ssevior erravit campis.

Nonne vides, ut tota tremor pertentet equorum Corpora, si tantum notas odor attulit auras !

Can the violent ebullition of life, so admirably described by this writer, be accounted for on any other principle, than that of some abnormal or at least transitory exacerbation of the inherent power and influence of the reproductive system, over the rest of the organisms? Do you think you can explain the many forms of


HYSTERIA. 463

excitement by merely referring to a modification of the systole of the heart, to a greater development of the calorific power, or to some sudden exacerbation of the general innervation, independent 01 the action of this essential force ? Are they not explicable, rather, only in view of the impression made by the aphrodisiac sense on the entire community of organs ; lashing them into fury by its passion and touching them with the contagion of its own exagge- rated intensity.

How can you reason upon the continued existence of the spe- cies, or their perpetuation upon the surface of the earth, with- out perceiving that their perpetuity could find its guarantee only in some great principle implanted deeply in the whole constitution of animals, able to exert, and able to manifest its might, dominion, and authority over their whole vitality.

But where are the seat and throne of this aphrodisiac power, this sixth sense, this reproductive perception, this conservative force of species and genera, as distinguished from all other facul- ties and forces? It exists in the reproductive tissues, and if you will excuse the term, wraps them all in the embrace of its aura; it is diminished by their diminution, it is augmented, pan joossm, with their development, and declines and dies with their extinc- tion.

Have we not, then, sufficient ground here, to establish the opin- ion, that certain states of the ovaries, the womb, and its append- ages, may be sufficiently impressed upon the rest of the system, to waken among the organisms all those modified manifestations of vitality, which we observe with so much surprise in a parox- ysm of hysteria?

I do not propose that, in hysteria, the womb is acutely or sub-' acutely inflamed ; that it is in a hypoa?mic or hypersemic condition ; the question is, whether the W'Omb is the seat of such a mode of vitality as enables it to impose upon other parts of the economy a touch of its own distemper.

Cannot the liver, the spleen, and the kidney do so, and shall a man deny to the stomach the power to distress the brain and other organs in states where its own apparent modality does not depart from the most healthful tone ? How, then, does the cephalalgia, the stupor, the coma, the precipitate movement of the heart, arise from the stomach, suffering, to say the least, no organic lesion, and evincing not the least sensible sign of disorder? It


464 HYSTERIA.

has been argued that the womb is not the seat and throne, the fens et origo, of hysteria, because we observe the most signal alterations of its texture, in disease, without the superinduction of hysterical affections; as well might we deny the influence of the stomach upon the brain, because we find the whole pyloric ori- fice of the organ invaded by carcinoma, without the supervention of the least headache, or coma, or spasm.

But it seems a waste of words to argue upon a point that might be readily settled by an answer to a question: Is a woman sub- ject to hysteria after the entire cessation of the menses? No!

The causes of hysteria are to be found in a great variety of conditions, both of internal and external origin ; among them may be named a highly nervous and sanguine temperament, the patho- logical propensities of which are promoted by a sedentary life and luxurious living, hot rooms, hot beds, highly stimulating food, the use of wine, of aromatics; a mind ill regulated, indulged, intolerant of control, highly impressible. In such an individual, any abnormal degree of excitement that might serve to add to the purely physiological action of the reproductive organs, you could well deem sufficient to send its aura forth upon its mission of mischief throughout the entire economy.

The greatest degree of the hypersemic excitement is in the hy- pogastric and pelvic regions ; but the blood is in commotion com- mensurably with the hypersemic status of the brain, and we see it rush in volumes to the vessels of the head, where it is mani- fested in the intense flush of the brow and the cheeks, and then commences the wild incoherent action of all the organs and func- tions that depend for their innervation upon the brain and cere- bellum.

The whole spinal cord vibrates under the tension of the vital forces, roused to excitement by the reproductive and aphrodisiac power ; cries, sobs, peals of immoderate laughter, tears in floods, stolid silence, perfect cataphora, spasm tonic or clonic, tetanoid closure of the jaws, the most extraordinary rhythmical movements of the symmetrical halves of the body, — zygozoar spasm, — rigid opisthotonos, sudden enormous meteorismus, profound coma, excessive secretion of limpid urine ; all followed suddenly by the profoundest calm of the constitution, and a feeling of the sweetest complacency and amiability. Such are the symptoms which


HYSTERIA. 465

leap, as it were, out of a profound repose, with a sudden and startling exaggeration.

Mr. Georget, in his observations upon hysteria, positively denies the assertion, that any distress is felt in the hypogastrium, as asserted by Louyer Villermay, by Gendrin, and others ; but, I am equally sure, that I have had my hand grasped with the most spasmodic force by a very delicate lady, which, in spite of my efforts to the contrary, was carried and jammed into the hypogas- trium of the sufferer, and retained there, with violence, amidst the exclamations of " Here, here, oh! here!"

I have seen three women, at the same moment, a mother and two daughters, all violently ill with aggravated hysteria, and all complaining of the most intense distress in the hypogastric region.

I have, in my note book, under the date of September 5th, 1842, the case of a young lady, stout, healthy looking, weighing about 130 pounds, subject to attacks of exquisitely marked hyste- rical passion — with sobs, laughter, and suffocation. In these fits, she always complains of something grasping her, — to use her own expression, — in the left hypochondrium, until she cannot breathe, and then suddenly letting go. I will not cite any further parti- culars of the case.

There is connected with the aphrodisiac influence, a singular propensity in some females to simulate disease, and that, without any appreciable motive of interest. The skill and the persever- ance with which the deceptions are carried on, exceed almost the powers of belief. Dr. Locock, in that most admirable work of his on Hysteria, a work for which he ought to be immortalized, as proving in him powers of judgment, reasoning, and perception beyond what appertain to most mortals, gives us some extraor- dinary examples of morbi simulati. I must refer you to Dr. Lo- cock's book, a copy of which was published by my friend Dr. Bell, in that useful work, the Medical Library. It is within the reach of every medical student, and there is no medical student who should be without it. I have no time to cite those cases here.

There are examples of women under the influence of whatT believe to be the hysterical malady, who are capable of develop- ing physical disease upon the surface of the body by some power of the mind concentrating morbid actions upon parts of the sur- 30


466- HYSTERIA.

face, producing there, the appearance of wounds. Such are the celebrated examples of the stigmated women, who, under an in- tense contemplation of the passion of the Saviour, have produced bleeding wounds in the palms, the soles, or even in the side: or at least seem to do so. We may believe this, sayftoujours, the fact, that morbus simulatus, the malingering power, is capable of deceiving all mankind. Persons instigated by interested mo- tives, such as desire to be discharged from military or naval ser- vice, or to escape from the performance of disagreeable duties, or to excite the compassion of the public, are found to make use of extraordinary means of deception. But, I have no doubt of the frequent occurrence of malingering from hysterical causes ; as I have known young women to require the use of the catheter for months in succession, under a diseased conviction that the urine could not escape but by the aid of the catheter, I, being equally convinced, that it was an hysterical affection; a urinary mono- mania, in fact.

I have seen a woman simulate the most intense spasm, fol- lowed by profound coma, pending which s"he endured, without wincing, the most painful treatment. In this case, although I suspected malingering at the time, I was wholly unable to verify it, until long after, when she confessed to me, that all her symptoms were assumed in order that she thereby might wreak revenge upon her husband, whom she wrongly suspected of infidelity.

I have seen hysterical cough assumed and persevered in for many consecutive weeks, with such violence as to shock and ex- haust in a great degree the health of the sufferer. She was in an eminent degree, an hysterical person, and it is probable that she coughed three or four times a minute, save when asleep, during the whole of this time ; and I know it was a malinger- ing cough. In one unfortunate lady of great beauty and accom- plishments, subject to exquisitely marked hysteria, I was the dis- tressed witness of a fatal termination in consumption, of a cough that was merely simulated at first, under the impulsions of an hysteric state.

What shall we say of the power of the aphrodisiac force when exaggerated into erotomania and satyriasis? — that power that drives from the conscience of the woman the last vestige of fe- male purity; and from her cheek the faculty to blush? The feats


HYSTERIA. 467

of Messalina are nothing to the manifestations of this power, sometimes met with in medical practice.

The diagnosis of hysteria is in general not difficult. The means of distinguishing the hysterical convulsion from the ordi- nary epileptic form; the hysterical from the apoplectic coma; the hysterical tetanoid from the tetanic spasm, are to be sought for in the history of the case ; the sex, the age and sanatary habits, of the patient ; in auscultation of the heart ; in careful comparison and judgment of the pulse; in the condition of the calorific power; in the duration of the paroxysm; in a certain character of the physiognomical expression, where there is absence of all those profound and dangerous impressions which are inseparable from such great disorders as I have just named.

In hysteria there is generally a moral cause, which sets in motion a machine already highly wTOught and prepared for the movement. The hysterical woman, like the highly electrified thunder cloud, requires but the point to draw the flash. She sits, like Tam O'Shanter's wife,

"Gathering her brows, like gathering storm, Nursing her wrath to keep it warm ;"'

when, suddenly and unexpectedly, some word, sign or gesture, or the failure of some word, sign or gesture, gives the occasion; and we have reproaches, tears, screaming, laughter, sobs, wringing of hands, tearing of hair, clonic convulsions, tonic spasms, stupor, stertor, smiles like a May morning, loud laughter again, floods of tears, and then a gradual return to a state of gentle composure, wherein the tenderest affections of the female heart come to re- sume, with unusual supremacy, their wonted sway over the soul. It is very true, that I have not always inquired, or have not upon inquiry, been always satisfied, as to the state of the uterus, and its appendages, in every case of hysteria that has fallen under my notice. But, I have in many of those cases, clearly discerned the connection between the morbid innervations and the known disorder of the sexual organs. In not a few instances, I have put a stop to the paroxysm of hysterical passion, by balanc- ing the uterus upon the point of my index finger, and thrusting it as far as I could carry it into the upper parts of the pelvic exca- vation ; thus relieving the innervation temporarily, from an irrita- tion of the reproductive apparatus proceeding from a prolapsion


468 HYSTERIA.

of the uterus, from which probably radiated the whole of the phenomena of the hysterical attack.

With regard to the treatment of the hysterical passion, some of the cases require therapeutical treatment, and some not : a patient may be brought to herself by letting her alone and leaving her alone ; but in the wild and confused operations of the nervous and sanguine systems, with the impetuous force of the blood ob- served in some of the cases, there may be danger for some of the great vital organs. I have seen a case of pure hysteria resulting in coma, which terminated in the death of the patient, probably from sanguine extravasation in the encephalon. I believe that whenever the momentum of the blood is increased to a dangerous violence, by whatever cause, that danger ought to be obviated by the means best calculated immediately to reduce it within safe bounds. A simple antispasmodic medication will not do in these cases ; and I think you will not do your duty to the patient, under the circumstances, unless by means of venesection you take away from the brain and the heart, the material power to excite, and to stimulate. You will diminish the production of neurosity by diminishing the intensity of the contact of the oxygenated blood with the neurine. It is a very common opinion, that in the nervous affections we do wrong if we take blood ; and persons who dive not beyond the surface of things, for the most part hold ta the opinion that you ought not to let blood except there be some inflammatory condition of organs, requiring that special therapia. I hope you will lay it to heart that a mere, simple, san- guine engorgement, the beginning of which has no connection with any inflammatory condition, or propensity, may speedily ter- minate in the ruin of the patient by allowing of effusions or extra- vasations, and that such propensities as clearly demand the use of venesection, as the most active and clearly marked inflammations. It is not true in fact that spasmodic, nervous, vaporous, hysterical disorders, neuropathias, require to be treated solely upon the principles of the antispasmodic medication, and he who adopts such sentiments, no matter by what school or by what authority they are instilled into his mind, thereby virtually ties up his hands in a thousand and a thousand instances, in which a perfect freedom from the bonds of such a prejudice, would render him a powerful and efficient practitioner of his art.

If you should decide upon bleeding in any case of hysteria,


HYSTERIA. 469

you may, after the abstraction of blood, concentrate the confused, heterogeneous, disturbed perceptions upon a point, or points of the skin, by violent frictions, and slapping of the hands, or lower extremities ; by hot, sinapised pediluvia, by mustard cataplasms, by Granville's lotion, by the powerfully concentrat- ing sensation produced by the dry cup, especially if applied to the nucha, and on the interscapular region ; after which you may avail yourself of the antispasmodic therapeutical power, which you can find in the assafetida, in the fetid gums, in castor, or in musk, or perhaps more than all in valerian, more particularly in the beautiful extract now prepared by means of ether. The inhalation of ether in this stage of the malady will be a safe and useful resource. I mean not the inhalation of ether to the extent of what is called etherization, and I advise you to make no appeal to such a power, since, — in the disordered and hetero- logue operations of the hemispheres, and of the tubercula quadrige- mina, of the cerebellum, of the spinal cord, and of what is always a deep participant in the hysterical manifestation, I mean the medulla oblongata, and the vagus — no man ought to arrogate to himself the right to plunge these organs into the temporary annihi- lation of etherization ; because, the co-ordination of their actions being destroyed in the hysterical paroxysm, there may be no re- gular succession in the influences of the ether upon the several parts of the brain. In that regular succession, the part that last yields is the medulla oblongata; what, if in this heterologue con- dition of the brain, it should be the first to yield ? It is the source of the respiratory power ; when it ceases to act, the respiration ceases; and is not a woman dead when the breath is out of her?

I presume that there is not among the whole armamentarium medicum, an article possessing the exclusive properties of an anti- spasmodic so perfectly as valerian ; and I beg you again to take an early opportunity of reading Prof. Trousseau's remarks upon it, in his article on antispasmodic medication in his therapeutics.

If you should resolve, in your cases of hysterical spasm and excitement, upon its use, I advise you to administer it as the fluid extract just before mentioned; or, if that be not conveniently attainable, to give it in substance reduced to fine powder.

A large teaspoonful of the fluid extract in a wineglassful of sweetened water, is a good dose, which may be frequently re- peated; or, a drachm of freshly powdered valerian root highly


470 HYSTERIA.

fragrant, may be divided into four powders ; of which, one is suit- able for a dose. Mix it in half a tumbler of fresh water, and make the patient drink it. Don't tell me that she can't drink it, or won't drink it; or that her jaws are set, and you can't make her swallow it. Her jaws will never be set so tight but that you can open them. How? Take two bits of ice, each as big as an egg ; wrap each of them up in the corner of a napkin ; then press the cold napkin against her masseter muscles on each side. As a general rule, the cold contact will scarcely be made before the masseter relaxes. But, suppose you find a case in which it won't relax; then, get the end of a spoon between her jaws, open them a little with this, and then substitute the end of a tooth-brush handle, now pour the liquid into her mouth : do you say she won't swal- low it? I reply she will swallow it, if with the end of the spoon handle you separate the base of her tongue from the velum pen- dulum palati, which will allow the mixture to get beyond the isthmus faucium, and when there, the oesophagus w'ill transmit it to the stomach.

Anybody can swallow ; I was almost ready to say, you could make a dead man swallow. I beg you never to say of your pa- tient, — he is past swallowing, — unless he be laboring under a paralysis of the pharynx and oesophagus; but you may practice for forty years, and never meet a case.

But to return, if the patient does swallow the powder, you will probably witness a very speedy diminution of all the spasmodic innervation, and a return of the constitution to a state of the pro- foundest calm.

Some time ago, I was summoned, in a hurry, to see a beautiful little child seized with most intense convulsions, brought on by her ingesta; among the attendants was a faithful nurse, who had lived a long time in the family — a highly hysterical and nervous individual. Having been very much excited and alarmed, on account of the condition of her little favorite, she went into an adjoining apartment, where she fell into a most violent fit of hys- teria. My attention being called to her, I wrote a prescription for half a drachm of powdered valerian, which was immediately brought to me, and I said to a young lady, standing near, "Please to mix the powder in half a tumbler of water, and bring it to me, and, with it, a tablespoon, and I'll show you something very curious. Now, see here," — said I, — "here is this woman,


HYSTERIA. 471

whose mind, for the time, is abolished, and her body is, as you see, tortured by these violent spasms; now, I'm going to make her swallow fifteen grains of the powdered root of valerian, and do you look on, to observe what strange powers are possessed by certain medicinal articles over the human body. You shall see that, in about fifteen minutes, this great storm shall become a great calm." The woman could not swallow, but I made her swallow the fifteen grains. "Now," — said I, — "look at her." In two or three minutes, her spasms became less, and in a quar- ter of an hour, she was perfectly well. "Now, what do you think of that, my dear?" — said I. "I don't know what to think of it, doctor, but it surprises me very much."

I have said nothing about opium ; what need have I to mention the name of opium in connection with such circumstances? It commends itself, by its very name, in all such cases; provided that you can render yourself sure, that there is not connected with the paroxysmal manifestations, some element of meningitis, or cerebritis, which you have not deprived of its mischievous na- ture, by the salutary interposition of your lancet.

With regard to the treatment of persons in the intervals of the hysterical paroxysms, to which they are liable, I should be guilty of the fault of iteration, were I to say much upon that subject, since I have so clearly expressed the conviction of my mind, that hysteria is truly hysteria, and not merely nervous sur-excitation. But, if hysteria be truly hysteria, it follows that, in the intra- hysterical periods, you should address your inquiries and your remedies to the condition of the reproductive organs, and those morbid states which are the "ipsissima causa morbi."

But I have spoken so much at length, in these letters, upon these morbid conditions, that I shall here close the present one, referring you to many of the antecedent pages of this volume,

C. D. M.

472 DISORDERS OF PREGNANCY. [and the rest of the text]

LETTER XXXVII.

Gentlemen : — The change in the condition of the reproductive organs brought about by pregnancy, is too great to fail, in the majority of instances, to produce phenomena approaching per- haps to the nature of disease.

It is necessary that the physician should render himself familiar with these phenomena. The pregnant state, in fact, is one full of interest to the medical student or the practitioner of physic. I feel it a duty, therefore, to say in these letters something to you of the state of pregnancy, and the maladies and the inconveniences with w^hich it is accompanied.

The fecundated germ, in attaching itself to the lining surface of the uterus, may affix itself to any part of the internal super- ficies of that organ. I say the fecundated germ, because I wish to express the opinion, that the germ may become fecundated with- out being followed by pregnancy. The germ is fecundated by the contact of the male sexual element, which imparts to it the power to develop the organisms, and the whole nature of the animal in question. But pregnancy cannot be deemed to take place, until the germ has established a mesenteric connection with the living surface of the mother. When, then, the mesenteric attachment takes place, the woman has conceived. Doubtless, thousands and millions of germs become fecundated, but which never form mesenteric attachments, and are consequently lost ; the womb is only pregnant when the mesenteric attachment is made. No matter where this mesenteric attachment is, the woman is pregnant when it is made. It may be effected in some part of the tractus of the Fallopian tube; or it may be made upon the surface of the ovary, the ovary being covered at the time by the fimbria of the tube. If the porule of the Graafian cell have been formed, and the male sexual element have been translated through the channel of the tube, and come in contact with the exposed ovule, still contained within the Graafian crypt, the ovule may be there fecundated, and may form its mesenteric attachment within the crypt, and then you will have an ovarian pregnancy, and there


DISORDERS OF PREGNANCY. 473

is not another way in which you can have one. It is probable that the germ may be fecundated within the grasp of the fimbria, and being thus endowed with the development power, it may fall into the peritoneal sack, and there form its mesenteric attachment; thus constituting a ventral pregnancy. An ovule, on its passage from the fimbria to the uterus, may become fecundated; it maybe arrested in the narrowest part of the tube, where it passes through the thickness of the uterus ; the delay and the pressure are probably the causes why it sometimes forms its mesenteric attachment there, and develops itself in the substance of the uterus outside of its cavity, thus constituting what is called interstitial preg- nancy.

Conception is never natural, never right, never safe, except when it takes place in the cavity of the womb. Please not under- stand me as stating, that fecundation always takes place out of the uterine cavity; it is probable that it most frequently takes place outside of the cavity, but it may take place within the cavity of the womb. The fecundation takes place in whatever place the contact of the sexual element happens to be made.

When a woman has conceived, the womb begins to increase in size; the increase taking place at first in the body and fundus, and not affecting the neck. This growth of the womb is so rapid, that it passes from the non-gravid state to the condition of the organ at full term of utero-gestation, in the short space of two hundred and eighty days ; a space of time in which the most remarkable changes occur in the character of the organ, and in the in- fluence of the organ upon the living economy. The non-gravid womb is about two and a half inches long, one and a half in the widest part, and one half an inch in thickness ; and its weight shall scarcely be found to exceed two ounces. The gravid womb at full term, is often twelve inches in length, and its transverse diameter is equal to eight or nine inches; its weight, freed from its contents, is scarcely less than one pound, or a pound and a half. It exceeds by from eight hundred to twelve hundred per cent, its normal weight.

The space occupied by it in the non-gravid state, is, as you have seen, very small; in the gravid condition it constantly in- trudes itself among the other organs, pushing them aside, dis- tending some, and compressing others, interfering with the flow of blood in the vessels and the ascent of the lymph in the tubes;


474 DISORDERS OF PREGNANCY.

and calling out of the general source of the circulation vast tor- rents of arterial blood, which it returns to the venous circulation, after having deprived it of its oxygen, and of much of its elements of assimilation.

Under such a view of the changes taking place in the womb, you have little reason to be surprised that the health of the woman is often disturbed. Do you imagine that the womb, when twelve inches in length by nine in breadth, and weighing a pound and a half, is the same organ that it was in the non-gravid con- dition? You call it, it is true, by the same name, uterus. But, if you inspect it, if you touch it, if you weigh it, if you analyze it, you will find it a totally different material.

Why is it that the womb undergoes these wonderful changes of form, of dimensions, of weight? These changes are compulsory. The uterus has received the fecundated germ ; that germ is an animal, and w^as before it came into the uterus wholly independent of it ; and will be while it remains in the womb, equally inde- pendent of that organ. That is to say, it will be as independent of the uterus as the plant is of the soil in which it grows; if the plant be torn from the soil, it will perish, because it can nowhere find the materials for its development; and if the ovum is torn from its attachment, it will perish for a similar reason.

The ovum grows by its own force ; it finds on the surface of the womb, the assimilative elements, which it knows how to assimilate for its own purposes. That assimilation, increasing constantly its weight and dimensions, it is inevitable that, if it is to reside in the womb, that organ must yield to the pressure of the growing ovum; and in yielding to that pressure, it is not de- stroyed ; on the contrary, it is developed ; it is augmented in size and in w^eight ; its uterine arteries and its nerves, and its absorbent vessels, all are increased, not in number, but in length and in diameter; greater quantities of blood furnish the material out of which this new growth takes place ; and thus the womb under the constant pressure of the augmenting ovum, is stimulated or excited to new efforts of uterine development force, — augmenta- tion.

You know this to be true, because you know that the uterus at any period of utero-gestation has a constant tendency, I had almost said a constant desire, to return to its non-gravid repose. You know that it will begin to return to that non-gravid condition,


DISORDERS OF PREGNANCY. 475

whenever with the point of a bougie or other instrument you rup- ture the membranes of the ovum, and allow the watery contents to flow off. You also know, that it occasionally happens, that the uterus refuses to yield to the distention of the growing ovum, which is ruptured and expelled, or is even expelled unruptured by the action of the muscular womb.

I don't know what better argument I can present to you in favor of the opinion I have expressed, of the compulsory nature of the uterine development in pregnancy, than the one above stated. If you remove the cause, the effect ceases, is an axiom in phi- losophy : I say, that the cause of the growth of the uterus resides in the ovum, and I prove it by stating that whenever the ovum is destroyed, the effect of its growth, to wit, the growth of the womb, ceases ipso facto.

I wish to make this statement to you, simply because it is a physiological truth, but more than that, because it contains the most important chirurgical principle, a principle which you will apply a thousand times perhaps in your practice ; a principle which, if you understand it properly, shall give you the gratifica- tion of rescuing multitudes of people from an untimely grave, save you from the grossest errors in practice, and enable you to do honor to the divine art that you profess, by showing its might and its beneficence, upon the most interesting and important occa- sions.

When the womb first begins to develop itself under the in- fluence of the growing ovum, it grows healthfully engorged, and of course grows broader, longer, and offers a larger surface of pres- sure to the superincumbent viscera. Both its augmented weight and volume, therefore, give it a tendency to descend toward the floor of the pelvis, and as it is attached to the bladder by the utero-vesical septum, and presses upon the rectum, which is both behind it and below it, the woman will scarce fail to have some symptoms of a prolapsus or descent of the uterus, evinced by a more frequent desire to pass urine, and a tenesmic feeling of weight and dragging about the loins, and in the two iliac regions. Such symptoms, therefore, in married women, or women exposed to the risk of conception, you should regard as rational or inferential signs of the gravid state; symptoms not absolutely to be relied upon, but still of no little value, when collated with those here- after to be mentioned.


476 DISORDERS OF PREGNANCY.

When the descent takes place, it happens, notwithstanding the augmented volume of the uterus, that the hypogastric region of the womb becomes less protuberant than it was in the non-gravid state ; so that the woman does not begin to grow larger, but really grows smaller in the early stages of pregnancy. Hence, the oft-quoted French proverb,

"A ventre plat, enfant il-y a."

Inasmuch, as I do not profess to know what the nerve force is, I cannot profess to tell you how it happens that the earliest modification of the state of the uterus is so commonly expressed by simultaneous modifications in the stomach and in the female breast. If I use the word sympathy to express it, you see that I shall only use a word, and not give you an explanation. A man who thinks he has an explanation, because he has the word sym- pathy at hand, is like those people in the Old Testament, of whom the prophet says, " They fill their mouths with wind, and their belly with the east wind." It is better to say, and to think, that, as the life of the whole constitution is made up of the lives of all the organs and organisms which that constitution inholds, it is reasonable to suppose that the pathological condition of any one of the important organs may disarrange the normal, ordinary rate of action of some other, and even of all the other organs : life, in the womb, is, under this view, the multiple of the parts of the womb, and so of the assimilating organs, of the oxygenating or- gans, and so on ; but the life of one of the integers being disturbed, the multiple itself may be disturbed. If you have a cube made up of many smaller cubes, of which you take one away, or alter its form, it will no longer be precisely a cube ; so, if you alter the physiological condition of the uterus, by making it pregnant, you will disturb the rate of action in other parts of the economy, whose properties and powers are modified, because an important integer of that economy is changed. This is the best idea of sympathy that I can present, and now I am ready to say that the stomach sympathizes with the uterus as the breast does, and that the sympathy is exhibited by anorexia, by acidity, by pica and malaccia, by nausea, by the most obstinate vomiting and by excitement of the salivary glands, to be looked upon as a part of the digestive apparatus ; and so on to modification of the nutri- tion, the coloration and the calorification of the patient, as v;ell


DISORDERS OF PREGNANCY. 477

as to changes both of her moral sentiments and her intellectual powers.

The same sympathy, to use the word, introduces speedy modi- fication of the lactiferous apparatus. The milk granules of the breast glands, which have been inactive since the woman has acquired the menstrual power, or rather the ovulation power, now become roused into an active conforraability to the wants of the constitution, and a new process of development is set up within them. This new force is manifested by an increase of the mag- nitude of the hemisphere of the breast, dependent more upon aug- mented deposit of adipose tissue, than upon immediate augmenta- tion of the lactiferous apparatus ; that augmentation is perceptible, but it becomes more strikingly so at a more advanced period.

The new life moving in the female breast, also exhibits itself in increased deposit of pigmentum nigrum on the mucous body of the skin of the aureole which surrounds the nipple, and the whole aureole becomes protuberant, so as to represent a segment of a sphere smaller than the hemisphere upon which it rests. The numerous papillae which are observed near the margin of the aureole, feel the genial influence of the new excitement, and be- come decidedly developed in size. These mutations in the cha- racter of the female breast are such constant attendants even upon the earlier stages of gestation, that they afford strong rational or presumptive evidence of that state. Pray, my friends, perpend the words, presumptive or rational ; and do not suppose yourselves authorized to decide the existence of pregnancy upon such grounds as these alone. It is but just to say that it deserves considerable reliance ; so considerable that Dr. William Hunter, to whom we are all indebted for his great reputation, as well as for the valu- able works he has left to posterity, — was accustomed to pronounce from it alone. Upon one occasion, being in the dissecting-room, Mr. Clift showed him the body of a young female, and Dr. Hunter, upon observing the state of the aureole, which was deeply colored by a deposit of pigmentum nigrum, said to Mr. Clift that the young woman had died pregnant; Mr. Clift rejoined that it was impossible, since the hymen was still intact; notwithstanding that. Dr. Hunter insisted upon it that she was in a state of preg- nancy, and upon opening the body an early ovum was found in the womb.

A woman who has become pregnant, has the womb occluded


478 DISORDERS OF PREGNANCY.

by the ovum, and even if the causes of menstruation still remain active, they cannot produce the bloody sign of menstruation, since the pregnant womb will not bleed: it may be the subject of the mensual engorgement, and doubtless is so; but, that mensual engorgement does not result in the menstrual hemorrhage, but it disappears after a few hours or after a few days.

If the menstrual doctrine is true, this is reasonable. Of the truth of that doctrine, I entertain no doubt ; and I believe you will find it everywhere admitted on the part of practitioners, as well as on the part of writers, that the early abortions are marked by a coincidence with the menstrual periods; and it is but a fair induction that the menstrual effort overcoming the resisting power of the vessels of the womb, is often the real cause of the hemor- rhage of abortion. Hence, you make the inference, that women who are prone to abortion, ought to be protected against that danger by all the precautions that are convenient or proper at or about their menstrual periods.

Supposing the woman to become pregnant, and that the succeeding menstrual effort fail, then she will miss of her ex- pected courses, and she will say, "I have conceived." She will have good reason to say so, if the ordinary state of her health had given her good right to expect the normal return of her cata- menia, and if no accident or morbid cause whatever could be accused of intervening between her and her natural function.

Upon missing the return, the woman, as I said, will suspect her- self to have conceived ; but, as one swallow does not make a summer, so one failure of her menstruation will not give her as- surance that she has become gravid. To show you, however, how strong this presumption is, on the part of women generally, any one of the upper ten thousand will begin at once to make arrangements to procure her nurse, and to provide for the exigen- cies of her accouchement. If she have the morning sickness, if she have the darkened aureole, if the next menstrual return should prove a failure, the inference becomes stronger. If the third men- struation fail, with the same accompanying phenomena, and with the addition of some augmented protuberance of the hypogastric region, the inference that she is pregnant is greatly strengthened.

The presumption that she is pregnant is strengthened by in- creased protuberance of the hypogaster and the other concomitants, and the more considerably if she fail at the fourth menstruation —


DISORDERS OF PREGNANCY. 479

still she does not know it. — At the fourth month, or more proba- bly at four and a-half, the child quickens, or, as the lawyers term it, becomes quick with life.

Quickening has been understood in the world to mean that the child has become alive, whereas it w^as not alive before. The lawyers begin now to recognize its rights in court; whereas previously, it had not any claims of the State. They will hang you for maliciously killing it after this act of quickening, but they will not call you in question on an indictment for the same act committed antecedently to the quickening. This is very great nonsense on the part of the lawyers, who would abolish their laws as to quickening if they understood the value of the term viability ; and they would transpose the claim to the protection of the State to the seventh month, or, more wisely still, make it commence with the conception.

Quickening is, however, in its true sense, not quickening; it is only the first perceived motion of the foetus. There was motion before — but motion so slow, so feeble, that the impulses against the w^omb were not strong enough to be felt, or perceived. The child at four or four and a-half months has acquired so much muscular development, that it can thrust its feet out, or move its hands, or suddenly extend its whole trunk and limbs, so as to make the mother feel it. — That is quickening. But do you not know that some children weigh four pounds, some seven, and some twelve pounds at birth ? i. e. children grow faster and stronger in some instances than in others. Hence, it must happen, that the period of quickening will vary in different women, and in the same woman in different pregnancies. Whence, the woman may feel her child at three or three and a-half months : many have felt it at three months: or the child maybe so small, feeble or torpid that it makes its spontaneous motion not perceptible till the fifth or even the sixth month ; and cases are recorded where it has never been felt until the birth had taken place.

The quickening of the child generally removes all doubt as to the gravidity of the woman. She knows she is pregnant — for the child is quick with life within her womb. — I say she knows it — but you do not know it — nor have you the right to say that she knows it.

Many a woman thinks ^he feels the motion of the child, when she feels some other motion ; and if you, relying upon her relation,


480 DISORDERS OF PREGNANCY.

or upon her good faith, should express your medical opinion, you might place yourself in a very unpleasant predicament. Suppose you rashly on oath declare to a court that you know her to be pregnant, when she is really not so, and knows she is not so! — Or suppose you assert she is so, and your professional oath serves to prove you rash or ignorant! Don't you see how wrong it would be to make professional assertions whose incorrectness must be exposed ; and how much harm you do to yourself and to everybody else of the brethren ? The scoffer has words put in his mouth — and the despiser wags his head at us all. For, in the worldly sense, DOCTOR is a genus — and if the scoffer can scoff" at you he can scoff" at me, and all of us. Don't, therefore, by false diagnosis disgrace yourself, and disgrace me, who am your teacher and you my pupil. It would be reversing the axiom — "the children have eaten sour grapes, and the Juther^s teeth are set on edge."

Depend upon it, if you confide in the rational signs of preg- nancy, you will come to the day when you will be deceived.

The signs of pregnancy are rational or sensible. I have mentioned seven of the rational signs, and two of the sensible signs — to wit, the swelling of the hypogaster and the quickening. There are other rational and other sensible signs.

Toothache is a rational sign ; since there are many women who never become pregnant without having toothache. I have heard them say : "Each pregnancy has cost me a tooth."

Hordeolum or stye, is also a sign, upon which women depend ; since some women always have a stye in the early stages of pregnancy.

Ephelis, or the dark broad freckle which stains the brow, the cheek, and often the whole neck and bosom, is a sign, which in- variably accompanies pregnancy in many women: it probably consists in the deposit upon the inner surface of the skin, beneath the internal lamina of the cuticle, of a portion of pigmentum nigrum, and has an intimate connection with the operation of the same causes which invariably produce deposits of pigmentum nigrum beneath the scarf skin of the aureole. The deposit of pigmentum nigrum is everywhere augmented ; there is a con- siderable deposition of it always in the axillae, upon the perineum, the external surface of the labise pundendorum and the mons; and there is some connection, which it is difficult to explain, be-


DISEASES OF PREGNANCY. 481

tween the new life force set up in the constitution, and the increased deposit of pigmentum nigrum.

One of the most common concomitants of the early stages of gestation, is that which I incidentally mentioned a little while ago : to wit, salivation.

This probably has some connection with the disordered condi- tion of the stomach, brought on as symptomatic of the new state set up in the uterus by its gravidity. For the most part, it is merely an observable phenomenon, and does not call upon you for any therapeutical intervention; but the examples are by no means rare where it has actually become so distressing a dis- order as to require that you should give advice in relation to its management. That it has a connection with, and indeed an im- mediate dependence upon, the state of gestation, is to be inferred from the fact, that it comes on with the beginning of pregnancy, and terminates with the termination thereof.

Here is an extract from my case-book. "September 6th, 1842. Last night I attended in her labor, Mrs. X : she was spitting saliva during the whole of the labor ; she says, and believes, that she has spit a pint and a half daily, for the last eight months. In the former pregnancies she spit about the same quantity; in both cases, the salivation ceased within three days after the birth of the child. This lady, in her pregnancy, therefore, lost 4,880 fluid- ounces of saliva, without appreciably acting in an injurious man- ner upon her health or strength.

"Mrs. Y., in her last pregnancy, spit at least a quart daily, from, the beginning to the end of the gestation. It ceased the day after the child was born. She discharged during her pregnancy at least sixty gallons of saliva, without making her the least weak or emaciated. This lady derived more comfort from keeping a few grains of burnt coffee in her mouth, than from any other remedy that could be prescribed to her, or could be found out by her own ingenuity or experiment."

I am sorry to tell you, that I know of no remedy at all to be depended upon for the management of these great salivations; they are the troublesome concomitants of the gestation, and they cease with the cessation of the gestation. They cannot be cured by alkalies or acids; by venesection or purgation; or by any the- rapeutical treatment with which I am acquainted. If it were just always to attribute the salivation to a state of the stomach, then 31 *


482 DISEASES OF PREGNANCY.

it would be reasonable to apply remedies with a view to correct a faulty state of that organ, in hopes of curing the salivation. But, you will observe, that the patient whose case I last cited to you, computed that she lost sixty gallons of saliva during her gestation, without rendering her thin or weak. Her digestive powers must have been very energetic, to have prevented great loss of weight under such circumstances; and in fact her appetite was good throughout, and I believe you may calculate on finding it so in persons laboring under this affection.

If I am right in this conception, don't you see how idle it would be to tease the woman with sickening drugs, in the vain hope of curing the salivation, dependent upon other causes than the state of the stomach?

If you should meet with a state of salivation so great as to bring the woman's life into danger, you might confidently promise to cure it, if allowed to terminate her pregnancy by bringing on abortion. I am not to be considered here as advising you to bring on abortion or premature labor on account of salivation, as I presume such a thing has never been done ; I merely speak of it now as one of the possible resources of the art in very extreme examples. I mean, samples in which the health is so greatly endangered as to warrant you even in proposing so extreme a measure.

, The nausea and vomiting of which I made mention in an earlier part of this letter, although not so rebellious against treatment as the salivation of pregnancy, yet, in some cases, occur so excessively as to give great embarrassment to the practitioner, and great distress to the patient. There are many of these cases which are uninfluenced by any treatment whatever, uninfluenced, I mean, to any considerable extent. I attended, a few years ago, a lady in Arch street, who began to be sick at the stomach, coin- cidently with the conception; there was no day in which she did not vomit, and it often happened that she vomited many times a day. When she had reached the full term of her utero-gestation, and had fallen into labor, the parturient force was very greatly contravened by the incessant sickness of the stomach, and violent efforts to vomit. I was so much annoyed by the perpetual irri- tation of the stomach, which appeared to me to protract her suf- ferings by interfering with the function, that notwithstanding she was a primipara, I resolved to violate the wholesome rule which


DISEASES OF PREGNANCY. 483

directs us not to rupture the membranes in primiparous women. From the moment that the gush of waters took place, when I had pierced the ovum, her sickness and vomiting totally disappeared, and never returned; the labor hastening to a favorable termina- tion in consequence of the relief of her nervous system produced by this discharge.

You will sometimes be astonished to receive accounts from your patients of a vomiting that shall follow every meal; and upon careful inquiry it will seem, — but it cannot really be so, — that the patient shall throw up the whole of the ingesta. I had a lady, in Spruce street, under my care, in her sixth or seventh gestation, who, from the sixth month until the completion of her term, vomited soon after taking her food every day, and it was in- comprehensible to me, that under such circumstances she grew neither weak nor emaciated,

I mention this case as having surprised me ; and you will find yourselves much surprised and embarrassed, when your patients apparently reject the whole of the ingesta. I have often been thus surprised during my long practice, and I beg you to believe when you shall meet with such cases, where, as I tell you, people seem to throw up all they take, and yet do not become emaciated, that, therefore, they do not throw up as much as they appear to.

September 18, 1842, I made the following note in my case- book: Mrs. n was married three years ago, and removed to

Texas. In the month of March she became pregnant for the first time; about the first of April she had sickness and vomiting, which she daily experienced. In June she came by steamboat from Galveston to New York, and thence to her friends here: she has been vomiting daily since the first of April.

"How many times a day?" said I; "ten?"

"Ten! why more than thirty."

"What! thirty times daily since the first of April?"

" Yes, sir, and more than that : I vomited every five minutes from New Orleans to New York, nor did I sleep one moment. I sailed from New Orleans on the 19th of June, in the even- ing, and arrived on the 27th, in the morning, at New York. I never slept; I vomited all day, and all night."

Her mother, who was present, says, " for many days toge- ther, I am sure that she has vomited more than sixty times a


484 DISEASES OF PREGNANCY.

day, and after straining long, she often brings up a thick, brown- ish, rust-colored, ropy fluid, at times stained with blood."

A very large wash basin filled wdth this substance stood by her bedside ; she is thin, but not very. I found her with a hectical frequency of pulse, and a red tongue : she has constant saliva- tion, amounting to more than a pint a day. Any rude motion of the child makes her stomach sick. She has distressing cardi- algia : her bowels are regular. I ordered for her a mixture of one drachm of carbonate of potassa, forty drops of laudanum, and six ounces of spearmint water, of which she was to take a table- spoonful occasionally. She could not take it, as it made her sick. On Tuesday I directed her to drink freely of champagne ; the follow- ing Friday she was very cheerful, had slept well, had eaten well, had not vomited, nor been sick at the stomach. She had been taking anti-emetic remedies, under the care of one of my friends, for six weeks without benefit; the champagne seems to have been a perfect remedy thus far; but I fear it will not hold.

On the 19th of September, I note, that she vomits no more, that she has a good appetite, sleeps well, is not sick, and has taken the contents of a basket of champagne. She stopped taking it tw^o days ago, and became sick ; the champagne was repeated ad libitum, that is to say, very freely, and her stomach recovered again. She rode twenty miles to a funeral without in- disposition. She returned to the city sick again, and then vomited until the child was born alive at full term. When she had com- pleted the eighth month, I was strongly tempted to bring on pre- mature labor; but she w^ent to term, and got w;ell. The child was unhealthy, and was covered with pompholyx and eczema; and died at last of atrophy.

I have given you the trouble, gentlemen, of reading this long extract, for the purpose of showing you that the vomiting of preg- nancy, may, by the long protraction of the malady of innervation, pass into a true gastritis, or gastro-enteritis, which was doubtless the case with the lady whose history I have just related. You see that I could not cure her gastritis, while her pregnancy continued, though I suspended it for a while by the use of the champagne, W'hich, all things considered, I find to be the best anti-emetic in these vomitings. I don't mean to say that it is always sure, but only that it generally succeeds. I have, at this moment, October 18th, 1847, under my care, the case of a young lady,


DISEASES OF PREGNANCY. 485

suspecting herself to be in the third month of pregnancy, and whose symptomatic vomiting has reduced her to a very ex- treme degree of emaciation, and whose stomach will by no means tolerate the champagne, which I lately prescribed in a confident expectation that it w^ould put a period to her distress.

I, however, dare very confidently to advise you in all cases of obstinate vomiting, connected with pregnancy, to allow your patients to drink champagne ad libitum; since, in a great multi- tude of examples of the kind, I have found it to procure a perfect

relief. In the case of Mrs. n, above related, the irritation of

the stomach had passed evidently into inflammation; and, not- withstanding I succeeded, by means of champagne, in appa- rently curing the malady of the stomach, you see that the pro- vocative cause being still in operation, the disorder returned and would not yield to the remedy ; nor would it yield to any other remedy which I could employ. You will suppose that I employed a great variety of means calculated to relieve the turgescence of the vessels of the stomach, both therapeutical and dietetical. But all my efforts were vain, for the cause still continued to act. The pregnancy was no sooner brought to its conclusion by the birth of the child, than all the phenomena disappeared, and as I before said, she recovered her health.

It is a curious fact, that a positive malady of the stomach, one which w^ould lead to the supposition that ramollissement of the tis- sues had taken place; one, characterized by such perverse and rebellious opposition to treatment, should suddenly yield upon the withdrawal of the gestative provocation.

In the simpler forms of the sympathy of the stomach with the growing uterus, when there are acidity, nausea and vomiting, a good degree of relief may be obtained by the administration of the alkaline mixture, of which I gave the formula a little while ago, and which maybe repeated from time to time, say every four hours. That particular combination of an alkali with the tincture of opium and an aromatic distilled w^ater, is well suited to the exigencies of such a condition. It will be proper upon occasion to add to the dose five to ten drops of the aromatic spirits of am- monia ; or to combine it with an infusion of ginger, or the fine extract of ginger, prepared by Mr. Frederic Brown, of Philadel- phia, a preparation which I am glad to recommend to your notice, as being quite equal in all respects, to the celebrated extract of


486 DISEASES OF PREGNANCY.

ginger prepared by Oxley of London; an article exceedingly useful in many of the gastric affections of pregnancy, as well as in some of the digestive maladies of children.

Many times have I been called upon to give counsel in case of morning sickness, as it is called, or the sickness of pregnancy; and unwilling, as I always am, to prescribe drugs when I can in any way escape such a necessity, and finding that the nausea is absent during the night time, while in bed, and that it returns upon rising in the morning, I have advised the patient to direct the servant to bring to her chamber at an early hour, a cup of coffee and her toast ; recommending to her to take a preliminary breakfast in bed before venturing at all to rise out of the recum- bent position, and after taking the breakfast to resume a recum- bent posture, which she should not quit for an hour or an hour and a half. During this time the gastric digestion is nearly com- pleted, and the stomach being fully occupied with, and set upon the train of vital actions upon which this gastric digestion de- pends, is enabled to resist the morbid sympathies to which, under other circumstances, it would infallibly yield.

Whether the philosophy of the experiment be true or false, the fact is very true, as to many instances in my practice. Where it fails, you have the consolation to reflect that it has cost nothing to the health of the patient, a consolation you do not enjoy when you have cupped and leeched, and blistered and calomelized, and teased both her inner and outer man, without having done her the least good, and with having done her a great deal of positive harm.

As the morbid sympathy in the nausea and vomiting of preg- nancy, must be admitted to take its rise in a qualitative state of the uterus, or the reproductive system, it is clear that we shall not err in our philosophy, if we suppose that means capable of chang- ing this quality of the uterus, may be resorted to for the sub- duction of the remote and troublesome symptomatic irritation. It is under this view that I have long been in the habit of endeavor- ing to subdue what I suppose to be some morbid or morbific con- dition of the gestative organ, by obtunding its sensibility by using anodyne applications as enemata. The sick stomach of pregnancy is in many instances greatly lessened, and in some of them, removed, by the use of forty-five drops of laudanum, mixed


DISEASES OF PREGNANCY. 487

in an ounce of mucilage or clear starch, as an injection, at bed time, and, if necessary, repeated at an early morning hour.

Riding in a carriage is often found to suspend the sickness of gestation. The soluble state of the bowels, maintained by the use of enemata, or by any simple aperient medicine, is an important part of the treatment ; and benefit has accrued in some of the cases, from the use of a tonic infusion, composed of red bark and cascarilla, slightly acidulated with sulphuric acid, and rendered a little warm by the addition of Huxham's tincture: such an infusion, carefully filtered, is by no means disagree- able to the taste, and serves to promote the appetite and the digestive power. I have tried leeches to the stomach, anodyne plasters, sinapisms, aromatic plasters, and a great variety of treat- ment, for the cure of the obstinate cases. After having been many years engaged in the practice of midwifery, I at this late day am obliged to confess that the sick stomach of pregnancy is a most intractable malady. I would certainly, had I a case again under my care, so distressing as that of Mrs. n, take mea- sures to bring on premature labor. I have to condemn myself for having permitted her to suffer so long as I did. She was in im- minent danger of losing her life ; and her happy recovery at the last does not confirm me in the opinion that I was right in allow- ing her to suffer so long.

When the patient has attained the seventh month of her gesta- tion, the uterus has risen considerably above the umbilicus, and the abdominal parietes are excessively distended in order to make room for the distending organ. In proportion as the parietes be- come distended, the dimple of the umbilicus will become shal- lower and shallower. At the seventh month it has risen to the level of the surrounding surface, or forms a protuberance ; and as the pregnancy proceeds, it even proceeds so far as to pro- duce what is called the pouting of the navel, which is enumerated as one of the signs of pregnancy. The umbilicus is concave in the non-gravid state, because, when the umbilical cord was cast off, six or eight days after the birth of the individual, the remains of the umbilical vein and the rest of the two umbilical arteries, which, like the umbilical vein, are converted into ligament by their condensation or contraction, have drawn the skin about the um- bilicus very deeply in toward the peritoneal lining of the abdomen : these ligaments have retained it there until the intrusion of the


488 SIGNS OF PREGNANCY.

womb has stretched them, so as to allow the umbilicus to pout, as it is said. Pouting of the navel is rather the sign of a big belly, than the sign of pregnancy; for, you find pouting of the umbilicus in ascites, in encysted dropsy, in chronic tympanitis, and in what- ever condition it may be, that may cause the belly to become enormously enlarged, so that protrusion of the navel is worth something or nothing as a sign of pregnancy.

Strange modifications of the appetite, or a desire for dry and ab- sorbent substances, is a common sign of the state of gestation. Some women are fond of eating chalk or magnesia, or charcoal, or anything that has an absorbent or alkaline character. This is the result of some gastric want, and not perhaps a result of preg- nancy; it is one of the accidents of pregnancy, not one of its necessary accompaniments.

Strange desires, called longings, are said to affect pregnant women. I have never known any woman affected with longings, but they tell very curious stories ; as of a baker's wife, for ex- ample, who longed to bite a piece out of her husband's shoulder. The value of such signs I leave you to appreciate.

There is a sign of pregnancy which is of some value. I mean the jutting of the hemispherical head of the uterus, above the plane of the superior strait, where its presence maybe detected by applying the palps of the fingers, while the patient lies upon her back with her thighs strongly flexed, so as to relax the ab- dominal muscles and integuments. But, such an experiment as this could only reveal to you the fact that the hemispherical head of the womb is there present, and the inference is strong that it is there because the womb is gravid ; but it carries with it no demonstration of the existence of pregnancy; and when hereafter you should find the uterus thus developed, I put you upon your caution not to pronounce your medical opinion upon the cause of the development. But, if the hemispherical head of the womb is there, and the woman from time to time, perceives certain move- ments or impulses in the uterine region, the inference that those motions depend upon a living fcetus, is a very reasonable one ; but still it will not give you authority to pronounce your medical opin- ion, forasmuch as you are liable, under such circumstances, to be deceived by a uterine tumor, and by a fancied, and not real perception of motions on the part of the patient. You may be well nigh sure, in your opinion, but you cannot be sure of such


OBSTETRICAL AUSCULTATION. 489

opinion. Many a pregnancy has been mistaken for a tumor, and many a tumor for a pregnancy. I have a womb in my collection which has the scar of a trocar in it made to relieve a supposed dropsy. How could you misapprehend the truth of the diagnosis, if you should carefully inquire whether the supposed tumor be alternately hard and soft, solid or unresisting? There is nothing could make it so save a muscular contraction. Hence, whenever you are at some trouble to decide whether the lump is a tumor or a womb, hold your hand on it for a long time — if it hardens and softens by turns, it is the womb, and it can be nothing else.

There are signs of pregnancy which will not mislead you: these signs are to be looked for in the double sounds of the foetal heart. It has been said that certain sounds perceived by applying the ear either immediately, or mediately through the stethoscope, over the uterus, and which are called by the French writers bruit de souffle uterin, are reliable ; for it has also been sup- posed that these are to be taken as signs of pregnancy. For my OAvn part I have not absolute confidence unless these sounds are accompanied by the beating of the fcetal heart ; when that is heard, absolute knowledge as to the existence of pregnancy is obtained, for nothing but a fcetal heart can give the double sound of the heart's action. The bruit de souffle uterin may be perceived under other circumstances, and therefore is not absolutely to be de- pended upon as a sign of gestation.

There is a work called Traite Theorique et Pratique d'Aus- cultation Obstetricale, par J. A. H. De Paul, of Paris. Paris, 1847: 8vo. pp. 400. This appears to me to be a very erudite and ac- curate work, containing a good exposition of whatever is known by the profession upon the subject of obstetric auscultation.

Dr. De Paul, at p. 243, commences some inquiries as to the earliest periods of pregnancy, at which it is possible to perceive this beat of the foetal heart ; and, after giving a statement of nu- merous experiments and observations which he had made for de- termining the question, he says, at p. 246 : " From the foregoing facts, it appears that the double sounds of the foetal heart have not been perceived earlier than three months and a half, although numerous attempts have been made to discover them earlier than this period. It further appears, that I have perceived those sounds in a much larger proportion of women who had reached the end of the sixth month ; and finally, that in pregnancy at four months


490 OBSTETRICAL AUSCULTATION.

and a half, the absence of these sounds is a very rare excep- tion."

Dr. De Paul says, at p. 247, " I was consulted two years since, by a young lady, eighteen years of age, who was married on the 28th of July, who had always been extremely regular in her courses, and had them last on the 18th of the same month, that is to say, some days before her marriage. At the end of October, [three months,'] when I was called to see her, all the rational signs of pregnancy had been for some time in existence. It was easy, through the supple and thin abdominal parietes, to feel the uterine globe, already jutting above the superior strait. As the lady ma- nifested a great repugnance to the vaginal exploration, I was obliged to content myself with a stethoscopic examination, which I effected with all the precautions requisite in such a case. My first researches were for a long time without result ; they termi- nated, however, in ascertaining the existence of the double pul- sations. They were feeble, and difficult to hear ; nevertheless, I could count them, and they were repeated one hundred and forty times per minute, while the pulse of the mother was scarcely eighty. The souffle uterin could not be discovered. Another examination, made eight days later, led to a precisely similar re- sult, to obtain which I was obliged, as in the first case, strongly to depress the abdominal wall towards the pelvic cavity. This pregnancy went on regularly, and terminated by a natural labor, at the end of the following month of April." Dr. De Paul, at the 248th page, says, that he "does not understand from this case, that the conclusion is established that such a result is always to be obtained." He is even inclined to suppose it a fortunate ex- ception.

I am tempted to cite another case from the same interesting volume ; and, as that volume has not been translated and pub- lished in this country, I shall translate it, and lay it before you. The case is as follows :

" Mad. T , who has already borne several children, had her

courses from the 10th to the 15th of April. From the 17th to the 20th of the same month, she cohabited with her husband : he then left Paris on a journey, which was to last only a fortnight. Upon his return, which was early in May, he found his lady confined to bed, with the early symptoms of a typhoid fever, which, in a few days, became perfectly well characterized, and lasted twenty-four


OBSTETRICAL AUSCULTATION. 491

or twenty-five days. Her convalescence required a lapse of time nearly as long ; and new sexual relations were not established until after her recovery. Nevertheless, upon the first of August following, as her courses had not reappeared, I was requested to see her with a view to determine whether this retention, which was very naturally attributed to the severe disease she had lately suf- fered, might require the employment of certain remedies for its cure. I confess, that I was at first very much inclined to give up the idea of a pregnancy begun antecedent to the commence- ment of the typhoid fever: I was little inclined to suppose it might exist, computing it from the new sexual relations that followed her convalescence; but the examination per vaginam, enabling me to detect a notable development of the volume of the uterus, I fell back upon the first opinion, of the propriety of which I became fully convinced, when, after having applied the stethoscope at various times upon the inferior part of the abdomen, I discovered the double pulsations, which were repeated one hun- dred and forty times a minute, while the pulse of the mother was only seventy-six. I could not hear the souffle uterin.

" Her confinement took place in the following January. The child, which was perfectly well developed, appeared not to have suffered the least during its gestation."

Here, then, gentlemen, you have a case in which the double sound of the foetal heart w^as discovered one hundred days, or, three months and ten days, after the fecundation had taken place. And in which the pregnancy continued two hundred and seventy- four days after these foetal sounds were detected by Dr. De Paul ; giving two hundred and seventy-four days for the duration of the gestation, assuming that the fecundation took place upon the 20th of April, and two hundred and seventy-seven days, assuming that it took place upon the 17th of the month. It is clear, that in this case, it might have taken place on the 17th, 18th, 19th, or 20th.

With regard to hearing the double sound of the foetal heart in auscultation of the uterus, though we may feel some surprise at the early detection of it in these cases, we cannot refuse to admit the exactness of the diagnosis, inasmuch as in both the cases we have statements of the rate of the mother's pulse. I examined this day, by auscultation, the uterine region of a young lady sup- posed to be three months gone with child; she has been very much reduced by a severe attack of the vomiting of pregnancy,


492 OBSTETRICAL AUSCULTATION.

accompanied with a hectical state of the circulation. There is nowhere to be discovered the least sign of the bruit de souffle ; but a rapid double sound, coinciding with the double sounds of the heart, is heard whenever the ear is placed over the uterus ; but these double sounds are those of the maternal heart, and not of the foetal heart, for they are perfectly coincident with her pulsa- tions, — but for this coincidence the diagnostic would be erroneous.

I relate these cases as encouraging you to hope to be able, in the course of your practice, to discover these proofs of pregnancy as early as they have been detected by Dr. De Paul ; yet I beg you to believe, that such an early discovery is more likely to be owing to a fortunate accident, than to any general facility to be met with, and on which you might rely for the expectation of being able to make so early a detection.

Dr. Evory Kennedy, author of Observations on Obstetrical Aus- cultation, etc., Dublin, 1833, lately Master of the Dublin Lying- in Hospital, says, at page 101 of his work: "Although we have, in a few cases, detected this sound even before the end of the fourth month, it will not, in the majority, be possible until a later period, and in those cases where it can be detected about this time, it is sometimes so delicate and feeble, as to render it neces- sary for the individual exploring, to have an ear well trained to stethoscopic sounds. In general, therefore, we look upon this phenomenon as not to be detected until after the period of quick- ening, when the uterus has risen out of the pelvis, and allows of our coming more immediately in contact with the part of it in which the embryo is contained."

Such is the opinion of one of the most practised obstetrical aus- cultators now living. I beg you to remember this opinion, ex- pressed by Dr. Kennedy, so that, when you come to make this obstetrical auscultation, you may feel no embarrassment, and ex- hibit none w^hen you fail to detect the sound in those stages of ges- tation in which the sound cannot possibly be perceived. When the child has acquired a degree of development, sufficient, not only to render its motions perceptible to the mother, but sufficient also to render the sounds of its heart audible in auscultation, there is little difficulty ; and the greater the progress of the pregnancy, the louder and more distinct the sounds ; so, that from the sixth month, to the conclusion of the full term, you will have just rea- son to expect to discover these sounds, where they really exist ;


OBSTETRICAL AUSCULTATION. 493

and not only to discover the sounds of the foetal heart in cases of single pregnancy, but those of two distinct hearts in cases of twins, the sounds being heard in difl'erent regions of the uterine globe.

I w^as going to say, that I implore you never to pronounce de- finitively upon the existence of a pregnancy, unless you can clearly make out the sound of the fcetal heart; or unless you can touch some part of the foetus in a vaginal examination ; for you may be deceived by supposed motions, supposed resistances, supposed dimensions and forms, ascertained through the abdominal pa- rietes. The two preceding methods on which I recommend you to rely can never deceive you. How desirable is it that a physi- cian shall not suffer himself to give an erroneous opinion. I as- sure you, that I think nothing could tempt me to give an opinion, except from one of the two signs above mentioned. I may be ready to admit the extreme probability of the existence of a ges- tation ; I may not dissent from the opinion of the patient herself; but for my part, I will not pronounce until I shall know. This unalterable resolution has conducted me safely through many diffi- culties, nor has it ever exposed me, as far as I know-, to the least inconvenience or danger.

The obstetrical auscultation, as it is called, was really disco- vered by the distinguished physician, Maior, of Geneva, though the credit of it is generally given to M. de Kergaradec. M. de Kergaradec read his communication upon the subject at the Royal Academy of Medicine, on the 26th of December, 1821, since which time great progress has been made as regards the pre- cision of the results to be obtained by this method of diagnosis.

While I am treating on this subject, it may be as well to say, that the obstetrical auscultation of the foetal heart is highly useful to determine questions as to the life or death of the foetus in utero, as well as questions relating to its health and safety, and the ne- cessity of doing, or forbearing to do, certain things in the conduct of a labor, as necessary for the conservation of the life of the child.

The same art of obstetrical auscultation may be most usefully applied for the purpose of ascertaining the presentation of the foetus; the extremity of the stethoscope being placed in the situa- tion the nearest possible to the beating heart, will determine the


494 OBSTETRICAL AUSCULTATION.

place of the heart ; which, being nearer the os uteri or the fundus uteri, will determine the presentation.

I am not writing a treatise upon midwifery, but I can very readily conceive, that the general practitioner who undertakes to treat the diseases of females, irrespective of their lying-in manage- ment, might have frequent occasion to examine the health con- dition, and the presentation of the foetus in utero; wherefore, I have proffered you these remarks.

There is a sound to be discovered by obstetrical auscul- tation, which is called the placental souffle, the uterine souffle, and the bruit de souffle uterin, as Dr. De Paul prefers it should be called. This is a sound which you hear with your stethoscope, or ear, applied over the globe of the uterus, in pregnant women. That is to say, it is a sound that is heard, provided the ear or the stethoscope be applied upon that part of the uterine globe imme- diately under which the cause of the sound exists; for it does not exist in all parts of the uterus, being mostly to be heard upon the sides, and also in the immediate vicinity of the placental attach- ment.

It is a blowing sound, and it often sounds like the rush of air issuing from the nozzle of a bellows, when one is blowing the fire. Sometimes it is musical, and resembles very nearly the note of a dove cooing at some distance from the ear. It is in some instances like a faint breathing, and in others like a loiid snore. It is un- attended with any shock or suddenness. While you listen to it, and hear it with the utmost distinctness, it often ceases to be heard, and then recommences, although, in the meantime, you have not removed the stethoscope from the spot where you heard it, and where you have continued to listen. It is probably owing to the motion of the blood in its vessels, and is attributable to the escape of the blood from a narrower into a wider channel. For exam- ple, if the posterior lateral surface of the uterus should press hea- vily upon the primitive iliac, the external iliac, or the internal iliac vessels, so as to lessen, at the point of contact, the calibre of the tube, the fluid issuing into the uncompressed portion, would pro- bably occasion the sound of the placental souffle ; just as the blood, issuing from the cylindrical portion of an artery, into an aneuris- mal dilatation of the same tube, gives out the aneurismal sound.

Some authors have supposed that the sound is occasioned by the rush of blood into the great sinuses and veins of the uterus;


PLACENTAL SOUFFLE. 495

that it is occasioned by the rush of blood from the veins of the uterus, into the so called cells of the placenta ; and a variety of explanations, that have been offered for it ; but nothing appears to me more clear than the one which I have presented to you above.

Dr. De Paul, whom I am willing to take as authority upon this point, thinks it is probable that the bruit de souffle exists for some time before it can be distinguished. I will allow myself in the criticism, that it would be better to say, that the causes of the bruit de souffle exist earlier than the bruit de souffle itself; for a sound that cannot be heard, is not a sound.

M. Kergaradec mentions a case, at page 276, in which he heard the bruit de souffle on the eightieth day.

M. Orfila refuses to regard this sound as a certain sign of pregnancy.

Dr. De Paul, at p. 206, says, " For my part, I do not hesitate to make the declaration, that the uterine souffle is not a certain sign of pregnancy." M. Jacquemier, of Paris, and M. Stoltz, of Strasburg, do not regard the bruit de souffle as a sign of preg- nancy.

You will find, in the course of your surgical studies, that tumors in the abdomen, from their pressure upon the great vessels, produce sounds not to be distinguished from the bruit de souffle uterin ; and it is not to be doubted that the empty uterus, after labor, in many cases, yields the same sound. Now if this repre- sentation be just and true, and I believe it to be so, what real value will you attach to the discovery of this sound in any case of obstetric auscultation ? It can have none at all, since it clearly proves neither the existence of the child, its life, nor its death. With these remarks, I shaU trouble you no further with the pla- cental souffle.

As pregnancy advances, the uterus becomes constantly aug- mented in size. In the primiparous woman, in whom the abdominal muscles and tegumentary tissues have never before been weak- ened by the distension attending the gravid condition, the globe of the uterus is strongly resisted in its ascent into the abdomen. This resistance presses it against the firm solid back part of the cavity. For the most part, the uterus is in a flaccid condition, grow- ing hourly, daily, weekly, larger under the compulsion exercised by the developing ovum ; yet, it is true, that from the beginning of pregnancy to its end, the contractility of the uterus is frequently


496 DISEASES OF PREGNANCY.

.exerted in such a manner as to condense and harden its fleshy textures. When so condensed, the hand applied on the exterior of the abdomen, meets with a firm, solid ball, incompressible during the contraction, its outline clearly definable by pass- ing the finger over it, but disappearing after from ten to thirty seconds, upon a restoration of the flaccidity of the tissue. When the uterus is thoroughly flaccid, it is impossible to define its out- line through the integuments, the whole belly presenting the ap- pearance of a uniform, soft, compressible, fluctuating tumor.

During the oft-repeated contraction of the uterus, and probably, also, while it is not in such a state of condensation, the organ presses more or less heavily against the arteries and veins, as well as the absorbent branches in the lumbar region, and also upon the sides of the pelvis, just above the brim. This compression of the absorbents, and of the veins, interrupts the free course of the lymph, and the venous blood, in their ascent towards the upper parts of the body. A strong pressure could not fail, in like man- ner, to contravene the freedom of the flow of blood, in its down- ward course, through the arteries ; for the pressure of the uterus produces the effect of the pressure of a tourniquet-pad, though in a very slight degree.

The interruption to the ascent of the lymph, and the detention of the blood, is necessarily followed, at first, by an increase of the halitus in the cells of the cellular tela, from some diminution in the power of the absorbents, which should carry it away; hence, by slow degrees, there is formed a collection of serous fluid in the cellular tissue of the lower extremities, which is manifested by an increase in the size of the ankle and foot, and which gives the lady a dis- position to go about slip-shod, or to take a larger pair of shoes. As the swelling increases, it becomes cedema ; if the cause con- tinue to act with a certain degree of intensity, the cellular tissue of the legs and thighs becomes thoroughly distended with fluid, which pits upon pressure, is incommodious from its weight, and not unfrequently painful from its distension. If the action of the absorbents is still more greatly contravened by the pressure of the uterus, the amount of the halitus produced will be pari passu increased, and, as the infiltr^ion goes on, the fluid in the upper part of the thigh passes into the cellular tela on the trunk of the body, where it infiltrates everything; it rises to the throat, which is enormously distended ; it fills the arms, and bloats the face ; so


DISORDERS OF PREGNANCY. 497

that the woman is, at last, afflicted with an enormous anasarca,' which is the result of no disease, but is dependent simply upon the accidental interruption to the action of the absorbent trunks in the lower extremity. It is probable, that you will meet with some cases of this kind, which will fill you with surprise on account of the enormous amount of infiltration.

As I have already spoken upon the subject of infiltration in my fifth letter, I do not deem it necessary to enter here into any conside- rable discussion on the subject ; my principal design and desire in the present mention of the topic being to make you clearly under- stand that there is a great difference between an anasarca arising from a morbid condition of the constitution, and an anasarca more properly to be denominated oedema gravidarum, or infiltration, which, taking its commencement in the lower extremities, depends solely upon the pressure of the gravid uterus upon vessels, and vanishes like snow before the sun, as soon as the pressure is taken oflT. It vanishes, I say, like snow before the sun, sometimes under greatly augmented discharges from the kidneys, and some- times without any perceptibly increased diuresis. A great diure- sis would not be necessary, provided the cause of its production were entirely withdrawn ; for the production having entirely sur- ceased, the power of elimination exercised at the ordinary rate, might be expected soon to remove every excess. It is hardly worth your while, under these views, to trouble your patient, and compromise the health of her stomach and bowels by the admin- istration of drugs; for she is not sick, nor will yoi^r drugs have any other effect than to make her sick. She does not want a drug ; she only requires that the pressure of the uterus should be taken oflf.

Pregnant women have a great tendency to become constipated, and to overload the colon with unknown and unsuspected accumu- lations of stercoraceous matter. Such accumulations add to the power of the pressure already too great, and common sense dic- tates that they should be obviated or removed. Let the woman keep her bowels in a soluble state : give her two or three rhubarb pills twice or three times a week ; but this is not so good treatment as to let her take a couple of Lady Webster's pills imme- diately after her dinner, when her stomach is full of food ; which is preferable to the use of rhubarb pills.

But this is physic, and you can give her a pleasanter remedy 32


498 DISORDERS OF PREGNANCY.

than this. Let her infuse half an ounce of senna in a pint of boiling water for two hours ; let her strain the liquor over a pound of prunes in a saucepan, adding to the mixture a handful of loaf sugar ; let the prunes stew until they become well cooked, soft, and pulpy, after which, they may be poured into a bowl or jar for use. Now, a prune cooked in this way tastes as plea- santly as if it had been cooked in spring water; it will amuse her to eat six or eight of them per diem ; they will keep her bowels open without griping or purging, and assist very materially in ob- viating the tendency to an increase of her oedema gravidarum.

I have no doubt that in case of pressure exercised by the womb, the veins and absorbents being the weaker vessels, suffer a greater degree of compression than the artery, which is endowed with an elastic coat, along the tube of which the blood is impelled by the energy of the heart's contraction; the blood of the femoral vessels, and of the popliteal, may reach their distal extremities with a momentum so great, that, favored by the diminished power of the veins, and the absorbents, it rapidly increases the effusion and the infiltration. Hence, where a primiparous woman has cause to complain of the infiltration of the lower extremities, and the arterial pulse exhibits a strength and momentum above the par of healthy action, it is highly reasonable, and sensibly con- ducive to her comfort and safety, to lessen the force of the blood's motion by bleeding a vein in the arm ; and this offers you an in- telligible rationale of the common method, which is to bleed a woman whose legs are too much swollen.

I repeat that I am not writing a treatise upon midwifery ; and that though you may not be obstetricians, yet, as physicians, you will often have charge of the health of pregnant women.

You have just considered the effect of pressure upon the blood returning from the extremities ; I pray you now to ponder upon the effect which the same pressure would have in diminishing the flow of blood in the arteries below the bifurcation of the aorta, and the inevitable polygsemia of the upper parts of the trunk and the members, coincident with such diminished flow downwards.

If your patient, in an advanced stage of pregnancy, wakes in the morning with her face bloated, her hands and wrists so swollen that she can wdth diflSculty flex or extend the fingers ; and this ac- companied with pricking sensations affecting the arm, as though


DISORDERS OF PREGNANCY. 499

the member had been asleep ; with sickness, pain in the head, or vertigo; you would at once refer such phenomena to their true cause, which is the polygsetnic state of the upper part of the trunk and limbs. In the progress of the day, as she sits up and moves about upon her feet, the polygaemia ceases, to return upon taking the horizontal posture, and to manifest itself again on the following morning, and so on from day to day. Such a woman ought to BE BLED, because, if this hyperoBmic condition be allowed to be renewed from day to day, for weeks in succession, the vessels of the brain will become habitually surcharged, exposing her to no little risk of apoplexy during her pregnancy, and greatly aggra- vating her liability to eclampsia when, to an habitual hypersemia, she comes to superadd the dangerous congestion which coincides with a first, hard, long, laborious labor. I shall now dismiss the subject of oedema gravidarum, satisfied that I have laid before you all the explanations relative to it which seem to be ne- cessary.

The duration of a human pregnancy may be stated at two hun- dred and eighty days, and if you have occasion to calculate -for your patient the probability as to the period of her confine- ment, you should inquire as to the date of the disappearance of her last menstrua. It is most probable that when fecundation takes place, it will take place soon after the disparition, within from one to four or five days ; more likely on the first than on the fifth. The Jewish women, as I mentioned in a former letter, do not return to the husband's bed until eight days after the dispari- tion, and yet they conceive and bear children, which is a proof that the deposited ovulum still preserves its vitality at that late period, and possibly as lale as the twelfth or thirteenth day; so that a Jewish woman, who is going to make her computation for two hundred and eighty days, would begin on the ninth day after her last menstruation. Some persons do always allow eight days to elapse before they commence the computation, and then add two hundred and eighty. But for more than thirty years that I have been in the habit of making the computation, commencing from immediately after the recovery, and allowing two hundred and eighty days, I have had no reasoh to change the method.

The same causes' which produce the_ distressing infiltrations of which I have been treating, act on multitudes of women with such intensity, as to establish for life a varicose condition of the veins


500 DISORDERS OF PREGNANCY.

of the lower extremities. I don't think that you will meet with a great many women who have repeatedly gone through the uterine gestation, in w'hom some of the veins of the lower limbs have not become permanently varicose ; that is to say, enlarged, distended, tortuous, causing the appearance of dark venous stains on the tractus of the vessels. While not pregnant, and not sustaining the w^eight and pressure of the womb upon the vessels within the pelvis, these varices, although they exist, are not always trouble- some ; but upon the re-establishment of the state of gestation, the interruption of the flow of blood exists to such a degree as to render them highly inconvenient and painful.

In proportion as a female approaches the term of her gestation, such a condition of the veins of her extremities becomes hourly more worthy of regard and attention ; for it is dangerous in the extreme, to allow the disorder to go beyond a certain limit, the overpassing of w-hich exposes the vessels to attacks of inflam- mation, which constitute phlebitis. I have seen a sample of frightful phlebitis supervening upon an unregarded varicose state of these vessels in a pregnant woman, and which resulted in her death from a pyogenic fever, taking its origin evidently from the points which I have just indicated. If there be in such a woman a condition warranting you to let blood, you ought to do so in ful- filment of a clear indication. Such a woman should be consci- entiously instructed and warned against the danger to w'hich she- would be exposed by being long in a standing position, and she should be earnestly advised to observe a recumbent posture, not only during the night, but frequently during the day time, with a view to allow the distension of the vessels to have some inter- mission.

Inasmuch as, under these circumstances, the texture of the vein may be considered to have lost its tone, its contractility, its power of resisting the lateral pressure of the blood column, you ought sedulously to provide some succedaneum for the lost tone, which you can only find in what the surgeons call position, or in the use of a laced stocking, gaiter, or bandage ; by either of which methods, the dangerous distension of the tube is prevented, and the patient safely conducted to the term of her accouchement ; when the pressure being taken ofl", she will no longer be subject to the varix gravidas.

I shall close this letter here, with the expression of my sincere respect. C. D. M.


DISORDERS OF PREGNANCY. 501


LETTER XXXVIII.

Gentlemen : — There are not a few persons, who, in the preg- nant state, become affected with seeming diseases of the heart, characterized by irregular action of that organ, such as palpita- tion, great augmentation of the superficies of pulsation, dyspnoea, orthopncea, paleness, convulsions, sudden loss of sight and hear- ing, followed in the long run by oedema and true anasarca. I am speaking of persons who seem to labor under disease of the heart, and I speak, having in my mind a vivid recollection of divers cases that I have had the charge of in the course of my practice.

A pregnant woman ought to pass through the whole of her gestation without any feeling of disease ; and many women do, in fact, conceive, develop, and bear their children without any apparent change of their health or comfort. I have seen young women not far from term, skip up and down stairs as if they had not been married, preserving all their activity, agility, and appe- tite, their good spirits, their color, and their temperature, enjoying food, sleeping, and waking, as if nothing was the matter with them. But there are some constitutions on which the influence of preg- nancy is disastrous in the extreme, constitutions in which the ges- tation seems to be a direful effort of the life forces that they can scarcely carry out, which they are often unable to perfect, and which, in some instances, is perfected at the expense of the wo- man's health and life.

A woman who develops her child requires an augmentation of her hasmatosic power; indeed, it is but fair to say that she requires an augmentation of the hsmatosic power for the uses of her own constitution, applying it to the maintenance of her own developments, which demand considerable reinforcements when the life force is exerted with a preternatural energy. The reaper in a harvest field requires more drink and more food than the idler; the woman who maintains not only her own development, but also furnishes the materials for the development of the child, may in respect to her wants be compared to the reaper in the harvest field.


502 DISORDERS OF PREGNANCY.

But, an augmented development power is a power augmented at the expense of the nervous constitution or matter. There are some nervous constitutions that can furnish it without detriment, whereas others suffer the greatest detriment in doing so.

If the nervous system becomes affected by these efforts, it may show the affection in some diminiition of its power, and the dimi- nution of its power will be most likely to manifest itself as to the specific tissues, that are most immediately subservient to the super- erogatory demands of the occasion. Inasmuch as all development takes place at the expense of the blood, of which the consump- tion and loss are very great in gestation, it is not, I think, unphi- losophical to suppose, that the specific tissue most likely to suffer under these circumstances, is the tissue which in former letters I have repeatedly mentioned under the title of the endangium, of Mr. Burdach, or blood-membrane, as I prefer to call it. But, if the blood-membrane, in consequence of exertion of its faculties, becomes weakened, becomes diminished as to functional force, then we shall have an imperfect blood, imperfect in regard to the proportion of its solid constituents, which are diminished while the watery part is abnormally increased, which would constitute a state of anaemia. But a condition of anaemia in a constitution bound to carry on the great operations of gestation, is one likely to be attended with faulty innervation; faulty innervation, not only of the cerebellar and cerebral and spinal nerves, but of the whole ganglionic system of nervous supply.

The patient will become emaciated more or less, while her cellular tissue is infiltrated with serum or halitus, giving her the appearance of an embonpoint which is likely to deceive the in- cautious diagnosticator. The increased proportion of water in her blood will give to her superficies a character of pallor or chlorosis, and the diminution of the universal tone will extend even to the heart itself, which may become so flabby as apparently to increase in magnitude and give rise to a great increase of its pulsative superficies on auscultation, misleading the inquirer, and causing him to believe in the existence of a disease of the heart, whereas the disease is essentially an anaemia, or an endangial malady only. These are most distressing cases ; they generally become aggra- vated in proportion to the advance of the pregnancy ; and not unfrequently admit of such extensive dropsical infiltrations, not only of the cellular tissues, but even of the serous cavities,


DISORDERS OF PREGNANCY. 503

particularly the thorax, as to bring the patient's life into the extremes! peril. Yet these maladies are not diseases of the heart ; they are samples of anaemia, from which, often, the patient reco- vers with surprising rapidity, when the cause — videlicet, the ges- tation — has been brought to its term by the birth of the child.

In cases of organic disease of the heart, I mean vast dilatation of its cavities, there is no reason to expect a rapid recovery, or perhaps a recovery under any circumstances. But the ansemical dilatation, or, if you permit me to use the term, the ansemical laxity of the heart's fibre, might well, and in fact does, for the most part, disappear under an appropriate treatment, when its provoking cause, to wit, the ansemia, has been removed. I am very desirous that you should give attention to this theory of the case, and that you should endeavor, whenever you shall come to take charge of a pregnant woman, affected with disease of the heart, to make a careful discrimination between the incurable orfjanic lesions of that important organ, and the modifications of its density and con- tractility, that may be superinduced by a too feeble innervation of. its tissues.

The most extravagant deviations in the heart's action that can be produced by the ansmical state, are for the most part found to be lessened and even to disappear wholly, when the patient is placed in a recumbent posture, and has had time enough to allow the accidental hurry and excitement which have been pro- duced by exertion, motion, or emotion, to subside, and the rate of all the functional forces to come down to a condition conformable to the wants of the economy in a state of profound repose. The ansemical disorder, under a supposed condition of perfect repose, disappears in so far, at least, as it can be manifested by the re- spiration or by the circulation. This is not the case in the true organic disease of the heart, where, though the derangements of the heart's action, aggravated by exertion, are frightful, indeed, yet they do not wholly disappear even in a state of the most profound repose, but leave their physical signs so plainly dis- cernible to the practised inquirer, that he cannot be misled by them. The hypertrophic throb of a thickened ventricle, and the feeble imperfect action of a coincidently dilated auricle, can be detected by the .ear, even after a long night's repose. But the irregular, disordered, anomalous, feeble beat of the anaemic heart.


504 DISORDERS OF PREGNANCY.

give place to a perfect rhythm, impulse, and superficies, after such a repose has been had,

I am very desirous that you should make a careful discrimina- tion in the cases supposed, and that you should not mistake the quick but feeble impulse of the ansemical heart, for the stern, re- solute and dangerous injective force of the hypertrophied ventricle. In the one, you will be prompted to use the lancet as a means of diminishincT the excessive general momentum of the arterial pulse; in the other, you would prescribe profound recumbent rest to save the constitution from the effects of the disordered and convulsive beat which follows every effort. You would direct a nutritious and light diet, you would give wine and iron, you would direct well ventilated rooms, you would prescribe the use of mo- derate anodynes and antispasmodics, to obtund the exaggerated sensibilities of a debilitated constitution ; and in so doing, you would conduct the patient wisely, if not safely, to the term of her utero-gestation, which, being completed, and the cause being removed, leave you afterwards nothing to do, but contend against the pathological causes of the simplest anaemia.

But I have already said so much in these letters upon that subject, that I shall not offer any further observations here, and I refer you to those letters, in the confident belief, that the pathological principles there explained, are founded in sober views of important truths.

In the treatment of these ansemical cases, you will meet with prejudices against the employment of ferruginous articles; for the public in general, who believe that iron is endowed with what are called forcing properties, as regards the menstrua, are timorous as to the use of such therapeutical agents during gestation. They suppose that forcing articles have the power to produce abortion or premature labor, because they thoroughly believe that such forcing articles are capable of bringing on menstruation, in season or out of season. To you Avho have adopted the doctrines of the periodical ovulation and deposit, I need not say, that the chaly- beates have no such forcing power as is supposed, and that the use of them during gestation is not less prudent and safe, than that of any other tonic medicine whatever, and I have not the least misgiving as to the propriety and safety of employing them for the cure of these endangial maladies in women pregnant, whether in the early or in the advanced stages of gestation.


DISORDERS OF PREGNANCY. 505

I attended here a few years since, a young woman during the latter half of her utero-gestation, and during the labor in which it terminated ; a case which was put in my hands by the advice of her medical attendant, on the ground that it was a very dangerous one, with which he was not disposed to charge himself.

She presented all the appearances of great dilatation of both the auricles and ventricles of the heart — the impulse of which was perceptible to the right of the middle of the sternum. The pulse, except when she was in a state of recumbent rest, was large, gaseous, unsteady and very sudden. The face and whole surface were pale and flabby, the cornea nearly uncovered of the upper palpebra. The respiration was troubled, and on the least motion or emotion, precipitate and difficult. At the end of the seventh month, the lower limbs became considerably infiltrated, and the power of muscular motion much curtailed in consequence of its being always attended with violent beating of the heart, breathlessness, and uneasy sensations in the head, as pain, ver- tigo, noises and dimness of sight.

The progress of the pregnancy was accompanied with aggra- vation of all these appearances.

On different occasions she had attempted to walk in her house, and had fallen on the floor in a state of insensibility. I, being hurriedly notified of such an accident, arrived on one of the occasions, at the house, soon after she was taken up from the floor and laid upon the bed.

I found her absolutely pale, scarcely able to speak, and com- pletely blind when I arrived. She knew my voice, and opened her eyes to look at me as I spoke : — the eyes were bright, the pu- pils natural, but she was wholly without sight. She complained of some degree of fulness of the head. The pulse was still agi- tated. In a short time the sight returned and was perfect as before. I do not recollect how many times she actually fell in this manner, and with such following phenomena, but the accident was repeated several times. In nearing the term, the swelling of the limbs from oedema was greatly augmented, so as to aflfect the thighs, and the buttocks, and labia; the pericardium became also the seat of a dropsical effusion, so that a complete orthopnoea soon declared itself.

My patient could not lie down day nor night. If she sat up with a pillow against her back and shoulders, the oppression be-


506 DISORDERS OF PREGNANCY.

came so dreadful, she was obliged to throw them away; but, requiring some support, she placed her back against one of the posts at the foot of the bed : leaning on the slender cylindrical bed-post, she could find the needful support or rest without the oppression brought on by pillows or cushions. Here she sat day and night for many days, with very bad thin blood, which was imperfectly oxy- genated, and so, greatly increased the disorders of the innervation. Her condition was truly deplorable, and it was difficult to imagine that the heart could ever recover its form, consistency and power, should she even escape death in the impending conflict of labor. In fine, labor came on, and in due time I delivered her with the forceps in order to save her from the necessity of exerting any voluntary force.

Soon after the birth of the child, she began to sleep upon pillows, which she allowed to be made up lower and lower; and, at the end of the month of her lying-in, it was no longer a ques- tion whether she w^ould recover her health. Her health soon became stronger, and now she is in consummate health. The heart presents no evidences of disease whatever.

I look upon it that all the distress and the peril of this young woman proceeded originally from an endangial malady, provoked into exaggeration by the demands of the gestative state on the blood-membrane. The v,'hole scene was a scene of the effects and complications of a simple anaemia. Ansmical girls — girls who have passed badly through their puberic age and crisis — are more liable to be affected as in the manner above described, than others, if they subsequently to marriage become the victims of pregnancy.

Women in pregnancy are liable to palpitation of the heart, especially dependent on anaemia.

I advise you, whenever you encounter the case of a pregnant woman who complains to you of sudden attacks of palpitation of the heart, to inquire carefully into the causes of such palpitations ; more especially is it your duty to do so, where the attacks of pal- pitation continue for a considerable length of time before the heart recovers its usual rhythm. A woman who, in her gestation, has an attack of palpitation which lasts her from two to six hours, is absolutely in need of good advice; for, notwithstanding I have seen cases of palpitation lasting from morning to night, and attended with the most distressing sensations, and the most com-


DISORDERS OF PREGNANCY. 507

plete disability of all the organs of relation ; the patient, upon recovering the normal rhythm of the heart, seemed to be from that moment perfectly well, save a feeling of debility, and per- haps some pain in the extremities, which, however, soon vanished by the aid of a little rest. I have seen the heart beating more than two hundred and twenty times a minute for ten con- secutive hours, and yet the patient who had been in such an ap- parently dangerous situation, has evinced no considerable signs of disorder a short time after the cessation of the palpitation.

I confess to you, gentlemen, that notwithstanding the frequent examples of perfect recovery from such extravagant palpitations, I can with difficulty imagine that the individual can be safe during the existence of them ; for the blood must reach the organs with a pressure, and with a momentum so different from those that attend a healthful state of the circulation, that the development force, one would think, could not fail to produce organic lesions in some of them.

But these irregular actions of the heart do, in fact, in some of these cases, give rise to organic changes, and the heart itself, which is the first organ served by the systemic circulation through its coronary vessels, is the one perhaps most likely to suffer. In- deed, it often does suffer, and through its own illness and imper- fect functional power, gives rise to a patible state of the brain, which, in consequence thereof, determines imperfectly its inner- vations to the organisms, and so the whole constitution is over- thrown and made a wreck.

What will you do with these palpitations, supposing that they are the result of pure anaemia ? Here I pray you to take into con- sideration the case that I proposed in a former letter, of persons breathing: at a vast elevation on the side or summit of a mountain, where the pressure of the mercury in the barometer allows the column to stand as low as sixteen or eighteen inches, not for want of a given number of cubic inches of atmospheric air, but for want of a given number of cubic inches of atmospheric air of a certain density. Such persons, you may remember, are per- fectly at ease while sitting down upon the snow, or on a projecting point of rock; their pulses beating naturally, and their respiratory act being performed without any notable exaggeration ; but, as soon as they begin to move, and call upon their innervative powers for extraordinary dotations of nerve force, the heart beats


508 DISORDERS OF PREGNANCY.

violently and irregularly, the diaphragm and respiratory muscles make the most violent efforts to carry on the respiration in the lungs ; the head aches and becomes dizzy, and the traveler, after taking some twenty paces, is obliged to stop, and give rest to his respiratory and circulatory organs, in order that they may recover their composure, and have time for the generation of an amount of nerve force conformable to the wants of the next succeeding efforts in ascending.

Now, your ana^raical patient, as I stated in the letter alluded to, is in precisely the same condition as to the oxygenating power, as the traveler on the top of Mont Blanc or the Yungfrau, and, if you permit her to continue to take exercise, or advise or compel her to do so, you act as unwisely as M. De Saussure would have done, had he insisted upon the members of his party continuing to make continued efforts to ascend, instead of allowing them to rest and recover their powers of innervation.

Continued exertion in an atmosphere so rare as that which is found in the highest altitude of mountains, is, perhaps, impos- sible ; but if it were possible to urge the traveler onward without rest, he would doubtless perish from apoplexy of the head, the lungs, or some other apoplectic tissue.

If your patient, then, continues to labor or to exercise under these conditions, there is great reason to fear that some of the important organs will be compelled utterly to give way; whereas, if you treat the case wdsely, there is little danger of any of the organs giving way, and your patient will go on to the full time of her pregnancy, experiencing, perhaps, occasional attacks of palpi- tation, but recovering from them well, and fitted to meet at last the conflict of labor without risk, and without much suffering.

When I meet with a case of extraordinary palpitation from an ansemic cause, I feel that I shall not cure my patient, until I cure her by means of a trained exercise. I shall expect my patient daily to walk many miles, before her health shall be completely established, but I do not allow her to begin the process of training, until first, by a long rest, sometimes by a rest of a week or more in bed, I have prevented her from experiencing the abnormal innervation of the heart, which every imprudent or excessive attempt at exertion had not failed before to bring upon her.

During this preliminary rest, I take advantage of the occasion to prepare her for the training treatment, by getting the skin into


DISORDERS OF PREGNANCY. 509

a favorable attitude, by procuring determination to the surface favoring the operation of all the secretory organs, invigorating a little their tonicity by nutritious diet, by cordials and by tonics ; and then, when I begin to allow her to take exercise, I direct her to adjust the amount to her ability, increasing a little by little, until I curry it up to the desired point.

If such a caution be necessary in the conduct of the cases of palpitation, even in the anaemia of the virgin, how much more desirable is it, that it should be applied to the cases of pregnant women ; since the sequelae of the palpitation are so distressing whenever there are superadded to them the constitutional excite- ment and the disturbance that must attend upon a violent or a protracted labor.

I find, that, notwithstanding my intention in a former part of this letter, to trouble you no more with observations on the sub- ject of ana3mia, I have not been able to overcome the disposi- tion I felt to give the above explanation. But I hope you w^ill consider the explanation now, for the necessity of rest is as ap- plicable to the cases of palpitation derived from the thickening of the valves, from their laxity, from their granulation, from dilata- tion of the cavity, from hypertrophy, from dilatation or w^eakness of the great vessels, or indeed from whatever causes of palpitation of the heart, as it is for those that depend upon simple, pure, un- mixed ancemia.

In cases of pregnancy, accompanied with palpitation, and convulsive, or rather what you might prefer to call nervous ac- tion of the heart, among the very best resources of the materia medica is the digitalis purpurea. This is a pure narcotic, which, by its influence upon the nervous system, when properly admin- istered, diminishes its excessive perceptivity, and in doing so, is capable of lessening the manifest result, within the organs, of that excessive perceptivity, which is always accompanied with exag- gerated action of the reflex innervation.

Everybody, whether painter or poet, musician, agriculturist or physician, becomes more or less a routiner; that is to say, he acquires habits in his actions; whence it is, I suppose, that you find some physicians who never prescribe digitalis except in pow- der ; others, who confide in it only when used as the tincture of the plant; while some never permit themselves to employ it ex- cept prepared according to the formula of Withering's infusion.


510 DISORDERS OF PREGNANCY.

I am in the latter category, and I scarcely ever give digitalis, unless in the form of Withering's infusion, except where I give it to young children, and then I always employ the tincture. In the class of patients of which we have just been speaking, I commonly prescribe, when I think the use is indicated, half an ounce of Withering's infusion of foxglove, which I direct to be repeated once in eight hours. But I think it is necessary always to add a very clear and understandable caution, as to the repeti- tion of the doses. No physician ought to trust himself to pre- scribe such a medicine, unless he can in person, or by means of a confidential agent, note the progress of its therapeutical force in bringing about the desired control of the circulation. When the pulse begins to fall in frequency, the administration of the drug should be either wholly, suspended, or lessened as to the doses, or augmented as to the periods; because, the collapse which follows the excessive action of the medicine, being sudden, is a thing not to be thought of for a pregnant woman, for it is frightful enough for the non-gravid. " In morbis pectoris, per vias urinae ducendum est," is an ancient precept, and the digi- talis purpurea, perhaps, of all the articles in the materia medica, is most highly endov.'ed with the diuretic force, which renders it peculiarly appropriate in the affection under consideration.

I need not lengthen this letter by specifying directions as to the prescriptions, and the formulce of prescriptions, which will be re- quired in the course of the treatment. If you be really well founded in the knowledge of anatomy and of physiology, you will be able, in contemplating the rate of the functions of the different parts of the body, so to direct your therapeutical prescriptions and your hygienical ordinances, as to correct, if possible, the local derangement, and by removing them, absolve the nervous system from the necessity of perpetually perceiving these local derangements, and perpetually contending against them by ex- citino; what is called reaction.

There is another distressing affection which accompanies preg- nancy, and about which I .am desirous to say a few words. I mean the inconvenience and pain resulting from a strain of the pelvic articulations. The symphysis pubis and the sacro-iliac junction ought to be firm; the least motion of the pieces of bone that are bound together by these articulations, is attended by a feeling of weakness, insecurity and pain, in the highest degree


DISORDERS OF PREGNANCY. 511

annoying. I have seen a patient who could not take ten steps across her chamber without producing a sensible motion of the right and left ossa-pubis ; so that, when she would stand upon her right foot, the os pubis of the right side would be raised at least a quarter of an inch above the left one, and vice versa. But if you understand the nature of the auricular symphysis, you will perceive that the pubis cannot become a movable joint without involving more or less motion in the sacro-iliac junction, and that such motion must give a feeling of unsteadiness, insecurity and debility, than which nothing can be more distress- ing: the woman feels as if she was going to fall to the ground between her thighs. Her inability is so great, that she is obliged to call for assistance to turn in bed, or if not assisted, she first sits up in bed and then lies down on the opposite side.

It is probable that the perpetual sprain, the weight, and the pressure occasioned by the presence of the gravid womb within the circumference of the superior strait, and the resistance of the abdominal muscles against the distending, growing uterus, all of which force, it must be admitted, is concentrated or expended upon the pelvic articulations, may determine a state of disease or abnormal vitality there, followed by infiltration and relaxation,' or partial softening of the fibrous material ; the result of which is the articular relaxation in question.

It is a vulgar opinion that the pelvic joints do naturally open to give escape to the child in labor ; and among the common people, it is by no means rare to find them making use of ointments and lotions for the purpose of promoting the softening and relaxation of the articulations. All such attempts are both unnecessary and futile ; whenever the relaxation does take place, it arises from the causes which I have just narrated; — causes that are, perhaps, fortified by a rheumatic vice which has fallen upon the parts.

The vitality of these low-lived tissues is so slow in its processes, that a great deal of time is required to effect any changes in their density, and I believe you will make a great mistake, if, when a woman, after her child is born, complains to you of relaxation of the symphysis, you should admit, what she will probably sup- pose, namely, that the relaxation was produced by the strain of the labor. A labor shall scarcely last long enough to effect such great modifications in the life of these half inorganic materials.


512 DISORDERS OF PREGNANCY.

I have met with a good many examples of this distressing acci- dent in my clinical practice, some of which have been perfectly cured in the course of a very few weeks, and some which have never recovered, and seem as if they were destined never to re- cover. The patient is so distressed, that she asks for a treatment ; nay, she asks for a cure. Now what shall be the treatment, what shall be the method of cure ? Suppose you had a patient laboring under an inflammation of the hip, of the knee joint, of the ankle, or of any other articulation, would you not treat it with a splint? And why with a splint? Would it not be, that by means of the splint, you might treat it by rest ? Now the word rest is the other expression for the word splint. An inflamed joint, like a broken bone, requires rest, as a general rule, although it may have more exceptions than the case of the broken bone ; yet it has few excep- tions, for even in the case of the broken bone, it might happen, that where a false joint is formed, or is about to be formed, the motion might determine a cure by re-exciting the power of the periosteum, which is the bone-producing power.

I don't see much use in giving drugs to a woman who com- plains of a loose articulation ; you might, perhaps, reasonably resort to some anti-rheumatic medication, in the cases which you should deem dependent on a rheumatic vice, existing either as the original cause of the relaxation, or continuing to prevent its cure, or as succedaneous, supervening upon a part weakened by the causes before indicated, and thus inviting an attack. Con- sider these points, and act accordingly.

I ought to have observed, that Prof. Moreau, author of the Traite Pratique des Jiccouchemens, at p. 47, vol. Ist of his admi- rable work, assigns pelvic relaxation as the cause of some of the slow and difficult labors that are occasionally met with. He says, the muscles that are auxiliary to the uterus, having no longer a firm insertion on the vacillating bones of the pelvis, painfully affect the symphyses by their contraction ; and that the w^oman, restrained by fear of the pain consequent upon the contraction, fails to bring into play these accessory powers. So that the uterus, left to the resources of its own energy alone, frees itself slowly, and with difficulty, from the products of conception.

I am about to violate again, a rule that I had laid down in the composition of these letters, which was, to put them in very few quotations from other authors ; but the disorders arising from the


RELAXED SYMPHYSES. 513

cause in question, are in all respects so interesting to the practi- tioner, that I will not resist the temptation I feel to lay before you a translation from the same Prof. Moreau's work, the reading of which will serve to throw an abundant light upon the subject; and as I have not met in my practice with any case so important, of our disorder, I think I shall do you a service in laying before you that of Prof. Moreau.

The following are M. Moreau's words: "Mad. D. of Paris, aged thirty-three years, of an apparently sound constitution, had been weak and delicate during her childhood, and had also exhibited some signs of rickets, marked by slight tumefaction of the articular extremities of the long bones. She became regular at fourteen years and a half, and then grew rapidly. From this time up to the period of her marriage, she enjoyed perfect health, saving that there was always a little weakness of the ligaments. She was liable to slight sprains, and had very little strength in her wrists. She was married at the age of six-and-twenty years, and soon became pregnant. The first steps of this new condi- tion evinced nothing extraordinary: at about the second month, an excursion of five leagues from Paris, which she made in the course of one day, brought on a general uneasiness accom- panied with sharp pains, that were thought to threaten an abor- tion. The physician had her bled in the arm, ordered her to rest, gave her tepid baths and directed a light regimen. The pains which during the first eight days had been so sharp that the patient while in bed was incapable of the least motion, be- came quiet ; at least, so that she could be placed on a sofa. At the end of a month, she tried to walk, but though the attempt gave her no pain, she could not take a step without finding her- self ill.

"This inability to walk continued for some time; however, towards the end of pregnancy the young lady gained strength, and w^as able to walk with a little less difficulty.

"Labor pains came on in the night of the 16th of October, 1830, and had continued for twenty-four hours, when the forceps was employed, to assist the delivery of a male child, in good health, whom the mother in vain attempted to suckle.

"During the first fortnight of the lying in, she had severe pains in the hips and the parts of generation, which were at- 33


514 RELAXATION OF THE SYMPHYSES.

tribiited to lacerations occasioned by the passage of the child's head and the use of the forceps.

"After this, she made an attempt to get into an easy chair, but fainted and was again put to bed.

"At the end of six weeks the lady attempted to walk from her bed to the sofa, leaning on the shoulders of assistants ; but at every attempt she had sharp pains in the articulations of the pelvis, and felt as if her body would slide down between her legs.

"Five months having elapsed, she went, by the advice of her physician, to the country. There, her hips being bound round by a bandage kept in place by understraps, she attempted to walk in the garden, but the attempts were always attended with suffering. Whenever the understraps were loosened, she said she had a sort of bursting sensation, with a desire to sit down, or to lie down.

"For ten months she made use of gelatinous baths, baths of Bareges-water, and saline or astringent injections, but without any appreciable advantage. A consultation was then held between the accoucheur and MM. Magendie and Amussat. It was determined at the consultation that there was relaxation of the symphyses of the pelvis, the effect of which was that when the patient was placed upon her feet and left to herself, she was incapable not only of maintaining such position or of walking, but also of adduct- ing the thigh.

" Madame D. was now ordered to wear a belt better constructed, and stronger than the one which she has hitherto used. This belt embraced the hips, both trochanters, and the upper parts of the thighs, so as to approximate them, and maintain the approxi- mation with great energy.

"When supported in this manner, it is certain that Madame D. could begin to walk, not without difficulty, in her chamber, and sometimes in the street ; but she could neither ascend nor descend a stair : it was necessary to carry her, to enable her to get up four or five steps. After two years of care, and of a treatment in which sulphurous, gelatinous, and aromatic baths had been em- ployed, her health improved; she could walk better. At the end of 1832, she was able to take short walks, prolonged sometimes to the extent of five and twenty minutes; still, however, she always had pain on the day following such an effort.

"In the month of March, 1833, she became pregnant again.


RELAXATION OF THE SYMPHYSES. 515

In the course of the first three months there was nothing peculiar, except that she experienced great difficulty in walking. At the end of three months, her sufferings increased ; at which time I was called in for my opinion in the case. In spite of her suffer- ings, and in hopes that the open air would give her strength, she continued until the fifth month to go to the gardens of the Luxem- bourg, a promenade from which she was separated only by the width of a street.

Towards the end of August, upon returning from a walk, she had such violent pains in the hips, thighs and loins, that she was obliged to keep first her chair, and her sofa, and then her bed, for the remainder of her pregnancy.

" On the first of December, 1833, at half-past four o'clock in the morning, after a labor of a few hours, which was neither long nor very painful, she gave birth, naturally, to a fine healthy boy.

"Immediately after this second accouchement, Madame D. lost all power of motion. In bestowing upon her the cares required by her condition, it was necessary to move her legs one at a time; but the limbs could never be moved without causing pains so violent, that the patient could not or would not move, even to satisfy the most imperative wants. She groaned incessantly; cried out whenever she was touched; and if, in her uneasy sleep, she happened to change her position, she was immediately awakened by the pain, and unable, without assistance, to recover the position she had just quitted. Still there was no fever, nor enlargement in the articulations of the pelvis, nor change in the color of the skin. The left leg was weaker than the other. The surface of the mons acquired such an extreme sensibility, that the patient believed that the hair had become sensible, because the least touch or the least friction gave her pain.

" Narcotic and emollient applications, without recourse to bleed- ing, diet, the use of diuretic and sedative drinks, and two slight doses of purgative medicine, coupled with the most perfect im- mobility, sufficed gradually to dissipate these sufferings, which, in the course of a month after her confinement, totally disap- peared.

"Nevertheless, the movements of the lower extremities became less and less free. One fact ought to be mentioned, in which the case differed from her former confinement ; she could not abduct her limbs. Whenever she wished to move them, she was obliged


516 RELAXATION OF THE SYMPHYSES.

to move them both together to the same side ; to effect Avhich, she was, and still is, obliged to flex the knees, by drawing up the feet towards the pelvis, and then incline both the limbs towards the right or the left, as in incipient paraplegia.

"On several occasions I expressed to the family my desire to be assisted by the advice of some of my brethren, and especially of those who had formerly had charge of the patient, and who still saw her from time to time.

"Consequently, at the beginning of April, 1834, I met MM. Magendie and Amussat. After an attentive examination, these gentlemen who had observed the case during the first confinement, ascertained that there was an enormous increase of the mobility and separation of the symphyses.

"It was agreed at the consultation, that, as a basis of treatment, the lady should be sent to the country, to a dry and elevated situa- tion, where she should be exposed upon her bed, to the influence of pure air and solar light; and that she should take saline, alka- line, sulphurous or aromatic baths ; that she should make use of an animal diet, which should be tonic without being too stimu- lating; and that above all, she should return to the use of a mode of constriction of the pelvis, which should be strong, methodical and permanent.

"My colleague M. Amussat, who took charge of the treatment, and gave the most assiduous attention to the patient, was kind enough to see that the bandage should be prepared by a careful artist ; a sort of mechanical girdle, which should embrace the hips, taking as its point d'appui the trochanters ; the pressure to be regu- lated by means of screws. When the apparatus was applied, the patient could bear it only for a quarter of an hour at a time, although the buckles and the screws were not much tightened. The result did not answer the expectations that had been indulged, for, as soon as the machine was applied, she was attacked by slight fever, accompanied with very decided nervous spasms; symptoms that were reproduced upon every repetition of the experiment. It was necessary to give up the means as too energetic, and to recur to the use of the simple bandage furnished with buckles and strong straps, which the patient could tighten at will.

"Notwithstanding the most careful attention, — in spite of the perseverance with which the above treatment has been carried out for two years ; in spite of the employment of other therapeutical


RELAXATION OF THE SYMPHYSES. 517

means, which we shall omit, with many other interesting details to mention, the lady remains very nearly in the state in which she was in the month of April, 1834.

"Having been called to her five or six weeks since, to take care of her in a new pregnancy, which began at the end of November, 1835, I find her in the following condition :

"In the course of the two years during which I had lost sight of her, she has grown thin ; the digestive functions are torpid, and often performed with pain ; the alvine and urinary excretions are voluntary and easy; the sexual organs retain the free exercise of their functions ; the sensibility of the legs and thighs natural, but they have sensibly diminished in size, are more flaccid, softer, and have almost entirely lost the power of motion ; flexion and exten- sion are still difficult ; it is impossible for her to lift up her limbs, and she cannot quit the horizontal posture. Upon exploring the symphysis of the pubis, either internally or externally, the bones are found more separate than in the ordinary condition. Upon lifting up one pubis, and pushing the other in the opposite direc- tion, I thought I could perceive a vacillation of the bones which the patient said she also could perceive."

I have nowhere met with a more interesting detail of the effects of the relaxation of the symphysis of the pubis, than the one which I have now laid before you. Nor have I seen one attended with so total a loss of power, as this described by Prof. Moreau.

I long had charge of the case of a lady, laboring under a strange susceptibility of the nervous system, accompanied with a loss of innervative power, so that, although she was at ease, and appa- rently well in a state of recumbent repose, a slight, even a very slight muscular effort was often observed to be followed by a severe attack of lypothymia. The digestive powers were not particularly affected, nor were the assimilative functions much interrupted by these strange maladies. It seemed at times that she was greatly benefited by the pelvic bandage, and I doubt not, that the motion of the lower extremities was much more possible, and much less painful, when the bones of the pelvis were held in contact by the aid of the girdle. She has recovered and lost again, two or three times, the power of voluntary exercise ; she has given birth to several children, and is now in the possession of comfortable health. I always supposed that her maladive condition took its radiating point from an affection of the pelvic symphyses, which


518 RELAXATION OF THE SYMPHYSES.

came on during fatiguing journeys, while pregnant with a heavy male child. I could also produce pain in the symphysis pubis, by pulling the cristse of the ilia apart with my two hands; I could never give any pain by pressing the pubes together by placing my hands on the exterior of the pelvis.

I believe that these cases ought to be regarded as cases of rheumatism of important articulations ; and whether they be rheumatic or not, in their incipiency, the sprain, and injury done to the joint, by gestation and labor, are sufficient to invite attacks of rheumatism, which, having once effected a lodgment in the tissue, can be with difficulty, or not at all displaced.

In cases of relaxation of the pubic symphysis refusing to yield to a treatment consisting of an absolute rest of the articulation, effected through recumbency and bandaging, there will also, I think, be good reason to accuse the part of rheumatism, provided we exclude from the diagnostic any possible condition of active inflammation tending to produce suppuration or caries of the joint.

In the case which I have cited at such length from Prof. Mo- reau, you see that the patient suffered for many consecutive years, and that the last note of the case left her in still very ill health. Do you think that such grave disorders of the health, and so great a persistence in them, could possibly depend upon mere relaxa- tion of the fibro-cartilage that binds the ossa pubis together? Do you not rather concur with me, in the opinion just now expressed, that there must be some disorder over and above the state of re- laxation in which the articulations are known to be? And is it not likely that the disorder is arthritic ? I should think that if you should come across a case such as that of Prof. Moreau, you would resort to an anti-rheumatic treatment ; and that for the sub- duction of the arthritic disorder, you would at least come to the conclusion that the use of a powerful counter-irritation and deri- vation like that of the seton, might assist to restore the patient's health. I should think that such a seton as that of Dr. Grauiex would scarcely be objected to by the patient herself, as it would afford some reasonable ground of hope to relieve a torturing and disabling disorder.

I have proposed such a seton to a young lady at present under my care, who has suffered for years from manifest relaxation of the interpubic ligaments, whose general health, however, has not


ABORTION. 519

been deeply mined, but who declines to admit of the application of the remedy.

C. D. M.


LETTER XXXIX.

Gentlemen: — Among the diseases and accidents of preg- nancy, none are more common and more vexatious than those connected with miscarriage and abortion.

The full term of pregnancy extends, as I have stated, to about the two hundred and eightieth day from the fecundation of the ovum ; it is more prudent, in making the calculation for the term, to begin the computation from the day of the last catamenial show: two hundred and eighty days from this date, the woman ought to expel the child. It is in this manner that I have made the computation for my patients for many years past, and as yet have found no reason for changing my method or habit. It is true that the Jewish women, as I mentioned in a former letter, begin their computation after the eighth day subsequent to the disappearance, and they say that the calculation serves them w^ell ; but the other method has also served me well.

Some years ago there was a trial in England involving the question of the duration of pregnancy. It was called the Gar- diner Peerage Case, and was instituted for the purpose of settling the title of a claimant to that peerage. Many eminent medical men in England were examined on the occasion, and the result was, that no absolute term of pregnancy was ascertained. Moved by the interest excited in that case, Dr. Merriman, of London, took the greatest pains to ascertain the duration of pregnancy in many women, and he succeeded in satisfying his mind of the great correctness of the computation for one hundred and fourteen cases of mature children. The results of these inquiries he pub- lished in the Lond. Med. Chir. Trans., vol, xviii. part ii., at p. 338. He gave a tabular statement as follows: There were born at


520



ABORTION.



255 days, 1


14 ir


I 39th week.


288 days, 5


256 " 1


274


days, 4


289 2


259 " 1


275


" 2


290 «* 2


3 in 37th week.


276


" 4


292 *' 4


262 days, 2


277


" 8


293 " 2


263 " 2


278


" 3


15 42d w^eek.


264 " 4


279


" 3


295 days, 1


265 '* 1


280


" 9


296 " 2


266 *' 4


33 in 40th week.


297 " 2


13 in 38th week.


281


days, 5


298 " 4


267 days, 1


282


" 2


301 " 1


268 " 1


283


" 6


10 43d week.


269 " 4


284


" 1


303 days, 1


270 " 1


285


" 4


305 " 1


271 " 2


286


" 3


306 " 2


272 *' 2


287


" 1


4 in 44th week.


273 " 3


22 41st week.



From the foregoing table it appears that the term, or the dura- tion of a pregnancy, is not absolutely fixed, or that there is a con- siderable latitude as to the number of days that the foetus may remain in utero; some of them being rendered "mature" sooner, and some later, according to the amount of vital force they are endowed with. It is relative, perhaps, also to the strength and abi- lity of the maternal constitution, and in some degree, probably, according to the placental attachment and connection, as more or less extensive and perfect.

But, while the natural term of a pregnancy is about 280 days, such is the delicacy of the attachment by which the foetus is united to its parent, that many causes are found sufficient to separate it from the lining surface before its time ; and numerous diseases, to which its frail nature renders it liable, serve to bring its life to a premature conclusion. By its death, the ovum becomes a foreign body, and is expelled by the womb which it now irritates patho- locrically, and thereby excites the contractile force of its muscles, so as to give rise to the pains or contractions of a miscarriage, as well as the bloody discharge that usually attends the contractions.

It should be considered, that though the foetus is contained within the cavity of the womb, it is prevented from all direct contact with that organ, except at one point. It floats in the water of the amnios, and the interior of the W'Omb is lined every-


ABORTION. 521

where by the amnion and chorion, and the decidua also, except at that part of the uterine surface which is invested with the pla- centa.

This placenta is to be properly esteemed as an expansion of the main trunk of the fcetal aorta — inasmuch as the aorta of the embryo divides, above its pelvis, into two umbilical branches, which, as they pass down towards its brim, give off the iliacs — and then reflecting themselves upwards on each side of the blad- der, proceed through the umbilical ring and along the cord to the placenta, which is another name for their umbel-like divisions, expansions, or ramifications. When the aorta has thus pushed its extremity against the living surface of the mother, it has suc- ceeded in establishing the utero-fcetal union, and this is the only point at which that union exists ; everywhere else the womb is protected against direct contact by the interposed membranes, as before observed. It might, without a violent stretch of the imagi- nation, be conceived, that, in this case, the heart of the foetus has projected its vessels to a great distance, and expanded them upon the vital surface of the mother, in order to obtain on that living surface the influences of the oxygenated blood of the parent; and we can discover an analogy in the case, to what happens in the brain, which, in order that it may receive the impressions of light, projects from its substance the optic nerves, extends them beyond the walls of the cranium, and expands them as retina on the choroid coat, in order that a larger surface may be exposed to the radiation. Or again, just in the same design, the trunk of the pulmonary artery divides itself into innumerable arteries, arterioles and capillaries, in order thereby to expose a given quantity of blood on a vast superficies, to the action of the oxygen of the atmosphere.

This point of attachment of the embryo to the womb, has been lately called its mesenteric attachment, and it must be* easy to conceive that, whatever may have power to destroy that mesen- teric union, has equal power to arrest the progress of the fcetal life, for if that attachment be partially destroyed, the foetus will slowly or suddenly perish; or possibly recover, if the injury be not very extensive.

For the most part, the union betwixt the placenta and the womb, is very slight ; it may be overcome by a blow on the wo- man's abdomen, acting directly on the place of union. Contrac-


522 ABORTION.

tions of the womb, affecting that part of the superficies of the organ, on which the afterbirth sits, may detach it. Sudden and violent augmentations of the momentum of the blood's motion in the maternal vessels, sometimes are sufficient to break the union; and this happens in consequence of the impulse causing some drops to escape from the womb, lodging betwixt it and the pla- centa — thus peeling or dissecting it off, little by little, until a suf- ficient quantity is removed to destroy the life of the embryo.

Sudden and violent muscular motions of the mother, as in recovering from falls, in stooping, in lifting heavy weights, in ascending stairs, in running, dancing, leaping, &c. ; in riding over rough roads, or on horseback; all these are sufficient, on certain occasions, to break the connection of the afterbirth with the womb.

Emetics — by the relaxing influence of nausea, followed by the intense efforts of the muscles in vomiting — also serve to detach the placenta in some individuals.

The violent and drastic operation of cathartic drugs, as aloetics, senna, &c., by the great tenesmic action they introduce, and by the affluxion and heat which they determine to the pelvic organs, are also sufficient causes of abortion.

The action of blisters, and the internal use of cantharides and certain essential oils, may also, by the irritation of the neck of the bladder, involve, in great irritation, the adjacent and con- nected womb, and so serve as causes of abortion.

Ergot is, doubtless, sometimes employed for the purpose of procuring abortion. I am aware, however, of only one case in which it was used for that object. A woman, a widow, about 40 years of age, in full, vigorous health, after an illicit intercourse, found herself pregnant. She had a large family of children, and fearing the consequences of her fault, she procured, from an apothe- cary, a portion of ergot, which she took, with a view to cause the expulsion of the ovum, at about the fourth month. The ergot made her very sick, and as the vomiting alarmed her for her safety, she sent for me in great fear of the consequences, and confided to me her painful secret. I warned her against the enormity of her fault, and seeing that the attempt to excite the womb's action was happily a failure, advised her to leave town for some months, which she did, in order to be confined at Boston. I have men-


ABORTION. 523

tloned this case, the only one within my personal knowledge, of the use of ergot in a healthful gestation, for the purpose of excit- ing the uterine contractions. In this case it signally failed ; and I am strongly inclined to believe that, although the power of ergot to excite the muscular action of the womb m labor is unde- niable, it is not certain that it can excite those motions ah origine. It very certainly often does fail to set the womb in motion when given to facilitate miscarriages already in progress, but going on too slowly.

If we consider for a moment the extreme tenuity of the mem- branes and vessels of the early embryo, we ought rather to be amazed at the power it has to live on to term, than surprised at the occasional cessation of its existence in the early stages of its intra-uterine life. The least obstruction of the delicate umbilical vessels, or of its omphalo-mesenteric apparatus, would destroy it. The least rupture, perhaps, of the hyaloid membranes of its re- ticulated magma would cause its death — and an error loci of its blood-globules, as they proceed to mark out the traces of its blood- vessels, might cause an inevitable cessation of its existence.

It is probable that a major part of the abortions met with in practice, are the results of a failure in the vital forces and arrange- ments of the embryo, and not of a faulty action of the womb it- self, or some accident, or emotion of the woman herself, some imprudent step, gesture, or posture.

If the embryo dies in utero, the ovum commonly soon ceases to possess any vital property, and then the womb, by some sort of organic perception ; by ceasing to grow or expand ; by the irritation of a present foreign body, comes to a full stop, or arrest of those living and progressive developments under which it has been act- ing since the commencement of the gestation — a new principle of activity is awakened in its organism, its muscular fibres begin to constringe themselves, the superficial extent of the uterine cavity grows less and less under these contractions, and the em- bryo and the ovum are cast out of its orifice into the vagina, from which they are soon pressed forth, or fall away by their own weight.

Although the death of the embryo involves a certain cessation of the projection of its blood to the vessels of the placenta, and notwithstanding this cessation generally, is very speedily followed by the expulsive action of the womb, it is not always soon fol-


524 ABORTION.

lowed by the latter effect. A lady conceived, about the 20th of April, 1842, and consequently made arrangements for her ac- couchement for the 20th of January, 1843. The pregnancy went on well until about the 5th or 10th of August, when she had a very slight show, and there was a complete arrest of the usual developments. She was at various times affected with slight ap- pearances of her catamenia, as she supposed, but without any flooding, until the 3d of January, 1843, when she sent for me, saying she had suffered extreme pain, like the pains of labor, for some hours, but was now easy, though she thought something was escaping from the vagina. Before examining the patient, I de- tected the ovum partly in the vagina, and partly embraced within the cervix, which I removed with the index finger, and, upon carefully examining it, found that it was the unbroken ovum of a foetus of three and a half months, apparently. The ovum itself contained a sort of granular brown and thick fluid, while the foetus, also of a mummy color, retained its lineaments, although considerably macerated by its long residence in the waters. The placental portion of the ovum was red and fresh looking, and had evidently retained more or less vitality up to the period of its separation from the womb.

I think I can safely assert that, in the course of my practice, I have met with near twenty cases of the protracted residence of the ovum in the womb, after the death of the embryo. I have had under my care, several cases where it has certainly remained five months after its death. Nor, indeed, is there any reason for sur- prise at this, if we reflect, that numerous examples have been met with, in which, in twin pregnancies, one of the foetuses has perished at the third or fourth month, and yet remained in utero until the other twin had gone to the full term of utero-gestation, become fully developed, and been safely delivered at the same time with the aborted twin.

A miscarriage is not always painful. Women sometimes ex- clude the ovum, when at an early stage, by such gentle and easy contractions, and by so ready a dilatation of the os uteri, that they are hardly sensible even of a degree of uneasiness. In general, however, it happens that when the womb does begin to contract for the expulsion of its contents, it does so with very great vigor, and the contractions are both long and frequently repeated. If they are violent, they press the ruined ovum into the narrow canal of


ABORTION. 525

the cervix uteri, which, by the resistance of its sphinctorian fibres, opposes with great energy the distending or dilating effort of the advancing ovum. This resistance causes pain, often of the most acute kind, so that women, now and then, have informed me that they suffered much more distressing pangs in this way, than in their labors at full term. This is not surprising, if we reflect upon the length of the canal of the cervix, and the thickness and density of its walls, pressed open thus, by a sort of direct violence or force.

Let it be observed here, that, in the early stages of pregnancy, the ovum inhabits the body and fundus of the womb, and that it has not hitherto appropriated any part of the structure of the cervix as its cavity or habitation. Hence it happens, that, though the body and fundus may have pressed and pushed the ovum quite out of their cavity, which is now nearly empty and unoccupied, they are unable to force it quite out of the canal or cavity of the cervix. This tubu- lar or acutely conical canal, now grasps it firmly, and will not let it go, keeping up a constant irritation and disturbance of the organ, that maintains the hemorrhagic nisus, if there be any, or ex- cites and produces it, if it do not already exist. The inference from this remark is that, in such cases, if the physician remove the half expelled ovum, or after-birth, from the grasp or gripe of the cervix and os uteri, he will remove the cause of distension, and allowing the womb to contract perfectly, bring about an instant cessation of the hemorrhage. It will, therefore, be his duty in all cases apparently depending on such cause, to ascertain its exist- ence and operation, and take the proper measures for its obvia- tion.

I have observed many cases, in which the ovum has been thus detained many hours, and even many days, keeping up, as before remarked, a constant irritation, with hemorrhage sometimes of frightful violence, that always ceased as soon as I could take away the mass in question.

The great and very important principle, that in order to the suppression of uterine hemorrhage, connected with gestation, if is necessary to empty the womb, ought to be more universally known or admitted, than it seems to be even among certain medical persons of considerable experience.

When called to a married woman who is flooding, the first ques- tion should be directed to the ascertaining if she be pregnant, or


526 ABORTION.

not. If she say she is not, and yet be of that age, and in those circumstances that expose her to the liability to be pregnant, I am reluctant to act upon her responsibility. . If she say, I was preg- nant, but I miscarried yesterday, or last week, or a month ago, and yet I am suffering hemorrhage at the present moment, I should always suppose her opinion, or that of any other person, not worth taking, until I should have learned for myself, by my ow^n sense of touch, that she was not misinformed — for what should cause a woman of the child-bearing age, and in good health, what, I ask, should cause her to flood? If permitted to make the examination by touching, I could satisfy my own judg- ment on the question. Such is the course I take, always, where the exigency of the symptoms of hemorrhage calls for it — and I must say, that in the larger proportion of cases, when there has been pain, and where hemorrhage has continued after the pain is gone, I have, upon touching, found the ovum grasped in the cervix, and upon dislodging it thence have found the hemor- rhage to cease at once. It appears to me to be inexcusable to permit a woman to lose pint after pint of her blood, rather than take this disagreeable mode of learning what our duty in the case may be. Such losses of blood are followed, in certain cases, by long terms of broken health, and sometimes by weakness which is never fully recovered from.

It is better, therefore, to determine with accuracy what the in- dication of treatment is, and having got that, the path of duty lies plain before you. I have the less reluctance to speak in this man- ner, because I have so many times been called upon in consultation where the patient had already lost a large quantity of blood, the medical attendant being persuaded either that there had been no pregnancy, or that the pregnancy had already terminated some time before.

Within three days a friend has sent me the uterus of a patient brought into one of the public institutions dying — who was said to have miscarried several days before. This uterus, which was in a state of sphacelation, contained the placenta of a fcetus of four months. It was partially detached from the placental super- ficies — a separation that had occasioned a hemorrhage of forty- eight hours' duration. From the situation and size of it, I sup- pose it could have been removed with a placenta hook, or a small pince a faux germe, without risk or difficulty. It is evi-


ABORTION. 527

dent, that the person who had the case under treatment, was not aware that the placenta was not delivered.

True it is, that, in some cases of abortion, it is not within the competency of the medical attendant to extract the placenta. The long cylindrical canal of the cervix closes soon after the ex- pulsion of the waters and embryo ; the womb sometimes ceases to contract, and the finger cannot gain access to the uterine cavity, and even if it can, it is not always possible to remove the placenta, which occasionally adheres with abnormal pertinacity. Attempts with a proper small forceps, with the placenta hook, by means of ergotism and other means, should always be carried as far as a sound discretion will permit ; but all rude and forcible attempts to procure extraction should be regarded as equally dangerous as the continued stay of the after-birth in the cavity. I have many times preferred to leave the remains of the ovum to mace- rate and putrefy in the womb, to the dangerous risk of provoking inflammation of the organ by forcibly tearing it from the womb. In my own practice, I had never occasion to regret my decision. Yet I saw in consultation, a lady, some two years ago, in whom the placenta of a four months fcetus was never extracted, and who lost her life by metritis some days afterwards. The case of the uterus, recently presented to me, and of which I just now spoke, is another one which ought to induce any medical man to pause and consider carefully the indications of duty, before he should either decide to act, or refrain from interfering.

To a young practitioner, or to the general practitioner unac- customed to the treatment of the disorders of pregnancy, a call to a case of abortion is a source of discomfort, embarrassment, and even of dread. I doubt not, my young friends, that in the commencement of your career, you will often have occasion to experience the pangs of doubt, and the consciousness of incapa- city, which the want of a familiarity with such scenes will inevi- tably produce. But, as I often told you in the lectures, your principles of medicine should guide you and protect you against any uncertainty, disquietude, or alarm.

In the present case, the principle chiefly concerned is that of the innervation of the womb. You, I presume, understand the principle well, and you will confidently depend upon its power to save your patient in the wildest and most frightful effusion of


528 ABORTION.

blood, because you will always know how to incite and invigorate the uterine innervation, where it may be possible to do so, and to stay the effusion of the blood.

But, wherever the means within your reach prove incompetent to rouse the languid, exhausted or expiring forces of the organ, I cannot well conceive how it should be, that the youngest and most inexperienced member of the Class, could suffer himself to be at fault for a moment in deciding upon the points of his duty. That duty will depend, in the first instance, upoa the actual state of the constitution of the patient, and upon the views he may take as to the propriety of preserving, or the necessity there may be of sacrificing or disregarding the ovum. If the woman be not evi- dently exhausted from the losses she has already sustained, it is easy to perceive that little danger will attend some additional loss. Or, if she be already much reduced in strength, — the condition to be discovered by inspection of her countenance; by inquiries as to the force of her muscular apparatus; the color of the surface as to paleness or the reverse; the circulation, as indicated by the arterial pulse ; the respiration, from observing its frequency and its degree ; the intellect, to be inquired into by eliciting from her some intellectual expression, — he will at once resolve to interfere for the immediate rescue of the female, or he will determine to let it go on.

I can see that a medical man, under such circumstances, has no right, in the exercise of his professional avocations, to do any act or thing which will insure the destruction of the young embryo, un- less the necessity of the case be so apparent and so urgent as to ex- clude entirely all idea of exposing her to further risks with a view merely to the conservation of the delicate creature within. For example, if you are called to a patient who is flooding in the third month of utero-gestation, you would, perhaps, immediately make the reflection that you have at hand a means of suppressing the hemorrhage as sure as the surgeon's ligature, or Petit's tourni- quet, — I mean the tampon or plug — which, filling the vagina, is capable of preventing the further escape of blood, by detaining between the tampon and the cervix uteri a quantity sufficient to form a coagulum, to extend through the canal of the cervix uteri into its cavity, offering a complete bar to the further issue of fluid from the bleeding vessels of the womb. But, if a woman be flooding, not dangerously, and if there be any hope that the


ABORTION. 529

flow of blood may be restrained by hemostatic remedies, or thera- peutic procedures, it will be unallow^able practice in you to em- ploy the tampon, since its use would inevitably destroy the mesen- teric attachment of the ovum, to so great an extent, as to insure its final destruction.

The force with which the blood, under a strong hemorrhao-ic nisus, is expelled from the interior of the bleeding vessels, is a force far superior to that by which the ovum is attached to the womb ; and the preseace of a tampon, which prevents the escape of the outflowing blood, cannot restrain the flow until the embryo, and often the placenta, become detached from the gestative w^all, and entirely encompassed by a coagulum, from which it is pos- sible, after the expulsion of the object, to pick out the unbroken membranes, as you would take the yolk of an egg from the midst of the white.

Here then, gentlemen, you perceive a great point of duty to be determined upon by you in settling your indications of treatment. I repeat, that you have no right to destroy the pregnancy, unless the woman's condition clearly points out the necessity for so doing; and I freely declare my opinion, that to use the tampon in the flooding of abortion, is as effectually to destroy the child, as the rupture of the membranes, or the plunging of a stilette into its body.

I am anxious to put you upon your guard upon this point ; I trust you will always act up to the principle that you must not do evil that good may come. Wherever a clear indication for the sacrifice of the tender embryo exists, no evil is done in procuring the greater good of the mother ; on the contrary, the act by which it is destroyed, is an act in morals as purely good, as the saving of a man's life. The lesser in morals must yield to the greater; the lesser is always included in the greater.

It is out of my power, gentlemen, to say how far you shall allow the hemorrhage to proceed, before interfering by means of the tampon. This is a point w'hich is to be determined in every spe- cial case ; it cannot be determined from any book written by any man. It cannot be determined, because no man can say to what extent a uterine hemorrhage may proceed, without destroying the life of the woman.

As a general rule, if a woman not advanced beyond the fourth month, loses a teaspoonful of blood, it is probable that she will 34


530 ABORTION.

miscarry; and yet, not unfrequently exceptions are met with of persons who previous to the fourth month, lose many ounces, so much in fact as to produce paleness and lipothyraia, and yet, after the cessation of the hemorrhage, find the pregnancy to go on as pleasantly and as regularly as if no such accident had happened.

It is not your province to decide upon mere probabilities. You cannot know in any case of early abortion, whether the embryo be living or dead at the time of your arrival; you cannot deter- mine this point, for the double sound of the foetal heart, your only ground as to a knowledge of its state, cannot be heard so early. You need feel no embarrassment on account of this un- certainty, since the principle which should guide you, must be this, namely, that not knowing it to be deprived of life, you are always to consider it as still existing, and as claiming your con- servative protection, as long as the mother's interest and safety permit its claims to be heard.

An attack of uterine hemorrhage in the early stages of preg- nancy invariably excites considerable trepidation and alarm, and the physician is sent for with the most urgent appeals for speedy attendance. Upon arriving at the scene of such occasions, the first object is to get rid of all the moral excitement, which is effected by a calm, dispassionate, intelligent conduct — the nerv- ous system becoming free to play its part among the organs, when the excitement and disturbance which has become developed in it, by powerful moral causes, shall have been allayed. In general, it is not difficult to convince the patient, however ill, that the physician has power over the case to control it — to handle it at will.

I have sometimes said to persons who I have found frightened half to death! " Are you frightened?" and when the reply has been in the affirmative, I have continued: "Well then, look in ray face — look right into my two eyes. Do you see me? and do you think that if I were presiding over a case in which a life so important as yours was in danger, I should be so utterly uncon- cerned as you see me ? Or, will you not take my assurance, that it is within the power of any intelligent physician to put a definite stop to this loss as soon as it shall, in his judgment, become expe- dient to do so? Or, will you believe me a person ignorant of my art, and on that account distrust me? Be calm. Be tranquil. Be obedient. Be still. — And I shall take good care of you. Do


ABORTION. 531

you understand me?" "Yes, sir." "Do you believe me?" "I do indeed!"

Having disposed of all the alarm and trepidation, the next thing to be done, is to determine, if possible, the amount of blood that has been lost; to which end, you should ask the nurse or attend- ant for an opportunity to examine the napkins, sheets, &c., that may have been soiled ; besides ascertaining by inquiry the amount of what has been thrown away. Don't take anybody's word on these occasions, if it be in your power to depend upon your own observation. I am very sure, that I allowed a poor woman, many years ago, to lose her life, because I neglected this rule; having trusted to the report of an ignorant nurse, and there are few nurses that are not ignorant on these subjects.

If the flooding is still in progress, ascertain its rate. Take a clean napkin, and having crushed it in your hand, in order to take out the hardening, let it be applied to the external genitalia; taking good care not to allow it to be soaked in a pool of blood which has, perhaps, been already effused. Leaving it some ten minutes, more or less, in situ, cause it again to be presented to you, so that you may judge of the amount of the stain. Should the woman have dipped it in a pool of blood, she will present it to you thoroughly soaked, though the woman have in the mean- time not lost a drop, and thus you may form a determination fatal to the life of the young embryo. I beg you, then, not to neglect this not trifling caution.

See that the woman be properly placed. If the day is warm, and the bed be situated quite out of the draught of the windows, or in the angle of the two walls — let it be conveyed into the centre of the apartment, where it is accessible on all sides, and where the woman will respire a purer air. If she be weak, don't allow her head and shoulders to rest upon pillows; if she be very weak, don't let her have any pillows at all under her shoulders, and if her strength be exceedingly reduced, take the pillows from under her head, even if she should lie upon an absolute horizontal plane. A ha3morrhage that would go on ad deliquium, will often cease by taking all the pillows away, because, the momentum of the blood in the vessels from which it escapes, is highly favored by its gravi- tating power. Sometimes, in excessively dangerous debility from hemorrhage, you should not only take away the pillows, allowing the head to lie upon the plane mattress, but the feet of


532 ABORTION.

the bedstead should be elevated four or five inches, by placing some books or blocks under the lower bed-posts. You have thus, all the advantages derivable from position, a term in surgery of which you doubtless comprehend the meaning and import.

Muscular contraction is promoted by the influence of cold; and the womb, when contracted by the tonic action of its muscular fibres, will not bleed so freely as if it remain in a relaxed con- dition. Apply cold, then, to the hypogastric region, to the groins, to the external genitalia, and to the inner surfaces of the thighs. Cold spring or well water, or iced water, should be mixed with a portion of vinegar, which is always at hand in every house ; or with some spirituous liquor. A large napkin, carefully and powerfully wrung out of the cold liquid, should be spread over the parts just mentioned, and above it a piece of oiled silk, or a square of flannel, to prevent it from wetting the bed clothes, or night dress of the patient.

She will probably be very thirsty, if she have lost a considerable quantity of blood, and should, therefore, be provided with very cold lemonade, or she should take from ten to fifteen drops of Elixir of Vitriol, in a wineglassful of water or a wineglassful of filtered infusion of roses, made as cold as possible ; the dose to be repeated every hour, or even every half hour, pro re nata, as long as the indication for its employment continues.

Or, we should take some of the alum and nutmeg powder, which I mentioned in a former letter ; say, five grains of alum with three grains of nutmeg, mixed in honey, or syrup, or any convenient vehicle; the dose to be repeated every hour, or half hour, according to circumstances. Or, you may resort to the haemo- static power of opium, which by its influence over the nervous system, whether in the brain or the distal fibril, may have power to quell the nisus hsemorrhagicus.

Or, you may give your patient two, three, or even five grains of acetate of lead, mixed with one-fourth, one-half, or even a whole grain of opium, the dose to be repeated from time to time, perhaps not oftener than once in two hours. Beware, however, of the sugar of lead ; there is no little danger of determining by its use the most obstinate vomiting, or the establishment of the whole series of morbid actions denominated colica pictonum.

A physician is scarcely pardonable who, in a considerable case of uterine hemorrhage, fails to explore the condition of the os and


ABORTION. 533

cervix uteri. Such an exploration reveals to him the fact of the dilatation, or non-dilatation, or the disposition to dilatation of the part. If the os uteri be dilated already, the question as to the ovum is already decided — it must be lost, and it is no longer deserving of our respect. Such a dilatation indicates the use of the tampon, if anything be indicated, beyond mere hygienic* interposition. It is far preferable to any therapia, because, it does not and cannot do any harm, whereas all the other procedures which I have above indicated are, to a certain extent harmful, saving only, the position, and the directions about drinks.

More than half of the physicians of the United States, probably, have the most incorrect notions of the uses of the tampon. I have seen those among them whom I esteemed excellent accoucheurs, make use of a bit of sponge no bigger than your thumb, and which absolutely floated free in the midst of the vagina dilated to the size of an immense fist ; for in all these hemorrhages, although the sphincter vaginae may close the ostium, the inner or uterine portion of the tube is always found to be extraordinarily relaxed, and its walls vastly extended, by the pressure and distension of the coagula, which they have at some stage contained.

Please, gentlemen, to look at the letter, number XXXIII., page 431, in which I have already given my opinion of the choice of the material, and the administration of this useful chirurgical means.

There is one point which is deserving of your careful remem- brance, and that is, the importance, nay the absolute necessity, of great care to avoid losing the proofs of a miscarriage.

A woman does not always recover as soon as the ovum is dis- charged ; on the contrary, the irritation of her constitution occa- sionally becomes still greater after the womb has become emptied, and if you don't know that it has become emptied, you are left entirely at a loss for the means of diagnosis. Don't you perceive, that if the diagnosis should be that the womb still contains the ovum, or a rest of the ovum, your treatment will be founded upon that very presence? Whereas, if the diagnosis should prove to be that of an emptied womb, your treatment would necessarily take some other form ? Some of the most dreadful miscarriages that I have ever met with, have been those of very early ova. But, if the ovum should not be larger than a black walnut, and be contained in the cavity of the uterus with an undilated cervix, its accesibility to any information except that derived from rational


534 ABORTION.

inference is impossible. As long as it remains there, it is fair to regard it as the cause of the mischief, but cannot be so deemed, when it has come away.

Now, if your nurse or the patient herself, upon discovering the discharged ovum, should throw it away, how are you to tell whether it has been thrown away or not, since, out of one thou- sand women, you will not find two and a half that could tell the difference between an early ovum and a clot of blood.

I have had clots of blood sent to me from very good doctors, for dissection and for preparation for my museum, under the suppo- sition that they were the organized products of a regular fecunda- tion. I have had a patient who had been be-deviled for three months by an eminent practitioner, under the supposition that she was laboring under menorrhagia, whereas nothing was the matter with her, but a dead and undischarged ovum. Look at the dia- logue at page 241.

I have told you before, and I tell you now again, that the pro- duct of conception may carry on its development for two, three, or four months and then die, and remain in the womb without exciting the least apparent tendency to contraction, for three, four, yes even for six months. Of course, you will not be surprised to find that where the muscular irritability of the womb is not excited by its presence, there may be, nevertheless, irritation produced, and the most probable form that the irritation \vill assume, will be that of the nisus hemorrhagicus.

Let me advise you again, never to take a woman's report as to the organic character of the substances discharged in an abortion or miscarriage, but make it an invariable rule of your art, to in- stitute careful inquiries as soon as you take charge of the case, as to all such appearances as may have been antecedently noticed, and to give the most particular and even solemn cautions, as to removing or throwing away any such as may afterwards appear during your administration of the case.

A man who has charge of a case of abortion, in which he can- not decide whether the abortion has taken place or not, is at sea without oars or sails — he does not know what to do ; in fact, he is like a bull in a china shop. I admit that he might back out without breaking the crockery, but he can scarcely turn without doing mischief. You see I speak feelingly upon this point, and I do speak feel-


ABORTION. 535

ingly, for I bear in my memory, the recollection of a case I at- tended here a few years since, in which I exhausted all the means of diagnosis w'ithout being able to come to a conclusion, while the patient was visibly drawing nearer and nearer to the brink of the precipice. She did not go over, gentlemen, but she recovered her health, and I have never yet been able to find out what be- came of the ovum, or why she continued after its discharge — if it was discharged — to have the same symptoms as those have in whom it has not been discharged.

You should, therefore, claim the privilege, which is justly yours, of inspecting with your own eyes all the uterine products, whether linen, coagula, shreds or solid substances. It is very clear, that when you have got a whole ovum unruptured in your hand, it is out of the woman's womb ; and no doubt can rest on your mind ; and if she continues sick after this, the diagnosis has lost all its difficulty. But, with a perfect diagnosis what do you want more ?

If the process of throwing off the ovum has gone to a certain extent, you will find it in the cervix, and perhaps with a large portion of it protruding below the os uteri, but still firmly held in the grasp of the tube^ and keeping on foot those irritations of the whole nervous constitution, that serve to keep up the vigor of the hemorrhagic effort. If you make such an examination and find the ovum protruding, you should place the patient with her shoulders upon the same plane with her hips. Direct the nurse so to arrange her dress, that there may be but one, and that the thinnest of her garments, interposed between your hand and her hypogastrium. Let her be upon the right side of the bed near the edge. There standing on her right side, press the palm of your left hand upon the hypogastric region, so as to push the in- teguments gradually and strongly down upon the plane of the superior strait, which will bring the os uteri as near as may be to the ostium vagina?. And now let her draw up both her feet close to the buttocks. If, while so situated, you carry the index finger of the right hand to the os uteri, it will not recede from the pressure, being maintained in situ by the pressure of your left hand upon the hypogastrium. The index can now be gently in- sinuated betwixt the protruding ovum and the wall of the canal of the cervix, and carried high enough in some cases, completely to command the product ; for if the finger be a little flexed at its


536 ABORTION.

last phalanx, the ovum may be caught upon it, as upon a hook, and turned out of its bed. If upon examining, there be reason to suppose that nothing has been left in the womb, you may tell your patient that it is probable that she will have no further trouble ; or you may go so far as to say that she is well already.

Where you cannot command it with the finger, you may some- times succeed in extracting the ovum, or its rests, by means of Dr. Dewees' placenta-hook, or by Mad. Boivin's pince a faux germe, or by my friend Dr. Henry Bond's placenta forceps, which you can get here, as manufactured by Messrs. Rorer, Schively, and other surgery Cutlers. I advise you, though, to be well upon your guard against the use of instruments in these cases. If you get hold of such a body with an instrument, you will be tempted not to let it go again, and if you pull too hard, you do so at the expense of tissues that are already in trou- ble, and will not kindly submit to any rude handling. I have seen a patient severely hurt by the violent extractive force that was applied by means of a wretched placental forceps, for the extraction of a dead ovum.

It is even better to wait and trust to the maceration, and the discharge in solution or fragments, of the ovum, than to wound or tear the orgrans. I have waited in cases where I had failed in any reasonable extractive effort; and have found the product to be wholly discharged as it macerated, without any other in- convenience than that occasioned by the tedious confinement, and the offensiveness of the odor. I have no idea that the patient is exposed to considerable hazard by this expectant mode of treatment, which leaves you with the daily, nay hourly, expecta- tion that the uterus will at last wake up to a sense of its condition, and free itself from its burden by the exercise of its expulsive power. At any rate, an examination, repeated from time to time, will make you acquainted with any progress that may be had in the expulsive action of the womb ; so that you may have the plea- sure at last of picking it out of the cervix, conscious that you are doing no injury.

I had a patient who, in two successive pregnancies, allowed the ovum to die between the third and fourth month. In one of them, it lingered for several months within the cavity of the womb before the organ became irritated to its expulsion. In the other, I was employed in the case, and having satisfied myself that there


ABORTION. 537

was a dead ovum in the uterus — notwithstanding the woman had neither hemorrhage, nor pain ; nor any discharge indeed — I deter- mined to try the power of ergot in the case. I gave her a drachm of the powder mixed in six fluidounces of cinnamon water, with directions to take a tablespoonful three times a day. Before she had finished the quantity, the uterine contractions were established and the ovum expelled without accident, or any consequent dis- order.

Ergot will often excite the contractions of the uterus in the early stages of gestation, but it is often found utterly to fail in the exertion of its peculiar therapeutic powers. But, as no inconve- nience is to be apprehended to the health from its administration, you should consider yourselves at liberty to employ it in fulfil- ment of a clear indication. The wine of secale given in tea- spoonful doses, and repeated from time to time, according to the exigencies of the circumstances, will be found a convenient and often an effective administration ; and I presume you would not, in any case of serious hemorrhage or protracted retention of the product, fail to put into play its extraordinary power over the muscular organ of the womb.

A woman who has miscarried, if no accident follow the event, will be likely to get rid of her lochial discharge in the course of a few days. It often disappears on the third day, but sometimes continues to the tenth, or twentieth, or even longer.

When the woman seems recovered, she thinks she ought to have the privilege to get up and take care of her affairs, or give herself up to her pleasures; but she will be highly imprudent to do so, nor will you fulfil your duty as medical counsel, if you ad- vise or allow her thus to expose her health. She should be kept very quiet for many days, during the greater portion of which, she should be in the recumbent posture, either in bed, or on the sofa or couch; nor should she be permitted to go about until all signs of miscarriage have entirely disappeared.

A miscarriage within the first four months is not followed by secretion of milk from the mammary gland ; but, should it go to five months and a half, before she loses the ovum, the woman is very likely to have an abundant secretion of milk. I attended a poor woman some years ago in Tenth street, who miscarried at five months and a half, and soon after, she became a wet nurse, at my


538 ABORTION.

request; having a supply of milk sufficient to support a strong healthy child.

A woman who has suffered one abortion, is probably more liable to the same accident in subsequent pregnancies, than she who has not suffered in this way.

There are many persons who suffer repeated miscarriages, and whose health is injured by the irritation and loss of blood accom^ panyingthe accidents; moreover, the disappointment experienced in regard to the hopes of offspring, occasions great disquietude ; so that it is extremely desirable to discover some method of obviating such an evil tendency. I have no doubt, as I before expressed, that in these cases the mensual effort is often at the foundation of such distressing occurrences ; for women are more apt to mis- carry at stated periods than at irregular times. Many of the early embryos that I have met with, have been so fresh and so firm in their texture, that I could not but suppose them cast off while still endowed with vital properties. Undej such circumstances, I could not but suppose that the accident of the casting off of the uterine product, was the result of a status of the womb itself, and not of the ovum.

I supposed that the ovary might have deposited a mature ovum, and that the uterus, obedient as usual to the provocative sanguine affluxion, became, as usual, mensually engorged, which resulted in the effusion of mensual blood at the expense of the attachments of the embryo, which began immediately to be cast off, and thus came into my hand, fresh, firm and recent, as above mentioned.

It is true that many causes of abortion besides this mensual cause do exist, — a blow, a violent succussion or shock, an irrita- tion of the womb consensual with intestinal irritation, some deep emotion of the soul, modifying the relation of the innervative forces of the whole constitution, alone, followed by sudden reaction in the force of the arterial injection; may well determine an in- stant polygffimia of the uterus, to be relieved only by an effusion of blood from its internal wall, at the expense of the mesenteric attachments of the embryo,

I had, some time since, a very perfect specimen of an ovum of two months and a half, which came off enveloped in the de- cidua. Having opened it, and placed the little embryo on the field of a Wollaston doublet, in order to inquire into its condition, I found that it had suffered from an apoplexy of its cord, for one


ABORTION. 539

of the omphalo-mesenteric arteries had given way and filled the tissue with extravasated blood. Probably myriads of young em- bryos perish from the delicacy of their organism and the feeble- ness of their vital forces. For, notwithstanding they are so care- fully and perfectly protected by the beautiful nidus in which they reside, which nidus itself is supported as it were upon the most elastic springs to save it from shocks and violent succussions, they must be deemed liable to the hazard of multitudinous derange- ments of their circulation and innervation, fitted to lead to their destruction.

There are also numerous women to be met with, who cannot carry the gestation out beyond a certain time, not absolutely fixed, but yet far short of full term. Their children always die, and they know that the child is dead, in the first place, from the absence of all spontaneous motion and from shrinking of the before well developed breast, and from a certain sense of heaviness, or sluggishness or strange ponderosity within. The womb, more- over, seems to fall from right to left, or from left to right, as the woman happens to turn from either of these positions. 1 have at this moment a woman under my care at the Pennsylvania Hos- pital, who has lost many children at about the sixth month. These children were always born dead, putrid, having remained from four to six weeks in the womb after the cessation of their existence. She applied to me for admission, informing me that the child was dead as usual, an opinion in which I concurred after careful auscultation, and which was confirmed by the birth of the child, after it had remained a month dead in the womb.

If you ask me, my young friends, why it is that these women lose their children in utero so repeatedly, I feel that I shall be compelled to say that I cannot give you any explanation of this strange occurrence. Thei^ do not, so far as I know, appear to suflfer from rigidity of the uterine texture, contravening its natural expansibility under the growing force of the ovum ; nor have I discovered in them any signs of general or topical ill health, save the one in question, if indeed that be one. It is most likely, I think, that the fault exists in the ovum itself, for I think it is not unphilosophical to suppose, that a woman may be possessed of all the signs of competent health in her own person, whereas, the ova which she produces may be weak, and unendowed with the usual amount of vital force. But it is vain to form or utter hypo-


540 ABORTION.

theses ; it is better to say on such occasions, we do not know, we do not understand.

A lady under my care, gave birth to a son at full term ; after which, she was sixteen times pregnant in vain ; sometimes going to the seventh month and giving birth to the child dead, putrid ; and sometimes going to the fifth, fourth, or third, and always suf- fering so great an amount of constitutional disturbance during pregnancy, and also sustaining so great loss of blood during the abortion, as to leave her at the last in a state of wretched health, consisting mainly in disorders arising from repeated, ex- cessive anaemia from hemorrhage. When she came under my care, after the sixteenth pregnancy, for the first time, I gave her directions which she carefully followed, and carried the child a little beyond the eighth month, when it w^as safely born. Another pregnancy, within two years, was followed by the birth of another son. When this child was between two and three years old, she died instantly of apoplexy while seated at her dinner table.

Doubtless, miscarriages often depend upon irritability of the womb, which refuses to dilate under the pressure of the growing ovum. The Hallerian irritability of the womb, or its muscular contractility, may be so great as to repress the advance of the ovum in growth. If you had such an ovum growing inside of a metallic sphere, it would necessarily die, because it is indispensa- ble for the embryo not only to live, but to grow, for its life does not consist in living but in developing itself. But, if the womb won't let it develope itself, will it not die ? and hence, don't you perceive that an unyielding, rigid uterus may cause the woman to miscarry again and again, whereas if you cure the rigidity and unyieldingness of the womb you may allow the woman to go out to the full term of utero-gestation ?

Suppose you were treating a case, taking such views as these as to the cause of the miscarriage, what could you do to give the uterus a kindlier disposition ? Could you not obtund its organic sensibility and at the same time diminish the vital force of its motor nerves, by bringing it occasionally, at proper intervals, under the sedative influences of opium, and under the relaxing influ- ences of venesection, of the warm bath, and of a cool and light regi- men? Could you not give to such a patient at bedtime five-and- forty drops of tincture of opium mixed with a wineglassful of thin boiled starch, to be used as an injection into the rectum. I have


ABORTION. 541

done so for a great many people, for a great many years, when I have deemed the cause of the disposition to miscarry, a cause connected with the status of the womb itself. I shall probably as long as I continue to practice, frequently employ this method, as I have every reason to believe that a great many persons have thereby been preserved from miscarrying, who have repeatedly done so under every other mode of treatment.

I have occasionally directed such an administration to be re- peated both night and morning, and it is as a sort of general rule with' me, in giving such a direction, to counsel the woman to use the anodyne enema daily, until after the quickening of the child takes place. I know of no objection to such a mode of pro- cedure, as I have never found the least inconvenience to result from it as regards the patient's health. Taking it all in all, as a methodus medendi, it is the most commendable one that I am acquainted with ; it was Doctor Physic's, and I learned it from his lips. Dr. Physic had very few methods that were not to be depended upon ; and the sanction of his opinion alone, would, in my estimation, make it worthy of the highest confidence.

If a woman is likely to miscarry from her menstrual cause, she might be confined to her bed at the menstrual period, a little be- fore, during, and for a few days afterwards. Her bowels should be kept free by gentle aperient medicine, or by enemata, which are less objectionable, as causing less disturbance; she ought to be bled, not too much, but moderately, at the arm, with a view to counteract the monthly engorgement of the uterine and spermatic branches ; an intention, which will be well sustained by the daily use of the anodyne enema, as before mentioned.

A woman might be supposed to miscarry in consequence of debility; in such a case, the use of proper tonics, wdth nutritious, wholesome diet, should be carefully prescribed.

Don't give a pregnant woman purgative medicines, if you can possibly avoid it ; since violent action of the bowels, particularly of the lower bowels, is extremely apt to bring the womb into sympathetic disturbance.

Women have the toothache in pregnancy, and will come to you to ask permission to have the tooth taken out. You should always decline to give your consent to this operation; an opera- tion, which cannot be performed, I think, without producing a dangerous shock to the nervous system, and violent succussive


542 ABORTION.

contractions of the diaphragm and abdominal muscles, quite as apt to disturb the connection of the ovum with the womb, as a fall, a blow, riding in a carriage, or any of those causes which physicians are so careful to guard their patients against. If a woman have in her pregnancy an insufferable toothache, you will often cure it by putting a couple of leeches on the gum, opposite the alveole, or by filling the carious cavity, if there be one, with opium, or it will get well after a few days, if she will but have patience with it. I will not deny that a toothache may be so in- supportably painful, as to warrant the patient in having it ex- tracted, and warrant you in giving your consent thereto ; but let me advise you never to do so, when you can find any rea- sonable ground for avoiding it.

Some physicians, when a woman applies for counsel for this habitual abortion, always advise her to go to bed and stay there, under the idea that motion or exertion is apt to provoke the abor- tion in those who are predisposed to it.

It may be that a woman is safer in her bed, or on her couch, than walking about town, or riding in her carriage, or engaging in domestic aflfairs ; and it is palpably true, that a woman who perceives some present threatenings of miscarriage ought to go to bed, and be still. I cannot but think, however, that sending a woman to bed, with the purpose to keep her there until the end of her pregnancy, not to be completed until the lapse of six, five, or even four months, is altogether preposterous; since I cannot well conceive, that a woman could, for so long a time, be deprived of exercise, of fresh air, and of solar light, without inducing modifi- cations of her nerve force, and of her nutrition, that would be more likely to lead to a miscarriage than the very exercise that is so much dreaded.

I am quite certain, that I have never been guilty of giving so preposterous an order as this, and that I have known many in- stances in which the practice hath signally failed. I believe, indeed, that it would be better for a woman to miscarry than to lie down for six months.

If a man break his thigh bone in the midst of the most con- summate health, and if he be taken to his house and laid upon his bed, and treated with Dessault's apparatus, or any other ap- paratus for the treatment of fracture of the thigh, then he will not have his bowels moved, for the first eight days, unless he take


ABORTION. 543

some eccoprotic article. His bowels do not become confined be- cause he has broken his leg, but they are constipated for want of the perpetual succussion, which it is designed they should re- ceive from the abdominal muscles which encase them. The man with Dessault's splint is like the woman who you put to bed for six months, they have neither the least occasion to use the abdo- minal muscles in progression, nor in daily exercise, and the ali- mentary tube, deprived of this usual provocative to its excitement, lies torpid, its muscular fibres scarcely, or with reluctance, per- forming their office of provoking motion in the canal.

In order to obviate this evil, you are compelled to give drugs, but a pregnant w^oman ought not to take drugs if there be any means to avoid it, and I think you will find it, upon a studied experience, which you will have, that it is best not to place her in a condition where your drugs will become necessary.

To allow her to become costive, is to disturb the whole of her splanchnic innervation. She gets a foul breath, a foul tongue, and restless nights; her appetite is mawkish, she loses the bright tint of her skin, and masses of the circulation tend inw^ards, pro- ducing engorgement of the greater trunks; and, if you succeed in carrying her to the end of her term, — an improbable expecta- tion, — you will deliver her of a child, when you shall have ruined her health.

I mentioned, at page 540, the case of a lady, who had been sixteen times pregnant in vain, who, after undertaking my direc- tions, gave birth to two children in succession. I said, there, that when she came under my care, after the sixteenth pregnancy, I gave her directions, which she carefully followed, and carried the child to the eighth month, when it was safely born. She had been repeatedly confined to the sofa, or the couch, during several con- secutive months. Several of the gestations w^ere conducted under the counsel of the late Professor Dewees, who had great confi- dence in protracted repose for the conservation of the gestation; but, as in all the cases, she had continued to meet with disappoint- ment, when she came under my care, and related the distresses of which she had been the victim, I made known to her my aver- sion to this treatment by rest. I said to her, "My dear madam, you place me in a very disagreeable predicament by appealing to me on this occasion. In all probability, seeing your present age and your present health, this will be the last of your gesta-


544 ABORTION.

tions; you have heretofore been under the care and the counsel' of the most distinguished practitioners of my art, in this country and in Europe, and it has, perhaps, become a principle with you to treat all such cases by profound and protracted rest. If I, who am opposed to such a method, should advise a contrary course, and the case should result in an abortion, as usual, you might hereafter accuse me of great imprudence in departing from a method so recommended ; and becoming never pregnant again, charge me with depriving you of the last chance of having offspring. Nevertheless, I shall guide you according to my judg- ment and my conscience. I believe that the best health that you can obtain, is the securest health for your pregnancy, and that health can only be had by exercise, sub dio, in the open air. Pray, then, take my advice, to walk out, or to ride out, daily; receive and return visits; go to the party and the ball, and try to forget that you are pregnant, acting, indeed, as if you were not; be always, however, a little careful of using violent muscular effort, or awkward positions of the body ; and above all things, do not tumble down stairs. Take an anodyne injection every night be- fore you go to bed, and let it consist of forty-five drops of lau- danum, in half a wineglassful of thin clear starch."

She did follow my directions implicitly, saving only the ex- ception, that she did tumble down stairs twice, and yet, I had the pleasure of delivering her of a child, as mentioned at page 540.

When I was an apprentice to my late master. Dr. Thomas Hanson Marshall Feudal, of Augusta, in the state of Georgia, I was acquainted with the circumstances of a case of abortion un- der his care. The lady in question, whose name I am bound to withhold, expelled an ovum containing a foetus of about three months, yet six months afterwards she gave birth to a male child at term ; so that it is possible for a woman pregnant with twins; to discharge an entire ovum of one of the twins, without destroy- ing the mesenteric attachment of the other, which goes on to the full term.

Such a case is so rare a one, that probably, if you live a long medical life you will never meet with one like it. It is well, however, to know that such things are in rerum natura.

I have seen one case in which, a woman giving birth to a child at full term, afterwards discharged a placenta, attached to which,


ABORTION. 5451

was a foetus of four months and a half, completely mummified and pressed as flat as a bit of deal. Some stupid people, upon such a sight, would lift up their hands and exclaim " superfoeta- tion!" Superfoetation has nothing to do with it; it is a case of abortion, with retention of the foetus four months and a half after its death.

You will find a beautiful drawing representing a precisely similar case, in the tenth plate of the Atlas to Mr. Pouchet's " Theorie Positive de P Ovulation spontanee.^^ The account of the case is related at page 436 : the child was, as in the case which I saw, compressed, its head being mashed flat by the pressure of the living ovum against the side of the uterus.

I think, gentlemen, that for the present I have nothing further to say upon abortion ; I have only a few remarks to oflTer you, on the subject of moles or false conceptions, which will sufiEice for the present, to close this subject.

In ancient times, the doctors were accustomed to have very curious notions on the subject of what are called moles; and some of their superstitions about them are very curious and amusing.

There is still a vague superstition that lurks in the female mind even at the present day, and which renders the production of a mole a subject of much talk and wonderment. They are called by most people in this quarter false conceptions, and are rarely met with without giving rise to much examination and cross-questioning, addressed to the medical attendant. They who have had a false conception, or a mole, are anxious to know why and how such a thing happens. Not only have I found the female worried about such an event, but I have also discovered that the husband is not without some uneasiness and self-condem- nation. It happens in this way.

When a woman conceives in the womb, she goes on in her pregnancy for some weeks, or for two months, perhaps, perfectly well and naturally — the embryo then perishes, and floating in the amniotic waters, undergoes a process of maceration and solution; so that it soon disappears completely, leaving a brownish dirty liquor still enclosed within the amnios.

The spongy or tufted chorion, having in the mean time estab- lished a mesenteric connection with the uterus, a sort of vitality continues to exist within it, provided the womb does not cast it 35


546 MOLES. HYDATIDS.

out by contracting its walls. — Under this low rate of life, the mass of the mole slowly increases in size, and becomes more and more solid and heavy. The mass continues to grow more or less rapidly, until the womb, no longer able to tolerate its presence, contracts, and expels it.

Such a mole is but a diseased and altered ovum — and the woman who is distressed with the notion that she has some pecu- liarity of nature that concerns her, the subject of such a misfor- tune, ought to be relieved of the false impression, which might render her unhappy.

Sometimes the ovum, instead of being converted into a firm, hard, and fleshy substance, becomes the seat of what is called hydatids of the womb. — In this case, every part of it is occupied by numerous vesicles of various sizes, from the bigness of a mus- tard seed to that of a large Malaga grape. These vesicles are filled with pellucid fluid — and they continue to be formed and to increase in magnitude until the womb acquires the dimensions of the gravid uterus of the seventh month. Or, the womb irritated by the pressure of such a foreign body, refuses any more to dis- tend, whereupon, contractions setting in, the whole heterologue product comes away, in quantity, sometimes, sufficient to half fill a wash-basin.

It is asserted by some writers, that the grape-like vesicles are really independent animals — acephalocysts, endowed with great powers of production ; but I am by no means of that opinion. They are, far more probably, derived from the distension of the altered spongioles and cellules of the placenta, which, by some endosmosic act, become filled with water, and thus dissect, so to speak, the whole mass of the mole or the altered placenta.

Now and then, you will meet with cases, where the child being born in good health, the placenta exhibits numerous specimens of these bullae. If very numerous, they could not fail to destroy the embryo, by destroying more or less completely its branchial organ, the placenta.

A case is not, in general, suspected of being a false con- ception, and it is not until it is cast off that the truth is known — still, when the pregnancy proceeds at a more rapid, or at a less rapid rate of development than natural, and when the woman is troubled with the frequent slight markings and discharges of blood per vaginam, she may be held as suspected.


MOLES. HYDATIDS. 547

The rapidity with which a bunch of hydatids may grow, is very great. I have, for example, now under treatment a young lady, married about a year ago, who became pregnant about the 20th July, 1847. On the 23d October, 1847, she discharged a large quantity, near a pint measure, of hydatids and altered pla- cental structure.

Pending the gestation, she was sick for twelve weeks, during a major part of which time she vomited daily, and many times a day. She became rapidly and excessively emaciated, and had for a long time a pulse above 120 per minute. Previously to the expulsive effort, the fundus uteri had risen nigh to the umbilicus, and yet she was only three months gone, at which period the fundus ought not to have jutted much above the plane of the su- perior strait.

The womb was always of a doughy feel, except when con- densed by its muscular contraction, which was often the case during the process.

My fears were greatly excited by her condition, until her pains coming on, the whole diseased mass was driven out of the uterine cavity — whereupon she immediately began to recover, and is now, Nov, 6th, 1847, in pretty good health, although still weak and pallid.

If you should take charge of a patient, pregnant, sick, suffer- ing occasional attacks of uterine hemorrhage, with great con- stitutional irritation, evinced by frequency of pulse, emaciation, and other signs of suffering — and if coincidently with such signs, there should be a too rapid development of the womb — you might very confidently make the diagnosis of hydatids. Because, in true pregnancy, the rate of development is decided by a generic- law — peculiar to each genus of animals — or to each species rather. If the rate of growth is non-generic, the product will be non-generic likewise, and leave you clearly at liberty to take measures for the cure.

In such a case, you cannot bring on premature labor — but you can bring on labor. There can be no prematureness for a thing that has no generic term of development. You might provoke contractions of the womb by doses of ergot, or if that should fail, by the use of sponge tent carefully placed in the canal of the cervix uteri. A sponge tent could hardly expand in the canal, without causing the fundus to enter into active contractions.


548 LYING-IN DISEASES.

There are some women, in whom the womb, during menstrua- tion, becomes filled with small coagula. A coagulura of blood as large as a walnut, in the non-gravid uterus, would be subject to a firm pressure ; the serum escaping, might leave the more solid parts within the cavity, which might remain therein undisturbed during an intermenstrual period. New coagulations taking place at the return of the menses, the mass becomes increased in size, and at last exciting contractions, is expelled, wuth the sharpest grinding and dilating pains.

I have seen a lump of fibrine larger than a black walnut, ex- ceedingly solid, and of a whitish yellow color, produced in this way.

It is not a false conception — but a lump of fibrine, out of which all the serum and corpuscles have been squeezed, and which may lie a longer or shorter time in the womb without exciting its ex- pulsive power — and at last come off with very violent grinding pains — so great, indeed, as to make the woman suffer as much as in the most painful miscarriage.

I shall here close this letter, with the expression of my sincere respect. C. D. M.


LETTER XL.

Gentlemen: — I am about to address you to-day upon a sub- ject of the extremest importance in any consideration of female complaints. I mean the diseases of the Lying-in. A treatise on midwifery might be, perhaps, more appropriately selected for such a discussion, — but, inasmuch as the general practitioner is liable to be called upon for his counsel in many of the purely puerperal affections, he ought to be as well prepared as the ac- coucheur himself to treat them properly.

Among the earliest and most serious of the disorders of the puerperal woman we should enumerate fainting and flooding. They generally go together, — so much so, indeed, that when a woman faints away shortly after the birth of her child, she should


LYING-IN DISEASES. 549

be immediately held as suspected of flooding, — whether there be any visible hemorrhage or no.

It is true, however, that a woman may faint immediately after the delivery of the child, and yet not be the subject of any con- siderable hemorrhagic discharge. This accident is most likely to occur to women in whom the womb has been excessively dis- tended, either with a twin pregnancy, or from the accumulation of a great quantity of the amniotic liquor. Such a person, having a very rapid labor, and speedy discharge of the after-birth, is likely to faint for want of a due amount of pressure upon the ab- dominal viscera. The same thing happens to those who are re- lieved, by tapping, of a large ascitic collection.

I was present a few years ago, when Dr. Jacob Randolph, of this city, tapped for me a young woman who had a vast ovarian cyst. A broad bandage, or binder, was put, as usual, around the abdomen, to be drawn tighter, in proportion as the water of the dropsy should run off through the canula. When rather more than half of the fluid had escaped, and the abdominal walls had lost much of their tension, I purposely relaxed the pressure of the binder, which I had taken by its ends in my hands. As soon as I left her solely to the pressure and support of her own abdominal integuments, she grew faint, but immediately recovered upon my tightening the bandage again. This experiment I repeated seve- ral times during the progress of the operation, with a view to satisfy my mind as to the relation between lypothymia and re- laxation of tegumentary tension.

A woman whose abdomen becomes very suddenly and greatly reduced in size by the escape of a full-sized child — a great quan- tity of waters, and an after-birth of more than a pound in weight, suffers, then, the same sudden withdrawal of abdominal tension as the patient under paracentesis, and requires, like that patient, the support of a bandage, or binder, adjusted to the abdomen. I published in the Philadelphia Pract. of Med., 2d ed., p. 204, a case, which is related in the following words: —

I attended Mrs. J. A. S., confined with her fifth child, in a labor that was perfectly natural relatively to the birth of the child, the delivery of the placenta, and the symptoms that immediately ensued the parturient state.

Having waited about half an hour, I took leave of the patient about two o'clock in the morning, and had proceeded a good way


550 FAINTING AFTER DELIVERY.

towards my house, when I was overtaken by the husband, who entreated me to hasten back to the lady, as she seemed near dying.

Upon returning to the house, I found my patient without pulse ; the face of an extreme paleness, and her whole state expressive of the last degree of sinking or prostration. The idea that became immediately obvious was, that she must have had a large effusion of blood ; but, upon placing the hand upon the uterine region, the organ was found to be well condensed ; while, upon a careful examination of the bed, no very considerable extravasation of blood was detected. I found that the abdominal parietes were remarkably flaccid ; to such a degree, as to strike me forcibly, as affording incompetent support to the viscera within. Indeed, the contractility of the abdominal muscles was so very slight, that it appeared to me the bowels could receive almost no support from their pressure.

After exhibiting such restoratives as were at hand, I folded two large towels into squares, and placing them upon the abdomen, as compresses, secured them by a bandage, which retained them in situ, and afforded such a degree of support to the contained viscera as I deemed sufficient to obviate the sinking and fainting tendencies that always ensue from a loss of this support or pres- sure, I enjoined rest in a horizontal position, removed the pillows from under her head, and found, when the forces of the consti- tution had rallied, there was no further alarm or distress. It has happened to me many times to meet with this syncopal state, after delivery, unaccompanied with hemorrhage, either external or internal ; and in all parturient persons who are enormously distended, or who are prone to such faintings after delivery, I take the precautions suggested by the above case in good time ; and I can safely say that such precautions generally result in success.

Fainting is caused by diminished tension of the blood-vessels of the encephalon suddenly produced, whether a pat hemate mentis, or hemorrhage, or other causes. There can be no such thing as fainting with the vessels of the brain full and tense. If you suddenly take away the support — I mean the extrinsic support that the great arterial and venous trunks, as well as the arterioles and venules and capillaries of the belly receive from the muscu- lar and other textural integuments, you suffer those vessels to


FAINTING AFTER DELIVERY. 551

yield to the lateral pressure of the blood-columns — to become dis- tended, and thus draw off the circulation from the superior parts of the economy, especially if the patient be permitted to sit up, or to lie too highly inclined. See to it, then, that the danger be obviated by substituting the bandage pressure for the lost pres- sure of the abdominal walls, — and that the patient be not allowed to sit up, or even have pillows, where the case requires such a precaution.

I ought now to put you on your guard against a mistake into which you might fall, were you to be governed in some cases by opinions like those just expressed.

You must not believe that the newly-delivered woman faints from withdrawal of pressure and tension of the integuments, when she in reality faints from loss of blood.

A woman may lose a quantity sufficient to cause an alarming and even a dangerous deliquium, without any visible signs of flooding upon the napkins or clothing about her person — and even when the globe of the womb appears to be well contracted.

On a great multitude of occasions, I have found women to faint after delivery, say in half an hour, and sometimes in an hour, or even as late as an hour and a half, subsequent to the expulsion of the after-birth. I have had the napkin immediately presented to me for examination, and found it scarcely stained. Upon placing my hand on the uterine globe, too, I have found it well reduced in size, and firm, and so small, as evidently to contain no con- siderable quantity of blood. Were one to trust to such a diag- nosis as this, he would, in many instances, make a great mistake, supposing that the fainting does not depend on flooding — and this is the very error against which you should most vigilantly guard yourself.

Let me explain.

A woman, after the delivery of the placenta, shall have a good contraction of the uterus. She shall have a napkin applied firmly against the privities — and suppose herself to be quite well and safe. In the course of half an hour, or an hour and a half, she shall ask to be fanned, or for some drink, or for the volatile salts, and say she is faint. Her pulse will be very small, and feeble, and fre- quent — or it may be, undiscernible. The attendant at once places his hand upon the hypogaster to discover the state of the uterus, which he finds small and sufficiently firm. He ascertains


552 FLOODING AFTER DELIVERY.

that there is no visible hemorrhage, and is apt thence to conclude that there is no hemorrhage at all. But if he trusts to restoratives and cordials, et id genus omne, he may lose his patient — for her vagina is fdled with coagula in quantity sufficient to make her faint away, and even to put her life at risk.

The vagina is extremely distensible always, but immediately subsequent to delivery it remains so dilatable that the slightest pressure against its walls makes them yield. It has lately been expanded to a dimension sufficiently great to contain the trunk of a child's body, which is very large. If the nurse, upon her delivery, should clap a large napkin against the exterior genitals, and the patient, in order to keep it there, should strongly adduct the thighs, the issue of the lochia would be impeded, or prevented entirely — but, even the condensed womb bleeds, more or less; and the blood that it sheds, passing into the vagina, and finding no issue at the ostium, becomes coagulated. The whole tube of the vagina becomes enormously distended with coagula, as large as the trunk of a child's body, and the woman faints for the loss of her blood. The napkin outside acts as an obturator — and the clot inside as a tampon. The lochia cannot find issue — and the quantity lost is considerable enough to produce fainting. But I have long been convinced that another principle, in addition to that mere one of the loss of blood, is concerned in the production of the phenomena. I mean to say that the woman will faint for the loss of the blood, and continue to faint again and again, pro- vided the coagula are not removed from the vagina and cervix uteri — but, she will immediately recover from her deliquium, upon their removal. There is some influence of a disturbing nature, as to the nerve power, that is connected with the presence of a large quantity of clots in the vagina — probably that influence may proceed from the distension of the walls, and their pressure on parts in relation to them exteriorly, and on a nervous im- pression they suffer. Be this as it may ; it is quite certain that if you should press two fingers of the right hand into the canal of the vagina, and with them break the clots to pieces, while, with the other hand upon the hypogastrium, you press the globe of the womb downwards into the excavation of the pelvis, exhorting the woman, meanwhile, to bear down, the coagula will all be expelled, the vagina will contract its tube, and the woman will at once be relieved, and scarce fail to express her satisfaction


FLOODING AFTER DELIVERY. 553

with much energy and emphasis. To take out the coagula, or " turn them out,^^ as I used to say to you, does not give the wo- man any more blood, or replenish her veins, and yet hundreds, yes, many hundreds of times have I seen women instantly re- cover from the most depressing feeling of faintness and prostra- tion, upon turning out the clots from the vagina. Hence, I re- peat, that to turn out the clots, is to relieve the patient of her deliquium. But, gentlemen, suppose you do not turn out the coagula ! why, then, you leave a tampon of clotted blood in the vagina! No sensible man would ever think of such wicked folly as that. Every sensible, well instructed medical man knows, that where the womb is jfirmly contracted, there is no flooding — and that where it is relaxed or uncondensed, it will bleed, and that the blood it sheds, will fill its cavity — and distend it more and more, in proportion as the blood floM's — and not only so, but, the larger it becomes, the more rapid is the effusion. The patency of the hemorrhagic orifices on the inner superficies of the uterus, aug- ments at a certain ratio to the augmentation of the superficies. There can be nothing, then, more preposterous than to place a tampon in the vagina of a newly-delivered woman, and nothing more careless than to leave one there, that nature may have ad- justed there in the shape of a clot of blood.

From all the foregoing it results, that a woman may faint from hemorrhage after delivery, notwithstanding that you can discover no great distension of the womb, and though there may be no external visible signs of a flooding — and the precept that arises out of it is this — viz., when you go into an apartment where a woman just confined is in a fainting state, your first act of duty is to place the hand on her hypogastrium in order to see whether the womb is any larger than it ought to be; — second, to make a careful investigation as to the quantity of blood contained in the clothes and bed-clothes about her person ; — and third, when the womb is well down and the clothes quite unstained, to pass two fingers of the right hand into the vagina and turn out the clots if any be there ; and if there be none there, nor in the womb, you have a clear diagnostic of deliquium from some cause unconnected with a flooding.

But, a woman shall flood very dangerously, without discharging any blood upon the napkins or bed-clothing about her ; and when you come to put the hand upon the abdomen in order to inquire


554 FLOODING AFTER DELIVERY.

into the condition of the uterus — you shall find that the womb has become very large again, and has risen up, so that its fundus reaches nearly as high as the navel. This is a case in which, not the vagina only, but the uterus also is filled with blood.

It is worthy of remark that the clot in the womb, in this case, always feels very solid : — so much so, in some of the samples, as to tempt to the belief that it is not clot, but a large portion of placenta. The woman's life is in danger until the blood shall be discharged ; and there is no time to be lost, therefore, in taking it away. This is to be done by compressing {he uterine globe with the palm and fingers of the left hand, while with the index and medius of the right, or sometimes with the whole hand passed beyond the sphincter vaginae, you are empowered to break to pieces the solid coagula in the womb itself. After having first got out those that may be detained in the vagina, exhort the wo- man to bear down : if she makes a proper eflTort, while you at the same time continue to break up the masses that descend within reach of your fingers — the whole will be found suddenly to gush forth — the womb will again become hard, condensed, solid, and very small — and that is the end of the flooding for the present. As soon as the uterus has become thus quite empty — you should endeavor to secure a good permanent contraction of its muscular fibres, by gently pressing or kneading it with the palps of the fingers of the left hand — and this you should do for a considerable length of time. You know that not the muscular fibres of the womb only, but also those of the bowels may be excited to contraction by frictions which serve to arouse and stimulate their irritable nature. These frictions, then, are very powerful means of keeping the texture of the womb hard and firm; but if the texture of the womb is thus kept hard and firm, don't you perceive that there can be no flooding? — since, in that firm and contracted condition, the vessels of the womb are crimped and constringed, and their lights, in many instances, almost put out. Surely you recognize the truth, that the great veins and sinuses of the womb, that are seen in it when at full term, are invisible in the non-gravid organ. Well, then, when you want to make those great veins and sinuses and arteries as small as possible, so they may carry as little blood as possible, you will do all you can do to make the womb approach, as near as possible, to its non-gravid magnitude.


FLOODING AFTER DELIVERY. 555

Let me put you on your guard, however, against too much confidence in the conservative power of this treatment. You are not to suppose that, because you may have dexterously relieved the patient in compelling the uterus to contract, she is, therefore, absolutely safe. It is true, you have arrested the flooding, for the present ; and it may not begin again : it is, however, still truer, that in most of the cases, the muscular irritability of the womb is below par, and that the effusion of the lochial blood, going on, however moderately, tends to fill up and again distend its cavity — which, the larger it grows, the more rapidly it bleeds, and so reproduces the feeling of faintness, with diminution or loss of pulse, anxiety, jactitation, and all the signs that attend ex- cessive sanguine effusion. Your most vigilant care is required to meet these symptoms in their very inception. You will dis- cover them early, if you be really panoptical in your vigilance — and you will put an end to the second and to the third attacks as easily as you did to the first ; and by the same method.

A strong compress, laid on the hypogaster, and confined there by a binder, consisting of a long towel or pillow-case, will aid you to keep the womb from expanding again and again.

As to a compress and binder — let me tell you, that I have many times been teased by them, when the tendency to repeti- tions of the hemorrhagic attacks was very strong — for the abdo- men being concealed beneath compresses and bandages, I found that I could not so perfectly observe the state of the uterus, which would steal a march on me by filling itself with a quantity large enough to make my patient ill before I could discover it. Much vexatious experience of this sort has taught me, long ago, that the best compress is my own hand, for it has the advantage of being not merely a compress, but an intelligent or perceptive one, one that is capable of telling me — "Sir, the womb is filling again. Take care it don't hurt her."

As soon, then, as you can feel satisfied that the disposition to be hemorrhagic is over, you should adjust the compress over the uterine globe, and secure it with a bandage round the body. I advise you to do this with your own hand, in all serious cases of the sort, because you can better trust yourself than any nurse whatever. At least, your mind will be at ease, as you will know what you have done ; but you cannot know what another has done under your direction.


556 FLOODING AFTER DELIVERY.

There is another point that is worthy of your most especial regard in such cases. I mean the position of the patient.

She must not sit up — she must not be inclined upwards, if she be really ill — she must have her head in the same plane as her hips — or, if she be very ill, you must, you must make her head lower than the hips, by putting some books, blocks, or bricks under the foot-posts of the bed, which will elevate the legs and hips, and depress the trunk and head. I have already said that faintins: results from diminution of the tension of the vessels of the encephalon. Suppose a person to stand up and be bled at both arms — he would faint for twelve or sixteen ounces — but suppose him to be bled while lying down, he would bear the loss of twenty ounces, and if he were to be held with his head down- wards, you might take four times as much, probably, without caus- ing deliquium — when the head is down, the blood does not quit the brain so readily ; but, as long as the encephalic tension is kept up by means of a due fullness of the vessels, there cannot be such a thing as a faintinfr fit.

The precept then is, in all cases of faintness from flooding, to get the head down as low as may be. Therefore, take away the pillows and bolsters — and refuse to restore them until all danger is clearly over. This precept is so clear, so plain, and the rea- sons for it so understandable, that I have often times, when called in consultations, been amazed to find a medical brother, in good practice, and of considerable experience, neglecting it. I have seen such an one alarmed as to the state of his patient, and using all means to arrest the fainting, save the first and best — namely, the getting of the patient's head down. It was but the other day that I was called, in consultation, to a case of desperate flooding from placenta prsevia. I found the woman's head well raised on pillows. These pillows I not only took away, but I elevated the lower end of the bed, and bringing the head over the edge of the bed, allowed it to hang or droop down over the side with a view to keep the vessels of the encephalon full, for I know that as long as the encephalon is kept duly distended by vessels full of blood, so long will the brain generate and radiate its nerve force, its biotic force to the organisms — but if the brain cannot produce and send forth the nerve force, wherewith shall w^e carry on life in the organs? the heart will not beat, nor the diaphragm move, nor the par vagum do their office — and she will then die.


FLOODING AFTER DELIVERY. 557

Here is another point. It should be a rule to ask for informa- tion as to the habits of a patient, who may be placed under your care, in labor. Has she always had fainting, and floodings, when confined? If she has always suffered in this way, there is reason to think she will do so again, if something be not done to prevent it.

Whenever I am informed, as to a patient about to enter upon her lying-in, that she faints and floods in labor, I invariably make arrangements to be provided with half a drachm of ergot. Let it be procured, and kept with the brandy, the laudanum, and the other preparations usually made for the exigencies of a labor.

If a woman, who is within some ten or fifteen minutes of the conclusion of her labor, should swallow ten or fifteen grains of ergot mixed in water, the ergotism could not be developed until after the child's deliverance ; but, within ten or twenty minutes subsequent thereto, it would begin to excite the nerves of the womb, and compel them to compel the uterine muscles to con- tract, and to remain contracted.

The power of ergot over the uterine nerves, and through them, over the muscles of the organ, is so great, that I confidently expect a woman, who has always flooded before, will not now suffer at all in that way if she take ergot. I say, I confidently expect it, but, I must admit, that an occasional disappointment is to be met with; occasional I say, but those occasions are so rare, that I repeat, I confidently expect to obviate them. As an ounce of prevention is worth more than a pound of cure, I hope, when you come to practise, you will prevent hemorrhages in this way. Yet, if a flood- ing has not been expected, and comes suddenly upon your patient, you will have good reason to expect a tonic contraction of the womb to follow a good dose, — say fifteen to thirty grains — of the secale; give it, therefore, for there is no danger nor inconve- nience, since it cannot hurt the child, who is already born, nor will it do any evil to the mother.

Do not be afraid of opium. Opium has a vast power over the hemorrhages, for it has a vast control over the innervative forces, and quells a hemorrhagic nisus as it quells a spasm of the sto- mach, or a toothache.

I shall not dwell on the therapia of floodings any further. I have but one principle of guiding importance on the subject, and that is, to ensure by all the means in my power, the condensation


558 AFTER-PAINS.

or contraction of the uterine texture; all other views and treat- ment are to be held subordinate to these views, and the treatment that, under them, tends to bring about and secure this desirable end. If you understand this, and understand it fully, you cannot go wrong; you never will act wrongly in your methodus medendi for such cases.

A woman who is confined for the first time, is not to be ex- pected to suffer from after-pains. A first gestation is, in general, insufficient to deprive the uterus of its tone ; but if a woman have gone through a gestation and a labor a second, a third, or a fourth time, the tonicity of the organ will be found to be less than it was after her first confinement; and although the nervous force may be sent to it energetically, yet it will not be sent into it in the steady, equable manner which characterizes the condensing power of the uterus that has not already been exhausted by antecedent pregnancies, and the throes of parturition.

There are some females, however, who preserve throughout life, and after repeated gestations, the same steady force as to the uterus, which- characterizes that of the primipara. I have at this moment, under my care, a woman confined, now five days since, with her sixth child, and who has not had since the birth of it, and who never has had after the birth of any of her children, a single after-pain. This woman always recovers progressively and steadily from the gravid condition, without hemorrhage, without protracted lochial discharge, or any unusual symptom. Her uterus, which at the commencement of her labor, is ten or eleven inches in length, by eight or nine in width, and which would probably weigh, immediately after the delivery of the after- birth, a pound and a-half, goes steadily on, reducing itself to its non-gravid condition, wherein it would not weigh over two ounces and a-half. She has this good fortune, in consequence of retain- ing the same uterine tonicity, the same taxic force, that she had in her early youth, — and one meets in practice with a sufficient number of examples of the sort to convince him that the case is not a very rare one.

You will find in your intercourse with the world, as a practi- tioner of midwifery, that the women, in general, are acquainted with this difference between the primipara and the muciparous female ; for they will say to you, — of the woman in labor, that, of course, she is not to have after-pains, because this is her first


AFTER-PAINS. 559

confinement, — or of another, of course, she is to have after-pains, because this is her second, her fifth, or her tenth labor.

What is an after-pain? The pain of a labor is the pain felt at the cervix uteri, and is the result of violence done to the texture of the cervix and os, by the overpowering contractile force of the fundus and body. The pain is at the resisting part; it is not suflTered by the compelling organs. If a man strikes you a blow with his fist, and knocks you down, he hurts you and not him- self; in the same way, the fundus and corpus uteri, when they strive to rive open, and overcome the resistance of the cervix and OS uteri, hurt them, excite pain in them, and sometimes even tear them to pieces. There are hundreds of women, in whom the circle of the os uteri is torn in labor; which is the reason why, in the examination of women who have borne children, you may find fissures in the anterior or posterior lip, or at the right or left angles of the lip, where the os is most likely to give way.

I ask you again: what is an after-pain? An after-pain is not designed to expel, unless there be a clot to be expelled ; and when there is in the womb a hard clot that will not break to pieces, and when the os uteri, immediately after the expulsion of the after- birth, has shut itself up like a steel trap, as it often does, the clot which cannot get out until the os uteri is again dilated, will ex- cite pain by dilating it, as the child did by "dilating it. But there are thousands of examples where there is no clot-to be expelled. When there is no clot to be expelled, the after-pains cannot de- pend upon the resistance of the cervix uteri to the contractions of the body and fundus. A woman who has an after-pain designed to expel nothing, will have the pain in the whole w^omb, not in the cervix, as in the labor pain. A pain in the whole womb in labor is a dangerous thing; it is a pain which proves the exist- ence of rheumatism in the uterus, or of a tendency to laceration of the organ. So that you see there is a difference between the true after-pain and the pain of labor. A woman in labor does not com- plain of pain and soreness if you press your hand upon the globe of the uterus, whereas, when she has just been delivered, she shrinks from the pressure, saying, " Sir, you hurt me — that is very painful." The whole womb is more sensible of pain, intolerant of pressure ; the function of its sensitive cords is exalted after labor. Now, during the moments of relaxation, while the sensitive fibres are not compressed in the tissues among which they are distributed, the


560 AFTER-PAINS.

woman feels no pain ; but as soon as the motor cords begin again to excite the muscular tissues, the passive tissues, among which the sensitive cords are also distributed, feel that pressure, and the woman feels the pain arising therefrom ; just as she feels the pain arising from the rude contact of your hand.

In a former letter, I spoke of the frequent occurrence of rheu- matism as seated in the uterus; and I have no doubt, that many of the violent after-pains which we meet with, are cases of suffer- ing aggravated by a rheumatic condition of the organ ; for, a woman who has suffered from rhematisraus uteri for weeks before the birth of her child, I have always found more prone than another to suffer from these after-pains. — I mean with regard to their intensity, and their rebelliousness against the usual modes of treatment.

An ordinary after-pain will be relieved by an opium pill weigh- ing one or two grains, or by tw^o or three such pills ; or, il disap- pears after a few doses of laudanum, consisting of twenty-five or thirty drops each: a dose less than thirty drops it is hardly worth while to give. A woman may take an opium pill of a grain, or thirty drops of laudanum, every hour, until she has taken two or three such doses; and it is rare to hear her complain of after-pains after taking the second, or more especially the third such dose. Camphor, also, has a very special power to take away the distress occasioned by after-pains: our good Dr. Physick was accustomed to say, that camphor seemed to have been made for women, with whom it always agrees, while it always disagrees with men. As a general rule, opium is preferable as a medicine to camphor, for it is less heating and less stimulating to the whole ecomony ; but, inasmuch as there are idiosyncrasies which, under the use of opium, render it distressing or intolerable for certain persons, you should prefer for such persons the camphor medication. Here is a good formula.

R. — Camphor 3ss ;

Pulv. gum. acacise sij ;

Sacch. alb. 9ij ;

Aq. cinnam. 3iij.

M. ft. Mist.

S. — The dose is a tablespoonful.

This will give you six doses, each containing five grains of the


AFTER-PAINS. 561

drug. You may give the second dose in half an hour after the • first; or in an hour or an hour and a half; the other doses may be repeated at longer intervals, pro re nata.

Don't follow the old fashion, which commanded us always to send an eight ounce mixture to the patient ; a fashion, good for the apothecary, but very bad for the patient ; for the nurse might make her sick by giving her a whole drachm, whereas she could not do her any mortal injury by giving her half a drachm of camphor. Drugs and medicines are a sort of edged tools; and nurses and unlearned people, generally, are not to be permitted to use them, a la discretion, as a French tavern-keeper says of the wine on his table.

After-pains irritate; violent after-pains, frequently repeated, may irritate the whole constitution, even so far as to develop strong febrile phenomena. Where they are accompanied with fever, or frequent pulse, how can you discriminate between the phenomena so arising, and those attendant upon the most mortal attacks of metritis or puerperal peritonitis ?

I pity you, gentlemen, from the bottom of my heart, for the distress and embarrassment you are destined inevitably to en- counter from the difficulty, nay, the almost impossibility of mak- ing a correct diagnosis in such cases. I think one of the most distressing nights of my professional life was passed in the apartment of a lady of the greatest worth, and of the highest social standing, who, after a long attack of rheum atismus uteri preceding her accouchement, gave birth to a feeble child which died a few days after it was born. The expulsion of the pla- centa was followed by severe after-pains, that deprived her of sleep during the night, and which, continuing in an aggravated form, during the following day, brought on a reaction of her heart and arteries, the pulse beating from one hundred and twenty to one hundred and thirty strokes per minute, and this, accompanied with the most intense pain of the abdomen as well as of the head. She was a person of great dignity of character, and the utmost propriety of conduct ; hence, the loud complaints she made con- vinced me, from my knowledge of her character, that her suffer- ing was nearly intolerable. I knew that she had had rheumatism of the womb before the birth of the child, and that the rheumatic condition had modified the muscular power of the uterus ; inter- fering with, and retarding the normal progress of the labor. But, 36


562 UTERINE NEURALGIA.

when I discovered, six and thirty hours after the accouchement, that she had a pulse of one hundred and twenty, with a hot skin, and the most acute pain of the abdomen, I could not but hold her life to be seriously threatened. I passed the whole night, as I have said, in her apartment, agitated by the most conflicting opin- ions. Certain motives induced me to refrain from letting blood in the case ; and yet, when her groans and cries prompted me to come to her bedside, to examine with the most minute care the state of the pulse, of the respiration, of the calorific power, of the tension and sensibility of the abdomen, as well as the sensi- bility of the vaginal cervix as ascertained by the Touch, I always returned to my seat, comforted with the conviction, that I was treating a rheumatic neuralgia of the uterus and the splanchnic branches. The diagnosis was, in my opinion, undeniable; yet, in half an hour, her cries and groans recalled me to her bedside to renew my diagnosis of rheumatism, and to go again and again through the same sea of trouble, of doubt, and misgiving as to the correctness of my judgment. For I said : If I judge wrong as to the diagnosis of the case, and if I lose this patient, I shall neyer again feel perfectly contented in this world. Happily for me, the morning brought a remission to the intense distress. My patient recovered from her Lying-in, and has continued ever since, now these many years, to suffer from distressing rheumatic neuralgia, in many parts of her person.

I should in vain endeavor to put down upon paper the discrimi- nating signs by which you are to ascertain that your patient is laboring under rheumatismus uteri, or neuralgia of the womb, and not under some acute inflammation of that viscus. It is idle to write such a relation; a picture cannot be written ; it must be painted — nature must paint it for you — and you will find the picture in the clinique of your practice. Perhaps, if you and I were standing by the bedside of a patient laboring under this disorder, I might be able to point out certain signs, — discoverable in the physiognomical expression, in the tone of the voice, in the frequency, quickness and volume of the pulse, in the respira- tory acts, in the ability to move the limbs; in the patient's tolerance or intolerance of palpation, whether abdominal or va- ginal ; in the discharge from the uterus, and in the state of the urinary bladder and the bowels — that should show you why the


UTERINE NEURALGIA. — LOCHIA. 563

case should be called neuralgia, and not metritis, or metro-perito- nitis.

If you have studied your profession well, so that you have made yourselves masters of guiding principles in diagnosis, you will be able to find your way through these devious paths, and I must leave you to your own resources in the matter.

I will not dismiss the subject, however, without first saying, that there is not a more difficult task to be performed by the phy- sician than to make the diagnosis in such cases. An antecedent rheumatic state of the womb may serve to lighten up the path of the observer, but, let him beware, oh! let him beware! that even rheumatismus uteri may pass into metritis or metro-peritonitis ; in which case, an error in judgment costs a human life; costs the dis- ruption of the bonds of the family compact, the overthrow of the family altar, and the suppression of the most grateful incense that can rise to Heaven — the smoke of the incense that ascends to declare the happiness of parents and of children.

The vessels in the interior of the uterus, that open upon the late placental superficies, continue to bleed after the delivery has taken place. In a womb recently emptied, there is a considerable number of patent orifices, of which you may see a very pretty drawing in Dr. Robert Lee's Treatise on some of the Diseases of Females, which represents the orifices arranged in such a fashion as to furnish them with a species of valve.

The blood discharged from these vessels is called the lochia ; to. ^oxia: ^.oxHa is the Greek word from which it is taken. It is called in German, Kindbettreinigung, and is called lochies in French. The discharge continues for several days. Between the third and fourth days, the abundance is less ; probably, because the forces are employed in determining the new movements towards the mammary glands, which now become centres of fluxion, whereby the granules of the gland are evolved, in order to the secretion of the nutriment of the new-born child. When the milk has been fairly secreted, the lochial discharge increases again; and on the sixth, seventh, eighth and ninth days, it becomes more abundant than on the fourth and fifth; so that, when your patients complain to you on the third and fourth days, of the diminution and almost disparition of the lochia! discharge, you should not be disconcerted, nor allow them to become so; seeing that it is not a morbid but a natural phenomenon.


564 THE LOCHIA.

In from six to ten days from the birth of the child, the red colored lochia has given place to a greenish or yellowish-green fluid, possessing a peculiar and often most offensive odor, power- ful enough to fill the whole of a large apartment ; and so intense, that no scrupulous cares on the part of the monthly nurse can keep the patient's person and bed-clothes free from the disagree- able exhalation. The odor sometimes approaches that of sub- stances in a state of putrefaction and maceration, and the inex- perienced practitioner can scarcely avoid a feeling of doubt and distress as to the safety of the patient, considering the intenseness of the stench. But I believe that I can truly say, the woman whose lochia is so disagreeable as above expressed, is scarcely more liable to attacks of disease than she from whom no offensive exhalation can be perceived. I say this, founding myself upon much observation, for I have often experienced this great distrust on such occasions, when, it seems, I had no reason to do so ; nor can I remember that the attacks of disease that I have met within my lying-in patients, have been characterized by an antecedent unusual lochial odor.

There are some women in whom the discharge continues until the end of the month; and it is by no means rare to meet with persons in whom it does not cease until the end of the sixth week. The greenish discharge, with its peculiar odor, gradually gives place to a colorless and bland mucus, which, for such women as have great powers of recovery, is gone entirely by the twenty-first day. I have seen a case in which the womb has apparently recovered its non-gravid magnitude in three weeks from the birth of the child; and I have seen a case in which the uterus, filled with coagulated blood, extended nearly up to the umbilicus of the woman on the eighteenth day after the child was born. A womb that remains very large is more likely to give rise to a protracted lochial excretion than one that firmly condenses itself, and approaches the state of the non-gravid uterus. You will have, then, a prognosis that is favorable or unfavorable, ac- cording as the womb is large or small ; — if the womb grows small rapidly, and puts an early end to the excretion, in consequence of its healthful condensing power, the woman is nSt likely to suffer danger from the cessation of the discharge; but if a womb remain large, and heavy, and doughy, and the discharge cease too early, or too suddenly, the diagnostic will be that of a pathological con-


THE LOCHIA. 565

dition of the organ, and the prognosis will flow out of that ; for an inflammatory condition of the organ could not but modify its power of excretion. In one case you may be called on to inter- fere therapeutically ; in the other, you do mischief by your inter- vention.

When complaints are made to you on occasions like these, you should give them careful attention, and institute such in- quiries as to the state of the lochial organ, as must suffice to dis- cover the truth as to whether it be morbidly deprived of its excretive power, or whether it be physiologically deprived thereof.

You will find, in the world, a foolish prejudice, especially among the less informed classes of the population, which induces them to allow the accumulated products of the foul excretions of the uterus to rest and putrefy upon the external genitals, from an ignorant fear they have of checking a discharge so essential to their safety. I hope you will always endeavor to dissipate all false notions in relation to this matter; and you will not find it difficult to do so, if you will take the trouble to explain to the patient or to the nurse, that the putrid exhalations arising from the accumulated blood and mucus, at the orifice of the vagina, or within its canal, expose the woman to the dangers of putrid infection; and you should direct the nurse, in all cases under your care, to keep the woman scrupulously clean, by ablutions of warm water and soap, to which should be added some spirits or wine. For persons whose circumstances will warrant such ex- pense, I generally direct my nurses to make ablutions with red wine and water. I find that some of the brethren, and even some of the monthly nurses, in this quarter, are in the habit of ordering the vaginal injection; the circumstances would be very peculiar which should induce me to make such a prescription ; for I con- ceive that, if the napkins that receive the discharge are changed several times a day; and if a sponge, squeezed out in warm soap and water, or wine and water, be used as a detergent, the contractility of the tissues within will always emulge them suffi- ciently, I am not quite satisfied that it is the dictate of prudence or caution to fill the patient's womb with soap and water, or any other material of injection.

In cold weather, and in the variable seasons, the spring and autumn, the woman should be carefully protected against the danger of taking cold, by undue exposure of these parts ; and


■«'■


566 THE LOCHIA.

let me advise you to caution the patient against going, even after the lapse of the month, to the privy, the exhalations and the damp and cold of which render her very liable to repercussion of the fluxional movements, which should be most sedulously avoided.

Some women have their lochia too profusely from getting up too soon: when they are too profuse, one of the most reasonable remedies will be found in ordering them to take again a recumbent or horizontal posture. Such a position, taking off the strain from the distal branches of the vessels, is alone, in many cases, suffi- cient to put an end to the morbid movement of the blood in its uterine and spermatic branches. When recumbency fails to cure, the question might present itself of the propriety of bleeding from a vein, in order to take off a portion of the injecting power of the systemic ventricle ; or, if such a procedure is not to be thought of, and if the excess be justly attributable to an ataxic or atonic con- dition of the uterus, one should direct the patient to take some astringent infusion ; such as of red roses acidulated wdth aromatic sulphuric acid; or infusion of cinchona and cascarilla; or quassia, or chamomile, or infusion of krameria, diluted tincture of catechu or kino ; or some doses of opium ; or the saccharum saturni ; or alum and nutmeg powders, so often mentioned in these pages ; or more than all, the vinum secale cornuti, or the secale in powder mixed with water.

I shall take advantage of the present occasion, to refer you to the 220th page of that charming volume, entitled, " Lectures on the Theory and Practice of Midwifery, delivered in the Theatre of St. George's Hospital, by Robert Lee, F. R. S., &c. &c.: London, 1844, 8vo.," a book which I could desire to be in the hands of every one of my pupils, as I look upon its author as the ablest man in all England, in this department of science and practice.

I told him, in 1844, that he might safely die now. " Why die?" said he. — "Because you are already ineffaceably in- scribed on the roll of Fame." "How's that? how's that?" said he. — "It is thus, my dear doctor: — first, you are the man who has made the profession know the true nature of phleg- raasia-alba-dolens ; it is you who have taught us the malady is crural phlebitis : — secondly, you are indissolubly united with that company of men who have established the spontaneous ovula- tion as a cause of menstruation. Nothing can separate your


THE LOCHIA. 567

fame from that of Negrier, Gendrin, Pouchet, Purkinje, Von Baer, Rudolph Wagner, &c. Thirdly, you have just now shown me your last and greatest discovery, that of the largest ganglion in the human body, to wit, the cervical ganglion of the womb. I don't see anything left for you to discover, and therefore, I say, you may die now ; nothing can prevent you from being immortal." Dr. Lee replied, " I'll no die yet ! I'll no die yet !" — and I am very glad to learn that he is still living and in excellent health. Such people ought to die of old age, aiid nothing else, as we say in America.

But, to return to his 220th page ; he says: — "This discharge from the uterus after delivery, called the lochial discharge, does not usually cease, altogether, until the uterus has contracted greatly, and become much reduced in volume by the absorption of its coats, blood-vessels and nerves. The uterus is much more rapidly absorbed in some women than in others, and this chiefly depends on the previous state of the patient's health, and the nature of the labor."

I cannot agree with Dr. Lee in the opinion that the uterus is absorbed; because, I look upon the virgin uterus as a gravid mXqxxx^ in potentia ; a uterus possessing every organ and part of an organ that is necessary to enter into the composition of the gravid womb ; which, when it returns to its non-gravid condi- tion, does so, doubtless, by the aid of much absorption, but not by the "absorption of its coats, blood-vessels and nerves ;" for I conceive them never to be absorbed. Dr. Lee might as well say that the granules of the female breast are absorbed after the weaning of the child, or that they do not exist in the virgin ; but he knows that Sir Astley Cooper has demonstrated them to exist even in the male gland. I offer this little criticism on the 220th page of my excellent friend's work, because, aldiough " aliquando bonus dormitat Homerus,^ Homer himself ought to be waked up when he nods.

It is customary to put a binder around the abdomen of a woman just confined; a precaution rarely neglected in this country; but which, being neglected, is assigned as the cause of much after- suffering and ill-health that the patient causelessly attributes to the ignorance and carelessness of her monthly nurse, or her medi- cal attendant.

It is necessary that you should be cautious in the use of the band-


568 THE BINDER. ASDRUBALI.

age; for, if the bandage be worn too strictly, and M'ith a heavy compress between it and the abdomen, it cannot but happen that the globe of the womb, which for a few days after delivery, is as large as a cricket ball, will be thrust down into the excavation, pushing the vagina before it, thus shortening the tube, on the upper extremity of which the uterus rests, and which, in fact, fur- nishes to the uterus nearly its sole support, amidst the bones of the pelvis. Suppose you were to fix one of the utero-abdominal supporters, as they are called, upon the hypogastrium of a w^oman just confined, and compel her to wear it for the forty days ensu- ing, or until the uterus had recovered its non-gravid magnitude and weight, would not your patient be sure to recover with a pro- lapsus uteri .

You will find, at page 208 of Prof. Asdrubali's work, " Tratato Generale di Ostetricia, Teoretica e Pratica,^^ vol. 2d, some excel- lent observations on the evils and abuse of bandages; and inas- much as, throughout the United States, the most incorrect and harmful notions exist on the subject, I think I shall do you no disservice if I translate the whole passage from that most learned and admirable author.

" The habit of binding up the abdomen of women in child- bed, was in use among all the ancients. Yet Peu and Mauriceau have declaimed against the abuse of it, though they did not admit that it should be wholly proscribed. Many of the moderns still advocate its employment, but with great precaution ; as if in doubt whether it might do most good, or most harm; but the majority of them have condemned the custom. Buchan looks upon it as absurd, and Gorter as mischievous, and as the occasion, almost always, of serious disorders.

" Among the motives that have prevailed among some, to re- commend the binder, the principal one was to furnish the patient with the same sort of aid as it is customary to give the patient in dropsy, after the operation for paracentesis, with a view to prevent attacks of lipothymia and syncope, likely to ensue upon the sudden and great evacuation of the abdominal cavity. An- other motive was, to restore to the abdomen its non-gravid size and form.

" It is not to be doubted that the cavity of the abdomen, when compressed by the binder, will find as much support for the com- pression of the viscera and blood-vessels, as it had previously


THE BINDER. ASDRUBALI. 569

received from the gravid uterus. But, inasmuch as, for the obtaining of this effect, the abdomen must be firmly bound, and as there is no other motive for it, the constriction, no doubt, is often sufficient to produce suppression of the lochia, whence may arise suffocation and pain, which are the beginnings of terrible maladies. How some recommend it without clear mo- tives, and others advise it under careful restrictions, is demon- strated by daily observation ; for it is observed that no evils befall those who make no use of the binder, but leave the abdomen per- fectly free: they pass through the puerperal state without the least untoward circumstance. Why should we resort to a method from which, as Dionis observes, there proceeds more mischief than good? In order to avoid deliquium and syncope, it is only necessary that the woman, as soon as she is confined, should pre- serve a horizontal posture; and if, unexpectedly, or by accident, deliquium should occur, certainly we might make use of remedies equal to the removal of the evil, and prompt in their action, and not trust to a mere bandage. If a woman should have an extra- ordinarily flaccid abdomen, it might certainly be advisable to con- tract it by a bandage made moderately tight, and kept so, for a few days.

" The second motive for recommending a bandage is, as ex- pressed in § 282, to reduce the size of the abdomen of the puer- peral woman. But experience shows that the restoration of its shape depends upon nature, and not upon any art whatever. The abdomen, as soon as it is relieved from its distension by the gravid uterus, recovers such form and size as it is susceptible of, under the contraction of its muscles and teguments : it would not, cer- tainly, be susceptible of a corrugation beyond the natural degree, by any restraint afforded by a linen bandage. How true this is, may be observed in many women, who, after repeated labors, find the abdomen relaxed and flaccid, notwithstanding their extrava- gant sacrifices to the dictates of fashion in dress. They look to the physician for this happy restoration ; they suppose that he, by means of his bandage, ought to restore the abdomen to its primi- tive condition; never reflecting, that they wear corsets without the least advantage, and that the support they require for too flac- cid an abdomen, is to be obtained from the ordinaiy corsets and busks, w^hich they can tighten at will, and to which they can give any form, adapted to their necessities or caprices." Professor


570 RETENTION OF URINE.

Asdrubali concludes his article with a considerable quotation from Lemoine, which I shall not cite to you for the present.

I have already, in a former letter, offered you some remarks upon the use of the bandage, as a means of suppressing the tendency of the uterus to expand soon after labor, and receive, and contain the products of what is called a concealed hemorrhage, for which I refer you to page 549. I likewise expressed the opinion, that certain women, after sudden deliveries, having had the womb enormously distended before, sutler from violent lipothymia and deliquium, for want of some abdominal tension, for want of a bandage. For such views, I hold the bandage to be laudable, and the use of it not to be pretermitted ; but as for the rest, I here fully give my approbation to the sensible, reasonable remarks of Professor Asdrubali. It is very probable that much of the pre- valence of prolapsus uteri in this country is due to the improper use of the binder. Pray attend to this point.

There is one point in the management of women newly de- livered, to which I must now advert. It is a very common occur- rence to find the woman recently put to bed, affected with reten- tion of urine; the occurrence is so common, that it is a rule of duty in the physician who has charge of the case, to make in- quiry into the matter. It cannot but be inconvenient, and not a little dangerous, to allow the products of the renal secretion to accumulate in the bladder to a great amount. But, that organ has been so much distressed, so much compressed, and, perhaps, so much contused in the transit of the foetus through the pelvis, that it must be, and, in fact, it is an exceedingly trite occurrence to find the woman allowing from thirty to forty ounces of fluid to accumulate in the bladder of urine, putting the cystic tissue dangerously on the stretch, compressing the uterus, exciting pain, urinary and rectal tenesmus, and even fever, which it is easy to guard against by a simple precaution. It is considered by accoucheurs, therefore, an invariable point of duty, to inquire, within a few hours after the birth of the child, whether the bladder of urine has been relieved.

If you, who read this letter, be not, and do not intend to be- come an accoucheur, you might nevertheless adopt the custom of the accoucheur in such cases. An accoucheur would not think, I suppose, of giving medicine to provoke a discharge of the urine in such a case. An accoucheur does not like his patient to be


RETENTION OF URINE. 571

disturbed by a dose of physic, or even by a common aperient enema, in the first two days at least of the lying-in. He knows that drugs are of no avail for this kind of retention, and he resorts at once to a remedy which cannot fail, which is not inconvenient, and in no wise painful : I mean the introduction of the catheter. If the woman should not be relieved in the course of from eiffht to twelve hours, the catheter should be introduced, and so on from day to day, until the powerof the urinary organ be quite re-estab- lished.

I pray you remember, that you might make a false diagnosis in the matter, if you be not careful. I have seen this false diag- nosis made a thousand times by nurses and by the patients them- selves ; they supposing the distress to arise from what is called after-pains, while, in fact, it depended solely upon retention of urine and extraordinary distension of the bladder of urine. If, for a woman complaining of after-pains, you should explore the case, by pressing your hand upon the hypogastrium, and finding there a well defined, resisting, orbicular mass, nothing w^ould be easier than to mistake it for the uterus. Sometimes, I have had a difficulty in making the discrimination, by trusting merely to my sense of touch: the difficulty of diagnosis has vanished from me always, however, upon ascertaining : — first, that the woman has had no urinary evacuation for a number of hours; and secondly, by saying to her, "Listen to me; attend. I am press- ing my hand upon a lump which I find here at the lower part of the stomach. I am going to press harder, in order to give you some increase of pain. Please give your attention to the sort of pain which I shall produce ; — and tell me whether or not the pain you now feel may be truly called a urinary pain. Is it a pain to make water ?"

"Yes, sir, it is !"

"Very well. — I understand the case now."

Afiler such an answer, a doctor would be very stupid if he should not propose the use of the catheter.

After severe labors, the bladder is occasionally found to refuse to resume its function of expelling the urine for three, eight, ten, and sometimes fifteen or twenty days. As long as it refuses to do its duty, the medical man should remove the urine twice a day, or, what is far better, leave a proper catheter in the hands of the patient; first instructing her to apply it for her own relief.


572 RETENTION OF URINE. MEDICINE.

There are many persons who can be trusted to do this little ope- ration, which is a having both to their own feelings and those of the medical attendant, for there is scarcely a more disagreeable operation to be performed than that of catheterism of the female ; an operation which, I should think, every gentleman would be glad to commit to other hands than his own. It does no mischief, I suppose, in such cases, to give a little sweet spirits of nitre ; to give a little weak solution of nitre ; to allow your patient to take infusion of watermelon seed ; of parsley root, of horseradish, or of juniper berries; which do little harm, and less good. If the patient will have a placebo, let her have the most innoxious one you can devise. After all, there is nothing for retention of urine like a good catheter.

It is not good practice to excite perturbations in the economy of a woman who has just gone through the pain and excite- ment of a labor. Such a person requires a long and profound repose of the organs and organisms, as well as of the spirit itself; for which all sorts of complacencies ought to be provided. A dose of cathartic medicine, administered within twenty-four hours, is sufficient, in some instances, to call up movements, whether nervous or vascular, that it would be far wiser to leave uncalled. Wake not the sleeping lion. Attacks of engorgement and inflam- mation have, I am sure, followed the interapestive exhibition of purgative medicines, by imprudent and assuming nurses. It is time enough, under all ordinary circumstances, to cause the bowels to be moved once or twice, after the lapse of from sixty to seventy- two hours; and the woman ought not to be disturbed with any kind of physic for at least this length of time after her delivery. When the time does arrive for giving some medicine, an aperient ought to be selected, and not a purgative. The patient is not sick ; she does not want physic ; her bowels are lazy, and merely re- quire to be roused a little ; the woman ought to have one or two alvine dejections, and not more, unless she be really sick. To procure this desirable end, pray select some article that you can depend upon. Can you depend upon magnesia, or upon the com- mon combination of magnesia and Epsom salt? No. A dose of magnesia will operate either not at all, or once, or eight or ten times. Will senna or rhubarb answer your purpose? Unfaith- fully ; because they bring on purging, if you give a sufficient dose ; and if you give a moderate dose, you will be disappointed in the


MEDICINE. DIET. 573

operation. What is the medicine that doesn't disappoint you? Castor oil. The dose of this medicine ought to be, as a medium, about half a tablespoonful. In ten cases of women just confined, a dessertspoonful of castor oil will be sufficient for nine of them, and the tenth one can repeat it after five or six hours, if she chooses. I advise you to follow this method ; and I confidently ad- vise you in this way, because "hand inexpertus loquor.'^^ Neither my friend, Dr. Samuel Jackson, nor I, would consent to give a woman a tablespoonful of castor oil under such circumstances, because we know that half a tablespoonful is a better dose for her. Dr. Jackson is a good authority in matters of therapeutics. I wish there were more like him in the country.

The diet of the woman is worthy of some consideration : many women are left by labor with their blood-vessels in a state of con- vulsion, so to speak; the tempest and whirlwind of their passion do not subside, for many of them at least, for hours after the provoking cause has been taken away.

If the woman has not lost a great quantity of blood by the de- tachment of the placenta; or if the lochial discharge should prove to be not very abundant, the materials for development left within her blood-vessels ought not to be deemed to require much refec- tion for two or three days. She is about to have a new cause of constitutional disturbance set up within her: both the mammary glands are destined to sudden, I was going to say, bursting de- velopment. They are both about to become suddenly instinct with life ; an operation attended, in the majority of cases, if not with fever, at least with a quasi febrile paroxysm.

These considerations render it expedient that her diet should consist of very light, digestible, and sufficiently nutritious mate- rials. I presume that in different parts of the country there are different modes of treating the lying-in woman as to her diet; but as for us in Philadelphia, a time-honored custom, which is uni- versally adhered to, commands the nurse to provide for her patient a diet of gruel made with oatmeal. Many of the nurses boil it into a thick porridge, and give it to the patient sweetened with sugar, after having made a very slender addition of salt; it is light, aperient, agreeable to the patient, and satisfies well the cravings of the stomach.

The woman is also allowed a cup of tea, and some dry toast or baked rusks ; or any simple preparation of bread. Tea and toast,


574 DIET. SITTING UP.

oatmeal orufl and cold water aie a lying-in woman's allowance, until after the millc comes, in IMiihulelphia. Hot till", or brandy aiul watei'; soups, meats, eggs; all animal substances, ought to be proscribed.

A woman ought to l<eej> her beil lor the first nine or ten days after her aci'ouehement ; if she gets up, the womb descends into the excavation, lower than the place it ought to occujiy. The womb will get well, notwithstanding such imprudence; but the vagina may be ruiiuci, and the woman's health maybe forever alter dis- turbed by a prolapsion, which always coincides with a shorten- ing of the vagina. Prolajisus uteri means, and is nothing else than shorti'iiing of the vagina; and you have nothing to cure in prolajisus uteri but a shortening of the vagina; and when it is cured, the woman is cured, and you have nothing else to do with it.

There is another motive why a woman should not get up, aris- ing from her extraordinary nervous susceptibility after labor. She may take coKl ; she may be seized with a rigor; and the rigor may give her an attack of weed in tht> breast; or the force of the re- action may fall upon the womb, or upon the peritoneum ; so that she shall pay for her imprudent early rising with a mammary abscess, or by loss of her life in a child-bed fever. I verily be- lieve, that one half of the vexations I have experienced in the course of my life, from such occurrences, have been the fruit of untimely, imprudent exposure as to diet, or as to too early rising from the bed. I tell my young lady-patients that if they keep the bed until they are cured, child-bearing will not make them break, — as it is called. A squaw^, with two pappooses, is nothing but a squaw. She might have been a very pretty woman still, if she had had a good nurse, and kept her bed until after the ninth day. She who gets up too soon will have wrinkles, and grow sallow and ugly before she is twenty-five.

After the ninth day has elapsed, if nothing has happened, the woman may be taken uj) for an hour in the morning, and again as long in the afternoon ; prolonging from day to day her leave of absence from the couch, until her strength being gradually re- stored, there shall seem no longer need for any restriction what- ever.

I shall refrain from oll'cring remarks here on the coming of the


RIDING OUT. VACCINATION. 575

milk, am] the manngement of the breast, as I intend to devote a separate letter to that eonsideration.

As to riding- out, it will dej)end ujwn the state of tlie patient's health; it is well, however, to have a rule; — my rule is to say, yon may ride out on the twenty-Hrst day, if you be well enough and the weather be inviting. An hour's ride is long enough for the first sortie. But, if the lochia are not gone, it is better to stay at home.

No woman ought to consider herself recovered from the efTects of her accouchement, until after the lapse of an entire month. The Jews, who inhabited a very warm climate, were consi- dered, by their Lawgiver, unclean for forty days after the birth of the child. Christian women are purified in thirty days, and I am afraid that some of them think themselves so earlier than that. I wish that the brethren could lend their infiuence to reinstate the Mosaic doctrine on this point. But, some people will jiot believe Moses nor the prophets ; nor would they believe, though one should rise from the dead to tell them, they are not well, if they but feel well.

Pregnant women ought not to be vaccinated. — This is a rule that I advise you to depart from only on the most urgent occasions. If a woman have been once vaccinated, and appeal to you to re- vaccinate her because there is a present variolous epidemic, I hope you will refuse to accede to her request. Small-pox is ex- ceedingly and peculiarly pernicious to pregnant women. — She who has it, and miscarries — or who is brought to bed at term, generally dies. It is, in ray opinion, inexcusable to expose her to so great a risk — a risk far greater than that from accidental con- tagion, or that of the epidemy. But the vaccine is identical with the variolous animal poison, saving some lessened intensity of its malignant form derived from its having been modified by the nature of another mammal. — To inoculate a cow with small-pox virus, is fo give her the vaccine disease, with the lymph of which you can vaccinate, but not reproduce unmodified small-pox. Keep your pregnant patients clear of small-pox in all its forms, whether modified or unmodified. — Do not vaccinate them. I have been the witness of dreadful distress from the operation. — Eschew it, I entreat you. C. D. M.


576 PUERPERAL FEVER.


LETTER XLI.

Gentlemen: — There is a "word of fear" that I shall pro- nounce when I utter the name of Puerperal fever; for there is almost no acute disease that is more terrible than this — even small-pox, which reduces the fairest form of humanity to a mass of breathing corruption, cannot be looked upon with greater awe, since, like an inexorable Atropos, it cuts off the thread of life for those to whom Clotho and Lachesis w^ould give the longest span. There is something so touching in the death of a woman who has recently given birth to her child; something so mournful in the disappointment of cherished hopes ; something so pitiful in the deserted condition of the new-born helpless creature, forever de- prived of those tender cares and caresses so necessary for it — that the hardest heart is sensible to the catastrophe. It is a sort of desecration for an accouchce to die.

The disease in question, from its liability to assume the cha- racter of a devastating epidemic, acquires an importance far greater than would appertain to it, were it limited to the occa- sional fatalities of its sporadic or accidental formulas — for when it does prevail as an epidemic, it sometimes rages over a great ex- tent of country, or districts, and lays not aside its destroying wrath, not for weeks only, or months, but even for a term of years ; carrying in its train fear, expectation of death, and the overthrow and desolation of the domestic altar.

The maladies comprised under the denomination of puerperal fever, for there are several of them, are so insidious in their ap- proach, so sudden and violent in the attack, and so rapid in their progress, that the fatal boundaries are not unfrequently passed before assistance is sought for from the hands of the physician. It is, therefore, clearly your duty to make yourselves accurately acquainted with its nature, signs and treatment. I shall accord- ingly, in the present letter, endeavor to lay before you such views upon the subject as I have been able to obtain from no little clinical observation of cases, from reflection upon what I have myself seen, and from conversation and reading.


PUERPERAL FEVER. 577

Puerperal fever, denominated, by the public, child-bed-fever, is also called peritoneal fever, puerperal peritonitis, metritis, metro-peritonitis, uterine phlebitis, and lastly, pyogenic fever: it is a disease consisting of inflammation of the serous coat of the abdo- men, or of some portion of it — inflammation of the ovaries — one or both of them; of the womb, with, or without coincident inflam- mation of the peritoneum; of the veins of the womb; or of the absorbent vessels of that organ.

It is probable, that a major part of the cases consist of serous inflammation only, — cases in which the sub-serous textures have little participation in the pathological modifications of the peri- toneum proper.

Many of these samples of peritonitis, however, coincide with violent inflammation of one or both of the ovaria — of the liga- menta lata, and of the external superficial tissues of the uterus.

In pure samples of metritis — or of uterine phlebitis, the inflam- matory modification of the tissues may not, on the one hand, or on the other may, extend to, and involve the serous lining of the womb, and spread far and wide throughout the various folds and reflections of the whole peritoneum.

Leaving out of consideration the nature of the recondite causes that operate upon the economy to develop the various puerperal inflammations ; such as an epidemic or an endemial influence ; or a poison conveyed in the clothing or persons of physicians and nurses, one would seem to perceive sufficient provocatives to the attack of inflammation, in the state of the parturient woman's con- stitution, and in the events of the labor by which she may have been brought to bed. Indeed, there is room for surprise, that the examples of violent inflammation of the tissues concerned in par- turition, are not far more numerous than they are really found to be.

In the first place, it is extremely rare to let blood for a patient pregnant and nigh to her term, without discovering the proofs of an inflammatory tendency, in the sizy and cupped appearance of the blood, when allowed to lie in a state of rest. I beg you to take notice, in your subsequent practice, of this point. — But if the blood be sizy in nearly all pregnant women, then all such women are, to say the least, in a state of proneness to inflammatory attacks — since that siziness of the blood indicates an excessive predominance of the fibrinous element. I beg you to allow me 37


578 PUERPERAL FEVER.

to repeat, that in 1,000 grains of healthy blood, there should be found not more than 3"5 of fibrine — but, if you bleed a pregnant female far advanced in the gestation, you will discover size enough in the coagulum to lead to the supposition that instead of 3'5 there must be not less than 10, or perhaps 15, of the plastic material.

Pregnancy, for most women, is carried on at the expense of an exalted general vital force, — for many of them, the latter weeks of gestation are weeks of feverishness ; and when, upon such a basis of dyscrasy of the blood, we come to superadd all the san- guine and nervous exaltations of the conflict of labor, which is attended with greatly increased action of the heart and arteries, we may well believe that the blood is invariably left in a patholo- gical condition at the delivery.

The nervous system, too, in most cases of hard labor, becomes exhausted, and is rendered thereby extremely impressionable by all morbific causes : all the causes of inflammation must act with redoubled intensity upon it, and inflammation once begun, may, with difficulty, be prevented from extending far and wide beyond its radiating point.

As to the serous lining of the abdomen, there is scarcely any portion of it that is not affected, in pregnancy, by the vast exten- sion of the peritoneal superficies of the womb and the abdominal integuments, or by the pressure eff*ected upon them.

The birth of the child takes off' this pressure — leaves much of the peritoneum in a state of relaxative flaccidity — and thus brings it into an ataxic condition, inviting the approach and onset of disease.

The repeated, protracted, and vehement contractions of the abdominal muscles, cannot but have a tendency to effect contu- sions in the opposite surfaces that are so violently jammed or ground together during the labor throes ; while the lower portions of the membrane or the cervical portion of the uterus, contain- ing within it the foetal presentation, are thrust with an incalculable force down below the plane of the superior strait, and oftentimes held for hours against some part of the osseous structure of the pelvis; so that one is amazed to find the tissues escaping wholly from disease, when it was probable they could not escape absolute destruction.

Consider also the state of the textures composing the womb


PUERPERAL FEVER. 579

itself; and reflecting that the power of the womb is resident only in its muscular fibres : see what and how great must be the mechanical violence done to the remaining elementary structures of the organ during the protracted and agonizing contractions of those muscles, — contractions that seem, in some instances, to make every sensitive cord feel the violence that is directed and occasioned by the motor cords.

The labor, too, is not the end of the scene, for the womb and the vagina, with their whole cortege of arteries, veins, capillaries, nerves, and absorbents, as well as the muscles and cellular tela, are passing, during forty days after the birth, back again into the non-gravid state ; a transition-period, full of hazard, and open to the attack of inflammation.

There are new determinations of blood to be established. The torrents that have poured for months, and in increasing volumes, along the uterine and spermatic branches, are suddenly cut off' in a measure by the closure or quasi obliteration of their accustomed channels ; and great veins and sinuses, as big as a little finger, must allow their walls to collapse, compelling their endangiumto re-enter the state of non-gravid abeyance from which the preg- nancy had forced them to issue.

Upon the interior surface of the uterus is left the cotyledynous superficies, with the patulous orifices of the lochial vessels, that were uncovered by the detachment of the placenta. Those mouths are often bathed with fluids of the most putrid and offensive and even acrid character, provoking inflammatory exaltation of the capillary and nervous textures, and the endangial tissue of the veins.

Finally, the new life-force in the breasts must begin ; and the firm tension of the mammary glands and galactophorous tubes developes fever, which is akin to inflammation.

In addition to all the causes above enumerated, it is proper to take into consideration the state of the skin. There are few women who go through with the labor without violent perspira- tion, which issues from the head and thorax, and flows in copious streams. Such a condition of the cutaneous exhalants leaves the delicate vascular and nervous apparatus of the skin in a highly susceptible or impressionable attitude, so that cold and damp ope- rate with peculiar intensity in causing disease.

There are, besides, many labors that are interfered with by the


580 PUERPERAL FEVER.

officious intermeddling practitioner, whether male or female, who happens not to have been well instructed in the duties of the obstetrician. Instruments are the not unfrequent causes of con- tusion, as well as of laceration of greater or less moment; so that multitudinous provocatives and causes of disease are to be discovered, even in the most simple healthful case of parturition.

There are, moreover, epidemic causes of puerperal fever. I cannot tell you what is an epidemic cause, since it is uncognos- cible, recondite, and beyond the ken of the human understanding. We can know that it exists, and we can witness the efficacy of its awful causation, in the frightful devastation of hospitals, towns, villages, and even large and extensive districts of country.

Dr. Sydenham showed long ago, that a constitution of the atmosphere may exert modifying influences upon the nature of diseases, and, that as the constitution changes from time to time, so w^ill the characteristic qualities of any disease undergo con- formable modifications from year to year. He showed that there may reign influences to render prevailing maladies either syno- chous, or typhous, so that the fiercest attack of pleuritis shall par- ticipate in the nature of the most ataxic forms of the typhus fever, or upon some unknown non-meteorological mutation of the quali- ties of the ambient air, the serous inflammations shall recover all their activity and red-hot intenseness.

No eudiometrical researches have hitherto succeeded in wresting from Nature her direful secret as to the essence of epidemic causa- tion. The poisonous exhalations from the bogs of the Valteline, or the marshes of theCampagna, in the eudiometer betray no combi- nations of the air different from those that rest on the pinnacle of the Shreckhorn, or the Faulhorn ; no additional infusion of car- bonic acid, no supersaturation of oxygen, nor excessive nitro- genous dilution. Hypotheses and conjectures, however specious and plausible, are all that we have to rest upon in the arduous and anxious explanation.

In the case of the confessedly contagious disorders, we seem to come at something like approximation to the truth. We can, in the case of small-pox, visibly and palpably demonstrate, if not the essence of the contagion, at least the contagious virus, a ma- terial in which it exists. We can take it from one, and transfer it a thousand leagues to another, and plant, as it w^ere, its seeds


PUERPERAL FEVER. 581

to spring up like a vast Upas, overshadowing with its arms of death, the whole area of a city or a county.

Perhaps there are other maladies, as scarlatina, rubeola, per- tussis, &c., that may be placed in the same category of contagious power. Yet, if we be compelled to admit that they are propa- gated by contagious force, we cannot deny that they are also extended among a population by epidemic causations. Willis, in his TractatxLS de Fcbribus, says, Peculiaris qusedam aeris dispositio variolas insigniter producit; hinc seepissime popularis evadit, ac per totas regiones, urbes, vicosque passim dessevit ; hinc etiam vere et autumno crebrior existit, &c. How are we to explain this epidemical power of a purely contagious malady, if we deny that there is a means of its evolution, utterly independent of all somatological sources of its production!

In the great example, the Asiatic cholera, we have seen that the epidemic causation has risen into activity in various latitudes and longitudes of the globe, commencing in the Delta of the Ganges, and spreading eastward to China, and westward to Persia; north- ward, to the shores of the Caspian, at Astracan, and to those of the Mediterranean, at Latakie ; ascending the Russian rivers to Mos- cow, and then invading Western and Southern Europe, and the countries of both North and South America.

In the disastrous spread of this great epidemic, which has pro- bably cut short the span of more than fifty-five millions of our race, how many thousands of the strongest proofs have been observed of its contagious power, and yet it is probably not more contagious than rheumatism, or gout, or ordinary ague and fever.

As to the contagiousness of small-pox, I cannot deny it, since I cannot deny the contagiousness of any innoculable malady. But the contagious nature of puerperal fever, though asserted by so many of the brethren, entitled to my respect for their learning, judg- ment, and humanity, I cannot for a moment admit. Its epidemic power is for me a sufficient explanation of all the asserted ex- amples of its communication by direct contagion.

Sydenham, as I have said, made us acquainted more exactly with the important fact that changes in what he calls the consti- tution of the air, by which he means certain non-cognoscible cosmic forces, are capable of modifying the intenseness of our vital sensibility and irritability. Those same influences exerted in space, whether vast or minute, may serve to explain how it


582 PUERPERAL FEVER.

happens, that in a district of country where a case of puerperal fever had been unknown in the memory of the oldest inhabitant, a major part of the puerperal women shall, for a series of months or years, become the subjects, and many the victims of it. An epidemic influence, be it what it may, can place the constitution in a predicament that renders it prone to be affected by the in- flammations that I have, in the beginning of this letter, deno- minated the textural lesions of our disease ; and to the end of conceiving of such epidemical influence, it is not necessary to imagine any fermentative or sporiferous element of propagation, nor any poisonous exhalation, material, or gas — since the small- est change in the atmospherical mixt, or constitution, can give the utmost vigor to the vital forces, or take them away, or reduce them to the minimum of power.

The gigantic ferns that lie buried beneath the ruins of the ante- diluvian world, and the inexhaustible deposits of carbon in the coal fields and in some of the rocky strata, have been presented by the geologist as proofs of a former different combination or mixture of the atmosphere, as to its carbonaceous portion. But, if the geolo- gist has a real foundation for such an hypothesis, we shall not do violence to the spirit of philosophy, in supposing that atmospheric combinations and mixtures, excluding the idea of poisons, may reign in hospitals, cities, counties, districts, or states, for the pro- duction of epidemic maladies.

If a disease be contagious, it must be so by virtue of a mate- rial, or essence produced in and evolved from the person of an individual ; and it is averred that A and B may propagate that cause from house to house, while C, D and E are admitted to have no such power of transmission. A physician has even been called a walking pestilence, because he has met with numerous ex- amples of puerperal fever in his practice, while his brethren have had no such trying occurrences to lament. He has been tracked, it is said, by the victims of a contagion transmitted by his person. And it is quite true, that we occasionally meet with inexplicable instances of the existence of the disease among the patients of a single practitioner, or of two or more medical people of a city or village, while the other brethren who continue their practice in obstetricy, encounter no untoward lying-in cases. It is a matter of vast moment to determine the question of the contagion, or the non-contagiousness of puerperal fever, a subject


PUERPERAL FEVER. 583

most difficult to investigate, and like the question of the contagious- ness of plague, of cholera Asiatica, of yellow fever, likely long to remain unsettled, after useless discussions and inquiries. It would, perhaps, be wrong to say useless, since such inquiries lead, in the long run, to the establishment of the truth.

Having practiced midwifery a great many years, and having been concerned in the visitation of the sick laboring under puer- peral fever, whether sporadic or epidemic, — visiting the same cases with those w^ho have so cruelly been abused, as performing the part of a walking pestilence, scattering death and desolation where they desired only to do good, — and seeing that I could never convict myself of being the means of spreading the contagion, I remain incredulous as to the contagiousness of the malady. I have gone from the dissection of the bodies of w'omen, dying at the hospital, with symptoms of the most violent puerperal peritonitis, prevailing epidemically there, and have never commu- nicated it to those whom I soon afterwards delivered in their labors. I have visited the patients of those, among whose patients the dis- ease seemed to extend because they were the attending physicians, yet I did not convey the malady into my own clinical practice, while they were loudly accused of so doing.

One of these gentlemen has had the kindness to furnish me with a note, in which he relates, that he has carefully examined his cases of puerperal fever, and finds that the whole number that he attended, amounted to ninety-five, of which there occurred — In 1841, .... 3 " 1842, .... 9 " 1843, .... 45 " 1844, .... 25 "■ 1845, .... 6 " 1846, .... 7 making in all ninety-five. The first case was on the 6th of Sep- tember, 1841, and the last on the 6th of June, 1846. Seventy- seven recovered, and eighteen of the cases terminated fatally; of which, two were cases of twins, and three were cases of presenta- tion of the arm. In eight of the cases, the child was born before the gentleman entered the chamber ; and in four the delivery of the placenta had taken place previous to his arrival.

Dr. Rutter, of this city, to whom I am obliged for the note in question, was engaged at that time in a most laborious midwifery


584 PUERPERAL FEVER.

practice ; a practice, for which he is eminently qualified, by his knowledge, skill, and temper. The result of his practice during a disastrous epidemic might be taken as proof of his ability, for he lost only eighteen out of ninety-five patients, or one in five and a half; and that, in a class of cases that were characterized by the utmost intensity of violence, as I can bear witness, having seen some of them along with him. During the prevalence of the same epidemic at the Dublin Lying-in Hospital, while the distinguished Dr. Robert Collins was Master of the hospital, eighty-eight cases occurred. Of these eighty-eight cases, fifty-six proved fatal, which is equal to the loss of two out of every three cases, and that, too, under the watchful care of the most scrupulous and consci- entious assistants, directed by a person of such high medical ability.

Gordon, up to the time of changing his mode of treatment, lost one in two of his patients; and the younger Hey, of Leeds, had a success not so good as this, until after he had discovered the Gordonian theory of the treatment of puerperal fever. Hey lost eight out of ten.

My friend Dr. Rutter, informs me, that to one of the cases, he was summoned on the night of his return to the city, after an ab- sence from it of ten days, at a distance of thirty-five miles. Pre- vious to visiting the patient, he entered a warm bath, had his head shaved, put on a new wig, new hat, new boots, and pocket handker- chief, and every article of his dress was bought new for the occa- sion ; leaving at home even his watch and pencil, and taking. care, after the bath, not to touch a single article of the clothing he had previously worn. The patient whom he attended, was immediately seized with the symptoms of puerperal fever. I was called to see her along with him, and attended her up to the period of her death, which took place on the eleventh day after the birth of the child.

Two years later, in 1846, he resorted to the same precautionary means, before taking charge of the case, which being seized with the disease, likewise terminated fatally.

Eleven of the children born in the ninety-five births, died with erysipelas, commencing at the umbilicus, after the mother had succumbed to the malady; and four others perished in the same way, wdiile the mother recovered from the attack.

If the malady, which many of my brethren in this city, sup- posed to have been propagated by the gentleman in question, had really been transmitted through his person, how shall we account


PUERPERAL FEVER. 585

for its attacking those women whose labor terminated previous to his arrival ; or how shall we explain the exemption not only of many of his own patients, but of mine also, and those of other physicians called by him in consultation, from the influence of a contagion so direful. Would it not be more philosophical to say, that one of those strange fatalities that are often found to occur, had brought him into contact with the cases of women ill, whereas his neighbors, and fellow practitioners, more fortu- nate than he, met only with the ordinary phenomena accompany- ing the lying-in state.

Another gentleman, a friend of mine here, who, during the prevalence of the same epidemic, unfortunately met with nume- rous violent and fatal cases, was also supposed by many persons to have carried the poison about his person. On one occasion he invited me to see an individual laboring under the malady, in the district of Kensington. She was moribund at the time of my visit ; and while deploring the event, he pointed out to me a house at no great distance, in which he had, shortly before, lost a patient laboring under the same malady. He informed me that the per- son in question, whom he was accustomed to attend in her con- finements, had engaged him to be present at her expected ac- couchement ; but having been rendered anxious by the late sad events of his practice in the existing epidemic, and hearing nothing from her at the time proposed, he had called at her door to ask after her health. He was informed that she had been confined two days previously, but so suddenly, and with so little difficulty, that, they had not thought it necessary to notify him, or give him the trouble to call. He was told she was now indisposed, and invited to see her; whereupon he entered her chamber, and found that the case, one of puerperal fever, had gone beyond the curable stages. So that she was added to the catalogue of the victims of this walking pestilence. You see how unjust it is, in making up the list of fatalities in the doctor's practice in the epi- demic, to put down such a case as this among the victims of con- tagion.

Dr. Collins, at page 387 of " The Practical Treatise on Mid- wifery,^ informs us that in 1829, when he was Master of the Dublin Lying-in Hospital, puerperal fever, which, for several months previous had prevailed there, increased much in intensity. Upon consulting with the medical committee, it was recommended


586 PUERPERAL FEVER.

that no patient, except the absohitely destitute, be admitted ; but that assistance be afforded at their own homes. He then had all the wards, in rotation, filled with very condensed chlorine gas for forty-eight hours ; the windows and all openings being carefully closed. The floor and wood work were then covered with chloride of lime of the consistence of cream, left on forty-eight hours; after this, the wood work was painted, and the walls and ceiling washed with fresh lime. The blankets, &c., were scoured, and all stoved in a temperature of from 120° to 130°. From this time, until the termination of his Mastership, in November, 1833, that is, a period of fifty-seven months, he did not lose a single patient by the disease.

These facts are strongly calculated even to prove that the fever derived its origin from some local cause, and not from any- thing noxious in the atmosphere. To this. Dr. Collins says he should assent, was not the evidence equally strong of its existence in the houses of the rich.

The prize work, by the younger Baudelocque, entitled, " Traite de la Peritonite Puerperale,'*^ a work of the greatest value, contains at page 127 Dr. Baudelocque's observations of the subject of the contagiousness of the malady. He speaks of the difficulty of dis- criminating the epidemic from the contagious character of a dis- ease, which is as true of epidemic puerperal fever as of any other epidemic ; and thinks, in the present state of our knowledge, it is impossible to decide as to the contagiousness of our malady. But notwithstanding the sentiments of the English physicians, Joseph and John Clarke, he inclines to the opinion of the non-contagion- ists, and cites Mr. Duges, who states that he has never known a case in which an eleve-sage-Jemme, charged in the hospital with the cases of two women confined, had carried the disease from a sick to a healthy woman : nor, has he ever known the disease to be propagated from bed to bed in the ranges of wards appropriated to healthy women.

M. Baudelocque looks upon these facts as opposed to the doc- trine of contagion, yet as not settling the question ; and it would be presumptuous, he thinks, to affirm that there is no conta- giousness; and, disbelieving in contagion, he should hold himself bound to act in any case as if contagion were possible.

Dr. Robert Lee, at page 492 of his ^^ Lectures on the Theory and Practice of Midwifery,^ expresses the opinion that it is our


PUERPERAL FEVER. 587

duty to act, in all cases, as if the contagious nature of the disease had been completely demonstrated. You ought to read Dr. Lee's thirty-ninth lecture, beginning at page 487, which is an excellent examination of the causes of inflammation of the uterus and its appendages in puerperal women. I fear that the cases he has recited may tend to establish in your mind the doctrine of the contagiousness of the malady. Nothing has yet served to con- vince me that it is transmitted by a physician or nurse ; yet, not- withstanding such an opinion, I cannot wholly divest myself of a feeling of obligation to take the most especial care not to be the agent of its transmission, under the supposition that the contagion- ists possibly are right, and the non-contagionists possibly in error. It is an incontestable fact, whether the disease be contagious or not, that one midwifery practitioner is liable to meet with numer- ous cases in his practice, while his brethren, equally engaged in the same streets, villages, towns, or districts, — shall meet with no cases at all. This was remarkably the case in the epidemic at Aberdeen, the history of which is related by Alexander Gordon. Dr. Armstrong tells us, that forty out of fifty-three cases observed in Sunderland, occurred in the practice of one surgeon and his assistant.

Gordon looked upon it as contagious ; and he considered that every person who had been with a patient with puerperal fever, became imbued with an atmosphere of infection, which was com- municated to every pregnant woman who happened to come within its sphere. — Vide, page 51, of the Philadelphia Ed., 1842.

If you insist upon it, that the cases, like those of my friend Dr. Rutter, and those referred to by Dr. Armstrong, were com- municated by contagion, you will be compelled to say, that the constitution or the clothing of one individual has some peculiarity which enables him to carry the fomites wherever he goes; while those of another person, apparently in the same state of health, and with a similar dress, is wholly incapable of transmitting it. This is a fact, and I conceive it to be an unanswerable one. I have proved it in my own case, over and over again, since I have gone from the houses of persons laboring under the most malignant forms of the disease, and from participating in necroscopic exami- nations without carrying the malady with me.

If you should assert that a medical man may generate the fomites of our disease in his own constitution, without being


588 PUERPERAL FEVER.

at the same time subject to any manifest signs of the malady himself, you will arrive at a conclusion far more probable than that of the contagiousness of this, generally speaking, serous malady.

I find an insuperable objection to the admission of its conta- giousness in the serous character of the malady, since the conta- gious maladies are, all of them, either mucous or dermal affections: it is true, that some of the cases of gangrenous metritis that we meet with, atlect the mucous surface of the womb, if it hath one, w^hich is still a subject of dispute among authors. I am more in- clined then, to reject the doctrine of the contagiousness of these maladies; and to look upon the occurrences that have gone so far to establish, in some men's minds, the opinion of its personal trans- missibility, as to be explained upon the doctrine of accidents. It is a fact, that accidents happen in groups : very frequently rail- road accidents happen in groups ; numerous accidents at saw- mills happen in groups; accidents or murders from fire-arms occur in groups ; fractures of the limbs occur in groups, without any known connection between the number of individuals who suffer or the occasions which bring about the results.

From all the foregoing, you will perceive, my young friends, that I assert my disbelief in the contagiousness of the various forms of disease that are grouped together under the title of puer- peral or child-bed fever; and you will have noticed at the same time, that, notwithstanding my plenary assertion of this disbelief, I am not able to fly in the face of the assertions, and opinions, and sentiments, of many of my medical brethren, worthy of my highest respect; so that, in fact, I do not feel at liberty to disobey their injunctions, as to taking all proper precautions against pro- pagating by my person, a malady so fatal in its nature. And I therefore most explicitly declare, and I beg you to bear in mind that I make this declaration, that I think it will always be your duty, whether you may believe in the contagiousness or not, of a malady, to avoid, as far as it may be in your power, all occasion to transmit, if it can be transmitted, this epidemical or endemical disorder.

It has often been observed, that the cases of puerperal fever have been particularly rife at the same time that there has been a considerable prevalence of erysipelatous diseases ; and you will often hear in conversation, and you will observe sometimes


PUERPERAL FEVER. 589

in your reading, that there is some connection asserted to exist between the nature of erysipelas and that of puerperal fever ; and further, that there is an identity in the causes which produce them.

In the Lying-in wards of our Pennsylvania Hospital, where puerperal fever has been repeatedly prevalent, it has been noticed, that numerous individuals laboring under wounds, whether from accidents or from surgical operations, have at the same period of time been laboring under erysipelas ; and, it has become a sort of custom of the house, to fear the outbreak of puerperal fever in our lying-in wards, whenever a remarkable rifeness of erysipelatous action is observed in the Surgery. Nevertheless, it is absolutely true, that erysipelas frequently prevails in the Surgery when there is no puerperal fever among the women confined in the estab- lishment.

Erysipelas is a disease of the skin ; I have no doubt that erysi- pelas is always an inflammation of the capillaries of the skin — it is always an angeio-leucite ; and although it is occasionally found to descend into the tissues lying beneath the skin, converting itself into what is called oedematous erysipelas, and perpetrating the most direful mischief in the cellular and adipose structures there, it is essentially a dermal disease, and can only affect the dermal structure. You might as well say, that a woman has an iritis of her pylorus, which would be absolute nonsense, since no such tissue exists there, as to say, that she has an erysipelas of the serous lining of her belly. It might be perfectly true, that she has erysipelas of her vagina, or an erysipelas of the lining membrane of her womb, — if she has one — a question still sub judice, — because, a mucous tissue is nothing more or less than a true skin turned inwards. Mucous textures and dermal are con- vertible terms ; skin may be converted into mucous membrane, and mucous membrane may be converted into skin, in one in- stance by bathing it in fluids, in the other by exposing it to the drying influence of the atmosphere. You will find the proof of this in the cases of chronic prolapsus uteri, or inversion of the vagina, met with in practice.

There is not, and cannot be any identity between erysipelas, a dermal disease, and the deadly inflammation of the peritoneum observed in lying-in women ; notwithstanding there may be some coincidence in the causes which, in the first case, render surgical patients liable to erysipelas, or in the other, lying-in women to the attacks of child-bed fever.


590 PUERPERAL FEVER.

The fallacy in the case arises from this ; both erysipelas and peri- toneal and pleiiritic inflammation are membranous maladies; in general, not extending beneath the subcutaneous and sub-serous textures ; and people have supposed, because they are membra- nous maladies, and are liable to spread along the surface of mem- branes, that they are all erysipelatous. If you choose to say, gentlemen, that every disease that spreads far and wide over a membrane is erysipelatous, I have no objection to your calling it so. But, T beg you to observe, that, in that case the duty will devolve upon you, of furnishing some new theory of the patholo- gical lesions in our malady, which in some of the most deplorable instances exhibits no signs whatever of membranous disease, but proceeds to destroy the patient at once, by a process of spha- celation, or ramollissement of the newly delivered uterus, reducing it in the space of six-and-thirty, or eight-and-forty hours, to a condition of softness so complete, that a man's finger may be thrust through it as through a pudding.

You had better say, therefore, that the disease is not erysipe- latous, but that when erysipelas is epidemic, or endemical, the persons who are to be confined, ought to take special care of themselves, since any intemperies of the air giving a tendency to erysipelatous inflammation, exposes the accouche to attacks of puerperal inflammation. This is not less true of the prevalence of typhus, of small-pox, or other great epidemic maladies, whose domination is so universal, that they compel all manner of diseases and diseased propensities to come beneath their sway.

There formerly lived at Aberdeen, in Scotland, a gentleman by the name of Alexander Gordon, whose name I have already men- tioned in this letter, and who enjoyed an extensive practice there, and in the country round about, and was a man of distin- guished ability, probity, and consideration.

Dr. Gordon encountered an epidemic of puerperal fever, in and about Aberdeen, in the end of December, 1789, which continued to prevail epidemically in that region, until the month of Octo- ber, 1792. In this epidemic, he attended seventy-seven persons, of whom there died twenty-eight, according to his Table, which you will find at page 36 of his book, entitled A Treatise on the Epidemic Puerperal Fever of Aberdeen, &c.

"It prevailed," he says, "principally among the lower classes of women," and, on account of his public office, and his exten-


PUERPERAL FEVER. 591

sive practice of midwifery, most of the cases came under his care. The disease, at the time of its onset, was new and unknown at Aberdeen. Dr. Gordon was unacquainted with its real nature ; and out of the first twenty persons that he attended, from Decem- ber 1789, to October 1790, he lost eleven, more than one-half of the cases; because he treated those cases without energy, and without intelligence. Having been taught, by woful experience, the inadequacy of his method; and having enlightened his mind by the dissection of a few of the early victims, he adopted a more energetic practice, founded upon the substantial proofs of phlogistic action, revealed by the necroscopic inquiries.

Dr. Gordon's volume is a small, unobtrusive book, written with- out arrogance or pretension: it is a plain, round, unvarnished tale ; being a history of his concern with the epidemic ; and car- ries so convincing and truthful an air into every page and line, that I cannot imagine anything better fitted to impress the mind of the reader with the warm and intense convictions of the writer. Half a century has elapsed since it appeared, and it is always quoted, or referred to, in treatises on the same subject; and never loses its good and solid reputation. Every medical practitioner, whether accoucheur or not, ought to read it with care ; and I am almost ready to say, that its perusal is indispensable to a right understanding of the history, nature, and treatment of puerperal peritonitis, — not that I intend to declare that Dr. Gordon's obser- vations, whether therapeutical or necroscopical, were suflficient to make plain the whole nature of the malady ; but, that if a man take up the modern books only, there will be in his notions of the subject, a void, as to its literary history, and the history of its treatment, that no other book than Gordon's can fill.

Whatever critics may please to say of Dr. Gordon's perform- ance ; however wofully they may have erred in their theory and practice in our malady ; Gordon must ever be regarded asjhe re- former of our therapeutics in child-bed fever: nor can it be denied, that since his publication, there is universally diffused a more perfect and sensible conviction of the inflammatory character of the disorder, and, what is of far greater consequence, the little re- gard that need be paid to the state of the pulse, in making up one's mind as to the necessity of treating it boldly in its curative stages. I say this even in view of Tonnelle's celebrated papers.

Gordon had neither leisure nor privileges for making numerous


592 PUERPERAL FEVER.

or elaborate dissections; that task has been well fulfilled, emi- nently well, by Robert Lee, of London, in his Treatise on Puerpe- ral Fever and Crural Phlebitis, which you will find at the 21st page of Barrington and Haswell's edition, before cited. It has also been admirably performed by Tonnelle, and others. All the researches since his time, have but added strength to the patho- logical explanations, that are first to be sought for in Gordon's volume. The newer and more minute essays, which proceed so much farther than Gordon had gone, ought to be studied by every one of you ; for, I do not believe, that the writings of Hey, of the younger Baudelocque, of Armstrong, of Mackintosh and Lee, of Legouais, or Collins, combined together, could carry such a ■weight of conviction to the mind of the reader, as the perusal of them after the study of Gordon's would do. Gordon is the first of the series, and the others wait on him, and honor themselves by illustrating him and their subject, in confessing their obliga- tions to the practitioner of Aberdeen.

If it were in my power, gentlemen, to put into the hands of every member of the class, a copy of Barrington and Haswell's volume, I would not take the trouble to write this letter; for I believe, that a study of that volume alone — I don't say merely the reading of it, but a careful study and a conscientious examination of that volume alone — is enough for a man's education on the subject of child-bed fever, whether sporadic or epidemic.

The pregnant woman approaching the time of utero-gestation, may be supposed, in general, to undergo many modifications as to the crasis of her blood, and to suffer no inconsiderable changes in regard to the recrementitial absorptions of her body, since the pressure, intrusion, and distension of important textures, all com- bined, cannot fail signally to interfere at many points, with the innervative, assimilative, secretory, and absorbing functions. I think it would not be extravagant to say, that few women march up to the termination of pregnancy, without falling into a state, deserving to be called pathological. When the child has been born, — often after the most cruel suflferings and the most protracted exertion ; amidst the most convulsive efforts of the will ; amidst doubt, anxiety and fear, — the uterus, returning upon itself, has- tens to recover its non-gravid form and dimensions, leaving the constitution under the necessity of disposing of the surplus fluids and solid parts, which the pregnancy had called into existence.


PUERPERAL FEVER. 593

Tissues have been pressed together, subjected to contusions, and often to slight and unsuspected fractures, or lacerations ; the pla- cental orifices of the uterine sinuses are left bleeding and recover- ing; so that thousands and thousands of provocations to sanguine engorgements and acute inflammations, always exist as to them. You will find a picture strongly drawn at the 475th page of ^^ Archives Generales,^^ t. 22, 1830, by Tonnelle, in which it is made manifest that gestation and parturition produce in the con- stitution eflTects not very dissimilar from those produced by the causes of typhus fever.

It is justly to be regarded as a matter of wonder, that so many thousands of women escape unharmed the operation of these un- favorable influences; nor should we be surprised when we meet with persons, in whom violent disease has been developed by the operation of such causes. In particular, ought w^e to feel no as- tonishment, if an aerial cause, having the potency of an epidemic principle, come to add its force to the personal ones just enume- rated.

We ought, then, to regard a newly-delivered woman as by no means freed from the perils of child-birth, because her child has just been born. In fact, so few women die in labor, or in conse- quence of direct injury done to the economy in labor, that it might almost be said, to be not at all dangerous to go through that pro- cess. The child-bed mortality is a post-parturient mortality, con- sisting mainly in the results of inflammatory action attacking the reproductive tissues, and the parts directly connected with them. A woman will now and then be found to perish from inflammation of the lungs ; from a cerebritis ; from an attack of diarrhoea ; from a bilious, or typhus fever, or some chronic ailment of the intesti- nal tube, forced into destructive activity by the parturient circum- stances ; and yet it is almost true to say, that wdien a woman dies within some eight or ten days after delivery, she has perished with puerperal fever, since so few of them are known to perish from other causes.

There is sufficient evidence of the fact, that occult causes, whether atmospheric or local, are capable of so impressing the human economy as to give it a tendency, when affected by mor- bific powers, to exhibit the eflTects of such forces, under taxic on the one hand, and on the other under ataxic forms. Thus, for a 38


594 PUERPERAL FEVER.

series of years, the lancet, and the most powerful antiphlogistic methods are generally adopted by the profession; whereas, another series shall succeed, during which such methods come to be pro- scribed, and generally, at last, abandoned by our people. If, then, puerperal fever be a true inflammation, that inflammation may be a very different sort of malady, when occurring in a con- stitution prone to ataxic forms of disease, from the same inflam- mation attacking an individual in a highly phlogistic and reactive condition of life. — The local disorders always take their tenden- cies from the state of the whole nerve force; and an inflammation of the womb, or of the peritoneum, may be either in the highest degree vigorous, or to the last degree typhous in its nature. The inflammation, however, always remains essentially the same malady, when regarded as local — the constitutional disturbances flowing out of it are widely different, in the two opposite, or taxic and ataxic formulae.

All the necroscopic examinations concur to show, that puer- peral fever is a febrile disease developed in the system from cer- tain points of local inflammation'of the reproductive organs. A puerperal fever that proves fatal, and leaves no trace of inflam- mation demonstrable by the necroscopic inquiry, ceases from that moment to have, in my opinion, the value of puerperal fever ; it is something else. ' I do not mean to say, that if you examine the body of a female who has died, as you suppose, of puerperal fever, and find no gangrene or softening of the uterus, no inflam- mation or deposits within the belly, you are, therefore, to sup- pose that you have been mistaken in your diagnostic ; you will find in the pathological records, abundance of examples of the" absence of these traces. But, these very cases, being those of persons who have perished with all the constant signs of our malady, are cases of endangial disease aflfecting the vessels of the uterus and parts in its vicinity: endangial disease, running early to the extent of pus production, or to the pyogenic extent, may rapidly destroy the patient from purulent infection of the whole mass of the blood. I have no doubt, that some of M. Tonnelle's cases were of this very kind.

The attack of puerperal fever generally begins previous to the fourth day after delivery of the child ; not a few examples are re- corded, in which it began previous to the labor. I have seen such a case myself. For the most part, the dangerous day is the third


PUERPERAL FEVER. 595

day, for that is the period at which the new fluxional movement towards the mammary glands begins to take place. If the occa- sional causes of the disease have been in action, this fluxional movement, itself alone, might become sufficient to act as the exciting cause; laying the foundation, perhaps, in a few moments of active operation, of an inflammation that shall spread with frightful rapidity throughout the most important textures.

It rarely happens that an attack of puerperal fever comes on, in the absence of the physician, without its being mistaken for an after-pain; and, in fact, the pain at the commencement is accom- panied with alternations of increased and lessening distress, which is likely to mislead in the diagnostic.

If the irritation is intense at the commencement, its constitu- tional influence is manifested by rigors, that may be dimply mode- rate rigors, or that may rise to the height of the most violent ague-fit. The chill may last twenty minutes, or two hours, or more, and is followed by febrile reaction more or less open and free, according as the powers of the nervous system' shall be able to direct a greater or less energy upon the sources of the circu- lation. The chill of puerperal fever is found, in some instances, to precede the attack of pain, from which you are not to conclude that the chill is the cause of the attack, because, it is certainly true, that the sensitive cords of a part attacked, are not always capable of transmitting to the sensorium, evidences of the distress of the organs to which they are distributed. The disorder, the irritation, the maladive condition, may, nevertheless, be capable of compelling those reflex actions of the nervous system, that are required to produce rigor, chill, or even ague.

A woman who is to be attacked with puerperal fever, is a woman in health, — or rather in a state of quasi health; she has not small-pox, nor. Syrian plague, nor yellow fever, though she may have a proneness to fall ill with what you call child-bed fever. If you fire a bullet through her womb, or tear it, or con- tuse it with a pair of forceps or a sharp crotchet, and she die of the inflammation resulting from the accident, she will die of puer- peral fever. And so, if from the intense irritation endured by the organ under after-pains; if from the impetuous momentum of torrents of blood determined upon its tissue during a rigor or an ague consequent upon swallowing a tumbler of iced water, or of getting out of bed while in a state of perspiration ; or of the intem-


596 PUERPERAL FEVER.

pestive action of a drastic purgative dose ; or if, from whatsoever cause, the blood-vessel system of the uterus becomes the seat of a local inflammation, that inflammation will determine in her the onset of child-bed fever, which you will denominate uterine phle- bitis, metro-peritonitis, ovaritis, simple peritonitis, or inflammation of the lymphatics of the uterus, according as the phenomena clearly made manifest during the life of the patient, or upon ex- amination after death, shall determine you to call it. Don't you see, my dear friends, how impossible it is for me, after writing the above paragraph, to admit the possibility of a specific con- tagion as the cause of this malady; a contagion, which, if it do exist, must, in a thousand instances, act without the intervention of the shortest imaginable incubative stage.

Sometimes the pain, which is, at the onset of puerperal fever, felt in the hypogastric region, is too intense to be borne by any human patience ; and no exhortation or recommendation, can prevent the woman from crying out aloud, or even screaming with her agony. I have seen patients, who not only appeared to suffer intolerable pain, but in whose minds that pain appeared to excite the most unspeakable terror. I think I have seen women who appeared to be awe-struck with the dreadful force of their distress, as you might imagine an ancient Roman matron to be, who might suppose such a pain to be inflicted by an ictus Jovis, the anger of the Gods. The pain, however, soon loses a portion of its inten- sity, and no doubt much of the earliest and sharpest pain is neu- ralgic, since it is not in the nature of pure inflammation to occa- sion such great sufferings.

The paroxysmal character of the disease, in metritis, must be deemed to be occasioned by a convulsive or spasmodic constriction of the inflamed tissues, under the irregular activity of the muscu- lar fibres of the organ, which soon ceases, allowing the pain to become more settled, steady, and bearable.

If there be a chill, there will be found, as in all chills, in- creased frequency of the heart's action ; the systole comes in a very short time, to be repeated, at the rate of 120 or even 160 beats per minute. This is necessarily accompanied with congenerous modification of the action of the respiratory muscles, and there is no part of the whole economy of the creature, throughout which the blood is not driven with an impetuous haste and force. But the brain cannot receive such modified


PUERPERAL FEVER. 597

injections of the blood, and of the oxygen of the blood, upon which depends its power to evolve neurosity, without irradiating its nerve power morbidly to every part and parcel of the tissues, of which she is composed. So that you see, gentlemen, there is no occasion to be surprised or astonished, when, after having left your patient at ten o'clock in the evening, comfortable, and ap- parently without any untoward symptom or accident, you find her, at six in the morning, a prey to the most unspeakable dis- orders of the innervation, the respiration, and the circulation.

The foregoing is sufficient to set forth my opinion as to the nature and beginning of the attack of child-bed fever. To show you what may be the organs involved in the ravages of a disease thus commencing, I shall cite for you some passages from Ton- nelle's paper, op. citat., page 482.

This author, in the great epidemic which he witnessed at the Maternite in Paris, when he acted as resident student there, under the guidance of the great Prof. Desormeaux, had the extraordi- nary opportunity, but still more wonderful industry, to dissect the bodies of two hundred and twenty-four women who died under his care; — more than perished at Contreras, Churubusco, or Chapultepec. He gives the following tables showing the tis- sues affected : - » 193 gave peritonitis. 197 gave disease, apparently of the womb.

4 represents the excess of the uterine cases over the cases of peritonitis. Table of one hundred and ninety cases, which gave — 79 of simple peritonitis.

29 of superficial ramollissement of the womb. 20 of deep-seated ramollissement of the womb. 58 of inflammation of the ovaries. 4 of inflammation of the ovaries, with abscess. Table, showing that

90 cases gave pus in the veins. 32 " gave pus in the lymphatics. 3 " gave pus in the thoracic duct. 9 " gave inflammation and suppuration of the lum- bar, inguinal, and other glands. The whole epidemic was characterized by three formulas of puerperal fever, as follows: —


598 " PUERPERAL FEVER.

Inflammatory, or simple infiam- C The peritoneum, the womb, and its mation of different organs. \ appendages.

rr 1 ■ -i r c 1. Consecutive suppuration of the veins ;

Typhoid form, or irom altera- I ' ^ '

1 tions of the blood. i °'"' accompanying putrescence or ramol-

I lissemeiit.

Ataxic form, or lesions of the innervation.

Now, this is sufficient to set forth in a clear manner, as far as it goes, the doctrines you ought to adopt as to the pathological seats of our disease; and let us therefore proceed to trace the effects of it.

Let us suppose that it is one of the peritoneal cases; a case in which the peritoneal surface of the womb, of one or both of the broad ligaments, or of an ovarium, is the radiant point, the first red specked point of inflammation. Suppose the inflammation to extend upon the intestines, to attack the meso-rectum, the peri- toneum covering the iliacus internus, the mesentery, the whole peritoneal coat of the smaller intestines and the omentum, — the mesocolon and the colon — the stomach, the peritoneal coat of the liver, and the entire lining of the diaphragm, as well as of the kidneys and spleen ; and then you will have an idea of a woman laboring in the lying-in state under a universal peritoneal inflam- mation.

Consider, now, that she has passed through the whole of the evolutions of a nine months' gestation ; through the convulsion, intellectual, physical and moral — of the conflict of labor ; and, to a certain extent, through the mutations of her constitution conse- quent upon delivery; her blood deranged as to- its crasis; her neurine exhausted by protracted exertion of its functional power, and her whole endangium in a condition in which it is highly prone to take on, if it have not already fallen into a pathological state.

What is the condition of your patient.-* Has she not hepatitis.' Has she not a pure hepatitis, whose whole peritoneal surface of the liver, is inflamed. If the whole outer superficies of your stomach is in a state of incandescent inflammation, have you not a gastritis } But suppose her mesocolon, her mesentery, her meso-rectum, her ligaraenta lata all burning, like a prairie on fire; are not all these parts in a state of inflammation. And if they be, what wonder have you to find her whole nervous system shocked, overwhelmed, staggering, as under a concussion, and


PUERPERAL FEVER. 599

crushed to death by a load of diseased perceptions and vascular and textural obstructions impossible to be borne?

This is a picture, not at all exaggerated, of some of the forms of puerperal fever. An individual is very tenacious of life, who fails to succumb under the earlier stages of the maladive progress of the inflammation. There are multitudes who die before it can come to such a pass; but it must come to such a pass in many of those whose peritoneal cavity is found to contain pints or quarts of serum, in which float masses of coagulated albumen, while the uterus and intestines and peritoneal surfaces, are tied to- gether by a complete magma of coagulable lymph, beneath which are to be found softening of the tissues, and other results of the most intense inflammatory action. Inflammation is mflam- mation; it is not weakness or debility; it is development force, violently exaggerated in the tissue which is the subject of that force.

I pray you, young gentlemen, do me the favor to turn back to Letter 21st, and you will find on the 267th page, my quotation of several paragraphs from M. Serres' '■^Anatomie Transcendente.' If you mean to read my letter on puerperal fever, I am very de- sirous that you should appreciate my meaning and intent, and the reading of JV'J. Serres' extract will be a good preparation therefor. It will show you that the products of inflammation are the products of a force, acting in progression, and not in retreat, and that inflammation is the result of an increased action of the development force, tearing or bursting to pieces the organs in Avhich it revels.

Let us take another case ; let us suppose a case, in which the endangial membrane of the uterine veins begins to be inflamed at their orifices, which are patent upon the now denuded placental surface, and, progressing rapidly along the membrane, involves the whole vascular system of the uterine sinuses and veins in its embrace.

Look at it now. Can't you see it with the eye of faith? What is faith ? The Bible tells you that faith is the evidence of things not seen. Have you not that evidence? Look at Tonnelle's paper, oj'). citat., page 483.

His table is as follows: — In ninety autopsies

32 had suppuration of the veins, with purulent degenera- tion of the uterus.


600 PUERPERAL FEVER.

11 had ramollescence or putrescence of the womb. 5 had metritis and ramollescence combined. 34 had peritonitis without other alteration. 8 had suppuration alone.

Here is the evidence, which your faith ought to see, of the state of suppuration of the veins, — a result of inflammation of the en- dangial tissues. Thirt3'-two out of ninety cases.

Look at it again. Don't you see two vast uterine arteries, coming off from the internal iliac or the ischiadic ? And don't you see, also, two powerful branches, which we call the spermatic, the sum of whose transverse areas or lights is a vast sum, through which is pouring, under the convulsive and disordered action of the systole, a torrent of blood to fill up the capillary circulation of the uterus, and which shall find no other way of escaping out of the wermb, than through the thickened, swollen, obstructed, and often totally obliterated tubes, of which I spoke ?

If you would read M. Raciborski's admirable Treatise on the Veins, you would learn from it that a vein, when it enters a vis- cus, leaves all its accessory coats at the entrance, and carries with it nothing but its endangium, or what Bichat calls its membrane commune. If this be the case in the vein-distribution within the womb, then you cannot doubt that uterine phlebitis will always be coincident with metritis — that is, with inflammation of some part of the substance of the uterine texture.

Look again — with your eye of faith — I say, and inquire how the volumes and torrents of blood that are becoming more and more packed and jammed into the capillary body of the organ are to flow off and let the organ recover by Mr. John Hiinter.'s process of resolution. Suppose it cannot flow off as fast as it arrives — will not the womb die? — will not the inflammation reach that height and intenseness, that must, as Dr. Physick used to tell us, trans- cend the power of recovery, and must therefore end in the de- struction or disorganization of the tissue! It will be destroyed, it will be disorganized — it will perish by gangrene, or by ramol- lissement, which virtually is the same thing, expressed in different words. The womb will die, and the woman will die in conse- quence; for she cannot continue to live, while her nervous system suffers the shock or the irritation attending upon such an intolera- ble organic perception as that. She will die, and it will not un- frequently happen that she shall die within thirty-six or forty-eight


PUERPERAL FEVER. 601

hours from the onset of the malady. She may die with this very malady alone; and when you come to explore the pathological lesions, you will find, perhaps, as in the ninety cases reported by Tonnelle, that eight of them exhibit no complication or extension of diseased action.

You- must cure these diseases: they are to be cured, however, promptly, or not at all. Such a malady as this hurries with hot and furious haste to the term, beyond which there is not, and can- not be any useful Therapia.

But it is time, gentlemen, to return to the consideration of some of the phenomena that accompany the malady when it is compli- cated with, or consists solely of peritoneal inflammation. The disorder attacks, in general, before the end of the fourth day. The womb remains, up to that period, very large; its fundus jutting far above the plane of the superior strait. Upon each side of the organ rests a psoas muscle, which overhangs, by its inner margin, the side of the brim of the pelvis. When this muscle is con- tracted, which is always done in the act of drawing up the knees, the belly of the muscle swells, and presses upon the side of the W'Omb; the pressure gives pain, and the woman knows it. She therefore dislikes to draw up the knees often, for fear of the hurt. When once drawn up, however, by the contractile effort of the psoas, the foot rests planted on the bed, and the psoas relaxes — so that it hurts her less when drawn up, than when extended. She soon instinctively draws up her knees, therefore, and keeps them up.

When you go into a lying-in chamber, and find the patient in this attitude, you ought to inquire why she prefers it. She may prefer it because the uterus is less compressed by the psoas; and also, because the peritoneal covering of the psoae being inflamed, is relaxed by the relaxation of the muscles.

For many years past, I have perhaps never called upon one of my accouchees within four or five days after the delivery, without asking her to show me whether she could draw up her knees without pain. If she can do so, I am always content.

The iliacus internus muscle that lies upon the fossa or venter of the ilium, gives pain if contracted, when the peritoneum that invests it is inflamed. Hence I cause my patient to rotate the lower extremity, in order to inquire whether the action of the


602 PUERPERAL FEVER.

muscle produces pain, and, if it does not, I cannot deem it co- vered by an inflamed peritoneum.

In all cases of a suspicious character, you ought to direct the monthly nurse to remove the binder for you, and then, covering the patient's abdomen only with the chemise, give you an oppor- tunity to make a careful exploratory palpation of the belly. By means of palpation and of percussion, you may come with great certainty and confidence, also, to a firm conclusion that the pain is, or is not, peritoneal or metritic, or ovaric.

You cannot make any useful researches, if one or two petti- coats, and other garments be interposed between the hand and the belly.

It is very difficult sometimes to say clearly that it is inflamma- tion, and not after-pain; or that it is, or is not rheumatism, or neuralgia, or colic.

Suppose the peritonitis to seize on the serous coat of the large and small intestines! Tympanites will commence very soon after the invasion. The muscles of the bowels are found torpified. and refraining, under a sort of teleological sense, to act, while their peritoneal investment is inflamed. The gases that are now extri- cated in great volumes from the ingesta, fill up and distend the alimentary tube, and the abdomen becomes as large as previous to the labor. This is tympanites.

I saw a case, and more than one, in which it became inflated in the course of a very few hours after the attacking chill had come on — and becoming hard and resisting, though highly sonor- ous on percussion, refused to yield to any kind of aperient or pur- gative means, as completely as if the peristaltic muscles were in perfect paralysis — the patient perishing within thirty-six hours.

Pray, my young friends, do not allow this ballooning of the belly to become too great, under some idle fear of the eflfect of purgatives. A patient often more urgently requires to purge off the intestinal gases, than the bilious or acid saburra that plague her. Whoever objects to the use of purgative doses upon some hypothesis of their being injurious in puerperal fever, must be a person of little reflection and less judgment.

An extreme degree of tympany implies an extreme inflation of large portions of the intestinal tractus, in which case the coats of the bowel become stretched like a drum-head, and are, under per- cussion, as sonorous as a tambourine.


PUERPERAL FEVER. 603

Reflect for a moment on the effects of such distension upon the play of several important functions. For example : reflect upon the capillary circulation in the intestinal textures while stretched to bursting. — Can there be a resolution obtained without previous detente of the bowel? Again. — Here is a great mass of inflamed intestines, and other organs that fill up and enormously distend the belly — they even thrust the diaphragm upwards as they push the abdominal muscles and tegumentary tissues outwards to the size of the gravid abdomen at term, and even farther than that.

Can the diaphragm descend in the aspiration, without crushing downwards before it this inflamed and highly sensitive mass? No ! Every breath gives pain — to make a long aspiration is impossi- ble; and to cough or to sneeze is to be agonized. The diaphragm works with short strokes, then; the respiratory piston descends only half-way down the cylinder of the trunk, and works like a steam piston cut off at half-stroke. In the meantime the oxygen is indispensable — and if a certain quantity cannot be supplied by the half-stroke, that stroke must be repeated twice, or thrice for once. Here, then, we have a new source of disorders in the re- doubled and trebled frequency of the respiratory acts. So much oxygen — or death — that is the alternative ; and, if the breathings must be repeated at half-strokes, or at quarter-strokes, at the rate of sixty respirations per minute, the medulla oblongata must furnish the biotic material. What an exhausting operation ! Here, then, you get the hurried, singultiform, staccato respiration of your puer- peral fever cases.

When this respiratory difficulty rises to a certain height — and the nervous supply grows feebler and feebler from the exhaustion of the neurine — the blood commences to be less perfectly decar- bonized, or less completely oxygenated. The oxygeniferous streams, in the brain, are changed for carboniferous streams, and, pari passu, with their increase the innervations lessen; they cease; and the life is fled at the moment of that cessation. Such are the evils arising from the tympany of child-bed fever. All the medicines that excite the peristaltic muscles of the bowels, to ex- pel this gas, are purgatives or laxatives. Is it true, tlRn, that purgative medicines are contra-indicated in our malady ? — What stupid misapprehension to say so! Is it not easy to perceive, that one of the most inconvenient and dangerous of the accidents that can happen to a female attacked with puerperal peritonitis,


604 PUERPERAL FEVER.

is this very inflation of the alimentary tube ; and that the means of obviating it, are among the most important that can be sought for as securities for the cure of the essential malady — I mean the actual inflammation?

We shall now, if you please, advert to the state of the heart in puerperal fever.

" The nervous filaments that animate the heart, come from the pneumogastric and the great sympathetic." These words I have cited from Longet's Anatomie et Physiologie du Systhne JYerveux, §'c., torn. ii. page 526. I do not ask you, however, to adopt any other opinion as to the source of the heart's motion than this, viz., that it depends upon the neurosity determined into it, or generated within it — and that this same neurosity is the result of the existence and combination of oxygen and neurine. I have no doubt, in my own mind, as to the power of the pnuemo- gastric and the sympathetic to modify, and, to a certain extent, co-ordinate the movements of the several parts of the heart. I am not at all surprised, then, to find that, when the organic and intellectual perceptivity of the woman are brought to feel the impressions made by an inflammation, whether metritis or metro- peritonitis, the reflex power of the nervous centres directed upon the heart, should rapidly and greatly augment its rate of action. A thought, a sentiment, a shock, can set the heart off at full speed. The profound impression of a great viscus in danger, can equally excite its forces.

The heart, then, in puerperal fever, beats with redoubled fre- quency, and we expect to find the pulses at the wrist rise to 120, or even 150 beats per minute.

Along with this great acceleration of the circulation, there will be a coincident great extrication of animal heat, and a coincident mischief to the constitution of the blood, whose normal rate of movement is expressed by a radial pulse of a certain volume, beating only seventy times a minute. See what great disorders are introduced into the actions of the economy — see w-hat you ought to do for your patient ! You ought to keep down the frequency of the fulse, in order to lessen the call on the sources of the heart's motion at the origin of the vagus, and in the sympathetic arches. You ought to lessen the evolution of animal heat, by lessening the intensity of the respiration and circulation. In short, you should look on all the phenomena exhibited by the


PUERPERAL FEVER. 605

constitution as the signs and results of a topical lesion — videl. the metritic, or the metro-peritonitic lesion — and you should use all the means within your competency to guard the constitution against the irritating and disordering influences of that metritis, phlebitis, or peritonitis. I am far from denying that a status of the constitution, a status, ante fehrem, may rule and modify the march of the malady ; it would be as unreasonable to deny it, as it w^ould be to deny that one individual is weak, and another strong — one prone to violent, and another to mere passive or ataxic forms of disease. But I contend that the disease is one and the same, everywhere, always; sporadic or endemial ; in pri- vate practice, or in the hospital clinic. It is essentially inflam- mation, and though not always to be approached by the same precise remedies, yet always on the same principles.

As to the mode of treatment for our disease, it is clear that your intentions of cure must flow out of your views of the whole of the phenomena, seen in the light in which they may be presented to your minds at the bed side. If you imbibe the idea that they de- pend upon a typhous attitude of the constitution, you will scarcely fail to treat it as typhus. M. Tonnelle remarks upon the fact that almost every observer selects and advocates a method; one of his own, to the exclusion of all others; one proclaiming the success of general bleeding — another of topical blood-letting; one -of mercurials, and another of ipecacuanha, or of purgatives. It seems to me that all this uncertainty arises from the imperfect etiology of the case as deemed of by the proneurs of each particular practical mode.

I have myself been condemned in some of the foreign journals as extremely sanguinary, as it is called, in my sentiments as to the treatment of the cases; and if by sanguinary is meant, that I look upon venesection as the remedy, I am willing so to be held. But let us proceed now, my friends, to inquire calmly and dispas- sionately, if we can, into the claims of the different methods of cure. Let us try to divest ourselves of all feelings like party feelings in the case, and investigate the subject wdth a heart-felt desire to discover the truth, that we may enjoy the benefits of the truth in going about doing good in our vocation. For ray own part, I hope that there is in me no wish to cause any particular theory to flourish, since, whether it flourish or fall, I am not inte- rested, as I am no founder of systems, but rather a mere humble


606 PUERPERAL FEVER.

imitator and grateful admirer of those good writers who have taught me my art, and to whom I, like you, am but a Pupil and Student of Medicine.

In a former part of this letter, I said that I considered Alex- ander Gordon, of Aberdeen, as the real reformer of our therapy in child-bed fever; let us now inquire further as to his claims to be considered so.

If I should retrace the history of our disease, I should write a whole volume, and not a letter. I cannot, therefore, entertain you with a retrospective review of child-bed fever.

It is enough to know that it was, before Gordon's time, exces- sively mortal — and is so still, where his book is not read or felt. Dr. William Hunter lost thirty-one out of thirty-two cases of it. In Paris there was an epidemic, in 1750, which killed every patient. Denman, Leake, and others, were afraid to treat it as it required to be treated; and Gordon, a man of sense, says that the " disease, when left to nature or improperly treated, generally proves fatal."

I have already said, that Gordon lost nineteen out of thirty- eight of the first cases that he encountered in his epidemic. It was the thirty-eighth case that afforded him the materials for dis- section, and he makes, at the end of the account of the case, the following remarks, after having given a statement of the inflam- matory results disclosed in the autopsy. "If," says he, "either the quantity of the blood taken away at the two bleedings, had been taken away at the first bleeding, or the purging been con- tinued, which was exchanged for sweating, I am thoroughly con- vinced that we should have been able completely to overcome the disease. This was the opinion which I formed from the dis- section, and its truth was confirmed by my success in all the succeeding cases to which I was called. Thus the loss of this patient, was the means of saving many others." He subse- quently attended thirty-nine cases of the disease, of which he lost only ten, and saved twenty-nine; so that, of his whole epi- demic, forty-nine patients recovered and twenty-eight died.

Dr. Gordon, at page 47, says : " Of those of these patients who got wine and cordials, under the idea that the disease was putrid, none recovered," which he considered as evidence that the puerperal fever is an inflammation. He admits that it fre- quently puts on a putrid appearance in its progress, which he


PUERPERAL FEVER. 607

most judiciously explains as the effect of the uncured, violent in- flammation; and he asserts, that when the disease is properly treated at the commencement of the inflammatory stage, no symp- toms of putridity appear.

I shall omit any notice of the intervening chapters, and refer you to his sixth chapter, on the cure of the malady. At the 55th page, you will find these words: "When I took away only ten or twelve ounces of blood from my patient, she always died ; but when I had courage to take away twenty or twenty-four ounces at one bleeding, in the beginning of the disease, she never failed to re- cover." He insists upon it, that the practitioner should never take away less than twenty or twenty -four ounces at one bleeding; and that, otherwise, he will fail in curing the patient. At page 56 it appears he had felt the prejudice against bleeding in full force, for he lost every patient from whom he took not more than twelve, fourteen, or even sixteen ounces. Please to understand that Dr. Gordon says, " This abstraction of blood must be made within six or eight hours after the attack, or it will fail;" and adds that he declined using the lancet at a later period, because he knew that it would fail, and he would not bring the remedy into discredit.

Let me cite for you from the 60th page ; which contains the summary of his precepts as to venesection, and although the period at which he would still bleed, is fixed rather later after the attack, I am disposed to take it as the last complete result of all his ex- perience. It is as follows:

"After much experience in the disease, and after mature de- liberation concerning the conduct which ought to be pursued in any peculiar situation, I came to the following resolution: If called to a case within twelve hours after the attack, I insisted on bleeding the patient, and promised for its success ; but, if at a later period, viz., from twelve to twenty-four hours after the attack, in this case, like Sydenham with the same remedy in small-pox, I thought it incumbent on me to propose it as the only effectual remedy; but I neither insisted upon it, nor promised for its success."

Mr. William Hey, practitioner at Leeds, who was a man of talent and candor, encountered puerperal fever in 1809-12, gives us the account of thirty of his cases. The disease was first seen by him December 9th, 1809, and, up to the time of his ninth case, in June 1810, Mr. Hey had not seen Gordon's treatise. His


608


PUERPERAL FEVER.


attention now being called to Gordon's doctrines, he adopted the author's recommendations, and went through the remainder of the epidemic wuth the most brilliant and happy success. You will find the same true of Dr. Armstrong's practice in the Sunderland epidemic, and of the fine practice of Robert Lee of London.

Hey does not inform us how many cases he had during the whole prevalence of the epidemic. He merely says, a great num- ber of them came under his observation. Of the thirty cases pub- lished in detail, the following is a tabular view of the dates, the


Case


1,


1819


December 9,


No


IOC, aiiu iiic It

vs.


. died.


2,


((


no date,


a


il



3,


i(


December 27,


li


li



4,


a


no date,


a


ii



5,


1810,


January 20,


a


li



6,


i(


" 26,


li


11



7,


((


February, 5,


ii


11



8,


a


7,


a


li


recovered


9,


a


June 18,


li


li


. died.


10,


li


July 9,


a


li


. cured.


Here, then, is a table showing, that of ten cases from December 9, 1809, to July 19, 1810, in which two recovered, and eight died, only the last, or No. 10, was really bled ; since the other, No. 9, was bled but seven ounces twice, and three ounces at other times, which had no efTect on the disease,

Mr. Hey having fearfully and timidly bled his patient No. 9, and having at that time, January 18th, six months after the break- ing out of the disease, become acquainted with Gordon's writ- ings, followed his rule in case ten, which was promptly cured — and which gave a fortunate turn to the direction of his views.— After stating the first acquaintance he got with Gordon's work, which opened his eyes to the truth, (see page 107, op. cifat.,) he uses these words at page 111. "The next case that occurred was the first of three, which were all that proved unsuccessful in my practice, out of a great number, — after the change of treat- ment adopted in the preceding case, (No. 10,) and I hope we shall be able to show that the method of cure we now employ, had not a fair trial in any of them ; and consequently, that they can- not be justly considered as instances of its failure." It is to be regretted that we do not know how many cases he had subse-


PUERPERAL FEVER. 609

quent to July 30, 1810; — he says, " a great number;" and you perceive, by his own showing, that the first examples under his care were very fatal, being eight out of ten.

There is an admirable paper, entitled Reflexions et Observations sur Pemploi des Saignees et des Purgatifs, dans le Traitement de la Peritonite Puerperale, by Legouais.

Dr. Legouais w^as resident physician at the Maternite, at Paris, where he had large opportunities of studying the malady in ques- tion. At page 21, he insists, like Gordon, upon one of the conditions of success in the use of blood-letting, which is, that the evacuation must be effectual — in an abundance suitable to the gravity and extent of the inflammation. " Experience," he says, at page 22, " has confirmed me in the belief, that blood-letting is never truly useful, except when it is able to destroy the malady at a blow, and blot it out — so to speak — at its very origin." It ap- peared to him that this is the very case to apply the *' jugulare febrira," so celebrated as a mot of Galen. He says that it is like the fabled Hydra, which cannot be conquered but by cut- ting off all the heads at one blow ; if a single one be left, it has suflfiicient vital force speedily to reproduce the monster, in a form more terrible than before.

But I am in danger of making out of this single letter, a whole book, and perhaps of expressing myself with the warmth of a parti- san, which I sincerely desire to avoid, I ought, therefore, to make no more citations; not even from the prize essay of the younger Baudelocque, in favor of the use of the lancet in the treatment of our malady ; nor from Mackintosh ; — nor from West ; — nor from David D. Davis ; — nor from Denman himself, after he had re- covered his senses upon the subject. But you must excuse me if I advert to the reports of cases under that distinguished author, Dr. Robert Collins, of Dublin. I should think that no work upon midwifery, that has appeared since the beginning of the present century, has acquired greater reputation for its author than the " Practical Treatise on Midwifery,' &c., by Dr. Robert Collins. It is certainly one of the most important contributions that has been recently made to the Obstetric art and science; and it contains the statistical results, most ably set forth, of 16,414 births, under his direction, at the great Lying-in hospital of the Irish metropolis.

I am sure, gentlemen, that no person interested in the advance- 39


610 PUERPERAL FEVER.

ment of our particular department of Medicine and Surgery, who reads that book, can fail to acknowledge its very great merit. I feel, nevertheless, that I have a just right to examine, and even disapprove, of certain parts of the treatise — not without the pro- foundest sense of my obligations to the author for much most use- ful information he has communicated.

If you will turn to Dr. Collins, (page 396,) you will find the following:

" The result of my observations upon the treatment of puerpe- ral fever, is, that general bleeding, except where there is a strong, full pulse, and the symptoms are of a highly inflammatory cha- racter, is injurious," &c. — The author prefers leeching, followed by the warm bath, stuping, calomel and ipecacuanha with opium, mercurial frictions, &c.

Dr. Collins asserts, very broadly, that his experience teaches him the above rule, or principles of action.

I beg you, however, to observe how this opinion is founded.

There occurred, under his administration of the house, eighty- eight cases; of which fifty-six died, and thirty-two recovered.

  • ' In fifteen only of the eighty-eight, did we deem it advisable to

bleed generally ; seven of the fifteen recovered." In the whole of the epidemic, therefore, ^^/eew were hled^ and seventy-three were not bled. Fifty-six died — of whom only eight were bled, and forty-eight that were not bled. Does not the question here arise: Why did forty-eight persons die who were not bled, while only eight perished that had been subjected to the treatment of Gordon? Is the inference a just one, that the eight died because they were bled, while forty-eight died because they were not bled?

If you will read Dr. Collins' article, you will find that he leeched his patients very freely, and thus bled them from the skin, while he did not approve of the loss of blood from a large vein.

It appears to me, that this simple statement ought to suffice to show you that Dr. Collins' objections to the use of the lancet are of less moment than they would seem to be upon a simple reference to his broad assertion of its inapplicability, and to his acknow- ledged reputation; since it appears that his experiment of the venesection was inconclusive from being early discontinued.

Dr. Robert Lee, in his " Lectures," &c., before cited, gives, at p. 457, et seq., a tabular statement of 160 cases of severe in- flammation of the uterus and its appendages, which occurred to


PUERPERAL FEVER. 611

him in London, from 1827 to the end of April, 1838. The table is presented in jfive columns — of which the first one contains the number of the case ; the second, names, residence and delivery; third, date of attack, and symptoms; the fourth, treatment; the fifth, result, and morbid appearances. This constitutes one of the most complete and accurate tables I have seen, and offers a good conspectus of the cases and modes of treatment. I have carefully analyzed Dr. Lee's table for you, and have divided it into

1st, Those who were bled and who died, &c.

72 who were bled; recovered.

34 who were bled ; died.

34 who were not bled; died.

15 who were not bled ; recovered. 5 no account of treatment.


160 cases.

Two-thirds, or 106 of Dr. Lee's cases were treated by venesec- tion, of which 72 recovered and 34 died; whereas 49 of the cases were treated without the lancet, of which 34 died, and 15 were cured : a difference in result from those obtained by Dr. Collins', that is very striking; 87 of Dr. Lee's people having been cured, while 68 died, under a bold and daring use of the lancet — where- as Dr. Collins lost 56 out of 88 cases in which he used the lancet very sparingly, and not at all according to Gordon's precepts.

But a truce to statistics, which ought never to be the physician's guide. I am no admirer of medical statistics, as I have already stated in an early letter. I would, however, cite the above to show you that Gordon's precept does not kill.

You will, by this time, perceive that I am an advocate for the use of the lancet in puerperal fever: my clinical experience concurs with my pathological views to render me so. I have not been de- terred by the reports of typhous forms of the malady, from viewing it as inflammation. Professor Moreau, who kindly showed me the whole interior of the Maternite, at Paris, in 1845, pointed out, on the occasion of my visit to that great hospital, several cases then under treatment. He was of opinion that in many cases venesection is the remedy, but, that seasons occur wherein the patient will not tolerate the loss of blood. M. Cazeaux, who was on duty at the Clinique d^ Accouchement, gave me the same opinion ;


612 PUERPERAL FEVER.

as did also Professor Retzius, of Copenhagen, whom I had the pleasure to see there while visiting M. Cazeaux's wards. All that I saw on those occasions, and all that I have myself witnessed before and since, confirm me in my admiration of Dr. Gordon's precepts ; and I adhere to, and adopt, and desire, as your Professor of Midwifery, to lead you also to adopt. Dr. Gordon's views.

Do you ask me if I expect to cure my patients by venesection, and do they never die under the treatment ? I answer, that the ma- lady is able, in many cases, to resist all sublunary power ; and that numerous instances must continue to occur in which the curable stages are overpassed before any manifestation of the disease can be discovered. But, where the disease is curable, it is more cura- ble by the lancet than all other means besides; and that patient is exposed to unnecessary and dangerous risks, whose life is confided to any other single anchor of hope and safety. I look upon it as child's-play, to attempt the cure of these great inflammations by doses of ipecacuanha — by calomel — by cathartics — by opium — by turpentine. I think that even the miserable far niente of the Homoeopathist is likely to cure the cases that are curable with- out the lancet — and that his nichts tkun will allow a patient to get well whose constitutional force is equal to the overcoming, by resolution, of a metritic or peritoneal inflammation.

What can calomel do in one of these great cases of peritonitis? Let me show you how inadequate is the remedy. See, now! The alimentary canal is not less than forty feet in length from the cardia to the rectum. If divided with the enterotome, and laid out on its mucous surface, it would average a breadth of four inches by a length of forty feet. If you reduce this into square feet, you have sixteen square feet of peritoneal surface, even leav- ing out of the computation the rest of the serous membrane of the abdominal cavity.

I entertain no doubt of having seen many individuals, in whom the whole of this vast superficies was in a state of inflammation. But the pain of a panaris, or the irritation of four or five square inches of erysipelas, will often suffice to disorder the whole con- stitution. What shall we think, then, of the disturbing power of an universal peritonitis in a woman just out of her gestation, and just escaped from the pains of her travail? And for such a case as this you propose to put — what ? — what is it you are going to do with such a solemn air? You are going to put two, or ten, or


PUERPERAL FEVER. 613

twelve grains of calomel upon the mucous membrane of the sto- mach, to cure sixteen square feet of red-hot serous tissue! Does it not seem preposterous?

Read Gordon. Learn to make your diagnostic of child-bed fever; and then freeing your spirit from the shackles of the schools, learn to act upon the promptings of your reason and judgment. Do not suffer yourself to be governed by a symptom. Be governed, rather, by a clear, dispassionate, perspicuous obser- vation of the state of the whole creature, and her wants. Be- lieve me, my dear friends, that there are many cases of grave constitutional disorders, in which the pulse is no guide to the physician; and that if you be but j)ulse-feelers, and nothing else, as long as you live, you will barely rise above the height of the Chinese doctor, who founds his diagnosis, prognosis and thera- peutical course, upon a judgment of the pulse of a lady, which is thrust through a hole in the door for his opinion as to her health and requirements.

I am very sure I have been many times zh\e , jugulare fehrim^ in puerperal fever, by a Gordon venesection, that I should not have dared to make had I been led only by my fingers. Are not a man's senses more than one? and shall one sense carry all the others away captive, and bind in chains the contrary judg- ments arising out of their perceptions?

In these great circumstances, neither you nor any man should trust for his guidance to the radial pulse alone. You should ex- amine the brachial, the carotid, the temporal arteries, and know them all. You should go to the fountain head of the circulation, and by a careful, prolonged auscultation of the heart, confirm or correct the more imperfect notions of the state of the sanguiferous system derivable from touching the radial pulse alone.

I repeat it — read Gordon; learn how many hours are fled ; and judge, whether the progress of the malady may have carried the victim beyond the curable stage ; for there is, there must be, a cura- ble stage! Is the woman past hope before her sickness is begun? Is she foreordained to death?

Having now laid before you, perhaps at too great length, my opinion of the indispensable necessity for venesection in our ma- lady ; its safety, and its superiority over all other means, I need not say anything further on the subject, except to warn you not to trust this operation to other hands than your own. You should always be present; the light should be good, in order that you may


614 PUERPERAL FEVER.

clearly observe the changes in physiognomical . expression that attend the flowing from the vein. The apartment should be in order; no noise, no movement, ought to be allowed. The patient's position should be carefully directed ; neither allowing her to be raised too much, nor to be on pillows too low. A man who is about to bleed in a puerperal fever, should be solemnized : there should be a ntit l)iilfc (!$ottcs sentiment about him ; for, on his operation hangs a human life. Death, widowhood, orphanage, are often the questions that are suspended upon this eventful ministry.

Many doctors prefer leeches in the treatment. — You may see what a very free use of them was made by Dr. Collins — and you may see, also, that the success could not have been much more unsatisfactory. Lee is no leecher ; he is a good Gordonian bleeder in our case, and owes his brilliant success to that. Desormeaux w^as a leecher and a mercurializer. You will find it so if you will read Tonnelle, wdio tells you he lost 240 patients with it at the Maternite. Chaussier was a good bleeder ; see what his intelli- gent eleve Legouais says about it.

I never could well understand the motives of those, who, though they are more frightened at the click of a spring-lancet than "a hurt fowl or a struck wild duck" is at the report of a caliver, yet find nothing at all distressing in the noiseless absorptions of two or three hundred leeches. They dread Dr. Gordon's direction to take twenty ounces at a bleeding, but they are not in the least alarmed at the abstraction of forty or fifty ounces by 300 leeches; not put on all at once, it is true, but in the course of a very few days.

For my part, I am afraid of leechings. — I am not afraid to bleed with my lancet, with a good light on the patient's face, and my fingers on the pulse ; for I can always feel satisfied that the flow is enough — not too little, and not too much. I can stop the jet w'ith the dossil of lint — I can interrupt, or arrest, or recommence the bleeding in an instant; — I can auscult the heart while it goes on, and feel that I am guiding a powerful, but docile servant of my ministry. In leeching, I always procure fatigue, pain, damp, and often, exhaustion, for my patient.

In puerperal fever the inflammation is on the intestinal perito- neum. All the blood of the inflammation is blood from the digest- ive arteries — the celiac, and the two mesenteries. — What reason have I to expect to control the action of their distal and capillary


PUERPERAL FEVER. 615

branches by leeches placed on the skin of the abdomen ? Would it not be as reasonable to leech the calf of the leg, as to leech the belly, for the cure of child-bed inflammation ? I shall not deny that I have, on occasions, applied leeches to the abdomen; but I have ever done so in doubt, and shall, probably, continue so to use them even less frequently than heretofore.

Great stress is laid upon the power of calomel to cure the dis- ease, and many physicians regard it as the sheet-anchor of hope and safety. I have no doubt that its aplastic therapeutical force is great, especially when given in large doses, and when its cathartic influence is lessened by combination with opium. A woman who has been attacked, and who has been bled, ought to take some ten grains of calomel with a grain of opium : a dose that should be repeated in the course of some four or six hours, provided the first one be not followed by alvine dejections.

A dose of the mild chloride of mercury almost invariably pro- duces a sensible degree of qualm, or nausea, which has a check- ing influence on the intenseness of the circulation ; thereby moderating the threshing power of the heart and the vessels so much, that it hinders the increase of the fibrinous element in the blood» — Remember, that the fibrinous element is expressed by 3*5 ; calomel assists to prevent its figure from going up to fifteen, or even twenty.

Calomel excites the secretory offices within the alimentary tube. As a general rule, the more abundant those secretions, the more completely are the remote branches of the digestive arteries disengorged. All those branches furnish secretions for the bowels, or for the liver ; they go nowhere else. — Calomel, then, is a good and reasonable, nay, a precious drug for the occasion. But to trust to it alone, is to lean on a broken reed that pierces the hand. Calomel is one of the leading juvantia in the cure, and nothing more.

So rapid is the rush of the attack and conquest, that " cita mors venit, aut IcBta victoria^' as Gordon quotes the lines from Horace. It is not a case in which a prudent man dare wait for the alterative influences of a mercurial ptyalism. If those in- fluences could be set up in time, they would often prove the effectual bar against the destructive advance or continuance of the malady.

Many a life may be saved, in the course of a long medical career.


616 PUERPERAL FEVER.

by means of the supporting consolations, and the recovering ex- hortations, that fall from the lips of a medical man, who is known to be worthy of confidence and trust, I hope that you will not believe, because you have got your Diploma in your hand, and because you have just been told in the College, the names and the doses of the various articles of the Materia Medica, that all you have to do in this w^orld, in your vocation, consists in meting out those drugs and medicines. I hope you will live long enough to know, that the function of the physician goes far beyond the exhibition of his doses, and that the power of his presence, of his deportment, of his opinion, and his decision, is a real power over the mind and the body of the patient, more true, and more useful, than the pretended Mesmeric force. An eloquent man can control the wildest mob, or sway the opinion of the gravest senators. Eloquence, however, is not found only in the harangue ; you may see it in the gesture; it is heard in the whisper; its most potent spell often breathes in that still small voice, in which, amidst terror and doubt and anxiety, he gives assurance of protection and restoration.

In the conduct of cases of puerperal fever, it will be a matter of no inconsiderable moment to determine the precise seat and degree of the lesion ; and for this purpose, it is not sufficient for you to go iato the patient's apartment and ask half a dozen questions as to the state of the bowels — feel the pulse, and ascertain the state of the tongue. You should examine your patient carefully. If she, for instance, lie in bed covered up with two blankets and a coun- terpane, it won't do for you to examine the state of her abdomen through the bed-clothes, petticoats and all, as I have seen people do. Her life is at stake, and it will be lost if you do not under- stand how it is at stake, and how to save it. She should be visited often, — many times a day. A careful note should be taken of the state of her pulse ; you should set down, on a sheet of paper, the state of her respirations, and insert memoranda of all the great points of her case — the doses of medicine, and the sen- sible effects produced by them.

Remember, that w'hen you feel the pulse, you do so for the pur- pose of knowing what her heart is doing, which you will not always be able to ascertain by touching the pulse alone; therefore, when- ever you pay a visit, examine the heart carefully ; note the im- pulse, the force, the area, and by comparing the impressions


PUERPERAL FEVER. 617

made upon your mind, communicated through your fingers, by the radial artery, with those conveyed by the heart itself, through the ear, endeavor to get a true and correct notion as to the general momentum and effect of the arterial circulation. The arterial system develops in the brain, in the whole nervous system, the flash of life ; where it is greater, the life is greater; where it is less, the life is less. Nearly the whole of your powers to modify the rate of life, are powers exercised upon this very force of the circu- lation ; and the physician never knows so perfectly the state of the life force in his patient, as when he gathers that knowledge from a perfect knowledge of the state of the circulation of the blood. Study the pulse, and let it be a constant study ; it has been ad- mitted of all times, that a good pulse-feeler is quoad hoc, a good physician, and that it is one of the greatest accomplishments of the medical station to know the pulse well; and why? Because, a knowledge of the state of the pulse reveals the state of the life forces. To know the pulse, may almost be said to constitute the V*5nmb!iraft of the medical ability. But, take heed that you be not pulse-feelers only.

You will suppose that your patient is doing well, if she has moderate perspiration, occupying the whole superficies of the body; and particularly, if the perspiration have an unctuous feel. A very thin and watery perspiration is not so favorable ; for, when it is unctuous, it shows, not only that the pores are free, but that the follicles are in a state of activity.

Your patient will be better, if the pulse is becoming less fre- quent, and at the same time losing its volume, after having been too large ; or if it is recovering its volume, and becoming less fre- quent, after having been too small. Your patient is not better, if the pulse becomes more and more frequent; for its increasing fre- quency indicates an increased distress of the whole constitution.

If her respiration become slower, deep, and long, more equable, she will be better; if it be saccadee, jerking, requiring the aid of the accessory muscles, the sign is almost to be held fatal.

If the urine is abundant, the sign is good.

If the tympanitic distension of the bowels is growing less, giv- ing to the muscles of the belly, relaxed after parturition, their usual soft, fluctuating feel, instead of the hard, elastic and swollen appearance which they before presented, it is favorable. If the abdomen become more and more distended, hard, intolerant of


618 PUERPERAL FEVER.

contact, the sign is bad. Nobody is better in a fever, in whom the hypochondria are tumid. Here is one of the aphorisms of Hip- pocrates: " Febricitantibus, quibus hypochondrise tument ma- lum," Here is another: " Febricitantibus, quibus hypochondrias non tument bonum," This aphorism was w'ritten four hundred years before the advent of the Saviour ; it expressed the truth then, ever since, and now.

If the thirst diminish, it is good ; if it become more and more insatiable, the sign is unfavorable. If the sensibility of the abdo- men, as tested by pressure, grows gradually, and not suddenly, less, the sign is good. But if the patient, having been extremely sore, ceases suddenly to complain, it is probable that she is nigh unto death ; for, the cessation of the pain depends upon the sud- den cessation of the disease. The disease was inflammation, and the inflammation having rapidly come to its last term by effusion, a copious effusion of lymph and serum and albumen into the belly, has cured the disease — and the patient is about to die ; just as the tension of the vessels of the brain, which gives the most intense pain, is relieved by the extravasation of the blood, which converts the headache into a fatal apoplexy. The people w-ill say that mortification has taken place. Why, a woman won't live in this malady until mortification takes place ; she has not time for mortification to take place ; therefore, in your autopsy, you will not find m.ortification.

In order to show you your prognostication upon the sudden ces- sation of pain in puerperal fever, I am going to quote a case for you, which is enough to make one feel something like awe in the reading of it. It is the first case related by Gordon, that of Andrew Low's wife — No, 15 in his table. It is at the 37th page of Bar- rington & Haswell's edition,

"Case I, John Low^s wife, "No. 15 in the Table. — In the af- ternoon of the 19th of August, 1790, John Low, miller at Justice- mills, came to my house, requesting me to go immediately to his wife, 'who,' he said, 'had swooned after delivery, and was in great danger,' I accordingly went, and found her in a dangerous situation ; she complained of an acute pain in the lower part of the abdomen, attended with a very great degree of fever, the ve- locity of the pulse being at the rate of 140 strokes in a minute.

"The disorder commenced with a violent rigor at six o'clock in the morning, being about 36 hours after delivery.


PUERPERAL FEVER. 619

"I had no difficulty in ascertaining the patient's disorder, hav- ing had previous opportunities of seeing it both in London and in the course of my practice in Aberdeen, for this was the fifteenth case I had attended since the epidemic began, though the first of which I kept a journal. And, in every respect, the disease an- swered the description of that known to practitioners by the ap- pellation of the puerperal fever, a distemper which so frequently proves fatal to women in child-bed, baffling the skill of the most eminent physicians. As, therefore, I had so often seen the dis- ease, I could not be puzzled in regard to the proper method of treatment; though, at the same time, I was well aware that I could by no means promise success.

"I accordingly ordered bleeding to the quantity of sixteen ounces, the abdomen to be fomented, and a glyster to be given; and, at the same time, I ordered large quantities of diluting drink. I likewise directed an anodyne diaphoretic draught to be given at night, and a cooling laxative the ensuing morning.

"On the 20th, when I visited the patient, I found the velocity of the pulse somewhat diminished, but no abatement of the other symptom.s (the pain and tension of the abdomen remaining as before).

"The laxative given in the morning had the desired effect ; the blood drawn exhibited a very thick inflammatory crust; the lochia were suppressed; the urine was scanty, and voided with pain; when recent, it was high colored, but when allowed to stand for a short time, it became exceedingly turbid.

" The fomentations were continued, and an opiate given in the evening.

"On the 21st, when I visited her in the morning, I was happy to find that she had been pretty easy throughout the night, and had enjoyed some hours' sleep. The pulse was 136. She was in a profuse sweat, which, I hoped, would prove critical, and, there- fore, endeavored to promote it by small doses of tartar emetic in the saline mixture. But I was sorry to find that I was disap- pointed in my expectation; for, when I returned in the afternoon, I found that the sweat had disappeared, being succeeded by a diarrhoea.

"The patient now complained of very great pain, and the swelling of the abdomen seemed to increase. I ordered an opiate in a large dose, and applied a blister to the abdomen.


620 PUERPERAL FEVER.

" On the 22d, I was sorry to find that the disease was making rapid progress, in spite of all the remedies employed ; and, as I perceived that the diarrhoea was not proving critical, (for the pain and tension were extended over the whole of the abdomen,) and that the patient's strength was sinking, all hopes of recovery were now totally abandoned.

"The patient's agony was now extremely great, and called loudly for relief; I therefore thought proper to administer opium both externally and internally, on purpose to mitigate pain, and, if possible, to procure rest.

"I went early in the morning of the 23d, to visit my distressed patient, and found that the storm was lulled into a calm. The friends received me with transports of joy, vainly thinking that the danger was over.

"The patient, supposing herself perfectly well, asked my per- mission to rise; for she seemed to feel no pain, and suffered me to touch and press the abdomen, without showing any signs of uneasiness ; a proof that the parts were in a state of gangrene : for this sudden cessation of pain in the puerperal fever, is a fatal symptom, which announces the approach of death, and denotes that a mortification has taken place. The friends, ignorant of this circumstance, were quite overjoyed to see the patient so com- posed, after such excruciating pain. However, notwithstanding this composure and apparent ease, it was evident, from the ghastly appearance of the countenance, from the tumefaction of the abdomen with the absence of pain, from the sunk state of her pulse, and from the coldness of the extremities, that death was not far off*. Accordingly, in a few hours, the scene was closed." Can one imagine a more distressing scene than this ? How per- fectly, how naturally, he paints it. I have looked upon such as it many times. It goes to the heart.

You will see that Gordon speaks of diarrhoea. I have not very often seen diarrhoea in patients affected with puerperal fever. I have met with it occasionally, however, and have been surprised to discover the power of the bowels to transmit liquids — for these stools are always fluid ones ; while several cubic feet of gases, constantly in the alimentary tube, were obstinately retained there, keeping up the enormous distension, and rendering the cure hopeless as long as it continued. If, when a patient has had a diarrhoea, it gives place to a more healthy character of the


PUERPERAL FEVER. 621

alvine dejections, and disappearance of the tympany, the sign will be good; but an increase in the frequency of the alvine dejec- tions, and, above all, their occurrence without the patient's con- sciousness of the circumstance being excited, are signs the most disastrous; particularly where the belly remains much distended.

When a patient is going to die of this malady, it happens, some time before the fatal event — some hours, or a day, or even two days beforehand — that she begins to have eructations. If these eructations are accompanied with a sound like hiccough — if they are singultiform, you need scarcely entertain the hope to rescue the patient from an impending fate. The eructations become more and more frequent; the fluid discharged may be at first whitish; it acquires at length a greenish tint, and everybody supposes she is bringing up bile ; it comes at length to be a slight vomiting; she brings up a spoonful at a time — a wineglassful, a teacup full: it becomes again brown, and looks like fine coffee- grounds; it becomes perfectly black — it is black- vomit. It is the black-vomit that accompanies the fatal serous inflammations of the abdomen: you will find it in almost all persons perishing from intussusception, from strangulated hernia, and various forms of enteritis. I have no doubt that when it begins, the serous coat of the stomach has begun to be inflamed ; and that the inflammation, increasing in intensity, coincides with the change of color, and quantities, of this ejected fluid. So that, at the last, that is to say, when she is bringing up half a basinful at a time of this vomito, her stomach is already half dead.

How painful it is to a physician, to stand by at the commence- ment of these vomitings, and to look through the dark vista along which the patient is seen by him to move ; while the friends and acquaintances are filled with the cheering hopes of health speedily to be restored. Mrs. Low's friends received Gordon with "trans- ports of joy."

If she has had an abundant secretion of milk, the secretion will be suppressed if she be violently ill with puerperal fever; for the abandonment of its duty by the lactiferous gland, is a dan- gerous symptom, expressive of extraordinary constitutional disor- der. The maintenance of the power of the milk gland is always to be held as of good augury in the case.

The total suppression of the lochial discharge is pernicious in


622 PUERPERAL FEVER.

its influence, and discouraging as a sign; the restoration of the discharge is hailed as a new attempt at recovery.

And now, I have a few last words to say before I close this letter. You should never take your leave of a patient who has been confined, without giving the clearest, the most impressive, directions, as to circumstances that might render your recall ne- cessary. The majority of these diseases come on in the night time, and many people are unwilling to awaken the physician, or even to call him at a very early hour in the morning; either because it is inconvenient to themselves to send, or that they dislike to give him the trouble to pay an extra visit. They will expect him to look after his accouchee, and are very apt to wait until the ex- pected hour of his call; as to which, they may be subjected to disappointment, since his assistance, in person, may be required elsewhere, and since, having left his patient well at the last visit, he is apt to consider her still so upon receiving no communica- tions.

You know Gordon says, that if you don't cure the puerperal fever within the Jirst six or twelve hours, you have little chance to effect a cure, and that the nearer you are to the time of the attack, the greater of course will be your expectation of suc- cess. I think I scarcely ever leave a patient, after she is put to bed, without addressing myself especially to her, and explain- ing to her the impropriety of taking anybody's advice as to her case, except that of her regular medical attendant. I tell her, that it is even very difficult for the physician to discriminate be- tween the various forms of disease in their attacking stages, and that it is impossible for unlearned persons to do so. I endeavor to make her understand, that some of the forms of disease that affect lying-in women, that are perfectly curable if treated promptly, may, in the course of from six to ten hours, pass entirely beyond the hope of recovery ; and I say, " If you are sick during my absence, see to it that I be instantly notified of it. Don't consult with any- body as to the propriety of letting me know that you are indis- posed. You have placed your safety in my keeping ; it will be the last degree of injustice to me, should you be taken sick in the intervals of my visits, not to inform me thereof, but instead of mine, to take the opinion of a nurse, or of some acquaintance. I charge you, therefore, that you let me know, as speedily as possible, if anything should happen to derange your health."


PUERPERAL FEVER. 623

I give similar directions to the monthly nurse, and, if I have the opportunity, I ask the husband of the lady to watch over her, in order that I might receive the earliest information of any indisposi- tion. This course I have pursued for years, and yet, up to this hour, I am unacquainted with a single household or individual in whom I can trust on such occasions. If the lady is taken sick, the nurse, or the grandmother, or she herself, will explain it as after-pains, or as headache, or as rheumatism ; and if the curable stage has been gone through before your visit, such signal diso- bedience of express directions, such enormous stupidity, is apt to be followed by the loss of the patient ; a loss so great, that there are no words in which I can set forth the mental distress it occa- sions. Please to understand, that if you scrupulously adopt the plan which I have above recommended, and should practice mid- wifery for half a century, you will scarcely find ten occasions in your whole life, in which a prompt information will be communi- cated to you ; and this it is that makes the life of an accoucheur more painful than that of the surgeon or the general practitioner.

It is very singular, but it is very true, that physicians are subject to these constant anxieties and mortifications. A woman will send a break-neck message after you, to call you out in night and storm and tempest, because her baby has had a bellyache, or possibly a green stool ; but she will not send for you, perhaps, if she is standing on the brink of the grave, as every woman is who is even threatened with this direful disease. She will ask the nurse to do something to cure her. Be not discouraged, however; the fault will not be yours if you should have taken all the pre- cautions in your power ; whereas, a heavy charge would lie upon your conscience, should a patient be lost in consequence of inat- tention, on your part, in issuing the needful directions.

After the death of a charming lady here a few years ago, I sent to her husband a copy of Gordon's treatise. She fell a victim to the imprudence and stupidity of her nurse, who allowed her to pass through the curable stage of an epidemic puerperal fever, de- claring that it was only after-pains, which she understood as well as the doctor, and that she would not have the doctor sent for. "Haven't I nursed," said she, "for thirty years and more, and must I have a doctor put on me because you've got an after- pain? Nonsense!" And so, v^hen her physician, who had left her well a few hours before, was at length requested to visit her,


624 PUERPERAL FEVER.

he found her far gone — past all hope of recovery. The gentle- man read Gordon, and when he returned me the volume, "Oh, sir!" said he, "why is it that this book is not to be found in every house? — If I had read these pages sooner, I should not, per- haps, now mourn over my irreparable loss."

I could relate to you many histories, setting forth the import- ance of early information in this case. But it is time to close this letter, in which I have endeavored to give you w^hat I regard as sound and wholesome views upon the subject of which it treats. If you will take my advice, you will buy Barrington & Haswell's book, and read it with the greatest care. And when you shall have read Gordon, Hey, Armstrong, and Robert Lee, if you will practice with ipecac, and calomel, and nothing else, I cannot be responsible for you, though I shall be very sorry for you.

C. D. M.


LETTER XLII.

PHLEGMASIA DOLENS; CRURAL PHLEBITIS.

Gentlemen: — There is a disease of which I have not yet spoken, and which is vulgarly known by the term Milk Leg. It has been called by the writers, phlegmasia alba dolens puerpera- rum, or the painful white swelling of the lying-in woman. Some of the Frenchmen still call it lait repandu, which is a transla- tion of the English word milk leg; a word employed to express the sense, that the milk of the woman has fallen into her leg, and inflamed and swelled it; and I suppose, indeed, that in this nine- teenth century, half gone as it is, you will have plenty of trouble to convince your patients that it will not be your duty always to get the milk out of the leg, or so to regulate your prescriptions, as to provide against the effusion of more milk into the cellular tissue of the limb. I suppose you will laugh, gentlemen, at the idea of having milk in a woman's leg, for you know milk is made in the breast, and not in the leg ; it is pretty much like saying, that a


CRURAL PHLEBITIS, 625

man has a salivation of his liver, or a diarrhoea of his kidney; in fact, it is sheer nonsense.

There are a great many doctors in this country — people who don't read books — who, while they don't suppose that it is milk in the leg, yet persist in believing that it is inflammation of the cellular tissue : though no man ever saw one suppurate, and though every man knows that when cellular tissue inflames, it is almost sure to suppurate. I should like to see a woman get well of an inflammation of the cellular tissue of the whole limb from the crista of the ilium to the os calcis, and from the pubis to the meta- tarsal bone of the great toe ! — one whose thigh is bigger than a man's body, and her leg swollen to the size of that of an elephant! — that is to say, get well without a suppuration, or, indeed, in any way.

Some persons have supposed that the swelling is produced by a disease of the absorbents of the limb ; and, in fact, nothing was known about it, until Robert Lee, the same Robert Lee of whom I have spoken so many times in these letters, made the discovery of it, and clearly demonstrated its true pathological nature ; showing that the lesion in the disease, is a lesion of the veins of the limb, for which, he gave to it the name of Crural Phlebitis, the name by which it is called by all physicians who know anything about it : it is called milk-leg only by those who know nothing about it. The old doctrine of milk-leg is still taught by persons in high places.

Dr. Lee, in his Essay on Crural Phlebitis, (Barrington and Has- well's ed., page 314,) after having given a literary history of crural phlebitis in puerperal women, says: "It is a remarkable circum- stance in the history of crural phlebitis, that nearly a century and a half should have elapsed, after it was first clearly pointed out by Mauriceau, before an opportunity was presented of ascertain- ing, by dissection, the precise nature of the disease. There had been opportunities, as I have shown, to determine the accuracy of the different hypotheses that had been advanced, but these were neglected, and the real nature of the disease, and its commence- ment in the uterus, were imperfectly understood, until I ascer- tained, by dissection, the true nature of the complaint." Dr. Lee's account of this dissection is in the Medico- Chirurgical Transac- tions, vol. XV., 1839.

The disease under consideration, commences in the endangium 40


626 CRURAL PHLEBITIS.

of the vessels; it is the same malady which most frequently carries off the chirurgical patient who has been subjected to am- putation of the limb. It is the same thing that happens to every blood-vessel, whether artery or vein, around which you cast a ligature, and tie it, for the suppression of hemorrhage. Fortu- nately, the application of your simple ligature develops only a sufficient amount of inflammation to effect the union of the dis- rupted endangium, and constitute a plug of lymph, fitted to be- come a bond of union for the opposing walls of the vessel, and thus restrain the hemorrhage after the ligature shall have fallen off.

Crural phlebitis may begin before the termination of the gesta- tion ; I have met with several cases in which it occurred six weeks before the child was born. It may commence soon after the end- ing of the labor, or not until the woman has begun to move about her chamber ; she is liable to it at any period within the lying-in month. A man is liable to it ; so is a child ; — it is by no means peculiar to the gentler sex.

Many of the cases of swollen limbs, that are looked upon by the Doctors, as cedema, coming on at the close of great chronic visceral diseases of the belly, such as enormous enlargements of the liver, or spleen, or great heterologue glands, that are pro- duced there; or cancer of the stomach — many of these swellings, I say, are not oedema, as the Doctors suppose, but they are crural phlebitis. I have known them to be so at the beginning, and have proved them to be so after death ; for I have found the great crural veins and internal iliacs filled with lymph, and pus, and coagu- lated blood, and, in some instances, totally obstructed. Dr. Lee has found some puerperal cases, in which the great crural vein, in returning into the body, has been lost, like an African river in the sands ; no trace of the vessels being left by the ravages of dis- ease, which had extended from the endangial lining into the circumvolved tissues within the abdomen.

Now, gentlemen, see a limb supplied by a great femoral artery and profunda, with its anterior and posterior tibials, and all the other branches: imagine these arteries healthy, strong, perfect in structure and volume ; and see a current of blood, driven into them by the contraction of the heart under the powerful excite- ment of a great fever; and then, imagine the femoral vein or the saphena, obstructed by thickening of its endangium ; by quanti- ties of plastic lymph which has exuded from the inner wall; by


CRURAL PHLEBITIS. 627

strong, firm coagula of blood, wliich have been arrested on its now irregular surfaces; by a quantity of serum exuded between the outer or fibrous coat of the vein and the cellular sheath in which it runs, so as to give you the feeling, when you pass your finger from Poupart's ligament down the limb to where the vessel pierces the triceps muscle, as if the finger were pressing upon a body as large as a man's thumb, and as hard as a stick. Now, tell me, what is to become of all the blood dashed into the limb by the force of an infuriated systemic ventricle ; and how is it to get out? How is the woman to avoid the great swelling of the limb, which you call phlegmasia alba, or milk-leg, but which you would better call crural phlebitis?

It is impossible to suppose such a condition of the vessels, with- out conformable swelling: for the vein which carries blood from the limb, is virtually compressed, as if you had tied it up with a ligature, preparatory to bleeding it. The vein is as if you had put the pad of Petit's tourniquet upon it, and left the artery per- fectly free and unobstructed. But it is not the crural vein alone that suffers in these cases; the inflammation not unfrequently extends into numerous superficial branches, which become extra- ordinarily sensible to the touch, and hard ; evidently containing within their cavities, quantities of coagulated blood.

But, the disease is called phlegmasia alba dolens. What makes the pain? Don't you know that the femoral artery, the crural vein, and the great crural nerve, constitute a fasciculus, and they are bound up in a common sheath or theca, until they reach the point where they perforate the triceps to get into the ham ? Well, then, the inflammation of the endangium of the crural vessels dips through the fibrous coat, and causes the infiltration I spoke of in the common sheath of the fasciculus; producing the long, hard, cord- like swelling extending from Poupart's ligament even into the ham. The whole crural nerve is thus compressed, gentlemen ; but if you compress the crural nerve, won't the woman have pain? Won't she have neuralgia? Well, the sensibility that the woman has, and the pain that she suffers in crural phlebitis, are essentially a neuralgia from pressure on the crural nerve.

The veins in the interior of the body are, for a long time, com- pressed by the gravid uterus; and sometimes, compressed with great force, which is increased enormously in the throes of labor. They are not only compressed, so as in some instances absolutely


^8 CRURAL PHLEBITIS.

to suffer contusion, but the whole of the veins of the lower ex- tremities are, in many women, for a long time, distended by the pressure of the womb, causing cedema gravidarum, and that very common occurrence, varix gravidse. Such a constant, long-con- tinued pressure upon the vessels, might well be supposed to have, in many instances, the effect of developing an inflammatory state there ; this would be endangitis. But the endangitisis more likely to affect the veins below, than those above, the point of pres- sure. There are many cases in which inflammation, commencing in the branches of the uterine veins, and spreading along the en- dangium to the internal iliacs, passes out beneath Poupart's liga- ment, along the external iliac to the femoral, and thence to all the veins which become subject to it in the leg. It will be first sus- pected by pain felt at the groin, or in the calf of the leg. I am very sure, that, in many of the cases I have met with, my first detec- tion of the existence of the malady, was made in consequence of complaints as to pain in the calf of the leg. When a woman who has been confined, or who is pregnant, tells me she has a pain in the calf of her leg, I put a thumb upon the spine of the tibia, and the fingers upon the calf, and then suddenly compress the gastro- cnemii and soleus against the bone ; if the woman shrinks from the pressure, and makes an outcry, I next ask permission to ex- amine the groin ; and if I feel the swollen ridge of the theca of the vessels, I know that my patient labors under crural phlebitis. I then examine the external iliac, by putting my hand on the same side of the hypogaster, and pressing the teguments against the brim or strait of the pelvis as far as I can push them ; when I am very sure to detect the evidence of inflammation extending up into the body, if it goes so far inwards.

The calf of the leg will be found hard. Let the woman lie upon her back, and be directed to draw both of the knees up in the bed until the tibiae become nearly vertical: you now take hold of the calf of the leg, lightly from behind, and endeavor to shake it from side to side. You will find you can't shake it, for the whole mass seems attached to the bone, or packed against it. If you shake the other calf, it will be perfectly flabby and movable in your hand; the result of this comparison will settle the diag- nostic.

As you will have to treat the case, you ought to be able to make comparison of its progress from day to day; to which end.


CRURAL PHLEBITIS. 629

take a piece of broad tape, cast it around the thickest part of the calf of the leg, measure it accurately, making a mark with a pen or pencil upon the tape, to show the exact circumference, with the date inscribed. Let this tape be carefully kept by the nurse for future reference ; and let this measurement be repeated from day to day.

If you detect the disease in its formative stage, or in its earlier stages, you will find it before there has been much swelling, par- ticularly of the thigh ; and you should announce that the thigh will become enormously swollen, provided your treatment should not succeed in assuaging it. There will also necessarily be fever, or the expression of constitutional distress, from so great and so painful a malady.

And now, gentlemen, as for the treatment. It is, rarely, proper to bleed for this disease ; because, the disease is seldom detected, until one of the terminations of inflammation has been reached. I say one of the terminations of inflammation, for the termination of an inflammation is reached, first, by resolution — second, by effu- sion — third, by suppuration — fourth, by adhesion — fifth, by spha- celation and mortification. But, when you find this great ridge, extending down from the groin, it is because effusion has taken place already; and, therefore, the bleeding stage has passed by. It may 6e useful to apply some leeches along the course of the swollen theca, because a topical depletion tends to prevent the further exterior or circumferential progress of the malady; it will have very little influence on the essential or endangial disease.

But, perhaps, gentlemen, the best and most efficacious of all remedies, is position, used in the chirurgical sense — T ought, perhaps, to say rest and position. The patient is to be irrecusa- bly confined to the dorsal decubitus; the whole limb to be placed upon pillows, or upon a bolster, so arranged as to incline the leg upwards at an angle, not above 7° or 10°. She should be told : "Now, madam, if you dare to put the foot upon the floor, even after you shall be almost cured of this disease, you will scarce fail to reproduce it with all its intenseness : the peril and the pain will be yours. Look to it, that you incur them not." Is not it very clear, that if she puts her foot to the floor, and stands upon it, she will have to lift the whole column of blood in the veins, from the sole of the foot to the cardiac extremity of the vena cava, at the expense of the most enormous strain upon the sides


630 CRURAL PHLEBITIS.

of the vessels ? It would be the grossest malpractice, to allow the woman even to sit up on a sofa, until the limb is safe.

Our great and learned surgeon, Dr. Physick, used to be proud of the certainty with which he treated cases of phlebitis, by his method. Dr. Physick's method was to apply a blister, covering the whole diseased tractus of vein, a little wider than that tractus. If you will take my advice, you will not neglect it ; for of Dr. Physick's practice it may be said, " JVil tetigit quod non ornavity

Well, what is the next thing to be done ? The limb is to be stuped, which should be done in this way: procure an old flannel petticoat — there is always a petticoat to be found where there is a woman — cut off the gathers; dip the flannel petticoat — the whole of it — into a large basin, filled with equal quantities of vinegar and boiling water ; the liquor should be very hot. Let the petti- coat be wrung out, as hard as four strong hands can possibly wringilf^ and with it let the whole member be carefully enveloped. To prevent the moisture of the fomentation from wetting the bed- clothes, a piece of blanket, or some oiled silk, should be spread beneath it. A blanket is better, for the blanket can be rolled over the whole stupe, keeping up its temperature and its moisture for a long time.

My custom is to keep up the stuping for six consecutive hours ; after which, as the woman becomes tired of it, I cause the mem- ber to be gently bathed with a mixture of warm sweet oil and laudanum, carefully wrapping it up afterwards in fine flannel ; and after leaving it so, for two or three hours, the stuping is re- commenced, and continued for five or six hours; and so, I alter- nate the stuping, and the inunction with the oil and laudanum, until the swelling has abated, or until I can shake the calf of the leg. After which, I inclose the limb in a common roller band- age, for the purpose of facilitating and hastening absorption.

When the woman has got well, I let her walk about; but, I always make it a rule to tell her, that her vein is reduced in size, and that it is no longer capable of carrying off from the limb, with the same facility as formerly, all the blood thrown into it by the arteries ; that if she will throw into it excessive quantities, by walking about too soon, or too much, she will have a swelled leg. Sometimes the leg continues swelled for thirty years; I have seen it so. Why should it not? The calibre of its vein is dimi- nished, and in some instances destrojeJ. Where it is totally


PUERPERAL CONVULSIONS. 631

destroyed, the woman can never expect to have the limb as small as it was before the malady — she should be thankful to God, for her escape with existence.

No prudent man would lay aside the charge of such a case, without directing his patient to wear a gaiter — to come up above the knee — for several months after the cure.

C. D. M.


LETTER XLIII.

Gentlemen: — Among the numerous sources of that anxiety to which the practitioner of midwifery is exposed, is the dread that he often feels, lest his pregnant or parturient patient should be at- tacked with eclampsia, or puerperal convulsions. I say the prac- titioner of midwifery — for I presume that it will be found, in ge- neral, true, that he who has much professional business in the line of those maladies, that are called Diseases of Females, will be also an Obstetrician.

Puerperal convulsions, or eclampsia, from fxxa^rf^^if, a flash, is a convulsion affecting a woman advanced in pregnancy, or in labor; or one in the first days of the lying-in.

It is a malady that is not met Avith every day — but it is one so horrible in appearance, so deadly in its tendency, so embarrass- ing sometimes in its treatment, that, although, as I said, it is not met with every day, it is solicitously expected, and probably ob- viated in many a case, which, but for such careful supervision, would swell its proportions in the statistical tables.

To show you the relative frequency of the attacks, in a given number of labors, I refer you to Dr. Collins' Midwifery.

Among the whole number, 16,414 labors, under his care, there were thirty cases of puerperal convulsion — of which twenty- five recovered, and five died. This shows you, that one woman out of every 547, was attacked with the disease. How many others were guarded against the threatened attack, cannot be known ; since, many of them may have been menaced, whose


632 PUERPERAL CONVULSIONS.

cases having ended happily, by being averted, do not appear in the statistical result. Out of 20,357 labors, under the care of the late Madame Boivin, at the Maternite, at Paris, the number of patients affected with eclampsia, was 19. So that, out of every thousand women in the Maternite, one was seized with the dis- ease. Dr. Churchill, {Midwifery, p. 447,) has collected tables of 96,903 labors, in which 159 cases of convulsions occurred ; giving one in 609.

These results, if you depend upon them, will mislead you in practice. They do not at all represent the risks that women run from this cause ; for in fact, if you become wise, sagacious, and prudent practitioners of midwifery, you will avert the attack in a very large majority of the instances that would, but for the pre- cautions made use of under your administration of them, add to the ratio in the tables. I have met with a good many samples of eclampsia, in the course of my obstetrical practice, but I am very sure that I have prevented a far greater number of attacks than I have witnessed. Some of those that have fallen under my observation, were wholly unexpected, sudden as a flash. Others came on after a long and anxious expectation of them, or after the careful and persevering employment of all the prophylactic means within my reach. Those means, in a far greater number of cases, have been employed when I had good reason to expect convul- sions ; but in which no convulsions occurred. I did suppose, that the remedies had hindered the attacks, and I still believe that they did so. Perhaps, however, I have many times indulged vain fears for the safety of my wards, and subjected them to treatment that was unnecessary.

Upon consulting my case books, and taxing my memory, I find that I have observed twenty-four instances of puerperal convul- sions ; and my colleague Dr. Huston, your Professor of Thera- peutics and Materia Medica, informed me in 1844, that he had observed thirteen cases. Of those under my observation, twenty recovered, and four died. Dr. Huston's cases show eleven re- coveries, and two deaths.

Primiparous women are most liable to eclampsia ; but all par- turient women are liable to the invasion.

Of eighty-five cases that are mentioned in the work of Collins, seventy-three were observed in primiparous women.

Women with short necks; those who are fat; those who possess


PUERPERAL CONVULSIONS. 633

considerable muscular strength; those whose tissues are firm, solid, hard, and unyielding ; those that are of a sanguine-nervous temperament ; those who have swollen feet and hands, and such as, upon waking in the morning, complain of numbness in the hands and bloating of the features; those who are affected with a feeling of great weakness, or with loss of sensation in one side of the face, or in one of the members ; those who have suddenly lost their hearing; those who have vertigo, cephalalgia, muscse volitantes, flashing of light within the eyes, dimness of sight, double vision, or half-sight; those who have sudden loud noises in the ears, and such as feel as if a violent blow had been re- ceived upon the head ; those, furthermore, who labor imder intense anaemia, with distension of the blood-vessels and heart — all such are to be held liable, and closely observed and protected.

Puerperal convulsions consist of violent, irregular, non-spon- taneous innervations of the voluntary muscles, characterized by strong rotation of the head to the right or left, and backwards, with violent jerking contractions of the muscles of the upper and lower extremities, back and abdomen. Spasmodic action of the diaphragm and muscles of expression, very rapidly repeated, always attend it. The lips and teeth are firmly closed and opened by turns, so that the rapid and violent breathing produces a loud, peculiar hissing sound. The tongue, which assumes a very dark livid color, and is almost in every case thrust forward between the teeth and jaws during the paroxysm, is often found to be severely bitten. The wounds of the tongue permit the saliva, and mucus of the mouth and throat, to be tinted with blood, which flies to a considerable distance through the compressed lips, staining the patient's face, her dress and pillows, and adding to the horror of the spectacle.

The rapid convulsive movement of the diaphragm, being ac- companied with spasm of the glottis, the blood of the lungs does not receive the benefit of a true and loyal respiration. It does not get its full dose of oxygen, but is hurried off imperfectly decar- bonated to the systemic auricle and ventricle, whence it is injected into the brain and the whole system. The darkening hue of the countenance; the deep venous tint of the tongue, and theblueness of the hands and feet, show that the patient is passing into a state of asphyxia; and she does blacken her blood more and more, until the brain, no longer receiving oxygen sufficient to extricate the


634 PUERPERAL CONVULSIONS.

nerve stream, the convulsive innervation ceases from want of the means to extricate any longer the nerve-force, or neurosity, as Dr. Cerise calls it.

During this extraordinary scene, one in which the organs that are innervated by the pneumogastric nerves chiefly suffer, the powers of the hemispheres and tubercula quadrigemina experi- ence a temporary abolition, or, rather, suspension of power. And it is a carious reflection, that, those important parts of the brain should be quelled into a sort of temporary death or oblivion, while the spinal cord and the cerebellum, which are the sources and directors of the motions, and also the medulla oblongata, which gives origin to the respiratory nerves, should be the seats of that intense though irregular evolution of power, whose effects we witness, in the writhings, and contortions, and agonies, of the eclampsia.

It is also a curious circumstance, and one well worthy of your attention, that the blackening of the blood, or its conversion into venous blood by the interruption of the respiratory or oxygenat- ing function, should be the means provided and designed by Providence for the cure of the paroxysm. When the whole san- guine mass has become carbonated, the brain and the spinal cord must cease to innervate the muscles convulsively; and the speedy relaxation of every rigid muscle permits the restoration to the lungs of their oxygenating power ; so that, in a few moments after the countenance has been black and deformed in every feature, you have the pleasure to see it recover its whiteness, though ghastly pale ; while the brain, I mean the whole brain, wakes up to the renewed performance of its organic as well as its intellectual offices. When, therefore, in looking upon these frightful scenes, you see the face of your patient growing darker and darker, you will discover in that very circumstance, the hopeful announce- ment of a speedy close of the distressing exhibition.

I think that, in a majority of the cases, you may expect to find the whole brain recover soon after the ceasing of the convulsive innervations ; but this is not always the case ; for, in some patients, I have noticed a profound coma to succeed the convulsions ; the hemispheres, the cerebellum, and the tubercula quadrigemina, remaining oppressed and extinct, as to power, while the medulla oblongata and the spinal cord had resumed a quasi regular ex- ercise of their forces.


PUERPERAL CONVULSIONS. 635

In a case that fell under my care in this city a few years since, the lady had convulsions, which occupied the hours from about 11 o'clock A. M. till near 5 P. M. During these convulsions she gave birth to a dead foetus of seven months; remaining wholly unconscious during the process. I say unconscious, though she moaned a little, during the labor-pains, like a person disturbed by some distressing dream, or like one under the influence of ether in a surgical operation. Some hours after the last convulsive attack, and after she had been lying profoundly still, as if asleep, she moved with spontaneous or voluntary motion, showing that the cerebellum was aroused to its true office of directing or co-ordi- nating the power extricated in the brain and spinal cord. She soon afterwards spoke and recognized the voices of friends, and was perfectly reasonable; showing that her hemispheres had waked up to their office of intellectual perception and combination. After having for some time spoken, and spoken well, she said, "How dark it is — why do you keep it so dark?" "It is not dark," replied I; "do you not see the candle?" "Oh no, there is

no candle here." "Yes, dear Mrs. , here is the candle —

see, I hold it just before your face." Her beautiful eyes were open, and she turned them at will, to look for the light which shone into their large dark pupils. "Do you not see the light?" said I again. " Oh no, Doctor ; why do you say so? I'm sure there's no light here." She was totally blind : that is to say, her tubercula quadrigemina were still oppressed, while the rest of her brain had recovered, being liberated from the thraldom of the congestion. After some time, the dawning light of day having considerably increased, she perceived it, and cried out, "Why, it's daylight!" and I then knew that the tubercula quadrigemina had also reco- vered .

There is a useful moral in this statement — it is that we should look to it, in the conduct of all such cases of disease, that all the parts of the brain recover — and that in so far as our measures may have efficacy, we fail not to employ them to the entire sub- duction of even the last vestiges of morbid action, or oppressed or suspended power. These vestiges of disease we may clearly discern in the intellection, and in the muscular innervations.

The successive recovery of the different parts of the brain in this case is interesting, as it is analogous to the incidents observa- ble under etherization. When a patient is subjected to the in-


636 PUERPERAL CONVULSIONS.

halation of ether, the different parts of the brain are affected in succession; but not always in the same succession. The sensi- tive cords of the cerebro-spinal axis are, in etherization, plunged into a state of insensibility — leaving the hemispheres capable to perceive and understand what the quadrigeminal tubercles see of any operation that the surgeon is performing. Or, the motor fibres are put asleep, yet the sensitive ones communicate to the conscious mind the painful impressions which the mind perceives — but which it forgets, as it forgets a painful dream.

If the etherization go very far, the hemispheres, the cerebellum, the tubercles, and the motor and sensitive cords, are all hushed in a profound state of aperception, both of the direct and the reflex influences or impressions : the medulla oblongata alone continues to do its work of irradiating the parts that are under the contact of the pneumogastric. If the ether be given long enough, and in quantity sufficiently great to quell its force of innervation also, the patient dies. Hence the medulla oblongata is called by M. Flou- rens the life-tie — the vital knot — le nmid-vital. The oxygenating power depends upon it, and without oxygen — no neurosity. Take away the ether in good time ; admit the pure atmosphere to the lungs, and the functions of the whole brain are revived — so, in our eclampsia, as soon as the abnormal state of the encephalic circu- lation gives place to a normal, or, one more nearly normal, the brain wakes up to its duties again, and the patient sees, hears, speaks and acts, with the most perfect co-ordination of all those vital forces that are dependent on the brain and cord.

If, in etherization, you press the administration of the drug to the point of quelling the vital-tie of the medulla oblongata, she will die, and you will find no necroscopic lesions in the encephalon. So, likewise, in the speedy dissolution under eclampsia puerpe- ralis; the autopsia discloses no lesion of any part of the brain. Are you surprised that the woman should die without perceptible physical lesions of the brain? You are not at all surprised if she disclose none such when destroyed by ether-inhalation. May not the brain perish under the one influence as well as under the other, and yet, dying, leave no sign ? In eclampsia, there is al- ways abolition, for the moment, of the power of the hemispheres, always of the tubercula quadrigemina, and always (perhaps!) of the cerebellum. All these revive, and are extinguished again and again, as the paroxysms are repeated or suspended by turns. When


PUERPERAL CONVULSIONS. 637

the case has come to its close, and the patient is restored, where are the lesions? No trace of them remains. But — and here is the explanation — if the medulla oblongata be affected equally with the others, the patient dies, because the sources of the respiration are cut off.

There are many circumstances, the concurrence of w^hich tends to the development of the eclampsic convulsions of pregnant, puerperal, and lying-in women. For many w^omen, the whole state of gestation from conception to labor, is a state of nervous excitement or hypersesthesia, which renders the subject specially obnoxious, under the application of exciting causes, to convulsive or irregular, non-conformable innervation. Whether this too sus- ceptible nature depends upon an altered crasis of the neurine, or whether it arises from modifications of the blood, developed during the gravidity, remains to be ascertained; and it contains questions full of interest to the pathologist and the therapeutist.

The sensorial system does, certainly, in many pregnancies, suffer from the intrusion, pressure and displacement that coincide with the immense augmentation of the volume of the uterus, which thus offers the perpetual provocation to what is termed irritation.

The globe of the womb, when it has attained a certain volume, presses by its weight and mass, (and is by the abdominal muscles pressed,) against the ventral aspect of the spinal column, as Deventer proposed. But, the great vascular trunks that lie along the front of the vertebrae, suffer compression by this vast womb ; and in the primiparous woman, whose abdomen resists the exten- sion of its walls, the uterus is pressed strongly against the aorta and the cava; more strongly than in those who have been many times pregnant. But if, in labor, the patient, in order to assist in the expulsive efforts of the womb, should hear down, by contract- ing her obliquus, rectus, and transversalis abdominis muscles, while the w^omb is at the same time hardened by the contraction or "pain," those great sanguiferous trunks must be so much com- pressed, as greatly to lessen their calibre, and diminish the flow of the blood through them.

This effect is demonstrated in the swelled or infiltrated limbs that we meet with in the last stages of pregnancy, the cedema gravidarum, of which I shall here say nothing more, having given a full explanation of its causes in my letter to you, No. XXXVII.,


638 PUERPERAL CONVULSIONS.

p. 496, to which I refer you. Now, if to the habitual over-disten- sion of the encephalic blood-vessels, we superadd the immense determination to the brain, caused by the straining efforts to bear down; by the hope; by the expectation; by the disappointment ; by the stings and agonies of the labor pains ; by the heated and quasi febrile condition of the whole mass of the blood ; by its aug- mented momentum and velocity; what wonder is it to find that the nerves of the spinal cord, both motors and sensorials ; that the par vagum, and the phrenic; in short, that the cerebro-spinal axis, over-strained, over-heated, over-stimulated, polygcemic, should yield to the coincident action of so many causes, and manifest its distress in the convulsive innervation of the muscular system, and in the temporary suspension of the perceptive facul- ties? and further, that the paroxysm being over-passed, the patient should speedily feel as if nothing had happened? Or what need have we for surprise if, the patient having perished in the attack, we can discover, in some cases, no marks of pathological action in the brain ? whereas, in some other samples, we find the evi- dences of sanguine extravasation or of serous effusions in the en- cephalon, under the wild, impetuous and irresistible rapidity, volume and momentum of the cerebral circulation.

A woman in puerperal convulsion, is one in whom the produc- tion of the neurosity is augmented beyond the control of the will ; and both exceeding the normal rate of production, and losing the healthful regular distribution of it. Such a convulsion endangers the brain which produces it — it endangers the lungs that are also essential to the production of it, and the circulation, which supplies the brain with its oxygen, its pabulum, its tensioh and pressure. The great nerve-centres, connected by the sympathetic, and ruled by the par vagum, are overthrown and trodden under foot, as it were, in the melee; and life becomes extinct from exhaustion, from engorgement, and from shock ; for all these causes combine to extinguish the vital flame ; and our necroscopic inquiry shows all the physical structures unaltered and even intact.

The inferences I deduce from these representations is, that our prophylactic, as well as our therapeutical ordinances, should be based upon an intention to save the brain. How? By hindering or curing that augmented momentum and determination of the blood to the brain, which is the most essential element of causa- tion in our disease. How is this to be effected ? By controlHng


PUERPERAL CONVULSIONS. ' 639

the heart's action, by the use of venesection ; by obviating excite- ment, by laxatives or enemata ; by lavinp^ the hands and face with cool water; by cool drinks; by cheering assurances; by order and quiet in the lying-in chamber; by abstaining from too frequent touching; by prompt delivery of the woman ; or by ceas- ing from premature attempts to deliver.

A w^oman in labor, or one near her time, before or after delivery, who complains of headache and other cerebral phenomena, is always to be esteemed as being upon the point of an eclampsic attack; and the medical adviser should look to it, that the attack be not formed. For many years past, I have never heard a woman complain of headache in labor, or soon after, or before it, without at once making this reflection. Occasionally, upon hear- ing such complaints, I have been induced, by motives which at

  • the time I deemed paramount, to abstain from very direct inter-

ference, and I have almost invariably had f ause to rue such de- termination. And I venture here to predict, that, if you, in like manner, should pass by, without regard, similar complaints made by your patients, you will have abundant cause for regret. It may be, that, upon hearing a woman in labor complain of headache, I may, on a very few occasions, have had no cause subsequently to lament that I disregarded it. However, the impression upon my mind at this mpment is, that whenever I have so disregarded the complaint, I have had a case of convulsions to treat, that I might readily, perhaps, have postponed, or wholly averted by giving to it the attention it really demanded at my hands. "Within a year, I sat at the bed-side of a lady in labor, which was making a perfectly satisfactory progress. After a pain that she had, she said to me, "Oh! how my head aches, doctor." I immediately rose, and ex- amined her pulse — for in her preceding confinement she had a frightful attack of eclampsia, on account of which I had bled her to a very large amount. Her health had never been very good since, whether in consequence of the derangement of her nervous system that expressed itself under the form of convulsion, or whether on account of the large abstractions of blood. As she approached the term of the present gestation, she had repeatedly complained of headaches; flashings of light ; tinnitus aurium ; sufiusions of the face and forehead ; on which account I had dieted and bled her, so as to have placed her, as I supposed, in a condition favor- able enough, as regarded the expected conflict of labor.


640 PUERPERAL CONVULSIONS.

When she now complained of this headache, I inquired as to its degree, place, &c., and as it very soon went off, I was averse to ordering the further loss of ^blood, the more particularly, as the child was quite near being born. / did not bleed her. She had two or three consecutive pains, after each of which the headache returned, but it was slighter. I resumed my seat, in order to take care of her at the moment of the delivery. A pain came on, and with it a short, quick, loud, hissing sound from her lips; her head rolled strongly in extension to the left ; her hands, arms, lower extremities, and indeed all the voluntary muscles, as well as the diaphragm, were in the most intense convulsions. I am as sure as that I am now recording these events, that she would not have had the convulsions, had I bled her ad deliquium, when she first said, "Oh! how my head aches, doctor!" The convulsions were repeated, so that she lost her life, to my great and lasting regret.

Perhaps some of you may be inclined to adopt the opinion that in the management of a labor, in which fear is entertained by the physician of eclampsic seizure, there is danger of its being brought on, and not averted, by the use of the lancet, agreeably to the reasons set forth by that able and distinguished physician. Dr. Henry Holland, in his ^^ Medical JYotes ajid Reflections.' Dr. Holland, at p. 52 says, "the use of the lancet is easy, and gives a show of activity in the practitioner, at moments when there appears peculiar need of this promptitude ; current opinions and prejudices are wholly on the side of bleeding; and the complexity and danger of the cases tend to obscure the results of the treat- ment pursued. The physician needs all his firmness to decline a practice thus called for; when the event is so doubtful, and where death may be charged upon his presumed feebleness, or neglect." Dr. Holland, while making these remarks, neverthe- less recognizes " in the fullest sense, the value and need of this remedy promptly and vigorously used, in various cerebral dis- eases, or in prevention of such, where well marked symptoms lead to their anticipation."

Should you admit any apprehension as to the liability to in- vite, instead of preventing the epileptiform convulsion of labor, by venesection, I trust you would take into consideration the very peculiar condition of the parturient patient, who is rarely found able to disembarrass herself of the fruit of the womb, without a most intense application of voluntary tenesmic force, in addition


PUERPERAL CONVULSIONS. 641

to the more normal iiterine power; and, that the exercise of that voluntary force is invariably attended with the signs of augmented encephalic determination. The sound and philosophical cautions of Dr. Holland, therefore, cannot apply to the instances of epi- leptiform attacks or menaces for the parturient woman, however earnestly they ought to be inculcated for some, — nay, many of the extra-gestative cases.

M. Flourens' experiments on the brain have thrown so clear a light on the symptoms that attend the encephalic disorders, that the path of the therapeutist is made straight for his cotemporaries. To show you clearly what is the nature, and what the appropriate treatment of our disorder, I ought, perhaps, to present you an abstract of his results. But, in fact, I have already done that for you, in placing within your reach, M. Flourens' little tractate,, called ^^ Phrenology Examined,^ a book which you could not read (and one may read it through in an hour), without finding much of the difficulty both of comprehending and treating puer- peral convulsion, obviated, or indeed nullified.

M, Flourens' results, then, can be applied to the diagnostica- tion of the state of the brain, and its several parts; and when you see the co-ordinating brain (the cerebellum), exerting its force abnormally, while the reasoning brain (the hemispheres), is either in a natural state, or stupefied with coma, — and so of the other parts of the brain, — you willreadily decide as to whether the signs demand, or forbid, the use of the lancet.

If I were treating a woman in labor, seized with the true puer- peral convulsion, I should certainly bleed her — provided the con- vulsion did not cease before I could effect my purpose — and should T, in any such case, open the vein, I should surely allow the stream to flow as long as any convulsive innervations were left imquelled. Provided the convulsion should return again, I should bleed her a second time, and allow the blood to flow until the spasmodic and convulsive phenomena should have again disappeared. I do not say I should do so a third time, and a fourth, though I have done so heretofore. I should act thus, because I cannot conceive of such a convulsion, in a person who has been sufficiently ex- hausted by venesection — since in such a person, the brain would be left incapable of issuing a sufficient amount of nerve-force to give rise to such phenomena.

After bleeding the patient, I should deem it, in almost every 41


642 PUERPERAL CONVULSIONS.

instance, proper to procure a copious alvine dejection, by means of an enema — one, or more. The article most suitable, because it is the most convenient, is common salt, dissolved in warm water ; two large tablespoonfuls of salt, dissolved in a pint of water, should be thrown into the rectum. This is so very powerful an excitant of the bowel, that it may be expected to operate within a few minutes, but it should soon be repeated if the first one fails.

Upon the operation of the enema, a judgment may be formed as to any further necessity in the way of procuring alvine dejec- tions ; and whenever it is ascertained that enough has been effected, advantaofe ouo-ht to be taken of the counter-irritant and revulsive power of the sinapism — accordingly, two large sinapisms, one to each leg, ought to be applied, and left in situ for some thirty minutes — not longer.

The next step should be to administer the opium. Everybody now gives opium, in puerperal convulsions, as soon as the de- pletion has been carried sufficiently far, and the bowels have been relieved by the enema.

A good dose ought to be given, say forty drops of laudanum, or twenty of the black drop ; or two grains of powdered opium ; or fifty drops of laudanum as an injection — fifty drops of laudanum mixed in a fluidounce of clear-starch, is the proper mixture.

If the coma, with stertor, continues, the question will arise as to cups or leeches to the temples : let that question be settled by careful inquiry as to the state of the circulation in the brain. Such applications are often useful.

The head should be kept cool. This cannot be properly done if the patient have a great quantity of hair. The hair, then, ought to be sacrificed. It should always be removed in eclampsia: and an objection will never be made, when the physician speaks with the proper tone and authority. To cut off the hair, and cover the head with an ice-bladder, or with cloths strongly wrung out of cold water, is indispensable. The cloths should be frequently changed.

The doses of opium ought to be repeated from time to time, as long as the mind of the patient, and her muscular actions, con- tinue to exhibit the direct influence of the paroxysm. But, when the reason returns, and the intelligence is re-established — and when the convulsive innervations of the muscles are at an end,


THE BREAST. 6^3

there may be no farther occasion to repeat the doses of opium— or at least, no reason for continuing them at the same rate.

I am not writing a book on Obstetricy, and I shall therefore not speak of the delivery, except so far as to say, that the woman ought to be delivered as soon as possible ; because, the child being taken away, one great cause of, and provocation to, the eclamp"^ sia, will be removed along with it. By the words " soon as pos- sible," I mean, as soon as it can possibly be done with propriety. Of that propriety the accoucheur must be the judge — yet no one can be held excusable, who absolutely forces the os and cervix uteri. This is a doctrine on which Dr. Dewees used to dwell with great emphasis. The os uteri is never to be forced. But, there is a wide difference between forcing it and persuading it to yield. It may be prevailed against, by means of the relaxing influence of belladonna ointment applied to its surface, or by gentle dilata- tion with the hand. But, I am lapsing into a discussion in Ob- stetricy, and shall therefore cut it short, by bidding you farewell.

C. D. M.


LETTER XLIV.

THE BREAST.

Gentlemen: — I found her lying in bed, and looking dull and dispirited, when I entered the apartment ; whereas, I had parted from her two days before, in excellent spirits, proposing to get up on the morrow; for by that time, her ninth day, the dies nondince would be complete. The child was in health; she had had an excellent labor ; the flow of milk was abundant ; and not the slight- est untoward event had occurred up to the end of the eighth day.

" I am sorry to find you have been obliged to send for me, ray

dear Mrs. . I left you so well the day before yesterday,

that, being much occupied, I thought I might lay aside my daily habit of coming to make you a salam in the morning; — you know that I have had nothing else to do since the birth of the infant..


644 THE BREAST.

You were cheerful and happy when I saw you last ; but now you look downcast and apparently sick. What can be the matter with you?"

" I have been quite sick, doctor, since yesterday afternoon."

"What! quite sick, and I not notified of it? Did you not say,

did not this nurse say, did not Mr. B say, that if, at any

time in the whole course of the month, you should be seized with any symptom whatever, great or small, I should immediately re- ceive a note, informing me of it? Here, now, you've been sick almost twenty hours before I am made aware of it. Was this just to me ? Was it just to yourself and your friends ? However, I suppose it will always be so with everybody, since I have found it so with everybody for thirty-seven years."

"But, the Doctor will please to observe that we did not like to trouble him. It was thought that the indisposition might readily pass away; and, indeed, I do feel a little better now than I have done in the night, or the early part of the morning."

"But what has been the matter with you? What have you complained of since yesterday afternoon?"

"I was taken with a chill, sir, at two o'clock, and I could not get warm for near two hours. This was accompanied and fol- lowed with pain in the head, in the back of the neck, and in the limbs, that I could hardly endure; and I became so w^arm, that I was obliged to throw off some of the coverings."

"Have you any pain in the stomach or bowels?"

"No sir, not the least."

" Can you draw up and extend the lower extremities without pain? Try it; does it hurt you ?"

"No, sir."

" Cough — I wish to know whether, if you cough, it will give you any pain in the lower part of the bowels. There ! that will do. Does that hurt you?"

" No, sir, it does not."

" Make a great aspiration of air for me. Breathe hard. Any pain?"

"Not the least, sir."

"Which of the breasts hurts you? — the right or the left one ?"

"My breast doesn't hurt me, doctor."

" Yes, it does."

"No, doctor!"


THE BREAST. 645

"But, I am sure that it does; and that the cause of your chill, and of the heat that you have had all night, and that you still have — for your pulse is quick — is seated in one or more of the branches of the milk tubes. Will you let me touch the breast?"

"Yes, sir."

"There, now, it hurts you at this point, does it not?"

"Ouch! Oh yes, sir! yes, sir, very much, indeed! Why I did not know that I had anything the matter with the breast!"

"But I did, you see."

"Yes, I see that you did. It is very strange that you should know that I had a pain, when I myself didn't know that I had it!"

"No, it is not at all strange; it is very easy to know that; because it is very easy to perceive, in the rate of your pulse ; your breathing; your heart; in the tint of your complexion; in your physiognomical expression; in your gesture and attitude; in the absence of pain in the abdomen; in the state of your intellect, evinced by your answers to ray questions, that nothing else could be the matter with you. In fact, as soon as you said, 'I had a chill yesterday afternoon,' I knew that you had an attack of what the ladies and nurses call the weed. You have got a milk-fever, my dear."

This conversation happened yesterday morning, Nov. 20th, 1847. To-day, the patient is very well again, for the weed has disappeared ; that is to say, the milk which had accumulated in excessive quantities in the lactiferous ducts of the mammary gland, or rather in certain of them, has been carefully drawn out; and the tension, pressure, irritation, intension, affluxion, heat, sensibility, redness, and swelling, all disappeared upon its evacua- tion.

I have been practicing my art now for a great many years, and I must have seen some hundreds of persons lying sick as this lady was ; some of them with intense fever, cracking headache, intole- rable pain of the nucha, back, and limbs, not unfrequently with nausea and A^omiting, and all this mixed up with distressing flying rigors — to whom I have said at once, "you have got a lump in your breast ;" to which it has often been replied, " no, I have not."

"Yes, you have."

"No, indeed I have not."

"Indeed you have." Whereupon the nurse rejoins, "Oh no!


646 THE BREAST.

there is not any at all, for I examined the breast very carefully, but just now."

" Let me examine it. There, now, does that hurt you?"

"No, not at all."

" Does not if/wif ?"

"'Oh! dreadfully, dreadfully indeed!"

" I told you so. It could not be otherwise. How should it be that I should not understand my business? I could tell you had the weed in your breast, if you v/ere in the moon, and I were looking at you with a spyglass."

If you are going to practice midwifery, ray young friends, you will have to submit to the aid of what are called nurses; and sup- pose you should meet, during your career, with a thousand differ- ent ones, you will not find more than two or three of them that ever saw a gathered breast. A man would as soon acknowledge that he had stolen a sheep, as a nurse confess in general that such an accident had ever befallen one of her patients. I saw a little dar- ling of a woman here, about two months ago, more patient than St. Anthony — who had been about two weeks confined. I had not seen her for four or five days. Upon receiving a summons, I re- paired to her house, and found her complaining of pain on giving suck to her child ; — pain in the nipple, extending back over the breast, towards its upper and exterior circumference. I took the breast between my thumb and four fingers, so as to compress the gland in the direction of its latitude or breadth, and found that gentle pressure gave her very severe pain. Upon touching it per- pendicularly, I discovered a mass of solidified texture, about two inches and a half in width, by three and a half in length; and, when I learned that she had had uneasiness in the breast for four or five days, I said to the nurse : " Did I not charge you to in- form me if anything should be the matter with my patient ? telling you to watch her in my absence, in order that I might have the earliest intimation of any accident or disorder that might affect her? Your disobedience has brought her in danger of a mam- mary abscess, which may make her ill for three, or even for six weeks, during which she will experience much pain and con- stitutional irritation. You have done very wrong; you have failed entirely in your duty to this person, who employed you to take care of her; — you have not taken care of her. I am afraid


THE BREAST. 647

that she'll have a gathered breast, notwithstanding everythino- 1 can now do to prevent it."

"Not she, doctor!" replied the nurse, "not she, indeed! I have nursed for twenty years, and I have never had a gathered breast yet, in anybody that /took care of."

" Very well, Mrs. Nurse ; you are about to extend the area of your experience, in this very case ; for I think it is very likely that you will have two; and I wash my hands of them ; for the blame is yours, and nobody else's. The right breast is gone so far, that I have no hope of curing it, short of a suppuration. The left one is inflamed, and the fever that your patient is going to have, will cause it also to suppurate, or I am very much mistaken."

This poor lady had two of the most detestable mammary ab- scesses that I have seen for the last four or five years.

Now, I have related this story to you for this purpose, namely, as an introduction to the precept, watch your patient yourself, for you cannot get anybody, for love or for money, to do your work as it ought to be done. You may lay down the most definite, clear, precise directions as to the management of the breast, and you will be sure to be disobeyed. If the breast will take care of itself, and not get into disorder, it is well ; but, it is very apt, in- deed, not to take care of itself, and to subject you to the mortification of an attendance upon a mammary abscess, — always the source of displeasure, disappointment, and irritation in the family; and, to a certain extent, of blame to the physician. It touches the nurse in a point of honor, to suppose that her patient could have a gathered breast, because she considers that her official function consists in taking care of the breast; and you might as well tell a physician that he does not understand the Harveian circulation, as to express any doubt as to the competency of the monthly nurse, to the entire charge of all the circumstances connected with lac- tation. I should in vain endeavor— devoting many pages of this letter to the purpose — to express the thousandth part of the vexa- tions and mortifications that I have experienced for more than thirty years, from the ignorance, carelessness, and presumption of those in whom I have been obliged to put my trust. There are happily some nurses one can trust ; but their name is not legion.

But, I began this letter, designing to speak of the management of the female breast ; let us proceed, therefore, to inquire what the breast is, its condition in gestation, and in the lying-in state ;


648 THE BREAST.

and what are the cares that it demands at the hands of the medi- cal attendant.

Beneath the skin on the front of the chest, there lies — one on each side — a fascia, which sends up fibrous and cellular digita- tions to attach it to the inner surface of the derm. Between these frequent digitations, exist many adipose cells that often are found to contain great quantities of fat, so that between the external surface of the fascia and the internal surface of the derm, is a chosen seat for the deposit of the adeps that gives to the breast its beautiful hemispherical form, its smoothness and softness. Within this fascia, of which I just now spoke, are to be found fifteen, and in some instances as many as twenty-one, efferent ducts of the granules of the milk gland, or mammary gland. Each of these ducts, called milk-vessels, passes out of the gland through the skin at the extremity of the nipple. The nipple is, in fact, a fasciculus of milk tubes, or galactophorous tubes, which are gathered up into a bundle, and protected amidst a number of blood-vessels, some cellular tela, nerve fibrils and ab- sorbents, within a very delicate derm, and a cuticle that should rather be called an epithelium. There is also a good supply of apparatus of sebaceous secretion, by means of which the delicate surface of the nipple is kept in a soft and unctuous state.

Each one of the milk tubes contained within the fascia of the gland, runs right and left, or perpendicularly upwards, or down- wards, as it divides into numerous branches, becoming finer as they go inwards from the nipple, and successively dividing, until each of the minute tubuli terminates in a spherical hollow granule, big as a white mustard seed, from the inner surface of which the milk is secreted; for that is the secreting surface of the milk. Fifty, one hundred, or any given number of these granules, are appropriated to the supply of a quantity of milk, sufficient to fill up and distend its own galactophorous tube, whose issue is found upon the extremity of the nipple.

If you had a syringe filled with delicate size, colored with ver- milion ; and if you should introduce the point of the syringe into one of the milk pores upon the end of the nipple, you might inject the milk tube, and distend it so much as to make it swell out to the size of a large swan quill, or, in some instances, to the size of your little finger. If the material of the injection should run inwards into every branch of the galactophorous tube, so as to fill


THE BREAST. 649

each granule at the extremity of its branch, you would make a beautiful injection of that part of the lactiferous apparatus. If you should afterwards fill the syringe with other colors, green, black, blue, yellow, orange, violet, indigo, or any of them, you might inject, in succession, each of the fifteen or twenty-one porules at the end of the nipple, with a different colored mixture, and thus fill up the breast completely with various colored injections; each of which w"ould run off to the branches of its oivn particular galac- tophorous tube, and nowhere else; so that you might say, as in boxing the compass, this one runs north, this one north by east, northeast, southwest, south and by east, northwest, west, and so on, until you have indicated the direction of each tube separate and distinct. Such is the anatomy of the heart, as explained by Sir Astley Cooper in his delightful work on that subject.

Now, these galactophorous tubes are supplied with the mate- rial for secreting an immense quantity of milk, consisting of a mixture of water, albumen in solution, casein, and oil \yhich you call cream. I have seen a w^oman, using a common breast tube, draw out two large tumblerfuls from one breast, at one sitting; not that she had two large tumblerfuls in the breast when she began to draw it, but that she began to form, and continued to pour out, this peculiar compound, which w^e call milk, until the power of the gland to produce it being exhausted, it at length gave up the last drops ; demanding rest for half an hour or an hour, until, recovering its secretory power, it was ready to give up as much more. A good cow has an udder, wdiich, if you could cut it off, you could readily put into a very small pail ; jet this same cow is capable of giving sixteen quarts at a drawling, which may serve- to show you the rapidity with which these extraordinary organs are capable of pouring out the material to serve for the nutrition of the young.

It must be clear to your minds, that such a great functional force cannot exist independently of a vast supply both of blood and of nerve; and accordingly numerous arteries, coming from within the axilla, and from the internal mammary artery; and a great variety of nerve fibrils, some of which are connected with the sympathetic, passing from within the chest, and others connected with the axillary branches, connecting it with the cerebro-spinal system of innervation, serving to ally the mammary gland to the whole nervous constitution of the woman, and to render it in the


650 THE BREAST.

highest degree liable to those development movements, that result in sanguine engorgements and inflammations.

At the period of puberty, among the first signs of the change about to be effected in the constitution of the young girl, those that take place in the breast are observable. The granules of the gland, and the efferent ducts, the galactophorous tubes, acquire a more positive development ; and the hemisphere of the mam- ma begins to rise from the general surface of the bosom. But it becomes protuberant, rather from an increased disposition to the deposit of adipose matter among the cellulo-fibrous digitations of the gland, than from actual development of the substance of the glandular matter itself, although that does, as I have said, in- crease a little. The nipple, at this period, is very small, and it is seated in the centre of the aureole, which is a reddish or rosa- ceous area, extending from the base of the nipple to a certain dis- tance pn the organ, in general not more than half an inch from the nipple, in every direction. Observe, that it is of a rosaceous hue, deeper or paler, according to a sanguine, or lymphatic, or nervous temperament of the subject. As the young girl becomes more and more perfectly developed, the breast becomes more and more augmented in size; so that you should expect a young per- son of eighteen or twenty, to have a larger one than a girl who has just changed.

The breast in general, is possessed only of such sensibility as appertains to the tactile power of the skin everywhere; but, upon particular occasions, it is different. For example, many young persons at the approach of, or during the mensual period, find the breasts a little larger and fuller, and more sensible; and affected with sharp pains and aching, which disappear when the catamenia begin to flow freely, and reappear at the next mensual epoch.

When a woman becomes pregnant, the breast very speedily begins to grow larger ; the fat deposited upon it is sensibly in- creased in quantity, and if the gland be taken between the thumb and four fingers, it is found that the fascia which encloses the materials of the gland, is fuller, and more tense, and has a granular feel; in many, it feels as if it were full of strings or ridges, giving in some women, a sensation as if it were filled with hard earth- worms. At the same time this process of augmentation within begins, the aureole increases its area, and, what is very singular,


THE BREAST. 651

and worthy of your observation, the corpus mucosum of the skin beneath the aureole, acquires the power of e^fcreting pigmentum nigrum; just as if the corpus mucosum had now become endowed with a pigmentary membrane, like that that lies beneath the skin of a Negro, a Malay, or an American Indian ; but which does not exist beneath the skin in the Caucasian race. In some women, the breast grows fat at such a rate, that the skin is pushed off, further and further from the fascia which encloses the gland ; and the milk tubes within, whose termini are upon the nipple, fail to stretch or elongate themselves pari passu with the rise of the skin. The nipple seems to be drawn inwards, so that, instead of its being a prominent mamilla upon the breast, there appears a depression like that which the carpenters call a countersink. This counter- sink of the nipple is produced in the same way as the countersink is produced in the navel of the young growing child ; for as the navel is held in, according to Billard's description, by the re- mains of the two umbilical arteries and the umbilical vein, so the countersunk nipple of the female breast is detained by the un- yielding galactophorous tubes, which refuse to be elongated while the rest of the tissue is being stretched. I suppose, gentlemen, that if our American ladies were in the habit of supporting their bosoms with the pretty Greek strophium, or Roman fasciola, which they were accustomed to wear in olden time, there would be less occasion to deplore the frequency of the troublesome countersink of the nipple. If the breast were left free to grow in all its parts, it is likely that the nipple would be produced, along with the rest of the tissues ; but the wearing of corsets and busks must neces- sarily interfere with the development of the organ, and lend a material aid to the nipple, in its refusal to come forward, along with the rest of the structures.

A young married woman, who should become pregnant, and who should find that her nipple is becoming countersunk in this way, should apply to the point of the breast a concave disc of very thin hammered silver, three inches in diameter, with an opening sufficiently large to allow the nipple to pass freely through it, and having a cylinder, a quarter of an inch in length, soldered upon the edge of the opening. The concave of the disc would adapt itself to the form of the breast, and the nipple projecting through the opening, and protected by the cylinder, would have a constant tendency to come forward, and draw with it its whole fas-


652 THE BREAST.

ciculus of galactophorous tubes ; so that, at the termination of the gestation, the nipple might be found in a fit condition to be seized by the lips of the child, instead of vexing it, and tormenting its parent with vain attempts to get it into the mouth. I have seen several women who could not nurse at all, on account of this coun- tersink of the nipple. All such are liable to irritation, and even to suppuration, in consequence of the impossibility of expressing the milk, formed in abundance by the granules of the gland ; and from abrasions and cracks of the nipple, produced by repeated and protracted attempts made with breast-tubes and pumps and various apparatus for what is called drawing the breast. After the above explanation, should you be consulted beforehand, as to the treat- ment of the affection, I should think you will have no difficulty in giving directions conformable to the wants of the patient.

Ladies will sometimes ask you, whether it is advisable to have the nipple drawn by a young puppy, or by the mouth of a friend or servant. Let your answer be, that God is all wise ; that he could not make a mistake; and that if it was necessary to have the nipple drawn before the child was born, he would have had the child born before its time. All the laws of life are generic laws; they cannot err; and it is perfectly ridiculous, for a mere human reason to dare to be superior to the will of God, as it is expressed in the simple words, "the laws of nature." Tell her to let it alone; it is just as reasonable to draw the nipple be- forehand, as it is to give ether to put a stop to the pains of labor. Let her know, that after her child shall be born, she will, after the third day, or earlier, put it to the breast; and that the mo- ment the child begins to irritate it with the tongue and lips, she will begin to feel an after-pain — that is a contraction of the womb — for there is now a connection between the breast and the uterus which affects them both interchangeably. To draw the breast, therefore, is to expose herself to the risk of exciting the action of the womb before the time. Surely, to draw the breast is to excite the womb into muscular activity!

Somewhere between the first and seventy-second hour after the birth of the child, the fluxional movement towards the mammary gland, begins to take effect; and the determination of the develop- ing-force of the economy proceeds in the direction of the secretory offices of the granules, manifesting itself by the production of the milk, Avhich flows into the great tubes of the breast, making it


THE BREAST. 653

hard, voluminous, hot, weighty, and painful. The whole of the gland being contained within its fascia, and being now greatly increased in weight, it hangs suspended upon the skin on the front of the thorax, and prolapses, stretching the skin, and often in- creasing the pain of the gland in consequence of the unequal ten- sion of the several parts of it, caused by its descent. The breast should always be held up ; it should never be allowed to hang by its own tissues. You would not think of treating an orchitis without a suspensory; nor should you think, in like manner, to take good chirurgical care of an overfilled breast, without pro- viding good means for its support. A Greek or a Roman girl always supported her breast by means of the strophium, or fasciola, which passed beneath it — you should provide a strophium for your patient. The most convenient one that can possibly be de- vised, in my opinion, is a linen strip of adhesive plaster, half an inch wide and ten inches long, placed upon the skin behind the breast on the side: it should be attached to the hemisphere, which is to be held properly upwards, and the upper extremity being carried upwards near the clavicle, should be adapted in such a way as to assist the corium to hold up the breast, charged full of fat, and granules, and bundles of milk tubes. This is far better than all the jackets, and corsets, and pocket-handker- chiefs that can be devised — I mean for the early stages of the lactative breast. The adhesive strip should be reapplied every second or third day.

In most cases, you would think a suspensory a sufficient remedy for an orchitis; in like manner, you will find that an ad- hesive strophium is sufficient for the slighter irritations of the female breast. You may apply it so as not only to support, but gradually and favorably to compress, the whole organ.

When the breast becomes filled, its sensibility is so greatly in- creased, that the woman does not willingly suffer it to be touched. You will often find it incompressible, and actually shining from the polish of its tension. It has a power to irritate the nervous and vascular systems equal to the power of an immense imposthume or abscess ; and the constitution will be found to react upon it ; and the woman will have a fever, ushered in with rigors, or even with a severe ague. These rigors and fever, like those of an ordinary intermittent or remittent, terminate in a copious perspiration.

The fever is not a tertian, it is an ephemera; it terminates after a


654 THE BREAST.

course of nineteen hours from the beginning of the cold to the end of the hot stage: this is its natural course. But then, a milk-fever is not a matter of indifference ; because, a milk fever attacks the constitution of a woman, when greatly modified by gestation and labor, and the puerperal state; and if the violence of the vascular movement happen to be very considerable, or if there have been any topical lesion, or accident, that may have happened in the course of the labor, it is apt to invite the fluxional movement upon itself, and thus become a new radiant point, whence inflammation may extend, into the depths of the tissues, or along their surfaces.

Don't say, therefore, "it is only a milk-fever," and requiring no special care ; but give it the attention it may deserve. If the milk- fever should be progressing favorably, and manifest a tendency to run out its natural course, and terminate at its term, your only duty would be to watch it, and take heed that it do no mischief within the bounds of the economy. Remember, the milk-fever is a constitutional irritation developed from a radiating point, videl.y the over-sensitive, over-tense tissue of the mammary gland; and see, in the reflection, that one indication of treatment is to de- prive the breast of this patho-radiant power. Well, but to deprive it of this power, you must make the tissues as flaccid as possible. How? What is it that chiefly renders them tense? It is the twenty-one milk tubes, whose trunks and branches are all distended to the extremest degree of tension, because they contain, at one time, eight or ten ounces of milk, constituting, perhaps, one-third of the whole weight of the organ. Take the milk out, and the breast that you could not indent with the palps of your fingers, will be left perfectly flaccid, completely cool, and admitting of the freest palpation and handling, without the woman making any complaint.

Tell the nurse to put the child to the breast often. How often ? As often as it is necessary. How often is that ? As often as the breast becomes hard. For thirty years past, I have told my monthly nurses these things; perhaps in these very words; never- theless, I cannot, to this very hour, go into a lying-in room, where I find a breast in a state of tension, and the constitution in a state of fever, without being told, "I did draw the breast, Doctor; the child took it this morning."

"How long ago, nurse?"

"Why, at seven o'clock."


THE BREAST. 655

"What o'clock is it now? twelve, is it not?"

" Yes, it is twelve o'clock."

" So you drew the breast five hours ago, did you?"

"I drew it at seven o'clock, sir."

"And it has been as hard as a paving stone ever since. Can't you see, that if you let the breast remain hard, it will inflame? This fever will increase and not lessen, and you will expose your patient to the risk of having a mammary abscess, or gathered breast, as you call it."

" Oh! never do you mind, doctor; I never had a gathered breast in my life. Do you think I ever allowed a patient to have a gathered breast?"

Excuse me, gentlemen, for writing in this style, for I have at this moment under my care two mammary abscesses produced by the faults of two most excellent monthly nurses.

I am sure, that you will be able to appreciate the importance there is of keeping down this mammary tension; for, if it is not kept down, the tissues must inflame ; and inflaming under such circumstances of great constitutional fluxion, you will not be able to avert the mischief of the threatened suppuration, except at the expense of the most vigorous antiphlogistic means. To draw the breast now, and not by-and-by, is to save the patient from vene- section, from leeching, from cathartics, from a disgusting series of poultices, and all the pain and exhaustion of protracted and difficult mammary suppuration. Take heed of it, then : see if you shall be able hereafter to be more successful than I, in making the patient herself, or those that attend on her, comprehend the true influences of mammary tension.

When you find that the tension of the breast produces a consti- tutional reaction of great violence, and that the fever is accom- panied with headache, pain in the neck and loins, aching of the limbs, and frequent rigors, you should look upon it as a serious matter ; which, though it be nothing more than a milk-fever, ex- poses the woman to the risk of dangerous local engorgements and inflammations.

You should lessen the constitutional reaction, by opening a vein in the arm ; by the exhibition of a cathartic medicine, whether saline or otherwise; by proper doses of the neutral mixture, and by insisting upon the free use of demulcent and diluent drinks. If you allow the fever to rise to too high a grade, it may be feared,


656 THE BREAST.

that, instead of coming to its term in nineteen hours, it will be- come a continued fever, which will have an inflammatory cha- racter, and which may plague you for a week or ten days; involv- ing you in the constant necessity of watching over the patient ; and exposing her to the greatest risks.

Sometimes, the breast becomes so hard, so rebellious, that it is found impossible to extract the milk from its tubes; they crowd each other, acting as compressors upon each other ; making it impossible to remove the accumulation. Under these circum- stances, the nipple is apt to become irritated and even inflamed. The frequent sucking of the nipple by the child, or by various instruments invented for the purpose, produces cracks and abra- sions of the surfaces, and then you have an ulceration established upon an inflamed base. Were the ulceration seated upon a non- inflamed base, it would cure itself; but you M'ill no more cure the nipple-sore, while the nipple itself is in a state of inflamma- tion, than you will cure a cancer-sore, while the ulcer is seated upon a carcinoma. I do not mean that it is incurable as the can- cer sore is, for the nipple will get w^ll, having in it no hetero- logue character; the cancer will not get well, for it rests upon a heterologue base.

You can have, at present, no idea of the vexations that women endure in nursing their children in the month, from sore nipples ; a complaint so common that I am always surprised w'hen I hear one of my patients say she does not suffer from it.

The sore-nipple most frequently consists in a long narrow ulcer, wide as a horse hair, and a sixteenth or sometimes an eighth of an inch long. This ulcer is so small that it requires a good light to see it ; and even then it often cannot be detected, except by bending the nipple over to the opposite side, which discloses it. The ulcer is, at most, a narrow line of painful gra- nulations; and it hurts the W'oman so very much, as to render her unwilling to suckle the child as often as it should be done ; which exposes her to the risk of having an overfull breast. I think it very probable that many cases of mammary abscess owe their origin to the reluctance of the mother to encounter the pangs of suckling the infant while these fissures or cracks of the nipple are uncured. When one of them occurs in a nipple the whole substance of which has become inflamed and hardened, it is very difficult to cure it; and it is even difficult to prevent it


THE BREAST. 657

from increasing both in length and breadth, since as often as the child takes the nipple into its mouth to stretch and to pull it, so often is the sore liable to be augmented. The pain is represented to be of the most intolerable kind ; and it must be, indeed, most insufferable, to judge from the appearance of the mother, from whose eyes the tears are seen to pour as she submits to the pain. I have often imagined the pain to be, in intensity, very similar to that which one feels who has received a bit of sharp angular sand in the eye, and which vellicates the lid or the globe, whenever they are moved, producing a pain and irritation that are truly intolerable. The sore would disappear, I presume, in forty-eight hours, were it not for the necessity of drawing the breast.

In treating such a sore, I generally avail myself of the anti- phlogistic and anodyne power of the nitrate of silver, the contact of which is, in some instances, sufficient to make a speedy cure, where the substantive inflammation of the nipple will admit of the cicatrization of the sore.

• I regard it as a matter of great consequence to touch only the granulations, and not the skin itself To this end I take a fine camel-hair pencil and dipping it in a solution of the nitrate, I carefully pencil the granulations only ; for I find it easy, with the delicate point of the pencil, to make the application exactly to the points I desire to touch. A solution of twenty grains to an ounce is strong enough. You will find, in many instances, that the extreme sensibility of the sore is lessened so much by the contact of the nitrate as to enable the woman to give suck to the child with much greater comfort.

Mrs. De Groot, a monthly nurse here, a most sensible woman, in whose prudence and knowledge of her business I can confide, tells me that the nipple rarely becomes sore under her method of managing it. As soon as the child has left the nipple, Mrs. De Groot cleanses it with a bit of moistened linen. She dries it per- fectly, and then, taking the mamilla between the thumb and two fino-ers, she gently compresses it, with a view to assist it in dis- engorging its capillary vessels that are rendered turgid by the suction. As soon as she has rendered it soft and flexible again, she covers it thick with fine arrowroot powder, and keeps it in that way perfectly dry. I do not remember that the ladies she has nursed for me have, any of them, suffered from this annoying disorder. 42


658 THE BREAST.

Dr. Physick taught me to cure a very bad nipple-sore in a patient he attended with me. He prepared a very delicate adhe- sive strip by spreading adhesive plaster on a narrow ribbon called, by the shopkeepers, taste.

"These gaping ulcers," said he, "are like gaping wounds. Their edges are separated too much; they will require a far greater quantity of granulations to heal them than if the edges should be approximated — bring them together then wdth the deli- cate strips of adhesive plaster, and keep them so — they will get well much sooner." This advice was followed, and the effect was soon perceived in the amendment of the lady.

Most of the French physicians use, for the treatment, an oint- ment made out of the juice of cucumbers — the pommdde de con- combres — and it certainly is one of the most emollient of the oint- ments. A good deal of it is employed here. In order to be useful, it should be freely applied.

Borax, dissolved in mucilage of slippery elm, is a very plea- sant wash. It should be put into a salt-mouth phial, the throat of which is large enough to receive the nipple. Let the phial be turned up on the nipple as soon as the child leaves it. If held thus to the nipple a few moments, the whole surface is effectually moistened by the wash.

Inflammation of the mammary gland, tending to abscess, is a warrant to order a venesection for a woman who is strong enough to bear the loss of blood, and there are few who are not strong enough, since those who are not, will, in general, not be found prone to these inflammations. You ought not then to hesitate to bleed for an inflammation of the gland, when the disorder threatens to be severe.

Leeches freely applied, so they be not set upon an inflamed portion of skin, are ver}' laudable. Many a hard nodule, threat- ening milk abscess, has been removed by twenty or thirty leeches; the operation to be repeated if the case demand it.

A poultice is manifestly a useful remedy. But poultices ap- plied to the delicate skin of the mamma, are apt to bring out an eczema that adds to the discomfort. I think I have never had any such additional trouble, when I used a poultice made with bread and milk thickened wdth the petals of chamomile. It is a habit or routinism of my practice, and I venture to recommend it to a trial under your direction.


THE BREAST. 659

Where the nipple has been greatly inflamed and swollen, I have on many occasions directed a number of leeches, six to ten, to be applied just outside of the areola. For this end, I cut a disk of linen, or of diachylon-plaster to fit the areola, leaving a fenester for the nipple. The leeches cannot puncture the areola itself, if this precaution be taken — but their bites are all made beyond the circumference of the disk. You should not allow them to wound the aureole, because it renders the act of sucking more painful, and because the erythema that always attacks the leech-bite, would pass on to the nipple and aggravate, instead of diminish- ing, its inflammation.

When the end of the nipple becomes abraded and inflamed, the inflammation runs along the milk tube deep into the substance of the mammary gland; and when it does so, a great difficulty is encountered in effecting a cure, short of the process of suppu- ration. When the end of the nipple, therefore, is abraded and ulcerated, you should give it a most careful attention, with a view to prevent so great a misfortune.

When the breast must suppurate, it ought to be favored by the use of demulcent poultices. Powdered slippery-elm makes a good one — so does flaxseed-meal — but probably none is better than bread and milk with chamomile.

When the suppuration has taken place, the matter ought to be discharged by means of a lancet, as soon as the abscess fairly points. When the cavity is become empty, by the discharge of the pus, let the breast be confined by means of strips of adhesive plaster, which constitute the most convenient suspensory and com- press for the organ. I am confident, the use of these adhesive strips has enabled me many times rapidly to cure a breast, which I should vainly have endeavored to cure in double the length of time by any other kind of dressing.

The breast having suppurated, and the pus being discharged, whether by a spontaneous opening, or by means of the lancet, milk is sometimes seen to flow out together with the purulent mat- ter. Such a waste of the milk prevents the aperture from healing ; and the cavity of the abscess becomes a milk-fistula, which con- tinues for an indefinite period to discharge milk. When I find such a one, I push to near the bottom of the canal a very small bougie, made extempore of cere-cloth. Filling the orifice of the^ fistula, and probably irritating the internal granulations to a more


660 THE BREAST.

healthful activity, the bougie, generally, soon arrests the flow of milk from the orifice. The bougie becomes daily shorter at each successive repetition, and the fistula heals.

If a woman have a suspicious nodule of long standing, in the breast, she ought not to nurse the child. The constant alterna- tions of fulness and flaccidity, and the augmented vital activity required to carry on the secretion of the nutriment, expose her to the danofer of an inconvenient increase of the tumor, and to inflammation radiating from its superficies. Let her wean the child, by giving it to a wet-nurse.

If you decide to remove the tumor or nodule by the bistoury, let it not be done until the milk has completely disappeared. The breast is not fit for the surgeon while it is a secreting gland.

And now, having nothing further to propose as to the breast, I shall bring this letter, the last of the series, to a close.

I wish, my dear friends, these letters w^ere more worthy of your perusal ; and I might, doubtless, have rendered them so, had I allowed myself, which I could not, more leisure from the daily business of my vocation, for their composition.

Many of them have been written while waiting on women in labor; and most of them at night, afl:erthe toils and anxiety of the day's practice : more than half of them, while suffering under a most distressing hemicrania. But I had made the promise to write and publish a series of letters to you, on the subject of Females, and their Diseases, in which I would speak, as nearly af? possible, in the same tone and manner I should employ in speaking on the subjects, with any one or two of you in my library here, where I am now writing.

I am aware that no man has a right to print a bad book; nor even apologize for faults in any book of his own making. I do not pretend to do so on the present occasion. I do, however, feel desirous that you should not forget the occasion that so suddenly prompted me to engage in this task ; nor overlook the fact that I did not begin these letters of 660 pages until about the middle of last May.

I have found the mechanical labor of it severe.

" Sed tna me virtus tamen, et sperata voluptas Suavis amicitirp. quenivis efferre laboreni Suadet ; et inducit noctes vigilare serenas Querentem diotis quibus, et quo carmine demum Clara tare possim prnrpandere lumina memi Res quibus occultas penitus convisere possis.'


THE BREAST. 661

These beautiful lines of the poet Lucretius, I quote from the Treatise dc Rerum Mature, and I do so in order that the dead Roman might speak, and say, in better language than any I could indite, how strong the motive that has induced me to this labor. Pray, then, receive this work of his head, his heart, and his hands, from your former Instructor, with kindness, and assist him to invoke for it the favorable consideration of all our brethren of the Medical Profession, who I hope will see in it the evidences of a sincere desire to promote the dignity and usefulness of our vocation.

I pray you ever to look upon the medical profession, not as a business, but as a great Morality — not as a trade, but as a Mission appointed by God, for the benefit of the children of men. Farewell, dear gentlemen, and believe me, affectionately, your friend and respectful servant,

CHARLES D. MEIGS. Philadelphia, 26th JYov. 1847.


INDEX.


Abdominal neuralgia, 131 Aberdeen fever by Gordon, 590 Abortion,

causes of, 150, 522, 538

diagnosis of, 525

habitual causes of, 540

tampon in, 528

treatment of, 530 Abscess of labium, 78

of mamma, 659 Absorption from pressure of pessaries, 176 Abyssinia, customs in, 82 Acetate of lead in menorrhagia, 433 Acid nitrate of mercury, 264 Acute ovaritis, 302 Alum in menorrhagia, 433 Amenorrhosa, 405

blood-letting in, 422

caution in diagnosis of, 406

debility as cause of, 421

rheumatism as cause of, 418 Amussat, M., 1 93 Anaemia, 145

Ancemia from polypus, 257 AuEemia, puerperal, 502 Anaemia, treatment of, 160 Analogy of labor and hysteria, 458 Anatomic Transcendente of Serres, 267 Anatomy of ovary, 386 Ann Ryder's case, 250 Ante version of womb, 219 Antispasmodics, 469 Aphrodisiac power, the, 462 Asdrubali's objections to binder, 568 Atresia vagince, 91 Aura hysterica, 457 Aureole of the breast, 650 Auscultation, obstetrical, 489 Avenzoars method in prolapsus, 141

B

Bad training, 165 Baer, Lager of, 30

on the stroma, 30, 394 Bulgrudery, Dennis, 23 Bandage after labor, 568


Barclay's, Col, training method, 155 Bee, larva of, non-sexual, 34 Bennet on ovarian dropsy, 307

on prolapsus, 137 Betton's, Dr., case of inversion, 241 Bichat's vital triad, 345 Bischoffon corpus luteum, 397 Bladder, inverted, 125 Bleeding in oedema gravidarum, 498

in amenorrhcea, 422 Blood,

ansemical, analyses of, 1 55

formation of, 340

healthy, analyses of, 153, 154, 410

menstrual, analyses of, 411

quantity of in body, 152

thin, 150 Blood-membrane, 152, 168 Blumenbach on the clitoris, 118 Blundell's pessary, 72, 181 Boivin's pince a faux-germe, 536 Boivin and Duges on physometra, 289

on ovaritis, 302 Boschismans, 87 Bougies, 89 Brainerd's case, 74 Breast, the female, 643

dialogue on the, 643

drawing the, 652

inflammation of the, 659

weed in the, 645 Brierre de Boismont, 378, 402 Brown's formula for tympanitis, 295 Browne, Sir Thomas, his Religio Medici,

29 Burdach, 342


Cancer,

cause of, 279 MuUer on, 281 of the womb, 278

treatment of, 283

Candor necessary, 26

Caoutchouc pessaries, 178

Carcinoma uteri, 278

Carmmative, Dr. Brown's, 295


664


INDEX.


Carus' curve, 129, 317 Case,

of abdominal neuralgia, 131

of abortion, 524, 536, 537, 544

of absence of vagina, 85

of anaemia from polypus, 257

of chlorosis, 389

of chronic retroversion, 206

of cohesion of vaginal walls, 97

difficult, of retroversion, 203

of disease of clitoris, 122

of double vagina, 110

Dr. Ingleby's, of retroversion, 204

of dysmenorrhcea, 439

of enlarged clitoris, 120

of excision of do., 122 of nympliEP, 117

of fatal distension of Fallopian tubes, 325

of fibrous tumor, 274

of habitual abortion, 540

of hysteria, 465, 469 "in male, 459, 460

of immobility of womb, 585

of imperforate hymen, 94

of inversion, 232, 234

of inverted bladder, 525

of large polypus, 285

of long retained pessary, 175

Mayor's, of retroversion, 203

of menorrhagia, 429

Miss Helen Blanque's, 145

of nymphomania, 123

of ovarian pregnancy, Granville's, 329

of ovaritis, 302

of protracted disease from false deli- cacy, 20

of puerperal ancemia, 5Q3

of puerperal convulsion, 633, 640

of relaxed symphyses, 513, 517

of retroversion, 198

of salivation, 480

of simulative pregnancies, 291, 292, 293

of tubal pregnancy, 279

of tympanitis uteri, 294

of ulceration of vagina, 98

of vaginal enterocele, 107

of vaginal fistula, 104

of vomiting, 483 Catheterism, 571 Causes of early fading, 355 Cazeaux, 193 Celery blanched, 159 Cell-life, 27 Cereoles, 89 Cerise, Dr., 168 Cervix uteri, structure of, 437

application of leeches to, 422

excision of, 282


Cesarian operation, motives for, 313 Champagne in vomiting, 484 Change of life, 444 Changes of puberty, 337

cause of, 444

dangers of, 446

management of, 448

time of, 453 Chapman on emmenagogues, 416 Child-bed fever, 576 Children, male and female, compared, 35 Chlorosis, 344

case of, 344, 359

causes of, 346

treatment of, 438 Chronic retroversion, 206 Churchill on round ligaments, 193 Cicatrix of perineum, 79 Circumcision in Abyssinia, 82 Cleanliness in cancer, 284 Climate of the United States, 355 Clitoris, the, 118

Blumenbach on, 118

enlarged, 120 Coherent labise, 113

nymphsB, 113 Cohesion of vaginal walls, 96 Colles, 59 Collins, Dr., 485 Colombat on inversion, 134 Common sense in practice, 26 Conduct, remarks on, 18 Congenital narrowness of vagina, 88 Constipation, 497 Contagion of puerperal fever, 580 Contracted vagina, dilatation of, 89 Convulsions in puerperal women, Letter

on, 631 Cork pessaries, 178 Corpus luteum, the, 32, 393 Counter-sunk hippie, 651 Crises of life, 335 Crosse's case of inverted bladder, 125

on inversion of the womb, 227 Crural phlebitis, 624 Cullen on emmenagogues, 417 Cure, spontaneous, of inversion, 237 Cysts in labium, 72

D

Daillez cases, 240

Debility as cause of amenorrhcea, 421

Definition of puberty, 333

Delicacy of the relations of physician

and patient, 19 Deleurye on the round ligaments, 193 Depaul on obstetrical auscultation, 498 Desormeaux and Paul Dubois on round

ligaments, 193 Development of womb, cause of, 474 Dewees, Dr., an opinion of his, 643


INDEX.


665


Dewees on inversion, 235 on pessary, 171 on placenta hook, 536 on retroversion, 205 volatile tincture of guaiac, 443 Diagnosis, hasty, 251 Dialogue on the breast and its disorders, 643 with a patient, 145, 199, 230, 254, 261, 354 Diet, for accouchee, 481

in anaemia, 161 Difficulties in diagnosis, 135 Digitalis, 509

Dilatation of contracted vagina, 90 Diseases of ovaries, 299 Disorders of pregnancy, 472 Displacements of womb, 127 Distension of bladder, danger of, 193 Distinctive characteristics of the female,

37 Doctor Henry Bond's placenta forceps, 536 Clarke's London practice, 2 1 Fendal's case, 544 Double vagina, 110 Dropsy of womb, 290 of ovary, 304 of ovary, diagnosis of, 305 Dublin Lying-in Hospital, 585 Duges, M., 586 Duration of pregnancy, 499 Dysmenorrhoea, 434 causes of, 436 pseudo-membranous, 442 symptoms of, 435 treatment of, 440

E

Early marriages, 376 Eclampsia, 631 Education of women, 369 Egan's account of Tom Crib, 155 Egg unfecundated, 30 Emansio mensium, 338 Embryo, non-sexual, 34 Emmenagogues, 416

Chapman's list of, 416

Cullenon,417 Encysted dropsy, cases of, 305, 306, 310 Endangium, 341

Burdach on, 342

in disease, 343

nature of 341

Raciborski on, 343 Engorgement of uterus, treatment of, 450 Enlarged clitoris, 120, 122

nymphfe, 116 Ephelis, 480 Epidemic influence, 582


Epidemic puerperal fever, 580

Ergot in polypus, 250

in menorrhagia, 429, 433 used to produce abortion, 522

Erysipelas connected with puerperal fever, 589

Etiolation, 1 59

Everted urethral membrane, 126

Excision of nymphjB, 117 of cervix uteri, 282

Exercise, importance of, 158, 357

Explanation of puerperal fever, 601

Exploration of a case of anaemia, 147

Exploration of flexio uteri, 224

External organs, 54


Fabricius, case by, 80 Fallopian tubes, 384

fatal distension of, 352

inflammation of, 325 False delicacy, case showing the effects

of, 20 False membrane in dysmenorrhoea, 442 Fasciola of adhesive plaster, 651 Felix Plater, 59

Female, distinctive characteristics of, 37 Fever, child-bed, 577

milk, 645, 653 Fibrous tumors, 264

cause of, 274

mechanical relief of, 275

nature of, 2C4, 271

treatment of, 276 Figure, 193 Fistula, vaginal, 104 Flexion of the womb, 223, 225 Flourens, M., referred to, 636, 641 Forbes, Dr., 27, 166 Formation of blood, 340 Free-Martin, 121 Function of ovaries, 300

G

Galactophorous tubes, 648

Gendrin on menstruation, 391

Generic laws, 381

Georget on hysteria, 465

Germiferous and fecundating attributes,

31 Germinal spot, 31 Germs, periodicity of the production of,

383 Globe pessary, 172 Gooch's canula, 255 Gordon on contagiousness, 587

on puerperal fever, 590 Graafian follicles, 300

cell, 32, 300 Granville's case of ovarian pregnancy, 329


666


INDEX.


Grauiex, Dr., of Brussels, 58 Guaiac, volatile tincture of, 443

' H

Hsematosic tissue, 340

Hale, Horatio, 81

Hasty diagnosis, 2G1

Heart, nerves of the, 604

Heberden, 141

Helen Blanque's case, 145

Henle on corpus luteum, 395

Hermaphrodism, 119, 121

Hervez de Chegoin, 172

Hey, Mr. William, 607

Hipijocrates on prolapsus uteri, 141, 143

Holland, Dr. Henry, 640

Honey-bee, 35

Hooper, Dr., 573

Hordeolum, 480

Horse-shoe pessary, 181

Hunter, John, on free-martin, 121

William, on retroversion, 199 Huschke, views, 387 Hydatids, 297

Hydrometra, treament of, 299 Hypertrophy, a physical sin, 244 Hysteria, 455

analogy with labor, 458

cases of, 465, 469

causes of, 456, 464

diagnosis of, 467

influence of womb on, 455

in the male, 459

symptoms of, 467

treatment of, 468


Ignorance of the public as to medicine,

19,23 111 success from fastidiousness, 18, 21 Immobility of the womb, 185 Imperforate hymen, 91 Influence of climate, &c., on menstrua- tion, 375

of pessary on excretion, 187

of pessary on conception, 187

of retroversion on general health, 195

of womb in hysteria, 455 Ingleby's case of retroversion, 204 Internal organs, 54 Inversion of womb, 227

case of, 232, 239

Colombat on, 234

Dewees on, 235

diagnosis of, 229

of mucous membrane of the vagina, 103

spontaneous cure of, 236

treatment of, 232 Inverted bladder, 125


Itching of vulva, 77

Jacquemier on the round ligaments, 193

K

Kennedy on obstetrical auscultation, 492 Krauss, 59


Labia pudendorum, 59

coherent, 113

injuries of, 60

laceration of, 69

cedema of, 60

puncture of, 61

structure of, 59

tlirombus of, 65

treatment of, 66 Labial abscess, 78 Labial warts, 73 Labium or labrum, 59

cysts of, 72

ruptured, 68

thrombus of, case, 65 treatment, 66 Laceration of perineum, 71

results of, 72 Lady Webster's pill, 368 Larva of bee, non-sexual, 34 Lawrence on the nymphse, 81 Laycock on morbi simulati, 465 Lee, Dr. Robert, on crural phlebitis, 625

on puerperal fever, 586

on puerperal fever and crural phle- bitis, 592

Dr. Thom. S., on polypus, 247

his tables, 306

on tapping, 307 Levators in prolapsus, 133 Levret on prolapsus, 134 Ligamenta rotunda in retroversion, 191

relaxed after labor, 209 Lisfranc on excision of cervix, 283 London practice, by Dr. Clarke, 27 Longet, M., 604 Longings, 488 Louyer Villermay"s case, 120

M Mackintosh's cases, 438 Macula germinativa, 31 Maidt's case of retroversion, 203 Malgaigne on vaginal rectocele, 106 Malignant degeneration of polypus, 254 Mammary abscess, 659

glands, 643 Marsliall Hall on hysteria, 458 Mauriceau's case of excision of nympha,

107 M. Baudelocque, Jr., 586 Mechanical disorders of pregnancy, 475 Medical notes by Dr. Holland, 040


INDEX.


667


Medicine for the accouchee, 507 Medicines, power of, 168 Membrana vasorum commune, 342 Menorrhagia, 424

case of, 428, 430

ergot in, 429, 433

styptics in, 433

tampon in, 429

treatment of, 430 Menstrua, ancient notions of, 413

the, 374 Menstruation, first, 375

causes of, 376

condition of ovary in, 389

during pregnancy, 404

premature, 376

return after labor, 402 Mensual discharge, rate of, 407

nature, 408

quantity, 408 Mental qualifications of physicians, 20 Merriman on retroversion, 194

on excision of clitoris, 122

tables, 520 Mery, Antoine de St., case, 90 Metro-peritonitis, 577 Migi-atory animals, 383 Millc, secretion of, after miscarriage, 527 Milk-fever, 645, 653 Milk-leg, 625 Milk-tubes, 648 Miquelard's iron, 161 Miscarriage, secretion of milk after, 527 Miss Helen Blanque, 145 Mons veneris, 55

diseases of the, 55 Monticuli, 59 Moreau,Prof, 51

case, 513 Motives to write, 17 MuUer on cancer, 281 Mystery and jargon in physic, 25

N Narrowness, congenital, of vagina, 88 Nascent polypus, 263 Nature of the menstrual fluid, 408

of endangium, 341

of vitellus of ovary, 394 Nausea and vomiting, 482 Neuralgia abdominal, 131 Neurosity, 169, 383 Neygrier on menstruation, 391 Ninth day, 574 Nipple, 648, 650 Nipple-shield, 651 Nipple-sore, 656 Nondinse, 574 Nymph OP, 79

coherent, 113

elongated, 116


Nympha;,

lost, cause of, 80

none in mammals, 81

torn, 82

ulcerated, 116 Nymphomania, 123

case, 123

treatment, 124

O

Obstetrical auscultation, 489 CEdema gravidarum, 60, 496

case, 62

labiorum, 60 Ovarian cysts, 303

Bennet on, 307

causes of, 301

disease, 300

dropsy, 304

pregnancy, 329

spontaneous cure of, 306

stroma, 386 Ovaries, diseases of, 299

function of, 304 Ovariotomy, 311

Simpson on, 313

statistics of, 316 Ovaritis, 302

case of, 302

treatment of, 303 Ovary, anatomy of, -386

state of during menstruation, 389 Ovulation, process of, 399

in mammifers, 391

periodicity of, 385 Ovulum, 30 Ovum, 32'

retained, 524


Pain of miscarriage, 524 Pales couleurs, 544 Palpitations, 501

causes of, 502

in chlorosis, 346

diagnosis, 503

treatment, 507 Pancoast's operation in spasm of vagina, 185

for vaginal fistula, 104 Parent du Chatelet, 120 Pelvic articulations, strain of, 510 Pennsylvania Hospital, 589 Perineum, lacerated, 71 Periodicity of menstruation, 377

of germ production, 383

of ovulation, 385 Peritoneal fever, 576 Peritonitis, 577 Pessary, Dewees, 171

absorption from, 176


668


INDEX.


Pessary,

Blundeirs, 72, 181 caoutchouc, 178 cork, 178 elastic, 172 en bilboquet, 180 globe, 172

horse shoe, 181

long retained, 175

Physick's, 171

relief derived from, 170

sponge, 178

Stem, 180

use of the, 174

ulceration from, 176

whalebone, 178 Pessaries, 141

ancient, 141

precautions as to, 187

rules for the employment of, 188

Warner's, 171 Pet-vaginal, 289 Phlebitis crural, 577

of the leg, 630 Phlegmasia alba dolens, 625 Phrenology examined, by Flourens, 641 Physical sin, 244 Physician and patient, 19

mental qualifications of, 20

personal appearance of, 28 Physick, Dr., his method in phlebitis, 630 Physick's pessary, 172 Physometry, 288

cause, 289 Pills of Quevenne's metallic iron, 161

Lady Webster's, 368 Placenta, 521

forceps. Dr. Henry Bond's, 526

hook, De wees', 526 Polypus uteri, 241

ansemia from, 257

cases, 250, 251

causes, 242

diagnosis, 249

ergot in, 258

large, case of, 245

Lee on, 247

malignant degeneration of, 254

mode of removing, 256

nascent, 263 Pouchet's views, 390 Pouting of the navel, 472 Pregnancy in retroversion, 208

cause of retroversion, 209

disorders of, 472

menstruation during, 404

ovarian, 329

signs of, 480

tubal, 326 Premature menstruation, 326 Process of growth, 340


Process of ovulation, 394 Procidentia uteri from lacerated peri- neum, 72 Prolapsus uteri, 178

causes of, 139

diagnosis of, 164

general treatment of, 174

hygienical means in. 174

in the unmarried, 183

simulative, 144

vagina in, 135

with neuralgia, 132 Pruritus vulvcp, 77 Puberty, 331

exercise in, 357

meaning of the term, 333

signs of, 337 Pubic symphyses relaxed, 37, 511 Pudenda, 54 Puerperal anaemia, 502

cases of, 633, 640

convulsions, 631

described, 633

diagnosis, 604

DubUn, 584

fever, 576

Gordon on, 607

symptoms, 604

treatise of, 641, 643

treatment, 604 Purification of accouchee, 575 Purkinje, 394 Pyogenic fever, 577

Q

Quackery, 23 Quevenne's iron, 161

marked effects of, 285 Quickening, 479

R

Raciborski on endangium, 343

on menstruation, '391

on veins, 600 Rapid growth at puberty, 339 Recumbency in habitual abortion, 542 Relaxed symphyses, 56, 513

Grauiex, seton in, 58, 513

pelvis, 56,513 Relief derived from pessaries, 170 Religio Medici, 129 Remarks on conduct, 1 8 Retained ovum, 525, 534

placenta, 526 Retroversio uteri, 1 90

Blundell's instrument, 217

causes, 191, 209

chronic, case of, 206

influence of, on health, 195

in pregnancy, 214


INDEX.


669


Retroversio uteri,

Mayor's case of, 212

pregnancy during, 208

reposited, 215

round ligaments in, 218

signs, 216,217

symptoms, 199

treated, 201, 205

Wier's case, 210 Return of menstruation after labor, 402 Rheumatism of womb, 408

cause of dysmenorrhosa, 436 Riding out, 575

Robert Lee on menstruation, 391 Round ligaments, Velpeau on, 193

Deleurye on, 193 Routineers, 32 Rudolph Wagner, 31, 394 Rule for employment of pessaries, 188 Rupture of labium, 69

to avoid, 70

of perineum, 71 Rutter, Dr., 583

his success, 584


Sachets, 177

Sea bath, 367

Seneca cited, 156

Serous inflammation of the abdomen, 578

Serres, M., extract from, 267

Seton, Grauiex, 58, 518

Sex, 30, 34, 38

derivation of, 34

proportion of, 34

undistinguishable ia early embryo, 34 Sieur de la Motte, 128 Simpson on ovaries, 313 Simulated diseases of hysteria, 465

pregnancy, 291 Simulative prolapsus, 144 Sin, physical, 244 Sitting up in the month, 574 Small-pox, contagion of, 511 Sore-nipple, 656 Spach's Gynceciorum, 142 Sponge pessaries, 178 Spontaneous cure of inversion, 236

cases, 237 Statistics, 23

of menstruation, Brierre de Bois- mont's, 402

of ovariotomy, 316 Stem pessary, 180 Strain of pelvic articulations, 510 Strangury, 510 Stricture of cervix uteri, 437

of vagina, 89 Strophium of adhesive plaster, 651 Suckling, 654


Suffita, 177

Suppression of catamenia, 351

Sydenham's case of hysteria in the male,

460 Sydenham on hysteria, 461 Symphyses relaxed, 56, 513.


Tablier des Hottentotes, 81 Tampon, in abortion, 528

in menorrhagia, 429 Tenesmus uteri, 134 Thrombus labii, 66 Tinct. bl«ck hellebore, in dysmenorrhcea,

442 Tissue hjEmatosic, 340 Tom Crib's training, 153 Tonic spasm of sphincter vaginae, 1 84 Tonnele, 593

tables by, 597, 599 Training, bad, 165 Triad, vital, of Bichat, 348 Tubal pregnancy, 326

case, 327 Tumors, fibrous, 264 Tympanitis, 293

cure of, 294

of puerperal fever, 602

treatment, 295

uterine, 288

u

Ulcerated nymphce, 116

vagina, 98 Ulceration from pessary, 179 Urethral membrane inverted, 126 Urine, retention of, 570 Use of pessary, 174 Uterine polypus, 241 Utero-abdominal supporter, 24, 188 Uterus, prolapsus of, 128

puncture of, 87


Vaccination of pregnant women, 575 Vagina, absence of, 85

cohesion of walls, 91

congenital narrowness of, 88

double, 110

inversion of mucous membrane of, 103

in prolapsus uteri, 134

relations of, 85

stricture of, 89

ulceration of, 98 Vaginal cystocele, 1 09

enterocele, 107 case, 107

fistula, 104

Pancoast's operation for, 104

rectocele, 106


670


INDEX.


Vaginal wall, cohesions of, 91 Vaginitis, 100

Value of hymen as a sign, 184 Vapors, 457 Varix graviJae, 499 Veins, Raciborski on, 600 Velpeau on round ligaments, 191 Venesection in retroversion, 205 Ventose pregnancies, 288 VerrucEe of labia, 73 Virginity, hymen as proof of, 185 Vital triad of Bichat, 398 Vulva, warts of, 73

pruritus of, 77 «>

W

Walking exercise, 147 Walking pestilence, 585 Warts of labium, 73 Whalebone ring pessary, 179 White's, Dr., case of inversion, 234 Wier's, Dr., case of retroversion, 2 10


Wigand, Justus Heinrich, 225 Willis de Febribus, 586 Woman, education of, 369 Womb, 127

ante version of, 219

cancer of, 278

treatment of, 283

cause of development of, 474

displacements of, 127

dropsy of, 296

engorgement of, 450

flexion of, 213

inversion of, 225

prolapsus of, 128

retroversion of, 190

rheumatism of, 418

tympanitis of, 288


Yelk ball, 30

how constituted, 31 Young Physic, 27, 166


THE END.


\


CATALOGUE


OF


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AND

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Cyclopajdia of Practical Medicine, by Forbes, Tweedie, &c., edited by Dunglison, in 4 super royal volumes, 3154 double columned pages.

Dunglison's Medical Dictionary, 7th ed., 1 vol. inrp-Svo., 912 large pages, double columns.

Hoblyn's Dictionary of Medical Terms, by Hays, 1 vol. large 12mo., 402 pages, double columns.

Medical News and Library, monthly at $1 a year.

ANATOMY.

Anatomical Atlas, by Smith and Horner, large imp. 8vo., 650 figures.

Horner's Special Anatomy and Histology, 7th edition, 2 vols. 8vo., many cuts, 1130 pages.

Horner's United States Dissector, 1 vol. large royal 12mo., many cuts, 444 pages.

Wilson's Human Anatomy, by Goddard, 4th edi- tion (1S4S), 1 vol. Svo., 252 wood-cuts, 580 pp.

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PHYSIOLOGY.

Carpenter's Principles of Human Physiology, by

Clytner, 1 vol. Svo., 752 pp., 317 illustrations,

3d edition, much improved and enlarged. Carpenter's Elements, or Manual of Physiology,

1 vol. Svo., 566 pages, many cuts. Connection between Physiology and Intellectual

Science, 1 vol. ISmo., paper, price 25 cents. Dunglison's Human Physiology, 6th edition, 2

vols. Svo., 1350 pages, and 370 wood-cuts. Harrison on the Nerves, 1 vol. Svo., 292 pages. Matteucci on the Physical Phenomena of Living

Beings, 1 vol. 12tno., 3S8 pp., cuts. Miiller's Physiology, by Bell, 1 vol. Svo., 886 pp. Roget's Outlines of Physiology, Svo., 516 pages. Solly on the Anatomy, Physiology and Pathology

of the Brain, 1 vol. Svo., 496 pp. and 1 18 cuts. Todd and Bowman's Physiological Anatomy and

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PATHOLOGY.

Abercrombieonthe Stomach, 1 vol. Svo., 320pp. Abercrombie on the Brain, 1 vol. 8vo., 324 pp. Alison's Outlines of Pathology, &c., Svo., 420 pp. Berzelius on the Kidneys and Urine, 8vo., 180 pp. Blakiston on Diseases of the Chest, 1 vol., 384 pp. Bennet on the Uterus, 1 vol. 12mo., 146 pages. Blood and Urine Manuals, by Reese, Griffith and

Markwell, 1 vol. 12mo., 462 pages, 6 plates, a

new work, 1848. Budd on the Liver, 1 vol. Svo., 392 pages, plates

and wood-cuts. Burrows on Cerebral Circulation, 1 vol. Svo.,

216 pages, with 6 colored plates. Billing's Principles, 1 vol. 8vo., 304 pages. Bird on Urinary Deposits, Svo., 228 pages, cuts. Hasse's Pathological Anatomy, Svo., 379 pages. Hope on the Heart, by Pennock, a new edition,

with plates, 1 vol. 8vo., 572 pages. Hughes on the Lungs and Heart, 1 vol. 12mo.,

270 pages, with a plate. Lallemand on Spermatorrhcea; 1 vol. Svo. , 320 pp. Philip on Protracted Lidigestion, Svo., 240 pp. Philips on Scrofula, 1 vol. Svo., 350 pages. Prout on the Stomach and Renal Diseases, 1 voL

Svo., 466 pages, colored plates. Ricordon Venereal, new ed., 1 vol. Svo., 256 pp. Vbgel's Pathological Anatomy of the Human Body, 1 vol. 8vo., 536 pages, col. plates. Walshe on the Lungs, 1 vol. 12mo., 310 pages.


Wilson on the Skin, 1 vol. Svo., new ed., 440 pp.

Same work, with colored plates. Whitehead on Sterility and Abortion,! vol. Svo.,

368 pages. Williams' Pathology, or Principles of Medicine,

by Clymer, a much improved edition, 1848,

440 pages, 1 vol. Svo. Williams on the Respiratory Organs, by Clymer,

1 vol. Svo., 500 pages.

PRACTICE OF MEDICINE.

Ashwell on the Diseases of Females, 2d edition,

1848, 1 vol. 8vo., 520 pages. Bartlett on Fevers, new edition, much enlarged,

a complete work on the Fevers of the U. S.

Now ready. 550 pages. Benedict's Compendium of Chapman's Lectures,

1 vol. Svo., 258 pages. Chapman on Thoracic and Abdominal Viscera,

&c., 1 vol. Svo., 384 pages. Chapman on Fevers, Gout, Dropsy, &c. &c., 1 vol.

Svo., 450 pages. Colombat de L'Isfere on Females, translated and

edited by Meigs, 1 vol. Svo., 720 pages, cuts. Condie on the Diseases of Children, 2d edition,!

vol. Svo., 658 pages. Churchill on the Diseases of Females, by Huston,

4th edition, 1 vol. Svo., 604 pages. Clymer and others on Fevers, a complete work

in 1 vol. Svo., 600 pages. Dewees on Children, 9th ed., 1 vol. 8vo., 548 pp. Dewees on P'emales, 9th edition, 1 vol. Svo., 532

pages, with plates. Dunglison's Practice of Medicine, 3d edition,

(1S4S,) 2 vols. Svo., 1500 pages. Esquirol on Insanity, by Hunt, 8vo., 496 pages. Meigs' Letters on Diseases of Females, 1 vol.

Svo., 670 pages. A new work, 1848. Meigs on Certain Diseases of Infancy, 1 vol Svo.

A new work, preparing, 1848. Thomson on the Sick Room, &c., 1 vol. large

12mo., 360 pages, cuts. Watson's Principles and Practice of Physic, 3d

edition by Condie, 1 vol. 8vo.,1060 large pages. West's Lectures on the Diseases of Infancy and

Childhood. (Publishing in the Medical News

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SITIGERY.

Brodie on Urinary Organs, 1 vol. Svo., 214 pages.

Brodie on the Joints, 1 vol. Svo., 216 pages.

Brodie's Lectures on Surgery, 1 vol. Svo., 350 pp.

Brodie's Select Surgical Works, 780 pp. 1 vol. Svo.

Chelius' System of Surgery, by South and Norris, in 3 large Svo. vols., near 2200 pages, or in 17 parts at 50 cents each.

Cooper on Dislocations and Fractures, 1 vol. Svo , 500 pages, many cuts.

Cooper on Hernia, 1 vol. imp. Svo., many plates.

Cooper on the Testis and Thymus Gland, 1 voL imperial Svo., many plates.

Cooper on the Anatomy and Diseases ofthe Breast, Surgical Papers, &c. &c., 1 vol. imp. Svo., pi'ts.

Druitt's Principles and Practice of Modern Sur- gery, 1 vol. Svo., 576 pages, 193 cuts, 4th ed., now ready, (1848).

Dufton on Deafness and Disease ofthe Ear, 1 vol. r2mo., 120 pages.

Durlacheron Corns, Bunions, &c., 12mo., 134 pp.

Fergusson's Practical Surgery, 1 vol. 8vo., 3d edition (1848), 630 pages, 274 cuts.

Guthrie on the Bladder, Svo. , 150 pages.

Jones' (Wharton) Ophthalmic Medicine and Sur- gery, by Hays, 1 vol. royal 12mo.,529 pages, many cuts, and plates plain or colored.


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Dunglison on New Remedies, 5th ed., 1 vol. Svc, 653 pages.

Ellis' Medical Formulary, 8th ed., much improv- ed, 1 vol. 8vo., 272 pages.

Griffith's Medical Botany, a new work, 1 large vol. 8vo., 704 pp., with over 350 illustrations.

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Pereira's Materia Medica and Therapeutics, by Carson, 2d edition, 2 vols. 8vo., 1580 very large pages, nearly 300 wood-cuts.

Royle's Materia Medica and Therapeutics, by Carson, 1 vol. 8vo., 689 pages, many cuts.

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Churchill's Theory and Practice of Midwifery, by

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LEA & BLANCHARD'S PUBLICATIONS.


PROFESSOR MEIGS' NEW WORK.— Now Ready.

FEMALES AND ThEIR DISEASES;

A SERIES OF LETTERS TO HIS CLASS.

BY C. D. MEIGS, M. D.,

Professor of Midwifery and the Diseases of Women and Children in the Jefferson Medical College, Phila- delphia. &c. &c. In one large and beaiitifiilly ■printed octavo volume of six hundred and seventh/ pages.

We think thai Dr. M. has done to his class, and lo the profession generally, a service for which they will be gratefnl, and for which he merits llie approbation of all. He has endeavored to perform his task, he tells us, "in a spirit of " freedom and abandon," very different from ihe dulness which has hillierlo characterized medical writings; and we think he has succeeded in producing a very agreeable, amusing, clever and in- structive book, which will be read with pleasure, and be likely to be impressive.— IV. Y. Annalist.

He ha« evidently seen almost every Ibrm and variety of female disease, and not only seen, but observed and reflected, and if we may judge by the innate evidence affoided by the volume itself practised success- fully. His volume contains many practical hints and suggestions which will repay perusal. — The Charleston MedicalJotirnal and Revieio.

The work is written in a free, animated conversational style, and is replete with sound practical instruc- tion. — 2'he Western Lancet.

We warmly commend the work of Professor Meigs as a highly interesting andinstrucuve volume. — iV. Y. Journal of Medicine.

The remaining affections of the womb, included in the volumes before us, are treated of very learnedly, and much valuable instruction is communicated concerning them. Dr. Meigs' views as to the nature and causes of these affections are generally correct, while his long and extensive experience gives lo his practical direc- tions no trifling weight. The work contains a very large fund of valuable mailer, and will, in all probability, become a very popular one. — Atnerican Medical Journal, Ja.n. lb4S.

His great reputation, the change in the book from the usual manner of writing, and the intrinsic merits with which the work abounds, will give il a wide spread circulation, and a very general perusal. — Nortliern and Western Medical and Surgical Journal.

The style is certainly not faultless, but yet it is one which, we venture to believe, will prove acceptable to most of the readers lo whom it is especially addressed. It is fresh, buoyant, varied and sprightly, and one is carried along by it without weariness.

"As lo the doctrine and the precept of these letters," we think with the author, that "he had a right, at his time of life, to be heard upon iheiu." and we are quite sure that he will be heard with great advanlRge. Whatever difference of opinion there may be respecting the manner of the letters, Ihere can be no diversity as to the matter. They are full of instruction II would be difficult to point lo a volume containing more valuable inlbrmation relative to females and their diseases.

We take leave of these Letters with the conviction that they will be productive of great good. They vvill be read with attention by many who would not have patience lo wade through an elaborate, systematic treatise on diseases of females, and there is something in the dashing, random style which serves lo impress iheir sen- timents upon the memory. We do not undertake lo say thai the style is the best; il would probably be hazard- ous lo assert that it is even a proper one for such a subject; but we must say. thai il has contributed its share towards the pleasure with which we have read this volume — The Western Journal oj' Medicine and Surgery.

MEIGS ON CHILDREN— Nearly Ready.

ON CERTAIN DISEASES OE INFANTS.

BY C. D. MEIGS, M. D.

In One Octavo Volume.


New Edition- --Revised for this Country, 1848.

THEORY AND PRACTICE OF MIDWIFERY.

BY FLEETWOOD CHURCHILL, M.D.,

Hon. Fellow of the Royal College of Physicians of Ireland, &c. &c WITH NOTES AND ADDITIONS

BY ROBERT M. HUSTON, M. D., &c. Third American Edition, Revised and Improved by the Author.

WITH ONE HUNDRED AND TWENTY- EIGHT ILLUSTRATIONS. In one very handsome octavo volume.

Preface to the Third American Edition by the Author. — I have been requested by the American publishers to revise this edition of my book, and to make such additions as the progress of science may have rendered necessary.

This I have done so far as time permitted; and though I confess that the work is far from being as complete as I could wish, yet I see no reason to modify or change the principles therein incul- cated. An extended experience will of course, in all such cases, involve the insertion of new mat- ter ; and, owing to the industry of my friend Dr. Huston, I feel satisfied that few facts of importance liave been omitted.

I owe a large debt of gratitude to my American friends, which I gladly take this opportunity of acknowledging, and also to the profession in America for the flattering reception they have given to my volumes. No reward could be more highly v.nlued by me, nor could anything make me more an.xious, by labor and study, to make my works as perfect as possible, than the knowledge that their usefulness may extend to another hemisphere. — Dublin, November, 1847.

As we have formerly called the atlentioii of our readers to the extraordinary merits of this work, we need onlyadd, that it continues lo occupy the foremost rank among publications connected with the obstetric art. The author has added also lo Us utility by posting np all the new facts and observations which have trans- piredsince the appearance of the last edition. — iV Y. Journal of Medicine.


LEA & BLANCHARD'S PUBLICATIONS.


Now Complete— THE GREAT SURGICAL LIBRARY.

A SYSTEM OF SURGERY.

BY J. M. CHELIUS,

Doctor in Medicine and Surgery, Public Professor of General and Ophthalmic Surgery, &c. &c. in the

University of Heidelberg.

TRANSLATED FROM THE GERMAN, AND ACCOMPAiMED WITH ADDITIONAL NOTES AND OBSERVATIONS,

BY JOHN F. SOUTH,

Surgeon to St. Thomas' Hospital.

EDITED, WITH REFERENCE TO AMERICAN AUTHORITIES,

BY GEORGE W. NORRIS, M. D.

Note complete, in three large ?vo. volumes of nearly twenty-tivo hundred page^. or in 17 numbers, at 50 cents.

This work has been delayed beyond the time originally promised for its completion, by the very extensive additions of the translator, and by the size of the very complete Index, extending to over 170 large pages in double columns. In answer to numerous inquiries, the publishers now have the pleasure to present it in a perfect state to the profession, forming three unusually large volumes, bound in the best manner, and sold at a very low price. The most learned and complete systematic treatise now extanv— Edinburgh MedicalJournal. No work in the English language comprises so large an amount of information relative to operative medl cine and surgical pathology.— Jl/cdicaZ Gazette.

We have, indeed, seen no work which so nearly comes up to our idea of what such a production should lie, both as a practical guide and as a work of reference, as this; and the fact lliai it has passed through six edi- tions in Germany, and been translated into seven languages, is sufficiently convincing proof of its value, ft is methodical and concise, clear and accurate ; omitting all minor details and fruitless speculations, it gives us all the information we want in the shortest and simplest form.— TAe New York Journal of Medicine.


ENCyCLOP.aiDIA OF MATERIA MSDICA.— Amply Illustrated.

THE ELEMENTS OF

MATERIA MEDICA AND THERAPEUTICS.

COMPREHENDING

THE NATURAL HISTORY, PREPARATION, PROPERTIES, COMPO- SITION, EFFECTS AND USES OF MEDICLXES. BY JONATHAN PKREIRA, M.D., F. R. S. and L. S.,

Member of the Society of Pharmacy of Paris; Examiner in Materia jAIedica and Pharmacy of the University of London ; Lecturer on Materia Medica at the London Hospital, &c. &c. Second A^nerican. from the last London Edition, enlarged and improved.

WITH NOTES AND ADDITIONS BY JOSEPH CARSON, M.D.

In two volumes octavo, containing Fifteen Hundred very large pages, illustrated by Two Hundred and

Seventy-fve Wood cuts.

Notwithstanding the large size of this work, and the immense quantity of matter contained in its closely printed pag> s, it is offered at a price so low as to place it within the reach of all.

This eiicycloposdia of Materia Medica for such it may justly be entitled, gives the fullest and most ample exposition of materia medica and its associate branches of any work hitherto published in the English language. U al/ouiiils ill research and erudiiion; its statements of facts are clear and methodically arranged, while its Iherapt utical explanations are philosophical, and in accordance with sound clinical experience. It is equally adapted as a text-book for students, or a work of reference for the advanced practitioner, and no one can con- sult its pages without profit The editor has performed his task with much ability and judgment. In the first American edition he adopted the Pharmacopoeia of the United States, and the formulre set ibrlh in that stand- ard authority ; in the present he has introduced an account of suhstances that have recently attracted attention by their therapeutic employment, together with the mode of forming the characters and uses of new pharma- ceutic preparations, and the details of more elaborate and particular chemical investigations, with respect to the nature of previously known and already described elementary principles : all the important indigenous medicines of the United Slates heretofore known are also descrilied. The vi'ork, however, is too well known to need any further remark. We have no doubt it will have a circulation commensurate with its extraordi- nary merits. — The Nete York Journal of Medicine.


CONDIE ON CHILDREN— New Edition, 1847.

A practicalYreatise on

^HIS ©HSMASSS OIF (SHHILIDMIiKro

BY D. FRANCIS CONDIE, M. D.,

Fellow of the College of Physicians ; Member of the American Philosophical Society, &c. Second Edition. In One large Octavo Volume. The publishers would particularly call the attention of the profession to an examination of this work, which has been extensively introduced as a text-book throughout the Union.

The best treatise on the diseases of children in the English language. — Medical Examiner. A far more complete exposition of its subject than any other treatise on the diseases of children -n the Eng- ish language. — American Medical Journal.

From Professor Patten, of the Vniversity of St. Louis. "I consider it the best treatise on the diseases of children that we possess, and as such have been in the tbabit of recommending it as a text-book to my classes."


LEA AND BLANCHARD'S PUBLICATIONS.


MANUALS FOR EXAMINATION NOW READY.


AN ANALYTICAL COMPETs^DIUM

OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE,

FOR THE USE AND EXAMINATION OF STUDENTS. BY JOHN NEILL, M. D.,

DEMONSTRATOR OF ANATOIIT IN TUE UMVEESITY OF PENXSYLVAMIA, LECTURER ON ANATOMY IN THE MEDICAL INSTITUTE OF PHILADELPHIA, ETC.,


FRANCIS GURNEY SMITH, M.D.,

LECTURER ON PHYSIOLOGY IN THE PHILADELPHIA ASSOCIATION FOR MEDICAL INSTRUCTION, ETC. ETC.

Forming One very large and handsomely printed Volume in royal duodecimo, of over Nine Hundred large pages, ivith about Three Hundred and Fifty Wood Engravings, strongly bound in hatha;

ivith raised bands.


The great progress of the Medical Sciences, and the increasing number and size of the standard text-booiis in the various departments of Medicine and Surgery, have created a necessity for Com- pends or Manuals, to assist tlie student in the prosecution of his labors, and the practitioner in refreshing his recollection of former studies.

The present work has been prepared solely to meet this want. No one could pretend to com- press into a limited space all the information necessary to the student or practitioner; but the authors hope to have succeeded in embodying in its pages the elements of medical science; as much, indeed, as is compatible with its character as an analysis. While, therefore, the volume is not offered as a substitute for the ordinary text-books, or to lessen the necessity of regular attendance on lectures, or close office study, it can hardly fail to be of practical use in facilitating the acquisition of know- ledge by the student. It is hoped, also, that the arrangement adopted will be found at once con- cise and intelligible, and that the mechanical execution of the work, its copious illustrations, and neat, cheap and compendious form will prove all that can be desired by the student and prac- titioner.

To adapt it still further to the use of the student, the work is divided into seven portions, cor- responding to the leading divisions of medical and surgical science. These are paged separately, and may be had done up in stout covers, each being perfect in itself, and forming convenient vol- umes to carry in the pocket to the lecture room, or fitting them to be sent by mail. It will thus be seen that this work affords, at a price unprecedentedly low, a series of digests of the medical and surgical sciences, clearly and conveniently arranged, and forming a complete set of

HANDBOOKS FOR STUDENTS,


as follows: —


ANATOMY5

180 large pages, wiih 157 Illustrations. Frice 75 Cents.


PHYSIOLOGY;

134 pages, with 40 Illustrations. Price GO Cents.


SURGERY;

122 pages, with 51 Illustrations. Price 60 Cejits.


OBSTETRICS;

114 pages, with 37 Illuslraiions. Price 50 Cents.


MATERIA MEDICA AND THERAPEUTICS;

116 pages, with 29 Illustratioiis. Frice 50 .Cents.


CHEMISTRY;

94 pages, with 19 Illustrations. Frice 40 Cents.


THE PRACTICE OF MSDICIITE;

152 pages, with 3 Illustrations.

Frice 50 Cents.


Any one of which may be had separate; or, the whole will be done up and mailed, with the post- age prepaid, on the remittance of §4; or, if $0 is remitted, The Medical Aews will be sent in addition.

It should be noticed that the amount of matter on a page is unusually large, thus making these Handbooks not only low priced, but extraordinarily cheap.


LEA & BLANCHARD'S PUBLICATIONS.


DISPENSATORY AND FORMULARY— Now Ready.

A DISPENSATORY AND THERAPEUTICAL REMEMBRANCER,

COMPRISING THE ENTIRE LISTS OF MATERIA MEDICA, WITH EVERY PRACTICAL FORilIULA CONTAINED IN TIIE

THREE BHITISH PHAHMACOPCEIAS. With Relative Tables subjoined, Illustrating by upwards of 660 Examples,

THE EXTEMPORANEOUS FORMS AND COMBIJf ATIOSS SUITABLE FOR THE DIFFERENT MEDICINES.

BY JOHN MAYNE, M. D., L. R. C. S., Edin., &c. &c. Edited, with the addition of the rormulse of the U". S. Pharmacopcsia,

BY R. EGLESFELD GRIFFITH, M. D.,

Author of '• Medical Botany," &c. In One Duodecimo Volume, of over three hundred large pages.

There is no work before the Profession, presenting in the same compass what the author and editor have attempted to embrace in this little volume— namely an unabridged practical formulary of the three British Pharmacopceias, and that of the United Slates ; a)id this in addition to a full amount of collective iuforniaiioii as to theu?es of the different medicines, and other important points relating to remedial means and appliances.

The various advantages derivalile from possession of a clear and comparative vievv- — such as is Iierein submitted— of llie officinal preparationsdirecled by ill e hish authorities referred to, are self-evident, and must be appreciated by the prescriber as well as the dispenser of medicines.

Another leature of originality, which it is expected will prove highly serviceable, is the introduction, wherever deemed requisite, of extemporaneous Ibrmidce into the work. These are separated from the phar- macopoeial or continuous text of each page in the form of foot-notes; and it need scarcely be explained, are intended to assist the practitioner's memory, by suggestions of Ibrms and combinations most suitable for the medicinal substances lo which they are annexed.

Mr Dear Matne: — I have looked over the proofs. Ycuir little work will be exceedingly useful. I shall he very glad to see a copy of it, and to notice my name as you propose to place it. Believe me, &c. &c. ROBERT LIcsTOX.

Clifford St., Nov. 3, IS47,

The neat typography, convenient size, and low price of this volume, recommend it especially to physi- cians, apothecaries and students in want of a pocket manual.

SARGENT'S MINOR SURGERY— A New Work, 1848.

ON BAKDASmS, AND OTHER POINTS OF MINOR SURGERY.

BY F. W. SARGENT, M. D.

In one handsome volume, royal \2mo., with nearly 400 Pages, and 128 Wood-cvts. CONTENTS.

Part I— Chapter 1, Instruments used in Dressing. Chapter 2 Surgical Dressings. Chapter 3, General Rules for Dressing. Chapter 4, On the use of Water (Irrigation, Douche, Bathing, Water and Vapor Baths), Fumi- gation, and Disinfecting Agents.

Va^t II- Bandages and their Application. Chapter 1, The Roller or Simple Bandage ; Compound Band- ages ; M. Mayer's System of Bandaging. Chapter II, Regional Bandaging, (head and neck, trunk, upper extremity, lower extremity.)

VAV.T \U— Bandages and Apparatus for the Treatment of Fractures. Chapter 1, General Considerations. Chapter 2, Fractures of the Bones of the Head and Trunk. Chapter 3. Fractures of llie Bones of the Slioulder. Chapter 4. Fractures of the Humerus, Forearm, Wrist and Hand. Cliapler 5, Fractures of the Bones of the liower Extremilv.

Part W— Mechanical means employed in the Treatment of Dislocations. Chapter 1, Bones of the Head and Trunk. Chapter 2, Bones of the Upper Extremity. Chapters, Bones of the Lower Extremity. Chapter 4, Compound Dislocations.

I'avlt V— Minor Surgical Operations. Chapter 1. Blood-letting, (General and Topical Bleeding ) Chapter 2, Modes of effecting Counler-irrilaiion, (Rubefacients, Vesicants, Suppurative Counter-irritants.) Chapter 3, INIodes of Arresting Hemorrhage. Chapter 4, Dressing of Wounds. Chapter 3. Introduction of the Catheter. Chap. 6, Administration of Injections; Means of Diminishing Pain during Operations. Appendix of Formulae .


IIBRIRY OF OniTHAMIIC MEDICINE AND SURGERY-Brouglit up to 1817.

A TREATISE ON THE"D^ISEASEB OF THE EYE.

BY W. LAWRENCE, F.R.S.,

Surgeon Extraordinary to the Queen; Surgeon to St. Bartholomew's Hospital, &c. &.c.

A NEW EDITION,

With tnany Modifications and Additions, and the Introduction of nearly Two Hundred Illustrations.

BY ISAAC HAYS, M.D.,

Surgeon to Wills' Hospital; Physician to the Philadelphia Orphan Asylum, &c. &c.

In one very large octavo volume of near ^iX) pages, with 12 plates and numerous ivood-cuts through the text.

This is among the largest and most complete works on this interesting and difficult branch of Medical Science.


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ATLAS OP ANATOMY, for the Medical Student.

Price only Five Oollara, in parts.


AN ANATOMICAL ATLAS

ILLUSTRATIVE OF THE STRUCTURE OF THE HUMAN BODY. BY HENRY II. SxMITH, M.D ,

Fellow of the College of Physicians, &c.

UNDEU THE SUPERVISION OF

WILLIAM E. HORNER, M.D.,

Professor of Anatomy in the University of Pennsylvania In One large Volume, Imperial Octavo.

This work consists of five parts, whose contents are as follows:

Pabt I. The Bones and Ligaments, with one hundred and thirty engravings.

Pakt II The INIuscular and Dermoid Systems, with ninety-one engravings.

Part III. The Organs of Digestion and Generation, with one hundred and ninety-one engravings.

Pakt IV. The Organs of Respiraiion and Circulalion, with ninety-eight engravings.

Pakt V. The Nervous System and the Senses, with one hundred and twenty-six engravings. Forming altogether a complete System of Anatomical Plates, of nearly SIX HUNDRKD AND FFFTV FiGURBS, executed in the best style of art, and making one large imperial octavo volume. Those who do not want it in parts can have the work bound in extra cloth or sheep at an extra cost.


HORNER'S ANATOMY, New Edition.

SPECIAL ANATOMT AND HISTOLOGY.

BY WILLIAM E. HORNER, M. D.,

Professor of Anatomy in the University of Pennsylvania, &c. &c.

SEVENTH EDITION

Willi many improvements and additions. In two octavo volumes, ivith illustrations on wood.

The name of Professor Horner is a sufficient voucher for the fidelity and accuracy of any work on anatomy; but if any further evidence could be required of the value of the present publication, it is atibrded by the fact ol its having reached a seventh edition. It is altogether unnecessary now to inquire into the particular merits of a work which has been so long before the profession, and is so well known as the present one, but in an- nouncing a new edition, it is proper to state that it has undergone several modifications, and has been much extended, so as 1o place it on a level with the existing advanced state of nnaiomy. The histological portion has been remodelled and rewritten since the last edition; numerr.us wood cuts have been introduced, and spe- cific references are made throughout the work to the beautiful figures in the Anatomical Atlas, by Dr. H. H. Sniilli. — The American Medical Journal for January 1847.


HORNER'S DISSECTOR.

THE UNITED STATES DISSECTORj

BEING A NEW EDITION, WITH EXTENSIVE MODIFICATIONS, AND ALMOST REWRITTENj OF

"MOIir¥ER'§ PKACTICAL, ANATOMY."

In One very neat Yolimie, royal lUmo., ivitli many Illustrations on Wood,

Anything emanating from the pen of Professor Horner, on anatomical science, js sure to be at once clear and correct. For more than 20 years this valuable little work has been before the profession, and during that period, sustained the high reputation of its author as a great practical anatomist. It is at the same lime con cise and simple in its arrangement, beginning with the alphabet of the science, and gradually leading the siu dent onward to the more ample part of the study. Every student who wishes to acquire a correct knowledge of Anatomy, sliould have a cojiy of this book spread before him on the dissecting table. — The Neiv Orleans Medical and Surgical Journal.


Much Enlarged Edition— Now Ready. THE HISTORY, DIAGNOSIS AND TREATMENT

OF THE

FEYERS OF THE UNITED STATES.

BY ELTSH.\ BAllTLETT, M.D.,

Professor of the Theory and Practice of Physic in the Medical Department of Transylvania University, &c. In One Octavo Volume of 550 Pages, beautifully printed and strongly bound. Decidedly the most valuable treatise on Fevers with which we are acquainted. As its title indicates, it contains the ■■ History, Diagnosis and Treatment oflhe Feversof the United States," comprehending Typhoid, Typlius, Periodicnl and Yellow Fevers. The work is remarkably systematic, and wrilien in a clear, perspi- cuous and easy style, it is eminently calculated to be useful to tlie profession, and cannot fail to secure to its 8l)le author a European reputation, as well as to reflect credit upon the medical literature of our country. — Southern Medical ajid Surgical Journal.


LEA & BLANCHARD'S PUBLICATIONS.


DUJXTGLISOW'S PRACTICE OF MEDICmE, Enlarged and Improved Edition, Brought up to 1848.


A TREATISE ON

SPECIAL PATHOLOGY AND THEEAPEUTICS.

THIRD EDITION.

By ROBLEY DUNGLISON, M.D.,

Professor of the Institutes of Medicine in the Jefferson Medical College ; Lecturer on Clinical Medicine., ^'c In Two Large Octavo Volumes of Fifteen Hundred Pages.

Professor Dunglison's work lias rapidly passed to the third edition, and is now presented to the profession as probably the most complete work on the Practice of Medicine that has appeared \n our country. It is especially characterized by extensive and laborious research, minute and accu- rate pathological, semeiological and therapeutical descriptions, together with that fullness of detail which is so important to the student.

The present edition has been considerably enlarged ; indeed the indefatigable author seems to have explored all of the labyrinths of knowledge, from which important facts and opinions could be gleaned, for the instruction of his readers. We cheerfully commend the work to those who are not already familiar with its merits.

It is certainly the most complete treatise of which we have any knowledge. There is scarcely a disease which the student will not find noticed. — Western Journal of Medicine and Surgery.

One of the most elaborate treatises of the kind we have. — Southern Medical and Surg. Journrd.

The work of Dr. Dunglison is too well known, to require at our hands, at the present time, an analysis of its contents, or any exposition of the manner in which the author has treated the several subjects embraced in it. The call for a third edition within five years from the appearance of the first, is, of itself, a sufficient evidence of the opinion formed of it by the medical profession of our country. That it is well adapted as a text-book for the use of the student, and at the same time as a book of reference for the practitioner, is very generally admitted ; in both points of view, for accu- racy and completeness, it will bear a very advantageous comparison with any of the numerous co- temporary publications on the practice of medicine, that have appeared in this country or in Europe. The edition before us bears the evidence of the author's untiring industry, his familiarity with the various additions which are constantly being made to our pathological and therapeutical knowledge, and his impartiality in crediting the general sources from which his materials have been derived. Several pathological affections, omitted in the former editions, are inserted in the present, while every portion of the work has undergone a very thorough revision. It may with truth be said, that nothing of importance that has been recorded since the publication of tlie last edition, has escaped the attention of the author ; the present edition may, therefore, be regarded as an adequate exponent of the existing condition of knowledge on the important departments of medicine of which it treats. — The American Journal of the Medical Sciences, Jan. 1848.

The Physician cannot get a better work of the kind than this, and when he masters its contents, he will have mastered all that such treatises can afford him. — St. Louis Med. 4~ Surg. Journal, June 1848.

DUNGLISON ON NEW REMEDIES.

NIiV7 EDITION.

NEW REMEDIES.

BY ROBLEY DUNGLISON, M. D., &c. &c.

Fifth edition, ivith extensive additions. In one neat octavo volume. A work like ihi? is obviously not suitable for either critical or analytical review. It is. so far as it sfoes, a dispensatory, in which an account is given ot' the die mica! and physical properties of all the articles recently added to the JNIateria iNIedica and their preparaiions, with a notice of the diseases for which ihey are pre- scribed, the doses, mode of administration, &c. — The Medical Examiner.


THE MEBICAL STUDENT, OR AIIS TO THE STUBY OF MEBIGINE.

A REVISED AND MODIFIED EDITION.

BY ROBLEY DUNGLISON, M.D.

I7i one neat V2mo. volume.


HUMAN HEALTH;

Or, the Influence of Atmosphere and Locality, Change of Air and Climate, Sea- sons, Food, Clothing, Bathing and Mineral Springs, E::ercise, Sleep, Corpo- real and Intellectual Pursuits, &c. &c. on Healthy Man: Constituting ELEMENTS OF HYGIENE. BY ROBLEY DUNGLISON, M. D. A New Edition with many Modifications and Additions. In one Volume. Bvo.


10 LEA. & BLANCHARD'S PUBLICATIONS.

THE GREAT AMERICAN MEDICAL DICTIONARY,

WBW AND ENLARGED EDITION, BROUGHT UP TO SEPTEESBER, 1848.


NOW READY,

SDICAL LEXICOi^ ,

A DICTIONARY OF MEDICAL SCIENCE,

CONTAINING

A CONCISE EXPLANATION OF THE VArxlOUS SUBJECTS AND TERMS, WITH

THE FRENCH AND OTHER SYNONYiMES; NOTICES OF CLIMATE

AND OF CELEBRATED MINERAL WATERS;

FORMUL/E FOR VARIOUS OFFICINAL AND EMPIRICAL PREPARATIONS,

ETC.

EY EOBLEY DUNGLISON, M. D.,

PKOFESSOR OF THE INSTITUTES OF MEDICINE IN THE JEFFERSON MEBICAL COLLEGE, PHILADELPHIA,

ETC. ETC.

SEVENTH EDITION,

CAREFULLY REVISED AND GREATLY ENLARGED,

In One very large and bcautifidly printed Octavo Volume of over Nine Hundred Pages, closely printed ill double columns. Strongly bound in leather, with raised bands.


Since its first publication, many years since, this work has been steadily advancing in reputation and increasing in favor with the profession, till it may now safely be pronounced

THE STANDARD AMERICAN MEDICAL DICTIONARY.

Never having been stereotyped, the author has been able, in the successive reprints, to embody all the novelties and improvements of science as fast as they have appeared, to accomplish which great industry as well as great judgment has been necessary. As an exemplification of the man- ner in which this work is kept up to the day, it may be stated that this edition contains

OVER SIX THOUSAND WORDS AND TERMS not embraced in the preceding, which, in its turn, had

TWO THOUSAND FIVE HUNDRED more than the Fifth Edition. The profession, therefore, can understand the manner in which this work has gradually increased until it contains satisfactory definitions of

OVER FORTY-FIVE THOUSAND WORDS.

Thus becoming a vast reservoir of medical Science in all its branches. It will thus be seen why it is regarded as the

STANDARD WORK OF REFERENCE FOR THE MEDICAL PROFESSION.

Every means has been employed in the preparation of the present edition, to render its me- chanical execution and typographical accuracy in every way worthy its extended reputation and universal use. The size of the page has been enlarged, and the work itself increased more than a hundred pages; the press has been watched with great care; a new font of type has been used, procured for the purpose; and the whole printed on fine clear white paper, manufactured expressly. Notwithstanding this marked improvement over all former editions, the price is retained at the original low rate, placing it within the reach of all who may have occasion to refer to its pages.

From among numerous notices of former editions, the publishers append a few.

The most complete Medical Dictionary in the Eng-lish lanciiajre. — Westfrn Lancet.

We but express the general opinion when we Siiy that Dr. Dunglison"s Dictionary has not its superior, if, indeed, its equal, in the English language. So much for the preceding editions. The present is, of course, an improvement on its predecei=.?Qrs, and contains all the new terms employed Ijy advancing science. "We hearti- ly recommend tliis Dictionary to medical men, as they will be able to tind in it almost every term used in the medical and collateral sciences, and almost every topic embraced by these long and voluminous annals.

It is a work destined to constitute the proudest monumeiitof iis authoi"s industry and learning — to perpetuate through coming centuries the memory of his name and his services to science — to reflect honor on American medicine. — St. Louis J\hd. and Surg. Journal.

The Dictionary of Prol"essor Dung-lison might, without any great stretch of propriety, be called a Cyclopedia of Medical Science, sn comprehensive is it in its scope, aud so minute in its details. In this respect it pos- sesses a great advinilage over its contemporary publications of the kind. Whatever one may expect to meet with in a dictionary of terms, he is pretty sure to find in its ample pages, besides a vast deal of matter not commonly embraced in medical leiicons, and not readily found in other publications. — The Medical E.'catnintr.


LEA & BLANCHARD'S PUBLICATIONS. 11

A NEW EDITION OF DUKGLISOS'S HIMAN PUYSIOLOGY.


HUMAN PHYSIOLOGY.

WITH THREE HUNDRED AND SEVENTY ILLUSTRATIONS. BY ROBLEY DUNGLISON, M.D.,

PROFESSOR OF THE INSTITUTES OF MEDICINE I.\ THE JEFFERSON MEDICAL COLLEGE, PHILADELrillA, ETC. ETC.

Sixth edition, greatly improved. — In two large octavo volumes, containing nearly 1350 pages. This work has been so lonsj received throughout the I']iion as tlie leading text- book on Physiology, that in presenting this edition the pulilishers deem it necessary only to remark that they have endeavored to render the mechanical execution of the work in some degree worthy its acknowledged merits by an advance in liotli the nutnber and beauty of the illustrations, atid an improvement in the style of printing. The name of the author is sufficient guarantee that each new edition I'ully keeps pace with the advance of science.


DUNGLISON'S THERAPEUTIC S-New and Mucli Improved edition.

GENERAL THERAPEUT!GS~AND MATERIA MEDiOA.

With One Hundred and Twenty Illustrations.

ADAPTED FOR A MEDICAL TEXT-BOOK.

BY ROBLEY DUNGLISON, M. D.,

Professor of Institutes of Medicine, &c. in Jefferson Medical College; late Professor of Materia Medica, &c. in the Uuiversuies of Virginia and Maryland, and m JelTerson Medical College.

Third Edition, Revised and Improved, in Two Octavo Volumes, well bound.

Out junior brethren in America will find in these volumes of Professor Dunglison a "Thesaurus Medica- Minum" more valuable than a large purse of gold. — London 3Iedico- Chirurgical Keuiew.


GRIFFITH'S UNIVERSAL FORMULARY— Nearly Ready.

THE UNIVERSAL FORMULARY:

A SYNOPSIS OF THE PHARMACOPEIAS, DISPENSATORIES AND FORMULARIES OF EUROPE AND AMERICA.

WITH NUMEROUS MAGISTERIAL FORMULAS FROM VARIOUS SOURCES. BY R. E. GRIFFITH, M. D., &c. &c.,

Author of "Medical Botany," &c. &.C. In One Octavo Volume.

This work is intended 1o embrace all that isof practical importaiy;e in the numerous Pharmacopoeias, Form- ularies and Dispensatories of Europe and of this eouniry, as well as such formulas as appeared deserving of notice in the Medical Journals, Treatises of Medicine, &c. &c.. together with many others, derived from pri- vate sources, which have never been hitherto published. It will therefore include all that is really useful in Redwood's Edition of Gray's Supplement to the Pharmacoposias, in Jourdan's Pharmncop^e, and the several works of Ellis. Fee. Paris, Thomson, Bnasley. Colten-au, Coole.y, J3ouchardaI. &c. As, in accordance vi'ith its title of a Universal Formulary, it will not he confined solely to medical formulas, the publishers hope that the numerous scientific receipts embraced, will render it of much practical importance to the Chemist and Manufacturer. It will contain

UPWARDS OF SIX THOUSAND FORMULAS, alphabetically arranged, with copious indexes, pointing out the diseases in which the preparations are to be used, &c. &c., and thus combining the advantages of all the different modes of arrangement and reference.


NEW AND COMPLETE MEDICAL BOTANY— Lately Published.

OR, A DESCRIPTION OP ALL THE MORE IMPORTANT PLANTS USED IN MEDICINE, AND

OF THEIR PROPERTIES, USES AND MODES OF ADMIJilSTRATIOiN.

BY R. EGLESFELD GRIFFITH, M. D., &c. &c.

In One large Octavo Volume, handsomely printed, with nearly Three Hundred and Fifty Illustrations

on Wood. The author of the volume is well known to be particularly qualified for this undertaking, by his botanical, as well as medical and pharmaceutical knowledge; and it strikes us, on cursory examination, that it has been prepared with much care and faithfulness, and that it will take its place at once as the standard work on the subject in this country. A succinct introductory chapter is devoted to the anatomy and structure of plants, their classical composition and products, and the outlines of classification. The officinal plants are introduced under their several natural orders, which, with the general systematic arrangement of De Can- dolle, are thrown into groups after the manner of Dr. T^indley. The plants which are really important in the Materia Medica are described in full, as well as the officinal part or production; the others are more briefly noticed; and the references, which are faithfully made, both to the botanical and medical authorities, will serve in all cases to direct the inquirer to the original sources of information. — Silliman^s Journal.


12


LEA & BLANCHARD'S PUBLICATIONS.


A NEW DISPENSATORY,

NOW READY. •


A DISPENSATOKY,


COMMENTARY ON THE PIIARMACOPffilAS OF GREAT BRITAIN AND THE UNITED STATES:

COMPRISING

THE NATURAL HISTORY, DESCRIPTION, CHEMISTRY, PHARMACY, ACTIONS, USES AND DOSES OF THE ARTICLES OF THE MATERIA MEDICA.

BY ROBERT CHRISTISON, M.D., V.P.R.S.E.,

PBESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH, TROFESSOR OF MATERIA MEDICA IN TUE "UNIVERSITY OF EDINBURGH, ETC.

Second Edition, Revised and Improved,

WITH A SUPPLEMENT CONTAINING THE MOST IMPORTANT NEW REMEDIES.

WITH COPIOUS ADDITIONS,

AND TWO HUNDRED AND THIRTEEN LARGE WOOD ENGRAVINGS,

BY R. EGLESFELD GRIFFITH, M.D.,

Al'THOR OF "A MEDICAL BOTANY," ETC.


SPECIMEN OF THE ILLUSTRATIONS.



Artemisia Absinthium, "Wormwood


In One very large and handsome Octavo Volume of over One Thousand closely prinicd Pages, with

numerous Woodcuts, beautifully prinicd, on fine white paper.

Presenting an immense quantity of matter at an unusually low price.


LEA & BLANCHARD'S PUBLICATIONS. 13

CHRISTISOTV AND GRIFFITH'S UISPEMSATORY— Continued.

The Dispensatory of Professors Wood & Bache has so long and so satisfactorily supplied the wants of the profession that the publishers, in presenting a new work of the same description, feel that it should possess additional attractions to entitle it to notice. The value of the original work of Dr. Christison is well known in England, where it has long occupied a position similar to that of the U. S. Dispensatory in this country. To this it is entitled by its clearness, conciseness, and completeness, and the care with which the author has kept it on a level with the improvements of medical science, by corrections^ and embodying in it all the new articles of the materia medica, &c. In preparing it for the use of the profession in this country. Dr. Griffith has made very exten- sive additions, introducing all the processes of the U. S. Pharniacoposia, as well as a full medical, pharmaceutical and botanical history of all articles recognized by our national standard which have been omitted by the author. In addition to this, the editor has made free use of all European and American authorities on Materia Medica, among which may more particularly be mentioned Red- wood's Second Edition of Gray's Supplement to the Pharmacopoeia, just issued, which has supplied liini with much useful information, and from which he has endeavored to convey all that appeared to him to possess especial interest — among other things, some very extended and useful tables, and accounts of various new remedial agents not as yet mentioned in the Pharmacopoeias of Great Bri- tain or of this country. In addition to this, over two hundred wood-cuts have been introduced, illustrative of articles of the Materia Medica, rendering this the only Dispensatory now before the profession presenting illustrations of the principal articles described therein.

The attention of practitioners and students, as well as of all druggists and pharmaceutists, is especially invited to this work as one embodying in the S7nallest practicable space and at an exceed- ingly low price, an immense amount of indispensable information, and as presenting a complete view of the present practical state of the materia medicas of the four leading pharmacopoiias, clearly arranged and concisely expressed.


From T. Romeyn Beck, M. D., Prof, of Mat. Med. in the Albany Medical College, and author of

"Medical Jurisprudence."

Albany, Sept. 8, 1S4S. "I received from you this morning a copy of the Second Edition of Cliristisoii's Dispensatory, edited by Griffith. I beg you lo receive my thanks for this most acceptable present.

"I have been a diligent reader of the first edition and know its value. 1 only regret that the Circular of our College has been published, or I would have placed it among my text-books. Next spring I will certainly do so if I live and hold the professorship."


From W. T. Wilson, M. D., Prof, of Mat. Med. in the Washington University of Baltimore.

Baltimore, Aug 31, lt48. "Allow me lo thank you most sincerely and cordially for your kind present of a copy of Cliristi.son and Griffith's Dispensatory, just published by you. After a cursory glance 8t the volume, which I shall peruse more at leisure hereafter, I most heartily join in your opinion in regard to its great merits, containing, as it does, all the most modern discoveries and improvements in the materia medica and pharmacy, anil r' ndered still more oceepiable to the American profession by its beautiful illustrations, the addition of Dr. Griffith, and the handsome style in which you have succeeded in bringing it out. I trust that your enterprise will be libe- rally responded to by those for. whom the work is chiefly intended."


There is not in any language a more complete and perfect Treatise. — A. Y. Annalist, Sept., 1S48.

It is not needful that we should compare it with the other pharmacopoeias extant, which enjoy and merit the confidence of the profession : it is enough lo say that it appears to us as perfect as a Dispensatory, in the present state of pharmaceutical science, could be made. If it omits any details pertaining to this brancli of knowledge which the student has a right to expect in such a work, we confess the omission has escaped our scrutiny.

We cordially recommend this work to such of our readers as are in need of a Dispensatory. They cannot make choice of a better. — The Western Journal of Medicine and Surgery, September, 1648.

In conclusion, we need scarcely say that we strongly recommend this work to all classes of our readers As a Dispensatory and commentary on the Pharmacopoeias, it is unrivalled in the English or any other lan- guage. — The Dublin Quarterly Journal. July 1848.

We earnestly recommend Dr. Chrisiison's Dispensatory lo all our readers, as an indispensable companion, not in the Study only, but in the Surgery also. — British and Foreign Medical Review.

It is exactly the work we would give lo the student for daily reading, or to the practitioner for regular refer- ence. Without being encumbered with unnecessary detail or research, it is sufficiently explicit in iis litera- ture to render it an ample encyclopredia of its subject; and at the same time, its practical information is so condensed and summary, yet without a sacrifice of even the least important fact, that to the student it cannot but be a text-book invaluable in its kind.

Had we said less concerning this volume we should have been wanting in common duty ; hut it is not ne- cessary that we should say more to convince our numerous readers that we consider Christison's Dispensa- tory to be the best English work extant upon the subject it embraces. — The Medical Times, June 1S48.

It comes not within our plan to enter into minute or detailed ciiticismof a work like the present. lis merits as a treatise on materia medica, chemical pharniacy, and pharmacology, we on a former occasion explained. It is sufficient to say that the reader will find the character given in that article most ably sustained by the present edition. The natural and chemical history of the articles is given with great clearness and accuracy. The important subject of adulterations and sophistications is throughout treated in detail. The pharmacolo- gical instructions show very great practical experience and knowledge, which can be obta'ned by experience alone. And lastly, the therapeutic directions are expounded in a judicious manner, avoiding the extremes of great confidence and unreasonable skepticism. In short, the work may be justly recommended as an excel- lent treatise on Materia Medica, Chemical Pharmacy, and Pharmacology. — The Edinburgh Medical and Sur- gical Journal, July 1543.

B.JRTLETT OJV CERT.IIJVTY' IJV JfIEBIC'IJ\'*E—A*ow Ready.

AN INQUIRY INTO THE DEGREE" OF CERTAINTY IN MEDICINE,

AND INTO THE NATURE AND EXTENT OF ITS POWER OVER DISEASE. BY EtISHA BARTLETT, M. D.,

Author of " Fevers of the United States," " Philosophy of Medical Scienxe." In, One small Volume, crown St'O, extra cloth.


14 LEA &, BLANCHARD'S PUBLICATIONS.

FOWNES' CHEMISTRY FOR STUDENTS.

A NEW AND IMPROVED EDITION.


ELEMENTARY CHEMISTRY.

THEORETICAL AND PRACTICAL. BY GEORGE FOWNES, Ph. D.,

Chemical Lecturer in the Middlesex Hospital Medical School, &c. &c.

With Numerous Illustrations. Second American Edition. Edited, with Additions,

BY ROBERT BRIDGES, M.D.,

Professor of General and Pharmaceutical Chemistry in the Plitladelphia College of Pharmacy, &c. &c.

In one large duodecimo volume, sheep or extra cloth. Tliough this work lias been so recently published, it has already been adopted as a text-book by many of the Medical Institutions throughout the country. As a work for the first class student, and as an introduction to the larger systems of Chemistry, such as Graham's, there has been but one opinion expressed concerning it, and it may now be considered as

THE TEXT-BOOK FOR THE CHEMICAL STUDENT. An admirable exposition of ilie present state of chemical science, simply and clearly written, and display- ing a thorough practical knowledgeof ilsdetails, as well as a profound acquaintance with its principles. The illustrations, and the whole ge;ting-up of the book, merit our highest praise.— JJc/a's/i and Foreign Med. Rev.

Remarkable for its clearness, and the most concise and perspicuous work of the kind we have seen, admi- rably calculated lo prepare the student for the more elaborate treatises —Phnrmncentical Journal. From JAMBS RENWICK, Professor of Chemistry, Columbia College, New York. "The very best manual of Chemistry with which 1 am acquainted in the English language."

New York, Feb. 12th, 1S4S. •

This work of Fownes, while not enlarging on the subject as much as Graham, is far more lucid and ex- panded than the usual small introductory works. Professors recommending it to their classes may rely upon its being kept up to the day by frequent revisions.


MANUALS on THE BLOOD AND URINE:

CONSISTING OF I. A PRACTICAL MANUAL, CONTAINING A DESCRIPTION OF THE GENERAL, CHE- MICAL AND MICROSCOPICAL CHARACTERS OF THE BLOOD AND SECRETIONS OF THE HUMAN BODY,

AS WELL AS OF THEIR COMPOUNDS, INCLUDING BOTH THEIR HEALTHY AND DISEASED STATES: WITH

THE BEST METHODS OF SEPARATING AND ESTIMATING THEIR INGREDIENTS. ALSO, A SUCCINCT

ACCOUNT OF THE VARIOUS CONCRETIONS OCCASIONALLY FOUND IN THE BODY AND

FORMING CALCULI.

BY JOHN WILLIAM GRIFFITH, M. D.. F.L.S., &c.

II. ON THE ANALYSIS OF THE BLOOD AND URINE IN HEALTH AND DISEASE, AND OiSr THE TREATMENT OF URINARY DISEASES.

BY G. OWEN REES, M. D., F. R.S., &c. &c.

m. A GUIDE TO THE EXAMINATION OF THE URINE IN HEALTH AND DISEASE,

FOR THE USE OF STUDENTS.

BY ALFRED MARK WICK.

The whole forming One large royal 12mo. Volume, of Four Hundred and Sixty Pages, With about one hundred figures oti five plates.

The three works embraced in the volume were published in London, separately, but the imme- diate connection of the subjects treated, and their increasing importance, have induced the Ameri- can publishers to embody them in a volume suitable for reference and preservation.

Although addressed especially to students, it contains almost all the iiUbrmaiion upon these matters which the practitioner requires. — Dublin Medical Press.

The clit-mical processes recommended are simple, yet scientific; and the work will be very useful to the medical alumni for whom it is m\e\v.\e.&.— Medical Times.

The author must be admitted to have attained his object in presenting a convenient bedside companion. — Dr. lianking'^s Abstract.


CHURCHILL ON FEMALES— Edition of 1847.


THE DISEASES OF FEMALES,

INCLUDING THOSE OF PREGNANCY AND CHILDBED.

BY FLEETWOOD CHURCHILL, M.D.,

Author of "Theory and Practice of Midwifery," &c. &c. FOURTH AMERICAN, FROM THE SECOND LONDON EDITION, WITH ILLUSTRATIONS.

EDITED, WITH NOTES,

BY ROBERT M. HUSTON, M. D., &c. &c.

In One Vohnne, Octavo.

The rapid sale of three editions of this valuable work stamps it so emphatically with the approbation of the

profession of this country, that the publishers, in presenting a fourth, deem it merely necessary lo observe,

that every care has been taken, by the editor, to supply any deficiencies which may have existed in Ibriner

impressions, and to bring the work fully up lo the date of publication.


LEA & BLANCHARD'S PUBLICATIONS. 15

]Ve-»v and Enlarged Kdttiou, Browglit up to 1848.

■WILLIAMS' PATHOLOGY. Now Ready.

PRINCIPLESl)F MEDICINE,

COMPRISING

GENERAL PATHOLOGY AND THERAPEUTICS,

AND A BRIEF GENERAL VIEW OF

ETIOLOGY, NOSOLOGY, SEMEIOLOGY, DIAGNOSIS, PROGNOSIS, AND HYGIENICS.

BY CHARLES J. B. WILLIAMS, M.D., F.R.S.,

Fellow of the Royal College of Physicians, &c.

EDITED, WITH ADDITIONS, BY MEREDITH CLYMER, M. D.,

CousuUing Physician to the Philadelphia Hospital, &c. &c. Third American, front the Second and Enlarged J^ontlon JEdtlion,

In One Volume Octavo,

The delay which has prevented the appearance of this edition until the present lime, has arisen from the extensive modifications and iiriprovemenis introdnced hy the author, bringing the work fully up to a level with the present stale of knowledge on the numerous and important subjects of wh'ch he treats. These ad- ditions pervade almost every portion of the work, but they preponderate in the following subjects, in which we can mention— in Etiology, mechanical, chemical, and dietetic caiises of diseases, defective cleanliness, ven- tilation and drainage. In Pathology, tlte tabular views of the eli^nents of disease ; reflex action and sympa- thy ; elementary changes in the blood; congestion; determination of blood ; inflammation, in its nature, manifold results, aiid tnodes of treat^nent ; degeneration of textures ; cacoplastic and aplastic deposits and their treatment, with cf notice of the action of cod liver oil ; and the whole chapter on Hygienics, comprising/bod/ clothing j air and tetnperature ; exercise; sleep; mental occupation and excretion. In addition to this, the editor hss introduced much new matter in the sections on Etiology, Diseases of the Co.nstitdents of THE Blood, Structural Diseases, Semeiology, Prognosis and Hygienics, and he has also added a section on the Signs op Disease.

It will be seen from this rapid summary, that the additions to this edition of Dr. Williams' Principles will fully maintain its high reputation, and render it worthy a continuance of tlie favor which has caused its in- troduction as a text-book into so many colleges throughout the Union.

It is entitled to claim the reader's best attention, and its perusal and sludy will be amply remunerative. It is a work calculated to elevate the character of medical science, from its correct and lucid exposition of the great principles of scientific investigation, and its plain, practical cliaracter, will recommend it to the student and practitioner of medicine and surgery.— .4?n. Medical Jo^irnal, July lfc4S.


ROYLE'S NEW WORK.

MATEETA MEDICA AND THERAPEUTICS;

INCLUDING THE PREPARATIONS OF THE PMARMACOPlEIAS OF LONDON, EDINBURGH, DUBLIN, AND OF THE UNITED STATES,

"WITH MANY NEW ]MEDTCI?IES.

BY J. FORBES ROYLE, M. D., F.R.S,

Late of the IMedical Staff in the Bengal Army, Professor of IVIateria Medica and Therapeutics, King's College

London, &c. &c.

EDITED BY JOSEPH CARSON, M. D.,

Professor of Materia Medica in the Philadelphia College of Pharmacy, he. &c. WITH NINETT-EIGHT ILlUSTRATIOIfS.

In one large octavo volume of about 700 pages. Being one of the most beautiful Medical works published in this country.

This work is ably done— the botanical part with great skill, and the chemical, natural history, and thera peutic department, most perfect and complete. — Edinburgh Medical Journal.

This is another of that beautiful and cheap series of manuals published by Mr. Churchill. In the execution of the wood cuts, of plants, flowers and fruits, Mr. Bagg seems almost to have exceeded his former doings. The work is, indeed, a most valuable one. It would be injustice to the learned author not to state that, in addi- tion to what other works on the subject necessarily contained, the reader will find here not a little that is original, or introduced for the first time, more especially in the details of botany and natural history. — British and Foreign Medical Review.


RAMSBOTHAM'S MIDWIFERY.

THE PRINCIPLES AND PRACTICE OF

OBSTETRIC MEDICINE AND SURGERY,

IN REFERENCE TO THE PROCESS OF PARTURITION.

ILLUSTHATED BY

One hundred and fortjf-etg-ht J.arg-e Fi^-ures on 55 TAthographic Plates,

BY f^RANCIS H. RAMSBOTHAM, M. D., &c.

A NEW EDITION, FROM THE ENLARGED AND REVISED LONDON EDITION.

In one large ituj^erial octavo volume, well bound. It is the book of IMidwifery for students ; clear, but not too minute in its details, and sound in its practical instructions It is so completely illustrated by plates (admirably chosen and executed), that the stuilent must be stupid, indeed, who does not understand the details of this branch of the science, so far, at least, as descrip- tion can make tliera intelligible. — Dublin Journal of Medical Science.


16 LEA & BLANCHARD'S PUBLICATIONS.

Now Ready, brought up to July 1848,

A New Edition of WESON'S HUMAN ANATOMY, much Improved.

A SYSTEM OF HUMAN ANATOMY,

GENERAL AND SPECIAL. BY ERASMUS WILSON, M. D.

FOURTH AMERICAN, FROM THE LAST ENGLISH EDITION.

EDITED BY PAUL B. GODDARD, A.M. M.D.,

Professor of Anatomy in the Franklin Medical College, Philadelphia.

WITH TWO HUNDRED AND FIFTY ILLUSTRATIONS.

Beautifully printed in One large Octavo Volume of nearly Six Hundred pages.

In passing through numerous ^editions, both in England and this country, this work has received

many improvements and modifications, and it may now be confidently presented to the profession

as containing all the important facts in general and special anatomy in a clear and lucid manner,

fully brought up to the present level of science. It has long been known as the favorite text-book

in this department of medical science, and it is now used in a large proportion of the colleges

throughout the country, to which it is further recommended by its admirable series of illustrations,

its beautiful mechanical execution, its neat and convenient size, and the very low rate at which it

is furnished.

In many, if not all the colleges of the Union, it has become a standard text book. — N. Y. Medical Journal.

From Granville Sharp Pattison, M. D., Prnfessor of Anatomy in tlie University of New York. " I have a very high opinion of the work of Wilson, and I feel that you have conferred a favor on the pro- fession by the very handsome edition of it which you have published."

From J. N. Bvbee, M. D., Professor of Anatomy in tlie Memphis Medical College. "I look upon this book as one of the best, if not the very best, in the English language, for the practical anatomist."

Prom Professor W. R. Grant, of the Pennsylvania Medical College. "I have heretofore considered Wilson's Anatomy as one of the best books for the use particularly of stu- dents, and as such have recommended it to the classes of the Pennsylvania Medical College."


FERGUSSON'S SURGERY-New and Improved Edition of 1848, Now Ready.

A SYSTEM OF PRACTICAL SUEGEEY.

BY WILLIAM FERGUSSON, F.R.S.E.,

Professor of Surgery in King's College, London, &c. &c. THIRD AMERICAN, FROM THE LAST ENGLISH EDITION.

With Two Hundred and Seventy-four Illustrations by Bagg, Engraved ty Gilbert.

In One large and beautifully printed Octavo Volume of Six Hundred and Thirty large Pages.

It is with unfeigned satisfaction that we call the attention of the profession in this country to this excellent work. It richly deserves the reputation conceded to it, of being the best practical surgery extant, at least in the English language. — Medical Examiner.

Professor Fergusson's work, we feel persuaded, will be as great a favorite as it deserves, for it combines the powerful recommendations of cheapness and elegance, with a clear; sound, and practical treatment of every subject in surgical science. The ilkustrations, by Bagg, are admirable — iu his very best style. — Edin- burgh Journal of Medical Science.


DRUITT'S SURGERY, NEW EDITION,

NOW READY, 1848.

THE PRiNOIPLES AND PBAOflGE OF MODERN SUBeERY.

BY ROBERT DRUITT.

A NEW AMERICAN, FROM THE LAST AND IMPROVED LONDON EDITION.

Edited by F. W. SARGENT, M. D., Author of "Minor Sdrgert," "With One Hundred and Ninety-three Beautiful "Wood Engravings-

In One well printed octavo Volume of Five Hundred and Seventy-six Pages.

The improvement of this edition will be found fully to warrant a continunnce of the favor so long extended to this e.^cellent work. The size of the page has been increased, and the volume itself enlarged by about fifty pages, giving ample space for the addition of all new and interesting matter which the progress of the science has rendered necessary since the appearance of the last edition. The wood-cuts have been thoroughly revised, many of them rejected and their places supplied by better designs, and numerous new engravings added. The amount of these changes may be esti- mated from the fact, that over half of the illustrations in this edition have appeared in no former one. The mechanical execution will also be found much improved.

An unsurpassable compendium not only of surgical but of medical practice. — London Medical Gazette.

This work merits our warmest commendations, and we strongly recommend it to young surgeons as an admirable digest of the principles and practice of modern Surgery. — Medical Gazette.


LEA & BLANCHARD'S PUBLICATIONS. 17


TAYLOR'S TOXICOLOGY. Just Published.

ON p6~isoiys

IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE.

BY ALFRED S. TAYLOR, F.R.S.,

Lecturer on Medical Jurisprudence and Cliemistry in Guy's Hospital, and author of "Medical Jurispru- dence," &c. &c.

Edited, ivitli Notes and Additions,

BY R. EGLESFELD GRIFFITH, M. D.

In one large octavo volume, to match the "ISIedieal Jurisprudence' of the same author.

It is, so far as our knowledge extends, incomparably the best upon the subject; in the highest degree creditable to the author, entirely trustworthy, and indispensable to the student and prac- titioner, and likely to prove of immense service to the local practitioner, whether engaged in the duty of prosecuting the criminal or defending the innocent from condemnation. — N. Y. Annalist..

It is sate to say, that the volume of Mr. Taylor forms one of the most complete treatises on poisons extant, and that it is a work whicli ought to be in the hands of every physician and lawyer. It is an elaborate epitome of all that is known on the subject of poisons. The suliject is one of deep interest. We shall avail ourselves of tlie earliest opportunity to say more about this excellent treatise.— The Western Journal of Me- dicine and Surgery.

We can most unreservedly recommend Mr. Taylor's treatise to our readers as the most complete, and at the same time, condensed system of Toxicology extant, and as the one which, we feel assured, will hence- forth rank in this country as the chief authority on the subject.— Medico-Chirurgical Review.

The reputation acquired by Mr. Taylor, by his researches in Toxicology and Legal Medicine, is j?r7OT/i facie evidence in favor of anything coming from his hands ; and we accordingly find that in the present treat- ise, he has not fallen short of his reputation. It, moreover, fills up what has been a gap in the science of Toxicology. Dr. Christison and M. Orfila have rather endeavored to elucidate the chemical history, modes of detection, and treatment in cases m poisoning Dr. Taylor, on the contrary, with fewer chemical details, has directed his inquiries towards a careful review of the symptoms peculiar to each poison, theexaminalion and comparison of the symptoms of each with the other, and with similar symptoms which may be developed by diseased actions in the economy. His work thus, besides being an excellent guide to the medical prac- titioner, in assisting his diagnosis in cases of poisoning, is also valuable to the medical man who is called upon to give his teslimony before a court in criminal cases. — The CharUston Medical Journal and Review.

For ourselves, we feel confident that it will ere long be the table-book of every medical practitioner who has the least regard for his own reputation, and be found in the circuit-bag of the Barrister, in company with Archbold's Criminal Pleadings, and Roscoe's Criminal Evidence. — The Dublin Quarterly journal.


•fust Published.

THE HUMAN BRAIN; ITS STRUCTURE, PHYSIOLOGY AND DISEASES.

WITH A DESCRIPTION OF THE TYPICAL FORM OF THE BRAIN IN THE

ANLMAL KINGDOM.

BY SAMUEL SOLLY, F. R. S., &C.,

Senior Assistant Surgeon to St. Thomas' Hospital, &c.

FROM THE SECOND AND MUCH ENLARGED LONDON EDITION.

In One Octavo Volume ; with One Hundred and Twenty Wood-cuts.

The most complete account of the anatomy, physiology, and pathology of the brain that has hitherto ap- peared. We earnestly advise all our professional brethren to enrich their libraries with this admirable treatise. — Medico- Ch irurgical Revietv.

In the arrangement of this admirable treatise we have, first, an excellent structural anatomy; second, a deeply interesting comparative anatomy, extending over many of the species of the different genera which make up the great classes of the animal kingdom; third, an account of the protective apparatus; fourth, a chapter on the weight; fifth, on the configuration of the brain. We have then an elaborate account of its dissection, and thai of the spinal cord, of the cerebral nerves and circulation, of the devejopmentof the brain, and lastly some remarks (and here occurs the only deficiency we have to complain of) on the physiology of the cerebrospinal axis, and some phrenological observations. All the preceding topics being treaied of ac- cording to the improved mode of dissection of ihe organ adopted at the present day, assisted by microscopi- cal research, and written professedly in elucidation of its internal structure, &c., by one of the ablest cere- bro anatomists, if we may coin a word, of the day, ii is useless to say that this treatise is an unsurpassed guide 10 the student in his investigations of the delicate and complex structure of this beautiful and curious organ.

The pathological portion of the volume occupies about one half of the whole, and we know of none better, and few as good. The various diseases to which the brain is liable are treated of scientifically, concisely, sufficiently, and ably; and many valuable and well recorded cases are related in illustration of symptoms, effects, and treatment ; and the whole is characterized by a profound knowledge of anatomy, and pathologi- cal anatomy, descriptive, histological and chemical. We should suppose that neither the encephalon, nor its diseases could be properly studied without reference to this volume — The Annnlist.

We have felt great satisfaction in again accompanying Mr. Solly in his lucid description of the exquisite structural arrangements of this wonderful organ; and we can unhesitatingly say, that the student will find comprehended in the first ten chapters of Mr. Solly"s treatise, a series of the most comprehensive and inte- resting anatomical details in the English language. We shall, however, chiefly confine our remarks lo the eleventh and concluding part of the treatise, (which, by the by, rather exceeds in quantity of letterpress the whole of the other ten taken together,! containing what the author modestly terms an "oullineof the diseases of the brain," but which we do not hesitate to characterize as a very excellent and practical de=cripiion of this important and obscure class of maladies. ♦ # * * This woik is one which fully deserves, and will certainly obtain a place among our medical classics. The subjects of which it treats, like almost all questions in anatomy and pathology, will doubtless, as science advances, receive numerous addilmns and modifications; but the. scope of the treatise is so ample, and the arrangement of its various topics so judi- cious, that we believe it need never be superseded as a standard work of reference. — London Med. Gazette.


18 LEA & BLANCHARD'S PUBLICATIONS.

WATSON^S PEACTICE.

A NEW EDITION. LECTURESONTHE

PRINCIPLES AND PRACTICE OF PHYSIC.

DELIVERED AT KING'S COLLEGE, LONDON.

BY THOMAS WATSON, M.D., &c. &c. Third American from the last London Edition.

REVISED, WITH ADDITIONS,

BY D. FRANCIS CONDIE, M. D.,

Author of a Work on the " Diseases of Children," &c.

In One Octavo Volume.

Of nearly ELEVEN HUNDRED LARGE PAGES, strongy bound with raised bands. The rapid s;ile of two large editions of this work is an evidence of its merits, and of its general favor with the American praotilioner. " To commend it still more strongly to the profession, the publishers have gone to a great expense in preparing this editioji with larger type, finer paper, and stronger binding with raised bands. It is edited with reference particularly to American practice, by Dr. Condie; and with these nume- rous improvements, the price is siill kept so low as to be within ihe reach of all, nnd to render it among the cheapest works offered to the profession. It has been received with the utmost favor by the medical press, both of this country and of Europe, some of the notices of which maybe seen in the Supplement to the Medical News for June 1847.


CARPENTER'S HUMAN PHYSIOLOGY.

LATELY ISSUED. A NEW, MUCH IMPROVED AND ENLARGED EDITION OF

THE PRINCIPLES OF HUMAM PHYSIOLOGY,

M'lTH THKIR CHIEF APPLICATIONS TO PATHOLOGY, HYGIENE, AND FORENSIC MEDICINE.

BY WILLIAM B. CARPENTER, M. D., F.R. S.,

Fullerian Professor of Physiology in the Royal Institution of Great Britain; author of " Elements

of Physiology," " Principles of General and Comparative Physiology," "Principles of

Animal Physiology," &c. &c.

THIRD AMERICAN FROM THE LAST LONDON EDITION,

WITH NOTES AND ADDITIONS BY

MEREDITH CLYMER, M. D.,

Consulting Physician to the Philadelphia Hospital, &c. &c.

Containing Three Hundred and Seventeen Wood-cut and other lustrations.

In One Large and Beautifully Printed Octavo Volume of over seven hundred andffty pages, f^ongly hound.


THE CYCLOPEDIA OF PRACTICAL MEDICINE;

COMPRISING

Treatises on the Nature and Treatment of Diseases, Materia Medica and The- rapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c.

EDITED EY

JOHN FORBES, M. D., F. R.S., ALEXANDER TWEEDIE, M. D., F.R. S., AND JOHN CONOLLY, M. D.

Revised, v/ith Additions, BY ROBLEY DUNGLISON, M. D.

THIS WOKK IS NOW COMPLETE, AND FORMS FOUR LARGE SUPER-ROYAL OCTAVO VOLUMES.

Containing Thirty-two Hundred and Fifty-Four unusually large Pages in Double Columns, Printed on Good Paper, with a New and Clear Type.

The whole well and strongly bound, with Raised Bands and Double Titles.

Or, to be had in Twenty-four Parts, at Fifty Cents each.

For a list of Articles and Authors, together with o;pinions of the press, seevarioKS Supplements to the Medical News and Library.


LEA & BLANCHARD'S PUBLICATIONS. 19

OTHER WORKS

IN

VARIOUS DEPARTMENTS

OF

MEDICINE AND SURGERY.

PUBLISHED BY

L^A AND BLANCHARD.


AMERICAN JOURNAL OF THE MEDICAL SCIENCES. Edited by Isaac Hays, M.D. Pub- lished quarterly at $5 per annum.

ARNOTT'S PHYSICS.— The Elements of Physics in plain or non-technical language. A new edition, edited by Isaac Hays, M. D. In 1 vol. 8vo., sheep, with 176 wood-cuts.

ABERCROMBIE ON THE STOMACH.— Pathological and Practical Researches on Diseases of the Stomach, Intestinal Canal, &c. Fourth edition, in 1 vol. 8vo., sheep.

ABERCROMBIE ON THE BRAIN.— Pathological and Practical Researches on the Diseases of the Brain and Spinal Cord. A new edition, in one octavo volume, sheep.

ASHWELL ON FEMALES.— A Practical Treatise on Diseases Peculiar to Women, edited by Goddard. New edition, 1S48, I large vol. Svo.

ALISON'S PATHOLOGY.— Outlines of Pathology and Practice of Medicine; in three parts; con- taining Preliminary Observations, Inflammatory and Febrile Diseases, and Chronic or Non-Febrile Diseases. In one neat octavo volume, sheep.

BENNET'S PRACTICAL TREATISE ON INFLAMMATION, ULCERATION AND INDURA- TION OF THE NECK OF THE UTERUS. In one small 12mo. volume, cloth.

BURROWS ON CEREBRAL CIRCULATION.— On the Disorders of the Cerebral Circulation, and on the Connection between Affections of the Brain and Diseases of the Heart. With colored plates, t vol. Svo., 1848.

BIRD ON URINARY DEPOSITS.— Urinary Deposits, their Diagnosis, Pathology and Therapeu- tical Indications. In one neat octavo volume, cloth, with numerous wood-cuts.

BIRD'S NATURAL PHILOSOPHY.— Being an Experimental Introduction to the Study of the Physical Sciences. Especially intended for the Use of the Medical Student. In one handsome royal 12mo. volume, with 372 cuts.

BERZELIUS ON THE KIDNEYS AND URINE. In 1 vol. Svo., cloth.

AUCKLAND'S GEOLOGY.— Geology and Mineralogy, with reference to Natural Theology; a Bridtjewater Treatise. In two octavo volumes, with numerous maps, plates, &c.

BLAKISTON ON THE CHEST.— Practical Observations on certain Diseases of the Chest, and on the Principles of Auscultation. 1 vol. 8vo., cloth, 1848.

BRODIE-S SURGICAL LECTURES.— Clinical Lectures on Surgery. 1 vol. 8vo., cloth.

BRODIE ON THE JOINTS.— Pathological and Surgical Observations on the Diseases of the Joints. 1 vol. 8vo., cloth.

BRODIE ON URINARY ORGANS.— Lectures on the Diseases of the Urinary Organs. 1 vol. Svo., cloth.

  • ^* These three works may be had neatly bound together, forming a large volume of

" Rrodie's Surgical Works."

BUDD ON DISEASES OF THE LIVER. — In one octavo volume, sheep, with beautiful colored plates and numerous wood-cuts.

BRIDGEWATER TREATISES. The whole complete in 7 vols. 8vo., containing Roget's Animal and Vegetable Physiology, in 2 vols., with many cuts ; Kirby on the History, Habits, and In- stinct of Animals, 'l vol., with plates; Prout on Chemistry; Chalmers on the Moral Condition of Man; Whewell on Astronomy; Bell on the Hand; Kidd on the Physical Condition of Man ; and Buckland's Geology, 2 vols., with many plates and maps.

BARTLETT'S PHILOSOPHY OF MEDICINE.— Essay on the Philosophy of Medical Science. In two parts; one neat octavo volume, extra cloth.

BRIGHAM ON MIND, &c.— The Influence of Mental E.xcitement>nd Mental Cultivation on Health. In one neat 12mo. volume, extra cloth.

BILLING'S PRINCIPLES OF MEDICINE.— The First Principles of Medicine. From the fourth London edition; in one octavo volume, cloth.

BENEDICT'S CHAPMAN.— Compendium of Chapman's Lectures on the Practice of Medicine. One neat vol., Svo.

CHAPMAN'S LECTURES ON THORACIC AND ABDOMINAL VISCERA. 1 vol. Svo.

CHAPMAN'S LECTURKS ON FEVERS, DROPSIES, GOUT, RHEUMATISM, &c. &c. 1 vol. Svo.

CARPENTER'S ELEMENTS OF PHYSIOLOGY.— For the Use of the Medical Student. One large vol. Svo,, with ISO illustrations.

CARPENTER'S VEGETABLE PHYSIOLOGY. — A Popular Treatise on Vegetable Physiology. With numerous wood-cuts; in one 12mo. volume, extra cloth.

CLATER AND SKINNER'S FARRIER.— Every Man his own Farrier; containing the Causes, Symptoms, and mofet approved Methods of Cure of the Diseases of Horses. From the 28th London edition ; edited by Skinner; in one l2mo. volume, cloth.

CLATER AND YOUATT'S CATTLE DOCTOR.— Every Man his own Cattle Doctor; containing the Diseases of Oxen, Sheep, Swine, &c. Edited by Youatt, and revised by Skinner; with wood-cuts; in one volume 12mo. COOPER (SIR ASTLEY) ON THE ANATOMY AND TREATMENT OF ABDOMINAL HERNIA. 1 large vol., imp. Svo., with over 130 lithographic figures.


20 LEA & BLANCH ARD'S PUBLICATIONS.

COOPER ON THE STRUCTURE AND DISEASES OF THE TESTIS, AND ON THE THYMUS

GLAND. 1 vol., imp. 8vo., with 177 figures on 29 plates. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST, WITH TWENTY-FIVE

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Cooper and J. C. Warren. 1 vol., Svo., with 133 cuts. CLYMER AND OTHERS ON FEVER.— Fevers, their Diagnosis, Pathology and Treatment. In

one large vol. Svo. DURLACHER ON CORNS, BUNIONS, &c.— A Treatise on Corns, Bunions, the Diseases of Nails,

and the General Management of the Feet. In one 12mo. volume, cloth. DEWEES'S MIDWIFERY.— A Comprehensive System of Midwifery, for the Use of the Medical

Student. Eleventh edition, 1 vol. Svo., with plates. DEVVEES ON FEMALES. — A Treatise on the Diseases of Females. Ninth edition, 1 vol. 8vo.,

plates. DEWEES ON CHILDREN.— A Treatise on the Physical and Medical Treatment of Children.

Ninth edition, 1 vol. Svo. DUFTON ON DEAFNESS AND DISEASES OF THE EAR. In 1 12mo. vol., cloth, with a plate. ELLIS'S FORMULARY. — The Medical Formulary, being a Collection of Prescriptions derived

from the Writings and Practice of the most eminent Physicians of America and Europe; to

which is added an Appendi.\, containing the usual Dietetic Preparations and Antidotes for

Poisons. By Benjamin Ellis, M.D. Eighth edition, with extensive alterations and additions.

By Samuel George Morton, M. D. In one neat Svo. volume. ESQUIROL ON INSANITY. — Mental Maladies, considered in relation to Medicine, Hygifene and

Medical Jurisprudence. Translated by E. K. Hunt, M. D., &c. In 1 vol. Svo. FOWNES' ELEJVIENTS OF CHEMISTRY for the Use of the Medical Student. In one handsome

volume, royal 12mo., with numerous cuts. Second American edition, by Bridges. GRIFFITH'S CHEMISTRY OF THE FOUR SEASONS— Spring, Summer, Autumn and Winter.

One neat vol. 12mo., with cuts. GUTHRIE ON THE BLADDER, &c.— The Anatomy of the Bladder and Urethra, and the Treat- ment of the Obstructions to which those Passages are liable. In 1 vol. Svo. HARRIS ON MAXILLARY SINUS.— Dissertation on the Diseases of the Maxillary Sinus. In

one small octavo volume, cloth. HOPE ON THE HEART.— A Treatise on the Diseases of the Heart and Great Vessels. Edited

by Peimock. 1 vol. Svo., with plates. HARRISON ON THE NERVES.— An Essay towards a correct Theory of the Nervous System.

In one octavo volume, sheep. HUGHES ON THE LUNGS AND HEART.— Clinical Introduction to the Practice of Auscultation,

and other Modes of Physical Diagnosis, intended to simplify the Study of the Diseases of the

Heart and Lungs. By H. M. Hughes, M. D., &c. In one 12mo. volume, with a plate. HOBLYN'S MEDICAL DICTIONARY.— Dictionary of the Terms used in Medicine. Edited by

Hays. 1 vol.roval 12ino. HASSE'S PATHOLOGICAL ANATOMY.— An Anatomical Description of the Diseases of the Or- gans of Circulation and Respiration. Translated and edited bySwaine. In one octavo volume. INTRODUCTION TO PRACTICAL ORGANIC CHEMISTRY; based on the Works of Brande,

Liebig, and others. In one volume ISmo., paper, price 2.5 cents. INTRODUCTION TO VEGETABLE PHYSIOLOGY.— With reference to the Works of De Can-

dolle, Lindley, &c. In one volume, ISmo., paper, price 25 cents. KIRBY ON ANIMALS.— The History, Habits, and Instinct of Animals. A Bridgewater Treatise.

In one large volume Svo., with p ales. KIRBYAND SPENCE'S ENTOMOLOGY.— An Introduction to Entomology ; or Elements of the

Natural History of Insects; comprising an Account of Noxious and Useful Insects, of their

Metamorphosis, Food, Stratagems, Habitations, Societies, Motions, Noises, Hybernation, In- stinct, &c. &c. In one large octavo volume, neat extra cloth, with plates, plain or beautifully

colored. From the sixth London edition. LISTON AND MUTTER'S SURGERY.— Lectures on the Operations of Surgery. One large vol.

Svo., with 216 cuts. LALLEMAND ON SPERMATORRHOEA.- The Causes, Symptoms, and Treatment of Sperma-

torrhcea. Translated and edited by Henry J. M'Dougall, M. D. 1 vol. Svo., 1848. LAWRENCE ON RUPTURES. — A'Treatise on Ruptures, from the fifth London edition. In one

octavo volume, sheep. MILLER'S PRINCIPLES OF SURGERY. One large vol. 8vo., 2d American edition, 1848. MILLER'S PRACTICE OF SURGERY. One large vol. Svo. MAN'S POWER OVER HIMSELF TO PREVENT OR CONTROL INSANITY. One vol. ISmo.,

paper, price 25 cents. MAURY'S DENTAL SURGERY. — A Treatise on the Dental Art, founded on Actual Experience.

Illustrated by 241 lithographic figures and 54 wood-cuts. Translated by J. B. Savier. In one

octavo volume, sheep. MEDICAL NEWS AND LIBRARY, published monthly at One Dollar per annum. MULLER'S PHYSIOLOGY.— Elements of Physiology. Translated by Wm. Baly, M. D., and

edited and arranged by John Bell, M.D. In one large octavo volume, sheep. MEIGS' COLOMBAT ON FEMALES.— Treatise on the Diseases of Females, and on the Special

Hygl^no of their Sex. Translated by C. D. Meigs, M. D. In 1 vol. large 8vo., with cuts. MATTEUCCI ON LIVING BEINGS.— Physical Phenomena of Living Beings. Edited by Pereira.

1 vol. royal 12mo., with cuts. PRACTICAL ORGANIC CHEMISTRY. ISmo., sewed, price 25 cents. PROUT ON THE STOMACH.— On the Nature and Treatment of Stomach and Renal Diseases. In

one octavo volume, sheep, with colored plates.


LEA & BLANCH ARD'S PUBLICATIONS. 21

PHILIP ON INDIGESTION.— A Treatise on Protracted Indigestion. In 1 vol. Svo.

PHILLIPS ON SCROFULA. — Scrofula, its Nature, its Prevalence, its Causes, and the Principles of its Treatment. In one neat octavo volume, cloth, with a plate.

ROGET'S PHYSIOLOGY.— A Treatise on Animal and Vegetable Physiology, with over 400 illus- trations on Wood. In two octavo volumes, cloth. A Bridgewater Treatise.

ROGET'S OUTLINES OF PHYSIOLOGY.— Outlines of Physiology and Phrenology. In one large octavo volume, cloth.

RICORD ON VENEREAL.— A Practical Treatise on Venereal Diseases; with a Therapeutical Summary, and a special Formulary. In one vol. 8vo., cloth.

ROBERTSON ON TEETH.— A Practical Treatise on the Human Teeth, with Plates. One small volume, octavo, cloth.

SIMON'S CHEMISTRY OF MAN.— Animal Chemistry with reference to the Physiology and Pa- thology of Man. One large vol. Svo., with plates.

TODD & BOWMAN'S PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN, with nu- merous illustrations. Publishing in the Medical News and Library.

TAYLOR'S MEDICAL JURISPRUDENCE.— With numerous Notes and Additions, and Refer- ences to American Practice and Law. By R. E. Griffith, M. D. In one vol. Svo.

THE CONNECTION BETWEEN PHYSIOLOGY AND INTELLECTUAL SCIENCE. 1 vol. ISmo., paper, price 25 cents.

THOMPSON'S SICK ROOM.— Domestic Management of the Sick Room, Necessary in Aid of Medical Treatment for the Cure of Diseases. Edited by R. E. Griffith. In one large royal 12mo. volume, extra cloth, with wood-cuts.

TRAILL'S MEDICAL JURISPRUDENCE.— Outlines of a Course of Lectures on Medical Juris- prudence. Revised, with numerous Notes. In one octavo volume, cloth.

VOGEL'S PATHOLOGICAL ANATOMY.— The Pathological Anatomy of the Human Body. Translated by Day. One large vol. 8vo., with plates.

WALSHE ON THE LUNGS.— Physical Diagnosis of the Diseases of the Lungs. In one neat 12mo. volume, extra cloth.

WILLIAMS AND CLYMER ON THE CHEST.— A Treatise on the Diseases of the Respiratory Organs, including the Larynx, Trachea, Lungs, and Pleura. With numerous Additions and Notes, by Meredith Clymer, M. D. In one neat Svo. volume, with cuts.

WHITEHEAD ON ABORTION AND STERILITY.— The Causes and Treatment of Abortion and Sterility, being the Result of an extended Practical Inquiry into the Physiological and Mor- bid Conditions of the Uterus. 1 vol. 8vo., 1848.

WILSON'S DISSECTOR. THE DISSECTOR, OR PRACTICAL AND SURGICAL ANATOMY. With 106 illustrations. Modified and re-arranged by Paul B. Goddard, M. D., &c. In one large royal 12mo. volume, sheep.

WILSON ON THE SKIN.— Anatomy and Diseases of the Skin. 2d edition, improved, 1 vol. Svo.

  • ^* Same work, with colored plates; also the plates sold separate.

YOU ATT ON THE HORSE.— The Horse: containing a full account of the Diseases of the Horse, with their Mode of Treatment; his Anatomy, and the usual Operations performed on him; his Breeding, Breaking, and Management; and Hints on his Soundness, and Purchase and Sale. Together with a General History of the Horse ; a Dissertation on the American Trotting Horse, how Trained and Jockeyed; an Account of his Remarkable Performances; and an Essay on the Ass and the Mule. By J. S. Skinner, Assistant Postmaster-General, and Editor of the Turf Register. In one volume octavo, with numerous cuts.


GARDNER'S MEDICAL CHEMISTRY— NowReady.

MEDICAL CHEMISTRY, FOiTtHE USE OF STUDENTS:

BEING A MANUAL OF THE SCIENCE WITH ITS APPLICATIONS TO TOXI- COLOGY, PHYSIOLOGY, THERAPEUTICS, HYGIENE, &c. &c. BY 1). PEREIRA GARDNER, M. D.,

Late Professor of Chemistry in the Philadelphia College of Medicine, and of Chemistry and Nat. Philos.

ill Hampden Sidney College. &c.

In One handsome royal 12mo. Volume, with Illustrations.

This work, while embodying a full course of modern Chemistry, has been prepared especially for the use of the student of medicine. With this view, the author has endeavored not so much to make a treatise on abstract Chemistry, as to present all the applications of the science to the various departments of medicine. There appears lo be a necessity for a book of this kind, which has not as yet been supplied among the nu- merous and excellent textbooks before the profession. 'Ihe limited lime devoted to ihe study in our medical college.s does not permit the teacher to point out the numerous and important applications of modern Che- mistry to Medicine, or enable the student to discover them for himself. These topics, therefore, have been dwell on al large by the author, while he has passed cursorily over those objects which are known only as chemical or mineralogical curiosities.

JONES ON THE EYE— Lately Published.

THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY.

BY T. WHARTON JONES, F.R.S., &c. &c.

WITH ONE HUNDRED AND TEN IIiL.USTRATIONS.

EDITED BY ISAAC HAYS, M.D., &c.

In one very neat volume, large royal V2mo., with Four Plates, plain or colored, and 9S well executed Woodcuts.


22 LEA & BLANCHARD'S PUBLICATIONS.

ILLUSTRATED SERIES OF SCIENTIFIC WORKS,

NOW PUBLISHING BY LEA & BLANCHARD. Tliis series comprises works of the hig'hest character on the various brandies of practical science. In their liluslralion and mechanical execution tliey are prepared wiihout regard to expense, and the publishers present them as equal, if not superior, to anything; as yet executed. Each volume is superiniended by a competent editor, who makes such additions as the progress of science in this country may require, and at tiie same time corrects such errors as may have escaped the press in London. The publishers, therefore, hope that these works may attract the approbation of the scientific pulilic by their intrinsic value, the cor- rectness of the text, the beautiful style in which they are produced, and the extremely low rate at which they are furnished.


THE FIRST VOLUME IS

PRINCIPLES OF PHYSICS & METEOROLOGY.

BY J. MULLER,

Professor of Physics at the University of Freiburg. WITH ADDITIONS AND ALTERATIONS BY THE AMERICAN EDITOR.

ILLUSTRATED WITH NEARLY FIVE HUNDRED AND FIFTY ENGRAVINGS ON WOOD, AND TWO COL'D PLATES.

In One large Octavo Volume.

The Physics of Muller is a work superb, complete, unique : the greatest vpant known to English Science could not have been better supplied. The work is of surpassing interest. The value of this contributio n to tlie scientific records of this country may be estimated liy the fact that the cost of the original drawings and engravings alone has exceeded the sum of £2 000.— Lancet.

'I'he style in which the volume is published is in the highest degree creditable to the enterprise of the pub- lishers. It contains nearly six hundred engravings executed in a style of extraordinary elegance We commend the book to general favor, itis the best of its kind we have everseen. — N. Y Courier Sf Enquirer.

We can safely say, that, if the forthcoming works be of equal merit, and produced in similar style, the series will prove one of a very invaluable character, which cannot fail to be in universal request. — North Ainericari.

From Wm. H. BartJett, Esq., Professor of Natural and Experimental Philosophy, U. S. Military

Jlcudcmy, West Point.

I deem this work a mo.«;t valuable addition to the educational facilities of the countr)^ and a rich source of information to the general reader, as it is truly au elegant specimen of typo- graphy.

West Point, March 15lh, 1818.


THE SECOND VOLUME IS

PRINCIPLES OF THE MECHANICS

OF

MACHINERY AND ENGINEERING. BY PROF. JULIUS WEISBACH.

Edited BY PROFESSOR W. R. JOHNSON, OF PHILADELPHIA.

Volume I., now ready, containing about 500 pages, and five hundred and fifty wood-cuts. Volume II., completing the work, will be shortly ready, of about the same size and appearance.

The most valtiable contribution to practical science that has yet appeared in this country. The work era- braces not only the subjects of Statics and Dynamics, but also Hydrostatics, Hydraulics and Pneumatics — each treated in sufiicient detail tor every practical purpose, and no demonstration calling in the aid of higher mathematics than elementary geometry and algebra. The work is beautifully got up as to letterpress and illustrations, the diagrams being the most picturesque that we have seen. — London Athtnaum.

From Professor Elias Loomis of the New York University.

I have examined Weisbach's Mechanics and Engineering with considerable attention, and I am much pleased with it. It is a work prepared with great care and judgment. The Prin- ciples of Mechanics are stated in a form which is clear, concise, and easily understood; they are reduced to precise rules or fermuloe, and are abundantly illustrated with numerical examples. The diagrams are numerous, neat, and well calculated to conve)"^ clear ideas. — The portion treating of the dynamics of fluid bodies is particularly rich, and the results both of theory and experiment are given in a brief and perspicuous form. The entire treatise is intelligible to one who is only familiar with the lower mathematics, and it must become a standard work with mechanics and engineers.

Nuw York, May 6th, 1848.

From Henry Velhake, Esq., Professor of 3fathematics in the University of Pennsylvania.

I have examined, with some care, the first volume of " Weisbach's Principles of the Me- chanics of Machinery and Engineering," and I have been not a little gratified in doing so. It is the most comprehensive, accurate, and best executed work, on the subject of which it treats, with which I am acquainted in the English language; and the labors of the American editor have considerably enhanced its original value. Let me say, too, that by presenting it, as well as the other volurnes of the series of which it is a part, to the American public, you will, in my opinion, contribute largely to raise the standard of scholarship in our country, especially in respect to the applications of science to the mechanical an chemical arts.

Philadelpuia, May 26th, 184:8.


LEA & BLANCHARD'S PUBLICATIONS. 23

Illustrated Series of Scientific "Works — Continued.

THE THIRD VOLUME IS

TECHNOLOGY; OR, CHEMISTRY

AS APPLIED TO THE ARTS AND TO MANUFACTURES. BY F. KNAPP.

TRANSLATED AND EDITED BY

DR. EDMUND RONALDS, AND DR. THOMAS RICHARDSON,

[Lecturer on Chemistry at the IMicUllesex Hospital.] [Of Newcastle.]

Revised, with American Additions, by

PROFESSOR WALTER R. JOHNSON, OF PHILADELPHIA.

WITH NUBIEROUS BEAUTIFUL WOOD-CUTS.

Volume I., now ready, containing about 500 pages, and 214 beautiful wood engravings. Vol. II., preparing, of a similar size and appearance.

This volume contains complete monographs on the subjects of Combustion and Heating, IHumination and Lighiing, Manufactures from Sulphur, Manufacture of Common Salt, Soda, Alkalimetry, Boracic Acid Ma- nut'acture, Saltpetre Manufacture, Gunpowder iSIanulacture, Nitric Acid Manufacture, and Manufacture of Soap, together with an appendix containing various miscellaneous improvements concerning the ibregoing subjects. The object of this work is purely practical, presenting in each topic, a clear and condensed view of the present state of the manufacture, with all the improvements suggested by the discoveries of science ; the whole illustrated with numerous large and well executed engravings of apparatus, machinery, processes, &e. &o.

One of the best works of modern times — N. Y. Commercial. June 1848.

The original treatise is one of great value ; it has been carei'ully translated by gentlemen themselves well versed in the processes it describes, and consequently familiar with their technical language— and it has received from them numerous important additions in which are described the most recent improvements in the various chem ical arts as practised in this counlry. — Medico-Chirnrgical Review.

When we saythat this volume begins another of ilie superb '-Library of Illustrated Books," republished from the London series by Lea& Blanchard, of which Muller's Physics and Meteorology, and Weisbach's Mechanics and Engineering, (the first volume of the latter) have already appeared ; thai the present work is on a subject coming home to the business and bosoms, because to the economic interests of Americans ; that its American editor is Prof AV alter R. Johnson, who has enriched it with numerous valuable additions, the results of his own industrious researches in the technological sciences ; and that it is illustrated and printed in the same superb style which marked the previous works ;— we have sufficiently explained to our readers the value of a work which will not need anv other commendation. — Norlh Aniiriran, June ISlS.

To be followed by works on THARMACY, CHEMISTRY, ASTRGNOiVIY, HEAT, HYDRAU- LICS, METALLURGY, PATHOLOGICAL ANATOMY, RURAL ECONOMY, &c. &c. Specimens may be had on application to the I*ubli»hers.


BIRD'S UATURAI. PHILOSOPHY. MOW READY.

ELEMENTS OF NATURAL PHILOSOPHY,

BEING AN EXPERIMENTAL INTRODUCTION TO THE PHYSICAL

SCIENCES.

ILLUSTRATED WITH NEARLY FOUR HUNDRED WOOD-CUTS.

BY GOLDING BIRD, M.D.,

Assistant Physician to Guy's Hospital. FROM TH8 THIRD LONDON EDITION.

IN ONE NEAT DUODECIMO VOLUME.

Containing about 400 pages and 372 Wood-cuts. This work is confidently presented to students in Natural Philosophy as a text-book, uniting advantages scarcely possessed by any other. By the use of clear small type, a very large amount of matter has been compressed into the limits of a single low priced duodecimo volume, embracing in a concise Imt intelligible manner the elements of all that is known on the subjects of Statics. Dynamics. Hydrostatics, Pneumostalics, Hyiirodynamics, Acoust'cs, Magnetism, Electricity, Voltaism. Electro-dynamics. Thermo-electricity, Gal- vanism, Unpolarized Light, Polarized Light, The Eye and Optical Apparatus, Thermo'.ics, and Photography.

"This book is written in a most pleasing style, and gives the results of abstruse researches in a form adapt- ed to the comprehension of the common reader. It appears to have been specially designed to meet the wants of medicaf students, whose circuirislances often forbid the study of more complete treatises: and it must prove highly acceptable and valuable to all who seek acquaintance witli Natural Philosophy, but have not the leisure or the inclination to devote much time to the mathematics "

Elias Loomis, Prof, of Nat. Phil, in the Univ. of N. Y.

New York, May Gth, 1848.


Now Ready— ILLUSTRATED DON QUIXOTE.

DON QUIXOTE 1)E LA MANCHA.

TRANSLATED BY JARVIS. WITH COPIOUS NOTES AND A MEMOIR OF THE AUTHOR AND HIS WORKS,

ABRIDGED FROM VIARDOT BY THE EDITOR.

With Numerous Illustrations after Tony Johannot.

In Two handsome Croicn Octavo Volumes, extra crimson cloth, half calf or morocco.


24 LEA & BLANCHARD'S PUBLICATIONS.

CAMP3ELUS LORD CHANCELLORS.

Now Complete in Scvcu Volumes.

LIVES OF THE LORD CHANCELLORS KEEPERS OF THE GREAT SEAL OF ENGLAND,

FROM

THE EARIIEST TIMES TO THE REIGN OF KING GEORGE IV. BY JOHN LORD CAMPBELL, A.M., F. R. S. E.

Nou' complete in seven handsome crown octavo volumes, extra cloth. ■ Of the solid merit of the work our judgment may be gathered from what has already been said. We will add, that from its infinite fund of anecdote, and liappy variety of style, the book addresses itself with equal claims to tlie mere general reader, as to the legal or historical inquirer ; and while we avoid the stereotyped commonplace of affirming that no library can be complete without it, we teel constrained to alTord it a higlier tribute by pronouncing it entitled to a distmguished place on the shelves of every scholar who is fortunate enough to possess it. — Frazer^s Magazine, April 1S43.

A work which will take its place in our libraries as one of the most brilliant and valuable contributions to the literature of the present day. — Atheticeum., Dec. 1847.


FRAl^CZ: UZ^DEB. LOUXS FHIIiXrP£:.»2?f ow Ready.

THE HISTORY OF TEN YEARS, 1830—1840: OE, FRANCE UNDER LOUIS PHILIPPE.

BY LOUIS BLANC,

Secretary to the Provisional Government of 1S48.

Translated by WALTER K. KELLY.

In tioo handsome crotvn octavo volumes, extra cloth, or six parts, paper, at fifty cents. A History of the Revolution of 18-30, and of the first ten years of Louis Philippe's reign, by a man who has

borne so prominent a part in the late events in Paris, cannot fail to possess striking interest at the present

moment.

This is a remarkable work. The ten years, 1830-1840, were troubled, stirring and important times to every Kuropean nation — to none so much as France. » * » ' L'Histoire de Dix Ans' is one of those works so often libelled by being called as interesting as a novel. It is a narrative of events, real, striking, absorbing — the subjects of immense interest to all readers— the style unusually excellent. — Foreign Quarterly Review.


HISTORY OF THE FRENCH REVOLUTION OF 1789.

BY LOUIS BLANC,

Author of "FRA^•CE under Louis Philippe," &c. TRANSLATED FROM THE FRENCH.

In one volume, crown octavo.


STSINMETZ'S HISTORY OF THE JESUITS —Now Ready.

HISTORY OfThE JESUITS. FROM THE FOUNDATION OF THEIR SOCIETY TO ITS SUPPRES- SION BY POPE CLEMENT XIV.;

THEIR MISSIONS THROUGHOUT THE WORLD ; THEIR EDUCATIONAL SYSTEM AND

LITERATURE; WITH THEIR REVIVAL AND PRESENT STATE.

Uy ANDREW STEINMETZ,

Author of "The Novitiate," '-The Jesuit in the Family."

In two handsome crown octavo volumes of about four hundred pages each, extra cloth.


HERVEY'S COURT OF GEORGE II. A^ow Ready.

MEMOIRS OF THE REIGN~OF GEORGE THE SECOND,

FROM HIS ACCESSION

TO THE DEATH OF QUEEN CAROLINE.

BY JOHN LORD HERVEY.

Edited from the Original Manuscript at Ickworth,

By the Right Honorable JOHN WILSON CROKER, LL. D., F. R. S.; &c.

In two handsome volumes, royal l2mo., extra cloth.


LEA & BLANCHARD'S PUBLICATIONS. 25

NOW COMPLETE.

STRICKLAND'S QUEENS OF ENGLAND.

Ticw and Improved Edition.

LIVES OF

THE QUEENS OF ENGLAND,

FROM THE NORMAN CONQUEST. WITH ANECDOTES OF THEIR COURTS;

Now First Published from Official Records, and other Authentic Documents, Private as well as Public, New Edition, -with. Additions and Corrections.

BY AGNES STRICKLAND.

In six volumes crown octavo, extra crimson cloth, or half morocco, printed on fine -paper and large type. In this edition, Volume One contains Vols. 1, 2 and 3 of the 12mo. edition; Volume Two contains Vols. 4 and 5; Vol. Three contains Vols. 6 and 1 ; Vol. Four contains Vols. 8 and 9; Vol. Five contains Vols. 10 and 11; and Vol. Six contains Vol. 12. The whole forming a very handsome series, suitable for presents, prizes, &c.

The publishers have great pleasure in presenting to llie public this work in a complete form. During the long period in which it has been issuing from the press, it has assumed the character of a standard work, and as occupying grouiid liitherto untouched; as embodyingnumerous historical facts heretofore unnoticed, and as containing vivid sketches of the characters and manners of the times with anecdotes, documents, &c. &c., it presents numerous claims on the attention of both the student of hisiory and the desultory reader.

Those who have been awaiting its completion can now obtain it, forming a handsome set, twelve volumes in six, in various styles of binding.

CONTENTS OF THE VOLUMES.


VoLTJME I— Matilda of Flanders. Matilda of Scotland.

Adelicia of Louvaine, Matilda of Boulogne, and

Eleanora of Aquilaine. Volume II. — -Berengaria of Navarre, Isabella of An-

gouleme, Eleanor of Provence, Eleanor of Castille.

Marguerite of France, Isabella of France, Pliilippa

of Hainault, and Anne of Bohemia. Volume HI— Isabella of Valois, Joanna of Navarre.

Katherine of Valois, Margaret of Anjou, Elizabeth

Woodville and Anne of Warwick. These three volumes make Vol. I. of the Neio Edition. Volume IV— Elizabeth of York, Katherine of Arra-

gon, Anne Boleyn, Jane Seymour, Anne of Cleves

and Katherine Howard. Volume V— Katherine Parr and Mary the First. These make Vol. II of the New Edition.


Volume VI— Flizabeth.

VoLUiME VII — Elizabeth (concluded) and Anne of Den- mark.

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Volume VIII— Henrietta Maria and Catherine of Bra-

ganza. Volume IX — Mary Beatrice of Modena.

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Volume X — Mary Beatrice of Modena (concluded),

Mary II. Volume XI — Mary II (concluded), Queen Anne. These make Vol. V. of the New Edition.

Volume XII— Queen Anne (concluded).

Making Vol. VI. of the New Edition.


It will thus be seen that this work pres-^nts an uninterrupted history of the Court of England and of the Royal Families from the Norman Conquest to the accession of the House of Hanover, naturally embracing an immense amount of singular and interesting matter, to be met with nowhere else.

These volumes have the fascination of a romance united to the integrity of history. — Times.


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30


THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES.


In calling the attention of the profession to the high character of the American Medical Journal, the publishers append an extract from the report of " The Committee on American Medical Literature," to the National Medical Association at their meeting in Baltimore, May, 1848. After adverting to other matters, they say : —


"The ' Philadelphia Journal,^ which has been | already mentioned, was succeeded by the ' Ame- \ rico?i Journal of the Medical Sciences,^ esta- / blished in 1827, and still continued, having reach- ed its forty-first volume. The long standing of ' this publication, the support which it has received ; from many of the best writers in ditlereni parts | of the country, and the elevated literary charac- 1 ter and spirit which have distinguished it, have J rendered it a favourite organ of the profession. I So much of what is valuable in our periodical : literature, during the long protracted period of^ its existence, has found a place in its pages, that : it would be going beyond the limits of this re- ; port to attempt an analysis of its contents. Here have been recorded many of those daring opera- ^ tions which are dwelt upon with so tnuch pride < by the American surgeon. Numberless cases,; of unusual interest have been here related by \ their observers, often accompanied by illustra- ^ tions, for the most part creditable to the art s which has furnished them. Many of the re- '< views which it contains are conceived and exe- \ cuted in a higher spirit than the mere mechanical ■ analyses and Taliacotian abstracts which sofre- ; quently usurp this department of scientific as < well as literary journals. This periodical is so ; well known through the country, and a com- \ plete series of it so generally contained in public ;; libraries, that a general index to it from the ; commencement would be one of the most ac- ' ceptable ofl'erings which could be made to the ' medical reader.

" The committee had prepared an account of-: the most prominent articles under their several ; heads, but it proves to be too voluminous for a ' report like the present. The names of some of j its contributors will be enough to show how j extensively it has been supported by the ablest ; writers and practitioners of the country. In j Aiiatoimj and Physiology, original papers have , been furnished by Drs. Horner, Moultrie, Coxe Mussey, Warren, Earle, Smith, Alison, Harri son, Gardner, Leidy and others. In Surgery, ; Drs. Godman, Mussey, Randolph, H. & J. M. :■ Warren, Coates, Mott, Norris, Kirkbride, Ged- ^ dings, Nott, Shipman, Markoe, Parrish, Met- \ tauer, Mutter, Horner, Pancoast, Watson, ; Atlee, Ilayward, are among those who have ^ lent their assistance, some of the best known ;■ among them in many elaborate articles. In the ,■ department of Practical Mediciiie, a great num- ' ber of original Reports and Essays have been ; supplied by Drs. Chapman, S. Jackson, Emer- ; son, Coxe, Horner, Hayward, Ware, Wright, ^ Jackson (of Northumberland), Parrish, Pen- nock, Gerhard, Fisher, Nichols, E. Warren, Paine, Bigelow, Webber, Lindsay, Forrey, Beck, Flint, Coale, Earle, Stewardson, Kirk- bride, Shanks, Parry, Mettauer, Whitney,


Pepper, Hall, Dexter, Jarvis, Beck, Wharton, Lovett, Nott, Moreton Siille, Doling, Tabb, Taylor, Porter, Tuck, J. B. S. Jackson, Pee- bles, Kneeland, Gardner, Buckler, Mendenhall, Lane, and R. S. Holmes. On Midwifery, and the Diseases of Women a?id Children, among the principal contributors of original papers have been Drs. Dewees, Horner, Bigelow, Hodge, Gerhard, Geddings, Lindsay, E. War- ren, Roberts, Lee, Kane, Shanks, Taylor, Bowen, Buel, Barwell, Bond, Sargent, Sims, and Baldwin. Many other names might be added to these lists, which, however, are suffi- cient evidence that the journal has been wil- lingly and heartily upheld by the profession."

After enumerating the other Medical Journals published in the United States, the report con- tinues : —

" The committee will now proceed to a brief enumeration of the more important articles, which have, within the past year, or at least recently, been presented to the profession in the medical journals of this country, taking them up in the order in which they have been enu- merated.

" American Journal of the Medical Sciences, — The number for January, 1847* contains one of Dr. Norris's admirable resumes, a ' Table showing the mortality following the operation of tying the iliac arteries.' It is founded upon a himdred and eighteen cases gathered from various sources, which are presented in a con- densed form and subjected to a careful analysis. The committee have already fully expressed their sense of the importance of Dr. Norris's labours. The paper which follows, by Dr. Trask of Brooklyn, N. Y., is worthy of suc- ceeding that just mentioned. Four very full tables containing the history of fifty-three cases of phlegmasia dolens are given in this essay, the final object of which is to establish the pa- thology of the affection. Articles like the two just cited, are necessarily of permanent value. They cannot be superseded, because they have a solid basis of fact, and even if some of their conclusions were erroneous, the materials would remain as the basis of future results. The in- creased number of these laborious analytical surveys is one of the most encouraging features of our medical literature. In the midst of in- terminable discussions upon the value of the numerical system, the simple fact that tabula- tion affords a final result respecting a given number of facts, which mere perusal fails to do, is making itself felt like every truth which has time and fair play. The next article is one by Dr. Kirkbride on Hospitals for the Insane, and the fourth a brief account by Dr. Wilcocks, of the epidemic remittent and intermittent of 1346. Then follow four cases of acute afiection of the


THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 31'

spinal marrow, with dissec»ions, by Dr. J. B. S. ~ have preferred the easier plan of ministering to Jackson of Boston, marked by his accustomed this altered condition by the ingenious and stu- accuracy of description. Several other cases pendous system of modern therapeutics.' He are reported in this number, which contains two ^ appears to believe, and as the Committee think, reviews of some interest, and the usual variety very justly, that much indirect benefit may re- in its minor departments. suit even from the experiments of the hydro- " The first article in the number for Aprill847, pathist and homoeopathist, notwithstanding the is one of great practical interest. It is the ' His- ■ illusions and impositions that surround the foun- iory of scceucasesof Fserido-memhranous Lanjn- '; Kaxn of the Silesian boor and the laburatory of git is or True Croup,' by Dr. J. F. Meigs. The the Saxon necromancer. The interest of Dr. fact that recovery took place, in four cases where ; Brown's account of his visit to the Cretins, in there was fibrinous exudation on the fauces, en- . the institution on the Abendberg, is owing not titles the history of these cases to the most care- ' merely to the novelty of the subject, which is fule.xamination, and affords a strong presumption just beginning to attract the attention of philan- in favour ofthe general plan of treatment adopted. ; thropists, but to the agreeable style of the nar- It is well known that long series of similar : rative. In a country which has done as much cases have been observed, every one of which ; as our own for the insane, the blind and the has proved fatal, and that the whole question of; deaf and dumb, it cannot be long before the treatment is considered as involved in perplexity; improvement of the condition of the unfortunate by many al>le observers. The paper which fol- ' idiot will be felt to be a public duty. Dr. Met- lows, by Dr. Baldwin, Obsercaiions on the Foi- \ tauer, whose name is familiar to the records of sonous Properties of the Sulphite of Quinine, ', operating surgery, reports two cases of vesico- has been most extensively quoted, and has called . vaginal fistula, with the operations for their out various other communications confirming ' relief, one of which was perfectly successful, the results at which he has arrived. In the ma- : and the other, though repeated again and again, larious regions of our country, where the "mon- was but partially so. But this, as Dr. Mettauer , ster doses" of this heroic remedy are so com- thinks, was owing to the patient's amiable in- monly given, it is of vital importance that all the discretions, and he is decidedly of opinion that risks they involve should be generally known, every case of vesico-vaginal fistula can be cured. Then follow various reports of medical and sur- Dr. Harris relates a case of doubtful sex, in gical diseases, among which Dr. Earle's eleven '; connection with which the editor quotes that cases of general paralysis of the insane cannot described by Dr. Barry, in the New York fail to be noticed for their psychological and Journal of Medicine for January, 1^47. Dr. pathological bearings, as well as the happy way , Bolirig's new sign of pneumonia of the apex of in which they are related. A practical essay by the lungs, needs confirmation by other observers. Dr. Ilildreth, on letting blood from the jugular ' The Committee can affirm, at least, that it is in diseases of children concludes the list of not constant. It was extraordinary if, as Dr. original communications. ; Boling asserts, the chest remained still resonant "The July number opens with another sta-;'on percussion over the apex of the lung in a tistical article from Dr. Norris, on the operation state of hepatization. This number contains a of tying the carotids, of the same high character long notice of Dr. Wood's Practice of Medicine, with those which he has furnished in previous ^ by one of the most searching and skilful review- numbers. The next paper is one by Dr. Hal- ^ers our periodicals have ever enlisted in their lowell, on cholera infantum, which he calls by ' service. It may be hinted, that one epithet, ihe singular name o( gaslrofollicular e?iteritis; 'fhowever judicious, must not be repeated too which would seem to imply inflammation of the J often; the accomplished reviewer remembers intestines seated in the follicles of the stomach. > Gyas and Cloanthus. The essay is an instructive one, based on con- ^ " The number for October, 1847, has for its


siderable experience and supported by two Heading article a continuation of Dr. Metcalf's reported cases with a tabular analysis of twelve ^Statistics in Midicifery, containing the results


posl-mortem examinations. A 'Note on theioi 937 cases observed in private practice. It is frequency of the pulse and respiration of t//e ^ a most creditable production to the author and aged,' by Dr. Pennock, adds authority to the Uhe friends by whom he was aided, and may curious results obtained by Leuret and Mitivie, > serve as an encouragement and a model to other who found the average frequency of the pulse ? practitioners situated at a distance from the more in young men to be (55 per minute, while that of;' active centres of scientific industry. Dr. Michel's the aged was 73; a statement in direct opposition { history of an early ovum is not without interest, to the prevailing belief on this point. 'Hydro- < though its illustration is less exquisite than the pathy, or the use of cold vmter for the Prevention ylcones' of Wagner, and the style is wanting and Cure of Disease,' by Dr. Kneeland, is thcMn the simplicity which should belong to an title of a Boylston prize essay, here published ;^ anatomical description. Dr. Harden's Essay on without any allusion to its laureate honours, 'i Isopathia. agrees with the general belief in The key to the author's position is found in the < maintaining the similarity of scrofula and phthi- following sentence: 'Instead of leading man ? sis, but will hardly be thought to have esta- back to the forsaken paths of nature, physicians^ blished the doctrine, that Bright's disease is


33


THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES.


isopatJiic with these affections. Why molluscum , all officers in the public service would discharge


should come under the same head is hard to ex- plain. In the days of isomerism and isomorphism, it is natural enough for a medical observer to be pleased with the thought of introducing some such parallelism of elements into medicine, but it may be questioned, how much is gained by the somewhat promiscuous erudition and finely drawn propositions of this elaborate essay, be- yond a harmonious name for a .well known


their professional debt as faithfully. Some of the author's expressions would seem to imply that proteine exists only in vegetables, which cannot surely have been what he intended to assert. Dr. Blake's paper appears to be founded on the same experiments which this ingenious physiologist reported some years ago to the British Association, and which have already taken their place in physiological science. The


principle. Dr. Kelley of Mobile, has given an ; indefatigable Dr. Earle gives a brief analysis of account of yellow fever as this disease has pre- Jfive hundred and ninety-four cases of delirium sented itself to his own notice, written in clear / tremensadmittedinto the Bloomingdale Asylum, and simple language, and keeping more closely ) Then follow several reports of interesting sur- than many writers on this subject have done to ;gical cases; under the name of ' Monograph' the strict results of observation. Some remark- ; we have next ' A Statistical Inquiry into the ' able surgical cases and operations, a case of in- l Causes, Symptoms, Pathology, and Treatment cision of the os uteri during labour on account ; of Rupture of the Uterus,' by Dr. Trask, of of its partial occlusion, some researches on the \ Brooklyn, whose labours have been already structure and functions of the ciliary processes, i mentioned with commendation, and the case of the murderer Freeman, with a " The first paper in the April number is an long review of some of the Boa Vista fever | account, by Dr. J. M. Warren, of Operations for documents, finish the list of original articles. In | Fissure of the Soft and Hard Palate, with the this number, October 1847, appears a new and ' result of twenty-four cases, at the close of which distinct head of medical intelligence, entitled ' is an important additional note upon the early ether inhalation as a means of aimulling pai7i. \ operation for hare-lip. Dr. Warren proposed, It is remarkable, that as so much patient de- some years ago, and has often executed, a new liberation was shown in preparing the abstract \ operation, which is fully described in this paper of what was before the public, on this subject, and the annexed cases. Dr. Peeble's ' Result an article like that of Dr. Pickford should be of cases of Pneumonia, treated chiefly by Tartar admitted, but more remarkable still, that any i Emetic,' may be well calculated to excite at- sensible reader should have been frightened out lention to the possible ill effects of that remedy, of receiving the last great gift of Mercy, by the ; but is deficient in the diagnostic elements of its assertions of such a writer, as would appear to / cases. The third patient, for instance, may have happened in at least one instance. have suffered, for all that appears, from phthisis

"In the number for January 1848, the leading with ulceration of the bowels. It does not ap- article is Dr. Leidy's paper on the Comparative ; pear from the record that the previous good Structure of the Liver. This is unquestionably ; health had persisted unchanged up to the period the most exact and complete Essay in the de- ofthe acute attack. Cases of successful vaginal partment of microscopic anatomy which has > hysterotomy and delivery by the forceps; of appeared in any American Medical Journal, traumatic trismus successfully treated; of a fatal The patient accuracy of the measurements, the' gun-shot wound ofthe neck; of ligature of both finish and clearness of the numerous illustrations i carotids ; of the extirpation of a tumour of the are nothing more than would have been antici- uterus, simulating ovarian disease ; of cancer of pated by those who know the zeal and talent of! the stomach, and of melanosis, are reported in this exquisite dissector and delineator. The , this number — certainly a very remarkable col- article which follows, by Dr. Frick, is one of' lection of important medical and surgical histo- the first attempts at the investigation ofthe che- < ries, and implying an ample supply of materials mical changes of the blood induced by disease, to allow of such selections. Add to this Dr. made in this country. Most of the conclusions > Parson's ' Statistics of Large Surgical Opera- arrived at by the laborious observations which j tions,' the Midwifery Statistics from private served as its basis, coincide with those of pre- < practice, by Dr. Pleasants, and the continuation vious observers. One peculiar and novel result < of Dr. Trask's paper on Rupture ofthe Uterus, arrived at by Dr. Frick is, that the quantity ofj probably the most complete account of that ac- the chlorides and phosphates of soda and potash | cident to be found inprint, audit must be owned is dependent, not upon the particular disease, that the patriarchal quarterly has not fallen be- but upon the season of the year in which the j low its own high standard of merit, at the point examination is made, being much higher in : where the Committee takes leave of it for the winter and spring than in summer and fall. Dr. present."*

Fohz deserves credit for printing his valuable i *,These extracts are from copies of the Report to T, ^ o, , T 1 1 . • , 1 , be furnished to the Chairman of that Committee, Vt.

Report on Scorbutus. It could be wished that Holmes of Boston.


For a more particular description of the Journal and News, with numerous notices of the press, &c., see Supplement to the Medical News and Library for Dec. 1847.


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