PROFESSOR BEDFORD'S NEW WORK. THE DISEASES OF WOMEN AND CHILDREN. BY GUXXIXG S. BEDFORD, A.M., M.D., Professor of Obstetrics, the Diseases of Women and Children, and Clinical Mid- wifery, in the University of New York. FOURTH EDITION, (AREFliLLY BEVIISED, 8vo. 602 pp. S. S. & W. WOOD, 389 BROADWAY, NEW YORK. The rapid and wide-spread circulation of this eminently practical work is, we think, without precedent—having reached its Fourth Edition in the brief period of Fifteen Months from the day of its first publication. It is a storehouse of knowledge for the student and practitioner of medicine—full of practical pre- cepts and bed-side information. Rarely has any medical publication met with such universal commendation from the medical press, both at home and abroad. " We hail the advent of such a work, abounding in practical matter of the deepest interest, and illustrated by principles and laws ordained by nature. Nor can we refrain from expressing our surprise and gratification at finding the book so remarkably exempt from the superficial views that abound in the great thoroughfare of medicine. The rapid sale of this work we believe to be unprecedented in the history of medical literature in thia country, which must be highly gratifying to the author, showing, as it does, the degree of estimation placed upon his labors by the medical public."—N. Y. Jour, of Med. and the Collateral Sciences. " We are quite sure that the work will be a welcome addition to professional libraries in Great Britain as well as America ; it is a very valuable record of cases as they occurred at the clinic."—Brit, and For. Med.-Chir. Review. " We think this the most valuable work on the subject ever presented to the profession. We have perused every page of the book with interest, and speak, therefore, from personal knowledge."—Cincinnati Med. Jour. " It is our pleasing duty to announce the third edition of this admirable work. It is not often that British critics commend an American book; so when their approval is obtained, we may rest assured that the work commended is of no ordinary merit. Dr. Bedford's book is characterized by Dr. Churchill as 'worthy of its author, a credit to his country, and a valuable mine of instruction to the profes- sion at large.1 We have read every page of the work, and feel called upon to say that we regard it the most valuable contribution on the subject ever offered to the profession."—Charleston Med. Journal and Review. i( A work of great practical interest—one well calculated to interest and instruct the busy practitioner ; it points out to him the most modern therapeu- tical agents, and their method of administration ; and, above all, gives beautiful and siitisfactory explanations, physiologically, of the symptoms of disease. This latter quality is a great merit of the book. As a faithful representation of the daily labors and duties of a physician of our day, and as an accurate delineation of the diseases of women and children, it is well deserving of our praise."— Virginia Med. and Surg. Jour. "The subjects have been developed with no ordinary powers of clinical in- ruction."—N. Y. Med. Times. " Dr. Bedford s book contains much useful and practical information, in- structive alike to pupil and physician; the number of subjects which receive consideration in the volume is very great; indeed, scarcely any disease properly included in the denomination of the work is left unnoticed."—IhMin Quarterly Jour, of Med. Science. "We have been both pleased and instructed by a perusal of the book, and confidently recommend it, therefore, to the profession, as an excellent reper- torium of clinical medicine. The eminently practical ideas of the author, clothed in simple and perspicuous language, are delivered in quite an attractive, affable, and off-hand manner."—Philadelphia Med. Examiner. "Professor Bedford's book is a good one. We like it, for we can digest a din- ner over it without going to sleep, and that is more than we can sav of most medical books."—New Jersey Mrd. Reporter. "The working men in America are always on the look out for the new lights rising over the old world, and they often too hastily adopt as the pure gold of science, the crude lucubrations which must find place with more valuable matter in the weekly medical press. But this observation does not apply to our author, who is creditably known by other works, and in the one before us shows himself to be a judicious physician, anxious alike for the good of his patients and of his pupils ; one who has acquired the happy art of teaching how to get at the characteristics of disease, and how to drag at the chain of effects, until the mind grasps the first link in the chain."—Rankin s Half- Yearly Abstract of the Med. Sciences. ""We have said, on former occasions, that the man who will bring forward clinical or practical instruction to Lear upon the medical teach :n.Ts of our country, will bd immortalized. We want practical observations—fresh from the bedside. Dr. Bedford's volume is drawn from an extensive clinic, founded by him in the University of New York, and is fortified by much reading and research. This is a good book, and the profession owes Dr. Bedford hearty thanks for the labor he has bestowed upon it."—Philadelphia Med. and Surgical Journal. "The work before us is eminently practical, and therefore valuable as a contribution to medical knowledge. Prof. Bedford's extensive opportunities have enabled him thus to bring together a large number of the most interesting cases of female and infantile affections, and to indicate his views of their treat- ment. In the accomplishment of the ta*k, the author has evinced a degree of discernment which will, doubtless, add materially to his already extended repu- tation.'-—Southern Med. and Surg. Journal, Augusta, Georgia. "No one can read this book without becoming convinced that it contains much valuable instruction, and is the result of a large experience in this speci- ality."—Xeto Hampshire Jour, of Med. "The work contains graphic descriptions of the diseases of women and children, with judicious advice as to treatment."—Boston Med. and Surg. Jour. "Many important facts are forcibly impressed, and the author's luminous ex- hortations even on subjects comparatively insignificant in themselves, are calcu- lated to impress correct rules of practice."—Western Lancet. "This book, in its detail of the various forms of disease occurring among women and children, will be found a counterpart of almost every case which the physician is called upon to treat. It has received, most deservedly, the highest commendations from the medical press, both of our own country and Europe. It should be in the library of every practitioner."— Monthly Review of Medicine and Surgery, Detroit. "We very cheerfully recommend this work to our readers, as being rich and full with practical suggestions in the treatment of disease at the bed-6ide ; it will be a very pleasant source of reference for physicians in the hurry and press of full pracice."—Cincinnati Med. Observer. - " Wo cordially add our testimony to its value as an eminently practical work, based upon the most approved physiological principles. We hope every practi- tioner and student will obtain a copy of the book.'*— Atlantic Med. and'Surgical Journal, Georgia. Price $3, by mail, free of postage. ______RECENTLY PUBLISHED. 8 Second edition of LECTURES ON MATERIA MEDICA AND THERAPEUTICS, Delivered in tho College of Physicians and Surgeons of-the University of the State of New York, by .JOHN B. BECK, M.D., Late Professor of Materia Medica and Medical Jurisprudence, prepared for the press by his friend C. R. GILMAN, M.D., Professor of Obstetrics, dbc, in the College of Physicians and Surgeons, Nfftc York. 1 vol. 8vo , price $8, free of postage. " Admirable for students. Everything is clear and concise."—.V. 1' Medical Times. "As a text-book for the use of students, we know of no better treatise, and very few indeed, that are so well adapted."—American Journal of Med. Science. • FOURTH EDITION OF VELPEAU'S OPERATIVE SURGERY; Translated by P. S. TOWNSEND, M.D., under the supervision of, and with Notes and Addi- tions by, VALENTINE MOTT, M.D., Professor of Surgery in the University of New York, r *•«**«» ««* y°ung practitioner, and we most oorfltoHy recommend 5t Bouchut s treatise, as thus presented to us by Mr. Blrd."-*..Z*»<*o» Lmott S. S, Sf W. Wood's Medical Catalogue, 5 MICROSCOPIC ANATOMY OF THE HUMAN BODY, IN HEALTH AND DISEASE. Illustrated with numerous drawings in color, by Arthur Hill H ass all, M.B.; Member of Royal College of Surgeons of England, Jersey Med. Reporter. " A most valuablo and admirable work it is—one which the interests of humanity will scarcely allow any physician to be without."—Peninsular Jour, of Med. " One of the most valuable books which ever issued from any press. No one, however learned, can read it without profit."—N. Hampshire Jour, of Med. " It Is certainly a very valuable work, and should go as the the companion and antidote of most of our works on the diseases of infants, to modify their reckless recommendation of the use of the most powerful drugs on tho susceptible constitutions of children."—Buffalo Med. Jour. THE ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF THE HUMAN TEETH: With the most approved Methods of Treatment, Including Operations, and the method of making and setting Artificial Teeth. With 30 Plates, BY PAUL B. GODDARD, M.D., M.A.N.S., M.A.P.S. Demonstrator of Anatomy in the University of Pennsylvania, aided in the practical part by Joseph E. Parker, Dentist. Price f 8 50, free of postage. " The account of the structure of the teeth is a very valuablo one, and is illustrated by some remarkably well-executed views of their microscopic structure."—American Journal of Medical Science. " The illustrations are both numerous and truthful, and add exceedingly to the value of a production of this kind, as descriptions of the parts concerned are better understood when the eye has something to rest upon."—Dental News-Letter. " Methodical in its arrangement, concise and practical in its style, and illustrated by numer- ous engravings, faithful in delineation and beautiful in their execution, it does credit to both the author and publishers; and is well calculated to elevate the profession to which it is devoted No dentist's library could be complete without it."—N. J. Medical Reporter. "It is one of the best illustrated works that pretends to treat of dental theory and practice. The cuts, illustrating the anatomy and physiology of the teeth, are alone worth more than the price of the work."—N. Y. Dental Record. "This book contains valuable information for the general practitioner as well as the dentist " —Peninsular Jour, of Med. " We especially commend this work to dentists residing at a distance from cities, and who are compelled to prepare their own materiel."—Stethoscope. " The work is one of the best we have examined,"—Nelson's American Lancet. FOURTH EDITION OF A SERIES OF ANATOMICAL PLATES, With References and Physiological Comments, illustrating the structure of the different rjaits °f^th?man body, with 200 Plates, 4to, by JONES QUAIN, M.D., Professor of Anatomy and Physiology in the University of London; and W. J. 2. WILSON, M.D., Lecturer on Practi ^ JOSEpTpIncc^^^M nhypi0f0g3r- K0'AHh ef^r- .Re?uk' ^^ddUicTalNots, by JU&iPH PANCOAST, M.D , Professor of General, Descriptive, and Surgical Anatomv in Mli^CuKraZaiR!l!eT t0™**« haTe been hitherto P^ed in this country."- htnl^ ?^u? ST tb;e,most Part exceedingly well executed. It is the cheapest work of th„ kind ever published in this country ."-American Journal of Medical Srtences. «iS«Sn/o?^.b0th bei"g eXC6UeDt«the b00k is R treMU* indeed."-^*™ Medical CLINICAL LECTURES ON THE DISEASES OF WOMEN AND CHILDREN. bt GUNNING S. BEDFORD, A.M., M.D., rf''""~ PROFESSOR OP OBSTETRICS, THE DISEASES OP WOMEN AND CHILDREN, AND CLINICAL MIDWIFERY, IN THE UNIVERSITY OP NEWjeET V r I^T~-- "Medicus curat morbos, natura sanat."—Hippocrates. FOURTH-EDITION, CAREFULLY REVISED AND ENLARGED. NEW YORK: SAMUEL S. & WILLIAM WOOD, 3 89 BROADWAY. 1856. V wp 18 S& Entered, according to Act ol congress, in the year 1855, by GUNNING S. BEDFORD In the Clerk's Office of the District Court of the United States for the Southern District of New York. stereotyped by feinted bt THOMAS B. SMITH. GROSSMAN AND WILM, < 82 4 84 Beekman Street 82 4 M Beekman s TO THE ALUMNI THE UNIVERSITY OF NEW YORK, THESE LECTURES JJrt nfUttinMUlu iM&usM, BY THEIR FRIEND THE AUTHOR. I PREFACE, Anxious to do all in my power to increase the facilities for the practical study of the diseases incident to women and chil- dren in connection with the chair, which I have the honor to occupy in the University of New York, I established for this purpose, in October, 1850, an Obstetric Clinic which, from that period to the present time, has been in constant and successful operation ; and which, with the exception of six weeks, is held on every Monday throughout the year. There have been pre- sented to my classes in the University, from October, 1850, to this date, over eight thousand cases of disease, and the present volume contains but an epitome, as it were, of the various mala- dies peculiar to women and children, which have been discussed and treated in the clinic. I have been induced to publish these lectures in this form from the repeated solicitations of my pupils and other friends; and I think it due to myself to say, that I claim for the lectures nothing more than what they really are- running commentaries upon disease as I understand it. There is no system in the order of these lectures, for the very principle on which they are delivered necessarily precludes the possibility of systematic arrangement. They have been reported by competent gentlemen, just as they were delivered at the time—in one word, they are a faithful representation of what occurs in the clinic. Objection, perhaps, may be made to the colloquial style of the lectures; but I preferred that the clinic should be represented vi PREFACE. as it really is, without any attempt to disguise what it professes to be, viz.: a school for the practical study of the diseases pecu- liar to women and children. The lectures have been reported by Drs. Win. Palmer Wood- cock, H. C. Cooper, and Thomas A. Gregory, and most of them have been published in the American Lancet. I beg leave to return my thanks to these gentlemen for the fidelity with which they have performed their office. With these remarks, I submit this volume to my professional brethren, and happy shall I be if it should meet with their approbation. GL S. BEDFOKD. New York, 66 Firra Avenue, June 1st, 1855. PREFACE TO THE SECOND EDITION. My Publishers having informed me that it is necessary to put to press a second edition of the " Clinical Lectures on the Diseases of Women and Children" it would be affectation in me not to express the pleasure I derive from the rapid sale of the work, which, it must be admitted, is not only novel in its general arrangement, but which constitutes a very distinct departure from the systematic treatises here- tofore presented to the practitioner and student of medicine. I was anxious that the Lectures should go forth to the profession without any concealment as to the circumstances under which they were delivered. The diseases discussed are, as it were, so many types of what the phy- sician is constantly called upon to treat in his daily rounds of duty, and, therefore, their character is essentially practical. To say that the first edition has been exhausted in a period of three months, is at once an acknowledgment of the kind appreciation of my professional brethren. But I should be wanting in candor if I did not add that, in my opinion, the success of the work has been materially aided by the flattering criti- cisms of my brethren of the medical press. To those gentlemen who have so generally and spontaneously, in language of kindness, spoken of my work, I beg leave most cordially to return my thanks. I feel much gratified with their flattering commendations. It will be seen that I have added to the present edition Formula of Remedies, which, I trust, will prove serviceable. October 1, 1855. PREFACE TO THE THIRD EDITION. I feel much pleasure in being again thus early called upon to express my grateful acknowledgments to the profession for the kind favor which they have extended to my work. The present edition has been carefully revised, and more than forty pages of new matter added. In the Appendix, at the end of the volume, are recorded the results of treatment in many of the more interesting cases which have been discussed in the Clinic; this, I hope, will prove an accept- able feature. It will also be seen that a carefully-prepared alphabet- ical table, embracing every topic treated of in the volume, will enable the reader at once to refer to any special subject. In conclusion, I think it but justice to return thanks to my publishers for the efficient manner in which they have performed their part of the labor, which is altogether worthy of their respectable and old-estab- lished house. March 1, 1856. PREFACE TO THE FOURTH EDITION. That a fourth edition of the " Clinical Lectures on the Diseases of Women and Children'''' should be demanded in a period of fifteen months from their first publication, is not only gratifying to me, but presents the most positive evidence that my labors to open an un- tried avenue for the practical study of disease have been fully en- dorsed by my professional brethren. This endorsement, which I cannot too highly appreciate, is an ample compensation for whatever toil and anxiety I may have experienced in establishing a Clinic for the practical observation of the diseases incident to women and chil- dren. I may be permitted to reiterate my grateful acknowledg- ments to the medical press, both at home and abroad, for their courteous criticisms, and the kind favor extended to my work. The present edition has been carefully revised, and will, I trust, continue to secure the approbation of the profession. September, 1856. CONTENTS. ■» ♦»-------- LECTURE I. Diseases of the Uterus, organio and functional—Their Impoitance—But little under- stood in Ancient Times—Hippocrates and his School—The Speculum and Toucher —The true Knowledge of Uterine Disease of Recent Origin—Circumstances which modify these Affections.—Why are Diseases of the Uterus more frequent now than in Olden Times ?—Indifference of Females to their own Health—Painful Consequences.—Profuse Menstruation from Debility in a married Woman, aged twenty-seven Years.—Acute External Otitis in a Boy, aged four Years.—Gonor- rheal Ophthalmia in a Boy, aged three Years.—Suppression of the Menses from Cold in a young Woman, aged twenty-one Years, complicated with Phthisis Pul- monalis.—Hooping-Cough in an Infant, aged ten Months......5 LECTURE II. Chlorosis in a Girl, aged eighteen Years, with Suppression of the Menses for the last b3x Months—Pathology of Chlorosis—Chlorosis not always dependent upon Amen- orrhoea.—Muco-purulent Discharge from the Vagina in a Girl, aged six Years, from Scrofula.—Pruritus Pudendi in a married Woman, aged forty-six Years— Final Cessation of the Menses.—Amenorrhoea in a Girl, aged seventeen Years, from Imperfect Physical Development.—Undue Lactation in a married Woman, aged thirty-eight Years, the Mother of four Children, the youngest six Months old—Passive Menorrhagia.—Irritation from Teething in an Infant, one Year old, with Constipation.—Anasarca and Asoites following Scarlet Fever in a Boy, aged four Years—Is Albuminuria the constant accompaniment of Scarlatina ? . . 23 LECTURE III. Enlargement of the Uterus produced by Hydatids, accompanied by a Periodical Watery Discharge per Vaginam, in a married Woman, aged twenty-seven Years, the Mother of two Children, the youngest four Years of age—Hydatids and Vomit- ing.—Procidentia of the Uterus in a married Woman, aged thirty-four Years, the Mother of four Children, the youngest six Weeks old.—Management of the Pla- centa in Natural Labor.—Concealed Pregnancy in an unmarried Woman, aged twenty-two Years.—Fibrous Tumor of the Uterus mistaken for Pregnancy in a young Lady, aged nineteen Years.—Diarrhoea Ablactatorum in an Infant, eight Months old.—Abscess of the Vulva in a married Woman, aged twenty-seven Years, the Mother of three Children, the youngest four Weeks old......41 LECTURE IV. Mucous Discharge from the Vagina in a married Woman, aged thirty-seven Years, the Mother of three Children, the youngest three Years old, produced by Warty X CONTENTS. Excrescences on the Vestibulum—Vaginal Discharges generally—The Importance of accurate Diagnosis—What is meant by the " Whites ?"—Intestinal Worms in a little Girl, aged four Years—The Variety and Origin of Worms in the Human Sys- tem.—Vascular Tumor of the Meatus Urinarius in a married Woman, aged twenty- six Years.—Ulcerative Carcinoma of the Neck of the Uterus in a Widow, aged forty Years.—Human Credulity—Heartless Exactions of the Quack.—Suppression of the Menses in an unmarried Girl, aged twenty Years.—Cholera Morbus in a Boy, aged six Years..............•* LECTURE V. Introductory Remarks.—Suppressed Lochial Discharge in a married Woman, aged thirty Years, the Mother of four Children, the youngest three Weeks old.—Follic- ular Stomatitis in an Infant, aged eight Months.—Injury from the Introduction of the Catheter during Pregnancy—Manner of introducing it; Stricture of the Female Urethra.—Inflamed Umbilicus in an Infant, aged four Weeks.—Vicarious Men- Btruation in a Girl, aged nineteen Years—What is Vicarious Menstruation ?—En- larged Tonsils, with Deafness, and a Sense of Suffocation, following Scarlet Fever, in a Boy, aged six Years.............M LECTURE VL Profuse Sanguineous Discharge from the Vagina, from Polypus of the Womb—Re- moval of the Polypus—The Causes of Sanguineous Vaginal Discharges.—Pityriasis Capitis in a little Girl, aged six Years.—Phlegmasia Alba Dolens in a married Woman, aged twenty-two Years.—Involuntary and Constant Spasmodic Movements of the Limbs in an Infant, five Weeks old.—Vomiting in an Infant, aged five Months, immediately after taking the Breast.—Can a Nursing Woman become Pregnant before the reappearance of the Menses ?—Delivery with the Forceps after a Labor of ninety Hours, with Safety to both Mother and Child.—Ergot, when to be employed in Child-birth.—Rupture of the Womb from the rash administration of Ergot—Death of both Mother and Child.—Defective Menstruation in a Girl, aged twenty Years—What is Defective Menstruation i......& LECTURE VII. Introductory Remarks .—Critical Period of Female Life.—Final Cessation of the Men- strual Function in a widow Woman, aged forty-nine Years.—Sympathetic Cough from Intestinal Worms in a little Girl, aged seven Years.—Pulse of Disease, and Pulse of Momentary Excitement.—Induration of the Neck of the Womb in a mar- ried Woman, aged twenty-nine Years.—Prolapsus of the Womb, occasioned by Jumping from a Carriage, in a young unmarried Woman, aged nineteen Years.__ Menorrhagia during Lactation in a married Woman, aged twenty-eight Yeare.__ Palpitation of the Heart in a Girl, thirteen Years of age.—Palpitation of the Heart in a young Lady, aged eighteen Years, produced by Temporary Disappointed Love, and cured by Matrimony.—Ophthalmia Neonatorum in an Infant, four Weeks old. —Chorea in a Girl, aged ten Years, from Intestinal Irritation. .... 88 LECTURE VIE. Retention of the Menses in a Girl, seventeen Years of age, with Habitual Constipa- tion.—Amenorrhoea divided into Retention and Suppression.—Phthisis Pulmonalia complicated with Peritoneal Dropsy in a Boy, thirteen Years of age.—Ulceration of the Neck of the Womb in a married Woman, twenty-two Years of age—The Speculum.—Ulceration of the Neck of the Uterus—Conflicting opinions respecting; are these Ulcerations frequent?—How Divided—Their Causes, Symptoms, Diag- CONTENTS. xi nosis, and Treatment.—Spina Bifida in an Infant, aged two Months.__Hydro- A°" Rachitis.—Mucous Discharge from the Vagina, with Pruritus of the Vulva, oc- casioned by Venereal Condylomata, in a married Woman, aged twenty-three Years................118 LECTURE IX. The Uterus and its Appendages—Their Structure—The Modifications of Structure in Pregnancy—The Uterus in Health and Disease—Its Physiological Action— Normal Position of the Organ—Does it Enjoy much Mobility ?—Ante-version of the Uterus from a Collection of Hard Faecal Matter in the Rectum—Removal of the accumulated Faeces by the Introduction of a small Spatula.—Constipation and Diarrhoea in Pregnancy.—Suppression of the Menses in a Girl, aged eighteen Years, the Suppression following an Attack of Scurvy—What is the Cause of Scurvy ?—Has it any Influence over the Menstrual Function ?—Falling 6f the Womb in a married Woman, three Months Pregnant, with Inability to pass Water................135 LECTURE X. Epilepsy in a Girl, aged twenty Years, from Suppression of the Menses for the last twelve Months, together with Sanguineous Engorgement of the Uterus; the Utility of direct Depletion.—Steatomatous Ovarian Tumor containing Hair.—A Sarcoma- tous Tumor containing Hair and Stearine, removed from the Womb in a married Woman, aged forty-seven Years.—Hemorrhage from Ulcerated Carcinoma of the Womb, mistaken for Menorrhagia.—Mucous Discharge from the Vagina of a Girl, aged six Years, produced by Ascarides in the Rectum.......152 LECTURE XL Double Encysted Ovarian Dropsy, with Prolapsion of the Mucous Membrane of the Vagina, in a Widow, aged fifty-one Years.—Suppression of the Menses from Cold in a Girl, aged seventeen Years.—Menstruation uninterrupted during Pregnancy, and occurring with marked regularity at its usual periods—Gestation five Months advanced.—Convulsions from Teething in an Infant, eleven Months old.—Purulent Discharge from the Female Urethra, occasioned by Ulceration of the Neck of the Bladder.—Dropsy in a Girl, eleven Year3 of age, with Albuminous Urine.—Pain in the Right Hypochondriac Region, with Cough, from Advanced Pregnancy— Pruritus Pudendi in a married Woman, aged twenty Years.—Defective Menstrua- tion in a Girl, aged twenty-four Years..........18S LECTURE Xn. Mammary Abscess in a married Woman, aged eighteen Years; How soon after Birtb should the Infant be put to the Breast ?-Warty Excrescences in the Vagina of a little Girl, three Years of age, accompanied with Mucous Discharge—Cephalhema- toma, or Bloody Tumor of the Scalp, in an Infant, five Weeks old.-Vesico-vaginal Fistula, produced by the unjustifiable Use of Instruments—Conservative Mid- wifery-Abuse of Instruments—Pregnancy complicated with Ovarian Tumor in a married Woman, aged twenty-four Years—Convulsions in an Infant, five Weeks old, from Constipation—Gonorrhoea in a married Woman, aged twenty-six Years. -How many Ligatures should be put upon the Umbilical Cord-Ozcena in a little Girl, aged four Years—Polypus of the Womb, removed with the Calculus Forceps. -Falling of the Womb, from Engorgement of its Cervix, in a married Woman, aged forty-three Years............. xii CONTENTS. LECTURE XIII. Retention of the Menses, with Hsematcmesis, in a Girl, seventeen Years of age- Vicarious Menstruation.—Threatened Paralysis of the Lower Extremities in a married Woman, aged twenty-one Years, from Defective Menstruation—Abdom- ino-rectal Hernia in a married Woman, aged twenty Years, confined six Months since with Twins.—Ulcerative Stomatitis, and Diarrhoea from Teething, in an In- fant, tiirht Months old.—The Mortality of Infanoy, is it from Necessity or from Neglect i—Sub-Mucous Fibrous Tumor of the Uterus in a married Woman, twenty- three Years of age, with Suppression of the Menses for tho last twenty-two Months.—Ovarian Tumor in a married Woman, aged twenty-two Years, projecting into the Triangular Fossa between the Uterus and Rectum—Diagnosis between this Form of Tumor and Retro-version of the Fundus Uteri—Introduction of the Uterine Sound............... LECTURE XIV. Puberty in the Female; its Signs; Changes, Physical and Moral, in the young Girl. —Menstruation, when does it Commence?—Its Causes, Symptoms, and Periodicity —What is the Source of the Menstrual Blood '.— Menstruation essential to Health, but not to Life.—Meteorism, with Globus Hystericus, in a young Girl, aged eighteen Years, the result of Hysteria.—Suppression of the Menses for the last six Months from Fright.—Five successive Miscarriages in a married Woman, aged twenty-five Years—Treatment of Miscarriage........228 LECTURE XV. Imperfonite Os Tincse in an unmarried Girl, aged twenty-two Years—Retention of the Menses—Perforation of the Os Tincse, and Evacuation of the Menstrual Blood. —Retention of the Menses, from Imperforate Os Tincse, in a married Woman, aged twenty-seven Years, mistaken for Pregnancy.—Vaginal-Hysterotomy in a married Woman, the Mother of two Children, from Criminal Attempts at Abortion, by Madam Restell—Safety to both Mother and Child.—Congestive Dysmenorrhea in a Girl, eighteen years of age—Spirits of Mindererus.—Pregnaney complicated with Ovarian Dropsy in a married Woman, aged twenty-two Years.—Case of a Patient Tapped three times for Encysted Dropsy during Gestation......248 LECTURE XVI. Introductory Remarks.—Undue Lactation in a married Woman, thirty-two Years ol age.—Anaemia—Paraplegia in a Child, twelve Months old, from Intestinal Irrita- tion.—Procidentia of the Womb in a married Woman, aged fifty-five Years, nine Years standing, with Venereal Ulcerations on both sides of the Organ.—Profuse Menstruation in a young Woman, twenty-two years of age, from Grief.—Incontin- ence of Urine in a married Woman, eighteen Years of age, from Paralysis of the Neck of the Bladder.—Falling of the Bladder in a married Woman, aged twenty- five Years, mistaken for Falling of the Womb.—Palpitation of the Heart, from Dyspepsia, in a married Woman, aged thirty-two years.—Encysted Tumor in the Posterior Wall of the Vagina in a married Woman, twenty-three Years of age. . 2M LECTURE XVII. The Diseases of Infancy, their Importance and Fatality—Is this Fatality unavoid- able ?—Peculiarities, Anatomical and Physiological of the Infant.—Vomiting in an CONTENTS. xm Infant, one Month old.—Suppression of the Menses, from Cold, in a youn* Woman "*" aged twenty-two Years—Melancholy Death of a young Lady from "wantonly trifling with her Health—Occlusion of the Anus in an Infant, one Week old- Operation.—Amenorrhcea, with Imperforate Os Tineas, and Encysted Dropsy of the Right Ovary, in a Girl, aged eighteen Years, the Lower Portion of the Ovary being prolapsed into the Triangular Space between the Uterus and Rectum.— Vaginal Hysterotomy, and subsequent Delivery with Forcep3, with Safety to both Mother and Child.—Atrophy in an Infant, aged twelve Months.....287 LECTURE XVIIL Management of the Placenta after the Delivery of the Fcetus in Natural Labor- Treatment of Uterine Hemorrhage.—Excessive Pain in the Uterus every time the Child is put to the Breast in a married Woman, twenty-three Years of age.—Pro- cidentia Uteri, with Venereal Ulcerations.—Suppression of the Menses of two Years and four Months' duration in a married Woman, aged twenty-six Years, the Mother of two Children, the youngest three Years old, from Imperforate Os Tincse, the result of Inflammation—Operation.—Physometra in a married Woman, aged thirty-two Years—What is Physometra ?—Introduction of a Silver Tube into the Uterus, followed by an Escape of offensive Flatus.—Occlusion of the Anus in an Infant, aged one Week.—Encysted Tumor, seated in the Posterior Wall of the Vagina, in a married Woman, twenty-three Years of age.—Partial Paraplegia in a married Woman, aged thirty-two Years, from Instrumental Delivery—Remedial Effects of Strychnia.—Epilepsy occurring at each Menstrual Period in a Girl, aged Bixteen Years........... . soft LECTURE XLX. Engorgement of the Uterus from Suppression of the Menses, resulting in Catalepsy, in a married Woman, nineteen Years of age.—Matrimony, its Effects on the Uterine Organs.—Suppression of the Menses occasioned by Periodical Hemorrhoidal Bleedings.—Vicarious Menstruation.-^-Emmenagogue Medicines not always indi- cated in Suppression.—Vomiting in an Infant, one Month old.—Periostitis, together with Venereal Condylomata in the Vagina, in a married Woman, aged twenty- Beven Years.—Abscess of the Right Labium Externum iD a married Woman, twenty-two Years of age, from difficult Parturition.—Retro-version of the Fundus Uteri in a married Woman, aged twenty-four Years—Connection between Retro- version and Paraplegia.—Importance of correct Diagnosis between Diseases of the Uterus and those of the Rectum.—Intense Pain during Sexual Intercourse from Internal Hemorrhoidal Tumors...........331 LECTURE XX. Complete Occlusion of the Meatus Urinarius, with Adhesion of the Walls of the Upper Fourth of the Vagina, together with a Vesico-Vaginal Fistula, in a married Woman, aged twenty-two Years, produced by Instrumental Delivery.—Premature Artificial Delivery twice in the same Patient, in consequence of Injury to the Vagina, with Safety to both Mother and Child.—Profuse Menstruation in a married Woman, aged thirty-nine Years, caused by Chronic Sanguineous Engorgement of the Uterus.—Strychnia and Ergot, action of.—Trismus Nascentium in an Infant, seven Days old—Ignorance of Midwives.—Utero-Lumbar Neuralgia in a married Woman, aged twenty-six Years.—Epileptic Convulsions in a married Woman, aged twenty-nine Years.............346 XIV CONTENTS. LECTURE XXI. TAC.i Hysteria from Defective Menstruation in a widow Woman, aged twenty-nine Years, the Mother of two Children, tho youngest six Years old.—Final Cessation of the Menses in a married Woman, aged forty-two Years, the Mother of five Children- Suppression of the Menses, of two Years and four Months duration, in a married Woman, aged twenty-six Years, the Mother of two Children, from ImperTorato Os Tincse, the result of Inflammation.—Physometra in a married Woman, aged thirty-two Years, the Mother of seven Children.—Engorgement of the Uterus from Suppression of the Menses, resulting in Catalepsy, in a married Woman, nineteen Years of age.—Complete Occlusion of the Meatus Urinarius—Operation.—Sup- pression of the Menses, occasioned by Periodical Hemorrhoidal Bleedings- Vicarious Menstruation.—Abscess of the Right Labium Externum in a married Woman, twenty-two Years of age, from Difficult Parturition.—Placenta Proevia in a Case of Twins, expelled from the Uterus after a seven Months' Gestation, with one Placenta, one Amnion and Chorion, both Cords inserted into the Placenta nearly in juxtaposition, each Foetus presenting Evidences of Incipient Hydroceph- alus, and each bearing Marks of having been Dead for two or three Weeks.— Deep Ulceration of the Cervix Uteri in a married Woman, aged thirty-one Years, the Mother of eight Children............3«8 LECTURE XXII. Ovarian Dropsy—Is it Curable ?—Prolapsus Ani in an Infant, five Months old— Why do Infants Cry ?—Anaemia in a married Woman, aged thirty Years, with Incipient Anasarca, the result of Profuse Flooding during a Miscarriage, three Months since , connection between profuse losses of Blood and Intense Headache —Two Forms of Ansemia.—Frequent Desire to pass Water in a married Woman, twenty-seven Years of age, from Protracted Labor.—Hysteria, from Defective Menstruation, in a widow Woman, aged twenty-nine Years.—Sympathetic Cough in a Child, eighteen Months of age, from Intestinal Worms.—Suppression of the Menses in a married Woman, thirty-one Years of age, of nine Years' duration, from Chronic Inflammation of the Uterus—Emmenagogue Properties of Mercury. —Inversion of the Mucous Membrane of the Urethra in a married Woman, aged forty Years.—Serous Infiltration of the Labia Externa in a married Woman, aged twenty-seven Years, six Months Pregnant.—Partial Paraplegia in a married Woman, aged thirty-two Years, from Instrumental Delivery.—Strychnia. . . 387 LECTURE XXIII. Leucorrhcea—What does it Mean?—Non-Sanguineous Vaginal Discharge.—Congest- ive Dysmenorrhea in a Girl, twenty Years of age—Varieties of Dysmenorrhoea.— Facial Hemiplegia in an Infant, ten Days old, from Instrumental Delivery.—Ab- scess in the Neck of a Child, two Years old.—Venereal Chancres in a Woman, twenty-four Years of age.—Gestation six Months advanced, complicated with Phthisis Pulmonale, in a married Woman, aged twenty-four Years—Does Preg- nancy exercise any Influence in Controlling either the Development or Progress of Phthisis Pulmonalis ?—Granular Vaginitis in a married Woman, aged twenty- four Years, accompanied with a thick, creamy Discharge.—Excessive Purging and Convulsions in an Infant, one Month old, produced by the Mother's Milk.—Ca- thartic Properties of the Colostrum.—Hypertrophy of the Nymphse in an unmar- ried Woman, aged twenty-seven Years, from Syphilitic Disease.—Congenital Enlargement of the Nymphse among the Boschismen Women.—Dysmenorrhoea in a married Woman, from Stricture of the Neck of the Womb. . . , .408 CONTENTS. XV LECTURE XXIV. Dropsical Effusions—Are they Common in Early Life ?—Their Causes and Treatment. *A°' —Ascites, together with General Anasarca, in a Boy, five Years old, the effects of Scarlet Fever—Importance of the Perspiratory Function.—Ascites in a Boy, three Years old, from Protracted Dysentery.—Convulsions from Suppressed Eruptive Disease in a little Boy, three Years old—What is the Connection between a Sup- pressed Exanthematous Affection and Convulsions ?—Retention of Urine in an Infant, three Days old—Difference between Retention and Suppression.—Sup- pression of the Menses for the last six Months in a Girl, twenty Years of age- Intermittent Fever—Has it any Influence over the Menstrual Function ?—Prolapsus Uteri, from Engorgement of the Cervix, in a married Woman, aged thirty-two Years.—Fistula in Ano in a married Woman, aged twenty-nine Years—Operation. —Neuralgia of the Right Labium Externum in a married Woman, aged twenty-four Years.—Mammary Abscess in a married Woman, aged twenty-five Years, the Mother of one Child, four Weeks old.—Agalaxy, or Absence of the Milk Secretion. Galactagogue Properties of the Bofareira {Rkinus Communis), as Tested in the Cape de Verd Islands.—Excessive Exhaustion from Flooding after Delivery- Remedial Properties of Opium............430 LECTURE XXV. The Diseases of the Nervous System in Infancy; their Frequency and Importance. —Laryngismus Stridulus in an Infant, seven Months old.—Asphyxia; its Meaning, its Causes, and Treatment.—Muguet in an Infant, ten Months old.—Prolapsion of the Mucous Membrane of the Vagina in a married Woman, aged twenty-seven Years, the Mother of three Children.—Thrombus, or Sanguineous Tumor of the Right Labium Externum, in a married Woman, aged twenty-two Years, the Mother of one Child, three Years old.—Convulsions, from suppressed Eruptive Disease, in a little Boy, three Years old.—Ulcerative Carcinoma of the Uterus in a married Woman, aged forty-two Years, the Mother of seven Children, the youngest five Years old.—Haemostatic Properties of the Perchloride of Iron.....450 LECTURE XXVI. Attentions to the new-born Infant; Tying and Cutting the Cord; Washing; Dress- ing ; Pins not to be employed; Examine the Infant to see if there be any Deform- ities ; Infant not to be exposed to the Light; Dosing and Drugging—their fatal results; The Mother's Milk the most suitable Medicine and Food for the new-born Child; The Colostrum—its Properties; Cleanliness necessary to the Health of the Infant; Dangers to the Mother who does not Nurse her Child; Kiestine—why Found in the Urine of Pregnant Women; Albuminuria and Puerperal Convulsions —Is there the relation of Cause and Effect ?—Rachitis—how produced in the young Infant; Phosphate of Lime; Experiments of Dr. Mouries; Opinion of Dr. Beneke. —Neuralgia of the Cervix Uteri in a married Woman, aged twenty-three Years, no Children.—Retro-Uterine Haematocele in a married Woman, aged thirty-four Years, the Mother of four Children, the youngest fourteen Months old.—Exploring Needle.—Convulsions and Excessive Purging in an Infant, one Month old, pro- duced by the Mother's Milk; Cathartic Properties of the Colostrum.—Suppression of the Menses, of nine Years' duration.—Amenorrhcea in a Girl, sixteen Years of age.—Danger of the indiscriminate Use of Emmenagogues— Retro-version of the Uterus in a married Woman, aged thirty-four Years.—Dysmenorrhoea; its Con- nection with Uterine Displacements.—Sore Nipples in a Primipara from Nursing. —Convulsions in a little Boy, two Years old, from excessive general Blood-letting. —Infantile Therapeutics.—General and Local Depletion—their comparative safety. —Neuralgia of the Right Labium Externum in a married Woman, aged twenty- four Years...............470 xvi CONTENTS. LECTURE XXVII. PAOl Mother's Milk, the proper Nourishment for the Intimt; Causes which disqualify the Mother from Nursing her Child; Requisites necessary in a Wet-nurse ; Absurd Practice of cramming Wet-nurses; Bringing up tho Infant by Hand—rules for; When should the Child be Weaned ? Milk deteriorates by being retained in the Breast.—Jaundice in a Woman seven Months Pregnant; why dangerous to the Foe- tus ?—How is the Blood elaborated in the Placenta ? F.jetal Circulation ; Transmis- sion of Hereditary Disease ; Puerperal Convulsions.—Vaccination—origin of; Is Re-vaccination necessary ?—Does Vaccination lose its Efficacy by Transmission ?— At what Age should an Infant be Vaccinated ?—Mode of Vaccination ; Is it proper to Vaccinate during the Existence of a Cutaneous Disease i—Signs of Genuine Vaccination...............496 LECTURE XXVIII. ?ulse in Infancy ; How Influenced; Examination of the Sick Child; Maximum, Minimum, and Average Pulsations in the Infant.—Tympanites Intestinalis, with Obstinate Constipation, in a married Woman, aged thirty Years, the Mother of •ne Child, aged two Years—Supposed Pregnancy.—Dr. O'Beirne's Method of Extricating Flatus from the Intestinal Canal.—Chorea in a Girl, six Years of age, from Fright—Connection between Chorea and Rheumatism—Value of Gymnastio Exercise in the Treatment of thiB Affection.—Abortion three successive times in a married Woman, aged thirty-one Years, during the Period of Lactation. . 510 LECTURE XXIX. Thoughts on Uraamia; what is Ursemia ?—Is Albuminuria always followed by Urse- mia ?—The Cause of Albuminuria—Do. Puerperal Convulsions and Albuminuria stand in the Relation of Effect and Cause ?—Urea ; Is it a Poison ?—Treatment of Ursemia—Colchicum, and Guiacum; their Influence over the Secretion of Urea.— Conclusions...............522 LECTURE XXX. Sterility.—Reproduction ; how Accomplished in the Female.—The Female Germ and the Spermatic Fluid of the Male—Voluptuous Sensation on the part of the Female not necessary to Impregnation—Fecundating Element in the Spermatic Fluid.__ The Causes of Sterility.—Is it possible to Catheterize the Fallopian Tubes ?—Dr. Tyler Smith's Operation.—Stricture of the Cervix Uteri, a Cause of Sterility.__Re- tention of Urine in an Infant, three Days old.—Scarlet Fever—Rules to be Ob- served during Convalescence from Scarlet Fever........535 LECTURE XXXI. Nausea and Vomiting in Pregnancy.—Modifications of the Uterine Organs under the influence of Gestation.—Membrana Decidua and Reflexa.—Is it ever justifiable to produce Abortion during the Vomiting of Pregnancy ?—Connection between an absence of Vomiting during Gestation and Miscarriage—Miscarriage; how pre- vented.—Vagiual-rectocele in a married Woman, aged thirty-six Years ; Varieties of Vaginal Hernia.—Excessive pain in the left Mamma, in a young Girl, eighteen Years of age.—Pudendal Hernia in the right Labium Externum, in a married Woman, aged forty-two Years ; Spasm of the Vagina in a married Woman, aged wenty-two Years—Difference between Spasm and Neuralgia of the Vagina. . 551 LECTURE I. Diseases of the Uterus, organic and functional.—Their Importance.—But little un- derstood in Ancient Times.—Hippocrates and his School.—The Speculum and Toucher.—The true Knowledge of Uterine Disease of recent Origin.—Circum- stances which modify these Affections.—Why are Diseases of the Uterus more frequent now than in Olden Times?—Indifference of Females to their own Health.—Painful Consequences.—Profuse Menstruation from Debility in a married Woman, aged twenty-seven Tears.—Acute External Otitis in a Boy, aged four Years.—Gonorrhceal Ophthalmia in a Boy, aged three Tears.—Suppression of the Menses from Cold, in a young Woman, aged twenty-one Tears, complicated with Pthisis Pulmonalis.—Hooping-cough in an Infant, aged ten Months. Gentlemen:—There is no chapter in the entire range of your pursuits more interesting, or more worthy of profound investigation, than the diseases, both organic and functional, of the uterus and its ap- pendages. These diseases were very imperfectly understood by the ancients, though you will find they thought and wrote much on the sub- ject. Their views were crude, because their pathology was false; their treatment was empirical, because it had no fixed scientific basis. Con- sidering, however, the condition of science at that time, the few ele- ments for the successful pursuit of truth, and the extremely limited means of diagnosis, we cannot but express surprise that the old school- men should have accomplished as much as they did on the subject of uterine affections. If they have given us but little that modern science will recognize as correct in pathology and therapeutics with regard to these disorders, they have at least evinced a laudable spirit, in the ab- sence of correct principles, for philosophical deduction. Hippocrates himself devoted, in his medical writings, two entire books to the consid- eration of the diseases of females. It is, however, to be borne in mind that the father of medicine, with all the importance he attached to the diseases of women, inculcated, and indeed exacted, the fulfillment of a maxim, which must of necessity have proved a barrier to solid advancement in the accurate knowledge of these maladies. The physician, he remarked, should depend upon the testimony of some capable woman, who, after subjecting the patient to an examination per vaginam, could give the result of this ex- amination to the medical man, who would then be able upon this testi- mony to base a rational and curative treatment! This maxim survived 6 CLINICAL LECTURES. unfortunately the times of Hippocrates, and was perpetuated almost until the fifteenth century ; for, up to this period, the vaginal examina- tions, when made, were conducted by matrons who were qualified neither by education nor tact for the responsible duty, and hence the little prog- ress made in the elucidation of this most interesting class of diseases. Our knowledge of the true nature of uterine affections may be said to be of recent origin; and the progress made on this subject is, in great measure, although not exclusively, due to the facilities which modern in- vention has furnished us of seeing and feeling diseased structure, and thus studying with certainty not only the progressive changes of morbid, but also the progressive stages of restorative action. The speculum and the toucher are two precious elements of investigation ; but, like all things good, they have been sadly abused. Kecamier, when he introduced to the attention of the profession the modified speculum, opened a new avenue to thought; and rich indeed have been the fruits of this instrument, when judiciously employed, as a means of diagnosis in affections which previously had been full of obscurity, and oftentimes mere questions of vague conjecture. The toucher, also, or examination by the finger, is another means of exploration to which too much value can not be at- tached. Limited, however, would have been the advantages of these physical agents, had it not been for the simultaneous advances in physiology and cor- rect therapeutic application ; for, with the speculum and toucher alone, we would have learned only the existence of lesion of structure, and had in our posssession the means of applying to the part affected the necessary remedies ; whilst the various nervous disturbances in different portions of the economy, dependent on organic and functional derangements of the uterus and its annexae, would have remained sealed mysteries, but for the light which modern physiology has thrown upon them. The re- searches, too, of the pathologist and chemist have not only tended to reveal new facts, but they have directed the mind to a correct etiology of disease, and, as a consequence, to a more rational and judicious treat- ment. The ample means, therefore, which we now possess of investigating uterine disorders, and the comparative facility with which the true na- ture of these diseases is arrived at, give to this class of special maladies an identity, which formerly did not belong to them; and hence what in the remote periods of our science were regarded as idiopathic affections of the head, chest, abdomen, etc., are now recognized to be symptomatic disturbances, or merely effects of disease in the uterine organs. This is really progress; not that progress which travels beyond judgment, and leads often to fatal issues, but a progress the result of truthful and philosophical investigation. You will frequently be asked, in the course of your professional duty, why it is that diseases of the uterus are so much more com- DISEASES OF THE UTERUS. 7 mon now than they were in former times; and you will occasionally meet with good old grandmothers who will shrewdly remark : " Why doctor, when I was young, I never heard of ladies having these com- plaints : what is the reason that we hear so much about them now ?" This question is readily answered. It is not a necessary sequitur that, because diseases of the uterus were not recognized, they did not exist. These affections, although no doubt much enhanced by the increasing neglect of the general ordinances of health, are of no recent date; on the contrary, they have formed their part in the catalogue of human suf- fering, and have not been inactive in the work of death from the earliest periods of creation. The revolutions of the sun, and the wonderful machinery of the physical world, were no less perfect thousands of years ago than they are at the present time; and yet how profoundly ignorant was man of the true nature of these things—how inadequate to explain what then appeared to him deep mysteries beyond the ken of human intelligence ! Where are these mysteries now ? They have yielded to the progress of science—they have become universal truths, perfectly understood, constituting the every-day lessons of the school-room! There are numerous causes which conspire to the frequent production of functional and organic derangements of the uterus; but numerous as these causes are, experience proves very conclusively how unequally they operate under different circumstances. Child-bearing, unrestrained sex- ual intercourse, abortions, precocious nervous excitement from the peru- sal of prurient books, the lascivious polka, and the various exciting scenes of city life, are so many influences, which are constantly exhibiting their destructive results on the females of the gay metropolis. Add to these, the uninterrupted rounds of excitement consequent upon balls, parties, the opera, etc., the liability to cold imposed by these amusements, and more than all, the fact that these disastrous influences—disastrous to health and happiness—are exercised on a physique too often without a single attribute of solidity—and you will at once have explained why it is that the females in the higher classes of our large cities decay long before they have attained the meridian of life. But you may ask, if city life be so destructive, why is not this influence universal, and why does it not fall with equal force on all—why do the lower classes who reside in the city enjoy, com- paratively at least, an immunity from these special diseases? The question is a legitimate one, and its solution establishes an important principle. The nervous system of the poorer classes in our cities fortified by constant exercise in the open air, and strengthened by frugal habits, unaccustomed, too, to those perturbations to which we have alluded, dispenses no unhealthy action on the uterine organs, and, therefore, is not, as is the case in the higher circles, a constant element of morbid action. You are not, however, to infer that the humbler classes of society enjoy an entire immunity from uterine affections. This 8 CLINICAL LECTURES. immunity is only comparative; for while it is true that these classes are less impressionable, and more free from nervous excitement, yet their measure of suffering is derived from exposure, and the influences usually attendant upon dependence and poverty. Age exercises a very remarkable influence in the production of dis- eases of the uterus. The two important climacterics of female life may be said to be puberty, when the menstrual function is first established— and the period of its final cessation, when the reproductive faculty be- comes extinguished. The former is an era of great peril to the young girl, and fortunate indeed is she should she pass it successfully ; the latter, the period of final cessation, is no less critical—for at this time diseases of the uterus and certain constitutional disturbances, which before may have been dormant, are frequently found to develop themselves. Should the female, however, attain this crisis, and encounter its perils with im- punity, she, too, will not only have cause for congratulation, but, as a general rule, will enjoy good health, and reach a ripe old age. There are other circumstances, also, which tend to modify affections of the uterus, and hence we find differences in these maladies, accordingly as they occur in the maiden, in the married woman who has never conceived, and in the child-bearing female. The distinctions, therefore, which these various conditions produce in the grade and character of the disease with which the uterine organs may be affected are worthy of the fullest con- sideration. There can be no doubt that child-bearing strongly predisposes to structural disease of the uterine organs; and it is not surprising that such should be the case, for it is only necessary to recur to the numer- ous changes in structure and function which these organs undergo during this period, to appreciate how much greater is their tendency to morbid action. The organic are much less frequent than the functional derange- ments of the uterus. These latter are characterized during life by various disturbances of the uterine and general systems, but do not after death reveal any lesion of structure; the former, the organic affections, on the contrary, are always more or less marked by structural changes. It was with the hope of affording you an opportunity of studying the various maladies of the female practically, and also the diseases of children, that I embarked in the enterprise of establishing an Obstetric Clinic, which would enable me to bring before you the most interesting of these affections, and discuss in detail their nature, causes, symptoms complications, and treatment. In no other way can these maladies be effectively studied. From books alone you can learn neither the diag- nosis nor treatment of disease, nor will didactic lectures remove the ob- scurity with which it is oftentimes surrounded. Books and lectures are useful for the inculcation of the principles of our science; but for the just and practical application of these principles, it is absolutely neces- sary that you should see disease—your minds must become familiar, by DISEASES OF THE UTERUS. 9 repeated and actual observation, with the Protean forms of morbid ac- tion, and in this manner only can you fully appreciate the difficulties of the profession, and learn how to overcome them. Clinical observation, gentlemen, is what the physician is most in need of; without it, he en- ters on the mission of his duties unprepared for the emergencies of pro- fessional life, and his career proves one of blighted hope to himself, and disastrous to those who may invoke his counsel. It is no trifling thing to become the guardians of human life with inadequate knowr edge; and remember what I now tell you, that the best physician will be he who, enjoying ample opportunities for the practical observation of disease, shall the most faithfully avail himself of the facilities thu. presented. Those of you who may contemplate giving special attention to the mal- adies of females, can not too seriously meditate on the necessity of ac- curate knowledge. If you have not a clear and comprehensive sense of all that appertains to these diseases, your success as practitioners will not only be doubtful, but oftentimes you will experience feelings of deep mortification. Error of judgment here will frequently lead to positive ruin; whilst, on the contrary, success in the treatment of diseases inci dent to the female will secure to you the gratitude of your patient, and prove beyond all doubt the corner-stone of your fame and fortune. In this city there is much and intense suffering among females from disease. Wealth and its associate influences can not stay the progress of this unrelenting enemy. The lady, who revels in luxury, and has around her, even to satiety, all the comforts and pleasures which opulence can secure, would gladly, whilst writhing under the agonizing pain incident to some formidable affection of the womb, surrender all these comforts to regain the health which, it too often happens, she has sacrificed by her own folly and imprudence ! She once possessed a good constitution— she relied too strongly on that constitution—she became careless, entered into all the dissipations of society, infatuated and bewildered by the constant excitement of fashionable life—a devotee to pleasure, she is heedless of the first manifestations of disease; but the disease, like the silent night, progresses—it brings with it physical infirmity and moral anguish—her strength is declining—her mind weakened, and, compelled by absolute sufferiug to withdraw from society, she finally invokes the aid of a physician. He investigates, with great care, her case, and finds that her disease is without remedy. She may, peradventure, be labor- ing under some organic affection of the uterus, which, if seen to in time, would have been perfectly manageable. Her days are numbered—and, instead of being the attraction and idol of the gay crowd, she now be- comes the victim of the most distressing bodily suffering—suffering so agonizing that she is impatient to die—and, when her last hour has come, she breathes a prayer of thankfulness to Heaven that her agony is at an end! There is, gentlemen, no fiction here; I am not presenting you an exaggerated picture—it is true in fact and in detail. I have been 10 CLINICAL LECTURES. compelled on more than one occasion to say, when my opinion was re- quested : " Madam, I can do nothing for you—your disease has made fearful progress—it is beyond the reach of science!" These words fall on the ear of the afflicted patient with chilling and disastrous effect; they bring to her mind with vivid truth the painful reminiscences of her own indiscretion—indiscretion which is about to consign her to an early grave, and make desolate the hearts of those to whom she was united by the ties of the closest affection. When will the females of the present day become rational, and eman- cipate themselves from the delusion which is constantly resulting in disaster and death? When will they hearken to the admonitions of common sense, and turn from the path of folly, which leads with the certainty of truth to unhappiness and misery ? Let them but take a brief retrospect of what has befallen their own immediate friends. Where is the lady, who has not been called to mourn the premature death of some fond and devoted sister—of some gay and cherished com- panion ? In the death of that sister, she may, perhaps, have learned the importance of attending to the early developments of disease, and appreciated the cruel wrong of allowing them to pass unnoticed and un- checked. Yet with these admonitions fresh in the memory of almost every female in the land—with the daily and lamentable experience before her of the consequences resulting from indifference to the first indications of deranged health, we see her—wayward and thoughtless as she is—passing to her own destruction ! I could enumerate many examples of melancholy suffering which commenced, in the first instance, in simple aberration of the menstrual function. This aberration, how- ever, was unheeded; it was permitted to continue month after month, until finally it terminated in the development of a malady which, after years of torture, occasioned the death of the unhappy victim. But, gentlemen, we must proceed with our cases. Profuse Menstruation from Debility, in a married Woman aged TWENTY-SEVEN YEARS, THE MOTHER OF THREE CHILDREN.--Mrs. P., aged twenty-seven years, the mother of three children, the youngest eight months old, menstruates every three weeks, the evacuation continuing for eight or ten days. She is much prostrated, presenting pallor of countenance feeble pulse, and cold extremities; she complains of palpitation of the heart ver- tigo, and says she often feels as if she would fall. " Have your courses always been profuse, madam ?" " No sir; they were always regular until four months after the birth of my last child." " You say you are the mother of three children ?" " Yes sir." " Did you nurse all your children ?" " I did, sir." " At what age did you wean them ?" " The first I nursed, sir, until he was fourteen months old, the second until he was twelve months, and I was obliged to wean the last when he was only six months of age." " Why were you obliged, madam, to wean your PROFUSE MENSTRUATION. 11 last child so early ?" " Because, sir, I was so weak, I could not nurse him any longer." " When did your courses commence to be profuse ?" "About ten months ago, sir." The conversation, gentlemen, to which you have just listened, between this patient and myself, discloses a very important fact, and satisfactorily accounts for her present condi- tion. You have heard her statement as to the necessity of weaning her last child—that necessity being extreme debility. Her physical sys- tem was not adequate to the duty of nursing, the previous nursing of her children having already made an inroad upon her health ; and you see, therefore, that this prostration of system is traceable primarily to undue lactation—a trying and oftentimes serious influence exercised on the frame of the female. There are two interesting circumstances con- nected with this case, which are of much practical value. In the first place, the physical energies of this woman have been sadly dilapidated by tlie long-continued nursing of her children; and secondly, this dilapidation of her health has given rise to a form of profuse menstruation which, if not arrested, must necessarily lead to disastrous consequences. As I shall have frequent occasion to remark to you, the derangements of the menstrual function are numerous, and the first duty of the practitioner in assuming to treat them is manifestly to comprehend their nature and causes. The term menorrhagia is employed to denote an excessive dis- charge of the menstrual blood, and is usually limited to this significa- tion ; while the word metrorrhagia, which literally means a hemorrhage from the uterus, has reference to those profuse bleedings, which may occur at any time, and are altogether unconnected with the menstrual function. A female may be attacked with uterine hemorrhage under the following circumstances: 1. When the uterus is in a state of vacu- ity ; 2. During the period of gestation; 3. During or immediately after delivery; 4. From intra-uterine growths. These comprehend the various conditions in which hemorrhage may occur; but you are to remember that in each of these conditions the causes are extremely numerous, and it is only by appreciating them that you can hope to be rational and effective in your treatment. The case of the patient before us presents an example of profuse menstruation purely from debility, and is the result of an atonic state of the system, and more especially of the uterine vessels which, together with the increased fluidity of the blood from the loss of its fibrin, will at once account for this particular form of hemorrhage. You will occasionally observe this character of passive menorrhagia in chlorotic women; but you are not in these in- stances to mistake the cause for the effect; for we know that long-con- tinued menorrhagia will give rise to the general symptoms of chlorosis. If the drain on the system of this woman be not checked, the constitu- tion will soon become involved in serious disturbance, and there will be a general giving way of the health. Drains like these, if suffered to continue, are extremely apt to terminate in dropsical effusion, constitute 12 CLINICAL LECTURES. ing the asthenic dropsy of authors. There are two symptoms of which this patient complains, and which are prominent in her case. I allude to the palpitation of the heart, and the vertigo. Do not be misled by these symptoms; each one of them may be produced by two opposite conditions of system. For example: a patient who is overloaded with red globules will, from the excessive stimulation of the brain and heart, have vertigo and palpitation ; and again, when there is a deficiency of these red globules the same result will ensue for the reason that the brain and heart, being deprived of their proper stimulus, become de- ranged in function, as is exhibited by the vertigo and palpitation. One word as to the diagnosis of this case. In all such instances, no matter how positive the conviction that the menorrhagia is purely the result of debility, yet, before having recourse to treatment, the physi- cian owes it to his patient, as well as to himself, to institute a vaginal examination, to ascertain the possibility of the bleeding coming from some organic disease of the uterus, such as a sub-mucous fibrous tumor, the ulcerative stage of carcinoma, &c. Before introducing this pa- tient to you, I instituted a vaginal examination, and have discovered no organic lesion—there is simply a relaxation of the uterine tissues, owing to defective contractility of the viscus. Treatment.—Here the treatment must be both general and local. In this particular form of menorrhagia, characterized as it is by debility, the mineral acids will prove serviceable. These have been regarded with more or less favor, but their true modus operandi appears only to have been recently explained. Indeed, it may be said that their use has heretofore been somewhat empirical. It is said that the true value of this class of acids, the chief of which is the sulphuric, is due to the power they possess of coagulating the serum of the blood. Sul- phuric acid exercises a peculiar influence on mucous membranes, and it is alleged that its efficacy is exclusively confined to hemorrhages from these surfaces. A table-spoonful of the following may be given three times a day: R Acid Sulphuric, dilut. . . . . 3 ij Syrup Aurantii . . ' . . . fivM. Alum in small doses administered internally will also be found in these cases an appropriate remedy; it is one of the most certain in its action, and, therefore, one of the most important of the astringent medicines. It may be employed with advantage in chronic mucous discharges, in pass- ive hemorrhages, &c. It is not limited, like sulphuric acid, to any par- ticular structure, but is universal in its astringent properties. Of the following a table-spoonful may be administered twice a day: R Aluminis..... . . 3 isa Aquae Rosar......."% v Syrup, simp. ... . aa § ss Syrup, papav. Alb. M. ACUTE EXTERNAL OTITIS. 13 One of the best local remedies in these cases will be an injection night and morning into the rectum of half a pint of cold water, com- mencing on the second day after the appearance of the menstrual flow. It is a simple remedy, but I have found it of signal efficacy. The cold hip-bath may also be resorted to with advantage; but it must not be forgotten that in the use of cold as a therapeutic agent, its activity should be proportionate to the facility with which the system reacts; or, in other words, to the facility with which the caloric lost by the application of the cold is restored, so that, with this view, the temperature of the water should at the commencement be adapted to the peculiar circumstances of the patient. Tannin is a vegetable astringent frequently of great benefit in these cases of passive menorrhagia, and may be given in doses of two grains every three hours. The regimen should be decidedly generous, consisting of roast meats, animal broths, &c; and perhaps after the menorrhagia has ceased, there is no better tonic, under the circumstances, for the purpose of restoring the wasted energies of the system, than quinine. The following formula may be used: R, Sulphat. Quinsa......gr. zii Acid Sulph. dilut.......gtt. xij Aquae Purae....... § iij FL sol. A table-spoonful twice a day. Acute External Otitis in a little Boy, four Years of Age.—Dennis W., aged four years, has for the last two weeks complained of distressing pain in the right ear; he has also labored under constipation, and general derangement of the digestive system. There is now a free purulent dis- charge, and the pain is much relieved; the discharge is extremely offen sive. We have before us, gentlemen, an example of acute external otitis, inflammation of the ear, or, as it is sometimes called, ear-ache, Otitis is divided into external and internal; in the former instance it is limited to the external ear, whilst in the latter it involves the structure of the internal ear, and frequently*proves very destructive. Scrofulous children are most liable to this latter form of the disease. Otitis is sometimes acute and sometimes chronic. Inflammation of the ear is not a rare affection in children; and you will observe it under a variety of circumstances. There is one fact worthy of recollection, viz., that the disease is almost invariably limited to one ear. I have never seen a case in which both ears were affected simultaneously. For practical pur- poses, otitis has been divided into primitive and symptomatic—and this is a division which you will often recognize. You have an example of symptomatic otitis in eruptive fevers, in scarlatina and measles, for in- stance, and you will also occasionally observe it in difficult dentition, es pecially where the process is more than ordinarily protracted. 14 CLINICAL LECTURES. Causes.—A very common cause of this affection is cold ; a collection of wax in the ear, or the introduction of irritating substances ; it may sometimes arise from inflammation of the throat, the inflammation in- volving the eustachian tube, and thus affecting the ear. The presence of small worms in the auditory canal has been known to produce the disease. Symptoms.—The first and prominent symptom of this affection is pain, which is occasionally most intense; there is sometimes redness about the ear, and exquisite sensibility on pressure; a child old enough to dis- tinguish the seat of pain, will place its hand on the affected ear, and moan; often deafness accompanies this affection from the very com- mencement; and, in secondary otitis, the result of scrofulous and erupt- ive diseases, the loss of hearing will be protracted, and occasionally be- yond remedy. In three, four, or more days after the inception of the disease, there will generally be a discharge of matter, the result of the suppuration in which the inflammation has terminated; in some rare in- stances, the discharge will be serous. In almost all cases of suppura- tion, the matter will be extremely offensive. When the ear discharges, the disease is then called otorrhoea, the duration of which will vary ac- cording to the particular form of otitis with which the child may have been affected. For instance, in symptomatic otitis, the duration of the discharge will depend in great measure on the character of the disease of which it is a result. In scarlatina, I have known the purulent secre- tion to continue for three, four, and six months ; and the same thing will often be observed in what may be termed with propriety scrofulous otitis. But, as a general rule, the continuance of the discharge does not exceed two or three weeks. It is important to mention, that as soon as the sup- purative process is complete, and the matter passes from the ear, the pain is very much diminished, and usually ceases altogether. Diagnosis.—In young infants, who have not the power of speech, or the faculty of communicating their sufferings, it is extremely important for the physician to exercise more than ordinary vigilance in arriving at a correct opinion as to the nature of the malady. An infant with this disease will cry incessantly; and oftentimes an error is committed in ascribing the crying and restlessness of the child to a wrong cause. In otitis, on a close examination of the ear, and particularly of the auditory canal, redness will be discovered, and on pressure there will be exquisite sensibility. Prognosis.—In external otitis, there is nothing dangerous; but in inter- nal otitis, especially that form connected with a scrofulous diathesis there must be some reserve in the opinion given. I have known, in this latter case, destruction of the small bones of the ear, entailing perpetual deafness, and other serious results. Treatment.—The first point in the treatment is, if possible, to remove the cause of the inflammation. For example : should there be a collec- tion of wax in the ear, it should be softened by the injection of warm GONORRHEAL OPHTHALMIA. 13 milk, and then removed; emollient poultices to the ear; and, when the inflammation and pain are very active, two or three leeches ap- plied round the mastoid process will be indicated. I have found in these cases much benefit from an onion poultice. When the matter be- gins to discharge, it will be right to continue the emollient injections for the purpose of cleansing the ear; and if the discharge should be protracted, astringent in lieu of emollient injections will be proper. One of the following may be employed: R Sulphat Zinci.......gr. ij Aquae Distillat.......§ij Ft. sol. R Lactis. Aquae Calcis........aa f j Tinct. Myrrhae.......gtt. xij M. This child has labored under constipation; it will, therefore, be neces- sary to attend to the condition of its bowels. It will, as a general rule, be good practice to administer in these cases a brisk cathartic, for the reason that it will act beneficially on the intestinal mucous surface; and, with the same view of revulsion, a styptic pediluvium during the inflammatory stage of the disease will be beneficial. Let the following cathartic be administered to-night, followed in the morning by % ss of castor oil: R Sub. Mur. Hydrarg.......gr. ij Pulv. Jalapae.......gr. vi Pulv. Antimonial. . . . . . gr. ^ Ft. pulv. During the inflammatory stage, the diet should be simple, consisting of diluents, boiled rice, potatoes, &c. Gonorrheal Ophthalmia in a little Boy, aged three Years.—Wil- liam J., aged three years, has a severe inflammation of the left eye, which is closed, and excessively tumid. The child appears to be in much pain, and altogether an object of distress. " How long, my good woman, has your child been affected with this sore eye ?" " I noticed it for the first time, sir, yesterday morning." " Was the eye closed when you first observed it was inflamed ?" " No, sir; but it closed up yesterday afternoon, and the poor child has been crying all night." " D6 you know what caused the eye to inflame?" "Indeed, I do not, sir." "Now, my good woman, tell me the truth, and I will do all I can for your child." " Well, doc- tor, I believe the child caught the contagion from its father." " What contagion ?" " Oh! sure, sir, you must know! My husband is a worthless man, and he has given my poor little child a dreadful disease, which will destroy his eye!" The reason, gentlemen, for my asking these questions, was to confirm the suspicion I entertained as to the par- ticular nature of this ophthalmia, and I have no doubt that it is a case of gonorrhoeal inflammation, one of the most rapidly destructive forms of 16 CLINICAL LECTURES. ophthalmia which can possibly present itself to the observation of the physician. My suspicion arose from two circumstances. 1st. The viru- lence and rapidity of the inflammation. 2d. The fact that only one eye is affected. It is an interesting circumstance for you to recollect that gonorrhceal differs from both Egyptian and the ordinary purulent oph- thalmia in the particular that, as a general rule, in the two latter forms both eyes are affected, whilst in the former the disease is limited to one only. Causes.—Authors have entertained various opinions touching the cause of gonnorrhoeal ophthalmia; and there is even now much difference of sentiment on the subject. It is contended by some that it is the result of inoculation of the tunica conjunctiva through the virus of the urethra; again, it is asserted that it is simply the effect of metastasis from the urethra to the eye; whilst others affirm that it is the consequence purely of irritation. Whatever may be the truth of these respective opinions, one fact is well established, that if gonorrhceal matter be applied to the conjunctiva, virulent and sudden inflammation will be the result; so that it may be assumed that inoculation is a very certain mode of producing this disease. It is often, I am sure, transmitted, as is the ordinary puru- lent ophthalmia, through cloths or towels, which have been used by those affected with gonorrhoea. It is, therefore, important when attending per- sons with this affection to caution them on the subject Symptoms.—As I have already remarked, but one eye is usually affected; the eye soon becomes the seat of active inflammation, the lids become closed, and very tumid from the distension caused by the muco- purulent secretion; the conjunctiva is first attacked, and, in a very short time, in the absence of proper treatment, the cornea is involved, and the eye oftentimes speedily destroyed. A characteristic symptom of this affection is a livid color of the lids. Treatment.—If the most active means be not resorted to, this little fellow will certainly lose his eye. In the first place, three leeches should be applied to the inner angle of the eye, the bleeding to be encouraged by warm fomentations. The following powder should be administered: R Sub. Mur. Hydrarg.......gr. iij Pulv. Jalapae.......gr. vi Pulv. Ipecac........gr. ss Ft. pulv. Let this be followed in six hours by the subjoined draught: $ Infos. Sennae.......§ ij Sulphat. Magnesias......3 i Mannae........3 ss M. The eye must be freely washed several times a day with a collyrium, which I shall presently prescribe, and the conjunctiva touched with a solution of the nitrate of silver. There is, gentlemen, some judgment necessary in making these applications, and I will now proceed to show SUPPRESSION OF THE MENSES. 17 you how the eye should be cleansed, and the manner in which the collyrium and nitrate of silver should be employed. I place the child's head in this manner on my knee, allowing the body to rest on the lap of the mother. Then, with a piece of fine sponge, moistened with tepid water, I remove the matter from the eye, and immediately, with another piece of sponge, bathe the eye freely with the following collyrium : R Oxymuriat. Hydrarg......gr. ss Sal Ammoniac......gr. ij Aquae distillat.......§ iv Ft. sol. When the eye has been thus cleansed, and after the application of the collyrium, the conjunctiva should be freely touched by means of a camel's hair pencil with the following solution: 5 Nitrat. Argenti . . . . . gr. v Aquae distillat.......§ i Ft. sol. Such is the activity of the inflammation, that it will be necessary, in addition to these means, to have recourse to one or more small blisters behind the ear, and this should be done from the very commencement, for the purpose of diverting as speedily as possible from the eye. To prevent the agglutination of the lids, you will find much benefit from the use of the red precipitate ointment. Fomentations with laud- anum and tepid water will be indicated, should there be much pain about the eye. The diet to consist exclusively of diluents. Suppression of the Menses from Cold, in a young Woman, aged twenty-one Years, complicated with Pthisis Pulmonalis.—Margaret D., aged twenty-one years, unmarried, menstruated for the first time in her fourteenth year. " How long, Margaret, have you been in ill health ?" " For the last six months, sir." " Was your health always good prior to that time ?" " Yes, sir; I was a healthy girl, and never lost a day's work by sickness." " What occurred six months ago to derange your health?" "My courses stopped upon me, sir." "Do you know what caused them to stop, Margaret ?" " I was washing, sir, and became very much heated; and I foolishly, without any shoes or stockings, walked on cold damp flags." " Were you menstruating at the time ?" " Yes, sir." " And after you walked on the flags, your courses became suppressed?" "Yes, sir." "Have you had them since that time?" " No, sir." " You have a very bad cough; how long have you had it, my good girl ?" " I took the cough, sir, about four weeks after my courses stopped; and it has been increasing ever since." "You have been losing flesh, have you not ?" " Oh! sir, I am wasted to almost nothing." "Does your cough trouble you much?" "Yes, sir; I can not get any rest, particularly at night." " Do you spit up much ?" " Yes, sir; I suppose I spit more than a pint of corrupted-looking stuff during the 2 18 CLINICAL LECTURES. day." « Do you have chills ?" " Yes, sir; I have chills running down my back." " Do you have much fever ?" " In the after part of the day, sir, I flush in the face." " Are you troubled much with night-sweats ?" " Yes, sir; I have had them for the last two months." This case, gen- tlemen, is an instructive one. The girl before you is twenty-one years of age, and enjoyed excellent health until six months since, when, from her own imprudence, her menstrual function became suppressed, soon followed by a cough, which is now in full development. This poor girl is laboring under pthisis pulmonalis. Her pulse is one hundred and twenty. She has purulent expectoration, chills, night-sweats, the hectic flush; in a word, she presents the entire cortege of symptoms of that most fearful and rebellious malady—consumption. You can, I apprehend, have no difficulty in understanding the starting point of this pulmonary affection. It was unquestionably the suppression of the courses. I shall have fre- quent occasion to call your attention to the important influence exercised by this function over the health of the female; and you will observe in practice that its integrity cannot be violated without involving the gen- eral system in more or less disturbed action. One of the most frequent causes of menstrual suppression is cold. This thoughtless girl, through her own folly, has brought upon herself a disease which bids defiance to remedies, and which will of necessity destroy her. If she had applied for professional advice when her courses became suppressed, and if the menstrual function had been promptly restored, the great probability is that she would have continued to enjoy her usual uninterrupted good health, at least for some time. Pthisis pulmonalis te-a disease which will remain, under certain cir- cumstances, for a long time dormant in the system. The elements of destruction are no doubt there, but, like the slumbering spark, they are harmless until brought into development by one or other of the various exciting causes which we know will convert latent phthisis into an actual and rapid malady. In this way, I think we can explain how it is that this disease is oftentimes one of the sequelae of suppressed or irregular menstruation. Treatment.—To attempt to restore the function now would not only be useless, but it would be cruel, for the reason that the system is too low to sustain medication of any kind. The indication here is, as far as may be, to palliate the cough, and support the strength. With the for- mer view, a table-spoonful of the following may be taken two or three times during the day: R Syrup Scillae.......z ij Mucil. Acaciae ..*.... ? iij Tinct. Opii. Camph. ) Syrup, simp. ).....aa ^ sa Sol Sulph. Morphiae......gtt. xx M. The strength should be sustained by animal broths, jellies, &c. HOOPttTO COUGH. 19 Hooping Cough in an Infant, aged eight Months.—Ellen S., aged eight months, has suffered from hooping-cough for the past six weeks. "Do you nurse your child, madam ?" " Yes, sir; I give it nothing but breast milk." " That is right, my good woman. Does it seem to suffer much from the hooping-cough ?" " It does, sir, when the cough comes on; it turns blue in the face, and can not get its breath for some time." " After the cough is over, does it appear quite cheerful ?" " Yes, sir." "How are its bowels?" "They are quite regular, sir." "Has it had convulsions since it was attacked with the hooping-cough?" "Never, sir. It seems perfectly well, except when the cough troubles it." The little infant before you, gentlemen, presents one of the affections in- cident to early age. Hooping-cough commences ordinarily with catar- rhal symptoms, which gradually abate, and are succeeded by a peculiar spasmodic cough, from which the disease derives its name. It assumes a marked character, paroxysmal in its recurrence, characterized by a dis- tinct hoop—the child during the paroxysm experiencing a sense of suffo- cation. Under ordinary circumstances, the little patient, notwithstand- ing the paroxysms, is playful in the internals of the cough. It has been supposed by some writers that hooping-cough and bronchitis are identi- cal ; but this is an error. Pertussis is rightly classed among the neuroses ; and when inflammatory symptoms supervene in the progress of the dis- ease, they do so merely as complications, and not as essential accom- paniments of the original affection. The stethoscope and immediate auscultation have abundantly established this fact. Nothing can be more variable than the duration of this disease; it sometimes, though rarely, runs its course in two weeks; on the other hand, it will continue for four, six, ten months, and I have known it to exceed one year. Observation justifies the division of hooping-cough into three distinct stages, each one being characterized by its own peculiar symptoms. In the first place, there is the stage of inception; secondly, the stage of excitement in which the disease reaches its maximum of intensity; and thirdly, the stage of decline. In the first, we observe the symptoms of ordinary catarrh, without spasm of the glottis, or that peculiar sonorous inspira- tion, which is the usual accompaniment of the more severe form of this affection. A very interesting fact is mentioned respecting the effect of inter- mittent fever in this disease. It is said that when intermittent fever prevailed at Milan as an epidemic, the hooping-cough was arrested at the time of the ague paroxysm. As I have already remarked to you, gentlemen, hooping-cough is not of itself a dangerous affection—it is rarely fatal when not involved in complications, and, therefore, the op- portunities for investigating its pathology have been comparatively limited. There is, I may say, no settled opinion upon this subject. Those, who regard this affection as a neurosis are variously divided in sentiment as to whether the disease is seated in the par vagum, in the 20 CLINICAL LECTURES. ramifications of the intercostal nerve, or in the brain; hooping-cough ia both epidemic and contagious; though it will occasionally exhibit itself as a sporadic affection. It is said by some writers that the exanthema- tous diseases exercise a remarkable influence on hooping-cough, and that it is checked during an attack of measles, small-pox, scarlatina, &c. This, however, needs confirmation. There is one circumstance in this connection worthy of note—and it seems to demonstrate that, in lieu of an antagonism between these affections and hooping-cough, there is rather a sort of relation between them. For example: scarlet fever, small pox, and measles are all contagious, and as a general rule attack the same individual but once. In these particulars, they accord precisely with hooping-cough. Again, hooping-cough will sometimes develop it- self a few weeks before the rubeolus eruption; and sometimes the cough consequent upon measles will assume all the characters of a veritable pertussis. Those clever observers, Rilliet and Barthez, have in their ample experience established these latter points. The complications of hooping-cough are numerous, the most frequent, of which is catarrh; then we have inflammation of the bronchial tubes and lungs; hydrocephalus and convulsions; diarrhoea and infantile remittent fever are also occasionally found to accompany this disorder. Hooping-cough is essentially a disease of infancy, though it has been known to attack the adult. More than one half of the children are at- tacked with it before the completion of the third year. It, however, seldom develops itself under six months of age; and is comparatively a rare affection after the tenth year. Its fatality depends very much upon the character of the diseases with which it may be complicated. Treatment.—No malady has, perhaps, called forth more specifics than the one now under consideration; but alas! they, like all such agents, have proved abortive in arresting its progress. This affection is to be treated on general principles, and, when not complicated with any of the maladies to which we have alluded, it will not prove rebellious to judi- cious medication. Should, however, inflammation of the lungs or bron- chial tubes, hydrocephalus, or convulsions, infantile remittent fever, or diarrhoea ensue, these affections must be treated energetically without reference to the hooping-cough. In simple pertussis, it will be neces- sary merely to regulate the bowels, put the child, if weaned, on light diet, and occasionally administer ten to twenty drops of the following: R Yini Ipecac.....• ^j Tinct. Hyoscyam......3 ij if When the hoop is severe, and distressing to the child, one drop of hydrocyanic acid may be given in a tea-spoonful of sweetened water • camphorated oil, or soap liniment may be advantageously rubbed on the chest for the purpose of slight counter irritation. But, under ordi- nary circumstances, the great remedy for hooping-cough is change of air. It has of late years been proposed by Dr. Joubert of Cherine and HOOPING COUGH. 21 Dr. Eben Watson, to cauterize, in cases of pertussis, the mucous mem- brane of the larynx, using for this purpose a strong solution of the nitrate of silver; and the results of this treatment have certainly been most satisfactory. In one hundred and seventy-five cases, there was suc- cess in all except eight. It does not appear difficult to explain the modus operandi of the caustic under these circumstances. It acts, no doubt, by diminishing the irritability of the laryngeal nerves, as also that of the medulla oblongata. It is because of the irritation of these nerves upon the medulla oblongata, and the reflex action of this nervous mass upon the larynx, bronchial tubes, &c, that we are enabled to explain the spasmodic contractions of these latter organs, so characteristic of hooping-cough. Upon the principle of diminishing the irritability of the medulla oblongata, and consequently its reflex action, escharotic appli- cations to the spine, the most efficient of which is the red-hot iron, are fre- quently of signal service. But in the use of these remedies, the extreme susceptibility of the system during infantile life must not be forgotten. It would scarcely be profitable to enumerate the various remedies, which, from time to time, have been suggested for this disease. It may, however, not be out of place to mention some few of them. Guernsant and Trousseau, of Paris, accord great value to emetics in hooping-cough. For this purpose, the syrup of ipecacuana is employed in tea-spoonful doses in very young children, every fifteen minutes, until free vomiting is produced. In Germany, the following is highly extolled: R Cocci cacti (cochineal) ) .. _ . t ..... aa 3j Bitart. Potasses i Sacchar. Alb.......§ j Aquae bullient......§viij Ft. Sol. Of this a dessert-spoonful to be given three times a day, at first; and afterwards, increase it. The subcarbonate of iron is much eulogized. It is administered as follows: R Subcarbonat. ferri gr. xxiv Sacchar. Alb. .....q. s. Divide in chartulas x—one powder every three "hours to children from one to three years of age. Belladonna has found its strong advocates, and it is regarded by some as a specific. Hufeland administers it as follows: R Pulv. Belladon....... gr. j Sacchar. Alb........3 j Divide in chartulas viij—one, morning and evening, to an infant from two to four years of age. Trousseau and Pedoux employ Belladonna in the following combination: B, Extract Belladon......aagr.iv Extract Opii. Aquo...... Extract Valerian. ...••• 3 ss Divide in pil. xvj—from one to four a day. LECTURE II. Chlorosis in a Girl, aged eighteen Tears, with Suppression of the Menses for the last six Months.—Pathology of Chlorosis.—Chlorosis not always dependent upon Amenorrhcea.—Muco-purulent Discharge from the Vagina in a Girl, aged six Tears, from Scrofula.—Pruritus Pudendi in a married Woman, aged forty-six Tears; final Cessation of the Menses.—Amenorrhcea in a Girl, aged seventeen Tears, from imperfect Physical Development.—Undue Lactation in a married "Woman, aged thirty-eight Tears, the Mother of four Children, the youngest six Months old Passive Menorrhagia.—Irritation from Teething in an Infant, one Tear old, with Constipation.—Anasarca and Ascites following Scarlet Fever in a Boy, aged four Tears.—Is Albuminuria the constant accompaniment of Scarlatina ? Chlorosis in a Girl, aged eighteen Years, with Suppression of the Menses for the last six Months.—Susan M., aged eighteen years, has, from the very commencement of puberty, been troubled with irreg- ular menstruation; and for the last six months the function has been entirely suspended. From early girlhood, her health was delicate; and she menstruated for the first time between the fourteenth and fif- teenth years of age; she is extremely pale, with a white-coated tongue; she is without appetite, and habitually constipated; complains of vertigo and palpitation of the heart, together with occasional severe pain over the left orbital region, and at times much distress along the course of the sciatic nerve; she has cough, which is, however, unaccom- panied with expectoration, and the pulse is not over seventy. Her nervous system is also much disturbed, as is evinced by her peevish- ness, restlessness at night, extreme irritability, &c. This case, gentle- men, is one calculated, in some of its symptoms, to lead the practitioner into error, and cause him to make a false diagnosis. The disease with which this girl is affected is chlorosis, a term derived from the Greek xhaqbs, which signifies simply pallor of the skin with a yellowish or greenish tint. It is known as the " green sickness," and is frequently so called by the old women and nurses. Pallor, however, of the cuta- neous surface is characteristic of various other morbid conditions, and we must, therefore, look for something more pathognomonic than this to prove the existence of chlorosis. This malady is comparatively of fre- quent occurrence, and usually exhibits itself as the period of puberty ap- proaches, more especially in young girls whose menstrual function has not become established, or, if so, is marked by more or less irregularity. CHLOROSIS. 23 But you are not to imagine that chlorosis is always essentially and necessarily connected with an absence or irregularity of the menstrual function; this would be, indeed, circumscribing this important affec- tion within limits by no means warranted by observation. On the contrary, chlorosis will sometimes exist in women whose menstrual function is perfectly normal as to time and quantity; married women and widows are occasionally the subjects of it; and instances are re- corded in which the disease has been recognized in the delicate of the male sex. Again, you will meet with examples of amenorrhcea, in which there is an entire absence of chlorotic symptoms. The pathology of chlorosis consists in a morbid condition of the blood, the serum being increased in quantity, whilst the crassamentum is sensibly diminished. You will observe in the course of your reading that authors enumerate a variety of organic lesions met with after death as the results of chlorosis. But this is an error into which they have fallen—these lesions have no direct connection with the disease in question ; they are simply the effects of maladies with which chlorosis has had no immediate rela- tion, but which have originated during its progress as mere complica- tions ; so that when it is asserted that, in one case, a post-mortem ex- amination reveals disease of the liver, in another an affection of the lungs, and in a third, serious lesion of the brain, heart, pleura, &c, you are not to refer these lesions to the special influence of chlorosis. It is well, however, to bear in mind that there are certain organic changes or peculiarities recognized in those who have died of chlorosis, but they are characteristic of its true pathology, viz.: an impoverished con- dition of the blood. The changes to which. I allude are as follow: the walls of the blood-vessels are pale and thin; the muscular tissue is ex- tremely flaccid, and deprived of its coloring matter; and the blood itself presenting all the evidences of alteration so strikingly illustrative of chlorosis. The experiments of Andral and Gavarret would seem to show that the modification of the blobd in this disease consists not only in the relative diminution of the red globules, but also in an alteration of the structure of these globules. Eisenmann has attempted to prove that chlorosis is not a disease essen tially of the blood. He maintains that the nervous system, and principally the spinal cord, is the primitive seat of this affection. He bases his opinion upon the following circumstances: 1. Becquerel and Rodier, in certain cases of chlorosis, have detected no change in the blood; 2. Chlorosis is much more frequent in the female than in the male, and it is well known that the nervous system predominates in the former; 3. The incipient symptoms of chlorosis are those of the nervous system, before any change occurs in the blood, and these nervous symptoms continue throughout the progress of the disease; 4. Chlorosis will yield to morphia, strych- nia, &c, which are known to act favorably in affections of the spinal cord. In addition to the above, other reasons are given as confirmatory 24 CLINICAL LECTURES. of the opinion that the primary seat of chlorosis is in the nervous sys- tem. For example: the efficacy of the cold shower-bath in this disease, which is also an efficient agent in many forms of disturbed nervous action, such as chorea, hysteria, &c. Another argument is that chloro- sis will sometimes yield to the internal administration of zinc, bis- muth, lead, copper, &c. But, gentlemen, I do not regard the above rea- sons as at all conclusive of the new theory; and if they be of any force, it is merely that they prove exceptions to a general rule—or, which I think nearer the truth, that the effects have been mistaken for the supposed causes of chlorosis. The relation between the nervous and vascular systems is so intimate, they are so mutually dependent one upon the other for healthy function, that original morbid action of the one may, without due discrimination, be confounded with original morbid action of the other. Excessive blood-letting, and this occurs more especially in young children, will be followed by great nervous per- turbation, extreme jactitation, and oftentimes convulsions. Would it, un- der these circumstances, be good physiology to refer these phenomena to original derangement of the nervous system, and more particularly of the medulla spinalis ? I think not. The original defect is the loss of blood, and under this influence the nervous centers become deranged, and hence the morbid phenomena to which I have just alluded. But it strikes me that, admitting the true pathology of chlorosis to consist in an alteration of the constituents of the blood, or, in other words, an impoverishment of this fluid, by which it is prevented from dis- tributing adequate nutrition and development to the various tissues of the system, another inquiry should press itself on the mind of the observant physician, which is this : Is this alteration in the blood primitive or sec- ondary ? or, to bring the question to a practical point—is the impover- ishment of the circulating fluid in a given case due to its original defective formation, or is it simply the result of morbid action in some of the va- rious organs directly connected with the healthy production of this fluid ? Indeed, it seems to me that all rational treatment of chlorosis must neces- sarily depend upon a decision of this question. For my own part, I believe that the primitive disorganization of the blood is among the extremely rare occurrences to be recognized by the practitioner; whilst, on the contrary, it will be found very generally as a secondary condition dependent upon the operation of one or more of the various causes capa- ble of deranging the digestive functions. Causes.—The causes which may give rise to chlorosis are numerous, and may operate separately, or, to a certain extent, collectively. An impoverished diet, exposure to a humid atmosphere, sedentary habits, long confinement, such as is practiced in manufactories, an enfeebled constitution, &c, may be classed among the causes of this affection. Constipation is so frequent an accompaniment of chlorosis, that we are inclined to think with Marshall Hall, that it is one of the most fruitful CHLOROSIS. 25 sources of this disease. It is insidious in its results, and often lavs the foundation of general derangement of the health. A late distinguished writer, Dr. Bennett, affirms " That functional disturbance, and organic disease of the uterus, have nothing whatever to do with chlorosis; but that this affection arises exclusively from disease of the blood." This opinion, although undoubtedly true as a general principle, is too sweep- ing, and is not sustained by observation; for chlorosis will occasionally date its origin from functional derangement or structural lesion of the uterine organs; and, in either of these cases, the impoverishment of the blood may arise from the morbid influence exercised by these disturb- ances on the ganglionic system of nerves, the healthy and unaffected condition of which is so essential to the proper performance of the as- similative functions. The opinion so emphatically expressed by Dr. Bennett is not without danger ; for, with this doctrine to guide us, our treatment of chlorosis would not only be useless, but absolutly destruc- tive in cases in which this affection is traceable purely to organic disease of the womb, or to aberration in the functions of this organ. Symptoms.—One of the most constant symptoms of chlorosis is pallor of the cutaneous surface, assuming not unfrequently a yellowish hue; but it is well to remember that this pallor is more marked in certain portions of the integumentary surface than in others; the tunica con- junctiva of the eye-lids, the mucous covering of the lips and nose, present in full this peculiar characteristic of the disease. The digestion is much impaired—no appetite—sometimes a longing for unnatural food; constipation; the tongue is white, and coated; sometimes there is great thirst; as a general rule, the urinary secretion is diminished; the cir- culation is more or less disturbed; palpitation of the heart, and inter- mittent pulse, often accompany this disorder; there is occasionally cough; the nervous system is always more or less deeply involved, as is exhib- ited in the sleepless nights, depression of spirits, headache, vertigo, throb- bing of the temples and ears, and not unfrequently many of the hys- teric phenomena. Of late years much has been said respecting certain abnormal sounds heard in the heart, and large blood-vessels of chlorotic patients. Bouil- laud, I believe, was the first to call attention to this subject. It is the opinion of Brown-Sequard that these sounds emanate from a tremor of the muscles peculiar to weak and aged persons. Neuralgia is a very constant accompaniment of chlorosis; and one of the principal features of this neuralgia is its fugitive character, passing from one set of nerves to another; sometimes it is over the orbit, sometimes in the track of the nerves passing to the teeth; again, it presents itself in the intercostal nerves, at other times in the sciatic nerve, &c. The menstrual function is usually deranged in this disease; sometimes there is amenorrhcea in one or other of its forms, viz., retention or suppression; and it becomes an important question in these cases for the practitioner to estimate the 26 CLINICAL LECTURES. exact relation of the amenorrhcea to the chlorosis—which is the effect, and which the cause ? In some instances, the menstrual function will continue with regularity, but then the blood is usually observed to be serous; and not unfrequently in chlorotic girls there is a leucorrhceal discharge, which, from its periodical recurrence, seems to take the place of the menstrual evacuation. In one word, the symptoms of chlorosis, like those of hysteria, may be said to be Protean in their character, and are subject to constant variation. Diagnosis.—In the diagnosis of this affection some degree of caution must be exercised; the pallor of countenance and cough may lead to the supposition of pthisis, whilst the palpitation of the heart might cause you to infer the existence of structural disease of this organ. The cough of chlorosis differs from that of pthisis in the following particulars: in the former, the cough is without expectoration; there is no hectic fever, nor is the cough increased on exposure to the air; neither is the pulse ac- celerated. On minute examination, the palpitation will be found to be merely functional, depending on general derangement of the system, and especially on an impoverished condition of the blood. The headache, and occasional severe pain in the side, may also lead to a false view of the malady; these are not the pains of inflammation. The headache, like the vertigo, is traceable to a want of healthy blood in the brain, and the pain in the side may be simply neuralgic, or may result from a loaded condition of the intestinal canal. Marshall Hall has instituted a very truthful analogy between excessive sanguineous losses and chlorosis —an analogy which all accurate observers will fully confirm, and which consists in the following points of resemblance: 1st. Head symptoms, simulating arachnitis; 2d. Palpitation of the heart; 3d. The condition of the general and capillary circulations; 4th. Occasional death from coma. Prognosis.—As a general principle, chlorosis is a manageable dis- ease ; but in its severer forms, and especially when it has existed for some time, and when accompanied by serious complications, prudence requires on the part of the practitioner some reserve in his opinion as to the final result. Treatment.—I think it a fundamental error in practice, unfortu- nately too common, always to regard amenorrhcea, when it exists in chlorosis, as the substantial feature of the case—the one above all, which calls for the attention of the practitioner. Hence, in these cases it is too usual to have recourse to emmenagogues for the purpose of bring- ing on the menstrual function without reference to the general condition of the system. This is wrong—it is an abuse from which females have suffered severely. If, with this partial view of the disease, the emmen- agogue treatment should result in establishing the menstrual flow, the general health suffers just in proportion to the loss of blood sustained. The true and only philosophical treatment consists in the administra- CHLOROSIS. 27 tion of those remedies best calculated to invigorate the system, and thus overcome the chlorotic type ; when this is accomplished, the resto- ration of the catamenia will generally follow as a necessary consequence. At all events, not until the chlorosis has been removed, will it be proper to have recourse to emmenagogue remedies, and not even then, except in those cases in which, after the subsidence of the chlorotic symptoms, the amenorrhcea shall still continue. Chlorosis presents itself under one of three forms, and it has, therefore, been divided into the incipient, confirmed, and inveterate. The young girl before us is an example of the confirmed stage of the disorder, which is characterized by pallor and tumefaction of the countenance and conjunctiva, puffiness of the eye- lids, a white-coated tongue, constipation, insomnolence, palpitation of the heart, &c. Her digestive functions have become so impaired by long-continued constipation, and her blood consequently so much im- poverished, that the indication is obviously, in the first place, the removal of the constipation, and secondly, the general invigoration of the sys- tem. Medicine alone will not accomplish these objects; and if, under any circumstances, a faithful observance of hygienic treatment be called for, it is in a case like the present, where the vital powers of the system are in a state of comparative dilapidation. It is, therefore, incumbent to impress on this girl the necessity of gentle exercise in the open air, clothing such as will protect her from the cold, the careful avoidance of a humid atmosphere, a tepid bath once a week, and frictions with a coarse towel. It will be well to commence with a brisk purgative, for, pale and delicate as she is, you will find she will bear with benefit a positive impression of this kind. Let her take, this evening, the follow- ing powder, and in the morning, % j of castor oil: $ Sub. Mur. Hydrag......gr. viij Pulv. Rhei. ......gr. xij Ft. Pulv. It may also be necessary, in order to excite a healthy" action of the liver, to give her occasionally, every third or fourth night, ij or iij grains of the hydrag. c creta.; and half a pint of tepid water thrown into the rectum, night and morning, will prove highly serviceable in promoting the peristaltic action of the intestines. When the bowels have been freely evacuated, a table-spoonful of the following may be given two or three times a day : gr. xv gtt. xv aa 3 ijj Svi M 9 Quinae Sulphat Acid Sulph. dilut. Tinct. Card. c. j Tinct. Humuli ) Infus. Roear. c. . 28 CLINICAL LECTURES. Or the following may be ordered: R Acid Sulph. dilut.......3 ij Syrup Aurantii. ......5 U Aquae Cinnamon......3 J M. A tea-spoonful in a wine-glass of cold water two or three times a day. The great remedy, however, for chlorosis is iron in some or other of its various preparations—so that, after commencing with the vegetable tonics, which, as a general principle, is a good rule for the reason that they are less likely to irritate the system, recourse may then be had to the ferruginous remedies. Iron may be given in some of the follow- ing forms: R Sulphat. Ferri........ Sub-carbonat. Potasses . . . . aa 3 j Divide inpil xxxxviij, commencing with one pill twice a day, and gradually increased to four a day. These are known as the pills of Blaud, and are in high repute. R Sulphat. Ferri. ...... 3j Extract Humuli ).....aagr. xv Extract Papav. Alb. j OL Cassias....... gtt. xv Divide in pil. xxiv—one pill twice or thrice a day. R Ferri. Iodid........3iss Tinct. Columb. c.......§j Aquae puree.......§ vij A table-spoonful three times a day. R Sulphat. Ferri ......3j Aloes Barbardens......3ij Ft. massa in pil. xx dividends—one pill twice a day. This is a capital combination in cases in which there is a tendency to torpor of the bowels. R Carbonat Ferri......3j Pulv. Rhei. ) Aloes Socotorin J Extract Humuli......q. s. Ut. ft. massa in pil. xXx dividenda—one pill three times a day. R Syrup Iodid Ferri......§ j An admirable preparation in chlorosis occurring in scrofulous habits. Thirty drops three times a day. R Sulphat. Ferri.......3j Extract Gentianae......3ij Ft massa in pil. xx dividenda—one piU two or three times a day. The diet should be generous—succulent meats, animal broths, horse- back exercise in the open air, &c. Bernard is of opinion that the cura- tive effects of iron in chlorosis are not due to the absorption of this agent into the blood; he has not been able to detect, after injecting into the stomach iron filings, the lactate of iron, &c, more iron than usual in the vena portae; but he observes that as iron exists in the food, it may perhaps require a certain combination in order that the metal MUCO-PURULENT DISCHARGE FROM THE VAGINA. 29 may be absorbed. He, however, insists upon a very important fact, viz., that the salts of iron exercise a special action on the mucous coat of the stomach, each portion of this surface touched by the metal im- mediately assuming a more active circulation. It is, therefore, a direct excitant. May not chlorosis, he asks, according to this, be due to an impaired digestion, and may not the iron, by the excitation it produces, re-establish and fortify the digestive functions ? Although this question is not completely solved, yet it must be admitted that it possesses much therapeutic interest. Muco-purulent Discharge from the Vagina in a Girl, six Years of age, from Scrofula.—Mary T., aged six years, is pale and delicate; of a lymphatic temperament, and scrofulous diathesis, with general tor- por of the bowels. The glands of the neck are slightly enlarged, and on exposure to cold they become painful. Her mother brings her to the clinique for advice, principally on account of a discharge from the vagina with which she has been affected for the last six months. The discharge is sometimes profuse, and occasionally of an acrid character, producing excoriation of the parts. This, gentlemen, is a case of singu- lar interest on several accounts. In the first place, the tender age of this child gives it importance; and when it is recollected that discharges of this nature in the female at so early a period have been mistaken for gonorrhoea, the practitioner can not fail to recognize the grave results involved in an erroneous diagnosis. It is much easier to excite than allay suspicion; and it is the duty of the physician under circumstances affecting character or the peace of families to be rigidly just. He is to separate himself from all cabals; he is to seek for truth alone, and guard it at all hazards with sacred vigilance. In cases, for example, like the one before us, it may be suspected that the discharge is the result of an attempt at violation ; an imprudent parent, by threats and pun- ishment, may extort from a timid child the admission of any and every thing—the poor child being influenced more by the hope of escaping punishment than by the revelation of the truth. In this way, it will not be difficult to implicate a third party, and the decision of the case must rest upon the testimony of the medical attendant. The causes of vaginal discharge in young children are as follow: 1st. Scrofula; 2d. Ascarides in the rectum ; 3d. Irritation of the genito- urinary organs, direct or indirect; 4th. Gonorrhoea; 5th. Dentition; 6th. This character of discharge will occasionally accompany scarlet fever. Dr. Cormack observes, that in twenty-three female patients whom he treated for scarlatina, all of whom were properly washed, and cleanly, twelve exhibited well-defined vaginitis. There were only two of the twenty-three patients above fourteen years of age, one twenty-six, and the other twenty-eight years old; both were married, and suffered from acute vaginitis, which presented a severer type than in any of the chil 30 CLINICAL LECTURES. dren. Dr. Cormack accounts for this inflammation of the vagina on what must be conceded a rational principle. He says it is simply an ex- tension of the exanthematous inflammation of the skin, similar in its na- ture to what is often met with in the mucous linings of the nose, ear, air passages, &c. Your first duty, therefore, gentlemen, on being consulted in a case of this description, is, by a thorough investigation, to ascertain to which of these causes the discharge is due; the child will thus be spared much suffering, and the mother and friends relieved from un- necessary anguish of mind. The symptoms are characterized by more or less pain in the parts, increased by exercise; excoriation, especially when the discharge is acrid; sometimes there will be irritation and a sense of burning when passing water, together with apthous ulcerations of the mucous mem- brane. The discharge varies in character—thin and sanious, sometimes purulent, and again muco-purulent. The general health usually suffers. The diagnosis merits all the attention of the physician; for in the ab- sence of correct views on this point, his treatment will be utterly unavailing. If the discharge be connected with a scrofulous diathesis, the general appearance and history of the child will disclose the fact. Ascarides, the small white-thread worms which lodge in the rectum, often occasion this discharge sympathetically by the irritation they produce on the mu- cous surface of the intestine. Their presence is indicated by itching of the anus, and the other symptoms usually attendant on worms, but es- pecially by their being observed in the faeces. It is important, therefore, in all cases of doubt, to request the mother to examine the evacuations of the child. In very young infants, the discharge may be the result of acrid leucorrhceal matter taken from the mother at the time of birth, giving rise to a purulent secretion similar to what is observed in the purulent ophthalmia of new-born infants. The fourth cause, gonorrhoea, is one which will require more than ordinary vigilance in order that an accurate opinion may be given. If the discharge be due to the irritation of teething, attention should be directed to that point. Treatment.—In the case of this little girl, the nature of the disease producing the discharge is well marked. She is affected with scrofula, and the secretion from the vagina is occasioned by this taint in the sys- tem. We employ the word taint, for it is in all truth such; as much so indeed, as the syphilitic virus, and we believe it to be in its general re- sults almost equally destructive. The discharge in this case is compara- tively of little moment; it is to be regarded merely as the effect of a grave affection—scrofula. The treatment, therefore, if it be exclusively local, will be without avail. The true cause, the scrofula, must be the special object of attention. The bowels should be freely moved by the following medicine: B> Hydrarg. c. creta......gr. iv Pulv. Rhei.......gr.vj M, PRURITUS PUDENDI. 31 Ihis powder to be taken at night, followed in the morning by % ss of castor oil. I should then be disposed to place this child on the follow- ing alterative course: • R Oxy. Muriat. Hydrarg......gr. % Tinct. Rhei. ) .. . Tinct. Cinchonae )......* Thirty drops twice a day in a dessert-spoonful of cold water. After continuing this medicine for two or three weeks, let it be suspended for awhile; and, in lieu of it, a wine-glass of the compound decoction of sarsaparilla, with six drops of the liquor potassae, should be given daily uutil the general health is found to improve. The corrosive sublimate solution may again be had recourse to, if necessary, and continued until the secretions and general system present a healthy aspect. Sarsaparilla often exercises a happy influence in scrofula, and the prevailing acid con- dition of the stomach and alimentary canal in this affection renders the liquor potasses a valuable adjuvant. The vulva should be frequently cleansed with tepid water and castile soap, and bathed once or twice a day with the following solution: R Sulphat. Zinci......gr. xij Aquae distillat,......% vj Ft. sol. These remedies, however, will be limited in their effects, unless aided by a nutritious diet and fresh air. These latter, in strumous conditions of the system, will prove essential elements of successful 'treatment. Here, too, a valuable remedy will be found in the syrup of the iodide of iron, of which ten or twenty drops may be taken three times a day. In scrofulous diseases, this is, perhaps, the very best preparation of iron. Pruritus Pudendi in a married Woman, aged forty-six Years— Final Cessation of the Menses.—Mrs. O., aged forty-six years, mar- ried, extremely plethoric, the mother of seven children, the youngest eight years old, seeks advice for a distressing itching of the external genital organs, with which she has been affected more or less for the last two months; and which has recently become so aggravated as to render existence, to use her own language, scarcely endurable. Her menstrual (unction, which had always been regular, except during pregnancy and lactation, ceased about six months since. This affection, gentlemen, is cne of a very annoying character, and it is one, too, which, if not promptly removed, will occasionally lead to serious consequences; for the irritation of the external organs will sometimes, through the in- creased afflux of blood to the parts, involve the uterus and its appendages in disease, and the nervous system oftentimes becomes greatly deranged. Under the influence of this irritation, digestion is impaired, the pa- tient emaciates, and general dilapidation of the health ensues. It ia 32 CLINICAL LECTURES. well to remember that pruritus of the vulva varies in character; it is sometimes constant, at other times intermittent. You will occasionally observe it to precede for a few days the menstrual flow, and then pass off with it. The causes of this affection are numerous, such as the final cessation or suppression of the menses; neglect of personal cleanliness; indolent habits; plethora; excessive heat of the season; excessive fatigue; scrofula, giving rise to an acrid and irritating vaginal secretion; and, under some circumstances, pregnancy will produce it. The symptoms are characterized by intense itching, rendering the patient wretched, and a burden to herself. She seeks relief by scratching, which is some- times carried to such an extent as to occasion ulceration. The diag- nosis is not difficult. Care, however, must be exercised not to confound the ulceration with venereal chancres, which might possibly be done by an inattentive physician. Treatment.—This will vary with the cause to which the pruritus is traceable. In the present instance, the irritation is, I think, dependent upon the final cessation of the menses, and the consequent plethora of the system. The patient should lose from the arm § viij of blood; and the subjoined powder administered to-night: R Sub Mur. Hydrarg......gr. x Pulv. Jalapae.......gr. xv Pulv. Antimonial......gr. i Ft. pulv. followed in the morning by R Infus. Sennae.......^ vj Sulphat. Magnesia?......3 ij Tinct. Jalapae.......3 i Mannae........3 ss M. The diet to be exclusively vegetable; the parts to be washed twice a day with castile soap and water. The following lotion should be freely used: R Sulphat. Aluminis......3 ij Aquae puree.......3 XYi Ft. sol. We have often found great benefit from bathing the parts with a strong solution of borax. The following local application deservedly ranks high; it is one of the most reliable and efficacious in use: R Amyl.........3V Camphorae.......3j if The parts to be sprinkled with this powder once a day ; observing the precaution to wash them each time the application of the powder is renewed. This was a favorite remedy of Lisfranc. AMENORRHCEA. 33 I have, in these cases, found benefit from the nitrate of silver in solu- tion: R Nitrat. Argenti......gr. xx Aquae puree........§ ij Ft. sol. Amenorrhea in a Girl, aged seventeen Years, from imperfect Physical Development.—Sarah H., aged seventeen years, has been delicate in health from her infancy. Her mother brings her to the clin- ique, feeling anxious because she has never menstruated, and begging that some medicine may be given " to make her right." This case, gentlemen, is instructive, and is precisely such as you will occasionally encounter in practice. Mothers, when their daughters attain their four- teenth or fifteenth year, usually manifest much alarm if their courses do not come on. They look merely at the age, and close their eyes to all other considerations. Such must not be the conduct of the physician. It is his duty to know that the function of menstruation is dependent not upon the mere age of the individual, but upon the proper develop- ment of the ovaries. There is no fact more important for you to remember than that menstruation is in absolute connection with the function of the ovaries. Menstruation is the specific office of the ovary, as is the secretion of bile the office of the liver, or the secretion of the fecundating liquor the function of the testes. What would you think of the practitioner who should attempt by medication to produce this latter secretion in the male before the normal development of the testi- cles ? You would, if you pronounced proper judgment, deem him mad; and yet, in a professional sense, he would not be more insane than the man who should hope to force menstruation in such case, for exam- ple, as the one now before us. I could cite more than one instance of the melancholy results which have followed this attempt to coerce na- ture. But you may inquire, what evidence is there that the ovaries are not developed in this girl ? Well, I will give you the evidence. In the first place, she has the appearance of a mere child, presenting noth- ing in the least of the physical embonpoint characteristic of an ap- proach to womanhood. Her breasts are like those of a child six years of age—her hips present also the same aspect—there is none of that increase of cellular tissue, none of that peculiar fullness of the hips and breasts, so strongly demonstrative of ovarian maturity. In a word, gentlemen, the girl before us, although seventeen years of age, is in all other respects but a child. " I think you said, my good woman, your daughter has been in delicate health from her infancy ?" " Yes sir, she has always been delicate." " Has she any cough ?" " No sir." " How are her bowels ?" " They are always more or less confined, sir." " Has she any appetite ?" " No sir." " I am not surprised at it, my good woman." Treatment.—The amenorrhcea in this case is entitled to no notice 3 34 CLINICAL LECTURES. whatever. The first and only therapeutic indication is to encourage and aid nature in giving to this girl a physical vigor, which will enable her, through the proper growth and development of her organs, to perform the physiological offices of her sex. hi the first place, it is essential to overcome the habitual constipation under which she labors; for this purpose let her commence with the following powder : R Sub. Mur. Hydrag.......gr- vj Pulv. Rhei. ......gr. xij M. In the morning § j of castor oil. The bowels being freely moved, let her afterward take one or two, as occasion may require, of the following pills, with a view of keeping the system in a soluble state : R Masses Pil. Rhei. c.......3 j Olei. Caryophyl.......q. s. TJt. ft. massa in pil. xij divenda. When the bowels have been regulated, a table-spoonful of the annexed vegetable tonic may be advantageously administered three times a day : R Infus. Gentianee c.......3 v Tinct. Gentiarae c. .....§ j Acid Sulph. dilut.......3 j M. After the system has become accustomed to the vegetable tonic, a a pill once or twice a day, consisting of one gr. of sulphate of iron and two grs. of extract of gentian, will be useful. The diet to be nutritious—this girl should be sent to the country, and, if possible, to the sea-shore; all confinement must be avoided; flannel to be worn next to the skin; and she should ,be carefully pro- tected against a damp or chilling atmosphere; whilst at the same time a bracing air will serve her. In fine, she should pursue such a course as is best calculated to invigorate her general system, and develop her physique. Undue Lactation in a married Woman, aged thirty-eight Years, the Mother of four Children, the youngest six Months old—Pass- ive Menorrhagia.—Mrs. P., thirty-eight years of age, married, is the mother of four children, the youngest six months old. She has uniformly nursed each of her previous children until twelve months after birth; and she now finds herself infirm in health; she is pale, bearing the aspect of exsanguification, with palpitation of the heart headache, vertigo, extreme restlessness, and her mind rendered morbid by this general disturbance of the nervous system; she is constipated, and much troubled with flatulence. " How long, my good woman since you begun to suffer in health ?" " I have not been well, sir, for the last three months." "Do you nurse your infant?" "Yes sir." "Is it a strong, healthy child ?" " Oh! yes sir, he is a remarkably healthy child." " Do you feed him sometimes ?" " No sir, he depends alto- gether upon me for his nourishment." " What was the state of your UNDUE LACTATION. 35 health previous to the last three months ?" " It was good, sir." " You were not what people call a nervous woman, were you ?" " No sir—I was always healthy, and did not know what it was to be restless or un- easy." "But now things have changed with you in that particular, have they not ?" " Yes, indeed, sir, I am not worth much now in the, way of health." " Does your child nurse at night ?" " He nurses almost all the time, sir ; and I think it is that which is making me feel so weak and sick." " Well, my good woman, I agree with you in opinion, and if you will follow my advice, I will restore you to health. Let me ask you one more question. Have you had your courses since the birth of your child ?" " Yes sir ; they came on me for the first time about a month ago, and I had them again in two weeks." " Were they rather free ?'' " Yes sir, they were different from what they ever were before—they were more abundant, and lasted longer—and I felt very miserable afterward." You have before you, gentlemen, a case of much practical value. This woman presents an example of the disturbing influences of undue lactation—her system has been taxed beyond its ability—the drain caused by nursing has seriously involved her nervous system, and you now see her laboring under that combination of troubles conse- quent upon this condition of things. Women, under ordinary circum- stances, enjoy good health during the period of nursing; and, as a gen- eral principle, they should be encouraged to nurse their children; it is, in the first place, a natural duty, and secondly, it provides the young infant with nutriment the best adapted to its frail powers of assimila- tion. But there are circumstances in which this duty may be carried too far, entailing certain injury upon both mother and offspring, and then it becomes the office of the practitioner to interpose, and indicate the best course to be pursued. The headache, vertigo, palpitation of the heart, the extreme restlessness, &c, are nothing more than the effects of this drain upon the system ; but another result of this undue lactation has developed itself—passive menorrhagia. The patient informs us that she has had her courses twice since the birth of her child—and that they were much more profuse, and continued for a longer period than usual. This form of menorrhagia is by no means an uncommon accom- paniment of that prostration of the physical forces so strongly marked in the patient before us. It is, however, but a symptom, and must, therefore, be treated not as a primitive but as a secondary or symptom- atic affection. In one word, the menorrhagia is consequent upon the gen- eral debility of the system—and as soon as this is removed, the profuse menstruation will cease. But undue lactation is not limited to the dis- turbances which we recognize in this woman. In some instances, it will occasion mania—whilst anasarca and serous effusions in the cavities are in no way uncommon sequelae. Functional and organic disease of the uterus, together with various nervous disturbances, such as hysteria, epilepsy, &c, are also occasionally developed. 36 CLINICAL LECTURES. Treatment.—The first object to be accomplished in this case is to remove the original cause of the morbid phenomena—the child must be weaned, or put to the breast of some other nurse; and the mother placed on such a course of treatment, as is calculated to invigorate the system, and repair the waste it has undergone. Should the child be weaned, it must be fed on cow's milk. The patient herself should have the following cathartic administered: R Hydrag. c creta......gr. vj Pulv. Rhei........gr. xij M. Let this be followed in the morning by 1 j of castor oil in § ij of catnip tea. I should then recommend one of the following powders twice a day: the combination is well adapted to the object in view : R Sulphat. Quinae......3i Pulv. Rhei........3ij Divide in chartulas xx— The diet should be generous, with half a pint of porter daily. The menorrhagia, which is but the result of the prostrated condition of the system, will no doubt yield as soon as the general health is re- stored ; but in the mean time, in order to check the profuse flow, it will be proper to have injected night and morning into the rectum, half a pint of cold water, beginning the second day after the menstrual flow commences, and let the injection be continued until it ceases. In order to secure sleep at night, ten gr. of Dover's powder may be given. Irritation from Teething in an Infant nine Months old, with Con- stipation.—J. W., aged nine months, is suffering from teething ; he is restless and feverish; the bowels are constipated. He has his four mid- dle incisor teeth; the gums are but slightly tumefied, but there is much irritation in the system. The period of dentition, gentlemen, is one of anxiety to the parent, and not unfrequently of peril to the infant. The age of infancy is characterized by rapid changes ; the growth and devel- opment of the various organs seem to be the chief object of nature in this early stage of existence; but you are to remember that this very rapidity of growth necessarily engenders a marked susceptibility to disease in the different tissues. The brain and medulla spinalis, and also the intestinal mucous surfaces, are often involved in morbid action sympathetically during the process of dentition. In the case of this little infant, it is quite obvious that the two important nervous centers and more specially the medulla spinalis, is in danger. What are the facts ? This infant is feverish and restless; its bowels are constipated • and its whole system is more or less irritated by the effort which nature is making to protrude the teeth. The natural inquiry now is, can any thing be done to save this little patient from the effects of the irritation under which it labors ? The intestinal canal, which is a most important ANASARCA AND ASCITES. 37 derivative surface, is in a state of torpor. Nature, when not interfered with in her plans, is in the constant exercise of conservative influences; and in no particular does she more beautifully exemplify her provident care of the economy than during the process of teething. Under ordi- nary circumstances, instead of constipation, there is rather a tendency to looseness whilst the child is engaged in cutting its teeth, and this very looseness, if kept within proper limits, is a salutary waste-gate, protect- ing the nervous centers, and other important organs, from harm. What, then, is to be thought not only of the absurd but too often fatal practice of attempting to allay the irritation of teething by the administration of opiates, or of checking a salutary diarrhoea by astringents! It re- quires about thirty months (the period varying according to individual and other circumstances) to produce the first or deciduous class of teeth, and they usually appear in the following order: the two middle incisors of the lower jaw, the two middle incisors of fche upper, the lateral inci- sors of the upper, and then the corresponding incisors of the lower jaw. Next in order, come the four first molars, usually of the lower jaw first, then the four canine teeth, and lastly, the four posterior molars. These constitute the twenty deciduous teeth; but various circumstances may interfere to prevent their regular and gradual succession. Treatment.—The great point in this case is to remove the constipa- tion, and determine to the cutaneous surface. With this view, one of the following powders should be given as circumstances may require, followed by oil; the child should be put in a tepid bath, daily, and it should be kept exclusively at the breast. g Hydrag. c creta......gr. vj Pulv. Rhei. ......gr. xij Pulv. Ipecac ......gr.j Divide in chartulas vj. Frequent ablutions of the mouth of a teething infant with cold water is not only grateful to the child, but tends to allay local irritation. You perceive, gentlemen, I do not incise the gums of this infant. This is too commonly resorted to ; indeed, it may almost be regarded as a routine practice in all cases of troublesome dentition. The incision of the gums can only be justified when they are extremely tumid, and more especially when the teeth are ready to penetrate the gum as soon as it is incised. A too early resort to the lancet in these cases is often- times followed by serious consequences. Anasarca and Ascites following Scarlatina in a Boy, aged four Years. Is Albuminuria the constant accompaniment of Scarlatina? —Peter R., aged four years, was attacked three weeks since with scarlet fever of a very mild form; his mother says he recovered under the ad- ministration of simple remedies, and appeared to enjoy his usual health 38 CLINICAL LECTURES. until within the last few days; about eight days since, he was exposed to a heavy shower; he complained of chills, followed by high fever; his abdomen enlarged, and still continues to increase in size. The pulse i quick and hard, there is pain on pressure, and distinct fluctuation i detected on percussing the abdomen; there is also anasarca of th< extremities, together with albuminous urine. The case before you gentlemen, is one of much interest; not that it is one of very rare occur rence, but more particularly because it embodies several practical points worthy of attention :— 1st. Dropsy of the chest, abdomen, and extremities, is among the sequelae of scarlatina, The effusion may be limited to one of these sur- faces, or it may involve all of them simultaneously; and, it must be borne in memory that anasarca is comparatively of rare occurrence after a severe attack of scarlet fever, whilst, on the contrary, it is often met with after a milder form of this affection. Of the various forms of effu- sion following scarlet fever, anasarca is by far the most frequent; and you must be careful when there is dropsy of the chest and abdomen, to- gether with anasarca, to examine whether or not the heart is not more or less involved, perhaps in valvular trouble. I mention this inciden- tally for the reason that, if this organ should be implicated, the prognosis must be guarded, for these cases are fraught with danger, and usually end in death. 2d. This child, when convalescent, was exposed to a shower. It took cold, and anasarca, together with effusion in the abdo- men, was the result. Cold is a very common exciting cause of those affections, which are recognized as the sequela? of scarlet fever, and hence the importance of enjoining upon the parent or nurse the neces- sity of guarding against this influence during the period of convalescence. 3d. The pulse is quick and hard, and there is pain on pressing the abdo- men ; there is also much febrile excitement. These symptoms disclose the character of the dropsy; it is of the sthenic type, resulting from in- flammatory action. This is the most usual form of dropsy following scarlet fever. 4th. The urine is albuminous; but albuminuria is not constant in the dropsies dependent upon scarlatina, as you may readily ascertain for yourselves. Albumen, indeed, is not recognized in the urine in more than one third of the cases. Dr. Bright supposed albu- minous urine to be peculiar to that affection of the kidney known as Bright's disease; but it is now well understood that this condition of the urine prevails in different inflammatory diseases, in which there is no disorganization of the kidney. Albuminuria is often the result of simple congestion of this organ. It is true that Bright's disease has manifested itself after an attack of scarlatina, but this must be regarded as merely inci- dental, and not as a necessary consequence. The pathology of scarlatinal dropsy may be said to be a vexed question; opinions are numerous but they are far from being concurrent. One tells you that it is due to con- gested kidney; another, to structural disorganization of this viscus • ANASARCA AND ASCITES. 39 whilst, again, it is contended that it is to the imperfect action of the skin—the physiological office of which we know becomes very much im- paired—that the effusion is to be referred. Now, no more solid fact is established than that a check of perspiration, under any circumstances, will often be followed by dropsy. How do we explain this ? Well, if the function of the skin, one of the largest and most important emunc- tories in the system, be interfered with, two consequences are extremely apt to follow, viz., 1st. Vitiation of the blood by a retention in it of those elements which should have passed off by perspiration; 2d. Congestion, and sometimes, as a consequence of the congestion, disorganized kidney. So that, whether the dropsy be referred to congested kidney, disorgan- ized kidney, or a vitiated state of the blood, these, it must be admitted, are but the effects of the condition of the skin peculiar to scarlatina. I am, therefore, inclined to the opinion, that it is to the inaction of the in- tegumentary surface that the effusions following scarlet fever, are, gener- ally speaking, primarily due; and this opinion is in perfect harmony with an observation of a clever man, Dr. Golding Bird, who says that he does not recollect, in a large experience, a case of dropsy occurring after scarlet fever, when the warm bath was daily used as soon as the skin began to exfoliate, and continued until a purifying healthy surface was obtained. Dropsy, when it exists in children, is almost always secondary or symptomatic of some previous disease; whilst, as a primary or idiopathic affection, it is of extremely rare occurrence. Secondary ascites may present itself under two forms. 1st. The sthenic or inflammatory type, sometimes called the acute type of dropsy, with fever, pain, &c, and this is most frequently the result of the erupt- ive fevers, more especially measles and scarlet fever; it is common, too, after an attack of what is termed albuminous nephritis, or Bright's dis- ease. 2d. The asthenic type, unaccompanied by any symptoms of inflam- matory action, and which is the result of long-continued drains on the system, a cachectic state of the health, &c. This form of effusion will follow protracted dysentery, diarrhoea, &c, and it will more especially be observed in a scrofulous diathesis, and where children have suffered for want of proper food, fresh air, &c. I need not admonish you of the importance of a just discrimination between these two forms of dropsy. On this discrimination must depend the propriety of the therapeutic remedies employed. Cases, such as the one before us, usually yield to judicious medication, if early and energetically employed; and whilst the possibility of an unfortunate issue should not be concealed, a reasonable assurance may be given of a favorable termination. Treatment.—As to the treatment of this child, there can be no embar- rassment; the indication is too obvious to admit of a moment's doubt. The inflammation which has given rise to the anasarca and abdominal effusion must be attacked vigorously; for if not promptly checked, seri- 40 CLINICAL LECTURES. ous consequences will result. Let this boy, without delay, lose from the arm I iv of blood, and the following powder administered: 9 Sub. Mur. Hydrarg.......gr- "j Pulv. Jalapae.......gr-"" Pulv. Antimonial......gr. ss J/ To be followed in four hours by R Sulphat. Magnesias......31 Infus. Sennas.......§ JJ Mannee .)......aa 3 ss i£ Tinct. Jalapae J In the treatment of this affection, the importance of diuretic medicines must not be overlooked. Great benefit will be derived in these cases from a combination of digitalis and the nitrate of potash. After the bowels have been freely evacuated, a table-spoonful of the following mixture may be given every two or three hours: R Nitrat. Potassae......gr. xxiv Tinct. digitalis......3 i Spts. Nitre Dul.......§ ij Syrup Rosar.......§ ij Aquae.......§vi M. In addition to the above, gentle frictions should be made over the ab- domen twice a day, with the following liniment, and the abdomen well protected afterward with flannel: R Tinct. Scillee ) .._.. Y ..... aa x n Tinct. Digitalis f 3 J The diet to consist exclusively, until the inflammatory action has subsided, of diluents, such as barley-water, toast-water, flax-seed tea, &c. LECTURE III. Enlargement of the Uterus produced by Hydatids, accompanied by a Periodical watery Discharge per Vaginam, in a married "Woman, aged twenty-seven Tears, the Mother of two Children, the Youngest four Tears of age.—Hydatids and Vomiting.—Pro- cidentia of the Uterus, in a married "Woman, aged thirty-two Tears, the Mother of Four Children, the Toungest six "Weeks old.—Management of the Placenta in Natural Labor.—Concealed Pregnancy in an unmarried Woman, aged twenty-two Tears.— Fibrous Tumor of the Uterus mistaken for Pregnancy, in a young Lady, aged nine- teen Tears.—Diarrhoea Ablactatorum in an Infant, eight Months old.—Abscess of the Vulva in a married "Woman, aged twenty-seven Tears, the Mother of three Children, the Toungest four "Weeks old. Enlargement of the Uterus produced by Hydatids, accompanied by a Periodical watery Discharge per Vaginam, in a Married Woman, aged twenty-seven Years, the Mother of two Children, the Youngest four Years of age.—Mrs. L., aged twenty-seven years, mar- ried, the mother of two children, the youngest four years of age, has suffered for the last two months from occasional bearing-down pains, simulating those of labor, and is much annoyed with nausea and vomit- ing ; the pains are periodical, occurring at an interval of ten or twelve days, and accompanied by a discharge of water from the vagina. The menses have been suppressed for the last six months; and the patient has the appearance of being five or six months pregnant. " When did your abdomen first begin to enlarge, my good woman?" "I noticed it, sir, for the first time about five months ago." " Were you troubled with sick stomach at that time ?" " Yes, sir; and I am tormented with it now." " Have you noticed any change in the breasts ?" " Yes, sir; they have grown fuller, just like they do when I am pregnant." [Here the Professor examined the breasts, and discovered them to be full and large —but no sign of the areola was present.] " Do you think yourself pregnant ?" " Yes, sir; if I am not in the family-way, I don't know what can be the matter with me." " When you have the discharge of water, do you always have a bearing-down pain ?" " I always have the pain, sir, at the time the water comes from me." " Does the water stain your linen?" "No, sir, it is quite clear." The case before you, gentlemen, is not altogether free from embarrass- ment ; and it is our duty not hastily, under these circumstances, to give 42 CLINICAL LECTURES. an opinion as to the cause of the abdominal enlargement. This woman thinks herself pregnant, and with this hypothesis there is no difficulty in accounting for the protuberant abdomen. But, from a very thorough examination before introducing the patient here, I have come to a differ- ent conclusion, and do not think the enlargement is due to pregnancy. [Here the patient was placed on the bed, and particular attention directed to the appearance of the abdomen ; the aspect presented was that of a six months' gestation, the fundus of the uterus being on a level with the umbilicus, &c] It seems to me that this case involves two considera- t tions : 1st. Is the enlargement of the abdomen dependent upon enlarge- ment of the uterus ? 2d. If so, what is the cause of the uterine develop- ment ? You should remember that the abdomen may become increased in size from various conditions, such, for example, as pregnancy, ascites, ovarian disease, tympanites, enlarged liver, a fatty omentum, physometra and hydrometra; hydatids of the uterus; from various morbid growths, polypus, sub-mucous fibrous tumor, sub-peritoneal tumor, interstitial tumor of the uterus, &c. The question, then, for us to determine is, as to which of these causes is in operation here. I have examined this patient both by the vagina and rectum, and I have very distinctly ascer- tained that the uterus is enlarged in size corresponding with the develop- ment of a six months' gestation. The cervix and body of the organ present no evidences of disease. I have made repeated attempts to rec- ognize the pulsations of the foetal heart, both by mediate and immediate auscultation ; in this I have failed. I have failed, also, in detecting either the active or passive motion of the foetus ; although the breasts are en- larged, there is an absence of the true areola, which I hold, with Mont- gomery and others, to be almost characteristic of pregnancy ; neither have I succeeded in detecting the bruit placentaire, that peculiar soufflet connected with the utero-placental circulation. In percussing the enlarged uterus, there is a dull, flat sound—no resonance ; and, therefore, I conclude it is not a case of physometra, which consists in a collection of flatus within the uterine cavity. So far there has been no flooding, and, therefore, I infer it is not a polypoid growth, or a sub-mucous fibrous tumor of the uterus, the prominent and almost universal characteristic of which is profuse hemorrhage. So, gentlemen, I might proceed with an analysis of the various causes of uterine enlarge- ment, but I do not deem it necessary. My own opinion is, that this patient is affected with hydatids of the uterus; and this view is based upon what my examination has revealed—in the first place, an entire absence of all the characteristic evidences of pregnancy; and secondly an absence of the other morbid pheno/nena capable of producing enlarge- ment of the organ. There is one peculiar symptom of hydatids of the uterus, and that symptom is present in this case—I allude to the period- ical discharge of water per vaginam. It is not difficult to explain this discharge of water. Uterine hydatids usually consist of small oblong HTDATIDS OF THE UTERUS. 43 sacs filled with serous fluid ; these sacs are pediculated, and hence have been compared, not inaptly, to a bunch of grapes. They become devel Dped in size, and those which are the most dependent in the uterine cavity, as they increase in volume, irritate the neck of the uterus; this or- gan is thrown into contraction for the time being; the dependent sacs are ruptured, and their contents, consisting of serum, are discharged through the vagina. The same thing occurs again in proportion as the sacs next in order become developed; and you see, therefore, why it is that the discharge of water in uterine hydatids is not continuous but periodical. There is much discrepancy of opinion as to the cause of these hydatid growths. The weight of testimony appears to refer their origin to con- ception, many authors of high name contending that the presence of these growths is undoubted evidence of previous pregnancy. That a diseased ovum may form the nucleus of hydatid development in utero cannot be denied. But, on the other hand, we believe that they may exist inde- pendently of conception, in the same way that polypi, fibrous tumors, and various other substances, sarcomatous and osseous, are occasionally found in the virgin womb. During the process of expulsion of the hydatid masses, there is often- times profuse hemorrhage, and this, indeed, constitutes the true danger of these formations. The hemorrhage is much more abundant than an ordinary bleeding in child-birth, and for this reason: in the latter case, the bleeding proceeds from the utero-placental vessels, which occupy comparatively but a small portion of the uterine surface, whilst in hydatids the entire inner portion of the organ is more or less a bleeding surface. The diagnosis of uterine hydatids is by no means without difficulty, and the practitioner cannot exercise too much vigilance in his investigation. 1st. As I have mentioned to you, they may be mistaken for pregnancy. 2d. For polypus. 3d. For physometra. 4th. For hydrometra. 5th. For cauliflower excrescence, &c. The stethoscope, the ballottement, and the active movements of the foetus, will determine the question of pregnancy after the fourth and a half month. In polypus, there is a mucous and bloody discharge, but no discharge of water; the polypus, also, can often be felt through the os tincse, when it does not project into the vagina. In cauliflower excrescence there is a discharge of water, and when the pellicle, covering the granules, which really constitute the disease, is rup- tured, there is also a discharge of blood; but in cauliflower excrescence, the watery discharge is continuous and not periodical, for the reason that it is a secretion from the pellicle, to which we have just alluded. Hydro- metra, or dropsy of the womb, is extremely rare; when it exists, the fluc- tuation will serve to distinguish it from hydatids. In the prognosis of this affection, the patient should be informed of its nature; there is nothing malignant in uterine hydatids, and the only danger, under ordinary cir cumstances, is the profuse hemorrhage which often attends their expulsion. Treatment.—Uterine hydatids call for no special treatment. They are 44 CLINICAL LECTURES. to be regarded as mere deciduous masses, which are thrown from the uterus during its contractions. The true danger, it may be repeated, is the hemorrhage, and the practitioner must protect his patient against its exhausting effects. One point of importance, however, in connection with the occasional dangerous floodings accompanying uterine hydatids is, that these floodings do not generally become serious until the uterus has attained a development equal to the sixth or seventh month of ges- tation. Let us now suppose that you are called to a case of a patient affected with hydatids of the uterus, and who is losing a quantity of blood, which places her life in more or less peril. What, in this case, is to be done ? The object is to arrest the bleeding, the most effectual mode of doing which is to cause contractions of the uterus, and the con- sequent expulsion of the hydatid masses. If the mouth of the organ be soft and dilahable, and the loss of blood profuse, you should not hesitate to remove the hydatids in the following manner: The hand, well lubri- cated with oil, should be introduced into the cavity of the uterus, and grasping the hydatids, they should be extracted, being careful, however, before withdrawing the hand, to detach, as far as may be, the entire mass from the internal surface of the womb. As soon as this is accomplished, the very stimulus of the hand will excite contractions, and the bleeding ceases. Should, however, the hemorrhage be profuse, and the mouth of the organ not sufficiently dilated to justify the introduction of the hand, what then is to be done ? In such case, ergot may be administered either in infusion or tincture— 3 ij of the powder to be infused in a tumbler of hot water; when cooled, a table-spoonful every fifteen minutes until efficient contractions are produced; or 3 j of the tincture in half a wine- glass of water every ten or fifteen minutes. A capital remedy, too, in such cases, is the introduction of a piece of ice into the vagina, carried up to the neck of the organ. This, sometimes, displays magic effects in producing uterine contractions, and upon a principle which has often been explained to you. The excitor nerves of the vagina becoming stimulated by the action of the cold, this stimulus is transferred to the spinal cord, whence an impulse is given to the motor nerves of the uterus, which soon becomes the center of powerful contractions. On the same principle, ice-water injected into the rectum, or against the mouth of the uterus, is a good remedy under these circumstances. When the hydatids have been expelled, and the patient is convalescent, it will be proper to place her under the action of mercury and sarsa- parilla, in order that any occult morbid action in the uterus, and more especially in its mucous lining, may be broken up. With this view, the following course may be pursued: g PiL masses Hydrarg......gr. xxiv. Pulv. OpiL......gr. nj. Fr. massa in pil xij. dividenda. One of these pills to be taken night and morning until ptyalism is pro- HTDATIDS OF THE UTERUS. 45 duced; after the salivation has been accomplished, let the patient drink half a pint of the compound decoction of sarsaparilla daily, and continue it for a month or six weeks. In the mean time, sexual intercourse should be prohibited. This treatment, together with change of air, sea-bathing, and a nutritious diet, will tend greatly to the restoration of the patient to health. In connection, gentlemen, with this subject, I think it will not be with- out profit to cite the following interesting case to which I was called some time since, and in which it became necessary to induce premature action of the uterus in a patient affected with hydatids.—I was requested to visit a lady in consultation with Dr. Whiting, of this city. Several medical gentlemen had, previously to my visit, seen and prescribed for this patient. When I saw her, in company with Dr. Whiting, she was apparently near dissolution. Her prostration was extreme; her coun- tenance almost Hippocratic; and, indeed, her friends had abandoned all hope of recovery. The particulars of the case are these: She was the mother of one child, seventeen months old; about a month previously to my seeing her, she had occasionally been troubled with nausea and vomiting, and for the last two weeks had vomited almost incessantly. She could retain nothing on her stomach, the vomiting having resisted every remedy that had been administered. It was under these circum- stances that I was called to her. The medical gentlemen who had pre- ceded me in attendance had ordered cups, leeches, blisters, &c, over the region of the stomach, with various other remedies, but all without the slightest appreciable effect. The vomiting was still unchecked, and her death hourly expected. In examining critically her case, I arrived at the conclusion that the vomiting was merely a symptom of trouble elsewhere—and that no remedy addressed to the stomach would be of the least avail in rescuing her from the imminent peril in which she was placed. On applying my hand to the abdomen, I found the uterus enlarged, and occupying the hypogastric region. The alarming situation of the patient would not justify delay; if her life were to be saved, every thing admonished us that it was to be done by instantaneous measures. My opinion of the case was, that the vomiting was sympathetic, and produced by irritation of the uterus. I, therefore, suggested the propriety of endeavoring to induce contraction of this organ, in order that its contents might be expelled. This view was concurred in by Dr. Whiting. Accordingly, with the Doctor's re- quest, desperate and almost hopeless as the case was, I introduced a female catheter into the uterus; in a short time the organ contracted, and a mass of hydatids was thrown off. Almost immediately, as if by enchantment, the vomiting ceased. The patient, after a tedious convalescence from her extreme prostration, recovered, and is now in the enjoyment o'f robust health. Let this case impress on you the importance of tracing effects to causes; and remember this cardinal truth—that the practitioner who prescribes for mere symptoms can never hope successfully to treat disease. 46 CLINICAL LECTURES. Procidentia of the Uterus in a married Woman, aged thirty-two Years, the Mother of four Children, the youngest six Weeks old ; Management of the After-birth.—Mrs. A., aged thirty-two years, married, the mother of four children, is laboring under procidentia of the womb; and is incapacitated from attending to her ordinary duties. The organ projects from her person, and she has no means of retaining it in place, for as soon as it is returned, it again protrudes. On being asked what occasioned it, she remarked that she was always a healthy woman until her last confinement, when she was attended by an old midwife, and, after a labor of about six hours' duration, she was deliv- ered of a living child. A few minutes after the birth of the child, the midwife seized the cord, and pulling it with great force brought away the after-birth. Since that time the patient has suffered from protru- sion of the womb. Here, gentlemen, is a case, which not only merits attention, but which is also calculated to call forth your sympathy. This poor woman is suffering from the effects of ignorance, and she is, indeed, paying the cost of her credulity. Poor, and entirely dependent on her own exertions, she has entailed upon her a malady, which in all truth will make her bread the " sweat of her brow." I shall have frequent occasion in the clinique to call your attention to the causes and treatment of procidentia and other deviations of the uterus; for the present I will merely observe that a very common cause, both of prolapsus and procidentia of the womb, is mismanage- ment of the placenta; and this case, it seems to me, presents an oppor- tune occasion to make a few remarks on this subject. There are few questions connected with this department of more inter- est—none, certainly, which it becomes you more thoroughly to under- stand. Indeed, the management of the placenta constitutes one of the most important duties of the accoucheur. As a general rule, the real dangers of parturition are more or less directly connected with the de- livery of the after-birth. Hemorrhage, inversion of the womb, prolap- sus of this organ, laceration of the placenta, tearing away the umbilical cord, are all so many accidents, most of them fearful in their conse- quences, resulting from the mismanagement of the placenta. You must therefore, gentlemen, be on your guard, and not suppose that your du- ties in the lying-in-room are terminated, or your patient's safety secured, by the mere delivery of the child. We will suppose that you are attending a patient in labor; every thing proceeds auspiciously—the child is born, the ligature is placed around the cord, and the infant sep- arated from its mother. What is next to be done ? This is an import- ant question; let us examine it a little in detail. I hold it to be not only a safe, but an indispensable rule, for the accoucheur the instant the child passes into the world, to place his hand on the hypogastrium of the mother for the single purpose of ascertaining whether the womb responds to the expulsion of the child, and contracts, or whether it be PROCIDENTIA OF THE UTERUS. 47 in a state of inertia. In the former case, it will present to the hand a hard ball in the hypogastric region ; in the latter, no such ball will be recognized, but on the contrary the abdominal cavity will be more or less filled with an uncontracted womb. Again, in the former case, you have the assurance that all is right, nature is performing her work well; in the latter, she is contravened, the uterus does not contract, and as a necessary consequence one of the most fearful complications of the ly- ing-in-chamber—flooding, is at hand. Let us, however, for the purpose of illustration, take the case in which the womb is contracted. Under these circumstances, a few minutes after the birth of the child, the mother experiences pain, which simu- lates in every particular, save in intensity, the throes of labor. These pains are followed by a slight discharge of blood, and are nothing more than the further contractions of the womb, being one of the processes instituted by nature to effect the complete separation of the placenta from the uterine surface. The discharge of blood is the result of such separation. These pains and the discharge continue at intervals of from five to ten minutes until the after-birth is detached. How do you know that this has been accomplished ? The evidence is furnished by the fact that, on introducing your finger into the vagina, you feel the placenta resting on the mouth of the womb. With this evidence before you, it is unnecessary to delay, and you are to proceed as follows to extract the after-birth. The cord being enveloped with linen, you make two or three twists of it around the fingers of the right hand, whilst you intro- duce the index finger of the other hand into the vagina, carrying it up to the mouth of the uterus; the finger then seizes the cord close to the after-birth, and makes traction downward and backward in the direction of the axis of the superior strait; when the placenta passes out of the womb, and is in the vagina, the extraction is to be made in the line of the inferior strait, always remembering to withdraw the placenta by rotating it, thus making a rope of the membranes whicn will give them a power of resistance, so that fragments of them will not be left in the uterus—a circumstance to be avoided, for it is almost always followed by unpleasant consequences. After the placenta has been thus removed you should carefully intro- duce the finger into the vagina, and remove any coagula of blood that may be there, and ascertain particularly whether there is a clot of blood keeping the mouth of the womb open ; if so, it should be immediately abstracted, for if it be suffered to remain, hemorrhage will frequently ensue, and the patient, under any circumstances, exposed to much un- necessary annoyance by the severe contractions of the womb, occasioned by the presence of the coagulum. It is necessary, also, to bear in mind that traction should never be made on the cord until the after-birth is de- tached from the uterine surface, for fear of the following accidents: 1. Breaking of the cord; 2. Flooding from sudden separation of the 48 CLINICAL LECTURES. placenta; 3. Inversion of the womb; 4. Prolapsus, or procidentia of the organ, &c. The abdominal bandage should not be applied until after the delivery of the placenta, and remember that the object of the bandage is not to produce pain by being drawn tight, but to give com- fortable support by its uniform and gentle pressure. Immediately after delivery, the female organs together with the peritoneum are more sus- ceptible to disease than under ordinary circumstances, and they can not be rudely pressed upon without the hazard of lighting up inflammatory action. Concealed Pregnancy in an unmarried Woman, aged twenty-two Years ; Fibrous Tumor of the Uterus mistaken for Pregnancy.— Miss----, aged twenty-two years, of robust constitution, complains of headache and nausea. She states that she contracted a cold about six months since, and has not had her courses from that time; she talks with much composure, and says she feels confident if "her monthly turns" were right, she would enjoy good health. Her abdomen, she re- marks, is much distended with wind. The appearance of this patient being somewhat suspicious, with enlarged abdomen, etc., the Professor deemed it prudent to question her privately; he did so, but could elicit nothing by conversation to confirm his suspicions. On placing the hand upon the abdomen, he thought he distinctly felt the uterus; and the breasts being examined, the areola was well marked by that peculiar emphysematous condition of the integuments, which is so characteristic. On intimating his suspicions that she was pregnant, the patient became indignant, and warm in defence of her own purity. She was assured, however, that there was no disposition to harm her; but, on the con- trary, that she should receive every proper attention in the event of her being pregnant; and being also informed that her life might possibly pay the penalty of her obstinacy, she consented to a vaginal examination. This at once disclosed her true condition; and she was told that beyond all doubt she was at least five months pregnant. Earnestly, and with much apparent sincerity, did she deny the possibility of such an occurrence. The case, gentlemen, which has just been before you cannot be passed over in silence ; and I am gratified in having an opportunity in the per- son of this patient to direct your attention to a subject so full of import and interest. The young woman tells a simple story; she is apparently honest in her statements; she talks confidently of her situation, and de- nies in the most emphatic manner the fact of her pregnancy. In a word, her manner, her speech, her whole bearing, are calculated to lead the physician astray. She presents herself for treatment with the broad avowal that she is laboring simply under suppression of the menses, and begs that some- thing may be administered to " make her right." You would not sus- CONCEALED PREGNANCT. 49 pect from her manner that, unmarried as she is, she is in a state of preg- nancy, and if you become satisfied with her declarations, and allow them to form the basis of your treatment, you will err egregiously. The pre- sumption is, that, under such circumstances, the very means had recourse to with a view of benefiting her would induce abortion, and probably subject her to serious hazard. These cases, gentlemen, are not uncom- mon in practice. One of the first impulses of our nature is to conceal crime; and no matter how lost to shame, the woman who has fallen will endeavor by every device to cover from the public eye the result of that fall. The man who plunders leaves no effort untried to screen himself from detection. He whose hands are yet wet with the blood of his victim, has no other object in life but to elude pursuit. So it is with the female who has been wronged, or who has voluntarily parted with her virtue. Her night and day dream is as to the best mode of conceal ment; she fabricates a story, and seeks for professional advice in the hope that her schemes may impose on the physician, and thus obtain from him something which may destroy the evidence of her guilt! The case before us should warn you that nothing is to be expected from the ad- mission of the patient; it will be for you to exercise a proper degree of vigilance; and whilst I would not have you fall into the opposite extreme of universal suspicion, yet you owe it to your profession, to society, and to yourselves, to elicit the truth by all the means which are legitimately within reach. The evidences of pregnancy I have already dwelt upon at great length in my lectures on midwifery proper, and you will remember that I place great reliance on the presence of the areola. I should have been willing to decide this girl's situation by this sign alone, so perfectly does it exhibit all the characteristic marks. In a medico-legal point of view, this case is not without interest, and it should serve to show you how complicated will be the questions which, in the discharge of professional duty, you will be called upon to determine—questions on the issue of which will often depend character, liberty, and life itself. In matters of doubt, your opinion will frequently be invoked by the judges and lawyers of the land; and on the accuracy of your decision may depend, not only the well-being of society, and the happiness of individuals, but human life itself will often be at your mercy. The question of the existence or non-existence of pregnancy is, under certain circumstances, one of the most embarrassing which by any possibility can be presented to the judgment of the physician. On the one hand, a female in the hope of gain, or urged on perhaps by some more malignant motive, charges the father of a family with having violated her person; and thus with a view to a successful plea feigns pregnancy. Again, a husband dies without issue—the widow, in order to secure his estate, assumes to have borne a posthumous offspring. But why cite cases when the importance of this subject must be manifest to all of you. In speaking of the diffi- 4 50 CLINICAL LECTURES. culties with which the physician has often to contend in arriving at a just opinion as to the existence of pregnancy, Van Swieten exclaims with great truth:—Uhdique fraudes, undique scepe insidiae struuntur in- cautis. Occasionally, also, it will devolve on you as practitioners of medi cine to shield innocence against the assaults of the base, and proclaim a triumphant acquittal of charges which have been preferred by a reck- less and cruel world. In the language of the christian code,—" It is better that ninety-nine guilty escape, than that one innocent be con- demned." As exemplifying this Christian principle, and at the same time with the hope of deeply impressing your minds with the responsibility so soon to devolve on you, I beg leave to mention the following interest- ing, but melancholy case to which I was called some time since : I was requested to visit a lady who was residing in the State of New Jersey, about thirty miles distant from New York. I immediately re- paired to her residence, and on my arrival was received by her father, a venerable and accomplished gentleman. He seemed broken in spirit, and it was evident that grief had taken a deep hold of his frame. On being introduced to his daughter's room, my sympathies were at once awakened on beholding the wreck of beauty which was presented to my view. She was evidently laboring under pthisis, and it was manifest from her wasted frame that death had claimed his victim. My presence did not seem to occasion the slightest disturbance, and, with the smile of an angel playing on her countenance, she greeted me with these words : " Well, doctor, I am glad to see you on my beloved father's account, for he will not believe that I cannot yet be restored to health. Life, how ever, has lost all its charms for me, and I long for the repose of the grave." These words were spoken with extraordinary gentleness, but yet with an emphasis that at once gave me an insight into the character of this lovely woman. Her father was a clergyman of high standing in the English Church, and had a pastoral charge in England, in which he continued until cir- cumstances rendered it necessary for him to leave that country, and seek a residence in America. At a very early age, this young lady had lost her mother, and had been almost entirely educated by her father whose talents and attainments admirably fitted him for this duty. When she had attained her eighteenth year, an attachment was formed between her and a young barrister of great promise and respectability. This attach- ment resulted in a matrimonial engagement. Soon after the engagement she begun unaccountably to decline in health. There was considerable irregularity in her menstrual periods, with more or less constant nausea. loss of appetite, inability to sleep, feverishness, and an uncontrollable dislike to society. In addition to these symptoms, there was a marked change in her personal appearance; her abdomen became enlarged with increased size of the breasts, etc. These changes attracted the attention FIBROUS TUMOR OF THE UTERUS. 51 of some of her female acquaintance, and the rumor soon spread that they were the result of pregnancy. The barrister to whom she was affianced heard of these reports, and, instead of being the first to stand forth as her protector, and draw near to his heart this lovely and injured girl, thus assuaging the intensity of grief with which she was overwhelmed, addressed a letter to her father, requesting to be released from his engagement. This was of course as- sented to without hesitation. The young lady, conscious of her own innocence, knowing better than any one else her own immaculate charac- ter, and relying on Heaven to guide her in this her hour of trial, re- quested that a physician should be sent for, in order that the nature of her case might be fully ascertained. A medical man accordingly visited her, and, after an investigation of her symptoms, informed the father that she was undoubtedly pregnant, and that means should be instantly taken to keep the unpleasant matter secret. The father, indignant at this cruel imputation against the honor of his child, spotless as he knew her to be, spurned the proposition, and immediately requested an ad- ditional consultation. This resulted in a confirmation of the opinion previously expressed, and the feelings of that parent can be better ap- preciated than portrayed. Without delay, that good man determined to resign his living, gather up his little property, and proceed with his daughter to America. On her passage to this country, she became extremely ill, and there being a physician on board the vessel, his advice was requested. After seeing the patient (she was affected at the time with excessive vomiting from sea-sickness,) he told the father there was danger of premature delivery. Such, therefore, was the general appearance of this lady, that a medical man, merely taking appearances as his guide, at once concluded she was pregnant. This was about the substance of what I learned respecting the previous history of this interesting and extraordinary woman, and my opinion was then requested as to the character of her malady. My feelings were very naturally much enlisted in her behalf, and I proceeded with great caution in the investigation of her case. Without entering at this time into details as to the manner in which I conducted the examination, suffice it to say, that, after a faithful and critical survey, most minutely made in reference to every point, I stated in broad and unequivocal language, that she was not pregnant. The only reply this gentle creature made on hearing my opinion, was, " Doctor, you are right." These words were full of meaning, and their import I could not but appreciate. They were uttered neither with an air of triumph, nor with a feeling of unkindness towards those who had so cruelly abused her. The father was soon made acquainted with the result of my ex- amination, but he indicated not the slightest emotion. His bearing was quiet and dignified. It was evident that he had never faltered for one moment in the belief of his daughter's virtue, and required no assurance 52 CLINICAL LECTURES. from me or any other living being, that his child had been shamefully wronged. He asked me with great solicitude whether something could not be done to restore her to health, and I thought the old man's heart would break when I told him that his daughter was in the last stage of consumption. I left him with the pledge that he would inform me of her dissolution, and afford an opportunity, by a post-mortem examination, of testing the truth of my opinion. About four weeks from this time, I received a note announcing the death of his daughter, and requesting that I would immediately hasten to the house, for the purpose of making the examination. Dr. Ostrum, now practicing at Goshen, at my request accompanied me, and assisted in the autopsy. It may surprise you, gentlemen, but yet it is an inter- esting fact to communicate, for it exhibits the true character of the man, that, during the post-mortem examination, the father stood by, and wit- nessed every stage of the operation; his form was erect, his face pale and thoughtful, and one tear would have broken the agony of his grief. As he stood before me, he was not unlike the stricken oak in the forest, which, though blasted and stripped of its branches, was yet upright and majestic. As I removed the tumor from the womb, he seized it con- vulsively, and exclaimed : " This is my trophy, and I will return with it to England, and it shall confound the traducers of my child." Here, you perceive, both character and life were sacrificed by error of judgment on the part of those whose counsel had been invoked. With- out a due appreciation of their responsibility—heedless, as it were, of the distressing consequences which would inevitably result from an erro- neous judgment of a case, in which character was so deeply involved, the medical gentlemen, unjust to themselves, and to the Profession of which they should have been in part the conservators, rashly pronounced an opinion which consigned to an early grave a pure and lovely being, and crushed the heart of a devoted and confiding parent. It was the misfortune of this young lady to labor under an affection of the womb, which simulated, in several important particulars, the con- dition of pregnancy; and which the world, in its ignorance, might have supposed did in fact exist; yet there was no excuse for the physician guided as he should have been by the lights of science, and governed by the principles of a sound morality. When I stated unequivocally to the lady that she was not pregnant, I gave an opinion which I knew would stand; my examination was conducted in a way which enabled me accu- rately to comprehend that the whole train of symptoms, indicating ges- tation, was occasioned by an enlargement of the womb, altogether un- connected with pregnancy, and produced by the presence of a large re- sisting tumor occupying the entire cavity of this organ. This opinion, I admit, was not arrived at without some degree of caution—caution fully justified by the peculiar nature of the issue involved in the decision. This, gentlemen, is a case well calculated to make you pause, and DIARRHCEA ABLACTATORUM. 53 contemplate with serious earnestness the position in which, by virtue of your diplomas, you will soon be placed. These diplomas will confer on you the right to practice your profession—they will intrust to youi keeping the lives and happiness of your fellow-beings—you will fre- quently be the sole arbiters, on whose decision must rest the honor of /our patients, and on whose judgment must stand all that is sacred in life. Diarrhoea Ablactatorum in an Infant, eight Months old.—Ann S., aged eight months, has enjoyed excellent health until within the last three weeks. The mother, in consequence of indisposition, was obliged to wean this child ; and it has been fed, as the mother states, with "al- most every thing." Two days after it was weaned, it became affected with diarrhoea, which has continued to the present time. The child is extremely reduced and languid. You will note, gentlemen, an impor- tant fact connected with this case; this infant, while taking its mother's milk, enjoyed good health; and as soon as " almost every thing," to use the mother's significant expression, was substituted for this bland fluid, the gastro-intestinal mucous surface became the seat of irritation, as is evinced by the occurrence of diarrhoea. With these facts before you, there can be no difficulty in arriving at a just conclusion in regard to the cause of the irritation; and on this point I desire to make a few ob- servations. Repair and waste are two processes constantly recurring in the human system ; and, in order that health may be preserved, and the proper development of the economy attained, there must exist between these two processes a proper balance, or proportion. In this little pa- tient, it is evident that this balance does not exist—the waste being far greater than the repair; the consequence is general derangement of the system, with emaciation and debility. It is well known that the adult has the power of maintaining life, and can even reach a good old age, upon either animal or vegetable food, and his organs are adapted to the digestion of the aliment taken into the system. Between the adult, however, and the infant there is a remarkable dif- ference in the facility with which food is assimilated; in the one, the organs are fully developed, and adequate to the office assigned them; in the other, on the contrary, they are extremely delicate, and are lim- ited in their powers of assimilation to food of the blandest nature. Under ordinary circumstances, children at the breast thrive well, and, if not meddled with by officious medication, they rarely need the ser- vices of the physician. But why do infants at the breast enjoy an immunity from disease, especially of their digestive organs, and why as soon as weaned does this condition oftentimes cease to exist? Milk is undoubtedly of all substances the best adapted to the nourishment of the infant; and all the elements either for growth or for the maintenance of animal heat are admirably combined in the milk of the mother. It is manifest that these elements are well fitted to the delicate organs 54 CLINICAL LECTURES. of the infant, and no difficulty is encountered in their proper assimila- tion. The child, with this diet, grows and enjoys health. When weaned, it is usually fed upon substances unsuited to its system; it has no power of digesting them; irritation of the gastro-intestinal mucous surface with diarrhoea ensues. Food taken into the system has two important objects to subserve—the one, to nourish the economy; the other, to maintain its temperature. It is also a fact that, in order to sustain life there must be a proper proportion between the elements of nutrition, and those of respiration. It has been shown that in milk, which is the natural and proper food of infancy, the elements of the former bear to those of the latter the proportion of one to two; whilst in sago, arrow- root, and tapioca, it is one to twenty-six. But the child when weaned is often fed with articles far more unsuited even than those just named, and waste and decay are not unusually the results. Few, I imagine, except anxious mothers and officious nurses, will be disposed to deny that another difficulty under which young children labor, and, one, too, which constantly predisposes the system to derangement and disease, is over-feeding. My observation will, I think, warrant the statement that this error is almost universal, at least in this country; and I regard it as one of the most fruitful sources of disease in child- hood. It matters not how excellent the quality of the food—the child will always suffer from excess. You will find it difficult, gentlemen, to persuade mothers of this fact—they will listen to you, and, whatever may be their convictions of your reasoning, their practice will be ad- verse to it. The late Dr. Cheyne, of Dublin, a practical writer of no ordinary merit, in order to designate the disease under consideration, employed the term atrophia ablactatorum; this term is not, in my opinion, suf- ficiently expressive. It is intended rather to point out one of the im- portant, and more or less constant results of the disease; I prefer to call this malady the diarrhoea ablactatorum, for it brings your attention at once to the fact of diarrhoea attacking children under peculiar circum- stances, and arising from a given cause. The cause of this affection is improper food, acting upon the delicate organs of the child. This form of diarrhoea is different from that result- ing often from dentition or cold; and the manner in which it is produced is altogether peculiar. It has no connection with the diarrhoea of teeth- ing. It will often be found to exist when the gums are in no way tume- fied, and when none of the symptoms of dentition are present. Indeed, this disease frequently occurs at the third and sixth month. We all know the important offices of the liver, and every day's experience shows the serious derangements which ensue to the general system when the functions of this viscus become impaired. Between the liver and alimentary canal there subsist very striking relations. The mother's milk, when taken into the system of the infant, excites no peculiar action DIARRH(EA ABLACTATORUM. 55 on the intestinal surface; the liver experiences no abnormal stimulus, and the proper balance between the liver and this surface is preserved. But when food incapable of assimilation is substituted for the milk, the gastro-intestinal mucous surface becomes the seat of irritation—this irritation extends to the liver, which throws bile more or less acrid into the duodenum, and free purgation is the consequence. Though the bile may not be acrid or irritating at first, it will soon assume that character, for the reason that the liver, under the influence of protracted stimulation, will have its secretion materially altered. The symptoms of diarrhoea ablactatorum are as follow: purging, with green-colored dejections, accompanied with griping pains; the color, however, of the evacuations is liable to become modified; sometimes natural, and at others white and green. Nausea and vomiting, with loathing of food; fever, thirst, restlessness, and emaciation. The diag- nosis of this affection is not obscure. It is to be distinguished from the diarrhoea of teething or of cold, by the usual circumstances which attend this form of disorder, always remembering that the characteristic of this disease is that it follows improper diet. Prognosis.—In the early stage, this affection is under the control of treatment; as it progresses, however, the fear of an unfavorable termi- nation is greatly enhanced. Treatment.—If what we have said as to the cause of this disease be true, it is quite obvious that the removal of the cause is the first object of the practitioner. Until this be done, medicine will not only be with- out avail, but it will positively do harm by adding to the general dis- turbance of the system. The first point, then, is to change the diet. Give such articles of food as are adapted to the organs of the child; assimila- tion will then take place, the gastro-intestinal mucous surface will cease to be irritated, and the probability is, that this, in recent cases, will be all that will be required to remove the diarrhoea. I would advise you to restrict the diet of the child to fresh cow's milk, sweetened with white sugar. It will be proper, with the view of removing any offensive matter from the primse viae, to administer a full dose of castor oil. Should the diarrhoea still continue, you will often find great advantage from a tea-spoonful of the following mixture twice a-day: R Creta? Misturse.......§ uj Tinct. Kino.......1} M. It will sometimes happen that this disease will prove rebellious to the above remedies, and the life of the child be seriously endangered. Under such circumstances, calomel will prove the sheet-anchor of hope, and I can speak with great confidence of its magic effects. It should not be given alone, for whilst you desire the influence of the calomel in changing the action of the liver, and bringing about its healthy secretion, there is also another important object to be attained—you must soothe the system by allaying the irritability of the intestinal canal. I know 56 CLINICAL LECTURES. of no better combination than the following, which was the favorite remedy of Dr. Cheyne. It has served me in many trying cases, and I regard it, if judiciously employed, not only a philosophical, but an al- most certain remedy in this form of diarrhoea : R Sub. Mur. Hydrarg......gr. vi Cretae pptt........gr. xij Pulv. Opii........gr. i Divide in cltartulas xij. One powder to be given night and morning, according to circumstances. The disease, gentlemen, to which I have just directed your attention, constitutes a fearful outlet to human life. If you look at the bills of mortality among children, in a city, for example, like New York, num- bering nearly a million of souls, you will there find the melancholy record of the triumphs which death claims over our science—triumphs to which that inexorable enemy is not justly entitled, but which fall to him through our own carelessness. We are too prone, in the treatment of disease, to regard effects rather than causes. Whilst the former alone occupy our attention, the latter are progressing with their work of destruction. Abscess of the Vulva in a married Woman, aged twenty-seven Years, the Mother of three Children, the Youngest four Weeks old.—Charlotte H., aged twenty-seven years, married, the mother of three children, the youngest four weeks old, complains of severe pain in the lower portion of the abdomen, and finds much difficulty in walking. She says her last child was taken away with the forceps after a pro- tracted labor. This patient, gentlemen, before introducing her to the clinique, informed me that she had a swelling on the lower part of her person; it was important, therefore, that a critical examination should be made in order to detect its true nature. Accordingly, after a careful investigation, I discovered an abscess of the right labium externum, with distinct fluctuation. This affection is by no means uncommon, and fre- quently results in serious consequences to the patient. A natural indis- position, from feelings of delicacy, to seek advice on the subject, often gives to these abscesses a dangerous latitude, causing them to terminate in fistulous openings, communicating with* the perineum, rectum, etc.__ in the latter case, giving rise to the passage of stercoraceous matter. You see, therefore, how important it is to ascertain at once the real char- acter of disease, in order that you may check the grave, and occasionally destructive results of insidious progress. The causes of these abscesses are:—1st. Injuries at the time of child- birth ; 2d. Injuries from sexual congress in newly-married women • 3d. Falls and blows; 4th. Cold; etc. It is highly probable that, in the present case, the abscess is the result of contusion from the use of in- struments. The symptoms characterizing abscess of the vulva are throb- ABSCESS OF THE VULVA. 57 bing pain, a burning sensation accompanied more or less by fever, and an inability to walk. The diagnosis of this affection is entitled to your fullest consideration, for, as you will presently see, fatal consequences may sometimes result from error of judgment. You are not to imagine that every enlarge- ment of the labia externa is a phlegmon; but you are to bear in mind that tumors form in these parts from various causes:—1st. There may be a descent of the intestine into one or other of the labia, producing vulvar-enterocele; 2d. There may be tumefaction from a collection of blood, constituting sanguineous engorgement; 3d. From a collection of serum, serous engorgement; and 4th, as in the case of this patient, from abscess, purulent engorgement. If you should mistake a hernial protru- sion for a phlegmon, and thrust your bistoury into it, life would be too short for you to bewail the fatal error. Be cautious, therefore, and be- fore you proceed feel that you have a basis for action. The prognosis of vulvar abscess usually involves no difficulty, except in cases in which fistulous openings have resulted. These may terminate seriously, and at all events prove protracted. Treatment.—Phlegmon of the vulva ordinarily terminates in the for- mation of matter. At the commencement, an attempt may be made to prevent this by leeching, saline cathartics, emollients, &c, but this object will rarely be attained. When the purulent secretion has taken place, a free incision should be made, followed by simple dressings. LECTURE IV Mucous Discharge from the Vagina in a married Woman, aged thirty-seven Tears, the Mother of three Children, the youngest three Tears old, produced by "Warty Excrescences on the Vestibulum.—Vaginal Discharges generally.—The importance of accurate Diagnosis.—What is meant by the "Whites?"—Intestinal Worms in a little Girl, aged four Tears.—The variety and origin of Worms in the Human System.—Vascular Tumor of the Meatus Urinarius in a married Woman, aged twenty-six Tears.—Ulcerative Carcinoma of the Neck of the Uterus in a Widow, aged forty Tears.—Human Credulity.—Heartless Exactions of the Quack.—Sup- pression of the Menses in an unmarried Girl, aged twenty Tears.—Cholera Mor- bus in a Boy, aged six Tears. Mucous Discharge from the Vagina, in a married Woman, aged thirty-seven Years, the Mother of three Children, the youngest three Years old.—Sarah W., aged thirty-eight years, married, the mother of three children, the youngest three years old, has been troubled for the last eighteen months with a discharge from the vagina. She has repeatedly applied for advice to physicians, and the only remedies prescribed were astringent washes, from which she has derived no bene- fit. On being asked if she had ever undergone an examination, she replied never. The patient before you, gentlemen, is one presenting as important and instructive a case for your consideration as any that has been brought before you this session; and I desire in connection with it to make a few observations on the subject of vaginal discharges gen- erally. It is my duty to guard you against a prevailing error in prac- tice, which seems to have been consecrated by almost universal custom. If a female labor under a vaginal discharge, whether mucous or puru- lent, she is supposed by her friends and herself to be affected with the " whites," or fluor albus, as it is sometimes denominated; and it is regarded simply as a female weakness. Discharges from the vagina are among the common disorders inci- dent to the female. They are, however, too frequently viewed with indifference by the practitioner from the very circumstance that they are of ordinary occurrence; and, in consequence of neglect at the inception of these discharges, disastrous results often ensue to the pa- tient. She employs for this supposed weakness the various remedies MUCOUS DISCHARGE FROM THE VAGINA. 59 suggested by her friends, but without relief. Finally, she sends for a physician, tells him she has the fluor albus, and wishes him to do some- thing for her. If the physician, as is unhappily too often the case, should allow the declarations of his patient to be his guide, he will in all probability prescribe an astringent wash from which no permanent benefit can accrue. Discouraged, and believing there is no remedy ade- quate to her case, she resolves to bear silently her troubles, which, if they do not produce serious consequences, will at least entail on her much annoyance and suffering. What, let us ask, is in reality meant by the term " whites ?" What is its signification ? So far as it dis- closes in the abstract any peculiar pathological condition, or directs the practitioner to a sound and philosophical treatment, it means absolutely nothing.* It is a term, so far as these objects are concerned, entitled to no consideration whatever—it is a mere vulgarism, a mantle, if you choose, for the concealment of ignorance. The expression is employed by the female to indicate that she has a discharge from the vagina, not of blood, but of a mucous or purulent nature. It is material for you to remember that the discharges from the vagina are four in number:— sanguineous, purulent, mucous, and watery; and it must also be borne in mind that there are various morbid conditions capable of producing each of these evacuations. When, therefore, you are consulted in regard to a vaginal discharge, your first duty will be to ascertain distinctly its character—is it bloody, mucous, &c. ? Suppose it be the latter; the next step to be pursued by the scientific physician is to investigate its true cause. The removal of the disease, or its resistance to remedies will depend upon the suc- cess which may follow your investigations on this subject. Those of you who may contemplate devoting yourselves to the study of the dis- * Dr. Marc d'Espine has published some interesting results as regards the na- ture of the discharges coming from the uterus. Out of seventy-four examinations in which the neck of the womb was healthy, he has found: 1 times a watery liquid. 28 " an albuminous transparent liquid. 13 " a half transparent albuminous liquid, containing white, grey, or yellow striae. 3 " an opaque liquid (white, twice, yellow, once). 2 " an albuminous liquid. Out of fifty-two explorations in which the orifice of the uterine cavity was redder than usual—but otherwise healthy: 3 times a watery liquid. 14 " a half transparent liquid, twice with yellow, and twice with white striae. 5 " an opaque liquid (twice, white, twice, yellow). 5 " an albuminous liquid. These facts are interesting because they prove, that, without inflammation or other svident disease of the uterus, this organ may be the seat of a secretion of liquid. 60 CLINICAL LECTURES. eases peculiar to females, will, when you shall have become engaged in the practice of your profession, soon discover that of all these maladies none will prove more rebellious to remedies in the hands of the general practitioner than those connected with vaginal discharges; and simply because the discharge, whatever may be its character, is too often looked upon as the disease, whereas it is only the effect of morbid action in some of the adjacent organs. I can not, therefore, too emphatically im- press on your minds the necessity, in all cases, of ascertaining definitely what produces the discharge. If you lay aside, for a moment, the grat- ification experienced by the physician in affording relief to suffering woman, there is another consideration, of a more ignoble nature it is true, which may have its influence in stimulating you to a rigid and thorough investigation of the subject now under discussion. It is this— if, in the practice of your profession, your object should he the accumu- lation of wealth, as certainly as I am now addressing yd, so certainly will that object be attained, if you be successful in treating the variout vaginal discharges so common among females. The gratitude of woman, and the eloquence of her tongue in praise of the man, who has re- stored her to health, will be of inappreciable value in carrying out this object. One successful case, which may have resisted every effort in the hands of others, will prove to you a rich harvest—it will repay you a hundred-fold in money; and I shall not attempt to describe the meas- ure of happiness, which every right thinking man will experience in feeling that, by the proper application of the principles on which his science is based, he has been enabled to conquer disease, and confer health and happiness on those who have faith in his skill and judg- ment. You remember the case of the little girl who was brought to the Clin ique, a few weeks since, in consequence of a mucous discharge from the vagina, with which she had been annoyed for several weeks. This case I called your attention to in detail; and you have not forgotten how earnestly I enjoined upon you the necessity of ascertaining the origin of the mucous evacuation. We traced the discharge to the presence of ascarides in the rectum. To the discharge itself we paid not the slight- est attention; we knew it was a result which something had produced. The ascarides constituted the cause, and our remedies were directed against them. As soon as they were destroyed, the irritation occasioned by their presence subsided, and the discharge disappeared. In the case before us, we have pursued the same course; before introducing this patient to you, as soon as I learned she had suffered for the last two years from the " whites," I examined her with great care, and discov- ered several excrescences studding the vestibulum. The uterus and va- gina are entirely free from disease, and there is no doubt that the dis- charge with which this patient has been affected is due to the presence of the excrescences. Small warty excrescences on the vestibulum or in the INTESTINAL WORMS. 61 vagina, are among the causes of mucous discharge. In order that you may fully appreciate the importance of a thorough investigation into the causes, instead of regarding effects in the treatment of disease, suppose that this patient had consulted one of you, and you had viewed her case, as physicians too often do, as one simply of the " whites;" you would most probably have ordered an injection of alum or zinc, and you would have failed in relieving her. A little sweet oil rubbed on the great toe would have had quite as much effect in removing the excrescences—the cause of the discharge—as the injection you prescribed ! Causes.—The excrescences occasionally found on the vestibulum, etc., result sometimes from a want of personal cleanliness; sometimes they are the sequelae of venereal disease; at others, they are produced by chronic inflammation of the parts. Symptoms.—Irritation of the parts, with a discharge of mucus more or less profuse. Diagnosis.—A careful examination will at once detect the disease. Prognosis.—No difficulty as to the result. A cure may be positively promised. Treatment.—With a pair of small forceps, or a tenaculum, you seize the excrescences, remove them quickly with a pair of curved scissors, and then apply the nitrate of silver freely to the cut surface. Daily ab lutions afterward with cold water. Intestinal Worms in a little Girl, aged four Years.—Margaret W., aged four years, is brought to the Clinique by her mother for ad- vice, having passed several round worms during the last five weeks. This case, gentlemen, will afford me an opportunity of calling your at- tention for a few moments to the subject of intestinal worms, as occa- sionally met with in the human subject. They are most frequent in childhood, but at times are also found in the adult. The older writers attributed many of the diseases of the digestive system in infancy to the presence of worms; and the symptoms indicative of their existence were supposed to be well marked. But in our day, this subject is better understood; and it is now a settled principle, that what were formerly imagined to be positive evidences of intestinal worms, may be the result of various morbid conditions of the digestive apparatus with which these entozoa have nothing whatever to do. There are five different kinds of worms usually found to inhabit the human intestines :—1. The ascaris vermicularis, the small thread worm, whose lodging place is ordinarily the rectum. They are the most com- mon of all these parasitic animals. Your attention was directed a few Cliniques since to this character of worm, when speaking of the vaginal discharge, which sometimes appears in young female children; 2. The ascaris lumbricoides, or round worm; 3. The tricocephalus dispar, or long thread worm; 4. The taenia latum; 5. The taenia solium. In addi- 62 CLINICAL LECTURES. tion, there are several species of these parasites found in other portions of the animal economy, so numerous that it is scarcely necessary to mention them, particularly as our observations on the pres- ent occasion will be limited exclusively to the consideration of intestinal worms. It may, however, be as well to observe that worms are occa- sionally detected in the urinary bladder, kidney, gall-bladder, liver, brain, eye, ovary, cellular tissue, bronchial glands, etc. In connection with the topic under discussion, there is one inquiry which should very naturally present itself to an intelligent mind, and yet it is one which is not com- monly examined by authors. What is the origin of intestinal worms in the human subject—how do they reach the alimentary canal ? This question is surely not unworthy of investigation, and it is one of some little interest. We must admit one of two theories; either they are generated in the intestines, or they are brought there from the external world. Both of these theories have found their advocates; but the for- mer is the one most generally admitted, and the only one which appears to be sustained by facts. It has been satisfactorily demonstrated that the structure of these parasites is altogether peculiar, differing essentially from worms found without the body; and when discharged from the human system, they survive but a short time. Well authenticated in- stances, too, are recorded in which worms have been discovered within the system of the foetus. In the latter case, certainly, their origin must be internal. Those who advocate the internal origin of worms differ aa to the modus in quo. Some contending that they are wholly formed in the system, receiving no aid whatever from without; others, on the con- trary, stating that the ova are furnished by the food, etc. This, under certain circumstances, I can readily imagine to be the case. The causes of intestinal worms may be considered, so far as conflict- ing opinions are concerned, a vexed question. Various theories have been advanced, and there is no little discrepancy of views on the subject. Whilst some refer the cause to climate and particular kinds of food, others contend that it is to be ascribed to sedentary habits, badly venti- lated dwellings, etc. We are inclined, however, to believe that an im- pairment of the digestive organs, together with a cachectic condition of system, are among the most frequent causes of these parasites. The symptoms which are supposed to indicate their presence are numerous. But there is one fact to which I wish especially to direct your attention, and it is this—the appearance of the worms in the evacu- ations is the only positive pathognomonic sign of their existence. All other evidences, so much insisted on by writers, may exist irrespective of worms, and be coincident with various morbid conditions of the alimentary canal. A capricious appetite, loaded tongue, offensive breath, irritation of the schneiderian membrane, tumidity of the abdomen colicky pains, emaciation, pain about the umbilicus, etc., are mentioned as among the prominent symptoms; and yet, I repeat, these symptoms INTESTINAL WORMS. 63 may be present, and no worms discovered in the system. The presence of worms in the intestinal canal, sometimes gives rise to singular sympa thetic influences in remote portions of the economy, which should not be lost sight of by the practitioner. A child will occasionally lose its voice from this cause—catalepsy and epilepsy will sometimes ensue—and you have had before you two extremely interesting cases, in which worms were the cause of paralysis. These children, you will remember, before ap- pearing at the Clinique, had, as the parents informed us, been treated in various ways in accordance with the views entertained as to the cause of the paralysis. After a careful examination of these cases, I was inclined to refer the paralysis to the irritation of intestinal worms acting on the spinal system. Medicines were administered, and you all recol- lect the very gratifying results. Worms in both instances were expelled from the system, and the children recovered from the paralysis in a few days afterward. The diagnosis of worms is occasionally obscure, for the reason already stated that the symptoms which usually indicate their presence, may result from other causes. It is necessary, therefore, in arriving at a just opinion, to exercise more than ordinary vigilance, and con- sider deliberately the circumstances of each case. The prognosis, on the contrary, is very simple; under ordinary circumstances, every assur- ance may be given of a favorable issue. Treatment.—The indications in the treatment of worms are two-fold: First, To cause their expulsion from the system; Second, To prevent their reproduction. In the case of the little girl before us, I shall recom- mend an infusion of Carolina pink root, followed by a brisk cathartic : R Spigelian Marilandicaa.....§ ss FoL Sennse.......3 ij Aquse bullient. ......§ iv Ft. infus. A table-spoonful twice a-day, to be followed when finished by: R Sub. Mur. Hydrarg......gr. ij Pulv. Jalapae.......gr. vj Ft. pulv. The next morning a table-spoonful of castor oil. After the expulsion of the worms, care should be taken to invigorate the system, and with this view, benefit will be derived from the admin- istration of the following tonic, together with nutritious diet, exercise in the open air, etc. R Sulph. quinae.......gr- ij Acid. Sulph. dil.......K<*-*J Aquae purse ......3 y A tea-spoonful twice a-day. Tht anthelmintic remedies are numerous. The pink root, or spigelia 64 CLINICAL LECTURES. Marilandiea, is a powerful one, and generally may be relied upon. It may be given in a variety of forms, some of which are subjoined : R Pulv. Spigeliae Mariland. . . . • gr- vi Sub. Mur. Hydrarg......gr. iv i/i To be taken at night, followed in the morning by castor oil. R Spigelian Mariland. . • • • 1sa Sennse J........Siaa Mannse J A.qu33 bulllent.......°J Ft. infus. A table-spoonful for a child not under two years of age, three times a- day, followed when all is taken by magnesia, Epsom salts, or castor oil. Vascular Tumor of the Meatus Urinarius in a married Woman, aged twenty-six Years.—Mrs. S., aged twenty-six years, married, the mother of two children, the youngest seven months old, presents herself for advice, in consequence of distressing pain when passing water, and also, when walking. It would, I apprehend, gentlemen, be impos- sible for you to prescribe for this patient with any hope of success, without knowing more particularly the nature of her malady. One of the great evils of our profession is that we are too apt to prescribe for mere symptoms. A patient consults you, and if she should have any difficulty with her water, there are nine chances to ten she will tell you that she has the gravel. If, therefore, you rely on her declarations, taking her opinion as a guide for treatment, the chances will be nine to ten that you will be defeated. Females suffer pain in passing water from numerous causes; so like- wise do various causes operate in rendering progression painful. I can not too emphatically admonish you to be cautious in your diagnosis; all successful treatment depends upon it. In a word, if you wish to remove the effect, the only true mode of accomplishing your object, is to attack and remove the cause—causa sublata tollitur effectus. This is the great secret of our profession—it makes our science one of philosophic truth, and gives it the impress of certainty. No such light guides the empiric; he is lost in darkness and doubt, and floats in a sea of conjecture, whilst the scientific physician proudly claims for his profession a basis firm and impregnable. The case of this patient is one of extreme interest, and we may promise with entire confidence, speedy relief. On examining her care- fully, I detected on the lower border of the meatus urinarius, a small scarlet tumor not larger than a pea. This tumor has been described by Sir C. Clarke, under the name of the vascular tumor of the meatus uri- narius. It is a soft fragile tumor, characterized by excessive sensibility. It occasionally projects within the urethra, and is common both to the mar- ried and unmarried. Sir C. Clarke when he first called attention to it ULCERATIVE CARCINOMA. 65 entertained the opinion that it was of rare occurrence. Subsequently, however, he changed his mind on the subject. My experience tells me that it is not so very uncommon, although I am satisfied it often eludes detection. I have repeatedly met with it, and this is the second case which has presented itself at the Clinique the present session. This tumor is almost always accompanied by a mucous discharge, and its characteristic symptoms are excessive pain in sexual intercourse, in passing water, and in walking. The contact of the chemise is productive of great suffering. In fine, the slightest touch gives rise to severe pain. Sometimes several of these excrescences will be detected within the urethra. Treatment.—No medicine which you can administer will have any effect. The only remedy is the removal of the tumor ; this may be done by ligature, the knife, caustic, or scissors. I greatly prefer the latter. Take a pair of curved scissors, and remove the tumor completely, then touch the cut surface freely with caustic. This is all that will be neces- sary. Occasionally serious hemorrhage follows the removal, which you can check by the nitrate of silver, or caustic potash, together with ice kept constantly applied. It is also recommended to apply to the cut surface nitric acid, being careful to guard the surrounding parts. The actual cautery is sometimes resorted to not only to arrest the hemor- rhage, but as a primary remedy and I should think it an efficient agent for either purpose. Ulcerative Carcinoma of the Neck of the Womb, in a Widow, aged forty Years.—Margaret H., aged forty years, widow, the mother of six children, the youngest four years old, has suffered for the last three months from sharp lancinating pains in the region of the womb, together with a sensation of increased weight; she has had for the last few weeks a discharge of matter more or less constantly from the vagina, of an extremely fetid odor, with occasional losses of blood. These latter have caused her to become uneasy in mind, and have prostrated her extremely. Her face is blanched, the extremities cold, and the pulse thready; her complexion is of a clayish color. She is much emaciated, and complains of distressing vertigo; she says she has taken a quantity of " Doctor's stuff," to make her " courses right," having been assured that as soon as this was accomplished, she would be restored! What, gentlemen, would you suppose to be the nature of this unhappy woman's disease, taking her description as the basis of your opinion ? Is it, think you, likely that you would mistake her malady for a menstrual irregu- larity ? I hope not; I should, I know, be mortified to think that any member of this class could by possibility commit so grave an error. The account given by this patient of her sufferings is so lucid, I might say so graphic, that it should at once awaken in your minds a just sus- picion as to the character of her disease. It is true, however, that ap> 5 66 CLINICAL LECTURES. parent as her disease is, you are not justified in giving a positive opinion without a vaginal examination. This I have made, and find what I was confident I should discover, that this patient is laboring under the third or ulcerative stage of cancer of the womb. On introducing my finger into the vagina, I felt the womb much enlarged and immoveable; the lips are everted and ragged, with deep ulcerations, and there is consider- able hardness in the surrounding tissues, the vagina and rectum both being involved in the induration.* On withdrawing the finger, it was covered with a sanguineo-purulent material emitting that offensive odor so peculiar to carcinoma. In cases like these, let me caution you against the use of the speculum. This instrument, I admit, is a useful one;— no one appreciates its value more highly than I do; but, like other use- ful things, it is circumscribed within certain limits. I pity the man who requires the aid of the speculum to enable him to recognize an advanced stage of ulcerative carcinoma. The objections to the employment of this instrument, under these circumstances, are: 1st. That it is not need- ed in order to arrive at a diagnosis. 2d. That it aggravates unneces- sarily the sufferings of the unhappy patient, and often gives rise to profuse hemorrhage. The third or ulcerative stage of carcinoma uteri imposes a limit to our science, and all that remains for us to do is to endeavor to palliate the sufferings of the patient, and sustain, as far as possible, her declining strength. This is what you are to aim at, and it is your duty to offer no encouragement beyond these objects, which, indeed, are rarely attained. The cause of the losses of blood in this stage of cancer you understand to be the ulceration of the vessels as the malady progresses, and the development of fungous growths. It is, gentlemen, in cases such as the one before you—for which science has no remedy—that we occasionally find practiced the most heartless impositions. You, who are just on the threshold of the profession, and have not yet been engaged in the field of practical duty, will scarcely credit the schemes resorted to in this city, under the guise of science, for the purpose of plundering the sick and the dying. I could cite several thrilling cases in confirmation of what I now state; but, for the present, one will suffice to convey to you some idea of the monstrous devices tolerated in the very heart of a Christian community. Some time since a lady of great intelligence, from one of our western cities, visited New York, for the purpose of * Although the cervix uteri is the part most usually affected at the commencement of carcinoma, yet this is not always the case. Professor Forget, of Strasbourgh, has recently recorded two cases of cancer limited to the body of this organ, and he is of opinion that this particular seat of the disease is not so unfrequent, as has been sup- posed. In both instances death ensued from peritonitis, and the location of the malady was only discovered through a post mortem examination. Madame Boivin and Duges have also mentioned three instances, in which this affection was developed in the body of the uterus. ULCERATIVE CARCINOMA. 67 seeking professional advice. Soon after her arrival, I was requested to see her; and after listening to the history of the case, I became satisfied that she labored under a formidable affection of the womb. Without however, expressing any opinion, I left her with the promise that I should visit her on the following day, and then give her my views of her case. Accordingly, after a careful examination per vaginam, I discovered that this lady was affected with ulcerative carcinoma; and being strenuously urged, both by herself and friends, not to disguise my opinion, but to state it unequivocally, I remarked to her that her disease was beyond permanent relief, and all that could be done was to palliate her sufferings. This opinion was received with composure by the patient; but, as I thought, with some degree of doubt. After continuing my visits for a week, it was very evident, from certain manifestations, that some influ- ence had been at work to destroy confidence in my judgment; and the patient expressed, with great kindness, yet with decision, her strong belief that I was in error in reference to the character of her malady. Under the circumstances, the course for me to pursue was a very obvious one; I, therefore, suggested that other counsel should be taken in order that the opinion I had given might be confirmed or set aside. My col- league (Professor Valentine Mott) was requested to see the case with me, and his examination corroborated in every particular the opinion previously expressed. I continued to visit this lady, and do all in my power to assuage her anguish; her sufferings were most severe, but they were borne with the fortitude and resignation of a Christian spirit. Her mind had become satisfied with the opinion that had been given; and, believing that there was no earthly hope, she was reconciled to die. At this time, an acquaintance put into her hands a pamphlet recounting wonderful cures of all sorts of maladies by Mesmerism ! This poor creature, weighed down by suffering, her form attenuated to a skeleton, her mind enfeebled, and her reason rendered infirm by protracted and agonizing disease—unable, of course, to form a competent judgment on any subject—placed the fullest faith in the statements set forth in the pamphlet; and at her earnest solicitation—the solicitation of a suffering and dying woman—the mesmeriser was sent for. After the first act of his jugglery, he informed her that the doctors were alto- gether deceived as to her disease—she had no cancer, but labored simply, as he termed it, under a " Concatenation of visceral deficiency ! /" This " Concatenation of visceral deficiency " he pledged himself to remove, and restore her to perfect health. The friends of the sufferer, passing as she was rapidly to the grave, although they had no confidence in the declarations of the heartless impostor, could not resist the fervent appeals of the dying woman; and he was, therefore, permitted to practice his unholy tricks. Day after day he continued his mesmeric operations, promising, with renewed emphasis, a speedy recovery. One morning, however, on arriving at the house, he was accosted by the nurse, who 68 CLINICAL LECTURES. informed him that the patient had expired the night before / Unmoved by this disclosure, and with perfect indifference—so dried up were the fountains of his soul—lost as he was to every emotion of humanity, he left the house without a word of comment, satisfied in his own mind that he had attained the object for which he had consented to desecrate his character—the wages of his wretched deception. The God of truth and justice will assuredly deny mercy to a man who could thus wantonly revel over the credulity of a dying woman ! It is time, gentlemen, to speak out on this subject; let every honest man rise up, and, by moral weapons, drive from our midst those fiends, who would thus speculate with human life, and bring disgrace on human character. The deeds of infamy practiced on the innocent and unwary in this enlightened city; and the fortunes accumulated by these traffickers in the happiness and lives of their fellow-beings, are subjects in every way entitled to the grave consideration of those, who by law are the conservators of the public weal. Our profession must be protected against the renegades who, under its mantle, impose upon public credulity. The science of medicine is a science of ages—it bears the impress and authority of an unbroken chain of mighty minds—and medicine at this day is a splendid superstructure raised in part on the principles laid down by Hippocrates himself. It is progressive, but yet it is stable—it is not a thing of caprice, nor does it claim any affinity with the transcendental novelties so popular in our own times. The principles of medical science are not so mutable that they can be accom- modated to individual taste, nor are they so complete a fiction that they can be adapted to the current fashion with the same facility that the tailor will alter the skirt of your coat, or the hatter the crown of your hat. Money can not purchase the secrets of her temple, nor will leger- demain ever be recognized as one of the elements on which she lays claim to public confidence. There is nothing ephemeral in the character of her precepts; nothing transitory in the well-deserved reputation of her vo- taries. The lessons which she inculcates, and the principles which she establishes, are lessons and principles confirmed by the experience of centuries, and hallowed by the testimony and sanction of the profoundest sages of ancient and modern times. We owe it to the great dead—to those glorious and learned fathers from whom these precepts have been derived, to guard them against desecration ; rather should they be looked upon as sacred oracles confided to our custody, and to be preserved with filial care and affection. It is a legacy rich and precious, and worthy to be transmitted to future generations. Let the chain of succession be perfect, so that the science of medicine may take its place among the enduring things of this world. You whom I am now addressing, will constitute in part the connecting link between the present and future and to you will that future turn for the preservation of the trust so soon to be committed to your charge. ULCERATIVE CARCINOMA. 69 Treatment.—Whatever may be the hopes of relief in the incipient state of carcinoma uteri, there are none, except through an exception to an almost universal rule, when the disease has passed to the stage of deep ulceration. We are then limited to mere palliatives. The an- guish of the patient is usually beyond description, and one of the prin- ciple duties of the practitioner is to alleviate as far as possible this suf- fering. With the view, therefore, of mitigating the pain, the various narcotic remedies are resorted to, such as opium, morphia, conium, bel- ladonna, hyoscyamus, etc., etc.—opium and morphia may be freely em- ployed ; always, however, be careful not to produce narcotism. A small blister on the side of the sacrum, dressed with the acetate of morphia will sometimes, through its endermic action, produce very great relief. Opium suppositories in the rectum, or injections of laudanum and water will prove useful. A remedy, also, from which I have often de- rived much benefit in allaying pain both in cancer of the womb and breast, is arsenic; five drops, three times a day, in the form of Fowler's solution, in a table-spoon of cold water, may be administered; if, how- ever, it should constrict the head, which sometimes it will do, it must be suspended. Constipation to be avoided by enemata of warm soap- suds and castor oil. The presence of fascal matter in the rectum fre quently aggravates the pain. The strength to be sustained by nutri- tious diet, and by attempting as far as possible to diminish the discharge both of matter and blood. You will find for the former an injection into the vagina of a decoction of carrots beneficial; for the latter, an injection of sulphate of zinc and rose-water 3 j to § xij : or sulphate of alum and water; for the offensive odor nothing better than a solu- tion of the chloride of soda thrown into the vagina—when the hemorr- hage is profuse, and threatens exhaustion, it will be proper to have recourse to the tampon. There is a symptom connected with the latter stage of carcinoma uteri, which is often extremely distressing—I mean nausea. Benefit will be derived in these cases by placing on the epigastrium a cloth saturated with laudanum. Cauterization.—Cauterization is sometimes resorted to in the ulcerative stage of cancer. I have no confidence, however, in it as resulting in per- manent cure when the disease is confirmed in its development. But it will frequently, by modifying the diseased parts, afford temporary relief —it will diminish the pain, and oftentimes check for the time being the offensive discharge. The substances employed for this purpose are numerous; viz., the acid nitrate of mercury, the Venetian paste, the potassa cum calce, and that most preferred by Jobert—the actual cautery. One word, gentlemen, in reference to the excision of the cervix uteri, and the total removal of the uterus. Cases, which have been reported as cured by these operations, are much exaggerated; they do not bear the seal of good faith. The operation itself is most dangerous, and 70 CLINICAL LECTURES. almost always fatal, especially the extraction of the uterus; and, there- fore, you will not be justified in resorting to it. Suppression of the Menses caused by Fright, in an unmarried Girl, aged twenty Years.—Nancy H., aged twenty years, unmarried of a plethoric habit, has labored under suppression of her courses foi the last three months. She complains of headache, and a sense of suf- focation, with dizziness. During her last menstrual period, a fire oc- cured at night in a house adjoining the one in which she resided. Her alarm was such that she fainted, her menses became suddenly arrested, and have not appeared since. There is nothing, gentlemen, inconsistent in this girl's story ; young women, who have suppression of the courses are occasionally objects of suspicion; and you have had several cases before you during the present session, in which it became my duty to exercise a proper vigi- lance, in order to discriminate between suppression arising from preg- nancy, and suppression produced by other causes. This patient is labor- ing under vascular repletion ; the flushed countenance, the engorged eye, the full and vigorous pulse, the heat of surface, all indicate vascular ac- tion. The headache, dizziness, and sense of suffocation are the results of this over-action, whilst the over-action itself is the result of a sup- pression of one of the periodical losses, which the female system is called upon, under ordinary circumstances, to sustain. The equilibrium is thus broken up, and the economy is in constant danger of some serious assault on one or other of the important organs from this derange- ment of the balance-wheel. If the suppression were due to pregnancy, this perturbed condition of system would not be likely to follow; for whilst gestation is going on, there is an ample demand for any surplus of blood. Cazeaux, indeed, has recently endeavored to show that true plethora of the system is extremely rare during gestation. Again, among the various causes capable of producing suppression of the men- ses, fright is one of the most certain. I repeat, therefore, this woman's story is not only consistent, but it is extremely probable. There is nothing in this case to justify the suspicion of pregnancy, and we shall therefore, treat it as a case of ordinary suppression. Treatment.—The object here is to diminish the circulating force; when this is accomplished, and the distribution of blood throughout the system equalized, it is not improbable that the menstrual evacuation will be restored. The patient should lose from the arm § viij of blood, and take a brisk cathartic of: R Submur. Hydrarg.......gj. yi Pulv. Jalapae.......gr. xij Pulv. Antimonial......gr.i\ To be followed in the morning by one ounce of salts. In these cases, it will be found useful to promote light serous dis- CHOLERA MORBUS. 71 charges from the bowels for some days, which may be done by order- ing a wine-glass of the following solution before breakfast: R Sulphat Magnesia? i Sup. Tart. Potassae j" .... §j aa Aq. Distillat. ......Oj Ft. sol. The diet to consist principally of vegetables. Should the menses not appear at their accustomed time, the patient may take one or two of the compound aloe and myrrh pills for two successive nights; and the styptic foot bath will also be found serviceable. Cholera Morbus in a Boy, aged six Years.—Hugh A., aged six years, has been vomiting, and had three or four evacuations from the bowels within the last ten hours. He complains of pain in the abdomen, and suffers from nausea. The mother, in order to allay the pain, ad- ministered a tea-spoonful of paregoric; the child was afterward at- tacked with high fever, and its countenance is now much flushed. On being questioned as to the nature of the child's food for the last day or two, the mother replied that she had taken him on a steamboat excursion, and he had eaten freely of pea-nuts and apples. This case, gentlemen, is worthy of your attention. You will often meet with such in your practice, and if your diagnosis should prove erroneous, you may destroy your patient. The paregoric, next to morphine or opium, was the most natural remedy for the mother to administer, for she looked merely at the pain which the child was suffering, and she knew that paregoric to soothe pain was a common and popular remedy. Abstract views, and abstract reasoning is an unsafe basis for the physician. His field of ob- servation must of necessity be more extended, if he wish to arrive at safe and just conclusions. He will, therefore, in a case of this kind, look beyond the pain, which he will regard as a feature only, and not the en- tire character of the ailment. In the pea-nuts and apples he will recog- nize the cause of the child's sufferings—they are yet in the stomach, un- digested, acting as a foreign substance, and thus deranging the economy of the system. The nausea, vomiting, and purging are the effects of the undigested mass. Let me, therefore, enjoin upon you in all cases like the one before us, whether they occur in adult or infantile life, to inquire rigidly as to the kind of food which the patient may have eaten a few hours previously. Treatment. The indication here is twofold : 1st, to relieve the stom- ach of the offending mass; 2d, to quiet the system by a gentle anodyne if necessary. With the former view, let this child take gr. vj of Ipe- cacuanha, and after he has vomited once or twice, let him drink freely of warm water. When the stomach has been evacuated, should it be necessary, a tea-spoonful of the syrup of poppies may be given. LECTURE V. Introductory Remarks.—Suppressed Lochial Discharge in a married Woman, aged thirty Tears, the Mother of four Children, the Youngest three Weeks old.—Fol- licular Stomatitis in an infant, aged eight Months.—Injury from the Introduction of the Catheter during Pregnancy.—Manner of introducing it; Stricture of the Female Urethra.—Inflamed Umbilicus in an Infant, aged four Weeks.—Vicarious Menstruation in a Girl, aged nineteen Years.—What is Vicarious Menstruation ?— Enlarged Tonsils, with Deafness, and a Sense of Suffocation, following Scarlet Fever, in a Boy, aged six Years. Gentlemen :—Our reception room for patients is filled to overflow- ing, and I regret that time is not sufficient to present to you all the in- teresting cases which have assembled for advice. The advantage of this Clinique must be apparent to you all. It brings before you, day after day, diseases of the most interesting character; it constitutes, as it were, the lying-in-chamber with all its details and complications. There is no effort made to collect, and array before you particular maladies; the poor of this city know that, on certain days, they can receive advice in this University upon all diseases peculiar to women and children. The announcement of this fact has filled our Clinique with every species of disease, presenting the very types which you will be called upon to treat, when you shall have entered on the field of practice. In this simple cir- cumstance consists the real advantage of the Obstetric Clinique; it brings before you every conceivable variety of disease, and your minds are thus familiarized with bedside observation, the want of which not only proves a stumbling block to the young practitioner, but often leads to mortification, and failure of professional success. In the treatment of the diseases of women and children, more, perhaps, than in any other of the departments of the profession, you need this kind of observation. That you appreciate the facilities afforded by our populous city for the investigation of these maladies, I desire no stronger evidence than your uniform attention, and the constantly crowded benches before me. You are all aware that when I first projected the establishment of an Obstetric Clinic, the idea was regarded as altogether Utopian by some • and our best friends expressed strong doubts as to its practicability. I thought differently. The result has shown that my confidence was not without foundation. If you will take a retrospect of the last few weeks SUPPRESSED LOCHIAL DISCHARGE. 73 you will find, on recurring to your note-books, that numerous cases of every day occurrence, the very character of cases which you are most in need of, because they constitute the every day work of professional life, have been brought before you. Their causes, symptoms, diagnosis, pathology, complications, and treatment, have been fully discussed. These cases, after having been prescribed for, have returned, and you have been the witnesses as to the result of the treatment; you have seen whether our views have been sound, and worthy of thought, or whether they have been speculative, and, like most hypothetical doctrines, apoc- ryphal, and, therefore, unsafe as guides in the practice of the healing art. I invoke your scrutiny, and if experience do not affix the seal of truth to the principles which I lay before you, no greater injury can befall you than to adopt them; they must be rejected not only as useless, but as pernicious lessons. Truth alone is worthy of your contemplation. Suppressed Lochial Discharge in a married Woman, aged thirty Years, the Mother of four Children, the Youngest three Weeks old.—Mrs. P., aged thirty years, married, the mother of four children, the youngest three weeks old, seeks advice in consequence of intense head- ache and vertigo. She complains of a sense of suffocation, and says she frequently feels as if she would fall: her eyes are occasionally affected with a blur, and she is apprehensive she will die in a fit. This woman is ex- tremely vascular, with powerful muscular development, and her bowels are habitually constipated. During her pregnancy she was bled twice with positive relief. Her present symptoms have been much aggravated' since her last confinement. On being asked if any thing unusual oc- curred at this time, she replied that after the birth of her child she had " never seen any thing," which means that she had not the lochial dis- charge which usually follows child-birth. Two days after the birth, her headache commenced, and has continued with unceasing severity ever since. This case, gentlemen, affords an instructive lesson; and there can be no doubt that, unless the patient is relieved by appropriate treatment, serious consequences are likely to ensue. The throbbing pulse, the flushed countenance, the feeling of suffocation, the headache, and the con- stipation are the effects of a disturbing cause, and portend trouble. The system is oppressed, the mechanism is deranged, and harmony of func- tion is lost. This general disturbed action must be controlled, otherwise it is probable that engorgement of some important organ will take place, and result in death. The connection between this excited condition of system and that of the patient at the time of her confinement is ob- vious—one of the ordinary processes of nature was interrupted—the lochial discharge did not appear; for some reason or other it was re- tarded, and the consequence is general derangement of the system. Females for a certain period after the birth of the child, averaging from 74 CLINICAL LECTURES. seven to twenty days, have a discharge from the vagina, at first sanguin- eous, then purulent, and afterward serous; this is called the lochial dis- charge. It proceeds from the womb, and is nothing more than the ex- udation, if I may so speak, from the tissues of this organ, to which, as you know, there is a constant afflux of fluids during gestation. The re- tention or suppression of the lochial discharge will give rise, under equal circumstances, to the same train of symptoms as are found to follow re- tention or suppression of the catamenial evacuation. In the case of this patient, the indication is palpable. The system is too full, and the ple- thora must be controlled by active depletion. The causes of retention or suppression of the lochia? are various. It may arise from sudden cold; it is almost uniformly the result of in- flammation either of the womb or peritoneum; febrile excitement from any cause will also occasion it. Women who menstruate sparingly have usually a very slight lochial discharge; those, on the contrary, of an op- posite condition are more profuse, but this law is not universal. This discharge is sometimes exceedingly offensive, and such will be found to be the case in persons of a scorbutic, cancerous, or scrofulous diathesis. A coagulum of blood, or a fragment of the placenta retained within the womb will also occasion a fetid odor. The symptoms of retained or suppressed lochiae will depend very much on the constitution and temperament of the patient. In a ple- thoric subject, such as the one before us, they will be characterized by all the evidences of vascular fullness. Treatment.—This patient should be bled from the arm, say ixij. The object is to make an impression on the system. She should then be purged with R Sub Mur. Hydrarg......gr. xij Pulv. Jalapae.......gr. xv Pulv. Antimonialis.....gr. ij Ft. pulv. Followed in six hours by §j of sulph. magnesias in §viij of water. The diet should be strictly vegetable, and the bowels continued in a soluble state by a wine-glass or more every morning of the following solution: R Sulph. Magnesias ) Sup. tart. Potassae J Aquae purae As a general rule, if the lochial discharge do not appear within a few hours after the birth of the child, or if it should not be free, a warm cata- plasm of flax-seed with 3 ij of powdered camphor applied every two hours over the vulva, will have the effect of promoting it. Conjointly with this, the feet and lower extremities should be kept warm with ■ &a3J . Oj. Ft. sol. FOLLICULAR STOMATITIS. 75 mustard water. These local applications alone will often suffice to bring about the object. Follicular Stomatitis in an Infant, aged eight Months.—Ann G., aged eight months, has cut four teeth, and is affected with sore mouth; she is irritable, and is much troubled with acid stomach. " When, my good woman, did you first observe that your infant's mouth was sore V " Only the day before yesterday, sir." " What called your attention to it ?" " Why, sir, the child was restless, and seemed to be in pain when it took the breast." " How are its bowels ?" " What passes it, sir, is green and sour." This, gentlemen, on examination, I find to be an example of simple or follicular stomatitis; it is what is known as the apthous or baby's sore mouth. Young infants, and children of a more advanced age, are quite liable to affections of the mouth, and these have been variously classified; they may, however, be embraced under the following divisions: 1st, Simple, or Follicular Stomatitis; 2d. Ulcera- tive Stomatitis; 3d. Gangrenous Stomatitis ; 4th, Mercurial Stomatitis ; 5th, Muguet. Simple, or follicular stomatitis consists essentially in in- flammation of the mucous follicles of the mouth—it is not a disease of danger, but usually causes the child to be fretful; it will readily yield to appropriate remedies. Causes.—This affection is rarely idiopathic; it is, on the contrary, almost always symptomatic. One of its commonest causes is the irritation of teething, and, therefore, it is frequently observed in children at the breast. It often, too, results from the different eruptive fevers, such as measles, scarlet fever, etc.; any local irritation applied to the mouth, will produce it. Frequently it is the effect of gastric derange- ment, and, on inquiry, you will generally discover that the child affected with the disorder has more or less acidity of the stomach, with an un- healthy condition of the evacuations. Symptoms.—One of the first indications of this affection, is restlessness on the part of the infant, and an indisposition to take the breast; it grasps the nipple, but immediately relinquishes its hold, and then be- comes fretful. On looking into the mouth, you will observe the small follicles in a state of inflammation, presenting at first a vesicular appear- ance, and if the inflammation be not promptly subdued, these vesicles will soon pass on to the ulcerative stage. Diagnosis.—The difference between this form of sore mouth and the other varieties, is so characteristic, that it can not well be mistaken. We shall undoubtedly have frequent occasion to call your attention to the other forms of stomatitis, and you will then more readily appreciate the distinctive characters of each. Treatment.—In the present case, the first point to be attended to, is the regulation of the bowels. The acid stomach must be controlled; and these objects will be attained by the administration simply of mag- 76 CLINICAL LECTURES. nesia dissolved in milk. Put vj. gr. of calcined magnesia into a wine- glass of sweetened milk, strain, and give the child a tea-spoonful two or three times a-day. As a local application to the mouth, you may employ : R Borat. Sodae ) . . . aa 3 ss if Sacchar. Alb. J Put a small quantity on the tongue twice a-day ; the saliva dissolves it, and it will be found useful. Injury from the introduction of the Catheter during pregnancy ; Manner of introducing it.—Stricture of the female Urethra.— Sarah J., aged twenty-four years, married, was delivered of her first child two months since. In the seventh month of her pregnancy, she experienced much difficulty in passing water, and having exhausted fruit lessly the various domestic remedies, she sent for a physician, who after several unsuccessful attempts, was finally enabled to introduce the ca theter. This patient says she suffered greatly from the efforts of the practitioner to penetrate the bladder. A slight discharge of blood fol- lowed, with excessive soreness at every attempt to micturate. A few days afterward she discovered a discharge of matter, which has con- tinued with pain, more or less constant, to the present time. She also experiences annoyance from a frequent desire to pass water. You see, gentlemen, before you, a patient who is laboring not under unavoidable disease, but which indeed may be denominated an unpardonable infliction. I have examined her critically; she has an ulcer on the lower surface of her urethra. After listening to her statement, there will, I apprehend, be no difficulty in tracing the cause of this ulcer to its legitimate source. It is the result of injury to the urethra in the attempt to introduce the catheter, for which there can be no justification. It is fortunate, however, for the poor woman, that there is a limit to her distress ; or, in other words, that the evil under which she labors, is readily within the reach of remedies. Her lot may have been far more distressing, for a urethro- vaginal fistula might have resulted from this combination of ignorance and force to accomplish an exceedingly simple operation. I characterize this operation as simple, and yet I feel that this term merits some qualification. It is simple only when the anatomy of the parts is well understood, and when the practitioner bears in mind the various modifications which the urethra undergoes in its direction during the period of gestation. The operation you may be required to perform under one of four circumstances : 1st. In the virgin; 2d. In the married woman • 3d. During pregnancy ; 4th. During, or soon after delivery. It will be a sad thing for you, so far as your reputation is concerned, to fail in the performance of this operation; and it becomes those of you especially, who are destined to practice in remote districts of country where con- sultations can not be had, to comprehend thoroughly the rules which are to guide you in the introduction of the catheter. You will remember MANNER OF INTRODUCING THE CATHETER. 77 when directing your attention to the anatomy and physiology of the female organs, I pointed out the urethra as an object worthy of your at- tention, in reference to the very subject now under consideration; and you were told that, in introducing the catheter, it is essential to be mindful of two important points. In fact, the facility or difficulty, the possibility or impossibility of the operation, will depend on your knowl- edge of these points, viz : 1 st. The position of the outer opening of the urethra, or meatus urinarius ; 2d. The modifications produced by preg- nancy and diseases of the uterus in the direction of the urethra itself. The female urethra measures from an inch to an inch and a quarter in length, and is remarkable for its great dilatability. Owing to this latter circum- stance, together with its shortness, urinary calculus in the female bladder is comparatively of rare occurrence ; stricture of the urethra is likewise extremely rare. Where and how are you to find the meatus urinarius? Before answering this question, allow me to impress upon you the pro- priety in this, as well as in other operations which you may perform upon the female, to protect her person from all unnecessary exposure. It was a maxim of the illustrious St. Francis, of Sales, that " a good Christian should never be outdone in good manners." May it not be said with equal truth, that the scientific physician should have for his aim, gentleness and refinement ? In his intercourse with his female patients, let him feel that he stands in the sanctuary of virtue, and his actions can not fail to be in consonance with this sentiment. I wish you therefore, distinctly to understand, that under ordinary circumstances, no exposure of your patient is justifiable in the introduction of the catheter. The true and only basis of success in the operation is an accurate knowledge of the anatomy of the parts; with this knowledge, nothing can be easier than to introduce the catheter ; without it, nothing more certain than defeat, and injury to the patient. The exposure of the patient's person would not aid in the slightest degree the practitioner ignorant of the anatomical relation of the organs—for he would be far more likely, even with the assistance of his eyes, to place the catheter in the vagina instead of the meatus urinarius, if, indeed, he did not " go further and fare worse," in receiving a severe rebuke from his patient for having performed a fundamental operation ! Now for the question: how and where is the meatus urinarius to be found ? If you trust to the rule usually laid down in the books, you will often find it a faithless guide. You are told, for example, to feel for the superior caruncula myrtiformis, and having placed your finger upon it, the meatus urinarius will be found immediately above it. The objections to this rule are two-fold : 1. In patients who have lost flesh, the caruncula myrtiformis is frequently absorbed; 2. Under other circumstances, it occasionally becomes so altered as to be difficult of recognition. There are two far more certain methods, which will enable you to accomplish the object with facility. 1. In the married woman, you may 78 CLINICAL LECTURES. introduce the index finger into the vagina carrying its radial surface along the anterior portion of the passage, your finger is thus necessarily brought in contact with the lower wall of the urethra; in gently with- drawing the finger along the course of the urethra, the apex of the finger will come in direct contact with the meatus urinarius. 2. Both in the married and unmarried female, you place the apex of the idex finger at the superior commissure, which you will remember is situated at the infe- rior and central portion of the mons veneris just at the point of bifur- cation of the labia externa. At this commissure, you feel the clitoris., immediately below which is the triangular space called the vestibulum. bounded above by the clitoris, on either side by the labia minora, o> nymphae, and below by the meatus urinarius, which is the object of your search. I should have premised that, in introducing the catheter the patient should be on her back, with her thighs flexed, and brought to the edge of the bed, so as to facilitate the manipulations of the phy- sician. Having placed the finger on the meatus urinarius, this serves as a guide for the catheter, which being previously oiled is introduced with the other hand. You carry the point of the instrument to the finger the extremity of which is placed on the meatus, and passing the catheter along the finger it will be found to enter the orifice. The instrument is to be introduced in an oblique direction from without inward in order that it may follow the course of the urethra, which is oblique in the un- impregnated state, and when the uterus is not complicated with disease. But in either of the latter cases, the direction of the urethra changes with the ascent of the uterus, so that, in the latter stages of pregnancy, the urethra will be found to be nearly perpendicular, passing along the internal surface of the symphysis pubis. In such case, therefore, as soon as the catheter enters the meatus, the opposite extremity of the instrument must be depressed, in order that it may penetrate the blad- der without the infliction of pain or injury. It can not be necessary to recall .to your minds what I have already said on a former occasion respecting the connection between the uterus and bladder. It is in con- sequence of this connection that the enlarged womb in its ascent (whether the enlargement be the result of gestation or disease) causes an alteration in the course of the urethra. If this circumstance had been recollected when the attempt was made to introduce the catheter in the case before us, this poor woman would have been spared much unnecessary suffering. Treatment.—It is useless to expect that the ulcer in this woman's urethra will heal spontaneously. There will, however, be no difficulty in removing it by the proper treatment. A urethral syringeful of a solution of nitrate of silver 3J to § iv of water should be injected once a day for two successive days, and the patient should drink freely of flax-seed tea. The injection may afterward be repeated, if necessary and in a few days a cure will be effected. INFLAMED UMBILICUS. 79 I have remarked to you, gentlemen, that stricture of the female urethra is extremely rare ; I have seen one case only of this affection, and it may not be unprofitable to mention it. I was requested to visit a married lady from an adjoining State. The history given by herself of her case was simple, and to the following effect: About four years pre- viously to my seeing her, she experienced uneasiness in the region of the womb, and slight pain in passing water. There was more or less discharge of mucus from the vagina, and sexual intercourse occasioned at times great distress. These were the incipient and only symptoms of her malady. A physician was consulted, and pronounced the disease to be falling of the womb. Pessaries were introduced, abdominal sup- porters applied, but without affording any relief; whilst on the contrary, the pessaries tended to aggravate the pain by the pressure they exerted on the seat of disease. The pain and difficulty in passing water having increased, the lady resolved to visit New York in search of professional advice. On hearing the history of the case, I at once told her I did not believe she had falling of the womb, for the simple reason that her symptoms were not characteristic of any such ailment. I proposed an examination, which was cheerfully assented to, as the patient was most solicitous to obtain relief. I found the uterus in a perfectly healthy state, and in its natural position. In passing my finger along the urethra, the patient experienced a sensation of pain; this circumstance, together with the difficulty of which she complained in passing water, attracted my attention particularly to this point. I could detect no disease in the uterus or vagina; in attempting to introduce a catheter in the ure- thra I was completely foiled; and on minutely examining the passage, I discovered that the lady's sufferings were entirely due to a stricture of the urethra. Stricture of the female urethra I had never seen previous to this occasion; and, as far as my knowledge extends, no case of the kind had ever occurred in this country ; at least no record of it has been made. Velpeau, in his great work, cites but three cases of stricture of the female urethra, and remarks that its occurrence is extremely rare. In the course of three months, I succeeded in removing the stricture, and the lady returned to her home restored to health. Dr. Satchwell, a graduate of this University, and now practising in North Carolina, vis- ited this patient with me on several occasions, and heard from her own lips the statement, which she made of what occurred previous to my seeing her. The only treatment had recourse to was mechanical dila- tation by means of graduated bougies. Inflamed Umbilicus in an Infant, aged four Weeks.—G. H., aged four weeks, is brought to the Clinique in consequence of the umbilicus not having properly healed since the sloughing of the cord. You will often, gentlemen, be called upon to treat cases of this kind. They are simple and perfectly manageable, although parents are rendered anxious, 80 CLINICAL LECTURES. supposing that some serious result will follow. You perceive that tho whole difficulty here consists in the fact that there is a small portion of proud flesh sprouting from the side of the navel. All that is necessary is to sprinkle it with calomel once or twice, followed by dressings with lint and simple ointment. In a few days, the umbilicus will be healed. You all understand the object of placing a ligature on the foetal portion of the cord—it is to prevent the possibility of hemorrhage. You are aware that I recommend but one ligature, whilst the general practice is to apply two, and sever the cord between them. I recommend but one ligature for the following reasons:—1st. There is no necessity for two, in as much as the small quantity of blood that escapes from the placental extremity of the cord as soon as it is cut, comes not from the maternal system, as is erroneously supposed, but is the disgorgement merely of the umbilical arteries and vein, as they ramify on the foetal surface of the placenta. 2d. From careful observation I am satisfied that, ordin- arily, this very disgorgement of the vessels facilitates the detachment of the after-birth. From three to six days after birth, the cord sloughs, and leaves the umbilicus in a healthy condition. Occasionally, however, as in the present case, there will be found proud flesh, and sometimes ulceration, which, except in certain neglected cases, will readily yield to remedies. Vicarious Menstruation, in a Girl, aged nineteen Years.—Emma J., aged nineteen years, unmarried, has not menstruated for the last two years. Her courses became suppressed at that time in con- sequence of a fright occasioned by the running away of a horse. She has suffered since from head-ache, which has been uniformly re- lieved for the last six months by a free bleeding from the nose, which has occurred with remarkable regularity every three or four weeks. Her system is usually constipated, and she is plethoric. Here, gen- tlemen, is a case of vicarious menstruation, illustrating one of the conservative principles, which so frequently guide nature in her varied operations. The menstrual function is an important one—periodical in its recurrence, and, except during pregnancy and lactation, the health of the economy requires its faithful and regular appearance until the ap- proach of the great climacteric of female life. It is one of the funda- mental processes instituted by nature in the female system, and it can not be interrupted without involving more or less seriously the general well-being of the individual. Frequently, from causes which nature can not control, this function becomes suppressed, and we occasionally find, as in this patient, some compensating discharge acting as a waste-f^ate, and thus protecting the system measurably from harm. The two sur- faces most likely to afford this vicarious dicharge are the intestinal mu- cous membrane and skin. Hence, diarrhoea often supervenes, and un. loads the system; again, hemorrhoids will appear; and, at other times, VICARIOUS MENSTRUATION. 81 we see periodical losses of blood from the mouth, bronchial tubes, blad- der, and, as in the present instance, from the nose; periodical eruptions, and bleeding ulcers on the extremities, etc. I recently saw, in consulta- tion with Dr. Lutkins, in Jersey City, a case of vicarious menstrua- tion from the umbilicus, in a young girl, nineteen years of age, who had never menstruated normally. I suspected, that in this case there might possibly be a mechanical obstruction, either by means of an im- perforate hymen, or an imperforate os tinea, and more especially did I think so at first, because of an enlargement of the abdomen ; from ex- amination, however, I found that my impression was not well founded, and the abdominal distension arose from a collection of flatus. The men- strual function became natural under the influence of aloes and iron, 2 gr. of the former, to 1 of flie latter, twice a day. Women, in whom the process of assimilation is well marked, and characterized by much vigor, are often protected for a time against the effects of suppressed menstruation by the increased deposit of adipose matter, which takes place in the various tissues; this circumstance is frequently salutary in females at the final cessation of the menses. It is, in fact, the exercise of a derivative action, affording a temporary equal- ization of the blood, and, therefore, preventing local engorgements.* You are to remember that, in vicarious menstruation, the discharge does not always consist of blood; it will sometimes be mucous, at other times purulent; and you will occasionally observe in practice a periodical leucorrhcea taking the place of normal menstruation. Be careful, in such instances, not rashly to arrest the leucorrhoea. Sometimes the vica- rious discharge will consist simply in profuse salivation, examples of which have been recorded by Siebold, Churchill, and others. Treatment.—In vicarious menstruation, the object is to establish the normal menstrual function. For this patient, I should recommend, in * Rayer, in a paper, entitled De L1 Hmmaturie endemique d Vile de France, has spoken of a singular form of hemorrhage, occurring in warm climates, which has been but little studied. He has, however, omitted certain points, which do not appear to have been known by him. In tropical climates it is quite usual for children to void bloody urine, and frequently the urine is milky or chylous. This loss of blood and of albuminous matter does not seem to impair the health; and as a general rule, this condition of the urinary secretion continues until the age of puberty, when the secre- tion of the semen takes place, or the menstrual function becomes established. Those children, however, who escape this attack of hsematuria, etc., are often affected with hem- orrhage either from the nose, mouth, intestinal mucous surface, etc., constituting a really vicarious menstruation. It would, therefore, seem that in these cases the hsematuria is altogether a conservative act, and not one, literally speaking, of morbid action. The explanation of these hemorrhages and loss of albuminous matter seems to be this—the quantity of food consumed in tropical climates is too great, and, con- sequently, congestions arise from the superabundance of blood, terminating in hem- orrhage in some one or other of the organs. I am indebted to my friend, Dr. Brown Sequard, for a knowledge of these facts, which have been observed by him in his native country. 6 82 CLINICAL LECTURES. the first place, the abstraction of I ij of blood from the arm at the period corresponding with the usual menstrual turn, and the like quantity in fifteen days afterward. Let this be continued as circumstances may require for several successive times. The system will thus be unloaded, an equalized circulation accomplished, and the determination to the schneiderian membrane broken up. I have very great confidence in this periodical bleeding, not only in vicarious, but in many other forms of chronic suppressed menstruation. In addition, it will be necessary to re- move the constipation, and to stimulate indirectly the uterine organs by appropriate carthartics. For this purpose, one or two of the following pills may be given every second or third night according to their effects: R Pil. Aloes c. myrrha 1 3 j Div. in pil........xij Should these not suffice, their action will be aided by two wine glasses of senna tea in the morning; styptic foot-baths, with cayenne pepper and mustard, and also the warm hip-bath, will be important ad- juvants. Enlarged Tonsils with Deafness, following Scarlet Fever, in a Boy, aged six Years.—W. M., aged six years, has much difficulty in swallowing; at night his breathing is oppressed, so much so, that the mother is alarmed for fear of suffocation. For the last few weeks, his hearing has become impaired, and he is now quite deaf. On being asked whether the child had been affected with scarlet fever, the mother replied that six months since he had been attacked, and at one time she despaired of his life. Before the attack of scarlet fever, his breathing and deglutition were natural, and his hearing unimpaired. I had, gen- tlemen, a particular object in making this inquiry of the mother, for the very difficulty under which this child labors, are among the ordinary sequelae of scarlet fever. One of the prominent features of this affec- tion is sore throat, often of an aggravated character. As a consequence, the tonsils suffer from the effects of chronic inflammation, they become enlarged, and deafness ensues from obstruction of the eustachian tube. You can not be too particular in your investigations as to the cause of disease—it is the beacon-light which guides you to successful treatment. Treatment.—I shall excise the tonsils; this is all that is necessary. The oppressed breathing and difficult respiration, together with the deaf ness, are the simple results of mechanical obstruction; as soon as the tonsils are removed, these effects will disappear. It may, however, re- quire some length of time for the hearing to be completely restored. I should mention to you that in certain severe attacks of scarlet fever, the hearing becomes permanently lost in consequence of destruction of the internal ear. LECTURE VI. Profuse Sanguineous Discharge from the Vagina, from Polypus of the Womb.—Re- moval of the Polypus.—The causes of Sanguineous Vaginal Discharges.—Pity- riasis Capitis in a little Girl, aged six Tears.—Phlegmasia Alba dolens in a married Woman, aged twenty-two Tears.—Involuntary and Constant Spasmodic Movements of the Limbs in an Infant, five Weeks old.—Vomiting in an Infant, aged five Months, immediately after taking the Breast.—Can a Nursing Woman become Pregnant before the reappearance of the Menses ?—Delivery with the Forceps after a Labor of ninety Hours, with safety to both Mother and Child.—Ergot, when to be employed in Child-birth.—Rupture of the Womb from the rash ad- ministration of Ergot—Death of both Mother and Child.—Defective Menstrua- tion in a Girl, aged twenty Tears.—What is Defective Menstruation ? Profuse Sanguineous Discharge from the Vagina, from Poly- pus of the Womb, in a married Woman, aged thirty-nine Years ; removal of the Polypus.—Mrs. B., aged thirty-nine years, the mother of two children, after being a widow for nine years, married twelve months since. Her health had been uniformly good, and her periods always regular until January last, when they became very profuse, accompanied with bearing-down pains. In consequence of these re- peated attacks of profuse loss, she has become extremely weak and blanched. The bearing down pain is always more severe at the time of the courses. She is nervous and greatly alarmed about herself. Here, gentlemen, is a case which requires all your attention. You will often be called upon when engaged in practice to treat patients laboring under profuse losses of blood from the vagina. A very common error under such circumstances—and one which I have repeatedly pointed out to you, is to regard the discharge of blood as the disease; whilst the entire attention is directed to remedies—the various astringents, for ex- ample—which are supposed to be efficient in restraining the loss. But it must not be forgotten that discharges of blood from the vagina, like those of mucus, pus, or water, are but results—they are fhe effects of certain diseases. Our first duty, therefore, in the case before us is to ascertain the nature of the profuse discharge of blood, and trace it to its true origin. In this way only can we hope to benefit our patient. When consulted in cases of this character, you should at once revolve in your mind the various causes of this kind of vaginal discharge—and 84 CLINICAL LECTURES. you will recollect they are as follow: 1st. Menorrhagia; 2d. Ulcera- tive carcinoma; 3d. Threatened miscarriage; 4th. The second stage of Cauliflower excrescence; 5th. Hydatids of the womb; 6th. Polypus of the womb, etc. There is nothing easier than to revert in memory to these facts, and they will enable you with a proper degree of care to make a just and satisfactory discrimination. When this patient stated her case, there were two circumstances, which caused me to suspect the possible existence of polypus of the womb, viz.: the discharge of blood, and the bearing down pains, which she remarked are always increased at the period of the menses. On making a vaginal examination, I detected a small moveable tumor projecting from the mouth of the uterus, and at once recognized it to be a polypus, which is the sole cause of her sufferings. Polypus of the womb is a pediculated tumor, the pedicle or stalk being attached to some portion of the internal surface of the organ. The volume of the polypus will vary from the size of a pea to that of a foetal head; it is confined to no particular age—it occurs in young girls, in married women of all ages, and in the advanced of life. Its presence is character- ized by profuse periodical bleeding, together with a discharge of mucus, accompanied with severe bearing-down pains simulating the throes of labor. In what way can we explain the discharge of blood, and the bearing down pains ? The sources of the hemorrhage are in the first place the mucous membrane covering the polypus, and secondly, the blood-vessels which exist in the tumor itself. The investing mucous membrane becomes much more congested at the approach of the men- ses, and hence the greater profusion of the discharge at this time. In- deed, it is an interesting fact, gentlemen, for you to record that one of the first circumstances, which creates alarm in the mind of the patient laboring under polypus of the womb is the unusual loss she sustains at the menstrual period. This increases with the return of the periods, and frequently, too, in the intervals of the " turns," there is more or less discharge of blood. The bearing down pains are the result of the irritation imparted to the uterus by the presence of the tumor. The point of interest, now, for you as well as this patient is, whether any thing can be done to relieve her of her sufferings. In regarding this case, and in order that it may present itself to you with its full interest, you must look beyond the walls of this lecture room. Soon, you will be vested with all the rights and privileges of the Doctorate; you will return to your homes; and, after receiving the congratulations of friends, you will commence the responsible and ardu- ous duties of your profession. The hypothesis is not so remote that it may not become a reality, that the very first case in which your counsel will be invoked may be one resembling in every feature the example before us. Suppose, for instance, a patient should consult you under the following circumstances: she informs you that for the last year she has POLTPUS OF THE WOMB. 85 suffered from profuse losses of blood from the vagina; she has con- sulted numerous physicians, and has had administered to her every variety of medicine; she has employed a' dozen different astringent injections, and all without relief. This constant drain on her systen has not failed to show its effects : her strength is gone—her face is blanched —her digestive powers almost destroyed—cold feet and hands—a circu- lation so feeble that her pulse can scarcely be felt—the slightest exer- cise producing palpitation, vertigo, syncope. In a word, she appears before you a perfect wreck, and to the ordinary observer, her case is without hope. Her measure of suffering is indeed full—she is sur- rounded by all the luxury that wealth can procure—but prostrated by disease, and now brought to the verge of the tomb, by a malady that has resisted all treatment, she would fervently pray for death, did not the strong and sacred ties of nature tell her that she has something be- sides herself to live for! She thinks of her husband and children—the former devoted and kind—the latter young and helpless; at an age too, when they are most dependent on a mother's love and care. These feelings touch her heart deeply, and she makes a last effort to regain her health, in the trust that she may be spared to her family. It is, therefore, gentlemen, under circumstances like these, when all earthly hope is cut off, and a lingering death in prospect, that you may be sum- moned to give your opinion. You investigate most carefully the whole history of the case. You direct your attention to the uterus—a vaginal examination is instituted—and you find projecting through the mouth of the womb a small tumor insensible to the touch, with its base downward, and its pedicle upward, attached to some portion of the in- ternal surface of the organ—it is a polypus. This is the disease—the flooding has been occasioned by it alone, and as long as the polypus is suffered to remain, so long precisely will the hemorrhage or drain be kept up, until finally the patient sinks from absolute exhaustion. You, therefore, proceed without delay to remove the polypus—the blood ceases to flow, the drain is closed—and by your science and skill the patient is not only rescued from impending danger, but she is restored to health, and the bosom of her family. She looks upon you as the kind friend, who with the sanction of Heaven has arrested her progress to the grave. On her heart are impressed feelings of abiding gratitude for the services rendered in the hour of need—and as long as that heart shall continue to beat, it will do so in grateful remembrance of one, who has been the humble instrument of prolonging the life of a cherished wife and mother, and dispensing happiness on those so dependent on her care. Such a victory would indeed be one of priceless value, and it is such conquests that are truly worthy the ambition of a scientific prac- titioner. Believe not, gentlemen, that I have presented you an exagger- ated picture; it is full of truth, and when you shall have become engaged in practice, you will have exhibited to your observation many of the 86 CLINICAL LECTURES. same character. If your minds be properly imbued with the principles of obstetric science, cases such as I have just described, should they be confided to your charge, will prove the foundation-stone of your fame and fortune. Causes.—Various opinions are entertained upon this subject; somG writers attributing these growths to sexual excitement, whilst a rcceni author, Dr. Lever, believes that they are more frequent in the unmarried. My own opinion is that they arise from disease of the mucous membrane, of the uterus, caused by abnormal menstruation, child-bearing, etc. Symptoms.—Frequent hemorrhage, with a discharge of mucus, bear- ing-down pains, irregularities in the menstrual function, irritation of the bladder, etc.; generally the polypus is insensible on pressure. Diagnosis.—Polypus of the womb may be confounded with inversion and prolapsion of the organ. The distinction, however, is simple; in polypus, the base of the tumor is downward—in inversion it is upward— in prolapsion, the apex of the tumor is downward, and the os tincse is felt by the finger. When the polypus is still within the cavity of the uterus, the diagnosis becomes embarrassing, but the enlargement of the organ, with the absence of symptoms indicating structural lesion, will tend to diminish this embarrassment. In such case, too, the introduction of the uterine sound, would indicate the existence or non-existence of the internal uterine growth. Prognosis.—When the tumor has descended into the vagina, you may state confidently that it can be removed, and the patient restored to health. Treatment.—The only remedy for polypus of the womb is its removal. This may be accomplished either by the knife, ligature, or torsion. When the polypus is small, as in the present instance, I prefer torsion with the finger, or what is frequently much easier, twisting it off with the ordinary male calculus forceps. If the tumor be still within the cavity of the uterus, it will be advisable to administer the tinct. of ergot, say I i. in a half wine-glass of cold water, two or three times a- day, with the hope of causing contraction, which will throw it into the vagina. As the polypus, however, in the case of this patient, projects into the vagina, there will be no difficulty in its removal; and as this poor woman is most anxious for relief, I shall proceed at once to its ex- traction. The only caution necessary, when the operation of torsion is resorted to, is to be certain that the stalk or pedicle of the polypus is alone grasped—or, in other words, that the uterus is not included within the instrument. It requires no very great skill to avoid this latter cir- cumstance, and nothing could justify a blunder on this point. [Here the patient was placed on the bed, and the Professor, taking the index finger of the left hand as a guide, introduced along the finger the calculus forceps, with which he seized the pedicle of the polypus ; this he twisted two or three times, and removed it apparently without the least difficulty, much to the satisfaction of the patient.] POLTPUS OF THE WOMB. 87 The patient was directed to have cold water injected into the vagina twice a day for two or three successive days; and to take one grain of quinine and two of rhubarb twice daily until her strength improved, to- gether with nutritious diet. You see, gentlemen, what a simple thing it is, under certain circumstances, to alleviate human suffering. From the very foundation of this Clinique to the present time, I have la- bored to inculcate upon your minds one leading principle in the treatment of disease, viz.: to trace effects to causes. It is the great and only certain element on which the medical practitioner can rely —it will prove to him a faithful guide, and make agreeable his many toilsome duties. To relieve this patient in the way I have done, affords me no little pleasure. It is true, I receive no fee—but her thanks so freely, and so sincerely given, are worth far more than all the dollars and cents she could lay before me. The poor are entitled to our benevolence. They, like the wealthy of this world, are subject to disease and suffering—and they, too, have their keen sensibilities. To allay these sensibilities, and smooth the pillow of the sufferer, la- boring under the double affliction of disease and poverty, is the duty of the Christian—it should, too, constitute the pleasure of the physician. The following case may not prove uninteresting to you : On the 12th of last May, I was requested to visit a married lady from Rockland county. She was forty-six years of age, the mother of nine children, the youngest two years old. She had for the previous twelve months experienced an uneasy sensation in the region of the womb; a torturing, pressing-down feeling as she expressed it. These sensations came on at intervals, and were always accompanied by more or less profuse dis- charges of blood. Her difficulties continued to increase, and the loss of blood at times was so profuse, that her health begun seriously to give way. The disease not yielding to the various remedies employed, and her system becoming drained by the hemorrhage, she was finally told she must die, as her malady was cancer of the womb. It was under these circumstances that my opinion was requested. I found her almost exsanguinated; utterly incapable of taking exer- cise ; palpitation of the heart, and hurried respiration on the slightest exertion; oedema of her lower extremities, and the coldness of death on her hands and feet; her general appearance gave strong indications of approaching dissolution. After receiving from her sister a full and graphic history of the case, I made an examination with the view of as- certaining the actual condition of the womb. The mouth of this organ was considerably dilated, and there protruded through it a tumor about the size of a hen's egg; the tumor was insensible to pain on touching it; its largest portion, or base was downward, and by carefully insinuating my finger within the uterus, I found the tumor began to narrow, and it was evidently pediculated. My opinion was at once given that there was no cancer, and that all her sufferings arose from the presence of a polypoid growth. The following day I applied a ligature to th* pedicle: 88 CLINICAL LECTURES. in thirty-six hours the pedicle sloughed, and the tumor was removed. The bearing down sensation ceased, and so did the bleeding, for the reason that the tumor which had caused both these results, no longer existed. This lady, on the 20th of July, left the city much improved in health, and agreeably to my suggestion, spent several weeks at Saratoga Springs. She is now in the enjoyment of excellent health, and is a happy woman. Pityriasis Capitis in a little Girl, aged six Years.—Catherine C, aged six years, has been troubled, for some months, with exfoliations of the cuticle of the scalp. This, gentlemen, is a case of pityriasis, called by some writers, I think improperly, porrigo, and has been variously divided by authors; hence you will find it described under the following heads: Pityriasis rubra, pityriasis nigra, pityriasis versicolor, and pity- riasis capitis. It is important that you should know the object of these divisions. The three former varieties receive their name from the fact that they are accompanied by change of color in the part affected, sometimes red, sometimes black, etc. These varieties attack different parts of the body. Pityriasis capitis, however, which you will more commonly meet with in practice, has one characteristic not possessed by the other varieties—it is not accompanied by change of color. It is a mild affection, and is of frequent occurrence; it is confined to no particular age—the old and young are alike subject to it—and you will often observe the pityriasis capitis, an instance of which you have pre- sented to you in this child, in the new-born infant. It is known in pop- ular language as dandriff of the scalp. Causes.—Want of cleanliness, impaired digestion, and a languid cutan- eous circulation, as also excessive irritation of the scalp, may be enum- erated among the causes of this affection. When the dandriff on the head is neglected, it is usually accompanied by much irritation, together with an acrid discharge, and alopecia, or falling of the hair. In this case, scabs form and fall off, constituting pityriasis scabida. This disease of the scalp is, I am satisfied, often the result of carelessness on the part of the nurse in brushing the hair of the new-born infant with a hard brush, producing irritation of the scalp ; and I think I have known the same effects to arise from the use of a too stimulating soap. Symptoms.—The first indication of this disease is a slight scurf observed on the scalp, which soon exfoliates, and the exfoliations are succeeded in a very short time, by other scurfs or scales. You perceive now how readily I can remove these little masses from the scalp, but they will soon be replaced by others. Usually there is more or less local irrita- tion, causing the child to scratch the scalp, and this aggravates the disease. Occasionally, pityriasis capitis will terminate spontaneously; and it is also, often quite rebellious to remedies. Diagnosis.—There can be no difficulty in distinguishing this affection PHLEGMASIA ALBA DOLENS. 89 from other exanthematous diseases—besides the previous history of the case, there is one feature peculiar t6 pityriasis, viz., the constant repro- duction of the epidermoid tissue. Prognosis.—This is an affection, which, though often protracted, pre- sents nothing of a dangerous character. Treatment.—All irritation of the scalp must be avoided—such as combing or brushing the hair. I have rarely found any difficulty in managing this affection, if taken in its incipiency, in the following man- ner : The bowels are to be kept moderately free by occasional doses of magnesia; and in giving this medicine to young infants, I usually direct the mother or nurse to put into a wine-glass one-fourth of a tea-spoon of magnesia, the wine-glass to be filled with fresh milk, as much white sugar as may be necessary to make it palatable; after being thoroughly mixed, the whole to be strained, and a tea-spoonful of the mixture to be given two or three times a day. This will be found a useful mode of administering magnesia to infants in a variety of gastric derangements, more particularly where there is a superabundance of acid in the primce vice. The portion of the head involved in the exfoliation should be lubricated at night with fresh olive oil, and in the morning freely washed with the following lotion; and this should be continued for one or two weeks as may be indicated : R Borat. soda?,.......|j Aquae purae,.......Oj Ft. sol. This treatment will generally be sufficient for the removal of pityriasis capitis, as it occurs in the new-born infant. But occasionally, when the inflammation is more or less severe, emollient applications will be use- ful. A remedy which I have found serviceable in these cases is the use of tepid water squeezed from a sponge: this may be employed sev- eral times during the day. It will mitigate the sense of itching, which sometimes is so annoying in this affection. A slippery-elm poultice will also prove beneficial. Alkaline lotions may be employed with good effect, none better than the sub-carbonate of potash and water. In cases of alopecia, or falling of the hair, the following ointment has been highly recommended: $ Sub. Mur. Hydrarg.......3j Adipis........§j Ft ung. Phlegmasia Alba dolens in a married Woman, aged twenty-two Years, the Mother of one Child, aged two Months.—Mrs. R., mar- ried, aged twenty-two years, the mother of one child, aged two months, seeks advice for an oedematous enlargement of her left limb. " How long, madam, have you suffered from swelling of that limb ?" " I have had trouble with it, sir, since the fourth day after the birth of my infant." " You do not mean to say that the limb on the fourth day after your 90 CLINICAL LECTURES. confinement was as large as it is now ?" " Oh! no, sir; but the trouble commenced then." " What kind of trouble do you speak of, my good woman ]" " I had pain, sir, in my groin, and it extended down my limb." " When did your limb begin to enlarge V1 " A few days after I felt the pain, sir." " Was it white and shining as it now is V " I did not notice, sir, particularly." " Do you have much difficulty in walk- ing?" "Yes, sir; I walk with great difficulty." "Had you a physi- cian to attend you in your confinement ?" " Yes, sir." " What did he do for the pain in your groin ?" " He applied a dozen leeches, sir, and gave me medicine." " You ought to be very grateful to your physician, my good woman; he did what was right for you." It was important, gentlemen, before expressing an opinion as to the character of this swelling, to ascertain some particulars touching its origin. The questions which I have addressed to this patient are suffi- cient, together with the appearance of the limb at the present time, to establish the nature of the disease. She is affected with what is some- times called the " swelled leg of the lying-in woman," and by the older writers the " milk leg." This latter term was employed from the sup- position, that the tumefaction was occasioned by a deposit of milk in the affected limb. The disease, with this view of its pathology, has received various designations. By the French, it was formerly called " la ma- ladie laiteuse." By others, oedema lacteum, metastasis lactis, etc. But now that its true nature, founded on a sound pathology, is better understood, these names have been abandoned. Drs. Robert Lee, Vel- peau, and others, have shown very conclusively that this affection con- sists essentially in inflammation of the crural and iliac veins. It can not, I think, be said that phlegmasia alba dolens is a frequent disease, and yet it is one of importance for you to understand. It may present itself under four different conditions: 1st, and most frequently, in the partu- rient woman; 2d. During pregnancy; 3d. In the unmarried female; 4th. In the male sex. Well authenticated examples of the latter have been recorded. You can readily understand, with our present knowledge of its pathology, why an cedematous condition of the limb should be the accompaniment of this disease; for it is well known that oedema is often- times the result of some mechanical obstruction in the venous circula- tion, and one of the very first effects of the disease in question is the arrest of the circulation in the femoral vein, which not only gives rise to tumefaction of the limb, but is at the same time the cause of acute suf- fering. Another familiar example of oedema ensuing from obstructed venous circulation is furnished by pregnancy; here, the enlarged womb, pressing on the veins, interrupts the free passage of blood, and hence the enlarged limbs so frequently the attendants upon gestation. Causes.—In parturient women, this disease is to be referred to the various influences brought to bear in connection with the process of child-birth; the unskillful use of instruments, too early getting up after SPASMODIC MOVEMENTS OF THE LIMBS. 91 delivery, cold, etc., may all be classed among the causes of this affection. Symptoms.—Soon after delivery, from four to ten days, the patient complains of more or less uneasiness in the groin, extending along the limb ; there is tenderness on pressure; the pain is sometimes preceded by one or more chills; there is tumefaction of the limb, presenting a white and shining aspect. The patient walks with difficulty in conse- quence of the size of the limb. When the inflammatory stage is severe, it will occasionally terminate in suppuration, giving rise to a serious complication, and sometimes terminating in death. Diagnosis.—The pain, and manner of the attack, will enable the prac- titioner to distinguish this disease from ordinary oedema, anasarca, etc. Prognosis.—This affection is rarely fatal, but often proves tedious, espe- cially in the chronic stage; it assumes, however, a more serious aspect when, as will sometimes be the case, it is complicated with purulent se- cretions, erysipelas, or gangrene. Treatment.—In the acute stage, leeches, purgatives, diet, and rest. In the chronic, diuretics will be particularly indicated, together with stimu- lating friction, and bandaging the limbs from the toe upward. Involuntary and constant Spasmodic Movements of the Limbs in an Infant, five Weeks old.—Joseph L., aged five weeks, has been affected from its birth with constant movements of the head and limbs. The mother says, when eight months pregnant, the ceiling of her bed- room fell down, a portion of which struck her. She became much frightened, felt singular sensations passing along her spine, was attacked with nausea and vomiting, when her labor commenced. After severe suffer- ing of twenty-four hours' duration, the child was born, apparently lifeless. It was, however, resuscitated, and from its birth to the present time it has been more or less constantly in motion. It has never taken the breast, not being able to grasp the nipple. Here, gentlemen, is an anomalous nervous affection, and one of singular interest presenting sev- eral points worthy of notice. In the first place, we may legitimately con- clude that the nervous system of this infant became affected while in utero in consequence of the fright experienced by the mother. Secondly, the sensations felt by the mother along the spine, and the chill which im- mediately ensued, afford ground to suspect that it was at that instant, and through that medium, that the infant became affected. Thirdly, when the spinal cord^becomes the seat of irritation in the infant, con- vulsions ordinarily follow; in the adult, on the contrary, a mere chill is developed, owing to the influence exercised by the brain over the spinal system. At birth, the functions of the brain are of but little account, and observation shows that convulsions, during the first years of infancy, are extremely frequent. In proportion, however, as the brain increases in size and function, the tendency to convulsions is diminished; so that, 92 CLINICAL LECTURES. whilst during the first year they occasion more than seventy per cent, of the deaths from affections of the nervous system, over fifteen years of age the mortality is brought down to less than one per cent. This is a remarkable and interesting fact. It is difficult to give the nervous disturbance with which this child is affected a name. In some respects it resembles chorea, and in others the resemblance is defective ; besides, chorea is not a disease incident to the new-born infant, nor is it congenital. I have recently met with two cases of convulsions in infants imme- diately after birth, in both of which instances the mothers were af- fected with eclampsia. One was in a patient of Dr. Stimpson of this city ; in consequence of protracted convulsions, it became necessary to resort to the forceps which, at the request of Dr. Stimpson, I applied, and as soon as the child was brought into the world, it became con- vulsed. The other was a patient of Dr. Murphy—she, too, had been attacked with eclampsia, I again resorted to the forceps, and the infant, when delivered was similarly attacked. What, it may be asked, was the cause of the convulsive movement in these two infants ? It was, in my opinion, traceable to the mother, and transmitted through the me- dulla spinalis. Treatment.—What shall we do for this little patient ? Under the circumstances, I know of no better course to pursue than the following: The infant should be placed daily in a stimulating warm bath; three drops of the tincture of hyoscyamus may be given once or twice a day in a tea-spoonful of sweetened water ; the bowels to be kept regular by occasional doses of manna dissolved in water, and sweetened with brown sugar. The food to consist of one-third cow's milk and two-thirds water, with the addition of some sugar. Vomiting in an Infant, aged five Months, immediately after tak- ing the Breast. Can a Nursing-Woman become Pregnant before the re-appearance of the Menses?—Margaret McD., married, aged twenty-two years, the mother of one child, aged five months, brings her little infant to the Clinique for advice in consequence of its having vomited for the last ten days immediately after taking the breast. "Do you nurse that child altogether, my good woman ?" " Yes, sir." " Do you not feed it sometimes ?" " No, sir, it has never taken any thing but breast-milk since its birth." " What has been the state of the child's health up to ten days ago, when you say it began to vomit ?" " It was perfectly healthy, sir." " Were its bowels regular ?" " Yes, sir; it was in every particular a healthy child." " What was the state of your own health ?" " It was good, sir, until about three weeks ago." " What took place then, my good woman ?" " Why, sir, I was sick at my stomach." " Did you vomit ?" " Yes, sir." " Tell me, if you please, whether you have any idea what made you sick at your stomach; did you eat any thing to disagree with you ?" " No, indeed, sir, I did not; VOMITING IN AN INFANT. 93 and I do not know what caused me to be sick." " Has the sickness of stomach continued on you until this time ?" " Yes, sir; I vomit every day." " At what time of the day are you sick ?" " As soon as I take my breakfast, sir, I have to throw it off." "How do you feel then?" " I am quite well, sir; generally until the next morning—but sometimes I throw my dinner off too." " As soon as you have ejected the con- tents of your stomach, you feel quite well, do you ?" " Yes, sir; and that is what makes me think it is nothing very serious that is the matter with me." " Have you any trouble with your water, my good woman ?" " Yes, sir ; I have to pass it quite frequently." " How long have you been troubled in this way ?" " For the last two weeks, sir." " Have you had your ' monthly turns' since the birth of your child ?" " No, sir." The information, gentlemen, elicited by the questions addressed to this patient confirms me in my original suspicion as to the cause of the vomiting in this little infant. I have very little doubt that the mother is pregnant—and her milk has become so modified as to be no longer suited to the infant, and hence it is ejected almost as soon as it is taken into the stomach. Gestation, you must remember, exercises usually a deteriorating influence on the milk, and one of the first evidences of the deterioration is the derangement produced in the nursing infant. My reasons for believing this woman pregnant are these: 1. She has herself been affected with nausea and vomiting—and the vomiting is of a peculiar nature—it occurs immediately after eating; when the con- tents of the stomach have been ejected she is quite well. This is, as a general rule, characteristic of the vomiting of pregnancy; 2. The fre- quent desire to pass water, which is a more or less constant accompani- ment of early pregnancy. For the first six or eight weeks after gesta- tion, the uterus does not ascend, but its tendency is to descend into the pelvic excavation; the bladder is connected, through the medium of cellular tissue, to the inferior third of the auterior surface of the uterus; consequently, the descent of the latter organ must necessarily, to a greater or less extent, displace the bladder; add to this the irritation produced on the neck of the bladder by the increasing volume of the impregnated uterus, and you can have no difficulty in explaining why it is that a frequent desire to pass water is one of the ordinary attend- ants upon early gestation. This symptom, too, characterizes the latter period of pregnancy—at the close of the eighth month, a few days be- fore labor commences, the uterus descends into the pelvic cavity, pre- sisely as it did at the commencement of this process, and hence from irritation produced on the bladder there is frequent micturition. There is a current opinion that nursing women cannot become impregnated until after the reappearance of the menses ; this is an error. The general rule, it is true, is that during lactation women are not liable to gestation, and more especially until after the menstrual evacua- 94 CLINICAL LECTURES. tion has returned; but the exceptions are by no means few, and you will observe in practice what I am confident the future will reveal to be the case in the patient before us, viz., pregnancy during lactation without any recurrence of the catamenia. On the presumption that I am cor- rect in my diagnosis, there can be no difficulty in prescribing for this infant. The only thing to be done is to remove the offending cause, which is the mother's milk—the infant, therefore, must either be given to another nurse, or be weaned. If the latter, it should be fed on diluted cow's milk and sugar. It is important, in weaning the child, that the mother should be instructed as to the management of her breasts, for if they remain distended with milk, inflammation and mam- mary abscess will be the result. When the breasts become painful from engorgement, they should be drawn ; frictions with the hand and camphorated oil will also be useful; the patient should, as much as pos- sible, refrain from fluids for some days—the diet should consist of pota- toes, boiled rice, vegetables, etc. And, in these cases, a point never to be omitted, is to keep up free serous discharges from the bowels; for this purpose, let a wine-glass of the following saline mixture be taken as cir- cumstances may require: R Sulphat. Magnesia? ) Sup. Tart. Potassae ) ^ Emet. Tart........gr. J Aquae purse.......Oj Ft. sol. Delivery with Forceps after a Labor of ninety Hours, with SAFETY TO BOTH MOTHER AND CHILD—THE LEFT Arm PASSING DOWN WITH the Head of the Child ; Ergot, when to be Employed.—Mrs. W., aged thirty-one years, was taken in labor in May last, with her first child; Dr. Finnel was summoned to attend her. The labor progressed slowly, notwithstanding strong uterine contractions, and the doctor watched her faithfully for a period of seventy hours. He then requested Dr. Woodcock to see the patient in consultation. At this time, her strength was giving way, and some uneasiness felt as to the result of the case. These gentlemen, however, as the head had not descended into the pelvic excavation, determined to do nothing more than attempt to sustain the strength of the patient, and secure her sleep; for the lat- ter purpose, they administered ten gr. of Dover's powder, which had a happy effect, producing a comfortable repose of four hours. On the following morning, the head having descended slightly, they judged it expedient to apply the forceps; the instrument was applied, but not locked, they finding it impossible to approximate the handles. Under these circumstances, I was requested to meet them in consultation. On examination, I found the left arm of the child had descended with the head, and lay immediately on the parietal bone, being thus included within the blades of the forceps. This was rather a formidable difficulty, ERGOT, WHEN TO BE EMPLOTED IN CHILD-BIRTH. 95 and at once explained why the instrument did not lock. With the con- currence of the gentlemen, I withdrew the instrument, and re-introduced it, adopting the precaution of sliding the blade between the head and the arm which, with some little difficulty, was accomplished. The head being high up (having just begun to descend below the superior strait) I found it necessary to employ extraordinary force, to accomplish the delivery which, however, resulted in the birth of a living child, without the slightest injury to the mother. The mother and child whose lives were hazarded in this protracted accouchement are now before you— and the fine health of the infant, together with the grateful smiles of the parent are our best reward. This is certainly a striking example of conservative midwifery—with less judgment than was exercised by my friends, Drs. Finnel and Woodcock, the lives of both mother and child might have been sacrificed. The practitioner who measures the danger of child-birth by its dura- tion, is extremely apt to become officious, and such practitioner, under the protracted duration of this labor, would probably have resorted to cutting instruments, for the purpose of bringing the child into the world piece-meal, and most likely entailing upon the mother, serious, if not fatal injuries. Conservative midwifery, gentlemen, should be your aim. Nature is full of wisdom, and she is too, oftentimes, when human confidence is at a stand, full of resources. You will bear witness that I am no timid practitioner; when there is necessity for a contest with disease, I love the fight, and am ever ready for the issue. But prudence and judgment must have a place in our counsels, and to their voice the practitioner should always lend an attentive ear. I am confident that in the case before us, an earlier attempt to deliver with instruments would not only have proved abortive, but would most probably have resulted in injury to the mother, if not fatal to the child. Many, no doubt, would, from the length of this labor, have been disposed to administer ergot—but why ? Certainly there was no indication for the use of this drug—there was no inertia of the uterus; on the contrary, the contrac- tions were marked by much force; and again, the administration of ergot, under the circumstances of the presentation, even admitting there was inactivity of the uterus, would, in my judgment, have been bad practice. I think there can be no doubt that the duration of the labor was owing to the presentation of the arm with the head, and if, in this condition of things, additional force had been imparted to the contractile effort of the uterus, through the operation of ergot, the serious hazard of rupture of the organ, would have been incurred. Whilst on this subject, allow me to say a few words as to the in- dications for the use of ergot in parturition. In the first place, you must remember that when this remedy is employed in child-birth, it is for the purpose of reviving or increasing the contractions of the uterus; but at the same time it must not be forgotten that even in in- 96 CLINICAL LECTURES. ertia of the womb, it is not always prudent to have recourse to this agent, and for its justifiable use, the following conditions must be present: 1 st. There must be no deformity either of the pelvis or soft parts; 2d. The mouth of the womb must either be dilated, or soft and dilateable; 3d. One of the obstetric extremities of the foetus must present, and by obstetric extremities we mean either the head, breech, knees, or feet; 4th. The woman must have sufficient strength to enable her to sustain the parturient effort; 5th. There must be inertia of the uterus. The abuse of ergot has given rise to the most fearful results ; both mother and child have been frequently sacrificed by the improper use of this medicine. I have in my museum two ruptured wombs taken from women to whom ergot had been given, and on whom attempts at version had been made; in one of these, the shoulder of the child presented! This latter case I was called to about ten years since; the unfortunate woman when I saw her, was in a dying state, but undelivered. About four hours before I visited her, she had been attacked with vomiting; she was nearly pulseless, and quite speechless, with pallor of countenance, cold extremities, and a clammy perspiration. The patient had been in labor about twenty hours, when the attending physician informed me he gave two doses of ergot; in about one hour after the administration of the drug, the above symptoms manifested themselves. In examining the case, I pronounced it to be one of ruptured uterus, and stated at the time that it would be madness to attempt to deliver, especially as there was satisfactory evidence that the child was not living. The physician in attendance concurred in neither of these opinions, but insisted upon attempting to deliver the foetus by the operation of turning. To this I could not consent, and left the house determined not to be a witness to what I conceived to be unjustifiable practice. The poor woman sunk in the course of half an hour, undelivered. A post-mortem examina- tion was requested, but refused. At 11 o'clock the same evening, the husband came to my house and said he was willing an examination should be made. My friend, Dr. Busteed, accompanied me, and the autopsy re- vealed the truth of the opinion previously given—the womb was lacer- ated to the extent of six inches in the left lateral wall, and the child had escaped into the abdomen. This was one of the melancholy results of the indiscreet use of ergot, followed by attempts at forced version. Defective Menstruation in a Girl, aged twenty Years ; What is Defective Menstruation ?—Maria G., unmarried, aged twenty years, has a flushed countenance, full pulse, torpid bowels, and more or less constant headache. Her health was good until within the last six months. Since that period her menstrual evacuation has been regular as to time, but defective as to quantity. She says her " courses " are not upon her more than one day. The case before you, gentlemen, is one which calls for the interposition of the practitioner. It is very evident that this girl DEFECTIVE MENSTRUATION. 97 is in a precarious situation; and if the true cause of her troubles be not removed, we may very naturally look for serious results. The state- ment which she has just made is sufficient to enable you at once to ascer- tain the source of her sufferings. The circulation in her system is dis- turbed—it is unequal—there is more blood than nature can dispose of; the flushed countenance, the bounding pulse, the headache, are the effects of this plethora, whilst the effects themselves are increased by the torpid condition of the bowels. You are, however, to carry your observation beyond these results, if you wish to remove them. It, therefore, be- comes you to note every circumstance in the case of this girl, in order that you may account satisfactorily for the symptoms of which she com- plains, and for which she now seeks advice. There is not, I am sure, one of you who does not at a glance perceive the real cause of her de- ranged health ; it is the condition of the menstrual function. This func- tion, so material to the preservation of harmony in the system, is not natural, it has become deranged—the quantity of menstrual fluid ordin- arily thrown off each month is less than usual, and the consequence is undue fullness of the economy. There is more blood than nature re quires; she is encroached upon, and disturbed action is therefore the consequence. To this form of abnormal menstruation I apply the term defective, and I think it a good term, for it expresses significantly enough the true condition of the catamenial function. It is defective in quantity —it is simply a case in which the monthly loss is less than nature re- quires, in order that harmony of action may pervade the system. The indication—if the reasoning be correct—is a simple one, viz., the restora- tion of the menstrual function to its natural standard; and for this pur- pose I shall recommend the following Treatment.—This girl should lose from the arm § ij of blood every two weeks, commencing a day or two before the menstrual period. In this way you will relieve the system from the surplus blood, for you substitute, for the time being, an artificial menstruation for the natural catamenial discharge. She should take to-night the following powder: R Sub. Mur. Hydrarg......gr. x Pulv. Jalapaj ......gr. xv Pulv. Ipecac.......• gr. i M. Followed in the morning by §j of Epsom salts in |vj of water. In order afterward to ensure a soluble state of the bowels, a wine- glass of the following saline mixture may be taken early in the morning, as circumstances may indicate : R Sulphat. Magnesia? } . . . . aa § i Sup. Tart. Potassse ) Aquas distillat....... VJ Ft. sol. The diet to be strictly vegetable. LECTURE VII. Introductory Remarks.—Critical Period of Female Life.—Final Cessation of the Men* strual Function in a widow Woman, aged forty-nine Tears.—Sympathetic Cough from Intestinal Worms in a little Girl, aged seven Years.—Pulse of Disease, and Pulse of Momentary Excitement.—Induration of the Neck of the Womb in a mar- ried Woman, aged twenty-nine Tears.—Prolapsus of the Womb, occasioned by jumping from a Carriage, in a young unmarried Woman, aged nineteen Tears.— Menorrhagia during Lactation in a married Woman, aged twenty-eight Tears.— Palpitation of the Heart in a Girl, thirteen Tears of age.—Palpitation of the Heart in a young Lady, aged eighteen Tears, produced by Temporary Disappointed Love, and cured by Matrimony.—Ophthalmia Neonatorum in an Infant, four Weeks old.— Chorea in a Girl, aged ten Tears, from Intestinal Irritation Gentlemen :—When you shall have become engaged in the practice of your profession, you will discover that the diseases of women and children will necessarily occupy much of your attention; your counsel and aid will frequently be demanded, and the happiness, and even the lives of those who thus give you their confidence, may rest entirely on your judgment and skill. Sacred, therefore, will be the responsibilities, which are so soon to devolve upon you ; and no man of conscience can contemplate them without having his mind filled with doubt and appre- hension, and firmly resolving to consecrate his best energies to the at- tainment of knowledge, which will enable him promptly and efficiently to meet those trying emergencies of professional life. Those of you whose taste may lead to a special study of the diseases peculiar to females, will discover that they are numerous, and almost of endless variety. They not only produce great physical distress, but often bring sorrow to the domestic hearth. Woman, at every period of her existence, is liable to disease and suffering; and it would, perhaps, appear to the careless observer, that God, for some wise yet mysterious purpose, had imposed on her penalties and afflictions far heavier than those which our sex is called upon to bear. Such may be the belief engendered in the vulgar mind after contemplating the constant and imminent perils by which the female is more or less surrounded during the various eras of life. But the philosophic eye, glancing as it does at the admirable laws on which all health is based, sees at once that it is the violation of these laws, more than any other circumstance, which produces such disastrous effects INTRODUCTORT REMARKS. 99 on the female frame. The refinements of civilization, and the consequent departure from those salutary influences so essential to that harmony of action, without which a healthy condition of the system can not be main- tained, are making fearful inroads on the females of the present day; so that, whilst on the one hand, the scholar is gladdened by the triumphs of civilization, the philanthropist, on the other, can not but lament the evils which necessarily follow in its train. It was the pride of the ancients to impart to their children robust constitutions and enduring health; and could a mother of those sensible times again visit earth, look upon the present condition of society, and witness its effects on the women of the present generation, she would, indeed, think that human nature had nearly run its course. She would search in vain, in our gay cities, for those who would remind her of her own ruddy and vigorous daughters; and from the fullness of her heart she would drop a tear over poor degenerate humanity. If the diseases incident to women be more frequent at the present time than formerly —and the fact no one will deny—the frequency is to be attributed to changes in modes of life and education, and to the increase of nervous excitement, the immediate effect of these changes. Whilst I would not desire to see the females of the present day subjected to the severe training imposed upon the young girls among the ancient Greeks, yet I would suggest that a useful lesson might be learned from reference to the discipline then exercised. History informs us that the Lacedaemonian father required of his daughter to support the weight of arms, and en- counter the labors of war, until the time of her marriage; and Hip- pocrates observes that the girls of Scythia were not permitted to marry until they had killed three men! In those days, it is asserted that hysteria and other nervous derangements were not of frequent occur- rence ! There is, however, even in our times, a remarkable difference in the aptitude of females to disease, and this arises from the differences of habit, education, etc. Compare, for example, if you desire fully to ap- preciate the influence of habit, education, and mode of life, on the health of the female, the buxom lass of the country with the tender and frail belle of this metropolis. And in order to obtain the just benefit of the comparison, let it be instituted at the period of puberty, a most trying and critical period—so critical, indeed, that it is often the index of future health, or of premature and painful decline. The function of menstrua- tion, which exercises such a controlling influence over the economy, ap- pears, generally speaking, in the former case with marked regularity, and in entire accordance with the appointments of nature; whilst, in the latter, in consequence of influences which have subjected the nervous system to continued excitement, thus prematurely developing the vital forces, and, as it were, forcing nature, menstruation is characterized by evident aberrations, and more or less derangement in the various func- 100 CLINICAL LECTURES. tions of the body. This departure from the exactions of nature is too frequently followed by the penalty of severe suffering and disease. Tlie young and thoughtless girl who, in her wayward career, so far contra- venes the laws of the system as to interfere with the menstrual function, imposes on herself a life of sorrow, if not of irremediable ill-health. Between this function and the thoracic viscera, as also other portions of the economy—as you have and will see exemplified in numerous cases in this Clinique—there is a close alliance, if, indeed, there be not a mutual dependence, which, unhappily, too often escapes the observation of the practitioner. Palpitation of the heart, asthma, haemoptysis, are not uncommon con- sequences of functional disturbance of the uterine organs; and, instead of being regarded as the effects of this form of derangement, should they be treated without any reference to their legitimate cause, serious, if not fatal results will oftentimes ensue. Look, too, at the condition of the nervous system in cases either of suppression or retention of the menses: it is thrown frequently into extraordinary excitement, producing convul- sion, hysteria, catalepsy, epilepsy, chorea, and even mania. Do not these facts declare in silent, yet eloquent language, the complete subjec- tion in which the uterine organs hold the general system, and at the same time point out to the physician the absolute necessity—when nature is incompetent to act for herself—of preserving, by judicious interference, the integrity of function appertaining to these most important organs? The truth, gentlemen, of this principle will be frequently elucidated by the various cases brought before you here. Woman, from her infancy to old age, is an object of constant interest; and it is not strange that a being so tender, and yet so full of endear- ments, should have called forth the admiration of the philosopher, and the fervid praises of the poet. Her history is but the narrative of good deeds. In health, she is our pride; in disease, our solace; and, in the faithful discharge of her duties to society, she is the idol of all hearts. Like a ministering angel, she soothes us in affliction; and, under the de- pressing influences of adversity, she inspires hope, and incites to renewed effort. Who has not felt the cheering influence of her smiles, and the encouragements of her eloquence in the dark hour of despondency ! Abandoned by friends, and left to the cold charities of a selfish and heartless world, the husband of her bosom then knows how to appreciate the depths of her love, and the sincerity of her vows. " There, drink my tears while yet they fall, Would that my bosom's blood were balm, And, well thou knowest, I'd shed it all To give thy brow one minute's calm. Nay, turn not from me that dear face— Am I not thine—thy own loved bride— The one, the chosen one, whose place, In life or doath, is by thy side ?" CRITICAL PERIOD OF FEMALE LIFE. 101 As wife, mother, sister—in a word, in every situation of life, virtuous woman is the kind and fast friend of man. Is it, therefore, not due to this self-sacrificing being, that we, who know so well how to value her excellence, should labor assiduously to diminish the sufferings, and as- suage the sorrows incident to her sex ? The duty of instructing you how to assuage these sorrows, and rescue her from the perils by which she is surrounded, devolves on me; and I need not say that I will endeavor most faithfully to perform this office. Critical Period of Female Life—Final Cessation of the Men- strual Function in a Widow, aged forty-nine Years.—Mrs. B., widow, aged forty-nine years, complains of vertigo, a feeling of suffoca- tion, and occasional severe palpitation of the heart; the bowels are con- stipated ; the pulse is full, denoting great vascular repletion. The ap- petite, however, is good, and she indulges it. She says she has noticed for the last six or seven months something peculiar about her vision, and when her eyes are closed she is much annoyed with a sense of sparks flying before her; she also complains of an unsteadiness in her gait when she walks, and a numbness in her lower limbs. Her menses have ceased for the last ten months. In this case, gentlemen, there are symptoms which indicate mischief; and they announce the palpable fact that there is disturbance about the brain, which can not be overlooked without sub- jecting this woman to serious peril. What is the true nature of this dis- turbance ? This is the question we are now to examine, for all rational treatment must depend on its proper elucidation. There are two periods in the life of the female which are in an eminent degree characterized by anxiety and danger—and these periods are directly connected with the menstrual function. The one is the period of puberty, when nature is struggling to establish for the first time in the system this function, which declares the girl no longer a child, but fitted in part to perform her office in the interesting yet mysterious work of reproduction. The other is the period—the climacteric of female existence—when the function no longer exists, and the reproductive faculty has exhausted itself. These two pe- riods have been not inaptly called the spring and winter of woman's life. There is no fixed rule as to the precise age at which the menstrual function finally terminates; some women have the " turn of life" as early as thirty-five, while others exceed the period of fifty years. There is, how- ever, one general principle, which seems to regulate the disappearance of this function, viz., when it commences early, it terminates early ; for example, in women living in the tropics in whom puberty begins at a very early age the menses terminate at a proportionately early period. It is not at all unusual, even in women whose menstrual function has been previously characterized by regularity, to observe as the period of the final cessation approaches varied deviations; sometimes, for example, the catamenia will become extremely profuse, at other times it will be 102 CLINICAL LECTURES. diminished in quantity ; again, it will be replaced by a leucorrhceal dis- charge, etc. It is not unusual, too, in these cases for the catamenia to be- come suspended for several months, and again reappear. These irregu- larities are important to remember in connection with the subject now before us. The time of the final cessation has with good reason been called the critical age of woman; and this very term indicates significantly enough that its advent is accompanied with more or less peril. There is a striking contrast in the physiological condition of the menstruating female, and the one in whom this important function has ceased. In the former, except during the period of pregnancy and lactation, there is a monthly discharge of blood from the system; in the latter, no such dis- charge occurs. It is to this very circumstance, the importance of which unfortunately is too often not sufficiently appreciated, that we are to as- cribe the serious derangements of health occasionally met with at this climacteric of the female. It frequently happens that local disease, either of the womb or breast, for the generation of which there may be a strong predisposition, will be held in check for years, and its development ob- served for the first time when the menstrual function ceases finally in the system. How often, for example, is the practitioner consulted by a lady from forty to fifty years of age, complaining of severe pain in the region of the womb, or having a lump in her breast; and when the case is ex- amined with care, how often, too, does it become the duty of that prac- tioner to avow the melancholy fact, that the uneasiness in the womb, or the lump in the breast, is but the development of that most loathsome and fearful malady—cancer! If it can be shown that the final cessation of the menses is frequently the starting point for the development of this and other maladies in the economy of the female, the intelligent student will not be content with the abstract knowledge of this fact, which is but the result of statistical observation, but he will at once endeavor to con- nect the fact with its antecedent. You are not, gentlemen, to be satisfied with results; this would be constituting the human mind a mere machine, a thing to receive impress- ions without knowing either their value or the source from which they are derived. Man is a reasoning being—his intellect was not given him without a motive—legitimate deduction should be his constant aim, and no amount of labor should deter him from an honest search after truth. Let him look to causes, and, finding them, he will have discovered a solid basis for opinion. The real cause, then, for the danger to be apprehended by the female at the time of the final cessation is this: during the cata- menial period, the womb undergoes a monthly disgorgement; this very disgorgement not only produces a salutary effect upon the uterus itself and more especially upon any malady to which it may have been predis- posed, but it also serves the general system, by equalizing the circula- tion, and preventing local congestions. This drain, therefore, being sus FINAL CESSATION OF THE MENSTRUAL FUNCTION. 103 pended, it is the duty of the practitioner to exercise a proper vigilance over his patient in order that she may not suffer from the approach of this interesting era of her existence. But, gentlemen, you may very properly ask, if this suspension be natural, and in keeping with the laws of the system, why should bad effects follow ? This question is not without force, and merits an answer. As a general rule, when a female has enjoyed good health and observed the usual ordinances of nature, the period of the final cessation of the menses is not one of peril—but, under contrary circumstances, injurious results are apt to ensue. To exemplify the truth of this proposition, we need but regard for a mo- ment the facts in the case before us. 1. The vertigo and sense of suffo- cation with the palpitation of the heart; 2. The unsteadiness of the gait, and the sparks before the eyes, are disturbances which can not be regarded lightly by the practitioner, especially in a woman whose men- strual function has ceased, whose appetite is good and indulged, and whose bowels are uniformly constipated. The inference is that if this patient, when her menses ceased, had restricted her appetite, and kept the bowels regular, she would not now be suffering from the above dis- turbances. There is one point in this case of very material import—it is the unsteadiness in the gait, which, taken in connection with the vertigo and the sparks before the eyes, indicates very positively trouble about the brain, and the apprehension is that apoplexy or paralysis may be the result. Indeed, this patient has about her the very symptoms which menace this state of things. Treatment.—Take from the arm § x of blood, and give the following powder: R Submur. Hydrarg......gr. x Pulv. Jalapse *......gr. xv Pulv. Antimonialis.....gr. ij M. To be followed in the morning by §j of Epsom salts; and in order to ensure a soluble condition of the bowels, a wine-glass of the following solution may be taken as circumstances require: R Sulphat. Magnesise ) aa 5 i Sup. Tart. Potassae ) Aquae Purse ......Oj Ft. sol. Diet strictly vegetable, and the patient to take daily exercise. A few moments since I remarked to you that statistical observation had shown that cancer was more apt to become developed in the system of the female at the period of the final cessation of the menses than at any other era of her existence. This is, I think, the fact—but its truth is by no means universally conceded. Lisfranc contended that this disease was most frequent between the ages of eighteen and thirty-five, and rejected the development of cancer in connection with the close of the catamenial function, as an absurdity. But well observed facts, and 104 CLINICAL LECTURES. carefully gathered statistics are of more solid weight than any comment that can be made upon those facts, no matter how high the authority, or how eloquent the commentator. You are not, however, gentlemen, to understand me to say that carcinoma commences at this period. I mean no such thing. I wish merely to convey the idea that the disease remains dormant for a long time in the system, and bursts forth in active development at this period for the reasons already stated. Sympathetic Cough from Intestinal Worms in a little Girl seven Years of age ; true and false Pulse.—Ann McD., aged seven years, is brought to the Clinique by her mother, who is much distressed, sup- posing that her child has the consumption. She has been troubled with a cough for the last six months—she is pale, restless at night, and occasionally quite fretful. Her cough is dry, unattended with expecto- ration ; the tongue is coated, the breath offensive, and the pulse about eighty-five, with constipation of the bowels. Both, gentlemen, in the adult and child, diseases of the respiratory mucous surfaces constitute a fearful outlet to human life; the mortality, it is computed, being as great as that resulting from affections of the nervous and digestive systems; when, therefore, you are consulted, and your opinion requested in re- gard to a cough, it is your imperative duty—the neglect of which noth- ing can justify—to ascertain positively the full meaning of that cough. Is it idiopathic or is it sympathetic ? Is it the result of direct irrita- tion of some portion of the respiratory tissues, or is it due to what I shall call reflected irritation, the nature of which will be immediately explained ? In examining the child before us, I can detect nothing which would cause me to suspect the existence of organic lesion, or even seri- ous local irritation of any of the organs of the chest. The respiration is undisturbed, percussion indicates a perfectly healthy condition of the lungs—and there is also an absence of the symptoms accompanying bronchial inflammation. The pulse, too, is not such as you would ex- pect to find in a child seven years of age, whose lungs are seriously invaded by disease. Tlie pulse is an important index in pulmonary affections; and yet it is subject to so many variations—not the result of morbid action—that the medical man can not be too circumspect in dis- criminating between what may be characterized the true and false pulse. The former being the pulse of diseased action, the latter the pulse of some sudden impression on the nervous system, and transitory in its character. It is important for you, who will have so much to do with the diseases of childhood, to understand the peculiarities, and progress- ive changes of the infant pulse. From a few days after birth to the sixth year of age, it averages in health one hundred and two beats in the minute; but momentary ex- citement may cause it to rise for the instant to one hundred and forty. Your very presence in the sick room, being a stranger to the child may STMPATHETIC COUGH FROM INTESTINAL WORMS. 105 induce this sudden acceleration of the pulse. Be cautious, therefore, and do not take the pulse for more than its real value as an evidence of dis- turbed action. Let us now endeavor to ascertain the true nature of the cough in this little girl. In my judgment, it is altogether unconnected with primary disease of any of the respiratory surfaces; or in other words, it is not idiopathic in its character. The question, then, natur- ally presents itself, what has produced the cough ? In children, especially, you will often meet with what is termed sym- pathetic cough; it sometimes occurs also in the adult, but not so fre quently. The doctrine has obtained that cough can not exist without inflammation of the bronchial tubes; this is an error, and you must recollect it in practice. There is no doubt that true bronchitis may exist simultaneously with the causes which are known to produce the sympathetic cough; but it is also true that the latter will often be pres- ent without the slightest inflammation of the respiratory mucous mem- brane. Perhaps you may be at this moment revolving in your minds the question—what in reality is a sympathetic cough, and in what way is it explained ? It is the result of reflex action, identical with what takes place when a portion of food or liquid enters the larynx, and the same thing is accomplished when the mucous membrane of the external auditory canal becomes the seat of irritation. The causes of sympa- thetic cough in children are worms, constipation, dentition, etc. When these causes exist, they act, the former by exciting the intestines, the latter, the gums—the spinal cord and medulla oblongata, thus become the centers of the irritation, and, by reflex influence, the irritation in- volves the special muscles, through the action of which the cough is pro- duced. How often, gentlemen, have I appealed to you to make the proper distinction between the shadow and the substance! The case before us exhibits an example of the necessity for this distinction. The cough here is the shadow ; the substance, which alone merits your atten- tion, is the producing cause. " What, madam, is the state of your child's bowels ?" " They are not very regular, sir." " Has it much appetite ?" " Yes, sir, its appetite is sometimes voracious." " Have you ever no- ticed any worms pass from it ?" "About six weeks ago it passed a long worm." You perceive, gentlemen, that the abdomen of this child is tumid, its tongue coated, with fetid breath, and, as the mother informs us, a voracious appetite. These symptoms, as I have remarked to you, were regarded by the old-school men as positive evidences of worms; but they are not so, for they may exist from other causes than worms. In the present case, however, I am inclined to attribute the cough to the presence of these parasites, especially as the mother says the child had passed one from its bowels. " Have you, my good woman, ever given your child any medicine for worms ?" " Yes, sir, I gave her some turpentine, but it did not have any effect." " Have you been told that your child's cough is probably 106 CLINICAL LECTURES. due to worms ?" " No, sir, but I have been told that she is in a decline." " Well, madam, you need not be anxious about her; that cough will do no harm, and you will find it will leave her in a short time." Treatment.—Brisk purgation, followed by bracing medicines, consti- tutes an excellent mode of treating worms under some circumstances, and I am disposed to have recourse to this plan of treatment in the present case, more particularly as this little girl has been much troubled with constipation, and her general health infirm. Let the fol- lowing powder be taken to-night: R Hydrarg. c creta......gr. iv Pulv. Jalapae ......gr. vi J£ and in the morning the annexed draught: R Sulphat. Magnesiae......3 i Infus. Sennae.......§ ij Tinct. Jalapae.......3 ss Mannae........3 ss M. When the bowels have been freely evacuated, the patient should then be put upon the following pills: R Sulphat. Ferri......gr. x Extract Gentianae......gr. xx Ft. Massa in pil. xx. dividenda. One pill twice a-day—the diet to be nutritious, consisting principally of succulent meats. Induration of the Neck of the Womb in a married Woman, aged twenty-nine Years.—Mrs. R., married, aged twenty-nine years, the mother of four children, the youngest thirteen months old, complains of a distressing bearing-down sensation in the region of the womb—much uneasiness in the lower part of the back, with more or less pain in the upper portion of the head; she is also troubled with a whitish creamy discharge from the vagina. You hear, gentlemen, the description of the symptoms of which this patient complains, and it would, without a more accurate knowledge of the case, be difficult for you to know how to pro- ceed in its management. There is reason, it is true, to suspect disease of the womb as the cause of her sufferings, but this you can not posi- tively affirm—at least its true nature can not be ascertained without an examination. This I have made, and find the patient to be laboring under induration of the neck of the uterus, with the organ slightly pro- lapsed. This condition of the uterine neck is not uncommon, and you will often meet with it in practice. But induration, like any other of the diseases of the cervix, must be clearly understood, and its real character well defined in your own minds, before resorting to remedial agents. You will receive much credit for correct diagnosis, and more particularly if your treatment should prove successful in affections of this kind • on the other hand, you will not only merit, but you will certainly have INDURATION OF THE NECK OF THE WOMB. 107 measured out to you severe censure in the event of erroneous judgment. Induration is a hardened condition of the cervix, and as there are two species widely differing the one from the other, it is essentially necessary that your distinction should be a just one. In the one case, the disease is completely under the control of judicious medication—whilst in the other, there will be ample ground for serious apprehension as to the result. Causes.—Induration of the womb is usually the effect of chronic in- flammation—and under such circumstances, is a manageable affection; again, it is occasionally met with as one of the stages of malignant dis- ease, being the result of morbid and destructive deposit. Symptoms.—Usually the same as accompany ulceration and engorge- ment of the cervix of the womb ; such, for example, as pain in the back, head, etc., and more or less discharge from the vagina. In addition, however, to these symptoms, there are others which it is especially necessary you should note in memory, such as a frequent desire to pass water, and a dragging sensation in the direction of the round ligaments. These latter symptoms arise from a partial prolapsus of the womb, the prolapsus being caused by the increased weight of the uterus, which is the effect of the increased size resulting from the induration. This is an important fact, and at once discloses the absurdity of attempting to remedy this form of prolapsus by the introduction of the pessary. This is a common error in practice. * . Diagnosis.—Here, gentlemen, is an extremely material point, for on a correct opinion will depend not only the welfare of the patient, but your own reputation. Suppose, for instance, you are called to a case of induration of the cervix uteri—the induration may be the result simply of chronic inflammation, or it may be the effect of malignant disease. Do you not at once perceive the importance of a clear appreciation of its true character ? In induration, the sequela of inflammation, the surface is smooth, equal, uniform. In the induration of carcinoma, it is uneven, irregular, often nodulated, and of a stony hardness. In simple indura- tion, the disease will sometimes be confined to one of the lips of the organ ; at other times, both lips will be involved. Prognosis.—The induration consequent upon chronic inflammation of the uterus, is within the control of remedies, whilst scirrhous induration oftentimes bids defiance to the best directed effort. Treatment.—In the case before us, I shall prescribe the protiodide of mercury, with the extract of cicuta. It is in these cases an admirable combination, and I am confident will restore the organ to a healthy condition. R Protiod. Hydrarg.......gr. vi Extract Conii.....* 3u Ft. Massa in pil. xxiv. dividenda. One pill to be taken every night, until the gums are slightly touched. In addition, some of the bitter infusions should be employed, for the 108 CLINICAL LECTURES. purpose of invigorating the patient's strength—the following may be ordered: R Infup. Gentianae......3v Tinct. Gentianae......3 J Acid Sulph. dilut.......3 ij M. A table-spoonful twice or thrice a-day, with nutritious diet. Prolapsus of the Womb, occasioned by Jumping from a Carriage, IN A YOUNG UNMARRIED WOMAN, AGED NINETEEN YEARS.--Josephine M., unmarried, aged nineteen years, complains of pain in the lower portion of her back, a dragging sensation in her groins, and a frequent desire to pass water, with occasional nausea. She was, she says, always a healthy strong girl, until about two years since; at that time, she was riding in a carriage, the horses became restive, and she jumped out, falling, with some violence, on her knees. A few days afterward, she experienced the above symptoms, which have continued more or less to the present time. " How are your courses, my good girl ?" " They are quite regu- lar, sir." " At the approach of your turns, do you have an increased diffi- culty with your water ?" " Yes, sir; I have to pass it much oftener." From the representation, gentlemen, which this patient made me previously to introducing her before you, I was inclined to suspect that the symptoms of which she complains were most probably owing to displacement of the uterus, produced by the fall from the carriage; and a vaginal ex- amination has shown that my suspicions were not without foundation. The organ I have discovered to be partially prolapsed, with a slight relaxation of the vaginal walls, occasioned, no doubt, by the pressure of the uterus; the organ is perfectly free from disease. This case is one of more than ordinary interest. In the first place, prolapsus of the womb is comparatively of rare occurrence in the unmarried woman; and secondly, falls are not among its usual causes. The very symptoms described by this patient are the common accompaniments of prolapsus uteri; and you will readily understand why a frequent desire to pass water should be one of these symptoms; and secondly, why the desire to micturate should be increased about the advent of the menstrual func- tion. The uterus, in its prolapsed state, irritates by pressure the neck of the bladder; and this irritation is greater at the time of the menses for the reason that the volume of the womb is increased in consequence of the afflux of blood to it. In the present case, I shall recommend care in keeping the bowels regular, for constipation is not only one of the constantly exciting causes of this form of uterine displacement but it invariably increases the prolapsus when it exists. Two of the following pills may be taken at night; they will be found useful as aperient pills: R Pulv. Rhei ) Pulv. Aloes)......M 3sa Saponis. Alb....... t>j Divide in pil. xx MENORRHAGIA DURING LACTATION. 109 Two ounces of the following solution may be thrown up the vagina twice a day. It will have a tendency to strengthen the vagina, and this may result in the restoration of the organ to its proper position. For the present, at least, we shall limit ourselves to this treatment: R Sulphat. Zinci ) . aa 3 j Sulphat. Alumin ) Aquae distillat....... Oj Ft Sol. A pessary in this case would be an absurdity. Menorrhagia during Lactation in a married Woman, aged twenty- eight Years.—Deborah J., aged twenty-eight years, married, the mother of one child, eleven months old, complains of great debility, ver- tigo, and palpitation of the heart; she is pale and nervous, and has con- tinued to nurse her child from birth to the present time. Four months after her child was born, the menses appeared, and have occurred every month since profusely, continuing for not less than ten days at each period. Previously to, and during her pregnancy, she enjoyed good health. The statement, gentlemen, which you have just heard from this patient is altogether satisfactory, for it at once discloses the cause of her dilapidated health, and directs you with unerring certainty to the indica- tion to be fulfilled. The case before us presents in one particular an important exception to a general rule. Nursing women, during lactation, usually do not menstruate. In this patient, however, the function ap- peared four months after the birth of her child, and in such quantity as to constitute menorrhagia, or profuse menstruation. The effects of this profuse monthly loss, together with the drain of lactation, you recognize in the pallor of countenance, the debility, vertigo, palpitation, and gen- eral nervousness of this patient. If you were to regard ,one or all of these symptoms as the disease, your treatment would be empirical, for it would be founded on a false basis. The vertigo, palpitation, etc., are merely effects—derangements, if you please—produced by the profuse monthly drain to which the system has been subjected, and which it was not adequate to sustain and still preserve its harmony of action. There is no difficulty in explaining why vertigo, palpitation, and gen- eral nervous disturbance should be among the sequels of a debilitating influence such as this patient has labored under for the last six months. I have repeatedly directed your attention to the important relations which subsist between the vascular and nervous systems, and the de- pendence of the one on the other. The case before you exemplifies very clearly a principle, which has often been discussed in this Clinique, viz., that symptoms of themselves prove nothing, for they may result from directly opposite causes. A patient may labor under palpitation of the heart, vertigo, and general nervous disturbance whose vascular system is redundant with blood discs. In such case, for example, the stimulus 110 CLINICAL LECTURES. imparted by the circulating fluid to the heart, brain, etc., is more than these organs can sustain consistently with the performance of their healthy and natural functions. You have, therefore, under these circum- stances, vertigo from over-stimulation of the brain, and abnormal action of the heart from the same cause. Again, how often do paralysis and other lesions of the nervous system follow vascular repletion ? What, allow me to ask, would be the intelligent course for the physician to pursue in order to relieve the vertigo, etc., in a patient such as I have just described ? Common sense, without resorting to science, would tell him that the obvious remedy would be the lancet, purgatives, diet, etc., with a view of diminishing vascular fullness, and thereby removing the cause of morbid action. But surely, gentlemen, you would not apply this system of therapeutics to the case before us. There is not one of you who would not arrest the hand of the practitioner who should attempt to abstract blood from this patient—she is already anaemic, without blood enough in her system to control healthy action, and every drop taken from her would only tend to aggravate, and make more perilous her situation. You have just seen the effects of over-stimulation on the brain and heart—the same results ensue from an impoverished condition of the blood. Therefore, symptoms are without value unless traced to their true cause. Causes.—Menorrhagia may result from several different causes. Ple- thora, for example, may produce it; and it may also ensue from an atonic condition of the uterine vessels. You can not be too vigilant in endeavoring to distinguish the source of the profuse flow. Diagnosis.—Sanguineous discharges per vaginam are among the im- portant, and often difficult derangements, which the medical man will be called upon to treat. The life of the patient, and his own reputation will frequently be involved in a just decision as to the cause of such discharge. This Clinique has brought before you numerous cases of females affected with loss of blood from the vagina, and you have seen that they are not all due to the same cause. Prognosis.—Menorrhagia is usually a manageable disorder. Treatment.—If you attempt to treat the case before us by the admin- istration of tonics, you will do the patient no good. The first object to be achieved is to close the waste-gate. Until this is done, general tonics will only add to the profuseness of the discharge. This is a cardinal error in practice. The patient herself, looking merely at the debility under which she labors, seeks relief in the abundant use of stimulants. Such practice is full of error, and often leads to fatal results. With the view of inducing contraction of the uterus, I shall recommend: R Tinct. SecaL Cornut......? ij Let the patient take a tea-spoonful three times a day in half a wine- glass of water, commencing the day on which the menses appear, and PALPITATION OF THE HEART. Ill continuing until the period is over. In addition to this, half a pint of cold water should be thrown up the rectum night and morning. When the menorrhagia has been controlled, a tea-spoonful of the following solution may be ordered thrice a day : R Sulphat. Quininae......gr. xij Acid Sulph. dilut.......gtt. xij Aquae Purae. ......§ iij Ft. sol. The diet should be nutritious. The above treatment, however, will be nugatory unless you enjoin on the mother the absolute necessity of weaning her child. The drain of lactation is too much for her. Palpitation of the Heart in a Girl thirteen Years of age.—Cath- erine R., aged thirteen years, has suffered for the last two months from palpitation of the heart. She is dejected in spirits, easily frightened, and is laboring under constipation. A thoughtless friend has told her that she has an incurable disease of heart. This case, gentlemen, is one of interest, and it is extremely important that we should understand what value to give to the prominent symptom—the palpitation. Fe- males are more liable to palpitation of the heart than the other sex; and this arises in part from the greater sensibility of their nervous system, and their comparative inability to resist external impressions. But there is another circumstance connected with the female very fruitful in the production of cardiac disturbance—viz.: functional disease of the uterus. Nothing is more common, at the approach of puberty, than pal- pitation of the heart—indeed, it often constitutes a leading symptom. When a patient labors under palpitation, there is very naturally much anxiety experienced ; the idea of organic disease of the heart with which sudden death is generally associated in popular minds, is well calculated to make the patient unhappy. Oppressed by a dread of this kind, the sufferer becomes a victim to imagination—unlimited latitude is given to thought, and the brain becomes wearied with constant apprehension. How essential, then, is it at the very incipiency of an affection which, by possibility, may be mistaken for one of an incurable nature, for the physician to make a proper discrimination, and, when he can do so, dis- pel from the mind of his patient those clouds of gloom which, if suffered to continue, will certainly result in serious disturbance of the system This little girl has been made unhappy by the opinion of a well-mean- ing, but officious friend. On a delicate constitution like hers, such intel- ligence must fall with disastrous effect; and an expression which, per- haps, was made in friendship, has caused days of distress to one for whose benefit the advice was volunteered. c; Madam, is your daughter troubled with palpitation all the time ?" " No, sir ! She is not troubled with it at night." " Is it increased when she exercises ?" " No, sir, when she walks in the air, and has her mind 112 CLINICAL LECTURES. occupied, she does not complain of the palpitation." The bearing of these two questions, gentlemen, you must at once perceive. They establish the interesting fact—a fact which will be appreciated by this girl, for it will dry up her tears, and substitute happiness for sorrow- that the palpitation is not the result of organic disease of the heart. In the palpitation arising from structural lesion of this organ, we do not find that the disturbed action ceases at night, or is suspended on taking exercise—but, on the contrary, the two characteristics of organic disease of the heart are unceasing palpitation night and day, with an increase in the heart's impulse when exercising. The first point of inquiry having been ascertained, whether the palpitation be due to organic or functional disturbance, the question becomes greatly simplified by the fact that it is solely functional. The causes of functional derangement of the heart are numerous. Dyspepsia, abnormal menstruation, the approach of puberty, indigestion, gastric repletion, depressing mental emotions, as also joy, etc., are among the common causes of palpitation. If you will look at the little girl before us you will observe, in addition to what we have gathered from the statement of the mother, an absence of those signs which usually indicate organic disease of the heart. There is, for example, no tumefaction of the face—the pulse is regular—no intermit- tence—no oedema of the extremities, etc., etc. In a word, gentlemen, you have before you a case simply of functional disorder of the heart— and if you will revert to the history of the case, you will, I think, find sufficient to account for the unnatural action. 1. This girl is thirteen years of age—the advent of puberty is at hand; 2. She is constipated, with dejection of spirits; 3. She is extremely nervous, and easily fright- ened ; 4. A friend has informed her that she has disease of the heart. Here, then, are several influences in combination, either one of which is sufficient, under ordinary circumstances, to produce the leading symp- tom in this case—the palpitation. The indication is quite manifest. The constipation—always the source of disturbed action, if not of dis- ease—is the first object of attention. When this is removed, and the bowels properly regulated, the nutritive functions must be-improved by the judicious use of the vegetable and metallic tonics. This, with exercise in the open air, a visit to the sea-shore if possible, and agreeable influences such as will contribute to a cheerful mind, will restore this girl to health. Treatment:— R Hydrarg. c. Creta......gr. viij To be followed in the morning by §j of castor oil. The following compound rhubarb mixture will be found beneficial in preserving a solu- ble state of the bowels, and of improving digestion : R Pulv. Rhei........3; Sodae Carbonat.......3 ij Pulv. Calumbae ••..*. 3 ij Aquae Menthae pip. ) Aquae Purse *.....5*3 M. A table-spoonful three times a day. PALPITATION OF THE HEART. 113 Should it afterward be necessary to have recourse to the metallic tonics, a mild and efficient one will be found in the sulphate of zinc: R Zinci Sulphat. ) _, , , z. .. >.....aa gr. xx Extract Gentianae ) Extract Hyoscyam......3j Olei Anthemi.......gtt. x Ft. massa in pil. xx. dividenda. One pill twice a day. In connection with the subject before us, I may be permitted to men- tion the following interesting case :— " About two years since a gentleman of this city called on me in great distress, stating that his only daughter, a young lady of eighteen, was laboring under organic disease of the heart; observing, at the same time, that her physician had pronounced her case utterly hopeless. On visiting the young lady, I found her in a state of unusual excitement; her nerv ous system shattered—a quick and irritable pulse—violent palpitation of the heart, with occasional intermittence of the pulse—inability to take ex- ercise, the slightest exertion increasing the palpitation—profound melan- choly—inability to sleep—torpor of the bowels, and entire loss of appe- tite—these, together with more or less uneasiness in the cardiac region, constituted her symptoms when I called to see her. An abstract view of her case would very naturally have led to the opinion that she labored under an organic affection of the heart. On a critical investigation of ner case, the following particulars were disclosed: About a year pre- vious to my seeing her, she had become clandestinely engaged to a gentle- man who, although in every respect worthy of her, was poor; he was not acceptable to her parents, and the engagement was, therefore, dis- solved. From that moment her health began to decline; she fell into a deep melancholy, her menstrual function ceased, and there was general derangement of her nervous and digestive systems, as characterized by the symptoms already enumerated, the most formidable of which, to an ordinary observer, was the excessive palpitation. After a deliberate view of her case, I became satisfied that there was no organic disease of the heart; there was simply functional derangement of this organ; and I am equally positive, such is the influence of mind over matter, that no medicines, either in the form of tinctures, powders, or boluses, would have had the slightest efficacy in restoring the suffering patient, until the original cause of ill-health was removed. Accordingly, finding her affec- tions centered on the gentleman, and there being no objection to him save his poverty, the parents were strenuously advised to yield consent; this was done. I continued to visit the young lady for several weeks, admin- istering such remedies as her situation indicated. She was perfectly re- stored to health. I received great credit for the recovery, it being looked upon as something miraculous; and yet I am convinced that, without the efficient aid of the lover, death would have triumphed over all professional 8 114 CLINICAL LECTURES. science and skill. Tlie renewal of their engagement was soon followed by matrimony, and the next important and very natural event in their history was the birth of a son." Ophthalmia Neonatorum.—Purulent Ophthalmia in an infant, four Weeks old.—Jane M., aged four weeks, has been affected for the last three days with inflammation of both eyes ; she appears at the Clinique with both eyes closed, the lids being distended by a purulent secretion ; she is fretful, and refuses the breast. The mother states that at its birth, it presented every appearance of good health, and continued to do so until within the last few days, when its eyes became affected. This case, gentlemen, is well worthy of attention. The disease under which this little infant labors is one of the attendants of the lying-in room, and, if not properly managed, leads to the destruction of one or both eyes. The affection has been denominated the ophthalmia neonatorum, the ophthal- mia of new-born infants; it is sometimes called purulent ophthalmia. Few diseases incident to the young infant are more rapid in their progress than the one now under observation, and it becomes the practitioner to exercise more than ordinary vigilance, in all cases in which the eye is inflamed at this early age. In this affection, the conjunctiva of the lids is first attacked ; it becomes involved in serious inflammation, resulting in purulent secretion. If the inflammation be not arrested, the cornea is next involved ; infiltration of pus within its laminae ensues, forming what is called onyx; the laminae themselves become ulcerated, and the eye is soon destroyed through the progress of the ulceration. Causes.—Ophthalmia neonatorum may be produced in several ways : 1st. Leucorrheal matter from the vagina of the mother at the time of birth; 2d. Cold ; 3d. Exposure of the eye to a sudden and bright light; 4th. Soap-suds applied to the eye of the infant during its ablution. Any of these causes may produce the ophthalmia, but one of the most com- mon is the inoculation by the leucorrheal discharge. I am in the habit, as soon as the new-born infant is washed and dressed, of examining very critically the eyes, with a view of ascertaining the presence of any irri- tating matter, and also of directing the nurse to be careful, whilst wash- ing the child, that the soap shall not come near the eye ; this latter is a common and injurious practice in the lying-in chamber. The nurse should also be directed not to expose the infant to a strong light, or to a current of air. Symptoms.—The symptoms of this affection are not difficult of recog- nition. At the commencement, one or both eyes appear weak; there is a slight weeping; in a few hours they become inflamed, and a muco- purulent discharge is observed; the lids become agglutinated and dis- tended by the accumulation of the morbid secretion; the child is restless and feverish, the tongue coated, and it is not unusual for the bowels to be constipated. CHOREA FROM INTESTINAL IRRITATION. 115 Diagnosis.—This affection might possibly be confounded with gonor- rheal ophthalmia, but the peculiar circumstances of the case, and the fact that, as a general rule, in gonorrheal ophthalmia, one eye only is affected, will enable the practitioner to avoid error. Prognosis.—This is not without interest; the mother necessarily be- comes much alarmed; she is fearful that the child may be deprived of sight, and her only consolation is in the assurance of her physician. Let this assurance, involving as it does the happiness of the mother, as also the reputation of the medical attendant, be based upon something more than loose conjecture. In his examination of the eye, if the practitioner should discover that the inflammation is limited to the conjunctiva, as is the case in this little patient, he may with entire confidence dissipate all anxiety on the part of the friends, and promise a speedy restoration. Should, however, the cornea be seriously implicated, the prognosis must necessarily be more guarded. Treatment.—When the conjunctiva is alone affected, local applications to the eye, if properly made, will promptly and effectually remove the inflammation. These applications are not to be confided to the nurse ; they should be made by the practitioner himself, in the following man- ner : The child being placed on its back, resting on the lap of the nurse, the practitioner places its head on his knee, and then, with a soft sponge moistened with tepid water, cleanses the eyes—:the lids are then gently separated, and, after everting them, the accumulated matter should be re- moved. The eyes should then be washed several times during the day with the following collyrium : R Hydrarg. Oxymuriat......gr. j Sal..Ammoniac......gr. iv Aquae tepidae ......§ vj Ft. sol. It may also become necessary to touch the inflamed conjunctiva by means of a camel's hair pencil, with the following solution of the nitrate of silver, twice a-day : 9 Nitrat. Argenti ......gr. v Aquae distillat.......1 j Ft. sol When the child goes to sleep, with a view of preventing their agglutina- tion, the lids should be smeared with fresh butter, fresh olive oil, or what, perhaps, is better, the red precipitate ointment. The bowels are to be kept regular with castor oil, or flake manna. And above all, the eyes to be protected against the light. Chorea in a Girl, aged ten Years, from Intestinal Irritation.— Hannah D., aged ten years, has been affected for the last eight months with irregular contraction of her muscles, particularly those of the face and extremities. In observing this little girl, gentlemen, you will at a 116 CLINICAL LECTURES. glance recognize the characteristics of ordinary chorea, viz., irregular and more or less constant contractions of some portion of the muscular sys- tem. Chorea, or, as it is sometimes called, St. Vitus' dance, may be con- sidered a disease of childhood, although it occasionally occurs in the adult. It is more frequent in the female than male, and most commonly exhibits itself between the ages of six and sixteen. It is an affection of comparatively rare occurrence. In Paris, there were less than two hun- dred cases among thirty-three thousand children. Causes.—Much discrepancy of opinion exists as to the causes of chorea; some attributing it to vascular fullness of the brain, others to debility. It is very evident that it owes its origin to no one cause, but may arise from various conditions of system. Fright, intestinal irrita- tion from worms or undigested food, cold, injuries to the head or spine, certain evolutions of the economy connected with puberty, repelled exanthemata, etc., may all be regarded as'capable of producing the disease. Symptoms.—The first indication of chorea is often a species of grimace, soon followed by twitchings or irregular contractions of the muscles, es- pecially of the extremities. There is unsteadiness in the walk, and the child usually drags one limb behind the other. Occasionally one or more of the extremities will become paralyzed; in fine, the patient affected with chorea is liable to every possible variety of muscular con- tortion. Diagnosis.—The affections with which chorea might possibly be con- founded are convulsions, delirium tremens, and hysteria. Prognosis.—Simple chorea is rarely fatal; but when complicated with serious disease of the brain or spinal marrow, it often destroys life. Treatment.—Authors differ with regard to the treatment, as they do in reference to the causes of this disorder; consequently, those who regard it as due to plethora, recommend depletion, whilst the various tonics are prescribed by those who trace it to debility. On the other hand, numerous specifics are resorted to, such as arsenic, iron, zinc, etc. It is a grievous error, gentlemen, in the practice of our profession to be- come obstinately wedded to opinion; and it is, indeed, a sad thing to make circumstances yield to preconceived theories. This is not philo- sophical ; it is at war with wisdom, is repudiated by common sense, and must necessarily lead to grave results in practice. In the treatment of this affection, you should sedulously direct your attention to the particular cause which has produced it. The mother has informed us, in reply to our questions on the subject, that on several occasions she has observed large round worms pass from the child. In addition to this testimony, the child is irritable; the tongue is coated; the abdomen tumid; the breath offensive; appetite variable, with disturbed sleep. These condi- tions are the ordinary accompaniments of intestinal worms, though they may exist without the presence of worms. On a former occasion, I re- CHOREA FROM INTESTINAL IRRITATION. 117 marked to you that the only pathognomonic symptom of these entozoa is their presence detected by the eye. It is highly probable that the chorea in this case is produced by the worms, and with this view I shall order the following treatment:— R Sub Mur. Hydrarg.......gr. iv Pulv. Spigeliae Marilandicas . . . . gr. vi M. Let this powder be taken at night, followed in the morning by oil. When the bowels have been properly evacuated, one of the following powders may be taken twice a day, with the object of improving the digestive functions: R Sub Garb. Ferri . . • 3iss Divide in chartulas x. To this may be added the shower-bath, which will act beneficially in re- storing nervous energy. One word, however, with regard to the shower- bath—if, after taking it, the system should not immediately react, and it should be followed by a chilling sensation, instead of an agreeable glow, it must be discontinued. LECTURE VIII. Retention of the Menses in a Girl, seventeen Tears of age, with Habitual Constipa- tion.—Amenorrhcea divided into Retention and Suppression.—Phthisis Pulmonalis complicated with Peritoneal Dropsy in a Roy, thirteen Tears of age.—Ulceration of the Neck of the Womb in a married Woman, twenty-two Tears of age.— The Speculum.—Ulceration of the Neck of the Uterus—conflicting opinions respecting; are these Ulcerations frequent?—How divided—their Causes, Symp- toms, Diagnosis, and treatment.—Spina Bifida in an Infant, aged two Months.— Hydro-rachitis.—Mucous Discharge from the Vagina, with Pruritus of the Vulva, occasioned by Venereal Condylomata, in a married Woman, aged twenty-three Tears. Retention of the Menses in a Girl, seventeen Years of age, with Habitual Constipation.—Eliza M.,aged seventeen years, is brought to the Clinique by her mother, who says her daughter has no appetite, is labor- ing under constipation, frequently passing a week without an evacuation from the bowels. The girl is nervous, and subject to a dejection of spirits. She has never menstruated, and is pale and delicate. The case before you, gentlemen, is one of more than usual interest on several ac- counts. When a girl has attained her seventeenth year, and the men- strual function has not appeared, it is quite natural that her friends should become anxious. You must remember, however, that the manifestation of this function is essentially connected with the ovaries; and it occasion- ally happens that the tardy maturity of these organs, is the sole cause of the retention. To attempt, therefore, under such circumstances, to establish this function by forcing medicines would be about as unphilo- sophical as to hope, by a process of medication, to cause a new-born in- fant to walk. That the ovaries are necessarily connected with menstru- ation is a truth about which there no longer exists a doubt. My motive in calling your attention to this subject is to guard you against an error too common in practice, and which often leads to the early destruction of the patient. When the ovaries have not attained their development, the physical appearance of the girl presents all the characteristics of the child; there is an absence of that fullness and embonpoint which mark womanhood, and which are due to the increase of cellular tissue about the chest and hips, directly dependant upon the growth of the ovaries. This absence, therefore, of physical development, is an index of no little import to the practitioner. It reminds him that nature has not com RETENTION OF THE MENSES. 119 pleted the edifice; she has been contravened in her efforts to perfect the system, and calls upon the physician for assistance. That assistance will be judicious or otherwise, precisely in proportion as he who extends it will understand the true difficulty under which nature labors. Should the practitioner permit his attention to be exclusively fixed upon the fact that the girl has reached her seventeenth year, and does not menstruate, he will institute a process of treatment which will not only prove abortive, so far as the attainment of the object is concerned, but will place in serious jeopardy the life of the patient. If, on the contrary, his mind be drawn to the important circumstance that the retention arises from the want of development of those organs so absolutely necessary to the existence of the menstrual function, his treatment would be scientific, and would most probably result in the restoration of health. He would have recourse to • those measures which are known to be best calculated to build up and invigorate a frail constitution, etc., etc. The term amenorrhea is em- ployed to designate an absence of the menstrual function, and is divided into retention and suppression of the menses. The former is that condi- tion of the system in which the function has never appeared; suppression, on the contrary, is that condition in which, having been established, it becomes, from certain causes, arrested. The case before us is one of retention. You have heard the statement made by the mother ; and she is much concerned because her daughter is without appetite. In addition to the loss of appetite and retention of the menses, the girl is affected with obstinate constipation. She is pale, de- jected, and extremely nervous. With all these troubles, however, she presents the physical evidences of womanhood. The pallor of coun- tenance is precisely such as you will see in chlorotic patients; the tongue, too, is pale, as well as coated. In reviewing all the circumstances of this case, I am disposed to attribute the general derangement of the system to the long-continued constipation. This is one of the most fruitful sources of ill-health among females, and it frequently is productive of serious, if aot irremediable results. It may be denominated the insidious cause of bad health, for the reason that the female, from false delicacy, conceals the fact from the physician. This, however, is no apology for the practitioner; it is his duty to examime critically into every circumstance connected with the health of the patient. He, it is presumed, comprehends the mechan- ism of the human system—its workings in health, and its derangements in disease; and nothing can justify a neglect of that minute investigation necessary to a thorough comprehension of the actual causes—so far as they can be ascertained—which have produced these derangements. Constipation, I repeat, is a common, and often an occult cause of ill-health. This observation can not surprise you, for it must be manifest that when it exists, the natural consequence, unless in rare exceptions, must be disturbed action more or less formidable. There is a dependence of the general system for healthy influence on the regular and healthy action of 120 CLINICAL LECTURES. the intestinal canal. This dependence is proved in part by the results which are known to follow habitual, and even temporary constipation. Surely the stomach and intestines, in connection with the chylopoietio viscera, have important functions assigned them—so important, indeed, that they can not be invaded without inducing more or less bad effects on the economy. We know that the human frame—no matter how perfect its physical mechanism—requires constant repair for the constant waste that is going on. Every hour of existence is one of physical waste, and if this be not repaired, decay and death are the results. For the elab- oration of food, and its conversion into blood, and the distribution of that blood to every tissue of the system, a most perfect mechanism has been provided. Something more, however, is necessary than this mechanism—the blood must first be formed, and this can only be done • through the process of healthy digestion. The stomach and intestines, like the lungs or brain, or any other organ, are required to perform ac- curately their various offices. Any deficiency here, and a corresponding deficiency will be observed in some portion of the structure. The object of digestion is the conversion of food into chyle, which is poured into the venous system, thence into the lungs, for the purpose of decarbonization, when it becomes arterial blood; this is distributed throughout the mech- anism as the essential nutritive element for the various organs. You see, therefore, gentlemen, that proper digestion is the very foundation of health, and just in proportion as this is deranged will there be dis- turbance of the general system. You are aware that one of the processes of digestion consists in the separation of the chyme, through the influence of the bile, into two portions—the chyle, and the effete matter no longer proper to sojourn in the system. Constipation necessarily causes the retention of this latter substance; and as it is in violation of one of the cardinal ordinances of nature, it is obvious that bad results must ensue. Hence, as the common results of constipation are to be noticed head- ache, loss of appetite, general nervous disturbance, pallor, etc., etc. These may be regarded as the ordinary consequences of impaired nutrition. Constipation, too, besides leading to derangement of the general health, is a frequent cause of uterine disease. There is one circumstance connected with the case of this girl which it is well for you to note—it is the state of her appetite. This, indeed, ap- pears to disturb her mother more than any other fact in her history. She imagines all that is necessary to restore health to her daughter is an ap- petite ! Let this case, gentlemen, in connection with the idea entertained by the mother, be an admonition to you. Remember it when you return to your homes, and let it guard you against the folly of surrendering your own good judgment to absurd popular caprice. Suppose we concurred in opinion with the mother as to the loss of appetite—as a necessary conse- quence this circumstance would exclusively engage our attention; and in RETENTION OF THE MENSES. 121 lieu of regarding it as one of the effects of the constipation, and treating it as such, we would address remedies to the stomach; or, in other words, this organ would become the recipient of the various tonics and stimuli with as much probability of relief as would follow friction with opodildoc on a limb that had become paralyzed from disturbance of the brain! Causes.—Retention of the menses may be the result of two classes of causes: 1st. Constitutional. 2d. Mechanical. Under the former head, may be mentioned general debility of the system, absence or imperfect development of the ovaries, plethora, etc. Under the second, imperforate os tincse, imperforate hymen, and stricture of the neck of the womb. Symptoms.—Retention is characterized by no particular chain of symp- toms—they are anomalous depending on the cause that produces it, as also on the peculiar system of the individual. In retention, however, occasioned by mechanical obstruction, there is one circumstance that can not too emphatically engross the attention of the practitioner—it is the enlarged abdomen, which results from the accumulation of the menstrual fluid contained in the womb. This latter organ becomes increased in size, and several of the symptoms of pregnancy develop themselves. I have often remarked to you that morning sickness, tumefied breasts, etc. etc., are common results of both functional and organic disease of the uterus. A girl, therefore, laboring under this form of retention may become the object of suspicion; and, under such circumstances, her only hope of protection is in the sound judgment and inflexible honor of her physician. The records of our science are not without cases of painful interest, in which both character and life have been sacrificed by error of judgment, or a craven fondness of subserving—by a too ready obedience to opinion—popular prejudice. A young female, for example, exhibits some of the evidences of gestation ; and, to the lasting dishonor of our nature be it said, that too often a thousand tongues are engaged in giving wings to the rumor that she has been very imprudent, and the cost of that imprudence is the destruction of character, for she is pregnant!! Char- acter, gentlemen, is a precious treasure; it is, indeed, without price. There is no substitute for it—once lost, and nothing but the worthless casket remains; once gone, and its recovery is beyond all peradventure. In woman, character is the great bulwark of her existence—it is the segis which gives her protection; with it, she is the veriest of all potentates; without it, she is less than the worm that crawls on the earth! Precious, however, as is the treasure, the world will sometimes sport with this sacred attribute of woman, and endeavor, by false imputations, to rob her of it. Lady Flora Hastings, the victim of prejudice and ignorance, is a case in point. Diagnosis.—Ordinary care will enable the physician to distinguish the peculiar kind of retention, and prevent his confounding it with pregnancy. Prognosis.—This will depend very much on the cause of the reten tion, and the constitution of the patient. 122 CLINICAL LECTURES. Treatment—The great end to be accomplished in the case before us is the removal of the constipation; and, perhaps, nothing will an- swer a better purpose to commence with than the following mercurial powder: R Hydrarg. c. Creta.....S1"- x To be followed in the morning by 5 j of castor oil. When the bow- els have been thoroughly evacuated, one of the following pills should be ordered twice a day, as circumstances may require—it is a capital com- bination in this chlorotic condition of system : R Aloes Barbad.......3ij Sulphat. ferri ......3j Divide in pil. xx. In these cases of retention from a debilitated system, after the health has somewhat improved by the foregoing treatment, to which, however, horse-back exercise would be a valuable adjunct, essential benefit will occasionally be derived from the warm hip-bath, the internal adminis- tration of the tincture of cantharides, commencing with ten drops; or the tincture of iodine, which is sometimes extremely serviceable, say five drops three times a day; electricity may also be employed with advantage. Lavagna, some years since, proposed injecting into the va- gina six or eight drops of the liquor ammonia: in §j of water, two or three times a day. I have not myself derived much benefit from this latter remedy. It will be at onCe seen that the object of the above remedies is to excite local action in the uterus; but this should not be attempted in a case such as the one before us, until the general health has become improved by appropriate constitutional treatment. The following will prove an excellent combination in amenorrhcea. R Tinct. Ergotae......• 3 ij Syrup CrocL ...... § ij Decoct. Aloes Comp...... § vj M. A table-spoonful three times a day. The diet should be nutritious, and daily exercise in the open air. Phthisis Pulmonalis complicated with Peritoneal Dropsy in a Boy thirteen Years of age.—Teddy 'M., aged thirteen years, arrived in America a week ago. He came in the ship John Shaw, with seven hundred passengers. He is very much emaciated, has a cough, and a protuberant abdomen. This poor sufferer was brought into the Clin- ique in the arms of his mother, whose deep sorrow excited the sympathy of the class. He was unable to walk, or sit up, and was placed on the bed. " Your child appears very sick, madam." " He is all that, sir!" " How many weeks were you crossing the Atlantic ?" " Five weeks, sir!" " Was the weather stormy ?" " Indeed it was, sir." " What was the health of your child before you left Ireland ?" " It was good, sir!" " Was he much exposed on ship-board ?" " Yes, sir, he took a heavy cold and a bad purging; and they have never left him." The questions, gentlemen, which I have addressed to this unhappy woman, PHTHISIS PULMONALIS. 123 have elicited answers which have given us some little insight into the previous history of this case. We shall now proceed with our investi- gation, and endeavor, if possible, to ascertain what it is that has produced this general decay of the system. The first and remarkable fact that presents itself to our observation, is the extreme emaciation of this boy. This, however, is not his disease—it is simply an evidence of serious organic derangement. Let us now see if we can trace this emaciation to its original source. The mother informs us that her child was at- tacked on ship-board with a severe cough and purging, which have con- tinued to the present time. These, so far, are the prominent features of the case. The cough may or may not involve serious organic lesion of the lungs—and the purging may or may not involve the same result in the intestinal mucous surface. These points are fit subjects of inquiry. In feeling the pulse of this boy, I find that it yields one hundred and twenty beats to the minute; the pulse is an important index, and with due discrimination on the part of the physician it becomes a very signi- ficant guide in the sick room. But the pulse, gentlemen, is subject to variations other than those which result from disease. You know, for example, how the position of the individual will modify it; and you have been told how materially the pulse is affected by mental emotions. In order, therefore, to give to this index its full and true value, a just discrimination must be made between those influences of a transitory character, and those which emanate from morbid action. It is evident that the accelerated pulse in this boy is owing to serious organic lesion of the lungs. [Here the professor percussed the chest, and all the phy- sical evidences of phthisis were detected.] You have before you, gentlemen, a case of disease beyond medication— the lungs are filled with abscesses—the quick pulse is the result of this pul- monary lesion—and the general emaciation is due in great measure to the same cause. Phthisis pulmonalis is the bane of human existence—it is the Upas whose impress is death—it is the malady which, so far, has not only paralyzed all effort to rescue the victim, but has forced the physician, in deep humility, to acknowledge that his science is indeed limited, and is unprepared to engage in an indiscriminate contest with inexorable death! In addition, however, to the pulmonary affection, this boy has a protu- berant abdomen. It is a matter of interest for us to ascertain the cause and nature of the enlargement. You perceive, as I percuss the abdo- men, not a dull, but a resonant sound, which arises from a flatulent con- dition of the intestinal canal, a very natural result of the chain of mor- bid phenomena developed in the system. Besides the tympanites, I very distinctly recognize fluctuation, which denotes an accumulation of fluid in the peritoneal sac. You find, therefore, gentlemen, that this wasted sufferer is affected with both consumption and dropsy. In speak- ing of the latter disease on former occasions, I have reminded you that it may be the effect of two opposite conditions of the system, viz.: 124 CLINICAL LECTURES. from over-action, and from debility—hence the division of dropsy into sthenic and asthenic. You can have no embarrassment in comprehend- ing the true character of the disease in this case—it is the asthenic form, produced, no doubt, by the long-continued diarrhoea, by no means an un- common cause of this character of effusion. Allow me here to direct your attention for the instant to the resonant sound of which I have just spoken. Although you will recognize it frequently when dropsy does not exist, yet it is almost always the accompaniment of asthenic dropsy, in which there is a general impairment of the nutritive functions. As a consequence of this impairment, the intestines become more or less distended with flatus, and float on the surface of the fluid enclosed in the peritoneal cavity. You are to be cautious, therefore, not to mistake dropsy and a flatulent condition of the intestines for simple tympanites. Treatment.—To subject this child, standing as he does on the verge of the grave, weighed down by disease which baffles all human skill, to a course of medication, would be the refinement of cruelty, and the very essence of folly. The only medication, under the circumstances, is, as far as may be, to palliate the cough, and sustain the strength by nutri- tious diet. The cold infusion of cherry bark occasionally through the day may impart a little tone to the stomach. For the cough, a dessert-spoonful of the following may be taken as occasion requires: R Syrup Scillae........§ ij Mucil. Acaciae........§ iij Tinct. Opii. Camph.......§ ss Syrup Simp........§ ss SoL Sulph. Morphia?......gtt. vj M. Ulceration of the Neck of the Uterus in a married Woman, twenty-two Years of age; The Speculum.—Mrs. P., aged twenty- two years, married, the mother of one child, five months old, com- plains of pain in the hips and back, with much pressure on the upper part of the head. She has also an impaired digestion, with a deposit of lithates in her urine, and a muco-purulent discharge from the vagina. " How was your health, madam, before the birth of your child ?" " It was always good, sir." " Was your labor a severe one?" " No, sir." These questions, gentlemen, I institute for the purpose of obtaining a starting-point to this case. It is material to ascertain when these symp- toms commenced, and then endeavor to trace them to their cause. I suspected, when this patient described her sufferings to me, that I should find disease of the uterus. With this view, I made a vaginal examina- tion, and detected chronic ulceration of the cervix. This is a disease to which the neck of the womb is liable; and, perhaps, there are few causes more active in the production of this form of ulceration than the various circumstances connected with child-bearing. The patient informs us that she recognized for the first time the pains, etc., of which she complains ULCERATION OF THE NECK OF THE UTERUS. 125 about six weeks after the birth of her infant. It is, therefore, legitimate to infer that the ulceration is the consequence of parturition. Ulceration, like induration of the cervix, is preceded by inflammation of the part. You have seen in this Clinique many cases of ulceration, and your attention has been particularly directed to the effects on the general system of this affection. For example, the pain in the head—usually on the upper part of the head—the pain in the back and hips, the impaired digestion, and the lithates recognized in the urine, in the case before us, are so many results, either directly or indirectly, of ulceration of the neck of the womb. I do not mean to say that in all cases of ulceration these effects will invariably follow; but it is a fact worthy of recollection that they are by no means unusual accompaniments. If this be so, the intelligent student will very naturally desire to trace the connection be- tween these results and the ulceration. He will not be content with the mere fact, but he will ask—Why is this so ? The connection can be estab- lished only through the multiplied nervous sympathies, which are known to exist between the uterus and other portions of the economy. There is scarcely an organ which is not, to a greater or less extent, through the agency of the nerves, in alliance with the uterus; and it is through this agency alone that we can explain why remote parts are almost always affected in both organic and functional diseases of the womb, whilst the patient, in many instances, experiences but slight pain in the uterus itself. This is what constitutes the stumbling-block in the treatment of uterine maladies; the pain in the head, the disordered stomach, the uneasiness in the back, etc., which are but the consequences of some derangement of the womb, being regarded as the disease. Remedies are applied to the head, stomach, etc., the patient experiences no benefit, and the prac- titioner derives no credit. The disease, in the mean time, is progressing insidiously, and often results in the destruction of health. The womb is supplied with nerves by the two great divisions of the nervous systems, viz., the cerebro-spinal axis, and the trisplanchnic nerves. The former presides over animal life, whilst the latter are essential to organic exist- ence. The pain in the back and head—the results of uterine disease—is conveyed through the cerebro-spinal axis, whilst the organic derangements, such as are observed oftentimes to occur in the stomach, heart, and diges- tive system generally, are due to the action of the ganglionic department. There is one feature in this case with which is associated a very im- portant and interesting fact—it is the character of the urinary deposit. Frequently patients will consult you on this subject; and if you re- gard the urinary deposit as a disease per se—if you connect it with some idiophathic affection of the kidneys, you will often err in judgment, and fail to benefit your patient. Lithates are not uncommon in th% urine of females ; and if your observation be directed to this point, you will discover that they are often the indirect results of disease of the womb. This character of deposit is one of the evidences of impaired digestion. 126 CLINICAL LECTURES. In diseases of the uterus, either functional or organic, this impairment, I have already remarked, is apt to follow through the operation of the tris- planchnic system of nerves. You see, therefore, how manifestly import- ant it is, before having recourse to therapeutic measures, to ascertain where the cause and effect exist. In the patient before us, the derange- ment of the nutritive functions is, I have no doubt, the direct, whilst the lithates in the urine are the indirect results of the ulceration of the uterus. If this reasoning be correct—and its accuracy you will be enabled to cor- roborate when you shall have become extensively engaged in the treat- ment of the diseases peculiar to females—what course of action does common sense suggest in the person of this patient ? Why, unques- tionably, in the first place, to distinguish between the producing cause and its results, then, with the removal of the former, the latter will have no existence, the effect of which will be the restoration of this woman to health. Treatment.—This will depend much upon the character of the ulcera- ation, whether it be acute or chronic, benign or malignant. In the case before us, the ulceration is chronic and benign in its character, and the object, therefore, of the local application is not to destroy, but simply to modify, or rather stimulate, the vitality of the tissues. For this latter purpose, there are two substances much employed, and with excellent effect, viz: the nitrate of silver, and the acid nitrate of mercury. As a general rule, in these chronic ulcerations of the os, I prefer the former, and usually employ it in the solid stick. Cauterization of these chronic ulcers answers two objects. 1st. The eschar formed protects the ulcer for the time being against friction of the upper and loose folds of the vagina; 2d. It stimulates the part to healthy and restorative action. The application must be made through the speculum. This instrument, gentle- men, is subject to abuse. It is often employed unnecessarily, and its intro- duction followed by an unjustifiable aggravation of the patient's sufferings. The speculum is not, in reality, an instrument of modern inven- tion—its origin dates back for a long period of years; but its intro- duction to the profession as a means of diagnosis in diseases of the uterus, may be said strictly to have commenced with Recamier, who gave it an impulse to popularity, which has been extended to it, more or less, to the present time. I need not describe to you the various modi- fications which this instrument has undergone, nor is it even worth the time to enumerate the number of different specula which authors and practitioners have suggested for the adoption of the professional public. Suffice it to say, that they are not only numerous, but, in my opinion, unnecessary. Each has his own favorite instrument, whilst I am sure in the great majority of cases, the object of the speculum—which is to see, an# make applications to the diseased surface—may be fully ac- complished by what is termed the cylindrical, and the valved speculum. So far as relates to diseases of the cervix uteri, the former answers every purpose when the cervix has not undergone much increase in THE SPECULUM. 127 volume. In this latter case, however, the valved instrument will be preferable, for the reason that there will be less probability of inflicting injury upon the diseased surface. Also, in cases in which it becomes necessary to make application to the walls of the vagina, as, for example, in granular vaginitis, etc., the latter form of speculum is to be employed. On account of the cheapness, the cylindrical glass instrument answers very well, but an objection to it is its fragility, and the occasional injury inflicted on the patient by its breaking in the vagina, owing to clumsiness in its use. Here I show you an ivory instrument, which I am in the habit of using; for ordinary purposes, it is, on many accounts, the best you can employ. The object of the speculum is, I repeat, to afford the prac- titioner an opportunity of seeing the part affected, and of accurately applying to it whatever remedy his judgment may suggest. I have often remarked to you that, comparatively speaking, I rarely have re- course to the speculum as a means of diagnosis; I much prefer the sense of touch. This I have sedulously cultivated, and find no difficulty, under ordinary circumstances, in arriving at a correct data with it alone. I advise you, gentlemen, to cultivate this sense of touch—it will spare many a pang to your suffering patient, and produce very satisfactory results. On more than one occasion I have found it necessary to protest against the use of the speculum, for the double reason that it was un- necessary, and added a keen edge to the already melancholy anguish of the invalid. For example, in the ulcerated stage of carcinoma, what will justify the introduction of the speculum as a means of diagnosis ? The physician who should require this instrument under such circumstances, would be just as much in the dark after its employment as he was be- fore ! Carcinoma, especially in its ulcerated form, speaks a very intel- ligible language—the simple touch of the educated practitioner will cause a complete and prompt recognition of this fearful malady. I remember on one occasion witnessing very serious consequences from the inoppor- tune use of the speculum. It was a case of cauliflower excrescence of the cervix uteri. The instrument was thoughtlessly thrust against the dis- eased mass—the delicate pelicle covering the granules, which consist of a congeries of vessels, was thus ruptured, and profuse hemorrhage followed. In introducing the speculum, the patient should be placed on her back, the hips brought to the edge of the bed, each foot resting on a chair. The room should be darkened, and when the instrument is. properly introduced, a light should be applied, which will enable the practitioner to make the necessary application to the diseased surface. You should be careful not to expose your patient; and, as you perceive in the case before you, exposure is not necessary to the successful em- ployment of the speculum. [Here the Professor introduced the instru- ment.] The speculum being well covered with oil, you separate, with the index and middle fingers of the left hand, the labia majora—the in- strument is then introduced, not violently, but gently and cautiously, 128 CLINICAL LECTURES. carrying it at first from before backward, and after it has penetrated the vagina about three inches, the direction imparted to the instrument should be backward and downward, for the reason that in the great ma- jority of cases, the cervix will be found inclined slightly toward the rectum. After carrying the instrument in this direction, it will then be necessary to depress the outer extremity of it, for the purpose of em- bracing completely within its focus the neck of the uterus. This is an important direction, and if you should omit it, the same thing may befall you that has often befallen others, viz.: to expose to view, and make your application upon the anterior portion of the neck of the womb, instead of one or other of the lips, which may be the seats of the ulcera- tion. Something more, gentlemen, is necessary to cure your patient of ulceration, than the mere use of the speculum—this instrument has no instinctive power of self-introduction—it can not find its way to, and bring into view the diseased surface, without receiving proper impulse from the hand that directs it. Every thing, therefore, will depend upon the modus in quo, so far as relates to its accurate introduction. Now you perceive I have introduced the instrument, and I can very distinctly recognize the os uteri and the ulcerated surface, which is the object of interest to us. With this piece cf sponge moistened, I remove from the ulcer the muco-purulent material, thus—and then touch the affected part with the solid nitrate. This application of the nitrat. argenti should be made once in five or six days. In order to secure a soluble state of the bowels, and at the same time impart a gentle tone to the system, two of the following pills may be taken two or three times a day, as circumstances require : R Extract Gentianae J Pulv. Rhei f.....3j Saponis . ......3ss Aquae........Q. S. Ft. massce in pil. xx. dividenda. Ulceration of the Neck of the Uterus—Conflicting Opinions respecting.—Few questions, gentlemen, in the department of ob- stetric medicine have excited, in late years, more controversy, or called forth a greater variety of conflicting opinions, than that in- volving ulcerations of the os uteri. It is, I think, to be regretted that medical men, like others in the various walks of life, are apt in their discussions to be swayed by pride of opinion, and influenced too much by love of victory. Truth is often obscured by such motives, and con- sequently a serious check given to the healthy progress of scientific inquiry. On reference to the contradictory opinions which have been advanced touching ulcerations of the neck of the uterus, full exemplifi- cation will be found of the accuracy of my statement.* For instance : * One of the latest writers on this subject, Dr. West, maintains that ulceration of the cervix uteri is not only far less frequent than is imagined by certain authors, but he ULCERATION OF THE NECK OF THE UTERUS. 129 Writers on this subject may be divided into two classes—the one class attaching but little value to these ulcerations, and often even doubting their existence—whilst the other, in all derangements of the uterine organs, can see nothing as a cause of these derangements but ulceration. Here, then, we have, on a cardinal point, two opinions directly opposed the one to the other. Both can not be right—which is the true one ? I have great confidence in accurate observation, and feel a profound re- spect for what may be termed clinical facts—facts, not of fancy, buft facts which have been confirmed at the bed-side, and which, therefore, have, if I may so speak, a high claim on the attention of the practitioner. Now, permit me to ask—What is it that the bed-side demonstrates on this vexed question ? In my opinion it establishes the following truths : 1. That ulceration of the os uteri is of frequent occurrence; 2. That, in many instances, this ulceration is little more than a simple abrasion, giving rise to no local or constitutional disturbance, and will readily yield to rest in the recumbent position; 3. That neither the abrasion nor ulceration can be strictly considered primary affections—the former being frequently connected with congestion, whilst the latter is the result of inflammation of the organ; 4. That oftentimes simple ulceration, unattended by any structural change in the uterus, will not develop either local or general disturbance of the system; 5. That in many cases ulceration of the os requires judicious local treatment; 6. That with the local applications there must often be conjoined constitutional measures ; 7. That the disturbances of the general system dependent upon either ulceration of the os uteri, or other derangements of the organ, will cease with the removal of these derangements; 8. That constitutional disturbances are often referred to ulceration of the os uteri, when no ulcerations exist—but, in lieu of which, there is some functional or organic disease of the uterus. attempts, also, to show that it is usually unaccompanied by much local or general disturbance of the system. Indeed, he seems to regard this form of disease as an isolated affection. Dr. West is a clever writer, and, I have no doubt, a careful ob- server ; his language bears the impress of candor, and yet it seems to me he has, in the pursuit of his inquiry, established some singular data for his opinions. For ex- ample, in speaking of the cervix uteri in a state of health, he observes: "But, if structurally so lowly organized—if physiologically of such secondary importance— if so much less subject than the body of the uterus to alterations in its intimate structure—and if so comparatively insensible even to rude modes of therapeutical interference—it certainly does appear to me that the assumption that some slight abrasion of the mucous membrane covering this part is capable of causing a list of ills so formidable as are attributed to it, ought to rest for its support upon some other and stronger foundation than any inference fairly deducible from anatomical or physiological data." (Page 22). Now, I readily concede all that Dr. West asks for the comparative insensibility of the cervix uteri in a state of health—but when under the influence of diseased action how different is the cervix I For then it becomes congested, oftentimes giving rise to profuse hemorrhage, and its sensibility is vastly increased. It is not, in my judgment, logical to measure pathological changes by the peculiar physiological or anatomical condition of a part in health. 9 130 CLINICAL LECTURES. These, gentlemen, are, I think, truly the revelations of the bed-side upon this disputed question—and they are valuable or otherwise pre- cisely as they may be found to accord with well-directed clinical observ- ation—observation unembarrassed by preconceived theory, with no hypothesis to sustain, but the sole object of which shall be the elimina- ion of truth. Ulcerations of the os uteri may be divided into the benign, malignant, and specific. The benign include all those ulcerations the result of simple inflammatory action—the malignant, the various carcinomatous developments—whilst syphilis, scrofula, etc., afford examples of the specific ulcerations. Ulceration is also divided into acute and chronic. Causes.—These are local and constitutional—the former may be divided into the predisposing and exciting. In examining the predispos- ing local causes of ulceration of the os uteri, we shall have explained why it is that this affection is comparatively of frequent occurrence. In the first place, the very position of the cervix necessarily predisposes it to inflammatory action. For example, it is situated in the most depend- ent portion of the trunk, its veins unsupplied with valves; and these two circumstances necessarily tend in a greater or less extent to an arrest in the circulation, thus inviting congestion in one or other of its forms. Secondly, the important function, menstruation, by occasioning a monthly afflux of fluids to" the part, predisposes in no small degree to morbid influences in the cervix of the organ. As I have frequently remarked to you, the uterus possesses one remarkable characteristic, viz., great mobility. This may also be enumerated among the predisposing causes of ulceration. The exciting local causes are numerous, such as child-birth, cold, menstrual irregularities, excessive sexual intercourse, irritating injections, pessaries, masturbation, etc. Among the gen- eral or constitutional causes may be mentioned, plethora, and its oppo- site, dilapidated health. Chlorosis is not an unfrequent cause of ulcer- ation, and you will often observe a peculiar form of ulceration in what is termed a scrofulous diathesis. In a word, gentlemen, I might pro- ceed at great length to enumerate the various conditions of system act- ing both as predisposing and exciting causes of ulceration of the cervix uteri, but I do not deem it at all necessary. The point for you to de- termine in practice is the particular cause in a given case, and this your own good judgments will generally enable you to do without difficulty. Symptoms.—The symptoms of ulceration are both local and general; but they are by no means uniform. Often there will be no pain about the uterus, the pain being confined to the back and loins, with shooting pains through the pelyis, etc. The discharge is sometimes purulent, muco-purulent; and when the ulceration is deep, it is more or less mixed with blood. Frequently, there is more or less menstrual irregularity, either dysmenorrhoea, menorrhagia, or suppression, and sometimes the irregularity consists in the quantity being simply defective. The general, or constitutional symptoms, are not only numerous, but extremely vari- SPINA BIFIDA. 131 able, consisting of pains in different portions of the system, such as the head, chest, abdomen, sides, etc.; more or less derangement of the stom ach, and nutritive functions generally; constipation, loss of appetite, etc. In fact, the constitutional disturbances consequent upon ulceration of the cervix resemble very closely those which result from other affections of the organ, either functional or structural, and to which your attention has oeen directed in the Clinique, as these affections have presented them- selves to our observation. Diagnosis.—In all cases of inflammation of the mucous membrane of the os uteri, there will not only be different phases of the inflammatory action, but there will also be different names given to the products of this inflammation, depending, in the first place, on the stages of the phlegmasia; secondly, on the particular part of the structure affected; and, thirdly, on the cause producing the inflammation, whether, for ex- ample, the disease be the result of pure, unmixed, or specific inflamma- tory action. Hence, some judgment will be required to note the various distinctions. In one case, there will be mere redness of the part, occa- sioned simply by a hypersemic, or congested condition of the vessels; in another, granulations will be detected; and, in this case, the seat of the inflammation will be the follicles of the cervix. Again, the stage of hy- peremia may have passed, or the follicular structure may not be spe- cially involved, and the morbid product will consist essentially in ulce- ration. The modes of distinguishing these various conditions will be by the toucher and speculum. There is, however, one fact of practical mo- ment connected with this subject, viz., that the local and general symptoms of hypersemia, granulations, and ulcerations of the cervix, bear a striking analogy to each other, and are ordinarily amenable to the same remedies. Treatment.—The remedies for ulceration of the os uteri are extremely numerous. They may be divided into general and local; the former embracing blood-letting, purgatives, rest in the horizontal position, baths, etc., whilst the local remedies consist in the topical abstraction of blood by leeches, or cups, hip-baths, vaginal injections, and, lastly, cauterization. The agents employed for this latter purpose are as follow: the nitrate of silver, the acid nitrate of mercury, the Vienna paste, the potassa cum calce, and the red-hot iron. It can scarcely be necessary to remind you that cauterization is not to be had recourse to in the acute stage of ulceration. Spina Bifida in an Infant, aged two Months.—James W., aged two months, has a congenital tumor, the size of an ordinary orange, on the lower portion of the spinal column. With the exception of the tumor, the child appears perfectly well, and exhibits every indication of good health. The case of this infant, gentlemen, presents an interesting ex- ample of what is termed spina bifida, which is a congenital deformity, and is traceable to defective ossification of the vertebrae, most commonly of the lateral arches and spinous processes. This defect in the organiza- 132 CLINICAL LECTURES. tion of the spinal column occurs usually, as in the case of this child, in the lumbar region, sometimes in the sacral, and rarely in other portions of the column; but instances are recorded in which the tumor involved the entire spine. In looking at this tumor, which you perceive projects more than two inches from the spine, it is not difficult to understand the mode of its formation. The tumor, in spina bifida, is sometimes large at its base, sometimes pediculated, and its volume is subject to numerous variations. In this affection, the spinal cord, its nerves and membranes, may all be in a healthy state; although, as a general rule, they are liable to more or less alteration. Paralysis of the bladder, rectum, and lower extremities, are not unusual accompaniments of spina bifida. It is im- portant, in your examination of this form of tumor, to avoid rude manipulation, for undue pressure has occasionally resulted, especially when hydrocephalus coexists, in coma and convulsions. It must be recollected that the spinal marrow in health is surrounded more or less with fluid. Occasionally, however, this fluid becomes mor- bidly increased, giving rise to the disease known as hydro-rachitis. Under these circumstances, the fluid is most frequently contained in the space between the visceral arachnoid and the pia-mater. In some instances, it ex- ists in the arachnoid sac, and in such case many believe that it has passed through a laceration into the visceral arachnoid, coming from the sub- arachnoid cavity. In other, but very rare cases, it is found in the canal of the spinal cord. When this morbid accumulation thus occurs, the dis- ease is similar to chronic hydrocephalus, and these two affections are often found to co-exist. You must, however, not confound the tumor, which necessarily arises from a spina bifida, with dropsy of the spinal marrow. In the former, in consequence of defect in the osseous matter, the natural fluid gravitates, and a tumor is formed because of the want of resistance. You see, therefore, that spina bifida and hydro-rachitis, or dropsy of the cord, are quite distinct the one from the other. Hydro-rachitis may exist without spina bifida; whilst the latter will occasion a tumor, which is not necessarily the result of morbid accumulation of fluid, but simply of the want of mechanical support. In the latter case, by elevating the pelvic extremities, and depressing the upper portion of the trunk, the tumor will be seen to diminish in consequence of the reflux of the fluid contained within the sac. In hydro-rachitis, on the contrary, this circum- stance is rarely noticed. My own opinion of the case before us is, that the tumor is not the result of dropsy of the cord, but arises altogether from a want of support in the vertebrae. You perceive I now elevate the hips of the child, and depress the upper portion of its body—the result in the tumor is quite obvious from its diminished size. Chaussier says, ac- cording to observations made in the Maternite of Paris, spina bifida oc- curs about once in a thousand births. Causes.—Defective ossification in some portion of the spinal column. Diagnosis.—The situation and character of the tumor define the nature of the disease. VENEREAL CONDYLOMATA. 133 Prognosis.—This affection is almost always fatal, although the infant may survive for several months, and even years. Treatment.—Authors have suggested various plans of treatment, among which are puncture and compression. Sir A. Cooper succeeded in effecting a cure by puncturing the sac with a needle, evacuating every fourth or fifth day the contents, and applying a roller bandage. Even this treatment, however, succeeds but rarely. Puncture, by the sub- cutaneous method, which is often preferred, because it prevents the entrance of air, has sometimes terminated in death. It should only be had recourse to in cases in which there is but little hope; and in this op- eration, it must not be forgotten that the spinal cord, which is frequently adherent to the internal parietes of the tumor, may become injured. Gen- tle compression is, perhaps, the safest plan to be adopted, and has in some cases proved successful. Chassaignac has published a case successfully treated by him by puncture, and injection of equal parts of water and tincture of iodine. In the case before us, I shall suggest nothing, at least for the present, with the exception of directing the mother to be cautious in protecting the tumor from injury. Mucous discharge from the Vagina, and Pruritus of the Vulva, OCCASIONED BY VENEREAL CONDYLOMATA IN A MARRIED WOMAN, AGED twenty-eight Years.—Mrs. R., married, aged twenty-eight years, no children, is much troubled with irritation in the vagina, accompanied with pain, and a sense of fullness in the parts. Her most distressing symptom is excessive itching, for which she says she has applied various remedies without any benefit. She is also affected with an annoying mucous discharge from the vagina. It would be a difficult matter, gen- tlemen, to prescribe for this patient, with any reasonable hope of success, without knowing something more of the case than the above symptoms indicate. You have had before you, during the present session, numerous cases of females complaining precisely of the same character of symp- toms described by this patient, and traceable to various causes. The first object, therefore, to occupy your attention, and the only sure basis for relief, is to ascertain, if possible, what it is that has produced the pru- ritus, mucous discharge, etc., in the present case. Fully realizing the difficulty of prescribing, with any degree of satisfaction, without more positive knowledge of the circumstances connected with her disease, 1 requested this woman to submit to an examination, to which she at once consented. I found, just within the vagina, several fleshy elevations, separated from each other, and pediculated, presenting a reddish color. The character of these growths excited my suspicion, and I questioned the patient very closely as to what had produced them. She frankly acknowl- edged that about four months since she had been affected with syphilis, contracted from her husband, a dissolute and worthless man. Growths, such as are exhibited in the person of this patient, are among the se- 134 CLINICAL LECTURES. quelae of venereal disease, and they demand much care, in order that they may not be confounded with excrescences in these parts, from other causes. They are sometimes called condylomata, vegetations, mucous tubercle, etc. They are more common in women than in men, and may result from either gonorrhea or syphilis. They sometimes are primary, but most frequently, I think, secondary. They are usually at- tended with pruritus and a mucous discharge. Treatment.—In the case before us, these condylomata are secondary; and, moreover, they are pediculated, which is not always the case. When pediculated, the readiest mode of removing them is with the curved scissors, and then touching the bleeding surface with the solid nitrate of silver. There are numerous local applications employed for the cure of these growths, such as the following : R Pulv. Sabinae .... gr. x Pulv. Sulphat Cupri . gr. x M. R Unguent Hydrarg.......§ ss Unguent Iodinae ...... 3j M. R Oxymuriat. Hydrarg......gr. ij Aquae Calcis..... § j Ft. sol R Sub. Mur. Hydrarg......3 j Adipis........|j Ftung. R Chloride Sod........% j Aquae distillat.......§ viij Ft. sol. R Nitrat Argenti......3j Aquae distillat.......§ j Ft. sol One of the chief points in the treatment is strict cleanliness, and for this purpose the patient should be directed to take a hip-bath daily. It will be proper, under the circumstances, for the patient to take in divided doses during the day a pint of the compound decoction of sarsaparilla, with 3 j of dilute nitric acid. " Will you allow me, my good woman, to remove these tumors ?" " Yes, sir." [Here the patient was placed on the bed, and the Professor, with a pair of curved scissors, removed the condylomata, Jive in number, and then applied the caustic to the cut surface.] " You must take a hip-bath, my good woman, every day, and use the medicine as above directed, for two or three weeks, and you will be restored to health. This case, gentlemen, is interesting on several accounts. In the first place, the pruritus and mucous discharge, the two prominent symptoms, could not be remedied without accurately under- standing the particular cause which had occasioned them. And secondly, these morbid growths are the product of a previous venereal contamination. LECTURE II, The Uterus and its Appendages.—Their Structure.—The Modifications of Structure in Pregnancy.—The Uterus in Health and Disease.—Its Physiological Action.— Normal Position of the Organ.—Does it enjoy much Mobility ?—Ante-version of the Uterus from a Collection of hard Faecal Matter in the Rectum.—Removal of the accumulated Faeces by the Introduction of a small Spatula.—Constipation and Diarrhoea in Pregnancy.—Suppression of the Menses in a Girl, aged eighteen Tears, the Suppression following an attack of Scurvy ?—What is the Cause of Scurvy ?—Has it any Influence over the Menstrual Function ?—Falling of the Womb in a married Woman, three Months Pregnant, with inability to pass Water. Gentlemen—The uterus, and its appendages, whether we regard them in connection with their physiological action, or their pathological changes, are among the most remarkable organs in the entire system. The truth of this remark you have had ample opportunity to test in this clinique, where you have seen almost every variety of disease and displacement to which these organs are subject. You have studied them in health; and you have studied them, also, in affections both functional and organic. You have marked the important influence they exercise over the economy—in health, insuring harmony to the mechanism, whilst, under the influence of morbid action, they produce the most varied disturbances. Hippocrates, centuries ago, observed : Uterus sexcentorum morborum causa ;" and if, in this remark, we recollect that he did not limit himself exclusively to the uterus itself, but intended to embrace what may be termed the reproductive organs of the female, whilst we admire his sagacity at that early period of our science, we can not but be struck with the truthfulness of his judgment. I propose to-day to make some general observations on the uterus itself, more especially in reference to its structure, its normal position, and the displacements to which it is liable. The structure of this organ is composed of various elements, and consequently it is subject to numerous diseases. Its structure may be said to present: 1. An external covering, which con- sists of anterior and posterior duplications of the peritoneum; 2. An internal covering or lining membrane, which is essentially mucous in its healthy functions, and in its pathological changes; 3. An interme- diate muscular tissue; 4. Blood and lymphatic vessels; 5. Nerves. 6. Ligaments. It must be apparent to you that the union of such varied 136 CLINICAL LECTURES. tissues in an organ must necessarily expose that organ to varied and numerous diseases. For example, its external investment, the perito- neum, becomes oftentimes the seat of inflammatory action, subjecting the patient to the greatest possible peril; the internal investment, the mucous lining, is also subject to inflammation, profuse hemorrhages, polypoid and other growths; the intermediate tissue, consisting essen- tially of muscular fibres, is the seat of rheumatic attacks, spasmodic contractions, interstitial tumors, calcareous concretions; the nerves sometimes become affected, giving rise to neuralgia; whilst the blood- vessels, under certain influences, enlarge, and endanger life by profuse bleedings : the ligaments, too, are liable to laceration and inflammation; again, the cervix uteri is frequently the center of serious morbid action —inflammation, ulceration, granulation, engorgement, hypertrophy, and the various malignant growths. In addition to all these maladies to which the uterus is liable, you are not to omit another most important class, composed of what may be called its functional derangements, embracing the various menstrual aberrations, &c. Again, study this organ amidst the numerous phenom- ena which develop themselves during gestation, the modifications of its texture during this period, the changes in its physiological action, the multiplied sympathies it evokes throughout the economy ; and remem- ber, too, that the increase of size in the impregnated uterus is the result of successive new formations which, commencing in the most rudiment- ary state, continue until the highest degree of organization is consummated. When the uterus has attained its full development under the influence of pregnancy, it then enters upon a new series of duty—it becomes the center, as it were, of two movements: one is the spontaneous and inde- pendent contraction of its muscular fibres, the other movement is the result of reflex action derived from the medulla spinalis. The object of these combined movements is an expulsive force, which enables the organ to throw the child into the world, after it has attained an intra- uterine development sufficient to prepare it for an individual or inde- pendent existence. As soon as this last act has been completed, the organ then undergoes new changes in its elementary constitution—the blood-vessels and nerves which, during gestation, were largely developed, now diminish in volume, and soon not a vestige can be detected by the eye; the muscular tissue becomes much less considerable through the diminution both in size and number of its elements—the musculo- fibre cells—and its alteration is such that it oftentimes assumes a fatty degeneration. In a word, the organ becomes invested again with a rudi- mentary character, which continues until stimulated to new formations and a more perfect organization by pregnancy. This, gentlemen, is but an outline, brief indeed, of the peculiarities of the uterus, and if, in addition to what has been said, you take into view the various displacements to which this organ is subject, involving such THE UTERUS AND ITS APPENDAGES. 137 an infinity of abnormal phenomena, and exposing it to such multiplied de- rangements, the wonder is, as has been well observed, not that the uterus is so often the seat of disease, but that it should enjoy even a comparative im- munity from disturbance. It is, indeed, not strange, that this cradle of man, as it has not been inaptly termed, should have excited the enthusi- asm of the fathers of our science. It is related of Galen, that on first beholding the texture of the uterus, he exclaimed, that he would sing hymns of thankfulness to the gods, for having been permitted to behold such a wonderful structure! This organ is essentially intended as a temporary domicile for the foetus, a place of sojourn until it has reeceivd from its parent sufficient development to prepare it for an external existence, and, therefore, is strictly an organ of gestation. Let us now examine very briefly the various elements, which, in the aggregate, con- stitute the volume of the unimpregnated uterus. 1st. The external or peritoneal covering.—The entire posterior surface of the organ is covered by peritoneum, whilst it extends only on the two superior thirds of the anterior surface; the inferior third of this surface being in contact, through the medium of cellular tissue, with the bas-fond of the bladder. The peritoneum passes down on the posterior surface of the bladder, and reflects on the two upper thirds of the uterus; this duplication forms the anterior fold of the broad ligaments, whilst the posterior fold is formed by the descent of the peritoneum on the anterior surface of the rectum, and its reflection on the posterior surface of the uterus. Thus, you perceive, these two duplications of the serous mem- brane, one anterior and the other posterior, embracing within their folds the uterus and its annexas, stretch transversely across the pelvic excava- tion, dividing it into two halves, the front one of which contains the bladder, and a small portion of the^ small intestine, whilst the posterior affords space for the rectum, and also a portion of the small intestine. It may be observed that the adhesion of the peritoneum to the subjacent tissue on the lateral portions of the organ, and to a part of the cervix, is not so marked as on the remaining surface, where it becomes intimately interwoven, as it were, with the substance of the uterus. 2d. The mucous or lining membrane of the Uterus.—There have been many opinions advanced with regard to the true nature of the membrane lining the cavity of the uterus; some contending that it is really and essentially a mucous surface, whilst others deny to it in toto this charac- ter, and declare it to be nothing more than an epithelial covering. Coste, and others, however, have, through their researches, estab- lished some exceedingly interesting points touching this question, and have demonstrated beyond all peradventure its mucous properties. It has been shown that the mucous membrane of the os and cervix uteri possesses very different characters from that which invests the body of the organ. This membrane on the free extremity of the os uteri is simply a continuation of the vaginal mucous surface, becoming, as it 138 CLINICAL LECTURES. passes on the os tincce, remarkable for its tenacity and strong adhesion to the proper tissue of the organ. On this free extremity, there are nu- merous mucous follicles, which secrete in health mucus, and under the influence of disease an acrid fluid, which oftentimes irritates the adjacent organs. During pregnancy, these follicles enlarge, and produce a secretion intended to lubricate, and prepare for their ultimate distension the uterus, vagina, etc. The mucous membrane of the body of the uterus is much less abundantly supplied with follicles than that of the os and cervix of the organ. There is another interesting fact con- nected with the mucous surfaces of the neck and body of the uterus— the former secretes a thick, viscid mucus, similar to the white of an egg—whilst the latter furnishes a thin and colorless material. Donne maintains that the vaginal mucus is acid, whilst that furnished by the internal surface of the uterus is alkaline ; and it would appear from more recent experiments made by Mandle and Fricke, that the mucus secreted by the body of the organ is also acid, whilst the only alkaline mucus is that which comes from the internal surface of the cervix. This is an important fact to be recollected, for it has a strong bearing on the difference in the diseases of the body and neck of the uterus. The entire uterine mucous surface is covered by epithelium, which at each menstrual period is thrown off, and again reproduced. I need not call your attention to the difference in the physical appearance and prop- erties of the true mucous membrane of the uterus and this epithelium. Frequently, they have been mistaken one for the other, and hence the opinion that the mucous coat is discharged often from the uterine cavity. There are a few well-established cases of this kind, but such an event is extremely rare. If you remember the source from which the mucous lining of the os and cervix is supplied with blood, and then contrast it with that from which the mucous coat of the body of the uterus derives its supply, you will at once have satisfactorily explained not only the difference in the vascularity of these surfaces, but you will also see a reason for the marked difference in the diseases with which they are re- spectively affected. For example, the cervix is supplied only from the ovarian arteries, which give it but a few small branches, whilst the larger portion of its branches unite with the uterine arteries, to furnish the • body and fundus of the organ, and especially the mucous coat; and it is to this circumstance that the latter owes its greater vascularity. This again explains another interesting fact, viz.: the remarkable difference in the engorgement of the body and cervix of the uterus at the menstrual crisis. Allow me here to call your attention to another interesting, and both in a physiological and pathological sense a most important circum- stance. It is this—the mucous membrane of the os and cervix uteri is comparatively void of sensibility in health, whilst that of the body of THE UTERUS AND ITS APPENDAGES. 139 the organ is characterized by more or less susceptibility to pain from external impressions. Every day's experience demonstrates this fact, but I may mention a solitary proof. In introducing the uterine sound, the patient rarely complains of suffering, whilst the instrument is trav- ersing the mucous membrane of the cervix—it is only when it enters the body of the uterus that she manifests pain. We do not, however, concur in opinion with Jobert de Lamballe, who says the cervix is ab- solutely deprived of sensibility, and that it does not receive any nerves; the researches of Ludovie, Hirschfeld, and others, demonstrate that there are at least some few nerve fibres in the cervix uteri. The mucous membrane of the uterus has been found to contain fibro plastic tissue, which is the ordinary element of the fibrous tumors not unfrequently seated on one or other of the two surfaces just described. These tumors, as has been shown more particularly by Dr. Charles Robin, are mere accumulations of a normal element. 3d. An intermediate muscular tissue.—Few questions have given rise to more earnest discussion than the peculiar nature of the intermediate tissue of the uterus. For a long time it was most emphatically denied that muscular fibre entered into any part of its texture, and even now there are some writers who maintain this latter opinion. But mere opinion is worth nothing unless it accords with facts. Indeed, the only value of opinion consists in its truth. Without this, it is worse than dross, and has served in too many instances to confuse, if not retard science. Now, with regard to this very question, what has the anatomist revealed, and what has he in the most satisfactory manner demonstrated ? He has both revealed and proved the existence of muscular structure in the uterus, and yet if you look for this demonstration of muscularity in the organ, when unimpregnated, you will be disappointed. Not that the muscular tissue is not there, but it is so modified that its identity is not easily recognized. If, then, you attempt to decide this controverted question by an inspection of the womb only in a state of vacuity, you may inflict a wrong upon science. It is like deciding a question of law by an examination of one or two points only of the evidence. The whole testimony or none, is a good maxim in law, and it is equally applicable in medicine. In the unimpregnated uterus, the intermediate tissue of the organ is whitish, and possesses extreme density; the muscular fibres are so firmly interwoven with each other, and so altered, that it is not only impossible to trace them, but almost as impossible to determine their true nature. On the other hand, you will have no difficulty in de- ciding as to the character of this tissue, if you examine the impregnated uterus—here every thing is changed, through the progressive develop- ments of the various structures consequent upon gestation, and the mus- cular fibre is not only plainly recognized, but its direction and general distribution are palpable. In fine, nothing is better settled than that the uterus is not only endowed with a really fibrous structure, but that it is es- 140 CLINICAL LECTURES. sentially in form and in action a hollow, or, if you choose, an orbicular muscle. The recent researches of Koelliker have proved that the mus- cular fibres of the uterus are, like the fibres of all the other muscles of organic life, composed of elongated cells, more or less adherent to each other. The office of the uterus is to afford accommodation to the foetus during its intra-uterine life, and then to accomplish its birth through an expulsive force derived from the contraction of its muscular structure. 4th. Blood vessels and lymphatic vessels of the Uterus.—The uterus de- rives its supply of blood from two sources, viz.: the ovarian and uterine arteries. The former generally pass from the aorta just below the origin of the renal arteries ; they descend along the vertebral column, behind the peritoneum, and in front of the psoas muscles and ureters; they then pass between the duplications of the broad ligaments, and dividing into several branches supply the cervix, body, and fundus with blood; anas- tamozing in the two latter portions of the organ with branches of the uterine arteries; these latter, the uterine arteries, one on each side, are given off by the hypogastric or internal iliacs, and proceed to the lateral portions of the uterus, and then in conjunction with the ovarian vessels distribute themselves through the substance of the organ. Before puberty, these vessels are extremely small, and convey to the uterus but little blood, for the reason that this organ is without function, and needs no more blood than is necessary for its nutrition. Indeed, in this particular they may be considered in some sense as analogous to the two branches of the pulmonary artery during foetal life; these convey to the lungs of the foetus, which are also without function, just blood enough to main- tain their vitality. But as soon as respiration is established, and the foetus commences its independent existence, the surplus blood which be- fore was conveyed through the ductus arteriosus to the aorta, passes through the right and left branches of the pulmonary artery, respectively to the right and left lobes of the lungs, for the purpose of purification. So also, when puberty has been attained, the blood vessels of the uterus have new duties to perform; the wants of the organ are greater, for the reason that its specific function, menstruation, commences. Hence, there is a monthly sanguineous congestion of the uterus. The veins are likewise distributed throughout the parenchymatous structure, and what is worthy to be recollected, they are without valves. This latter circumstance, together with the peculiar position of the uterus, preventing the free return of venous blood, is oftentimes a predisposing cause of undue congestion of the organ, thus exciting in it mora or less disturbed action. The lymphatic vessels of the uterus communicate with the pelvic ganglia, and those of the cervix communicate also with the lymphatics of the anterior portion of the vagina. You will occasionally observe, in carcinoma and other affections of the cervix uteri, engorgement of the inguinal glands. This may be explained by the anomalous dis- tributions of these lymphatics to which attention has been directed by THE UTERUS IN HEALTH AND DISEASE. 141 certain writers. In metritis, supervening upon child-birth, the lymphatic vessels of the uterus will frequently be found filled with pus. 5th. Nerves of the Uterus.—The uterus is supplied with nerves from the ganglionic and cerebro-spinal systems; the former, the ganglionic nerves, come from the renal and hypogastric plexuses, and are distributed freely throughout the structure. The cerebro-spinal nerves are furnished by the sacral plexus, and are distributed by anastamosis, and otherwise, with the ganglionic nerves, on the various portions of the uterus. It has been very positively denied that the uterus receives any nerves whatever from the cerebro-spinal axis, and one of the most formidable advocates of this opinion is M. Bouillaud; on the other hand, Jobert maintains that the projecting portion of the cervix uteri is entirely deprived of nerves, and is, under all circumstances, insensible. As to the complete insensi- bility of this part of the cervix in some cases, he is, perhaps, not alto- gether wrong; but to deny that it never becomes the seat of pain, is at variance with actual experience. To the opinions of Bouillaud and Jobert may be opposed the researches of Hunter, and, in our own times, of Tiedemann, Robert Lee, Muller, Herschfeld, and Boulan, who have positively recognized in the uterus, in the cervix, as well as in other por- tions of the organ, distributions of the cerebro-spinal nerves. It is a great question, not yet decided, whether the nerves of the uterus become enlarged and more numerous during pregnancy, or whether they retain the peculiarities which marked them when the organ was in a state of vacuity. This question has given rise to rather a warm controversy between Dr. Robert Lee and Dr. Snow Beck. The former, after Tiede- mann, endeavored to prove, that the increase, both in number and vol- ume is considerable; whilst Dr. Beck, after J. Hunter, denies this alto- gether, and maintains that the increase is only in appearance, for the reason that the microscope reveals the fact, that the neurilema and certain fibrous bands connected with it have been mistaken for nerves. How- ever this question may ultimately be decided, there is one circumstance which, from analogy, would seem to give strength to the views of Dr. Lee, and it is this, that in hypertrophy of the muscles of animal life— and the same thing is observed in hypertrophy of the heart—as first pointed out by Dr. Lee, and afterward completely proved by an able German micographer, Dr. Cloetta, there is an increase in the number and size of the nerve-fibres. Normal position of the Uterus—does it enjoy much mobility ?—The uterus is contained within the pelvic excavation, supported below by the vagina, having in front the bladder, with the bas-fond of which it is con- nected at its inferior third, posteriorly the rectum, between which and the posterior surface of the uterus is the triangular fossa; and above, in front and behind, the small intestines. These are the respective relations of the unimpregnated womb; its long axis is slightly oblique from above downward. The question now naturally arises, is the uterus an organ 142 CLINICAL LECTURES. which enjoys a great degree of mobility 1 You will find, gentlemen, that there are few organs in the system which possess this property to a greater extent. In the first place, the bladder, which is immediately in front, often becomes greatly distended with urine, and thus exerts a pressure against the uterus, to which this latter yields, constituting a retro-version; again, a distended rectum will throw it forward, and thus we have ante-version; the small intestines, if much loaded, will exercise a pressure which will dispose the organ to become prolapsed, whilst the vagina, relaxed under the influence of disease, or from the effects of child- birth, will become measurably unable to give the organ its proper sup- port, and hence again prolapsus to a greater or less extent. In addition to these, there are other causes which will produce deviations of the uterus, such, for example, as the weight of a fatty omentum, the accu- mulation of fluid in the abdominal cavity, enlarged ovaries, the presence of tumors, the corset, and other absurdities, had recourse to by the devo- tees to fashion, for the purpose of imparting grace to the figure, a grace oftentimes purchased at a heavy cost. An enlarged, as also a contracted pelvis, will greatly, under certain circumstances, influence the position of the uterus. To these various influences may be added falls, blows, etc. You see, therefore, that the uterus is characterized by great mobility, resulting frequently in displacements, some of which are transitory, whilst others are more permanent, calling for the interposition of science. When you consider the numerous causes of uterine displacement, more or less constantly in operation, together with the peculiar offices of the uterus itself, you can not regard this mobility of the organ in any other light than as a conservative act of nature. Suppose, for instance, the case of a distended bladder; if the uterus, under such circumstances, were fixed, and did not yield to the pressure exercised against it, the consequence would be serious inflammation of one or both organs, be- tween which and displacement no comparison, so far as the safety of the patient is concerned, can be instituted. Again, many women suffer se- verely from injury to the neck of the uterus during sexual intercourse, especially in cases where there is disproportion between the male and female organs. How much more frequent, and more intense would this suffering be if the uterus at the time of intercourse were immovable! Its very mobility is, in this case, its only protection against excessive injury. Fallopian Tubes.—These are two in number, and may be considered the excretory ducts of the ovaries as they afford a channel of passage for the ovule from the ovary to the uterus. They are situated on the superior border of the broad ligaments, at the lateral and superior angles of the uterus, with the cavity of which they are continuous, and termi- nate at the ovaries by a free or fimbriated extremity. The fallopian tubes have, like the uterus, an external or serous coat, an internal or ANTE-VERSION OF THE UTERUS. 143 mucous coat, and an intermediate muscular tissue. They are supplied with blood from the same source as the ovaries. Bound Ligaments.—The round ligaments arise from the lateral bor- ders of the uterus, just below and in front of the fallopian tubes ; they then pass outwardly and downward, and, after traversing the inguinal canal, terminate at the pubes. These ligaments are intended, no doubt, to antagonize the action of the distended bladder, and in this way pre- vent the more frequent occurrence of retro-version of the uterus. Ovaries.—These are essentially the organs of generation in the female —they are the analogues of the testes in the male, and hence are called the testes muliebres. Without the ovaries, the female can not become impregnated, for the reason that she can not furnish the ovule, this being a secretion of the ovaries themselves. These bodies are two in num- ber, small and almond-shaped; and are situated on the sides of the uterus to which they are attached by the ovarian ligament. The ova- ries remain small and are without function until the age of puberty, and become atrophied in old age. The structure of these bodies is pecu- liar—they are composed, 1st. Of a dense fibrous texture, called the tunica albuginea, which is invested by, and in close adhesion with, the perito- neum ; 2d. Of a spongy, vascular tissue, glandular in its nature. To the former, the albuginea, Baer has given the name of the stratum superfi- dale, whilst the term stratum intimum seu proprium is applied to the sub- jacent or glandular substance, which is in fact the proper ovarian tissue. In this latter one is imbedded the graafian vesicles, varying in the adult from ten to twenty in number. These vesicles at the catamenial period approach the surface, and in their maturity become detached, and pass off with the menstrual fluid, should fecundation not take place. Ante-version of the Uterus from a collection of hard Fjscal Matter in the Rectum ; removal of the accumulated Faeces by the introduction of a small Spatula.—Mrs. W., aged twenty-five years, married, the mother of one child one month old, complains of a severe bearing-down pain in her back passage, with a frequent desire to pass water, but an inability to void more than a small quantity at a time ; she is laboring under obstinate constipation, sometimes a week elapsing without an evacuation, and then after excessive straining, she is only able to pass a small piece of hardened faecal matter. " How long, my good woman, have you suffered from constipation?" "I begun to be bound in my bowels, sir, about four months after I became preg- nant, and I have been troubled in that way nearly all the time since." " How long have you felt the bearing-down pain in your back passage ?" " Ever since the birth of my child, sir." " Now tell me, if you please, whether you have had this frequent desire to pass water a long time ?" " No, sir, I was not troubled with it until my babe was born." This case, gentlemen, is one of much practical interest; I have made a very 144 CLINICAL LECTURES. careful vaginal examination, and have no difficulty whatever in account- ing for the bearing-down pain, the frequent desire to void urine, etc., of which this woman complains. She is laboring under ante-version of the uterus, that form of uterine displacement in which the fundus of the organ is thrown forward, pressing more or less against the bladder, and the cervix is thrown in the opposite direction. Ante-version, though much more rare than retro-version in the unimpregnated state, is, how- ever, occasionally met with. It is generally said by authors that this character of displacement never occurs in pregnancy. This may be true, or at least I can readily imagine its comparative rarity in the ear- lier periods of gestation before the fundus uteri has ascended above the brim of the pelvis. I have never seen a case of ante-version under these circumstances; but at a later period, especially from the sixth to the ninth month, ante-version does sometimes really take place, not in primiparae, but in women who have borne several children, and whose abdominal parietes have become so relaxed as to be inadequate to give proper support to, and retain in its position the developing uterus. In such case, the fundus falls forward, giving a peculiar and remarkably protuberant aspect to the abdomen. I have seen two cases of this kind, one of which has been reported. The case I allude to was that of the lady at Fort Hamilton, whom I saw in consultation with Drs. Carpen ter and Elwes; she had been in labor for several days—the fundus of the womb had fallen forward, and the cervix was directed backward, so that all effort on the part of the uterus to expel the child was abortive, for the reason that the head was pressing against the sacrum. In this in- stance I performed version, and saved both the mother and child. But let us return to the case before us. This woman complains of pres- sure on the back passage, obstinate constipation, a frequent desire to pass water, etc. It is by no means an uninteresting point to inquire whether any connection can be established among these phenomena, and whether such connection will stand in the relation of cause and effect. In the first place, we are informed by this patient that she has suffered more or less from constipation since the fourth month of her pregnancy. Secondly, the bearing-down pain, and difficulty with her water, have only manifested themselves since the birth of her child. These facts are so far very important in tracing this connection ; and now let us see what has been developed by a vaginal examination. I find, by this examination, the fundus uteri pushed forward pressing upon the bladder, whilst the cervix is turned in the opposite direction ; and another most important fact I have ascertained, viz.—the rectum is greatly distended with lumps of hard fecal matter. Here, then, is a case of displacement of the uterus, ante-version, pro- duced solely by the mechanical pressure of the distended rectum against the posterior surface of the organ: in the absence of any antagonizing force the uterus has fallen forward, and hence the displacement. With ANTE-VERSION OF THE UTERUS. 145 these facts, nothing is easier than to establish the connection to which I have alluded. The constipation is the first link; the collection of faecal matter in the rectum, the immediate result of the constipation, is the second link; the ante-version, the direct consequence of the distended intestine, is the third link; and the frequent desire to void urine, etc., the result of the pressure of the fundus uteri against the bladder, is the fourth link. Now, gentlemen, permit me to ask you, what is the course of treat- ment to be pursued in this case—what is the indication which common sense points out ? Why, undoubtedly, to remove the constipation by appropriate remedies. It is, however, most desirable in these cases in which there has been a collection of faecal matter for a long time in the rectum, not to wait for the operation of medicines, but to remove it with an instrument. If I were to order an enema for this woman, the great probability is, that it would not pass into the intestine because of the obstruction ; and the operation of a cathartic would be very apt to be greatly retarded by the presence of these lumps of faeces. But the important argument in favor of removing the faeces with an instrument is, that it will afford immediate relief to the patient—for as soon as the distension of the rectum subsides, the uterus will cease to be pushed for- ward, and the symptoms consequent upon the displacement will also cease to have an existence. " Now, my good woman, if you desire it, I will relieve you from your suffering by a very simple operation." " You won't cut me, sir, will you ?" " Indeed, I will not; but I will necessa- rily be obliged to give you a little pain." " Well, sir, if you will only relieve me, I will submit." " That's right, my courageous woman." I now propose, gentlemen, to bring away the faecal matter from the rec- tum, which may be done either by means of this small spatula, or by the introduction of the index finger; and here allow me to remind you that a physician should never be above his duty, even if that duty in- volve the necessity of a fundamental operation. [The patient was placed on the bed on her left side ; the Professor then having oiled the spatula introduced it into the rectum, and by gentle manipulation re moved in successive lumps a large quantity of faeces. The patient after the whole had been brought away expressed herself much relieved, and said she had not felt so free from suffering since the birth of her child.] The next thing to be done for this woman is to prescribe a cathartic; and for this purpose, I shall order R Olei. Ricin-.......|j If, after this, she should need other medicine, let her take, as occasion may require, a wine-glass of the following saline mixture: R Sulphat. Magnesiae ) aa 5 i Sup. Tart. Potassae f Aquae Purae.......Qj Ft. sol 10 146 CLINICAL LECTURES. Conshpation and Diarrhcsa in Pregnancy.—We have had in the clinique, from time to time, a great number of pregnant females, some seeking advice for one trouble, others for another, etc.; but the almost constant fact, which we have observed, and which accords with daily experience in practice is—that all were more or less subject to constipa- tion. Indeed, it may be said that regularity of the bowels during gesta- tion is the exception, whilst constipation is the general rule. If this proposition be correct, and there is no question as to its truth, the in- quiry naturally arises—Why is this ? Laying aside those cases of con- stipation, which are to be attributed simply to carelessness and neglect, there are numerous others continually occurring during the pregnant state, which need some other explanation. We know very well that the uterus in a state of gestation awakens in the economy numerous sympa- thies—and these sympathies can not exist without more or less derange- ment of the healthy or natural functions of the particular organs with which they are connected. For example, nothing is more common in pregnancy than disturbance of the stomach—hence vomiting is one of the usual accompaniments of this state; so likewise do the heart, lungs, kid- neys, liver, and the nervous centers, etc., become more or less deranged in their respective functions; and these sympathetic influences are pro- duced through the ganglionic system of nerves, which, becoming more or less the seat of irritation in the uterus, transmit this irritation through ganglia and plexuses to other organs of the system. I believe that to a certain degree the constipation so common in pregnancy may be ex- plained in the same way, the regular action of the intestinal canal being modified in consequence of a want of healthy nervous power from the ganglionic nerves: this, at all events, in my opinion, is the true explana- tion of torpor of the bowels in the earlier months of gestation ; and I, therefore, am disposed, as a general rule, to regard constipation as an ac- companiment of pregnancy for the same reason that I do nausea, vomit- ing, etc., each being traced to the same cause, viz., irritation of the gang- lionic system of nerves. But at a later period of pregnancy, there is an additional cause brought into operation, pressure of the uterus against the intestine; this shows itself most sensibly during the last four months of gestation, for at this period the uterus compresses the large intestine just as it passes from the left iliac fossa to the sacrum, and hence there is more or less obstruction at this point to the descent of the faeces into the rectum. It may be asked why, when the impregnated uterus becomes largely developed in the abdominal cavity, the whole intestinal canal does not suffer from compression ? The simple reason is, that the intes- tines above the pelvis enjoy great mobility, and are, therefore, from this cause enabled to accommodate themselves to the distended uterus. But, gentlemen, you will occasionally encounter an opposite state of the bowels during gestation—I mean diarrhoea; and it is proper for you to remember that the same causes capable of producing diarrhoea when CONSTIPATION AND DIARRHOEA IN PREGNANCY. 147 pregnancy does not exist, may also display their action during this state —such as improper food, cold, etc., and again diarrhoea in pregnancy, as in other conditions of the system, will sometimes be the direct conse- quence of the constipation. Have you never, for example, seen a case of protracted constipation followed by severe diarrhoea ? If you have not, such instances will undoubtedly occur to you in practice. In these cases, the intestinal canal becomes excessively irritated by the presence of faecal matter, and the consequence is more or less profuse diarrhoea. Now, one word, by way of parenthesis, as to the treatment of this latter form of diarrhoea. Give astringents, and you will probably destroy your patient; on the contrary, administer a good cathartic medicine— sweep the whole intestinal canal, remove the offending cause, viz., the accumulated faecal matter, and you will not only arrest the diarrhoea, but you will restore your patient to health. There is, however, gentlemen, what may be called the diarrhoea of pregnancy—that is to say, diarrhoea will sometimes supervene upon pregnancy almost simultaneously with the inception of this state, produced by a peculiar condition of the gan- glionic nerves; so that, although far less frequent than constipation, yet diarrhoea may be considered an occasional symptom of gestation. Al- though both constipation and diarrhoea may be said to be, under certain circumstances, the accompaniments of pregnancy, yet they will sometimes, if not controlled, lead to serious consequences, and they, therefore, re- quire the attention of the physician. For example, constipation will oftentimes be productive, especially in plethoric women, of headache, general nervous irritability, fever, insomnolence, etc.; and diarrhoea, also, may, by debilitating the system, give rise to unpleasant results ; but what is most to be apprehended is its tendency in women of great nervous suscep- tibility to produce miscarriage. Treatment.—It is very desirable during gestation to assist nature in overcoming the usual torpor of the intestinal canal; and for this purpose I am in the habit of ordering a simple enema of warm water early in the morning—or what very frequently answers an excellent purpose, a tumbler of cold water drunk as soon as the patient leaves her bed. Sometimes it may be necessary to give a little manna dissolved in water; and again one or two of the following pills may be administered, accord- ing to circumstances: R Massae Hydrar.......gr. xij Saponis,.......gr. xij Assafcetidae,.......gr. vj Ft. Massa in pil. vj dividenda. Much may, however, be accomplished by diet, such as vegetables, fruits, etc., in overcoming this tendency to constipation. The diarrhoea must be treated on general principles—should it result from improper food or constipation, a purgative will be indicated; if from nervous ir- ritability, calming enemata, etc. 148 CLINICAL LECTURES. Suppression of the Menses in a Girl, aged eighteen Years, the Suppression following an Attack of Scurvy. What is the true Cause of Scurvy ? Has it any Influence over the Menstrual Func- tion ?—Ann V., unmarried, aged eighteen years, has suffered from sup- pression of her courses for the last four months. " How long, my good girl, have you been in this country ?" " Just two months, sir." " Are you from Ireland ?" " Yes, sir." " Had you a long passage across the Atlantic ?" " We were ninety-seven days, sir, coming over." " What was the state of your health before you left the old country ?" " It was always good, sir." " Were your turns regular ?" '• Always, sir, until I got the scurvy at sea." " How do you know you had the scurvy?" " O! sir, there were fifty of the passengers who had it, and eleven died. We were all in a dreadful state, sir, and the doctor said it was a wonder we did not all die." " Had you any sores about you ?" " Yes, indeed, sir, we were all troubled in that way." " How long after you were at- tacked with scurvy was it when your courses stopped ?" " I caught the scurvy, sir, a month after I was on board the ship, and I have not been regular since that time." " What had you to eat on ship-board ?" " For the first month, sir, we lived on potatoes and rice; but the passage was so long that our vegetables gave out, and we had nothing but salt meat for nearly two months." Here, gentlemen, is a case of menstrual sup- pression under what, perhaps, may be denominated extraordinary cir- cumstances. I have no doubt that the irregularity was produced by the disease—scurvy—contracted by this girl on ship-board. Functional diseases of the uterus are of both local and constitutional origin; and in the case of this girl you have an example of the latter in- fluence in determining the menstrual suppression. The pathology of scurvy is an alteration in the blood—and this alteration is undoubtedly due to a peculiar kind of diet to which the individual has been subjected. The fact, I think, is abundantly established, that the exclusive use of salt provisions is the true cause of this disease, through the changes they pro- duce on the blood. It has been shown that, in a state of health, the blood presents a fixed composition, viz., fibrine, globules, serum, salts and water, in certain proportions; and that both food and disease are capable of modi- fying this character of healthy blood. There have been several attempted explanations of the modus operandi of salt provisions in the production of scurvy ; and there is one theory propounded by Dumas, which is not unworthy of consideration. He has shown, by experiment, that the color of the arterial blood is traceable to the red globules, and is altogether independent either of the albumen, serum, or fibrine in the circulating fluid, and even of the vital action of the animal itself. Again, he has established the fact that certain salts enable the blood to become aterial- ized, whilst others deprive it of this property. Among the former, he classes the sulphate of soda and phosphate of soda, etc.; and among the latter, the muriates of potash and soda. Now, as the proportion of the FALLING OF THE UTERUS. 149 muriate of soda in salt meats is very great, he establishes between the exclusive use of salt meats and scurvy the connection of cause and effect. Treatment.—This girl appears to have recovered completely from her attack of scurvy; and were it not for the irregularity under which she labors, she would be in the enjoyment of good health. It is to be re- marked that she does not present those general constitutional symptoms of disturbed action, which are so common in this form of menstrual aberration, and to which your attention has been so often directed. She exhibits, as you perceive, the aspect of an anaemic patient—her pulse indicates but little force, and in every respect she appears to need a tonic treatment. With this view, I shall order the following pills, one to be taken night and morning: R Aloes Barbadens......3ij Sulphat. ferri.......3j Ft. Massa in pil. xx. dividenda. Falling of the Uterus in a married Woman, three Months Pregnant, with Inability to pass her Water.—Mrs. W., aged twenty-nine years, married, the mother of two children, the youngest fourteen months old, says she feels a very uncomfortable pressure about her front passage, and has great difficulty in passing her water; for the last twelve hours she has not been able to evacuate the bladder, and she is now in much distress. " How long, my good woman, have you felt this pressure on your back passage ?" " I have felt it more or less, sir, since the birth of my last child." " Had you any difficulty with your last labor ?" " No particular difficulty, sir; but I suffered for three days before my child was born." " How long after the birth of your child did you leave your bed?" "I was obliged to leave it, sir, the next day." " Why so ?" " Because I had no one to do anything for me, and I had to look after my little fam- ily." " What was the state of your bowels at that time ?" " They were confined, sir; and I am a good deal troubled in that way now." " Did you nurse your last child?" "Yes, sir; and I am nursing it now." " Have you had your courses since its birth ?" " No, sir; I never have them while I am nursing." " Do you think you are pregnant ?" " O ! no, sir; I never become pregnant until after I wean my children." " Well, my good woman, I can assure you that in this instance there is an exception to the general rule, for you are pregnant. The case before you, gentlemen, presents several points of more than usual interest, which are well worthy of attention. This patient I have very carefully exam- ined, and find her condition to be as follows: 1st. She has prolapsion of the uterus; 2d. She is at least three months advanced in pregnancy; 3d. She experiences much difficulty in passing her water, and for the last twelve hours she has suffered from complete retention of it. Another circumstance of interest is the fact that she has become pregnant whilst nursing her child, and without a recurrence of her courses since her last accouchment, a circumstance which you will occasionally see in practice, but which must be regarded as an exception to the general rule. The first 150 CLINICAL LECTURES. point of inquiry is as to the cause of the prolapsion of the uterus. In reply to my question, you will remember this patient stated that she left her bed the day after her confinement, and that she had been habit- ually constipated. You have, therefore, with this statement before you, no difficulty in connecting cause and effect, so far as the displaced uterus is concerned. I have often reminded you that a common cause of pro- lapsed uterus is too early getting up after delivery. At this time the uterus is much increased in size and weight, the vagina is greatly relaxed, and the almost necessary result of the upright position under these cir- cumstances will be falling of the organ to a greater or less extent. If to these circumstances be added constipation, you can without difficulty im- agine how rarely a recently delivered female, under the operation of these combined influences, will escape displacement of the uterus. The practical conclusion, therefore, is never to permit your parturient patient to leave her bed, or at least to assume the erect position, until after the expiration of the tenth day, and sedulously to guard against constipation. It is not usual to observe prolapsion of the uterus after the third or fourth month of gestation, whilst it is proper for you to remember that you will occasionally observe it previous to these periods. As I have ex- plained to you on former occasions, the uterus ascends after the third month, and, consequently, as a general rule, the organ becomes in this way replaced. You can readily understand why this patient should suf- fer from difficulty in passing her water. The prolapsed uterus makes undue pressure on the neck of the bladder, and thus mechanically pre- vents the free evacuation of the fluid, and has for the last twelve hours caused complete retention. These same obstructions you will sometimes encounter in the last months of pregnancy, from the fact that the anterior segment of the neck of the uterus tends to descend, and thus presses on the bladder. Treatment.—I have repeatedly called your attention to the absolute necessity of comprehending thoroughly what the matter is before attempt- ing to suggest remedies. You must at once perceive how emphatically this precept applies to the case before us. Here, for example, is a woman, who complains of an uncomfortable pressure on her front pass- age, and a difficulty in voiding her urine, with entire retention for the last twelve hours. The pressure on her front passage may arise from various causes; but it is highly important that you should entertain no doubt on the subject, and proceed with due care to ascertain in what the true difficulty consists. Again, a female may experience difficulty in voiding her urine from numerous influences. Not to mention other causes, I will merely state that she may be unable to pass water, because there is none secreted. Is it not, therefore, of cardinal importance to make just distinctions in these cases 1 What would be the consequence if we were to treat this patient for suppression instead of retention 1 Why, undoubtedly, we should not only aggravate the difficulty, but it -—^,1^ v^ fortunate^ indeed, if we did not cause rupture of the bladder FALLING OF THE UTERUS. 151 from over-distension, and, consequently, the death of the patient. We have ascertained that the true difficulty with regard to the water is the mechanical obstruction caused by the prolapsed uterus. The general indication, therefore, is, as far as may be, to remove this pressure, and liberate the bladder from the obstruction imposed on it. But there is another more immediate object to be fulfilled, which is to relieve the patient from the retention under which she has labored for the last twelve hours, and this must be done by the introduction of the catheter. [Here the patient was placed on the bed, and the professor introduced the catheter, and drew off more than a quart of fluid, to the evident relief of the woman, who said she had been in much agony for the last four hours.] The next point to be attended to in this case is to remove the pressure of the uterus from the bladder; and for this purpose something may be gained by position. The patient should be kept as much as possible in the recumbent posture, with her hips elevated. But this is a mode of treatment to which the poor and dependent can not submit, for their time is their capital, and they cannot afford to remain idle as long as they are free from serious disease. In such cases, the pessary may be employed with a view of giving support to the uterus, and preventing pressure on the bladder. I shall use in this case the globular India rubber pessary, which you will find well suited to these cases. It will be necessary, be- fore introducing the instrument, to replace the uterus, which may be ac- complished without difficulty, if you will bear in mind the peculiar di- rection necessary to impart to the organ as you attempt to replace it. The uterus, you will recollect, is not out of the vagina; it is simply in a state of prolapsion, the mouth of the organ bordering on the outer portion of the vulva. Therefore, in this condition of things, you must, with your fingers lubricated with oil, gently grasp the lower portion of the uterus, and push it upward in a line parallel to the axis of the superior strait. As soon as this is accomplished, the pessary is then introduced. [The professor, in following the directions just given, first replaced the pro- lapsed organ, and then introduced the globular instrument.] This pa- tient, it is very probable, after the fourth month of her pregnancy, will not require the use of the pessary. Let me here, gentlemen, caution you against one circumstance, which it may appear unnecessary to allude to, but which has sometimes resulted seriously to the patient, and in chagrin to the practitioner. It is this—suppose the patient has a pessary in her vagina at the time of labor, would not common sense tell you that it should be removed ? Such would very naturally be the suggestion of common sense, and yet the history of obstetric medicine records more than one instance in which it having become necessary to employ the pessary during early gestation for prolapsion of the uterus, the instru- ment had been suffered to remain in the vagina during labor until, for- sooth, it was ascertained in consultation that the impediment to delivery was occasioned by the presence of the pessary ! LECTURE X, Epilepsy in a Girl, aged twenty Tears, from Suppression of the Menses for the last twelve Months, together with sanguineous Engorgement of the Uterus ; the Utility of direct Depletion.—Steatomatous Ovarian Tumor containing Hair.—A Sarcoma tous Tumor containing Hair and Stearine, removed from the Womb in a married Woman, aged forty-seven Years.—Hemorrhage from ulcerated Carcinoma of the Womb, mistaken for Menorrhagia.—Mucous discharge from the Vagina of a Girl, aged six Years, produced by Ascarides in the Rectum. Epilepsy in a Girl, aged twenty Years, from Suppression of the Menses for the last twelve Months, together with sanguineous Engorgement of the Uterus ; the Utility of Direct Depletion.— Ann T., aged twenty years, reached this country from Ireland one year ago; she has had suppression of her courses for the last twelve months, not having had any return of them since her arrival here. Her mother says she is attacked with fits once a month, just about the time her men- strual function is due. " Do you know, madam, when your daughter first had her courses ?" " Yes, sir, she was just turned of fifteen years." " Did they continue regular from that time until twelve months since, when they became suppressed ?" " Yes, sir, and she was a very healthy girl." " Do you know what caused them to stop on her ?" " They stopped at sea, sir." " Did you have a very boisterous passage to this country ?" " O yes, sir, it stormed almost all the time, and we thought we should all be lost!" " Was your daughter much frightened ?" " Indeed she was sir, and I think that's what did it." " Well, my good woman, you will find we entirely agree with you on this point." " When was this young woman first attacked with fits ?" " We had just landed two weeks, sir, when she had the first one." " What kind of a fit was it ?" "Why, sir, she fell down, and began to foam at her mouth." " Did she lose her senses ?" " O! dear, yes sir, she did 'nt know any thing." « How long did the fit continue ?" " I don't recollect, sir, but after struggling for some time, she would fall into a sleep." "How many of these fits has your daughter had, my good woman ?" " She has them every month, sir; and poor thing, she is almost worn out with them." " Does she have more than one fit at each month ?" " Yes, sir; she sometimes has eight or ten." " When she is affected with the fit, is her breathing much EPILEPSY. 153 ditsurbed, and does she become black in the face ?" " O yes, sir, and it is dreadful to look at her." This girl, gentlemen, presents an instructive case to you. There can be no doubt that she has been affected at each month with epileptic con- vulsions, nor is there in my mind the slightest hesitation as to the true cause of these convulsions. This is but one of many similar cases which have been presented to you at the clinique. What are the facts in the instance now before us ? 1 st. This girl is twenty years of age ; 2d. She menstruated for the first time when she was fifteen years old ; 3d. Her menstrual function was always regular from the time she was fifteen, until twelve months since, when the function became suppressed, and during the period of regularity her health was uniformly good ; 4th. Her courses became suppressed at sea, under the operation of one of the commonest causes of this form of menstrual aberration, viz., fright; 5th. One month after the suppression, she was attacked with epileptic convulsions, and these paroxysms have continued to the present time every month, sometimes numbering eight and ten, etc. If these facts are of any value, it is because of the demonstration they present as to the real source of the epilepsy. Do you not perceive from the state- ment of the mother, that this patient was always regular in her menstru- ation until twelve months since, and that during the period of her men- strual regularity, her health was uninterruptedly good ? Again, the first convulsion with which she was attacked occurred just two weeks after arriving in this country, and about one month after her courses became suppressed at sea from fright. Take these circumstances together, give to them their due measure of importance, and if they prove any thing, they establish the very significant fact that the epileptic convulsions ai'e the result of the suppressed menstruation. I was curious to ascertain the true condition of the uterus, and accord- ingly I examined the girl per rectum. The organ is increased in volume, evidently the effect of a sanguineous engorgement. There is no unnatural hardness, nor is there, as far as I have been able to detect, any evidence of change of structure in the uterus. It is simply a case of sanguineous engorgement, a very common sequela of suppression of the menses. But you may, perhaps, ask how do you associate epileptic convulsions with menstrual suppression, and is there really between these two conditions of system the relation of effect and cause ? In order to comprehend the modus in quo of the convulsive movement in this case, and connect it with the menstrual aberration, it will be necessary merely to refer to the two great physiological truths, for which we are indebted to the researches of Flourens and Marshall Hall. The former has demonstrated that muscular action can not be produced by irritation either of the cerebrum, cerebellum, or cerebral nerves, if the irritation be confined to these por- tions of the nervous mass; and he has further shown that muscular action can be produced only by irritation of the true spinal cord and muscular 154 CLINICAL LECTURES. nerves.* This, it will be conceded, was not only a brilliant revelation, but it must be considered as one of the most important developments of modern physiology. This great discovery, however, needed one more fact to impart to it its full interest, both in a physiological and pathological sense. The fact has been supplied by Marshall Hall, who has demonstrated that irrita- tion of the spinal cord may be excited through certain incident excitor nerves, f Before this latter fact was developed, it was supposed that all nervous aberrations, involving irritation of the spinal marrow, were centric, or in other words, were the result of an influence applied directly to the spinal cord. But now that the action of the incident excitor nerves is understood, we have another division of nervous disturbance, viz., eccentric, in which an irritation is produced on the peripheral extremity of one or more nerves, and the impression thus made is conveyed by the nervous trunks to the spinal cord; the impression, which is independent of mind, becomes a sensation, which results in a motor impulse; this latter is reflected back to certain muscles, and hence a movement is pro- duced. This constitutes what is known as reflex action. With these facts before you, there can be no difficulty, I apprehend, in understanding the influence of the suppressed menstruation in the production of epilep- tic convulsions. The uterus, under this arrest of function, becomes the center of irritation, which is conveyed through the excitor nerves to the spinal marrow, whence proceeds a motor impulse, the result of which is spasmodic or convulsive action of the muscles. There are now two points to which, for the instant, I shall call your attention: 1st. Why is it that the epileptic fits are periodical, or occur only at the time corre- sponding with the periods at which the menstrual function should appear? 2d. Why does the nervous disturbance assume an epileptic form, instead of a cataleptic, hysteric, tetanic, or the development of some other fea- ture of nervous aberration? To the first question I answer—that, with the return of each month, the uterus becomes more or less engorged with blood, constituting the menstrual molimen, of which I have repeat- edly spoken to you; this monthly engorgement can not occur without, to a greater or less extent, exciting increased irritation ; and it is under * When we speak of the spinal cord in connection with its physiology, it must be remembered that we do not allude to the medulla spinalis of the anatomist, but to the true spinal cord as described by Marshall Hall, viz.: the medulla spinalis, medulla oblongata, pons varolii, and tubercula quadrigemina. f I may, perhaps, be wrong in the remark that Marshall Hall was theirs* to de- monstrate this interesting fact, for the circumstance had been previously noticed and recorded by Whytt, Redi, Prochaska, Mayo, and others; but I think it must be con- ceded that without the practical application made by Marshall Hall of this great physiological truth, its benefit to science would have been extremely restricted. To him, therefore, is due the merit of having faithfully and perseveringly insisted not only upon its importance, but its indispensable necessity for the diagnosis and treat- ment of disease. EPILEPSY. 155 the influence of this increase of impression that the epileptic spasm is provoked. To the second question I answer—that in suppression of the menses, one woman will have intense headache, another hysteria, a third a species of mania, another epilepsy, whilst another will escape all these evils, and the result will be simply a malaise, a sensation of undefined but general indisposition. The assumption of one or other of these various disturbances will depend upon a multitude of circumstances, such as idiosyncrasy, susceptibility to impression, etc. I am not so sure that epilepsy, and the various other nervous perturbations of the system, may not sometimes, in cases of suppression, be traceable to the action of cer- tain acrid or poisonous matter in the blood acting on one of the nervous centers—the brain or spinal cord. The case before us, gentlemen, is one which should impress upon you the necessity of just discrimination. The whole practice of medicine, I maintain, stands upon a rational basis; the more you see of disease, and investigate its causes and phenomena, the more you will become convinced of this truth. Without this basis you would, I think, fall into serious error in your therapeutic manage- ment of this young girl. The prominent, if not the absorbing feature of the case to an abstract mind would be the epilepsy. But not so to the cor- rect reasoner—to one who arrives at his conclusions, not from an isolated fact, but from the aggregate of testimony. The epilepsy, in this instance, is not idiopathic—it is a result, simply an effect of morbid action in the uterus, this morbid action being produced by functional derangement of that organ. There can be no doubt of the connection occasionally existing between disease of the uterus, both functional and organic, and epileptic convulsions. We have had many examples of this connection in the clinique ; and it will not be forgotten how satisfactorily, under such cir- cumstances, the epilepsy yielded as soon as the uterine affection was con- trolled. Marrotte, in a paper recently published, has very fully confirmed this opinion, and deduces from his researches on this subject the following conclusions: 1st. That epilepsy is not unfrequently produced by the derangements of menstruation; 2d. That epilepsy, when it does not originate from these derangements, will become aggravated by them ; 3d. That this affection will sometimes become developed when the men- strual function is perfectly regular. He might have added that the epi- leptic paroxysm is occasionally the result of organic disease of the uterus, and also of displacement of this organ. Both hysteria and epilepsy I have known to follow displacement of the uterus, especially retro-version and ante-version. Is there any thing extraordinary in this latter fact, or incapable of explanation ? I think not. In certain sensitive women, the slightest dislocation of the uterus will give rise, oftentimes, to serious nervous disturbance; and in the more aggravated forms of retro-version and ante-version (from irritation occasioned by pressure on the sacral and other nerves), it is not strange that hysteria, epilepsy, and othei nervous derangements, should be the consequence. The interesting point 156 CLINICAL LECTURES. however, connected with this latter cause is the necessity, on the part of the medical man, of accurately recognizing its existence. Without this recognition, it can scarcely be necessary to add that all treatment would be unavailing. It is important to remember that the ordinary cause of hystero-epilepsy (i. e., a nervous disease, consisting in the co-existence of hysteria and epilepsy) is a functional or structural affection of the womb or its appendages. Treatment.—After this cursory review of the general features of the case before us, the question now presents itself—what is the therapeutic indication ? Assuredly, if what we have said respecting the cause of this girl's difficulties be true, there can be no hesitation as to the course to be pursued—our whole effort should be directed toward the restora- tion of the menstrual function. The uterus is in a state of sanguineous engorgement, the direct result of the suppressed catamenia. At the time of the menstrual molimen, or fluxionary movement toward the organ, you have seen that the nervous disturbance reaches its maximum of in- tensity, as is proved by the epileptic convulsions; and after the period at which she should have menstruated has passed by, the excitement of system becomes much less, and she is comparatively comfortable. It would seem, therefore, that the indication is obviously to remove the local engorgement by provoking the menstrual evacuation. Under these circumstances, I have great confidence in direct depletion. I shall, there- fore, order one dozen leeches to be applied to the vulva one week before the expected menstrual period—and, four days afterward, the application of an additional half dozen. The warm hip-bath to be freely used immediately after the leeching, and the patient to be protected from ex- posure to cold, and all exciting influences. Should it become necessary, the local depletion to be continued as just directed. One of the follow- ing pills two or three times a day, with 3 i of the sulphate of magnesia, in half a tumbler of water, the next morning, to insure a soluble state of the bowels: R Sub. Mur. Hydrarg.......3 ga Saponis Crotonis,......gr. vj Pil. Colocynth et Hyoscyam, gr. xxiv. Ft. Massa in pil. si) dividenda. The diet to be strictly vegetable. A Steatomatous Ovarian Tumor containing Hair.—I have an oppor- tunity, gentlemen, through the politeness of our clever demonstrator, Dr. Darling, of exhibiting to you this interesting specimen of a dis- eased ovary taken in a post-mortem examination. It is, as you per- ceive, the size of an ordinary orange, and its contents, though not fluid, are soft, consisting of stearine or suet, giving rise to that character of tumor described by pathologists as steatomatous. I have already, on several occasions, called your attention to the subject of ovarian disease* and you have been told that of the various morbid developments occa- A SARCOMATOUS TUMOR. 157 sionally met with in these bodies, encysted dropsy is, perhaps, the most frequent. The feature of particular interest in the specimen before you is the fact that it contains hair. Authors are divided in opinion as to the original cause of this production in the ovary; and many are of the con- viction that it is conclusive evidence of previous pregnancy. This opin- ion merits some attention, and can not be accepted as universally true, without necessarily, under certain circumstances, involving the rights of character. The same remark holds good with regard to other substances found in the ovary, such, for example, as bone, teeth, etc. I can not understand why there should be any difficulty in explaining the pres- ence of these substances in the ovaries upon the same principle precisely that we explain them when found in other unusual portions of the human system. Hair is sometimes detected in the brain and heart; and teeth have been observed in the liver, spleen, etc. How do these substances be- come deposited in these organs ? Does their presence rest for its explana- tion on the absurd hypothesis of cerebral, hepatic, or splenic pregnancy; or, does not common sense, without invoking the lights of science, tell us that they are the products of morbid secretion ? The point, then, on which I desire to insist is this—That although the existence of teeth, hair, etc., either in the ovary or womb is no evidence in the abstract of ante- cedent gestation, yet, under certain circumstances, where pregnancy has occurred, and, under the influence of morbid action, the ovum has become degenerated, these substances may be found as the remains of that de- generation. The following interesting case to which I was called some time since, and in which I performed almost in extremis an important operation, may not be without instruction. It was published in the New York Journal of Medicine, for January, 1849. A Sarcomatous Tumor containing Hair and Stearine, removed from the Womb.—On Wednesday, 7th of April, Mr. D. called at my office, and requested me to pay a professional visit to his wife. She had been attended for seven weeks by two medical gentlemen, who, on the Sunday before I saw her, had voluntarily withdrawn their attendance under the conviction that her case was beyond remedy, and with the opinion fully expressed to Mrs. D. and her friends that, in all proba- bility, she would survive but a few hours. Her husband in his inter- view with me spoke kindly of the physicians, and remarked that he was without the slightest hope, he and his friends having watched with the suffering patient the two previous nights expecting her death at every moment. With such a representation of the case, I frankly told the husband I thought a visit from me useless, but if it would afford him any gratification, I would cheerfully accompany him. He repeated his desire that I should see his wife; and, on being introduced into her chamber, I found her lying on her back, her face pale and ema- ciated, with every indication of extreme prostration; the expression of 158 CLINICAL LECTURES. ner countenance, also, gave evidence of great suffering. Her pulse was thready, and beat one hundred and twenty to the minute. Such was her exhaustion, that when I addressed a question to her, it became necessary for me to place my ear to her lips to distinguish her answer, and then her articulation was almost inaudible; in fact, the appearance of the pa- tient was that of a dying woman. Her respiration was labored, and the abdomen as much distended as is usual at the ninth month of gestation. On percussing the abdomen I distinctly recognized fluctuation; and, in attempting to introduce my finger into the vagina with a view if possi- ble of ascertaining the character of the enlargement, I felt at the opening of the vulva a soft elastic tumor projecting through the mouth of the womb, which was dilated to the size of a dollar-piece. The parietes of the mouth of the womb thus dilated were extremely attenuated, and did not appear to be thicker than common writing-paper. I found no diffi- culty in introducing my finger between the tumor and internal surface of the cervix, the adhesion being so delicate as to yield to the slightest effort. I satisfied myself that there was no action in the womb ; the pa- tient had not experienced any thing like labor-pains, and the dilatation of the cervix was the result merely of mechanical pressure produced by the tumor within the uterus. Whilst pressing gently with my finger on the tumor as it presented at the mouth of the womb, and grasping with the other hand the abdominal enlargement, I could again distinctly feel fluc- tuation, and found also that I comprehended the tumor between my two hands thus applied. Again, on placing my finger on the outer portion of the posterior lip of the uterus, and seizing with the other hand the upper surface of the tumor through the abdominal walls, alternately elevating and depressing the two hands, it was evident that I embraced the womb itself, which was immensely distended by the growth of the tumor. In making an examination per rectum, I could without difficulty detect the enlarged uterus. These circumstances, together with the im- portant fact that the abdominal enlargement was uniform on its surface, possessing nothing of the features usually attending extra uterine growths, such as ovarian and fibrous tumors, etc., caused me to arrive at the con- clusion that, in the present case, the tumor was exclusively intra uterine. It will be perceived that on this decision depended the remote hope of giving to my suffering and almost dying patient even temporary relief from her agony. Having, therefore, formed my opinion as to the seat of the tumor and partially as to its nature, I stated to the husband, that, desperate as the case was, and imminently perilous as would of necessity be any at- tempt to remove the tumor in the exhausted and almost hopeless situa- tion of his wife, yet it was my opinion that the tumor could be removea —although the serious hazard was that she would sink under the operation. This opinion was given emphatically, without reserve, and unaccom- panied by a word of comment calculated to urge consent to an operation, which presented but little prospect of permanent relief, and could only be A SARCOMATOUS TUMOR. 159 justified by the reasonable expectation, that, if the patient should survive the removal of the tumor, her sufferings would be mitigated, and her progress to the grave rendered comparatively comfortable. The opinion was communicated to the patient by her husband, and she expressed an ardent desire that the operation should be performed without delay, re- marking that she was prepared to encounter every thing, even death it- self, with the remote hope of temporary relief from the agony occasioned by the pressure of the tumor. The husband and friends acquiescing fully in this appeal of the unhappy patient, I left the house for the neces- sary instruments, promising to return in half an hour, and perform the operation. On my return, I was accompanied by Dr. Detmold and two of my pupils, Messrs. Woodcock and Burgess. These gentlemen heard with me the following particulars of the case as related by the husband and sister of the patient. Mrs. D. was forty-seven years of age, and married in 1832. Soon after her marriage, she was at- tacked with cholera; and during her convalescence from this disease, she miscarried. Her health had been more or less infirm for the last ten years. Pier menstrual periods had always been regular, with the excep- tion of the last year, during which time they occurred about once in two or three months, and then not freely. This she imputed to change of life, and the circumstance did not attract any particular attention. Her ab- domen had begun to enlarge in July, 1846, and continued to do so to the present time. In January last, she suffered greatly from distention of the bladder, and could not void her urine except in small quantities at a time, accompanied by excessive pain. For this she consulted a medical man, who found it necessary to introduce the catheter, from time to time, to relieve the bladder. She commenced as early as January to be constipated, and defecation was attended with excruciating suffering. These difficulties about the bladder and bowels continued to increase, and for weeks before I saw her, she repeatedly passed over ten days without an evacuation—medicines having no effect, and injections per rectum immediately returning, without bringing away any faecal matter. Her urine was voided in very small quantities, not more than two table- spoonsful at a time, and it was nearly the color of blood. It was im- possible for her to evacuate the bladder except when resting on her elbows and knees; this position, however, occasioned so much fatigue, that in her present exhausted condition, she could not avail herself of it. In a word, the agony of this unhappy sufferer was induced almost en- tirely by the pain consequent upon the attempt to evacuate either the bladder or rectum. With these facts before me, together with a knowl- edge of the position and bearings of the tumor, it was not difficult to arrive at the important conclusion that the pain and distress in the blad- der and rectum were due to mechanical pressure of the intra-uterine growth. At my request, Dr. Detmold examined the patient; and, in view of all the circumstances of the case, concurred with me in opinion 160 CLINICAL LECTURES. that, without an operation, she could survive but a feio hours ; whilst, if she did not sink under the attempt to remove the tumor, her distress would be sensibly palliated, and her life possibly prolonged. With the understanding, therefore, of the uncertainty and immediate danger of the operation, an understanding fully appreciated by the pa- tient and her friends, I proceeded to remove the tumor in the following manner : A mattress was arranged on a table, and Mrs. D. placed on her back, her hips being brought to the edge of the mattress, the thighs flexed on the pelvis, and an assistant on either side to support the feet and limbs. I then introduced the index finger of the right hand into the womb, steadying the tumor with the other hand applied to the abdomen, and succeeded in directing my finger its full length between the tumor and cervix of the uterus; this was done with great caution, for the parietes of the cervix were so extremely thin, that indiscreet manipula- tion would almost certainly have produced rupture of the womb. With the view, therefore, of preventing such a result, I thought it more de- sirable to break up the adhesions of the tumor simply with the finger than incur the hazard of introducing instruments into the uterine cavity. In proportion as the adhesion yielded, I grasped the tumor, and without much effort was enabled to remove it with my hand in fragments. Having brought away in this manner all the solid portions of the tumor, and carrying my hand well into the cavity of the womb, I distinctly felt a sac, pressing as it were against my finger. This I immediately rup- tured, and there escaped by measurement three quarts of fluid, which re- sembled in all its physical qualities, with the exception of the smell, pure pus. This fluid was collected in a vase as it passed from the womb, and half an hour afterward, on examining it, we found it no longer liquid, but presenting a solid mass, precisely like hardened lard. It was evident, therefore, that the temperature of the body kept this substance in a fluid state. As soon as the fluid had escaped, I introduced my hand still higher up, and felt something resembling in touch human hair. It was, in fact, a large mass of human hair matted together, with no other vestige of an embryo—there was no trace of scalp, or any thing else, save the hair. I grasped this body, and removed it from the womb en- tire, it being so compact as not to separate in fragments. The womb, thus freed of its contents, contracted, and there was no loss of blood. After the solid parts of the tumor had been removed, there escaped from the bladder an incredible quantity of high-colored urine, which gave such relief to the patient that it caused her to exclaim, in simple, yet emphatic language, " Doctor, I am in heaven !" It may here be asked, why the catheter had not been introduced before commencing the opera- tion. In answer, I would merely remark, that every proper attempt had been made to effect this desirable object, but it was found physically impossible, without inflicting serious injury on the patient, from the pressure of the tumor on the neck of this organ. HEMORRHAGE FROM ULCERATED CARCINOMA. 161 Mrs. D. bore the operation with a heroism which greatly surprised us, and although it became necessary to suspend occasionally all manipula- tion to rally her from fainting, which occurred three different times, yet considering her extreme prostation, it may well be deemed a matter of amazement that she did not sink. The operation being completed, the patient was placed comfortably in her bed. In the course of half an hour, her breathing became easy, the pulse fell ten beats in the minute, and there was an expression of composure about her countenance, which gave sincere joy to all of us, feeling as we did an intense and unaffected anxiety as to the immediate issue of the case. Without the aid of an anodyne, she fell into a sleep which lasted six hours, the first repose she had enjoyed for many long nights of agony. When she awoke, she ap- peared greatly refreshed, and although extremely prostrate, she seemed to take pleasure in gazing on her friends, to each of whom she gave a look of recognition. On the morning after the operation, her bowels were spontaneously and freely moved, a large quantity of hard faecal matter passing away. Subsequently, simple injections of warm water sufficed to afford her a daily evacuation, and the urine was discharged freely and without obstruction. Mrs. D. continued to improve in appe- tite, digestion, and strength, and although her friends were admonished not to be too sanguine as to her recovery, yet they regarded the fear of any other issue as utterly groundless. On the 22d of April, fifteen days after the operation, she began to fail, and in defiance of every thing which could be brought to bear in her case, she continued to sink, and expired on the 25th of April, having survived the operation eighteen days. I have no doubt that the anomalous mass found in the womb of this patient was the product of a blighted ovum, and it may be reasonably asked whether her chances of recovery would not have been enhanced, if the tumor had been removed at an earlier period, before the powers of the system had become exhausted by long-continued and uninterrupted suffering. The adhesions, it will be remembered, of the shapeless mass to the internal surface of the womb were slight. The stearine which escaped after the sac was punctured, I regard as nothing more than the fetal brain, and other fatty portions of the system in solution. These circumstances, together with the quantity of human hair removed from the womb, and the fact that the tumor was comparatively of rapid growth, are, in my judgment, strong proofs of previous conception. I can not conclude without returning my thanks to Dr. Detmold, for his prompt and efficient aid, not only during the operation, but also in the subsequent attendance. My pupils, Messrs. Burgess and Woodcock, are also entitled to the highest commendation. Hemorrhage from Ulcerated Carcinoma of the Neck of the Womb, mistaken for Menorrhagia.—Mrs. R., aged thirty-nine years, 11 162 CLINICAL LECTURES. married, the mother of seven children, the youngest fourteen montha old, seeks advice in the hope that she may find a remedy for the frequent and profuse losses of blood from her womb. The case before you, gen- tlemen, is one of painful interest,—it is another of those melancholy triumphs of disease over science; and we are compelled, as humiliating as is the admission, to acknowledge that we can do nothing to arrest the malady, which is hurrying with certain and fearful progress this unhappy woman to her grave. She is blanched from the heavy drain on her sys- tem ; and her nights and days, she informs us, are nights and days of agony, which she has no language to describe. You perceive the peculiar fetid odor emitted by the disease with which this patient is affected; it is completely characteristic of carcinoma of the uterus. The old writer who said, " Let me smell the air of the chamber, and I will tell you whether the female is laboring under carcinoma," spoke with more truth than authors have been willing to award to him. He was right; and those who have attempted to throw a shade of ridicule over this unmistakable evidence of carcinoma uteri, especially in the ulcerative stage, are wrong. The odor emitted by a female affected with cancer of the womb, is a something that can not be described ; it is, in the fullest sense of the term, sui generis. It is unlike every thing else; but once recognized, so marked is its nature, it never can be mistaken. There are two other circumstances in connection with carcinoma to which it may be useful for the moment to allude, viz.: 1st. Pain ; 2d. Vaginal discharge. The general belief is, that a woman laboring under cancer must of necessity suffer pain. This is not uniformly so; and it is im- portant that you should remember it. Some women will pass through all the phases of this lamentable disease, and yet without having experi- enced any physical suffering. The same remark may be made touching the discharge. So you see, gentlemen, ignorance of these two facts might sometimes lead you to a false diagnosis. Louis and Valleix have both mentioned a circumstance in connection with the development of this disease, to which too much value can not be attached. It is this— before any organic changes have taken place in the uterus, it will some- times happen that the very first symptoms of cancer will be profuse menstruation. They regard this, under certain circumstances, as an im- portant prelude to the development of this loathsome disease, and as ad- monitory of its advent. What do you suppose is the cause of these losses of blood in the case before us ? If this patient had applied to one of you for advice, what would have been the first object of inquiry ? Would you have regarded the bleeding as a disease, or would you have viewed it merely as a result of disease ? Before introducing her into this hall, I made a careful ex- amination of her case, and discovered what I strongly suspected I should find, the entire neck of the womb involved in ulcerated cancer. The hemorrhage is the result of the progress which the disease is constantly HEMORRHAGE FROM ULCERATED CARCINOMA. 163 making, involving, as it does, every tissue in destruction; when it reaches the blood-vessels, it lays them open, and in this way you account for the frequent bleeding. Treatment.—Nothing can be done but to palliate this poor creature's sufferings, and endeavor, if possible, to check the hemorrhage, at least measurably. For the mitigation of pain in carcinoma, you will find arsenic a great remedy in some cases, whilst, again, it is utterly value- less. Let this woman take of the liq. arsenicalis five drops three times a day. If it should disagree with the stomach, or produce stricture of the head, it must be suspended. With the hope of checking the hemor- rhage, two female syringes full of the following solution may be thrown up the vagina, as occasion may require: $ Sulph. Zinci.......3j Aquas Rosarum......§ x Ft. sol The patient's strength must be sustained as far as possible by nutritious diet. The careful introduction of a piece of soft sponge into the vagina and pressed against the bleeding vessels will sometimes answer a good purpose. The following case, gentlemen, which presented itself to my profess- ional observation may not be without point as connected with the con- dition of this patient. Some months since a respectable tradesman from London arrived in this city with his wife and five children. He came here with the view to establish himself in business. About four months before his arrival in this country his wife's health began to decline. She suffered greatly from pain in the region of the womb, and her menstrual periods were very irregular, occurring sometimes once in two months, and again once in two weeks; but at each return they were more pro- fuse than usual, and were followed by extreme debility. Her physician in London had treated her for profuse menstruation, and assured her there was no cause for alarm. Her husband stated to the physician that he contemplated coming to America to reside, but would abandon all idea of doing so if there were any probability that his wife would not recover her health. He was, however, assured that there was not the slightest ground for apprehension, and, accordingly, made his arrangements to em- bark for this country. The week after his arrival in New York I was requested to visit his wife professionally. I found her in an extremely prostrated condition; her face was pale and waxen. She complained of intense and burning pain in the womb; and she was subject to occasional losses of blood from the vagina, which had reduced her to a state of alarming exhaustion. The husband made an earnest appeal to me not to deceive him. He spoke touchingly of his little children, and their de- pendence on their mother; he was, as he remarked most feelingly, in a land of strangers; and he said, with all the emphasis of truth, " Doctor, if it be the will of God that my wife should die, let her die among her 164 CLINICAL LECTURES. friends; do not deceive me, and if you can not restore her, tell me so at once in order that I may take her home." These words, gentlemen, are simple, but are they not eloquent ? Are they not full of meaning, and calculated to reach the heart, unless that heart be of adamant ? O ! they tell the story of professional responsibility, and point out professional duty far more graphically than any language or argument I can employ. The sequel of this case is soon told. On making a vaginal examina- tion my fears were at once realized; the unfortunate patient was labor- ing under the last stage of that frightful malady, cancer of the womb. The character of the disease was such that the entire neck of the uterus had yielded to its destructive progress, and the adjacent parts were now becoming involved in the merciless grasp of a malady which, of all others, is the most fearful with which poor suffering woman can be afflicted. The flooding was now easily accounted for; the disease, phagedenic and unrelenting as it is, sparing no tissue, and laying open vessel after vessel, had thus caused profuse periodical hemorrhages. I remarked to the husband that the case was without hope. I flattered him not, but told him the melancholy truth. In ten days from the morn- ing on which this opinion was given, his wife was a corpse! There is in this tale of sorrow a moral. Think sometimes of it when you shall have left this university, and become engaged in active professional duty; and let it admonish you, that when disease can not be controlled by human skill, agonized friends should at least be spared the additional pang of disappointed hope. Mucous Discharge from the Vagina of a Child six Years old, produced by Ascarides in the Rectum.—Jane T., aged six years, is brought to the clinique by her mother, who feels greatly distressed in consequence of a mucous discharge, with which she has been affected for the last six months, and which has resisted every attempt to relieve it. Mucous discharges, gentlemen, from the vagina of young females can not be passed over with indifference by the practitioner. They often assume an acrid character, giving rise to inflammation of the vulva, and exciting in the minds of parents the most fearful suspicions as to the possibility of a cruel wrong having been inflicted upon the person of their child; you have had before you this winter an exceedingly inter- esting case of this character, which you will not soon forget. You remember, I am sure, with interest the little girl, Mary S., aged four years, brought here by her mother. It was difficult to dissuade the mother from the conviction strongly impressed on her mind that her child had been violated. You remember her tears and sobs—and the appeal she made to us not to deceive her can not so soon have passed from your memory. After a full investigation of the case, we assured her that her suspicions were without foundation—that the discharge was due to scrofula, etc. Mucous discharges from the vagina of young chil- MUCOUS DISCHARGE. 165 dren may be owing to the irritation of teething—to a scrofulous diathe- sis—or to ascarides in the rectum. It is your duty, therefore, in all cases like the one before us, to examine with care every circumstance con- nected with the previous and present history of the child. Take noth- ing for granted—receive the declarations of the mother, on the one hand, with courtesy—and, on the other, you may listen kindly to her suspi- cions—but allow neither the suspicions nor the declarations to form the basis of your opinion. It devolves upon you alone to ascertain what the discharge signifies; you are to trace it to its source, and in this way only will you be enabled to remove it. This child is six years of age; and, therefore, has passed the period of irritation from teething—there is nothing in her appearance or history which indicates a scrofulous cachexy—and we must consequently look to some other cause for this discharge. " Madam, have you at any time noticed very small white worms in the evacuations of your child ?" " I have, sir, on several dif- ferent occasions." " Have you ever seen them on the person of your child passing from the bowel ?" " I have not, sir." These questions, gentlemen, are addressed to the mother with a two-fold object. The only pathognomonic evidence that the ascarides exist is the fact of their being seen in the faeces, or observed passing from the rectum. Under these circumstances, they sometimes reach the vagina, and become located there, producing irritation. This irritation, which may be considered direct in contradistinction to the irritation these entozoa induce when lodged in the rectum—the indirect or sympathetic—is the cause of the mucous discharge. Treatment.—There are numerous remedies for ascarides—some of which are as follow: 3 Aqua? Calcis........% iv Muriat Tinct. Ferri......3 ij One half to be thrown into the rectum two nights consecutively—and followed the third night by R Sub. Mur. Hydrarg.......gr. ij Pulv. Jalapae.......gr. vj M. And the next morning § ss of castor oil. The following is an efficient enema for the purpose R Semin Santonici......3 hj Aquse bullient.......I vj Ft. infus. One half to be injected into the rectum two consecutive nights, followed by a brisk cathartic. Or the subjoined enema may be employed, the whole to be thrown at once into the bowel: R Syrup Alii Sativi......§ ss Olei Terebinthinae......3 ij Decocti HordeL......1 iij Ft. enema. LECTURE II. Double encysted Ovarian Dropsy, with Prolapsion of the Mucous Membrane of the Vagina, in a Widow, aged fifty-one Tears.—Suppression of the Menses from Cold, in a Girl, aged seventeen Years.—Menstruation uninterrupted during Pregnancy, and occurring with marked regularity at its usual periods—Gestation five Months advanced.—Convulsions from Teething, in an Infant, eleven Months old.—Purulent discharge from the Female Urethra, occasioned by Ulceration of the Neck of the Eladder.—Dropsy in a Girl, eleven Years of age, with Albuminous Urine.—Pain in the right Hypochondriac region, with Cough, from advanced Pregnancy.—Pru- ritus Pudendi in a married "Woman, aged twenty Years.—Defective Menstruation in a Girl, aged twenty-four Years. Double encysted Ovarian Dropsy, with Prolapsion of the Mu- cous Membrane of the Vagina, in a Widow, aged fifty-one Years.— Mrs. W., aged fifty-one years, widow, and mother of one child, is in very delicate health; she has suffered from enlargement of the abdomen for the last ten months, the enlargement gradually increasing. She says her womb is down, because on the slightest exertion she feels it protrud- ing from her person, and she is much incommoded in walking. Her bowels have been uniformly constipated since the abdominal enlarge- ment, and she now seeks advice because of the general distress occasioned by the distention; she is occasionally unable to pass her water, etc. You have, gentlemen, just heard the statement of this patient. What does it import ? If it mean any thing, its import is that the patient before you has an enlarged abdomen, and is laboring under procidentia of the womb. For a medical man, however, tins is too indefinite, there is nothing tangible, not a point in the narration which will justify an opinion without careful investigation. Enlargement of the abdomen may arise from various causes, and the protrusion from the patient's person may or may not be the womb. We have nothing but her own statement to guide us, and, as I have often told you, individual declarations usually prove faithless guides to the physician. We must, therefore, ascertain for ourselves the true nature of her case. [Here the patient was placed on the bed, and the Professor proceeded to examine the condition of the abdomen. After a careful examination, he pronounced the enlargement to be due to a double encysted ovarian dropsy. He then made a vaginal examination, and found the uterus in DOUELE ENCYSTED OVARIAN DROPSY. 167 its proper position, whilst the protrusion from the vulva consisted m an inversion of the mucous membrane of the vagina.] This, gentlemen, is a case of double encysted ovarian dropsy, the first that has presented itself at this Clinique, although we have had ten examples of simple ova- rian disease during the present session. Here, both ovaries are affected, and you perceive in what way the two tumors meet each other. They come in contact at about the mesial line, and as I place the cubital por- tion of my hand at the point of junction, you recognize a distinct fissure marking the line of separation. As I have so repeatedly, during the winter, called your attention to the causes, symptoms, pathology, and treatment of ovarian growths, I shall for the present limit myself to one or two observations respecting the inversion of the mucous mem- brane of the vagina. This is not of common occurrence, but when it takes place it becomes a question of great moment not to confound it with other protrusions, such, for example, as the womb, bladder, a poly- pus, etc. It might too, under certain circumstances, be mistaken for the " bag of waters " during labor. A point of interest in the present case is as to the cause of the inversion. What has produced it ? My ex- planation is as follows : This patient in the first place is extremely feeble and relaxed, the mucous membrane of the vagina participating in a large degree in this relaxation; she has been laboring under habitual constipa- tion ; on making a vaginal examination and carrying my finger upward and backward, I distinctly felt a soft fluctuating tumor resting in the tri- angular space or cul-de-sac, which is bounded anteriorly by the posterior surface of the womb, and posteriorly by the anterior surface of the rectum. The tumor is unquestionably the depending portion of one of the en- larged ovaries; and the soft fluctuating sensation imparted to the finger is the result of the fluid contained within this organ. Three influences, therefore, have contributed to the inversion of the vaginal mucous membrane: 1st. The relaxation of the vagina; 2d. The habitual con- stipation, and consequent straining in attempting defecation; 3d. The pressure from above, increased at every effort at defecation, of the de- pending ovary. The case before you is well calculated to excite your sympathy; here is a poor woman in feeble health, affected with a formidable disease, and yet compelled to seek her living by her own labor. Poverty, indeed, is no crime, but it is a trying inconvenience. [Here the patient exclaimed, " Yes! doctor, dear, it is inconvenient with this load of sickness upon me—but the Lord has afflicted me because I am a sinner, and I am content, and will bear my sufferings with all the strength I can."] What an example is this poor woman to the discon- tented and dissatisfied of the earth! She is tranquil in mind, and sub- missive under her severe distress. Causes.—These are the predisposing and exciting—the former consist in frequent labors, long-continued discharges from the vagina, drains of any description on the system; in a word, any influence calculated to 168 CLINICAL LECTURES. debilitate, may be enumerated among the first class of causes. The ex- citing causes, on the contrary, are obstinate constipation, unusual expul- sive efforts at the time of parturition, instrumental delivery, too early getting up after child-birth, undue pressure upon the vagina, carrying heavy burdens, etc., etc. Symptoms.—Prolapsion of the mucous membrane of the vagina may be complete or incomplete, and the only difference in the symptoms, in either instance, is that they are more aggravated in the former case. In the instance before us, we have an example of complete prolapsion of the membrane. In this woman, there is, as you have seen, a projecting tumor from the vulva, consisting of the lining coat of the vagina; there is pain in walking, with more or less difficulty in passing water ; a heavy, dragging sensation about the loins; the tumor itself is excoriated from the friction against the thighs, and the passage of urine, etc. Diagnosis.—As I have remarked, prolapsion of the mucous membrane of the vagina might be confounded with procidentia of the uterus, and it will require some little attention not to fall into this error. In both of these displacements, there is a tumor projecting from the vulva, and in both there is an opening at the inferior portion of the protrusion. In the former case, the opening consists of the inverted membrane ; in the latter, procidentia uteri, the opening is the os tincse. How then are you to distinguish ? You will observe in the first place, that, usually in prolapsion of the vaginal mucous membrane, the tumor is largest at its lower portion—the contrary is the case in procidentia of the womb ; in the latter case, it is almost impossible to introduce the finger into the opening; whilst in the former, the finger can be readily introduced, and if carried far enough, will come in contact with the os tincoz. This dis- placement may also be mistaken for polypus and inversion of the uterus. The distinction, however, is not difficult. In polypus, (which rarely pro- jects beyond the vulva,) the base is downward, and the apex, consisting of a pedicle, is upward, and there is no opening. In inversion of the uterus, there is also an absence of any opening. Prognosis.—In this affection, the opinion given as to the result must be somewhat guarded, for under certain circumstances there is more or less danger; for example, when the protruded organ becomes inflamed, it has been known to terminate in deep ulceration, gangrene, etc. Treatment.—This is palliative and curative ; the palliative treatment consists in the introduction of the prolapsed membrane, and its future support by means of pessaries, etc. A soft sponge, in these cases, an- swers a good purpose, retained in place by a T bandage ; also the india- rubber ball, which you have seen me employ in cases of procidentia of the womb; astringent washes, the free use of cold water to the parts, and, in case of much irritation, emollient applications will be found highly serviceable. The curative treatment consists in removing a portion of the prolapsed membrane. Dieffenbach has proposed the SUPPRESSION OP THE MENSES. 169 operation of Dupuytren, in prolapsion of the rectum, for the difficulty under consideration, and he has actually had recourse to it in these cases. He first returns the prolapsed membrane, and then to prevent its protrusion, he excises the relaxed folds from the internal surface of the labia externa. The dressing consists in cleansing daily the small cut surfaces; these heal, and cicatrices result, which contract the outer open- ing of the vagina, and impart to it its original resistance, thus prevent- ing the future prolapsion of the mucous membrane. Marshall Hall, some years since, proposed the removal of an elliptical flap from the mucous lining, causing an immediate union of the wound by suture. In the case before us, I shall restrict myself altogether to palliative measures ; circumstanced as this patient is, and in her debilitated con- dition, we are not justified in having recourse to those remedies, the beneficial effects of which you have seen in several cases of ovarian dis- ease during the present winter. I shall, therefore, limit myself to three objects : 1st. The constipation must be removed ; 2d. The general sys- tem invigorated; 3d. The protruding membrane returned, and supported by mechanical means. With a view of regulating the bowels, a table- spoonful of the following draught may be taken three times a-day: R Infus Sennae comp. .....§ iij Syrup Rhei.......§ iv Spirit Nucis Moschat.....§ ij Ft. mistura. A.s a general stomachic, a table-spoonful of the following may be taken twice a-day, after the bowels have been acted upon: R Infus. Gentian c.......§ iv Syrup Aurantii......3 iv M. For the support of the protruding mucous membrane, after returning it, I shall use the india-rubber ball. [The patient being placed on her back with the thighs flexed on the pelvis, the Professor having previously lu- bricated his fingers with fresh lard, returned the protruded membrane, and then introduced the ball pessary. The patient was then requested to walk, which she said she was enabled to do with comparative ease.] Suppression of the Menses from Cold, in a Girl, aged seven- teen Years.—Eliza K., aged seventeen years, seeks relief for a head- ache and sense of suffocation, from which she has suffered for the last four months. Within the last three weeks, these difficulties have so in- creased upon her, that she has been obliged to leave service; her face is flushed, she has a bounding, vigorous pulse, and the bowels are torpid ; she often feels as if her head would burst, and on several occasions she has fallen down from dizziness. Previously to the last four months, her health was always good. What, gentlemen, is the nature of this girl's troubles ? Will you tell me how to prescribe for her ? There is a link wanting in the chain 170 CLINICAL LECTURES. of evidence necessary to a correct diagnosis in this case—and, before attempting to administer remedies, that link must be supplied. The headache, the sense of suffocation, the bounding pulse, all indicate dis- turbed action, but its features are not so broadly depicted as to define its true cause. When this girl told me of her present sufferings, I strongly suspected they were due to some abnormal condition of the menstrual function; the question was, therefore, addressed to her on this subject—and her reply was that four months ago whilst menstruat- ing, she was exposed to a heavy rain—her menses suddenly became suppressed, and she has seen nothing since that time. The ground of my suspicion was as follows: the girl had been healthy up to the period alluded to—this fact together with her age, and the circumstance that she was enabled to attend to her duties until within the last three weeks, all gave me reason to believe the difficulties of which she complained were most probably due to menstrual derangement. They are the very difficulties, which are most apt to ensue from suppression of the " courses " in a plethoric system ; they are by no means to be regarded lightly by the practitioner. You have heard the statement, which this patient has just made, viz.: that on several occasions she has fallen down from dizziness. How do you connect this circumstance—which is the material fact in the case—with the suppression ? Your attention has been repeatedly drawn to the subject of menstruation; and you have been told that this function is one of such vast importance to the economy, that it can not be subjected to aberration without involving to a greater or less extent the entire system. As a general rule, it is sim- ultaneous in its first appearance with the period of puberty; it is the silent yet emphatic declaration of nature that the ovaries are developed, and the female prepared to perform her part in the important but mys- terious act of reproduction. The integrity of this function—except during the periods of pregnancy and lactation—is demanded by nature as constituting one of the cardinal ordinances on which the health of the female is to depend. Nature is provident in her arrangements, but she is severe in her exactions. If her laws be violated, the penalty promptly follows. Her physical mechanism is one of perfection—but its action is perfect so long only as the laws which regulate it are in accordance with that harmony, without which there can be no such thing as health. If, for example, the menstrual function be too profuse—if the loss be too slight—if the function become suppressed, or has never been estab- lished, then derangement of the system ensues; and it devolves upon the medical man to estimate duly the true cause and extent of the de- rangement. In the case before us, the suppression has continued for the last four months—or, in other words, the monthly drain which nature has declared necessary for the health of the female has not taken place —the consequence is, the system has labored under repletion—headache MENSTRUATION UNINTERRUPTED DURING PREGNANCY. 171 and dizziness have been the results ; the dizziness being such as to cause the girl to fall down, a state of things closely bordering on apoplexy. Do you not, therefore, at once connect this condition of the brain with the suspension of the ordinary discharge; and is it not evident that both the dizziness and sense of suffocation are but the results of the suppression ? It is, you see, manifest that if the menstrual function be not restored, this girl's existence will be in serious jeopardy from cere- bral congestion, or engorgement of some other organ essential to life. Causes.—Cold, fright, and the various mental emotions. Cold, per- haps, is the most common of all the causes of suppression. Young girls often subject themselves to serious illness, by placing their feet in cold water while their menses are upon them; and many a fair creature, whose morning of life was serene and beautiful, has found an early grave by this rash and thoughtless act! Symptoms.—Suppression is accompanied by various symptoms depend- ing upon the peculiar temperament and system of the individual. In plethoric women, headache and cerebral fullness are very common results. In girls of a nervous temperament, hysteria and other forms of nervous disturbance are apt to display themselves. Diagnosis.—Attention being- directed to the menstrual function, the fact is at once disclosed. Prognosis.—Serious, if not fatal, consequences may result from con- tinued suppression, especially in a plethoric habit of body. Treatment.—The object here is to diminish the vascular fullness of the system, and restore the function. This patient, in addition to her other difficulties, is laboring under torpor of the bowels. I shall order 3 viij of blood to be abstracted from the arm, followed in the evening by: $ Submur. Hydrarg.......gr. x Pulv. Jalapae.......gr. xv Pulv. Antimonialis......gr* ij Ft. pulv. In the morning § j of sulph. magnesia? in a tumbler of water; and, in order afterward to prevent constipation, let her take, as circumstances may re- quire, a tea-spoonful of epsom salts in half a tumbler of water. The diet should be strictly vegetable, and the patient should take daily exercise. If, after the full operation of these medicines, the menses should not return, two of the following pills may be given every second night, and a styptic foot-bath of warm water, cayenne pepper, and mustard, every night for two or three successive nights immediately preceding the ex- pected period: . R PiL Aloes c Myrrha......3j Div. in pil No. xij. Menstruation uninterrupted during Pregnancy, and occurring with marked regularity at its usual periods--gestation five months advanced.—Mrs. R., aged twenty-four years, married, the mother of 172 CLINICAL LECTURES. one child, eighteen months old, which she nursed until within the last six months, seeks advice under the apprehension that she has some serious disease about her. She says her " courses," since she weaned her child, have occurred with regularity—her abdomen is enlarged, and she is con- fident she is pregnant, from the fact that two weeks ago she felt life. Her fears are that something is wrong, for she says women who have their " courses " should not be pregnant. This case, gentlemen, is in- teresting, and its interest is disclosed in the simple statement of the patient. It is, as it were, a case out of the ordinary record; and the woman indulges in unhappy apprehensions on this account. You are aware that, as a general rule, the catamenial discharge becomes sup- pressed during pregnancy ; and it was the opinion of Denman that preg- nancy could not exist without this suppression. No fact, however, is better established than the occasional co-existence of pregnancy and the regular monthly evacuation. The patient before you is undoubtedly pregnant; and this opinion is not based upon what she says as to her having felt life, for there is often much deception on this subject, women frequently supposing that they feel the motions of the foetus, when, in fact, the sensations are merely morbid. But I pronounce her pregnant from the sensation imparted to my hand when I place it on the abdomen —the movements of the foetus are very distinctly felt. The areola is well defined in this patient, and you here perceive it with all its charac- teristic developments. I place very great confidence in this sign, and should be willing, in the present case, to trust to it alone for the truth of my opinion. I am happy the opportunity has occurred of introducing this case before you. It is one of comparatively rare occurrence, and you can now say that you have witnessed a case of pregnancy without suppression of the menses. " Madam, you have no disease about you." " O ! sir, I am very much afraid there is something wrong." " There is nothing wrong, madam, which time will not make right. You have no cause for apprehension. You can go home, and place full confidence in what I say to you. The only prescription I shall suggest is a cheerful mind, and good faith in what I tell you. If you will inform me of the time of your accouchement, I will see that you are provided with proper medical attendance." " Thank you, sir!" Convulsions from Teething in an Infant eleven Months old- Danger of Opiates in Infancy.—William N., aged eleven months, at the breast, has been attacked with convulsions twice within the last four days. He has cut four teeth, and the gums are now much tumefied. The child has been constipated and feverish for the last week, very rest- less, could not sleep, and has refused the breast. The mother, in order to procure sleep for her infant, gave it twenty drops of paregoric. In two hours afterward, it was attacked with convulsions. The case before you, gentlemen, is not of unusual occurrence, and you CONVULSIONS FROM TEETHING. 173 can have no difficulty in explaining why convulsions have ensued. In the present instance, three causes have combined to disturb the nervous sys- tem of this child, either of which, under some circumstances, would have sufficed to originate the convulsive spasm. 1st. Teething; 2d. Consti- pation ; 3d. The administration of the paregoric. I know of no more injurious, and often fatal practice, than the one so popular with most mothers of administering opiates, in some form or other, to tranquilize the system of the young infant, or, as the mothers say, to put it to sleep. The motive for such a course is unquestionably good, but the reasoning and practice are bad. Nature in the plan she ordinarily pursues, during the process of dentition, has pointed out quite significantly the duty of the physician when she has been frustrated in her operations. Teething is almost always, at least this is the general rule, accompanied more or less with looseness of the bowels. This very looseness is one of the con- servative measures adopted by nature to protect the system from harm, and more particularly the brain and its dependencies. It is, in fact, a waste-gate, which will prove salutary under proper regulations. If the diarrhoea should be too profuse, and the child weaken under it, it then obviously becomes the physician to keep it within proper control. But suddenly to arrest it, is to entail upon the infant the most serious conse- quences. The diarrhoea breaks the force of the irritation accompanying dentition; it is a sort of revulsive action by which the nervous system is protected against harm. If this view be correct, what are you natur- ally and almost necessarily to look for when a child is suffering from the irritation of teething, and at the same time labors under constipation ? If you desire a stronger provocation to disease, and more especially to convulsions, you have it, as is the case in the little patient before you, in the administration of the paregoric. Convulsions constitute a fearful outlet to human life among chil- dren; and their occurrence is so frequent that the practitioner can not be too guarded in enjoining upon parents, as far as practicable, the necessity of avoiding those influences which are known to pro- duce them. The nervous system of young children, liable as it is to this frequency of disorder, merits much of your attention. In the early part of the session you were informed somewhat in detail of the fact, that in children the medulla spinalis predominates in its action and susceptibility over the brain, and hence the frequency of morbid results from reflex action during infancy. It has been shown that during the first year of existence the brain is imperfectly developed, and almost without function. During this period, convulsions are of extreme fre- quency. In the two following years, in consequence of the greater de- velopment and control of the brain, the mortality from convulsions diminishes nearly a third; and just precisely as the brain becomes more perfect in organization, and its functions more fully developed, the ten- dency to convulsive movements is proportionately lessened. 174 CLINICAL LECTURES. Treatment.—Let the tumefied gums of this child be freely lanced, and the following powder administered, with a tea-spoonful of castor oil, the next morning: 8 Hydrarg. c Creta ) aa irr ij Pulv. Rhei J ' Pulv. Ipecac.......g1"- $ M- A soluble condition of the bowels should afterward be ensured by oc- sional enemata of warm water and olive oil, or a solution offtake manna given internally. The great point, in this case, is to prevent constipation, and keep the child from all exciting influences. Nitrate of potash, say gr. ij to a wine glass of water will have a cooling and beneficial effect on the system. Purulent Discharge from the Female Urethra occasioned by Ul- ceration of the Neck of the Bladder, in a married Woman, aged twenty-seven Years.—Mrs. C, aged twenty-seven years, married, the mother of two children, the youngest four months old, has been troubled more or less since the birth of her last child with a discharge of matter, and a scalding sensation in passing water. The discharge of matter, and the pain in micturition have very much increased of late. What, gen- tlemen, is the nature of the case before you, or, in other words, what is the cause of the discharge of matter I Vaginal discharges constitute a very important, and oftentimes a very difficult chapter in the field of practice; and there is, perhaps, no class of disorders which prove more rebellious to remedies, simply from the fact that they are regarded as idiopathic affections, and not as symptoms of disease. The discharges from the vagina are as follow, and it is important in all cases in which you may be consulted clearly to understand what it is that produces them: 1st. Sanguineous; 2d. Mucous; 3d. Purulent; 4th. Watery. Various causes may give rise to each of these forms of discharge; and successful treatment will of course depend on the accuracy with which the source is ascertained. For example, a purulent discharge, such as this patient is affected with, may arise from venereal chancre, gonorrhoea, the ulcerative stage of carcinoma, inflammation and ulceration of the neck of the bladder, uterus, etc. After hearing her statement, I made an examination, and found the uterus and vagina in a healthy state. In passing my finger, however, along the urethra and neck of the bladder great pain was induced; and the patient observed, as one of these points were touched, " That's the place, doctor." This was very signifi- cant language, and it implied that these parts alone were the seats of disease. It was not a case of gonorrhoea, for its history proved the fact. It was not ulcerative carcinoma, nor was there any venereal chancre. There was simply inflammation and ulceration of the neck of the bladder and urethra. On questioning the patient closely, she informed me that her last parturition was extremely painful and protracted, having been in DROPSY WITH ALBUMINOUS URINE. 175 labor sixty hours. May it not be that the long continued pressure of the head against the neck of the bladder was the exciting cause of the inflammation, which has thus resulted in ulceration ? Treatment.—This is an annoying and painful malady, and must be treated energetically. In the first place, the patient should be freely purged with saline medicines, and one of the following powders taken thrice a day in a tumbler of flax-seed tea : R Nitrat. Potassae......3 ij Div. in Chart. No. xij together with a free use of diluent drinks. The great remedy, however, is an injection into the urethra of an urethral syringe-full of the follow- ing solution once a day until there is a decided amendment in the symp- toms : R Nitrat. Argenti......3ij Aquae Purse. ......§ viij Ft. sol You need have no hesitation in the use of the solution for this pur- pose ; it is the remedy of all others. I have frequently employed it, and always with good results in affections of this kind. But you must remember that the patient can not throw the solution into her bladder; you must do it for her. The patient being placed on the bed, the Pro- fessor injected into the urethra a solution of the nitrate of silver. Dropsy in a Girl eleven Years of age, with Albuminous Urine.— Rachel M., aged eleven years, is brought to the Clinique by her mother in consequence of general ill-health, and an extremely distended abdo- men. This girl's health was good until within the last six weeks when her abdomen begun to enlarge, and has continued to increase to the present time. It is now so much distended that it is with difficulty she can breathe in the recumbent posture. Her countenance is pale and waxen—the pulse rapid and feeble. There is considerable tumefaction of the face, and a general infiltration of the lower extremities. The case before you, gentlemen, is one of peritoneal or abdominal dropsy, accompanied with general anasarca. The term dropsy implies a collec- tion of fluid in the cellular tissue, and natural cavities of the system, and is designated by different names, depending upon the particular seat of the effusion. For example, when the effusion occurs in the brain, it is called hydrocephalus—in the chest, hydrothorax—in the abdomen, ascites; and when the fluid is enclosed in one or more cysts, as is the case in ovarian, omental dropsy, etc., it is termed encysted. Infiltra tion, general or partial, of the cellular tissue is denominated anasarca. Perhaps no disease has called forth a greater variety of opinions than the one now under discussion. Theories have been promulged, and rea- soning founded upon these theories has been advanced with a view to sustain the respective notions of authors—and yet there is much to be 176 CLINICAL LECTURES. explained respecting many of the phenomena of dropsy. With regard, however, to this disease there are two well established facts, viz.: 1. That the affection constituting dropsy may arise from too much or too little action, the former being an example of sthenic, the latter of asthenic dropsy ; 2. That dropsy is the result of a want of balance between ex- halation and absorption, more fluid being poured out than is taken up. These two propositions are broad and undeniable ; and they form, as it were, a basis on which to pursue the inquiry touching the general char- acters of this disorder. There is one point in the case of this little patient to which I desire for a moment to direct attention—it is the condi- tion of the urine. Here is a small quantity in a cup, and having been subjected to the influence of nitric acid it coagulates, this circumstance being due to the presence of albumen. Healthy urine contains no albu- men ; and it was the opinion of Dr. Bright that the presence of this substance in the urinary secretion was unequivocal evidence that the disease, which through courtesy the profession has denominated Bright's disease, existed. Bright is not alone in this opinion, and among others who support his views may be mentioned Dr. Christison. Bright's dis- ease of the kidney consists in a peculiar change of structure, which is often a cause of dropsy: this structural change being ordinarily charac- terized by coagulable urine. If Dr. Bright had been content with this assertion, there would perhaps have been a very general concession to his opinion—but he has gone farther, and maintains that the presence of coagulable urine is undoubted proof of the existence of the affection which he has described. So far from albuminuria being peculiar to this disease of the kidney, it is found under various circumstances altogether un- connected with disease of this organ. For example, it often follows the administration of mercury—it is one of the ordinary accompani- ments of that form of dropsy consequent upon scarlatina, and is also the result of inflammatory action, etc. You are, then, gentlemen, to bear in mind that the mere coagulability of the urine in dropsy is no positive evidence that the dropsy results either from organic or func- tional disease of the kidney. The opinion of Dr. Bright is far too ex- clusive, and if adopted it will often lead to serious errors in diagnosis. With this view of the subject it is only necessary to detect albumen in the urine in any given case of dropsy, in order at once to trace the effu- sion to disease of the kidney ! Dropsy may present itself under vari- ous heads—acute or chronic—idiopathic or symptomatic—general or local, etc., and it is highly important for you to ascertain the true con- dition of the system before attempting to remove the effused fluid • indeed, all rational treatment must be based on this distinction. As a general rule, you will find that dropsy is symptomatic of some func- tional disturbance, or organic lesion, and may, therefore, under such cir- cumstances, be considered a result. The little girl before us is laboring DROPSY WITH ALBUMINOUS URINE. 177 under a form of dropsical effusion known as ascites, a term used to designate a collection of serum in the peritoneal cavity ; and the first object of inquiry should be to connect the effusion with the cause that has produced it. We shall, therefore, interrogate the mother. " Madam, when did your child begin to decline in health ?" " About six weeks ago, sir." " Was she in the enjoyment of good health previous to that period ?" " Yes, sir." " Before she begun to enlarge in her abdomen, did she complain of pain, and had she fever?" "About six days before I noticed the swelling in her stomach, she took a heavy cold ; she was very sick, had a high fever, much thirst, and complained of pain." " Did you apply at that time to any physician ?" " Yes, sir, and he gave me some powders which purged and sweated her, and took blood from the arm twice." The replies, gentlemen, of this woman throw ample light on the origin of this affection, and if you associate with these replies the important fact that the girl enjoyed good health until within six weeks since, you will have no difficulty in appreciating the true cause of the ascites, and of determining the nature of the affection. It is of the inflammatory type, constituting the sthenic form of dropsy, produced by cold—the inflammatory symptoms, however, exist no longer, and you have before you the effects of the inflammation, an effusion in the peritoneal cavity. Causes.—Acute or sthenic ascites may be produced by cold, repelled exanthemata, the suppression of the catamenia, granular disease of the kidney, scarlet fever, disease of the liver, lungs, etc. While chronic or asthenic ascites is due to drains on the system, such as diarrhoea, hemor- rhage, etc. Symptoms.—These are various, depending upon the particular form and circumstances of the disorder. Sometimes there will be previous evidence of general impairment of health—and again the effusion forms insidiously without apparently involving the constitution. Frequently ascites will be preceded by oedema of the extremities. The urinary se- cretion is usually diminished. Prognosis.—This will depend much on the particular cause of the dropsy, its duration, the constitution, etc. For example, in ascites fol- lowing organic disease of some of the important viscera, the prognosis will, of course, be unfavorable. Diagnosis.—Errors have often been committed by confounding peri- toneal dropsy with other morbid conditions of the system; and when I tell you that ascites has been mistaken for pregnancy, and vice versa, you will at once understand how much it becomes the medical man to exer- cise vigilance in arriving at a just opinion. It may also be confounded with encysted dropsy of the ovary, or of the liver, with tympanites, etc. To distinguish ascites from pregnancy, you must ascertain whether the symptoms characterizing the latter exist—is there any change in the uterus—how is its cervix—what the condition of its body and fundus, etc. ? 12 178 CLINICAL LECTURES Can you detect the pulsations of the foetal heart, the ballottement—does the areola exist ? In ascites, the enlargement commences in the lower part of the abdomen, and spreads ; in pregnancy, the enlargement also commences below, but it is central. In ascites, there is usually derange- ment of the general health. The fluctuation, however, which is ascer- tained by placing one hand on the side of the abdomen, and gently tap- ping the opposite side with the other hand, will remove all doubt. But pregnancy may co-exist with ascites. Encysted dropsy is so well defined by its own peculiar symptoms, that you can not mistake it. In ascites, however, you must remember that if you percuss the abdomen, a reson- ant sound will be yielded, such as results in tympanites; this arises from the fact that, in ascites, the intestines, more or less filled with flatus, float upon the surface of the fluid. In tympanites intestinalis, however, there is no fluctuation; the abdomen is hard, and is alternately diminishing and increasing in size in proportion to the escape or accumulation of the flatus. Treatment.—I shall not speak of the treatment of dropsy generally— but shall limit myself to the consideration of the case now before us. Under what circumstance does it present itself to our observation ? Cer- tainly not in the acute stage, it is now in its chronic form, and the time for anti-phlogistic treatment has passed. The indication here is to act powerfully on that important emunctory, the skin, and sustain, as far as possible, the strength of the patient by nutritious diet, etc. Opium, in its various preparations, has proved a great remedy through its diaphoretic and strengthening effects in this form of dropsy; for it is a well-ascer- tained fact, that opium and diaphoretic medicines not only diminish the effusion of fluid, and the quantity of albumen in the urine, but, at the same time, they impart vigor to the system. I shall, therefore, order for this child the following treatment: R Pulv. Doveri......gr. xxiv Nitrat. Potassas......3iss Div. in Chart. No. vj. One of these powders to be given every four hours until free diaphoresis is produced ; and to be continued afterward as circumstances may sug- gest ; the vapor-bath would be a valuable auxiliary, but from the poverty of the patient it can not be had. The bowels should be moved with enemata of warm water, molasses, and oil. The child would probably bear with advantage a weak solution of quinine: § Sulphat. Quinae......gr. iv Acid. Sulph. Dil.......gtt. iy Aquae puras.......% ij Ft. sol. A tea-spoonful twice a day. The diet should consist of animal broth and jellies, and as a general drink Cremor Tartar water. It will also b» PAIN IN THE RIGHT HYPOCHONDRIAC REGION. 179 beneficial to make frictions on the abdomen, twice a day, with the fol- lowing liniment: R Tinct. Digitalis ) . _.. Tinct. Scillse J......** §1J Pain in the right Hypochondriac Region, with Cough^ from ad- vanced Pregnancy.—Mrs. D., aged twenty-three years, is eight months pregnant; she has cough, and an annoying pain in her right side. " How long, Mrs. D., have you had a cough ?" " About ten days, sir." " Have you had fever with it?" "No, sir." "Do you expectorate much?" " What is that, sir ?" " I wish to know, madam, whether, when you cough, you spit up much phlegm ?" " Oh, no, sir; my cough is quite dry." " Do you cough much in the day time while attending to your duties ?" " No, sir." " It is only at night that I am troubled with it." "Do you begin to cough as soon as you lie down?" "That is it, sir." " As soon as I go to bed, I am bothered all the time with the cough." "Do you sometimes find it necessary to rise up in order to be relieved from the cough ?" " Indeed, sir, if I did not get up, I should suffocate, I feel so much distress." " Are you certain, Mrs. D., that you have not had the cough more than ten days ?" " Indeed, I am, sir." " What else do you complain of, madam ?" " A pain, sir, in my right side." " Will you place your hand, if you please, over the part in which you feel the pain ?" [The patient places her hand over the right hypochondriac region.] " When did you first notice that pain, Mrs. D. ?" " About two months ago, sir." " Is the pain constant ?" " Indeed, it is, sir, and it hurts me a great deal." " Do you ever experience any relief from it ?" " When I am on my left side, sir, it is always better." " How are your bowels ?" " They are confined, sir." " Do I give you any pain, madam, when I press on your side?" " No, sir, not the least." " You are confident that you have not had that pain in the side more than two months ?" " Yes, sir, quite confident." " Did you ever have any thing like it before your pregnancy?" "Never, sir." Now, gentlemen, amidst the numerous cases of interest which you have had brought before you in this Clinique, and I think you will agree with me, that in variety and importance they have far ex- ceeded the most sanguine calculation, you can not point to any which embodies more practical value, or is more entitled to attention than the one exhibited in the person of this patient. What are the two leading features in her case ? Cough and pain in the side. These two conditions, under some circumstances, portend serious mischief, and fatal results can only be prevented by timely and judicious interference on the part of the practitioner. You have heard the questions which I have ad- dressed to this patient; and they, I am sure, have been duly appre- ciated by you. They were not without an object; and, in the pursuit of that object, I have had the true nature of this cough revealed to me. 180 CLINICAL LECTURES. Turn to the questions, and see what has been elicited. 1st. Tlie patient has had the cough for ten days; 2d. No fever; 3d. No expectoration; 4th. The cough shows itself only at night as soon as the patient lies down. 5th. Instant relief when the upright position is assumed. And, lastly, gentlemen, I now feel this patient's pulse, and find it tranquil, yielding sixty-eight beats to the minute. This is not the cough of inflammation— it is not an idiopathic cough—but it is purely and essentially a mechanical cough, produced by the pressure of the uterus against the diaphragm, thus irritating the lungs, and thus, if you please, producing the cough. In the latter stages of pregnancy, women are not unfrequently the sub- jects of this form of pulmonary irritation, and it must be quite manifest to you how important it is to make a just discrimination. In addition, however, to the cough there is pain in the right side. The pain has none of the features of inflammation—no excitement of pulse, no tenderness on pressure, relief when resting on the left side, etc. It was first noticed, the patient informs us, about the sixth month after gestation. Then, gen- tlemen, what is the nature of this pain ? Is it a mere incidental circum- stance, or is it connected with the peculiar condition of the patient ? It is an interesting example of pain in the right side dependent upon preg- nancy. About the sixth or seventh month (sometimes, but rarely as early as the fifth,) women will occasionally complain of this pain, which is generally supposed, and I think with great truth, to be due to pressure on the liver by the ascending uterus. The pain usually continues until after delivery, when nothing more is heard of it. It is aggravated by constipation, and the excretions are ordinarily dark-colored. Treatment.—Both the cough and pain in the side are increased by the constipation, and the removal of the latter is the only indication in the case before us. I shall recommend, with the view of acting freely on the liver, which is apt to become torpid from the pressure of which we have spoken, the following: R Hydrarg. c. Creta......gr. viij Let this be taken at night, followed in the morning by R Sulphat. Magnesia?......3 ii Infus. Sennae.......§ vi Mannae........3j Tinct. Jalapae.......3 ij M. The above mercurial and mixture may be repeated occasionally with de- cided benefit. " Madam, you need feel no uneasiness about the cough or pain; they will both leave you as soon as you are confined. When you need a physician, if you will let me know, I will have you provided with a good doctor, who will take care of you." " Thank you, sir, a thousand bless- ings on you!" " Much obliged, my good woman; good morning." Pruritus Pudendi in a married Woman, aged twenty Years.— Mrs. B., aged twenty years, the mother of one child, eighteen months PRURITUS PUDENDI. 181 old, says she has been a great sufferer for the last two years. " Well madam, why do you come to the Clinique ?" " Because I wish to be cured, sir." " That is right, madam; we will endeavor to serve you. Do you suffer much!" " O ! indeed, I do, sir. I am tormented nearly out of my senses." " What is it, madam, that torments you ?" " It is a constant itching, sir. I have suffered from it for two years; and I have never had any thing do me any good." " What was the state of your health previous to your marriage ?" " It was excellent, sir; I never knew what it was to be sick." " How soon after your marriage did you complain of this distressing itching ?" " About six months after my marriage, sir." " Were you pregnant at the time ?" " Yes, sir, about four months." " The itching you complain of is about your genitals, is it not, my good woman ?" " Yes, sir." " Do you sometimes become sore, and bleed from scratching yourself?" " 0 ! yes, sir, I am nearly crazy with torture." Here, gentlemen, is a case of practical interest— for it is precisely such as you will meet with after you shall have com- menced your professional labors. It will not be confined to the poor and humble in life, such as constitute the recipients of our charity in this Clinique—but it will sometimes be found among the gay and wealthy of this world. You have heard the language of this poor woman—it is, indeed, graphic in description, and conveys most truthfully the character of her sufferings. The disease under which she labors is called Pruritus Pudendi—it is rarely an idiopathic, but almost always a symptomatic affection. When consulted in cases of this kind, you can not exercise too much vigilance; the anguish of the unhappy sufferer is beyond any thing you can imagine; and it is your duty, by skillful and prompt treat- ment, not only to appease that anguish, but to remove its cause. Causes.—Pruritus pudendi may be produced by numerous causes, viz.: pregnancy; final cessation of the menses; inattention to personal cleanliness; the presence of what are termed the pediculi pubis, known as the small parasitic insects which occasionally infest these parts; acrid discharges from the vagina; ascarides in the rectum, etc.* You see, therefore, gentlemen, from the simple enumeration of the principal causes of this affection, how necessary it is for you to employ due circumspec- tion in the examination of each case that may present itself to your ob- servation. Symptoms.—The characteristic feature is the intense itching; some- times, also, small vesicles, containing a sero-sanguineous fluid, will be observed on the inner surface of the parts; and, in some cases, ulcera- tions will follow the constant scratching to which the patient has recourse in the hope of momentary ease. * In some instances the worms will pass from the rectum to the vagina; and two cases have recently been published by Dr. Vallez, in which pruritus pudendi haa resulted from the presence of worms exclusively in the vagina, none having been found in the rectum. In these cases, mercurial ointment will prove an efficient remedy. 182 CLINICAL LECTURES. Diagnosis.—From the history of the case, as given by the patient, I am inclined to the opinion that the pruritus was due to pregnancy—but you must remember, gentlemen, that if I be correct in this view, the case is rather an exception; for we generally find that pruritus resulting from gestation usually ceases after delivery. In the present instance it has not done so. Treatment.—This will depend upon the cause of the pruritus, and the condition of the parts. It is not improbable that an abstraction of a small quantity of blood from the arm, together with saline cathartics and a lotion of the borat of sodae, say §j to Oj of water would have sufficed to relieve this patient, if early employed. But from the description of her sufferings, something more potent will, no doubt, be required. This, however, can only be determined by examining the true condition of the. parts. [Here the patient was placed on the bed, and the Professor pro- ceeded with the examination. The internal surface of the labia majora, the vestibulum and clitoris, were seats of extensive ulceration.] You perceive, gentlemen, as I separate the vulva, the extent of morbid action in which these parts are involved; and it is truly lamentable to think that this poor creature, who is dependent for her daily bread on the " sweat of her brow," should have been so long afflicted with this painful affection. " My good woman, I neglected to ask you whether or not your bowels are regular ?" " They are much confined, sir." " How is your appetite ?" " Very bad, sir. You see, sir, I am losing my flesh because I can't eat." Pruritus pudendi, gentlemen, is very apt to lead to emaciation; and, in the case before us, marked as it is by general decay of the constitution, if we limit our remedies to local applications, we shall fail in affording relief. We must conjoin general with local treatment. The first thing that I shall do will be to touch the ulcerated surfaces freely with the solid nitrate of silver. [Here the Professor cauterized the ulcerations.] Under the circumstances of the case, I pre- fer this application to any other. It should be repeated every fourth or fifth day, as may be indicated by the progress of the disease. The parts should be cleansed with castile soap and tepid water; and, as far as prac- ticable, rest enjoined on the patient. This woman will be benefited by a brisk cathartic, and I shall, therefore, order the subjoined pills, to be followed in the morning by § j of epsom salts: R Massae Hydrarg.......gr. iv Aloes ........ gr. iv Saponis . . . . . . . . gr. ij Divide in pil ij. When the bowels have been freely moved, a table-spoonful of the fol- lowing may be taken three times a day : R Pulv. Rhei........3j Carbonat. Sodae ) Pulv. Calumbae f • • • • . fia 3 ij Aquae Menthae ) _3 _ . ,, k -o t.....a* 5vj K Aquae Purae ) ° * DEFECTIVE MENSTRUATION. 183 Diet nutritious, with half a pint of porter daily. You will sometimes gentlemen, meet with a form of prurigo of the genital organs, assum ing the character of eczema, which is extremely difficult to manage, often proving obstinately rebellious to remedies. In this particular condition of things, the following treatment has been proposed by M. Tournie. You will remember the case of Elizabeth Richardson, who came here in November last, and in whom the treatment to which I allude was quite successful, after repeated failures with other means. M. Tournie recom- mends, as topical applications, calomel ointment, and a powder of cam- phor and starch. Should the parts be covered with scabs, emollient poultices are first to be employed; when the scabs are removed, the ointment is to be applied twice a day, 3J of calomel to §j of lard; after each application, a powder, consisting of four parts of starch to one of finely-powdered camphor, to be freely used. Defective Menstruation in a Girl, aged twenty-four Years -— Mary M., aged twenty-four years, unmarried, a red-faced, plethoric girl, seeks advice for a headache and sense of suffocation. " How long, Mary, have you suffered from headache ?" " I have had it, sir, for more than a year." " Does the headache never leave you ?" " Yes, sir, I am much worse at times than I am at others." " How is the suffocation, is that worse at times too ?" " Yes, sir." " Are you much troubled with dizziness ?" " Yes, sir ; when my head is bad, I feel as if I would tumble over. I am so light-headed, I am afraid to walk about." " Do you know where your heart is, Mary ?" " It is here, sir, I believe." [The patient puts her hand over the region of the heart.] " Do you have any beating there ?" " Yes, sir, and that is what distresses me so much." You have heard, gentlemen, what this girl has to say about her sufferings, and I am sure it would perplex any of you to know how or what to prescribe for her, without some further insight into the case. This is an example of what will often be presented to you in practice, and it is the very kind of case which will generally resist treatment, and linger on until mischievous consequences ensue, simply because the source of the trouble is not understood. I can not say positively, for as yet I have made no inquiry on the subject, but it appears to me that the cause of this girl's sufferings is obviously traceable to menstrual derangement. Let us examine this point. " Mary, you observed a few minutes since, that it is now more than a year since you first complained of these diffi- culties." " Yes, sir." " How were your monthly turns previous to that time ?" " They were always regular, sir, until about fifteen months ago." " What took place at that time ?" " I was scrubbing, sir, and took a heavy cold, and my courses stopped on me for two months." " How have they been, Mary, since that time ?" " I see very little, sir. They come on at the right time, but they do not continue more than a day, and as soon as they stop, then my sufferings begin." You perceive, gentlemen, I am not guilty of error of judgment as to the cause of this 184 CLINICAL LECTURES. girl's distress. Your attention has been repeatedly directed in this Clinique to the importance of the menstrual function, and you have been told that its integrity can not be violated without involving, in a greater or less disturbance, the general system. If this girl be not speedily re- lieved by judicious treatment, the result will not be limited to disturbed action, but the disturbed action will terminate in some serious, if not fatal lesion. The indication here is so broad, the duty of the physician so obvious, that not the slightest ground for doubt exists. Without delay, means must be resorted to for the purpose of re-establishing the natural and healthy menstrual function; as soon as this object is ac- complished, harmony will be restored to the economy, and this girl will cease to suffer from headache, palpitation, a sense of suffocation, etc. Treatment.—Let her lose from the arm § viij of blood, and then the following powder administered: R Sub Mur. Hydrarg......gr. x Pulv. Jalapae......gr. xv Pulv. Antimonial ... gr. i M. In the morning |j of castor oil. In cases like the one before us, after the above treatment, we are par- tial to what we have denominated artificial menstruation, which is ac- complished as follows: commencing as near the time of the expected " courses " as possible, § ij of blood should be abstracted from the arm. In two weeks § ij more should be abstracted. Let this be continued regularly every fifteen days, until the menstrual function becomes natural. In addition to the bleeding, two of the following pills should be taken for three successive nights, commencing a night or two before the menstrual period: R PiL Aloes c. Myrrha.....3iss Divide in pil vj. On the nights that the pills are taken, the patient should use the styp- tic pediluvium, composed of two table-spoonfuls of mustard and one of red-pepper in a bucket of warm water. To ensure a free state of the bowels, a wine-glass of the following mixture to be taken each morning, as circumstances may require : R Sup. Tart. Potassae ) v . * . . . aa x i Sulphatis Magnesia? ) * Aquae purae.......Oj Ft. sol The diet to be exclusively vegetable. " Mary, I will send a doctor to bleed you as ordered, and you must faithfully observe the directions about the medicine, etc." " Indeed, I will, sir." " Good morning, my good girl, and return here one month from this day." " Thank you sir." LECTURE XII. Mammary Abscess in a married "Woman, aged eighteen Years.—How soon after Birth should the Infant be put to the Breast?—"Warty Excrescences in the Vagina of a little Girl, three Years of age, accompanied with Mucous Discharge.—Cephalhsematoma, or bloody Tumor of the Scalp, in an Infant, five Weeks old.—Vesico-vaginal Fistula, produced by the unjustifiable use of In- struments.—Conservative Midwifery.—Abuse of Instruments.—Pregnancy com- plicated with Ovarian Tumor in a married "Woman, aged twenty-four Years.— Convulsions in an Infant five Weeks old, from Constipation.—Gonorrhoea in a married Woman, aged twenty-six Years.—How many Ligatures should be put upon the Umbilical Cord.—Ozcena in a little Girl, aged four Years.—Polypus of the Womb, removed with the Calculus Forceps.—Falling of the Womb from En- gorgement of its Cervix, in a married Woman, aged forty-three Years. Mammary Abscess in a married Woman, eighteen Years old. How soon after birth should the infant be put to the breast?--mrs. b., aged eighteen years, the mother of one child, four weeks old, is labor- ing under abscess of the breast. The left breast, which is the seat of the abscess, is enormous, as large as the head of an adult. The infant was not put to the breast for four or five days after its birth, because the mother did not think she had any milk; and when she put it there, the child could not draw the milk, because the nipple was so flat it could not take hold of it. The patient says she has not been able to sleep for the last two weeks—she has been in constant agony with her breast, and begs most piteously that something may be done to relieve her. You have, gentlemen, in the person of this young woman—young, in- deed, to be a mother—an example of what you will often meet with in practice; and the question naturally arises, has her suffering been the result of necessity, or has it arisen from positive carelessness ? That the latter is the true cause of her present condition does not admit of a doubt, and is perfectly susceptible of demonstration. What are the facts ? A woman is delivered of an infant, the breasts become filled with milk—there is no outlet, and the quantity of milk is still accumu- lating every hour. Every hour, therefore, the breasts become more distended—the milk glands and other tissues being unduly engorged. The elements of trouble are present, and if not removed they light up serious inflammatory action—pain and fever ensue—and, in a few days, 186 CLINICAL LECTURES. matter is secreted; and the breast, as is the case in the instance before us, becomes enormously distended with purulent fluid. During the stage of suppuration, the patient can tell you far more emphatically than any language of mine can convey, the intensity of her sufferings. " Yes! Doctor, dear, I can tell—I know what suffering is now—my eyes have not been closed for many days." You hear, gentlemen, the simple but truthful language of this poor woman; let it be a lesson to you, and never inflict this amount of misery on any of your patients by a careless discharge of duty. When you attend a female in confine- ment, you are to remember that your office as practitioners is not lim- ited to the mere supervision of the birth of the infant—you are to take cognizance of every circumstance connected with the lying-in chamber —so far as the welfare of your patient is concerned—from the very commencement of labor until she has entirely recovered from the effects of her parturition. Any thing short of this full and thorough attention as to every detail, which may possibly involve the comfort or safety of your patient, is a delinquency of duty, which can not be justified. On the present occasion, I shall limit myself to a brief view of what is to be done in order to protect the breasts from harm, and prevent the for- mation of abscess, which is one of the most painful, and oftentimes pro- tracted complications of the Lying-in-room. This brings me to the con- sideration of an important question—How soon after birth should the infant be put to the breast? I know that there exists a difference of opinion on this subject; but the rule which I recommend to you, and which future observation will prove to be correct is this : as soon as the mother has recovered somewhat from the fatigues of her labor, say about four or six hours, let the child be put to the breast. The advan- tages of this practice are the following: 1st. The very suction of the child's mouth on the nipple encourages the secretion of milk. 2d. The early application of the child to the breast enables it the more readily to seize the nipple—for as great as the instinct is, which leads the new- born infant to take hold of the nipple as the fount from which it is to derive its nourishment, yet I am satisfied that the instinct diminishes with the delay, which oftentimes occurs, from either prejudice or care- lessness, in putting it to the breast. 3d. If the child be not applied early, the breast becomes hard, and the milk is not only abstracted with difficulty, but with much pain to the mother. 4th. If the child be allowed to nurse a few hours after birth, it will draw from the breast that portion of the milk which is known to be purgative; in this way, the meconium will be removed from the intestinal canal, and the infant saved from that improper but popular practice of the administration of medicine simultaneously with its birth. You should remember that human milk varies in its properties. For example, when it first flows from the breast after delivery, it is yellowish and thick, containing a much greater proportion of cream than under ordinary circumstances— MAMMARY ABSCESS. 187 and this constitutes not only an efficient, but the natural cathartic for the new-born infant—this cathartic removing from the system that dark viscid matter known as the meconium, and which, if it be suffered to remain in the intestines, very frequently gives rise to convulsions, etc. 5th. The early application of the child to the breast will, as a general rule, ensure the free discharge of milk, and, therefore, prevent the unnat- ural distention of the breast, which is the common cause of milk ab- scess. But there may be some circumstances, which will obstruct the flow of milk from the nipple notwithstanding the early application of the child—and these may arise from the infant itself—such for example, as debility, tongue-tied, sore mouth, malformation, etc., etc.; or from the mother, because of the flattened condition of the nipple, so that it is impossible for the infant to grasp it. Under such circumstances, there is a very simple and effectual means of overcoming this difficulty—take a pint bottle, and fill it with hot water—then pour the water out, and apply the bottle over the flattened nipple—as the bottle cools a vacuum results, and a powerful suction is exercised on the nipple, which becomes at once elongated, and the milk is seen to spout out. As soon as the bottle is removed, the child must be applied to the breast, and it grasps the nipple without difficulty. This is far better than suction pumps, and other irritating contrivances usually resorted to. You are to bear in mind that the great remedy for the prevention of milk abscess is to protect the breasts against undue distention. When the milk does not escape with sufficient freedom, it is important, in order to control, to a certain extent, its too abundant secretion, to place your patient on solid food, such as boiled rice, potatoes, etc., and forbid drinks, for these increase the mammary engorgement. The bowels, too, should be kept soluble by saline medicines, which are preferable to all others in these cases, for they produce, as you know, serous discharges. The following may be administered with advantage: 9 Sulphat. Magnesias.....§ iss Inf. Rosar. C.......§ viij Ft. sol. A wine-glass once or twice a day as circumstances may indicate. In the case before us, however, there is a large secretion of matter—the breast is filled with it. What is to be done ? The indication is obviously to evacuate it without delay by a free opening with the lancet. Make your incision below so that the matter may escape without obstruction. [Here the Professor introduced the lancet into the depending portion of the abscess, and not less than a pint and a half of matter escaped; a small piece of lint was inserted between the lips of the opening, with directions to remove it every four hours to allow the matter still further to escape—the breast to be poulticed for two or three days.] In addi- tion, gentlemen, to what has just been done for this patient, it is neces- 188 CLINICAL LECTURES. sary to invigorate the general system. The diet should be nutritious, and one of the following powders taken twice a day: R Pulv. Rhei........3ij Sulphat. Quinae......3j Div. in Chart. No. xx Warty Excrescences in the Vagina of a little Girl, three Years of age, accompanied with Mucous Discharge.—Julia S., aged three years, is brought to the Clinique by her mother for advice. The mother says the child complains of great irritation about the vagina, often cries, and says she has pain in that part. Before introducing this little girl to you, gentlemen, I deemed it necessary in order that I might ascertain the true state of things, to examine her, and I have discovered enough to account for all the symptoms of which she complains. The vestibulum; and outer and lateral portions of the vagina are studded with small warty excrescences, which give rise to a great deal of irrita- tion, and cause this child much discomfort. These excrescences are extremely rare in so young a patient, and when they exist, are apt to pro- duce much anxiety in the mind of the parent. You understand how essential it is to know with precision the nature and extent of morbid action. Suppose one of you had been consulted about this little patient, and had become satisfied with the simple story of the mother, that her child complained of uneasiness and irritation in the region of the vagina. If you had gone no farther than her statement, any treatment which you might have suggested, would of necessity have been unscientific, and in all probability vain, if not hazardous. The child likewise has a mucous discharge from the vagina. How do you explain the presence of this discharge ? What produces it ? I have on several occasions directed your attention to this subject. Scrofula, ascarides in the rectum, the irritation of teething, and these warty growths, are all so many causes of this form of discharge in the young girl. The discharge of mucus, therefore, in this case, is not the disease—it is not the feature which is to engross your attention, it is merely an effect—whilst the cause, the ex- crescences, are alone entitled to your consideration. Remove them, and the discharge will disappear. But you may very properly ask in what way do these morbid growths produce a secretion of mucus? I will explain. These ex- crescences are not natural; they are the result of morbid action ; their presence is a source of irritation. This very irritation increases the afflux of fluids to the parts, and hence the mucous discharge. You have had before you, the present session, two interesting cases of pro- fuse mucous secretion from the vagina in women, and in both instan- ces we traced the discharge to the presence of warty excrescences in the vestibulum; these were removed by the curved scissors, and the patients were restored to health. You will meet nothing in practice among females more rebellious to remedies than the various discharges CEPHALHEMATOMA, OR BLOODY TUMOR OF THE SCALP. 189 from the vagina. They are rebellious, however, not from necessity, but simply because their real source is not ascertained. If you should prove successful in treating them—and nothing is easier if you will only regard them as effects, and trace them to their true causes—you will not only derive great reputation, but you will readily accumulate a fortune, if that should be the object of your ambition. In the case of the little girl before us, there can be no doubt as to the proper course to be pur- sued, and we shall therefore suggest the following: The excrescences should be sprinkled once a day with the subjoined powder; it will be found effective, and I have no doubt the mother will return here in a few days, happy and delighted at the restoration of her little daughter to health : R Acetat. Cupri) Pulv. Sabinaa f......** * V- Cephalhematoma, or Bloody Tumor of the Scalp, in an Infant, five Weeks old.—Catherine C, aged five weeks, is brought for advice by her mother who is in great affliction, supposing that her little infant must necessarily die because of a large tumor on its head. The swelling commenced, the mother says, about twenty hours after birth, and was at first not larger than a walnut. It is now nearly half the size of the en- tire head of the child, situated on the upper and lateral portion of the eranium. The child is restless and fretful, and the mother the picture Df despair. The case before you, gentlemen, is one of not very com- mon occurrence, and I am indebted for the privilege of showing you this interesting character of tumor to my friend, Dr. John Simmons, to whom I am under many obligations for several important cases brought to my Clinique. The swelling on this infant's head is a cephalhaemato- ma, which means a bloody tumor. You perceive from the distress of the mother, and the hopeless view she takes of the case, that it is one calculated to excite deep sympathy. There is, in my judgment, not the slightest cause for anxiety, and you will find that this infant will be relieved of the swelling, and the mother made happy. In examining the tumor critically, we observe that it is characterized by two circumstances : 1st. It is soft, slightly compressible, and without pain ; 2d. The integuments covering it are without change. It is nothing more than an extravasation of blood under the scalp, caused by pressure on the head during parturition. Much difference of opinion has existed as to the proper treatment of these tumors. Some have recom- mended free incisions—this is bad practice, and has resulted in more than one instance fatally. The object to be accomplished here is the reduction of the tumor, if possible, through absorption. For this purpose, therefore, I shall recommend evaporating lotions, and gentle pressure. Pieces of adhesive plaster, one-half inch wide, and long enough to pass over the tumor in its length and breadth, must be applied. This is all that I shall suggest, and you will see the result. " Madam, you may dry up your 190 CLINICAL LECTURES. tears, and take your child home with perfect confidence that nothing will befall it from that tumor. Bring it here next Monday a week from to- day, and you will find that I have not deceived you," " Oh ! thank you, sir, and many blessings on you." I speak, gentlemen, very confidently about this case, and I hope the result will prove that I am correct. Vesico-vaginal Fistula, produced by the unjustifiable use of In- struments, in a married Woman, aged forty-two Years.—Mrs. C, aged forty-two years, widow, the mother of four children, the youngest seven years of age, comes to the Clinique, and says she has been in a deplorable state since the birth of her last child. She is constantly troubled with a discharge of water, which scalds and irritates her, and often produces such distress as to incapacitate her from performing her daily labor, by which alone she is enabled to earn a few shillings for the support of her- self and little children. Her previous labors were always without the slightest difficulty; she states that, in her last confinement, only six hours after her labor had commenced, her physician attempted to deliver her with forceps, and, after several unsuccessful efforts, during which she suffered ex- cruciating agony, he abandoned her! Left alone, her labor continued four hours longer, when she was delivered, without assistance, of a living child. The head of the infant, however, was much bruised by the rude attempts of the doctor to apply the instrument. From the birth of her child to the present time she has been unable to retain her water, and she presents her- self at the Clinique in the hope that something may be done for her. Here, gentlemen, is a case for your sypmathy; it presents an in- structive lesson, and one which I trust will make an abiding impression on you. Cases like these should not be suffered to pass without severe rebuke. Unpardonable ignorance, or wanton officiousness—ac- cept either horn of the dilemma you please—has entailed upon this unhappy woman, not only unnecessary suffering, but a disease both loathsome and difficult to cure. As soon as she related her case to me, I suspected the existence of the trouble, which was fully confirmed on examination. This unfortunate patient, poor and dependent for her daily bread on her daily toil, is an example—not, I regret to say, a solitary one—of the cruel wrongs inflicted on suffering woman by un- feeling and reckless men, who, under the mantle of a diploma, forgetting the high prerogatives, and sacred responsibilities involved in the pos- session of that document, proceed with utter indifference in their work of destruction! What do you suppose is the cause of this woman's melancholy condition ? The attempt which her doctor made to deliver her with forceps, an attempt for which there was no justification, as the sequel of the case proved, caused a rent in the bladder, producing a large fistulous opening between it and the vagina, thus most probably entailing upon this patient a life of misery. These fistulous openings, always more or less difficult to cure, present occasionally, as in the case before VESICO-VAGINAL FISTULA. 191 us, not the slightest prospect of relief. The fistula here is jagged and large, the former condition being most probably due to previous ulcera- tion ; the edges are hard and thickened, and altogether one of the most unpromising forms of vesico-vaginal fistula which could possibly present itself to the attention of the practitioner. With the hope of changing the character of the thickened edges, I shall touch them freely with the solid nitrate of silver; and, for the present, recommend the sponge pes- sary as a mere temporary means of protecting this poor woman from some little of the inconvenience attending the constant discharge of water. If, hereafter, we shall find a reasonable prospect of relief by the ligature, we shall have recourse to it. A case of vesico-vaginal fistula was brought before you during the session of last winter, and you will recollect it was materially benefited by the actual cautery, which I ap- plied in your presence. Allow me now, gentlemen, in the most solemn and emphatic manner, to caution you against an error which, unfortunately for suffering humanity and the honor of our profession, has too generally prevailed. I allude to the indiscriminate and unpardonable use of instruments in the practice of midwifery. That they are resorted to in this city most unjustifiably, and with results the most disastrous, I know to be a fact. If the grave could speak, how touching and fearful would be its revelations on this topic—how monstrous the guilt of those who revel in innocent blood! Not long since I was visited by a young medical gentleman, who had been in practice but a short period. In the course of conversation the subject of operative midwifery was introduced; and he remarked to me that he had enjoyed the best opportunities of becoming familiar with the use of instruments, for his preceptor had performed the operation of embryotomy on an average sixteen times a year!!! To you, gentle- men, an announcement of this character may appear like romance, but I have myself witnessed in this city scenes of blood sufficient to satisfy my mind that this is not an exaggerated picture; and I will take the lib- erty of citing one case, among several others now fresh in my memory, to show you that I do not speak without cause when I protest against the unholy acts of men, who were intended neither by Heaven nor Nature to assume the sacred duties of the lying-in-chamber. The particulars of the following case I have mentioned in my edition of Chailly's Mid- wifery : " Two years since I was requested to visit a poor woman who resided a few miles from this city. She had previously borne two living chil- dren, and her confinement had not been attended with any unusual cir- cumstance. On arriving at the house, there was presented to my view a scene which I can never efface from memory. It was a spectacle at which the heart sickened—it was humiliating to my professional pride, and I could not but experience feelings of deep mortification. This un- fortunate sufferer had been in labor twenty-six hours, when two medical 192 CLINICAL LECTURES. gentlemen, for reasons which I trust were satisfactory to themselves and their consciences, determined on the use of the perforator. This instru- ment of death was accordingly thrust into the brain of a living child; the labor, however, did not advance, and they proceeded to remove the foetus piecemeal. After four hours' desperate toil—and I ask, where could have been their feelings of humanity—they succeeded in bringing away the entire foetus in a mangled condition, with the exception of the head, which was still in the womb. Tlie friends of this poor creature— for, destitute as she was, she was not without friends in this her time of trial—her friends, I repeat, became alarmed; their confidence was lost, and the serious apprehensions entertained for the safety of the woman induced them to call in additional aid. I was sent for; and on hearing the particulars of the case as far as the messenger could communicate them, I hastened to the house, accompanied by my former pupils, Drs. Busteed and Burtsell. The patient was pale and exhausted; her coun- tenance was that of a dying woman. She was almost pulseless, with cold extremities, and the perspiration of death on her. In her death ag- ony, she supplicated me to save her, and said, with a feeling that none but a mother can cherish, that she was willing to undergo any additional suffering if she could only be spared to her children! Poor creature! her measure of anguish was indeed full; and had she known that she was about being removed from her children by the atrocious butchery of men, to whom she had intrusted her life, she would not have made the appeal she did. In approaching the bed of the dying woman, and on attempting to make a vaginal examination to ascertain the condition of the womb—the head of the foetus being still in its cavity, having been separated from the trunk—you may well imagine my feelings on finding a mass of small intestines protruding from the vagina, and lying between the thighs! The operators had not contented themselves with slaughter- ing the infant, but they ruptured the uterus, through which the intestines had escaped; and, in this condition, they had abandoned the woman! She lay in this situation three hours before I saw her, the doctors having left the house, stating that nothing more could be done ! ! Verily, death does terminate all human effort. " The question now may be asked, why was embryotomy had recourse to in this case ? I never could ascertain. There must have been some secret reason for it; the burning love, perhaps, which some men have for the eclat of bloody deeds. There was no deformity of the pelvis, the head of the foetus was of the usual size; and, as far as I could learn, it was an ordinary labor. The doctors judged it advisable to do some- thing, and they decided to turn and deliver by the feet. They accord- ingly proceeded, and, mistaking a hand for a foot, pulled it into the vagina. They were then foiled, and, in order to complete the delivery, com- menced cutting up the foetus, and extracting it piecemeal. Thus were two lives wantonly sacrificed. The patient died in about two hours after PREGNANCY COMPLICATED WITH OVARIAN TUMOR. 193 I arrived; and half an hour before she sunk, she observed: ' My poor child was alive, for I felt it move when the doctors were tearing it from me /' Such language, uttered under such circumstances, was indeed graphic and eloquent in condemnation of those who had been participators in this cruel tragedy." Pregnancy Complicated with Ovarian Tumor in a married Woman, aged twenty-four Years.—Mrs. J., aged twenty four years, came to the Clinique to-day, bringing with her an interesting little infant, five weeks old; she had another child eighteen months of age. This patient, gen- tlemen, presented herself here last February, under peculiar circumstan- ces ; and, on reference to your note-books, you will find that the little infant now smiling in her arms affords very conclusive evidence of the truth of the opinion I gave her at that time. The history of the case, according to the record, is briefly this: Last February, when she first came to the Clinique, she was the mother of a child thirteen months old. About two months after the birth of the child, she observed a small tumor in the left iliac region, which continued to increase in volume. She nursed her child until February, and it enjoyed good health during the whole period of lactation. From the birth of this child to the time that she applied here for advice, she had not menstruated. She became very much alarmed in consequence of her increasing size, and imagined she would die. After a very full and thorough examination of this case, you will remember that the decision at which I arrived was—that the patient before us was pregnant, probably between four and five months, and was also laboring under considerable enlargement of the left ovary. This case is interesting in several points of view : 1st. About two months after the birth of her first child, she observed a small tumor in the left iliac region; 2d. She had continued to nurse her child until thirteen months of age, and notwithstanding her being between four and five months pregnant, the child suffered no derangement; 3d. From the birth of her first child, she had not menstruated ; 4th. The pregnancy was complicated with ovarian tumor. These four points may be considered as exceptions to general rules, and, therefore, are invested with more than ordinary interest. When the patient first presented herself at the Clinique, she did not entertain the slightest suspicion of her being preg- nant ; nor was she disposed to place much value on my opinion, when I assured her that she was actually four or five months advanced in gesta- tion. Her attention had been exclusively fixed upon the tumor, and she ascribed her increased size altogether to its presence. " Well, madam, do you now believe I told you the truth ?" " 0! yes, sir." " How does the tumor compare in size with what it was before the birth of your child ?" " I think it is much larger, sir." It is by no means an easy matter, gentlemen, to arrive at a correct diagnosis in cases like these; under certain circumstances, it is almost 13 194 CLINICAL LECTURES. impossible, with the presence of an ovarian growth, to state positively whether or not pregnancy exists. In the case before us, you will recol lect I made a very thorough examination. It was quite apparent tha there was an enlarged ovary; and on the following evidence I based my opinion that, together with the enlarged ovary, pregnancy existed. 1st. The areola was well developed, presenting all its characteristics; 2d. The womb was enlarged, and could be distinctly felt three or four fingers' breadth above the pubes; 3d. The neck of the uterus was full and pre- sented those peculiar changes—to which I have often alluded in my Lectures on Midwifery—and which always accompany pregnancy; 4th. The evidence conclusive to my mind was the passive movement of the foetus, or " ballotement," which I very distinctly recognized after several unsuccessful attempts. It was, therefore, gentlemen, on this testimony that I grounded the opin- ion, viz.: that the patient was laboring under disease of the ovary, and was also four or five months pregnant. That this opinion was true is established by two circumstances—1st. The little infant now in the arms of its mother; 2d. The existence of the tumor, which you perceive here passing obliquely from the left iliac region towards the umbilicus. [Here the patient was placed on the bed, and the tumor thoroughly examined.] There is one point about this case to which I desire for a moment to direct your atten- tion. You will remember that, when interrogating her upon the subject, the patient replied that the ovarian tumor is much larger now than it was previous to the birth of her child. There is nothing singular in this circumstance; but, on the contrary, it is in keeping with what is usually observed to be the fact in ovarian disease complicated with gestation. During pregnancy, these enlargements ordinarily remain stationary, for the reason that the action going on in the uterus, and the supply of blood necessary for the maintenance of the placental circulation, divert, for the time, the nutritious elements, which would otherwise pass to the ovary, and facilitate its development—for you must recollect, that diseased, like healthy structure, is dependent for its increase on the aliment it receives. As soon, therefore, as pregnancy is completed, the current of fluids sets toward the ovary, and its growth ordinarily becomes rapid. " What is the state of your general health, my good woman ?" " It is good, sir." " Do you nurse your little infant ?" " Yes, sir." " Have you sufficient nourishment for it ?" " 0 ! plenty, sir." " Is your ap- petite good?" "Yes, sir; I have a very good appetite, and my general health, I think, was never better." " Are your bowels regular ?" " That is the only thing, sir, that troubles me; they are rather confined." You may think it strange, gentlemen, that, with the disease of the ovary, I should not recommend this patient to wean her child. But I do not do so for the following reasons: 1st. Her general health is good, and she has ample nourishment for her infant; 2d. The very act of nursing, through the diversion made to the breasts, may, for the time being CONVULSIONS IN AN INFANT FROM CONSTIPATION. 195 retard the development of the ovarian growth; 3d. Without decided objection, the young infant should be nursed by the parent, for the reason that the mother's milk, other things being equal, is best adapted to its wants, and powers of assimilation. For the present, therefore, I shall simply recommend this patient to take at night, as circumstances may require, two of the compound rhubarb pills. Convulsions in an Infant five Weeks old, from Constipation.— Julia E., aged five weeks, is brought by her mother to the Clinique for advice; the mother says her infant, three weeks after birth, was attacked with convulsions, and they have continued to occur at intervals of four and five days. The mother is much alarmed, and fears there is no hope for her child. Convulsions, gentlemen, under any circumstances, and at any age, are well calculated to inspire alarm; and we can not, there- fore, be surprised at the anxiety exhibited by this woman in behalf of her little infant. The nervous system in infancy is extremely suscepti- ble of disturbed action, and although convulsions in the young child are often transitory in their effects, and pass off without involving any por- tion of the nervous system in organic lesion, yet this is not always so; and it becomes the physician to exercise more than ordinary vigilance in all cases in which convulsive movements present themselves. Convulsions, I have remarked to you on former occasions, are much more common in early childhood than in adult age—and this arises from the fact that in early age, the spinal cord holds the ascendency over the cerebral mass; while, as age advances, the brain predominates, and con- trols those reflex actions of the medulla spinalis, which are so common during infancy, and which at once explain the greater frequency of con- vulsions at that period. Although the brain at birth is insignificant in function, and exercises the slightest possible influence on the system, yet its growth is extremely rapid. During the first two years of existence, such is the rapidity of its development, the brain doubles its weight; and just in proportion as this organ grows and becomes developed in function, does it assume a higher control over the nervous system, and more especially does it preponderate over the spinal cord. This is an interesting physiological fact, and accounts for the decline in the fre- quency of convulsions as the child grows older. Years ago, when phy- siology was in its infancy, and the practice of medicine a question often of conjecture—necessarily so from the want of those lights which phy- siology and pathology have since supplied—convulsions whether in the adult, youth, or infant, were traced directly to the brain, and the unhap- py patient treated upon this hypothesis. The lancet, leeches, purga- tives, blisters, etc., constituted the remedies of hope; but how seldom alas! was hope realized, and how multiplied the deaths, which resulted from this routine system of therapeutics! You live, gentlemen, as it were, in another age; and while those who preceded you in the study 196 CLINICAL LECTURES. of our noble science were but too frequently obliged to grope in the dark, and substitute false reasoning and unsupported theory for truth and well established principles, you, by the invaluable contributions to medicine, through the zeal and labors of the physiologist, pathologist, and chemist, have comparatively an easy duty to perform—every step of your progress is made radiant by the lights which mind has devel- oped, and every fact thus given you is a basis for the erection of a super- structure of solid truth. Be not, however, content with the rich advan- tages you enjoy—intellect must not be satisfied with what has been accomplished—it must push on its investigations, and a glorious harvest is at hand for him, who prosecutes with an earnest zeal the wonders and beauties of nature—for, after all, nature in her strange and often- times mysterious evolutions should be a constant object of contempla- tion to the physician. Her mechanism, perfect and marvelous, you learn from dissection—a knowledge of the varied actions and uses of that mechanism you derive from physiology—while pathology teaches you the character and variety of its numerous derangements. Chem- istry, too, throws a flood of light on the phenomena constantly observed both in healthy and morbid structure, and opens a new avenue, by phil- osophical deduction, to the application of remedial agents. Causes.—Infantile convulsions, which are generally symptomatic, are traceable to a great variety of causes. To enumerate them all at the present time can scarcely be necessary. Among them may be men- tioned, as operating during the first few weeks of life, a retention of the meconium or urine, injury to the child during delivery, constipation, improper food, flatulence, gripings, sudden and loud noises, etc., etc. Symptoms.—These it is not necessary to describe, for when convul- sions occur, their presence becomes sufficiently manifest, and the symp- toms characterizing them will be modified according to numerous cir- cumstances. Diagnosis.—The practitioner will be at no loss to decide as to the nature of the affection; for convulsive spasms, unless as occasionally occurs they be masked, are too evident to lead to any embarrassment on this head. Prognosis.—The issue of convulsions in infants will depend very much on the cause producing them, and the peculiar nervous suscepti- bility of the system. The next question for us to consider is the Treatment.—You see this interesting little infant before you, and you have heard the state- ment of the mother that a week after birth it was attacked with convul- sions, which continued to occur at intervals of four or five days. Is there any thing in this statement, which will enable you to prescribe for the infant ? There is absolutely nothing to guide you, for the plain rea- son that you know nothing of the cause which has produced the convul- sions. Is it, for example, a retention of the meconium or urine ; is it an CONVULSIONS IN AN INFANT FROM CONSTIPATION. 197 injury sustained during birth, or is it constipation, improper food, etc. ? There is not one of you who is prepared to answer these interrogatories, and until something more is ascertained in reference to what the convul- sions are due, any medication which may be suggested will be more or less empirical, because it would be founded upon nothing stable. We shall, therefore, endeavor to ascertain the condition of the child previous to the attack, and then see if we can connect the convulsions with the cause that produced them. " Madam, what was the character of your labor, was it protracted and severe?" "I was in labor, sir, sixteen hours." " Were your infant's bowels free soon after birth ?" " Yes, sir." " What was the color of its evacuations ?" " They were black, sir." This question, gentlemen, I ask for the purpose of ascertaining whether he meconium passed off. The black material of which the mother peaks, was undoubtedly the meconium. " Did you put your child to he breast soon after birth, and have you sufficient nourishment for it ?" " I put it to the breast, sir, a few hours after birth, and I have an abund- ance of milk." " Have its bowels continued to be free up to this time ?" " No, sir. One week after birth it became very much confined in its bowels, not having a passage more than once in four days, and then after much straining, only a few lumps passed from it." " What, madam, is the condition of your own bowels ?" " Very confined, sir. I have been troubled in this way for the last four months, and since the birth of my child I have been afraid to take medicine, because I thought it would injure it." Do you not now, gentlemen, appreciate the importance of the in- terrogatories which I have just addressed to this woman, and do not her answers clearly indicate the cause of the nervous disturbance in her infant, for which she seeks advice at this Clinique ? An infant must be made of rock, or of something equally unimpressionable, to have its bowels moved but once in four days, and then only a few lumps pass away, and not suffer as a consequence under serious nervous derange- ment. Constipation, therefore, has produced the convulsions. But there is another interesting fact connected with this case. The mother says that she herself has also been affected with confined bowels, and it is highly probable that the torpor of the infant has been derived through the milk from the parent. It is a principle which you are to bear in recollection, that nursing-children are extremely liable to this character of indirect action transmitted by the mother. The presumption is that if our remedies be limited in this case to the infant, they will be without any permanent avail. We shall, therefore, whilst directing medicines for the constipation of the infant, not omit proper attention to the mother. Treatment.—The indication here is to regulate the bowels of both mother and child: R Hydrarg. c. creta......gr. ij Divide in Chart. No. ij. 198 CLINICAL LECTURES. One of the powders to be given at night to the infant, and followed in the morning with a tea-spoonful of castor oil. Let the other powder be given the second night, and next morning be followed by a solution of flake manna. R Sub. Mur. Hydrarg......gr. X This powder to be taken by the mother, followed in the morning by the annexed draught: R Sulphat. Magnesia?.....3 jsa Infus. Sennas.......1 iv Mannae........3j Tinct. Jalapae......• 3 j M. Gonorrhoea in a married Woman, aged twenty-six Years.— Harriet C, aged twenty-six years, married, complains of excessive pain in passing water, she says the scalding is such that it produces great an- noyance, and is accompanied with a discharge of matter. Her health was always good until ten days ago, when she first experienced a fre- quent desire to pass water, accompanied with pain and scalding. Here, gentlemen, is an interesting case for you. A frequent desire to urinate, attended with a scalding sensation, in the female, may arise from various morbid conditions of the parts; for example, ulceration of the urethra or neck of the bladder, bloody tumor of the meatus, chronic inflamma- tion of the mucous membrane of the bladder, the irritation from undue pressure of a diseased or prolapsed womb, gonorrhoea, etc., are among the causes capable of producing these symptoms, for you must remem- ber that the scalding and frequent micturition are mere symptoms of some disturbing cause—they are simply disclosures made by nature that something is wrong in the mechanism—and it becomes you, as the artizans, who are acquainted with that mechanism, and under- stand how to repair its derangements, to ascertain accurately what it is that has occasioned the disturbance. This, I can not too often repeat, is the leading principle of safety with the practitioner. Without it, he is tossed about in a sea of conjecture, mere chance is his only guide, and defeat the almost inevitable result. When this patient stated her case to me, I made an examination, and found the parts much inflamed, with a purulent discharge from the urethra; the womb is healthy and in place. On questioning her closely, she expressed the apprehension that she had contracted a disorder from her husband. Her suspicions I have con- firmed, for it is evident that she is affected with gonorrhoea. This disease is much more manageable in the female than in the male, and this arises from the shortness and greater dilatability of the urethra in the former. Treatment.—This woman should, in the first place, be freely purged; and for this purpose let her take at night the following powder, and in the morning | j of Epsom salts: R Sub. Mur. Hydrarg......gr. x Pulv. Jalapae ...... gr. xv Pulv. Ipecac. ... gr. j Ft. pulv, THE UMEILICAL CORD. 199 The following lotion should be freely applied to the parts several times during the day: R Liq. Plumbi acetat. dilut. . . . . § xij When the bowels have been properly moved, a table-spoonful of the annexed mixture three times a day :— R Bals. Copoibae.......§j Misturae Camphorae......§ ij MuciL Acaciae.......§ iij Jf. The patient to drink freely of barley water, flax-seed tea, etc., and abstain from stimulating diet. The little infant, gentlemen, which was presented to you a few moments since, with an ulcerated umbilicus, brings to my mind a question to which I shall briefly allude, viz.: How many ligatures should be placed on the cord ? The general practice of physicians is to apply two ligatures, and separate the cord between them. For this practice I can see no valid reason; and the one which is usually advanced is full of error, because it is founded upon a false hypothesis. It is alleged that if only one ligature be applied, the mother will be exposed to all the hazards of flooding through the untied extremity of the cord. Let us examine this question. The after-birth, or placenta, which is the medium between the mother and foetus whilst in utero, is divided into two surfaces, and possesses two distinct circulations; or, in other words, two distinct cir- culations are going on in the placenta. The two surfaces are called, the one the maternal, or uterine, the other the foetal, or membranous. The former has its connections with the uterus, the latter is covered by the amnion and chorion, and regards the foetus. The two circulations are the maternal and foetal; the former is carried on by the utero-placental vessels, the latter by the vessels composing the umbilical cord, which ramify on the foetal portion of the placenta, viz.: the two umbilical arter- ies, and one umbilical vein. These two circulations are distinct and inde- pendent—there is no continuity of canal between them. If you attempt to inject the umbilical vein, the injection will pass into the radicules of the umbilical arteries, but not into the utero-placental vessels. So much for anatomical injection in demonstration of the fact that these two circula- tions are not carried on by continuity of vessel, and are, therefore, distinct. If we now invoke physiology, additional proof as to the independence of these circulations will be exhibited. To suppose, for a moment, that the blood circulating in the system of the mother passes directly into the system of the foetus, unchanged and unelaborated, is not only to suppose a physical impossibility, but it would be the admission of a principle at variance with all sound physiology. If the blood of the mother be analyzed, it will be found to be very different from that in the system of the foetus, and utterly unfit, without modification, for the nourishment of the latter; and again, the blood discs in the maternal 200 CLINICAL LECTURES. blood could not, by any possibility, pass into the small and delicate vessels of the foetus. The question naturally arises, where does this change take place, and what is the character of the modification to which the maternal blood is subjected before it supplies the fcetal system with its elements of nutrition. These questions have, for a long time, con- stituted points of controversy, and have elicited a free and full discussion. The elaboration is undoubtedly perfected in the placenta by a sort of endosmose movement; for example, on the maternal portion of the placenta the arterial blood, coming directly from the system of the mother, imparts to the blood brought from the fcetal system by the um- bilical arteries, which ramify on the fcetal portion of the placenta, a vivify- ing principle, or, in other words, oxygenates it; this blood thus decar- bonized, and freighted with fresh elements of nutrition, is taken up by the radicules of the umbilical vein, and carried into the system of the foetus. If you object to this explanation—which is now the accepted one— and maintain the old notion that actual contact is necessary in order that decarbonization may be accomplished, it is only necessary for you to reflect for an instant how this process is effected in the lungs. You are aware that there is no direct contact there between the oxygen of the atmosphere and the carbon of the venous blood—and yet, decarboniza- tion, so essential to life, is going on without interruption from birth to death; and the familiar experiment of placing a bladder filled with venous blood in a jar of oxygen gas, which results in the decarbonization of the blood, is another very striking proof that contact is not essential to this process. Now, gentlemen, if you will bear in mind what I have just said as to the arrangement of the two placental circulations, and their inde- pendence the one of the other, it does appear to me that you can have no difficulty in appreciating how futile the apprehension is of flooding when but one ligature is applied to the cord; and how unnecessary it is, espe- cially in single births, to have recourse to two ligatures. I never apply but one for the following reasons: 1st. Two are unnecessary, because the small quantity of blood which flows from the untied extremity of the cord consists merely of the disgorgement of the vessels on the foetal por- tion of the placenta, and does not come directly from the system of the mother; 2d. This very disgorgement, in my opinion, assists in the more prompt expulsion of the after-birth. Oz^ena in a little Girl, aged four Years.—Mary H., aged four years, has been affected for the last four months with a discharge of offensive matter from the nose. The interest of this case, gentlemen, is to ascertain, if possible, what has given rise to the discharge. You have had before you on several occasions young infants laboring under more or less mucous discharge from the nose, constituting an affection of the Schneiderian membrane, termed coryza—there are two forms of this disease, the coryza simplex, and the coryza maligna. The former is POLYPUS OF THE WOMB. 201 usually trivial, and readily yields—the latter, which sometimes prevails alarmingly in hospitals where large numbers are congregated, is often a rebellious and fatal malady. The proper name of the disease in this little girl is ozmna, derived from a Greek word, which signifies stench. Ozsena consists in an offensive purulent secretion from the nose; it is necessarily an annoying affection, and occasionally proves extremely destructive, involving the bony structure itself. " Madam, has your child ever had the scarlet fever, or the measles ?" " No, sir." " Have you ever observed any swellings about its neck ?" " Yes, sir; it for- merly had lumps in its neck, and the doctor lanced one of them." The reason, gentlemen, of my asking these questions is this: scarlet fever and measles will sometimes be followed by ozsena—and scrofula is a very common cause of this affection. On examining the neck of this little girl, you perceive the cicatrices resulting from the incisions formerly made in the tumors, and some of the lymphatic glands are still tumefied. There can be no doubt that this child is scrofulous; and the discharge from the nose may be regarded as one of the circumstances connected in her case with this diathesis. Treatment.—The nose should be cleansed several times a day with castile soap and water, and then touched once a day, by means of a camel's hair pencil, with the following solution:— R Nitratis Argenti......gr- vj < Aquae purae.......§ j Ft. sol. The child should be in the open air, and, if possible, sent to the sea-shore. Diet nutritious. This little girl would, I am sure, be much benefited by the syrup of the iodide of iron, of which let her take fifteen drops twice a day. Polypus of the Womb, removed with the Calculous Forceps, in a married Woman, aged thirty-nine Years * Mrs. B., aged thirty-nine years, the mother of two children, came to the Clinique to-day to re- turn thanks for the benefit she had received. This case, gentlemen, you will I am sure, remember with much satisfaction. The patient before you, when she first presented herself here, exhibited a very different countenance; she was then pale and almost exsanguinated; and, as she told us, without hope. She had been subject to repeated floodings, ac- companied with bearing-down pains, simulating the throes of labor. After an examination, I discovered that the flooding and pains were oc- casioned by a polypus of the womb. The patient being a sensible woman, and most anxious for relief, consented to an operation; and, in your presence, I removed the polypus by twisting its pedicle with the ordinary calculous forceps. " Madam, how is your health compared with what it was when you first applied for advice?" "O! sir, I am now a happy woman, and I have come to tell you how much obliged I am for restor- * Page 83. 202 CLINICAL LECTURES. ing me to health." " Has the flooding ceased ?" " Yes, sir ! and my courses are now quite regular ; I have no pain, and every day I am gain- ing strength." In the removal of polypus of the womb, it is important to remember that if you should employ the ligature, it will be neces- sary, should the patient complain of pain, at once to loosen it, for the manifestation of pain is strong proof that you have embraced within the ligature the cervix of the uterus ; and should you be heedless of this fact, death will most likely ensue. Under ordinary circumstances, a polypus is insensible, and the patient suffers- no pain on the application of the ligature to its pedicle. Falling of the Womb from Engorgement of the Cervix in a mar- ried Women, aged forty-three Years.—Mrs. B.,aged forty-three years, married, the mother of two children, the youngest two years of age, says she has been in poor health since the birth of her last child ; she can not walk with any comfort in consequence of a bearing-down feeling; she has pain in her back, and a dragging sensation in her groins; frequent desire to pass water; occasional nausea, and is always more comfortable in the recumbent posture. The symptoms, gentlemen, which this patient has described are too vague to enable us, with any degree of precision, to ascertain their true cause; and this is the character of case, which you will often meet with in practice, and which, simply because you do not understand its real nature, proves rebellious to treatment, and brings discredit on you, and your profession. Better for you to retire from the field of practice, than subject yourselves to the mortifying results of routine treatment, or the fatal hazards of empiricism. The profession of medi- cine has its toils and sacrifices—but it is not without its pleasures and its triumphs. These last, however, are enjoyed only by the scientific practitioner, who is enabled in the first place to trace morbid action to its legitimate source, and then, by the application of correct principles remove it, and impart health and vigor to his suffering patient. I am gratified that this patient has presented herself at the Clinique, for it affords me an opportunity of directing your attention to a very impor- tant and interesting subject. Before introducing her to you, I found it necessary—in order that there might exist no doubt as to her disease— to make a vaginal examination. This I did, and discovered that she was laboring under falling of the womb, the uterus being on a level with the vulva, and the cervix much enlarged. So far as my own personal observation will enable me to judge, the ma- jority of females, who have any uterine derangement, are extremely apt to refer them all to falling of the womb. This is a serious error, because it too often leads the practitioner to a false judgment—not the practitioner, who thinks and acts for himself, but he who suffers his mind to be swayed by the declarations of his patient, and permits these declarations alone FALLING OF THE WOMB. 203 to form the basis of his treatment. In all cases, therefore, in which pro- lapsus is supposed to exist by the patient herself, or suspected by the practitioner, it is absolutely necessary to institute an examination in order that the true condition of things may be ascertained. Allow me briefly to call attention to the position and attachments of the uterus in its nor- mal state, with a view to a better understanding of the operation of certain influences, which are known to result in the displacement of this organ. The uterus is situated in the pelvic excavation, the bladder being in front, and the rectum lying posteriorly; the small intestines rest on its upper surface or fundus, while the lower surface or cervix is encircled by the superior extremity of the vagina. Between the poste- rior surface of the womb and rectum there intervenes what is termed the triangular space ; into this space the small intestines sometimes fall, and become strangulated; and the ovary, both in its healthy and dis- eased state, will occasionally be felt there, giving rise to various, and oftentimes distressing symptoms. The entire of the posterior surface of the womb is covered by peritoneum, while only the two superior thirds of the anterior surface are invested with this membrane, the in- ferior third being in contact, through the medium of cellular tissue, with the bas-fond of the bladder. The uterus is supplied with several ligaments, viz.: the broad, or ligamenta lata, which are simple duplications of the peritoneum, and the round, or ligamenta rotunda. The broad ligaments are calcula- ted to a certain extent to maintain the uterus in its parallel position to the axis of the superior strait of the pelvis; while the round liga- ments, which arise from the upper, lateral, and anterior surface of the organ tend to prevent retro-version. The ligaments of the womb, I am well satisfied, exercise very little influence in preventing pro- lapsion; indeed, they have no control over those causes, which are known to be the most common in the production of this form of displacement. The natural foundation of the uterus, and that which gives it due support, under ordinary circumstances, is the vagina. It is necessary, therefore, that you should clearly comprehend the connections of this passage, in order that you may appreciate its ability in a healthy state to sustain the organ in situ. The vagina is a crooked canal, cor- responding more or less accurately with the curves or axes of the pel- vis. The concavity of its curve is anterior, while the convexity is posterior. The vagina is divided into an upper and lower orifice, an an terior, and a posterior surface. Its upper orifice encircles the neck of the womb—its lower opens upon the vulva. Anteriorly, the vagina is in connection with the bladder, and a little lower down with the urethra, constituting the septa, known as the vesico-vaginal, and urethrovaginal. To facilitate your knowledge of the posterior relations of the vagina, we shall divide this passage into five parts; the superior fifth is floating, and also as a peculiarity is covered by the peritoneum—the three middle 5£ths are in close connection with the rectum, forming the recto-vaginal 204 CLINICAL LECTURES. wall or septum; and the inferior fifth is separated from the rectum by the intervention of the perineum. You can not fail to observe how admirably, by these connections, nature has provided for the due support of the uterus; but you must not forget that the ability to furnish this support on the part of the vagina ceases to exist when the uterus, through morbid action, undergoes an increase in its volume. Without at this time directing your attention to the various causes of uterine displacement, I shall limit myself to the consideration of one cause only, viz., an increase in the weight of the uterus. This organ is liable to several forms of displacement: 1 st. Ante- version ; 2d. Eetro-version; 3d. Prolapsus; 4th. Procidentia, etc., etc. If the womb should become the seat of enlargement on the anterior por- tion of its fundus or body it will be ante-verted, if the enlargement be on the posterior surface retro-version will occur; but should the increase of volume be on the cervix, then prolapsus, and sometimes procidentia ensues. There is no fact of more importance for you to bear in mind than this; indeed, it may be considered as one of the cardinal principles always to be vivid in the mind of the practitioner who undertakes to treat displacements of the uterus. The honor of having first called the atten- tion of the profession to this subject belongs, I think, to Lisfranc, who has contributed so largely and profitably to our knowledge of uterine pathology; and if this principle, so earnestly inculcated by him, had been more generally observed, displacements of the womb would not only have been treated with far more success, but much unnecessary anguish would have been spared unhappy sufferers. It is not only unphilosophical; it is, indeed, little else than empiricism to regard morbid action in an abstract point of view. Abstract reason- ing is, in my judgment, the leading fault of the medical practitioner, and it is the true secret of failure in the application of therapeutic agents. A patient has fever. Is it not material before attempting to subdue that fever to ascertain what has produced it ? Another is laboring under fracture of the limb. Is there but one plan of treatment for fractures, or will the treatment depend upon the character of the fracture ? The enlightened sur- geon will tell you that the latter is undoubtedly true. Your presence is suddenly demanded in a case of apoplexy. If you be a routinist, and look merely at the fact that your patient is attacked with apoplexy, you will seize your lancet, and abstract blood copiously from the arm ; and yet that apoplexy may result from gastric repletion, the remedy for which would have been an emetic! In such case, your bleeding is without avail; the patient sinks, and friends are agonized simply because you looked at one point only, instead of taking a comprehensive view of the disease. Apply these remarks, gentlemen, to prolapsion of the womb, and see how full of truth they are! The patient before us is laboring under this affection. The womb has fallen down; it is no longer in situ. If, then, you regard the displacement as the disease, you will probably resort to some mechanical means to give it support, perhaps the pessary. But I FALLING OF THE WOMB. 205 tell you, that to apply a pessary in prolapsus, such as is now before us, would not only aggravate the sufferings of this poor woman, but it would afflict her with additional disease, and generate a new train of morbid phenomena. And why? This is an important question, and I will briefly answer it. The prolapsion here is not the disease, it is the effect of disease; the womb has descended from its proper situation in con- sequence of its increased weight, the increased weight arising from en- gorgement of the cervix of the organ. The introduction of a pessary, under such circumstances, would not meet the difficulty; it would, how- ever, exert an injurious pressure against the engorged surface, producing ulceration, and, perhaps, far more serious results. Here, then, the en- gorgement is the disease, the prolapsion the effect. Engorgement of the neck of the uterus may result from ulceration, chronic inflammation, &c, of the organ; engorgement, however, is not always confined to the cervix, it sometimes involves the entire uterus. There are several forms of it, such, for example, as sanguineous or con- gestive engorgement, cedematous engorgement, and what is termed the hard engorgement; this latter, though amenable to remedies, will occa- sionally degenerate into schirrus of the womb. The patient before us is affected with congestive engorgement. In these cases, the menstrual function is very apt to become deranged, either defective in quantity, or altogether suppressed. On inquiry, I find that this woman has suffered from a deficiency of the catamenial flow. Treatment.—To be consistent, and true to our reasoning, we shall pay no sort of attention to the prolapsus; but shall direct all our treatment to the engorgement, which is the sole cause of the displacement in this case. Sanguineous engorgement of the uterus is usually quite a man- ageable affection. It consists principally in a distended condition of the uterine vessels; and the indications of treatment are twofold: 1st. To disgorge the vessels by occasional bleeding, together with astringent washes; 2d. To invigorate the general strength. With the former ob- ject, therefore, we shall recommend the application of six leeches to the cervix once in ten days for two or three successive periods; and as soon as the leech-bites have healed, the following injection may be used freely during the day: R Sulphat. Ferri........3j Decoct. Quercus.......Oj Ft. sol. Two of the following pills, which will be found laxative and tonic, may be given twice a day: R Extract Gentianae ) Pulv. Rhei J......J Saponis........3 ss Aquae........q- s. Ft. massa} in pil. No. xxxx. dividenda. The diet to be nutritious, and the patient to observe the recumbent posture as far as circumstances will permit. LECTURE XIII. Retention of the Menses with Haematemesis, in a Girl, seventeen Years of age.—Vi- carious Menstruation.—Threatened Paralysis of the lower extremities, in a married Woman, aged twenty-one Years, from defective Menstruation.—Abdomino-rectal Hernia in a married Woman, aged twenty Years, confined six months since with Twins.—Ulcerative Stomatitis, and Diarrhoea from Teething, in an Infant, eight Months old.—The Mortality of Infancy; is it from necessity or from neglect ?—Sub- mucous Fibrous Tumor of the Uterus, in a married Woman, twenty-three Years of age, with suppression of the Menses for the last twenty-two Months.—Ovarian Tumor in a married Woman, aged twenty-two Years, projecting into the triangular Fossa between the Uterus and Rectum.—Diagnosis between this form of Tumor, and Retro-version of the Fundus Uteri.—Introduction of the Uterine Sound. Retention of the Menses with Haematemesis, in a Girl, seven- teen Years of age.—Vicarious Menstruation.—Margaret M., aged seventeen years, of a plethoric habit, has never menstruated. She com- plains of fullness about the head, and says she frequently has her vision obscured, with beating in her ears; her bowels are habitually consti- pated, and she has thrown up blood several times within the last four months. The case before you, gentlemen, is one embodying much practical interest, and I invite your attention to it as one of more than ordinary instruction. This girl has never menstruated—she may, there- fore, be said to labor under amennorrhcea. Amennorhoea is, as you know, divided into two forms, retention and suppression; in the former, the function has never appeared; in the latter, on the contrary, the men- ses having been established, become from some cause or other arrested. The aspect of this girl is not one of disease; she looks as if she en- joyed good health, and so far as the popular eye is concerned, and her own looks indicate, the judgment would be that she is a vigorous, healthy young woman. The physician, however, must look beyond the sur- face, mere appearances are of little value, for they are oftentimes false lights. There is, in this city, many a bruised heart under a fashion- able exterior; the tinsel of dress and ornament may deceive the specta- tor, but it can not appease the anguish of a broken spirit. Too often, indeed, in my professional rounds, has occasion caused me to bear testi- mony to this truth! Our profession opens to us, if I may so speak, the portals of the human heart—its joys and its sorrows, its longings and its prejudices, its natural and its forced impulses, its outward demonstra- VICARIOUS MENSTRUATION. 207 tions and its secret pinings, are all so many points worthy of the pro- found attention of the medical practitioner. These remarks are equally applicable, in many instances, to diseased action. You will occasionally be called upon to prescribe for patients, whose aspect is that of health, but who, on investigation, will be found to labor under serious derange- ment. It is for you, therefore, not to suffer your judgment to be led astray by mere appearances, but to pursue your investigations with a determination to ascertain, in the first place, whether disease exists, and secondly, if it be found to exist, to recognise if possible its true charac- ter. These are the two essential duties of the physician; they are in fact the necessary elements of successful practice. Apply these obser- vations to the case before us, and see whether they will enable us to embrace fully all its features. As I have already said, the patient has the appearance of good health, but her statement, which you have just heard, establishes very conclusively the fact that her system is much deranged, and requires the interposition of science. The fullness of the head, the obscure vision, the beating in the ears, the haematemesis indicate disturbed action. It is for us to decide as to the true value of these morbid conditions; in other words, are they primary or secondary ? are they results, or are they causes ? There is another important circumstance connected with the history of this girl—a circumstance so essential, that to pass it by, would be to re- move all foundation of correct diagnosis—she has never menstruated, and yet she is seventeen years of age, with a fully developed physique; she is no longer a child, but bears all the external evidences of womanhood. Whilst laboring under retention of the menses, she presents at the same time an example of great vascularity. Are you surprised with these facts before you, that the patient should complain of fullness of the head, etc. ? Can you not at once connect this fullness of the head, the obscured vision, the beating in the ears, and the haematemesis with the amenorrhcea ? Have you any difficulty in placing them under the chapter of effects, while you at once recognize the amenorrhcea as the cause ? Nature is always conservative; she has been unable to establish the natural menstrual function; something or other has contravened her purpose, and in order to protect the system from the plethora consequent on the amenorrhcea vicarious menstruation presents itself in the haematemesis. Far better that this girl should bleed from the stomach, than that the brain should become invaded, and death ensue from apoplexy! The haematemesis, or vomiting of blood, is the feature in this case. In a word, it is an example of vicarious menstruation. It is totally unconnected with any organic disease of the stomach, and it is simply a derivative influence, instituted by nature to diminish the general plethora, and thus guard the economy against more serious injury. Probably of all the causes of haematemesis, there is none more common than retention and suppression of the menses, or the suppression of a hemorrhoidal discharge. 208 CLINICAL LECTURES. This discharge of blood can not fairly be termed idiopathic; it is a symptomatic bleeding, and is the result of an absence of the catamenial function through the uterine organs. Both men and women bleed from the stomach from different causes; sometimes the hemorrhage is the effect of ulceration of the vessels, etc. But in the case before us, there is no disease of the stomach, and the blood that is thrown from it, is a simple capillary hemorrhage from its lining or mucous coat. You will sometimes observe this vicarious menstruation from the lungs, in girls laboring under retention of the menses, and in this case, too, the bleed- ing is not the result of pulmonary disease, but the consequence of rup- ture of the capillary vessels. This character of bleeding from the lungs may go on for years, without in any way affecting the integrity of these organs. How important, under such circumstances, are just dis- tinctions, or perhaps in more professional language, accurate diagnosis. How easy would it be, under these circumstances, to mistake a com- paratively harmless hemorrhage from the lungs, for the fatal haemoptysis of consumption! Treatment.—The indication in the case before us, is to establish by judicious medication, the catamenial function. The haematemesis is but a shadow, and will cease as soon as the uterine organs perform their office properly. Let § vj of blood be taken at once from the arm, and in order to act freely upon the bowels, the following powder should be taken at night, and in the morning, |j of epsom salts in a tumbler of water. B Sub. Mur. Hydrarg.......gr. x Pulv. Jalapae.......gr. xv Pulv. Ipecac........gr. j Ft. pulv. Just before the next attack of haematemesis, let 4 leeches be applied to each groin, and the bleeding encouraged with warm fomentations. One of the best means of promoting the bleeding, after the leeches have fallen off, is by soft sponges wrung out of hot water. The con- stant application of these will prove very efficient for the purpose and are much better, and more at hand than poultices. The patient should have her feet put into a foot-bath, with a table-spoonful of mustard and one of cayenne pepper. This to be repeated for two or three nights and in addition let two of the following pills be taken for two successive nights: R Pil. Aloes c. Myrrha.....No. vj. The object of the above treatment is to divert the blood from the stomach to the uterine organs. It will be proper to let this girl drink ice-water, and use ice freely. It will have a good effect in preventing the congestion of the gastric mucous surface. Threatened Paralysis of the lower Extremities in a married Woman, twenty-one Years of age, from Defective Menstruation.— THREATENED PARALYSIS OF THE LOWER EXTREMITIES. 209 Caroline W., aged twenty-one years, a muscular red-cheeked young woman, complains of more or less constant dizziness; her menstrual evacuation is deficient in quantity ; the bowels are predisposed to con- stipation ; she takes very little exercise, and indulges her appetite, which is generally very good. " What brings you, my good woman, to the Clinique?'' "I am anxious, sir, to have something done for the pain and dizziness in my head ; I have been troubled in this way for some months, and I am very uneasy, sir, about myself." The interesting feature, gentlemen, in the case before us is the fact that this young woman suffers from pain and dizziness in the head—these two circum- stances appear exclusively to absorb her attention; and she expresses much apprehension for fear they should result seriously. Her appre- hensions we shall find are not without force. " Do you sometimes feel as if you would fall down ?" " Very often, sir." " Have you any un- steadiness in your gait, as if you had not proper control over your limbs ?" " Yes, sir, they often feel so." " Are you often troubled with nausea?" "Sometimes, sir." "Have you ever lost the power of speech ?" " No, sir—but I lost about ten months ago the use of my lower limbs for two weeks, and I recovered after being bled, and blis- tered on my head." " Well, my good woman, why did you not tell us this before ?" " Why, sir, I thought you would find it all out." I do not regret, gentlemen, the conversation which you have just heard —it has thrown ample light on the case before us, and at once explains my motive in addressing the above questions to this patient. If I were to ask any one of you to tell me what that motive was—or, in other words, what object I had in view by the questions I have just propounded, you would say without hesitation that I was endeavoring to ascertain whether or not symptoms of paralysis had not exhibited themselves in the per- son of this patient. The character of my interrogatories was so obvious and their bearing so manifest, that you could not but appreciate the point at which I was aiming; and the patient, you perceive, has fully confirmed my suspicions by the voluntary statement that ten months ago she lost the use of her lower extremities. I have had frequent occa- sion in this Clinique to direct your attention to the subject of paralysis —and I have pointed out to you the two characteristic peculiarities of this affection, as it occurs in the adult and early childhood. In the former, it is usually connected with disturbance of the brain, and is gen- erally more or less permanent—while in the latter, it is commonly the result of reflex irritation of the medulla spinalis, and is more or less transitory in its character. You have had before you numerous cases of paraplegia in children, which we have traced to intestinal disturbance reflecting upon the spinal marrow, and thus causing loss of motion in the lower extremities, accompanied sometimes but not always with loss of sensation. These cases have yielded to treatment, and you have participated with me in the pleasure I have derived from the result. 14 210 CLINICAL LECTURES. Let me for a moment allude to a circumstance connected with this case. You perceive that while the patient complains of headache and vertigo, and presents a combination of derangements indicating serious trouble of the nervous system, yet her appetite and digestion are good. In a word, the functions of organic life appear to be undisturbed. You will very frequently observe this fact in the course of your professional career, and it is important that you should be able to explain what to the popular mind may seem an inconsistency, but to the educated physician is a striking evidence of the wisdom displayed in the arrange- ment of the human mechanism. Man enjoys two lives—one is animal, the other organic. In a degree, these are independent of each other, and are controlled respectively by each of the two nervous departments. The former is regulated by the nerves of the cerebro-spinal axis, or as they are called, the nerves of animal life; the latter is dependent for the harmony of its functions on the distribution of the trisplanchnic system of nerves, denominated the nerves of organic life. I have told you that these two existences are separate, and to a certain extent inde- pendent of each other. Hence, how often do you observe, in the paralytic and imbecile, digestion vigorous, and the functions of organ- ic life unimpaired ? But, there is a beautiful, and at the same time striking exemplification of this independence in the two lives at the ap- proach of death. Have you ever watched over the couch of a dying friend, and noted the phases of his last agony ? If so, memory will crowd your minds with reminiscences—melancholy, indeed—but graphic and conclusive of the truth of what I have just stated. While one life is dead—the other exists—and it is not until the extinction of the latter that man ceases to live ! Animal existence is the first to die, organic the last. When the eye and ear have ceased to perform their functions, and the tongue has lost its power of articulation—when the intellect is merged in stupor, and cut off from all consciousness of external things —in a word, when animal life is extinct, organic existence still main- tains its vitality—and it is not until the last beat of the heart that the triumph of death is complete! Treatment.—The question now to determine—the one which so deeply interests this patient—is the course to be pursued with a view of pro- tecting her against another attack of paralysis. You can have no doubt as to the cause of the paralysis—it is vascular fullness, increased by the defective menstrual loss; the brain has thus been crowded with blood, and the result, you see, has been serious derangement of the nerves of animal life. Take from the arm § x of blood, and give two of the fol- lowing pills every four hours until free purgation is produced :—■ R Sub. Mur. Hydrarg. .... . 3j Olei Tiglii....... gtt. ij Pulv. Ipecac. ... gr. ij Syrup. Simp.......Q. S. Ft. Massa in pil. x. dividenda. ABDOMLNO-RECTAL HERNIA. 211 In addition to the above, let this girl, just before the expected menstrual period, lose from the arm § ij of blood, and the same quantity in two weeks; this bleeding from the arm to be continued until the function is sufficient in quantity. The bowels to be kept in a soluble state by epsom salts, with exercise in the open air. The diet to be vegetable; and, as a salutary waste-gate to the brain, a seton should be put in the back of the neck. Abdomino-rectal Hernia in a married Woman, twenty Years of age, confined six Months since with Twins.—Margaret R.,aged twenty years, married, was delivered, six months since, of twins, and presents herself to-day for advice, in consequence of what she terms " a large tumor " in her abdomen. I am enabled, gentlemen, to show you, in the person of this patient, a most interesting, and, I may add, remarkable case of displacement. If your attention had never been drawn to this subject, you might, when engaged in practice, become much embarrassed in forming a correct diagnosis. When this woman told me she had a tumor, I was, of course, anxious to ascertain its true character; and, on instituting an examination, I discovered that, in certain positions, I could very distinctly feel an unusual protrusion from the central portion of the abdomen, the protrusion being elongated and narrow; while, in other positions, the protrusion entirely disappeared. In connection with this circumstance, I also noticed an extraordinary flaccidity of the ab- dominal integuments—they hung in large folds, and looked more like an empty sac than the parietes of a primipara. Successive parturitions produce, by repeated distension, flaccidity of these integuments; and the flaccidity is usually in proportion to the number of pregnancies. It is not common, therefore, in a first gestation, to observe much change in this particular. [Here the patient was placed on the bed in the recum- bent posture, and the Professor, in directing attention to the abdomen, observed:] You perceive, gentlemen, the extraordinary appearance of the abdominal integuments—they have lost all their elasticity, and, as you see, lay in large folds; they possess no resistance, having lost all power. If I were to ask this patient when she became affected in this way, I could very readily anticipate her answer. O! sir, observed the patient, I never had any thing like it before the birth of my children. This is precisely the reply I should have expected; and it is for us to explain why she should be an exception to the general rule, which I have already mentioned, viz.: that women with their first children usually do not, after birth, have much flaccidity of the abdominal integuments. In this case the abdomen has been so enormously distended by the pres- ence of twins, that the integuments have lost all power, and hence the re- markable relaxation, which you observe. Again, while the patient remains on her back in the recumbent position, there is not, as you perceive, the slightest vestige of a protrusion. The abdomen is flat, and the only 212 CLINICAL LECTURES. thing remarkable is the relaxation of the integuments. She now assumes a demi-recumbent position, and you immediately observe a protrusion passing through the central line, extending some six inches in length. You remark now that she is in the erect posture, the protrusion is much increased in volume, occupying precisely the same direction. What, gentlemen, is its character ? Is it an abnormal growth ? Under what classification of tumor do you place it ? These are the questions which very legitimately present themselves for solution. The only thing ab- normal about the case is this: the immense distension, which the ab- dominal walls have undergone, has resulted in the separation of the two recti muscles, and through this opening there is a protrusion from the abdomen—and for the want of a better name, I have termed it abdomino- rectal hernia. Treatment.—All that is required is to give, by means of a properly- adjusted bandage, uniform support to the abdomen. There is nothing dangerous—nothing to be apprehended from this form of protrusion. Obstinate constipation, however, might result in serious difficulty; and, therefore, it should be guarded against. " Madam, you have no tumor. You may go home with the assurance that there is no cause for uneasi- ness." "Thank you, sir." Ulcerative Stomatitis and Diarrhcea from Teething, in an Infant eight Months old—Mortality of early Infancy—Its Causes.—Wm. F., aged eight months, has been affected with diarrhoea and sore mouth for the last two weeks; it has refused the breast for the last two days, and is extremely fretful. " Has your child any teeth, madam ?" " It has two, sir." " What was the condition of its health previous to this attack of diarrhoea ?" " It was good, sir; it had not any sickness since its birth. Do you think you can cure it, sir ?" " Yes, madam, if you will follow our directions." There are, gentlemen, many outlets to the life of the young infant—and it is indeed fearful to contemplate the mor- tality of the first year of human existence. In France, where so much has been accomplished in the way of hygienic measures, of one million of children annually born two hundred and fifty thousand die at the end of twelve months. You see, therefore, that one-fourth of the infants born are swept from earth before the completion of the first year! It is stated by the Registrar-General, that in 1846, of fifty thousand per- sons who died in London, more than fifteen thousand were less than two, and over twenty-one thousand were under ten years of age! Again, of every one hundred persons born in London, thirty-five die before they attain their tenth year ! What a melancholy picture for contemplation __a picture which would have no existence if the obligations of society to the destitute were properly discharged. I can not understand why London, with its numerous and well conducted hospitals for adults, should have so completely neglected the wants of sick children. In that great MORTALITY OF EARLY INFANCY. 213 metropolis, there is but one hospital especially devoted to children, and that containing not over sixty beds! ! Well may common sense ask, Where, citizens of London, is your philanthropy, where your equalized charity ? Is it that young children, the most helpless and dependent of the human family, are unworthy of your care, that you should have be- stowed all your benevolence on the older and less dependent members of that same family ? London stands almost alone among the cities of the civilized world in this cruel neglect of the helpless child, when weighed down by disease; and if the philanthropist wishes to know how this neglect has operated, let him ponder over the tables of mortality as given under the authority of the Registrar-General. In these tables, he will find something for reflection, if not for bitter remorse, at the shame- ful wrong committed against those little creatures, who, though they can not plead their own cause, are in every way entitled to the warm sym- pathies and protection of those on whom the smiles of fortune are con- stantly playing. What are young children, but so many links between the present and the future ? If it be true, that the human family, like nations, is perpetuated through succession; and if the pride and honor of each country is to be represented hereafter by the young of the pres- ent day, does it not become all, who look to the glory of the future, to spare no labor on the moral and physical well-being of those on whom the character of that future is to depend ? I think so; and it is in part because of this opinion that I lament the wants of the little children in the metropolis of England. It is not until the termination of the second year of existence that the infant may be said to have passed the dangers incident to it. At the end of the second year the first dentition is completed. Abstract reasoning might impress you with the belief that the melancholy mortality of in- fancy is attributable to the process of dentition; but you must take a more comprehensive view of this subject; as rational men you must, in your calculation, start with broad and tenable premises, and your deductions will then be more likely to approximate the truth, and be- come data for correct opinion. It is not, as a general rule, until the sixth or seventh month that the infant begins to suffer from teething, and yet long before that period it is subject to diseases which oftentimes prove fatal. How true, indeed, is it that the existence of the infant, even before its birth is completed, is placed in serious peril. As soon as the head has passed the vulva, untoward delay on the part of nature, or offi- cious interference by the practitioner, may cause the extinction of life. Again, the first hour after birth is too often the starting point of dis- ease, which, sooner or later, proves fatal. Unnecessary medication, the sojourn of the meconium, improper food, bad air, general neglect, are among the causes which obtain in the early destruction of life. The new-born infant, too, has scarcely come into the world when we find it frequently attacked with what may be termed one of the accompaniments 214 CLINICAL LECTURES. of the lying-in-chamber—purulent ophthalmia. You have had before you in this Clinique numerous cases of this affection commencing a few days after birth. If to these circumstances be superadded scrofula, rachitis, syphilis, etc., the melancholy legacy often entailed upon offspring, you will, I think, acknowledge that the first months of infancy, before den- tition and its accompanying troubles commence, is one of positive dan- ger. But I can not believe that this fatality is other than relative. To suppose that it is a necessary result, would be in my judgment detracting from the beneficent acts of Him, who controls all things eartldy, and whose power tends not to the destruction, but, on the contrary, to the preservation of the human family. When I say, therefore, that the mor- tality of early infancy is relative, I mean to imply that it is, ceteris pari- bus, in proportion to the neglect of those principles, which both common sense and science have told us constitute the very foundation of human health. A child, for example, comes into the world with syphilis, and it dies either from the disease, or the effects of the medicine incautiously administered to arrest the poison. Will you tell me that this child dies from necessity ? As well might you argue that the inebriate, who walks into the river, goes there by the direction of Providence! He goes there because, in making a beast of himself, he has become deprived of that intelligence which God has given him, and which intelligence, if properly used, will guide him safely through life. So is it with the new-born in- fant affected with syphilis; it comes into the world with a taint received from its parents, and its life is forfeited through treachery to natural obli- gations. You perceive, therefore, that the mortality of early infancy is not to be ascribed so much to necessity, as to the violation of those leading ordinances, the integrity of which nature has declared essential to the preservation of health. How important, then, is it for the practitioner to have his mind imbued with a knowledge of these ordinances—and how imperative the duty to see that they are observed. I would not, how- ever, have you suppose from what has been said that the period of den- tition is not one of peril. On the contrary, from the age of six months to the termination of the second year—the period included in the first dentition—there is a vast fatality. But this is not to be attributed ex- clusively to the fact that the child is teething. You must remember that here too there is a combination of circumstances tending to the destruction of life. The period of infancy is one of uninterrupted growth, with evolutions so wonderful and rapid that indeed it may truly be said that the young child is in a state of constant transition. Every hour almost brings with it remarkable changes in the physical organism —and these changes, so rapid and constant, and so necessary, too, foi the completion of the mechanism, do of necessity predispose the young infant to a variety and complication of derangements. It is a physiolo- gical truth that the young child enjoys almost exclusively an organic 01 MORTALITY OF EARLY INFANCY. 215 vegetative existence—in it, nutrition appears to be the great object of nature, and hence we notice the rapid growth of the physical machine. It soon attains the perfection of development, and then the balance- wheel—repair and waste—is brought into active duty. Should this balance-wheel perform its offices agreeably to the exactions of nature, harmony of function and health will be the result. Should, however, either repair or waste preponderate the one over the other, derangement and disease will naturally follow. The period of dentition is apt to be accompanied by certain morbid conditions, which it is highly important for the practitioner thoroughly to comprehend; and he should be enabled to distinguish between the morbid phenomena which depend more or less directly on the irritation of teething, and others which are merely incidental in their occurrence. A child while teething is extremely liable to irritation of the lining membrane of the mouth—and this will show itself under various forms; such as stomatitis, apthous eruptions, diptheritic deposits, etc. In the case before you there is an example of stomatitis as the accompaniment of dentition. This affection has been divided into four kinds ; 1 st. Fol- licular; 2d. Ulcerative; 2d. Malignant; 4th. Mercurial. This little child is affected with ulcerative stomatitis. The stomatitis in this case has been produced by the irritation of the gums—it is, however, ob- served in infants of an earlier age, and is often traced to gastric derange- ment, particularly when there is an excess of acid in the stomach. To this subject, however, your attention has already been directed on former occasions. In addition to these local troubles connected with teething, the constitution frequently becomes more or less involved, as is evinced by the frequent occurrence of convulsions, cutaneous eruptions, diar- rhoea, etc. The subject of convulsions from the irritation of teething we have repeatedly discussed in this Clinique. You have also been admon- ished not rashly to interfere with the various eruptions, which, from time to time, show themselves at this period, on the head, face, etc. I am firmly impressed with the accuracy of the ancient doctrine in regard to those eruptions occurring at the time of dentition—they are salutary waste-gates—so many derivative influences, which nature supplies to break the force of irritation. The duty, therefore, of the practitioner is not suddenly to heal, but simply keep them within reasonable check. Again, observation exhibits an interesting fact with regard to these eruptions, viz.: that they very often disappear when the process of den- tition has been completed, after having resisted every attempt at medi- cation. With regard to the diarrhcea ordinarily observed at the time of dentition, I think, too, that the opinion entertained by the older writers is far more philosophical, and more in accordance with daily observation than the views on this subject promulgated by certain modern authors. What are the facts which the observant physician is constantly called upon to notice in an infant who is suffering from the irritation of teething ? 216 CLINICAL LECTURES. They are facts of no little moment, for they embody a practical truth of great value. If you interrogate a practitioner of experience, he will tell you that the general rule is this: as soon as the gums of the infant begin to swell, the irritation is transmitted to the intestinal mucous sur- face, the result of which is looseness of the bowels. The exception to this rule is constipation. No one, I imagine, will attempt to deny the truth of these two propositions. If, therefore, they be conceded, the diarrhcea will stand in relation to the swollen gums as effect and cause. Let us proceed a step further, and what do we observe ? Should the diarrhcea not be so profuse as to debilitate the energies of the system, it will be found that the child will improve under it; or, in other words, that the constitutional disturbance, especially of the nervous system will be so far controlled as to prevent those serious, and oftentimes fatal con- vulsive movements so appalling both to the mother and practitioner. Suppose, however, that the physician should regard the diarrhoea as a primary disease, and as totally unconnected with teething—and this is a common and fatal error in practice—he would administer some astringent medicine which, while it would arrest the diarrhoea, thus clos- ing the waste-gate which nature in the exercise of her conservative power had opened, would most probably prove fatal to the infant. Do you wish the proof of this ? See what occurs in the teething infant whose bowels are constipated—fever, convulsions, and death ordinarily follow. I am aware that the doctrine has been proclaimed ex cathedra that to regard diarrhcea as the usual effect of dentition is merely to perpetuate a crude and vulgar notion. But allow me to say that, crude and vulgar as this notion may be deemed, it is a principle which nature herself in- culcates, and she silently but eloquently urges you to adopt it as a prin- ciple of safety in the management of children suffering from the irritation of teething. The lesson she enjoins is this : when the diarrhcea in a teething infant is so profuse as to interfere with the general harmony of its system, it is the duty of the practitioner, not hastily to check it, but to keep it under proper control. Again, nature urges—when the teeth- ing infant is constipated, its only safety is in proper purgation. I would remark further, that when the diarrhoea accompanying dentition is an idiopathic affection, it is so as an exception to a general rule, for it is almost always symptomatic. This form of diarrhcea is as much entitled to the name of tooth diarrhcea, as is the tooth cough, or worm cough, or liver cough, which were fully explained to you a few Cliniques since as merely symptomatic disorders—between which and primary or idiopathic affections it is important for you to distinguish. Treatment.—If you will view this case according to the standard that I have endeavored to place before you, and be governed by my reason- ing, you will regard the stomatitis and diarrhcea simply as results, oc- -casioned by the process of teething; and how far the diarrhcea is to be checked becomes a matter for you seriouslv to determine. Is it so pro- w SUB-MUCOUS FIBROUS TUMOR. 217 fuse as to debilitate the infant, or is it within reasonable, or, if you choose, salutary limits ? This is the first question to be decided. That the former is true admits of no doubt. The infant presents all the in- dications of prostration. Therefore, with a view to limit the diarrhcea, I shall order a tea-spoon of the following mixture once or twice a day, ac- cording to circumstances: R Cretae Misturae.......§ ij Tinct. Kino ) ... ., Tinct. Catechu 1"......gtt. vnj if. The lower middle incisors have pierced the gums while the portion of gum corresponding with the upper middle incisors is very much swollen, and the teeth appear to be ready to protrude. It is, therefore, proper under these circumstances, to lance the gums freely, which will be at- tended with the double advantage of allowing the upper incisors to pierce the gum, and at the same time relieve the irritation by the slight bleed- ing, which will follow the incision. In the ulcerative stomatitis you will find an efficient remedy in the chlorate of potash; it is also one of the very best remedies in what is termed cancrum oris, or phagedenic ulceration of the mouth in children. I have employed it with the happiest results. I think its use for this purpose was first suggested in Germany. It may be employed in the case of this infant as follows: R Chlorat. Potassae......3j Sacchar. Alb........3 ij Aquae distillat........§ iij M. A dessert-spoonful two or three times a day. Sub-mucous Fibrous Tumor of the Uterus in a married Woman, twenty-three Years of age, with Suppression of the Menses for the last twenty-two Months.—Mrs. M., aged twenty-three years, presents herself at the Clinique for advice, in consequence of ill health for the last two years. She has been married three years, has had no children, nor was she ever pregnant; she has labored under suppression of the catamenia for the last twenty-two months, and is greatly emaciated. She complains of a swelling in the lower portion of her abdomen, which she says she has observed for the last eighteen months. " Madam, what was the state of your health previous to your marriage ?" " It was good, sir." " Were your periodical turns regular ?" " Yes, sir." " Did you enjoy robust health ?" " Indeed, I did, sir. I was a strong, hearty woman, and I did not know what sickness was." " Do you know what caused your courses to become suppressed ?" " I do not, sir, unless it was a cold I took." " You say that they have been suppressed for the last twenty-two months ?" "Yes, sir." " Was your health good before that time ?" " It was, sir." " For the last twenty-two months what has been the condition of your health ?" " Bad, very bad, sir. I have been failing every day, and you see I have fallen away to a mere shadow." 218 CLINICAL LECTURES. " Has the swelling in the lower portion of your abdomen, increased in size ?" " Oh ! yes, sir. It was quite small at first." " Have you had, since you first noticed the tumor, a frequent desire to pass water ?" " Yes, sir, that has troubled me very much." " How are your bowels ?" " Very confined, sir." " Have you any pain when you have an evacua- tion ?" " Yes, sir, a great deal." " Do you sometimes feel a numbness in your lower limbs ?" " Yes, sir." " Do they swell." " They do, sir." The case before you, gentlemen, is well calculated to arrest your at- tention, for it presents several points of more than ordinary interest. While the questions which I have addressed to this patient have elicited prompt and satisfactory answers, yet they contain nothing which will enable you to arrive at a just conclusion as to the nature of her malady. What duty, then, devolves on the practitioner in order that he may clearly comprehend the true character of the case before us ? He should institute a careful and thorough examination ; endeavor, if possible, to ascertain the nature and origin of the swelling of which this patient complains, and see if he can connect it with the general derangement of health under which she labors. This I have done ; I have made with much care a vaginal examination, and I am now prepared to tell you what I have discovered to be the facts in the case. 1st. On introducing my index finger into the vagina, I very distinctly recognized a consider- able enlargement of the uterus, and on placing the other hand on the abdominal walls, I could readily grasp the upper portion of this organ ; with an alternate movement of elevation and depression of the two hands thus applied, it was very evident that I embraced between them the enlarged womb; 2d. The neck of the uterus is shortened, and its parietes expanded, while the os is sufficiently dilated to enable me to introduce the apex of the finger, and feel a substance within its cavity, of uniform surface, and slightly hard to the touch; 3d. In examining the iliac fossae, I found them free from all fullness, and the tumor I felt is in the central and lower portion of the abdomen. The tumor is not sensi- tive to the touch, and it is very manifest that it is not pediculated. This want of sensibility is rather an exception to the general rule. As soon as I had ascertained these facts, a very natural question for me to ask this patient was, whether or not she had been subject to pe- riodical hemorrhages. She replied, No! adding that for the last twenty- two months she had not only labored under suppression of her courses, but had been entirely free from any character of sanguineous discharge from the vagina. You will presently understand why I asked this ques- tion, and you will gather the fact that, in her case, the absence of period- ical floodings is also an exception to what is almost always observed in the character of disease with which she is affected. This patient has a fibrous tumor in her uterus growing from the internal surface of the organ, and causing the organ to enlarge precisely as the tumor becomes SUB-MUCOUS FIBROUS TUMOR. 219 developed. The uterus is subject to various morbid growths, such for example, as the fibrous tumor, divided into the benign and malignant, polypoid formations, which are pediculated, etc. In the case of this pa- tient we have what is known as the sub-mucous tumor of the uterus. Fibrous growths connected with the womb are not of rare occurrence— and in the course of your practice they will present themselves to your observation. When they exist, they will be found in one of three po- sitions, and hence they have been divided into three varieties, the variety depending on the exact location they occupy. 1st. The sub-mucous; 2d. The sub-peritoneal; 3d. The interstitial. It is important that you should have an accurate idea of these three forms of tumor, for on this knowledge may frequently depend proper therapeutic applications, and in some instances, will prevent inconsistent if not hazardous interference on the part of the practitioner. When the tumor is situated within the cavity of the uterus, it is under the mucous membrane, or in other words, the mucous membrane of the womb forms its outer covering, and hence it is called sub-mucous. When, on the contrary, the tumor grows from the external surface of the uterus, the peritoneum is its investing membrane, and hence it is sub-peritoneal. When it becomes developed amid the muscular fibres of the organ, it is called interstitial. You see, therefore, there is propriety in the denomination of the growth from the position it occupies. The progress of these tumors is extremely uncertain. Sometimes they remain dormant for years, and occasion very slight uneasiness to the patient; they sometimes degener- ate into bony matter, and are expelled from the womb—again, through the progress of inflammatory action, abscesses form in the tumor, mat- ter is discharged, and the patient often recovers her health. The matter is sometimes discharged through the cervix uteri, sometimes through the rectum, and occasionally from the urethra. The presence of a fibrous tumor in the womb is not incompatible with child-bearing, but it neces- sarily enhances the perils of parturition; and by the pressure of the fcetus against the tumor during labor, the suppurative process will often be much more early developed. The fibrous tumor occasionally, too, originates on one of the lips of the os uteri, and as it becomes devel- oped, to a greater or less extent, it encroaches on the vaginal walls.* * About two years ago, I saw, in consultation with Dr. Palmer of WiUiamsburgh, an interesting case of disease in a lady, the mother of three children, the youngest two weeks old. About eight days after the birth of her last infant, she complained of rigors followed by fever. Pressure on the hypogastric region was attended with much suffering. In a word, she had all the symptoms of inflammatory action; and much apprehension had been felt for fear of puerperal peritonitis. On the fifth day after the first rigor, the patient had a copious discharge of matter from the urethra. It was at this juncture that I was invited by my friend, Dr. Palmer, to visit his pa- tient. After a very careful examination, we arrived at the opinion that the discharge of matter proceeded from an intra-uterine tumor, the opening between the uterus and bladder having taken place at the bas-fond of the latter organ. The lady was 220 CLINICAL LECTURES. There is one feature in the case before us, which is well worthy of your attention—it is the general emaciation of the patient. She states that before the suppression of the catamenia, and previous to the existence of the tumor, she was not only a healthy, but a robust woman. Since, however, she first recognized the presence of the tumor, she has gradu- ally continued to lose flesh, and is now, as you perceive, comparatively a mere shadow. This is by no means an insignificant circumstance; and the question at once presents itself, what has occasioned this general atrophy of the system ? The patient is without cough—she has not been subject to a protracted drain of the economy, from diarrhoea, dys- entery, menorrhagia, diabetes, etc.,—what then has produced this gen- eral decay of structure ? This question, to which we have heretofore directed your attention, in connection with affections of the womb and ovaries, involves a leading principle in uterine pathology—a principle so fundamental indeed, that if it be suffered to pass unnoticed by the practitioner, will often lead to false diagnosis, and consequently empirical treatment. The emaciation here is the result of local disease—the nerves of organic life, whose healthy influence is so essential to the maintenance of the nutritive functions, have suffered impairment from the diseased condition of the uterus, and hence they have been unable to transmit to the digestive organs their proper supply of nervous power. How often have you seen this principle exemplified in the Clinique, both in functional and structural disease of the uterus! It is a principle which those of you who intend to make a speciality of the maladies peculiar to women must have constantly before you. Often will it prove a faithful guide, and enable you to reach the truth which, without it, would be unattain- able. It is not improbable that the patient herself, as well as her friends, imagine that the emaciation is the absorbing feature in the case—and with this view, their therapeutics would consist in the administration of tonics to generate an appetite, etc. But to you, this decay of structure presents a very different aspect—it is the effect of a disease, which alone is to occupy your attention; and if you can succeed in arresting it, then the nutritive functions will be the recipients of healthy nervous influence —digestion will be improved, and the patient will gain flesh and strength. This, at least, is the fair reasoning in the case—reasoning, which all experience proves to be correct. You must, however, remem- ber that although as a general rule the functions of the sympathetic nerve become impaired in diseases of the uterus, yet there are occa- sional exceptions to its application. Some women, of iron constitutions, resist this indirect influence of morbid action on their nutritive organs, and do not become wasted in tissue; so that while you recollect the rule, you must not forget the exception. placed on tonics, and rapidly recovered. She has since borne a child, and is now in the enjoyment of good health. SUB-MUCOUS FIBROUS TUMOR. 221 Causes.—Those of you whose attention has not been particularly directed to this subject, may be surprised to learn that fibrous tumors of the uterus are far more frequently met with in the unmarried and barren, than in those who have borne children. Such, however, is a well established truth ; and the existence of this form of uterine growth is by no means of rare occurrence. The cause of these tumors is in- volved somewhat in obscurity—and authors differ in opinion on the sub- ject. External violence will sometimes lay their foundation; and men- strual suppression will, in my judgment, be found a common antecedent to their development. In the patient before us, it is a rational conclu- sion that suppression has been the cause. Dysmenorrhoea, too, of the congestive type, will, I think, be found among the causes of this class of uterine tumors. Symptoms.—The symptoms, which result from fibrous tumors of the uterus are of a mixed character—general and local. Sometimes nausea and vomiting, and enlargement of the mammary glands supervene. But the principal disturbances are local—such, for example, as a fre- quent desire, and sometimes an inability to pass water from mechanical pressure of the tumor against the bladder. Indeed, the latter will occasionally become much distended, and the distention will even reach the ureters and kidneys, giving rise to a comatose condition of the brain. Pain in defecation, hemorrhoids, prolapsion of the mucous membrane of the rectum, constipation, also, from pressure of the tumor, may be classed among the effects a» symptoms of fibrous growths of the uterus. Bearing down pains, with displacement of the womb, the displacement depending on the portion of the uterus at which the tumor is found. There is one symptom attending the sub-mucous fibrous tumor, which is almost always present, and which constitutes much of the danger, but in this case it is absent I allude to the profuse hemorrhages, which, as a general rule, may be said to characterize the sub-mucous tumor. You may ask—and very properly so, what is the source of the hemorrhage in these cases ? The bleeding proceeds from the mucous or investing membrane which becomes congested, the vessels relieving themselves in this periodical loss of blood, which at times is fearfully profuse, and ex hausting to the patient. Why should this usual accompaniment of the sub-mucous fibrous tumor be wanting in the case before us ? Is not the fact explained in the pale and anaemic aspect of this patient's counte- nance? Comparatively, there is no blood in the system—and what is there has lost, through disease, its ordinary properties. This excep- tion, then, to a very general rule, imparts additional interest to the case. Diagnosis.—This is an important subject for us to consider; and it will oftentimes require all your sagacity and vigilance to distinguish be- tween fibrous tumor of the uterus, and the various conditions of the organ, which occasionally simulate the presence of the tumor. The fol 222 CLINICAL LECTURES. lowing may be mentioned among those conditions: 1st. Pregnancy; 2d. Ovarian disease. Pregnancy. In a married woman, who, of course, has a right to be pregnant, the distinction may not always be of the same paramount importance; but in the unmarried, whose character and hap- piness become involved in the decision, there is no higher obligation im- posed on the practitioner than a prompt and just decision of the case. In fibrous tumor, as in pregnancy, there will usually be enlargement of the breasts, and nausea—but in the latter only will the true areola be observed, characterized by the oedema of the nipple and surrounding sur- face, and enlargement of the follicles, with more or less moisture and emphysema. According to the best observation, in fibrous tumor, as in other morbid conditions of the uterus, the areola is usually of a dark color, and the follicles are numerous—but it is wanting in the true char- acteristics of the areola of gestation, the adema and moisture. You should not regard these appearances of the breast lightly; they are ira- portant indications, and possess a precious value in all cases of doubt. Again, in pregnancy, there are the various changes in the os and cervix uteri, to which I have so repeatedly referred in my Lectures on Mid- wifery ; the regular surface and ovoid shape of the uterus; the pulsations of the fcetal heart, the bruit placentaire, the active movements of the fbetus, the ballottement, the Kiestine in the urine, etc. Ovarian Disease. Your distinction between fibrous tumor of the uterus and ovarian disease is to be drawn from the following circumstances : In the latter, the tumor will be found to have commenced in one of the iliac fossae, while in the case of fibrous growth, it commences in the central line; in ovarian disease, too, there is a greater degree of mobility, and in raising the uterus with the finger per vaginam, the ovarian tumor does not become elevated, except in cases in which, as the result of inflammation, adhesions form between the ovarian enlargement and the womb. In fibrous tumor, the os uteri is thrown downward, while in ovarian disease it becomes elevated. The uterine sound of Simpson, which you have seen me use, will remove all error on the subject. In ovarian disease, if you intro- duce the sound into the cavity of the womb, you can usually separate this organ completely from the ovarian mass, and thus your diagnosis is placed beyond all doubt. Prognosis.—It is difficult to decide how these tumors will terminate ; they will sometimes remain stationary for years; again, they grow with great rapidity, and, by their pressure on the different organs, produce serious, and often fatal results. Pathology.—There is some difference of opinion in regard to the true nature of these uterine fibrous growths; and a recent writer of much weight in his opinions (Dr. Ashwell), maintains that they are invariably of a cancerous nature. This view he endeavors to sustain by various arguments, but, I think, without success. The entire ground of his argu- ment may be opposed, and, it appears to me, triumphantly, by the fol- SUB-MUCOUS FIBROUS TUMOR. 223 lowing facts: 1st. In fibrous tumor of the uterus we do not observe that characteristic feature of carcinoma, viz., the facility of converting into its own peculiar and malignant substance adjacent tissues; and we might also add that the peculiar cachectic condition of system, together with the striking odor, so constantly the accompaniments of cancerous develop- ment in the uterus, are not, as a general rule, recognized in fibrous formations of this organ. Again, uterine cancerous growths are almost uniformly fatal; fibrous tumors, on the contrary, often exist without at all involving the safety of the patient. I have examined many fibrous tumors of the uterus, after death, and while in some I have detected true schirrous development, yet in the greater number no evidence of malig- nant growth has been recognized. But the frequently non-malignant character of these tumors is also proved very conclusively by the suc- cess of judicious treatment. Lebert says that fibrous tumors of the uterus differ from the same character of growth in other portions of the system, in the fact that the former resemble more perfectly in their structure the normal tissue of the uterus, containing numerous fibro-plas- tic cells, and true muscular fibres of organic life. Treatment.—There exists much discrepancy of opinion, not only as to the efficacy of treatment in fibrous tumors, but also in reference to the value of specific agents. Dr. Clarke states that he has known these tumors to become spontaneously absorbed; while Dr. Ashwell mentions cases which have yielded to the administration of iodine. In the case before us, such is the delapidation of the general health, but little is to be expected from any plan of treatment. With a view, however, if possible, of checking the growth of the tumor, I shall recommend the following ointment, which has been successful in fulfilling the indication just named:— R Ungt. Hydrarg. fort. ) Cerae flavae r.....§ ss Adipis 3 Ft. Ungt. Let the os uteri be well lubricated night and morning with this ointment, and externally the following may be applied once a day:— R Ungt. Hydrarg.......f ss Hydriod. Potassae......3 j Iodin purae.......gr. v Adipis.......• 1} Ft. Ungt. For the purpose of regulating the bowels, and at the same time exciting a little action in the stomach, two of the following pills may be taken ac- cording to circumstances:— R Pulv. Aloes.......3j Extract Gentianae......3 ss Olei Carui .....gt. x Syrup........Q- S. Ft. fianl piUulce, xx. 224 CLINICAL LECTURES. When the tumor projects into the vagina, it should be removed by ligature or the knife. Lisfranc, when within reach of the finger in the cavity of the womb, divided the mucous membrane, separated the attachments of the tumor with his finger or knife, and removed it. Amussat says these fibrous tumors usually are but slightly adherent to the uterus, even when completely surrounded by the tissue of this organ; and he has, therefore, proposed to remove them by enucleation. He lays bare the tumor by an incision, and then detaches it with his fingers, Extraordinary success has followed this operation, in the hands of Amus- sat, but such has not always been the result with others; the patients frequently succumbing from inflammation. Ergot will sometimes be found useful in expelling these tumors, through the contractions it produces.* Ovarian Tumor in a married Woman, twenty-two Years of age, projecting into the Triangular Fossa, between the Uterus and Rectum—Diagnosis between this form of Tumor and retro-version of the Fundus Uteri—Introduction of the Uterine Sound.—Mrs. C, aged twenty-two years, married for the last three years, no children, has been afflicted for two years past with distress and bearing down pains in the region of the womb, and particularly with a pressure on the rectum. In addition to these troubles, she has labored under dysme- norrhoea. This case, gentlemen, was brought to the Clinique by my friend, Dr. Simmons, and I think you will find in it several points of more than ordinary interest. Dr. Simmons informs me that this patient has been, from the time her menses commenced, affected Avith dysmenorrhoea. Every character of medication had been resorted to both in hospital and private practice, with the view of affording her relief, but without avail. On applying to Dr. Simmons, he instituted a careful examination, and was of opinion that the dysmenorrhoea in this case was due to stricture of the cervix uteri—a cause of painful menstruation to which your at- tention has been repeatedly directed—and he at once had recourse to Macintosh's remedy, viz.: mechanical dilatation by means of the bougie, which was followed by the happiest effects, and resulted in relief to the patient. This, therefore, is an extremely interesting feature in the case before you. But, as we proceed, we shall notice other points of moment connected with it. " Madam, have you ever noticed a swelling about your person ?" " Yes, sir; I feel a lump here [the patient places her hand on the right iliac region], and it gives me pain." " How long is it * Dr. Washington L. Atlee has recently published an interesting paper on the subject of these uterine growths, and has cited several cases in support of his views in reference to the mode of removing them. He believes "these tumors are very imperfectly organized; consequently their vitality may be very easily destroyed; a section made through their investing membrane will sometimes be followed by the death of the whole mass," etc. He also is in favor of enucleation. OVARIAN TUMOR. 225 since you first observed it ?" " About two years ago, sir." " Are your bowels confined ?" " Very much so, sir." " Do you suffer pain when you have an evacuation ?" " Yes, sir; I suffer agony." " Do you have numbness in your limbs ?" " Sometimes, sir; and I almost always have a dull pain in them." You probably, gentlemen, do not appreciate the object of these ques- tions ; but in a moment you will understand why I have addressed them to this patient. I have, before introducing it to you, examined this case very critically, and have discovered an interesting state of things. There is enlargement of the right ovary, and the lower portion of the tumor has fallen down into the triangular space bounded anteriorly by the posterior surface of the uterus, and posteriorly by the anterior sur- face of the rectum. This accounts for the pressure of which the patient complains, and likewise for the pain accompanying an attempt at defeca- tion ; the rectum being encroached upon by the presence of the tumor, there is necessarily a mechanical impediment to a free passage from the bowels. In addition to this, from the same cause there is undue pres- sure on the sacral plexus of nerves, which would be apt to produce a sensation of numbness in the extremities, and at once accounts for the dull pain which the patient says she experiences. You now see the ob- ject of my questions. You have had presented to your observation in this Clinique fourteen cases of ovarian disease, and you have been told that invariably, on questioning the patient closely, you will learn that the tumor was first felt not in the central portion of the abdomen, but on either the right or left side, occupying the position of one of the iliac regions. This is an important diagnostic fact. Your attention has been so often called to the various points connected with ovarian disease, that I shall for the present dispense with a general discussion of this affection, and confine myself to one or two features only. The most common form of ovarian disease is encysted dropsy. Whether the case before us is one of this nature, it is impossible to decide for the tumor is so small, fluctuation can not be detected, even if fluid should exist. But the engrossing feature of the case—that which gives it intrinsic value—is the circumstance of its position between the rectum and uterus. In describing the pelvic viscera the other day, you will remember that your attention was very particularly directed to the triangular fossa found between these two organs; and you were informed that occasion- ally a fold of the small intestines falls into it, resulting sometimes in strangulation. At other times the ovary, either in its healthy or morbid condition, projects into this space, giving rise to a variety of phenomena, the character of which it is essential for the practitioner clearly to com- prehend. An example of the latter case you now have before you ; and it can scarcely be necessary for me to enter into an elaborate argument to prove the necessity, under such circumstances, of accurate diagnosis. I prefer rather to instruct you as to the manner of forming your opinion, 15 226 CLINICAL LECTURES. and the means of distinguishing between this affection and others, which may, in their symptoms, very closely simulate it. The affections which may be mistaken for this character of disease are: 1st. Faecal matter in the rectum ; 2d. Prolapsion of the small intestines ; 3d. Retro-version of the fundus of the womb. When the rectum is distended by faeces, the practitioner will be able to ascertain the fact by moving with his finger the different portions of faecal matter; and, under ordinary cir- cumstances, this can be accomplished without causing pain to the patient. When the small intestines have become prolapsed, the nausea, and occa- sionally when strangulation ensues, the symptoms characterizing this latter condition will develop the fact. The more common affection, however, the one calculated to deceive the practitioner, and cause him to mistake it for a prolapsed ovary is retro-version of the womb. How, then, are you to distinguish between these two affections ? This is an important question, and in every way well worthy of care- ful consideration. In retro-version of the womb, and in a prolapsed ovary, the symptoms bear a striking resemblance ; and you will, there- fore, be called upon to exercise a very nice sense of discrimination in order that you may not confound the one condition with the other. If you make a vaginal examination of a female who is laboring under retro-version of the womb, you will discover two important facts: 1st. The retro-verted fundus can be distinctly felt by the finger pressing more or less against the rectum; 2d. The cervix uteri will be to a greater or less extent inclined forward; not so in prolapsed ovary. Again, with one finger introduced into the rectum, and the other into the vagina, the two fingers embracing respectively the fundus and cervix of the organ, the momentary replacement of the uterus by the finger in the rectum will immediately be followed by a central position of the cervix in the pelvic excavation; not so in prolapsed ovary. This proves conclusively that the tumor felt in the triangular space is a retro-verted womb. If, too, the female should be in the recumbent position, with her abdomen toward the bed, the uterus will often spontaneously return to its proper position; not so in prolapsed ovary. But the infallible means of diagnosis between these two affections will be the introduction of the uterine sound—an ingenious and highly useful, but at the same time, incautiously used, a most dangerous instrument, which was first introduced to the attention of the profession by Dr. Simpson, of Edinburgh. It has since undergone some modifications by Huguier, Valleix, and others. The instrument is not unlike a male sound, having a handle, and a curve of some three or four inches. It is recommended to introduce the sound into the womb with the aid of the speculum. The speculum, in my opinion, is not only unnecessary, but renders the introduction of the instrument difficult. I take the index finger of my left hand as a guide, and introduce it thus. [Here the professor introduced the sound without any apparent pain to the patient.] OVARIAN TUMOR. 227 The instrument, gentlemen, is now introduced, and the curved portion has passed parallel to the long axis of the uterus. If the case before us were one of retro-version of the organ, having by means of this instru- ment placed it in proper position, I should not, of course, feel the retro- verted fundus pressing against the rectum. I now, as you perceive, in- troduce my finger into the vagina, and find the tumor occupying the same place in the triangular fossa between the womb and rectum. It is manifest, therefore, that it is not a retro-verted womb. What, then, is it? It is clearly a case of ovarian enlargement. With my finger introduced into the vagina, and the other hand placed on the right iliac fossa, I can very distinctly embrace the ovary. The nature of the tumor having been ascertained, the next question is—What can be done in the way of restoring this patient to health ? This brings me to the consideration of the Treatment.—The patient before us will sustain depletion, and under the circumstances I shall recommend the following course to be pur- sued : Half a dozen leeches should be applied to the tumor, either in the iliac fossa or in the vagina, once in two or three weeks; the patient should be freely purged with the saline mixture, and a nitric acid issue placed upon the side of the sacrum; the diet to be vegetable. This treatment may have a tendency to check the future growth, and even diminish the size of the tumor * * Were I positive in this case that the enlarged ovary was one of unilocular encyst- ed dropsy, I should be strongly tempted to perforate the ovary through the vagina, and, after evacuating the contents of the cyst, inject into it the tincture of iodine; from which I think we are justified, from recorded cases, to anticipate one of two re- sults, either an arrest of the secretion through the modifying influence of the iodine, or an adhesion of the sides of the cyst, which, of course, would destroy altogether the secreting surface. LECTURE XIV, Puberty in the Female ; its Signs; Changes, Physical and Moral, in the young Girl.—Menstruation, when does it Commence ?—Its Causes, Symptoms, and Peri- odicity.—What is the Source of the Menstrual Blood ?—Menstruation essential to Health, but not to Life.—Meteorism, with Globus Hystericus, in a young Girl aged eighteen Tears, the result of Hysteria.—Suppression of the. Menses for the last six Months from Fright.—Five successive Miscarriages in a married Woman, aged twenty-five Tears.—Treatment of Miscarriage. Gentlemen :—The period of puberty is one of the most interesting, and, at the same time, important eras of female existence—interesting, because, in a physiological sense, it may be said to be the starting point of her physical life, her first introduction, as it were, to the pleasures and cares of womanhood; important, because, as a general rule, in propor- tion to the facility or difficulty with which this period and its various phenomena are established in the economy, will be the future good or bad health of the girl. Puberty in the female is characterized by certain developments, the most prominent and remarkable of which is menstrua- tion. Indeed, it may be said that the appearance of the menstrual func- tion is the positive evidence afforded by nature that the various physical modifications or developments, more or less directly connected with the advent of puberty, have been completed. I propose to make some gen- eral observations on this subject, with a view more especially of directing your attention to the marked influence exercised by the approach and establishment of puberty over both the physical and moral condition of the female. First, as to the physical changes. At the approach of puberty, the gen- erative organs undergo a very rapid and remarkable development, which, when conpleted, gives to them the peculiar characteristics which they preserve during the rest of life. The pelvis enlarges, the organs of gen- eration increase in volume, the integuments begin to be covered with hair, and the internal surface of the labia majora is moistened with a fluid se- creted by the sebaceous follicles, which also at this time become enlarged, and enter upon function. Besides these, there are other changes no less important to be remembered. The hips become more expanded, which is due to two causes: first, the growth of the pelvis, and, secondly, the increase of cellular tissue. The breasts also enlarge; in a word, the PUEERTT IN THE FEMALE. 229 entire person of the girl loses its orginal form and features of the child, and assumes, through these successive changes, the graceful tournure of the woman. Closely allied with, and directly consequent upon these modifications in the physique, are to be observed certain differences in the morale of the individual. Before this, the girl was not only in reality a child, but she was conscious of the fact; and hence all her thoughts and acts were those of the child—she was gay and sportive, wayward and without care. But now there is a something which tells her that she en- ters upon a new existence—new responsibilities devolve upon her—and, if I may be permitted to say so, her sex is defined—hence, we find her reserved—she feels that she is a woman, and instinct points out the modest bearing so emphatically the attribute of her character. When these various physical and moral developments have been completed, and even before, the most important function in the female economy com- mences—I mean menstruation. The menstrual function consists usually in a monthly muco-sanguineous discharge, which commences at puberty, and continues periodically, except during pregnancy and lactation, until the fortieth or fiftieth year of age, when its final cessation takes place. There is, however, much irregularity both as to the time of commence- ment, and the period of termination of this function; and its early ad- vent or final cessation will be controlled by various circumstances. Men- struation is the direct consequence of congestion of the ovary, in the first place, and, secondly, of the uterus—these congestions being the result of the ripening or maturation of the graafian vesicles, and the discharge of the ovules which they envelope; this emission of the ovules takes place at each menstrual crisis. There is, indeed, a striking similarity in this respect between the menstrual period in woman, and what is termed the period of heat in animals. The doctrine is very generally maintained that menstruation is peculiar to the human female. If by this it be in- tended to convey the idea, that the function as it exhibits itself in woman, with all its phenomena, its duration, etc., is exclusively recognized in her, then I can see no objection to the doctrine, for it is founded upon unde- niable evidence. If, on the contrary, it be argued that during the period of heat, certain animals do not have any sanguineous discharge, no matter how slight or for how short a time, then I object to the doctrine, for it is against the evidence furnished us by accurate observation. Examine, for example, the slut at the time she is about to take the dog (her period of heat), and you will find not only congestion of the parts, but also a slight sanguineous secretion; and during this time of heat the same thing is observed which is so characteristic of the menstrual function in woman, viz., the spontaneous maturation and subsequent escape of ovules. This periodical maturation of the ovules, and their separation from the ovary at the menstrual crisis is now the accepted doctrine, for which we are indebted to the united labors of Bischoff, Gendrin, Negrier, Raciborski, and others. 230 CLINICAL LECTURES. Period of the first Menstruation.—The period at which the menstrual function appears for the first time in the female varies according to nu- merous circumstances, constituting so many influences which either hasten or retard its establishment; among these influences may be men- tioned : 1st. Climate; 2d. Education and mode of life; 3d. Tempera- ment and Constitution; 4th. Race. A clever writer, Roberton, has attempted to show that climate exerts no influence over the early or late appearance of the menstrual function, but in my opinion he has signally failed in the proof. His arguments are certainly plausible at first sight, but when closely analyzed, they, like the facts he adduces in support of his opinion, are not only unsatisfactory, but entirely void of strength. Nothing, I think is more completely settled than the influence exercised by climate on this function. Here, for example, in New York, girls, as a general rule, all things being equal, begin to menstruate from thirteen to fourteen years of age, while in more southern countries, such as In- dia, Egypt, Turkey, etc., it is not unusual for the function to commence at nine and ten years of age. In Sweden, Siberia, and other cold regions, the usual period is from sixteen to eighteen years. Education and mode of life also exert a remarkable influence even under the same climate. The girl, for instance, reared and educated under the blandishments and excitements of city life, her head filled with the prurient ideas engendered by the perusal of lascivious books, and a spectator of, if not a participator in, the more lascivious dance, will men- struate earlier than the girl who is reared in the country, and whose pur- suits and education are more in keeping with good sense and good health. In speaking of the influence of temperament and constitution on the menstrual function, Brierre de Boismont gives the following statistical tables as the result of his observation, which certainly has been extensive and well directed: temperaments. menstruation commenced. Sanguineous, .... 14 years and 6 months. Lymphatico-sanguineous, . . 14 years and 7 months. Lymphatico-nervous, ... 14 years and 7 months. Lymphatic, . . . . 15 years and 4 months. constitution. menstruation commenced. Robust,.....14 years and 6 months. Good,.....14 years and 8 months. Middling,.....14 years and 9 months. Delicate,.....15 years and 4 months. Some very interesting facts have been mentioned by Raciborski in connection with the influence of race over the late or early appearance of the menstrual function, which appear to show that this influence is su- preme, and is not affected, or very slightly so, even by climate. Thus, if a young infant born of English parents in London should be taken to India, and reside there permanently, she will menstruate no earlier than if she had remained in London. Reverse this, and bring an infant born MENSTRUATION, WHEN DOES IT COMMENCE? 231 in India, of Indian parents to London, the same influence of race will be observed. The fact is undoubtedly one of interest. You will read in the books of cases of children menstruating as early as two, three, or five years of age, etc., but all these records must be received cum grano salis; at all events, they can be regarded in no other light than ex- tremely rare exceptions. Such, however, is not the case with those in- stances of tardy menstruation, not only recorded in books, but which you will occasionally encounter in practice. For example, we have had in the Clinique a patient, thirty-five years of age, whose function had never appeared; this case you will remember was one (as we judged,) of atrophy of the ovaries. We have had also before us numerous in- stances of girls of seventeen, eighteen, and twenty years of age, who had not menstruated; and in several of these latter, on inquiry we ascer- tained that they had suffered for months from more or less profuse leu- corrhceal discharge. This character of discharge you will find not un- common under these circumstances, and in such cases, as also in women whose menstrual function having been established becomes from some cause or other suppressed, you will observe not unfrequently that the leucorrhoea takes, as it were, the place of the catamenial function, and in these instances, it becomes a grave question for the practitioner to decide how far he is justified in arresting the leucorrhceal discharge. As a general rule, I have remarked that in cases of suppression, as also in cases of tardy menstruation, those women who are affected with leucorrhoea, enjoy a much greater immunity from the constitutional and local disturbances usually consequent upon an absence of the menstrual function—another proof to my mind that the leucorrhoea, in these cases, acts as a sort of salutary waste-gate, and is, if I may so term it, a species of substitute menstruation. In a word, my general rule is not, under such circumstances, to interfere with the leucorrhoea, but to proceed, when treatment is indicated, with remedies proper when it has never ap- peared to promote the menstrual function, and when suppressed to restore it. In confirmation of the propriety of this practice, I have usually re- marked that soon after the catamenia is established, the leucorrhoea ceases. Surely, then, it would be unphilosophical to regard the leucor- rhoea in these cases as a pathological condition. I am rather inclined, on the contrary, to rank it in that category of numerous and admirable contrivances resorted to by nature, when there is any interruption in the functions of the economy, to break the force of morbid action. You must, however, bear in mind that some women, in whom the menstrual function is perfectly regular, will be affected with leucorrhoea for several days after the period ceases; while in other cases, the leucorrhoea will show itself a few days before the catamenial flow, and terminate with it, etc. But let us take another view of this question. It is, I believe, ad- mitted that the menstrual fluid is composed of two distinct parts, one con 232 CLINICAL LECTURES. sisting of an increased mucous, or epithelial secretion, and the other of blood which escapes from ruptured blood-vessels. In both cases, the fluid comes from the mucous membrane of the uterus. The mucus is simply an exhalation, while the blood, we know, can not be exhaled, for the reason that as it contains red globules, these can not pass by endos- mosis or percollation through the walls of the vessels. Therefore, when the true menstrual blood is discharged, it is because the vessels have become ruptured. The same principle precisely is observed with regard to the absorption of pus into the blood ; it is only the thin portion of the pus which passes into the circulating fluid ; the pus globules can not, under any circumstances, while the vessels maintain their integrity, com-. mingle with the blood. Indeed, I am clearly of opinion that women, under certain conditions of system, have their menstrual periods repre- sented mostly by a discharge of mucus, and it is, therefore, incumbent, as I have already remarked, not rashly to interfere with this mucous or leucorrhceal discharge. Its sudden arrest will oftentimes be followed by the same morbid phenomena, which usually characterize suppression of the menstrual evacuation when occurring in its normal condition. Causes of Menstruation.—In reading the various and conflicting opin- ions advanced by authors to explain the cause of the menstrual discharge, you can not but be struck with two facts : 1st. The manifest want of agreement, and 2d. The absurdities to which mere hypothesis will often- times lead its supporters. Some ascribe the menstrual crisis to the in fluence of the moon ; others say that it is produced by general plethora of the system ; others maintain that it is due altogether to local plethora, etc.; and so I might proceed to enumerate the different theories which have been projected on this subject, but cui bono ? Women menstruate not only at every phase of the moon, but they menstruate every hour and day in the year. What then becomes of this supposed lunar influ- ence, a doctrine, I may mention of very ancient date, and which has been warmly defended by some of the early fathers. Again, you will occasionally see females in infirm health, the very opposite of plethora, have their menstrual turns with more or less regularity, but why should this be, if the menstrual function be owing to general vascular fullness of the system—a doctrine which also has had its eloquent advocates. A truce to theory, and let us come to facts. When a girl menstruates, it is because she has attained a point in her physical development, which enables her to perform this function. Function, in a physiological accep- tation, is the specific act performed by, and peculiar to, a given organ. For example, the lungs decarbonize the blood; the liver secretes bile ; the kidneys urine; the heart receives into its right cavities venous blood, and throws from its left cavities arterial blood, etc. These, together with numerous others, are functions, which commence with the birth of the child, and which are more or less directly connected with the main- tenance of life. They, therefore, differ from the menstrual function in CAUSES OF MENSTRUATION. 233 the broad fact, that the latter does not manifest itself until some years after the birth of the being; and while its periodical recurrence is mate- rial to the health, yet it is not essential to the life of the individual. Now, it appears to me that the true explanation of the cause of menstruation consists in the elucidation of the simple question, viz. : Why is not the function of menstruation, like the functions of the lungs, heart, liver, kid- neys, etc., simultaneous with the birth of the child? The solution of this interrogatory is, in my opinion, the only philosophical explanation of the cause of menstruation; and we proceed, therefore, in a very few words, to answer the above question. As soon as the child is born, and its existence becomes independent, the lungs commence their office of decarbonization, simply because the lungs are developed, and prepared for this duty; the heart receives venous blood and disposes of arterial blood, because the heart is developed and fitted for this office; the liver secretes bile, and the kidneys secrete urine, for precisely the same reason. But the difference with menstruation is this—it, like the other func- tions, is the offspring, if I may so speak, of organic action; and the rea- son that it is not co-existent with birth, and does not become established until a later period, is that the organs, of which it is the specific function, have no physiological existence—that is, they lack physical development, and, therefore, have not yet become participators in the acts of the sys- tem. What, pray, are these organs ? They are the ovaries, the essential and only organs of generation, strictly so called, in the female. The development of the ovaries occurs at the period of puberty, and then it is that their physiological action commences. At this time you will observe, on the surface of these bodies, the graafian vesicle, this latter containing the ovule, which I have told you, escapes ordinarily with the menstrual blood. As these ovules on the surface become matured, the ovary itself forms the center of a sanguineous afflux, a veritable conges- tion, in which the fallopian tubes and uterus participate ; this congestion results in the escape of mucus and of blood, which pass from the uterus through the os tincae into the vagina, and thence externally—and this is menstruation. But why should this function of menstruation be period- ical, that is, occur once in twenty-eight days, instead of being continuous and uninterrupted like most other functions in the system ? This is a perfectly legitimate question, and its solution easy. If you examine an ovary in its congestive state you will observe on its surface the matured ovules of which I have spoken, or at least the ruptured vesicles from which they have escaped; examine the organ still more closely, and you will find imbedded in the sub-jacent tissue other ovules, which are not matured, but which, as they approach the surface of the ovary, become so, precisely as did the first. So, in this way, there is at each monthly crisis a constant succession of ovules to be observed, which either become fecundated by the seminal fluid of the male, or, in the absence of such influence, escape with the 234 CLINICAL LECTURES. catamenial fluid. This periodical maturation of the ovules continues fix m the period of puberty until the final cessation of the menstrual function. There is a singular coincidence as to the physiological condition of the ovary before the age of puberty, and at the time the woman ceases finally to menstruate. Previous to puberty, the ovaries are undeveloped, en- joy no action—in a word, they are inert; after the function has ceased, these same bodies fall into a state of atrophy, and are no longer engaged in the affairs of the economy. The similarity of condition in these or- gans before and after the menstrual period is explained in this way— menstruation is the evidence which nature furnishes that the female is susceptible of becoming impregnated, that she is in a state to carry out that cardinal office of her sex, the reproduction of her species. Menstru- ation is, as it were, but the result of the ripening of the ovules, which the female is required to furnish in order that she may perform her part in the great and interesting work of increase. The reason, therefore, that her ability to perform this latter duty is restricted to certain limits, is because it is only within these limits—from the period of puberty un- til the final cessation of the menstrual function—that the ovaries are capable of secreting ovules, which constitute the sine qua non of procrea- tion, so far as the female is concerned. What is the source of the menstrual blood ?—This has been for some time a vexed question; but it is now very generally conceded that the menstrual fluid is derived from the internal surface of the uterus ; this latter organ, as well as the fallopian tubes, participating in the periodical congestion, which commences in the ovaries. The uterus at the time, and one or more days before the menstrual crisis, becomes congested— its weight increases, and hence from this latter cause the female will oftentimes complain of more or less bearing-down pain, a more frequent desire to pass water, etc. But some women menstruate, though rarely, during pregnancy. What, under these circumstances, is the source of the catamenia ? Certainly, in such case, the menstrual fluid is not derived from the internal surface of the uterus—but from the surface of the cervix, from the os tincae, and even sometimes from the upper portion of the vagina. These latter facts have been well established by the ex- amination of pregnant women, with the speculum, while menstruating; it being distinctly observed that the blood proceeded from one or other of the parts just mentioned. What are the symptoms of Menstruation ?—The symptoms of menstru- ation may be divided into local and general, and they will vary accord- ing to numerous circumstances. So far from there being any uniformity in these symptoms, it is much nearer the truth to say that their variety is almost incalculable; and you will find in practice that some females menstruate without any of those premonitory and accompanying troubles, which usually characterize this event. As a general rule, for some days, and, occasionally, for weeks before the menstrual period, the girl will STMPTOMS, AND PERIODICITT. 235 experience more or less uneasiness about the hips, in the sacral region, and in the loins—a sense of bearing down, with unusual heat about the vagina; this latter organ, together with the external organs and os tincae, will undergo a degree of tumefaction. There will be sometimes severe colic, with a tympanitic condition of the abdomen. The breasts enlarge, and at times become extremely painful. There will be more or less derangement of the stomach, loss of appetite, insomnolence, and at other times, on the contrary, a constant disposition to sleep. The face, and sometimes the lower extremities, become cedematous; tume- faction of the eye-lids, with heaviness of the eyes, and a dark blue and defined line bordering the under lid. In addition to these symptoms, there will be others, such as cephalalgia more or less intense, tinnitus auri- um, deafness, indistinct vision, and, in some cases, almost every variety of nervous disturbance—hysteria, epilepsy, catalepsy, mania, etc. In truth, as I have already mentioned, the first advent of the menstrual function, as well as its subsequent recurrence, may be preceded or ac- companied by such a variety of abnormal phenomena, that I can do nothing more than give you, as I have briefly done, the general outline. But there is one point of great practical importance connected with the first menstruation, to which I desire, for the moment, to advert. It is this—it is not at all unusual for young girls, after the function has ap- peared for the first time, to pass several months without.its recurrence. These cases usually excite much anxiety on the part of the mother, and her first appeal is to the physician, begging him to do something " to make the poor child regular." Now, in all such cases, my advice to you is, unless there be some positive derangement of the health calling for special treatment, do nothing. Nature abides her time, and when she has completed her arrangements, will establish the function in its proper order. Officiousness in these cases on the part of the practitioner almost always leads to ruinous results. What is the true time between the menstrual periods, and what is the loss sustained by the female at each of these periods ?—All that can be said upon these two questions is, that there is no absolute rule with regard to either of these points of inquiry. Some women will menstruate every twenty-eight days (and this is the most ordinary period), others every thirty days, and others again every thirty-five days; while again you will observe in some the menstrual period occurs every twenty-five days, in others every twenty-one days, and in others every fourteen days. These and other variations with regard to the periodicity of this function will be observed by you in practice. Precisely the same dif- ference will present itself in regard to the quantity of fluid lost at each catamenial evacuation. The average quantity may, perhaps, be esti- mated at from four to six ounces. But some women will lose eight, others four, others two, and others again only one ounce. I think, gen- tlemen, 1 have given you the true facts with regard to these points; at 236 CLINICAL LECTURES. least, they are in perfect accordance with my observation in the field of practice, and I have no doubt, too, with the experience of others. Now, allow me to urge upon you another caution on the score of officiousness. Suppose a female applies to one of you, and says—" Doctor, I am not as I should be; I have my courses every two weeks." Another says— " I have them only every six weeks;" and a third tells you " that she does not lose more than one ounce of fluid at each period;" while a fourth advises you that " at each of her turns she loses from six to eight ounces." Here, then, are four patients each with her own peculiarity, and each one, too, demanding at your hands professional treatment. If these patients should apply to me, the first question I would address to them would be this—How is your general health ? If they were to answer me that their health was good, and the only circumstance that caused them anxiety was this irregularity as to the time of the cata- menia, and the quantity lost at each period, I would say to them—Give yourselves no uneasiness; you do not require medicine. Go home and be content with good health, for it is a prize more easily lost than gained. Indeed, I might very appositely, under such circumstances, quote those familiar lines inscribed on the tombstone of an unfortunate victim to medication: " I was well; I wished to be better; I sent for the doctor, and here 1 am." Meteorism with Globus Hystericus in a young Girl aged nineteen Years, the results of Hysteria—Suppression of the Menses for the last six Months from Fright.—Lucy R., aged nineteen years, seeks advice for an enlargement of the abdomen, which she says causes her such excessive pain that she is fearful she has inflammation of the bowels. " How are your courses, my good girl ?" " I have not had them, sir, for the last six months." " Were you always regular pre- vious to the last six months ?" " Yes, sir." " Do you know what caused you to become irregular." " Yes, sir; it was a fright I took." " What caused you to be frightened ?" " Why, sir, the lady with whom I lived lost her watch, and she said I had stolen it. She told me if I did not give her the watch, she would have me taken up by the police." "Well, did you give her the watch?" "Oh, no, sir ! indeed, I did not take it. The lady found it in her carriage." " Had you your courses on you at the time you became frightened?" "Yes, sir, and they im- mediately stopped." " Did any thing occur after you became irregu- lar?" "That very night, sir, I thought I was dying. I felt a large lump in my throat, and I had a sort of fit; they called it ' falling-fit.'" "Did you have your senses about you at the time you had the fit?" "At first sir, I knew every thing that was passing around me; but after some time I lost my mind." " How many of these fits have you METEORISM, WITH GLOBUS HYSTERICUS. 237 had ?" " I have had them every month, sir, since I became irregular." "Do you always have the lump in your throat at those times?" "Always, sir, and I can not swallow." "Do you always lose your consciousness ?" " Not when the fit first comes on, sir; but after some time." Now, gentlemen, permit me to ask you—what is your diagnosis of this case ? It is one of great interest in a practical point of view, and it is important that you should clearly understand its nature. The two features about the case, which appear to absorb the attention of this girl, and which have induced her to seek advice at the Clinique, are: 1st. The enlargement of the abdomen; 2d. The excessive pain, which she apprehends is caused by inflammation of the bowels. These, I repeat, are the two principal circumstances of the case in the judgment of this young woman. Let us now examine whether they have in reality any abstract importance, or whether they are not simply the results of a cause, which, perhaps, is not yet apparent to you. ' It appears from the conversation which has just passed be- tween this girl and myself that, until the last six months her health was good; but since that time she has been subject to "fits," as she terms them, and now comes to the Clinique because of an enlargement of her abdomen, and severe pain, which she attributes to inflammation of the bowels. With these facts before you, it is quite evident that, in endeavoring to comprehend the true nature of the morbid phenomena exhibited in the person of this patient, and with a view, too, of applying the appropriate remedies, we should inquire minutely as to what occurred six months since, when it appears the derangement of her health first commenced. We have made this inquiry, and you have heard the statement of this girl, viz.: that while she was menstruating six months since, the func- tion became suddenly arrested in consequence of the fright she expe- rienced in being charged with having stolen her mistress' watch. On that very night, a few hours after the suppression of her courses, she says " she thought she was dying; she felt a large lump in her throat, and had a sort of fit: they called it the falling-fit." These, you will remember, are her own words, and so far as they elucidate the question of diagnosis, they are full of significance. There is no doubt that the "fits" to which this girl has been subject are hysteric paroxysms, and the " lump in her throat" together with the enlarged and painful abdomen are but accompaniments of this hysteric condition. Let us examine the evidence a little more minutely. As the lawyers say, the following facts are before us: 1st. Six months ago the girl became frightened, the consequence of which was a sudden stoppage of her menses ; 2d. A few hours afterward she had a " fit " with a " lump in her throat," etc.; 3d. She has those fits every month; 4th. Every time she has the fit she has the " lump in her throat" together with difficulty 238 CLINICAL LECTURES. in swallowing; 5th. At first, she does not lose her consciousness, but she does after the fit continues for some time; 6th. These two phenom- ena, viz.: the " lump in the throat" and the gradual loss of conscious- ness are present every time she has the " fit." If we subject these facts to an analysis, we shall encounter no difficulty in forming an accurate diagnosis. There is no doubt that the fright experienced by this girl was the starting point of her deranged health. One of the commonest causes of suppressed menstruation is mental emotion, such as fright, etc. ; and you perceive that the second link in the chain of morbid phenomena in this case is the arrest of the menses. A few hours afterward we have the occurrence of the " fit." We must now see whether it is possible to trace any direct connection between the fit, and the menstrual suppression. To you, whose atten- tion has been so repeatedly called to the marked influence exercised by the uterine system over the general economy, under the operation of diseased action, it can not be necessary to enter upon an argument to establish this connection. Both in functional and organic affections of the uterus, there are striking sympathetic phenomena exhibited in the system—and these phenomena are modified according to a variety of circumstances. In one case there will be hysteria, in another epilepsy, in another catalepsy, etc. In the case of this girl, I have no hesitation in denominating the fit of which she speaks one of hysteria—a nervous affection, which assumes myriads of forms, and which has called forth numerous and conflicting opinions. There are three pathological condi- tions connected with this case, which it may not be unprofitable for us to examine somewhat in detail, especially as they may be classed among the ordinary phenomena of the hysteric paroxysm—the conditions to which I allude are as follow: 1st. The globus hystericus; 2d. The meteorism ; 3d. The fit with subsequent loss of consciousness. At a very early period of our science, indeed almost coeval with its history, it had been observed that women affected with hysteria had a swelling in their throat, the globus hystericus, which oftentimes impeded respiration. The Ancient Fathers were remarkable for accuracy in ob- servation, although they were unable frequently to explain the various morbid phenomena, which presented themselves to their view. Their attempted explanations appear sometimes indeed ludicrous in the ex treme, but before pronouncing judgment against them, should we not remember how completely they were deprived of the resources with which modern science furnishes us ? They imagined that the globus hystericus was occasioned by the ascent of the uterus to the throat! This we know to be an absurdity—and yet in full view of the untena- ble hypothesis, we can not close our eyes against the cardinal fact that the Ancients possessed not only accurate views with regard to the pathology of hysteria, but at the same time they were far more unanimous than the moderns in maintaining those views. They contended that the hys- SUPPRESSION OF THE MENSES FROM FRIGHT. 239 teric paroxysm originated in disturbed action of the uterine organs. All subsequent observation has demonstrated the truth of this opinion—it has, and will continue to survive the disputations of the men of our own times on this vexed question. So that, if on the one hand we may be disposed to smile at the absurdity of an hypothesis, we have good rea- son, on the other, to yield our profound respect to the fidelity of obser- vation exhibited by the early patriarchs of our profession. We who understand at the present day, through the developments of the physiologist, the beautiful and harmonious workings of the nervous system in health, and its perturbing action under the influence of disease, can have no difficulty in explaining the various symptoms which usually accompany hysteria; and the globus hystericus, which is one of the most constant attendants of this affection, is simply the result, if I may so speak, of depraved nervous influence. Nothing is more common in hysteria than tumefaction of the hypogastrium and abdomen, disturbance of the diaphragm giving rise to hiccough; tumefaction and spasm of the esoph- agus, trachea, etc., producing in the one case difficult, and sometimes im- possible deglutition, and, in the other, disturbed respiration, and a sense of suffocation. Now, what are all these phenomena but so many evi- dences, not of primary derangement of the nerves distributing themselves to these different parts, but disturbances of the nerves of an important center—the uterine system—with which these parts are in close alliance by means of the ganglionic distributions. It is scarcely necessary for me to trace these nervous connections, but in recalling your knowledge of anatomy you will at once appreciate both their interest and import- ance. Commencing with the great trisplanchnic nerve as found on the uterine organs, you recognize an unbroken chain of connection through which either healthy or morbid influence is transmitted, including the different abdominal ganglia, and especially the semi-lunar ganglia and solar plexuses; and then passing along the other connections, you will remember the coeliac, diaphragmatic plexuses, the various thoracic gan- glia, the cardiac nerves, not forgetting that important link, the pneumo- gastric, then the cervical ganglia, etc. With this brief retrospect of the various nervous distributions, you have the key which explains to you how derangements in the nerves of the uterine system will, to a greater or less extent, involve distant organs —at one time causing derangements in the abdomen, at another in the thorax, at another in the throat, etc.; and you must also remember that by the same character of connection the brain oftentimes will become disturbed. The globus hystericus is, therefore, the result of primary irritation of the uterine nerves, this irritation being transmitted, link by link, through the whole chain until it reaches the nerves of the esophagus and trachea. Let us now, for the instant, inquire as to the manner in which the meteorism or flatulent distention of the abdomen—another usual accompaniment of hysteria—is produced. It is precisely in the 240 CLINICAL LECTURES. same manner—the abdominal ganglia, together with the solar and semi. lunar plexuses, become secondarily the seat of irritation, the digestive functions suffer derangement, as is exhibited in various ways, such as the sudden secretion of gas, giving rise to a veritable meteorism, pains, etc. One word now touching the convulsive paroxysm and the subsequent loss of consciousness. You will occasionally observe the most frightful con- tortions during an attack of hysteria, and at other times the convulsive paroxysm will be comparatively slight. Indeed, it may be said that the intensity of the paroxysm varies according to an infinity of circum- stances. I have seen instances in which it required several persons to hold the patient to protect her against harm during the attack; and again, I have encountered cases in which there was a very slight approach to what may be called a convulsive effort. But there is one feature connected with hysteria to which it may be useful to call your attention—it is the loss of consciousness which some- times supervenes in the attack. It has been seriously doubted whether in hysteria there is ever loss of consciousness, but on what grounds, I am sure I can not understand. To my mind, there is no fact more em- phatically established than that women, laboring under an hysteric par- oxysm do lose for the time being all sense of the external world, while, again, you will find that this want of consciousness is only partial. But there is a circumstance, which has been well observed by authors, and which you, too, will recognize in practice, it is that in hysteria the mind does not become lost at the commencement of the attack, but the uncon- sciousness is always gradual. This constitutes a very important diag- nostic symptom between hysteria and epilepsy, in which latter, one of the very first and most prominent symptoms is immediate and complete loss of consciousness. In questioning this girl, you will remember how particularly I interrogated her on this point. My question was, " Do you always lose your consciousness in these attacks ?" She replied, " Not when the fit first comes on, sir, but I do after some time." It may, how- ever, be observed, that this derangement of the intellect is not a uniform accompaniment of hysteria. You would, perhaps, very naturally con- clude, that in the more severe forms of hysteria, the heart and vascular system participate "in a very marked manner in the general disturbance produced by the convulsive spasm. Such, however, is not the fact. In simple hysteria, no matter how violent the paroxysm, the pulse is usually undisturbed. Treatment.—If, gentlemen, you have followed this case closely in all its details, and if the comments I have just made are not the veriest of all fictions, the conclusion at which we must arrive as to what should be done for the purpose of restoring the girl to health can not admit of two opinions. The origin, the very starting point of her troubles, the real basis of her hysterical attacks, etc., is unquestionably the suppression of her menstrual function ; and until this function is restored, she will be, so FIVE SUCCESSIVE MISCARRIAGES. 241 far as the recovery of health is concerned, without hope. And have you forgotten a most important disclosure made by this girl, viz., that her at- tacks of hysteria come on once a month, at the very time that her men- strual function should appear ? What stronger fact than this to demon- strate the connection between this patient's ill health, and the absence of her catamenial discharge ? " When, my good girl, is the time for you to have your courses ?" " I ought to have them, sir, in three or four days; but I am sure they will not come on." " Very well, we will do something for you to make you right again." " O ! thank you, sir." The reason of my making the last inquiry must be obvious to you. In all cases in which, in sup- pression of the menstrual function, it may become necessary to have recourse to remedies for the purpose of promoting the catamenial dis- charge, you will find that the efficacy of these remedies will be greatly enhanced by applying them at the opportune time. Although the func- tion is suppressed, you must recollect that at each month there is what is termed the menstrual molimen, or, in other words, more or less con- gestion of the uterine organs ; and it is during the presence of this moli- men that your remedies will be most likely to be followed by good effects. We shall, therefore, order for this girl the application of four leeches to each groin to-night; to-morrow night, and the succeeding one, a styptic pediluvium of cayenne pepper and mustard, one table-spoon- ful of the former to two of the latter in a bucket of warm water before going to bed. As a temporary remedy for the meteorism, and also with a view of producing a free purgative effect, let her take to-night the fol- lowing :— R Olei Ricini ) „. Olei Terebenthinae ) " Now, my good girl, do what I have told you ; and do not fail to re- turn here on next Monday, and report the state of your health." " I shall do so, sir." Five Successive Miscarriages in a married Woman, aged twenty- five Years—Treatment of Miscarriage.—Mrs. T., married, aged twenty- five years, says she is very much exhausted, and begs that something may be done to give her a little strength. She is extremely pale, and labors under general nervous disturbance—such as palpitation of the heart, vertigo, restlessness at night, with inability to sleep. She exhibits a striking example of anaemia from losses of blood. " How long, my good woman, have you been married ?" " Three years, sir." " Have you ever had a living child ?" " No, sir." " When did you have your first miscarriage ?" " About four months after my marriage, sir." " Do you know what caused you to miscarry at that time ?" " I was carrying a heavy basket of clothes home, sir, and I fell down; that same night I 16 242 CLINICAL LECTURES. was taken sick, and the next day miscarried." " Did you lose much blood ?" " No, sir, not a great deal, but I nearly died in my last mis- carriage from the quantity of blood I lost." " When did you miscarry the second time ?" " Just nine months after my marriage, sir." " Do you know what caused you to miscarry this time ?" " No, sir." " When did your third miscarriage take place ?" " Just one year ago, sir." " Do you remember any particular circumstance that caused it ?" " No, sir, I do not." " When did you miscarry the last time ?" " Two months ago, sir." " What caused you to miscarry this time ?" " Indeed, I don't know, sir." " Did you lose much blood ?" " O ! yes, sir, I nearly died, and I am so weak now that I can scarcely get along." The case before you is one of special interest—it involves some points of practical value, to which I shall for a few moments call your attention. The subject of miscarriage is a most important one for the practitioner, and it is necessary that he should comprehend and appreciate its causes, its perils, and its treatment. Human life has oftentimes been sacrificed through ignorance in the management of miscarriage ; and when death ensues, it usually does so from the profuse hemorrhage which takes place before, during, or after the expulsion of the ovum. There is one pecu- liar feature in the case before us well worthy of attention—and you will remark that I elicited the fact by the questions which I addressed to this patient. The point to which I allude is this—when a female miscarries, especially in her first pregnancy, she will be very apt to have subsequent miscarriages, and this is what may be denominated miscarriage from habit. A knowledge of this fact inculcates, in the first place, the neces- sity of the practitioner enjoining on his patient, in her first pregnancy, the great necessity of avoiding all those causes which are known to favor a premature expulsion of the ovum ; and secondly, in the event of a miscarriage, to exercise more than ordinary vigilance in the subsequent pregnancies. This woman has very satisfactorily accounted for her first miscarriage—which was, no doubt, occasioned by carrying the heavy basket, together with the fall of which she speaks. But she is unable to account for her subsequent troubles, and 1, therefore, refer them, in the absence of other known causes, to that remarkable influence exercised in these cases by habit. The general causes of miscarriage are numerous, some of which appertain to the mother, and some to the foetus; and it must be borne in mind that these causes act mostly through their im- pressions on the nervous system. Hence they may be divided into those which irritate directly the medulla spinalis, and those which irritate it indirectly through an impression made on the excitor nerves. Thus the causes are either centric or eccentric. There is great value to be attached to this classification, for it opens an interesting chapter of inquiry, and presents substantial guides for practice. We are much indebted to Dr. Tyler Smith for what he has done on this subject—he has, if I may so speak, elaborated the physiology propounded by Marshall Hall, and ap- TREATMENT OF MISCARRIAGE. 243 plied it more especially to obstetric medicine. The causes which belong to the parent may be divided into the predisposing and exciting. Among the former, may be enumerated excessive plethora ; undue irritability of the nervous system, inducing premature action of the uterus ; the various diseases of the uterus; general debility, etc. Among the exciting causes you may class bodily injury, such as proceed from violence of any kind, falls, blows, etc.; fright, anger, sorrow ; drastic purgatives ; irritating enemata, etc. Those causes which proceed from the foetus are : its death ; implanta tion of the placenta over the mouth of the uterus; disease of the placenta. etc. The question may now be asked—what is a miscarriage ? This> has been variously defined by authors; but, for all practical purposes, it may be said to be the expulsion of the ovum at any time during the first six months of gestation. The next question is: how do the causes, cap- able of inducing this premature effort of the uterus, act, and what are the phenomena which result from the operation of these causes ? These are practical queries, and are entitled to attention. The various causes may be said to exhibit their effects in different ways, depending upon the direct or indirect influence they exercise on the uterus and its con- tents. For example, in one case, they may induce an increased flow of blood toward the organ, and hence, hemorrhage and its consequences ensue— in another, pain may be the result, and hence contraction of the uterus, and expulsion of its contents; while in a third instance, the cause, what- ever may be its nature, may induce detachment of the placenta, which will result in hemorrhage and miscarriage. No matter what may be the cause of the miscarriage, the phenomena connected with the expul- sion of the ovum resemble closely those of an ordinary labor. The expulsive force is the same, viz.: the contractions of the uterus. As a general rule, unless the membranes be ruptured by the rude manipu- lations of the accoucheur, previously to the expiration of the third month the ovum is usually expelled entire with its envelopes. It is not neces- sary for me, on this occasion, to enumerate the different symptoms of miscarriage ; they may be embraced in the two terms pain and hemor- rhage. When a female is threatened with premature expulsion of the embryo, these two phenomena, pain and hemorrhage, will almost always, to a greater or less extent, be present. But allow me here to guard you against a false diagnosis in regard to these two phenomena. In the first place, a pregnant woman may suppose herself menaced with a miscarriage simply because she has pain. But this is not sufficient— the pain of miscarriage, like the pain of labor, is peculiar, it is recur- rent, marked by distinct intervals. It is in a word, nothing more than the contractions of the uterus, which you know are never continuous, but always intermittent, when engaged in the expulsion of the ovum, whether at full term, or at an earlier period. The pain which the female 244 CLINICAL LECTURES. may mistake f'*r labor pain may result from colic, indigestion, and vari- ous other circumstances, which have no possible connection with any specific action of the uterus. You see, therefore, it will be for you to determine as to the character of the pain, and whether it portends dan ger to the mother and embryo, or whether it is an ephemeral matter, which will yield to the administration of appropriate remedies. Again, a pregnant woman, especially in the earlier months of her ges- tation, may have a discharge from the vagina, without being at all threat- ened with a miscarriage. This sanguineous discharge may be nothing more than menstruation which, you are aware, sometimes occurs in pregnancy, examples of which you have seen in the Clinique. As a general rule, you will be enabled to distinguish menstruation from the hemorrhage of miscarriage in several ways : 1st. Its occurrence will usually accord with the menstrual periods previous to pregnancy; 2d. It is unconnected with any of the causes of miscarriage; 3d. Tlie patient is in good health, etc.; 4th. The flow is not profuse, and lasts generally but two or three days. But a very important point, both for the patient and practitioner, connected with the subject under discussion is—How is a miscarriage to be managed? When summoned to a female who supposes herself to be menaced with a miscarriage, the first and obvious duty of the practi- tioner is to ascertain whether she is in fact menaced, or whether her fears are without foundation. If it be discovered that she is really threatened—his duty will be confined to the attainment of one of two objects—either the prevention of the miscarriage—or, if this can not be accomplished, he must limit himself to those measures, which will ena- ble him to conduct his patient safely through her troubles. Now, with regard to the prevention of a threatened miscarriage, I wish very em- phatically to remark that this can often be accomplished, even when ap- parently there exists no longer any hope of attaining this desirable object; and you must allow me to impress upon you not only the neces- sity, but the high moral obligation imposed on the practitioner, of em- ploying in the most faithful manner those means which are best calcu- lated to arrest the premature action of the uterus. Let us now exam- ine in what these means consist. The prevention of a threatened mis- carriage is not to be accomplished by any act of empiricism—it is, on the contrary, to be accomplished in the first place by a just discrimina- tion of all the circumstances by which each individual case may be sur- rounded, and secondly, by a proper adaptation of remedies to the pecu- liar condition of the system at the time. There is, I think, great want of judgment, generally speaking, in the management of these cases—and this arises either from gross ignorance, or unpardonable carelessness. What, for example, is the first remedy usually resorted to when a miscarriage is apprehended ? It is the ap- plication of cold to-the hypogastrium, thighs, etc. Now, let us inquire TREATMENT OF MISCARRIAGE. 245 for the instant what, physiologically speaking, will be the action of cold thus applied? You all know that its tendency is to produce uterine contraction, through the operation of reflex influence. Then, is cold an appropriate remedy under these circumstances ? On the contrary, is it not of all agents the very one best calculated to defeat the object the practitioner has in view, viz.: the prevention of miscarriage ? If you can prevent the contractions of the uterus, you will also prevent the premature expulsion of the ovum—and the converse of this is equal- ly true—if the contractions be not arrested, expulsion of its contents will be the inevitable result. You see, therefore, that the practice usu- ally had recourse to in these cases, is not only bad practice, but it is the veriest offspring of ignorance. We will now suppose that you are at the bed-side of a pregnant female who has both pain and a discharge of blood from the vagina—and that you have satisfactorily ascertained that these two phenomena are positively connected with a threatened miscar- riage—what is the first thing to be done ? It is this—take a survey of the general condition of your patient for the purpose of ascertaining some of the following points: 1st. Is she laboring under marked ple- thora ? 2d. Is she of an extremely nervous temperament ? 3d. Has she been exposed to any sudden emotion, such as fright, anger, depression of spirits, etc. ? 4th. Has she experienced any violence, from a blow, a fall, etc. These are some of the principal queries, which a vigilant practitioner would naturally institute in his own mind. Treatment.—You must remember that, in the management of a mis- carriage, no matter what may be the cause which has determined it, ab- solute rest must be enjoined. This is a sine qua non as to success with the remedies to which you will necessarily be obliged to resort. The patient should be placed in the recumbent position, with her hips slightly elevated. Suppose, now, that she is very plethoric, with more or less febrile excitement. What in this case should be done, especially if there be a reasonable hope of preventing the expulsion of the ovum ? Why, obviously to reduce the plethora, which you will find not an un- common predisposing cause of miscarriage. For this purpose general blood-letting is the great agent. In addition to the abstraction of blood, give your patient ten grains of nitrat potassae in a tumbler of water, with vj. gtt. of tinct. digitalis. Let this be repeated every four or six hours, together with abstemious diet. Again, your patient is not labor- ing under plethora, but she is of an extremely nervous temperament. What in this case is indicated ? Certainly not the abstraction of blood, but, on the contrary, the employment of such remedies as will tend to calm and fortify the system, such as the various anti-spasmodics, ner- vines, etc. In these cases, I have experienced benefit from the injection of laudanum and tepid water into the rectum, lubricating the os tincce with the ungt. belladon. 3 j ext. belladon. to § j of lard, opium suppo- sitories introduced into the rectum, etc. Internally, a table-spoonful of 246 CLINICAL LECTURES. the following mixture may be given every hour or so until the object is attained: R Syrup Papav........3 ij Mucil. Acaciae........% ij Sol. Sulph. Morphise......gtt. xx Ft. Mist. The above remedies, together with cheerful and encouraging assur- ances that things are going on well, will oftentimes have a capital in- fluence in these cases of threatened miscarriage from purely excessive nervous susceptibility. Allow me here to make one remark in refer- ence to the impregnated uterus in cases of primiparae. You will find as a general rule that women of an extremely nervous temperament, who may be termed, in fact, very impressionable, are more apt than others to miscarry in their first gestation, and the fact is readily explained. In primiparai the uterus distends with less facility than in subsequent preg- nancies, and in women of great nervous susceptibility this very difficulty encountered in the distension of the organ very frequently leads to pre- mature action of the uterus, and the consequent expulsion of the ovum. In such cases, even before there was the slightest manifestation of trouble, I have been in the habit of recommending the lady to foment freely, but without using friction, the hypogastric region with warm sweet oil and laudanum. This, I am sure, will often prove an efficient remedy in these cases, and I can speak of it with much confidence. Its rationale is too manifest to need explanation. But let us present to you another view of miscarriage. The treat- ment which we have thus very summarily suggested is intended for the prevention of a threatened miscarriage. Let us now call your attention for a moment to those remedies which will be indicated in cases in which it will be impossible to prevent the expulsion of the ovum, and in which the duty of the practitioner will be limited to saving the life of the mother. The true danger to the mother is the profuse hemorrhage, and instances are not few in which she has sunk from the loss of blood. When, then, it becomes an ascertained fact that the miscarriage can not be arrested, there are certain remedies to which the practitioner can have recourse for the purpose of causing strong uterine contractions, which not only facilitate the expulsion of the ovum, but which also ar- rest the hemorrhage. These remedies are: 1st. Cold; 2d. The tampon; 3d. The secale cornutum. Cold water dashed suddenly upon the abdo- men will oftentimes be productive of the happiest effects; so also will it result beneficially when injected into the rectum. In these desperate cases this agent should never be neglected. The tampon, under these circumstances, acts, if I may so say, in a two-fold capacity. In the first place it arrests, for the time being, the hemorrhage, and, secondly, the irritation produced by the tampon on the mouth of the uterus provokes contractions of this organ, and thereby facilitates the object in view. TREATMENT OF MISCARRIAGE. 247 The tampon consists of numerous small balls of linen, or of pieces of sponge, introduced into the vagina as far as the os uteri, until the vagina is completely filled up. The whole is then to be kept in place by a com- press and bandage. The influence of the secale cornutum in inducing uterine contractions is now no longer a question for discussion. The tincture may be used for this purpose, say 3 j in half a wine glass of water every ten or fifteen minutes, as circumstances may require, or 3 ij of the powdered ergot may be infused in g vj of boiling water, and a table-spoon- ful given every fifteen minutes until proper contractions are induced. Having thus very generally alluded to the indications to be fulfilled by the practitioner in the treatment of miscarriage, I desire to say one word on a point closely connected with this subject, and you will, I am sure, note it useful to be remembered. When a female has had one or more abortions, you will find it to be essential that she should not become pregnant for at least several months after the last trouble. This should be distinctly enjoined ; and if your advice be not followed, the censure will not be with you, but with those who, having rejected your counsel, can not consistently hold you responsible for results. It now remains for me to suggest a course of treatment for the patient before us. She is, as you perceive, much exhausted, and presents a striking example of the inroads which frequent miscarriages will make upon the general health. This patient needs building up, and for this purpose nothing, perhaps, is better suited to her case, as a medicine, than quinine: R Sulph. Quinae......gr. xx Acid. Sulph. Dilut......gtt. xx Syr. Zingiberi......§ iv Ft. sol. A tea-spoonful of the above solution to be taken three times a day—a nutritious diet, and half a pint of porter daily. " Do you wish, my good woman, to recover your health ?" " Indeed I do, sir." " Then I would recommend you to send your husband to Texas for at least twelve months." " Oh, sir, I would not like him to go so far; but he has an offer to go to Pennsylvania to work in the mines." " Well, Pennsyl- vania will do as well as Texas, provided he leaves you at home." " I am not going, sir." " That's right. Good morning!" LECTURE XV, Imperforate Os Tincse in an unmarried Girl, aged twenty-two Tears—Retention of the Menses—Perforation of the Os Tineas, and Evacuation of the Menstrual Blood.— Retention of the Menses from imperforate Os Tineas, in a married Woman, aged twenty-seven Tears, mistaken for Pregnancy—Vaginal-Hysterotomy in a married WomaD, the Mother of two Children, from criminal attempts at Abortion, by Madam Restell—Safety to both Mother and Child.—Congestive Dysmenorrhoea in a Girl, eighteen Tears of age—Spirits of Mindererus.—Pregnancy complicated with Ovarian Dropsy, in a married Woman, aged twenty-two Tears.—Case of a Patient tapped three times for Encysted Dropsy during Gestation. Imperforate Os Tince in an unmarried Girl, aged twenty-two Years ; Retention of the Menses ; Perforation of the Os Tincae, and Evacuation of the Menstrual Blood.—Jane T., aged twenty- two years, has never menstruated; her general health is much impaired; the abdomen is enlarged, and she has suffered for the last few years from more or less nausea, and bearing-down pains, which have occasioned her much distress. She says she has taken a great number of pills and powders to set her right, but all without effect. " How long, my good girl, has it been since you first begun to enlarge ?" " I don't know, sir, exactly, but I think I commenced to notice it when I was eighteen years old." " Do you observe that you are larger at certain time? than at others ?" " Yes, sir, I have bearing-down pains which distress me very much every month, and then I notice that I am larger than at any other time." " But the enlargement never leaves you entirely, does it ?" " Oh no, sir." I am happy, gentlemen, to be able to present this case before you ; it is one of no slight importance, and is full of professional in- terest. What are the facts ? Here is a young, unmarried woman, a<*ed twenty-two years, whose menstrual function has never appeared, and the abdomen is as much enlarged as you would expect it to be in a preg- nancy of five months ; she has suffered from occasional nausea and bear- ing-down pains for several years past. These are the actual symptoms of which this patient complains, and now the question arises, what do these symptoms portend ? You have heard her statement that she has taken a number of pills and powders to set her right, but all without effect, and she, indeed, may have added that with the conversion of her system into a veritable apothecary's shop, she would still have been without benefit, for the obvious reason that drugs can not meet the indi- IMPERFORATE OS TINCE. 249 cation in her case. Before introducing her into the Clinique, as soon as I heard her statement I subjected her to a critical examination; she is most anxious to be relieved, and like a sensible girl has afforded me an opportunity of ascertaining, beyond a doubt, the true cause of her trou- bles ; in return for this exhibition of good sense, I have promised to re- lieve her, and I shall make good that promise before she leaves this room, provided she will permit me. " Oh! sir, I will consent to any thing, if you will only make me well." " That I certainly will do, my good girl." You perceive, gentlemen, that I speak of the result of this case with great confidence ; perhaps, you may think with too much confidence, but you will be pleased to bear in mind that I have " a reason for the faith that is in me." I have, in the first place, from a very careful inves- tigation, recognized beyond all peradventure, the source of this girl's sufferings, and I know, as clearly as I know that to-morrow's sun will rise, that the difficulties with which she is affected will yield to judicious treatment. In my examination, the first point of inquiry was as to the nature of the abdominal enlargement. Is it, I asked myself, an enlarge- ment produced by an ovarian tumor, or peritoneal dropsy ? Is it tympanites intestinalis, or tympanites abdominalis ? Is it a fatty omentum, or an enlarged liver, spleen, etc. ? And then I started the in- quiry—if none of these causes be in operation, is the enlargement of the abdomen dependent upon an enlargement of the uterus, and if so, what is the cause of the distended uterus ? Is it pregnancy, hydatids, physo- metra, hydrometra, etc., or may it be the retained menstrual blood, which has produced the enlargement ? With these objects in view, I proceeded with the examination as follows: the patient was placed on her back, with the thighs flexed upon the abdomen. I soon discovered that the enlargement of the latter was caused by distension of the uterus. I ar- rived at this conclusion, 1st. From the shape of the tumor ; 2d. From its ascending parallel with the mesial line ; 3d. In the lumbar regions, on either side of the tumor, there was evidently an unoccupied space, which yielded under percussion a sound of resonance, while the sound from the tumor itself was flat and dull; 4th. I could distinctly circumscribe the upper boundary of the tumor, which was below the umbilicus, and when I introduced the index finger into the vagina, with the other hand grasping the upper surface of the tumor, by the movement of elevation and depression, I found I completely embraced between my hands, thus applied, the enlargement, and that its ascent and descent were perfectly under control, depending upon the direction of the movement imparted by either one or other hand ; 5th. I detected fluctuation on percussing the enlarged uterus through the walls of the abdominal cavity, and with the finger introduced either into the rectum or vagina, the finger press- ing against the body of the womb, the sense of fluctuation was again per- fectly manifest; 6th. In addition to the above facts disclosed by this 250 CLINICAL LECTURES. examination, there is another which is conclusive as to my diagnosis, viz : the os tinea;, or mouth of the womb, is closed; or in other words, is imperforate ; there is an entire absence of the two lips, and in the middle and lower portions of the organ corresponding with the os, there is a slight circular depression, flattened and imperforate. There can be no doubt about the sound and fluctuation of which I have spoken, they are palpable, and are quite easy of recognition. The fluctuation is not gen- eral in the lower belly; it is, on the contrary, circumscribed, being not on the sides of the abdomen, but central and below. Again, the patient, you will perceive, presents all the general physical appearances of woman- hood ; this fact is conclusive that the amenorrhcea in this case is not owing to a want of ovarian development. You will remember, too, that I asked the girl whether the enlargement was greater at certain times than at others, and the reply was, that it is greater when she has the bearing-down pains which she experiences each month. This, in connection with the other circumstances of the case, is an in- teresting fact, and is readily explained. In the first place, a portion of the menstrual fluid poured out is very likely absorbed between the pe- riods ; and, secondly, the uterus is in a state more or less of conges- tion at the menstrual crisis, and thus increases for the time the bulk of the abdomen. The opinion, therefore, at which I have arrived is this— that the girl before us is affected with retention of her menses caused by an imperforate os tinea, and that the enlargement of the uterus is de- pendent upon the presence of the menstrual fluid, which is poured out monthly; but which, having no means of exit from the uterus, accumu- lates, and thus gives rise to distention of the organ. Retention of the menstrual blood within the womb is not always the result of an imper- forate os tinea, it sometimes is caused by an imperforate hymen, and again by a complete closure of the vagina. This latter, as well as the imperforate os tinea, may be either primitive or secondary; that is, these obstructions may be congenital, or they may be the effects of injury to which the parts have been subjected. When the retention is due to an unbroken and resisting hymen, there is one peculiar symptom not ob- served in the other forms of obstruction, viz., a portion of the menstrual blood passes into the vagina, and presses consequently against the hymen, so that the accoucheur, with his finger applied to the hymen, will be en- abled oftentimes to detect fluctuation. Treatment.—Now that we have determined our diagnosis, the next point for decision is as to what is to be done for the relief of this girl. The indication is obvious—the menstrual blood must have an outlet; and this is to be accomplished by an operation, which consists in the in- troduction of a curved trochar into the central and inferior portion of the neck of the uterus, for the purpose of making an opening, or, if you choose, an artificial os tinea. This operation is not a difficult one, al- though it is not altogether free from hazard, especially in unpracticed RETENTION OF THE MENSES. 251 hands. " My good girl, you have heard what I have said about your case, will you allow me to relieve you ?" " Yes, sir." [The patient was placed on the bed, and the Professor proceeded as follows: The index finger of the left hand being introduced into the vagina, and the apex carried to the central and lower portion of the cervix uteri, to serve as a guide, the Professor introduced, with the other hand, the curved trochar, with which he penetrated the uterus, passing the instrument from below upward parallel to the axis of the organ. As soon as the organ was pen- etrated, the instrument was withdrawn, and there immediately escaped about two quarts of liquid blood.] You perceive, gentlemen, that with the escape of the blood, the abdominal enlargement has diminished; the blood which has passed from the uterus in this case is, as you notice, quite fluid, and without odor. This is not always so; it is occasionally viscid and thick, and accompanied with a fetid smell. In order to prevent the healing of the opening which I have made, it will be necessary to introduce and retain for a few days a soft bougie. This is all that will be required; and that the bougie may not be disturbed, the patient must keep the recumbent posture. " Well, my good girl, how do you feel ?" " Oh, sir, I am so much obliged to you; I am so happy. I wish I was able to pay you for what you have done." " I am, my good girl, abundantly paid by your thanks." Cases, gentlemen, like the one now before us, are among the gratifying incidents of professional life, and for me they possess a priceless value. They break the monotony of the professional circuit, and impart a fresh charm to the oftentimes arid and uninteresting field, which the medical practitioner is called upon to traverse. The grateful thanks of this girl are more acceptable than the richest fee she could offer me in the shape of dollars and cents. It may not be out of place, in this connection, to call your attention to the fol- lowing case, which presented itself to my observation some time since : A respectable woman, the wife of a mechanic, married about six weeks, requested my professional advice. She stated that her husband, a month after marriage, had begun to treat her cruelly, in consequence of suspicions he entertained in regard to her fidelity toward him. When I saw her she had the appearance of being about six months pregnant; and she remarked that some of the female relatives of her husband had impressed him with the belief that she was pregnant when he married her ; hence his cruel treatment. The poor woman was in deep distress, and supplicated me to satisfy her husband that she was true to him, and his suspicions unjust; assuring me at the same time that she would cheerfully submit to any examination that I might suggest. She in- formed me that she was twenty-seven years of age, and had never men- struated ; her health had been wretched from early girlhood. On call- ing to see her the following day, I observed that there was an indis- tinct and circumscribed fluctuation perceptible at the anterior portion of the abdomen, and extending upward within one inch of the umbilicus. 252 CLINICAL LECTURES. On introducing my finger into the vagina, and reaching the cervix uteri, I discovered an entire absence of the os tinea, the lower and central por- tion of the cervix being quite smooth and uniform on its surface. With the other hand applied to the abdomen, I grasped the fundus of the womb, and felt that I embraced this organ completely between the hand externally, and the finger introduced into the vagina. The diagnosis was plain, viz.: that the fluctuation perceptible in the first instance was the menstrual blood contained within the uterus; and, that, in conse- quence of there being no outlet, this fluid had accumulated, producing a distention of the womb, and giving rise to the suspicion of pregnancy. After this examination, I stated my opinion very fully to the husband, and told him that his wife could be relieved by an operation, at the same time assuring him that his suspicions were entirely unfounded. Having obtained his consent, and his wife being most anxious to afford her husband evidence of good faith to him, assisted by two of my office pupils, Messrs. Burtsell and Morris, I introduced a speculum into the vagina, and brought distinctly to view the cervix uteri. This I pene- trated at its lower and central portion; and instantly not less, I am sure, than two quarts of blood were discharged from the uterine cavity. It is as well to mention that the perineal strait of the pelvis was some- what contracted in its transverse diameter. The operation was attended with very little pain ; the uterus was restored to its ordinary size, and the patient recovered in the course of a few days, when I was much gratified with a visit from both herself and husband, the latter appear- ing truly contrite, while the former assured me of the happiness she experienced in being restored to the love and confidence of her husband. Precisely six months from the day I operated, I was called on by this patient, who informed me that she believed herself pregnant, which I found to be actually the case. I attended her in her confine- ment, and after a severe labor of twenty-eight hours, I deemed it neces- sary to apply the forceps, and delivered her of a fine living son, assist- ed by two of my pupils, Messrs. Meriwether and Whipple, of Alabama. The following case of imperforate os tinea in a pregnant woman, the result of injuries to the neck of the uterus from repeated attempts at abortion, and on whom I performed the operation of vaginal-hysterotomy with safety to both mother and child, is not without interest, and, there- fore, I avail myself of this connection to direct attention to it. This case was published in the New York Journal of Medicine, for March, 1843. December 19th, 1843, Drs. Vermeule and Holden requested me to meet them in consultation, in the case of Mrs. M., who had been in labor for twenty-four hours. On arriving at the house, I learned the following particulars from the medical gentlemen: Mrs. M. was the mother of two children, and had been suffering severely, for the last fourteen hours, from strong expulsive pains, which, however, had not caused the slightest VAGLNAL-HTSTEROTOMT. 253 progress in the delivery. I was likewise informed that, about four hours before I saw the case, Dr. Miner, an experienced physician, had been sent for, and, after instituting a vaginal examination, remarked to the attending physicians, that, " in all his practice, he had never met with a similar case." Dr. Miner suggested the administration of an anodyne, and, having other professional engagements, left the house. Mrs. M. was taken in labor Monday, December 18th, at seven o'clock, p.m., and on Tuesday, at seven p.m., I first saw her. Her pains were then almost constant; and such had been the severity of her suffering, that her cries for relief, as her medical attendants informed me, had attracted crowds if persons about the door. As soon as I entered her room, she exclaimed, '■' For God's sake, doctor, cut me open, or I shall die ; I never can be delivered without you cut me open." I was much struck with this lan- guage, especially as I had already been informed that she had previously borne two children. At the request of the medical gentlemen, I pro- ceeded to make an examination per vaginam, and I must confess that I was startled at what I discovered, expecting every instant, from the in- tensity of the contractions of the uterus, that this organ would be rup- tured in some portion of its extent. I could distinctly feel a solid, re- sisting tumor at the superior strait, through the walls of the uterus ; but I could detect no os tinea. In carrying my finger upward and backward toward the cul-de-sac of the vagina, I could trace two bridles, extending from this portion of the vagina to a point of the uterus, which was quite rough and slightly elevated; this roughness was tranverse in shape, but with all the caution and nicety of manipulation I could bring to bear, I found it impossible to detect any opening in the womb. In passing my finger with great care from the bridles to the rough surface, and ex- ploring the condition of the parts with an anxious desire to afford the distressed patient prompt and effectual relief, I distinctly felt cicatrices, of which this rough surface was one. Here, then, was a condition of things produced by injury done to the soft parts at some previous period, resulting in the formation of cicatrices and bridles, and likewise in the closure of the mouth of the womb. At this stage of the examination, I knew nothing of the previous history of the patient more than I have already stated, and the first question I addressed to her was this: Have you ever had any difficulty in your previous confinements ? Have you ever been delivered with instruments, etc., etc. She distinctly replied that her previous labors had been of short duration, and that she had never been delivered with instruments, nor had she sustained any injury in consequence of her confinements. Dr. Vermeule informed me that this was literally true, for he had attended her on those occasions. This information somewhat puzzled me, for it was not in keeping with what any one might have conjectured, taking into view her actual con- dition, which was undoubtedly the result of direct injury done to the parts. 254 CLINICAL LECTURES. I then suggested to Drs. Vermeule and Holden the propriety of ques- tioning the patient still more closely, with the hope of eliciting something satisfactory as to the cause of her present difficulty; remarking, at the same time, that it would be absolutely necessary to have recourse to an operation for the purpose of delivering her. On assuring her that she was in a most perilous situation, and, at the same time, promising to do all in our power to relieve her, she voluntarily made the following con- fession : About six weeks after becoming pregnant, she called on the notorious Madame Restell, who, learning her situation, gave her somt powders with directions for use; these powders, it appears, did not pro duce the desired effect. She returned again to this woman, and asked her if there were no other way to make her miscarry. " Yes," says Madame Restell, " / can probe you ; but I must have my price for this operation." " What do you probe with ?" " A piece of whalebone." " Well," observed the patient, " I can not afford to pay your price, and I will probe myself." She returned home, and used the whalebone sev- eral times; it produced considerable pain, followed by discharge of blood. The whole secret was now disclosed. Injuries inflicted on the mouth of the womb by these violent attempts had resulted in the cir- cumstances as detailed above. It was evident, from the nature of this poor woman's sufferings and the expulsive character of her pains, that prompt artificial delivery was indicated. As the result of the case was doubtful, and it was important to have the concurrent testimony of other medical gentlemen, and as it embodied great professional interest, I requested my friends, Drs. Detmold, Washington, and Doane, to see it. They reached the house without delay, and, after examining minutely into all the facts, it was agreed that a bi-lateral section of the mouth of the womb should be made. Accordingly, without loss of time, I performed the operation in the fol- lowing manner: The patient was brought to the edge of the bed, and placed on her back. The index finger of my left hand was introduced into the vagina as far as the roughness, which I supposed to be the original seat of the os tinea; then a probe-pointed bistoury, the blade of which had been previously covered with a band of linen to within about four lines of its extremity, was carried along my finger until the point reached the rough surface. I succeeded in introducing the point of the instrument into the center of this surface, and then made an incision of the left lateral portion of the os, and, before withdrawing the bistoury, I made the same kind of incision on the right side. I then withdrew the instrument, and in about five minutes it was evident that the head of the child made progress; the mouth of the womb dilated almost immediately, and the contractions were of the most expulsive character. There seemed, how- ever, to be some ground for apprehension that the mouth of the uterus would not yield with sufficient readiness, and I made an incision of the posterior lip through its center, extending the incision to within a line CRIMENA.U ^..^oaMf'ns AT ABUAnoN. 255 of the peritoneal cavity. In ten minutes from this time, Mrs. M. was delivered of a strong, full-grown child, whose boisterous cries were heard with astonishment by the mother, and with sincere gratification by her medical friends. The expression of that woman's gratitude, in thus being preserved from what she and her friends supposed to be inevitable death, was an ample compensation for the anxiety experienced by those, who were the humble instruments of affording her relief. This patient recovered rapidly, and did not, during the whole of her convalescence, present one unpleasant symptom. It is now ten weeks since the opera- tion, and she and her infant are in the enjoyment of excellent health. I omitted to mention that the urethra was preternaturally dilated. I introduced my finger as far as the bladder without any consciousness on her part, such was the degree of its enlargement. About ten days after the operation, Dr. Forry visited this patient with me, and heard from her own lips the narrative of her case, so far as her visit to Madame Restell is concerned, and which I have already stated. On Saturday last, January 20th, Dr. Forry again accompanied me on a visit to this woman, and a vaginal examination was made. The mouth of the womb was open, and permitted the introduction of the end of the fore-finger; the two bridles were distinctly felt, extending from the upper and posterior portion of the vagina to the posterior lip of the os tinea, which they seemed firmly to grasp. The urethra was very much enlarged, and somewhat tender to the touch. At my last visit to this patient with Dr. Forry, she made some additional revelations, which I think should be given not only to the profession, but to the public, in order that it may be known that, in our very midst, there is a monster who speculates with human life with as much coolness as if she were en- gaged in a game of chance. This patient, with unaffected sincerity, and apparently ignorant of the moral turpitude of the act, stated unequivo- cally, to both Dr. Forry and myself, that Madame Restell, on previous occasions, had caused her to miscarry five times, and that these miscar- riages had, in every instance, been brought about by drugs administered by this trafficker in human life. The only case in which the medicines failed was the last pregnancy, when, at the suggestion of Madame Restell, she probed herself, and induced the condition of things described, and which most seriously involved her own safety, as well as that of her child. In the course of conversation, this woman mentioned that she knew a great number of persons who were in the habit of applying to Madame Restell for the purpose of miscarrying, and that she scarcely ever failed in affording the desired relief; and, among others, she cited the case of a female residing in Houston Street, who was five months pregnant; Madame Restell probed her, and she was delivered of a child, to use her own expression, " that kicked several times after it was put into the bowl." It, indeed, seems too monstrous for belief that such gross violation of 256 CLINICAL LECTURES. the laws of both God and man should be suffered in the very heart of a community professing to be Christian, and to be governed by law and good order. Yet these facts are known to all who can read. This crea ture's advertisements are to be seen in most of our daily papers; there she invites the base and the guilty, the innocent and the unwary, to ap- ply to her. She tells publicly what she can do, and, without the slightest scruple, urges all to call on her who may be anxious to avoid having children. Here, then, is a premium offered for vice, to say nothing of the prodigal destruction of human life that must necessarily result from the abominations of this mercenary and heartless woman. With all the vigilance of the police of our city, and with every disposition, I am sure, on the part of the authorities to protect public morals, and bring to merited punishment those who violate the sanctity of the law, this Madame Restell, as she styles herself, has as yet escaped with impunity. Occupying the position I do, and fully appreciating the important trusts confided to my care in connection with the department over which I have the honor to preside in the University, I have felt it to be a duty I owe to the community, to the profession, and to myself, publicly to expose the facts of this case ; and I fervently hope that the disclosures here made may tend to the arrest of this woman, and the infliction of the severest penalty of the law. In a professional point of view, this case is not without interest. It must be evident to all that, without the operation, the patient must have sunk. She had been in labor precisely twenty-nine hours when I made the section of her womb, and for twenty hours previously the con- tractions were most energetic, possessing all the characteristics of true expulsive pains. But yet, with all this suffering, not the slightest change had been effected in the parts. If nature, therefore, had been competent to overcome the resistance, sufficient time was allowed for this purpose. Longer delay would undoubtedly have placed the lives of both mother and child in extreme peril; for, from the reiterated but unavailing efforts of the womb, there was reason to anticipate rupture of this viscus, which would most probably have compromised the life of the mother; while, at the same time, the child was exposed to congestion from constant pressure exerted on its head by the contractile force of the uterus. I am not aware that this operation has ever been performed in this country, at least I have found no record of it. It has, on several occa- sions, been resorted to in Europe, but not always with success. Congestive Dysmenorrhoea in a Girl eighteen Years of age— Spirits of Mindererus.—Margaret M., aged eighteen years, was re- ported by her mother as much improved since she first applied for ad- vice. You remember, gentlemen, the case of this patient. She had suffered during her menstrual periods excessive pain, so much so, indeed, that she was disqualified from attending to her ordinary duties. It was, CONGESTIVE DTSMENORRHCEA. 257 we stated to you at the time, an example of congestive dysmenorrhoea the pathology of which consists in the exudation of coagulable lymph' coating the cavity of the uterus. This is thrown from the organ in fragments, and hence the extreme pain so characteristic of the malady. The treatment ordered for the patient was intended to break up the congestive tendency, and consisted in the local abstraction of blood from over the sacrum every two weeks, together with free purgation and vegetable diet. " Is your daughter's health improved, madam ?" " It is very much improved, sir." " Has she suffered less pain during her turns than she did when you first brought her to the Clinique ?" " She is like a different person, sir; and I wish I knew how to thank you for what you have done for her." " No thanks necessary, madam. It af- fords us great pleasure to relieve the suffering, and you will always find us happy to do what we can for you and any friends who may need pro- fessional advice. This is a large city, and contains many poor but wor- thy people, who, in their sickness, will always cheerfully have accorded to them whatever benefit it may be in our power to confer." " Thank you, sir." " That will do, madam. Good morning!" Dysmenorrhoea, gentlemen, is an affection which you will often en- counter in practice, and it is highly important that you should make a just distinction as to its various causes. • Allow me here to call your attention to a remedy suggested by authors in the congestive form of dysmenorrhoea—a remedy which, unquestion- ably, does produce, under some circumstances, the happiest results, but the modus operandi of which, as far as I know, is not understood, nor do I believe that any explanation has as yet been attempted. Indeed, in prescribing the remedy, practitioners content themselves with the state- ment, that past observation has satisfied them of its efficacy. They pre- scribe it, they admit, empirically, having no knowledge of the manner in which it acts. The remedy to which I allude is the liquor ammonia acetat. known as the spirits of Mindererus. It has occurred to me that the manner of its operation is susceptible of explanation, as follows:__ 1st. The menstrual blood while within the cavity of the uterus differs from the menstrual blood in the vagina, the difference being due to the fact, that while in the uterus it coagulates because of its fibrin. In the vagina it does not coagulate, because it loses its fibrin. 2d. In the ute- rus the menstrual blood undergoes an alkaline re-action; in the vagina, on the contrary, an acid re-action. The mucus of the vagina contains more or less acetic acid, and this is a solvent of the fibrin. These two propositions, I believe, are accepted doctrines, and upon them I shall base my hypothesis. 3d. In the dysmenorrhoea of conges- tion there is an exudation of coagulable lymph—a diphteritic deposit similar to what occurs on the internal surface of the larynx in croup, and this coagulable lymph lines the cavity of the uterus, forming a deciduous membrane, which, during the menstrual crisis, is thrown from the organ 17 258 CLINICAL LECTURES. in fragments. 4th. The liquor ammonias acetat. when taken into the system, passes into the blood, and tends, in my opinion, to lessen tlie fibrin in the menstrual fluid of the uterine cavity, thus in a measure de- stroying its coagulability, and thus, to an extent, interrupting the forma- tion of the deciduous membrane. I believe, therefore, that the true ex- planation of the efficacy of the spirits of Mindererus in dysmenorrhoea is the fact that it modifies the character of the blood before it passes from the uterus, partially dissolving its fibrin, and thus removing the element to which it owes its power of coagulation. I am aware that to this hy- pothesis it may be objected—1st. That the liquid acetate of ammonia, as taken into the system, is soon changed into the carbonate of ammonia in consequence of the oxygen which it receives from the arterial blood; and, secondly, that, as alleged, the whole of the ammonia passes from the system through the renal secretion. The first objection in no way invalidates my position, for the carbonate of ammonia is as much a sol- vent of fibrin as is the liquid acetate of that alkali; and in reply to the second objection, I would remark that while the fact is conceded that the greater portion of the ammonia is excreted through the urine, yet the conjecture that no part of it circulates through the entire system rests entirely upon negative proof. Until recently, on the same character of proof was sustained the opinion that mercury did not pass into the cir- culation ; but the researches of Personne have shown the contrary, for he has detected mercury in the milk of the mother, who had been sub- jected to its administration. This fact opens a new avenue to our views on the action of that much abused but precious remedy, mercury, and removes all foundation from the theory, very generally entertained, that this agent passed from the system with the fasces. Pregnancy complicated with Ovarian Dropsy, in a married Woman, aged twenty-two Years.—Mrs. B., aged twenty-two years, is the mother of one child, ten months of age. The case before you, gentlemen, came to the Clinique last June; and those of you who were here at that time will remember the interesting particulars connected with it. " How old, madam, was your child when you first applied here for advice ?" " It was about four months old, sir." " When did you first notice a swelling in your abdomen ?" " About two months after the birth of my infant." " Where did you observe it ?" " In the lower portion of my person, sir, on the right side." " Did it give you much uneasiness ?" " It did not give me any pain, sir—but it made me unhappy, because I did not know what it was." " Did it grow very rapidly ?" " It has grown very rapidly since you first saw it—and I am afraid something else is the matter with me." " Do you suppose you are pregnant ?" " I am afraid so, sir." It is now five months, since this patient applied at the Clinique for advice—at that time, as reference to your notebooks will inform you, I told you she was laboring under encysted dropsy of PREGNANCT COMPLICATED WITH OVARIAN DROPSV. 259 the right ovary. The abdomen, as you now perceive, is greatly en- larged, and the patient presents the aspect of being in the ninth month of gestation. It then becomes an extremely important question to decide whether this increased size of the abdomen is due exclusively to the enlarged ovary, or whether there may not also be the co-existence of pregnancy. This question necessarily imparts additional interest to the case before us, and it demands deliberate consideration. I might cite many instances in which the decision of this question would strike directly at character—that precious possession than which nothing is more valuable; let an individual be without character, and he is not only the scorn of the earth, but the most pitiable of all God's creatures. Character, gentlemen, is an segis for all time—it not only serves you during life, but it consecrates the memory after death—it embalms you in the recollection of the good, and protects you against the assaults of the degraded hypocrite. Under certain circumstances, few things are more difficult than to decide as to the simultaneous existence of pregnancy and ovarian dis- ease. In the married woman, who has a right to be pregnant, an erroneous decision would not involve character; but how different in the case of the unmarried, who, simply laboring under enlarge- ment of the ovary, should be charged with being pregnant! These questions constitute the great and delicate points of the profession— points which demand, and should receive, the fullest consideration of the medical practitioner who, in matters like these, is the only um- pire, and on whose judgment must rest the issue of happiness or misery. Before presenting this patient to you this morning, I made a critical ex- amination, and have no doubt that she is pregnant, probably between four and five months. This opinion I have formed from the condition of the womb, and the change in its cervix, the appearance of the circle around the nipple, constituting the areola, which, I have stated on former occasions, possesses for me a strong evidence of pregnancy. I do not allude to the simple discoloration of the circle—for this may, and does occur in numerous morbid conditions of the uterus—but I speak of the moisture and emphysematous character of the integument—two attri- butes of the areola, to which, I believe, attention was first called by Montgomery in his valuable work on the signs of pregnancy. The true areola, in my judgment—and this opinion is founded on careful and extensive observation—is not recognized, except as a conse- quence of gestation; and its presence, in the case before us, together with the confirmatory evidence furnished by the changes in the uterus, places the question of pregnancy beyond all doubt. In addition to this testimony, I might have recourse to auscultation, but the difficulty of detecting the sounds of the fcetal heart, under existing circumstances, with the abdomen enormously distended by an ovarian growth, would be greatly enhanced—and for the same reason, we are deprived of the evi- 260 CLINICAL LECTURES. dence furnished by the bollottement, or passive movement of the child, which is determined by the accoucheur by placing one finger on the posterior surface of the cervix uteri, and the other hand on the fundus of the organ, and thus with an upward impulse communicated by the finger to the neck of the uterus, the foetus is made slightly to ascend in the organ, and it then immediately rebounds—in consequence of its floating in fluid, the liquor amnii—and imparts to tho finger a sensation winch constitutes unequivocal proof of pregnancy. No other object than a foetus could impart such a sensation—for of all intra-uterine growths, it is the only one that floats in fluid. Although, therefore, we are deprived of the important evidence derived from auscultation and the ballottement, yet I feel no hesitation in expressing my opinion that this patient is undoubtedly pregnant. The important consideration now arises—what is to be done ? Under existing circumstances, we shall do nothing in the way of treatment with the simple exception of keeping the bowels in a soluble state; and for this purpose one of the following powders may be taken in half a tea-cup of tepid water at night, as cir- cumstances may require : R Sulphat. Sodas.......3 jj Pulv. Rhei. .......3 j Pulv. Zingiberi.......3j . Div. in Chart. No. x. The fact that pregnancy exists, prevents any other, at least for the pres- ent, than palliative treatment. It may, however, become necessary, be- fore the birth of the child, to tap the patient with the view of removing the abdominal distention. You will permit me, in connection with this subject, to mention the fol- lowing interesting case, to which I was called some years since, and which, in several particulars, has a strong bearing on the one now before us: I was requested to visit Mrs. B., aged twenty-seven years, from whom I heard the following particulars: She had been married nine months and a half. Previous to her marriage she had always enjoyed good health, and her " monthly courses" had observed a marked regularity. About six weeks prior to her marriage, she thought she observed a very slight swelling in the right iliac region; it produced no uneasiness, but actuated, no doubt, by a proper feeling of delicacy, Mrs. B. consulted a physician, to know whether, under the circumstances, it would be proper for her to marry. She was assured that the swelling would amount to nothing, and, therefore, felt no further anxiety in regard to it. Her " courses" never returned after marriage, and the various presumptive and probable symptoms of pregnancy soon manifested themselves. With the exception of frequent indisposition to sleep at night, and torpid bow- els, nothing remarkable occurred until about eight and a half months after her marriage. At this period, the pain in her back was at times excessively severe, and the abdominal enlargement had increased so PREGNANCT COMPLICATED WITH OVARIAN DROPST. 261 rapidly that she found it necessary to seek medical advice. A surgeon was accordingly sent for, and, after reflecting on her case for some days, told the husband of Mrs. B. that, if his wife would consent, he would remove the tumor. To this proposition, she, in common with her hus- band and friends, objected. Another medical gentleman was then re- quested to meet the first in consultation. Nothing, so far as I could learn, of professional interest was agreed on by them. The husband, naturally anxious to know the precise condition of his wife, called on these gentlemen, and requested them to say whether they considered her pregnant. They declined giving an opinion, and said they would prefer waiting, as a few days would decide the nature of the case. Dissatisfied at not receiving more encouragement than was embodied in the above conversation, the gentlemen were told that their services were no longer required. This is the purport of what transpired previous to my seeing the case, and the facts are stated as taken down by me at the time from the lips of Mrs. B. in the presence of Dr. Washington. On visiting the patient, I found her excessively enlarged, and laboring under very acute distress; the integuments on the abdomen appeared ready to burst. She was feverish, and much troubled with constipation. Her respiratory and digestive organs suffered greatly from pressure, and her general appearance of emaciation evidenced much internal trouble. For the last two weeks Mrs. B. had been compelled, such was her dis- tress, to leave her bed frequently during the night and walk the room. After a very rigid investigation, by way of question and answer, as to the history of the case, I was unable to elicit any facts other than those which have already been mentioned. Mrs. B. being then arranged in bed on her back, with the thighs flexed on her pelvis, I made an abdominal examination of the tumor. It was very evident that the enlargement was wanting in uniformity, and it assumed somewhat a diagonal position as regarded the abdomen. There was no pain when the tumor was pressed upon; and, in percussing the abdomen, a very distinct fluctuation was perceptible. It was plain that this was not a case of ascites, for the fluc- tuation, though tolerably diffused from the great size of the tumor, was certainly circumscribed ; and ascites, we know, at least in a majority of cases, is preceded by such symptoms of disease as will at once enable the careful practitioner to detect the malady. From the previous history, therefore, of the case, together with the symptoms present, I had no hes- itation in concluding that the patient labored under ovarian dropsy. An examination, per vaginam, was next made, and it was discovered that the womb was enlarged. There was nothing remarkable about the cervix uteri—no pain on pressure, and its structure appeared perfectly natural, nor was there the slightest vaginal discharge. The finger being intro- duced into the rectum, the posterior surface of the womb evinced a de- cided development of this viscus, and this latter examination fortified me in opinion as to the probable amount of uterine enlargement. 262 CLINICAL LECTURES. The question now to be decided was an exceedingly important one. Did the enlargement of the womb depend upon pregnancy, or was it the result of disease, or might it be owing to the presence of something in its cavity other than a foetus ? That it was not disease, the perfect ab- sence of pain, and all the symptoms ordinarily attending a morbid con- dition of this viscus, seemed clearly to demonstrate. The patient was fully under the impression that she was pregnant, and had, together with her female friends, attributed all her distress to this condition. She, how- ever, had never felt the motion of the foetus. It will thus be seen that I had arrived at a portion only of my diagnosis, and the duty devolved on me to endeavor to account for the enlargement of the womb. Ac- cordingly, I resorted, as the only means now left, to auscultation. I made repeated attempts, simply with my ear applied to the abdomen, to de- tect the pulsations of the fcetal heart, or the " bruit placentaire." I did not succeed. On the following day, I requested my friend, Dr. Washington, to visit the patient with me. She was again examined with great care, and several attempts were made both with the ear and stethoscope, but without success. Under all the circumstances of the case, we felt ourselves jus- tified in giving the following opinion, which was stated to the patient and her friends, viz.: that Mrs. B. labored under ovarian dropsy, complicated most probably with early pregnancy. The distension of the abdomen was now so great, and the distress from injurious pressure so marked, that it became my duty to urge on Mrs. B., as a means of temporary relief, the necessity of being tapped. The suggestion was not assented to, and palliatives were directed, keeping the bowels in a relaxed state, and ordering such articles of diet as were most easy of digestion. Mor- phine procured her comparative rest at night. She continued in this state until the 15th of July, when I operated on her in the presence of Dr. Washington, Professor Alban Goldsmith, Drs. Caldwell and Hib- bard. One gallon and a half of amber-colored fluid, of the consistence of melted calf's foot jelly, were drawn off, which gave her immediate re- lief. On the following day, Dr. Washington and myself again had recourse to the stethoscope, and the pulsations of the fcetal heart were dis- tinctly heard. This was most gratifying, so far as it confirmed the diag- nosis. It is highly probable that the great size of the tumor had ma- terially interfered with our arriving at this result earlier. On the 20th of July, Mrs. B. quickened. From the period of the operation until the following October, Mrs. B. enjoyed comparatively good health; her digestion was much improved, and she gained flesh. In October, how- ever, it again became necessary to draw off the accumulated fluid. One gallon was taken away; in two weeks afterward, the distension was much increased, and on the 19th of October, half a gallon of fluid was drawn off. It is worthy of remark, that in performing this last operation, not PREGNANCT COMPLICATED WITH OVARIAN DROPST. 263 more than an ounce of fluid passed through the canula. A probe was introduced to remove the obstruction, but none was found to exist. It was, however, very evident that there was yet a great quantity of fluid in the ovarium, and the distress of the patient obviously indicated the removal of at least a portion of it. The trocar was therefore intro- duced into another part of the tumor, when not more than two ounces passed away. The instrument was then withdrawn, and on looking at- tentively at the ovarium, a pouting was observed at its upper portion, immediately under the last rib. The trocar being introduced at this point, sufficient fluid escaped to make the patient quite comfortable. The cause of the difficulty was owing to the fluid being enclosed in cysts, each distinct in itself, and it seems to me that a useful lesson can be derived from the recollection of this fact. For example, in hydatid dropsy of the ovarium, post-mortem examination reveals to us that the various cysts or compartments vary in size, some containing a gallon or more, while others are so small, as not to yield, when punctured, an ounce of fluid. Now, let us suppose our opinion to be formed as to the existence of ovarian dropsy in any given case, and in the event of an operation, if, in puncturing one of the small cysts, not more than a large spoonful of liquid escape, we might at first suppose that we had failed in our diagnosis. The bare mention of the fact will, I apprehend, be sufficient to put practitioners on their guard against the possibility of such an error, involving as it certainly would, their professional reputa- tion, if, indeed, it did not compromise the safety of the patient. After the last tapping, Mrs. B. passed on with more or less distress to the period of her confinement, which took place on the 29th of October. She was in labor only two hours, and was delivered of a still-born, un- natural, and sickly-looking infant. The placenta followed almost imme- diately the expulsion of the foetus, and the uterus was well contracted. In two hours after the birth of the child, the abdomen commenced en- larging, and in thirty-six hours after her delivery, this poor woman breathed her last, the abdomen being ready to burst from gaseous dis- tension of the intestines. The husband and friends had been fully ad- monished of the almost certain result of the case, soon after we had first visited the patient. In the post-mortem examination, in which I was kindly assisted by Dr. Caldwell, the uterus was found to be perfectly healthy, the left ovarium was immensely large, and filled with a number of hydatid cysts. The right ovarium preserved its natural character in every respect. LECTURE XVI, Introductory Remarks.—Undue Lactation in a married Woman, thirty-two Tears of age.—Anemia.—Paraplegia in a Child, twelve Months old, from Intestinal Irrita- tion.—Procidentia of the Womb in a married Woman, aged fifty-five Tears, nine Tears standing, with Venereal Ulcerations on both sides of the Organ.—Profuse Menstruation in a young Woman, twenty-two Tears of age, from Grief.—Incontin- ence of Urine in a married Woman, eighteen Tears of age, from Paralysis of the Neck of the Bladder.—Falling of the Bladder in a married Woman, aged twenty- five Tears, mistaken for Falling of- the Womb.—Palpitation of the Heart from Dyspepsia, in a married Woman, aged thirty-two Tears.—Encysted Tumor in the posterior wall of the Vagina, in a married Woman, twenty-three Tears of age. Gentlemen :—The diseases peculiar to females are often extremely obscure, and the practitioner must remember that successful treatment depends on a just discrimination of the nature of the malady. Many a valuable life has been sacrificed by error of judgment in this particular, and discredit brought upon our science by mistaking effects for causes. In the present state of physiological knowledge, it would indeed be dif- ficult to present such a classification of these diseases as shall accord perfectly with pathology and therapeutics. The old doctrine, howevei as propounded by the early Greek writers with regard to these maladies and especially hysteria, have yielded to the advances of modern science The functions of the nerves, as now understood, have thrown a flood of light on points formerly obscure and unsatisfactory; and we may be permitted to predict, in view of what has already been accomplished through our knowledge of the brain and nervous system generally, that all rational deductions in disease will sooner or later be based on the anatomy and physiology of this system, taken in connection with the important disclosures of chemistry. That there subsists, between the nerves of the uterus and the general economy, an intimate connection can not for one moment be doubted. Deny this, and we are at a loss to explain many of the phenomena so constantly occurring in the sys- tem of the female. For example, the diseases which may be considered as peculiar to women are, with good reason, divided into organic and functional. The pathology of the former can be determined without difficulty, for they involve lesion of structure, which becomes manifest to the sense either of touch or sight. This organic lesion will occasion- TREATMENT OF DISEASES OF WOMEN. 265 ally give rise to the same series of phenomena, which are known to fol- low mere functional disturbance. The only evidence that these phenom ena are due to structural, and not functional disease, is furnished by the fact that a lesion does in truth exist. The pathology, therefore, of or- ganic disease of the womb is simple, and of easy comprehension ; not so with the functional derangements of this organ, for here there is no change of structure—none at least appreciable in the minutest autopsy. We have already seen that the important function of the uterus—that which is in fact the balance power between health and disease in the female, menstruation—can not, under ordinary circumstances, be inter- rupted ; or, in other words, can not depart from its normal standard, without involving, to a greater or less extent, the general economy in constitutional disturbance; and this result is produced through the me- dium of the ganglionic system of nerves, and the cerebro-spinal axis. There are two points you are constantly to keep in view, so far as the diseases of women are concerned : 1st. Is the disease organic, or is it functional ? 2d. Is any given disturbance in the system local, or is it de- pendent on the structural or functional derangement of the uterine or- gans ? If you will steadily bear in memory these two interrogatories— suffering your minds on no account to be diverted from the true issue— you will have overcome one of the principal difficulties in the treatment of these special maladies. In order that you may clearly appreciate the value of the principle we are inculcating, let us, for example, take the case of a lady who consults you in the hope that she may derive from your skill a remedy for a distressing headache—so distressing, indeed, that her mind almost becomes bewildered. Your first duty, in a case of this kind, is to decide whether the pain is the result of an affection of the head, or whether it is a mere symptom of trouble in some remote organ. You see at once how essentially your treatment, if rational and effective, must depend on a just distinction. Again, if the headache should be found to proceed from functional disturbance of the womb, which is a very usual circumstance, it must be remembered that two opposite, or, if you choose, two contradictory conditions of this organ are alike capa- ble of producing the same result—intense headache. For example, a lady whose menstrual evacuation is deficient in quantity is extremely liable to severe cephalalgia; precisely the same thing occurs in a female whose system has been drained by an excessive loss of blood. Hence, in miscarriage, where the patient has become nearly exsanguinated, a very common result will be, distressing headache. If you should de- cide erroneously in these two cases—if, for instance, you should mistake the one condition of system for the other, the most serious consequences may ensue to your unhappy patient. Headache, produced by deficient menstruation, will yield to judicious abstraction of blood, cathartics, diet, etc., these remedies being employed, not empirically, but in refer- ence to the peculiar circumstances which may exist at the time. Head- 266 CLINICAL LECTURES. ache, on the contrary, the result of excessive loss of blood, would not only be aggravated by this treatment, but fortunate, indeed, would it be for the sufferer, if her life did not pay the forfeit of erroneous judgment. You will frequently be consulted by ladies for a supposed disease of the liver; pain in the right side over the region of this organ, giving rise to the belief that the liver is affected. Under this conviction mercurials are administered, and frequently serious mischief ensues to the general system. The pain does not yield to the treatment; the mercury is still continued, and oftentimes the most fearful ravages result from the ad- ministration of this valuable but much abused remedy. The plan for you to pursue is a simple one ; if your opinion be invoked in a case of this kind, do not take it for granted that because the patient suffers pain in the right side she is, therefore, laboring under disease of the liver. You must remember that this very character of pain is sometimes the result of pregnancy, and occasionally an important symptom of disease of the womb. In engorgement without ulceration, and in ulceration of the neck of this organ, I have frequently known this pain to be present, and it exists, also, in other derangements of the uterus. In a word, gen- tlemen, the distinction between the scientific physician and the empiric is this—the former traces effects to causes; before prescribing, he en- deavors to ascertain what there is wrong in the wonderful machinery of the human fabric; he will not content himself with mere conjecture, but true to the principles of his science, and devoted to its interests, by dili- gent investigation he discovers what the matter is, and then applies the remedy. The latter, the heartless empiric, true to the principles of his calling, speculates with human life as the broker does with dollars and cents—the great object of his existence being the amassing of wealth— makes human nature his study, and devotes his nights and days to the formation of schemes by which he will be the better enabled to practice on human credulity Undue Lactation in a married Woman, thirty-two Years of age.—Anaemia.—Mrs. H., aged thirty-two years, married, the mother of seven children, the youngest eight months old, says she is very weak, and wishes some strengthening medicine. She has been married nine years, and previously to her marriage her health was excellent, she being a vigorous and hearty woman; is the mother of seven children, and nursed all of them, until they were twelve months old, with the excep- tion of the one before the last, which she did not wean until he was sixteen months of age. Her health began to fail her about four months before she weaned this child, she becoming extremely nervous, restless at night, with palpitation of the heart, and vertigo, together with consti- pated bowels. " What is the age of your last child, madam ?" " He is eight months, sir." "Do you nurse him?" "Yes, sir." "How UNDUE LACTATION. 267 was your health when you were carrying him ?" " I was better, sir, but soon after he was born, I began to feel sick again, and I am very bad now, sir." " Well, madam, you need not tell us that; your very appearance shows that you are in bad health. Have you any cough ?" " No, sir." In addition, I find this patient is laboring under profuse menstruation, her turns having come on about three months after the birth of her child, and continue for ten days at a time; she is quite unhappy, and is strong- ly impressed with the belief that she can not recover her health. In some particulars she may be said to be hypochondriacal, one of the characteristic symptoms of which is dejection of spirits, together with a despondent hope. There is no difficulty in understanding why this woman should be despondent, as her nervous system has undergone such a re- markable depression, and her vital forces are so dilapidated that her natural strength of mind and energy have yielded to the encroachments of disease. These are the cases, which require not only judicious treatment, so far as mere medication is concerned, but also the encouraging and confident assurance of the physician. Encouraging language, and the excitement of cheerful hopes are oftentimes important aids to the medi- cal man, and, under almost any circumstances, constitute an acceptable boon to the patient. There is a striking analogy between our profession and religion—both require works, and both need faith. The physician who, in the treatment of disease, shall limit himself to the mere ad- ministration of drugs, will frequently find himself unrequited by suc- cess. But if, with the judicious employment of remedial agents, he will combine a sensible, moral treatment, he will oftentimes discover that he has obtained a victory which could be accomplished in no other way. I am a firm believer in the operation of mind upon matter. The patient before you presents an interesting example of dis- ease, for which you will often be consulted in practice; it is unfortu- nate, however, that its nature and causes are too generally overlooked. It is only necessary to observe the pallid cheek of this woman, and note the feeble pulse, together with the general evidences of prostration pre- sented in her system, to be satisfied that her vital forces have from some cause or other undergone a severe shock. She is perfectly anamic ; the red corpuscules, which formerly were in abundance, are now no longer to be recognised, and she exhibits the aspect literally, if I may so speak, of a bloodless woman. You must bear in mind that the patient is thirty- two years of age ; she was always a healthy woman until four months previously to weaning the child before the last. She has no cough, and as far as we can learn by questioning her, she has not labored under any acute disease. How then do you explain this pallor of countenance, and general decay of the vital energies ? These latter are evidently the results of some antecedent disturbance, the nature of which it is the duty of the physician thoroughly to examine. If something be not done to arrest the gradual decline of this woman's strength, it is quite mani- 268 CLINICAL LECTURES. fest that she must die; her whole frame is shattered, and she is rapidly failing. A close analysis of the circumstances connected with the case before us, will at once explain the dilapidated state of this woman's health. Her physical powers have been too severely taxed, and she exhibits in the pallor of countenance, weak pulse, cold extremities, the vertigo, and palpitation of the heart, the effects of a drain on the system, which she has not been adequate to sustain, and at the same time preserve that harmony of action which constitutes health. This case is full of practi- cal import; it is of frequent occurrence, and it will be your duty when consulted, to understand the nature of the influence which has resulted in such complete derangement of the vital forces. This is clearly an example of the exhausting effects of undue lactation. The patient has nursed her child too long. The connection between the nervous and cir- culating systems has frequently been explained to you, and the natural dependence of the one on the other you can not fail to understand. This dependence the practitioner should never lose sight of in the treatment of disease; oftentimes it will afford the only sure basis for correct thera- peutic application, and the cardinal element of successful treatment. In plethora, the nervous system is unduly stimulated—in anaemia, it is de- pressed. In plethora, organic or nutritive life is excessive—in anaemia it is defective. In this case, the anaemia is the result of the long continued lactation. You will remark, in the course of your professional observation, that undue lactation is not always limited in its effects to a bloodless condi- tion of the system; and as an evidence of the influence of anaemia on the nervous structure, you have only to look at the various shades of nervous derangements, which often follow this drain on the economy. In one case, you have hysteria under one or other of its multiplied forms, while in another, the brain itself becomes so deeply involved as to result in positive insanity. It is, therefore, gentlemen, manifestly of the greatest moment to watch with scrupulous care the insidious progress of this drain, capable as it is of producing not only functional derangement, but even insanity and death. There is one difficulty which you will almost always encounter in the treatment of undue lactation—a difficulty which arises directly from that sacred and unwavering love of her child which is the distinguishing attribute of woman. In the love she bears her offspring, woman forgets self—her whole heart is centered on her child—it is the idol of her affections, the object of her devoted care by day and by night. Her own pallid cheek and trembling frame are but trifles in contrast with her duties to her infant—and too often, alas! this intensity of maternal affection displays itself at the expense not only of health, but of life it- self. There is something beautiful, but at the same time heart-rending, in the contemplation of this undying affection of woman. Nothing can abate it but the grave! Whether in poverty, or under the weight of UNDUE LACTATION. 269 mental depression, in sickness, or in the midst of the keenest physical suffering, woman's heart still beats for her child, and her last breath is but an aspiration to Heaven for its protection and guidance! " Madam, do you wish to recover your health ?" " Indeed, I do, sir ?" " Then, you must follow my advice strictly." " I will, sir." " The first thing for you to do is to wean your child." " 0 ! sir, I can not do that!" " Why not, my good woman ?" " Because, sir, I am afraid it will die if I stop nursing it." " But you are not able to nurse it—you have not sufficient strength—and your milk is not proper for it." " I will take any kind of physic, sir; but I can not wean my child, he is too delicate." " You will allow me to say, my good woman, that I know more about this matter than you do; and if you do not follow my advice, you will certainly fall into a state of health which will not only prevent you from taking care of your child, but will ultimately destroy you." " Then, sir, I will do what you say." In cases like these, gentlemen, you must remember that all medication will fail, if you do not, in the first place, remove the cause of the exhaustion—the nursing infant. This being done, the next object is to repair, by appropriate remedies, the waste incurred by the mother. You will not have forgotten in the questions which I have addressed to this woman, that she has informed us of a very material circumstance, viz., that in addition to the drain of lactation, her " monthly turns" are too profuse. This latter arises, no doubt, from an atonic condition of the vessels, constituting a form of passive menorrhagia. This, therefore, must not escape your observation, and will require imme- diate attention. Treatment.—With the view of controlling the profuse menstruation, you will find that cold water injections will prove very effective. In this character of menorrhagia I frequently employ them, and with the happi- est results, as follows: Two days after the courses commence let half a pint of water, cold from the pump, be thrown slowly up the rectum night and morning; and this should be repeated daily during the menstruation, until the function becomes natural. It may be found necessary to repeat the injection for two or three successive periods. The salutary influence of this simple but efficient remedy is due to the tone it imparts to the uterine organs. In addition, let the patient take during the menstrual flow 3 j. of the tincture of ergot twice a day in a half wine glass of cold water; this to be continued for two or three days, as circumstances may indicate. For the purpose of improving the digestive functions, and invigorating the general health, one of the following powders may be taken twice a day: R Pulv. Rhei.......3ij Sulphat. Quinae......3j Divid. in Chart, xx. The diet should be nutritious, with half a pint of porter daily. While, however, we prescribe for the mother, we are not to forget the infant. 270 CLINICAL LECTURES. Its diet, for the present, should consist of two-thirds cow's milk and one of water; equal parts of milk and barley water, or rice water ; panada, made of soda biscuit, etc., etc. " Now, madam, if you will pay strict attention to what we have told you, I am quite confident you will have no cause to regret it; but, on the contrary, both you and your infant will be benefited. Come here, my good woman, one month from this day, and report yourself." Paraplegia in a Child twelve Months old.—Rachel L., aged twelve months, is brought to the Clinique by her mother, who is in great dis- tress because her infant has lost the use of her lower limbs. " How long, madam, is it since you noticed that your child could not move its limbs ?" " I first noticed it, sir, about three months ago." " Have you done any thing for your child ?" " Yes, sir; I have rubbed it with lini- ments." "Well, madam, you need not use any more liniments, for they will not restore to your infant the use of its limbs." " Oh, sir, can nothing be done for it ?" " Be patient, madam; we will tell you as soon as we know more about the cause that has produced the loss of power. Was your child healthy at its birth ?" " Yes, sir; it was a beautiful babe." " Did it continue healthy to the time that it lost all power over its limbs ?" " It appeared sick, sir, about two weeks before that time." " What was the matter with it, madam ?" " Its bowels were out of order, sir." " Were they confined ?" " Not at first, sir." " In what condition were they, madam ?" " Dark slimy stuff passed from them, sir." " Did you give it any medicine ?" " I gave it some oil, sir." " How were they afterward ?" " Oh, they have been all the time confined, sir. Sometimes nothing passes it for four or five days." " Do any lumps come from it ?" " Yes, sir; white lumps; they look sometimes like curdled milk." " Now, my good woman, please to re- collect how soon after the bowels became deranged did you first notice that your infant had no power over its limbs ?" " About two weeks, sir." I think, gentlemen, as the law has it, we have made out our case. Paraplegia in children is produced by various causes, and is usually transitory in its nature. In this latter respect it differs from paraplegia in the adult, whieh is commonly connected with some cerebral distur- bance, and is generally permanent. The causes of paraplegia in infancy and early childhood are cold, fright, intestinal irritation, etc. You have had an opportunity of seeing more than twenty cases of this affection in the Clinique, and you have enjoyed with me the pleasure of witnessing nearly all of them yield to remedies. In the case before us, I have no doubt that the paraplegia is occasioned by intestinal irritation. You have heard the statement of the mother, and that statement, which ap- pears to bear the seal of good faith, informs us of a very important fact, that previous to the loss of power in the limbs, the infant's bowels were much deranged, at first by vitiated secretions, and afterward by consti- PROCIDENTIA UTERI. 271 pation—white lumps, etc., passing from it. It is very natural, however, for you to ask what connection there is between intestinal irritation and paraplegia ? This I have repeatedly explained at former Cliniques in the following manner :—The intestines and abdominal viscera are almost entirely supplied with nerves from the sympathetic or ganglionic system. At the same time fibrils of nerves from the spinal marrow unite with the branches of the ganglionic nerves as they distribute themselves on the intestinal canal. In this way, you perceive, there is a connection by nervous influence between the intestines and medulla spinalis. When the former become the seat of irritation, this irritation is oftentimes con- veyed by means of this connection to the medulla. The nerves, as you know, which pass to the lower extremities, proceed from the spinal mar- row. These nerves, therefore, will lose their power of controlling mus- cular action as long as the source from which they are derived is the seat of irritation. What now is to be done for this child ? Emphati- cally nothing but to remove the cause of the paraplegia. With this ob- ject, we shall recommend the following course to be pursued : R Hydrarg. c. Creta......gr. iv. Let the infant take this powder to-night, followed in the morning by castor-oil, and every third night afterward, for three successive times, let it take half a grain of the hydrarg. c. creta, with a view to its altera- tive action, and in the morning flake manna dissolved in warm water. Procidentia Uteri in a married Woman, fifty-five Years of age, nine Years standing, with Venereal Ulcerations on both sides of the Organ.—Mrs. C, aged fifty-five years, complains of much pain and soreness. She says there is a large lump protruding from her person, which has lately become extremely tender, and occasions her much un- easiness when she walks. She has been troubled with the lump, as she terms it, for the past nine years, ever since the birth of her last child. On being asked whether she had a severe labor in her last confinement, she remarked that she was in labor four days, and suffered most intense- ly ; she also observed that the " Doctor told her the after-birth grew to her side, and that he pulled it away." " Did you leave your bed, my good woman, soon after the birth of your child ?" " Indeed I did, sir. I was at my wash tub the day after my child was born." This is not a solitary example of what the suffering poor have to encounter in this me- tropolis. The rich of this world know but little of the sacrifices entailed upon poverty. Necessity compelled the poor woman to leave her bed the day after the birth of her child, and as a consequence she is badly afflicted. The patient before us, gentlemen, is laboring under procidentia uteri, which fact I have ascertained by an examination previously to introduc- ing her into the Clinique. The questions which I have just addressed to her, and the answers she has given, will at once disclose the circumstances which have operated in the production of this uterine displacement. This is the fifth case of procidentia uteri which has been presented to 272 CLINICAL LECTURES. your observation since the commencement of the Winter Session of Lec- tures. Besides the displacement of the organ, there is connected with this case another feature of more than usual interest, and well worthy of attention—I allude to extensive ulcerations on each side of the protruded organ. These ulcerations are of a peculiar character, and are not alto- gether free from danger. They are venereal, and, as you will see im- mediately, they have, from their phagedenic nature, made rapid and frightful progress. " How long, madam, have you had those sores about you ?" " Six weeks, sir." " Have you had any thing done for them." " No, sir." " Why, my good woman, did you not apply to some doctor for advice ?" " O ! I did not think they would signify, sir; and besides, I am a poor miserable woman; I have no money to give to the doctors." " Well, I am glad you have come here. We shall do what we can for you. The poor are always welcome at this Clinique. There is no money required here, my good woman; and you and your fellow-suf- ferers in poverty will always find us ready to befriend you." " Thank you, sir—a thousand blessings on your head!" [The patient was placed on the bed, and the Professor pointed out the peculiarities of the proci- dentia together with the ulcerations, which were nearly as large as a four-shilling piece.] Here, gentlemen, is a melancholy state of things. This poor woman is in deep affliction. Together with poverty, which brings its own sorrows, she is laboring under a formidable displacement of the womb, and, at the same time, is affected with a loathsome malady ! Be- cause this unhappy patient presents in her own person the effects of venereal disease, she is not to be disfranchised from your sympathies, nor is she to be regarded as a worthless and abandoned woman. In reply to my inquiries as to the manner in which she contracted this affection, she told- a simple, and, I think, consistent story. She has a dissolute husband, from whom she received the disease. Under any cir- cumstances, however, it is our duty to do all in our power to restore her to health. Allow me, for a moment, to direct attention to one or two points of interest connected with this case. You perceive here, as I hold the uterus, there is a peculiar condition of the os tinea. Its long diam- eter, instead of being transverse, is from above downward, and this arises from the fact that the chancre has destroyed the lower and central por- tion of the inferior lip of the os uteri. Again, you observe that I now grasp with my finger and thumb the bladder, which is connected by cellular tissue to the inferior third of the anterior surface of the womb, and if you will remark, for the instant, the direction of the chancres, you will see that they have nearly in their progress reached the bladder itself! Should this organ become involved, you can readily imagine the melan- choly consequences which would most likely ensue. The internal sur- face of the thighs, too, are much inflamed from the constant friction against the ulcerated surfaces of the womb. PROFUSE MENSTRUATION. 273 Causes.—Procidentia of the uterus may arise from badly-managed labors; too early getting up after delivery; carrying heavy burdens • constipation; falls, etc. Symptoms.—Pain in the back and loins; difficulty in passing water; impeded progression; pain at the umbilicus; severe pulling sensation in the groins, etc. Diagnosis.—Procidentia might possibly be mistaken for polypus—in- version of the womb—inversion of the mucous membrane of the vagina —fibrous tumors, etc., but the blunder would be without apology. I have repeatedly called your attention to the diagnostic marks of each of these morbid conditions. In procidentia uteri, the presence of the os tinea at the extremity of the tumor, defines the character of the affection. Treatment.—The first object to be attended to in the case before us is the healing of the ulcerations by local treatment; and, secondly, guard- ing, by appropriate medication, the constitution from secondary syphilis. To attempt to return the uterus, and secure it in situ with the venereal chancres unhealed, would be merely to expose the vagina to fresh ul- cerations. We shall, therefore, proceed with the following treatment: —I now, as you perceive, freely cauterize the chancres with the nitras. argenti—and, to protect them against friction, it will be well to cover them with patent lint smeared with the spermaceti ointment. One of the following pills to be taken three times a day until ptyalism is pro- duced :— R PiL Massse Hydrarg.......2>ij Pulv. Opii.......gr. iv Ft. massa in pil. xx divid. As a local application to the ulcer hereafter the following may be em- ployed with advantage:— R Sub. Mur. Hydrarg......gr. iv Aquas Calcis . ,.....|j Ft. Sol. " Madam, you can go home—and return here on Monday next. If you will follow our directions strictly, we will endeavor to cure you of the ulcers—and then contrive an instrument for the support of your womb, so that you will be much more comfortable than you have been for years." Profuse Menstruation in a young Woman, twenty-two Yeabs of age, from Grief.—Susan M., aged twenty-two years, unmarried, is pale and nervous; complains of dizziness in her head, excessive palpitation of the heart, and inability to sleep. Her health was always remarkably good until six months since, when the death of her brother caused hei so much grief that her menstrual function, from always being previously regular, became extremely profuse, and has continued so to the present time—in fact she says her menses are on her, more or less, constantly. It is only necessary to look at this poor girl, and see her pale cheek and 18 274 CLINICAL LECTURES. shattered health to appreciate the marked changes which undue losses of blood will occasion in the system. Until six months since she had always enjoyed excellent health—now she is the very embodiment of dilapidation! It shows you how important it is to check early these wasting influences. I commend this case, gentlemen, to your observation as one well worth a place in memory. We have in the person of this young woman an example of menorrhagia, or profuse menstruation from grief. Mental despondency and grief usually produee suppression—in this instance, however, the opposite result has occurred. How do you connect the vertigo and palpitation of the'heart with the profuse menstruation? The connection is so obvious that there is not one of you who can not instantly explain it. The profuse loss has brought on an anaemic condi- tion of the system—the brain and heart are both supplied with impov- erished blood, and hence the dizziness and palpitation. Treatment.—The dizziness and palpitation are not the cardinal fea- tures in this case—they are the effects of a more important derange- ment, which must first occupy our attention. This drain upon the sys- tem must be checked. This being done, the next object will be, by judicious treatment, to repair the waste consequent on the deranged menstrual function. With a view of arresting the profuse discharge, let a tea-spoonful of the following mixture be taken three times a day: R Tinct. Cantharid. ) Tinct. Cubeb. J-.....aa 3 j Tinct. Capsici, ) Mucil. Acacise.......§ ij M. In addition to this, half a pint of cold water should be thrown up the rectum every night, until the discharge sensibly diminishes. In order to procure sleep, which is a most important element toward the restor- ation of this girl, a table-spoonful of the following mixture may be taken every hour after retiring to bed until sleep is produced: R Syrup. Papaver.......3 ij Mucil. Acaciae.......| ij Sol. Sulph. Morphiae.....gtt. xx if! Incontinence of Urine in a married Woman eighteen Years of age.—Mrs. T., aged eighteen years, married, says she has no control over her water; it passes from her involuntarily, and renders her life miserable. " How long have you been married, madam ?" " Four years, sir." " Why you have just told me you are but eighteen years old, Mrs. T." " Yes, sir, that is so." " How old were you when you were married ?" " Just turned fourteen, sir." " You married rather young, madam !" " Indeed, I did, sir; but it was not my fault, I was coaxed into it." " That is the way, madam, with a great number of young women." "Was your health good before your marriage?" INCONTINENCE OF URINE. 275 " Yes, sir, it was very good." " Have you any children ?" " None alive, sir; I have had three premature births." " When did you first complain of the disease for which you now seek advice ?" " About a week after I had the first birth." " You are positive you had no diffi- culty with your water previous to that time?" "Yes, sir, I am very certain." " Do you say that your water passes from you, more or less, constantly ?" " Yes, sir, and I hope you will do something for me." " Indeed, I shall my good woman; and I hope I shall be able to relieve you." Here, gentlemen, is an interesting case of disease, entailing on this poor woman much annoyance. What do you suppose is the real cause of the affection, under which she labors ? This, in fact, is the only question for our consideration; and in order that there may be some basis for the opinion at which we shall arrive, let us, for a moment, in- quire what the causes are which give rise to watery discharge from the vagina. This is the course which common sense—I regret to-say too much-neglected in forming our judgment of disease—would naturally suggest. Speculation in medicine, like speculation in commerce, more frequently leads to bankruptcy than to truthful and substantial results. To prescribe for this patient by hypothecating a cause for her malady would, according to the doctrine of chances, not only be unprofitable to her, but most probably would tend to an aggravation of her sufferings. Let us, then, pass briefly in review the various influences capable of producing discharges of water in the female, and then examine which one of these influences corresponds with the case before us. This is the true mode of investigation—an investigation based upon that necessary principle in philosophy—of tracing effects to causes. It is a principle, which will serve you in all time in the practice of your profession; let it be the foundation stone on which your opinions are to be erected, and you will find such opinions resisting the revulsions in the scientific, as does the mountain-rock grow firmer amid the tempests in the physical world ! A female may have a discharge of water from the vagina un- der the following circumstances: 1st. From hydatids of the uterus; 2d. Cauliflower excrescence; 3d. "Vesico-vaginal fistula; 5th. Hydro- metra; 6th. Paralysis of the neck of the bladder, etc. With the excep- tion of hydrometra—which means a collection of water in the womb— there is not one of the above maladies to which your attention has not been specially directed in this Clinique, and you have had ample op- portunity of hearing their various features discussed ; you have en- joyed, too, the privilege of seeing examples of each of these affections. Without now reiterating what I have on former occasions fully explained in reference to the causes, symptoms, diagnosis, and treatment of these diseases, I shall merely remark that the patient before us is laboring un- der incontinence of urine from paralysis of the neck of the bladder. There is no enlargement of the uterus—no disease of its cervix—the 276 CLINICAL LECTURES. vesico-vaginal, and urethrovaginal septa are uninjured. These facts I have ascertained by a vaginal examination; and because of these facts, as well as the symptoms, which characterize the case before us, have I formed the opinion, which I have just stated. Causes.—Incontinence of urine in the female may arise from various causes—such, for example, as defective action of the sphincter around the neck of the bladder, constituting partial or complete paralysis of the part—and this paralysis may be traceable to injuries of the brain or spinal marrow, cold, long-continued pressure of the foetus during preg- nancy, or parturition, immoderate sexual intercourse, the extraction of a calculus through the urethra, etc. Diagnosis.—Incontinence of urine from paralysis of the bladder is marked by a more or less constant dribbling of the urine, the patient having no control over its escape; and the incontinence from this cause is distinguished from vaginal watery discharges produced by other mor- bid conditions by the absence of the lesions and circumstances, which accompany these conditions. Prognosis.—Usually the affection yields to judicious treatment. Treatment.—The management of this affection will depend on the par- ticular cause to which it owes its existence. In the present case I shall recommend ten drops of the following to be taken in a wine glass of flax-seed tea three times a day : R Tinct. Cantharid.......§j This, together with a blister over the sacrum, is all that I shall sug- gest for the present. " Madam, you must follow the directions, and re- turn here on this day week." " Thank you, sir, I shall." " Good morn- ing, madam." Cantharides, gentlemen, as you are aware, exerts a specific influence on the neck of the bladder, producing on the part a very decided and marked action. Nothing is more common in practice than to notice cases of strangury, the result of blisters, the strangury being produced by the absorption of the cantharides. Falling of the Bladder in a married Woman, aged twenty-five Years.—Mrs. C, married, aged twenty-five years, the mother of one child, six months old, seeks advice for what she supposes to be falling of the womb. " How long, madam, have you been an invalid ?" " I have not been well, sir, since the birth of my infant." " How long have you been married ?" " Eighteen months, sir." " What was the state of your health previous to your marriage ?" " It was always good, sir." " From the time of your marriage until your confinement was your health good ?" " It was, sir, except that in the latter part of my preg- nancy I became rather weak." " Do you know, madam, what caused you to be weak ?" " I do not, sir, unless it was overwork." " That is FALLING OF THE ELADDER. 277 a very common cause, my good woman, of weakness, and it is one of the trials to which the honest and industrious poor of this city are con- stantly exposed." " Indeed, it is, sir; but I could not help it, for I was obliged to work to get along." " I am not censuring you, my good Mrs. C.; I am only lamenting the necessity which imposed this hardship upon you." " Thank you, sir." " Was your labor a severe one ?" " Yes, sir ; I suffered very much. I was sick nearly four days." " Do you mean to say that you were in labor for four days ?" " Yes, sir." " How long after your confinement did you leave your bed ?" " The next day, sir. I had no help, and was obliged to stir about to get my husband something to eat when he came from his work." You hear, gentlemen, the simple story of this honest woman. She makes no complaint of her situation in life, and her plain yet eloquent language is an earnest of the truthfulness of her statement. Poor and dependent as she is for her bread on her daily labor, I will venture the opinion that she is far happier than thousands in this metropolis, who have at their control all the glitter and luxuries of this world. " Indeed, I am very happy, because my conscience does not trouble me." " I am sure of it, madam." " Why do you think you have falling of the womb, Mrs. C. ?" " Be- cause one of my neighbors told me so, sir." " Is that neighbor a doctor or a woman ?" " Oh, her name is Mrs. Mulligan. But the doctor told me so, too." " What is Mrs. Mulligan's business ?" " She takes in washing, sir." " Does she practice medicine ?" " Oh, no, sir." " What does she know about falling of the womb ?" " I don't know, sir; but she told me that her cousin, Mrs. Higgins, had falling of the womb, and she knew I had it too." Well, gentlemen, this is one species of logic, and you will often meet with it in practice. " When the doctor told you that you had falling of the womb, did he examine you before giving his opinion?" "No, sir; he was Mrs. Mul- ligan's doctor, and he called over one day and said that Mrs. Mulligan was right, and I had falling of the womb." " Did he order you to do any thing ?" " Yes, sir, he told me to put a plaster on my back." " Did Mrs. Mulligan know that the doctor ordered the plaster?" " Yes, sir, and she said it would cure me, as it did Mrs. Higgins." " Did you use the plaster ?" " No, sir, because I don't see how a plaster on my back could draw my womb up." " Nor I, either, my good woman." This conversation, gentlemen, is not altogether unprofitable. There is a point about it, and your own intelligence will deduce from it all that is material for you to remember. One thing, however, is very evident, that, according to the statement of this patient, there was an entire con- currence of opinion between Mrs. Mulligan and the doctor as to the nature of the disease, which is not always the case in more learned con- sultations. " Will you be kind enough, my good woman, to tell me whether you suffer any pain ?" " I am much troubled, sir, with a fore 278 CLINICAL LECTURES. ing down." " Do you have any difficulty in passing water ?" " I want to pass it very often, sir, and that's what gives me so much trouble." " Do you leave your bed frequently at night for that purpose ?" " Yes, sir ; I am more distressed at night than in the day time with my water." I wish you, gentlemen, particularly to note this latter circumstance. I shall allude to it again in a few moments. " Do you have any other kind of pain than the forcing down of which you speak?" "Yes, sir; I have a dreadful dragging here [the patient places her hand on the um- bilicus], and it is always worse just before I pass my water." This is another important fact, gentlemen, which I wish you to note, and to which your attention will be immediately called. " Are you troubled, madam, with a discharge ?" " Yes, sir; I have the whites." You perceive, by the answers which have been elicited, only a part of the case now before you. This patient has been told by her friend Mrs. Mulligan, and also by Mrs. Mulligan's doctor, that she is affected with falling of the womb. This belief is strongly impressed upon the patient's mind, so strongly, indeed, that she comes to the Clinique in the hope that she may obtain relief for this supposed affec- tion. Before presenting the case to you, I examined it thoroughly in the presence of my assistants, Drs. Martin, Savage, Butler, Steves, and Tichenor, and what do you suppose is really the difficulty under which this patient labors ? Certainly not falling of the womb, for this organ is very nearly in situ, but falling of the bladder. It is, I think you will agree with me, a matter of some moment to distinguish between the dis- placement of these organs. And what I wish more particularly to im- press on your recollection is this—never allow the declarations of your patient, or those of her friends, to form the basis of your own professional opinion. For your own opinions you are justly responsible; see, therefore, that they rest neither on ignorance nor conjecture, but that they stand on the broad foundation of truth. Falling of the bladder is not of frequent occurrence ; but when this form of displace- ment exists, it is extremely important that there should be no error in the diagnosis. Your own honor as practitioners, and the welfare of your patients call for this accuracy. Causes.—Any thing that is calculated to relax the walls of the vagina will necessarily, more or less, predispose to falling of the bladder; such, for example, as repeated births, too early getting up after delivery, etc. Carrying heavy burdens, severe fits of coughing, and constipation, may be enumerated among the exciting causes of this displacement. The bladder may be slightly prolapsed, or it may protrude beyond the vulva (as is the case in the patient before us), forming an external tumor. Symptoms.—In this form of displacement, there will be a sense of fullness and pressure downward, or, as the patient expresses it, a forcing down. This is generally more annoying at night, when the patient is in bed, than at any other time, for the reason that the protruded portion of FALLING OF THE BLADDER. 279 the bladder becomes more or less distended with urine, and hence also the more frequent desire for passing water at night. You will recollect in my interrogation of this woman, she remarked that " she was more distressed at night than at any other time with her water." You now have the explanation of this circumstance. There is another symptom of falling of the bladder, to which it is necessary to refer—it is the drag- ging pain at the umbilicus, which you have heard the patient complain of, and which also is a symptom of procidentia uteri, because in this latter displacement the bladder is also brought down, it being connected to the inferior third of the anterior surface of the uterus by cellular tissue. Sir Charles Clarke claims to have been the first to direct attention to this pain at the umbilicus as an effect of procidentia vesicae; and explains the connection between cause and effect on very rational grounds. The su- perior ligament of the bladder, formed by the remains of the two um- bilical arteries, passes from the fundus of the organ to the umbilicus. The bladder being prolapsed, the ligament is put upon the stretch, and hence the pain. When lecturing on the signs of pregnancy, you will not have forgotten that I spoke particularly of the fact that the first six weeks after gestation the uterus descends into the pelvic excavation; and for this rea- son there is very often pain at the umbilicus; and, therefore, this pain is classed among the early signs of pregnancy. Another effect, or, if you prefer it, symptom of prolapsed bladder, is a mucous discharge, more or less profuse. This discharge is what the patient characterizes as the " whites." Diagnosis.—Procidentia of the bladder might, through carelessness, be confounded with procidentia uteri, inversion of the mucous membrane of the vagina, encysted tumor of the vagina, and with other growths of this part. But I apprehend, ordinary attention would readily obviate error on this subject. In procidentia uteri, the os tincae is immediately de- tected ; in inversion of the mucous membrane, and in the various tumors occasionally found in the vagina, you will observe that there is no dimi- nution in the bulk of the enlargement, whatever it may be, when the bladder is evacuated. Not so in procidentia of this latter organ, for the protrusion in this case is always diminished when the contents of the bladder are removed. [The patient was placed on the bed, and the pro- fessor proceeded to show the protruding bladder, and directed special attention to several points of interest.] You perceive here, gentlemen, I gently grasp the bladder between my thumb and the index finger—its protrusion is very evident, as you can see—but may it not be, you may ask, that this is not the bladder, and that it is something else ? Let us test this question. Here is the meatus urinarius, the outer opening of the female urethra, slightly turned upward. I introduce, as you per- ceive, into the urethra and bladder the female catheter. The catheter is now in the bladder; I raise the free extremity of it thus, and push the other extremity outward and downward, and the result is that I here 280 CLINICAL LECTURES. feel the extremity of the instrument very distinctly against the protrud ing bladder. This, then, is demonstration irresistible that our diagnosis is accurate. Prognosis.—Procidentia vesicas is not usually attended with danger; its chief features are the annoyance and pain consequent upon it. Treatment.—Here the indications are twofold: 1st. To restore the organ to its position; 2d. To prevent by proper support its future pro- lapsion. For the latter purpose, recourse must be had to the pessary. Of these instruments, there is, as you are aware, a variety. A very good pessary, in a case like the one before us, would be a sponge, or what is, perhaps, still better, the India-rubber ball, which you have frequently seen me use in this Clinique in cases of procidentia uteri with great bene- fit. As there is much relaxation of the vagina, I shall recommend the following wash, two syringes full of which must be thrown up the vagina twice a day, first taking the precaution to remove the pessary: R Decoctus Quercus......Oj Sulph. Zinci ) Sulph. Aluminis )...... Ft. sol. It is proper to keep constantly in the bladder a catheter, which will prevent the accumulation of urine, always an impediment to recovery in these cases. In obstinate cases, more particularly when the female has passed the child-bearing period, an operation may be per- formed for the purpose of diminishing the capacity of the vagina, and thus preventing the prolapsion of the bladder. The operation consists in removing by dissection a fold of mucous membrane from the vagina, and bringing the edges together by suture; some employ the stronger escharotics, and even the actual cautery for this purpose. All straining and carrying of heavy burdens must be avoided. Con- stipation would give rise to straining, and is always found to aggravate either procidentia of the bladder or womb. This, therefore, must be guarded against. " I neglected to ask you, madam, whether your bowels are regular ?" " No, sir; they are very much confined." Two of the following pills to be taken at night, as circumstances may re- quire : R PiL Rhei C........3 i Divide in pil. xii. Palpitation of the Heart from Dyspepsia, in a married Woman, aged thirty-two Years.—Mrs. B., aged thirty-two years, married, no children, complains of palpitation of the heart, which she says has troubled her more or less for the last two years. She is very much alarmed, and is fearful that she has disease of the heart, which will cause her to die suddenly. " You say, madam, you have had palpitation of the heart for the last two years ?" " Yes, sir." " What was the state of your health previous to the last two years ?" " It was excellent, sir." " How long PALPITATION OF THE HEART FROM DYSPEPSIA. 281 have you been married ?" " Four years, sir." " Is your husband liv- ing ?" " Indeed, he is, sir." " You have stated that you have no chil- dren ?" "I have no children, sir." " Do you know what caused your health to give way two years since ?" " I had a great deal of suffering, sir, at that time." " What kind of suffering, madam ?" " It was in my mind, sir; I lost an only sister, and I grieved so, that I have never had any health since, sir." " Did you lose your appetite ?" " Yes, sir, and my stomach swelled." " What do you mean by your stomach swelling, madam ?" " It used to get big and hard, sir." " Did it continue large all the time ?" " Oh, no, sir. I would gulp a good deal of wind, and then my stomach would get small." t" Did you always feel relieved after you gulped up the wind ?" " Always, sir. It was the only thing that gave me any ease." " How was the palpitation after you got rid of the wind ?" " It was always a great deal better, sir, and it did not trouble me until my stomach swelled again." " Then, you have not had the palpitation all the time ?" " No, sir; I am sometimes free from it for several days ?" " How are your bowels, madam ?" " Very bad, sir." " What do you mean by that, my good woman ?" " They are very much confined, sir." There are few derangements of the human system more calculated to fill the mind with serious apprehension, than abnormal palpitation of the heart. Whether it attack the philosopher, the statesman, the mer- chant, the mechanic, the result is usually the same—fearful forebodings ! Death, at all times, brings its terrors as well as its sorrows. There is something fearful in its contemplation, even when the mind is best pre- pared for its approach. To die ! What words are there in the language which we speak, so momentous in meaning, so true in fulfillment ? Let all else fail, let language be proved a mass of chaotic terms, and let the sophist attempt to demonstrate that the existence of an eternal God is founded on fiction, yet he even will admit that one of the infallible things of this world is that man must die. If any thing be required to give a keen edge to this fearful truth, it is the constant dread of sudden death from a supposed incurable affection of some important organ. I have been, almost unwittingly, led to these remarks by the circum stances of the case before us. Here is a poor woman, who has labored for the last two years, more or less, under palpitation of the heart, and she has associated in her own mind with this palpitation, the most mel ancholy result—sudden death. " Indeed, I have, sir, and I have been a very unhappy woman." " Be quiet, if you please, madam ; I will show directly that you have been unhappy without a cause." " Can I be cured, sir?" "I will promise to cure you, my good woman, if you will not interrupt me again." " Oh, sir, I won't speak." To impose silence on a woman is emphatically curtailing her of her greatest prerogative. If, now, I were to ask any of you to point out the leading feature in the case before us, you would unquestionably say it is the palpitation. But 282 CLINICAL LECTURES. it devolves upon us as medical men, whose duty it is to discriminate between the substance and shadow, to give to this palpitation its true ralue. Sometimes the disturbed action of the heart is a most signifi cant and fearful symptom, when, for example, it arises from organio lesion of this viscus, and more especially, from valvular disease. And again, the palpitation is frequently, and this happily is the case in the majority of instances, the result simply of functional derangement. Whenever, therefore, your opinion is requested in cardiac disturbances, remember that the first object of inquiry is this : Is the disturbance or- ganic or functional ? It was with a view to this distinction that I have asked the questions which you^have just heard, and I feel positive that the palpitation in the case before us is purely functional. The heart's ordinary action, as you are aware, is due to the influence which it derives from the sympathetic nerve, and you can readily comprehend how this nerve may modify the contractions of the heart in cases in which the functions of organic life are impaired. But there is another influence exercised over the heart, which you are not to lose sight of—it is through the pneumo-gastric nerves. It has been proved that if the galvanic bat- tery be applied to these nerves, the heart becomes so disturbed that all action for the moment ceases, and the contractions are resumed as soon as the battery is suspended. This experiment is conclusive proof of the manner in which the heart is affected by mental emotions, for it is through the pneumo-gastric nerves, that the irritation is transmitted from the brain. Causes.—Palpitation may arise from various causes : 1st. Structural disease of the organ; 3d. Plethora, the blood discs producing by their stimulus over-action ; 3d. Anaemia, in which the impoverished condition of the blood is inadequate to supply the necessary stimulus for normal action of the heart; 4th. Mental emotions, dyspepsia, hysteria, chlo- rosis, etc., may be classed among the causes of what is termed functional palpitation. Symptoms.—In palpitation, the result of valvular disease, the disturbed action of the heart, as a general rule, undergoes no diminution, but be- comes more and more aggravated. The pulse intermits, the palpitation is increased by exercise, and oedema, etc., follows. In mere functional disease, on the contrary, we are very apt to notice what is exhibited in this case, viz.: the patient is one day better, and the next not so well. Diagnosis.—In organic disease of the heart, auscultation, either me- diate or immediate, will develop the fact. In functional disease, much too may be learned from this mode of physical examination, because if carefully instituted, it will at once detect the absence of those circum- stances, which indicate structural lesion. Again, the practitioner in a careful survey of all the points in each individual case, will be enabled, without embarrassment, to form a just opinion. Treatment.—The case before us is clearly one of abnormal palpitation ENCYSTED TUMOR IN THE VAGINA. 283 from dyspepsia,—producing a general derangement of the nutritive func- tions, and thus sympathetically affecting the natural order of the heart's pulsations. You have heard what this patient has said as to the starting point of all her sufferings, both mental and physical. It was profound grief at the death of an only sister ! Previously to that occurrence, she was a rugged woman. Grief, when deeply felt, is a powerful agent of disturbed action. Often it dethrones reason, and places the mightiest intellect on a level with the imbecility of the idiot! Do not, therefore, undervalue the influence of mental depression in the production of mor- bid action. Its sway is far greater than you at present imagine, but its true influence will be appreciated by you when, ceasing to occupy these benches, you shall have become actively engaged in the practical duties of your profession. I have just remarked that this patient is laboring under dyspepsia,— this is a broad term, and means much or little precisely as it is inter- preted. It presents a variety of shades, and is susceptible of numerous divisions. I shall simply recommend one or two of the following pills as circumstances may indicate : R Pulv. Aloes)......aa3j Pulv. Rhei. ) Saponis ....... grx Divide in pil x. These will tend to regulate the bowels—and when this object is attained, a tea-spoonful of the subjoined tonic may be taken three times a day in half a wine glass of water: R Acid. Sulphur. Dilut.......3j Syrup. Aurantii.......I iss Aquae Cinnamomi ......% ij M. Diet to consist, as far as possible, of animal broths, and lean meats— no vegetables. " You must be careful, madam, to follow the directions as nearly as you can; and return here a month from to-day, and report the state of your health." " Oh! sir, I will certainly do so, if the Lord spares me. I am very grateful to you, sir." " Not one word of thanks necessary, madam. You are quite welcome. Good morning!" Encysted Tumor seated in the Posterior Wall of the Vagina in A MARRIED WOMAN, TWENTY-THREE YEARS OF AGE.--Mrs. I., aged twenty three years, married, the mother of two children, the youngest eight months old, seeks advice for a swelling, which she says troubles her very much at times. " How long have you had the swelling, madam T " I never felt it, sir, until after the birth of my last child." " Had you any particular difficulty in your last labor ?" " No, sir." « Were you delivered with instruments ?" " Oh! no, sir." " How are your bow- els, madam?" "They are very irregular, sir." "What do you mean 284 CLINICAL LECTURES. by that, my good woman ?" " That I always require medicine, sir; they are so confined." " Do you notice that the swelling becomes larger, when you attempt to have an evacuation from your bowels ?" " Yes, sir; that's the time it gives me so much uneasiness." "What kind of uneasiness, madam ?" " A forcing, sir, as if something wanted to pass from my person." "From your front passage?" "Yes, sir." " Do you have the same forcing sensation, when you cough ?" " Yes, sir, exactly." " Have you ever had any thing done for this swelling, my good woman ?" " Yes, sir, I wore an instrument." " What kind of instrument ?" " There it is sir." [The patient shows a hard globular pessary.] " How long did you wear that instrument, madam ?" " Only one day, sir." " Why not longer ?" " Because it made the swelling worse; and it gave me a great deal of pain." " You were a sensible woman, madam, not to use it more than one day ; and you would have been still more sensible if you had not used it at all." " Oh ! sir, the doctor told me it was the only thing to cure me." " What did he say was the matter with you ?" " Why, sir, he told me my womb was down." " Did he examine you, madam ?" " Yes, sir, twice." " Then he made a mistake, madam ; your womb is not down." " Thank you, sir." " Quite welcome, madam." This, gentlemen, is an instructive case on two accounts. In the first place, the patient before us has been treated for a disease which does not exist; and secondly she presents an example of what may be con- sidered, comparatively at least, a rare affection. When you shall have left these halls, and entered the field of professional duty, you will occa- sionally have presented to your observation examples, like the present, of erroneous judgment on the part of the practitioner. It is, indeed, a very common error to suppose that prolapsus uteri exists. This dis- placement of the organ is not unlike dyspepsia, liver complaint, con- sumption, etc. When a patient has some obscure affection, and it taxes the brain of the practitioner too severely to give it a just and proper name, one of the above affections is commonly selected as a mantle for his embarrassment; or in more expressive language, his ignorance. So, too, with regard to ailments about the female organs. Prolapsus here serves the purpose of a mantle. Have you not seen to-day in the Clinique two cases in which the patients were told that this was their disease, when in fact the uterus was, in both instances, perfectly in situ! Let these cases teach you a lesson! I have labored earnestly to bring your minds to the full appreciation of accuracy in diagnosis—in the treatment of disease it is, I may say, the sine qua, non. What is it that constitutes the basis of practical medicine ? Is it not anatomy, that beautiful science which discloses the wonderful structure of the hu- man fabric—a fabric perfect in itself, and in every part revealing the evidences of unearthly wisdom ! Physiology, too, teaches us the mechan- ENCYSTED TUMOR IN THE VAGINA. 285 ism of that structure, and points to harmony of action as the great requisite of health. Disease, which always results, in a greater or less extent, from an interruption of this harmony, assumes one of two forms —it is either organic or functional. In the latter, there is disturbed ac- tion—in the former, lesion of structure. The object, therefore, of our science I hold to be threefold: 1st. To ascertain whether disease ex- ists ; 2d. To distinguish between organic and functional disturbance; 3d. To restore, by appropriate remedies, the system to its normal ac- tion. These, then, are the three cardinal duties of the practitioner—to discharge them properly pre-supposes necessarily an adequate knowl- edge of the principles on which all scientific medicine is based, compre- hending also a thorough acquaintance with the therapeutic application of remedial agents. The patient before you has not, as I have remark- ed, falling of the womb—yet she has a swelling or tumor which, under certain circumstances, projects from the vagina. The question, then, for us to determine, is, as to the nature of that swelling. This for the pres- ent is the only question; that being disposed of, the next inquiry will be as to the remedy. When this patient spoke to me, about half an hour before the Clinique, and gave me a history of her case, I told her very frankly that I could not give an opinion worth a thought without an examination. This she readily assented to, and I have ascertained that she has an encysted tumor on the posterior portion of the vagina the size of a pullet's egg, and in an attempt at defecation, and in coughing (as you shall imme- diately see), the tumor projects beyond the vulva. This form of tumor, although more common than the fibrous tumor, is not frequently found in the vagina. It is, however, occasionally met with in this part, as well as in one or other of the labia externa, and when it does exist, it is manifestly the duty of the practitioner to recognize its true character. Causes.—The origin of encysted tumor of the vagina has been referred to inflammation of one or more of the mucous follicles with which the lining membrane of the organ is supplied. In a state of health these follicles are small, and secrete a bland fluid, which is intended for the lubrication of the vagina, and under the influence of chronic inflamma- tion they pour out a whitish fluid, constituting vaginal leucorrhoea. It was the opinion of Sir Astley Cooper that these follicles became en larged in consequence of the obstruction of their orifices, and thus the en- cysted tumor was the result of the enlarged follicles. These tumors have received various names, depending on the nature of their contents. There is the atheromatous, meliceritous, and steatomatous form of en- cysted growth. In the first, the contents of the cyst are pus-like; in the second, a fluid like honey; and in the last, a substance resembling suet or fat. Symptoms.—The tumor, when very small, will not be likely to cause much annoyance, but when of larger growth it will very naturally result 286 CLINICAL LECTURES. in more or less pressure on the parts, and in some instances, by its de- velopment, it may interfere not only with sexual intercourse, but also with parturition. * Diagnosis.—The encysted tumor is soft and elastic to the touch. It is moveable, and, carefully examined, fluctuation will often be detected. [Here the patient was placed on the bed, and the professor examined the tumor with much care.] This, gentlemen, is the tumor of which I speak. It is situated, as you see, on the posterior surface of the vagina. Madam, will you be kind enough to cough? You now notice how the tumor protrudes under the exertion of coughing. That this is not a va- ginal enterocele is evident from the fact that, by placing my two fingers beyond it, I can, as you observe, draw it to the entrance of the vagina, proving in the first place its great mobility, and secondly its independ- ence of surrounding parts. It is not an abscess, for there is no pain on pressure, nor is there the discoloration of abscess. Treatment.—There are two modes of treating encysted tumors of the vagina. One consists in excision, the other in merely evacuating the con- tents of the sac. The former is sometimes attended with difficulty, and, in my opinion, is rarely necessary. I shall now with my lancet pene- trate the sac, and allow its contents to escape. The operation is a very simple one, needing only a free incision of the sac in order that its con- tents may be evacuated. Notwithstanding the simplicity of the opera- tion, yet this is a case which, if properly treated, will give you reputa- tion. A patient is not apt to forget the medical man who has relieved her after others have failed. You perceive, gentlemen, nearly a wine glass of tenacious fluid has escaped through the incision I have made. The vagina should be in- jected with castile soap and water twice a day for three or four succes- sive days, and nothing more will be required. In order to remove the constipation under which this patient labors, two of the following pills may be taken as circumstances indicate: R Massas Hydrarg.......3j Pulv. Aloes.......3isa Divide in pil. xv. " You may go home, madam. You will have no more trouble from that tumor." " Oh, sir, I am so much obliged to you." "You are quite welcome, my good woman. Come to the Clinique two weeks from this day, and report whether or not we have told you the truth." " Indeed, I will, sir." " Good morning, madam." LECTURE XVII. The Diseases of Infancy; their Importance and Fatality; is this Fatality unavoida- ble ?—Peculiarities, Anatomical and Physiological, of the Infant.—Vomiting in an Infant, one Month old.—Suppression of the Menses from Cold, in a young Woman aged twenty-two Years.—Melancholy death of a young Lady from wantonly trifling with her health.—Occlusion of the Anus, in an Infant one "Week old; Op- eration. —Amenorrhcea, with imperforate Os Tinea?, and Encysted Dropsy of the right Ovary, in a Girl aged eighteen Years, the lower portion of the Ovary being prolapsed into the triangular Space between the Uterus and Rectum.—Vaginal Hysterotomy, and subsequent Delivery with Forceps, with safety to both Mother and Child.—Atrophy in an Infant, aged twelve Months.—Purulent discharge from the Female Urethra.—Convulsiong in an Infant, five "Weeks old, occasioned by in- testinal irritation. Gentlemen :—You have had before you during the present session of lectures a great variety of infantile diseases; you have observed the mal- adies peculiar to the new-born infant, and have not failed to contrast them with those which develop themselves at a later period of childhood. In the study of the diseases of infancy, there is a peculiar interest; and if no other motive should urge the physician to a faithful investigation of these affections, philanthropy alone, it appears to me, presents irresistible claims. The bills of mortality exhibit a fearful picture, and while they are humiliating to our science, they should prompt an earnest endeavor to check this melancholy outlet to human life. If we are to credit sta- tistical tables, gathered with great care, and with a definite object, one- fourth of the children born in France die before they have completed their first year! To the philosopher, to him who reasons, is fond of demonstration, and wishes data for his opinions, the following question in connection with the above results, will very naturally present itself: Is this fatality in infancy unavoidable, and beyond the limits of science ? It becomes us to examine this question; it stands at the very foundation of the topic now under discussion, and exhibits for the contemplation of the physician subjects of the deepest interest. I assume the negative side of this question. It can, I think, be demonstrated that the mortality of early life is due not to necessity, but to various causes which, measurably at least, are within control. It is unfortunate that authors, and also teachers, in their discussion of infantile diseases, have described them too much in the abstract. 288 CLINICAL LECTURES. Take, for example, most of the treatises on this subject, and what do you find ? A given affection is spoken of, its causes, symptoms, diagnosis, prognosis, pathology, and treatment are minutely discussed; but the principal point is passed over in silence, the point most material for the physician to remember, and without which he can have no basis of hope that his treatment will prove curative. The point to which I allude is this—that the diseases of infancy differ from those of the adult as do the structure and physiology of the one from those of the other; there is sim- ply an analogy, nothing more. With few exceptions, the error of which I speak pervades the works put into your hands as guides for the treat- ment of the maladies incident to early childhood; you go forth on your mission of duty with false principles, and, as a necessary consequence, in your conflict with disease defeat will be your portion. The true requisite for the physician, if he desire to treat successfully the diseases of infancy, is to understand the peculiarities of that tender age; he must examine and study with no ordinary attention the characteristics of structure, and his mind must become familiar with its special physiology. A work on the physiology and pathology of infancy, with a direct reference to the differences of healthy and morbid action as it exists in the young and adult subject, is what at this time is much needed; it would shed fresh light on one of the most interesting departments of the profession, and would lead to a salutary influence in our application of therapeutic agents. The new-born infant is altogether a different being from the adult; the mechanism of the one is imperfect, while that of the other is com- plete and perfect in all its parts. The one is engaged, if I may so speak, in the work of development, while the other, whose development is achieved, is occupied with the repair of the waste to which its organs are constantly subjected. In the infant, the nutritive functions, through which the general fabric is completed, are in full activity—organic life, indeed, is here so exclusive that it may be said with truth, that in the earlier periods the infant enjoys but one existence—the animal functions are yet in slumber, the intellectual faculties undeveloped. Ratiocination is not one of the attributes of the new-born child, nor does it enjoy the power of locomotion. Both these latter are but results of healthy development, the former of the brain, the latter of the bones, muscles, and nerves. From the moment of birth, nature becomes actively engaged in perfect- ing the various organs of the infant; this work of development is neces- sarily rapid, and the constant and hurried transitions through which the child is passing are not only fruitful causes of disturbed action, but re- quire a special and guarded therapeutics. The young infant possesses no language of the tongue to tell its sufferings, hence the difficulty of the physician oftentimes to detect the true nature of the disease. Conjecture is thus frequently substituted for positive knowledge, and conclusions hast- ily arrived at, not only unjustified, but too often fatal. Though the in- THE DISEASES OF INFANCY. 289 fant can not speak, yet it possesses a language perfectly intelligible to the accurate observer—it is the language of expression. Some one has said, and most truly so, " that the countenance of the young child is the mir- ror of nature." Yes, gentlemen, it is a faithful reflex—its smile is that of pleasure and sincerity, while the indication of pain is but the offspring of suffering. Its countenance knows not the guile of the hypocrite— its expression is that of truth, and hence in health, under the influence of physical quietude, every feature bears the impress of tranquillity. Billard and Jadelot in France, and Underwood in England, have given great attention to this subject—they have studied carefully the counte- nance in health and disease—the eye, the mouth, the nose, the cry, the respiration, the gestures, the attitude—in a word, the tout ensemble of ex- pression, has constituted for them a subject of profound reflection; and their varied and constant opportunities for observation, have led to im- portant results. Bouchut, in his Traite pratique des Maladies des Nou- veaux-nes, has elaborated this subject, and you can refer to his able work with much profit. Hippocrates has drawn particular attention to the change of physiognomy in the different diseases of the adult, and in this he has been followed by some of his successors. Little, however has been said with regard to these changes in the infant—and it has been left for the moderns, our own cotemporaries, to deduce practical and important inferences respecting morbid action in the infant, based upon the peculiar expression of countenance. This is a topic worthy of your consideration. I have on various occa- sions called your attention to it in connection with the numerous infantile diseases which have been presented at the Clinique—and I shall continue to do so, for I regard a knowledge of this language of expression as one of the indispensible elements of success in the management of the mala- dies peculiar to infancy. But in what way is the knowledge to be ob- tained ? Exclusively by observation. All that is valuable in the prac- tical part of your science is the result of observation. Simple hypothesis is simple conjecture, but when tested and proved to be true by re peated observation, it then becomes a reality ; it loses its hypothetical character, and is accepted as a fact. So, too, with the language of ex- pression as a means of diagnosis. You have already seen that the first year of existence is one of alarm. ing fatality—and I am disposed to believe that of all the causes which conspire to this early destruction of human life, there are two peculiarly constant and unerring in their effects—I mean improper food and over- drugging. If you will consult your note-books, they will tell you of the numerous cases of emaciation from diarrhcea which have been presented at the Clinique almost in the last stages of decay, and which were traced to food which the infant could not assimilate—the food, consequently, became a source of irritation to the muco-intestinal surface, keeping up frequent and profuse discharges, involving the entire system in disturbed 19 290 CLINICAL LECTURES. action, and ultimately leading to death. Count the multitudes of young children swept from earth by what the bills of mortality denominate " cholera infantum," and you will then be enabled to approximate some idea of the fatal effects of food unfitted to the frail and sensitive organs of the infant! Nature has abundantly provided for the nourishment and development of the foetus during its sojourn in its mother's womb— and, after its birth, that same nature, always vigilant, and governed in her actions by a conservative principle, has also provided a nutriment suited to its wants and physical capacity. Under ordinary circum- stances, if the infant be permitted to take this nutriment thus prepared, and of such easy elaboration, it will be found to thrive, and pass with much greater certainty through the period of life usually so fatal to it. But, unfortunately, nature has to contend with many rivals in the persons of experienced nurses, and occasionally officious physicians. The infant has scarcely come into the world, certainly not longer than to be washed and dressed, before its little stomach is made the receptacle either of medicine, which it was never intended it should take, or va- rious compounds, such as teas, tisans, panadas, etc.,—and on the sole ground that the " poor little dear" must be purged, or that it is hungry. If it should cry, then the evidence of its hunger is beyond all doubt! This is all wrong. It is a pernicious practice, and one which I trust will never meet your sanction. There is a striking analogy in the laws instituted for the regula- tion of the health of man, and those which obtain in the health of animals. Instinct affords you very strong, I might say irresistible evi- dence that nature, when not interfered with, is quite adequate, while disease does not exist, to provide for the internal wants of the new-born child. Are any of you fond of the canine species ? If so, how often must you have observed the little pup soon after its birth—look at that pup, and see how true it is to the impulses of nature! It is scarcely in the world, before it seeks the teat of its mother. It draws ad libitum upon that fountain to which it has a birth-right, and from which it extracts the elements not only of nutrition, but of health. No medicine or arti- ficial food given here, and consequently none of those derangements, the immediate result of officiousness. And why is this ? Simply because where instinct prevails, nature exercises a sovereign control, and exhibits in full beauty her power and perfection. Man boasts of his reason, but oftentimes, through his own perversion of it, he finds that, in many of its operations, it is less than instinct! I leave you to reconcile the para- dox—all experience proves that my remarks are just, and susceptible of demonstration in a thousand different way^. But to our cases. Vomiting in an Infant one Month old.—Mrs. B., aged twenty-six years, married, the mother of two children, the youngest four weeks old, brings her infant to the Clinique for advice, because it has vomited more VOMITING IN AN INFANT. 291 or less for the last two weeks. " Do you nurse that child, madam ?" " Yes, sir, indeed I do." " Do you have plenty of nourishment for it ?" " Yes, sir, more than it can take." " Does it nurse as if it had a good appetite ?" " O ! yes, sir; and I am sure it gets enough." " That little infant does not look as if it were sick, my good woman." " It has no sickness at all, sir, but the vomiting; and if you will only cure that, doctor, you will make me very happy." " When did it first begin to vomit ?" " About two weeks ago, sir." " Had it been sick before that time ?" " No, sir; it was the healthiest babe you ever saw." " What was the state of its bowels ?" " Beautiful, sir!" " What do you mean by that, my good woman ?" " They were so regular, sir." " Were they regular from its birth ?" " Yes, sir." " Are they regular now ?" " Yes, sir." " Have you ever given it any medicine ?" " Never a grain, sir." " Then, my good woman, you are one of the most sensible mothers I have met with in some time ; and I wish your example was more frequently followed. Does your child sleep well ?" " Yes, sir." " Is it playful when awake ?" " Yes, sir, you see now how cheerful it looks, and it is always so, except when it vomits." " Now, madam, will you be kind enough to tell me how often your child vomits during the day ?" " It always vomits, sir, as soon as it is done sucking." " How long does the vomiting continue each time ?" " O ! sir, it is over im- mediately—as soon as it lets go the breast, it throws up, and then it is quite well again." " What does it throw up ?" " Nothing but milk, sir." You must not suppose this case unworthy of consideration; it is one of great importance, because it enables me to direct your attention to a point of more than ordinary interest. When you shall have become practitioners of medicine, you will not be unlike jurors; it will be your place not only to listen to evidence, but it will become your solemn and constant duty to analyze it, and take it for what it is worth, and nothing more. Evidence in law, as in medicine, is intended to direct the mind to truth, but in order to do this, it must be positive, substantial evi- dence. False evidence is to the lawyer or physician, what a false light is to the mariner—they both lead to false deductions, and oftentimes false issues. Before proceeding further with this case, I desire to ask one or two questions : " Madam, is your own health good ?" " Yes, sir, thank God, I am perfectly well." " Do you know whether you have eaten any thing to disagree with you ?" " No, sir, nothing." " You have not been disturbed in your mind in any way ?" " Oh, no, sir, I have nothing to worry me." The inquiries which I have addressed to this woman are intended to develop the true nature of the vomiting, with which her little infant has been affected for the last two weeks. Vomiting in early infancy and childhood is sometimes a most significant symptom, and whenever it occurs, it is the duty of the physician to examine scrupulously every circumstance connected with it, in order that he may ascertain its real 292 CLINICAL LECTURES. import. As a prelude to eruptive diseases, especially scarlatina, vomit- ing is very common, so also in cerebral disturbance, whether from the effects of concussion, or other circumstances ; it is often, too, the accom- paniment of diarrhoea and dysentery ; food which the stomach can not digest will occasion it. Mental emotions of the mother, improper food, the return of the catamenia, will oftentimes so alter the character of the milk, as to cause the child to eject it from the stomach. You perceive, therefore, that there are various causes capable of producing this gastric irritability in the young infant, and in a case like the one before us, it is a matter of moment that the practitioner should distinguish the true cause of the disturbance. This little infant, about which the mother ex- presses so much anxiety, is the picture of health in appearance, and from the questions I have asked, it is evident that in every particular it enjoys an immunity from disease. It is without fever, its bowels are regular, it sleeps well, has a good appetite, and is cheerful—but for the last two weeks it has been troubled with vomiting. What does this vomiting mean ; or, in other words, what is it that produces it ? This is the sole question for our consideration, and it was with a view to its proper elucidation, that I have asked the various questions which you have heard—the answers have established unequivocally that the vomiting is the result of gastric repletion—the infant's stomach each time it nurses becomes overcharged, and it has no other alternative but to relieve itself. Would it not, allow me to ask, be a cruel thing to subject this poor little child, whose health is excellent, to medication ? And yet, if you allow the anxiety of the mother alone to govern you, such would probably be the course you would pursue. Let this case teach you a lesson. Re- member it when in practice, and it may serve you as well as those who will look to you for counsel in real as well as supposed illness. " Madam, I can not give your infant any medicine." " Oh, doctor, please give it a little just to stop the vomiting." " Would you have me injure your child ?" " Oh, indeed, I would not, sir." " Then you must permit me to exercise my own judgment, and not be influenced by your anxiety, which is altogether without foundation. Your child vomits because its little stomach becomes overloaded with milk whenever it nurses, and if you wish to arrest the vomiting, you must see that it does not take more into its stomach than it can comfortably contain." " Well, doctor, was I not a silly woman not to find that out ?" " No, my good woman, you were not so silly as you imagine; you did what many others would have done, you centered your attention exclusively on the vomiting, without looking to the cause that produces it. Take that child home, and give it the breast less frequently, and be sure that it nurses only a few minutes at a time. This is all that will be necessary, and if you follow these simple directions, your infant will cease to vomit, and you will no longer be an anxious mother." " Oh, thank you, sir, I am so glad." " Good morning, madam." SUPPRESSION OF THE MENSES. 293 Suppression of the Menses from Cold in a young Woman, twenty- two Years of age—Melancholy Death of a young Lady from wan- tonly trifling with her Health.—Mary J., twenty-two years of age, unmarried, is plethoric, with flushed countenance, and a bounding pulse. " What do you complain of, Mary ?" " My head feels, sir, as if it would burst." " How long have you had that sensation in your head ?" " For the last two months, sir." " It is a sense of fullness, is it not ?" " Yes, sir, and I am so dizzy, that I feel like falling down." " Do you feel sick at your stomach sometimes ?" " Yes, sir, lately I felt so very often." " What other trouble have you, Mary ?" " Why, sir, my chest is all stuffed up, so that I can not breathe freely." " Any thing else ?" " Yes, sir, my head beats very much, and I feel very bad, sir." " What was the state of your health, Mary, previous to the last two months ?" " It was very good, sir. I could attend to my work, and never complained of any thing being the matter with me." "Are your bowels regular ?" "No, sir; they have been very much confined lately." If, gentlemen, you were called upon to prescribe for this girl, you would not, I apprehend, do so successfully without knowing something more of the case than has yet been developed through the questions which I have addressed to her. All the knowledge we have obtained by her statement is this: She has had, for the last two months, intense headache, with dizziness and occasional nausea, a sense of suffocation, and confined bowels. These are the leading features of her case, and their true import can only be interpreted by tracing them to their antecedent or cause. Women may have these symptoms from various disturbing influences, and it becomes the practitioner, as far as may be, to trace them back by a rigid analysis to their original source. "Are your turns regular, Mary ?" " I have not had them, sir, for the last three months." " Were they always regular before that time ?" " Always, sir, and I was very healthy." " Do you know what caused them to stop on you ?" " I do not, sir, except that I was caught in a very heavy shower, and got very wet." " When was it, Mary, that you were caught in the shower ?" " Three months ago, sir; the last time my turns were on me." " Did they stop on you suddenly?" "Yes, sir, and I have not seen them since." " How long after you were exposed to the shower did you feel the headache?" "The next day, sir." "Did you do any thing for yourself?" " I put some vinegar on my head, sir." " You might as well have taken a pint of the muriated tincture of nonsense, Mary." " I hadn't any, sir." " Well, no matter about that." Here, gentlemen, is a practical case for you—the very type of what you will constantly see in practice. This girl's system is thrown into disturbance because of the arrest of the menstrual function—a function which, I have repeatedly told you, can not be unduly interrupted with- out involving the general economy in more or less difficulty. Among 294 CLINICAL LECTURES. the causes of this sudden suppression, there is none more frequent in its action than cold. This fact is well understood by those beyond the pale of the profession, and it will fall to you, as it has frequently done to me, to witness in the more elevated spheres of society the effects of the wanton manner with which young ladies, availing themselves of this knowledge, trifle with their health. I have now before my mind a mel- ancholy example of this thoughtless temerity in the person of a pure and lovely creature, whose life was forfeited, and whose death caused a blank in the parental heart, and threw a gloom over the domestic hearth which no time can dissipate. Without guile, and full of purity, this young girl, unconscious that the rash act would prove her destruction, plunged her feet into a bucket of ice-water a few hours after her menstrual flow commenced. The function became immediately arrested, and such was the reaction on the brain, that in less than six hours she was a corpse from apoplexy. It is not for me, gentlemen, to depict the anguish of that hour, or to tell you of the bleeding hearts that hung in the bewilder- ment of grief over the lifeless body of that beloved daughter, and fondly cherished sister. Let it suffice to tell you that I was a witness to the scene, and that night, in harrowing but graphic truth, revealed to me how death can sport with human affection. It is a great misfortune that young girls budding into life should be kept in such profound igno- rance of their own peculiar mechanism, and of the laws by which its har- mony is maintained. Interrogate the grave, and ask that last and dis- mal abiding place to reveal its triumphs, obtained through this ignorance, and it will tell you their name is legion. On us, as medical men, de- volves the sacred duty of admonishing mothers to instruct their daughters as to their physical well-being. What parent who is not a maniac would give to her infant an open razor with which to amuse it ? Would not her common sense at once disclose the absurdity of such an act ? She would see that this was placing in the hand of her child an instrument of destruction, and if forfeiture of life were not the result, it would be only because of the interposition of a merciful Providence to protect the child against the insanity of the parent. The open razor to the young child is not more fatal in its effects than are the multitude of vicious practices, countenanced by society, to the young girl. The whole system of female education among us is, in my judgment radically wrong, and the wrong strikes at the very foundation of all hap- piness—health. The three leading objects which should interest a mother in behalf of her daughter are—healthy physical development, high men- tal cultivation, and a moral training, which will not only cause her to appreciate, but will also enable her to perform with inflexible fidelity her duties to society. Does the present system of education—do the prurient books with which the boudoir and chamber are crowded—does the no less prurient dance, which so few have the moral courage to re- sist, though in their hearts they condemn it—tend to the accomplish- OCCLUSION OF THE ANUS. 295 ment of these objects ? No, gentlemen, they are like the fatal Upas, whose touch is withering, and whose impress is death. But let us return to our patient. There can be no doubt as to the 3ause of this young woman's suffering—suppression of her menstrual function. Let this be restored, and the headache and other symptoms will disappear. Treatment.—Let § viij of blood be taken at once from the arm. To- night the three following pills: R Submur. Hydrarg.......gr. vj Croton Tiglii.......gtt. 1-2 Pulv. Ipecac........gr. j Ft. massa in pil. iij div. To be followed in the morning by the subjoined mixture: R Sulphat. Magnesia?......3 iij Infus. Senna?.......§ vj Tinct. Jalapae.......3 iss Manna?........3j M. The diet to be strictly vegetable; and in order afterward to insure a soluble condition of the bowels, a wine glass of the following saline mix- ture every morning, as circumstances may require : R Sulphat. Magnesia? > „ . Sup. Tart. Potassa? j ... % J Aqua? Pura?.......Oj Ft Sol. Occlusion of the Anus in an Infant, one Week old. Operation.— Joseph B., aged one week, has had nothing to pass its bowels since its birth. It is apparently in great agony—refuses the breast—and is con- stantly moaning. " That is not your child, madam, is it ?" " No, sir; it's mother is too weak to come out." " So I should think, my good woman." "That little infant is rather young to be brought here." " Yes, sir; I know it is, but the poor little dear suffers so much that its mother begged me to let you see it." " Well, madam, we will do what we can for it." " Are you certain that it has not had a passage since its birth ?" " Oh ! yes, sir—I know it has not." " Does it pass its water ?" " Yes, sir." " Have you given it any medicine." " Indeed, sir, it has taken all sorts of things." " What has it taken, madam ?" " Molasses and water, and castor oil, and rhubarb, and "—" There, my good woman, that will do." " Why, sir, I have not told you half!" " You have told me sufficient to satisfy my mind that that poor little infant, young as it is, has passed through a martyrdom! Does that child vomit ?" " Oh, yes, sir; for the last four days it could not keep any thing on its stom- ach." " Is its little belly large ?" " Oh, yes, sir, it is very much swell ed." " Has it been attended by a doctor ?" " Yes, sir; and he said the child's bowels had the torpids." " You mean torpor, do you not, madam ?" " Well, sir, it was something that way." " I think we shall discover, my good woman, that the torpor was in the doctor's brain." 296 CLINICAL LECTURES. The case before you, gentlemen, is one of singular interest, for several reasons. In the first place you see a little infant but a week old, who has had no evacuation from its bowels since its birth; and it seems to have resisted every attempt by medicine to effect this object. It is now, as you perceive, suffering severely; its abdomen very much distended, with irritable stomach, and no desire for the breast. Its moans indicate great distress, and its whole aspect portends a fatal issue. Is there one of you who is not strikingly impressed, in looking at this little sufferer, with the soundness of that principle which I have so often told you is fundamental in the investigation of disease, viz.: a just distinction be- tween the substance and shadow ? The feature in this case which, at the sacrifice of every other consideration, has attracted attention, is the fact that the bowels have not been moved since birth. To overcome this supposed torpor of the system various medicines have been admin- istered, but all without avail; and the result of this partial or abstract view, is protracted suffering which will result most probably in death. In his contemplation of disease, the observation of the physician must be critical—his reasoning based on a broad foundation, and his deduc- tion, if not always just, should at least be rational. I do not yet know certainly, for I have made no examination to ascertain the fact, but I am disposed to suspect from the whole history of the case that this infant has had no evacuation because of a mechanical obstruction, constituting occlusion of the anus. [Here the infant was examined by the professor, and his suspicions were soon confirmed. There was occlusion of the anus, and the want of action in the bowels at once accounted for.] You perceive I am right; and you understand, too, at what little cost I have been enabled to arrive at a correct judgment as to the true cause of this infant's distress. In this case, the inactivity of the bowels is the shadow, while the occlusion of the anus is the substance. In other words, the latter is the cause, the former the effect. The absurdity, therefore, of attempting to produce an evacuation by medicine is too manifest to need one word of argument. In my lectures on Midwifery, I have spoken very fully of the duties of the practitioner to the new-born infant; and among these duties, there is one of special interest; it is this: as soon as the infant has been properly washed, it should be minutely examined, with a view of ascertaining whether or not there exists any congenital deformity. The urethra and anus should be inspected—for if either of these outlets be occluded, the future safety of the child may very mate- rially depend upon the fact being known early. " Madam, it is not necessary for me to tell you that this child is in a very dangerous situa- tion." " Oh! no, sir, I see it, poor little dear." " There is but one thing, my good woman, that presents the slightest ground of relief, and that is an operation." " What, sir, to open its stomach ?" " No, mad- am we do not open stomachs here—and you need have no fear of the operation of which I speak. Shall I do what I think is proper, and AMENORRHCEA. 297 which, in fact, is the only thing that can be done ?" " Yes, sir, I am sure the poor babe's mother will consent to any thing." " What I propose doing, gentlemen, is to divide by a simple incision the membrane which, you perceive, has caused an imperforation of the anus. [Here the infant was placed on its back, the thighs elevated by an assistant, and the occlu- sion being well exposed, the professor with a bistoury, made the incision.] Immediately a large quantity of meconium passed from the bowels, the tumefaction of the abdomen became very much diminished, and the in- fant's countenance gave evidence of relief. In order that the incision I have made may be kept open, it will be necessary for a day or two to introduce into it a small pledget of lint well smeared with simple cerate; and it will also be proper to throw up the bowel two wine glasses of tepid water this evening, with a view of promoting a free evacuation. In almost all cases of congenital occlusion of the anus, the sphincter ex- ists ; and hence after the simple incision of the membrane closing the anus, the latter and also the rectum are usually found normal. An oc- clusion of the rectum is extremely rare. " Take that child home, mad- am ; and tell its mother we have done all we could for it; tell her also, that we can not promise that it will live, although its chances for life now are a thousand to one what they were a few moments since." " In- deed, I will tell her, sir, what you say—and I am sure she will be very thankful to you." " Good morning, madam." Amenorrhea, with imperforate Os Tincae, and encysted Dropsy of the right ovary in a glrl aged 19 years, the lower portion of the Ovary prolapsed in the triangular space between the Uterus and Rectum.—Mary R., aged 19 years, arrived in this country from Ireland five months since. Her mother says her health began to decline at the age of fifteen. She is pale, emaciated, with no appetite, and labors under extreme prostration. She has an enlargement of the abdomen, which is traceable from the right iliac fossa, in an oblique di- rection, to within a short distance of the umbilicus. She has never menstruated, is habitually constipated, and has been so, more or less, for the past two years. She complains of a distressing pressure on her back passage ; has taken a quantity of medicine, she says, for the pur- pose of regulating her bowels and bringing on her " turns ;" but nothing has done her good. " When, my good woman, did you first discover this enlargement in the abdomen of your daughter ?" " I think, sir, that was the commencement of her ill health. She first called my attention to it when fifteen years of age, the time that her health began to decline." " Do you remember, my good girl, in what part of the abdomen this tumor first commenced ?" " Yes, sir; it commenced in my right groin." The case before you, gentlemen, embodies a combination of extraor- dinary circumstances, and as such will not very frequently present itself to your observation. This girl I have examined in the most critical 298 CLINICAL LECTURES. manner; both she and her mother are anxious to secure her relief, and she consented to a thorough exploration of her case, tho result of which I will now give you. In the first place, the girl, although 19 years of age, has never menstruated ; secondly, there is an imperforate os tinea;; thirdly, the right ovary is affected with encysted dropsy, giv- ing the girl the appearance of being five or six months pregnant; fourthly, the lower portion of the encysted tumor has projected low down into the triangular fossa between the uterus and rectum, and dis- tinct fluctuation is felt there, as well as in the abdomen; fifthly, the obstinate constipation is the effect of the pressure of this tumor on the rectum. This poor girl has been a great sufferer, and in the hope of lulling her pain, she has been in the habit of resorting to anodynes. The uterus, though there is an imperforate os tincae, and the girl has never menstruated, is not enlarged. On a vaginal examination, I ascer- tained this fact, and on introducing the other finger into the rectum and pressing upon the prolapsed ovary, I very distinctly felt the uterus fall slightly forward. Moreover, I was enabled to push the uterus up- ward, and discovered in this way that it had undergone no increase of size. It is not, under the circumstances, remarkable that this organ is not enlarged, and does not contain menstrual blood, for the disease of the ovary nas most probably been the cause of the non-menstrual accumulation. You see, therefore, that a girl, 19 years of age, may have never menstruated. She may have, at the same time, an imperforate os tincse—which you know is sometimes the cause of retention—and yet there may be an entire absence of the menstrual blood in the cavity of the uterus. I have examined with all necessary caution the abdominal tu- mor, and find it to be an enlargement of the right ovary, consisting essentially in dropsy of this organ. Perhaps, of all the forms of morbid action to which the ovary is liable, dropsy is the most frequent. This is called encysted dropsy, in contra-distinction to other dropsies, for the reason that the fluid is contained within one or more cysts. According to my observation, and I think this accords with the experience of others, disease of the ovary is comparatively rare in a girl so young as the one before us. I shall, on another occasion, speak more particularly of the causes, pathology, symptoms, treatment, etc., of ovarian dropsy, and for the present I shall merely remark that marriage and child-bearing, together with suppression of the menses, both in the married and un- married, are among the common causes of this affection. In the diag- nosis of ovarian dropsy, it must not be forgotten that enlarged cysts, presenting all the usual symptoms of ovarian dropsy, are occasionally located in the abdominal cavity, altogether unconnected with disease of the uterus and its appendages; the omentum, peritoneum, etc., consti- tuting the seats of these enlargements. The fluid of ovarian dropsy may be contained in one cyst, or it may be in several; hence the division of dropsy of this organ into unilocular and multilocular. The interesting, AMENORRHCEA. 299 and I may say the unusual feature in this case, is the fact that the en larged ovary is prolapsed into the triangular fossa, and that distinct fluc- tuation can be detected at that point. I have met with this peculiarity in ovarian disease, but, I repeat, it is not common. I have also seen cases in which the ovary, entirely free from disease, has fallen into this fossa ; it is as well to mention that occasionally the small intestines become prolapsed in it; and instances are recorded in which death en- sued, under these circumstances, from strangulation of the intestinal mass. Treatment.—In the present case, but little is to be expected from medication. This poor girl is weighed down by an accumulation of troubles, and I have no faith that medicine will avail much in securing her health. One thing, however, is broadly indicated, and that is to lessen the size of the ovarian tumor, which will result in the removal of the severe pressure against the rectum; and while she will thus be tem- porarily relieved from pain, an opportunity will be afforded of remedy- ing the constipation, which arises almost entirely from the mechanical pressure of the ovary against the lower intestine. The next indication will be to sustain the strength, as far as possible. I propose to penetrate the ovary with a trochar, through the vagina, at the most dependent portion of the tumor, which will not only afford a readier passage for the escape of the fluid, but will enable me to prevent the evils of its re- accumulation, by keeping permanently in the opening a sound through which the fluid will pass as soon as it is secreted. I do not think this a suitable case for injection into the ovarian sac—this latter practice has been resorted to, more particularly in France, with a view of producing adhesive inflammation of the sides of the cysts, and thereby destroy the secreting surfaces. The injection employed has been the tincture of iodine, port wine, a solution of sulphate of zinc, etc. " Madam, you have heard what I have said about your daughter's case—will she consent to an operation, which I candidly confess to you will not, in my opinion, restore her to health, but which will relieve her of much suffering ?" " Yes, sir, she will consent, I know, to any thing you may judge best to be done." " Well, my good woman, I will be at your house to-morrow morning at half-past eleven o'clock, and do what I think is most advise- able in the case." [According to promise, I visited this girl, and, in the presence of Pro- fessor Gross, of the University of Louisville, Drs. Newkirk, Forbes, Finnell, and Gregor, I introduced along my finger the curved trochar into the vagina, and penetrated the ovary immediately behind the cervix uteri, taking care to direct the instrument, as soon as it entered the tumor, upward, in order to avoid injury to either the uterus or rectum. As soon as the trochar was withdrawn, there escaped through the canula more than three quarts of" a tenacious and dark colored fluid. Imme. diately after the ovarian sac had been evacuated, a large quantity of faecal 300 CLINICAL LECTURES. matter, consisting principally of scybala, passed off from the rectum, which the poor girl observed afforded her much relief. The end of the canula was left in the ovary, and so fastened as to allow the free escape of the fluid. The girl was directed to take occasionally one of the fol- lowing pills, a good combination in a case like this where, with the con- stipation, there is evidently defect in the action of the liver: R PiL Gambogia? c......gr. xxiv PiL Massa? Hydrarg......gr. xij Ft. massa in pil. vj dividenda. With a view of imparting tone to the stomach, a tea-spoonful of the fol- lowing tonic twice or thrice a day: R Sulphat. Quina?......gr. vj Acid. Sulph. Dilut......gtt. vj Syrup Zingiberi......§ ij Ft. sol The diet to be bland and nutritious.] In connection with this subject, allow me to direct your attention to the following interesting case of imperforate os tincae in a pregnant lady, on whom I performed successfully the operation of vaginal hysterotomy. The case has been reported in the American Journal of Medical Sciences. Vaginal Hysterotomy and Subsequent Delivery with Forceps, with safety to both Mother and Child.—On Saturday, Nov. 6th, at 6 a.m., Dr. Alexander Clinton was summoned to attend Mrs. L., aged thirty-six years, in labor with her first child. Dr. C. had been for some time the family physician of Mrs. L., and had attended her in re- peated, and occasionally severe attacks of nephritis. On arriving at the house he found Mrs. L. in labor, the pains being decided, and occurring with regularity at intervals of fifteen and twenty minutes. In his ex- amination per vaginam, the doctor was unable to detect the os tincae ; he very cautiously explored the vagina, and presenting portion of the womb, with his finger, and after several fruitless attempts to find the mouth of the uterus, he came to the conclusion that the difficulty of reaching the os was owing to the malposition of the organ, probably re- troversion of the cervix. Accordingly he waited until evening, when the pains increasing in violence, and assuming an expulsive character, he ex- amined his patient, but without better success. He then proposed a consultation, the patient having been in labor fourteen hours. Professor Mott was sent for; on hearing the particulars of the case he made a vaginal examination, and after repeated attempts, failed in finding the mouth of the womb; Professor M. suggested that possibly some change might occur during the night in the position of the parts, which would enable him to reach the os uteri, and left the house with the promise that he would return in the morning. Dr. Clinton continued with his patient during the night, and the pains occurred regularly with more or VAGINAL-HYSTEROTOMY. 301 less force. He made several examinations in the night, and could feel nothing but a globular surface. In the morning, Nov. 7th, at ten o'clock, Professor Mott returned; the pains were then much more violent, and the patient suffered severely. He again attempted by examination to reach the mouth of the womb and again failed. To use his own language, " I have seen a great many obstetric cases, and have attended almost every variety of parturition • but it is the first time after thirty-six hours' labor, that I could not feel the os tincae." The case was now assuming a dangerous character • the pains were frequent and expulsive, with an obliterated mouth of the uterus. The fear, therefore was rupture of this organ, and death of the patient, with but little chance for the life of the child. The husband and friends were informed of the precarious situation of the patient. Drs. Mott and Clinton decided to have additional consultation, and at the request of these gentlemen, I met them at one o'clock on Sunday, the patient having been in more or less active labor for forty hours. On examining her I could not feel the slightest trace of the os tincse, and I became satisfied, after a thorough exploration, that it was entirely ob- literated. Under these circumstances, the death of the mother being inevitable without an operation, it was proposed to lay the womb open through the vagina, and at the request of the gentlemen, I proceeded to perform the operation, as follows: with a probe-pointed bistoury cov ered to within a few lines of its extremity with linen, and taking my finger as a guide, I made a bilateral section of the neck of the womb, extending the incision to within a line or two of the perito- neal cavity. The head of the child was immediately felt through the opening. The pains continued with violence, but there was no progress in the delivery ; the neck of the uterus was extremely hard and resist- ing, and presented to the touch after the incision, a cartilaginous feel. Dr. Mott and myself then left the patient in charge of Dr. Clinton, and returned again at six in the evening. At this time, although the pains had been severe, the head had not descended, nor had any impression been made on the opening. I then made an incision through the poste- rior lip ; the patient was not in a condition to sustain blood-letting, and a weak solution of tartar-emetic was administered, with a view, if pos- sible, of producing relaxation. Dr. Clinton remained with his patient, and promised if any thing occurred during the night, to inform us of it. We were both sent for at two o'clock. Dr. Mott having arrived be- fore me, and finding the patient suffering severely from violent and ex- pulsive pain, all of which produced little or no change in the position of the child's head, enlarged the incision which I had previously made in the posterior lip of the cervix. We remained until seven o'clock in the morn- ing, when we left. The patient being much fatigued, a Dover's powder was ordered, which procured a comfortable sleep, and temporary im munity from suffering. 302 CLINICAL LECTURES. We called again at eleven o'clock. The opening had somewhat dilated, and the head could be more distinctly felt, but it had not begun to engage in the pelvis. There was much heat about the parts, and the scalp was corrugated. The pains continued with regularity, losing nothing in vio- lence, and at six o'clock in the evening of Monday the patient's strength, which had been cautiously guarded, was evidently giving way, and her pulse rose to one hundred and forty! In a word, the symptoms were most alarming. The question now presented itself—What was to be done ? After mature deliberation, being essentially conservative in the whole management of the case, we determined to make an attempt to deliver with the forceps, certainly not an easy thing to do with the head of the foetus at the superior strait, not having begun to engage in the pelvis, and the mouth of the womb rigid and unyielding. The forceps, however, after a full view of all the circumstances, presented to us the most feasible means of effecting delivery. At the request of Drs. Mott and Clinton, I applied the instrument, and was fortunate enough, without much loss of time, in locking it. The head was situated diagonally at the upper strait, with flexion but partially made. At first, I directed my traction downward and backward, the handle of the forceps forming an acute angle with the axis of the inferior strait of the pelvis; and when I succeeded in flexing the chin of the child upon the sternum, I then rotated the handle of the instrument for the purpose of giving the demi-spiral movement to the head. In this way, after very great effort, I succeeded in bringing the head to the inferior strait, and with powerful, but well- guided tractions, drew it more than one half into the world. At this stage of the operation, my arms and hands were nearly paralyzed, such was the force necessary to overcome the difficulty. I requested Dr. Mott, who was by my side, to relieve me, and after no inconsiderable effort he succeeded in bringing the head into the world; and our gratification was in no way diminished by the fact that the child was alive, an event cer- tainly not to be expected. As strange as it may appear, the only inconvenience experienced by the mother after delivery was an inability to pass her water; this con- tinued for about two weeks, rendering it necessary to introduce the cathe- ter twice daily for the purpose of emptying the bladder. The mother and child are in the enjoyment of excellent health. It may, perhaps, be thought by some that the patient should have been delivered sooner, and that we subjected her to serious and unneces- sary hazard in delaying delivery by forceps. This reasoning might pos- sibly be sustained on general principles; but I think it will be conceded that, in this individual case, we were not only justified in the delay, but the result proved the wisdom of the course we pursued. In my opin- ion, nothing, under the peculiar circumstances of the case, could have warranted an attempt at artificial delivery, save an approach to exhaus- tion on the part of the mother, or the occurrence of some accident plac- ATROPHY IN AN INFANT. 303 ing life in imminent peril. The position of the fcetal head, and the condition of the mouth of the womb, were such as to render extremely probable the failure of any attempt at delivery. The obvious indica- tion, therefore, was to trust to nature as long as she was capable of act- ing, and for the accoucheur to proceed to artificial delivery the moment the general system exhibited unequivocal evidences of prostration. It may be very properly asked whether this was a case of primary or secondary closure of the os tinea. That it was secondary is manifest from two circumstances : 1st. The patient always menstruated regularly previous to her pregnancy; and secondly, to suppose that she could have become impregnated with an imperforated os tinea, is to suppose what, under the circumstances, may be called an absurdity. There are cases, however, recorded in which sexual intercourse was had through the female urethra, followed by impregnation, but in these examples there was a communication between the bladder and uterus. In the present instance there existed no such communication. The only explanation of the closure of the mouth of the uterus in this patient is, that it was the result of inflammation of the os uteri. Atrophy in an Infant aged twelve Months.—John R., aged twelve months, is brought to the Clinique by its mother, and exhibits a degree of emaciation apalling to look upon. It is constipated, often not having an evacuation for four or five days, with more or less nausea and vomit- ing, and it is extremely fretful. Its evacuations are lumpy and white. For the first five months after its birth, it was a healthy child in every respect, and quite large for its age. Since that period, however, it has continued to decline, and has now become so emaciated, that it has more the aspect of a skeleton than a living being. The term atrophy, gentle- men, is employed to signify defective nutrition, and is divided into gene- ral and local, the former where all the tissues of the economy are in- volved in the loss, the latter where some particular organ or portion is the seat of disease. In the case before us, involving as it does the ema- ciation and decay of the living structure, the term marasmus is often applied by writers. One of the fundamental ordinances of nature is, that life can not be long maintained without a constant repair of waste, and the proper equilibrium between these two processes, waste and sup- ply, will secure to the various organs of the body their due nutrition. Nutrition becomes interrupted only when either the repair or waste pre- ponderates the one over the other. If there be excessive repair, hyper trophy will be the consequence ; while atrophy is the result of excessive waste. The powers of assimilation in the young infant are exceedingly feeble; indeed the infant is not required to perform much duty in this particular, for the material which Nature has prepared for its suste- nance requires but little elaboration after being taken into the economy. The mother's milk is the proper nourishment for the infant, or the 304 CLINICAL LECTURES. reason that, of all known substances, it is the best adapted to its deli- cate organs. You see, therefore, that nothing is more simple than the proper and speedy assimilation of these elements; and it is in this way that chil- dren at the breast, if not interfered with by officious nurses, as a general rule, thrive and grow fat. General atrophy may result from two causes: 1st. Insufficient food ; 2d. Food of improper quality. In order that the wants of the system may be provided for, it is not only necessary that waste should be re- paired, but the animal temperature through the respiratory process must also be maintained. Food, therefore, when taken into the system is intended to—and must in fact, in order that health may be preserved —accomplish these two objects, viz.: the repair of waste, and the sup- ply of material for the respiratory process. If you will bear in mind these two propositions, I will endeavor to explain the true cause of atrophy of the system as it occurs to my mind. My theory may possi- bly not account for every case of inanition, but I am confident it will tend to elucidate the subject, and what is of cardinal importance, if true, it will lead to the application of salutary therapeutic principles. 1st. The physiologist has declared that perfect nutrition is the result of the proper elaboration of the ingesta. 2d. The ingesta, when elabor- ated, repair waste, and furnish material for the respiratory function. 3d. The material for the respiratory process is eliminated from the bile; that is, it produces the oily materials from which the carbon and hydro- gen are derived. Without a due supply of these substances, you un- derstand that the animal temperature can not be preserved, and life, therefore, becomes extinct. 4th. According to the experiments of Schwamn, if a ligature be placed around the ductus communis chole- dochus, the animal gradually emaciates and dies, for the reason that the oily materials of the bile are not furnished—there are consequently no carbon and hydrogen, for the want of which respiration can not be maintained. 5th. When death ensues from starvation, the gall-bladder is found turgid, and no bile is observed in the intestines. With these facts before me, in connection with another broad fact that, in the great majority of children affected with atrophy, the function of the liver is so deranged as to become almost dormant; or, in other words, there is an absence of biliary secretion, I am of opinion that in many, if not all cases of this decay of structure, we can trace the cause to imperfect action of the liver, which results in a deprivation of carbon and hydro- gen so absolutely essential to the maintenance of the animal tempera- ture. You may, perhaps, not be disposed to attach much importance to this reasoning, but you will be pleased to bear in mind that it was on this hypo- thesis alone that we have based our treatment of four cases of atrophy, which have been presented to you during the present session; and if you ATROPHY IN AN INFANT. 305 will turn to your note-books, you will find the record of these cases—you will see that, in every instance, the children were restored to health. There is not one of you who does not recollect with interest the case of Kate B., the little sufferer of six years of age, who, many of you thought, would not survive its return home, such was the degree of its emaciation. The views which I have just expressed to you as to the cause of atrophy are not views of to-day—nor are they the sudden graspings of a mind en- slaved to theory. I have seen many cases of extreme emaciation in children—I know that they are generally considered as beyond the effi- cacy of our science, and these cases too often prove fatal simply because of the opinion that they are beyond medication. Basing my opinion upon past success, I regard the great majority of these cases as being completely within the limits of our science; they are amenable to remedies. You will all bear witness that I have no fondness for theory—my liking is for facts, I have told you that every fact in medicine is a gem, it is pro tanto a firm foundation on which you can stand with reliance. Facts should be the constant object of your pursuit; without them the science of medicine is a blank, and its practice the most positive of all uncer- tainties. He who can erect, by careful observation, a pyramid of facts, will find in that pyramid a monument of Truth ! My attention was first drawn to the cause of atrophy, as I have already explained to you, from the circumstances of its great fatality. Believing, therefore, as I do that its true cause is traceable to inactivity of the liver, thus cutting off the proper supply of oily matter from which are derived the carbon and hadrogen so necessary to the physiology of the respiratory movement, I recommend the following Treatment.—As a general rule, in atrophy the intestines are more or less loaded with offensive fcecal matter ; and as the first step to success- ful treatment, a brisk purgative should be administered, such, for ex- ample, as the following:— R Submur. Hydrarg.......gr. ij Pulv. Jalapae.......gr. iv Ft. Pulv. Let this powder be given at night, followed in the morning by two tea-spoonsfuls of castor oil. As soon as the bowels have been thorough- ly evacuated, it is proper then to commence with alterative doses of: R Hydrarg. c. creta.......gr- vj Div. in Chart. No. xij Let one of these be taken every second night'. When the evacua- tions afford evidence that the biliary secretion is in action, the powders should be discontinued; and half an ounce of comp. decoct, of sarsa- parilla with gtt. iv. of liquor potassae given twice a day. There is no remedy, perhaps, better calculated to invigorate the drooping powers of the system under these circumstances than the sarsaparilla, when properly prepared. After continuing the sarsaparilla for two weeks, 20 306 CLINICAL LECTURES. we usually suspend it for a time, and substitute the following old, but admirable alterative: R Oxymur. Hydrarg.......gr. 1-4 Tinct. Rhei. i &a 5 i Tinct. Cinchona? ) Ft. sol. Twenty drops twice a day—in two weeks it may give way to the sarsaparilla. An alternation of these remedies, according to the sound judgment of the practitioner, will prove invaluable in the management of this affection. Medicines, however, will be of little avail without close attention to diet, fresh air, etc. The stomach, it must be borne in mind, is extremely debilitated—its function has been nearly destroyed —and the most scrupulous care must be observed not to overload, or annoy it with improper food. Rice jelley—biscuit jelley—sago—tap- ioca jelly—chicken and beef tea, delicately prepared—and when it agrees with the stomach, cream; all will be found proper articles of food. Purulent Discharge from the Female Urethra, occasioned by Ulceration of the Neck of the Bladder.* Mrs. C, aged 27 years, married, the mother of two children, who had sufferd from a dis- charge of matter, with a scalding sensation in passing water since the birth of her last child, returned to-day and stated that she had entirely recovered. This case, gentlemen, you will not have forgotten, for it was one of more than usual interest. After hearing the statement of this patient when she first came to the Clinique, I gave it as my opinion that she was laboring under ulceration of the neck of the bladder, pro- duced most probably by a protracted and severe labor, her labor having lasted over sixty hours. The treatment ordered consisted in an injection every second day of a solution of the nitrate of silver into the urethra, until there should be a decided amendment in the symptoms : R Nitrat. argenti.......3ij Aqua? Pura?.......§ viij Ft. Sol The patient was also freely purged with saline medicines, and ordered to take 10 grains of the nitrate of potash in a tumbler of flaxseed tea twice a day. The result of this treatment you now perceive in the complete restora- tion of the patient. " You can go home, madam." " Thank you, sir. I am greatly obliged 'for what you have done." " Very welcome, my good woman. Good morning." Convulsions in an Infant five Weeks OLD.f Julia E., aged five weeks, was returned to-day by her mother, who reported her quite re- stored. This case, gentlemen, is one of deep interest to you. You will, by turning to your notes, be reminded that this little infant, al * Page 174. f Page 195. CONVULSIONS IN AN INFANT. 307 though but five weeks of age,iad been subject to repeated attacks of convulsions. These not only caused the mother much anxiety, but in- duced her to abandon all hope of recovery. Your attention was called very particularly to the subject of infantile convulsions, and the various interesting points connected with them fully discussed. On questioning the mother as to the cause of the convulsions, she observed she could not tell what produced them—but in answer to another interrogatory she told us that " her little infant frequently passed four and five days without an evacuation, and then nothing but small lumps came from it, and also that she herself was habitually constipated." With this intel- ligence, extracted, as you will remember, by a rigid cross-examination, there was no difficulty in accounting for the convulsions, which were evidently the result of intestinal irritation. The indication was to dis- regard the convulsions, which were simply effects, and apply our reme- dies to the removal of the cause. This was done, and you now have in the bright eyes and cheerful countenance of this infant ample testi- mony of the result. Its bowels were regulated by minute doses of the hydrarg. c. creta, followed by castor oil; and as the mother nursed it, it became necessary to overcome the constipation with which she was affected. She was accordingly ordered the necessary remedies for this purpose. " Well, madam, how is your little infant now ?" " Thank you, sir, it is quite well—it has not had any convulsions since the medi- cine took effect." " How are its bowels ?" " Quite regular, sir; it has two passages every day." " Did you notice what passed from it when it took the medicine ?" " It was lumpy, green stuff, and very offensive, sir." It can scarcely be necessary for me to make any comments on this case. It tells its own story. " You can go, madam; your infant is now well, and if you desire to keep it so, you must be more careful in future." * LECTURE XVIII. Management of the Placenta after the Delivery of the Foetus in Natural Labor.— Treatment of Uterine Hemorrhage.—Excessive Pain in the Uterus every time the Child is put to the Breast, in a married "Woman twenty-three Years of age.—Pro- cidentia Uteri, with Venereal Ulcerations.—Suppression of the Menses of two Years and four Months' duration, in a married "Woman aged twenty-six Years, the Mother of two Children, the Youngest three Years old, from imperforate Os Tinea?, the re- sult of Inflammation ; Operation.—Physometra in a married "Woman, aged thirty- two Years; "What is Physometra ?—Introduction of a Silver Tube into the Uterus, followed by an escape of offensive Flatus.—Occlusion of the Anus, in an Infant aged one "Week.—Encysted Tumor, seated in the Posterior "Wall of the Vagina, in a married "Woman twenty-three Years of age.—Partial Paraplegia, in a married "Woman aged thirty-two Years, from Instrumental Delivery; Remedial Effects of Strychnia,—Epilepsy occurring at each Menstrual Period, in a Girl aged sixteen Years. Management of the Placenta after the Delivery of the Fcstus in Natural Labor—Treatment of Uterine Hemorrhage. Gentlemen—the case of Mrs. W., who appeared before you a few mo- ments since, presenting an example of the dilapidating effects of profuse loss of blood at the time of delivery, affords me a proper occasion to make a few practical observations on the management of the after-birth. To the young practitioner, there is no topic of higher interest in the whole range of midwifery than that which treats of the conduct of the accoucheur immediately after the expulsion of the child. Gooch, an emphatic and practical writer, says, " It is too common an error to suppose that as soon as the child is delivered, all danger is at an end." The true danger of parturition, in an ordinary labor, commences with the birth of the child, and is more or less connected with the delivery of the placenta. The rules for the management of the after-birth are few and simple, and upon their faithful observance oftentimes depends the safety of the mother. In the first place, what do you understand by the placenta, and what are its relations to the uterus ? These are two primary and leading ques- tions, and their solution will at once remove all embarrassment in the discussion of this subject. The placenta is a deciduous mass, composed almost entirely of blood-vessels, and is divided into two portions, the maternal, which is in adhesion with the uterus, and the foetal, which is covered by the two membranes, the chorion and amnios. There are two circulations in the placenta, one on the maternal, the other on the fcetal MANAGEMENT OF THE PLACENTA. 309 surface. The former is carried on by the utero-placental vessels, the latter by the vessels in the umbilical cord, viz., the two arteries and one vein. These circulations are entirely distinct and independent of each other, so far as continuity of canal is concerned. This fact has been abundantly proved, and it is material that you should remember it in connection with what we shall have to say on the subject of uterine hemorrhage. We shall now suppose that you are in the lying-in cham- ber administering to the wants of the parturient woman; the labor has commenced, and progresses favorably, nothing untoward occurs; the child is expelled through the maternal organs, and the question now is—What are you next to do ? Allow me here to enjoin upon you a rule, which admits of no exception, and to which I very fully referred in my lectures on midwifery. The instant the infant is expelled, before doing any thing else, place your hand on the abdomen of the mother, and ascertain whether or not the uterus responds to the delivery of the child, or, in other words, whether it contracts, which fact can be readily recognized by feeling this organ in the hypogastric region, hard and of diminished volume. If the uterus be contracted, you need have no fear of hemorrhage ; should it not be contracted, there will necessarily be hemorrhage, and the advantage of the rule I give you is that you are thus early informed that flooding exists, and can apply your remedies in time, before your patient is so much exhausted, by loss of blood, as to render the issue of the case doubtful. Let us, however, assume that the uterus does respond to the expulsion of the foetus, and this being ascertained, what is your next duty ? Undoubtedly to attend to the child. I have on a former occasion explained the rules by which you are to be governed in placing a ligature on the cord, and shall, therefore, not allude to them at present, except that you should use one and not two ligatures. The usual prac- tice, I am aware, is to apply two ligatures, but the principal argument in favor of this practice, viz.: " that in using but one ligature, the mother will be exposed to hemorrhage through the untied extremity of the cord," is not only without foundation, but discloses an utter ignorance of the anatomical and physiological peculiarities of the placenta. Where, for example, does the blood come from—always small in quantity—which flows through the placental extremity of the cord as soon as the latter is divided ? Certainly, not from the maternal system, for it is demon- strated that there is no continuity of canal between the maternal and fcetal circulations in the after-birth, and therefore there can be no feai of flooding. The small quantity of blood, on the contrary, which is ob served to pass from the untied extremity of the cord, is nothing more than the disgorgement of the umbilical arteries and vein, which ramify on the foetal portion of the placenta; and, in my opinion, this very dis- gorgement, while it in no way endangers the safety of the mother, fa- cilitates the delivery of the after-birth. Therefore, abandon the common practice, which is baeed upon an idle 310 CLINICAL LECTURES. fear, and employ but one ligature. When the ligature is applied, what next ? The child is then given to the nurse, and we shall now confine our remarks altogether to the delivery of the after-birth. This organ is at- tached to the internal surface of the uterus—most commonly at the upper and lateral portion—the principal medium of attachment being the utero-placental vessels, through which is carried on the circulation on the maternal surface of the placenta. As a general rule, nature separates the placenta from the womb, and this is accomplished through the instrumentality of uterine contractions. Five, ten, or twenty min- utes—the time varying from different influences—after the birth of the child, the patient will complain of pain, and the pain will be followed by a slight discharge of blood; these two circumstances—the pain and dis- charge of blood—are the evidences that nature is engaged in the detach- . ment of the placenta. The pain is recurrent like labor-pain; it is a natural process, and therefore must not be interfered with. But how are you to know that the detachment of the placenta has been accomplished ? A very important question, the solution of which you must thoroughly understand, for it has much to do with the propriety of your conduct on this occasion. Under ordinary circumstances, when the after-birth is completely detached from the uterine surface, it will be found resting over the mouth of the womb, either center for center, or a portion of its circumference will be felt, sometimes protruding into the vagina. There are two extremes which the practitioner must sedulously avoid in the management of the placenta—the one is premature and officious interference with the operations of nature, the other a hesitation to act when nature has achieved her part of the process, and calls upon him to interpose. This remark has special reference to the duty of the ac- coucheur, after the placenta has become detached from the uterus, and this organ is found contracted with the after-birth resting over the cervix. It very often happens that the young practitioner remains at the bed-side of the patient hour after hour, expecting every moment the expulsion of the after-birth—this does not take place, the patient becomes alarmed at the delay, and all the consolation she experiences, is the assurance that it will soon be all right. Another hour elapses, and no expulsion. A consultation is now proposed by the friends—this of course is acceeded to, and when the consulting physician arrives, he proceeds like a man who understands his business—he finds that the uterus is contracted, intro- duces his finger into the vagina, feels the detached placenta resting over the mouth of the womb, and delivers it without any delay, in the follow- ing manner: The cord being enveloped "with linen, he makes two or three twists of it around the fingers of the right hand, while he intro- duces the index-finger of the other hand into the vagina, carrying it up to the mouth of the uterus, this finger then seizes the cord close to the after-birth, and makes traction downward and backward in the direction ' of the axis of the superior strait; when the placenta falls out of the womb, UTERINE HEMORRHAGE. 311 and is in the vagina, the extraction is to be made in the line of the infe- rior strait, always remembering to withdraw the placenta by rotating it, in order that the membranes may be twisted into a cord, which enables them to resist the pressure of the os uteri as they pass through it, and thus there will be no fear of any fragments of them remaining in the uterine cavity, which would often result in more or less annoyance to the patient. The moment the delivery of the placenta has been accomplished, the accoucheur should carefully introduce his finger into the vagina, and re- move any coagula of blood that may be there, and he should particularly ascertain whether there is a clot of blood keeping the mouth of the womb open. If so, it must be immediately removed. Should it be suffered to remain, the patient will be exposed to much unnecessary suffering by the severe contractions of the uterus, occasioned by the presence of the coagulum. When the placenta is still high up in the womb, and not separated from the uterine surface, the accoucheur should not make trac- tion on the cord, for he will incur the hazard either of lacerating the pla- centa or cord, or, if the adhesions between the after-birth and uterus be sufficient to resist the force of the traction, the latter organ will often be inverted. In order to facilitate the detachment of the after-birth, fric- tions may be made on the abdomen with a view of stimulating the con- tractions of the uterus. As soon as the placenta is removed—and not before—the accoucheur should have a bandage applied around the body of his patient. This bandage consists of a double fold of linen, about fourteen inches wide, and sufficiently long to encircle the body. It should be brought down well under the hips, and secured with pins. The pressure of the bandage should be gentle and uniform—the object being to give proper support, and not to occasion painful annoyance. Many fashionable women are in the habit of using variously-constructed corsets for this purpose. These corsets are usually stiff and unyielding, like the prejudices of these patients, and often prove injurious. The rules which I have just indicated apply especially to the manage- ment of the after-birth in cases of ordinary labor, when nature separates this body from the uterus, and when the duty of the practitioner is limited to its mere extraction. Let us now, gentlemen, view this sub- ject in a different aspect; and in order that you may fully appreciate the fearful responsibilities which you are so soon to assume as practi- tioners of midwifery, and the extent of the obligations to be imposed upon you, we will suppose that, as soon as the child is delivered, in placing your hand on the abdomen of the patient, you discover that, in- stead of a hard - contracted body in the hypogastric region, the uterus is enlarged, uncontracted, or, if you please, in a state of inertia. Under these circumstances there will of necessity be flooding, constituting one of the most perilous and, if not promptly met, one of the most fatal complications of the lying-in room. If you should not be adequate to this pressing emergency—if, through indifference to your studies, you 312 CLINICAL LECTURES. should have neglected to learn the principles which are to guide you in these trying cases, deep will be your lamentation, and abiding the regrets which this delinquency will engender. If you be not prepared to treat a case of uterine hemorrhage, the lying-in room is no place for you. Its threshold is too sacred, its trusts too momentous, to be confided to an incompetent practitioner. Allow me to say to those of you, who have never been engaged in practice, that if there be one thing more than another in the routine of professional duty calculated to strike terror into the heart of the practi- tioner, and for the moment paralyze his best energies, it is a case of flooding after the birth of the child. One moment's hesitation or doubt on the part of the accoucheur, and death speedily terminates the scene. Nature has opened her flood-gates, and if they be not instantly and skill- fully closed, all chance of rescue is at an end. In order to present this subject to you in full force, imagine that you are summoned to attend a lady in confinement. The labor is natural, and of ordinary duration. While in conversation with the nurse, your attention is attracted to the patient. You are struck with the sudden change in her appearance. You approach the bed. Her face is pale and ghastly; she is speechless, without pulse; in a word, death is written on her countenance. It is a case of flooding. To hesitate an instant is to deprive your suffering patient of the last earthly hope. On you, therefore—on your science and skill—on your prompt and efficient action—must depend the life of this being. There is no time for consultation here. On your own re- sources alone rests the issue of life or death. Every eye is turned to- ward you. The confusion of the scene has awakened the household. The husband and, peradventure, the little children seek the chamber of their mother, and, overwhelmed as they are with grief, in the agony of their distress, they exclaim in tones which will reach the very depths of your heart, " Doctor, save my wife." " Oh, save our mother!" This appeal, if made to a practitioner inadequate to the emergency, will prove a withering comment on past neglect, and cause him to bewail in tears of blood the fatuity which urged him thus to sport with human life. But should this appeal be made to one who possesses science and skill— to one who, when he crosses the threshold of the lying-in chamber, feels that he is competent faithfully and promptly to discharge his duty—and if, in the exercise of his knowledge, he rescue the patient from her im- pending danger, and restore her to her husband and children, he will have accomplished one of the most glorious of all human triumphs. It appears to me that the subject of flooding after the birth of the child can be disposed of in a very simple manner. I shall not occupy your time with any elaborate discussion on this topic, but will limit my self to one or two points, which, I think, will sufficiently embrace the entire question, at least in all its practical bearings. In the first place hemorrhage, after' the expulsion of the foetus, may be either external or TREATMENT OF UTERINE HEMORRHAGE. 313 internal. The former when the blood flows through the vagina—the latter when its escape is prevented either by a coagulum of blood or the detached placenta resting over the mouth of the uterus. Both external and internal hemorrhage are due to the same cause—want of uterine contraction. Both are to be arrested by the same remedies, the object of which is to make the uterus contract, and to diminish the force of the circulation in the organ itself Again, both in external and internal hem- orrhage, the source of the loss of blood is the same, viz., the utero- placental vessels, and therefore the danger in either form of flooding is identical. Treatment.—Remember this great principle that, in profuse uterine hemorrhage, delay on the part of the practitioner in the application of the proper means to induce contraction of the uterus is in most instances the certain prelude of death. In flooding, the placenta will either be partially or completely detached from the uterine surface; in either case, the treatment is precisely the same. There is no greater error than to suppose that hemorrhage will be arrested by the removal of the lifter-birth. This body is not the bleeding surface—and whether it be in cr out of the uterus is a matter of entire indifference, so far as the chief object is concerned—the bringing on uterine contractions. Therefore, do not imitate that negative, and oftentimes fatal practice of removing the placenta as the first and chief thing to be done with a view of ar- resting hemorrhage. On the contrary, have recourse to a more reliable and effective means of accomplishing the object. Introduce your hand into the uterus, carry it up to that portion of the organ to which the placenta is partially attached, or from which it has been completely sep- arated—with the expanded dorsum of the fingers make a gentle but uniform pressure against the bleeding vessels—with the other hand ap- plied to the abdomen make counter-pressure. Should the womb not contract, without an instant's delay employ the cold dash—let a pitcher of ice-water be thrown from a heighth, say two feet, suddenly upon the abdomen—and repeat it without hesitation, should it be necessary. These are the heroic, substantial, common-sense remedies in these cases of desperate hope—and they will often serve you faithfully in the hour of need. As soon as the uterus begins to contract, you can gather up the after-birth in your hand, and keep it within your grasp until by powerful contractions it, together with your hand, is expelled. I have occasionally found great benefit from introducing a small piece of ice into the vagina—the contact of cold thus suddenly applied will some- times produce immediate contraction of the uterus by the stimulus im- parted to the excitor nerves, thus inducing the full benefit of reflex ac- tion. In speaking of the application of cold as a remedy in inertia of the uterus, it is important to bear in mind that cold too long applied loses its effect, or, in other words, becomes in-excitor; and it has been demonstrated that the alternation of heat and cold constitutes a most 314 CLINICAL LECTURES. positive excitor of the medulla spinalis. In profuse uterine hemorrhage, however, I do not think this alternation is called for, because the appli-