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- cation of the cold will not be of such long duration as to diminish its influence in bringing on the contractions of the uterus. But the prin- ciple is one of precious value, and can be, as is evident, employed in a variety of conditions with marked advantage. It can scarcely be neces- sary for me to remind you that when it has become important to resort to refrigerants for the purpose of bringing on uterine contractions, as soon as this latter object has been accomplished, and consequently the hemorrhage arrested, no time should be lost in giving warmth to the patient by the application of bottles of hot water, warm flannels, etc. ; but remem- ber this is to be done without moving the patient, for the slightest ex- ertion would be likely to induce syncope. I omitted to mention the occasional efficacy of iced-water as a drink in uterine inertia—it pro- duces contraction of the organ through its impression on the pneumogas- tric nerve, which is an excitor of the uterus. Oftentimes, I have found benefit from the administration of iced-water in cases of passive menor- rhagia dependent upon an atonic condition of the uterine organs. I have, as you perceive, alluded only to two remedies for uterine hem- orrhage, viz., the introduction of the hand for the purpose of making pressure on the uterine surface, and the application of cold ; and these I regard as the heroic remedies, which, more than any others, are to he relied on in cases in which the life of the patient is placed in \mminent peril, and in which prompt and immediate action is required. But there are, besides pressure and cold, various other means recommended by authors, which, perhaps, need a passing notice. One of the popular remedies commonly resorted to in these cases, and which has received the approbation of very high authority in the profession, is ergot; many practitioners are in the habit of relying upon this agent as all-sufficient in uterine hemorrhage, no matter how profuse, or how seriously it may threaten the life of the patient, but this is bad practice. The action of ergot is not instantaneous; on the contrary, it often requires ten or twenty minutes before its effects become manifest. With this, there- fore, as the sheet-anchor of hope, death will often ensue before the rem- edy acts. My advice to you, with regard to the administration of ergot in these cases, is as follows : Do not rely upon it as a heroic agent—if you give it, to which there can be no objection, let it be administered simply as an auxiliary means of overcoming the hemorrhage through its well-known influence on uterine contraction—but never let it take the place, in perilous flooding, of the two great and efficient remedies—press- ure and cold. One word now, as to the employment of the tampon as a means of controlling hemorrhage after the birth of the child. This is also a favorite remedy with some practitioners. My advice to you, gentle- men, is—never resort to the tampon as a means of checking hemor- TREATMENT OF UTERINE HEMORRHAGE. * 315 rhage after the birth of the child, for the reason that it exercises no pos- sible good in controlling the cardinal object in view—the contraction of the uterus—but, on the contrary, its direct and necessary tendency is to convert an external into an internal hemorrhage, thus, by the arrest of the flow of blood through the vagina, lulling the practitioner into false hope, and insidiously but most certainly destroying the patient— for, as I have already remarked, whether the hemorrhage be internal or external, if it be not checked, the tendency is the same—death. The younger Baudelocque proposed, some years since, pressure of the ab- dominal aorta as an efficient means of arresting uterine hemorrhage. This has been resorted to successfully in some cases, but its efficiency is far from universal. There appear to me to be two solid objections to it: 1st. In fat women, it will be difficult to make the necessary press- ure ; 2d. Compression of the aorta will more or less obstruct the cir- culation in the vena cava. As to the injection of vinegar, lemon-juice, and other irritating sub- stances into the uterus in these cases, they are all pernicious in their tendency, and without a solitary advantage in their favor. I might here, also, speak of electricity, so much lauded by certain English authorities —but the principle objection to it is the delay connected with its appli- cation, simply for the reason that the apparatus is not at hand and, often, before it could be obtained, death would have claimed his victim. Let us now suppose that through the prompt application of proper remedies, the hemorrhage has been arrested, the next question is—What will be the condition of the patient, and what should the practitioner do. If the patient should have lost much blood, you will find her in a state of great prostration—frequently without pulse, cold extremities, etc.— in a word, she will, to all appearances, be more or less in a moribund condition. Under these circumstances, I know of no remedy so effica- cious as laudanum: give it in tea-spoonful doses every ten or fifteen minutes until reaction is brought about. The first indication of its good effects will be disclosed by the return of the pulse in the radial artery, together with warmth of the extremities, and cutaneous surface gener- ally. As soon as reaction is established the laudanum must be suspended, and the patient's strength afterward sustained by animal broths, etc., should there be nothing to contra-indicate these latter. One of the commonest effects of this profuse loss of blood will be intense head- ache. Be careful how you mistake this symptom, together with the in- tolerance of light, which usually accompanies it, for phrenitis. This error has been committed more than once; the lancet has been resorted to, and death the almost necessary consequence. I have already called your attention to the subject of headache, which so frequently is found to accompany profuse losses of blood, and which often, too, is one of the prominent symptoms of anaemia. 316 CLINICAL LECTURES. Excessive Pain in the Uterus every time the Child is put to the Breast, in a married Woman, twenty-three Years of age.—Mrs. H., aged twenty-three years, married, the mother of one child, three weeks old, complains of great distress in her womb whenever she allows her infant to nurse. " How long have you been married,madam ?" "About eighteen months, sir." " Was your health good before your marriage ?" " Yes, sir; I was always a healthy woman." " Has it been good since your marriage?" "Always, sir; I have not had a day's sickness." " Did you ever suffer from pain in y,our womb before the birth of your child ?" " Never, sir." " When do you feel this pain of which you speak ?" " Only, sir, when my babe takes the breast—and then I suffer dreadfully in the lower part of my stomach." " Does the pain leave you when the child finishes nursing ?" " Always, sir." " Is the pain as severe now as it was soon after the birth of your infant ?" " No, sir ; but it troubles me a good deal yet." What do you make of this case ? It is one of more than usual in- terest ; and when you meet with it in practice, it will serve you greatly if you should understand how to manage it. This you can only hope to do by first comprehending its full meaning. Pain in the uterus is often- times the result of disease in that organ ; but it is also occasionally the effect of an influence transmitted from a remote portion of the system. You might infer, merely from the statement of this patient, that she is laboring under some local affection of the uterus, and the pain of which she complains might be referred by you to this cause. But you are not to judge either of the existence or the measure of disease from the dec- larations of your patient; you are to form your opinion from the evi- dence which will be presented to your senses. In order that there should exist no possible doubt on the subject, I have examined this woman per vaginam, and find her uterus perfectly healthy, nor is there any thing in the adjacent organs to account for the pain. What, then, produces her suffering ? It is explained altogether upon the principle of reflex action. The traction of the child's mouth on the nipple excites an action in the spinal nerves, which is immediately transmitted to the medulla spinalis, and this latter, becoming the seat of irritation, imparts to the nerves of the uterus an influence, which induces contraction of this organ, and con- sequently pain. But you may ask, do all nursing women complain of this pain ? By no means—some never experience the slightest incon- venience ; while others, on the contrary, of a sensitive nature, suffer for some time after birth much annoyance. The best remedy is patience ; as the breast becomes accustomed to the child's mouth, the irritation gradually diminishes, and in a short time the uneasiness about the uterus, which is but an effect of the mammary irritation, will subside. Procidentia Uteri in a married Woman, fifty-five Years of age, nine Years standing, with Venereal Ulcerations on both Sides of PROCIDENTIA UTERI. 317 the Organ.* Mrs. C, aged fifty-five years, returned to-day to the Clinique. " How are you, my good woman ?" " Thank you, sir; I am much better." " How are the ulcers ?" " They are nearly healed, sir." " Then you must be much more comfortable." " Indeed I am, sir." This poor woman, when she first came -here, excited our sympathies by the simple and, I believe, truthful story she told of her sufferings. She had been affected with procidentia uteri for the last nine years ; and it was occasioned by her leaving her bed too early after confinement—a very common cause of this affection. You can not have forgotten her emphatic remark in reply to the question I addressed to her: " Did you leave your bed soon after the birth of your child ?" " Indeed, I did, sir: I was at my wash-tub the day after my child was born !" In addition to her other troubles, this poor woman contracted from her dissolute husband, six weeks before she piesented herself here, the syphilitic disease —and you will remember the two venereal ulcers on the sides of the uterus. " You say, my good woman, the ulcers are better ?" " O ! sir, they are nearly healed." [Here the patient was placed on the bed, and the Professor called the attention of the Class to the appearance of the chancres; on one side of the womb the ulceration was entirely healed— and on the other, the chancre was not larger than a shilling piece, with a healthy and restorative aspect.] If you will turn to the report of this case, you will find that, in speaking of the Treatment, the following was my language: " 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:"— 9 PiL Massa? Hydrarg......3ij Pulv. Opii.......gr. iv Ft. Massa in pil. xx dividenda. " Did you take the pills as directed, my good woman ?" " Yes, sir; I took fourteen, and my gums became sore, and then I did 'nt take any more." " That was right. You may now take one of the remaining six pills every third night, until you have finished them." It is important, in cases like these, in order that the full effects of mercury may be had, to continue at intervals the medicine for two or three weeks even after salivation has been accomplished. After she has completed the pills, it will be proper for her to take during the day half a pint of the compound * Page 271. 318 CLINICAL LECTURES. decoction of sarsaparilla, to be continued for at least six weeks, occasion- ally suspending its use for a day or two. " You can now go, my good woman—and return here two weeks from to-day. By that time the other ulcer will be healed, and I will then introduce an instrument, which will give support to the womb, and en- able you to attend to your duties with comparative comfort." Suppression of the Menses of two Years and four months' du- ration in a Married Woman, aged 26 Years, the Mother of two Children, the youngest three Years old, from imperforate Os Tincae, the result of Inflammation.—Operation.—Mrs. D., aged 26 years, the mother of two children, the youngest three years old, presents herself at the Clinique for advice. " What's the matter with you, my good woman ?" " Oh ! sir, I am not well." " Where do you feel sick ?" " I feel sick all over, sir." " Then you are considerably out of repair, madam." " Indeed I am, sir." " How long have you been married ?" " Six years, sir." " What was the state of your health previous to your marriage ?" " Good, sir." " You say you have two children ?" " Yes, sir." " What is the age of the oldest ?" " It is five years old, sir." " How was your health after the birth of your first child ?" " It was perfectly good, sir." " How old is your youngest child ?" " It is three years old, sir." " Did you nurse both of your children ?" " Indeed I did, sir." " That was right, madam." " How long after the birth of your first child was it when your courses returned ?" " Five months, sir." " Did they continue regular until you became pregnant the second time ?" " They did, sir." " When had you your turns after the second child ?" " They came upon me, sir, three months after my second child was born." " How long did they continue regular ?" " Until I was taken sick, sir, about two years and four months ago." " Do I under- stand you to say that you have not had your courses for two years and four months ?" " Yes, sir ; I have not had them since I was sick, and that was about two years and four months ago." " What do you mean by being sick two years and four months since; what kind of sickness do you speak of?" " Oh ! sir, I had a miscarriage, and I am sure that was the beginning of all my troubles." " Did you suffer much at the time of your miscarriage ?" " Indeed I did, sir." " Had you a physician to attend you ?" " Yes, sir, and a very kind one, too ; he did a great deal for me." " I am glad to hear you pay this tribute to your physi- cian—you should always think well of your doctor. Did you suffer much pain after your miscarriage ?" " Oh ! sir, that is what made me so miserable. I had inflammation of my womb; and the doctor leeched me three times, and gave me medicine, and then put a blister on me." " Well, madam, that was the right kind of treatment for inflammation." " Indeed it was, sir." " Have you had your courses since you were at- tacked with inflammation of your womb ?" " No, sir." SUPPRESSION OF THE MENSES. 319 You will not regret this conversation, gentlemen; I have purposely instituted it for your especial benefit. The case before you is of ex- tremely rare occurrence ; and you will in a few moments appreciate the object of my questions. " Have you, madam, taken any medicine to bring on your courses ?" " Oh ! sir, I have taken so much medicine that my stomach is quite turned over." " What do you mean by that, Mrs. D. ?" " Why, sir, it is all out of order." " Are you much troubled with nausea ?" " I am sick at my stomach nearly all the time, sir." " Do you have any forcing pains about your womb ?" " Yes, sir; I have them every month—and that's the time the doctor told me to take the medicine, for it would bring on my turns." This case strikingly exemplifies the truth of the principle I have often inculcated in this Clinique, viz.: that the duty of the physician is not only to ascertain that disease exists, but he must also appreciate the true nature of the malady. What does this woman tell us, and wh&l is the real point elicited by the conversation to which you have just listened ? It is simply this—that she is 26 years of age, the mother of two children, in the enjoyment of good health until two years and four months ago, when she had a mis- carriage, followed by inflammation of the womb, since which time her courses have been suppressed. The feature, then, of this case is the suppression of the courses—but I shall prove to you that, in regarding the suppression in an abstract point of view, and attempting upon this partial basis to restore the function, you would not only fail in the ac- complishment of the object for which your remedies are administered, but you would aggravate the sufferings of your patient, and lapse into positive empiricism. In reply to a question addressed to her a few moments since, she says : " I have taken so much medicine that my stomach is quite turned over ;" —and again, she observes: " I have forcing-pains every month, and that's the time the doctor told me to take the medicine, for it would bring on my turns." If the declarations of the patient are of any value —if they establish any fact, it is this—that the sole object of the doctor was, through the medicines he ordered, to restore the menstrual func- tion ; but he has, as you perceive, from the testimony of the patient, failed in the attainment of his purpose. Does it occur to any one of you why he has failed in affording relief to this woman ? The entire in- terest of the case before us is embraced in this simple interrogatory; and its solution will shed a flood of light on the extraordinary circum- stances which have caused the interruption of the menses for a period of two years and four months. You have seen in the Clinique numerous cases of suppressed menses, produced by various causes—and you have likewise witnessed how readily they have yielded to judicious treatment. But the suppression in the case of this patient differs materially from that of all others which have been before you; and with a field for ob- servation of no limited circuit, and with a practice of fifty years, you 320 CLINICAL LECTURES. would probably not meet with one similar in its leading features. Those of you who have attentively analyzed the conversation which has just passed between this patient and myself, will, perhaps, be struck with the important fact disclosed in the dialogue, viz.: that two years and four months ago she had a miscarriage, followed by inflammation of the womb, and since that time her courses have been suppressed. Before introducing this woman to you, I interrogated her very fully, and as soon as she made the above announcement, I begun at once to suspect the cause of the suppression—and I immediately asked her whether she had not an enlargement in the lower portion of the abdomen. On her re- plying in the affirmative, I told her it would be necessary to institute an examination in order that I might ascertain the true nature of her dis- ease. To this she consented, and the examination has revealed a most interesting and unusual state of things. Before proceeding further, h£. yever, it is proper that I should tell you the motive and object of my suspicion. 1st. It occurred to me that this might be a case of menstrual suppression from an occlusion of the os tinea?; 2d. This opinion was formed from the circumstance that the sup- pression commenced immediately after the inflammation of the womb, and has continued to the present time. Supposing my suspicion to be confirmed by an examination, what connection, you may ask. is there between an occluded os tinea? and an enlargement of the lower portion of the abdomen ? When the menstrual blood is secreted, and has no outlet, it necessarily accumulates, under ordinary circumstances, from month to month in the uterine cavity, and thus the enlargement is pro- duced. In my lectures on pregnancy, you will not have forgotten how emphatically your attention was directed to this subject, and how earn- estly you were cautioned against mistaking, especially in the unmarried, this state of things for gestation. But what gives peculiar interest to this case, and constitutes it an ex- ception to a very general rule, is the fact that there is an imperforate os tinea in a female, who has borne two children. The fact of her having given birth to two children necessarily presupposes that the mouth of the uterus was not always imperforate, or, in other words, that the oc- clusion was not congenital. What, then, has produced the occlusion ? The whole history of the case seems to demonstrate that it is the result of the inflammation with which the patient was affected after her mis- carriage. This is the third example of imperforate os tinea I have met with during the last few years in married women, who had previously given birth to children. In the two former cases, I was called when the patients were in labor, and performed the operation of vaginal hystero- tomy, and in both instances the mother and children were saved. [The first case was reported in the New York Journal of Medicine for 1843, the second in the American Journal of the Medical Sciences for 1848.1 As soon as I had satisfied myself as to the true condition of the patient SUPPRESSION OF THE MENSES. 321 before us, I requested two of my staff, Drs. Martin and Savage, to insti- tute an examination, and thus afforded them an opportunity of testing the truth of my diagnosis. Now, gentlemen, permit me to ask you what is the moral of this case ? It is clearly this—that symptoms are not only faithless guides, but lead often to negative, if not to destructive results. Fortunately, in the present instance, the treatment has been limited to a negative issue. The indication here is obviously to remove, by an op- eration, the occlusion. It is the first step, without it all other medication would be abortive, and purely empirical. I propose, therefore, to introduce a trochar within the cervix uteri for the purpose of removing the obstruction. If I am right in my diagnosis of the case, the operation will demonstrate the fact, for when the cavity of the uterus is penetrated there should necessarily be a discharge of the accumulated menstrual fluid. When a medical man has, from a judic- ious survey of all the surrounding circumstances, arrived at a decision, he owes it to himself, I think, to show his confidence in that decision by promptly carrying out the treatment indicated. If this patient, there- fore, will consent, I shall proceed at once to do for her what my judg- ment tells me is most in accordance with the demands of .her case. " Now, my good woman, you have heard what I have said." " Yes, sir." " Well, then, will you permit me to relieve you ?" " Any thing you say, doctor." " Then, madam, I will do what is right for you." [Here the patient was placed on the bed, and the tumefaction of the abdomen in the hypogastric region was clearly visible. The professor observed that he would use the curved trochar for the purpose of penetrating the imperforate os; and, accordingly, taking his index finger as a guide, he introduced the instrument to the central and lower portion of the cervix, and carrying the trochar upward parallel to the long axis of the uterus, penetrated the lower portion of the organ without the slightest difficulty. The instrument was then withdrawn, and immediately Simpson's sound introduced, showing conclusively that the neck of the uterus had been penetrated. As soon as the sound entered the organ, there was a dis- charge of nearly a quart of grumous blood, which the professor regarded as the menstrual fluid which had been accumulating within the cavity of the womb.] You perceive this operation is a simple one, and yet it is not without danger if incautiously performed. In order that the os tincce may be kept open, it will be proper for a few days to introduce a gum- elastic bougie. This is all that will be required. The good sense of this patient in submitting to the operation has enabled us to relieve her, and she will have, I am confident, no cause to regret what has been done. The result has been very gratifying, and has established the truth of our opinion. "You need give yourself no anxiety, madam, but have faith in what I tell you—that you will, in a short time, be restored to health." " Thank you, sir." Physometra in a married Woman, aged thirty-two Years.—In- 21 322' CLINICAL LECTURES. TRODUCTION OF A SlLVER TuBE INTO THE UTERUS, FOLLOWED BY AN ES- CAPE of Offensive Flatus.—Mrs. C, aged thirty-two years, married, tho mother of seven children, seeks advice for an enlargement of the abdo- men, which commenced about eighteen months since, and which has caused her much anxiety of mind. " How long have you been married, madam ?" " Ten years, sir." " You say you are the mother of seven children ?" " Yes, sir." " Are they all living ?" " All but the last, sir." " When did it die, madam ?" " It was dead, sir, when it was born." " Was it taken from you with instruments ? " No, sir." " Did you go to your full time with it ?" " Yes, sir." " Do you know what destroyed it?" "I do not, sir. The doctor told me it was dead two months before I was delivered." " Did you see it after it was born ?" " No, sir." " What is the reason ?" " The women thought I should not see it." " Why so, madam ?" " I do not know, sir, except that they said it had been dead too long." Now, if you will connect this conversation with other circumstances which will soon be revealed in the history of this case, you will, I think, understand my motive, and appreciate the ground on which I predicate my diagnosis of the disease before us. There could, I apprehend, have been but one motive actuat- ing the friends who would not permit this patient to see her child after its birth—the motive of humanity. The child, in all probability, was de- composed, and unfit for the sight of the parent. I desire for a few moments to direct your attention to some of the peculiarities of this abdominal enlargement. In the first place, as you perceive, the enlargement is peculiar in shape, representing very accu- rately the form of an impregnated uterus; 2d. If you will now listen to the sound as I percuss, you will notice that it is resonant, and not dull. No matter on what portion of the enlargement I percuss, the sound emitted is still the same, uniformly resonant. It is the sound which accompanies a tympanitic condition of the abdomen. You notice, on the contrary, when I percuss above, or on the sides of the tumor, no such resonance—the sound is dull. Before we proceed any further in this investigation, I shall ask one or two questions. " Madam, does this tumor sometimes become smaller ?" " No, sir." " Are you certain of that ?" " Indeed, I am, sir. From the first time I noticed it, which was about two weeks after the birth of my last child, it has rather increased." Why do I ask whether the enlargement becomes sometimes diminished ? How repeatedly have you seen, in this Clinique, cases of abdominal dis- tention from flatus in the intestines, constituting what is known as tym- panites intestinalis, and how repeatedly, too, has your attention been called to the fact that one of the principal grounds of diagnosis is the alternation of increase and diminution in the size of the abdomen, the diminution depending on the escape of flatus, either by the esophagus or rectum? No such circumstance exists in the case before us ; you have heard the statement of the patient that there is no diminution in the PHYSOMETRA. 323 size of the abdomen, but its tendency has been to increase. It is quite evident that there is a collection of flatus somewhere; it is also evident that the collection is circumscribed. Two questions then present them- selves: 1st. Is the flatus the cause of the enlargement? 2d. In what is the flatus contained ? From a careful examination which I made of this case before introducing it to you, I am of opinion that the enlarged ab- domen is caused by tympanites of the womb, a disease known under the name of physometra. This affection is of rare occurrence, and indeed some authors have doubted the possibility of its existence. I have myself never met with an instance of unequivocal physometra, and therefore the case before us presents to me more than ordinary interest. When I commenced my examination of this patient, the idea of physometra did not occur to my mind, and I have now arrived at this diagnosis for the simple reason that in no other way can I account for the enlarged abdomen. It is not philosophical to become blindly wedded to opinion; such prejudice too often controls judgment and limits thought, it breaks the chain of logical induction, and substitutes error for truth. This is a great principle in the. investigation of morbid action—a principle in entire harmony with that substantial maxim in law, that you are to decide by the evidence, so help you God ! The physician, like the juror, has nothing to do with pre-conceived opinion; his mind must be free from all bias, and his convictions derived from an honest exercise of judgment. The feature in the case before us is the enlarged abdomen, and while in our investi- gation it is right that we should revolve in memory the various causes capable of producing this condition of things, yet it is due to truth and science, that no opinion should be formed which is not at least founded on a rational basis. Tumors of various characters, hydatids, pregnancy, tympanites intestinalis, tympanites abdominalis, a fatty omentum, molar gestation, ascites, encysted dropsy, various diseases of the uterus, etc., etc., are all so many circumstances, which may, in given cases, occasion a distended abdomen. In my examination of this case, I have had be- fore me these different circumstances, but there is no evidence that either of them exists, and therefore I am driven from necessity to some other explanation of the enlargement, which, as I have already stated, I believe to be due to physometra. Causes.—It has been urged by some writers that air enters the uterus through its cervix, and thus the collection is formed. This, to say the least, is improbable. When tympanites uteri—physometra exists, it is, I believe, in consequence of certain chemical changes, the immediate result of morbid action in the womb itself. A blighted ovum, a retained and decomposed placenta or foetus, or the decomposition of any intra- uterine growth, may result in the extrication of a gaseous fluid, which constitutes the affection before us; and my own opinion is, that this patient is an example of this very cause. You remember the important fact to which she alluded, in reply to my questions, viz.: that the women 324 CLINICAL LECTURES. would not permit her to see her infant after its birth, for the reason, as we suppose, that it was in a state of decomposition. This is a very in- teresting circumstance in connection with the case, and, I believe, fully explains the presence of the uterine flatus. Physometra may also result from retention of the menses, or of the lochial discharge. Baudelocque, Lisfranc, and others, have recorded cases of physometra in hysteric women, without having been able to detect any cause for it. May not, in these cases, a secretion of gas have taken place in the womb, such, for example, as occasionally occurs in the stomach of dyspeptic patients? Symptoms.—The principal symptom of physometra is the enlargement of the uterus, together with the local and general uneasiness necessarily more or less dependent on this circumstance. It is alleged, and I can readily imagine it to be so, that, in this affection, there is usually sup- pression of the menstrual function. This patient has informed me that she has not had her courses since the birth of her infant. Diagnosis.—It is possible that physometra might be mistaken for pregnancy ; but it would be an unpardonable error on the part of the physician. In physometra, there is an absence of all the symptoms of gestation, except the enlarged uterus and suppressed catamenia. The resonant sound on percussion, the lightness of the womb, the absence of the changes in the cervix, etc., are all so many circumstances to guard the medical man against embarrassment. Prognosis.—-I see no reason why a favorable opinion should not be given, under ordinary circumstances, as to the issue of the case. Treatment.—If there should exist within the uterus any decayed sub- stance, the first thing to be done is its removal; but if there should be nothing of this sort in the uterine cavity, and the distention be consider- able, I should have no hesitation in introducing a small tube into the organ for the purpose of evacuating the flatus. It may be necessary to repeat this operation several times. Having done this, I know of no plan of treatment, which presents a more rational hope of permanent relief than at once to change the morbid secretions of the lining membrane of the uterus, which will, I think, in this affection, be generally found more or less involved in diseased action—and restore to the uterus its healthy and tonic condition. For this purpose, I shall recommend the following course to be pursued: After evacuating the gas, which I shall attempt immediately, the patient will be directed to take one of the following pills twice a day until p.tyalism is produced. When this object—which I consider a sine qua non to the restoration of healthy action in the pres- ent case—is attained, the patient should drink in divided doses during the day half a pint of the following decoction, and continue the use of it for six or eight weeks: R Pil. Massa? Hydrarg.......3ij Pulv. Opii.......gr-iv Ft. Massa viipil. xxiv dividenda. # Decoct. Sarsaparilla c......Oviij Acid Nitric dilut.......3vj M. OCCLUSION OF THE iNUS—ENCYSTED TUMOR. 325 " Now, my good woman, you have heard my opinion of yciur case ; will you allow me to do what I think best for you ?" " Yes, sir." [The patient was placed on the bed, and the Professor introduced into the uterus a silver tube, through which there immediately escaped a quantity of offensive flatus, giving rise to a crackling sound.] You see, gentle- men, that this escape of gas from the uterine cavity is pretty conclusive evidence of the truth of the opinion at which we have arrived as to the cause of the distention. This evidence is gratifying to me, and I trust will not be without profit to you. Occlusion* of the Anus in an Infant aged one Week—Operation.* —Joseph B., aged one week, is brought to the Clinique by his mother, who appears to be very happy because her infant has been relieved. You will scarcely recognise, gentlemen, in this infant the little sufferer brought here some time since apparently in a moribund condition. To be frank with you, I am surprised to see it alive. This is the infant, you will remember, with imperforate anus, on which I operated when it was but a week old. The poor little thing had nothing to pass its bowels from the time of its birth. A variety of medicines had been ad- ministered, the doctor supposing this was all that was necessary to over- come the difficulty. On examining it, we found that the anus was oc- cluded. Of course there was but one thing to be done, viz., to remove the occlusion. This we did by a simple incision of the integument with a bistoury. As soon as this was accomplished, a large quantity of me- conium was discharged; the tumefaction of the abdomen became much diminished, and the countenance of the child gave evidence of relief. At the time I performed the operation, I very distinctly mentioned that, such was the low condition of the infant, I could make no assurance of a successful issue. I am now agreeably disappointed, and this recovery affords another evidence of the extraordinary tenacity of life. " Well, my good woman, I am very much pleased to see you here with that smiling little fellow in your arms. You must take good care of him." "Indeed, I will, sir, and I am very thankful to you, sir, for what you have done." " No thanks, madam. Good morning." Encysted Tumor seated in the Posterior Wall of the Vagina in a married Woman, twenty-three Years of AGE.f Mrs. L., aged twenty- three years, the mother of two children, the youngest eight months old, reports herself cured. You certainly, gentlemen, remember this patient. She had suffered for the last eight months from a tumor in the vagina, which gave her much distress. The tumor had been mistaken for pro- lapsus uteri, and a pessary had been introduced for the purpose of sup- porting the womb. On examination, we discovered that so far from the uterus being displaced, it was perfectly in situ, and the supposed prolap- sion was an encysted tumor imbedded in the posterior wall of the vagina. * Page 295. t Pa£e 283. 326 CLINICAL LECTURES. The causes, symptoms, diagnosis, and treatment of this character of tumor were fully discussed, and you will recollect I penetrated the tumor with a bistoury, and there escaped a wine-glass of tenacious fluid. The patient was directed to inject the vagina with castile soap and water for three or four successive days. No other treatment was ordered. The result you now have before you. The patient is relieved of much suffering and mental anxiety. Partial Paraplegia in a married Woman, aged thirty-two Years, from Instrumental Delivery—Remedial effects of Strychnine.— Mrs. W., married, aged thirty-two years, the mother of one child, ten months old, seeks advice for a sensation of numbness and loss of power in her lower extremities. " How long, madam, have you complained of numbness in your limbs ?" " Ever since the birth of my child, sir." " Were you quite well previous to your delivery ?" " Yes, sir, my health was always good before that time." " Had you a severe labor V " Yes, sir; I was in labor over two days, and I was delivered with in- struments." " Is your child alive ?" "Yes, sir." " I am glad to hear it, madam." This case, gentlemen, is one of unusual interest. You have in the person of this patient an example of partial paraplegia resulting from a difficult labor, together with the use of instruments, and it is proper that you should understand the connection between this character of labor, the partial numbness, and loss of power in the lower limbs. It is the relation of cause and effect. The numbness may have resulted in one of two ways—either from direct pressure on the nervous plexuses, or through reflex action on the spinal cord. How are you to distinguish between these two influences, and ascertain correctly whether the source of the trouble be in the spinal cord, or exclusively in the nervous plex- uses ? This certainly is an important question, and you determine the fact as follows :—When the numbness, etc., is occasioned by pressure on the plexus of nerves, but one limb will be affected; when, on the contrary, it arises from reflex influence, both limbs will be involved. This is the distinction made by the physiologist, and confirmed by observation. In the case before us the spinal cord has become involved, as is shown by the fact that both extremities are partially numb. It is an interest- ing circumstance for you to remember, that in enlargement of the uterus from various diseases, such as chronic inflammation, carcinoma, polypus, suppressed menstruation, etc., partial and sometimes complete paralysis of the lower extremities is occasionally the result. It is, however, usually evanescent, being completely under the control of remedies. It is not at all an uncommon circumstance to observe paraplegia following an attack of severe acute inflammation of the uterus. When, therefore, these cases present themselves to your observation in practice, you will, by a just discrimination of their nature, be enabled to EPILEPSY. 327 confer happiness on your patients, and reputation on yourselves, by the well-grounded assurance that the case is within the limits of treatment, and will speedily yield to remedies. Incipient paraplegia, as I have fre- quently reminded you, is often the first symptom of cerebral disturb- ance ; and in these cases, unfortunately, our prognosis will be more or less unfavorable. You see, therefore, how important it is in a case of paraplegia to be correct in your judgment as to the true source of the derangement. Correct treatment, and also correct opinion as to the issue, will necessarily depend upon this knowledge. " Are your bowels confined, my good woman ?" " They are not very regular, sir." Treatment.—It is important that the bowels should be freely moved, and for this purpose I shall order the following prescription: R Sub. Mur. Hydrarg......gr. x Pulv. Jalapse.......gr. xv Pulv. Antimonial.......gr. ij M. Ft. Pulv. Let this powder be taken this evening, followed in the morning by §j of castor oil. After the bowels have been properly moved, I shall place this patient under the influence of strychnia, which is the active principle of nux vomica. You are aware that strychnia exercises a specific influence on the spinal cord, but this influence is much more positive on the motor nerves than on those of sensation; muscular contraction is produced by this remedy through its action on the excito-motory center of the econo- my—the spinal cord. From the stimulus directed to this latter, a new impulse is imparted to the motor nerves, on whose action you know muscular contraction depends. Strychnia, then, being capable in this way of exciting muscular contraction, and, consequently motion, is a remedy admirably suited to those forms of paralysis in which especially there is no marked lesion, but simply functional derangement of the ex- cito-motory center. It is a remedy, however, to be employed with cau- tion, for the reason that an over-dose is often followed by serious, if not fatal consequences. Nothing is easier than- to produce tetanus by the injudicious use of this agent—and this is a complete demonstration of its influence on the spinal cord; for tetanus, when not complicated, is the result purely of irritation of this nervous center. In the use of stry- chnia, too much caution can not be exercised. It is proper to commence with minute doses, and watch the effects with guarded vigilance. One of the following pills may be taken twice a day: R Strychnia?.......gr. ij. Confect. Rosae......q. s. Utft. pil. xxiv. Epilepsy occurring at each Menstrual Period.—Jane A., aged sixteen years, whose case has been reported, was brought to-day by her 328 CLINICAL LECTURES. mother to the Clinique. The case is one of great interest from tho fact that this young girl had enjoyed good health until within a year past, at which time the menstrual function appeared. The very day on which the function manifested itself, she was attacked with epileptic convul- sions—and they have continued to occur with marked regularity at each menstrual crisis. You will not have forgotten, gentlemen, the opinion I expressed when this case was first brought before us. The epilepsy I regarded as the effect of irritation upon the cerebro-spinal axis induced sympathetically by the extreme nervous sensibility of the uterine or- gans, which sensibility being so much increased at the period of the catamenia resulted in the production of epileptic convulsions. The treatment ordered for the girl was intended to diminish the sensibility of the uterine organs, just before and during the menstrual crisis, with the hope that the irritation reflected on the cerebro-spinal axis being broken up, or at least measurably removed, the convulsions would either yield, or become modified in intensity. Epilepsy has often proved rebellious to remedies simply because it has been regarded as a disease per se. It requires only an accurate observation to show that it is in ninety-nine cases out of a hundred a result or, if you please, a symptom. If, then, this be true, it is the duty of the scientific prac- titioner seduously to pursue the inquiry—of what is it the effect, or, in other words, what has produced it ? The causes of epilepsy are quite numerous. Marshall Hall called the attention of the profession some years since to an important distinction in the origin of convulsive diseases—a dis- tinction founded upon physiological truth, and which should never be lost sight of in the treatment of these affections, which are usually regarded as the opprobrium of our science. He started with the broad proposition that the causes of these nervous diseases were traceable to impressions made either on the nervous centers, or upon the peripheral extremities of the nerves themselves. Hence the distinction into cen- tric and eccentric convulsions. Who will not at once recognize in this simple, yet truthful, classification of these nervous maladies, the good sense and logical mind of Marshall Hall, who has strewed the field of medicine with many a physiological flower ? If you reject his proposition, you can not in any way satisfactorily account for many mor- bid phenomena, which are constantly developing themselves in the hu- man system. But the proposition is not broad enough, for instead of speaking merely of convulsive affections, he might have included paralysis, va- rious neuralgic pains, etc. You are aware, for example, that irritation of the nerves of the stomach, either through disease, or the sudden ap- plication of cold, will oftentimes result in pain of the head, and more particularly of the forehead; and you are familiar with the fact that pain in the right shoulder is one of the ordinary consequences of an im- EPILEPSY. 329 pression made on the nerves of the liver. Numerous facts recorded by Graves and others, have shown that paralysis of the limbs, and more es- pecially of the lower, is frequently traceable to various diseases of the lungs, pleura, liver, stomach, intestines, ovaries, uterus, kidneys and prostate gland. In admitting, therefore, that paralysis, as well as convulsions, may re- sult secondarily from irritation of some of the centripetal nerves, it is easy to understand how a child, whose intestines are filled with undi- gested matter, may be attacked, as a consequence, sometimes with para- lysis, and sometimes with convulsions; and upon the same principle, paraplegia will occasionally be observed to follow a severe attack of dysentery, or enteritis. But why is it, you may very naturally ask, that there are sometimes convulsions, and at other times paralysis ? If the irritation be sudden, and the nervous centers characterized by much excitability, then convulsions will occur—and, under other circumstan- ces, paralysis will be developed—but it is not, I believe, yet determined positively why or how paralysis is produced or not produced. It is not improbable that an alteration in the nutrition of the spinal cord results from irritation of the centripetal nerves, but the modus in quo of this altered nutrition is a question of some obscurity. Dr. Brown-Sequard suggests that it may be from the action of the nerves on the blood- vessels ; he has also pointed out another cause of alteration in the spinal cord, and supposes it may result in paralysis. His argument is this : that the modification of a diseased viscus may be transmitted from the vis- cus to the spinal cord in one of two ways. 1st. If inflammation supervene in the neurilema of the nerves of the organs, it may pass on to the spinal cord itself; 2d. The nerve-tubes being endowed with capillarity may propagate, through their extremities in the altered viscera, the fluids in contact with them, and a portion of these fluids may then be conveyed by the fibres of the anterior roots (as they do not pass through a ganglion) to the spinal cord, in which they may light up inflammatory action, or in some other mode involve its nutrition. When the patient now before you first presented herself at the Clinique, I remarked that I felt a deep interest in the result, and regarded the epilepsy in her case as one of eccentric origin, explained as follows: At each menstrual crisis the peripheral extremities of the spinal nerves, which you know are distributed on the neck of the womb, as well as the same extremities of the sympathetic, which pass to the upper portion of the organ, being subjected to unusual irritation, this irritation is trans- mitted directly by the spinal nerves, and indirectly by the sympathetic filaments to the two great nervous centers, the brain and spinal marrow; and in this way the epilepsy was produced. At least, this was my theory and reasoning to explain the condition of the girl. The treatment was predicated upon the theory, and we shall presently learn what the result has been. 830 CLINICAL LECTURES. In epilepsy there is a loss of consciousness, and consequently the cere- brum, as well as the spinal cord, is more or less involved ; but in chorea, where consciousness is undisturbed, and where there is merely involun- tary muscular motion, certain parts of the so-called true spinal cord are alone the seat of irritation. " Now, madam, will you be kind enough to inform us whether your daughter has improved, or otherwise, under the treatment ?" " She has improved, sir, in one particular." " What is that, madam ?" " She does not have her fits as she formerly did, at the time of her courses, but she has them about ten days afterward." " Are they as frequent and severe as they were before she came to the Clinique ?" " They oc- cur once or twice between her turns, but they do not last as long." " Well, madam, from what you state, I am encouraged to believe that we shall restore your daughter to health, and I am sure such an event will make you both very happy." " Indeed, it will, sir, and many blessings on you!" You perceive, gentlemen, that the treatment which I ordered for this girl, has accomplished the object I proposed, and the result fully justifies the view I took of the cause of the epilectic convulsions. The nervous irritability of the uterus was quieted by the pills of camphor, hyoscyamus, and Dover's powder, together with injections of laudanum and tepid water into the rectum, which you remember were the remedies sug- gested, commencing two days before the expected menstrual period, and continuing until its termination. The result, so far, has been most sat- isfactory, and you are bound to accept it, not as the result of chance, but as a legitimate deduction from fair reasoning. What, now, is to be done, in order that the convulsions may be entirely removed, and this girl, who is just, as it were, on the threshold of womanhood, restored to health, and be enabled to play her part in the great drama of life ? For this purpose, and as a link in the original chain of argument, I would suggest that the same treatment be continued at the next menstrual turn, and in addition, after five days shall have elapsed from the termination of the menses, let fifteen drops of laudanum in a wine-glass of tepid water, be thrown up the rectum for three successive nights. This will probably so diminish the sensibility of the uterine organs, as to prevent a recur- rence of the convulsions. If the injections tend to constipate the bowels, the patient should take a seidlitz powder as circumstances may require. LECTURE XIX. 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 Bleed- ings.—Vicarious Menstruation.—Emmenagogue Medicines not always indicated in Suppression.—Vomiting in an Infant one Month old.—Periostitis, together with Venereal Condylomata in the Vagina, in a married Woman, aged twenty-seven Years.—Abscess of the right Labium Externum in 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. Engorgement of the Uterus from Suppression of the Menses, RESULTING IN CATALEPSY, IN A MARRIED WOMAN, NINETEEN YeARS OF age—Matrimony, its effect on the Uterine Organs.—Mrs. T., aged nineteen years, says she has been subject for the last four months to the falling fits. "How long have you been married, madam?" "Five months, sir." " What was the state of your health previous to your marriage ?" " It was not good, sir." " What did you complain of, my good woman ?" " The difficulty, sir, was with my courses." " Do you mean to say that they were not regular ?" " Yes, sir; I never had them but once, and that was when I was just seventeen years old, and they only continued one day." " When your courses were on you, did any thing particular occur that you remember ?" " Yes, sir; I lay it all to a fright I took." " What frightened you, my good woman ?" " I went in a boat sailing, and we were very near being upset, sir." " Well, madam, that was enough to frighten you. You say you have not had your turns since that time ?" " No, sir, I have not." " Do you suffer any pain?" "Oh, sir, you do not know how much I suffer every month." " What kind of pain is it ?" " Such a heaviness, sir, and bearing-down, and my back feels as if it would break." " Do you only feel the pain every month ?" " I have the bearing-down distress all the time, but it is so much worse at each month, when my turns ought to come on." " Are you troubled with sick stomach ?" " Almost all the time, sir." " Have you headache ?" " Yes, sir, my head troubles 332 CLINICAL LECTURES. me nearly all the time." " When did you have the first falling fit of which you speak ?" " Just three weeks after my marriage, sir." " Did you ever have one before your marriage ?" " No, sir." " Did you ever take any medicine to bring on your courses before your marriage ?" " Yes, sir, I took a great many pills, and my aunt gave me some tanzy- tea." " You are positive you never had a fit until after you were mar- ried ?" " I know I never had a fit, sir, but I used to feel very bad—so nervous that I did not know what to do." " How often have you been attacked with these fits since your marriage?" "They don't come on, sir, regularly. Sometimes I have them once in ten days, and I have gone three weeks without an attack." " Do you lose your senses when you have a fit ?" " I don't know any thing about them, sir." " Here is my aunt, who will explain it all." " Are you the good aunt who admin- istered tanzy-tea to this patient ?" " Yes, sir, indeed I am." " Why did you give the tanzy ?" " Because, sir, I thought it would help the poor thing." " I have no doubt, madam, that your motive was good, but your practice was bad." " Have you ever seen your niece in these fits ?" " Yes, sir, often." " When the fits come on her, does she know you ?" " No, sir, she is like a dead woman." " Does she move about ?" " No, sir, she is perfectly still; and I have seen her fall on her face, and one arm would be raised up in the air, and it would remain in that posi- tion, just as if she held it so on purpose." " You are quite positive she does not move or twitch when she falls down ?" " Indeed, I am, sir. I never saw such fits, sir. I have seen other people in fits, but they have always struggled." " Have you ever had any idea of what first caused these fits, madam ?" " Yes, sir, I always laid them to that fright in the sail-boat." " Well, madam, you are not far from right, and I shall show that the fright of which you speak was indeed the starting-point of the trouble. What was the state of your niece's health before her courses came on ?" " It was very good, sir." " She never had any fits previous to that time ?" " No, sir." I have a very special object, gentlemen, in asking these questions. The answers develop a state of things extremely interesting to the prac- titioner, and will tend, I think, to impress upon you the necessity of thorough investigation before forming your opinion as to the real nature of morbid action. This young woman presents a singular condition of system; and, to the popular eye, the principal feature of her case is the nervous disturbance, resulting in " fits." The practitioner, however, whose duty it is to look beyond the surface, will give to the " fits" nothing more than their true value—and his first object will be to ascer- tain what it is that has produced them. Before proceeding further, allow me, for a moment, to call your attention to the peculiar character of nervous disturbance with which this patient is affected. The description given by the aunt is so perfectly characteristic, that there can be no doubt as to the nature of this disturbed action. It is not epilepsy, nor ENGORGEMENT OF THE UTERUS. 333 is it hysteria, neither is it tetanus—it is evidently catalepsy. There is one peculiar feature, which marks and distinguishes this form of abnor- mal nervous action from all others, viz., the fact that the muscles of animal life remain during the attack unchanged, and in the same condi- tion in which they were previous to the approach of the convulsions. This is an important diagnostic symptom of catalepsy. There is no movement in this affection—no struggling—but the patient remains per- fectly quiet, with loss of consciousness, and the muscles contracted pre- cisely as they may have been before the paroxysms came on. You heard, for example, what the aunt told as to the position of this girl on one occasion when she was laboring under a cataleptic attack. Her lan- guage is, " I have seen her fall on her face, and one arm would be raised up in the air, and it would remain in that position, just as if she held it so on purpose." This is a graphic description of catalepsy, and exhibits the character- istic which distinguishes it from all other nervous derangements. In order that this case may lose nothing of its interest, and that you may appreciate it in all its bearings, I will suppose that, when you shall have entered the field of practice, one precisely similar in every detail shall present itself to your observation—or, in other words, that your opinion will be requested, and on the accuracy of your judgment is to depend the serious question of whether or not the patient is to experience relief. This is the fair putting of the argument; and, under these circumstances, I call upon you to say what would be the course which both common sense and science would point out as the one to be pursued ? Suppose, for example, that this woman had applied to one of you for advice, and by questions addressed to her you had drawn forth the statement which you have just heard. What would the statement have suggested as to the probable cause of the " fits" with which she has been affected ? This, after all, is the great point in the case before us, for if testimony is worth any thing, it is because of the amount of truth it establishes. A brief analysis of this case presents the following important facts : 1st. This woman menstruated for the first time when she was seventeen years of age; 2d. The menstrual function continued only one day, it having become suppressed in consequence of a fright in a sail-boat; 3d. From that time to the present she has never had a return of her courses ; 4th. Soon after the suppression, though she had no " fits," she became ex- tremely nervous ; 5th. She suffered more or less constant bearing-down pain, but it is very much increased every month, showing evidently the in- crease of pain to be due to the menstrual molinem ; 6th. This patient is 19 years of age, and has suffered from fits for the last four months, the first fit having occurred three weeks after her marriage; 7th. Previous to the first menstruation, her health was good. This is briefly a resume of the material points in this case, and it is proper I should tell you that, before introducing the patient here, I had 334 CLINICAL LECTURES. questioned her very closely. I did not entertain a doubt that the suppres- sion of the menstrual function was the origin of her nervous derangement; but without a vaginal examination I could not positively affirm to what extent the organic structure of the uterus was involved, if at all, and consequently whether the disturbance in the nervous system was owing simply to functional or organic derangement of this viscus. With the consent of the patient, I instituted an examination, and have ascertained that the uterus is about four times its natural size, slightly tender on pressure, but without any solution of structure ; in a word, the patient before us is affected with chronic engorgement of the organ. Without this examination per vaginam, I could in no way have arrived at a cor- rect conclusion as to the true condition of the uterus; I might, to be sure, have indulged in conjecture; but, as a basis for the judicious treat- ment of disease, we require something more substantial and positive than hypothesis. Having ascertained that the uterus is in a state of engorge- ment, the next question to be decided is, what has produced the engorge- ment, and what connection has it with the nervous disturbance develop- ing catalepsy ? The history of the case, if it prove any thing, establishes very clearly that the engorgement is a direct consequence of the sup- pressed menstruation. Suppression, however, is not always followed by engorgement of the uterus; but in the present case it is proved, by a chain of irresistible facts, that the engorgement is the direct consequence of the suppression. Here, then, we have an interesting state of things; a patient men- struates at seventeen years of age, the courses become suddenly sup- pressed, and do not again* appear. She marries when she is about eight- een years and six months of age; and three weeks after marriage she is attacked with cataleptic convulsions, which have continued at intervals to the present time. Although the suppression of the catamenia was the starting-point of the difficulty, yet it can not be considered the. exclusive cause of the convulsions. The engorgement has performed its part, also, in the production of this nervous derangement. This is not the place for me to speak of the different kinds of uterine engorgement, but I might mention, en passant, that a woman, whose menstrual function is normal is subject every month to a congestion of the uterus; as soon as each menstruation ceases, the congestion ceases. Again, a female may have what is termed the menstrual molimen, or monthly congestion, but no show of menstruation. In such case, it usually happens that the con- gestion subsides spontaneously, and does not re-appear until the following period. There are, however, exceptions to this rule, and you will oc- casionally observe, that, owing to some morbid condition of the mucous membrane of the uterus, perhaps a constricted state of the capillary vessels, the blood is not discharged under these circumstances, and it may occur that the congestion does not subside; the next period ap- ENGORGEMENT OF THE UTERUS. 335 proaches, the congestion is increased, and still no discharge of uterine blood. These phenomena may continue sometimes for several successive months, and the effect will be, as I think is fully exemplified in the case before us, a chronic engorgement of the uterus, resulting in serious dis- turbance of the constitution. This form of engorgement, produced as I have just explained, oftentimes makes insidious progress, and in some in- stances lays the foundation of malignant, and other degenerations of the uterus. You have been attentive witnesses, gentlemen, to the questions which I have addressed to this patient, and you will not have forgotten among her statements one to which I attach much practical value, for it elucidates very clearly an important, principle never to be lost sight of in the treatment of the diseases peculiar to women. You will remember she remarked that she had never been attacked with a " fit" previous to her marriage, although from the time that her menses became suppressed until her marriage she had felt extremely nervous and agitated; in other words, suffered from disturbance of the nervous system, but not to a de- gree to experience a convulsion. And she goes on to say that the first "fit" occurred just three weeks after marriage. To me this last disclosure is extremely significant, and I have no difficulty in establishing a connec- tion between the cataleptic convulsions and the peculiar circumstances under which they first occurred. You perceive that even before marriage the nervous system became unbalanced by the uterine engorgement; but it was not until after marriage that the engorgement, suddenly increased by the fresh afflux of fluids brought to these parts by sexual intercourse produced, through eccentric influence on the nervous system, the true cataleptic convulsion. That marriage does induce this afflux of fluids to the parts, is univer- sally conceded; and so generally is this fact understood, that nothing is more common, in cases of amenorrhcea in young girls, after medication has been unavailingly tried, to recommend matrimony as the only means left of bringing about the function. Fatal error in many instances—an error which has laid in an early grave many an interesting young crea- ture ! I have, gentlemen, cautioned you, until I am sure the caution yet wrings in your ears, never to form your opinion of disease from partial or abstract views—abstract reasoning is too often false reasoning, and is, therefore, not suited to the investigation of our science, the object of which is the development of truth. If you desire an illustration of the fallacy of abstract reasoning, suppose the case of a young girl, seventeen or eight- een years of age, in whom the menstrual function has never appeared. Looking merely at the fact that the menstrual function has not been insti- tuted, and utterly regardless of the various circumstances which are capa- ble of producing this condition of things, the physician will commence with emmenagogues, in the form of pills, powders, fluids; and when, after repeated efforts, he not only fails in the accomplishment of his ob- 336 CLINICAL LECTURES. ject, but greatly aggravates all the symptoms, he will recommend mat- rimony. The marriage is solemnized, and the poor girl and her friends doomed to disappointed hope. Her health continues to fail, and she dies, not from necessity, but simply because the true nature of the amenor- rhcea has not been understood. You will find, in the course of your pro- fessional observation, that there are many cases of amenorrhcea caused by a congested condition of the uterus; and if, under such circumstances, you administer emmenagogues and forcing medicines, the immediate re- sult of which is to throw an increased quantity of blood upon the uterine organs—precisely the same effect that results from matrimony—you will fail in affording relief to your patient, and at the same time almost cer- tainly provoke an early death. Our profession is not one of uncertainty, if its well-settled principles be taken as a guide; but it is one of cruel results, if its practice be left to surmises and vague conjecture. The question may occur to some of you—Why has this woman been affected with the cataleptic form of convulsion ? To this question it is only necessary to reply that the derangement of the nervous system aris- ing from diseases of the uterus, either functional or organic, are numer- ous, viz., epilepsy, catalepsy, hysteria, chorea, and sometimes mania; and whether it be one or other of these forms which is developed, will depend upon various circumstances, such as constitutional idiosyncracy, the grav- ity of the uterine affection, etc., etc. Treatment.—The nature of this patient's difficulty now being perfectly understood, and the true distinction having been made between cause and effect, the next point for consideration—the one in which this woman is deeply interested—is, What can be done to afford her relief, and restore her to her original health ? You will recollect she told us that she had taken a great many pills, and you are not to forget, also, the tanzy-tea administered by her good aunt. Without knowing the particular com- position of the pills, I will venture the opinion that they were emmena- gogue in their nature, and given for the same specific object for which the tanzy-tea was suggested, and, therefore, only tended to aggravate the morbid condition of the uterus. In a word, the broad indication here is to diminish the engorgement of the organ, which, as I have already remarked, is the cause of the cataleptic convulsions; and which, if it be not controlled, will very probably lead to more serious, if not malig- nant degeneration of the uterus itself. When the engorgement is rem- edied, the menstrual function will become restored. I shall order the following treatment: One dozen leeches to be applied to the vulva, and the bleeding to be promoted by warm fomentations and poultices; the three following pills to be taken to-night, followed in the morning by |j of castor oil: R Sub. Mur. Hydrarg......gr. xij t Pulv. Ipecac.......gr. j Ft Massa in pil. iij. div. VICARIOUS MENSTRUATION. 337 The bowels should afterward be kept in a soluble state by a wine-glass of the following saline mixture, as circumstances may require : R Sulphat. Magnesias ) Sup. Tart. Potassae 1.....aa 3J Aquae purae....... Oj Ft. Sol. At the time of the expected menses, when the bearing-down pain is in- creased because of the menstrual molimen, one dozen leeches should again be applied to the vulva. The diet to be strictly vegetable, and the patient to exercise as little as possible. " You will be kind enough, my good woman, to follow the directions, and return here one month from to-day." " Indeed, I shall, sir." " Good morning, madam." Suppression of the Menses, occasioned by Periodical Hemorrhoidal Bleedings—Vicarious Menstruation—Emmenagogue Medicines not always indicated in Suppression.—Mrs. L., aged thirty-two years, widow, the mother of two children, the youngest eight years old, has enjoyed good health until the last two years. " Are you certain, madam, your health was good until two years ago ?" " Yes, sir; I was perfectly healthy." " Do you know what caused your health to decline at that time ?" " My courses, sir, stopped on me, arid I have not had them since." " Do you mean to say that you have not had your ' turns' for the past two years ?" " Yes, sir." " Do you know what caused their suppression ?" " No, sir, unless it was hard work." " Have you taken any medicine to bring them on again ?" " Yes, sir, indeed I have; and the physic has made me feel very miserable; it has made my piles so bad that I am all the time in pain." " How long have you had the piles, my good woman ?" " I have had them for two years, sir." " Do they bleed ?" " Yes, sir, and then I always feel better." " Did they bleed when you were first attacked with them ?" " Yes, sir; and I have not had my courses since that time." " What was the state of your bowels before you suffered from the piles ?" " For about a month before they came on me, sir, mybowels were very much confined—and that has been my great trouble for the last two years; I don't sometimes have any thing pass me for three and four days." " Were your courses al- ways regular until you had the piles ?" " Always, sir; I never missed a ' turn' except when I was carrying and nursing my children." This conversation, gentlemen, reveals an interesting state of things • and you will not, I think, have failed to appreciate the peculiar point of the case. The patient before us has labored for the past two years under suppression of the catamenia. If, in prescribing for this woman, you permitted your minds to be exclusively engrossed by the mere fact of the suppression, you would very likely order emmenagogue medicines with a view of restoring the function. Look at the circumstances as detailed by this patient, and then tell me if, in your judgment, such treat- ment would either be rational, or likely to accomplish the object. I 22 338 CLINICAL LECTURES. have no doubt that the suppression in this case is due to the bleeding hemorrhoidal tumors, constituting a species of vicarious menstruation. One of the most frequent causes of hemorrhoids is constipation. Here, then, are several circumstances to be fully considered by the physician before attempting to restore the menstrual function. They are, however, to be considered in reference to their respective influence, and in the order of their action. 1st. The constipation; 2d. The hemorrhoids; 3d. The suppression. With this brief analysis of the case, it appears to me that the indications to be fulfilled are too obvious to need comment. If, instead of investigating the true cause of the suppression, you were to attempt to restore the function by the administration of emmenagogue medicines, you see plainly the inevitable result of such practice—your emmenagogues would increase the afflux of fluids toward the uterine and adjacent organs, and in this way would aggravate greatly the cause of the suppression—the hemorrhoidal tumors. Thus, while you would be defeated in relieving your patient of the suppression, you would, by this irrational treatment, render her case still more distressing. Treatment.—The point to be attended to in the management of this case is to arrest the vicarious discharge ; this can only be done by re- lieving the hemorrhoids, but as these are the effects of constipation, it follows that the first step in the treatment is to overcome this, and by producing a soluble condition of the bowels, the presumption is that the hemorrhoids will disappear, and this waste-gate being closed, the men strual function will become restored. If, however, when the constipation is overcome, the hemorrhoidal tumors should still continue, then it will be necessary to remove them by ligature, which you have seen me dc twice in the Clinique. All that I shall direct for this patient at present will be the following mild aperient, to be taken each night at bed-time in a glass of water or milk; it will be found often very useful in hemor rhoidal affections: R Sulphuris precipitat......gr. xv Magnesia......9 . 3j M. All stimulants should be avoided, with the use of simple diet. Vomiting in an Infant one Month old.* The little infant, aged foui weeks, who, it will be remembered, had been troubled with vomiting more or less for two weeks, was brought by its mother to the Clinique. and reported perfectly well. This little infant, gentlemen, vomited, &% many young infants will do, from a mechanical cause—gastric repletion. We ordered it no medicine, being satisfied that none was needed. A1J that we did was to direct the mother to nurse it less frequently. " Well, madam, did you follow the directions?" "Yes, sir, indeed I did." " Your infant is now quite well, is it not ?" " Yes, sir; there is nothing in the world the matter with it, thanks to you, sir." " Good morning, madam." * Page 290. VENEREAL PERIOSTITIS. 339 Venereal Periostitis together with Condylomata of the Vagina in a married Woman, aged twenty-seven Years.—Mrs. L., married. aged twenty-seven years, no children, complains of distressing irrita- tion in her genitals, and says that she has some lumps there which occasion her much annoyance. [Here the patient was placed on the bed, and on examination the professor discovered several venereal con- dylomata within the labia externa.] " My good woman, do you know what caused these little tumors, or lumps as you call them ?" " Yes sir, I contracted the bad disorder from my husband about six months ago, and I have never had my health since." " Well, madam, you are very honest, and I shall ask you no more questions, but will order a treatment which will remove these tumors, and restore you to health." " Oh! sir, you will do me a very great service." These tumors, gen- tlemen, which you perceive here, constitute one of the forms of second- ary syphilis, which you will occasionally meet with in practice—a good name for them is venereal condylomata. It is important that you should be correct in your diagnosis, and not confound them with other growths about the vulva, with the production of which syphilis has no concern. Besides the declaration of the patient, I have other evidences that these are of venereal origin—she is also affected with periostitis, another of the secondary results of the syphilitic taint. " Have you ever taken any mercury, my good woman ?" " Yes, sir, the doctor gave me some pills, and made my mouth sore." "You should be very thankful to the doctor, madam, for what he has done. If he had not given you the pills, your situation would be far more lamentable than it is." You are aware that much discussion has of late years taken place as to the mercurial and non-mercurial modes of treatment in venereal disease. By some, mercury has been altogether rejected, while it has been em- ployed by others as the only remedy of safety. Whatever controver- sialists, who, unfortunately, are too apt to aim more for victory than for fact, may say on this subject—or whatever may be the practice of physicians, I tell you with all the emphasis of truth that in the primary forms of syphilis, mercury is the heroic remedy—it is the sine qua non ; it is, in a word, the agent which alone can neutralize the poison that con- stitutes the essence of the malady. There are, however, two important circumstances which contra-indicate the use of mercury in the primary disorder, viz.: a sloughing chancre, and a scrofulous condition of sys- tem. But while we eulogize mercury, and regard it as the sheet-anchor of hope in this loathsome affection, we must not forget that it forfeits all claim to that distinction when incautiously administered. Its abuse results in the development of a mercurial cachexy, no less destructive to the health—nay, far more so under some circumstances—than the syph- ilitic disorder itself. Indeed, it is sometimes exceedingly difficult to distinguish between this form of cachexy, and secondary venereal. Treatment.—The following powder should be sprinkled on the tumors 340 CLINICAL LECTURES. once or twice a day—you have seen the good results from it in similar cases, which have been before you in the Clinique : R PulvSabina, >...... Sulphat. Cupri. ) Besides this local application, there is something more to be done for this patient—her system must be guarded against the effects of the sec- ondary disease under which she is laboring; and, perhaps, there is no medicine which will so completely accomplish this object as the iodide of potassium. To Dr. Williams, I believe, is due the credit of directing the attention of the profession to the almost magic effects of this remedy ; and its general use in these cases bears ample testimony to its value. In secondary syphilis, in which mercury has been previously employed in the primary state with judgment, the iodide of potassium rarely fails to effect a cure. It appears, among other things, to possess a peculiar control over irritation, and hence its remarkable and prompt efficacy in periostitis. It may be given either in substance or solution. I prefer the latter. A table-spoonful of the following may be taken twice a day: R Iodid. Potass. ......3 ij Infus. Quassiae.......§ ij Ft. sol. Abscess of the right Labium Externum in a married Woman, twenty-two years of age, from difficult parturition.—mrs. s., aged twenty-two years, married, the mother of one child three weeks old, seeks advice for a swelling, which she says has troubled- her more or less since the birth .of her child, and for the last four days has increased so much in size, and become so excessively painful, that she has not a moment's comfort. " When did you first discover, my good woman, that you had this swelling ?" " A few days after the birth of my child, sir." "Were you delivered with instruments?" "No, sir." "Was your labor severe ?" " Yes, sir, I thought I would have died." " How long were you in labor ?" " Three days, sir." " Is your child alive ?" " Yes, sir, and very healthy." " I am glad to hear it, madam." " Thank you, sir." [Here the patient was placed on the bed, and the swelling was examined by the professor, who pronounced it an abscess of the right labium externum.] This case is one of much practical interest, and it is extremely important that you should not err in your opinion as to the true nature of the swelling. Women, married and unmar- ried, are occasionally subject to tumefactions or enlargements of the labia externa, and, as you can readily appreciate, it is a matter of no little moment that you should form a just opinion as to the nature of the swelling. The first thing for you to do, in being consulted in a case like the one before us, is to revolve in mind the various causes of tume- faction in these parts. You will recollect that they may be as fol low: 1st. Hernial protrusion; 2d. Serous engorgement; 3d. Sanguin- RETRO-VERSION OF THE FUNDUS OF THE WOMB. 341 eous engorgement; 4th. Purulent engorgement from abscess; 5th. Sim- ple hypertrophy of the labia. The distinction between these different conditions of the parts is not difficult, if proper judgment be exercised; but a hasty opinion might re- sult seriously to your patient, and reflect but little credit on you as practitioners. Suppose, for example, through rash judgment, you should mistake a hernial protrusion for purulent engorgement. Your treat- ment in such case—plunging a bistoury into the swelling for the purpose of evacuating the pus—would not only be grossly improper, but would almost certainly destroy your patient. In all such cases, therefore, let me caution you to be prudent. I would not have you timid practitioners. On the contrary, I wish to cultivate in you a courageous spirit. But before the exercise of your courage, you must be satisfied in your minds that you are right. You now perceive, as I present this tumefaction to your view, that its nature is well defined—it is an abscess of the labium ; the fluctuation is quite easily recognized. The causes of this form of labial engorgement are injury to the part from instrumental delivery, or from undue pressure of the foetal head in a natural parturition, falls, blows, undue sexual intercourse, etc. The treatment may be divided into three stages. 1st. To attempt the discussion of the tumefaction; 2d. To facilitate the suppurative process ; 3d.. When matter is formed, to open the abscess freely. With the first view, evaporating lotions may be employed, nothing perhaps better than the liq. ammonise acetat.; to accomplish the second object, emollient poultices ; third, the bistoury or lancet. In the event of its becoming necessary to open the abscess, when the matter is evacuated, all that is required will be simple dress- ings. In these various stages it will be proper to enjoin upon the pa- tient rest in the recumbent position. " Now, my good woman, if you desire to be relieved, I will open this swelling, and you will very soon be restored to health." " Oh ! sir, it will hurt me very much." " On the contrary, it will give you immediate relief." " Well, sir, you may do what you think proper." [Here the Professor opened the abscess, and half a tumbler of pus was evacuated.] Retro-version of the Fundus of the Womb, in a married Woman, AGED TWENTY-FOUR YeARS.--CONNECTION BETWEEN ReTRO-VERSION AND Paraplegia.—Mrs. L., aged twenty-four years, married, the mother of two children, presents herself at the Clinique for advice, because of a painful pressure on her rectum, and a sensation of numbness in her lower limbs. " How long, madam, have you suffered from this pain in your back passage ?" " Ever since the birth of my child, sir." " Do you experience any difficulty in walking ?" " Yes, sir, when I stand up or walk, the bearing-down is much worse, and my' limbs are quite un- steady." " Do you feel as if you had not perfect control over them ?" " Yes, sir, and I am afraid I will lose the use of them." " Were 342 CLINICAL LECTURES. you quite well before the birth of your child?" "Yes, sir." "Had you any difficulty with your water after your delivery ?" " I could not pass it very well, sir." " Did you speak to a physician about it at the time ?" " No, sir, I thought it would pass over." " How long did you experience difficulty in passing your water?" " Oh ! sir, I was sick in that way more than a month." " Did you take nothing for it ?" " Yes, sir, I took some parsley-tea, and had warm cloths applied to me." " Do you mean to say that you did not pass your water for a month ?" " No, sir, I don't mean to say that; I could pass it, but very little at a time." " Did the lower part of your stomach become hard at that time ?" " Yes, sir, and it gave me great distress." " What has been the state of your bowels since this pressure on your back passage." " They have been very much confined, sir, and it almost killed me, when I had a pass- age. That makes me think, doctor, that the disease is all in my bowels." " Well, we will see about that, my good woman." This case, gentlemen, which, before introducing it here, I have exam- ined very thoroughly, is one of retro-version of the fundus uteri. On instituting a vaginal examination, I recognised the fundus of the uterus thrown backward, and resting upon the rectum—the uterus is also some- what enlarged. This is one of the displacements of the organ, which you will occasionally meet with in practice. Its diagnosis is not diffi- cult, but you will often experience much embarrassment in restoring the uterus to its normal position. I have repeatedly called your attention to this form of displacement, and there is a peculiar feature attending the present case, not unworthy of attention—it is the sensation of numb- ness experienced by the patient in her lower limbs. Do any of you see the connection between this condition of the lower limbs, and the retro-version with which she is affected ? I am sure, if you reflect for a moment, you will explain the connection, and you will do it in this way —the fundus of the uterus being turned backward, and also somewhat larger than usual, presses not only against the rectum, but also against the sacral plexus of nerves, from which originate the nerves which supply the lower extremities. It is this pressure, therefore, on the plexus, that explains the peculiar sensation of which the patient com- plains. Indeed, another circumstance is not to be lost sight of—the irri tation on the sacral plexus might have been sufficient to produce com- plete paraplegia. Suppose, then, when you return to your homes, the very first case in which you are consulted should be one of paraplegia in a married wo- man. You would not, I am sure, be very likely to suspect that the paraplegia was due to retro-version of the uterus ; for it is scarcely even spoken of as a cause of this form of paralysis. You would be more likely to refer it to some other influence. You would then, in a case like the present, fail in affording relief for the reason that the true causr of the paraplegia had not been recognized. What service do you imag- RETRO-VERSION OF THE FUNDUS OF THE WOMB. 343 ine this patient would derive from leeches, cups, blisters, etc., and the various remedies, among which you may place strychnia, which have been recommended for this species of paralysis ? The routinist would, perhaps, rely upon them ; but you, who seek for explanations of morbid action, and who demand a rationale of its effects, would probably not be content with a superficial view of the case—you would push your in- quiries beyond the surface—the paraplegia you would regard as the ef- fect, and in the absence of any other cause satisfactorily to account for its presence, you would refer it to its true source, the retro-version. The first object, then, would be to restore the uterus to its natural position, and thus relieve the sacral plexus from pressure. You will recollect that this patient suffered for a month, more or less, from retention of urine ; the bladder consequently became distended, and this is one of the most common causes of retro-version of the womb. Just in proportion as the bladder becomes enlarged by an accumulation of urine, it presses back- ward on the uterus. This pressure for a time is antagonized by the round ligaments, but ultimately they yield to the continued force of the distended bladder, and hence the retro-version. Treatment.—You will find few things in practice more difficult to treat than this character of uterine displacement. It is the bane of the surgeon, and, I might say, the plague of the accoucheur. Various plans have been suggested—pessaries of different kinds, instruments, etc., and I might here speak of the intra-uterine pessary, so much lauded by Valleix; but all these contrivances frequently fail even under the most favorable con- ditions for their use. I am much disposed to adopt the views of Amus- sat on this subject; and if this patient will consent, I shall have recourse to the remedy which has succeeded in his hands, and which certainly has the merit of explaining very satisfactorily and simply its mode of cure. Amussat, in such cases, cauterizes the posterior lip of the os tincse with the solid potassa cum calce, and he also touches with the same substance the upper and posterior portion of the vagina ; an eschar is thus formed, and adhesion is the consequence between the posterior lip and upper and posterior portion of the vagina; of course when the adhesion takes place the cervix uteri is drawn backward, and the fundus is placed in its natu- ral position. This is common sense—the operation has succeeded sev- eral times, as I have mentioned, with Amussat. " Madam, do you wish to be relieved ?" " Oh ! indeed I do, sir." " Then if you will come here next Monday, I will do what is necessary to restore you to health." " I will do whatever you say, sir." " That is right, madam. Good corning." The patient, gentlemen, who has just been before you, suggests, by a remark she made, the propriety of directing your attention for a few moments to a very important subject, viz., the necessity of a just diag- nosis between the diseases of the uterus and those of the rectum. You will 344 CLINICAL LECTURES. recollect, in reply to the question as to the state of her bowels, she re- marked "that it almost killed her when she had a passage, and that made her think the disease was all in her bowels." I am quite confi- dent that a false diagnosis is not unfrequently arrived at on this subject, and that original disease of the uterus is often mistaken for a supposed affection of the rectum. Lisfranc, I think, was one of the first to call at- tention to this practical point, and it is one in every way worthy of your special consideration. How often, for example, does it happen, in cer- tain displacements of the uterus, that the patient complains of no pain in the organ itself, but refers it all to the rectum, in consequence of the serious pressure made on the latter by the displaced uterus. Suppose a case of retro-version of the cervix, with more or less engorgement or induration, what would be more likely in such case than severe pain in the rectum, and yet the entire disease is limited to the uterus, the pain in the intestine being simply the result of mechanical pressure. Again, do you not at once comprehend the reason why the patient who has just left us suffered so severely every time she attempted to evacuate the bowel ? It was manifestly because, in the first place, the capacity of the rectum was diminished by the falling backward of the fundus of the womb, and, secondly, because of the sensibility of the uterus itself as the hard faecal matter pressed upon it. Oftentimes, I am sure, this very state of things has been referred to stricture of the intestine, and instruments have been introduced, of course without benefiting the stricture, for it never existed, but with positive injury to the patient from two causes, viz.: 1st. For the rea- son that the error in diagnosis substituted an imaginary for a real disease; and, secondly, the introduction of the instrument into the rectum could scarcely be otherwise than followed by more or less injury to the retro-verted uterus. The practical inference to be de- duced from these remarks is—be cautious in your diagnosis, and be sure not to confound symptomatic trouble with primary or idiopathic disease. I recollect having some time since been consulted by a lady from Bermuda, whose mind was full of apprehension that she la- bored under some serious affection of the womb. She had been mar- ried about three months, and for the last month sexual intercourse had become so painful, that it almost threw her into convulsions. It was under these circumstances that my opinion was requested. On visiting the patient, and listening to her story, nothing was more natural than for me to suspect that the cause of her sufferings was due either to dis- ease of the vagina or uterus, more especially as the intercourse of the previous two months had not been attended by any unusual difficulty. In instituting an examination, I discovered both the vagina and uterus to be entirely free from disease, but on the posterior wall of the vagina, just within the vulva, I felt a slight tumefaction, which, on pressure by the finger, was followed by the most intense pain, and caused the patient RETRO-VERSION OF THE FUNDUS OF THE WOMB. 345 to exclaim, " Oh, sir, that is what hurts me so much; that is what gives me so much pain." What do you suppose, gentlemen, occasioned the tumefaction of which I speak, and which constituted the entire cause of the lady's sufferings ? The tumefaction consisted of internal piles, or hemorrhoidal tumors, which had become extremely sensitive, and which, on the slightest touch, occasioned severe pain. This patient was soon relieved by the following treatment:—The bowels, which pre- viously had been much confined, and to which circumstance, no doubt, the hemorrhoids were due, were rendered soluble by mild aperients The patient was then recommended to have injected into the rectum every night half a pint of cold water, and for three or four hours each day a metallic rectum-bougie was introduced into the intestine, the object of which was, by its mechanical pressure, to diminish the volume, and ultimately remove the tumors. This treatment, perseveringly continued for four weeks, completely restored the patient to health. This case is not without instruction, and elucidates very fully the necessity of judicious discrimination before the application of remedies. Dr. Brown, of Lon- don, has, in a recent work on the " Surgical Diseases of Women," made some valuable remarks on the connection between diseases of the uterus, and more especially displacement of this organ, and certain secondary affections of the rectum. This subject is one of much practical import, and demands the attentive consideration of the practitioner. Women are, it is well known, more liable to diseases of the rectum than the male sex, and this, although in part it may be attributed to the more sedentary habits of the former, and the consequent constipation, " yet," as Dr. Brown observes, " another reason of the greater frequency is nc doubt to be referred to mechanical pressure of the uterus in pregnancy and to the influence of displacement and morbid action." 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. Complete Occlusion of the Meatus Urinarius, with Adhesion of the Walls of the Upper Fourth of the Vagina, together with 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.—Mrs. R., aged twenty-two years, married, complains of an inability to pass her water in the natural way, and says it runs from her nearly all the time through her front passage. " How long, madam, have you been married ?" " Just twenty-six months, sir." " Were you a healthy woman before your marriage ?" " Yes, sir ; I never had a day's sickness, thank God!" " You have had a child, have you not ?" " Yes, sir." " When was it born ?" " Fifteen months ago, sir." " How long were you in labor ?" " Three days, sir." " Was your labor severe ?" " No, sir, but it was lingering." " Had you any one to attend you ?" " Yes, sir ; there were two doctors with me." " Was your child born alive ?" " O ! no, sir ; the poor little thing was all bruised, and its head was a good deal injured." " Why so, madam ?" " The doctors did it, sir, with the in- struments." " Then you were delivered with instruments, were you ?" " Yes, sir; indeed I was, and a poor sufferer have I been ever since !" " No matter, my good woman, do not deplore the past—you have been cruelly wronged, but we will endeavor to do something for you—at all events, we will make you more comfortable." "Thank you, sir." " Before your delivery, had you any trouble with your water ?" " None in the world, sir." " How long after the birth of your child did you COMPLETE OCCLUSION OF THE MEATUS URINARIUS. 347 experience trouble in this way ?" " Since the birth of my child, sir, my water has always troubled me—it runs from me, and I can not help it." " Did you call the attention of the doctors to this circumstance ?" " No, sir—for they never came near me after I was delivered!" " Then, madam, they did not do their duty." " Indeed, they did not!" " How long was it after the birth of your child that you were able to leave your bed?" "I could not go about, sir, for nearly six months." " Have you had your courses since your confinement ?" " Only once, sir, about two months ago, and I thought I would have died from the forcing-pain I had." " Did the usual quantity pass from you ?" " No, sir ; very little, indeed." The case before you, gentlemen, exhibits another of the many instances of professional brutality constantly occurring in this populous city; and it is time that something should be done to arrest the reckless temerity of men calling themselves physicians, who, if we are to judge them by their acts, place a very insignificant estimate on human life. But the melancholy feature of this whole business is, that these assaults on health and life are made under the protection of a diploma, and therefore are perfectly within the record ! No; a diploma, though it may serve the purposes of the holder, is insufficient to justify the moral wrong of the sufferings entailed on this unhappy woman ! They are sufferings, as I shall show you, of gross ignorance, or a wanton disregard of life. A diploma without knowledge is a curse to its possessor, and a fearful in- strument' of destruction to the community. With knowledge, too, must be conjoined a refined morality based upon that Christian principle, " Do unto others as you would wish others to do unto you." You have before you a poor woman, whose health is her only capital, whose daily bread is the product of her daily labor, and who has had entailed upon her, either through ignorance or unpardonable carelessness, a complication of maladies which, even if they be measurably relieved, will cause her more or less distress during her entire existence ! The first question which naturally presents itself to the mind in viewing the serious afflictions of this patient is this: What has produced this state of things, and could it, by a proper exercise of judgment, have been avoided ? She was delivered with instruments, and to their unskillful and unnecessary employment is to be referred all her present difficulties. There is no evidence before us that the use of instruments was at all indicated. The patient tells us that " her labor was not severe," it was " only lingering!" She, then, has fallen a victim to that " hot haste," which too often prevails in the lying-in chamber; or to that undying fondness which some men cherish for operative midwifery. Let this case be a lesson to you—think of it in your hours of meditation, and let it act as a shield for those who confide their lives to your custody! In the eye of heaven murder loses nothing of its atrocity because concealed from the ken of human observation; so is it with the dark deeds of our 348 CLINICAL LECTURES. profession. The diploma may afford a mantle, so far as earthly juris- prudence is concerned—but the time of reckoning will come with ap- palling retribution. In my lectures on instrumental delivery, I have endeavored to impress upon your recollection the necessity of constantly keeping in view these two principles: 1st. A moral justification for the use of instruments; 2d. Such an employment of them as shall secure, as far as may be, the maximum of good, viz.: safety to both mother and child. In the case before us, no such result has been accomplished; on the contrary, to use the language of the mother, " the little child when delivered was all bruised, and its head was a good deal injured!" And now I shall pro- ceed to show you the lamentable situation of this poor woman—she is, indeed, an object of sympathy, and calls for our kind consideration. I have already examined her with great minuteness in my private room, and several of my staff—Drs. Styles, Bostwick, Beauchamp, and Gregory —have each recognized the singular complication of injuries with which this patient is afflicted. [The patient was placed on the bed, and the Professor proceeded to direct attention to the different points of in- terest.] Here you perceive the meatus urinarius, or outer opening of the female urethra; I now endeavor to introduce into it a female catheter. You see I can not introduce it. I now take a small probe, and repeat the attempt—and again I fail. [And the Professor requested Drs. Brown- Sequard and Tunison, who were sitting by him, to make the attempt to introduce the probe into the urethra—they both tried and both failed.] There must be some reason for this failure; and the impossibility of in- troducing the probe is one of the results of the instrumental delivery, viz.: entire occlusion of the anterior portion of the urethra. I have never before met with an occluded female urethra the result of injury ; and I do not remember of having seen an instance of the kind recorded in the books. It must of necessity be extremely rare. You are aware that inflammation of the mucous surfaces usually termi- nates in suppuration, and not in adhesion; and it is only in cases of ag- gravated inflammatory action that the latter result is possible. On one occasion, I attended a lady with stricture of the urethra, the only exam- ple I have ever met with, and which, also, is of extreme rarity. This case was seen by my friend, Dr. Satchwell, a graduate of the Univer- sity, and now practicing in North Carolina. The next point of interest in this case is the vesico-vaginal fistula, and it is through this fistula that the urine passes more or less constantly into the vagina. I now call your attention to another circumstance, also of extremely rare occur- rence. As I introduce my finger into the vagina I find at the upper fourth an adhesion of its walls, there being near the central portion of the adhesion a small opening, through which I now introduce this probe. You have heard the statement of the patient that she has menstruated but once since her confinement, and you will recollect her remark that COMPLETE OCCLUSION OF THE MEATUS URINARIUS. 349 " she thought she would have died in consequence of the forcing-pains she had." I can not tell what the real condition is of the os uteri, but the small opening in the vagina will very satisfactorily explain the char- acter of the pain experienced during the menstrual flow. Here, then, is a sad state of things resulting from gross carelessness or ignorance on the part of those to whom this woman had confided her health and life. There is, however, another feature not to be passed over without allusion—such is the condition of this poor sufferer that intercourse with her husband is utterly impossible ; and this impossibility will continue to exist until an operation shall be performed by which the cohesion of the walls of the vagina shall be removed. I told you that this was a case of complicated injury, and you now see for yourselves in what the complication consists: 1st. An occluded urethra ; 2d. A vesico-vaginal fistula; 3d. A cohesion of the upper fourth of the vaginal walls. Treatment.—What can be done with a reasonable prospect of afford- ing relief to this poor woman ? It is very evident that no operation for the present can be resorted to for the purpose of remedying the fistulous opening—for, suppose we succeed in doing this, how would she be ena- bled to evacuate the contents of the bladder, there being an occlusion of the anterior portion of the urethra ? The indications, according to my judgment, are as follow: To remove the cohesion of the vaginal walls; this being done, then to operate on the urethra, and render it pervious, and lastly to attempt the restoration of the fistulous opening. These three operations will require to be performed singly, as nothing could justify an attempt to perform them at the same sitting. " Now, my good woman, you have heard my opinion; are you willing to submit to an operation ?" " I will submit to any thing, sir, that you say—for I can not be worse off than I am now!" " Well, if you will be guided by my advice, I will do all in my power to relieve you." " But you will not perform any operation to-day, will you, sir ?" " No, if you prefer it, I will delay it for one or two weeks, or any time that will be most convenient to you." " I will consult my husband, sir." " That is right, madam; if he gives his consent, come here two weeks from this day, and you shall be attended to." " Thank you, sir." " Good morn- ing, madam !" There is one feature about the case of the patient before us which deserves more than a passing remark. I allude to the vesico-vaginal fis- tula with which she is afflicted, for in all truth it is an affliction. There is an opening between the bladder and vagina, through which the urine is constantly escaping, thus entailing upon this unhappy sufferer distress and annoyance, the full measure of which can be known only to herself. This form of fistula is oftentimes the result of the unskillful use of in- struments, and it will sometimes be the consequence of long-continued pressure of the child's head against the vesico-vaginal septum, inducing inflammation, and subsequently ulceration. In my lectures on midwifery, 350 CLINICAL LECTURES. you will remember how emphatically, when upon the subject of forceps delivery, I directed your attention to the danger of blind obedience to some of the rules laid down by certain distinguished writers. I told you that, occasionally, the use of the forceps will be indicated when there is not the slightest disproportion between the foetus and maternal pelvis. The labor, for example, may have been perfectly natural, and all things have gone on well until the head reaches the inferior strait. At this stage of the labor, either convulsions, exhaustion, haemoptysis, rupture of the womb, etc., etc., may occur, and render immediate delivery abso- lutely necessary. It is important that the rule for artificial delivery, under these circumstances, should be clearly understood, and that the lessons inculcated by some of the latest English writers on the subject should be suffered to pass unheeded. I can not but view the directions given by these authors, with regard to the time of applying the forceps, as fraught with evil not only to the safety of both mother and child, but also to the reputation of the accoucheur. Let us, for example, take Dr. Ramsbotham, one of the most recent authorities on the subject, and whose work is, no doubt, in the hands of many of our American students'. In speaking of the rules for the application of the forceps (page 216), he says, " Before the forceps can be applied, the os uteri must be entirely dilated, and the head must have come down into the pelvis sufficiently low to enable us to feel one or both ears distinctly. It is necessary to touch one or both ears, because they become the guide to the proper adaptation of the blades." Again, at page 228, the same author observes, " If no pro- gress have been made for a number of hours, and, especially, if impaction should have existed for four hours, then, provided an ear can be felt, and the parts are not so rigid as to endanger laceration, we are justified in employing the forceps." The underlining here is my own, and I wish particularly to call the attention of the pupil to the words as italicised. According to Dr. Ramsbotham—and almost all English authors agree with him—the ear of the child's head must be felt before it would be justi- fiable to apply the forceps. In the first place, I would observe that my own experience teaches me that it is not an easy thing to reach the ear, even when the head is at the inferior strait; and, secondly, if the rule as laid down by Dr. Ramsbotham be adopted, fatal consequences must in- evitably often ensue to both mother and child. To illustrate this point, let us suppose that the head is in the pelvic cavity; the mother suddenly becomes exhausted, either from hemorrhage or the fatigue of antecedent effort. No matter what the cause may be, she is exhausted, and immediate delivery is indicated. The accoucheur introduces the finger, and endeavors to reach the ear; he does not suc- ceed ; the patient's situation becomes more and more alarming; he again makes the attempt to find the ear; he fails ; he feels in his heart, indeed every thing clearly indicates that the forceps should be applied, but he can not reach the ear; he delays, in the hope that " the head may VESICO-VAGINAL FISTULA. 351 come down into the pelvis sufficiently low to enable him to feel one or both ears distinctly." Alas ! this proves fallacious. The assistants supplicate him to do something to relieve the patient, for they see she is dying; and what will it avail, under these melancholy circumstances, for him to exclaim, " I can do nothing, for the ear of the child can not be felt ?" His patient, of course, sinks, and here are two lives sacrificed because of a precept in which I can see neither propriety nor meaning. Let it not be supposed that this is an overdrawn picture. Such results must in- evitably ensue from an adherence to the rule to which I have just alluded. When Dr. Ramsbotham says that " it is necessary to touch one or both ears, because they become the guides to the proper adaptation of the blades," he makes use of language that, I must confess, surprises me not a little. If there be any meaning in what he says, it is simply this, that unless the ears are felt, it will be impossible to know how to arrange the blades of the forceps, because of the ignorance of the accoucheur as to the posi- tion of the head. Admitting the truth of this author's reasoning, when the head is at the inferior strait, which I most unequivocally deny, how is the position to be ascertained when the head is still at the superior strait ? Certainly not by feeling the ears, for these can not be felt once in a thousand times, before the head has descended into the pelvic cavity. The position of the head can be told both at the inferior and superior strait by the direction of the fontanelles, sagittal suture, etc., etc. ; and these will indicate the manner of applying the forceps, and of seizing the head in its bi-parietal measurement. The rule, therefore, for you to adopt, is to pay no regard either to the ear or the length of time the head may have been in the excava- tion, but to proceed to artificial delivery the moment the life of either mother or child becomes seriously endangered. The very essence of forceps-delivery, that which commends it so strongly to the consideration of the profession, is the ability with which it enables us to save both mother and child. Therefore, if artificial delivery be indicated, have recourse to it before the life of the child has been sacrificed, or the vital force of the mother so far expended as to render her recovery extremely doubtful. I do not advocate a meddlesome midwifery, but I do most strenuously recommend such an opportune application of the means put into our hands of affording relief as will achieve the maximum of good to both mother and child. Treatment of Vesico- Vaginal Fistula.—Few lesions have proved more difficult of cure than the one of which we are now speaking. Various methods have been proposed, and with varying success. Such, for in- stance, as cauterization with the nitrate of silver, actual cautery, etc. The suture has proved successful in the hands of many surgeons ; and, among our own countrymen, may be more particularly mentioned Dr. Hevward, of Boston, and Dr. Marion Sims, formerly of Alabama, and now of New York. The suture employed by the latter he calls the 352 CLINICAL LECTURES. " clamp" suture, and it is now recognized as one of the most efficient means of remedying the lesion in question. An interesting account of the operation as recommended by Dr. Sims, will be found in the American Journal of Medical Sciences for January, 1852. Jobert of Paris, in his Traite des Fistules Vesico-uterines et Vesico- vaginal, etc., gives a full account of his mode of operating in these cases, in many of which he has succeeded. In connection with this case it may not be unprofitable to mention the following instance of injury to the vagina, in which I operated, and in- duced premature artificial delivery with safety to both mother and child, twice successively. It was published in 1844, in my edition of Chail- ly's Midwifery: "The lady was a native of Canada. Her husband, some months after marriage, took her to South America, where she was delivered of a child. He stated to me that she was suffered to remain in labor five days; and after experiencing the most agonizing pains, she was sponta- neously delivered of a putrid foetus of immense size. In two months after her delivery she began to walk about the room, and although weak, she was otherwise in tolerable health. The first intimation she had of any thing wrong was the excessive pain in any attempt at sexual inter- course ; this proved to be impossible. In the course of a few weeks they sailed for New York, and as soon as they arrived, my late lamented friend, Dr. Bushe, was sent for, and was requested to take charge of the case. At this time his health was so infirm as to disqualify him from attending to general practice, He sent a note to me by her husband, requesting that I would take this lady under my professional charge. On visiting her, and making an examination, I found that the entire vulva was in a state of adhesion, allowing only a small opening for the meatus urinarius. After hearing an account of her labor, this condition of things was easily explained. From the long and severe pressure of the head of the foetus against the walls of the vagina, violent inflammation ensued, resulting in sloughing and a consequent adhesion of the vaginal parietes. The indication in this case was obvious—the vagina needed restoration. Accordingly, I commenced an incision just below the mea- tus urinarius, and extended it about an inch downward; the scalpel soon came in contact with cicatrices, so resisting that it appeared almost as if I was cutting on iron. As soon as I completed the incision, I introduced a small sponge covered with oil-silk, and retained it in situ with the T bandage. By occasionally withdrawing the sponge and renewing it, I found that the vagina yielded slowly to this sort of pressure. With the aid of a small-sized rectum-bougie, carefully introduced twice a week, and after being withdrawn, replaced by the sponge, the vagina, in the course of a month, permitted the introduction of the finger; then I had an op- portunity of ascertaining its condition. It was filled with hard and unyielding cicatrices, in the form of rings. Having succeeded in dilat- PREMATURE ARTIFICIAL DELIVERY. 353 • ger and Jacobi. Dr. Barnes himself reports a case, successful in its issue, in 1851. 356 CLINICAL LECTURES. questions which I have addressed to this patient. The particular feature of the case is the discharge of blood from the vagina with which she has been affected more or less constantly for the last year. But you are to remember that, in order to afford her relief, the physician requires some thing more definite than the simple fact that there is a loss of blood, and that there are forcing sensations on the back passage, a frequent de- sire to pass water, nausea, etc. To each and all of these circumstances he must give a due value; and it will devolve on him, by a just analysis, to solve the question: What has produced these phenomena ? In order that no doubt may exist in your mind as to. the truth of this reasoning, allow me to tell you that various conditions of the uterus may give rise, not only to this profuse sanguineous discharge, but also to the other symptoms which you have just been informed are its accompaniments in the case before us. For example, polypus, sub-mucous fibrous tumor, carcinoma uteri, an atonic state of the exhalents on the internal surface of the womb, and an op- posite condition, inflammatory congestive engorgement, may each produce the series of symptoms of which this patient complains. If this be cor- rect, and no shade of doubt can exist on the subject, what does common sense indicate as to the course to be pursued preliminary to any plan of treatment which may be suggested ? Why, undoubtedly, to ascertain the existing cause of the discharge, and other phenomena. There is but one mode of arriving at this knowledge—a vaginal examination. This I. have made, and have discovered no polypus, or sub-mucous fibrous tumor, no carcinoma, but a congested condition of the cervix uteri, in which the body of the organ also participates. This congestion or en- gorgement is not recent, it is not acute, but it constitutes an example of what is known as chronic engorgement of the uterus. To the touch, the organ presents a sensation of softness, forming a peculiar and interesting species of engorgement; and it is a very important matter not to con- found it with other engorgements of the uterus, the essential and almost constant accompaniment of which is hardness, not, however, the hard- ness of true schirrus. The " soft engorgement" is always accompanied by a sanguineous discharge more or less profuse; and if the true nature of the uterine engorgement be not undertsood, its progress is not only certain, but in that progress there will be developments of morbid action, which will ultimately result in the production of destructive organic disease. This form of engorgement is by no means uncommon, and you will often meet with it at the period of the final cessation of the catamenial function. You would, perhaps, imagine, a priori, that the menorrhagia would necessarily relieve the congested vessels; but such is not the re- sult in the particular form of engorgement now before us, for here the tissues of the uterus are soft—the vessels have lost their power of con- tractility—they are constantly more or less full of blood, and, under PROFUSE MENSTRUATION. 357 these circumstances, the sanguineous discharge per vaginam does not relieve—in other words, disgorge them. While, then, the discharge does not relieve the uterine engorgement, you are not to lose sight, at the same time, of the certain effects of this drain on the general constitu- tion. You can not fail to appreciate in a case of this kind the absolute necessity of a vaginal examination before instituting a plan of treatment. Without the examination, it would be utterly impossible to comprehend the peculiar condition of the uterus, and consequently the true cause of the more or less constant loss of blood. Now that we know that " soft engorgement" exists, we can readily explain why it is that the sanguine- ous discharge is a necessary consequence, and, still further, the treatment proper to adopt in order first to remove the engorgement of the uterus, and secondly its effects. It can scarcely be necessary for me to repeat to you what I have so frequently stated, that there are several causes of menorrhagia. For ex- ample, in one case it will be owing to plethora, the remedy for which will be well-directed depletion. In another it will be due to a peculiar spasmodic or irregular contraction of the uterus, the cure for which will be anti-spasmodics, at the head of which, for this specific purpose, may be placed ipecacuanha, in tolerant doses. But if we were to apply either of these modes of treatment in the instance before us, we should not only fail in restoring this woman to health, but we should very probably aggravate her suffering—for here, there is neither spasm of the muscular fibres of the uterus, nor fullness of habit, but simply a passive conges- tion of the uterine parenchyma, with loss of tonicity in the blood-vessels. The remedy, therefore, which I shall recommend, under these circum- stances, as the one peculiarly adapted to overcome this state of things, and impart to the uterus its normal and healthy action is ergot. The secale cornutum is a most efficient remedy in many cases, and, under judicious administration, it will prove its excellence; but, like many other good medicines, it is liable to abuse, and oftentimes, from this cause alone, it is destructive in its results. There is some difference of opinion as to the true modus operandi of ergot. Some contend that its influence is not limited to the uterus, and, therefore, that it is not exclu- sively emmenagogue in its action; and in order to sustain this view, they allege that it will arrest hemorrhage in other organs than the ute- rus, simply because it acts as astringent on the capillary and exhalent circulation generally. This, I think, may be doubted. At all events, further confirmation is required to establish the fact. It is, however, generally admitted that ergot exercises a specific action on the uterus, and this is shown by the severe contractions which usually follow its ad- ministration. It, therefore, has a claim to be classed among the special stimulants which we know do not act upon the entire nervous system, but only on particular portions of it. There is no better example of a special stimulant than strychnia, the action of which is directed specifi- 358 CLINICAL LECTURES. cally to the medulla spinalis and the nerves which originate from it. Ergot acts also, as does strychnia, on the spinal marrow and its tribu- taries, and it may, therefore, be considered par excellence the remedy in all cases of uterine inaction, except where the co-existence of certain cir- cumstances contravene its use. There are two other remedies which possess this peculiar influence over the uterus, but not in so marked a manner, such, for instance, as rue and borax. For the purpose, then, of tightening, if I may so speak, the parenchymatous structure of the uterus, I shall order the following prescription : R Tinct. Secal. Cornut......§ ij A tea-spoonful in a wine-glass of cold water twice a day ; and, as an aux- iliary to the ergot, half a pint of water, taken cold from the pump, may be thrown every morning into the rectum. In order to keep the bowels regular, two of the following pills may be taken at bed time: R Massas Hydrarg. ~i Assafoetidse >......aa 3j Saponis 5 Ft massa in pil. xx dividenda. Trismus Nascentium in a female Infant seven Days old.—Lucy W., aged seven days, has been affected with spasms for the last forty-eight hours. "Why do you bring that infant here, my good woman?" " Oh! Sir, it has the ' fits.' " " You are not its mother, are you ?" " No, sir, its mother is sick in bed, and I have brought the babe here, sir, to see if you can do any thing for it." " That child, madam, is too young to be brought here; you should have known better than to expose it in this way. Was it a healthy infant when born ?" " Yes, sir." " When did it first take the fits, as you term them." "The day before yesterday, sir; it would not take the breast, and it cried and worried a good deal." " Well, what then took place ?" " Its little jaws got stiff, and it had all sorts of twitches." This case, gentlemen, is interesting in several aspects. The little infant before you is laboring under a disease, which unfortunately is almost always fatal; many of you, perhaps, have never had an opportunity before of witnessing an example of it. It is known as the Trismus nascentium, a species of tetanic convulsion ob- served in infants soon after birth. Its true nature has been a topic of much discussion, and conflicting opinions have been expressed on this subject. There are two points, however, in which there appears to be a concurrence of sentiment, viz.: its almost uniform fatality when fully developed, and its defiance of remedies under almost all circumstances. It is proper, therefore, that you should be able to recognize this affec- tion, and to state plainly, while you are doing all that science can sug- gest, that in the great majority of cases it is a fatal malady. It will sometimes appear as early as twelve or twenty-four hours after birth—■ TRISMUS NASCENTIUM. 359 though, as a general rule, it is more frequently observed to commence between the fifth and tenth days. This disease is not uncommon among the negroes of the south, and it is the opinion of Dr. James Clarke that it is produced by the smoke of the green wood consumed in the cabins. It is, I think, much more prob- able that the disease is due to the ignorance of midwives in attend- ing to the umbilical cord. A melancholy tribute has been paid to the ignorance of those old women to whom, through a mistaken judgment, are committed the wives and daughters of the southern country, at the most interesting, if not the most perilous period of their existence, I mean at the time of parturition. It is for you, by your appeals to com- mon sense, to eradicate this prejudice—prove to those to whom you are endeared by ties of affection that human life is too sacred, its tenure too frail, to be entrusted to the uneducated midwife, whose ideas are scarcely adequate to, and rarely beyond the management of the poultry- yard ! I feel that I have a right to speak on this subject—I am a south- ern man not only by birth, but in pride and in heart. The interests of the South are mine—and I am identified in truth and in feeling with all that touches her, whether it be her institutions, her general prosperity, or the moral and physical well-being of her sons and daughters! Trismus nascentium occasionally prevails as an epidemic, a remarka- ble example of which occurred in the Lying-in Hospital at Stockholm in 1834; and it is said that at that time a singular coincidence was ob- served between its greatest prevalence, and the changes of temperature. This affection is common in the West Indies, and it is computed that in the colony of Demarara one half of the new-born infants die from it. Some have supposed that trismus is peculiar to warm climates; this, however, is not strictly true, for, according to Dr. Holland, nearly all the children born on the south coast of Iceland die of this affection, and the only means of preventing depopulation is through immigration. Causes.—The production of this disease can not be exclusively trace- able to climate, for it occurs both in the tropical and arctic regions. After death in this affection, post-mortem examinations have, in many instances, revealed an effusion of blood in the thecae of the spinal cord, and also in the membranes and sinuses of the brain; and hence many have been disposed to attribute the disease to congestion of these nerv- ous centers. Admitting, however, the truth of these autopsies, it must not be too hastily concluded that engorgement of either the brain or spinal cord is the cause of trismus—for, in the first place, it is an im- portant fact for you to remember that the quantity of blood circulating in the nervous centers of the young infant, compared with the quantity in the nervous centers of the adult is relatively greater; and secondly, if the effusion noticed in trismus prove any thing, it proves, in my judg- ment, that it is simply an effect of the convulsive spasm, and not the cause. You know very well that one of the ordinary consequences of 360 CLINICAL LECTURES. fatal eclampsia, either m the adult or in the infant, is more or less effu- sion in the nervous centers. Another opinion, according to Romberg, has been recently advanced by Dr. Scholer, which appears much more plausible; he says, in eighteen children who died of trismus, he discov- ered inflammation of the umbilical arteries in fifteen, the arteries having been found swollen at the point at which they approach the urinary bladder. The same observer has failed in all examinations of infants who have died of other complaints, to detect inflammation of the um- bilical vessels. I am quite disposed to believe there is much truth in the views of Dr. Scholer, and, moreover, that this inflammation of the umbilical arteries is owing to the rude manner in which frequently the cord is tied—sudden and undue pressure on these vessels by a round string being apt, I think, to excite inflammation, which is soon propa- gated to the vessels in their progress toward the bladder. To avoid this unnecessary constriction, I recommend you to employ a piece of flat tape, by which an equable pressure only, and all-sufficient at the same time, will be made on the cord. The influence of vitiated air in the production of certain forms of inflammation is incontestable, and this very influence has been fully demonstrated by the tables of Dr. Clarke in the affection which we are now discussing. He remarks that up to 1782, of seventeen thousand children born in the Dublin Hospital, two thousand nine hundred and forty-four died of trismus; when, through the introduction of a better discipline, by which the wards were more freely ventilated, the mortality was four hundred and nineteen out of eight thousand and thirty-three! This is an interesting fact, and proves at least the connection between this malady and an impure atmosphere. Mental emotions affecting the milk of the mother may also be enumer- ated among the causes of this affection; as also a retention of the me- conium. Trismus nascentium, whatever may be its exciting cause, is unquestionably a nervous affection, resulting from reflex action. Symptoms.—Before the disease is developed, the infant becomes rest- less ; its sleep is broken; it seems anxious to take the breast, and then immediately refuses it. The muscles of the jaws become rigid, as also those of the tongue; other muscles soon become affected, and there is sometimes complete opisthotonos. The stomach and bowels are often deranged, and jaundice is not an unfrequent complication. Prognosis.—Trismus nascentium is perhaps the most fatal disease of infancy. Treatment.—On the hypothesis that inflammation of the umbilical arteries may sometimes be the cause of trismus, I repeat what I have already remarked to you, viz., secure the cord with a piece of flat tape, and you may at the same time spread over the cut portion of the cord collodion, which Latour has found so serviceable in the prevention of internal inflammation. Should the meconium be retained, prompt means must be taken to have it evacuated. Warm baths, frictions with cam- UTERO-LUMBAR NEURALGIA. 361 phorated oil, etc., may also be resorted to. A case is recorded in which an infant was saved in this disease by the administration of one drop of laudanum every hour, 3 ss having been given before recovery was com- plete. Some interesting facts have been published by Drs. O'Shaugnessy and O'Brien in connection with the tincture of Indian hemp in the treat- ment of tetanus in the adult, sixty and eighty drops having been given every hour. Another mode of treatment appears to have been em- ployed with success; it is the inhalation of chloroform. The results recently published by Professor Simpson and others are quite favorable to the influence of anaesthesia produced by chloroform, in cases of tetanus and of trismus nascentium. It may be useful, in this affection, commenc- ing with three or four drops. Utero-Lumbar Neuralgia in a married Woman, aged twenty-six Years.—Mrs. S., married, aged twenty-six years, the mother of one child, aged two years, complains of pain in the region of the uterus, from which she has suffered for the last six months. She is also troubled with a mucous discharge from the vagina. " How are your ' courses,' my good woman ?" " They are quite regular, sir." " Is the pain in your womb severe ?" " Yes, sir; it troubles me very much, and I am afraid there is something serious the matter with me." " Have you any pain in the back ?" " Yes, sir; when I rub my back, I always feel a spot that seems tender—when I touch it I feel pain." I have frequently, gentlemen, directed your attention to the various sym- pathies excited in different portions of the system in consequence of functional and organic derangements of the uterine organs; and you have been admonished, in your diagnosis of disease, to exercise a careful vigilance in order that you may institute a just distinction between these sympathies, which are nothing more than effects, and the true cause to which they owe their origin. The case of the patient before us affords me an opportunity of dwelling a few moments on what I consider, in its practical bearings, one of the most important points connected with that wide, if not unlimited field of inquiry, uterine pathology. Until within comparatively a short time, there prevailed, if not posi- tive ignorance, at least very confused notions respecting the numerous forms of pain, which occasionally display themselves in the uterus itself, in the vagina, in different portions of the pelvis, in the back, abdomen, chest, etc.; these pains being sometimes regarded as effects of disease of the uterus, sometimes as idiopathic, and, again, without any determinate view of their pathology, they have been treated on principles purely empirical. Now, however, through the researches of Valleix, Malgaine, Mitchell, and others, we have not only the true explanation of certain morbid phenomena, which previously had been entirely misunderstood, but we have also at hand the remedial agents, which will remove these phenomena, and lead to a restoration of health. This woman, whose 362 CLINICAL LECTURES. story you have heard, complains of pain in the back and pelvis, and also in the uterus. She has told us, that in rubbing her back, which she was recommended to do by some of her friends, on touching one particular spot she has felt considerable uneasiness. In addition to the pain of which she complains, she has a discharge of mucus from her vagina. These are the only manifestations of morbid action in the case of this patient. Will you permit me to ask what they indicate, and whether you can form a correct opinion as to their true signification ? You would, I am sure, be embarrassed in your diagnosis without additional light on the subject. When this patient stated her case to me, I examined her per vaginam very minutely, and discovered the uterus and adjacent organs entirely free from any appreciable disease. Not only is there an absence of structural lesion, but also of any menstrual derangement. The pa- tient, nevertheless, is troubled with a mucous discharge from the vagina, which it is important to bear in mind, and to which we shall allude more particularly as we proceed. There- are one or two features, however, which I have observed, and to which I wish to make allusion for a moment, in order that you may at once comprehend the characteristic peculiarities of the case before us. On making the vaginal examination, there was nothing recognized at all abnormal, until, on gently pressing the cervix uteri with the finger, the patient said it occasioned her much uneasiness. I then examined the spine, and on the side of the second lumbar vertebra there was a cor- responding sensation of pain. You are aware that the existence of pain is not in accordance with a perfectly healthy condition of the economy. It denotes some infraction of that harmony without which, if I may so speak, unity of function can not continue, and, therefore, it is the duty of the physician, under these circumstances, to analyze the pain in direct connection with its accompanying circumstances. The term pain is al- together relative. It may in one instance be the result of inflammatory action. When the surgeon amputates, the pain is simply the effect of irritation. And, again, there is the pain of neuralgia, which is strictly of the irritative kind. You need not look beyond the present case to become convinced of the truth of what I tell you. The very symptoms of which this patient complains, if you confine your attention exclusively to them, you will recognise to be the symptoms of various morbid con- ditions of the uterus and vagina. They occur in chronic inflammation, in carcinoma, in dysmenorrhea, etc. How, then, are you to discriminate between the pain of these affec tions, and pain from other causes ? The reply is obvious. By a careful digital examination (the well educated sense of touch being preferable to the speculum) you ascertain the existence or non-existence of the two former conditions; and by addressing questions to your patient you will soon learn whether or not there is any thing wrong in the menstrual function. But, gentlemen, I have made this examination, and, as I have UTERO-LUMBAR NEURALGIA. 363 already mentioned, there is neither chronic inflammation, carcinoma, dysmenorrhea, nor any other structural or functional disturbance of the uterine organs, excepting the discharge of mucus. What, then, is it that produces the pain ? This is the simple question for us to decide, and on its proper solution will depend the failure or success of our remedies. The disease with which this patient is affected has been described by Valleix under the name of utero-lumbar neuralgia, which is a species of a more comprehensive affection to which, I believe, he also first directed the attention of the profession—the lumbo-abdominal neuralgia. The former malady, the utero-lumbar neuralgia, consists essentially in an ir- ritation of the lumbar nerves, the irritation usually concentrating itself on the cervix uteri; and in connection with -this subject Valleix men- tions an important fact, viz.,. that when the neuralgia is limited to one side of the lumbar region, the pain in the neck of the uterus is also con- fined to one side; and when it exists on both sides of the vertebrae, the pain in the cervix is more decided on the side in which the neuralgia is the most intense ; and he further observes that it may, perhaps, be urged that the pain in the uterus is not the result of lumbar neuralgia, but the effect of disease primarily seated in this organ, thus producing sensibility of the nerves—the principal argument in favor of this hypothesis being the circumstance that cauterization of the cervix uteri is frequently fol- lowed by a cessation of pain both in the uterus and back. But this, he properly continues, is no proof at all, for every day's experience demon- strates that a blister applied near the knee will very often remove the pain which previously had existed in the whole extent of the sciatic nerve. Here, then, gentlemen, is an example of morbid action not so uncommon as you might be disposed to imagine, in which the palpable feature is pain. Some authors would call this rheumatism of the womb, others hysteralgia, etc.; but these terms are too general, for they do not express the true nature of the affection; they do not indicate its pathol- ogy, and consequently lead to no sound therapeutic application. You may remark that there is another feature which accompanies this case— the discharge of mucus. You are not, however, to conclude that there must of necessity be organic disease of the uterus because there is a dis- charge of mucus from the vagina. In speaking of this form of secre- tion, I have already reminded you that it may be the result of various diseased conditions, and that, under some circumstances, it will be rec- ognized where there is no appreciable disease either of the uterus or vagina. The interesting tables of Marc D'Espine which I have cited elsewhere, when speaking of leucorrhea, show very conclusively what you will your- selves recognize in practice, that a discharge of mucus from the vagina, more or less profuse, will occasionally be observed, constituting a species of leucorrhea dependent exclusively, as has been proved, on a peculiar ir- ritation of the uterine nerves. That the nervous system does exercise a 364 CLINICAL LECTURES. very decided influence over secretion—and this latter will be modified by the various phases to which the nervous structure is liable by incidental and other circumstance—is a truth which few will be disposed to contro- vert. Have you never experienced in your own persons the sudden effect of a savory dish on the increased secretion of saliva? If you wish to see this influence exhibited in a very positive manner, hold a piece of meat before a dog, without permitting him to touch it, and you will soon observe the saliva to run in quantity from his mouth. If you will ap- ply this same principle to the uterine organs, you will have no difficulty, I apprehend, in comprehending the practical operation of a law which you should never lose sight of at the bed-side—a law which establishes the fact that uterine catarrh may exist irrespective of any inflammatory action, and merely as the result of a peculiar state of the nerves of the uterus. This important principle in uterine pathology has been fully discussed by Reclam, Mitchell, Malgaine, Beau, and others; and, assum- ing it as a basis for their therapeutics, they have abandoned the absurd practice of treating every case of vaginal mucous discharge as one simply of " whites," the routine remedy for which has consisted in the different astringent washes. On the contrary, in keeping with their views of its pathology, they have treated, and successfully too, this particular form of uterine catarrh consistently, viz.: through revulsive agents applied to the lower portion of the spine, such as blisters, cauterization with the red-hot iron, etc. I can not direct your attention to a more important practical fact, worthy to be stored in memory, than the strongly-marked reciprocal connection between the nerves of the lower portion of the spinal cord and the organs of generation. This connection is developing new and important remedial agents, and must lead to results of great value—another of those striking evidences of substantial progress in our science, through the march of mind. Suppose you should be consulted in a case bearing the distinctive marks of the one before us; it is not unlikely that you would altogether misapprehend its true character—the mucous discharge you would prob- ably regard as an evidence of some structural disease of the uterus, while the pain might possibly incline you to the opinion that it was due to any thing else than its true cause—irritation of the utero-lumbar nerves. Many women are annoyed for years by these two symptoms—pain and a discharge of mucus from the vagina—and they are subjected to every variety of medication; they fail in obtaining relief; they have hoped against hope; life becomes a burden, and finally, with exhausted patience, they seek in the embraces of empiricism what they in vain looked for in the legitimate walks of science! How true is it that the success of quackery depends not on its own merits, but on the carelessness of thoso to whom are entrusted the sacred rights of medicine. Causes.— Utero-lumbar neuralgia is undoubtedly the result of a pecu liar condition of the nerves of the lower portion of the spinal cord ; what it is that gives rise to this peculiar state we do not probably understand; EPILEPTIC CONVULSIONS. 365 but we know from observation that there exists between these nerves and the genital organs, both in the female and male, a reciprocal influ- ence. An interesting example of this influence in the latter is furnished by a specific pain in the testicle, which has been called ileo-scrotal, from the fact that it is merely the spread of neuralgia, through the ileo-scrotal nerve, from the lumbar region to the scrotum; and in the same way is explained the existence of severe neuralgia in the labia externa of the female, the pain being propagated through the ileo-pudendal nerves. Symptoms.—The patient complains of pain, sometimes quite distress- ing, in the uterus; there is also more or less pain in the back, rendered perceptible by pressure; the uneasiness in the uterus is always increased by a digital examination, or sexual intercourse, and also by the introduc- tion of the speculum. There is often a discharge of mucus accompany- ing uterine neuralgia. This malady may be complicated with other affections of the uterus, but most frequently it exists alone. It occasion- ally is marked by periodicity. Diagnosis.—Pain on pressing the cervix uteri; pain, also, from press- ure on the side of the lower extremity of the spine.. Prognosis.—A favorable termination may certainly be promised, provided the nature of the malady be fully understood. Treatment.—This consists essentially, and I may say exclusively, in powerful revulsives to the spine, or in cauterization of the cervix uteri. Mitchell, of Dublin, of whose practice we have already spoken, relies on the red-hot iron to the spine ; Valleix resorts to repeated blisters. The latter, however, commends also the application of the actual cautery to the cervix; while Malgaine prefers scarifications of that portion of the uterus. I very much prefer, as preferable to the red-hot iron and blis- ters, the insertion of a nitric acid issue on the side of the lumbar verte- bras ; it is less repugnant than the former to the feelings of the patient, and is more positive in its action than blisters; and besides, it is not followed by irritation of the bladder, so common an effect of the absorp- tion of cantharides. When the utero-lumbar neuralgia is characterized, as will sometimes be the case, by distinct periodicity, it will usually yield to the sulphate of quinine. Epileptic Convulsions in a married Woman, aged twenty-nine Years.—Mrs. H., aged twenty-nine years, married, the mother of three children, has suffered for many years from periodical attacks of epilepsy. " Do you remember, madam, when you were first attacked with convulsions ?" " Between thirteen and fourteen years of age, sir." " Had you menstruated at that time ?" " No, sir; my courses did not come on until I was fourteen, and after that I did not see any thing until I was in my sixteenth year." " You say the first attack was between thirteen and fourteen years of age, before you had menstruated." " Yes, sir." " When had you the second attack ?" " Just before I had my turns the second time, when I was sixteen." " After you passed your 366 CLINICAL LECTURES. sixteenth year, were your courses always regular ?" " They were regu lar, sir, as to time—but I was not sick at any period more than on« day." " You mean, then, to say that you were not like other females in this particular ?" " I mean to say, sir, that at my periods the show was very slight, and I knew something must be wrong." " When had you the third attack of convulsions ?" " They always came on me a day oi two before my courses; and sometimes two or three days afterward. 1 can always tell, sir, when they are coming on by my feelings." " What are those feelings, madam ?" " A great fullness and headache." " You have, I believe, three children ?" " Yes, sir." " During your pregnan cies, were you free from these convulsions ?" " Yes, sir; I never had any attack while I was carrying my children." This dialogue, gentlemen, which you have just heard is not without profit; it removes much of the obscurity of the case, and puts us in possession of very important facts. The testimony is of the most positive nature; it is not what the lawyers term circumstantial—but it is direct and thorough, proving broadly every point, and establishing with moral certainty the cause of the epileptic convulsions, viz.: abnormal menstru- ation. This testimony will bear a searching analysis ; you can not shake it by any cross-examination, no matter how ingeniously instituted, or how adroitly it may be conducted. I have repeatedly spoken to you of the numerous and important sympathies of the uterine organs—they have been exemplified both in health aud disease; and you have been told how these sympathies undergo shades of difference in organic lesion, as well as in functional derangement. Your attention has been directed on several occasions in the Clinique to epilepsy as connected with uterine disturbance. The case of Ann K., aged nineteen years, whose menses had been suppressed for a year, and who, as a consequence, had been attacked with epileptic convulsions, you must remember with interest; and you will not have forgotten the treatment, which restored her to health. Both in retention and suppression of the menses, as also when the loss is defective, various nervous disturbances display themselves. In one patient, depending upon peculiarity of temperament, you will have hysteria; in another, catalepsy ; in another, chorea ; in another, epilepsy ; and sometimes even mania will present itself. These are examples of eccentric nervous disturbance to which I have very fully alluded in pre- vious lectures. Let me call attention to one interesting circumstance in the case before us. In reply to a direct question, this patient states that during her three pregnancies, she never had a convulsive attack. The intelligent student will not be willing to pass this fact by without giving to it due value. It is, indeed, one of the most significant features in the case. He will see that gestation produced for the time being an entire change in the economy—the attention of nature was especially directed to the uterus during pregnancy—there was an afflux of fluids setting toward it, and the utero-placental circulation was a sort of derivative influence, in- EPILEPTIC CONVULSIONS. 367 terrupting temporarily those morbid phenomena which resulted in the convulsive spasm. Now, the question presents itself—What is the pros- pect of relief in this case? The length of time this patient has been subject to the epileptic convulsions, is much against the prospect of permanent relief. Yet it is our duty to spare no effort, and give her all the advantage of rational and judicious treatment. The object is to en- deavor, if possible, to establish a healthy menstrual function. For this purpose, I would again recommend the favorite plan of artificial men- struation. Let her lose from the arm every two weeks 5 ij of blood, and give her one of the following pills every second night:— R Barbad. Aloes.......3ij Sulphat. Ferri.......3j Ft. Massa in pil. xx dividenda. An occasional styptic foot-bath at night will be useful. In addition to the above treatment, I would suggest a nitric acid issue on the side of the lumbar vertebrae with a view of diminishing the uterine irritation.* * For the past few years, the treatment of epilepsy has called forth some important researches, and various therapeutic agents have been suggested. The modes of treat- ment found most successful may be, I think, embraced under the following heads: 1st. Tracheotomy; 2d. Cauterization of the larynx and pharynx; 3d, Application of the red-hot iron, and other escharotics to certain portions of the head or neck; 4th. The section of a nerve in cases in which there is a decided aura; 5th. Certain special remedies, such as the oxide of zinc, ammoniated copper, the cotyledon umbilicus, etc., etc. Tracheotomy was proposed by Marshall Hall as the most efficient treatment in those cases of epilepsy in which there is what he terms laryngismus, i. e., spasm of the glottis, preventing the free passage of atmospheric air. "Whatever may be thought of the theory, it would seem that the results are not very favorable to this operation. Dr. RadclifFe has shown that in seven cases in which tracheotomy was had recourse to, one only was positively cured, two died, and the others but slightly improved. The conclusion, then, is that this operation should not be performed unless the pa- tient, during the epileptic paroxysm, be positively threatened with suffocation. Cauterization of the larynx, first proposed by Dr. Brown-Sequard, is comparatively so slight an operation, that there can be no objection to its employment, together with other means, as he has already suggested; but the rationale of this mode of treatment is not altogether without obscurity. At first Dr. Sequard was inclined to the opinion that its efficacy was traceable to its power of preventing the laryngismus; since, how- ever, he has found that a single cauterization of the larynx or pharynx will prevent the occurrence of an expected fit. Cauterization of the back of the neck with the actual cautery has sometimes been followed by good results, and it is alleged that its efficacy is due to a change thus produced in the nutrition of the nervous centers. In this way has been explained the restoration of the cases reported by Leberton, Mettais, and others. In some instances of epilepsy there is what is called a positive aura epileptica, and if the aura originate from pressure of a tumor on a nerve, the ex- tirpation of the tumor has been followed by the relief of the patient; but should there be no tumor, it has been proposed by Dr. Sequard to divide the trunk of the nerve, which supplies branches to the part from which the aura arises. In the use of the oxide of zinc and ammoniated copper, Dr. Herpin, of Geneva, has recognized the happiest results; but others, in the employment of these remedies, have not been so successful. The cotyledon umbilicus, also, has been followed by good effects, according to the testimony of those who have employed it in epilepsy. LECTURE XXL Hysteria from Defective Menstruation in a Widow "Woman, aged twenty-nine Tears, the Mother of two Children, the youngest six Years old.—Final Cessation of the Menses in a married "Woman, aged forty-two Tears, the Mother of five Children.— Suppression of the Menses of two Tears and four Months duration, in a married Woman, aged twenty-six Tears, the Mother of two Children, from Imperforate Os Tincse, the result of Inflammation.—Physometra in a married Woman, aged thirty- two Tears, the Mother of seven Children.—Engorgement of the Uterus from Sup- pression of the Menses, resulting in Catalepsy, in a married Woman, nineteen Tears of age.—Complete Occlusion of the Meatus Urinarius.—Operation.—Suppres- sion of the Menses, occasioned by Periodical Hemorrhoidal Bleedings.—Vicarious Menstruation.—Abscess of the right Labium Externum, in a married Woman, twenty-two Tears of age, from Difficult Parturition.—Placenta Prasvia in a case of Twins, expelled from the Uterus after a seven Months' Gestation, with one Placenta, and one Amnion and Chorion, both Cords inserted into the Plaoenta 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 Tears, the Mother of eight Children. Hysteria from Defective Menstruation in a Widow Woman, aged twenty-nine Years.—Rachel M., aged twenty-nine years, the mother of two children, the youngest six years old, has, for the last six months, suffered from menstrual irregularity; she is regular as to time, but irregular as to quantity, the function not continuing at each period more than one day. She is greatly depressed in spirits at times, and her nervous system is much deranged, with occasional paroxysms of laugh- ter, alternating with those of sobbing; she complains of a ball in her throat (globus hystericus), together with a sensation of choking, palpita- tion, and a frequent desire to pass water. " Were your courses always regular, madam, previous to the last six months ?" " Always, sir." " Did you ever experience the nervous turns of which you speak before that time ?" " Never, sir; they have only come on me within the last four months." " How are your bowels ?" " They are confined, sir." The case before you, gentlemen, is one of hysteria, an affection which has been variously described, and variously understood. It is a disor- der of frequent occurrence, and though seldom fatal, yet, through the phenomena which accompany it, hysteria necessarily produces more or less anxiety. The ancients entertained singular, if not ludicrous views HTSTERIA FROM DEFECTIVE MENSTRUATION. 369 respecting this affection ; they attributed it in part to certain wanderings of the uterus, imagining that this organ, or an aura from it, passed from one portion of the system to another, and thus caused the hysteric par- oxysm. Again, another doctrine prevailed, which taught that hysteria proceeded directly from the brain—hence you will read in the books of uterine hysteria, and cerebral hysteria. It is a very remarkable fact that the early fathers, ignorant of physiology, and unable as they were to summon to their aid, in their diagnosis of disease, the beautiful laws which this science has developed, should so often have approached the truth, without being able to give, if I may so speak, " a reason for the faith that was in them." In their exposition of hysteria, they were right in one sense*—but their attempted elucidation of opinion was ludicrous in the extreme. They were right in referring the phenomena of hys- teria to the uterine organs, and this was because they were accurate observers ; they were absurd in the explanation of their hypothesis, be- cause they were deprived of the knowledge which physiology alone can supply. All honor to the early fathers of our science! I love to look. back upon those ancient men, whose history is written in their works, and to whom is due the merit of having laid the broad foundation of that glorious superstructure which, though not complete, is in rapid and healthy progress through the well-directed efforts of the men of our own times. Hysteria, I believe, to be a disease traceable, in most instances, to irritation of the sexual organs, and this can be demonstrated in the best of all schools—that furnished by the bed-side. With this explanation of the Protean forms assumed by this singular malady, there can be no difficulty in understanding how completely, under ordinary circum- stances, it will be within control; while on the other hand, regarding it as an idiopathic affection, it can be readily seen how necessarily it must prove rebellious to remedies. Hysteria is an effect, a reflex nervous derangement due to sexual irritation. The focus of irritation lies in the sexual system—the evidences of this irritation displaying themselves in the abnormal acts of one or more of those organs dependent for healthy function on the undisturbed condition of the spinal cord. That hysteria is the result of reflex action seems to me to be abundantly demon- strated. Sir Benjamin Brodie relates some striking instances in proof of this fact, such, for example, as pressure on a sensitive ovary, producing the hysteric paroxysm. The same distinguished authority also mentions a curious circumstance sometimes observed in the progress of hysteria, viz.: a peculiar relaxation of the joints, followed by sub-luxation. Some authors deny that hysteria is entitled to be classed among the disorders of reflex nervous disturbance from sexual irritation, for the reason that there is oftentimes in this affection an entire want of sensation in the uterus and ovaries. It has, however, been demonstrated that the pres- ence of sensation is not material to the exhibition of the reflex phenom- 24 370 CLINICAL LECTURES. ena. You will often recognize, in certain affections of the uterus, an absence of suffering on pressing the part affected, and yet hysteria will occasionally be present. Although in a very large proportion of cases it has been found that hysteria is accompanied with more or less organic lesion of the uterine organs, varying from the simplest form of struc- tural disease to the most destructive and malignant, yet this lesion is not absolutely necessary to the production of the malady, for the evi- dence is conclusive that hysteria will arise from nervous irritation alone of these organs; such, for example, as frequently supervenes from merely functional disturbance.* This, it appears to me, is the only practical view that can be taken of this affection. After all, what avails hypothesis in our profession, so far as the regulating of the deranged mechanism is concerned, unless it lead to substantial results, which will enable us to repair that mechanism, and impart to it a natural and healthy play ? Tlie preservation of health, and its restoration when deranged, are the two great objects of our science. To the attainment of these objects, therefore, the physician can not give attention too pro- found. I have just told you that the bed-side reveals the close connection which subsists between hysteria and irritation of the sexual organs, and practitioners of careful observation, those who are not content with iso- lated facts, but look to the aggregate of testimony, will concur fully in the interesting statistical tables of Landouzy upon this subject. In three hundred and fifty-one cases of hysteria, this disease was observed most frequently, 1st. Between .the ages of fifteen and twenty years; 2d. From twenty to twenty-five ; 3d. From ten to fifteen; 4th. From twenty-five to thirty ; 5th. From thirty to thirty-five. It is an affection neither of early childhood nor of advanced life—in a word, it develops itself during the period in which the sexual organs, if I may so call them, are active and dispensing centers. At the period of puberty, when the irritation consequent upon the transition state of these organs is well-marked, and of no equivocal character, hysteria is of frequent occurrence ; while, on the contrary, at the period of the final cessation of the menstrual func- tion, when these organs have completed their office, and the summer of woman's life has passed into the cold shades of winter, this affection is * Landouzy gives the following as the results of his observation in the autopsy of persons affected with hysteria, who have died of some other affection. In thirty- nine cases, only three exhibited lesions of the brain, three lesions of the respiratory organs, while in twenty-nine there was structural disease of the uterus, or its an- nexa3. If, on the other hand, we look at the results of observation in hysterical women, during life, the important fact is established that in twenty-seven cases, dis- ease of these latter organs was recognized in twenty-six instances. This certainly, as far as it goes, is very strong, if not conclusive, testimony in favor of tlie connec- tion between hysteria and an abnormal state of the sexual system, whether from structural lesion, or functional derangement. [Traite complete de L'Hysterie, Paris, 1846.] HTSTERIA FROM DEFECTIVE MENSTRUATION. 371 extremely rare. It has been assumed, by certain writers, that hysteria is confined exclusively to the female sex; others, however, state that it will occasionally present itself in the male. I can not conceive why sexual irritation in the male should not, as in the female, result in the development of this affection. It is, indeed, comparatively rare in the former, but that it does sometimes exist, I have no doubt; indeed, I have positive evidence of the fact. About four years ago, I was consulted in the case of a boy, aged sixteen years, who for six months previously had exhibited the leading phenomena of hysteria. He had been sub- jected to a variety of medication, without deriving the slightest benefit; his health was declining, and much anxiety felt in his regard. On being consulted, I examined the case with care, and after a thorough investiga- tion of its entire history, I discovered, through the confession of the boy, that he had fallen a victim to that most dangerous vice—onanism. With this fact before me, I had no difficulty in connecting the hysteric affec- tion with its true cause—sexual irritation. By a systematic course of treatment, and constant appeals to the good sense of my patient, whose intelligence was of a high order, and who deeply deplored the weak- ness of which he had been guilty, I succeeded in breaking up this vicious propensity, and the hysteria, which was but an effect, soon disappeared. Causes.—All those influences which are calculated to give early de- velopment to the sexual organs ; hence females who are educated in the midst of excitements incident to large cities are much more subject to this affection than girls who are reared amid the more frugal circum- stances of country life. Hysteria does not appear, according to the ob- servation of those who have attended particularly to this subject, to be more frequent among prostitutes. On the contrary, continence and restraint from sexual intercourse, among those who have been accustomed to it, seem to exercise a marked influence in the frequent production of this disorder. Women of extreme nervous susceptibility are much more predisposed to hysteria than those of a more equable temperament. It has been supposed that the disease is hereditary; I should rather admit that the temperament which predisposes to the affection is hereditary, and that, caleris paribus, it would be more likely to occur in a female whose mother had been subject to it. The prominent causes of hysteria are diseases of the uterine organs, both structural and functional, and I have known both ante-version and retro-version of the uterus to give rise to it. Hysteria is sometimes traceable to the peculiar condition of the blood; for example, in anaemia the hysteric paroxysm is often ob- served, as is proved by its occurrence in chlorosis. Among the circum- stances which favor the production of hysteria, there is one which seems to exert a very marked influence—I mean a warm climate; and this is in harmony with what we have said touching the influence of the sexual organs on this disease, for affections of these organs are extremely fre quent in tropical climates. Some years ago, the idea was not only 372 CLINICAL LECTURES. prevalent, but popular, that hysteria was due to spinal irritation. There is a fashion in medicine, as there is in dress and other toilet articles, and it is my duty to guard you against the seductive allurements of fashion, so far as your profession is interested. Griffin, Tate, Teale, Brown, and others, published their several experiences on " spinal irritation." The former in a work entitled " Functional Affections of the Spinal Cord," and " Ganglionic System of Nerves;" and Tate in his work on " Hysteria." On the appearance of these publications, a new idea seemed to take hold of the profession, and, for the time being, the doctrine of " spinal irrita- tion," was in the ascendant. It had been observed by these writers that there was a certain coincidence between hysteria and " spinal irritation," and the conclusion had been too easily reached that the latter was the cause of the former. With this exclusive view of the pathology of hys- teria, I need not tell you what unnecessary suffering was often inflicted by issues, blisters, escharotics, etc., nor need I remind you that, with such abstract views, hysteria frequently proved rebellious to remedies. That hysteria will occasionally, and perhaps oftentimes does exist simul- taneously with " spinal irritation," is a fact familiar to every observing practitioner, but that " spinal irritation " does not necessarily bear to hysteria the relation of cause and effect is a fact no less obvious. Have I not frequently exemplified by cases in this Clinique, the interesting pathological truth that the spinal cord does sometimes, instead of being the primary seat of irritation, become secondarily affected, and this, too, through the afferent nerves, constituting another instance of eccentric nervous disturbance ? If this be true, and the fact is now universally conceded, being the result of that important physiological law of reflex action, first explained by Marshall Hall, is it not at once manifest that spinal irritation will very frequently be the effect instead of the cause of hysteria, and is not this latter fact in perfect harmony with the opinion we have expressed, that hysteria is traceable to irritation of the sexual organs ? Both in organic and functional disturbance of the uterus, there is very often tenderness of the spine. So that, when " spinal irritation " exists, before attempting to remedy it, first ascertain when the irritation commenced in this nervous center, and whether it be the result of irrita- tion originating in the peripheral extremities of the nerves. Symptoms.—Very often, but not always, there will be a series of phe- nomena exhibiting themselves for one or more days, preliminary to an attack of the paroxysms—these phenomena consisting in depression of spirits, restlessness, frequent desire to pass water, etc. Hysteria is sometimes characterized by convulsive movements ; at other times, no convulsions are present during the attack. The symptoms of this disor- der are sometimes local, sometimes general. In the former case, the disturbance is limited to the respiratory nerves, producing spasm of the glottis, bronchii, etc.; the patient has turns of laughing, crying, palpita- tion, etc.; the globus hystericus, that peculiar sensation of a ball in the HTSTERIA FROM DEFECTIVE MENSTRUATION. 373 throat, is also quite characteristic of this affection. In general hysteria, the muscles of animal life will be involved in both clonic and tonic spasms affecting the limbs of one or both sides, as also other portions of the body. Tympanites intestinalis is often an accompaniment of hys- teria, and a profuse discharge of limpid urine not unfrequently takes place as the disease is about subsiding. In some cases, paralysis occurs. Another interesting feature of this disease is connected with change in sensibility, which has been pointed out by Beau and others. They have shown that touch, pain, and temperature, may be either separately or collectively increased, diminished, or lost. These modifications in sen- sibility, however, can not be considered as pathognomonic of hysteria, for they are recognized also in chorea, chlorosis, hypochondria, etc. Sight, smelling, hearing, and taste, may also become more or less affected during an attack of hysteria. In one word, it is now admitted that every variety of paralysis of the motor, sensitive or sensorial nerves, may occur not only during the attack, but for days, weeks, and even months subse- quently. These morbid conditions, as well as the paralysis, will some- times subside spontaneously; and, as a general rule, there is no form of paralysis so readily curable as what may be termed the hysteric paralysis. Sometimes, in lieu of anaesthesia, there is in hysteria an increase of mor- bid sensibility, either in the organs of sense, or in the nerves of other por- tions of the body. It is even stated that the same part may be alternately anaesthetic and hyperaesthetic. The pulse, in hysteria, is rarely much affected; usually, it is somewhat slower than natural. There is seldom entire, but sometimes partial loss of consciousness. Diagnosis.—Hysteria, under certain circumstances, might be mistaken for epilepsy and eclampsia; hypochondriasis and insanity, too, are classed among those affections with which possibly it might be confounded. But, as a general rule, hysteria is so well defined by the symptoms peculiar to it alone, that error of opinion as to its true nature can scarcely arise. In epilepsy, there are invariably unconsciousness and a state of anaesthe- sia ; in hysteria, unconsciousness is rare, and never complete, active stim- ulants always producing more or less sensation. In eclampsia, there is no constriction of the throat, no globus hystericus, but there is loss of consciousness, and the interval between the paroxysms is marked by coma more or less profound. Prognosis.—Hysteria can not be considered by itself a dangerous affection. Post-mortem examinations do not reveal any lesions of the nervous system when death, from other causes, ensues. As a general rule, the hysteric paroxysm is suspended during gestation. Treatment.—It can scarcely be necessary for me to discuss in detail the various remedies recommended in hysteria. These remedies can only prove serviceable when administered with a good and justifiable motive. The propriety of the motive must necessarily depend upon the adaptation of the remedies to the removal of the particular cause which gives birth 374 CLINICAL LECTURES. to the hysteric phenomena. The first duty, therefore, of the physician in being called to a patient laboring under hysteria is to investigate care- fully all the circumstances of the case. He will ask himself, Is it due to organic disease of the uterus, or to functional derangement of this organ, in the form of some one of the menstrual aberrations constantly observed in practice, or may it be traced to simple displacement of the uterus ? Does it originate from an anosmic state of the system, etc. ? These are the questions which are first to be determined, and on their just solution will, as a general principle, depend the successful issue of the case. I have repeatedly directed your attention to the means to be employed in the various organic and functional derangements of the uterus; and, there- fore, I shall not refer to them now. In hysteria, resulting from anosmia, quina, or its various preparations, is the remedy on which you are chiefly to rely. Here I might, however, mention that the anaesthetic remedies, such as sulphuric ether, and chloroform will, by their action in diminish- ing reflex sensibility, prove highly serviceable, if not as curative, at least as palliative agents in breaking the intensity of the paroxysm. As to the treatment of paralytic hysteria, it would seem that galvanism is the most successful remedy; and it is not a little strange, as has been proved, that a single application of a powerful galvanic current will cure a paral- ysis of sensibility which has continued for days, and sometimes for weeks. Now, gentlemen, allow me to ask you to recur in memory to the con- versation, which took place a few minutes since between this patient and myself, and you will, I think, experience no embarrassment in referring the hysteria in her case to its proper cause, viz., defective menstruation. Let this function be properly reestablished, and you will probably hear nothing more of the hysteric phenomena. Under ordinary circumstances, m the management of a case of hysteria, you are not to forget the im- portance of moral treatment. In certain forms of this affection the pa- tient can often exercise through her will a salutary influence. I think, in the case of the patient before us, the following combination will have a beneficial effect: R Aloes Earbad........3 ij Sulphat. Ferri.......3j Ft. massa in pil. xx dividenda. Let one of these pills be taken twice a day. Final Cessation of the Menses in a married Woman, aged FORTf- two Years.—Mrs. S., aged forty-two years, the mother of five children, the youngest five years old, has always menstruated with regularity, except during the periods of pregnancy and lactation. Her general health has been good until within the last ten months. Her menses ceased one year ago; since that time she has suffered from headache, vertigo, and a sense of suffocation; her bowels, also, have been quite torpid. She is a woman of strong muscular development, with a flushed countenance, and a pulse indicative of a plethoric condition of system. FINAL CESSATION OF THE MENSES. 375 This case, gentlemen, is but the type of what you will frequently meet with in practice. The symptoms are the direct consequences of extreme vascular fullness, and this state of system is not unusual in what is termed the period of final cessation. The system, it must be remembered, has been accustomed for a number of years to a monthly sanguineous evac- uation per vaginam ; when this evacuation ceases, plethora is not unusu- ally the result. The final cessation of the menstrual function does not occur at any uniform period; various circumstances will influence the early or late advent of this important climacteric in the female. It may be said, as a general rule, to occur between the fortieth and fiftieth years of age ; but there are numerous exceptions to this rule, some women ceasing to menstruate as early as thirty years, and examples are recorded on accepted authority of the menstrual function continuing as late as the seventieth year. For my part, I am disposed to regard these latter as somewhat apocryphal, and believe, if carefully analyzed, they will be found not really cases of menstruation, but simply the evidences or re- sults of morbid action. The period of final cessation has, with much propriety, been called the critical time of female life, and for the follow- ing obvious reasons : 1st. If there should be a tendency to carcinomatous or other malignant disease, either of the breast or cervix uteri, this tend- ency during the menstruating period will be measurably held in check by the monthly loss which the female sustains; 2d. Should there be predisposition to apoplexy, or engorgement of any organ, including the womb and ovaries, its development for the same reason will be more likely to occur at the time of the final cessation of the menses, for the waste-gate, which has hitherto proved so salutary, is now closed, and no derivative influence is exercised to hold in check this predisposition. Attention, therefore, is always to be paid to the female at this critical climacteric, and it is the duty of the physician sedulously to guard her, as far as may be, by appropriate treatment against the various morbid influences, which are so apt to follow the final suspension of the men- strual function. It is asserted by Wilkinson King, that nearly one half of the women who die at about forty-four years of age, succumb from cancer. In addition to structural and malignant diseases, so common at this period of female life, the brain and nervous system become both primarily and secondarily the seats of irritation ; these important por- tions of the economy, however, are much more frequently affected in a sec- ondary manner, giving rise to that series of nervous phenomena described under the term of eccentric nervous disturbance. Hence, it is not very uncommon to observe at this crisis the various forms of paralysis—some ephemeral, others permanent; while the varieties of simple nervous irritation, without involving any particular lesion, are beyond calculation. It must be remarked, however, that many women, especially those whose lives have not been marked by any excess, pass this period of danger with impunity; and I have generally observed that, in such cases, they 376 CLINICAL LECTURES. become loaded more or less with adipose matter; the abdomen, from the deposit of this material on the omentum, etc., becoming protuberant. It is in instances like these that the protuberant abdomen has sometimes been mistaken for pregnancy, particularly in women who have never borne children, and who have indulged in an ardent desire for offspring. It is worthy of recollection that these women usually escape those nerv- ous derangements to which we have already alluded, and it is explained in this way : the blood, which would otherwise, if I may so speak, crowd and irritate the nervous system, is diverted into other channels for the formation of adipose tissue, thus, in fact, opening a waste-gate, which protects the economy from harm. In the case of this woman there is hap- pily no organic disease of the uterus, or other viscus. I have examined her per vaginam, and find the uterus, etc., in a healthy condition. The prominent symptoms of which she complains, and which, in fact, con- stitute her entire trouble, are the headache, vertigo, and a sense of suf- focation. What are these ? Nothing more than nervous phenomena from an undue pressure of blood. In a word, the nervous system is op- pressed ; it needs relief. Treatment.—Let the patient be bled to § viij. The following powder should be given this evening, followed in the morning by § j of epsom salts : R Sub. Mur. Hydrarg......gr. x Pulv. Jalapae.......gr. xv Pulv. AntimoniaL......gr. ij M. Her bowels should afterward be kept regular by a wine-glass of the following mixture every morning, as circumstances may require: R Sulphat. Magnesise / .- - z • Sup. Tart. Potassas j......^ *J Aquas Pura.......Oj Ft. Sol. The diet to be exclusively vegetable. The patient to take regular exercise. This treatment will, in a short time, remove the plethora, the circulation will become equalized, and the cephalalgia, etc., will dis- appear. I am in the habit in these cases where blood is rapidly made, and the plethora does not yield to ordinary treatment, of having re- course to an issue either in the arm or on the side of the spine. The issue which I prefer is made with the strong nitric acid. Suppression of the Menses of two Years and four Months du- ration in a married Woman, aged 26 Years, the Mother of two Children, the youngest three Years old, from imperforate Os Tincae, the result of Inflammation—Operation.* Mrs. D., aged 26 years, the mother of two children, the youngest three years old, comes to the Clinique to-day with a cheerful countenance, and full of thanks for the benefit she has received. "'Ah! madam, I am glad to see you." " Well, sir, I thought you would be pleased to know that I am cured." * Page 318. PHTSOMETRA. 377 "Certainly, madam, that is the great object of our profession." This case, gentlemen, is one of peculiar interest. If you will turn to your note-books, you will have your minds refreshed as to its history. This patient, two years and four months before she came to the Clinique, had a miscarriage, and inflammation of the womb supervened. From that time she had labored under suppression of her courses, and suffered greatly from this circumstance. You will remember what she said with regard to the efforts made to bring on the menstrual function by means of forcing-medicine, etc., but all without effect. In making an examina- tion per vaginam, I discovered that this woman had an imperforate os tincae, the result, no doubt, of the inflammation with which she had been attacked two years and four months previously. I discussed the whole case with much minuteness, and called your attention emphatically to its interesting feature, viz.: an imperforate os tinea in a female who had borne two children. The uterus was also enlarged in consequence of the monthly accumulation of the menstrual fluid, there being no exit for it to pass from the system. In a word, gentlemen, I remarked to you that no medicine, no matter how potent its emmenagogue properties, could possibly cause fluid to pass through the vagina, for the simple reason that there was a physical obstruction—the imperforate os tincae. This patient, being a sensible woman, consented to an operation which, you will i\ )t have forgotten, I performed in your presence. The opera- tion consisted in the introduction of a trochar into the central and infe- rior portion of the cervix uteri, parallel to the long axis of the organ. As soon as this was done, there was a profuse discharge of grumous blood, which was unquestionably the menstrual fluid contained within the cavity of the womb. A gum-elastic bougie was introduced daily for a few days, with a view of keeping the os tincae open, or, in other words, preventing an agglutination. " My good woman, have you had your courses since the operation ?" " Yes, sir, twice." " Were they natural?" "They were free, sir." "How is your general health?" " Oh, sir, I never was better in my life." " Then you do not regret what has been done for you." "No, indeed I don't, sir!" "Good morning, madam." Physometra in a married Woman, aged 32 Years, the Mother of seven Children.* Mrs. C. returned to the Clinique "to-day, and re- ported herself entirely restored to health. "I am glad to see you, madam ; what is the state of your health ?" " Oh ! thank you, sir, I am quite cured." " Has the swelling entirely subsided ?" " Yes, indeed, sir, I have nothing of it now." " Did you do what I directed ?" " Yes, sir, I followed your orders." " Did your gums become sore ?" " Yes, sir, the pills made them quite sore." " Did you take the decoction I ordered ?" " Yes, sir." " You are certain that your health is now quite restored ?" " Indeed I am, sir, and have come here to-day to thank * Page 321. 378 CLINICAL LECTURES. you for your kindness." This patient you will remember, gentlemen, had suffered for the last eighteen months from enlargement of the abdo- men ; and the distention had increased to such a degree that it caused her much anxiety. When she first came to the Clinique we examined her with great care. Your attention was particularly directed to the peculiar form of the swelling, its resonance under percussion, the fact that it did not alternately diminish and increase in size, etc., etc.; and after a very full investigation of every feature of the case, looking at its history and all the circumstances attending it, we pronounced it physo- metra, which, as you know, means a collection of flatus within the womb. In the course of the questions addressed to the patient at that time, one very important fact was developed, viz.: that her last child, when born, was in a state of decomposition. To this latter circumstance I attributed the flatulent distention. Some authors are of opinion that physometra results from the entrance of air through the cervix of the organ. This I am disposed to doubt; and I believe it is due to certain chemical changes taking place within the cavity of the womb itself. Hence a blighted ovum, a retained and decomposed placenta or foetus, or the de- composition of any intra-uterine growth may all be enumerated as among the causes of this affection. The treatment suggested was as follows : to introduce into the cavity of the uterus a tube for the purpose of evacuating as much as possible of the flatus. This I did at once with decidedly good effect. The pa- tient was then ordered the following medicine : R Pil. Massse Hydrarg......3ij Pulv. Opii.......gr. iv Ft. Massa in pil. xxiv dividenda. One pill to be taken twice a day until ptyalism was produced—and then half a pint daily of the following decoction, for six or eight weeks : R Decoct. Sarsaparilla c......Oviij Acid Nitric dilut.......3 vj M. [Here the patient was placed on the bed—there was not the slightest trace of distension ; the abdomen was flat; and, on an examination per vaginam, the Professor ascertained that the uterus presented its normal dimensions.] This case is gratifying in its results, both as regards the diagnosis and treatment. Engorgement of the Uterus from suppression of the Menses, resulting in Catalepsy, in a married Woman 19 Years of age.* Mrs. T., aged 19 years, who, it will be recollected, had suffered from cataleptic convulsions for the past five months, returned to-day and said she was much relieved—her courses had appeared, and since their return she had no attack of catalepsy. This case, gentlemen, is full of interest. You will remember when the patient first presented herself here, I dis- cussed very fully the various points, and directed your attention to the * Page 331. COMPLETE OCCLUSION OF THE MEATUS URINARIUS. 379 fact that the catalepsy was due to the menstrual suppression and the con- sequent engorgement of the uterus, affording another example of eccentric nervous disturbance. The catalepsy, we told you, was simply an effect. We paid no sort of attention to it, but directed our remedies to the restoration of the menstrual function, and removal of the engorgement. For these purposes we recommended the following treatment: One dozen leeches to be applied to the vulva, and the bleeding to be promoted by warm fomentations and poultices ; the three following pills to be taken at night, followed in the morning by § j of castor oil: R Sub. Mur. Hydrarg......gr. xij Pulv. Ipecac.......gr. i Ft. Massa in pil. iij div. The bowels afterward to be kept in a soluble state by a wine-glass of the following saline mixture, as circumstances may require : R Sulphat. Magnesia? ) Sup. Tart. Potassae )......^ ^ Aquae purae.......Oj Ft. sol At the time of the expected menses, when the bearing-down pain is in- creased because of the menstrual molimen, one dozen leeches should again be applied to the vulva. The diet to be strictly vegetable, and the patient to exercise as little as possible. These were the directions given to this patient when she first came here. " Now, my good woman, will you be kind enough to tell us whether you faithfully observed what we told you ?" " Indeed I did, sir; every thing was done just as you ordered." " How often were you leeched ?" " Twice, sir." " How is your health now ?" " It is much better, sir." "Have your courses become restored?" "Yes, sir." " Have you had a convulsion since they appeared ?" " No, sir, and I feel better than I have done for ten years." " I am glad to hear it, my good woman." I am much gratified with the result of this case ; it is an important one to be remembered, for it involves a valuable principle. Complete Occlusion of the Meatus Urinarius, with Cohesion of the Walls of the upper fourth of the Vagina; together with Vesico-Vaginal Fistula, in a married Woman aged 22 Years, pro- duced by Instrumental Delivery.* Mrs. E., aged 22 years, married, returned to-day to be operated on for the adhesion of the walls of the vagina. This case, gentlemen, you will remember with much interest. It is one of the results of careless and unpardonable practice. I pro- pose to-day to divide the adhering portions of the vagina. [Here the patient was placed on the bed, and the Professor proceeded with the operation as follows: taking his finger as a guide, he introduced a blunt pointed bistoury, and cut carefully upward and downward, thus separating * Page 346. 380 CLINICAL LECTURES. the walls of the vagina—a sponge tent covered with oil-silk was then in- troduced.] This is all I shall do for the present. It will be proper to remove the tent once a day, and gradually to introduce one of a larger size. The objeQt of the tent is twofold : 1st. To prevent reunion of the parts; 2d. To produce a dilatation of the opening. Suppression of the Menses occasioned by Periodical Hemorrhoid- al Bleedings—Vicarious Menstruation.* Mrs. L., aged thirty-two years, widow, the mother of two children, the youngest eight years old, returned to-day to the Clinique. " Well, madam, what is the state of your health now ?" " Thank you, sir, I am much better." " Did you take the sulphur as directed ?" " Yes, sir." " Are your bowels more regular than they were ?" " Yes, sir, and my courses have returned upon me." The patient before you had suffered for the past two years from, suppression of the courses. She also had been afflicted with bleed- ing piles. It was a case of vicarious menstruation. The indication, I mentioned to you, was to remove the constipation, which, no doubt, was the cause of the hemorrhoids. " How are the piles, madam ?" " They don't trouble me now, sir." " I am glad to hear it, my good woman. Good morning!" Abscess of the right Labium Externum in a married Woman, twenty-two years of age, from difficult parturition.--mrs. s., aged twenty-two years, married, the mother of one child, three weeks old, returned to-day, and stated that she was entirely relieved. This patient, gentlemen, a few days after the birth of her last child, com- plained of a swelling in her genitals. Her labor had been severe, and of three days' duration, the consequence of which was a tumefaction of the right labium externum. You will not have forgotten how particularly I directed your attention to the necessity of a just discrimination as to the true nature of the swelling with which these parts occasionally become affected. I told you that the swelling might result from, 1st. Hernial pro- trusion ; 2d. Serous engorgement; 3d. Sanguineous engorgement; 4th. Simple hypertrophy; 5th. Purulent engorgement from abscess. In the examination of this patient, we discovered that she had an abscess of the right labium. Fluctuation was very distinct. I opened the abscess in your presence, and half a tumbler of pus immediately escaped. An emollient poultice was ordered, and this constituted the entire treatment. " You are quite well now, my good woman, and you can go home." " Thank you, sir." " Very welcome, madam. Good morning !" Placenta Previa in a case of Twins which were expelled from the Uterus after a seven Months' Gestation, with one Placenta, and one Amnion and Chorion, both Cords inserted into the Pla- centa NEARLY IN JUXTAPOSITION, EACH FfETUS PRESENTING EVIDENCES * Page 337. PLACENTA PREVIA. 381 of Incipient Hydrocephalus, and each bearing marks of having been dead for two or three Weeks.—Mrs. K., aged thirty-two years, the mother of three healthy children, consulted me on the 6th of October last in consequence of an anxiety she experienced in not having felt for the past week the motion of her child, she then being about six months pregnant. She remarked at the time that a few days before consulting me she had become very much frightened by a horse, and since that time she had not felt life. With the exception of words of encouragement, and recommending thirty drops of the tincture of hyos- cyamus when she became nervous, nothing was suggested in her case. On the 6th of November the husband requested me to visit his wife, stating that she thought she was in labor, and was now flowing very pro- fusely, having been troubled more or less in this way for the last week. In an hour from the time I received the message I saw the patient, and found her with labor pains just commencing, and flowing quite freely. In making a vaginal examination, I discovered the os uteri dilated and soft, and distinctly felt a doughy substance presenting, which I recog- nized to be the placenta, and which at once accounted for the hemor- rhage. With the amount of blood the patient was losing, together with the fact that the mouth of the womb was soft and dilatable, it was obvi- ously my duty to lose no time, but to proceed without further delay with the delivery. In accordance, therefore, with this object, I carried my hand to the neck of the uterus, and separated about one fourth of its attachments to the placenta, which enabled me to feel the presenting part of the foetus, which I soon recognized to be the breech. It was my intention at once, in separating the placental attachments, to introduce the hand into the uterus, and terminate the delivery by bringing down the foetus. As, however, the uterus contracted with great efficiency soon after I had recognized the presentation, and as it was quite evident that the breech of the foetus was descending into the pelvic excavation, I judged it advisable to submit the delivery to nature. The pains increased so rapidly in expulsive force that not more than five minutes elapsed before the birth of the foetus was accomplished. As the child was passing into the world, with one hand applied to the abdomen of the mother, I soon discovered that although there was a sensation of hardness imparted to my hand, the uterus was but slightly diminished in volume. At the same time my attention was drawn to the peculiarity exhibited by the umbilical cord. At the first glance it occurred to me that it was an example of what authors have described as the knotted cord, two instances of which I have had in my practice. In this character of cord there are distinct knots, formed most probably by the evolutions of the foetus in utero. I soon discovered, however, that no such peculiarity existed in the present case. The enlarged uterus caused me to suspect the presence of another foetus, and, in carrying my hand up, my suspicion was confirmed. The uterus contracted with en 382 CLINICAL LECTURES. ergy, and in less than ten minutes the second foetus was expelled. Both were in a state of decomposition. The peculiarity of the umbilical cord is explained as follows : The cord of one foetus was completely twisted round that of the other in its whole extent, presenting the aspect of the knotted cord. On the expulsion of the second foetus, the uterus became diminished in size, and was felt in the hypogastric region well contracted. I then passed my hand up, and removed the placenta, a portion of which I had previously detached from the cervix. There was but one placenta. The two cords were inserted into it nearly at the same point. There was but one chorion, and one amnion. The two flatuses were about equally decomposed, presenting the strong probability that their death was simultaneous. About one hour and a half after the delivery, the foetuses and placenta were seen and ex- amined by my colleague, Professor Van Buren, and also by my friends, Dr. George T. Elliott, resident physician of the Lying-in Hospital, and Dr. McNiel, who has charge of the dispensary connected with the Uni- versity. I should have remarked that the cord which was twisted around the other, having its length curtailed, and also decomposed, be- came detached from the placenta on the birth of the second foetus. Professor Van Buren immediately detected, by means of the blow-pipe its place of attachment, which was in juxtaposition with the other cord. The above, gentlemen, are the details of an interesting case of mid- wifery to which I was recently called, and 1 am happy to have it in my power to exhibit to you to-day the foetuses and placenta, which, on some accounts, may be regarded as unique. [Here the Professor exhibited to the class the foetuses, etc., and pointed out their peculiarities.] In re- viewing the circumstances connected with this delivery, there are several points of interest, which naturally present themselves to our considera- tion, and when all the peculiarities of the case are examined, they cer- tainly do present an aggregate which are not only unusual, but, in my opinion, without a parallel. What, then, are the peculiarities to which I allude? They are as follow: 1st. Implantation of the placenta over the cervix of the uterus; 2d. One placenta, one chorion, and one amnion ; 3d. Both cords being inserted into the placenta in juxtaposition; 4th. Each foetus presenting evidences of incipient hydrocephalus; 5th. The evidences disclosed of the probable simultaneous death of the two foetuses; 6th. Breech presentation of both foetuses. These constitute the peculiarities of the case, and, I repeat, as a combination, as far as my knowledge extends, they stand alone. But what imparts special interest is the fact of one placenta, which, is single and perfect in itself; it is not, as you see, composed of two united into one, the points of union easy of recognition, as sometimes happens in plural births, but it is one entire placental mass. If, nowfyou examine the membranes, you will find also that there is not a double set, but one distmct amnion and one chorion. In fact, there DEEP ULCERATION OF THE CERVIX UTERI. 383 is here, with the exception of the two cords, precisely what we should ex- pect to find in a delivery in which there is but one foetus. Some authors have doubted the possibility of a twin birth with but one amnion, without a cohesion of the embryos. Without entering at this time into an argu- ment to show how invalid this objection is, we have only to look at the case before us to become satisfied that it is possible for twins to exist with but one amnion, and no cohesion of parts ensue. Another interest- ing fact connected with this history is, that although there is but one placenta, and both cords are inserted into it, yet the umbilical vein and two umbilical arteries belonging respectively to each cord have a distinct circulation; or, in other words, do not communicate with each other. If, to this circumstance, be added the fact that there is not the slightest evidence of decomposition in the placenta, but, on the contrary, as you perceive, an aspect of freshness, precisely such as you would expect to find in the case of a healthy living foetus, we then have the curious coin- cidence of a healthy fresh placenta co-existing with two foetuses bearing the evidences of having been dead for some two or three weeks. This, certainly, presents a point for physiological discussion. Again, would it have been possible in this case for one foetus to have survived the other, as sometimes happens in cases of twin-births ? My opinion is decidedly in favor of the negative. I now call your attention particularly to the aspect presented by these foetuses. They are both partially decomposed; and the interesting fact is, that each one exhibits a singularly identical amount of decomposition. You can detect no difference between the two; and the circumstance fortifies me in the conviction that vitality must have been destroyed in each at the same moment. The mother had a prompt recovery, and is now in the enjoyment of good health. Deep Ulceration of the Cervix Uteri in a married Woman, aged thirty-one Years, the Mother of eight Children.—Mrs. McD., aged thirty-one years, married, the mother of eight children, the youngest nine months old, says she has been in bad health for the last six years. " How long have you been married, madam ?" " Ten years, sir." " Were you a healthy woman before your marriage ?" " Yes, sir." " When did you first feel that your health was declining ?" " About six years ago, sir, after the birth of my third child." " What did you complain of at that time ?" " Pain in my back and hips." " Any thing else ?" " Yes, sir; I suffered much from headache." " On what part of your head did you feel the pain ?" " On the top of my head, sir." " Were you troubled with a discharge at that time ?" " Not much, sir; but for the last'two years I have suffered very much in that way." " Did the discharge color your linen ?" " Yes, sir; it looked like corruption." " Does it continue now ?" " Oh! yes, sir; it is getting worse every day." " Before you first noticed the symptoms which you have just mentioned, were you a 384 CLINICAL LECTURES. fleshy woman ?" " Indeed I was, sir; I weighed one hundred and fifty- five pounds." " How much do you suppose you weigh now ?" " Oh! sir, I am sure I have lost thirty pounds." " Have you any cough ?" "No, sir." "How is your appetite ?" "Very poor, sir." "Are youi bowels regular ?" " No, sir; they are all the time confined." " When did you begin to lose flesh?" "I think I have been losing flesh, sir, for the last four or five years." " Do you notice any thing peculiar about your water ?" " Yes, sir, there is always a sediment in it; and I think, sir, there is something wrong about my kidneys." " Has any one ever told you that your kidneys were affected ?" " Yes, sir; and I have been taking medicine for the gravel." " How long since you noticed the sedi- ment in your water ?" " Oh! a long time, sir; as much as twelve or eight- een months." The questions, gentlemen, which I have just addressed to this patient have elicited answers which will not be without profit to you. I have purposely instituted this conversation in order that you may ap- preciate, in the first place, its object, and, secondly, that you may thor- oughly comprehend how clearly her replies establish the nature of the disease with which the patient is affected. You will very often, in the course of your practice, meet with cases of this character ; and if you do not exercise a proper judgment, you will fail in affording relief. Cases like this, if successively treated—and the only element necessary to in- sure successful treatment is to know the true nature of the malady—will give you solid reputation, and secure you patronage equal to your high- est aspirations. There is no difficulty in accumulating a fortune by the practice of your profession—it is in our profession as it is in the various walks of life, good workmen, men who are masters of their art, will always command occupation, and the highest prices. You have a glori- ous future opening before you—you live in a great country, and in a great age—and, allow me to say, you are now prosecuting a noble profession, one which will repay you a hundredfold for all the toil and sacrifice it costs you to understand its principles. No truer maxim was ever promulgated than that which emanated from the mind of Lord Verulam : " Knowledge is power." For the physician it is the guiding star which, the more brilliantly it shines, with the greater certainty will it lead him to truth! Seek knowledge ; with it you will go forth from this University well armed for the battle-field, a battle-field not radiant with the glitter of arms, nor marked by a thirst for human blood. Oh no ! the contest in which you are to be- come engaged is with disease and death! These are the enemies of our profession, and if not promptly and efficiently met, their triumph will be complete. In the case of the patient before us, it is quite manifest that sponta- neous cure is out of the question. Without proper assistance, she must die—with it she will live. You have heard her story. She has pain in DEEP ULCERATION OF THE CERVIX UTERI. 385 her back and hips, headache, a purulent discharge from the vagina, loss of appetite, is constipated, is losing flesh, urine turbid, etc. What is her disease ? Is it in her back, or head, or kidneys ? Where is it ? The troubles just enumerated are not diseases—they are shad- ows reflected from a source which has not yet been alluded to. This patient, I have very carefully examined, and find that she is laboring under deep ulceration of the neck of the uterus. This is the starting point of the difficulties—and on this alone is your attention to be con- centrated. Eemove the ulceration, restore healthy action to the uterus, and you will hear nothing more of the headache, etc., etc. Causes.—Parturition, sexual intercourse, abortion, irritating injec- tions, pessaries, instrumental delivery, etc., are among the causes of ulceration of the cervix uteri. Symptoms.—Pain in the back and hips—often in one of the iliac fossae—purulent discharge from the vagina, headache, nausea, loss of appetite, impairment oftentimes of the digestive functions, lithates in the urine, etc., are the usual accompaniments of this form of uterine disease. The connection between ulceration of the cervix and the symp- toms just enumerated I have often explained to you. Treatment.—You have heard this patient say that she has been treated for the gravel! It is not the first patient who has been treated for gravel, because of lithates in the urinary secretion resulting indirectly from ulceration of the neck of the womb. It is the very course a man would be likely to pursue who, in the practice of his profession, is in the habit of mistaking effects for causes. The patient became alarmed at the sediment in the urine, she mentioned it to the doctor, and he, looking no further than the sediment, proceeded with his therapeutic ap- pliances. This fact is full of importance to you, and it should not be forgotten. We shall proceed with our treatment on different, and we think, more rational grounds. We shall pay no attention to the effects, but shall at once attack vigorously the cause. Ulceration of the cer vix may be either acute or chronic. In the case before us it has as sumed the latter character. The indication in this form of ulceration is twofold; 1st. Removal of the ulceration by local applications; 2d. The invigoration of the general health. As the ulceration in this case is deep and of long standing, I shall employ as a local caustic the potassa cum calce, a preparation admirably suited to this character of disease. The profession owe much to Dr. Bennet for the success which has attended his efforts to consolidate, like the nitrate of silver, into a stick this important remedy. The consolidation with the lime deprives it of all objections to its use as the potassa fusa, which, with the great- est possible care, will oftentimes destroy healthy structure, and produce unpleasant results. [The patient was placed on the bed; the speculum introduced, and the ulcerated surface freely cauterized.] 25 386 CLINICAL LECTURES. This application must be repeated once in six days. For the consti pated bowels the following to be taken : R Hydrarg. c. creta.......gr. x. In the morning |j of castor oil. In order afterward to ensure a soluble state of the system, and at the same time with a view to its tonic effects, let a wine-glass of the following mixture be taken twice a day: R Sulphat. Ferri...... gr. x Sulphat. Magnesia?..... 3 ij Acid. Sulph. Dilut. ..... 3j Infus. Gentianae c. i . . aa ? iv. JC Infus. Rosas, c. ) " Now, madam, you can go home; return here next Monday, and you may feel quite certain that, if you will strictly follow our directions, you will, in the course of a few months, be restored to health." " Thank you, sir." " Good morning, madam." LECTURE XXII. Ovarium Dropsy—Is it Curable ?—Prolapsus Ani in an Infant, five months old.—Why do Infants cry ?—Anaemia in a married Woman, aged thirty Tears, 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 Anaemia.—Frequent desire to pass Water in a married Woman, twenty-seven Tears of age, from Protracted Labor.—Hysteria, from Defective Menstruation, in a widow Woman, aged twenty-nine Tears.—Sympathetic Cough in a Child, eighteen Months of age, from Intestinal Worms.—Suppression of the Menses iu a married Woman, thirty-one Tears of age, of nine Tears' 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 Tears.— Serous Infiltration of the Labia Externa in a married Woman, aged twenty-seven Tears, six Months Pregnant.—Partial Paraplegia in a married Woman, aged thirty- two Tears, from Instrumental Delivery.—Strychnia. Gentlemen—During the present winter you have had an oppor- tunity of seeing several cases of ovarian dropsy, all of which have been introduced at the Clinique; and I endeavored, in discussing each of these cases, to direct your attention very particularly to the circum- stances connected with their origin, progress, diagnosis, pathology, and treatment. You will recollect that I have emphatically expressed to you my opinion that ovarian disease, which is usually regarded as be- yond the limits of medication, is, on the contrary, often under con- trol ; and if we are not always able to remove the tumor, very often we shall have it in our power, by judicious and persevering treatment, not only to check, but even diminish sensibly the enlargement. In con- firmation of this opinion, I remarked that I could cite to you several cases which have occurred in my private practice, in which success has followed treatment; but I much prefer presenting other testimony— testimony which will be perfectly satisfactory to you, for it proceeds directly from the cases which have been treated in this Clinique ; you are familiar with their history—your note-books will refresh your mem- ories as to the condition of the patients when we commenced treating them, and you will have an opportunity, by inspecting these very cases to-day, of ascertaining whether any impression has been made on the tumors. To show you that I do not speak without authority that these cases are considered as beyond medication by men high in the profes- sion, Dr. Ashwell holds the following language: " Much can not be expected from medicines in this formidable disease (ovarian dropsy) al- 388 CLINICAL LECTURES. though remedies as powerful as iodine, mercury, and the strongest diuretics have been ably and perseveringly used." Dr. Robert Lee observes: " Blood-letting, mercury, iodine, diuretics, emetics, long-con- tinued friction or percussion, and a variety of other remedies have all been employed in encysted dropsy of the ovary, and in most cases with- out the slightest benefit." Mr. Safford Lee, one of the most recent writers on this subject, says: " In no disease has the application of medicine, hitherto, been of so little avail, as in ovarian dropsy. It has been acknowledged by many, and indeed by nearly all, who have at- tempted its cure, that medicine has no power over it." This, gentlemen, is strong and positive language, and comes from men of distinguished character, who possess the respect and confidence of the profession. Against these opinions, however, I beg leave to record my solemn pro- test. Opinions such as I have cited, given as they are ex cathedra, and carrying with them the weight of authority, unless substantiated by over- whelming evidence, will prove opinions not only of mischief, but of positive danger. If you receive them as oracular, and suffer them to become your guides in practice, they will not only paralyze all efforts on your part to disprove them, but they will, at the same time, deprive many a suffering patient not only of hope, but of remedial benefit. In a word, adopt these opinions, and to a patient who may consult you, labor- ing under ovarian dropsy, you will have little else to say than: Madam, your disease is without relief—I can offer you nothing in the way of hope, but I can say with certainty that death is your portion. I shall now introduce to you successively three cases, which have been under treatment, and you shall judge whether with advantage or not: Case I. Presented at the Clinique for the first time, Monday, October 10th, 1851.—The following is taken from the record of that date : Mrs. R., aged forty years, widow, has one child, two years old. Menses regular. About eighteen months since, a small tumor appeared in the right iliac fossa, and has continued to increase to the present time. The abdomen is now larger than at the full term of pregnancy. The tumor presents an oblique aspect from below upward. The abdomen is ex- tremely distended, the integuments are drawn tightly over the tumor, and they present a shining appearance. The patient complains of distress in the abdomen, difficulty in passing water, and obstinate constipation, a week often elapsing without an evacuation from the bowels. From her great size, Mrs. R. experiences much difficulty in walking, and is unable to attend to her ordinary duties. Distinct fluctuation is detected in the tumor. Treatment.—With a view to a proper purgative effect: R Submur. Hydrarg.......gr. x Pulv. Jalapae.......gr. xv Ft. Pulv. To be followed in the morning by 5 j of castor oil. OVARIAN DROPST. 389 A wine-glass of the following saline mixture every morning, to ensure a soluble condition of the system: R Sulph. Magnesiae ) sa ? ' Supertart. Potassae ) Aquae distillatae......Oj Ft. sol. When the bowels have been freely opened, the patient to take one of the following pills every night: R Protoiodid. Hydrarg......gr. vj Ext. Conii.......3ij In pil No. xxiv divid. And a small portion of the following ointment to be freely rubbed over the abdomen once a day: R Ungt. Hydrarg. ^ ...... §j Hydriod. Potassae......3 ss Iodin. purae.......gr. iv Ft. Ungt This treatment to be continued until ptyalism is produced. Then dis- continue the pills, and use the ointment twice a week. At the Clinique of November 25th, Mrs. R. reported herself, and the following is taken from the record of that date: Continued treatment as ordered for five days, and profuse salivation occurred. She says she is now greatly relieved; breathes freer; walks with more comfort; con- stipation removed ; tumor is somewhat softer ; thinks she feel a throb- bing sensation in it. Omit pills, and continue ointment three times a week, with the saline mixture. At the Clinique of December 27th, Mrs. R. returned. Bowels regu- lar ; appetite improved; sleeps well; great diminution of pain in the abdomen ; passes water freely, and walks with much more ease ; com- plains of rigors, and a throbbing sensation. Continue ointment and saline mixture as heretofore ; omit pills. Ten drops of liquor potassae twice a day in a wine-glass of flax-seed tea. Diet nutritious. At the Clinique of January 20th, the patient returned greatly im- proved in every particular. Can walk comfortably; sleeps and eats well; bowels regular; tumor soft, and evidently diminishing; no pain in the abdomen. Treatment.—The following ointment to be rubbed on the tumor three times a week: R Ungt. Hydrarg. .....|j Hydriod. Potassae.......3 ss Iodin. pura?.......gr. vj Ft. Ungt. Liquor potassae 3 ij in a pint of compound decoction of sarsaparilla once a day ; nutritious diet. At the Clinique of February 15th, Mrs. R. returned much improved in health. She declares the tumor has diminished one third; she knows 390 CLINICAL LECTURES. it from the dresses she could not wear two months ago, and are now too large for her. The abdomen was shown to the class, and there was but one opinion as to the diminution in its size, and the general improved state of health. Omit ointment; continue the liquor potassae and sarsa- parilla ; one pill twice a week. Case II. Oct. 23d, Mrs. H, aged 28 years, married five years, no chil- dren. Four years since she noticed a small lump the size of an egg in the right iliac fossa. Her menses had previously been irregular. The tumor now fills about one half of the abdominal cavity ; obstinate con- stipation and irritation of the bladder. Treatment.—For the constipation, two of the following pills as cir- cumstances may require: R Pulv. Aloes) • ,. , Pulv. Rhei \.......Sa38S Pulv. Ipecac........gr. ij Saponis........3 iss Aquae puree..... . q. a Ft. Massa in pil xxx div. The following ointment to be rubbed on the tumor every night: R Ungt. Hydrarg.......f ss Iodin. purae.......gr. ij Ft. Ungt. Liquor potassae gtt. xij in a wine-glass of infusion of Colombo three times a day. At the Clinique of November 29th Mrs. H. returned, and the follow- ing is from the record: Constipation removed—appetite improved— sleeps well. Continue treatment; if salivation occur, discontinue oint- ment. At the Clinique of December 28th Mrs. H. was reported as fol- lows : General health much improved—salivation commenced two weeks since—tumor softer and smaller—use ointment every other night—and one of the following pills every fourth night. R Protoiodid Hydrarg......gr. vj Ext. Conii.......3ij Ft. Massa in pil xxiv div. Discontinue infusion of Colombo, and in lieu, one pint compound de- coction of sarsaparilla, with 3J of liquor potassae, daily. Case III. Mrs. J., aged 45 years, was married twelve years ago. She has been an invalid for the last ten years, and has never had children. About ten years since she first discovered a tumor in the left iliac region, the size of a walnut. Three months after noticing the tumor, she placed herself under the care of a professional gentleman ; and in defiance of all that was done, it continued steadily to enlarge, until it completely filled the abdominal cavity, and rendered it almost impossible for the patient to walk with any degree of comfort. Mrs. J. has suffered a long OVARIAN DROPST. 391 time from confined bowels, and this has constituted one of her greatest difficulties for the last few years. " The tumor has preserved," observes the patient, " a uniform and remarkable hardness." " Madam, will you be kind enough to state when it was you first con- sulted me ?" " Last February, sir." " What did I tell you at that time ?" " You stated that from the long continuance of the tumor, and its immense size, you could hold out no encouragement." " Did I say any thing else ?" " You told me that I had a disease of the ovary which, from its great size, made injurious pressure on my digestive organs, and this was the cause of my constipation." " Well, madam, when I told you that I could promise you nothing, but if you were willing to take the remote chance of being benefited, I would have no objection to see what I could do, did you believe your case to be without hope ?" " Cer- tainly I did; for I had been assured by all the physicians I had consulted that there was no help for me; and it was only through the persuasion of a friend that I had consented to see you, not that I had the slightest hope of receiving any benefit." My object, gentlemen, in this conversation, is to inform you of the true state of things at the time I took charge of this case, in order that you may be fully posted up with its history, and judge from the present condition of the patient what have been the results of treatment. Treatment.—For the purpose of freely opening the bowels, the follow- ing powder was ordered: R Submur. Hydrarg.......gr. xij Pulv. Jalapae......gr. xx. Ft. Pulv. To be followed in the morning by : R Sulph. Magnesiae......3 ij Infus. Sennas......§ iv Tinct. Jalapae......gtt. xxx Mannae.......3j Ft. Sol. The following ointment was ordered to be rubbed over the tumor once a day: $ Ungt. Hydrarg.......§ij Hydriod. Potassae......3 ss Iodin. purae.......gr.vj Ft. Ungt. A pill containing one fourth of a grain of protoiod. hydrarg. and two grains of ext. of cicuta once a day. The ointment and pills to be discontinued as soon as salivation is produced; the patient then to take liq. potassae 3j in half a pint of compound decoction of sarsaparilla once a day, and use the following ointment as soon as ptyalism is over : $ Hydriod. Potassae......3 ij Iodin. purae.......gr- vj Adipis.......3iv Ft Ungt. 392 CLINICAL LECTURES. A pint of tepid water was ordered to be thrown daily up the bowels, in order to keep them in a soluble state. Together with the above oint- ment, the pills of protoiodid. hydrarg. and conium to be resumed, taking one every third night. In July last, there was a very decided change, not only in the general health of the patient, but also in the character and size of the tumor. This lady, whose residence is in the western part of this State, returned home, and remained there during the months of August and September, but previously a nitric acid issue was placed on the side of the tumor. All treatment was ordered to be suspended during these two months, with the exception of the last ointment, which was used freely twice a week, and the sarsaparilla and liq. potassae, which was taken daily, as prescribed above. In October last, this patient returned to the city, and so marked is the change in the tumor, that she, as a personal favor to me, has kindly consented to appear before you, and allow you not only to see the present condition of the tumor, but also to hear from her own lips an account of the case since it came under my professional care. [Here the patient was placed on the bed, and the tumor examined—the Professor very fully calling the attention of the Class to the various points of interest connected with it.] The following conversation be- tween the Professor and his patient in the presence of the Class will tend to elucidate the results so far obtained from the treatment. " Madam, how is your health now, contrasted with what it was last February, when I first saw you, and how does the present size of the tumor compare with what it was at that time ?" " I am, doctor, not the same person. Then, I could not walk but with great distress; I was unable to attend to my domestic duties; dejected in spirits, without sleep, without appetite, without hope. Now, I can attend to the concerns of my house ; I can walk with much more comfort; I sleep and eat with relish, and my mind is happy, because I know the tumor which has dis- tressed me for so many years, has greatly diminished." " How much has it diminished, madam ?" " Should think at least one third. Look here, [the patient grasped the integuments covering the tumor, showed how much they were relaxed,, and she pushed the tumor with facility from one side of the abdomen to the other.] I could do nothing like this last February; on the contrary, my greatest suffering was from the tightness of the skin over the tumor. The skin," she continued," was as tight as a drum, and the tumor perfectly immovable." " Madam, how is it with your dresses ?" " A wrapper, which I have not been able to make meet round me for four years, is now quite loose for me," etc., etc. This case, gentlemen, is one in which I feel a deep interest. The suc- cess of treatment is so manifest, that it seems to me impossible to doubt it, and yet I should have felt some reluctance in speaking of the case, if I had not been able to prevail on this good lady to appear before you, PROCIDENTIA OF THE WOMB. 393 and tell her own story. I have great confidence that I shall succeed in diminishing still more notably the bulk of the tumor. Ovarian dropsy has called forth a great variety of remedial agents, other than those I have mentioned, and much difference of opinion exists as to their respective efficacy. Tapping, for example, is advocated by some, while others, and this has been especially tried with more or less success, recently, in France and England, suggest after the removal of the fluid, the injection into the sac of the tincture of iodine, with the hope of in- ducing adhesive inflammation of the walls of the sac, as takes place in hydrocele. Tapping and pressure have been resorted to, and several cases are reported as having been successfully treated in this manner; also artificial fistulous openings, with a view of drawing the fluid as fast as it accumulates, have been of late years highly recommended. This is the revival of a practice suggested by a distinguished French surgeon more than a hundred years ago. Excision of a portion of the cyst after the removal of the fluid by the trochar, and lastly extirpation of the entire ovary, have likewise been resorted to. I might also mention a favorite practice, in these cases, of Dr. Hamilton, said to have been successful in his hands, and indeed I think I have myself recognized good results from it. It consists in patting the tumor with the ends of the fingers several times during the day, together with pressure, and the internal administration of a solution of the muriate of lime. Procidentia of the Womb op five Years' standing, in a married Woman, aged forty Years.—Mrs. C, aged forty years, married, has one child, seventeen years of age. She has always been a hard-working woman, and enjoyed good health, until within the last five years, when she began to complain of pain in her back and sides, with severe drag- ging sensations in her groins, and occasional sick stomach. At that time she experienced much difficulty in passing water, and her attention was drawn to a tumor which projected from her person. She could only pass water by re-introducing the tumor into the vagina. Various instru- ments had been employed with the hope of supporting the tumor, but all without effect. Her walk is very much impeded by its presence, and she attends to her ordinary duties with much inconvenience and pain. [The patient being placed on the bed, the tumor was examined by the Professor, and shown to the Class.] This, gentlemen, is a case of procidentia of the womb, not simply falling of the organ, but a case in which the organ is completely out of the vagina, and between the thighs of the patient. This is but one of several examples of this kind of displacement which you have had an opportunity of examining, the present session, in the Clinique; and allow me to tell you that physicians in a practice of forty years, will rarely see two cases of procidentia of the womb. It affords me great pleasure to have the means, through the good sense of this patient, to exhibit to 394 CLINICAL LECTURES. you so perfect an example of this form of uterine displacement. The organ, as you perceive, projects nearly three inches beyond the vulva. Here you recognize the os tincae, rounded and contracted, which is usually the case in procidentia. The womb is completely between the thighs, and you can imagine the difficulty the patient encounters in an attempt to move about. I now place my finger on the lower third of the anterior surface of the projecting organ, and you see it comes directly in contact with a portion of the bladder. When describing the anatomy and rela- tions of the pelvic viscera, you will not have forgotten that I told you of the difference in the arrangement of the peritoneum on the anterior and posterior surfaces of the uterus. On the latter, it is distributed throughout, while it covers only the two superior thirds of the former. The lower third, which is not supplied with peritoneum, is in contact through the medium of cellular tissue with the bas-fond of the bladder. You understand, therefore, why in procidentia of the womb, there should also be prolapsion of a portion of the bladder. You likewise perceive that the vagina is inverted, and the rectum is also partially prolapsed. From the long exposure of the uterus, the lining membrane of the va- gina has the appearance of the ordinary integuments, and this very fact has sometimes given rise to the suspicion of hermaphrodism. One point of special interest to which I desire to call attention, is the change in the natural direction of the urethra. Here is the meatus looking directly upward, and this is the necessary consequence of procidentia uteri. In this circumstance you find the explanation of the difficulty in the attempt to pass water, and you must not allow this change in the direction of the urethra to escape memory, when called upon to introduce the catheter in cases like the one before us. [Here the Professor introduced the cathe- ter, and drew off a pint of urine.] Causes.—These may be divided into the predisposing and exciting; among the former will be found an unusually capacious pelvis, repeated pregnancies, and the consequent relaxation of the vagina, long-contin- ued vaginal discharges, increase in the weight of the uterus, whether from disease, or from the superincumbent pressure of tumors, etc. Among the exciting causes may be mentioned constipation—which I consider a very common cause of uterine displacement—too early " get- ting up" after delivery, violent efforts, and carrying heavy weights, unnecessary traction on the umbilical cord with a view to extract the placenta, increased weight of the organ from chronic congestion, lacer- ation of the perineum, etc. Symptoms.—Pain in the back and groins, nausea and sometimes vomiting, irritation of the bladder and rectum, inconvenience and dis- tress m walking, oftentimes inability to pass water without replacing the uterus, and sometimes serious ulceration of the sides of the organ from friction, etc. Diagnosis.—Procidentia of the womb may possibly be confounded PROLAPSUS ANI. 395 with inversion and polypus of this organ; and I have seen one case of entire inversion of the mucous membrane of the vagina which had been mistaken for procidentia uteri. In inversion of the womb there is no os tincae—in polypus, also, there is no os tincae, the tumor is generally insensible, and its pedicle, attaching it to some portion of the internal surface of the uterus, is upward. In complete inversion of the vagina, however, you will discover an opening which may be mistaken for the os, but by introducing the finger into this opening you will reach the true os tincae within. Prognosis.—Although there is nothing immediately dangerous in pro- cidentia uteri, yet it becomes the medical man to be cautious in prom- ising a permanent cure. Treatment.—This may be divided into palliative and curative. For the former object, pessaries of various construction and material are recommended. As a general principle, I am opposed to pessaries, for they are mischievous, if not destructive, by the extreme irritation, which oftentimes they produce. I have seen sad havoc from their long-con- tinued use, deep and serious ulceration being the consequence. In the present case, however, I shall introduce, after returning the womb, a common india-rubber ball, which is soft and unirritating, and which I have found, in displacements like this, to answer the purpose of sustain- ing the uterus better than any other pessary. The ball, as you perceive, has a small opening in it through which the air can be excluded, before introducing it into the vagina; as soon, however, as it has been intro- duced, it again fills with the atmosphere, and thus gives support to the uterus. It should be renewed every few days, and cleansed. It will be found very beneficial to throw, several times during the day, cold water into the vagina; and also cold hip-baths should be employed freely. [Here the Professor restored the womb to its natural position, and introduced the ball—the patient was then requested to rise from the bed and walk around the room, which she did with ease, and said she felt great support, and the uterus did not come down.] The curative remedy for procidentia consists in an operation in which the surgeon makes a triangular incision on the sides of the vagina; as a substitute for the knife, the actual cautery, or lunar caustic is employed; a cica- trix is thus formed, and the womb is supported by the consequent con- traction of the vagina. Prolapsus Ani in an Infant five Months old—Why do Infants CRY ?—Mary F., aged five months, has been troubled for the last two months with prolapsion of its bowel, which causes it much uneasiness. " Has your child, madam, suffered from dysentery or diarrhcea ?" " No, sir." " Have its bowels been constipated ?" "No, sir." Prolapsus ani, gentlemen, is often the result of two opposite causes, viz., diarrhoea and constipation; and you can readily understand why these conditions of 396 CLINICAL LECTURES. the system will be likely to produce falling of the bowel, or rather of the mucous membrane of the rectum. In diarrhcea, and especially in dysentery, the lining membrane becomes relaxed; and in addition to this relaxation, the child encounters in dysentery the effects of tho tenesmus, which strongly tends to the production of the complaint. In constipa- tion, too, the straining, in the attempt at defecation, often results in the prolapsion of the membrane. The mother, however, informs us thai neither of these causes has operated in this case, the child not having suf fered either from diarrhoea, dysentery, or constipation. We must thei seek for some other cause. " Does your child cry much ?" " Oh! yes, sir; and I think that has done it." " When it cries, does it sometimes strain and hold its breath ?" " Yes, sir." It is an interesting fact for you to remember that this excessive cry- ing, accompanied, as sometimes it will be, by straining, is another cause of prolapsus ani. " Do you know, madam, why your child cries ?" " I do not, sir." " Perhaps, madam, it is a little cross by inheritance!" " Yes, sir, I think that's it." Allow me, gentlemen, for an instant, to call your attention to the subject of crying in an infant, for it is well worthy of your consideration. Some infants are naturally cross, for, like children of an elder growth, they have their shades of temper. It often happens, however, that infants cry from positive pain, and this may be produced by over-feeding, colic, cold, etc. There is another cause, which I have observed on more than one occasion, and I shall mention it with the hope that it may hereafter benefit you in your diagnosis. Suppose, for exam- ple, you should be called to an infant, which from its birth had enjoyed excellent health, no derangement of its bowels, and its various functions in proper condition; with all this good health, it had not been given to crying, but, on the contrary, enjoyed a high reputation for uniformly good behavior. Suppose, again, that you are suddenly called to this in- fant, and find it almost in convulsions from the effect of crying. In reply to your interrogatory, the mother, perhaps, would tell you that the child had been perfectly well, and playful as usual; she had just completed its toilet and as she was about placing it in its cradle, it commenced shriek- ing as if it were in great pain. She could not still it; and anxious to know what had produced this change, one of you is sent for. This hypothecated case will sometimes in practice become a reality, and it is proper that you should appreciate all its bearings. In a case such as I have described, I would advise you to adopt the plan which I have pursued, under like circumstances, more than once, viz., have the child stripped, and, in examining its little person, you will probably find a pin or needle piercing it. This may appear to you as a very simple matter, and scarcely within the circle of scientific discussion. But I hold that nothing is unworthy of the attention of the physician which, by possibility, may result in disease of body or mind. Again, in finding the pin or needle piercing the infant, what have you accomplished ? You AN22MIA WITH INCIPIENT ANASARCA. 397 will have accomplished that which is the true object of professional in- quiry—you have discovered the cause. In lieu of attempting to lull the child to repose by the administration of anodynes—which is a pernicious and oftentimes a destructive practice—in lieu, too, of permitting the child to writhe under protracted suffering, which would be very apt to result in convulsions and death—you have exercised common sense; and while in the exercise of common sense you have relieved the infant and imparted intense joy to the mother, you have done something for yourself. These matters do not pass for trifles in the sick room ; they receive their full measure of appreciation. It is as true that the solid reputation of the medical practitioner rests upon details, as that aggre- gation in the physical world depends upon the accumulation of parti- cles. Treatment.—In prolapsus ani, produced by constipation or diarrhoea, the first object of the practitioner is to remove the cause of the prolap- sion. In the former case, the constipation must be overcome; in the latter, the diarrhoea checked. The bowel, too, should be carefully re- turned after each evacuation; the best mode of accomplishing this is to take a piece of fine sponge, well oiled, and by gentle pressure on the pro- lapsed surface, it will be returned within the sphincter. A compress with a bandage may then be employed. For the purpose of producing an astringent effect on the returned membrane, a small syringe-full of the following may be thrown up the rectum twice a day : R Tinct. Catechu ) Tinct. Hyoscyam.......3j Aquae purae ;......§ iij M. Anaemia in a married Woman, aged thirty Years, the mother of four Children, 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 Anaemia.—Mrs. R., aged thirty years, married, labors under great exhaustion, with a yellowish pallor of countenance andincipient anasarca, together with Other general symptoms characterizing an anaemic condi- tion of the economy. " How long, madam, since your health begun to decline ?" " I have been gradually losing my health, sir, for the past three months." " Previous to that time what was the state of your health ?" " It was very good, sir; I had no reason to complain, and I could attend to my work without any trouble." " Do you know, my good woman, what caused your health to give way three months ago ?" " I had, sir, at that time a miscarriage, and I flooded so much I thought I would have died." "After the flooding, had you much headache?" " Yes, sir, I was almost distracted with my head, and they said my brain was inflamed." "Did the light affect you, and increase your headache ?" " Yes, sir, I was obliged to keep my room dark, I suffered 398 CLINICAL LECTURES. so much from the light." " When did your limbs begin to swell ?" " About six weeks after my miscarriage, sir." " Are you much troubled with dizziness and palpitation of the heart ?" " Yes, sir, I have swim ming in my head, and a great deal of beating about my heart." The case before you, gentlemen, is one of great interest for several reasons, and presents two or three features which are full of practical import. There is no doubt that this patient is laboring under anamia— a term derived from two Greek words—a, privative, and di/xa, blood— which mean literally a deficient quantity of the circulating fluid, or a bloodless condition of system. You will observe that this woman whose health is now so feeble, dates her sufferings, and very truly so, from a miscarriage which occurred three months since, accompanied with profuse loss of blood. The unusual loss of blood is undoubtedly the original source of her present troubles, and will fully explain the various morbid phenomena which are so distinctly marked in her case, viz.: 1st. The great exhaustion; 2d. The intense headache, with intoler- ance of light; 3d. The icterode pallor of countenance; 4th. The vertigo and palpitation of the heart; 5th. The incipient anasarca. Allow me here, for the instant, to dwell with special emphasis on one of these phe- nomena resulting from loss of blood—I mean the headache, with intoler- ance of light. It is a feature connected with exhausting hemorrhages in every way worthy of your consideration. An error in diagnosis on this subject will be at too heavy a cost, and you must, therefore, exercise in such cases a careful judgment, in order that the truth may be developed. This woman informs us that one of her prominent troubles was intense pain in the head, with intolerance of light. These are two of the symp- toms of inflammation of the brain, and you have heard the statement that, in her case, these symptoms Were referred to inflammation of that organ. This is a very common mistake in practice, and coupled with it is another, that of confounding the palpitation, the simple result of loss of blood, with the palpitation the effect of organic disease of the heart. You see, therefore, in the case before us another exemplification of the fact, to which your attention has been so often directed, that symptoms without their defined measure of value are false lights, and frequently tend, so far as the application of remedies is concerned, to disastrous results. If, through an erroneous diagnosis, this patient had been treated for phrenitis, she would have died by the very hand that was raised to save her! Nothing is more common than this intense headache and palpita- tion of the heart in puerperal women, who have suffered from severe hemorrhages. These two symptoms will yield as soon as the waste is repaired, and they require, therefore, tonic instead of depleting reme- dies. Let us now turn to another feature in this case, and see whether we can satisfactorily explain its true origin—the incipient anasarca. A few years since the doctrine prevailed that certain forms of dropsy were traceable to an impoverished condition of the blood. This, however, ANJEMIA WITH INCIPIENT ANASARCA. 399 was too general and vague; there was an absence of application about it so essential to the practitioner in his just appreciation of morbid action. An impoverished condition of the blood may mean too much, or it may mean too little, depending upon the particular interpretation which may be given to it, and under no circumstances, without a more precise un- derstanding of the term, can it lead to salutary results either in diag- nosis or treatment. Andral, in his admirable essay on " Haematology," very significantly remarks that the blood may become impoverished by the loss of its due quantity of fibrin, red globules, or albumen. In either of these three cases the blood will have lost its richness. But, he adds, does each of these conditions lead to dropsical effusions ? The answer to this question is, that the diminution either of the fibrin or red globules of the blood does not necessarily induce dropsy ; and, moreover, when serous effusions occur simultaneously with the loss of either of these elements, they do so as exceptions, and may be ascribed to other circumstances. The true impoverishment of the blood, which leads to dropsy is that condition of the fluid, in which it is deprived of its albumen. This was the opinion advanced by Andral; but, perhaps, he did not go far enough, for he maintained that the blood could be de- prived of its albumen only through the kidney; or in other words, as a consequence of albuminuria. The fact that the albumen of the blood becomes diminished in dropsies following Bright's disease of the kidney had previously been ascertained by Christison, Burrows, and others. It was, however, left for Becquerel and Rodier not only to confirm the views of Andral as to the connection between certain forms of dropsy and the loss of albumen in the blood, but they also, if their researches should be sustained by future observation, have shown that this diminu- tion of albumen may occur irrespectively of albuminuria* * In their memoir presented to the Academy of Medicine in 1850, they offer the following as the results of their investigation on this subject: 1st. In the same manner that there exists an anaemia through a diminution of the red globules, we ought also to admit a pecuhar pathological state characterized by a diminution of the albumen. 2d. This diminution of albumen may be produced in a rapid manner, and is then accompanied with pallor, icterode hue of the face, great debility, and especially ana- sarca, without albuminuria. 3d. A large number of acute dropsies, still regarded as essential, should manifestly be attributed to this pathological state. 4th. The diminution of albumen in the blood may develop itself slowly; it then constitutes a chronic pathological condition, characterized by particular symptoms, such as pallor, with an icterode color of the face, extreme debility; and finally, gen- eral dropsy more or less intense, without albuminuria. 5th. The greater part of the dropsies, formerly regarded as essential and passive, belong to the preceding class. 6th. The diminution of albumen in the blood is completely independent of the numerical amount of the red globules. These two alterations in the blood, however, 400 CLINICAL LECTURES. The conclusions arrived at by Becquerel and Rodier are but addi- tional evidences of sound progress, and they give strength to the lan- guage I used to you some time since " that physiology and chemistry are fast revealing a new basis for the treatment of disease—thought is now in the right direction, and a bright future is at hand. In less than ten years, therapeutics will have received a new character—the practice of medicine will be more certain, because its principles, through the investigations of the chemist and physiologist, will have become conse- crated as so many unerring developments of truth." If the researches of these observers prove any thing, they prove a very substantial and important fact, viz.: that there are two forms of anamia, one depend- ent on the loss of red-globules in the blood, as in chlorosis; the other dependent on the loss of albumen, such, for example as in the exhaust- ion following profuse sanguineous losses, an impoverished diet, etc. In order that you may fully appreciate the importance of a just distinction between these two forms, if I may so call them, of blood-lessness, it is only necessary to observe that, without this distinction, you can have no rational hope of applying the appropriate remedy. If you desire the proof of this, it will be afforded you in the essential truth that in the anaemia resulting from the loss of red globules, iron is the remedy. In the anamia, on the contrary, dependent on the loss of albumen, iron has no remedial effect whatever. Again, in chlorosis, quinine is a per- fectly negative remedy—while, in the other form of anaemia, it is heroic in its results. Treatment.—The practical inference to be deduced from the remarks we have made in reference to the different pathological conditions con- nected with these two characters of anamia is simply this : that their successful treatment must necessarily depend upon an accurate diagno- sis, and a due consideration of the causes. In the case before us, for in- stance, there can be no doubt as to the starting-point of the derangement exist very often together, and it is sometimes the one, and sometimes the other, which predominates. Vth. The diminution of the red globules is altogether incapable of producing dropsy, unless there be at the same time a loss of albumen. 8th. The causes capable of producing a diminution of albumen are insufficient food, profuse sanguineous losses, protracted diarrhcea, paludal poison, etc. 9th. The same effects are produced under the influence of organic diseases, such as an affection of the heart, Bright's disease of the kidney, constituting a veritable cachexy. 10th. The pathological state to which in general is given the name cachexy, is noth- ing else than a combination of symptoms, which result from a diminution of albumen connected or not with a certain loss of the red globules. The first of these causes explains those dropsies which are so frequent, accompanied with discoloration of the skin, and the profound exhaustion of the patient. The second explains the cardiac and vascular bruits de souffle, the dyspnoea, palpitation, etc. 11th. The preceding distinctions exercise a great influence and should be well considered in the diagnosis, prognosis, and treatment of these dropsies. FREQUENT DESIRE TO PASS WATER. 401 under which this patient labors—it was the profuse hemorrhage conse- quent upon the miscarriage; and the anasarca is the effect of the loss of albumen in the blood consequent on the hemorrhage. The effusion here is not of the acute form; it is, on the contrary, chronic and as- thenic. The obvious indication is to remove this tendency to general dropsy by doing all that science will enable us to accomplish with a view of restoring to the blood its lost albumen. With this object, therefore, I shall recommend the following course to be pursued: R Sulphat. Quinae......3 sa Pulv. Rhei.......3 j Divide in chartulas xxx. One of the powders to be taken thrice a day; the diet to be nutritious, consisting of animal broths and succulent meats, with half a pint of porter daily; to which should be added pure country air, and exercise without fatigue. The chronic dropsies, which are so frequently observed to accompany wasting diseases, such as carcinoma of the uterus, etc., and which are also often consequent upon undue lactation, may be classed under that form of anaemia, which results from a loss of albumen in the blood. How else are we to account for these affections, especially in cases in which there is no obstruction to the circulation either from the pressure of tumors, disease of the heart, liver, etc. ? Frequent Desire to pass Water in a married Woman, twenty- seven Years of age.—Mrs. O., aged twenty-seven years, married, the mother of three children, the youngest four months old, complains of much uneasiness about the bladder, and says she feels the necessity of passing water as often as twenty times during the day and night, but is able to evacuate only a small quantity at each time. " How long, madam, have you suffered from this irritation of the bladder ?" " I have been troubled with it, sir, ever since the birth of my last child." " Was your last labor a difficult one ?" " Yes, sir; I was in labor for four days, and suffered very much." This case, gentlemen, is one of interest, and happily one which is within the control of remedies. It is an affection of extreme annoyance, and when you encounter it in practice, it will be your duty, before at- tempting any treatment, to ascertain its true cause and nature. Irrita- tion of the bladder will arise from various conditions of the system, and hence the necessity of an accurate judgment. I have examined this patient per vaginam, and, on pressing my finger gently against the neck of the bladder, and along the course of the urethra, I find there is much tenderness, accompanied with a muco-purulent discharge from the urethra. From these facts it is manifest that the frequent desire to pass water is the result of inflammation of the urethra and neck of the bladder; and I 26 102 CLINICAL LECTURES. have no doubt that the inflammation of these parts has been produced by the severity of the labor. It is not, in cases of difficult parturi- tion, unusual for the patient to experience trouble about the bladder, such as incontinence of urine from partial or complete paralysis of the sphincter, a frequent desire to micturate from irritation, inflammation, etc. Treatment.—One syringe-full of the following injection should be thrown into the urethra once in two or three days, and repeated at this interval as often as may be necessary : R Nitrat. Argenti.......3j Aquae distillat........I iv Ft. sol. You need have no apprehension as to the use of the nitrat. argenti in these cases—I often have recourse to it, and with decided benefit. In addition to the injection, the patient should put the contents of one of the following papers into half a pint of boiling water; let an infusion be made, and the half pint should be taken cold in divided doses during the day: R Fol. Diosma Crinat......3 xx Divide in chartulas x. Hysteria from Defective Menstruation in a widow Woman, aged twenty-nine Years, the Mother of two Children.* Mrs. M., widow aged twenty-nine years, the mother of two children, the youngest six years old, returned to-day, and reported herself much improved in health. This case, gentlemen, you will remember, was one of hysteria, which we attributed to defective menstruation. The hysteric paroxysms we re- garded merely as results, and directed our attention, in the treatment, to the restoration of the menstrual function to its normal standard. The patient was regular as to time, but defective as to quantity. If you will turn to your note-books, you will see what was said, and the treatment ordered when this case was first presented here. " You say, my good woman, you are improved in health ?" " Yes, sir." " Be pleased to tell us in what particular you are better." " My monthly turns, sir, are quite regular now in all respects, and my nervous attacks have almost entirely left me." " I am glad to hear it. Good morning, madam." Symptomatic Cough in a Child eighteen Months of age.—Sarah R., aged eighteen months, is reported by her mother cured. When this little patient was brought here, the mother was in great distress for fear her child was in consumption. I called your attention particularly to the subject of cough, and reminded you that children are frequently affected with what is called symptomatic cough, the causes of which are worms, constipation, dentition, etc. In the case of this little patient, our * Page 368. SUPPRESSION OF THE MENSES. 403 opinion was that the cough was due to the irritation of worms, and the following treatment was ordered: R Fol. Spigelias Mariland.....§ ss Fol. Senna?.......| sa Aquae Eullient......| vj Ft. Infus. A table-spoonful twice a day, until all is taken, followed by R Sub. Mur. Hydrarg......gr. ij With 3 ij of castor oil the ensuing morning. The diet to be of the bland est kind. Should any worms be expelled, the child to be placed on a gentle tonic, such, for example, as the following: R Sulphat. Quinae......gr- ij Acidy Sulph. dilut......gtt. ij Syrup Zingiber!......§ ij A tea-spoonful twice a day. " Did any worms pass from your child, madam ?" " Yes, sir, it passed four after it took the calomel powder." " How is its cough ?" " The cough has left it, sir." Suppression of the Menses in a married Woman, thirty-one Years OF AGE, OF NINE Years' DURATION, FROM CHRONIC INFLAMMATION OF THE Uterus—The Emmenagogue properties of Mercury.—Mrs. M., mar- ried, aged thirty-one years, no children, has labored under suppression of the menses for the past nine years. " Do you know, my good woman, what caused your courses in the first instance to become suppressed ?" " I think, sir, it was a cold I took." " Cold, madam, is a very common cause of this affection. You are certain that you have not had your turns for the last nine years ?" " Yes, sir." " Have you felt much uneasiness about your hips ?" " Yes, sir, and I have suffered a great deal of pain about my womb." The case before you, gentlemen, is one of chronic suppression of the menses, and it is well worthy of attention. These are the cases which so often bid defiance to remedies, and lead to a gradual decay of the system. This patient, in addition to the suppression, is also affected with chronic inflammation of the uterus. The tissues of the uterus are evidently thickened, and the organ is enlarged. You have seen in this Clinique a numerous variety of suppressed menstruation, and you have also seen the cases yield to appropriate treatment. In the present in- stance, it appears to me, we possess a remedy which is admirably adapted to restore this woman to health—it is, in this particular form of suppres- sion, one of the most certain and effectual emmenagogues—I mean mer- cury. I can speak with great confidence of this medicine—it has often served me when all else has failed. As a deobstruent, mercury enjoys an excellence above all other reme- dies, and it is to this particular virtue that we are to ascribe its extra- ordinary powers in overcoming long-standing menstrual suppression, 404 CLINICAL LECTURES. with which there is almost always associated chronic inflammation or congestion of the uterus. The great object to be attained in the admin- istration of mercury in these cases, is its gradual but positi /e influence on the system. Ptyalism must be effected, and though it is not desirable that excessive mercurial action should take place, yet it is absolutely essential that the system should be under its influence for at least three or four months. It is in this way only that we can hope to see exempli- fied its great efficacy as a remedy in chronic suppression. There is, I am aware, a strong popular prejudice against the use of mercury—and the prejudice has sprung from the frequent abuse of this potent medicine. I do not speak of mercury as prescribed by the charlatan—I speak of it, on the contrary, as a remedy in the hands of the skillful physician who comprehends its power for doing injury, and understands its influence in controlling morbid action. Take mercury from the materia medica, and how feeble would be our means of subduing inflammation, especially of the chronic type, and how restricted our resources! There are, however, certain conditions of system, which contra-indicate the administration of mercurial preparations; such as scrofulous diathesis, inflammatory affec- tions accompanied with exhaustion, nervous irritability, etc. In these cases mercury, generally speaking, would do harm, and should, therefore, be avoided. It is desirable, when salivation is contemplated, to conjoin opium with the mercury, for the reason that it will be more likely to be retained in the system, and, therefore, its full effects more certain. The various preparations employed are calomel, blue pill, hydrarg. c. creta, etc. Calomel, perhaps, is more reliable as well as more certain in its action. We shall order the following prescription : R Submur. Hydrarg......gr. xxiv Pulv. Opii.......gr. iv Ft. Massa in pil. xij div. Let one pill be taken night and morning until ptyalism is produced; and in order that the action of the mercury may be continued, one pill should afterward be given at intervals of four or five days, as circum- stances may require. Mercurial inunction is sometimes resorted to in these cases, but I think the internal administration of the medicine preferable. Inversion of the Mucous Membrane of the Urethra in a married Woman, aged forty Years, the Mother of seven Children.—Mrs. P., aged forty years, married, the mother of seven children, the youngest four years of age, complains of a difficulty in passing water, with which she has been more or less troubled for the last three years. " What is the nature of the difficulty of which you complain, my good woman ; is it that you can not retain your water ?" " Oh ! no, sir ; my difficulty seems to be an obstruction at the outer passage ; there is a small swell- ing there, which gives me much trouble sometimes, and seems to prevent INVERSION OF THE MUCOUS MEMBRANE. 405 the flow of water." " Does the swelling cause you any pain ?" " No, sir; except sometimes when I walk it feels irritated." This case, gen- tlemen, is a peculiar one, and for those of you who have never seen an example of the kind, it will present more than usual interest. I have had frequent occasion to allude to the causes of difficult micturition, but I do not recollect that a case of this particular character has before presented itself at the Clinique, although it can not be considered one of extreme rarity. You would, I judge, be somewhat perplexed to form a correct opinion of the disease before us without some additional data beyond the mere statement which you have heard from this patient. Before intro- ducing her here, I examined with much care the condition of the urethra, and I have discovered the cause of her difficulty to consist in a prolap- sion, or perhaps, more properly speaking, an inversion of the mucous lining of that passage; and I have also ascertained another interesting circumstance, viz., that the inverted mucous surface is ulcerated, the consequence, no doubt, of friction of the dress. This condition of the urethra is sometimes the result of protracted and severe labors; and sometimes, too, you will find it connected with a dilapidated constitution, where the tissues are in a state of general relaxation. The particular condition of this urethra might possibly be confounded with another form of disease to which this passage is liable, and several examples of which you have seen in the Clinique—I mean " the bloody tumor of the meatus urinarius." But the distinction between these two affections is so sim- ple that error in diagnosis can not be justified. In the latter disease, as you know, there are usually three characteristic symptoms : 1st. Ex- cessive sensibility; 2d. Extreme scarlet redness; 3d. Bleeding on in- jury. All these symptoms are absent in the present case. Treatment.—In recent cases of inversion of the urethra, you will often succeed in remedying the difficulty by well-directed and persevering pressure through the agency of bougies, together with the free use of cold ablutions. In the present instance I despair of success by such means. Before, however, attempting any remedy for the inversion, the first object of attention is the healing of the ulceration ; this can readily be accomplished by the occasional application (two or three will probably suffice) of the nitrate of silver in solution, say 3ss to §j of water. After the ulceration is removed, the remedy for a permanent cure in this case, is the excision of the projecting fold of membrane. There is no danger in the operation, and it is one that is perfectly justifiable under the circumstances. [Here the patient was placed on the bed, and the Professor, with a camel's hair pencil, freely touched the ul- cerated surface with the solution.] " Return here next Monday, my good woman, and I will do what is proper for you." " Thank you, sir, I shall." In addition to the local treatment, this patient will need some constitutional remedies : her health, as you perceive, is bad, and she re- quires invigoration. " How are your bowels, my good woman ?" " They 406 CLINICAL LECTURES. are very much confined, sir." " Are your courses regular?" " No, sir, they are vtry scanty." Let the following prescription be ordered: » P^.Rhei ,.....-a3ij Carbonat. Magnesia? | Aromat. Confect.......3 isa Infus Rhei ) , „. . I......aajiv Aq. Cmnamom f FtM. A wine-glass early in the morning as circumstances may indicate. In addition to the above, it would be judicious, I think, for this patient to take, for two or three successive nights, just previous to the menstrual period, § j of tinct. aloes co. Her diet should be nutritious, and after the bowels have become regulated, she may substitute for the above mixture, the following: R Sulphat. Ferri.......3j Extract Gentianae......3 ij Divide in pil. xx One pill twice a day. Serous Infiltration of the Labia Externa, in a married Woman, aged twenty-seven Years, six Months Pregnant.—Mrs. P., married, aged twenty-seven years, six months in gestation, seeks advice for a large swelling in the lower part of her person. " How long, my good woman, have you been married?" " Two years, sir." " Is this your first preg- nancy ?" " Yes, sir." " How long have you been troubled with this swelling of which you speak ?" " About one month, sir, but lately it has increased so much, that it gives me great uneasiness." " Do you swell in your feet and legs ?" " Oh, yes, sir, my feet are more than twice their usual size. [Here the patient was placed on the bed, and, after an examination, the Professor pronounced the swelling a serous infiltra- tion of the labia majora.] This, gentlemen, is a case of much practical interest. The patient before you is in her sixth month of pregnancy; her lower extremities are marked by extreme oedema, which is often the accompaniment of gestation from pressure on the lymphatic vessels by the distended uterus; and you also perceive that the oedema has extended to the labia majora, enlarging each one of them to the size of an ordinary fcetal head. The labia majora are liable to distension from several causes: 1st. Abscess; 2d. Sanguineous engorgement; 3d. Serous infiltration; 4th. Hernial protrusion; 5th. Aneurismal cysts; 6th. Varicose veins, etc.; and you can not, therefore, exercise, in such cases, too much caution in endeavoring to ascertain the true cause of the enlargement. The labia are abundantly supplied with cellular tissue, and consequently are predisposed to accumulations of serum, whether connected with a gen- eral hydropic diathesis, or simply the result of transitory or accidental influences. Occasionally, only one labium is affected, but most usually both will become the seats of distension. One of the first points of PARTIAL PARAPLEGIA. 407 inquiry in this form of infiltration is, whether the serous accumulation be due to ordinary dropsy, or merely the effect of some mechanical or temporary cause. It is very manifest from an examination of the case, that this patient is not affected with ascites, though she is evidently an- asarcous—the sub-cutaneous cellular tissue being more or less infiltrated. The patient needs relief, and the question is, what can be done for her ? Treatment.—In cases like these, much will be gained by position. As far as possible, the recumbent posture should be maintained, the hips elevated, and the head and shoulders as low as convenient. This will tend to diminish the volume of the labia; and for the general infiltration much benefit will be derived from the following: R Submur. Hydrarg.......gr. vj Pulv. Digitalis......gr. ij Div. in chart, ij One of the powders at night, followed in the morning by § ss of sulphate of magnesia in half a tumbler of water. It will sometimes be necessary, from excessive distension, to evacuate the fluid in the labia by puncture. There is, I am aware, objection urged against this practice on the ground that incisions here are apt to become serious through erysipelatous and other forms of inflammation. I do not think these objections well founded as a general principle, and should, therefore, not hesitate when indicated to resort to incisions as a mode of relief. But a short time since, Dr. Martin, of Kentucky, one of the stu- dents in this university, was intrusted by me with a case of midwifery. In the course of the day, he requested me to see the case with him. I found the labia externa enormously distended, so much so that it was im- possible to make a vaginal examination. Without any delay, I freely punctured both labia; more than a quart of fluid was evacuated. The patient was delivered in about twelve hours afterward by Dr. Martin. Her recovery was prompt, and she and her infant are in the enjoyment of good health. Partial Paraplegia in a married Woman, aged thirty-two Years, from Instrumental Delivery.* Mrs. W., married, the mother of one child, ten months old, says she feels more power in her lower limbs and finds she can walk with much more ease than she has been able to do since the birth of her infant. This case, gentlemen, when it was first pre- sented here, I discussed very fully. This woman was delivered with in- struments, and the result was a partial loss of power over the lower limbs. She was treated with strychnia, which, you know, is the active principle of nux vomica, and which exercises a specifie influence on the spinal cord, this influence being more marked on the motor nerves than on those of sensation. One of the following pills was ordered to be taken twice a day: R Strychnia*.......P- ij Confect. Rosarum......-.... aa gr. vj Submur. Hydrarg. ) Pulv. Antimonial.......gr. j. Divide in pil. No. iij. The bowels should afterward be kept soluble by a wine-glass of the fol- lowing saline mixture, as may become necessary: R Sulphat. Magnesiae ) ?, Sup. Tart. Potassae )......^J Aquae purae.......Oj Ft. sol. This treatment, together with a diet strictly vegetable, will equalize the circulation, break up the congestive tendency, and restore the girl to health. In cases like the one before us, instead of local depletion in which I have great confidence, I am often in the habit of recommending small revulsive bleedings from the arm, say § ij at the time of the catamenial flow, and § ij in fifteen days, to be continued as long as circumstances may indicate. This was the favorite practice of Lisfranc, and I have very great faith in it from repeated success. It will, however, be neces- sary to do something at the time of the menstrual crisis to quiet the pain, which is so significant and annoying a symptom of this form of dysmenorrhoea; and for the purpose you will find great power in opium. Let an opium suppository, containing one grain, be introduced into the rectum; or what will often prove highly serviceable, twenty drops of laudanum, in a wine-glass of tepid water as an enema. I have derived CONGESTIVE DTSMENORRHCEA 417 much benefit from lubricating the neck of the uterus with a portion of the following ointment, and it will sometimes have a magical effect in soothing the pain: R Extract. Belladonnae.....3 sa Adipis........|sa Ft. Ungt. In another place I have spoken of, and endeavored to explain, the modus operandi of the liq. ammonias acetat. in congestive dysmenorrhoea. It may be given in 3 ij doses in a table-spoonful of cold water three or four times a day while the pain continues. Congestive dysmenorrhoea is, I think, a common cause of sterility, which is explained as follows: The successive formations of the decidu- ous membrane on the internal surface of the uterus, produce, to a greater or less extent, a morbid influence on the lining membrane of this organ ; and it is this morbid condition of the mucous surface which prevents a healthy gestation. It is in such cases that we meet with what is termed molar pregnancy. If, therefore, this patient were a married woman, I should in addition to what has already been advised, place her under the full effects of mercury, which I believe to be the only remedy capable of removing that morbid state of the uterine mucous surface, which ex- perience has shown to be adverse to healthy gestation. Dr. Lever, in a paper published in the " Transactions of the Royal Medico-chirurgical Society, in 1839," remarks that, according to all the evidence within his reach, this variety of dysmenorrhoea is the most frequent antecedent of carcinoma uteri, and it stands in the proportion of 54.19 per cent. There is a form of dysmenorrhoea which will sometimes prove trouble- some ; it arises from inflammation of the ovary, which Tilt has termed the dysmenorrhoea from ovaritis. The diagnosis is not difficult—the prominent symptom will be excessive pain in the affected ovary, much increased by pressure. The remedies consist in leeches, purgatives, rest in the recumbent posture, vegetable diet, and, after the leeches, a blister will be of signal service. You will also have frequent occasion to prescribe for patients suffering under what may be properly termed nervous dysmenorrhaa ; this is met with in females whose nervous system is exquisitely sensitive, and who suffer, from this circumstance, excessive pain during the menstrual period. It is important that a clear diagnosis should be made of the case. The following treatment in pure nervous dysmenorrhoea, will rarely fail to accomplish a cure. For one day before the menstrual flow, let the patient take one of the following pills twice a day—and during the period of the menstruation, one of the pills every two hours, until the pain is mitigated. R Extract Hyoscyam. } G. Camphorae >.....&a3j Pulv. Doveri ' Ft. Massa in pil. xx dividenda. 27 418 CLINICAL LECTURES. In addition, should it become necessary, an opium suppository may be introduced into the rectum. But the radical cure of this character of dysmenorrhoea will depend upon properly controlling the morbid con- dition of the nervous system, which will be best accomplished by a tonio course of treatment during the interval between the menstrual periods The shower-bath, horseback exercise, etc., will be useful. Facial Hemiplegia in an Infant, ten Days old.—J. H., aged ten days, is brought to the Clinique by its aunt, who says its mother is much alarmed for fear her little infant will never get its face right. "Madam, was that child delivered with instruments?" "Yes, sir." " So I thought, my good woman." Here, gentlemen, is a case of para lysis of the face in the new-born infant, which you will sometimes ob serve in practice, and it is important that you should understand the facts connected with its production, viz.: 1st. That it is almost always the result of undue pressure of the forceps on the side of the face; 2d. It is usually evanescent, and productive of but little harm, excepting the anxiety experienced by the parent. Cold is also a cause of this form of hemiplegia. The paralysis consists essentially in injury to the seventh pair of nerves. Treatment.—All that is necessary is to bathe the affected sides of the face several times during the day with camphorated oil or soap liniment. Occasionally, in protracted cases, a small blister will be useful behind the ear. Abscess in the Neck of a Child, two Years old.—R. R., aged two years, has a small abscess on the right side of the neck, which causes her to fret. " How long, madam, since you first observed that swelling?" " About ten days ago, sir, I noticed it for. the first time." " Have you ever observed any lumps in the neck of your child before this one appeared ?" " Never, sir." " Has its health always been good ?" " Yes, sir, she has never had a day's sickness until this time." Abscesses, gentlemen, will form in the neck of young children from various causes ; you will sometimes find them connected with a scrofulous diathesis ; they often result from cold, injury, etc. These swellings may be congenital or acquired. They are sometimes encysted ; at other times they are, as is the case in the present instance, simply the result of ordinary in- flammation terminating in suppuration. It is very evident that there is a collection of matter, and I shall, therefore, without delay, evacuate it. [Here the Professor opened the abscess, and half a wine-glass of pus escaped.] " Take that child home, madam, and use a bread and milk poultice for a day or two, and your child will soon be well." It is important in these cases to evacuate the matter as soon as it is formed, for the reason that it alleviates the pain, and facilitates the restorative process. GESTATION COMPLICATED WITH PHTHSIS PULMONALIS. 419 Venereal Chancres in a Woman, twenty-four Years of age.__ J. M., aged twenty-four years, seeks advice for a discharge from her va- gina, which she says she has had for the last week. The patient before you, gentlemen, complains simply of a discharge from her vagina. Our duty, before attempting any relief, is obviously to discover in the first place the character of the discharge, and then its cause. These two facts I have ascertained. The discharge is purulent, and proceeds from a ve- nereal chancre in the vagina. [The patient was placed on the bed, and the chancre on the inside of the left labium externum fully shown.] This is a case of primary syphilis. There is as yet no bubo, and we shall probably be enabled to prevent its formation, which is always a desirable object. Treatment.—This will consist of both local and constitutional measures. I now, as you perceive, cauterize the chancre with the solid nitras. argenti. This is the only local application I shall employ for the present. The constitutional treatment is intended thoroughly to neutralize the venereal poison, and guard the system against the disease in the secondary form, and will consist as follows : R Massae Hydrarg......gr. xxxij Pulv. Opii......gr. iv Divide in pil. xvi. One pill twice a day until ptyalism is produced ; then, one every other day, in order that the effects of the mercury may be continued for some time; when the ptyalism is over, the patient should take daily half a pint of the compound decoction of sarsaparilla. Gestation six Months advanced, complicated with Phthisis Pulmo- nalis, in a married Woman, aged twenty-four Years.—Does Preg- nancy EXERCISE ANY INFLUENCE IN CONTROLLING EITHER THE DEVELOP- MENT or Progress of Phthisis Pulmonalis.—Mrs. J., married, aged twenty-four years, six months advanced in pregnancy, is laboring under confirmed phthisis ; her pulse is one hundred and twenty, with copious purulent expectoration, night-sweats, and general emaciation. " How long have you been married, my good woman ?" " Just ten months, sir." " What was the state of your health previous to your marriage ?" " It was quite good, sir." " Had you any cough ?" " No, sir, my cough commenced about four months ago." "Were you regular in your courses before your marriage ?" " Always, sir." " Are your parents living ?" " My mother died, sir, about two years ago, but my father is alive." " Do you know what caused your mother's death ?" " She died of consumption, sir." " Have you any sisters or brothers ?'•' " I have two sisters and one brother living, and have lost one brother with consumption." The case before you, gentlemen, is not uncommon in practice. I have seen many such. Here is a young woman, just as it were budding into 420 CLINICAL LECTURES. womanhood, six months advanced in gestation, weighed down by a disease the most fearful and certain in its termination, of all the mala- dies on the calendar of human suffering. It requires no sagacity to pre- dict the sad end of this affection—its nightly and daily progress suf- ficiently indicates its unrelenting character, and points with unerring truth to its fatal termination. It bids defiance to the medical man, and its truces are but so many delusive hopes to cheer, for the instant, the unhappy sufferer, and make more poignant the grief of disappointment. This case suggests to my mind a few thoughts on a subject about which I think there has, and does still exist an erroneous opinion—I allude to the supposed salutary influence exercised by pregnancy on the develop- ment and progress of phthisis pulmonalis. It was one of the favorite doctrines of the older writers, that pregnancy prevented the develop- ment of phthisis pulmonalis, and if developed, checked for the time being its progress; you will find also that this opinion is to a great ex- tent participated in by recent writers. Some, indeed, of the great names among the practitioners of almost our own times belong to this latter class; among them I might mention Desormeaux and Dug6s. On the other hand, there are many who are disposed to doubt that any such influence is exercised by gestation, and among these are Louis and Rayer, whose opinions are founded upon careful personal observation. I might here allude to an interesting memoir by Grisolle, who has given some extremely interesting statis- tics, which fully, as far as they go, demonstrate two important facts: 1st. That women laboring under phthisis rarely become impregnated; 2d. That phthisis, in cases in which there is predisposition to the disease, is very apt to become developed during gestation, and this latter state, in lieu of checking, seems to increase its progress. I can not myself understand why pregnancy should in any way prevent the development, or arrest the progress of pthisis pulmonalis; and I think the opinion has been arrived at through a loose observation of facts. On the con- trary, it appears to me that there are strong grounds for assuming that pregnancy is positively favorable not only to the development of the disease, but also to its increased progress. This conclusion has been the result partly of my own personal observation, and moreover it is, in my judgment, susceptible of explanation. It is well known that predispo- sition to phthisis may exist under certain circumstances in a dormant state for a long time in the system, and will not become apparent ex- cept through the operation of some one of the numerous exciting causes, which exercise a marked influence in the development of tuberculi- zation. Then the question presents itself—is there any thing in the impreg- nated state calculated to facilitate this development? This question will be more satisfactorily solved by a brief allusion to the ordinary condition of the system during gestation. I do not intend to assert that GRANULAR VAGINITIS. 421 pregnancy is strictly a pathological state, for we see many women pass through this period without inconvenience, and in the full enjoyment of uninterrupted health; but this is not always so, as must be manifest to every observant practitioner; and instead of uninterrupted health, preg- nancy is frequently characterized by numerous disturbing influences such as: 1st. Greater activity in the circulation, as is evinced by a more frequent pulse, together with increased fullness and hardness; 2d. Con- stipation, which is so often an accompaniment of this state, and which certainly can not continue for any length of time without involving the general system in more or less disturbance, and thus tending to the de- velopment of disease in any organ in which there already exists a pre- disposition to morbid action; 3d. The severe and protracted vomiting, which occasionally supervenes upon gestation, often interfering with the healthy play of the nutritive functions; 4th. The various nervous dis- turbances, which usually present themselves during pregnancy; 5th. The change in the character of the blood which, according to the experi- ments of Andral and Gavarret confirmed by Cazeaux, becomes similar to the blood of chlorotic patients. Again a very common result of sup- pression of the menstrual function in the young girl is the development of phthisis pulmonalis—this is a fact of which every practitioner is cog- nizant ; and how far, therefore, the suppression of this function during pregnancy may tend to facilitate the manifestation of the disease is a question, I think, worthy of consideration. In a word, the various phe- nomena to which I have just alluded are, in my opinion, so many influ- ences calculated to bring into action the latent tubercle, and, in connec- tion with certain statistical facts mentioned by Grisolle and others, they go far to sustain the opinion that pregnancy is favorable to the develop- ment of phthisis pulmonalis. How often is the suggestion made that marriage is the only remedy in the case of a young girl threatened with consumption; and how often alas! does this suggestion tend to the shortening of human existence! Think of this subject—it is one alto- gether worthy of attention. Granular Vaginitis in a married Woman, aged twenty-four Years, accompanied with a thick, creamy Discharge.—Mrs. N., mar- ried, aged twenty-four years, has been affected for the last few months with a thick, creamy discharge from the vagina, together with a sense of uneasiness in the part. " Have you any children, madam ?" " No, sir." " You have never been pregnant ?" " No, sir." " Are your courses regular ?" " They have not been as free as usual, sir, for the past few months." " Have you noticed that they have been less free since this discharge appeared than they were previously ?" " Yes, sir; before the discharge came on my turns were always right." I have often, gentle- men, called your attention to the subject of vaginal discharges, and have told you that they require, in order that all error may be avoided, great 422 CLINICAL LECTURES. circumspection on the part of the practitioner. Here is a married wo- man, who complains of uneasiness in the vagina, and is also aflected with a thick, creamy discharge ; and connected with this discharge is another important feature—a diminished secretion of the menstrual fluid. This latter circumstance is not uncommon in these cases, and may, I think, be regarded as standing in the relation of effect and cause. Women who suffer from losses of a non-sanguineous character from the vngina, are extremely apt to have a scanty menstrual flow. But the question of in- terest for us to determine is—What is the true pathological state of this woman ? A question which can only be solved by an examination per vaginam; for, as you well understand, this discharge may be the result of various morbid conditions, the real one of which can be recognized only by an accurate examination. Before introducing her here I care- fully investigated the case of this patient, and 1 have ascertained that the uterus is entirely free from disease ; the disease does not proceed from that organ, and is limited to the vagina. But non-sanguineous discharges from the vagina may arise from several different causes; such, for ex- ample, as simple acute or chronic vaginitis, blenorrhagia, etc. In the present instance, however, neither of these affections exist; I have discovered, in carrying my finger cautiously over the surface of the mu- cous membrane of the vagina, small elevations which, on the application of the bivalved speculum, I recognized to be granulations. These are the true source of the discharge, and the disease with which the patient is affected is granular vaginitis. This affection is essentially chronic, and is, according to Deville, who was, I believe, the first to call particular at- tention to it, very frequently the accompaniment of pregnancy ; and he, moreover, states that it is not unusual for a spontaneous disappearance of these granulations to follow delivery. Whatever connection there may be, however, between this pathological condition of the vagina and gestation, it is undoubtedly true that granu- lar vaginitis may exist irrespectively of pregnancy. Though not a very common affection, yet I have seen several well-marked examples of it, and in the case of this patient you will see fully developed the striking peculiarities of the disease. [Here the patient was placed on the bed, and the Professor pointed out the characteristics of the affection—such as the small indolent granulations in the vagina, exhibiting in the present instance a confluent form; and attention was also called to a thick, creamy discharge connected with the granulations.] These small eleva- tions which you have just seen are not always confluent; they are some- times isolated, and occasionally will be found in the upper portion of the vagina; while again, you will notice them involving more or less the entire surface of this canal. It has been supposed that granular vaginitis is necessarily of a syphilitic character; but this is denied by Deville, who maintains that it may occur in the unmarried and virgin state. There is. however, under certain circumstances, a peculiar acridity CONVULSIONS AND EXCESSIVE PURGING IN AN INFANT. 423 in the discharge accompanying granular vaginitis, which is capable of producing in the male an irritation closely simulating blennorrhagia; and it will, therefore, in such cases need much caution to make a proper distinction between the discharge which is purely one of irritation, and the discharge the result of specific virus, constituting gonorrhoea. Treatment.—This affection will yield readily to the use of the nitras. argenti, together with frequent ablutions of tepid water. Many prac- titioners are in the habit of recommending the nitrate in the form of in- jection. To this there are two objections : 1st. The patient will rarely employ it properly ; 2d. It passes immediately from the vagina, staining the clothes and also the parts external to the vulva. I much prefer the following mode of employing it—the granulated surfaces should be ex- posed to view with the bivalved speculum, and they should be freely painted by means of a camel's hair pencil with a solution of the nitras. argenti in the proportion of 3J to §j of water. This may be repeated daily, having previously injected into the vagina two or three syringes of warm water for the purpose of removing from the granulations the morbid secretion, which is more or less constantly forming on them. This, together with the free use of the tepid hip-bath, will suffice to ac- complish a cure. In the more advanced periods of pregnancy, and in gestation at any period in women of great nervous susceptibility, I should suggest the omission of the solution, and simply the use of injections of tepid water, and frequent ablutions. Convulsions and excessive Purging in an Infant one Month old PRODUCED BY THE Mother's MlLK ; CATHARTIC PROPERTIES OF THE CoLOS- rRUM.—The prevention of Milk Abscess after Weaning.—Mrs. C, aged twenty-six years, married, the mother of one child one month old, says her infant has been very much disturbed in its bowels, ever since its birth, and has had several convulsive fits. " Do you nurse that in- fant, madam ?" " Yes, sir." " Do you confine it to the breast, or do you sometimes feed it ?" " It has never taken any thing but breast-milk, sir, since its birth." " Does it take the breast eagerly ?" " Always, sir ; it has never refused it; but as soon as it finishes nursing it begins to purge, and it will have ten and fifteen passages a day." " What do its passages look like, my good woman ?" " Sometimes, sir, nothing passes it but curdled milk, and sometimes it is like green slime." " Was it a healthy infant at its birth ?" " Yes, indeed, sir; it was a beautiful child." " You say your infant has had convulsions ?" " Yes, sir, it has had four." " When was it first attacked with them ?" " About ten days ago, sir." " Have you given it any medicine ?" " No, sir; it purged so much, I was afraid to give it medicine." " What is the state of your own health, madam ?" " It is not good, sir ; I am so unhappy about my child that I am miserable." " Was your health good during your pregnancy ?" " Yes, sir, until about a month before my child was 424 CLINICAL LECTURES. born." " What happened then ?" " My husband, sir, is a sea-faring man. I heard he was shipwrecked, and I was so much disturbed I could not sleep, and I have never been well since." " I hope, my good woman, you will yet receive tidings of your husband." " Oh ! sir, it was a false report; he is safe home again." You have, gentlemen, in the person of this little infant a most instruct- ive example of disease; and it will need but little reflection to enable you fully to appreciate two important facts connected with it—1st. The cause of the purging and convulsive spasms ; 2d. The absolute necessity of removing this cause as speedily as possible. If you look at the atten- uated form of this little sufferer, and connect with it the very significant circumstance that it has been recently attacked with convulsions, you will, I think, agree with me that no time is to be lost in rescuing it from the operation of an influence, which has so completely disturbed its health and placed its life in imminent peril. The conversation which has just taken place between the mother and myself has elicited data sufficient to enable us to form a just opinion as to the original cause of the purging ; and I have no hesitation in referring it to the unhealthy character of her milk. The convulsions, too, are the almost necessary consequence of this improper aliment through the ir- ritation which it has produced primarily on the intestinal mucous surface, and secondarily on the medulla spinalis, thus evoking the convulsive movement. In reply to my question, the mother very emphatically answered that the infant had taken nothing since its birth but breast- milk ; and you will not have forgotten what she said in reference to her own health during her pregnancy. She observed that her health was good until a month previous to the birth of her child. At this time she says she received intelligence that her husband was shipwrecked; and from that period to the present she has labored more or less under dis- turbance of the system. What inference, allow me to ask you, do you deduce from these facts ? Is there any connection between the mental affliction of this woman on hearing her husband was lost, and the present ill-health of the infant? To my mind, the connection is positive, as is proved by a chain of concurrent testimony altogether irresistible. Her infant was healthy when born—its only nutriment was its mother's milk ■—and the question now arises—Was there anything peculiar in the milk to make it unsuited to the delicate system of the child; and if so, to what circumstance is this peculiarity to be ascribed ? I have spoken to you on former occasions of the many influences which are calculated to impair the mother's milk; and these influences may originate during pregnancy, or they may arise after delivery. Among them, I may cite mental emotion, no form of which is more absolute in its effects than grief and depression of spirits. But I have a stronger proof still that the milk is the true cause of the infant's illness. On hearing the statement of the mother, I subjected her CONVULSIONS AND EXCESSIVE PURGING IN AN INFANT. 425 milk to the test of the microscope, and I have recognized a very interest- ing fact, viz.: that it is characterized by the presence of numerous yellow corpuscules distinctly granulated, which appear to be the true attributes of what is termed the colostrum. This latter, as you have been told, represents the fluid first secreted by the breasts after delivery, and it differs from ordinary milk in the important circumstance that it possesses cathartic properties. The new-born infant contains within its intestinal canal a viscid material, called the meconium ; if this be not promptly evacuated, it will become a source of irritation, and not unfrequently give rise to much disturbance, terminating in convulsions. The meconium appears to consist of a mixture of bile and products secreted by the in- testinal mucous surface. All experience proves that its sojourn after birth will lead to serious consequences; and you see how consistent and true nature is in the conservative influence she exercises over the econ- omy. The very first draught the infant receives from its mother's breast is provided with elements intended by their purgative action to remove from the system this noxious matter. As a general rule, the first discharges of the child are dark colored, consisting of the meconium, and such may be the character of the evacuations for twenty-four or thirty-six hours, and sometimes for a longer period. After the meconium has passed off, if the parent be healthy, the infant not interfered with by officious medication, and its aliment confined strictly to the breast, we shall rarely be called upon to prescribe for it. I do not know that it has yet been determined at what particular period after birth the milk ceases to retain its colostric properties; but both reason and observation seem to show that a few days only elapse before this change takes place. A point, however, of great interest to the medical man is this: if, through any exception to a general rule, the colostrum should, beyond its due time, continue to constitute a part of the milk, it proves dangerous to the infant by the excessive purging it produces. That this is the real cause of this infant's ill-health I entertain no doubt; and whether it be the mental depression of the mother, or some other influence which has caused to be retained in the milk this cathartic element, is not so material as the broad fact that this element does really exist, and is the source of the child's sufferings. Now, what is the point of this whole case—what its practical bearings ? Here is an infant which has been confined rigidly to its mother's milk—it has taken no other nourishment—nor has any medicine been administered to it. But we find it has been laboring under severe irritation of the intestinal mucous membrane, and recently has been attacked with convulsions. In addition to these facts, you must remember it was a perfectly healthy child when born. The practical point, then, I apprehend to be this— that to attempt to relieve the purging and convulsions by medicine, without having previously analyzed every circumstance of the case, and traced the disturbed action to its source, would be sheer nonsense, and 426 CLINICAL LECTURES. the veriest imaginable quackery. No medicine which you can admin- ister will have any salutary tendency until you first remove the cause of the irritation—the improper nourishment, which the child extracts from its mother's breast. Treatment.—This infant must have another nurse immediately ; if this can not be procured, it should be weaned. A fresh and healthy breast will do more for it than all the compounds of the Materia Medica. " Madam, if you continue to nurse your child it will die ; but if you will prove yourself a sensible woman, and follow our advice, we will do what we can to restore it to health." " O ! sir, I am willing to do any thing you think best." " Well, madam, can you procure a nurse for your infant ?" " Yes, sir, I have a friend, who has just lost her child, and she will be very glad to nurse mine." " How old was her child, my good woman ?" " Six weeks old, sir." " Is she a healthy woman ?" " Very, sir." " Then I recommend you not to lose a moment, but take your infant to her at once. I shall order for this child no medicine; and shall, for the present at least, rely exclusively on a change of nourishment. " Will you come here, madam, next Monday, and report how your child is ?" " I shall, sir." " One word before you go, my good woman. If you are not care- ful you will have trouble with your breasts; and to avoid this, you must follow the directions which I shall now give you. Take every morning, for four or five days, a tea-spoonful of epsom salts in half a tumbler of water; let your diet consist of solids, such as boiled potatoes, rice, etc., and use as little fluid as you can possibly get along with. Apply cloths wet with spirits of camphor to the breasts; should they become hard and painful, you must have them drawn, not with a forcing-pump, or any such abominable contrivance, but by a pup. Let them be drawn only when they become painful from distention. If you will pursue these suggestions, you will have no trouble from inflammation or abscess of the breasts." Hypertrophy of the Nymph^e in an unmarried Woman, aged TWENTY-TWO YeARS, FROM SYPHILITIC DlSEASE--CONGENITAL ENLARGE- MENT OF THE NYMPH^E AMONG THE BoSCHISMAN WOMEN.--Rachael S.. unmarried, aged twenty-seven years, is laboring under considerable en- largement of the nymphse, which causes her much annoyance in walk- ing. [The patient was placed on the bed, and the nymphse, or labia interna, were found very much enlarged, and projected at least two inches beyond the vulva.] This, gentlemen, is not a very common form of disease, but you will occasionally meet with it, and I am gratified, therefore, in being able to show you so complete an example of it as is presented in the case before us. The nymphse may be enlarged from congenital deformity, which, however, is of rare occurrence. They may become enlarged from excessive excitement of the parts, and also from HTPERTROPHT OF THE NTMPH^E. 427 venereal disease. In the latter case the structure of these organ's be- comes altered, degenerating often into a state of schirrus. Such is the condition of the parts in the person of this young woman, and she has frankly acknowledged that she has been severely affected with syphilis. Whenever you meet with an instance of enlarged nymphae, the first question for consideration is—Does the enlargement (if in a married woman) interfere with marital rights, or does it render progression diffi- cult or painful ? In either of these cases it will be your duty to relieve your patient, the effectual remedy being excision of the hypertrophied organs. This may be accomplished either with the curved scissors or bistoury. The ligature is sometimes preferred. Even when resorting to the knife or scissors, it is recommended to pass a number of threads through the roots of the nymphae, so that, after the excision, the bor- ders of the wound may be brought together, and united by the first in- tention. This will certainly facilitate the healing process. The nymphae, considering their smaller volume, are much more vas- cular than the labia majora, but the vessels with which they are supplied are small, and you need, therefore, have no fear of hemorrhage from their removal. Pressure, or the nitrat. argenti, will suffice, under ordi- nary circumstances, to arrest the bleeding, It has been stated by some writers that enlarged nympha are peculiar to the Hottentot women. This question has called forth various opinions, and we have the conflict- ing testimony of travelers on the subject. It would seem, however, ac- cording to Dr. Davis, that the weight of evidence establishes the follow- ing facts: 1st. That there is a congenital enlargement of the external genitals, not among the Hottentot women, but peculiar to a numerous race known as the Boschismans ; 2d. That it is not a prolongation either of the nymphae or labia majora, but that the enlargement takes its ori- gin from the superior commissure of the external labia, whence it gradu- ally becomes developed in width, and descends in two pendulous folds, forming a sort of pudendal apron, said to be characteristic of the Bos- chisman women. " My good woman, have you taken any mercury ?" " Yes, sir, and my mouth became sore." " Do you wish to be relieved from the an- noyance occasioned by these growths?" "Indeed I do, sir." "Then will you consent for me to remove them." " Yes, sir." [The Profes- sor, grasping the nymphae with a small forceps, excised them with a bistoury. The cut surface was then freely cauterized with the nitrate of silver.] Simple dressings are all that will now be necessary, and in a few days this patient will experience no further difficulty. It is im- portant, however, with a view of purifying the system, to place this pa- tient upon half a pint of the compound decoction of sarsaparilla and 3J of nitric acid dilute, daily, and let it be continued, with its occasional suspension of a few days, for about six weeks. 428 CLINICAL LECTURES. Dysmenorrhea in a married Woman, aged twenty-four Years, from Stricture of the Neck of the Womb—Dilatation of the Stric- ture by the Introduction of the Sound.—Mrs. IT., married, aged twenty-four years, no children, has suffered for the last eight years from excessive pain during her menstrual periods. " When you have your turns, my good woman, how long do your courses continue on you ?" "About three days, sir ; but I lose very little, and suffer so much pain, that I am almost out of my mind." " Do you have much forcing-down pain ?" " Yes, sir; that is it exactly ; I feel as if my bowels would be forced out." " Have you taken any medicine for these pains ?" " Yes; indeed, sir, I have taken almost every thing, but nothing does me any good." Here, gentlemen, is one of the forms of menstrual aberration which you will be occasionally called upon to treat, and you must not fail to bear in mind that your treatment, to be successful, must have some defi- nite object—it must be directed against the real, and not the imaginary cause of the difficulty. This patient is affected with dysmenorrhoea, which, as you know, is a term applied to that character of menstruation marked by unusual suffering. But I have reminded you, on former oc- casions, that there are several varieties of painful menstruation, depend- ent on the special causes which produce them. Without repeating what I have elsewhere stated on this subject, I will merely remark that the case of this patient is one of striking interest. She has suffered for eight years—from the very commencement of her menstrual function— and though remedies have been freely administered, you hear her state- ment that they have been without effect. What do you imagine this failure of relief is owing to ? Plainly and emphatically to the fact that the true cause of her suffering has escaped attention. I have examined this patient very thoroughly, and I find she has stricture of the neck of the uterus. The cause, then, of her excessive pain is mechanical obstruction. There is not, in consequence of the stricture, space enough for a free out- let to the menstrual fluid. This is the explanation of the extraordinary forcing-down pains which characterize her menstrual periods. The remedy is one exclusively mechanical in its operation, and will consist in overcoming the stricture by gradual dilatation. This, I think, will be the most effectually accomplished by this instrument (a very small-sized metallic male catheter), which I much prefer to the ordinary bougie, which is usually recommended. I will now introduce this instrument, the rules for doing which are extremely simple. In the first place, gen- tlemen, you must recollect that the uterus is ordinarily parallel to the axis of the superior strait of the pelvis, and its two lips are encircled by the upper portion of the vagina. This latter organ—the vagina—is a crooked canal, its curves corresponding with those of the pelvis—the upper portion being in accordance with the superior, while the lower DTSMENORRHCEA—STRICTURE OF THE CERVIX UTERI. 429 portion is in the direction of the inferior strait. The point of junction between the two axes of the pelvis results in the formation of an obtuse angle. Now, as the mouth of the uterus represents the direction of the superior strait, and the external opening of the vagina that of the infe- rior strait, and as this instrument which I am about to introduce within the cervix uteri is also curved, it follows as a necessary consequence that, to ensure its safe penetration into the womb, it must be introduced with a special view to the curves of the pelvis, and the peculiar position of the vagina and uterus. [Here the patient was placed on the bed, and the Professor proceeded as follows : With the index finger of the left hand introduced into the vagina as far as the os tinea, he then placed the handle of the instrument at a right angle with the abdomen of the woman, and gently glided on his finger from before backward the curved extremity. As soon as this reached the os tinea, he depressed the handle, and gave an upward direction to the curved portion of the in- strument, corresponding with the axis of the uterus. As soon as the in- strument had entered the cervix, he gave two or three gentle turns from right to left, and then withdrew it.] " Now, my good woman, have I hurt you ?" " No, sir." " If you will come here on Monday next, I will do the same thing again, and in the course of two or three months you will be free from all distress at your monthly periods." I feel great confidence, gentlemen, that this woman will be restored to health without any other aid than this simple dilatation of the stricture. LECTURE XXIV. Dropsical Effusions—Are they common in early life?—Their Causes and Treatment - Ascites together with General Anasarca in a Boy, five Tears old, the effects o\ Scarlet Fever—Importance of the Perspiratory Function.—Ascites in a Boy, three Tears old, from Protracted Dysentery.—Convulsions from Suppressed Eruptive Disease in a little Boy, three Tears old.—"What is the connection between a Sup- pressed Exanthematous Affection, and Convulsions ?—Retention of Urine in an In- fant, three Days old—Difference between Retention and Suppression.—Suppression of the Menses, for the last six Months, in a Girl twenty Tears 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 Tears.—Fistula in Ano, in a married "Woman, aged twenty-nine Tears—Operation.—Neuralgia of the right Labium Externum, in a married "Woman, aged twenty-four Tears.— Mammary Abscess, in a married "Woman, aged twenty-five Tears, the Mother of one Child, four "Weeks old.—Agalaxy, or absence of the Milk Secretion.—Galacta- gogue Properties of the Bofareira, {Ricinus Communis) as tested in the Cape de Verd Islands.—Excessive Exhaustion from Flooding after Delivery—Remedial Properties of Opium. Gentlemen.—There is a disease among the affections of earlv life to which I desire for a short time to direct your attention, es pecially as we have among the' children, who are to be presented t& you to-day, several examples of the malady to which I allude—I mean dropsy. It is a singular fact, the truth of which you will be enabled promptly to confirm by reference to your text-books, that dropsy n early life, especially that form of it denominated ascites, has not attracted much attention from authors. I am the more surprised at this silence, for the reason that it can not be considered a rare affection, and very often involves seriously the safety of the child. Serous effu- sions, you are aware, may occur in various portions of the system—at one time in the tunica arachnoidea, at another, in the pleura, pericar- dium, peritoneum, etc.; and again, the brain and lungs will sometimes be- come the seat of the exhalation; in the latter case, constituting what is known as oedema of the lungs. In addition to which, there is often a de posit of serum, to a greater or less extent, in the cellular tissue, giving rise to anasarca. The ancients, whose knowledge of disease was mostly the result of observation, entertained opinions of surprising accuracy DROPSICAL EFFUSIONS. 431 respecting the general causes, symptoms, and treatment of dropsy. They were aware that serous infiltrations often originated from enlarged liver, disease of the kidney, etc.; you will find that Hippocrates dwells particularly on the influence of a humid atmosphere in the production of serous effusions, and speaks very emphatically of re- peated hemorrhages, chronic and wasting diseases, as frequent causes of dropsy. What, then, is the true difference between the knowledge of the ancients on this subject, and that possessed by us ? It is this : The knowledge of the old-school men was general, purely the result of ob- servation ; ours is more specific and tangible, though not yet altogether satisfactory, made so by the researches of modern science. Pathological anatomy, that unerring light which never dawned upon the ancients, has not only revealed to us the truth of the opinions enter- tained by the fathers of medicine as to the causes of dropsy, but it has enabled us to explain the operation of these causes, and penetrate deeply into the secrets of morbid action. The ancients were aware, as the result of repeated observation, that serous exhalation would often fol- low engorged liver and diseased kidney ; they knew, too, that drains on the system was a common cause of this character of exhalation; but their knowledge did not extend beyond these naked facts. All else con- nected with the etiology of dropsy was to them a subject of profound darkness, and, in the absence of our present knowledge, they had no means of removing the obscurity. In order to illustrate the truth of this proposition, I need merely mention, as has already been stated, that the ancients had observed the connection between profuse losses of blood and dropsical effusions; but they were unable to explain the circum stance, nor did they understand why serous infiltrations and profuse hemorrhages should so often bear to each other the relation of effect and cause. We, through the labors of cotemporaries, can satisfactorily ex- plain this relationship. In hemorrhages, the blood is deprived of its albumen; and it is the loss of this element in the circulating fluid, which tends to dropsy, either general or partial. Again, among the primitive writers, it was known that dropsy was oftentimes connected with disease of the kidney ; but nothing more than this broad fact was ascertained, and no scientific elucidation attempted. How stands the question now ? Christison, I believe was the first to show that in renal dropsies, the blood also becomes deprived of a portion of its albumen, and in these affections there is a diminished secretion of urine—the blood thus being deprived of its albumen becomes more fluid, and transudation, therefore, through the exhalents is accomplished with greater facility. Bright in England, and Payer in Trance, have contrib- uted largely to our knowledge on this interesting subject of renal dis- ease. Magendie has proved : 1st. That when the blood is subjected to pressure in its vessels, the watery parts exhale through the walls ; 2d. That the injection of a certain quantity of water into the veins causes an 432 CLINICAL LECTURES. abundant exhalation—a positive dropsy; 3d. That absorption is com- pletely suspended by a fullness of the vessels. We are indebted to Bouillaud for the capital fact that when the circulation is obstructed in a large vein, effusion of serum is the consequence. I recall these points to your recollection merely to show the progress of our own times, and make more striking the contrast between the original and present con- dition of our science. But I have nearly strayed from the object of these remarks, which was to remind you that dropsy, especially the abdominal type, is by no means a rare affection in early life. In seems, however, according to the observation of several recent writers, among whom may be men- tioned, Rilliet and Barthez, that it is very seldom- a primary disorder, being almost always the effect of previous disease. My own experience accords entirely with this opinion. One of the most fruitful causes of serous effusion in children is traceable to the various exanthematous dis- eases—more particularly, perhaps, scarlet fever, erysipelas, and measles. Ascites, then, when found to exist will most frequently be recognized as the effect of some morbid influence, and its danger as well as its control by remedial agents will depend very much on the nature of the affec- tions of which it is the result. This secondary dropsy, as it has been termed, may present itself under one of two forms—acute and chronic, or active and passive. The former is more frequent, marked by symp- toms of inflammation, and usually accompanied by fever; the latter, on the contrary, assumes the chronic type, and is unattended with febrile symptoms. Of these two dropsies, the former is far more destructive. A multitude of causes have been cited by authors as capable of giving rise to dropsical effusion; but of late, Becquerel and Rodier, whose researches have thrown so much light on this subject, have endeavored to show that every character of serous effusion may be explained as follows: Either from an obstruction in the venous circulation, or from a dimin- ished quantity of albumen in the blood. This division certainly imparts a degree of simplicity to the whole question, and liberates it from much of the embarrassment by which it had previously been surrounded. With this hypothesis, there is no difficulty in satisfactorily explaining the serous exhalation which follows the operation of either of these causes— for Magendie has proved the effect of pressure or obstruction in the ves- sels, viz., the effusion of the watery part of the blood; and when this fluid loses its albumen, it, of course, becomes more serous, and hence the greater facility of exhalation. A material point for consideration in reference to the subject of dropsy is the particular treatment to be pur- sued, and you see how plainly this is indicated by the division of the causes to which we have just alluded. But we shall have frequent oc- casion to discuss this subject when speaking of the individual cases which from time'"to time will be presented to you at the Clinique. ASCITES WITH GENERAL ANASARCA. 433 Ascites, together with General Anasarca, in a Boy five Years old, the Effects of Scarlet Fever—Importance of the Perspiratory Function.—Michael M., aged five years, is laboring under acute and general anasarca, the effects of scarlet fever, with which he was attacked two months since. Here, gentlemen, is an example of general infiltra- tion of the cellular tissue, together with serous effusion in the abdominal cavity. Anasarca is one of the ordinary results of scarlet fever, and you will occasionally observe, as is the case in the present instance, that it will be complicated with peritoneal dropsy, and sometimes, too, with hydro- thorax, or a collection of water in the chest. Anasarcous effusions may be local or general; in the case before us, it is general, every portion of the cellular tissue being more or less involved in the disease. This is rarely an idiopathic or primary affection; it is almost always the result of some previous malady, and, therefore, it is legitimately entitled to be termed secondary. Many have supposed that in all cases of anasarca, the result of scarlet fever, there co-existed Bright's disease of the kidney, and, consequently, albuminuria. This opinion, however, is not sustained by facts; and although there is sometimes a co-existence, yet it is now conceded that the connection is not a necessary one. There is no difficulty in appreciating why anasarca, and even dropsy of the cavities, should so frequently follow scarlatina and other eruptive affections. In these diseases, the skin, one of the most important emunc- tories in the system, becomes seriously affected; its function, perspira- tion, is, for the time being, arrested, and the consequence is an increased quantity of serum in the blood, and at the same time an increased ex- halation of watery particles through the walls of the vessels. To give you some idea of the importance and magnitude of the perspiratory function, I might remind you that the fluid of perspiration passes through numerous glandula, which are distributed on the skin. It has been es- timated by Mr. Wilson that over thirty-five hundred of these glandulae are found in each square inch of surface on the palm of the hand; each one is formed of a single tube measuring a quarter of an inch in length, so that in one square inch of integument on the palm of the hand, there will be found a length of tube equal to more than eight hundred inches, or seventy odd feet. Mr. Wilson further states that the average number of glandula to a square inch in other portions of the body is twenty-eight hundred. In a man of ordinary size, there are, it is computed, about twenty-five hundred square inches; this will make the number of glan- dula, or pores, seven million! The skin, therefore, must be considered in no other light than that of a most important portion of the economy, and its function can not be suspended for any length of time without necessarily producing more or less disturbed action. The patient before us is now suffering from the interruption of this function, which has re- sulted in an extraordinary exhalation of serum. Treatment.—In all cases of dropsy, or anasarca, before attempting any 28 434 CLINICAL LECTURES. medication, the first points of inquiry should be, Is the affection primary or secondary—is it acute or chronic ? and, finally, what is the nature of the disease which has preceded the effusion ? These are cardinal ques- tions, and no judicious treatment can be instituted until they are properly disposed of. In looking at this child, it is very evident that he is labor- ing under acute or inflammatory dropsy, the sequela of scarlet fever. He has a full, hard pulse, much febrile excitement, and presents all the evidences of a vigorous constitution. This is the very case for the prompt employment of the antiphlogistic remedies. I shall, therefore, order loss of blood, if from the arm, 1 iv, if by leeches, let four be ap- plied around the anus, which, under circumstances like these, is a point of value for the abstraction of blood. Should I direct one of you to bleed this child from the arm, you would fail in carrying out my direction— and why ? Simply, because of the excessive anasarcous tumefaction, it would be impossible to find a vein. But the patient requires to be bled, and, therefore, your reliance must be upon leeches. The application of the leeches may be repeated, should it be necessary; but as to this neces- sity, a sound judgment must always be exercised. Remember what I have often told you, that young patients, as a general principle, sustain losses of blood badly, and hence the greater necessity for a just discrimina- tion. The subjoined powder should be administered with a view to a free action on the bowels: R Sub. Mur. Hydrarg......gr. iv Pulv. Jalapas.......gr. vi Pulv. Antimonial.......gr. \ M. Followed in six hours by this draught: R Sulphat. Magnesias ... . 3 j Infus. Sennas.......3 ij Tinct. Jalapas.......Z} M. Diuretics are most cogently indicated in these cases; and for the patient before us, there is, perhaps, no more suitable combination than digitalis and nitrat. potassae: R Nitrat. Potassae.......3 j . Tinct. Digitalis.......3 ij Aquas distillat. ......3 vj M. After the bowels have been freely evacuated, a table-spoonful every six hours, according to circumstances. You are aware that digitalis will oc- casionally be attended with injurious effects. In its administration, there- fore, caution is to be observed. A warm-bath daily would prove highly efficacious in promoting an action upon the skin. The child to be kept upon spare diet. Ascites in a Boy, three Years old, from Protracted Dysentery.__ Arthur J., aged three years, is affected with peritoneal dropsy. " How long, madam, has your child had this swelling of its abdomen?" " About CONVULSIONS FROM SUPPRESSED ERUPTIVE DISEASE. 435 two weeks, sir." " What was the state of its health before the swelling commenced ?" " It was sick, sir, four weeks with the dysentery." " How do you know it had the dysentery, my good woman ?" " Why, sir, it used to pass blood; and it was always straining, sir." " That is a good definition of dysentery." " How was its health previous to that time ?" " It was good, sir; it was always a healthy child." " Does it pass blood now, madam ?" " No, sir; it has not passed any for the last three weeks.'' In this child, gentlemen, you have an example of ascites the result of a drain on the system, constituting one of those forms of dropsy of which Becquerel and Rodier have spoken, viz., an effusion following the loss of albumen of the blood. [Here the little patient was placed on the bed, and the Professor proceeded to examine the abdomen.] You perceive that the abdomen of this child is extremely distended ;• and you can readily understand why it labors under oppressed breathing, the oppres- sion being greater in the recumbent posture; it is because of the pressure of the fluid in the abdomen against the diaphragm, thus curtailing the capacity of the thorax, and, consequently, interfering with the healthy play of the lungs. You recognize, when I percuss the upper portion of the abdomen, a sound of resonance; while, on the contrary, in the lower portion the sound emitted is dull and flat. This must not mislead you. Above, the intestines more or less filled with flatus float on the surface of the fluid, and hence the resonance. Below, the dull sound is emitted, because I percuss simply the accumulated fluid. With one hand placed on the side of the abdomen (in this manner), and striking the opposite point thus with the other hand, I distinctly feel the wave of fluid. You are not to forget that it is very usual for young children to have an enlarged abdomen, in no way connected with dropsy; and sometimes a distended bladder may be mistaken by a careless practitioner for ascites. Treatment.—This little patient is anaemic; it is suffering from the loss of albumen. The indication is to build up the dilapidated system, and repair the waste which the blood has sustained. Invigoration, therefore, is the great object. For this purpose I shall recommend, in the first place, £ grain of quinine three times a day mixed with sugar; a gener- ous diet, consisting principally of animal broths; frictions, together with pressure on the abdomen, the frictions being made with equal parts of tincture of squills and digitalis; the latter will act promptly on the renal secretion; the former, compression, will tend to promote absorp- tion. The cod liver oil, if it agree with the stomach, is an admirable remedy in this form of dropsy. Convulsions from Suppressed Eruptive Disease in a little Bo*, three Years old—What is the Connection between a Suppressed Exanthematous Affection, and Convulsions.—John B., aged three years, has been sick for a week; he has no appetite, is feverish, and has 436 CLINICAL LECTURES. had three convulsions within the last four days. " You say, madam, your child has been sick for a week ?" " Yes, sir." " What was the state of his health previous to that time ?" " It was very good, sir." " What has been his condition for the last week ?" " He has been very restless and feverish, sir ; he sleeps heavily, and jumps about and moans when he is in bed." " When had he the first convulsion ?" " Last Thursday, sir." " Do you know what produced the convulsion ?" " No, sir, indeed I do not." " Had he eaten any thing which disagreed with him." " No, sir." " Had he been eating apples, or nuts, or raisins ?" " No, sir." " Do you know whether he has ever passed any worms ?" " No, sir, I don't think he has ever passed any." " Have his bowels been confined ? " No, sir, they were always quite regular." " Do you know, my good woman, whether your child has been frightened lately ?" " Oh, no, sir, nothing of that kind." " Have you noticed since he was taken sick a week ago, any eruption on his person ?" " Yes, sir, three days after he began to decline, I noticed some small red spots on his face, arms and neck, but the next day they all disappeared, and then he had the spasms." " Before your child became so sick that he was obliged to be kept in bed, did he have any running from his nose ?" " Yes, sir, and his eyes were very weak." " Did he vomit ?" " Yes, sir." " Has he ever had the measles ?" " No, sir, but a friend of mine, when she saw the spots on his person, told me it was the measles he had." " I think your friend was right, my good woman." You must not suppose, gentlemen, that I have instituted the questions, which the mother of this child has just answered, without a motive. This little boy has been indisposed for a week, and within the last four days he has had three convulsions. What, under the circumstances, is the first duty of the physician ? Surely, not blindly to prescribe medi- cine, but to ascertain, if possible, the true nature of the affection, and the real meaning of the convulsive spasm. Convulsions, as you have repeatedly been reminded, are by no means uncommon in early life— indeed they may almost be considered as peculiar to this age. Their causes are numerous; such, for example, as intestinal irritation, whether from improper food, worms, constipation, etc.; dentition, fright, cold, a sudden recession, or a sickly development of, the various eruptive dis- eases, are also to be classed among the influences capable of provoking the convulsive movement. Convulsions, especially in early life, are almost always symptomatic, or, if you choose, the result of indirect irri- tation of the spinal cord, and whether this irritation be produced by den- tition, worms, or repelled exanthemata, is for the physician to determine. In the case before us, what basis have we for a correct opinion ? It appears that this little boy previous to a week since, when his indispo- sition commenced, was a healthy child. For the last few days, however, he has been feverish, heavy, restless; a slight eruption has appeared on his face, arms, and neck—this receded, and convulsions followed the reces CONVULSIONS FROM SUPPRESSED ERUPTIVE DISEASE. 437 *hout the cause of the danger being at 472 CLINICAL LECTURES. all suspected. Having ascertained all that is necessary as to tho exist- ence or absence of these deformities, the child is then to bo dressed, which, under ordinary circumstances, will be done by the nurse without much supervision, except that it is well to caution her against binding the little infant too firmly. This latter practice is a pernicious one, and is by far too common. Well, the dressing is accomplished, and what next ? If the nurse should have her own way, she would, probably, as soon as the toilet is completed, take the infant to the window, if in the day time, or, if at night, hold it before a strong light, to show its papa, or some other happy relative, the beautiful and striking features of the " dear babe"—not thinking that this very act is, of all others, best calcu- lated to injure, if not destroy, one of the most important features—the eye. The sudden glare of light on the tender conjunctiva, and on the other membranes of the eye, is a very common cause of the purulent ophthalmia, to which we have already alluded. But whether the infant escape this exposure to the light or not, it will, in ninety-nine instances out of a hundred, be doomed to all the discomforts and dangers of another abominable practice, which, including both nourishment and medicine, may be embraced under the term dosing. This brings us to the consideration of a most important point in connection with the wants of the new-born infant, and so essential is it, that I am clearly of opinion that, of all the causes of deranged health, and early death in in- fancy, dosing is the most fruitful. As soon as the child is dressed, there is, unfortunately, a routine practice to which it is subjected. 1st. It must take a little oil to purge it; and secondly, the poor " dear, is hungry, and must be fed "—and hence, almost simultaneously with its birth, it becomes the victim either of ignorance or a false phi- lanthropy. I have elsewhere stated to you that the infant, almost as a universal rule, requires no medicine, nor does it need any other nour- ishment than that elaborated in the breasts of its parent. The mother's milk has been prepared with an exclusive reference to the wants of the child ; at first, it contains what is termed the colostrum, an element pos- sessing purgative qualities, and which readily and efficiently removes from the intestinal canal the meconium, a black viscid material found in greater or less quantity in the intestines of the new-born infant. In addition to the colostrum, the composition of the mother's milk is in perfect accordance with the necessities of the infant, and of all sub- stances the best adapted to its assimilative powers. The rule, then, which I desire most earnestly to inculcate upon you is this: Do not de- fraud the infant of its natural rights; before birth, no one will deny that nature was competent to suppy all its wants, as is proved by its perfect physical development. Why should officiousness, as soon as the child is thrown into the world, interfere with those processes which ex- perience shows are, as a general principle, not only necessary but all- sufficient for the healthy growth of the child! Instead, therefore, of THE MOTHER'S MILK. 473 drugging and feeding the infant as soon as it comes into the world, let it be put to the mother's breast after she has recovered somewhat from the fatigues of her labor, say in two or three hours. I have already spoken to you of the necessity and advantage of this practice, both as regards the mother and child, and need not refer to them again. One of the great elements of health in the new-born infant is cleanliness; and the nurse should be instructed to have it well washed every day with tepid water ; in the event of acrid evacuations from the bowels it sometimes happens that the child becomes chafed, and if this be not promptly attended to, the surface will become excoriated, giving rise to an unpleasant condition of things, and causing the infant to be fretful. In these cases, the decoction of flax-seed should be freely used in order to bathe the parts every time the child has an evacuation; if this be faithfully done, it will be found, generally speaking, an efficient remedy. I am in the habit of having the infant's mouth washed several times dur- ing the day with cold water; it is not only grateful to the child, but it cleanses the mouth, and oftentimes protects it against the various forms of stomatitis, to which your attention has already been directed. The mother's milk, as we have already remarked, is the most suita- ble nourishment for the infant; and when there is nothing to forbid her nursing it, such as ill-health, the absence of the milk secretion, etc., she should not only regard the nursing of her child as an imperative duty, and, therefore, derive pleasure from the act, but she should also remem- ber that, without sufficient justification, in depriving that child of the food, which nature has not only prepared for it, but which she has de- clared more or less essential to its healthy development, the mother is alone responsible for whatever results may ensue from an obstinate and cruel refusal to discharge an obligation, which all right-minded women look upon as sacred. It must, however, be conceded that you will occa- sionally meet with mothers, whose minds filled with the nonsense of the day, and their hearts steeled against the eloquent appeals of nature, will peremptorily refuse this boon to their child. When you encounter such, it will be your duty to admonish them not only of the wrong they inflict upon the infant, but also of the hazard to which they expose their own health. Thus, upon the principle that selfishness is the great impulse to human action, you may accomplish, by operating upon their fears, what you failed in doing, when you addressed yourselves simply to their hearts. I have often spoken to you of the sympathy existing between the mammary glands and uterus, and I will, on this occasion, mention one circumstance in this connection to show you the peril to which women subject themselves who do not nurse their children. These lat- ter are extremely liable to congestion of the uterus, for the reason that lactation, under its full operation, is one of the most effectual modes of preventing this congestion by its derivative influence upon the breast. 474 CLINICAL LECTURES. I need not tell you, for we have often spoken of it, that congestion of the uterus is a most insidious condition; it rarely fails, especially when not attacked in its very inception, to lead to serious disturbing influ- ences—and it sometimes is the commencement of a disease the most loathsome, and unhappily the most rebellious entailed upon woman— cancer. There are, however, other perils to which the female who refuses to nurse her child is exposed. You will observe that almost as a universal rule, the urine of pregnant women will differ from urine under other cir- cumstances in one remarkable particular, viz.: It contains an element called Kiestine, which in its essential qualities resembles casein. Why should this element, Kiestine, be found in the urine of the pregnant and parturient female ? It is absurd to suppose that it is there as a mere coincidence, and we, therefore, are justified in asking some explanation for its presence. Is the Kiestine in the urine any thing less than a de- monstration that the system is engaged in the preparation of food neces- sary for the infant as soon as it is born—and is the passage of this substance from the system through the kidneys any less of a demonstration, that its accumulation in the blood would be productive of injurious con- sequences ? The kidneys, we know, are among the most important emunctories of the economy ; while the liver extricates bile, the lungs carbonic acid, the skin the poison of perspiration, etc., the kidneys per- form their office in furnishing an outlet for deleterious substances, such as urea, and, I believe, Kiestine, etc. Let us now, for a moment, consider another fact in this connection. When the child takes the breast, and the secretion and excretion of milk through the mammary organs are in complete operation, there is no longer any Kiestine to be detected in the urine. This, I think, is strong evidence that its sojourn in the blood, without any outlet, is not in accordance with the ordinances of nature, and therefore, until free lactation commences, a temporary exit is furnished for this material by the kidneys. Again, women who do not nurse their children, are often affected by serious nervous disturbances—some have delirium, others I have known to be convulsed, and again puerperal mania will ensue. Why is this ? I think these morbid phenomena may be explained in this way—the Kies- tine, through its accumulation, acts as an irritant upon the nervous cen- ters, just as bile in the blood will produce coma, or urea, uraemic intoxi- cation. You hear much of the third-day fever, or, as it is termed, the milk-fever, among women recently delivered—is this commotion in the system not readily explained by the fact that after delivery, before the breasts are in full duty, the nervous system becomes the seat of irrita- tion from the increase of Kiestine ? It would seem so for the reason that as soon as the milk begins to flow freely, tranquillity again prevails throughout the economy. It will yet be found, I am confident, that during pregnancy Kiestine is not the only element in the urine proper to ALBUMINURIA AND PUERPERAL CONVULSIONS. 475 milk. It has already been ascertained in the case of a female who did not nurse her child, that the urine contained butyric acid. If, then, the kidneys act as a temporary outlet for the various elements composing the milk, only until after the birth of the child, when, according to' na- ture's requirements, this outlet is no longer necessary, because of the escape of these materials through the breasts, can we regard the inaction of the mammae in any other light than as a circumstance necessarily calculated to produce morbid phenomena ? Again, much has been said recently, touching the connection between albuminuria and puerperal convulsions, and some writers have attempted to show that eclampsia is exclusively the result of the presence of albumen in the urinary secre- tion. How stand the facts ?—for after all, the stability of human opinion, whether upon science, commerce, or any other subject, will depend upon facts. It has been demonstrated that albuminuria is of frequent occur- rence in pregnant women; it has also been demonstrated that puerperal convulsions are comparatively of rare occurrence. Among forty-one pregnant females observed by Blot, in the Mater- nite at Paris, in all of whom albuminous urine was detected, only seven were attacked with convulsions. This certainly does not look like cause and effect. Again, may not this alleged frequent presence of albumen proper in the urine be simply the result of that process to which the presence of Kiestine is due, or may not its supposed frequency be the result of inaccurate tests ? It would seem so, for the reason that case- in, which so closely resembles Kiestine, is, in all its essential properties, albumen. If there be any truth in this assumption, an interesting ques- tion arises—May not puerperal convulsions be due, not to albuminuria, but to an excessive accumulation of Kiestine in the blood ? And in con- nection with this interrogatory, it strikes me as of great importance to ascertain first the relative frequency of eclampsia after delivery in women who do and do not nurse their children, and secondly, the rela- tive proportion of Kiestine in the urine of those who escape, and of those who are attacked with convulsions. In a physiological sense, the nursing of the infant by its parent is an act full of interest, and if any one circumstance more than another, in the general provisions of the human mechanism, reveals both the wisdom and benevolence of Divine power, it seems to me that circumstance is found in the peculiar elements composmg the mother's milk, as connected with the necessities of the child. Let us, for a moment examine this subject. It is ascertained, through the investigations of the chemist, that the milk of the mother contains every element necessary for the nourish- ment and growth of the infant, and this milk is composed of water and solid substances. The latter consist of caseum, butter, saccharine mat- ter, and certain incombustible salts. Each one of these substances has its own office assigned it, or, in other words, answers a special purpose in the important act of nutrition. Food, you are aware, is intended, 476 CLINICAL LECTURES. when taken into the system, to accomplish two purposes: 1st. Tho de velopment of the various tissues of the body ; 2d. The production of animal heat, which is effected through the respiratory process, and thus dependent upon a proper supply of what is called respiratory food. The first of these objects, the development of the tissues, is attained through the caseum; while the second, the maintenance of animal heat, is achieved through the butter and saccharine matter, which is the true respiratory food. But something more is needed than the mere increase of tissue and the production of animal heat in the young infant. In addition to these, it requires consolidation—the bony system, which constitutes the basis of the mechanism, must be strengthened and made adequate to the duties imposed upon it. This process of consolidation is accomplished by another element in the mother's milk—the phosphate of lime. How simple and yet how perfect this provision of nature for the wants of the young child ! In the first place, she points to milk as the best adapted, because of its blandness, to the feeble assimilative powers of the infant, and yet in that bland fluid are contained the various elements for perfect nutrition. Guerin has shown that rachitis is frequently produced in young infants in two ways : 1st. By not being nursed, but fed upon im- proper food; and, secondly, by being nursed for too long a period, and confined exclusively to breast-milk. He has succeeded in producing rachitis in young animals, either by interrupting their regular course of nursing, or by confining them too long to the exclusive use of the mother's milk. The explanation of the fact is as follows : Milk contains a certain proportion of the phosphate of lime, especially intended for the formation of bone in the young infant; while, on the contrary, oftentimes the food given to the child immediately after birth, as a substitute for the mother's milk, contains comparatively but a small quantity of the salt. In these latter cases, the infant is not provided in sufficient abundance with the material necessary for the consolidation of its osseous system, and hence the development of rachitis. At a later period the child requires more of the phosphate of lime than is contained in the milk, and if another diet be not substituted the same consequences ensue. In addition to these views of Guerin, it must be recollected that rachitis, and more especially local or limited rachitis, as it has been termed, may exist without reference to the elements contained in the food. In an interest- ing paper recently published by Vischow, it has been shown, after re- peated microscopical examinations, that the arrest of the normal growth of the osseous system, in part or altogether, may result from two con- ditions: 1st. Insufficiency of earthy salts in the nutriment; 2d. From some impediment to the deposit, within the osseous structure, of these earthy salts—the impediment being occasioned by some peculiarity either of the blood or of the ossifying parts, or by something abnormal in the circulation and nutiition of the bone itself. NEURALGIA OF THE CERVIX UTERI. 477 1 might here allude to some extremely important facts lately brought to the attention of the profession by Dr. Mouries, and which have re- ceived the sanction of the French Academy of Medicine. He seems to have proved, 1st. That the diseases and mortality of infancy are in great part due to the insufficiency of the phosphate of lime in the ordinary nourishment; 2d. That by mixing a certain amount of this salt with the daily food of nurses, pregnant women, and children, both the number of deaths and of diseases is greatly diminished. In confirmation of his views, he presents the following satisfactory and striking results: Of seventy children under one year of age, to which he administered the phosphate of lime, the deaths were one in six; while, according to the official statistics, the deaths, under ordinary circumstances, in the city of Paris, within the first twelve months of existence, are one in four. The views of Dr. Mouries have been also very satisfactorily confirmed by Dr. Pegot-Ogier, who gives the following as the results of his experience : He selected eighteen women who, in the aggregate, had borne twenty-two children, eight of which had died in the first year, the fourteen others were weak and lymphatic. Under these unfavorable circumstances, the influence of proper nourishment was fully tested. To some, Dr. Pegot- Ogier gave food with the phosphate of lime during their pregnancy, and to others during the period of lactation. During this change of diet, they had eighteen children, only three of which died during the first year, from accidental causes ; while the remaining fifteen were remark- able for good health. So that the same women who, with their ordinary nourishment, had lost eight children out of twenty-two, lost only three out of eighteen when their diet was changed by the addition of phosphate of lime during pregnancy or lactation; and, again, the former children were lymphatic and delicate, while the latter exhibited all the ap- pearances of robust health. In addition to the above interesting facts, Dr. Mouries has shown that in rachitic children the use of the phosphate of lime with the food not only improves nutrition, but will arrest the progress of the disease. Dr. Beneke has also developed, at some length, the efficacy of the phosphate of lime not only in rachitis, but likewise in scrofula and other wasting diseases; and he makes this significant re- mark in reference to these special effects of the phosphate of lime, viz.: It should be kept in mind that the phosphate always increases the forma- tion of cells, and prevents the rapid and fearful waste of tissues. Neuralgia of the Cervix Uteri in a married Woman, aged twenty- three Years, no Children.—Mrs. S., married, aged twenty-three years, complains of intense pain in the womb, from which she says she has suffered more or less for the last four months. " What was the state of your health, my good woman, previous to the last four months ?" " It was good, sir." " Were your turns regular ?" " Always, sir." " How have they been since you have complained of this pain ?" "They have 478 CLINICAL LECTURES. been regular, sir; but I have suffered at the time more than I ever did in my life." " Are you troubled with a discharge ?" " Yes, sir; there is something that passes from me like water." " How long have you had this discharge of water ?" " Only, sir, since I have had the pain in my womb." "Is the pain constant?" "No, sir; it comes and goes." This case, gentlemen, is one which, perhaps, would cause you some embarrassment in your diagnosis; but with due attention you will be enabled to ascertain the nature of the trouble with which this woman is affected. It can only, however, be done by a vaginal examination. I have satisfied myself, by this mode of exploration, that the case before us is what is termed neuralgia of the neck of the womb, an affection which you will occasionally meet with, and which oftentimes is mistaken for some other disorder; and there is no disease with which it is more likely to be confounded than chronic congestion of the uterus. Uterine neuralgia is sometimes symptomatic of disease of the uterus, such as engorgement, ulceration, etc.; sometimes, also, of displacement. Again, it will occasionally present itself as a primary affection entirely uncon- nected with any lesion of structure. This is the case in the instance before us. On an examination, per vaginam, I have recognized no change what- ever in the position or structure of the uterus—the organ is in all re spects natural, except in one particular—in pressing with my finger on the os uteri the patient complains of extreme suffering. This is one of the material diagnostic symptoms of this affection; and, taken in con- nection with two other circumstances—the intermittent character of the pain and the discharge of water—there can be no doubt as to the nature of the malady. In enumerating the causes of watery discharge pef vaginam, I have told you that simple irritation of the mucous membrane will sometimes produce it—and you have an example of this influence in the case of the woman now before us. As to the intermittent character of the pain, you know very well that this is one of the usual, though not constant accompaniments of neuralgic affections. Neuralgia of the uterus is not only a most distressing malady, but it is also frequently protracted and rebellious to remedies, simply because it is confounded with other affections. It is not always confined to the neck of the organ —on the contrary, it will sometimes be seated in the annexfe of the uterus, and at other times in the fundus and body. As a very general rule, patients laboring under this affection will suffer more or less from painful menstruation. Valleix considers uterine neuralgia as a form of the lumbo-abdominal neuralgia to which your attention has been directed on a former occasion; and, according to his experience, there will be pain in the hypogastrium, and more or less uneasiness along the course of the first pair of lumbar nerves. In all cases of uterine neuralgia, which have fallen under my observation, I have invariably examined NEURALGIA OF THE CERVIX UTERI. 479 the lumbar region, and, as a general rule, have detected sensibility on pressure. Causes.—This affection will be produced by engorgement, ulceration, and displacements of the uterus ; and in such cases the neuralgia is, of course, symptomatic. When, however, it presents itself as an idiopathic or primary affection, the causes are oftentimes obscure. However, cold, o, suppressed menstrual or leucorrhceal discharge, mental emotions, etc., may be noted among the causes capable of giving rise to it. Symptoms.—Pain is the prominent characteristic symptom of this af- fection ; the pain is experienced in the loins, through the pelvis, in the lower portion of the abdomen, and uterus ; and sometimes extending to the thighs. It is usually intermittent, and again it is continuous, and marked by exascerbations, during which it will occasionally become so intense as to produce various disturbances of the nervous system, such as hysteria, convulsions, and even mania. I once saw a case of uterine neuralgia in which, during the maximum of suffering, the pain seemed to locate itself with a concentrated force in the urethra, occasioning a desire to pass water, but resulting in an inability to do so in consequence of the strong contractions of the sphincter of the bladder; and it is an in- teresting fact for you to remember that the introduction of the catheter was not only followed by a free evacuation of urine, but a complete cessation of suffering. Sexual intercourse, or the slightest touch in an examination per vaginam, will aggravate the pain in uterine neuralgia ; and one of the first indications of this affection will frequently be distress during intercourse. Diagnosis.—If a patient complain of pain in the uterus, and the pain be the result of idiopathic neuralgia, there will be no change in the structure of the organ, but there will be very acute sensibility on press- ure. Therefore, in these cases, you can affirm with positive certainty that the pain is altogether neuralgic. Again, these pains are not unfrequently the consequences of disease of the uterus, such as engorgement, ulcera- tion, etc. In these latter instances, the recognition of the particular affection of the uterus will of course enable you to establish in your own minds whether the neuralgia is primary or secondary, an important dis- tinction so far as the treatment is involved. Treatment—It can scarcely be necessary to remark that the treatment of secondary uterine neuralgia consists in the removal of the disease which produces it, whether it be ulceration, engorgement, displacement, etc. Not so, however, with idiopathic, or primary neuralgia. In these cases, you can have recourse to various remedies, and generally with complete success. Two or three cauterizations of the neck of the womb with the nitrate of silver, or, as Jobert prefers, the red-hot iron, will, in the majority of cases, suffice to effect a cure. An issue or repeated blis- ters on the sides of the lumbar vertebrae, or in the hypogastric region, are also valuable remedies. When the pain is marked by distinct inter- 480 CLINICAL LECTURES. vals, I have known it to yield most promptly to quinine, as recurrent neuralgia oftentimes yields to this agent when seated in other portions of the system. Malgaigne speaks of repeated success from the intro- duction of a small sound into the uterine cavity, on the principle that it modifies the nervous sensibility of the mucous membrane. For the pur pose of giving temporary relief during the paroxysm of pain, belladonna ointment, laudanum injections, etc., may be resorted to.. Retro-Uterine Hematocele in a married Woman, aged thirty- four Years, the Mother of four Children, the Youngest fourteen Months old—Exploring Needle.—Mrs. L., married, aged thirty-four years, the mother of four children, suffers from very severe pain in her back passage, and says she has a frequent desire to have an evacuation from her bowels, but passes very little. " How long, madam, have you suffered from this pressure on your back passage ?" " For the last two months, sir." " How was your health previous to that time ?" " It was always good, sir." " Did any thing occur two months ago to which you can in any way refer this pressure of which you speak ?" " Nothing, sir, except a fall I had." " How did you fall, my good woman ?" " I was coming down stairs, sir, with a tub of water, my foot slipped, and I fell down a whole flight of steps." " Were you much injured at the time ?" ." No, sir; but I was terribly jolted." " How soon after the fall did you begin to feel this pressure ?" " The next day, sir." " Were your bowels regular previous to the fall ?" " Yes, sir." This case, gen- tlemen, is one about which it is impossible even to approximate an opin- ion without a minute vaginal examination. Pressure on the rectum may be the result of various conditions, such as retro-version of the uterus, prolapsion of the ovary or small intestine into the triangular fossa, a collection of hardened fasces, internal hemorrhoidal, and other tumors. [The patient was placed on the bed, and the Professor proceeded to insti- tute the necessary examination.] From the examination I have just made, it is obvious that the pressure on the rectum, and difficulty in defecation, are owing to a tumor in the fossa, between the intestine and uterus. The next question to be decided is, as to the particular nature of this tumor. That it is not the retro-verted uterus, I am assured from the fact that the cervix of the organ is rather inclined backward while the fundus is thrown somewhat forward by the pressure of the tumor; and I am equally confident it is not a prolapsed ovary from the two following cir- cumstances : 1st. There is no indication of any disease of either of the ovaries; and, secondly, if the tumor were occasioned by the descent of a healthy ovary, which sometimes happens, it would be characterized by great mobility, which is not the fact in the case before us. The pressure is not occasioned by a collection of faecal matter, as I have ascertained by the introduction of the finger into the rectum. What, then, is this tumor ? In my opinion, we have in the person of this patient an ex- CONVULSIONS AND EXCESSIVE PURGING. 481 ample of a most interesting form of tumor—I believe it to be a collec- tion of blood, or what may be termed an haematocele; and from the posi- tion it occupies, is entitled to the name of retro-uterine haematocele. The reasons for my opinion are these: 1st. The fall would be likely to produce an extravasation of blood; 2d. To the touch, the tumor is soft, elastic, immovable, and evidently contains fluid. If I am correct in this view, a most interesting question arises, What is to be done? Nelaton, in cases like these, recommends the use of the exploring needle in preference to incision, for the reason that there is more or less danger from hemorrhage if incision be had recourse to; and, moreover, he finds that the tumor often becomes absorbed; while, in other instances, the blood escapes through the rectum or the genito-urinary organs. " Now, my good woman, if you will permit me, I will ascertain the true cause of your suffering, and will do all in my power to relieve you." " You may do any thing you think best, sir." " That's a sensible woman, as full of courage as you are of common sense." [The Professor here in- troduced the index finger of the left hand into the vagina, and passed along the finger a small exploring needle, with which he penetrated the tumor, between the rectum and uterus, directing the needle upward. It was evident that the diagnosis was a correct one, for, as the tumor was penetrated, blood escaped.] You see, gentlemen, in the blood which passed from the sac as soon as it was entered, the best evidence of the accuracy of the opinion we had formed touching the nature of the tumor. I do not feel disposed, under the circumstances, to do more than introduce occasionally the needle for the purpose of allowing a small quantity of the blood to escape, for I have very little doubt that this, together with the action of the absorbents, will suffice to disperse the extravasated fluid. It will be proper, however, to keep the bowels in a soluble state, and, in order to accomplish this, I shall direct a pint of tepid water to be thrown up the rectum every night. Convulsions and Excessive Purging in an Infant one Month old, PRODUCED BY THE Mother's MlLK—CATHARTIC PROPERTIES OF THE CoLOS- trum.* Mrs. C, aged twenty-six years, married, returned to-day to the Clinique, and expressed many thanks for the restoration of her little child. " Is that infant, my good woman, the poor little attenuated ob- ject you brought here two months ago ?" " Indeed it is, sir; and I thought you would be very glad to see how much he has improved?" " Well, I suppose I must believe you, but I certainly should never have recognized it." No case, gentlemen, amid the thousands we have had, has as yet presented itself at this Clinique, which embodies more interest and strictly practical illustration than the child you now see before you. You will recollect that it was affected with excessive purging, and was attacked with convulsions. Its only nourishment was its mother's milk; and you will not have forgotten that, after a full examination of all the 31 * Page 423. 482 CLINICAL LECTURES. circumstances, I attributed the purging and convulsions to the irritation of this milk, in which, through means of the microscope, I recognized the presence of the colostrum, which you know is characterized by numerous yellow granulated corpuscules. The colostrum exists in the milk with the birth of the child. It contains cathartic properties, and purges off the meconium, which is in greater or less quantity in the intestines of the new-born infant. It usually leaves the milk a few days after birth; but should it continue beyond a certain time, it becomes an irritant, anc" in this way may produce excessive purging and convulsions. If you wil. turn to your note-books, you will probably read with profit what was said when the child was first brought here. Under the head of treat- ment you will find that I prescribed no medicine whatever, but used the following language : " This infant must have another nurse immediately —if one can not be procured, it must be weaned. A fresh and healthy breast of milk will do more for it than all the compounds of the Materia Medica. Madam, if you continue to nurse your child, it will die ; but if you will prove yourself a sensible woman and follow our advice, we will do what we can to restore it to health." I quote this language to show you that there was no doubt in my mind, in the first place, as to the cause of the purging and convulsions, and secondly as to the course to be pursued. " Did you wean your child, my good woman ?" " No, sir ; but I stopped nursing it, as you directed, and got a friend, who had lost her infant, only six weeks old, to nurse mine." " Does she still con- tinue to nurse it ?" " Oh ! dear, yes, sir, and you see how it thrives !" " That's right, my good woman—keep your wet-nurse, and have nothing to do with physic, and your child will do well." Suppression of the Menses in a married Woman, aged thirty-one Years, of nine Years' duration, with Chronic Inflammation of the Uterus—The Emmenagogue properties of Mercury* Mrs. M., mar- ried, aged thirty-one years, no children, who, it will be remembered, had labored under chronic suppression of the menses for a period of nine years, returned to-day, and reports that she had a slight return of her courses a week since. This patient, when she first came here, I examined with much care, and ascertained that, in addition to the suppression, she was afflicted with chronic inflammation of the uterus—the tissues of the uterus were thickened, and the organ consequently enlarged. I called your attention, in cases of chronic inflammation such as this, to the ex- cellence of mercury as a remedy. I spoke to you of its deobstruent properties, and stated that it had often served me when all else had failed, in restoring the menstrual function after a protracted suppression, especially when connected with chronic inflammation of the uterus. The following treatment, you will remember, was ordered : R Submur. Hydrarg.......gr. xxiv Pulv. Opii.......gr. iv ^ n ,„„ Ft. Massa in pil. xii div. * Page 403. r J AMENORRHCEA. 483 One pill to be taken night and morning until ptyalism is produced— and in order that the action of the mercury may be continued for some time, one pill should afterward be given at intervals of four or five days, as circumstances may indicate. " Did you take the medicine as directed, my good woman?" "Yes, sir." "Did your mouth become sore?" " Yes, sir; it became sore after I took six of the pills." " Is it sore now?" "No, sir; but it continued tender for nearly two months." " Do you feel better in your general health ?" " Very much better, sir." I have no doubt, gentlemen, we shall succeed in the complete restoration of the menstrual function in this case, and I shall attribute it entirely to the action of the mercury. " Now, my good woman, you need take no more pills, but I would advise you to drink in divided doses during the day half a pint of the compound decoction of sarsa- parilla. Amenorrhea in a Gtrl sixteen Years of age, from an Atonic Con- dition of System.—Danger of the Indiscriminate use of Emmena- gogues.—Mary W., aged sixteen years, is brought by her mother to the Clinique; she complains of general lassitude, a disinclination to take exercise, and says she has no appetite ; for the last six months, she has been much troubled with headache, is restless at night, and extremely nervous—the pulse is feeble, and the tongue coated. " Your daughter has always been rather delicate, has she not ?" " Yes, sir." " Has she ever had her turns ?" " About four months ago, sir, she had a very slight show, but nothing since; every month, she suffers a great deal of pain in her back and hips, and I think, sir, if you could give her some- thing to bring on her courses, she would get well." " We will see about that, my good woman. How are her bowels?" "Always confined, sir." Here, gentlemen, is a young girl, sixteen years of age, laboring under one of the forms of amenorrhcea, viz.: Retention of the menses. You are aware that retention may be caused by numerous conditions of system; in one case, mechanical obstruction, such as imperforate os tincae, imperforate hymen, occlusion of the vagina; in another, plethora; in another, a leucorrhceal discharge, which may for some time become the substitute of the menses ; while again, the retention may be due to a general or local atonic condition ; in the former case, the general sys- tem is at fault; in the latter, the lethargy is confined to the uterine organs. Amenorrhcea, either in the form of suppression or retention, is a very common affection, and it is of the greatest importance that you should clearly understand, when called upon to treat it, to what condition of sys- tem either the one or the other is due. It can scarcely be necessary for me to dwell at length on the case before us; you have only to look at the pallid cheek of this girl, examine her debilitated pulse, and observe her coated tongue, to be convinced that the entire machinery of the system 484 CLINICAL LECTURES. is out of order. Her mother says that she is uniformly confined in her bowels, has no appetite, is troubled with headache, is restless at night, and suffers every month from pain in her back and hips. What do all these phenomena indicate ? Why manifestly, an unnatural, dilapidated condition of system. The vital forces are too low, the vis naturalis of the economy is deficient; and, as a necessary consequence of this state of things, there is functional inactivity of the uterus, simply because of tho want of nervous power, and good healthy blood to supply the ovaries with their required quality and amount of nourishment. Without a just discrimination, much injury might befall this girl by injudicious medica- tion. Emmenagogue medicines, whose effects are altogether local, being confined to the stimulation of the uterine organs, would not only be with- out avail here, but would prove positively injurious. With the loss of appetite, headache, feeble pulse, coated tongue, and general prostration of the system, what benefit could you reasonably expect from the ad- ministration of emmenagogue remedies, that ruinous system of practice too often resorted to by the routine practitioner ? If you should antici- pate a successful result from such treatment, you would be sadly disap- pointed ; but if, on the contrary, you desire to aggravate in every par- ticular the morbid phenomena which already exist, you would not be deceived in your expectations. Treatment.—As debility is the prevailing feature in this case, old women—and would that the suggestion were limited to " old women," for then the danger would be greatly abridged—will recommend hearty food, and stimulating cordials, etc., as the remedies par excellence, calcu- lated " to make the girl right " and give her strength ! What would you think of a miller who, knowing that the mechanism of his mill was deranged, should obstinately continue feeding it with wheat and corn ? Do you suppose that, under such circumstances, he would be rewarded for his labor by the production of good flour or meal ? He would not. But if a sensible man, he would first repair the derangement, make per- fect the machinery of his mill, and he would then cease to lament over unrequited industry. Apply this reasoning to the case before us; the mill here, which is represented by the system, is sadly out of order, its mechanism must be made perfect, and then harmonious action will be the result. I do not consider the amenorrhcea as the disease; it is merely an effect of the general impairment of the system; this latter, therefore, should be the first and special object of our attention. Having attended to the wants of the general economy, if the menstrual function should not become established, we shall then have recourse to remedies for the purpose of exciting local action. This girl, I am sure, would be much benefited by an emetic; the coated tongue and offensive breath indicate the propriety of commencing with this remedy: R Pulv. Ipecac........gr. xij Emet. Tart........gr.j I RETRO-VERSION OF THE UTERUS. 485 Let this powder be taken in half a tea-cup of warm water; and after she commences vomiting, the girl should drink plentifully of water, so as to facilitate a free emetic action, and also break the violence of the effort. The night following the emetic, she should take: R Hydrarg. c. creta.....' . gr. xij and the next morning §j of castor oil. This will probably produce an active cathartic effect, which this patient is much in need of, and which will unload the prima via by bringing away quantities of hardened faeces and vitiated matter. With a view afterward of keeping the bow- els in a soluble state, and at the same time invigorating the general sys- tem, I shall order the following ferruginous aperient, a table-spoonful of which may be taken twice a day: R Sulphat. Ferri.......gr. vj Sulphat. Magnesiae......3 ij Acid Sulph. Dilut.......3 ss Infus. Gentianae i „ ... Infus. Rosar. c. J ? Ft. Mist The diet should be simple, but nourishing ; after the system has be- come relieved by this treatment, and the health measurably restored, it may be proper to place this girl under the influence of iron and aloes, or even the electric current applied from the back to the uterus, all of which remedies are calculated to do good in this form of amenorrhcea, after the general health has been improved. Retro-version of the Uterus in a married Woman, aged thirty- four Years, the Mother of four Children, the youngest two Years old.—Dysmenorrhoea—Its connection with Uterine Displacements. —Mrs. P., married, aged thirty-four years, the mother of four children, the youngest two yoars old, complains of more or less constant pressure on her back passage, and says she has great difficulty in evacuating her bowels and bladder. " How long, madam, have you suffered from this pressure on your back passage !" " Nearly a year, sir." " Are you much confined in your bowels ?" " Very much so, sir, and I always suffer a great deal of pain when I have them opened." " You say you can not pass your water freely ?" " No, sir; I am often very much troubled in that way." " Have you sick stomach ?" " Yes, sir." " Have you a feeling of numbness in your lower limbs ?" " Yes, sir; I feel sometimes as if I could hardly drag them along." " How are your courses ?" " They are regular, sir, but I suffer a great deal of pain when I have them." " Have you always had pain at that time ?" " No, sir; only since I have had this pressure on my back passage." The real na- ture of the case before you, gentlemen, it would be difficult to appreciate without further evidence on the subject; and this evidence can be fur- nished only by a vaginal examination. This examination I have made, and the difficulty under which the patient labors is fully revealed. The 486 CLINICAL LECTURES. pressure on the bacK passage is occasioned by the falling backward of the fundus uteri upon the rectum, constituting what is known as retro- version of the organ. The uterus, you are aware, is divided into its cer vix, body and fundus. The cervix, beside ante-version and retro-version, is liable to two other forms of displacement, viz., ante-flexion, and retro- flexion, in either of which cases the cervix is bent as it were on the body like the beak of a retort. These flexions of the uterus have sometimes been mistaken for other diseases, and more especially for tumors. This latter error it is most important for you to guard against, for there is more than one case on record in which the knife has been employed for the removal of the sup- posed tumor, when in fact the heedless surgeon has, through an unpardon- able error in diagnosis, excised the cervix uteri. The fundus of the uterus may be displaced by falling forward or backward. In the former case, there will be ante-version, in the latter retro-version. Retroversion is the more common, and is also attended with more serious consequences, for the reason that constipation and retention of urine are ge|erally the uniform and distressing symptoms, under an aggravated state, of this character of displacement. The uterus is situated between the bladder in front, and the rectum posteriorly ; the paquet of small intestines being above, regarding the upper surface of the fundus, while the inferior por- tion of the organ, the os, is encircled by the upper extremity of the va- gina. The uterus, with these relations, is far from being an immovable organ; on the contrary, mobility may be said to be one of its charac- teristics, not only in the unimpregnated state, but also in the earlier stages of pregnancy ; so that, under the operation of certain influences, the various displacements to which it is liable may occur both in the impregnated and unimpregnated condition. Retro-version, although sometimes met with in the absence of gestation, is most likely to be ob- served during the three or four first months of pregnancy; and there is a remarkable instance recorded by Hunter in which, from the impossi- bility of reducing the retro-version in a case of gestation, the woman died, and on an examination after death, the long axis of the uterus was found completely wedged in the antero-posterior diameter of the pelvis. Causes.—Among the causes of retro-version may be mentioned a de- formed pelvis with an increased capacity, undue pressure of the viscera, particularly the distended bladder, falls, blows, etc.; and I can well imagine how that ridiculous contrivance of fashion—the destructive cor- set—by its pressure from before backward, below the umbilicus, may act as a cause of this displacement. Symptoms.—There is a wide difference in the severity of the symptoms accompanying retro-version of the uterus ; and this difference will de- pend upon one material circumstance, viz., whether the displacement be partial or complete. In the latter case, all the distressing sensations will be much aggravated, such as pressure on the rectum, tenesmus, urgent but RETROVERSION OF THE UTERUS. 487 neffectual efforts at defecation, a sense of dragging in the groins and lumbar region, nausea, difficulty, and sometimes inability to pass water. You will recollect the connection between the bladder and uterus to be as follows : The inferior third of the anterior surface of the uterus, the only portion of this surface which is not covered by peritoneum, is in contact, through the medium of cellular tissue, with the bas-fond of the bladder. With these relations between the two viscera, you can at once under- stand how, in the event of retro-version, the bladder, more or less dis- tended with urine, will necessarily tend to increase the displacement. For example, in this case the bladder can not ascend into the abdominal cavity without drawing the cervix of the uterus upward, and at the same time making increased pressure on the retro-verted uterus, so that the bladder itself loses, in a certain degree, its vertical position, and hence the fact that retention of urine is an important symptom of retro-version. From the pressure excited on the rectum by the fundus of the womb, there is very apt to be an accumulation of faecal matter above, and this not only aggravates, but tends, by the superincumbent pressure of the faeces, to depress the fundus still lower—thus adding not only to the suffering of the patient, but, at the same time to the difficulty of successful treatment. Nausea and vomiting are common accompaniments of retro- version ; and it should be particularly borne in mind that not only in retro-version, but also in ante-version, as well as in retro-flexion and ante- flexion of the uterus, dysmenorrhoea is oftentimes a prominent symptom. Nothing can be more impbrtant than the recollection of this fact, for it is evident that, when dysmenorrhoea is traceable to uterine displacement, without a knowledge of the circumstance, all medication will be useless, if not injurious ; and yet how many women linger on for years with in- creased suffering from this form of menstrual aberration—the cause of the dysmenorrhoea never having been suspected by the practitioner. It is needless to state that in such case the remedy for the dysmenorrhoea is the removal of the displacement. Hysteria, with its multiplied and varying phenomena, may also be classed among the occasional accom- paniments of mal-position of the uterus ; and, lastly, partial or complete paralysis of the lower limbs may be the consequence not only of retro- version and the other forms of displacement of the organ, but also of its derangements from chronic inflammation, polypus, carcinoma, etc. Diagnosis.—Is it possible to mistake a retro-version of the uterus for something else? I answer—Without due caution,the practitioner may fall into the error. It may, for example, be confounded with a collection of faecal matter in the rectum, with a prolapsion of the ovary into the triangular fossa between the uterus and rectum, or it may be mistaken for an enlargement of the posterior surface of the fundus, or body of the uterus. In retro-version, when the finger is introduced into the vagina, the cervix will be found forward, while the body and fundus 488 CLINICAL LECTURES. will be pressing more or less backward on the intestine, and these dis- placements will be greater or otherwise depending upon whether the re- tro-version is complete cr partial. A collection of fiecal matter, simu- lating the retro-verted uterus, will soon be made to disappear by a brisk purgative, or an enema. In prolapsion of the ovary, the prominent symptom is pressure on the rectum, with a tendency to ante-version of the fundus. The most certain mode of discriminating between retro- version of the uterus and prolapsion of the ovary, is the introduction of the uterine sound, which you have seen me employ several times in the Clinique, When the sound has penetrated the cavity of the womb, in case of retro-version, the organ will be made to assume its normal posi- tion, and consequently no tumor will be found pressing on the rectum. In prolapsed ovary, on the contrary, the introduction of the sound will not remove the tumor, and it will be felt as distinctly as before the sound was introduced. In simple enlargement of the posterior surface of the fundus, or body of the womb, there will be little or no displace- ment of the cervix. Prognosis.—In complete retro-version, great difficulty may be encoun- tered in overcoming the displacement, and, under some circumstances, the reduction may prove altogether impossible, so that the prognosis will not always be of the most favorable kind. Treatment.—This consists in attempts, through manipulation, to re- store the uterus to its original position. The patient should be placed on her back or side—the rectum and bladder having been previously emptied. The practitioner then introduces his index and middle fingers into the vagina, carrying them backward, and when they reach the retro- verted organ, an effort is made to push it upward, while, at the same time, with the index finger of the other hand, he endeavors to depress the cervix. This plan, however, though it may appear feasible, often fails, and indeed I am of opinion, contrary to some authors, that the successful treatment of a retro-verted uterus is among the most difficult duties of the medical man. There are two other modes which have been proposed, and they have been followed by tolerable success. One consists in the introduction of the intra-uterine pessary of Simpson and Valleix, the other of the rectal tampon. Recently the intra-uterine pessary has called forth much dis- cussion, and the profession appear to be divided in opinion as to its utility.* I have no doubt that, under some circumstances, this instrument * The subject of uterine displacements, in connection with the intra-uterine pes- sary, has of late occupied much of the attention of the French Academy of Medicine. It may, indeed be said that the examination of this question brought out the full strength of the Academy, for among those who took part in the discussion, are the names of Velpeau, Huguier, Malgaigne, Amussat, Piorry, Dubois, Hervez de Chegoin, Robert, Cazeau, Depaul, etc., a constellation certainly of bright and high names in France. The committee originally appointed by the Academy to report on the subject of the intra-uterine pessary, as a remedy for the various RETRO-VERSION OF THE UTERUS. 489 is one of vake, but it has at the same time been sadly abused. The rectal tampon has proved efficient with Huguier and others, and consists of a rod eight or ten inches in length, with a tampon made of old linen at the extremity. This, being smeared with oil, is introduced into the rectum, displacements of the uterus, consisted of MM. Robert, Huguier, and Depaul, the latter of whom acted as chairman, and delivered the report, which led to a pro- tracted and interesting discussion. Depaul and Valleix may be said to be re- spectively the representatives of two opposite schools on this subject; the former repudiates the idea that uterine displacements produce, of themselves, any patho- logical conditions of the organ, and maintains that, in most of the alleged cases of disturbed action, the disturbance is due not to the displacement, but to some complication, such as ulceration, engorgement, granulation, etc., of the uterus. He also affirms that science possesses for these displacements a treatment far more rational and efficient than intra-uterine pessaries, and he states that the facts cited as proof of the successful treatment by these instruments tend only to de- monstrate their utter inefficiency; and lastly, he avows that the employment of the intra-uterine instrument has been followed by the most serious results, and even by death itself. On the other hand, Valleix is the uncompromising advocate for the use of the intra-uterine pessary, and maintains with vigor its undoubted efficacy. It seems to me that the discussion which this question has provoked is some- what tinctured with pride of opinion—there appears to have been an obstinate determination, on the part of the respective disputants, to make a struggle for victory, and, in accordance with this resolution, most else was forgotten in the debate, save that which would tend to the accomplishment of this one object. This, perhaps, may be regarded as extremely free criticism, but I am strongly impressed with the conviction that I am right. Let us now briefly examine the material points of the controversy. One of the prominent positions assumed by Depaul in his report is, that " the influence of uterine displacements has been greatly exaggerated, and that the symptoms attributed to these deviations belong to some other pathological conditions." Is this a truth recognized in practice, or is it simply an assertion for the forum ? If the former, then it is of value, if the latter, it is entitled to no consideration whatever, so far as the elucidation of the question under debate is concerned. I am, indeed, much surprised at the sweeping declaration, for it is against all experience. "Will the learned reporter undertake to assume that pure displacements of the uterus, unaccompanied by com- plications of any kind, are incapable of giving rise to morbid phenomena ? If I understand his language, such is its import. Now, what are the facts which daily experience reveals to us ? They are as follow: In deviations of the uterus, such as ante-version, retro-version, prolapsion, etc., the usual morbid phenomena resulting from the displacement will be, irritation of the blader and rectum, some- times amounting to great distress, deranged menstruation, constitutional disturb- ance of various kinds—in one female, for example, there will be hysteria, in another, paraplegia, etc. There is no speculation in these statements, they are the broad results of daily observation, and therefore must be accepted as the revelations of the sick room, where, after all, the true merits of this controversy must be weighed and decided. I do not pretend to deny that, under certain cir- cumstances, a female may have displacement of the uterus, without suffering much, if any, inconvenience. But this is the exception, while the reverse consti- tutes the general rule. Again, how frequently is the fact illustrated in practice, that the serious 490 CLINICAL LECTURES. the object being to press the retro-verted fundus upward, and restore it to its natural position. Amussat, fully appreciating the difficulty of re- taining the uterus in situ after the displacement has been reduced, and having tested the failure of the various contrivances proposed for this troubles consequent upon uterine deviations subside almost simultaneously with the restoration of the organ to its proper position. Depaul, besides denying the connection between displacement of the uterus and any morbid phenomena which may ensue, not only refers these phenomena to complications, such as ulceration, granulations, etc., but maintains, in the most unqualified manner, that it is only necessary to cure the granulations, or ulceration, in order to accomplish the return of the uterus to its natural situation. This assertion is certainly not warranted by the experience derived from the field of practice, and is full of mischievous consequences both to the patient and practitioner. "We know very well that prolapsion of the uterus is often the result of engorgement, or hypertrophy of the cervix, and in such case, the remedy for the prolapsion is the removal of the engorged or hypertrophied condition. But this is very differ- ent from the broad statement that ulceration or granulation of the uterus stands so intimately in the relation of cause and effect with displacements of the organ, that to remedy the latter, it is only necessary to remove the former. Moreover, I think it can be shown that ulceration, etc., of the organ, instead of being causes of uterine deviations, are often the result of these deviations. For example, in ante-version or retro-version, and even in prolapsion, the cervix becomes, from more or less contact with the bladder, rectum, or the folds of the vagina, the seat of irritation, and this irritation not unfrequently terminates in the develop- ment of disease, which may assume the form of simple erosion, granulation, or ulceration. If, now, we look at the other side of the question, it will, I think, be quite evident that Valleix, in his strong advocacy of the intra-uterine pessary, as the great and almost universal remedy for displacements of the womb, inculcates a doctrine not only at variance with facts as observed at the bed-side, but which, if carried out to the extent he claims, must of necessity result in injury more or less serious to the patient. In the first place, the introduction either of the sound or pessary into the cavity of the uterus requires, on the part of the practitioner, a certain degree of skill, and a thorough knowledge not only of the normal position and connections of the displaced organ, but also of the modifications to which tho position and connections are liable as a consequence of the deviation, whatever it may be. And secondly, no matter how judiciously the instrument may be introduced, yet in order that it may remain there for weeks, as inculcated by Valleix, will need on the part of the female, if she wish to escape accident, more than ordinary vigilance. I will not speak of the dangers of injury to the mucous surface of the womb, of lacerations, of the hazard of impaling herself, etc., if due caution be not observed by the patient. These are accidents which are the legit- imate and necessary results of either ignorance or carelessness in the promis- cuous use of these instruments, and can not occur without placing in more or less jeopardy the safety of the patient. The instruments which are employed for the purpose of entering the uterus, and which have given rise to the discus- sion in the Academy, are of two kinds: 1st. The uterine sound, which is known as Simpson's sound—but it is now admitted that Recamier had several years pre- viously employed a similar instrument, which was soon afterward adopted by Amussat. The uterine sound is used as a means of diagnosis, and it is also available in restoring the uterus to its natural position, but is not intended, as is SORE NIPPLES IN A PRIMIPARA. 491 object, has suggested an operation, which has proved highly successful in his hands. The operation is simple and rational, and is performed as follows : Having placed the patient in a convenient position on the bed, he applies the potassa cum calce to the posterior lip of the os uteri, and also to the corresponding portion of the vaginal wall; a slough is soon formed, and falls off; inflammation of the two surfaces is the consequence, and adhesion takes place between the vagina and posterior surface of the os uteri. The effect of this adhesion of the os posteriorly is to draw the body and fundus of the uterus forward, and maintain them in their natural position. I think well of this operation, and shall have recourse to it in the case before us. " Now, my good woman, if you will consent to what I think best to do for you, I will endeavor to relieve you of your sufferings, and restore your womb to its proper position. I can not readily perform the operation here, but if you say so, I will go to your house, and do what I can for you." " I will submit, sir, to any thing to get well." " Then, madam, I will be at your house to-morrow, at eleven o'clock." You will recollect, gentlemen, that I have had recourse on one occasion to this method of Amussat, and with decided success. It will be well for the patient to take, for the present, occasional small doses of epsom salts, for the purpose of acting on the bowels. This, perhaps, will be better than any thing else until the uterus is replaced, for the reason that the salts will bring away serous discharges, which will encounter no difficulty in passing the contracted rectum. Sore Nipples in a Primipara from Nursing.—Mrs. W., aged twenty- two years, married, the mother of one child, four weeks old, applies for advice in consequence of the extreme pain she experiences every time the child is put to the breast. " How long, madam, have you suffered from this pain ?" " I began to suffer from it, sir, about four days after the birth of my child, but I am in such agony now, that I don't know what to do." [The Professor examined the breasts, and discovered the cause of this woman's sufferings to be sore nipples.] the intra-uterine pessary, to remain permanently in the uterus. I have spoken to you on former occasions of the value of this sound as an instrument of diag- nosis, and you have seen me repeatedly resort to it for this purpose; 2d. The intra-uterine pessaries, which are intended not only for the replacement of the uterus, but for its permanent restoration, for which latter purpose they are retained within the organ for a greater or less period, depending upon the par- ticular circumstances of the case. These pessaries are of various construction, and there is a difference of opinion as to who originally suggested them, whether Simpson, Kiwisch, Amussat, or Velpeau. They consist of the wire pessary, sometimes called the pubic pessary, having a stalk which enters the cavity of the uterus, while the other extremity rests on the pubes; then there is the spring pessary, the galvanic pessary, consisting of zinc and copper, the ball pessary with a stalk, and lastly, the dilating pessaries employed in stricture of the cervix uteri, sterility, etc 492 CLINICAL LECTURES. This patient, gentlemen, presents one of the most vexatious annoy- ances of the lying-in chamber, and you will often be baffled in your attempts to remedy it. It is a case of sore nipples, or, as it is some- times called, fissured nipples. The suction of the child's mouth irritates the delicate integument surrounding the nipple—inflammation ensues, and then the nipple becomes cracked or fissured. Every time the child is applied to the breast, the fissure is opened, bleeds, and is a source of intense suffering to the patient. The application of the child to the breast, under these circumstances, is a constant struggle between mater- nal affection on the one hand, and physical distress on the other. This affection proves obstinate and rebellious to remedies, for the reason that while the child continues to nurse, there is no time for the healing pro- cess ; the fissures are being constantly opened afresh, and hence, often- times the protracted duration of the malady. It is said that the prevention of disease is a great point in medicine, and I think the maxim is fully exemplified, and presents peculiar force in the question now under consideration. It is a good practice, and one which I am in the habit of pursuing, to prepare the nipples for nursing ; this is what is termed the process of hardening, and is a very simple matter. About two months before the expected confinement, direct the female to make gentle traction of the nipple, with the finger and thumb, at least once or twice every day, or frictions with brandy and water, tincture of'myrrh, etc. Under this treatment, the integuments lose their irritability, and are enabled to resist the impression of the child's mouth. This, however, is merely the preventive treatment; let us now see what is to be done when the affection really exists. There is a long catalogue of remedies for sore nipples, but unfortunately they are more numerous than efficient. As I have before remarked to you, the only difficulty in the suc- cessful management of these cases, is the constant repetition of the cause of the inflammation, viz.: the nursing of the infant, so that in the treatment of this affection, we are reminded somewhat of the web of Penelope—what is done by night is undone by day. Should your attention be called to a case of this kind, before the fissures have formed, when there is simply redness and pain in the nipple, you will occasion- ally be enabled to arrest further progress, by the use of some mild as- tringent, such as the following : alum whey; sulphate of zinc gr. ij to §j of rose-water; tincture of catechu or myrrh ; a solution of borax ; tinc- ture of kino, etc. When the fissures have formed, I have found nothing as a local application, superior to the nitrate of silver gr. x to 1 j of water. If the mother's health should decline from the sufferings incident to this affection, it will be absolutely necessary to wean the child, or provide for it a wet-nurse. Sometimes I have succeeded in relieving this affec- tion, by suspending for two or three days, the application of the infant to the breast, with a view of allowing the fissures to heal, but you must INFANTILE THERAPEUTICS. 493 recollect that in such cases you will be between Scylla and Charybdis, for while, through the temporary withdrawal of the child from the breast, you may succeed in relieving the sore nipple, you may, without due cau- tion, inflict upon your patient a more serious malady—mammary ab- scess. Therefore, in all such instances, remember that you are to adopt at once those remedies best calculated to prevent engorgement of the milk ducts, which is the true cause of milk abscess. These remedies are the following: Gentle frictions on the breast with warm oil, which will tend to promote a flow of milk through the nipple, and thus prevent undue distention ; and at the same time, you must not neglect the capi- tal point, under such circumstances, of purging your patient with saline medicines. Nothing better for this purpose, than the following, of which a wine-glass may be taken as occasion may require: R Sulphat. Magnesia?......§ iss Infus. Rosar c.......| viij Ft. Sol. Be careful that the patient is restricted in the quantity of her drinks, while the infant is weaned from the breast. Nipple shields, to which is attached the cow's teat, or the gutta-percha teat, are highly recommended, but according to my experience, in the great majority of instances, they are useless. Convulsions in a little Boy, two Years old, from Excessive gen- eral Blood-letting—Infantile Therapeutics—General and Local Depletion; their Comparative safety.—John W., aged two years, is brought to the Clinique by.his mother, who says he had an attack of pleurisy about three weeks ago, was bled twice in one day from the arm, and in one hour after the second bleeding, he became rest- less, rolling about the bed, and was very soon attacked with con- vulsions. " Was that the first time your child had an attack of con- vulsions." " Yes, sir, he was always a healthy fine boy until he took the pleurisy; and he was bled so much that I am sure it nearly killed him." " How many convulsions has he had since he was bled ?" "Six, sir." "He appears to be very weak, does he not?" "Yes, sir, he is not like the same child." This case, gentlemen, is one of unusual importance in a practical point of view, and I am happy to have an opportunity of presenting it to you, as it affords me an occasion to make a few general remarks on the subject of infantile therapeutics, than which there is no topic of deeper interest to the practitioner who proposes to devote himself to the treatment of the affections peculiar to infancy. There are in the system of the young child certain prominent and characteristic features, both physiological and pathological, which are not only important to be remembered, but which are lucid com- mentators of the normal and morbid phenomena peculiar to that ten- der age. 494 CLINICAL LECTURES. lou all understand the preponderance and extraordinary activity of organic life in the young infant; and your attention has been often called to the extreme susceptibility of the nervous system, especially the medulla spinalis, which is the active and ruling nervous center of this period of existence. If the young child enjoy a high degree of or ganic life, and be enabled in this way, through the activity of the nutri tive processes, rapidly to develop the various tissues of the system, il must be remembered, also, that its powers are easily prostrated eithei by disease or injudicious medication. In a word, the vital forces of the infant are readily depressed, but they have at the same time great facil ity of recuperation. There can be no doubt—and the fact is almost universally admitted—that the child sustains blood-letting badly; its nervous system, from its striking susceptibility, becomes affected in a very marked manner, and among the phenomena indicative of this form of excessive depletion will be jactitation and convulsions, and the latter are more likely to occur if syncope should have been produced. There is an interesting connection between convulsions and losses of blood, and the connection has been abundantly established by experiment. When an animal is bled to death, its dissolution is preceded by convul- sive spasms; both Sir Charles Bell and Marshall Hall have shown that the convulsion is not the consequence of loss of blood sustained by the brain, but by the spinal marrow. You, therefore, perceive the neces- sary and direct connection between the vascular and nervous systems, and when you recollect the peculiarities of the latter in the young child, you can not but appreciate the value of great judgment in the employ- ment of so powerful a depressor as general blood-letting. While I would not, in all cases, interdict a resort to the lancet in the treatment of infantile diseases, yet I would say to you, Be careful, you have in that instrument a double edged-weapon, one which in incautious hands, may produce disastrous results. As a principle, allow me to suggest, that, when bleeding is indicated in the child, local is preferable to general depletion; but you are to bear in mind that serious results may also arise from the abstraction of blood locally, if not confined to proper limit's. The great point, gentlemen, which I desire to impress on you is this: the young child is inadequate, from the peculiarity of his organization, to sustain large bleedings; and when the abstraction of blood is indicated, all things being equal, local in lieu of general blood-letting should be resorted to. It is not, perhaps, on this occasion out of place to caution you against the too free employ- ment of blisters in the treatment of infantile disease; without great cau- tion in their use, they do much harm. The loss of sleep produced by their local and constitutional irritation is most injurious to the child ; be- sides, much is to be apprehended from the secondary effects of the can- tharides, viz., ulceration and gangrene. The application of blisters, both in the child and adult, is apt to be followed by distressing pain in passing NEURALGIA OF THE RIGHT LABIUM EXTERNUM. 495 water, known as strangury, which means literally the passing of urine drop by drop. One of the best remedies for this state of things will be found a combination of hyoscyamus and camphor: for an adult, one of the following pills may be taken every two hours until relieved: R Extract Hyoscyam. ) .. .. n r, v [.....aa gr. xij G. Camphorae ) Divide in pil. No. vj For an infant, the tincture of hyoscyamus may be given, say from three to six drops, in a tea-spoonful of sweetened water every two hours, or what is better, when applying the blister, let it be previously sprinkled with powdered camphor. This will almost invariably prevent the distressing effect of the cantharides on the urinary organs. It is well also to bear in mind that camphor is a valuable remedy in various other irritations of the bladder. In the case of the little boy before us, I have no doubt that we have an example of convulsions from irritation of the medulla spinalis, caused by the excessive abstraction of blood. The therapeutic indication here is to fortify the system, and endeavor by appropriate treatment to regain the loss which has been sustained. " How are your child's bow- els, my good woman ?" " They are quite regular, sir; but he has no appetite, and is very restless at night." Treatment.—I would recommend for this child the following course of treatment: R Syrup Iodid. Ferri......§ j Ten drops three times a day ; and the nourishment to consist of animal broths, the yolk of a soft-boiled egg, etc. In order to procure sleep, and at the same time with a view of quieting the nervous system, he should take at night ten drops of the following, or three grains of Dover's pow- der: R Tinct. Hyoscyam.......§ ss Neuralgia of the right Labium Externum in a married Woman, aged twenty-four Years.* Mrs. E. returned to the Clinique to-day, and says she has been very much relieved by the treatment which had been recom- mended for her. You will not, gentlemen, have forgotten this case; it was one of excessive pain in the right labium, and all that was recom- mended was an issue on the side of the lumbar vertebras with strong nitric acid. You will remember the reasoning employed on the occasion, and the return of this patient with the avowal of improvement, is satisfactory evidence that there was a good basis for the remedy suggested. It is an instructive example of disease, and the result, so far, has been most satis- factory. * Page 443. LECTURE IXV11. Mother's Milk, the proper Nourishment for the Infant—Analysis of Human Milk con- trasted with that of the Cow and Goat; Causes which disqualify the Mother from Nursing her Child; Requisites necessary in a Wet-nurse; Absurd Practice of cramming "Wet-nurses; Bringing up the Infant by Hand—rules for; When should the Child be Weaned? Fashionable Mothers; Neglect of the young Infant; Milk deteriorates by being retained in the Breast.—Jaundice in a Woman seven Months Pregnant—Why is Jaundice dangerous to the Foetus ?—How is the Blood which passes from the System of the Foetus through the Umbilical Arteries elaborated in the Placenta ?—Foetal Circulation—Transmission of Hereditary Disease—Puorperal Convulsions.—Vaccination; origin of—Is Re-Vaccination necessary ?—Does Vac- cination 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 ?—Signs of genuine Vaccination—Spurious Vaccination. Gentlemen :—I have told you that the parent's milk is the proper nourishment for the new-born infant, and also how important it is to the health of the mother, when not contra-indicated by disease or other cir- cumstances, that she should nurse her child. Milk, whether in the human subject or in animals, is composed essentially of the same ele- ments, the difference being only in the relative proportion of these con- stituents ; and to us it is an extremely interesting fact that the proportion of the constituents, as a general rule, varies according to the special necessities or wants of the young of the particular animal. But, perhaps, you can better appreciate the fact by analyzing the following table, which furnishes the relative proportions of the elements found in the milk of woman, the cow, and goat: Casein. Sugar. Butter. Human Milk................32 36 29 Cow's Milk.................63 28 40 Goat's Milk.................80 40 40 There is, as you perceive, a striking difference in the proportions of the principle constituents, the casein, sugar, and butter; for example, in human milk the casein is to the sugar and butter as 32 to 65 ; in the cow the casein is as 63 to 68; while in the goat it is in the proportion of 80 to 80. You can not, certainly, as intelligent students, observe this variation in the milk without asking why this discrepancy in the relative proportions ? The solution of this question is not only important, but THE MOTHER'S MILK. 497 is full of interest. While in human milk the proportion of casein is 32, in the milk of the cow it is 63; and the reason of this difference is, that the calf, almost simultaneously with its birth, walks, and, therefore, the necessity for an early development of muscular fibre, which is accom- plished through the casein of the milk. The new-born infant, on the contrary, does not walk, does not need this early growth of muscular tissue, and, therefore, nature has not felt the necessity of supplying it with the same quantity of casein. But, again, the new-born infant, though it does not need rapid muscular development, receives relatively a larger supply of respiratory food, and hence the remarkable dispro- portion of casein and respiratory food in the milk of the human female and cow—in the former it is as 32 to 65, while in the latter it is as 63 to 68. I need not pursue this inquiry further to impress upon your minds the constant evidences furnished by science of the beauty, harmony, and wisdom displayed by the Creator, in the adaptation of means to the wants of all living things. It is an edifying subject for contemplation, and is replete with rebuke to those who, in their ignorance or stupidity, have charged upon our profession the unfounded slander that its study leads to infidelity! The study of medicine, so far from leading to in- fidelity, is constantly developing truth, and bringing before the mind the irresistible proof of design; and, therefore, its tendency is unequivocally to direct thought to the Divine source, from which emanate all wisdom and perfection in arrangement. Although, all things being equal, it is far better, both as regards the well-being of mother and child, that the parent should nurse her infant, yet there are certain conditions of the maternal system which would not only not justify this duty, but which imperatively require that it should not be performed. Among these conditions may be enumerated the following: Consumption, scrofula, haemoptysis, syphilis, dropsy, the various cutaneous diseases, an irascible temper, etc. If, therefore, any circumstance should forbid the nursing of the infant by its mother, the question arises—What is the best substitute for the parent's milk ? Why, undoubtedly, the milk of a healthy wet-nurse; and this leads me to make a few observations touching the qualifications of an efficient and healthy nurse. 1st. As a general rule, a woman is most competent to fulfill this duty between the ages of twenty and thirty-five years; 2d. She should be free from all existing or hereditary disease, and possess a cheerful and agreeable disposition; 3d. Her child should not be more than two or three months older than the one she takes to nurse—and usually it is better, especially when a new-born infant is to be nursed, that the milk of the wet-nurse be as recent as possible; 4th. If the men- strual evacuation should have returned, it is, I think, an objection, al- though this is not the universal opinion. It does seem to me that the catamenial discharge, if it exercise no other bad effect, diminishes the 32 498 CLINICAL LECTURES. quantity of the phosphate of lime in the milk, which we have seen is material to the wants of the young infant; 5th. It can scarcely be necessary to say that pregnancy contra-indicates the propriety of nurs- ing; 6th. Good teeth, healthy gums, a sweet breath, and personal clean- liness, are essential requisites for a good nurse; 7th. It is extremely important to ascertain that both breasts are in good condition, for some- times there is milk only in one breast, and in this case the child must suffer; 8th. Are the nipples healthy—are they developed, so that the infant can grasp them readily ? 9th. Is the milk of proper quality, and is it nourishing ? One of the best evidences of the affirmative of this question is the child of the nurse—if it be healthy, well-developed, and presents all the indications of a thriving child, this is pretty strong tes- timony that the milk is of good quality. There is a very simple mode of testing the quality of the milk, which may be done in the following manner: Place a drop on the finger-nail, having the nail somewhat inclined, and if, when it falls from the nail, it leaves a whitish mark, it is good. Again, if in pouring two or three drops of milk into a glass of water, the water should become slightly clouded, and gradually afterward become clear, it is an evidence that the milk is of proper quality. 10th. As a general rule, women from the country make better wet-nurses than those reared in the city. The milk of a healthy and efficient nurse is oftentimes materially in- jured by the too prevalent error of over-feeding. A woman, for exam- ple, accustomed to plain but nutritious diet, and under such diet, in the enjoyment of robust health, is selected by some family of wealth as a wet-nurse. With the natural anxiety of the parents that their infant may thrive, every care is taken to cram the nurse with the richest food, and, in addition, she is well supplied with porter, toddies, etc. At the same time that her diet is thus suddenly changed, there is also a marked change in her habits. Previously, with a wholesome diet, she was ac customed to constant exercise in the open air, and enjoyed uninterrupted health. Now, under a species of stuffing, she is confined within doors, and becomes, as it were, a sort of fixture in the nursery. What, under such a condition of things, can be expected but deranged health, and milk unsuited to the wants of the infant? A little common sense and reflec- tion would suffice to show that, instead of deranging the system bv fill- ing it with food it can not digest, and curtailing the exercise to which it had been accustomed, every precaution, on the contrary, should be taken to preserve the health by nutritious but simple food, and adequate daily exercise, etc. Let us now suppose, however, that the mother can not nurse her child, neither can a wet-nurse be obtained. What, in such case, is to be done ? The infant must then be brought up, as it is familiarly called, by hand. On account of the facility with which it can be obtained, fresh cow's milk is the most suitable article of food for the young infant, WHEN SHOULD THE INFANT BE WEANED? 499 but if you will only remember, gentlemen, the analysis of cow's milk when contrasted with human milk, you will readily understand why it should undergo a modification, in order that it may be suited to the sys- tem of the infant. In cow's milk there is an excess of casein, with a comparative diminution of saccharine matter. Therefore, in order to diminish the former, and increase the latter, let the milk be diluted at first with two thirds water, adding to it sugar, for the purpose of supply- ing the deficient saccharine material. In the course of two or three weeks, let the dilution be one half water to one half milk, and in two months the infant may take the milk undiluted. It may also be mixed with barley-water, rice-water, carefully-prepared gruel, strained panada- water, etc. Great care should be taken in the preparation of the infant's food, and not more should be provided at a time than can be consumed by the child. This latter precaution will necessarily involve some little trouble, but the mother, whose special duty it should be to supervise the preparation of her child's food, will be abundantly com- pensated for any trouble it may involve by securing to her infant what is most to be desired—good health. Many an infant has been sacrificed for the want of proper care in this particular, and a constant supervision, therefore, should be exercised. The child should not be fed with a spoon; it is far preferable to let it suck from a bottle—the biberon, as it is termed—through a cow's teat, or a gutta-percha teat, or, what is now found an excellent substitute, one made of softened ivory. The advan- tage of the latter is, that it is liable neither to alteration nor an unpleas- ant odor, and is kept clean without difficulty. When should the infant be weaned ?—This is an interesting question, and its solution depends upon a variety of circumstances—such, for ex- ample, as the health of the mother or nurse, the health of the infant itself, the season of the year, etc. If the mother has a good breast of milk, and she suffers no inconvenience from nursing, she should not wean her child, as a general rule, under a year, and it is important to select for this purpose, if possible, the season of the fall or winter. I do not mean to be understood to say that the child, if nursed for a year, should be confined rigidly to breast-milk during that period. On the contrary, nature very broadly indicates when the infant may take with impunity other diet, and this is when dentition has fairly commenced, and the first teeth have pierced the gums. The teeth are intended for a special pur- pose, viz.—to masticate the food before the process of deglutition is called into action. Fluids do not require mastication, and therefore it is in obedience to the counsels of nature to give the child, as soon as it has cut the first teeth, something more substantial than fluids. But what shall this food consist of? The breast of chicken, lamb-chops, tender beef, etc., chopped into the minutest possible fragments, may be given, very little at a time, with decided benefit, say at nine or ten months, if there be nothing to contra-indicate this change; also, the infant may take 500 CLINICAL LECTURES. nicely-prepared chicken or beef-tea, with the crust of bread, or crackers, softened and broken up in it. All this, however, is a matter of judg- ment, which must depend upon the individual circumstances which may surround each case. In concluding these general remarks upon the subject of lactation, I may observe to you that in all cases in which an infant at tho breast fails in its health, without any ostensible cause, it will become necessary to ascertain whether it may not be owing to the improper character of the milk ; for, remember, that this is not unfrequently an occult cause of the decline and death of the child. The milk, for example, may be too rich, or it may be deficient in its ordinary elements; in either case it will prove injurious, and you perceive, therefore, how important it is to ascertain the existence of either of these circumstances, in order that the necessary remedy may be promptly applied, viz.: the substitution of another nurse or the weaning of the infant. You are not hastily to infer that because a child languishes in health, it, therefore, necessarily requires medicine. Thousands of children have found an early grave from this false reasoning, and the equally false practice which it has suggested. You all remember the case of the little child, one month old, which was brought to the Clinique some time since; it had, from its birth, been affected with diarrhcea, and the intestinal irritation resulted in convulsions. The child had received no nourishment but its mother's milk; on examining the milk we ascertained that it was loaded with col- ostrum, the peculiar uses and nature of which we have already discussed. We directed the mother to procure a wet-nurse for her child. This was done, and you have not forgotten that the infant was returned to the Clinique perfectly restored. Not one atom of medicine was adminis- tered, for the simple reason that it was not needed. The disturbing cause was the improper food; this was changed, and the child, as a mat- ter of course, recovered. There is an extremely interesting fact connected with*actation to which it is important, for the moment, to allude. It has been shown that milk drawn from the cow only once in twenty-four hours is not only less abundant and rich in butter than when taken every eight or ten hours; but also, that the milk first drawn in the pail is always more serous, while that which is taken last becomes richer in cream. It is impossible, with these facts before us, not to deduce from them a principle abso- lutely essential to the health of the infant. Some fashionable and way- ward mothers, forgetting that their first duty should be to their child, are in the habit of allowing a long interval to intervene between the applications of the infant to the breast; for example, the well-adjusted toilet can not be deranged, the child must wait until its thoughtless mamma has gone her rounds of out-door visits, or completed the period allotted to her brilliant home receptions. Oftentimes, in this way, many hours elapse, and the child, though hungry and suffering, is not put to JAUNDICE. 501 the breast, if, indeed, it even have a thought passed upon it. Under these circumstances, the milk becomes changed, it is unfitted for the nourishment of the infant, and the latter, neglected by its parent, lan- guishes and dies ! What a commentary upon the follies of life; what a sad picture of maternal heartlessness! But, thank God, these exam- ples are comparatively few, and become, as it were, insignificant in con- trast with the undying love and self-sacrificing devotion so generally exhibited by mothers toward their offspring. In a healthy breast, the secretion of milk is in proportion to the frequency with which it is emp- tied ; so that, a strong child, with suction sufficient to obtain a full draught of nourishment, receives a much more nutritious fluid than the delicate infant whose powers are so feeble as scarcely to enable it to ex- tract more than a modicum each time it is put to the breast. I am con- fident that this condition of things is often the cause of continued bad health in the child, a cause, too, which usually escapes observation. In all such cases, the mother should be Instructed to have her breast drawn two or three times a day by another child, or what will do equally well, a pup, so that when her own child nurses it may be furnished with suitable aliment. This is an important direction, which, if faithfully carried out, will be the means of protecting many an infant from the sup- posed necessity of medication, and preserving its life by providing it with what it is most in need of—proper nourishment. You see how much depends upon just discrimination, and how frequently and rashly we employ medicine without the slightest indication for its use. Jaundice in a Woman seven Months Pregnant—Why is Jaundice, during Pregnancy, dangerous to the Foetus ?—How is the Blood, which passes from the system of the fffitus through the umbilical Arteries, elaborated in the Placenta?—Transmission of Heredit- ary Disease.—Mrs. T., aged twenty-three years, mamed, seven months in gestation, presents an example of aggravated jaundice. She is as yellow as an orange, and the whites of the eyes deeply tinged with bile. " How long, my good woman, have you suffered from jaundice ?" " I began to turn yellow, sir, about six days ago, and I have been getting worse every day." " How is your urine ?" " It is just like saffron, sir." " Do you feel sleepy ?" " Yes, sir; I can scarcely keep my eyes open, I am so heavy and dull." " How are your bowels ?" " They are very much confined, sir." " Have you noticed the color of your evacuations, when any thing passes from you ?" " Yes, sir, what I pass is like lumps of clay." There are, gentlemen, several points of interest in this case, to which it is important briefly to allude. In the first place, this patient is labor- ing under a severe attack of jaundice, a disease, under ordinary circum- stances, perfectly manageable and without danger; yet it will sometimes assume a serious aspect, and, if not properly treated, may result fatally. 502 CLINICAL LECTURES. In jaundice, the bile does not pass in its usual abundance through the ductus communis choledochus into the duodenum, but mixes with the blood, and in this way the yellowness of the cutaneous surface is accounted for. It is an interesting fact for you to remember that, as a general rule, when the skin is of a deep yellow in this disease, it is a more favorable symp- tom than when the color is light and undefined; usually in these latter instances, it has been found that jaundice is the result of some serious organic affection of the liver, and more especially of schirrus of that organ. Again, in these cases, there is very little, if any, bile in the urine. When the urine is loaded with bilious matter, it may be re- garded as a favorable indication, for the reason that an outlet is furnished for the passage of the biliary secretion which would otherwise be in such rapid accumulation in the blood as to depress the powers of the system, and more especially the brain. In severe cases of jaundice, when the disease proves fatal, death usually ensues from coma; this latter condition being the result of the action of the biliary poison on the cerebral mass. Sometimes, however, death will be preceded by convulsions, and in this case the poison acts not on the brain, but on the medulla spinalis, and its continuation in the encephalon, for you have been told that convulsive muscular movement can not occur except as a consequence of irritation, direct or indirect, of the spinal cord. You see from this how important it is in all cases in which the bile becomes absorbed into the circulating fluid, and, therefore, an irritant, that prompt measures should be adopted to restore the biliary secretion to its legitimate channels, and thus protect the system against harm. But, gentlemen, there is a special point of interest in the patient before us, to which I have as yet made no allusion—she is in her seventh month of gestation, and consequently is surrounded, in this attack of jaun- dice, by more than ordinary danger, both to herself and the foetus she carries in her womb. If she be not relieved, the danger to herself will be twofold—either coma or convulsions. Again, if this biliary poison be suffered to remain in her blood, the foetus will be exposed to immi- nent peril, and it may be destroyed either by convulsions or imperfect nutriment, in consequence of the unhealthy condition of the mother's blood. Let us for a moment examine this subject. When describing to you the anatomy and offices of the placenta, I told you that this mass is divided into a maternal and fcetal portion, and that it possesses in its structure, composed essentially of blood-vessels, two circulations, which are entirely distinct and independent of each other. On the maternal surface, the circulation is carried on through the utero-placental vessels, while on the fcetal surface, it consists of the passage of blood through the vessels of the umbilical cord—the two arteries and one vein. There is between these two orders of vessels on the maternal and foetal sur- faces 'io continuity of canal; that is, the vessels on the fcetal surface have no direct communication with those on the maternal surface, but, JAUNDICE. 503 at the same time, the radicules of the umbilical arteries and vein dc communicate with each other by direct canal. Now, with a simple glance at the manner in which the blood circulates through the system of the foetus, and is again returned to the placenta, you will be prepared for the question—How is the blood which is brought back to the placenta elaborated ? The blood-vessels immediately engaged in the foetal circu- lation are those found in the umbilical cord, viz. : one vein and two arteries. Though called a vein, yet this vessel possesses the function of an artery, for it conveys arterial blood from the placenta to the foetus, and in the same way, the umbilical arteries perform the office of veins, for they return the blood which has lost its nutritious properties in its round through the system of the foetus, to the placenta. When the blood is thus returned to the placenta, for the purpose of becoming purified, it does not pass into the system of the mother, for you have just seen that there is no direct communication between the foetus and mother, but the elaboration is accomplished as follows: The blood in the radicules of the umbilical arteries receives, through a spe- cies of percollation, oxygen and albuminous matter from the maternal arteries, and thus becoming, as it were, decarbonized, it again enters upon its round of circulation through the foetus, being immediately taken up by the radicules of the umbilical vein. Mialhe has. shown that albu- men can not pass through membranes, but we know that albumen is necessary to the nutrition of the foetus, and he has developed the inter- esting fact that a substance is formed from albumen, called albuminose, which has the power of percollating membranes, and it is this substance from which the foetus in utero derives its nourishment. Robin and Ver- deil have demonstrated that what was supposed by Guillot, Le Blanc, and others, to be casein, in the blood of pregnant women and nurses, is essentially albuminose, which, after all, is similar to casein and kiestine. From what has been said, it must be evident to you that when the blood of the pregnant woman is impure, either from the accumulation in it of bile, or any other poisonous matter, the foetus which is nourished by that blood, must necessarily be exposed to more or less danger. There is another interesting feature connected with the condition of the blood in the pregnant female, and it is this : It is not uncommon to find women attacked with eclampsia or puerperal convulsions bring forth dead children; sometimes when the child is not destroyed, it will itself have convulsions immediately after birth ; I have seen two remarkable cases of this kind, which have already been reported. With the doc- trine that convulsions are but the results of irritation upon the spinal cord, either through poisonous blood or some other influence, the expla- nation of the transmission of the convulsive movement to the foetus is readily explained. The poisonous elements contained in the mother's blood are communicated to the embryo through the act of percollation of which I have spoken, and these elements will produce, cateris paribus, 504 CLINICAL LECTURES. morbid effects on the latter, precisely similar to those observed in the system of the mother. Allow me here to make a remark in reference to the transmission of disease from parent to offspring. That this hered- itary transmission is more or less constantly taking place, is a fact unhappily too well established, and it constitutes a veritable blight upon the race. Scrofula, syphilis, phthisis, carcinoma, etc., all of which I hold to be constitutional taints, may be transmitted either by the mother or father, and this will depend upon whether the former or latter be affected with the malady thus transmitted. For example, a scrofulous mother will pass the disease to her child through the ovule which she furnishes, that very ovule being a part of her system, containing either the elements of health or of disease, just precisely as the case may be. Suppose, again, the mother is free from all taint of scrofula, syphilis, etc., yet, under these circumstances, either of these affections may be propagated by the father, should he have the misfortune to labor under the infliction of either of them, or of any other constitutional malady capable of transmission, and it is propagated through the spermatozoa which he throws off during sexual intercourse, and which, as you know, is the true and essential fecundating liquor. Treatment.—I shall order for the patient before us the following treat- ment : Let her take the subjoined powder to-night, and in the morning, | j of Epsom salts in § viij of water : R Suhmur. Hydrarg.......gr. x Pulv. Ipecac........gr. j M. After she has been freely operated upon by this medicine, should the yellowness of the skin still continue, she will be much benefited by al- terative doses of mercury under the following form : R Hydrarg. c. creta......gr. xij Div. in chart vj. One powder to be taken every third night, followed the next morning with 3J of Epsom salts. Vaccination of an Infant aged three Months.—Mrs. J., the mother of one child, three months old, brings her infant to the Clinique to be vaccinated. She says she is much alarmed, because there is a case of small-pox in the neighborhood. The subject of vaccination, gentlemen, is one which deserves full at- tention. You are aware of the circumstance which led to the important discovery that the introduction of vaccine matter into the system is a protection against small-pox. The circumstance to which I allude is this: In the latter part of the last century, the fact was observed that cows are subject to a peculiar pustular eruption on their teats, and that those engaged in milking them, if they contracted the eruption, enjoyed an im- munity from small-pox. This, as you may readily imagine, was a fact of too much moment to be passed by in silence, and accordingly, under VACCINATION. 505 the able observation and experiments of Dr. Edward Jenner, the simple circumstance noticed in the humble milk dairy has become not only a matter of history, and constituted an important and interesting era in our profession, but has greatly diminished the bills of mortality by pointing out to us the means of protecting the human family against a most fearful and loathsome disease. Jenner, in the pursuit of his inves- tigations on this subject, maintained the following points : 1st. That the essential difference between cow-pox and small-pox is the comparative virulence of the two affections, the cow-pox being the milder form ; 2d. That persons vaccinated with matter taken from the cow, resisted inocu- lation by variolous matter. 3d. That the preservative influence of vac- cination against small-pox is perpetual in the same individual, and, there- fore, re-vaccination is not necessary. This latter proposition has, within recent years, called forth much dis- putation, and there still exist differences of opinion on the subject. Those who contend that Jenner was in error, base their argument upon the fact that in certain epidemics of small-pox, persons who had pre- viously been, vaccinated became affected with the disease; and they, therefore, conclude that after a certain time the vaccine matter loses its impression on the system, and that re-vaccination is absolutely neces- sary. In whatever way this question may ultimately be decided, one fact seems to be abundantly proved, viz., that small-pox is comparatively extremely rare after vaccination, and that it always assumes a milder type. It seems to me, however, that the necessity of re-vaccination de- pends strictly upon the solution of the following question—When small- pox occurs after vaccination, is the proof positive or equivocal as to the character of the vaccination, or, in other words, was the vaccination genuine or was it spurious ? If the latter, nothing surely is proved ; if the former, it is demonstrated simply that after genuine vaccination an attack of small-pox is possible. But in order to give this latter ad- mission its true value, and derive from it practical deductions, it is ma- terial to investigate the subject further, with the view of another devel- opment, viz.: How stands the proportion of cases in which small-pox occurs after healthy vaccination, with the proportion in which the vac- cine proves a preservative against the affection ? Suppose, for example, it should be shown that this proportion is insignificant; then, it ap- pears to me, all that can be proved is, that an attack of small-pox, after a genuine vaccination, is nothing more than a rare exception to a very general rule. Again, is it not a well-ascertained fact that an individual may have a second attack of small-pox ? Undoubtedly. But this, too, may be regarded as a very rare exception. If, in a word, the disease itself, under certain circumstances, may be reproduced in the same in- dividual, it would seem absurd to claim, even for genuine vaccination, what is not conceded to a first attack of small-pox, viz.: universal pro- tection. But the popular mind is in favor of re-vaccination—and now 506 CLINICAL LECTURES. it becomes a question whether you are justified in pandering to popular prejudice by repeating the operation. My answer to this query is a very plain one—no bad results follow re-vaccination, and as it may sometimes prove useful, more especially in cases in which the first vaccination was spurious, and as it quiets apprehension, you should not refuse to re-vac- cinate when requested to do so. Does vaccine lose any of its efficacy by long-continued transmission from one to another?—It is maintained by many that it does—and it is, there- fore, suggested that the vaccine should be taken, at certain intervals, from the cow, in order that its full effects may be insured. This is a point, however, about which there is some doubt; and there are valu- able statistics recorded which tend simply to show that the continued transmission of the vaccine from person to person does not subject it to deterioration. In connection with this subject, it may be stated that matter taken fresh from the cow, when inoculated into the system, is usually followed by more constitutional disturbance than in vaccination under ordinary circumstances ; so that while, under the influence of con- tinued transmission, its activity may, so to speak, beeonje somewhat diluted, yet it is by no means proved that it also becomes inefficient. At what age should an infant be vaccinated?—There is much difference of opinion on this subject—some say at ten months, others at six months, others at four months, and others again at two months. It is very evi- dent that in the event of an epidemic of small-pox, or even of its exist- ence in the sporadic form in the immediate neighborhood, the question of age should have no influence—the great question being the protection of the child against the affection. Therefore, in such case, the vaccination should not be delayed, but had recourse to immediately, even if the in- fant be but a week old. As a general rule, if the bad health of the child should not contra-indicate it, I vaccinate from one month to six weeks of age. This I think a judicious period for the operation; and one thing is very certain—if without sufficient cause the vaccination be delayed beyond this time, and small-pox should by any possibility de- velop itself, the physician would never be forgiven, and for all time he would be held accountable for any result that might ensue. This latter consideration, therefore, in the absence of any valid objection to the practice, is, in my judgment, a good argument in favor of early vac- cination. When the choice of season can be consistently made, I think the fall and spring preferable to the winter or summer. It has been shown that no age is too advanced for vaccination, and that it will suc- ceed at any period of life, provided the individual has not been attacked with small-pox. Mode of vaccinating.—This is a simple operation, but yet it requires some care. So far as the ultimate result is concerned, it matters not on what part of the body the virus is introduced, but, as a general rule, the arm is selected just below the deltoid muscle. It is customary with some VACCINATION. 507 practitioners, more particularly among the Germans, to insert the vaccine virus into both arms at the same time, or, if confined to one arm, to make several incisions at a little distance from each other, in order to insure a number, say three or four vesicles; and it is even asserted by high au- thority that consecutive small-pox never occurs in cases in which there are over four cicatrices from the first vaccination. All that I can say on this subject is, that, according to general experience, I believe it will be found that if the matter be genuine and fresh, and it be properly in- serted, the system will be abundantly protected by one vesicle; and with the latter, the constitutional, as well as the local disturbance, will be much less than when there are several punctures, and, consequently, sev- eral vesicles. The matter employed for this purpose may consist of the lymph taken from the vesicle between the sixth and tenth day, though the lymph is considered purest and most fit for use when taken between the sixth and eighth day; or a paste may be made of the scab, which exfoliates and falls off between the eighteenth and twenty-fifth day. The scab I much prefer to the lymph, for it is more under control, and may be preserved for a longer time, and with less difficulty than the lymph. If the latter be employed, the following is the mode to be adopted: The point of an ordinary lancet is to be gently introduced into the vesicle between the sixth and tenth day, and then the lymph is re- ceived on the convex surface of small pieces of quill prepared for the purpose. Some practitioners, however, prefer introducing the lancet into the vesicle, and having both sides of the point armed with the virus, make a small puncture in the arm of the infant to be vaccinated; this, though an old mode of vaccinating, and one still in fashion, is not thorough. I much prefer, if the lymph be used, to have it on the quill, and then with the lancet a very slight scarification of the arm should be made, crossing the lines at right angles; as soon as this is done, the convex portion of the quill should be gently rubbed over the scarified surface—the matter in this way is more perfectly absorbed. If the scab be employed, it is first to be made into paste with cold water, and then introduced upon the scarified surface. After the vaccination, the arm should be exposed to the air, in order that the surface may become dry, and also that the virus may not be removed by the friction of the dress. After this, all that is necessary is to place loosely around the arm a small bandage of old linen. Is it proper to vaccinate during the existence of a cutaneous disease?—On this subject there is much discrepancy of opinion. Some maintain that the vaccine vesicle will modify, and even remove any cutaneous affection that may exist, while others state that an eruptive disorder, no matter of what kind, will prevent the absorption of the vaccine virus, and, therefore, nullify its protective influence against small-pox. Jenner him- self entertained this latter opinion, and it is not without advocates at the present day. It does not seem, however, to be sustained by facts. I 508 CLINICAL LECTURES. have been obliged more than once during the prevalence of small-pox to vaccinate infants affected with eruptive disease, and I have not experi- enced any difficulty in producing a genuine vesicle, but I certainly have noticed, under the circumstances, a gradual giving way of the antecedent eruption. This may not always be the case, but I am inclined to think the mere existence of a cutaneous affection is no objection to the vac- cination of an infant, when there is danger to be apprehended from small- pox. On the other hand, I should not advise, as a general rule, vaccina- tion during the presence of an eruptive disease; in this latter case, it should only be resorted to when, from the prevalence of an epidemic, or other circumstances, the probability of contagion is enhanced. Signs of genuine vaccination.—It is very important to note the pro- gress of the vesicle after vaccination, in order that a just distinction may be made between the spurious and genuine. In the latter, nothing special is observed for the first two or three days after the inoculation; but, usually, at the end of the third day, and sometimes later, a small red spot is apparent, and on the fourth day the redness is more decided; on the fifth day, the vesicle begins to distend with a serous exudation ; on the sixth day, the vesicle assumes a circular or oval form, with a whitish surface, and presents an umbilicated appearance; on the seventh day, the vesicle becomes more full, and the inflammation extends to the sub-cu- taneous cellular tissue; on the eighth, and sometimes not until the ninth day, the vesicle attains its maximum of development, and is surrounded by a scarlet redness; at this time the tumefaction increases, sometimes involving the glands in the axilla, and there is more or less febrile ex- citement ; on the tenth day, the circle surrounding the vesicle begins to lose its redness, the inflammatory symptoms subside, the serous exuda- ■ tion assumes a purulent character, dessication commences, and the vesicle becomes changed into a circular scab of a mahogany color, which falls off between the eighteenth and twenty-fifth day after inoculation. The ex- foliation of the scab is followed by what has not been inaptly termed a honey-comb cicatrix. There is a difference of opinion as to the perma- nence of this cicatrix; the general belief is that it never disappears, while others claim that it is not only not indelible, but that its absence is no proof whatever that previous genuine vaccination had not taken place. In spurious vaccination, the phenomena proceed differently; for example, the period of incubation does not exist; instead of an exuda- tion of lymph, there is a purulent secretion from the third or fourth day; a scab will sometimes form, and exfoliate on the fifth day, and become reproduced again, simulating in this respect what is observed in the dif- ferent kinds of ulcer. Again, in spurious vaccination, it sometimes hap- pens that many weeks elapse before the scab falls off, and whether it ex- foliates early or later, it is not succeeded by the peculiar form of cicatrix characteristic of the genuine or healthy inoculation. In 1845 an interesting discussion took place in the French Academy VACCINATION. 509 of Sciences on the subject of vaccination, and the following is an analysis of the report on that subject: 1. Vaccination is absolute as a preservative for the great majority, and temporary for a small number ; even in the latter it is preservative until adolescence. 2. Small-pox rarely attacks those who have been early v.»ccinated, before ten or twelve years of age, from which period, until thirty or thirty-five years, they are more liable to the disease. 3. Besides its preservative power, vaccination modifies the symptoms of small-pox by diminishing its duration and danger. 4. The vaccine matter fresh from the cow develops symptoms of greater intensity, and is more certain in its effects than old vaccine; but after a few weeks transmission through the human economy, it does not produce the same degree of local disturbance. 5. The protective nature of vaccine does not appear to be necessarily dependent upon the intensity of the symptoms it produces ; yet, in order that it may not lose its preservative influence, it should be obtained fresh from the cow as often as possible. 6. The only and direct source for the regeneration of vaccine matter, after it has lost its properties, is the cow. 7. Ee-vaccination is the only mode of distinguishing those of the vac- cinated who are completely protected from the small-pox from those who are only more or less partially protected. 8. Successful re-vaccination is no positive proof that the individuals would have, in the absence of re-vaccination, contracted small-pox. It is only presumptive evidence that they were liable to it. 9. Under ordinary circumstances, re-vacoination should be resorted to at the end of fourteen years, but much earlier if there should be an epi- demic of small-pox. LECTURE XXVIII, Pulse in Infancy—How Influenced—Examination of the sick ChDd—Maximum, Minimum, and Average Pulsations in the Infant.—Tympanites Intestinalis, with obstinate Constipation in a married Woman, aged thirty Years, the Mother of one 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 Gymnastic Exercises in the Treatment of this Affection.—Abortion three successive times in a married Woman, aged thirty-one Years, during the Period of Lactation. Gentlemen :—The pulse is an important guide in our appreciation of disease in the adult; and in the derangements of infancy it is also a valuable index. In the latter, the physician in forming an opinion of the nature and extent of morbid action, can expect no assistance from the intelligence of his patient. The infant does not enjoy the advantage of speech; it has no power of articulation, no means of communicating its sufferings. The medical man, therefore, is restricted in his facilities of diagnosis, and is confined in great measure to what has been aptly termed the language of expression—that language which, when prop- erly understood, is a faithful exponent of the physical condition of the infant; and hence, we find great attention has been paid to the changes of countenance, and the aspect of the features as illustrative of the va- rious morbid conditions to which the young child is liable. I have alluded, you will remember, to this subject on a former occasion, and for the present I propose to call your attention to a few points touching the pulse in early life. There are many circumstances, other than dis- ease, calculated to modify the pulse of the infant. As a general riJe, it is more quiet and less rapid during sleep; sudden mental emotion will accelerate it, and it is asserted by Trousseau that, after the third month, it is more frequent in girls than in boys, thus at this early period assum- ing the distinctive characteristic which marks it in after life. Yoa will occasionally observe a curious circumstance connected with the pulse in young infants, and it is proper that I should caution you against 8v false deduction. The circumstance to which I allude is this—an habitual irregularity in force and rapidity of pulse in children who are in tho enjoyment of excellent health. Authors have, with good reason, directed attention to this peculiarity; and you perceive that, in the infant as in PULSE IN INFANCY. 511 the adult, there may be a departure from the normal beats of the heart without necessarily being the result of disease. How frequently, for example, are these discrepancies recognized in individuals; one man in undisturbed health will have an average pulse of forty, another one of ninety, etc. These facts are familiar to the observant practitioner, and are to be attributed to what is termed constitutional idiosyncrasy. I do not think I can guard you too strongly against the effect of fright in the young child, not only as regards the rapidity of the heart's ac- tion, but in reference, too, to other forms of nervous disturbance. Fright will produce convulsions in one case, chorea in another, diarrhcea in a third, paraplegia, etc. The ridiculous habit prevalent among fool- ish nurses and weak-minded mothers of holding the doctor up to the little child as a bug-bear, the very personification of terror, is one that has exhibited its bad results in thousands of instances. How often is the phraseology employed, " If you don't be good I '11 send for the doc- tor, and he will bleed you," or " he '11 cut your head off!" And pray, allow me to ask, what kind of a personage is that doctor so cruelly wronged by the thoughtless nurse, or foolish mother? Is he not, at least should he not be regarded as the dearest friend of the household- is not his office a high one—nay, does he not fulfill a most sacred duty, and in the darkest hour of affliction, when the contest with death is most fearful, and the result full of doubt, is not every eye fixed upon him as the only being, under Providence, who can lull the storm, and bring comfort to the lacerated heart! Why, then, should folly place him in a false position ? Away with the absurdity, and let it be your duty to impress upon mothers that the stronger the affection of the child for the physician, and the more closely he looks upon him as a friend, the greater, cateris paribus, will be the probability, when true skill is re- quired, of victory over disease. The physician, when he approaches the couch of the invalid child, should do all in his power to divest his pres- ence of every thing bearing on terror; he should, in a word, possess that important attribute so much needed in the sick room as well as in other situations of life—the savoir faire. A cheerful smile, the tak- ing his watch in his hand, and presenting it to the little patient, any thing in fact to divert the attention, will oftentimes remove all appre- hension, and prevent those numerous perturbations which are so apt to mask the true nature of disease, and lead the practitioner to a false diagnosis. It is far better, as a general rule, to examine the condition of the child when asleep, especially the pulse; how much, for instance, can be learned from the expression of countenance, the breathing, the beating of the heart, etc., when liberated from the influence of any external ex- citement ? If these phenomena are irregular, and beyond the record of normal or healthy action, the absolute departure from this standard can be much better appreciated when not complicated by any momentary 512 CLINICAL LECTURES. disturbance, such as would be likely to follow emotions of any kind. In one word, in your judgment of the nature and intensity of disease in the young child, you must be cautious to discriminate between the influ- ence of positive morbid action and the influence of transitory causes, be- tween which and true disease there is a wide difference. Authors have en- deavored to approximate the number of beats in the infant pulse during health, and there is a great want of concurrence in their statements. In order that you may form some estimate of this discrepancy of opin- ion, and have before you a fair statement of the general views on this subject, I present you the following table, for which I am indebted to the valuable work of Rilliet and Barthez. TABLE OF THE NUMBER OF PULSATIONS AT THE DIFFERENT AGES OP INFANCY. Age. Max. Mln. Average. Authors. At birth....................... 94 72 83 Lediberder. Four minutes after birth......... 208 140 160 Lediberder. First day...................... 156 96 126 Jacquemier. First day...................... 160 100 123 Gorham. Four to twenty hours........... 112 88 101 Farge. One to eight days............... 160 96 128 Gorham. One to eight days............... 140 16 106 Farge. One to ten days................ 180 80 --- Billiard. Eight to fifteen days............124 104 112 Farge. Two to twenty-one days.........104 76 81 Valleix. Fifteen days to one month....... 164 120 137 Trousseau. Fifteen days to one month....... 140 120 127 Farge. One to two months.............150 60 --- Billiard. One to two months.............158 96 136 Trousseau. Two to three months...........110 70 --- Billiard. Two to six months.............. 162 100 128- Trousseau. Six months to one year.......... 140 100 113 Trousseau. Five months to two years........ 158 100 130 Gorham. Seven months to thirty-one months 140 106 126 Valleix. One year to twenty-one months... 140 96 118 Trousseau. Three to five years.............. 11.0 72 98 Rilliet & Barthez. Six to ten years................104 64 84 Rilliet & Barthez. Eleven to fifteen years........... 80 60 70 . Rilliet & Barthez. Tympanites Intestinalis, with obstinate Constipation, in a married Woman, aged thirty Years, the Mother of one Child aged two Years—Supposed Pregnancy.—Mrs. O., married, aged thirty years, the mother of one child two years old, is in delicate health, and is exces- sively nervous, with an enlarged abdomen, and habitual constipation. She believes she is pregnant, having, as she says, felt the movements of the child. " How long, my good woman, have you had this enlarge- tnent of your abdomen ?" " I have had it off and on, sir, for several months." " Then it sometimes diminishes in size, does it ?" " Yes, sir, and I always feel better and less distressed when my bowels are moved, TYMPANITES INTESTINALIS. 513 but that is my great trouble." " When did you first feel the move- ments %f your child?" "About three months ago, sir." [The patient was placed on the bed, and the abdomen was found to be very much distended, causing an enlargement equal to the ninth month of preg- nancy. After a full examination, the Professor remarked that the en- largement was due altogether to flatus, constituting a case of tympanites intestinalis.] This form, gentlemen, of abdominal distension is often met with in nervous women, especially those who are more or less predisposed to *hysteria. The first point of interest in the case is the enlargement, which might possibly be mistaken for pregnancy—a delusion under which the patient before us has labored, as I shall presently prove to you. In a married woman this error, though awkward, if committed by the practitioner, would be comparatively harmless; but in the unmarried, in whom of necessity such a blunder would involve the dearest prize of woman—character—the consequences would be momentous. The second point of interest is, What has produced the distending agent, the flatus ? And, thirdly, What is the best mode of removing it, and restoring this woman to health? In my lectures on midwifery, when speaking of ges- tation, I have told you that women of a nervous temperament are apt to imagine they feel the movements of the foetus, when in fact no preg- nancy exists. This delusion often arises in cases of tympanites, in which the passage of the air from one portion of the intestine to the other is mistaken for the active motion of the child. These delusions are quite common in hysterical women, and the practitioner must exercise a due degree of vigilance, otherwise he, too, may fall into error, and give endorsement to that which has no existence. The patient before us en- tertains a strong conviction that she is pregnant, and I have had some difficulty in dissuading her from that impression. The sensations which she has experienced, and which she has mistaken for fcetal movements, are nothing more than the ordinary results of the tympanites with which she is affected. In all these cases, however, when the conviction of the patient is firm as to the existence of gestation, the practitioner should not express an opinion without having previously made a thorough vaginal examination —for it must be recollected that, in some instances, pregnancy may co- exist with large collections of flatus in the intestinal canal. Before in- troducing this woman here, I made the necessary examination, and I find the uterus to be in a perfectly normal state, entirely unaltered in size. She is not pregnant. Now, as to the origin of the flatus in these cases of tympanites: You will generally observe that the accumulation of air in the intestinal canal is more or less connected with defective diges- tion, and, therefore, is most commonly met with in hypochondriacal and nervous persons. There is no doubt that the mucous membrane of the stomach and intestines, and, indeed, under certain circumstances, the 33 514 CLINICAL LECTURES. various mucous surfaces of the economy, are endowed with the property of secreting gas, and, therefore, the process of secretion will sometimes explain its presence. But a prominent cause of intestinal flatus is un- questionably traceable to the ingesta, more particularly of the vegetable kind. It is also true that air may be taken into the system in the act of deglutition. Although the expulsion of the flatus from the intestines is always followed by more or less relief, yet it occasionally happens that the patient is unable to extricate it, and the suffering is consequently very great. This inability to expel the gas was ascribed by the old schoolmen to a paralytic condition of the intestinal muscular fibres—the paralysis being due to one of two causes, viz., over distention, or defect- ive nervous power. This explanation of the early Fathers is not without some degree of foundation. Treatment.—In the management of tympanites intestinalis, two objects are indicated : 1st. The evacuation of the gas ; 2d. The prevention of its re-accumulation, by improving the digestive functions. It will some- times be necessary to resort to mechanical means for the purpose of ex- tricating the flatus, and you will find the elastic tube recommended by Dr. O'Beirne an admirable instrument for this object. It is introduced into the rectum and carried up the bowel for several inches above the promontory of the sacrum. The flatus escapes through the tube, and tho patient experiences almost instant relief. With a view of restoring the functions of the digestive apparatus, various remedies are employed. In some cases, there may be collections of excrementitious matter in the intestines. Under these circumstances, it is of the first importance to have this matter evacuated, which may be accomplished by either of the following medicines: R Olei Ricini Terebinthinae [......aaU R Pulv. Jalapae......gr. xij Sup. Tart. Potassaa.....3j M. When the bowels have been properly evacuated, any of the following medicines will be found more or less benficial: R Ext. Colocynth c. } Saponis \......"KT-y Olei Jump........gtt. ij Ft. Pil The above pill to be given twice a day. R Decoct. Aloes.......?j To be taken once or twice a day. R Gum Camphorae......gr. ij Ext. Colocynth c. ) Sulph. Quiniae J.....&'M Ft. Pil This pill to be taken once in four or five hours. CHOREA. 515 IroD, in its various preparations, is quite serviceable in these cases. R Carbon Ferri .... . . gr. xxiv Pulv. Rhei \ Pulv. Zingiberi >•.....aa gr. xij Ext. Gentianaa ) Ft. Massa in pil. xij dividenda. One pill three times a day. I should not omit to mention the efficacy of cold water. It is an an- cient remedy, one suggested by Hippocrates himself. A tumbler of ice-water will sometimes, by its tonic impression on the intestinal canal, be followed by the happiest effects. This, too, was a favorite remedy, in these cases, of Cullen. All articles of diet which easily ferment should be scrupulously avoided ; and you know, therefore, that vegetable food, as a general principle, should not be allowed. Chorea in a Girl, six Years of age, from Fright—Connection between Chorea and Eheumatism.—Elizabeth H, aged six years, is brought to the Clinique by her mother, who feels much anxiety in con- sequence of nervous twitchings with which her daughter has been affected for the last two years. " Do you know, madam, what first occasioned this disease in your little daughter ?" " Indeed, I do not, sir, unless it was a fright she took." " When was she frightened, madam ?" "About two weeks before she began to twitch, sir." " What was it that produced the fright ?" " She saw two men fighting, sir, and she was afraid they would kill her." The case before you, gentlemen, is an example of chorea, known in ordinary language as St. Vitus' Dance. The latter term, it is said, owes its origin to the fact that certain women of deranged mind were in the habit of repairing annually to the chapel of St. Vitus, where they spent the night and day in dancing. The only limit to the dance was the ex- haustion of those who participated in it. Chorea is essentially a disease of childhood, but it is not exclusively confined to that period. Instances of it are occasionally observed in the adult, and also in old age. It ex- hibits itself most frequently between the ages of ten and fifteen years, and is often recognized in the female at the approach of puberty. To a disinterested spectator, the contortions of countenance, and singular evo- lutions characterizing this affection, present an idea of the ludicrous. Not so, however, with the parent, whose melancholy office it is to wit- ness the accompaniments of this disease in the person of her own child. Her heart is torn by the most exaggerated apprehensions, and the vista through which she looks is indeed one of unbroken gloom. Happily, however, the malady ordinarily yields to judicious treatment, and it becomes our duty, as well as our pleasure, to assuage the grief of the parent by the assurance of recovery. In conversation with the mother, we learn that the child before us, two weeks previous to the appearance of the affection, became fright- 516 CLINICAL LECTURES. ened. This is important intelligence—for among the causes of chorea, fright holds a prominent place, and is, I think, much more frequent in its operation than is generally supposed. You remember the case of little Hooker, who was brought here a few weeks since from New Jer- sey. His was a well-marked case of chorea produced by fright on seeing a horse run away. This disease is fortunately not of frequent occurrence. During a period of ten years, among 32,976 patients, admitted into the Children's Hospital at Paris, of which 17,214 were boys, and 15,703 were girls, chorea was observed only 189 times, and the following are the statistics of its occurrence as given by Rufz : Age. Boys. Girls. Total. One to four years............ 3 2 5 Four to six " ............ 2 3 5 Six to ten " ............16 45 61 Ten to fifteen " ............30 88 118 51 138 189 From this table, which is amply confirmed by the observation made both in hospital and private practice, it will be seen that chorea occurs much more frequently in the female than in the male. If to this be added another important fact, that the disease manifests itself often about the advent of puberty, and also, under certain circumstances, during pregnancy, it is not unreasonable to suppose that it is frequently connected with irritation of the uterine organs, and what confirms this view, is, that in young women it will sometimes spontaneously subside with the appearance of the catamenial function, and in pregnancy, imme- diately after parturition. Chorea is a disease consisting essentially in abnormal contractions of one or more series of muscles, and these con- tractions appear to be quite independent of the brain. You are aware that the influence of the spinal cord over muscular action is well proved, and experiments have demonstrated that for the production of flexion, extension, adduction, etc., the cerebral mass is not at all necessary, and other muscular phenomena also occur independently of any action of the brain. These facts, which are now well understood, have been shown by the decapitation of animals. A very simple circumstance, which you have no doubt frequently noticed, is the fact that a chicken, after its head is removed, will perform numerous muscular evolutions, all of which are of course independent of the brain, and accomplished through the agency of the spinal cord. The spasmodic muscular contractions characteristic of chorea, become suspended during undisturbed sleep ; but, according to Marshall Hall, they are apt to recur if the patient dreams. Dr. Bright, I believe, was the first to call the attention of the profession to what he supposes to be a connection between chorea and rheumatism ; both articular rheumatism, and rheumatic pericarditis,* and his opinion * I have no doubt that patients affected with chorea have often been supposed to tabor under disease of the heart, because of the recognition by the stethoscope, of CHOREA. 517 is now advocated by a number of clever writers. It is the opinion of See, who has devoted much study to the subject, that chorea, in many instances, occurs after an attack of rheumatism, or co-exists with it. He, indeed, regards it as a rheumatismal affection. It may, I think, be questioned whether these two affections do positively bear such relation to each other. That rheumatism does occasionally present itself as a complication of chorea, I admit, but that there is a necessary alliance between the two affections, I am, for the present, at least, much disposed to doubt. We have had, in the Clinique, thirteen cases of chorea, and in only one instance, could we trace any connection between it and rheumatism. You will remember the case of Mary Owen, aged nine years, who had become overheated by play, and was afterward exposed to a shower of rain. The next day she was attacked with inflammatory rheumatism, which continued for five weeks. On her convalescence, chorea developed itself. Causes.—Chorea may be produced by intestinal irritation, such as worms, constipation, vitiated secretions, fright, cold, etc.; it is also sometimes the result of imitation, and on this account it is judicious, as far as practicable, to separate a child affected with this disease from others who are in health. This direction applies particularly to boarding- schools and hospitals. The change produced in the system of the female at the advent of puberty constitutes another cause of this af- fection. Symptoms.—These vary infinitely; usually, the first indication will be twitchings in the muscles of the face, and these are followed by irregular contractions of the various portions of the muscular tissue, unsteadiness in the gait, etc. The twitchings are sometimes limited to one portion of the body, such as one arm. Chorea is occasionally complicated with paralysis, and cases are recorded in which paralysis existed on one side, and the full development of chorea was displayed on the other. It is not unusual to find the twitchings increased by the presence of the phy sician; and now you will observe, when I ask this little girl to place this tumbler to her mouth, how strangely she attempts to do it. In a word, as you perceive, in every attempt she makes, the most singular, if not ludicrous motions ensue. Speech and intellect are sometimes slightly affected in this disease. Its duration is variable, from one to six months. Diagnosis.—The hysteric paroxysm, catalepsy, epilepsy, tetanus, and other morbid condititions of the nervous system, have been enumer- the bellows-murmur. But you are not to forget that this sound will be emitted by the vessels of the neck and aorta, where the organ is entirely free from disease, being caused altogether by the anaemic condition of the patient. May it not, therefore, be that the confounding of these two sounds may have had something to do with the supposed relation between rheumatism and chorea ? At all events, proof must ac- cumulate in order to settle the question definitely. 518 CLINICAL LECTURES. ated by writers as being possibly mistaken for, and confounded with, chorea. The probability of such an error can scarcely be conceived with ordinary care. Prognosis.—As a general rule, chorea is under the control of medica- tion ; and, therefore, a favorable opinion may be given as to the issue. It rarely proves fatal. In one hundred and fifty-eight cases cited by See, there were but nine deaths. Sometimes, however, relapses occur, and it is important to inform the friends of the possibility of such an event. Pathology.—The pathology of chorea has provoked much controversy. It is admitted, by general agreement, that the irritation is in the nervous system ; but whether in the brain or medulla spinalis, is a question on which exists a difference of opinion. Marshall Hall believes the irritation to be in t le spinal marrow, while Todd and others refer it to the brain itself. Treatnwnt.—Here, again, we have differences of opinion. Sydenham and Cullea, two great names in the medical calendar, recommended blood-letting and purgatives; and these views were generally adopted by the men of their time. This system of therapeutics appears now, how- ever, to 1 ieet with but little favor, and, we think, with good reason. As a general principle, chorea will be found an affection connected more or less with diseased or defective nutrition, and, therefore, calls for invigo- rating remedies. But, gentlemen, chorea, like all other affections, must be treated on rational principles. You have seen in this Clinique two interesting cases of this disease, which we traced to intestinal worms, producing irritation in the medulla spinalis, and in this way provoking the muscular spasms characteristic of the malady. The worms were dislodged, and you remember the gratifying results in both cases—entire restoration to health. Arsenic has had its advocates, and justly so, as a remedy in chorea, but is often without benefit. Some very remarkable and satisfactory reports have been made with regard to the efficacy of the sulphate of zinc in this disease, and I have myself observed the best re- sults from its administration. The case before us, I think a proper one for its trial, and we shall, therefore, order the following course to be pursued: R Sulph. Zinci.......3j Extract Gentianae......3 ij Ft. massa in pil xx. dividenda. One pill a day, increasing gradually to six a day. In addition to the pills, I shall recommend a generous diet, and regular exercise in the open air, and also the shower-bath every morning. " Oh! sir, I have tried the shower-bath for my child, and it almost puts her in fits." " I am much obliged to you, madam, for that information; the shower-bath must be omitted." There are, gentlemen, certain temperaments and idiosyncra- cies which can not sustain the shock of the shower-bath. Under such cir- ABORTION DURING THE PERIOD OF LACTATION. 519 cumstances, obstinately to insist on its use would often result in serious consequences. Iron, judiciously employed, is an important remedy in chorea. The hydro-cyanate is preferred in Germany, while in England the carbonate is the more popular form. From three to eight grains of the former, and 3ss doses and upward of the latter, according to the age of the patient.* Abortion three successive times in a married Woman, aged thirty- one Years, during the Period of Lactation.—Mrs. H, married, aged thirty-one years, the mother of three children, says she has miscarried on three different occasions during the time she was nursing her children. " How long, my good woman, have you been married ?" " Thirteen years, sir." " How many children have you had ?" " Three living children, sir, and I have lost three by miscarriage." " When did you miscarry the first time?" " My child, sir, was just twelve months old when I had the first miscarriage." " Were you nursing at the time ?" "Yes, sir." "And how was it with the other two miscarriages?" "They took place, sir, in the same way, while I was nursing." "How long did you nurse your children ?" " I nursed them all until they were twelve months old, and I should have nursed them longer had it not * It may be interesting to note the beneficial results of gymnastic exercises in the treatment of chorea, as exhibited in the Hopital des Enfants, of Paris. Dr. See has made some important statements on this subject. Since 184'7, there were ninety-five children affected with chorea, sometimes so obstinate as to resist every devised method of treatment, and all were cured, either by gymnastics alone, or in connection with other means. Dr. See remarks, that in applying these exercises to chorea, care should be taken to graduate them to the severity of the case. They are to be repeated daily, not longer than fifteen or twenty-five minutes, in order to avoid fatigue and palpitation. Improvement, he says, is sometimes noticed even after the first lesson, and, at the latest, after the fifth or sixth, so that at the end of a week, judgment can be formed as to whether the treatment will prove efficacious. If at this time manifest progress has not been made, it is doubtful whether a cure will be accomplished. Dr. See has observed, that when other remedies are conjoined with the gymnastics, the proportion of cures is less, and the period of their attainment later; and he suggests that no other means be employed than good diet. The sulphurous baths, as recommended by Baudelocque, constitute another remedy of great value, there having been fifty-eight rapid and positive cures in sixty-five cases. Thirty drachms of sulphuret of potash are added to each bath, at a tempera- ture of 91°. The bath to be used one hour, daily. Usually, amendment is per- ceptible after the second or third bath, but sometimes not until after twelve or fifteen days, a mean of twenty-two days having served for the cure of fifty-seven cases. Where the cure is retarded, it ordinarily depends upon the patient's powers being lowered by other remedies, or insufficient diet, upon irritation of the skin induced by the bath, or upon acute inflammation of the internal serous membranes—circumstances Bontra-indicating the baths. The conjunction of other remedies rather retards than &ids the cure. Deducting the cases in which the bath was improperly used, there re- main but nine true failures in eighty-one cases, these being almost all examples of recent or rheumatic chorea.—Brit, and For. Medico- Chirurgical Review, Jan. 1852, p. 15. 520 CLINICAL LECTURES. been for the miscarriage." " Were you a strong, healthy woman while you were nursing ?" " I was, sir, for the first eight or nine months, but after that I found I grew rather weak." " Did your courses come on during your nursing period ?" " Yes, sir, they always came on about the ninth month." The case of this patient, gentlemen, presents one or two peculiari- ties worthy of note. In the first place, she has become pregnant on three different occasions while nursing her children, and this you are aware is rather an exception to the general rule; and secondly, she has miscarried each time. There is no subject of more interest to the practitioner than that of abortion, and it is also one in which the health of the patient is materially involved, for frequent abortions tend to a marked disturbance of the vital forces. Women whose menstrual function returns during lactation are much more apt to become im- pregnated than those in whom the catamenia is suspended; and it is a fact of importance to be remembered that if lactation be continued after pregnancy has occurred, abortion may be regarded not as an un- usual result. One, therefore, of the practical deductions to be drawn from a knowledge of this circumstance is to enjoin upon the female the necessity of weaning her child as soon as her state of pregnancy is ascertained. But let us examine, for a moment, why it is that lac- tation exercises an influence in the production of abortion. The causes of abortion, as I have remarked to you on former occasions, are numer- ous, and may be divided into those of a centric and eccentric origin. Among the former may be enumerated mammary irritation, and this, especially in cases of protracted lactation, is very likely to induce pre- mature action of the uterus, and the consequent expulsion of its con- tents. It often happens in these cases of prolonged suckling that there is a deficiency of the milk secretion, and this but adds to the irritation of the mammae, as the child is constantly making traction on the breast without securing a passage of sufficient milk, and the irritation, through the sympathy existing between the mammas and uterus, is readily com- municated to the latter organ upon the principle, of which we have so often spoken—reflex action. In this way contractions of the uterus are provoked, which terminate in abortion. But women, no doubt, occasionally miscarry during the nursing pe- riod from another cause than mere mammary irritation; for example, you have had in the Clinique many cases of anaemia from undue lacta- tion, and you have seen how much the general system becomes dis- turbed under the operation of this bloodless condition of the economy. Anaemia, therefore, strictly so called, may be classed among the causes of abortion not only in nursing-women but also in women under other circumstances. In females of a cachetic habit of system, whose health has become dilapidated by protracted disease, and in whom the circula tion is marked by great languor, there will oftentimes exist a chronio ABORTION DURING THE PERIOD OF LACTATION. 521 leucorrhceal discharge ; in such, you will observe as a frequent accom- paniment of this general impairment of the health, a hemorrhagic dis- charge during pregnancy, which almost always results in abortion. Miscarriages are, as a general rule, much more frequent during the ear- lier months, say the first two or three, of pregnancy, and this, I think, may be explained as follows: 1st. The adhesions between the caduca and internal surface of the uterus are at this time comparatively feeble; 2d. The placenta is, as it were, in its formative stage, and has not be- come, so to speak, sufficiently condensed to resist the operation of cer- tain causes of abortion which, at a later period of gestation, prove inop- erative ; 3d. In women of nervous temperament, and more especially in primiparae, the uterus is more likely to be thrown into action soon after impregnation than at a later period, when it becomes more accus- tomed to, and can sustain with more or less impunity the successive developments consequent upon gestation. Treatment.—The patient before us requires a tonic treatment—the waste her system has undergone must be repaired. She is, as you per- ceive, quite anaemic, partly in consequence of undue lactation, and partly from her repeated abortions. I shall recommend the following course \ R Sulphat. Quinae......gr. xxiv Extract Gentianae......3ij Pil. Rhei c........3iv Ft. massa in pil xxiv dividenda. One pill three times a day, with nutritious diet, consisting principally of succulent meats and broths, and half a pint of porter daily. An injection of cold water into the rectum at night, and an occasional cold hip-bath will have a good effect in giving tone to the uterus. LECTURE XXII Thoughts on Uraemia; what is Uraemia?—Is Albuminuria always followed by Urae- 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 Uraemia-—Colchicum and Guiacum; their Influence over the Secretion of Urea.— Conclusions. Gentlemen :—Nothing, perhaps, more clearly indicates the progress of mind in our profession than the recent valuable researches in refer- ence to the healthy and morbid states of the urine. The deductions drawn from these researches by observers, if not always sound, afford at least a new field for inquiry, and invite the cooperation of all who are zealously engaged in the pursuit of truth. Until within comparatively a short period, authors were silent on the subject of the poisonous proper- ties contained in the urinary secretion, or, at least, they did not attach to it that specific interest, which late discussions have excited; and hence the term toxaemia, or blood-poisoning, was not employed, as it now is, to denote a very peculiar and important condition of the economy. While toxaemia hi the generic term, there are various species or grades of blood- poisoning ; and I propose, for the present, to limit myself to the consid- eration of ihat form denominated uraemia. The existence of uraemia has been differently explained by authors; for example, some contend that it is due to the presence of albumen in the urine, ethers that it is caused by urea in the blood, while, again, both of these opinions have been rejected, and a new one advanced, viz., that uraemia results from the transformation of urea into the carbon- ate of ammonia. It will not be denied that these are interesting questions, and involve much that is important in the treatment of disease. They, therefore, merit a careful and minute examination, which I propose to institute under the following heads: 1st. What is uraemia? 2d. Is albu- minuria always followed by uraemia ? 3d. What is the cause of albumi- nuria ? 4th.' Is urea a poison ? 5th. What is the true explanation of uraemia ? 6th. What is the treatment of uraemia ? What is n '•amia ?—Uraemia consists in disturbed action of the two nervous cent* vs—the brain and spinal cord—producing either coma, par- tial or compl< le convulsive paroxysms; these disturbances being directly traceable to the action of the peculiar poison constituting uraemia on IS ALBUMINURIA ALWAYS FOLLOWED BY UREMIA? 523 these nervous centers. They may be affected separately or together; and hence, according to Carpenter, there may be three forms of uraemic poisoning: 1st. A state of stupor supervenes rather suddenly, from which the patient is with difficulty aroused, soon followed by complete coma, with stertorous breathing, &c, as in ordinary narcotic poisoning; 2d. Convulsions of an epileptic character, often affecting the entire muscular system suddenly occur, but without loss of consciousness. 3d. Coma and convulsions may be combined. The term uraemia is employed to denote a peculiar kind of poisoning, which, it is supposed, results from an accumulation of urea in the blood. It will be one of my objects to examine the propriety of this term. Is albuminuria always followed by uramia ?—That the presence of albumen in the urine is not necessarily followed by uraemia is abundantly proved by observation; and it appears to me important that this fact should be well understood, for the reason that much error has arisen from the opinion entertained by certain writers, that there is a direct connection between uraemia and albuminuria. This error is not so much owing to any inherent difficulty of the subject, as it is to that loose appreciation of facts, or, more properly speaking, to that want of healthy digestion of well-settled principles, which, unfortunately, too often characterizes the writings of professional authors. I might cite a long list of observers to show that albumen very frequently exists in the urine without any devel- opment of uraemic intoxication, but I apprehend this would be unneces- sary. I shall, therefore, limit myself to two or three undoubted refer- ences. Franz Simon, for example, says he has frequently detected albu- minuria in persons apparently in the enjoyment of good health; also, others have observed it in articular rheumatism, in inflammation of the thoracic organs, intermittent and typhus fevers, in measles, cholera, chronic affections of the liver, etc. In transitory renal catarrh, such, for instance, as occurs in erysipelas, nearly as often as in scarlatina, albumen, together with the well-known epithelial cylinders of Bellini's ducts, is found as constantly in the urine as in inflammatory affections of the kid- neys, where it exists in connection with the fibrinous plugs from the same ducts, as in true Bright's disease.* Edouard Kobin says, " The urine becomes albuminous in croup, in as- cites, aud in cases of capillary bronchitis, with emphysema, accompanied by dyspnoea; in pulmonary phthisis, in gestation when sufficiently ad- vanced to occasion an habitual congestion of the kidneys; in cyanosis, diabetes," etc., etc.f hi order to prove that albumen may exist in the urine independently of any disease of the kidney, and without any of those nervous disturbances * Physiological Chemistry, by Lehmann, t. i. p. 345. f Ed- Robin, London Lancet, Jan. 24, 1852, p. 96. 524 CLINICAL LECTURES. characteristic of uraemic intoxication, Dr. M. F. Tegart mentions the following interesting and conclusive experiment upon himself, and also confirmed in the person of one of his friends: He made for some time a portion of his ordinary nourishment to consist of half a dozen eggs, and albumen as a consequence was soon detected in his urine.* There are but few practitioners of careful observation who will not endorse these statements. Indeed, I conceive the principle to be so well established that the existence of albuminuria is not necessarily connected with the presence of urea in the blood, that further citations can scarcely be necessary to demonstrate the fact.f We now proceed to the examination of the third question, which is one not only of great interest to the medical man, but one which has called forth numerous and conflicting opinions, viz: What is the cause of albuminuria?—According to Edouard Robin, the passage of albumen into the urine is the result of imperfect combustion. He maintains that urea is produced by the oxygenation of the albumen in the blood, and that if this oxygenation do not take place, the result will be albuminuria. This hypothesis has one attribute—that of ingenu- ity—but can its truth be demonstrated ? We think not, and for this ob- vious reason, that when albumen passes into the urine, the quantity of urea, as a necessary consequence, should not be increased in the blood. It is, I believe, conceded, that although albumen does occasionally exist in the urine without a diminution in that fluid of urea, yet the converse of this is very often observed, viz., an increase of urea in the blood co- existing with albumen in the urine. This is in direct conflict with the ex- planation as given by Robin. Dr. Williams says that "per se, albuminuria indicates nothing more than congested kidney." Now, we shall attempt to prove that other causes than simple congestion of the kidney will produce albuminuria; and, in doing this, it will follow that Dr. William's opinion is far too sweeping. It is quite certain that the presence of albuminuria is not traceable to any one cause, for we find it under a great variety of circum- stances ; and I shall endeavor to show that the passage of albumen into the urine is due to one of the following conditions : 1st. A change in the * These sur la Maladie de Bright, Paris, 1845. Gazette Medicale, Paris, 1846, p. 39. ■j- Recently much has been written, and questions proposed by learned academies, respecting the connection between albuminuria and puerperal convulsions; and the writers are almost unanimous in the opinion that albuminuria is the cause of these convulsions. Now, we contend that puerperal convulsions are nothing more than uraemic phenomena, as is proved by their causes, symptoms, diagnosis, pathology, etc., etc. If, then, puerperal convulsions be the result of uraemic intoxication, they are not necessarily produced by albuminuria. There is often a co-existence of puerperal con- vulsions, albiuninuria, and oedema, general or local; but each one of these conditions may, and has existed irrespectively of the other. CHANGE IN THE COMPOSITION OP THE BLOOD. 525 composition of the blood ; 2d. A change in the kidney, either structural or dynamic; 3d. Pressure on the renal veins. 1st. Change in the Composition of the Blood.—It was a favorite doctrine of the old-schoolmen, that the blood contained certain deleterious ele- ments, which could not continue in the system without generating dis- ease. This, too, was the opinion of Sydenham, Pitcairn, Cullen, etc.; Snd the master-minds of the present day, with all their supposed pro- gress, are compelled to admit that there is something more than mere conjecture in what was formerly termed the " peccant humors." The particular organs through which these humors or poisons pass from the economy are called glands; and each gland has its specific office as- signed to it—that is, one of these glands furnishes an outlet for one character of material in the blood, and another gland for a different sub- stance. Thus, while the liver is engaged in the secretion of bile, etc., and the kidney water, urea, etc., we find the intestines the media through which certain effete materials are thrown off. These different offices are performed through what is called secretion, the true nature of which is still involved in mystery. We understand certain general principles respecting the secreting pro cesses, but we must acknowledge that we are unable to explain many of the phenomena connected with this fundamental part of the physical mechanism. Although, therefore, we are ignorant, if I may so speak, of many of the processes connected with glandular elaboration in a state of health, yet it does not follow that we can not explain some of the causes which, interfering with healthy secretion, result in morbid action. Now, then, in order to apply this reasoning to the question before us, we will suppose—what will not be controverted—that in most of the diseases which we have enumerated as being occasionally accompanied with albumi- nuria, such, for example, as cholera, scarlatina, diabetes, etc., the constit- uents of the blood become changed by the introduction either of a poison or some other unusual substance. If this occur, it is quite manifest that the blood is no longer normal—and because of its altered condition, its elaboration in the kidney will also be modified. In other words, in lieu of the ordinary elements contained in the urine, we shall sometimes find albumen, an absence of urea, etc. May this not be satisfactorily explained on the principle that the product of endosmosis will be modified in proportion to the changes in the fluid on which it acts ? Again, the blood is changed in pregnancy, various cir- cumstances tending to this modification, viz., the formation of Kiestine, the secretion of milk, the quantity of blood materials passing through the circulation of the foetus, and the diseases of the embryo itself, not to speak of its excretions, some of which we know enter the blood of the mother. These, then, being so many influences capable of altering the constituents of the blood, will they not account, in some instances, for the occasional presence of albuminuria in the pregnant female ? And 526 CLINICAL LECTURES. when albumen is discovered in the urine after the completion of gestation, may it not be owing to the changes in the blood produced by the milk fever, lochial discharge, etc. ? But, in my opinion, there is another circumstance which is calculated to modify in a very special manner the blood of the pregnant woman. The general rule is that, during gestation, the menstrual fluid is suppress- ed. Now, I am not so confident that Pliny, and many of the writers among the Arabians, did not at least approach the truth when they ad- vanced the opinion that the catamenial discharge contained certain noxious elements. Many of their comparisons, it must be admitted, were fanciful, and some of their illustrations supremely ridiculous ; but, laying these exuberances aside, I believe there is much truth in the ag- gregate of opinion they entertained on this subject. Most modern writers, however, are disposed to smile with something less than con- tempt at what they are pleased to term " the crude notions" of the early Fathers respecting the properties of the menstrual blood. The smile might be pardoned if those who indulge in it had given us something positive and well-defined touching this question, so interesting both in its physiological and pathological relations. It will be found that there exists much discrepancy of opinion on this subject by the writers of the present day. One, for example, Donne, says, " the menstrual blood, when examined by the microscope, contains, like ordinary blood, both fibrin and red corpuscules." Carpenter tells us that " the catamenial discharge appears usually to consist of blood deprived of its fibrin, etc." Simon says " there can be little doubt that there is fibrin in the men- strual secretion, etc." Vogel failed to detect fibrin in his analysis of the menstrual fluid. Dr. Letheby,* in his examination of this fluid, which had been retained in the uterus because of an imperforate hymen, found it to be entirely free from fibrin. In this way, I might proceed to show the numerous conflicting state- ments made by recent authors as to the real nature or properties of this secretion. I have no experiments to offer with the view of demonstrating that the menstrual blood positively contains noxious materials—but I argue the affirmative of this question from certain pathological states, which we observe to follow an abnormal condition of the catamenial function. For instance, in one hundred unmarried women who may labor under suppression of the menses from the operation of any of the influences known to produce this result, such as cold, mental emotion, etc., we will discover that in at least ninety-five the suppression will be followed by more or less disturbance of the nervous system. In some, it is true, the symptoms will be light and evanescent, but in others they will assume a more marked character, sometimes even producing mania, and at others coma, epilepsy, catalepsy, chorea, etc. May not these * See London Lancet, Aug. 2, 1845. CHANGE IN THE KIDNEY. 527 phenomena be due to a species of toxaemia traceable to the poison of the menstrual blood upon the nervous centers ? This opinion seems to be confirmed by the important fact that all the nervous disturbances cease with the return of the function. I have enjoyed full opportunities for observing the effects on the system of the various forms of menstrual aberration; and I have also noticed an extremely interesting and significant circumstance—a circumstance which certainly tends to corroborate the hypothesis that the derangements of the nervous system under unnatural suppression, etc., of the menstrual function, are owing to a species of blood-poisoning. The circumstance to which I allude is this : when the catamenial discharge becomes sud- denly, or otherwise abnormally arrested, the urinary secretion is usually diminished in proportion to the intensity of the nervous symptoms—and what is still more significant is, that the nervous disturbance will yield in proportion to the effects of diuretic and sudorific remedies. There is no error as to the fact—its truth is readily susceptible of demonstration. 2d. A change in the Kidney, either structural or dynamic.—Every structural change in the kidney may result in albuminuria, but we do not yet comprehend in what essentially these various changes consist. For example, though it may be true that the presence of albumen in Bright's disease, in scarlatina, &c, may be due to a desquammation of Bellini's tubes, yet this can not be said of many other diseases of the kidney, in which albuminuria exists, but in which no desquammation takes place. Several interesting experiments have been made to prove that the urinary secretion is not absolutely dependent upon the nervous system by Segalas,* and some of a more decisive character by Dr. Brown-Sequard ;f while, on the other hand, it has been satisfactorily shown that the nervous system may, under certain circumstances, exer- cise a marked influence over this secretion, as is demonstrated by the researches of Brachet, J. Muller,J and Marchand. The latter has pointed out a very important fact connected with this subject. He produced in a dog not only all the symptoms of uraemia, after placing a ligature on the renal nerves, but also discovered urea in the blood, and in the matter vomited by the dog. Kramer states that he has detected albumen in the urine of animals, after dividing the sympathetic nerve in the neck. This, however, seems to need confirmation, as the same result has not followed the experi- ments of others. Dr. Sequard, after repeated trials, has failed in estab- lishing the fact mentioned by Kramer. Budge has found albuminuria * Bulletin des Seances de TAcad. de Med. de Paris. (Seances des 27 Aout et 23 Septembre, 1844. f Experimental Researches applied to PhysioL and Pathol. Philadelphia, 1852-3, p. 13. X Manuel de Physiol, trad. Fran9aise de Jourdan. Edite par E. Littrc. Paris, 1851; t. i., p. 391. 528 CLINICAL LECTURES. after a puncture of the cerebellum ; and CI. Bernard* has occasionally obtained the same result after puncturing the medulla oblongata. In addition, however, to these demonstrations, we have numerous instan;es occurring constantly in practice illustrating the influence of the nervous centers, when laboring under disease or traumatic injury, over the urinary secretion; and it is quite possible that the irritation of the uterine nerves during pregnancy, and in many of the diseases, both organic and func- tional, of the uterus may, by reflex action of the medulla spinalis, produce various morbid changes in the urine. Again, it does appear to me that if it can be proved that sudden emotions, shocks, etc., have an influence on the peculiar processes by which the blood is continually ridding itself of its deleterious materials, we shall, in this way, have opened to us a new field in our investigation of disease, we shall be enabled to elucidate many morbid phenomena which have heretofore been obscure, and, as a necessary consequence, deduce rational therapeutic principles. It is only a few days since I was called to Brooklyn to see a lady under the following circumstances: She was twenty-eight years of age, had been married two years, no children, nor had she ever been pregnant. Her health had always been good from early childhood; no menstrual irregularities, &c. Five weeks before I visited this patient, while giving some directions to her servant, who was arranging her library, a large book fell on her head. This was soon followed by vomiting, but in two or three days the effects of the concussion on the stomach passed over, and the lady thought nothing more of the matter. Within the last two weeks, however, she has noticed a gradual swelling of her lower limbs, with an increased tumefaction of her abdomen. It was on this latter account that I was requested to see her. There was evident oedema of her limbs, with peritoneal dropsy. Here, then, was not only an interesting, but a remarkable state of things. Without any manifest cause, a patient previously in the enjoyment of good health is attacked with dropsical effusion. The only circumstance which had occurred was the blow on the head by the fall of the book, followed by vomiting. But what connection is there, it may be asked, between this transitory concussion and the dropsy ? None, certainly, of a direct nature. I was, at first, utterly at a loss to ac- count for the disease with which my patient was affected, and I requested that some of the urine should be put aside, in order that it might be ex- amined. Accordingly, on the following day, the urine was tested, and albumen detected with no diminution of urea. It was now not very diffi- cult to account for the dropsy—certainly not as difficult as it was satisfac- torily to explain the existence of albuminuria. The serous effusion was undoubtedly the result of the albuminuria ; but what caused the latter ? In my judgment, the starting-point of the dropsy was the concussion of the brain—the blow upon this nervous center modified the urinary secre- * Comptes Rendus de l'Acad. des Sciences de Paris; t. xxviiL, p. 393. PRESSURE ON THE RENAL VEINS. 529 tion, which previously had been perfectly normal, and the result of this change was an abstraction of albumen from the blood, and its presence in the urine. This, at least, is the view I have taken of the case, and my treat ment has been based upon this hypothesis. It has been essentially restorative, with the object of supplying to the blood its lost albumen. If I can succeed in accomplishing this purpose, the presumption is, if my opinion of its pathology be correct, that the case will terminate favor- ably. Every physician much engaged in midwifery practice has occa- sionally observed cases in which the foetus has died in utero from the effects of sudden mental emotion experienced by the mother. I think this result is susceptible of explanation as follows : The shock upon the nervous system of the parent may so modify the character of her blood as to render it destructive to the child—producing, in a word, a state of toxaemia. Now, if it be asked why this poisoned state of the blood does not also affect the mother, my answer is, that there are not only different grades of toxaemia, but there are also differences in the susceptibility to its influence. Do we not see, for instance, one woman thrown into vio- lent convulsions from uraemia, and another, with the same amount of poison in her blood, exhibit no disturbed action of her nervous system? Surely, then, if there exist this difference in the constitution of the adult, there can be no difficulty in appreciating far greater differences in the mother and the foetus she carries in her womb. 3d. Pressure on the Penal Veins.—Whatever may be the other causes which operate in the production of albuminuria, there is a mass of irre- sistible testimony to demonstrate the positive influence of an obstructed renal circulation. G. Robinson,* Meyer,f and Frerichs, have abun- dantly proved that a ligature tied more or less completely around the renal veins, will cause albumen to pass from the blood into the urinary secretion; and again, when the renal veins have become obliterated, in every instance in which the urine was examined, albuminuria was de- tected. Cases of this nature have been observed by Dance, Rayer, Duges, Velpeau, R. Lee, Cruveilhier, Stokes, Blot, Leudet, etc. In gesta- tion, and especially in primiparae, albuminuria is often caused by the pressure of the impregnated uterus on the renal vessels. Dr. Rose Cor- mack, I think, was the first to call attention to this subject. In 106 multiparas, Blot has found eleven women whose urine contained albu- men, while in 99 primiparae thirty exhibited albuminuria. The propor- tions, therefore, for the former are as 1 to 10—the latter as 1 to 3. This is a remarkable difference, and must be due to some special cause, which I hold to be explained as follows: Women in their first preg- * Medico Chirurg. Transact, of the Royal Med. Chirurg. Soc. of London. 1843. Vol. viii., p. 51. f Gaz. Med. de Paris, 1844, p. 419. 34 530 CLINICAL LECTURES. nancy have a very different condition of the abdominal walls from thoso who have already borne children. In the former, these walls are firm and resisting; in the latter, they are relaxed, and have lost much of their original tension. For this reason, in primiparae the impregnated uterus is more perfectly in the line of the axis of the superior strait of the pelvis. In multiparae, on the contrary, this organ is disposed to fall for- ward, constituting ante-version of the fundus. Precisely in proportion, therefore, to the departure of the uterus forward from the direct line of ascent will be the probability of diminished press- ure on the renal circulation. I believe, also, there is another reason why albuminuria is observed less frequently in multiparae than in primiparae. It is a well known fact, that women are much more disposed to miscarry in a first than they are in subsequent pregnancies ; and, cateris paribus, this is no doubt owing in a measure to the greater irritation of the uterine nerves consequent upon a first gestation, together with the increased diffi- culty encountered by nature to distend the uterus for the accommodation of the developing germ. May not, therefore, this excess of irritation, by modifying the urinary secretion, be occasionally a cause of the more frequent presence of albuminuria ? I think so ; and again, when, under these circumstances, the passage of albumen into the urine is followed by the presence of urea in the blood—as is often the case—even admitting that full uraemia does not take place, may not the nervous system become so much excited by the existence of urea as to induce premature action of the uterus, and consequently miscarriage ? If there be any force in this reasoning, the preventive treatment of miscarriage in this condition of system may prove far more successful than it has heretofore been. It is quite evident from the facts I have mentioned, that albuminuria is of frequent occurrence in pregnancy; and Cahen* has endeavored to show that it is caused by disease of the kidney. It can not be de- nied that disease of the kidney may co-exist with gestation, and in such case the albuminuria may be traced to the disease of this gland; but to say that albuminuria can not exist in pregnancy other than as a result of disease of the kidney, is in direct opposition to well established ob- servation. Blotf demonstrates the fact as follows: 1st. The rapidity with which albuminuria disappears after delivery in almost every case, very often in two or three hours, sometimes in one, after the expulsion of the child; 2d. Absence of the symptoms of diseased kidney; 3d. certain characters of the urine entirely different from those of Bright's disease, as, for instance, increase in the density of the urine, and the presence of more salts, and particularly urates; 4th. In seven women, who died, and in whom albuminuria had been detected, only three had slight pathological alterations in the kidney. The opinion is now well settled, and concurred in by a great majority * De la Nephrite albumineuse chez les Femmes enceintes. These, Paris, 1847. f De TAlbuminuric chez les Femmes enceintes. These, Paris, 1849. IS UREA A POISON? 531 of writers that albuminuria is, in many cases, simply the result of an active or passive congestion of the kidney. Any thing, therefore, capa- ble of obstructing the renal circulation, whether it be an enlarged uterus from pregnancy or disease, an ovarian tumor, or enlargement of the abdo- men of any kind, may be enumerated among the causes of albuminuria. Christison, Rayer, and others, maintain that the diminution of urea in the urine, and consequently its accumulation in the blood, is in pro- portion to the quantity of albumen; but this does not appear to be invariably the case; for Bence Jones has recorded an instance of molli- fies ossium, in which he presents an analysis of the urine, showing that albuminous matter may exist in great quantity, while the amount of urea remains perfectly natural. Is Urea a Poison?—Urea was, I believe, first discovered in 1771, by Rouelle, who detected it in the urine. It owes its present name, however, to Fourcroy and Vauquelin; it was obtained pure for the first time by Dr. Prout in 1817. There is one interesting circumstance con- nected with this production—it is the first instance known of an organic compound being artificially produced, which was effected by Wohler from cyanic acid and ammonia. The true nature of urea is variously described by authors, the general opinion being that it is a poison. Todd,* Williams, f Cormack,J Simon,§ and others, regard it in this light, and contend that its presence in the blood will occasion coma, convulsions, and other nervous phenomena. Indeed, it may be said that this has been the prevailing opinion; it is proper, therefore, that its merits should be examined. Opinions in our science, unless fully confirmed by well-directed ob- servation, are not abiding; they do not present that fixedness, if I may so speak, which will alone entitle them to be classed among accepted truths. If urea be a poison, capable of producing convul- sions, etc., the numerous experiments made on living animals in no way establish the fact. Among others, Prevost and Dumas, || Segalas, Tiedeman, Gmelin, Mitscherlich, CI. Bernard, Barreswill, Stannius,<[ and Frerichs, have extirpated the kidneys, and have never known convulsions to ensue. This, it may be argued, is only negative proof. Negative, however, as it is, it must be admitted that it is testimony not without value; and to it may be added the interest- ing experiments of Bichat, Courten, Gaspard, Vauquelin, Segalas, Stan- nius, Frerichs,** and others, who, after injecting into the veins urea * Lumlian Lectures in London Med. Gaz., 1849 and 1850. f Principles of General Pathology. \ London Journal of Medicine, 1849, pp. 690 and 699. § Lectures on General Pathology, Amer. edit. p. 151. | Annales de Chimie et de Physique, v. vxiii, p. 90. ■f Gaz. Med. de Paris, 1841, p. 168. ** Die Bright'sche Nierenkrankeit, 1851. Analyzed in Braithwaite's Retrospect, 1852, part xxv. p. 135. 532 CLINICAL LECTURES.' and urine, never in a single instance observed a case of convulsions. Again, Bright, Christison, Rees, and Frerichs have cited cases in which a large quantity of urea existed in the blood of man unaccompanied by any of the symptoms of uraemia; and Frerichs says, in one instance in which he detected the greatest amount he had ever observed, there was no approach to uraemic disturbance. Vauquelin and Segalas, so far from regarding urea as a poison, have proposed to administer it as a diuretic. The conclusions, therefore, from these facts appear irresistible that urea, to say the least, is not a virulent poison, its excess in the blood will not per se produce uraemic intoxication, nor will it explain the numerous phenomena which are so frequently found to accompany its presence in the circulation. It was in view of all these circum- stances, that Frerichs attempted to demonstrate that uraemia depended neither upon a diminished quantity of urea in the urine, nor upon an excess of this substance in the blood, nor upon albuminuria; but was traceable solely to the existence of carbonate of ammonia in the sys- tem which, he says, is formed through the agency of a ferment, from the urea itself. In other words, Frerichs' doctrine is, that uraemia is ex- clusively due to the transformation of urea into the carbonate of ammo- nia. The modus in quo as to this transformation is not clear; there is no proof as to the manner in which it is accomplished; but the major point, viz.: the dependence of uraemia on the presence of the carbonate of ammonia, seems to rest on strong and cumulative testimony. Many years ago, Orfila produced convulsions in an animal by giving it internally the carbonate of ammonia; the animal, after becoming convulsed, died. This fact seems to have escaped the observation of G. Zimmerman, who, in objecting to the theory of Frerichs, says " car- bonate of ammonia given internally in large doses produces neither con- vulsions nor coma." CI. Bernard and Barreswill have detected carbon- ate of ammonia in the stomach and intestines of animals after the re- moval of the kidneys; and Lehmann has also observed it in the matter vomited by patients affected with cholera. Christison, Jakchs, etc., have recognized, under certain circumstances, an ammoniacal odor in the blood. Until, however, the exposition of the peculiar views entertained by Frerichs as to the true cause of uraemic intoxication, no significant value was attached by authors to the presence of the carbonate of ammonia in the exhalations. Frerichs states that he has ascertained, by chemical analysis, the existence of carbonate of ammonia in the blood in all cases in which the symptoms of uraemia are developed; but the quantity of the salt varies considerably. He further remarks that the two following propositions he has demonstrated beyond a doubt: 1st. That in every case of uraemic intoxication, a change of urea into the carbonate of ammonia takes place; 2d. That the symptoms which characterize uraemia can all be produced by the injection of car- bonate of ammonia into the blood. After citing many experiments TREATMENT OF UREMIA. 533 to fortify his opinion, he says he has frequently detected the alkaline salt in the expired air of animals deprived of their kidneys, and into the veins of which he had injected urea; these animals remained quiet and awake as long as the expired air was not impregnated with the ammonia; but the moment the ammonia was observed, the various dis- orders of the nervous system characteristic of uraemic poisoning devel- oped themselves. If future observation should confirm these views of Frerichs, it will undoubtedly tend, not entirely but in part, to settle a vexed question, which has called forth the ingenuity of both the physiologist and chem- ist. It may, however, be that the future will reveal the existence of other poisonous materials in the blood, which to the present time has eluded observation; and, in their recognition, we may find addi- tional causes for the production of toxaemia. It has, indeed, been suggested that in Brights' disease, the accumulation of oxalic acid in the blood will develop the symptoms of uraemic intoxication. It is a well-known fact that profuse losses of blood and starvation, are frequently followed by intense headache, and sometimes even by mania. Whether the blood be deprived of its albumen by hemorrhage, or arti- ficial depletion, or by the passage of this substance into the urine, the general constitutional effects of this anaemic condition of the system are more or less the same, and will develop more or less nervous disturb- ance, so that even without uraemia the mere deprivation of the blood of its albumen may satisfactorily account for a variety of phenomena, resulting directly or indirectly from the exercise of a morbid influence on the brain. Coma does not, I imagine, exclusively depend upon an undue afflux of blood to the brain ; it sometimes ensues from a deficiency of nutritious blood, and hence its occasional development in prostration of the vital energies from disease, or excessive depletion. Nothing is more marked than the effects of exhaustion in early infants. Thousands of children die from coma, the immediate result of excessive depletion, and when the symptoms of stupor supervene, these are too often regarded as an additional motive for the continuance of the anti-phlogistic treat- ment. Marshall Hall, Abercrombie, and Gooch, have rendered a solid service to science, by directing attention to this practical fact, but humanity has not received a tithe of the benefit, simply because the fact has not been sufficiently heeded in the sick-room. Physiology and chemistry are fast revealing a new basis for the treat- ment of disease—thought is now in the right direction, and a bright future is at hand. In less than ten years, therapeutics will have assumed a new character—the practice of medicine will be more certain, because its principles, through the investigations of the chemist and physiologist, will have become consecrated as so many unerring developments of truth. Treatment of Uramia.—If there be any force in the above observa 534 CLINICAL LECTURES. tions, it follows as a necessary consequence, I think, that the treatment of uraemia involves two objects: 1st. The immediate restoration of the principal eliminators of the system, such as those of the kidney, skin, and bowels, with a view of diminishing through these outlets, the quan- tity of urea and noxious substances which may exist in the blood; 2d. The protection of the nervous centers, as far as may be, against the injurious effects of the carbonate of ammonia. Dr. Maclagan, of Edinburgh, has recently drawn attention to the value of the colchicum autumnale, in uraemic poisoning. The excellence of this remedy consists in its power of increasing the amount of urea in the urine. This fact, I believe, was first discovered by Chelius, of Hei- delberg. Professor Krahmer,* of Halle, has made some very inter- esting experiments on the subject of diuretic medicines. According to him, the average of urea secreted during the day in healthy urine, is 19.64 grammes, while the tables of Becquerel give 16 grammes. Krahmer has shown that under the influence of colchicum, the urea is increased to 22.34 grammes, and under the administration of guiacum, to 22.74 grammes. From the experiments of Krahmer, therefore, it appears that colchicum and guiacum produce a greater secretion of urea than any other known remedies. Conclusions.—1st. Uraemia is a nervous disturbance arising from a peculiar blood-poisoning. 2d. Albuminuria is often connected with uraemia, but is not the cause of it. 3d. Disease of the kidney will often produce albuminuria, but in a great many cases albuminuria exists without true disease of the gland, and as a consequence of an active, or a merely passive congestion, and it will also result from a variety of nervous disturbances. 4th. If urea be a poison, the quantity of it which accumulates in the blood in cases of extirpation of the kidneys in animals, or in suppression of urine in man, is not sufficient to produce any manifest deleterious effect. 5th. According to Frerichs, uraemia is merely a poisoning by the car- bonate of ammonia, which is a product from the decomposition of urea. 6th. The treatment of uraemia must consist in the free use of diuretics, sudorifics, and purgatives—the most suitable diuretics for this purpose being colchicum and guiacum. * British and Foreign Medico-Cbirurgical Review, July, 1848, p. 250. LECTURE XXX. Sterility its importance.—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.—"What is the true Fecundating Element in the Spermatic Fluid ?—The causes of Sterility; the poor and the rich; the former increase, and the latter decrease in their families; reasons for.—Is it possible to Catheterize the Fallopian Tubes?—Dr. Tyler Smith's Operation.— Mamma? and Uterus; sympathies between.—Stricture of the Cervix Uteri a cause of Sterility.—Case successfully treated.—Retention of Urine in an Infant three Days old.—Tumefaction of the Glands of the Neck in a little Boy, aged four Years, resulting from Scarlet Fever.—"What is Scarlet Fever ?—Its Varieties, Causes, Diagnosis, and Treatment.—Rules to be observed during Convalescence from Scarlet Fever. • Gentlemen :—The subject of sterility is one of much importance, and is oftentimes the source of unhappiness to the female. It is proper, therefore, that we should examine the causes of this condition, and ascer- tain, if possible, the best means of removing them. Reproduction, in a physiological sense, is replete with questions of interest, and the study of its various phenomena presents a chapter which not only invites, but is worthy of profound contemplation. It is, indeed, a sort of mystery, which science has partially, but not completely penetrated. The first act in the reproductive scheme is intercourse between the sexes, and this results in what is termed fecundation. This latter consists in the im- parting of life, or vitalizing the germ furnished by the female. In order that you may clearly understand the act of fecundation, you must recall to your recollection what I stated to you on this subject in my lectures on reproduction. You were then told that the generation of the human being is the joint product of the male and female, and to each of these are assigned special duties for the accomplishment of this greatest of nature's works. At each menstrual crisis, the ovaries become the center, as it were, of a sanguineous afflux, and one or more ovules are detached from the surface of these bodies—the ovules being the peculiar secretion of the ovaries, and constituting the germ, or egg, which either lives and becomes developed, or passes off with the menstrual blood as deciduous matter. The special office, therefore, of the female in the reproductive process is to furnish the ovule or egg—but this of itself would be 536 CLINICAL LECTURES. entirely negative in its results were it not for an influence imparted to that egg by the male. Now, then, the question arises, What is this influence ? During inter- course, when the intercourse is followed by pregnancy, the spermatic fluid, secreted by the testes, is the vivifying or life-imparting material, and the fluid reaching the ovule vitalizes it; as soon as this is accom- plished the work of development proceeds, and after a stated sojourn in the uterus, which is nothing more than a lodging-place for the embryo, the foetus, through a succession of most interesting processes, becomes prepared for an external or independent existence. You see, therefore, that the duty of the female is to furnish the egg, while the office of the male is limited to the simple but important act of vitalizing it. Where does this contact between the ovule of the female and the spermatic fluid of the male take place, and in what manner is the contact accom- plished ? These and kindred questions have for years been propounded, but it may be said, in all truth, that they have not yet received satis- factory elucidation. One tells us that the fecundating liquor of the male passes to the ovule in a species of vapor, an aura seminalis; another that it becomes absorbed, and, after entering the circulatory mass, it reaches the ovule, and thus performs its special office of vitalization. These, however, are but crude hypotheses, unsupported by facts, and, therefore, in no way entitled to credit. It *is maintained by some that the contact takes place in the uterus, by others that it occurs in the fal- lopian tube, while it is also asserted that it is on the surface of the ovary that the union is accomplished. Here, again, we are lost in uncertainty —for there is nothing positively demonstrated on the subject, except that in certain cases, such, for example, as tubal and ovarian pregnancy, it is quite evident that the contact does not occur in the uterus. A very general opinion has prevailed that pleasurable excitement during intercourse is essential to a successful fecundation. This is an error, for it is well known that women, in whom intercourse is not only without the slightest voluptuous sensation, but even repugnant, become readily impregnated. The opinion that pleasure is necessary on the part of the female has more than once been cited in courts of justice as proof against the purity of a woman on whose person a rape, followed by im- pregnation, had been committed. This latter circumstance, however, is no proof at all either in favor of the consent, or adverse to the chastity of the female; and it is well for you to remember the fact, for it may be through your testimony that the scales of justice will be rightly poised, and character sustained. But now to the question of sterility. The term sterility, in its largest acceptation, signifies an inaptitude on the part of the female to become impregnated; it must, however, be recollected that women sometimes remain barren without any special inaptitude on their part, but owing to circumstances directly connected with impotence in the husband. I REPRODUCTION. 537 do not propose to discuss the latter question at this time, but some of the causes of male impotence may, in passing, be briefly enumerated— such, for instance, as an imperfect development, or diseased condition of the testicles, defective development of the penis, or deficiency of healthy elements in the fecundating liquor itself. It has been maintained that disproportion between the male and female organs is also a cause of non- impregnation, but this is not so, for numerous facts prove that in order that fecundation may be accomplished, it is not necessary that the sperm- atic fluid of the male should be thrown against the orifice of the uterus; if it be simply made to reach the external opening of the vagina, im- pregnation will often follow. Among other proofs, may be cited those of pregnancy occurring in cases of a rigid and resisting hymen, which prevented the entrance of the male organ further than the very orifice of the vagina. In this latter fact there is nothing surprising, if it be remembered that the true ferti- lizing element of the spermatic liquor consists in what is called sperma- tozoa, small filamentous bodies, which enjoy the power of spontaneous motion ; it is for this reason that these spermatozoa were for a long time regarded as animalculi. It seems now, however, to be shown that they are not animalculi, but partake of the character of the reproductive por- tions of plants, which also enjoy a spontaneous movement as soon as they have been thrown from the parent mass. With this important fact before us, it is not difficult to comprehend how impregnation may ensue when the spermatic fluid merely reaches the external opening of the vagina, for the spermatozoa, with their power of movement, can readily pass on to the ovule, and then fecundate it; and why may it not be that this is the true explanation of the contact between the female germ and the fecundating liquid of the male ? Why, also, may there not exist between these an affinity which, cateris paribus, always ensures con- tact, and, therefore, fecundation ? Let us now consider, briefly, the causes of sterility directly connected with the female herself, and I think you will find them to be as follow: 1st. Any malformation of the female organs, such as will necessarily prevent the fecundating fluid of the male from reaching the ovule; 2d. Serious disease of both ovaries, though pregnancy, simply with disease of one ovary, is not unusual; 3d. Partial or complete oblitera- tion of the fallopian tubes, the result of inflammation; it has been shown by Mercier that this obliteration is not uncommon after the inflamma- tory affections which sometimes follow delivery, and he also affirms that women, from this reason, are apt to remain sterile after attacks of peri- tonitis, metritis, etc.; 4th. Organic diseases of the uterus, although they do not necessarily prevent impregnation, yet they undoubtedly render the liability to this condition much more probable; the same observation may be made respecting the various displacements of the uterus; 5th. All menstrual aberrations, and more especially dysmenorrhoea, may be 538 CLINICAL LECTURES. classed among the causes, if not of positive sterility, at least of a predis- position to it; 6th. Women who are burdened with fat, usually do not conceive; there is an interesting relation between the activity of the ovaries and an absence of excessive adipose matter, and the relation is such, that the function of these bodies is, as a general rule, impaired in women who are remarkable for an excess of fatty material; 7th. Leu- corrhceal, and other morbid discharges from the uterus and vagina, may also be classed among the causes of sterility, and they may act in one of two ways, either by the changes they produce on the lining membrane of the uterus, or by causing the death of the spermatozoa, these being unable to live, even for a short period, in the morbid secretion. This latter opinion has been advanced by Donne, and I am inclined to believe he is right; he has made some interesting microscopic experiments on the subject. We do not know how long the spermatozoa remain in the vagina after being ejected from the male organ, or what length of time may elapse before they reach and fecundate the ovule, whether it be one hour or several days, so that it is not difficult to imagine how their death may ensue from even a short sojourn in a fluid full of the elements of disease ; (8th. Excessive sexual intercourse is unquestionably adverse to child-birth, and this may affect the uterine organs in two ways, first by the excitement produced, and secondly by the inertia which is so apt to follow the exciting influence^ It has often been asked why the poor have more children than th« rich; the fact is easily explained—the former perform laborious duty. and live frugally; the latter are inactive, and continually lapse intc habits of luxury and ease. Temperance, frugality, and labor, are all calculated to increase the human family, while their opposites, stimulants, luxury and indolence, have quite the contrary effect. With these facts, it is at once obvious that the inevitable tendency of the families of the wealthy, is to become extinct, while those of the poor " increase and multiply," and were it not for the occasional intermarriage between the opulent and the poor, this principle of extinction would be recognized in a more marked degree. A cause of sterility, which, contrary to the opinion of many writers, I am inclined to believe by no means of ex- treme rarity, is stricture of the neck of the uterus, and according to my experience, the stricture is most frequently met with at the internal orifice of the organ. Dysmenorrhoea is ranked, and with good reason, among the causes of sterility—it is the congestive type of this form of menstrual aberra- tion which most usually proves a barrier to impregnation, but it must be recollected that dysmenorrhoea is sometimes purely the result of stricture of the cervix, the narrowing being such that the menstrual blood can pass only with great difficulty, subjecting the patient to extreme suf- fering. I have had several marked cases of this character, and in all 1 have been fortunate, not only in affording relief by removing the stric- THE MANAGEMENT OF STERILITY. 539 tu. , but invariably the removal of the stricture has been followed by pregnancy. The remedy consists in mechanical dilatation by means of properly graduated bougies. The dilatation involves no pain, and in judicious hands, no danger. Yet it is proper that I should caution you against the rash introduction of an instrument into the uterus—for, in more than one instance, it has been followed by death. But this, gentle- men, like all other operations, requires an intimate acquaintance with the anatomy and position of the organ, and no one who values his reputa- tion, or cherishes a proper regard for human life, would attempt the ope- ration without these pre-requisites. You have seen me in the Clinique introduce, on several different occasions, both the sound and bougie into the uterus, and I have elsewhere given you the necessary rules to be observed in their introduction. While on this subject it may be as well to call your attention, for the moment, to an operation proposed some time since by Dr. Tyler Smith for the purpose of removing any obstruction that may exist in the uter- ine extremity of the fallopian tubes. He suggested the introduction of a uterine catheter, the extremity of which, after entering the cavity of the organ, is to be passed toward one or other of the fallopian orifices. Steadying the catheter in this position with one hand, he introduces the whalebone fiber through the catheter into the fallopian tube to the dis- tance of an inch and a half, and, as he states, with the greatest facility. I have much personal respect for Dr. Smith, and entertain a high opinion of his skill. I do not mean, therefore, to doubt that he has performed this operation, which he affirms he has done on repeated occasions; but I conceive it my duty to say to you that, although in the hands of Dr. Smith, this operation has proved successful, yet in my judgment, it is a precedent not to be imitated; it is not only next to impossible to pene- trate the tube in the living subject, but the very attempt is full of peril to the patient. You may form a correct idea of the difficulty by open- ing the cavity of the uterus, and endeavoring with all the advantage of inspection, to penetrate either fallopian orifice even with a bristle. In one word, I can not regard the suggestion in any other light than as one of those transcendental refinements with which, for the benefit of the patient, and the tranquillity of the practitioner, it is at least prudent to dispense. The general directions for the management of sterility are few and simple. In each case which may present itself to your observation, the first inquiry should be—What is the peculiar cause ? If this can be recognized, the next point to be decided is—Is it within the control of remedies ? Should you ascertain the existence of dysmenorrhoea, it then becomes an essential question—What is the character of the dys- menorrhoea? Is it the congestive type, is it the result of ovaritis, is it due to extreme nervous irritability, or to stricture of the cervix uteri ? Suppose, for example, in another case, the female should be troubled 540 CLINICAL LECTURES. with a morbid vaginal discharge. Then the question to be determined is—Does this discharge proceed from the uterus, or is it limited to the vagina; is it idiopathic or symptomatic, etc. ? If in another case, you should detect organic disease of the uterus, the question naturally pre- sents itself—Is the disease beyond treatment, or is it under the control of remedial agents ? Suppose, for example, you have a patient who has never conceived, and who for years has been troubled more or less with a profuse discharge of blood from the vagina. In this case, before attempting relief, it is essential that you should know precisely to what the loss is due. Is it from serious organic lesion, polypus, fibrous tumor, etc., or is it simply a case of menorrhagia ? If this latter, is it the menorrhagia of plethora, or is it the atonio or passive form ? These, you perceive, are so many fundamental questions to be deter- mined before proceeding to treatment. We have on various occasions discussed very freely the best means of removing the above causes when they exist, and it is, therefore, not necessary to recur again to them, at this time. Marshall Hall, basing his opinion on the well-known sym- pathy between the mammae and uterus, suggests in two opposite condi- tions of the uterus, viz.: In an atonic and congestive state, the applica- tion of an infant to the breast for a week before and during the cata- menial period, and he maintains that this will oftentimes prove an effect- ual remedy for sterility. We know very well that women, about the advent of the menstrual flow, suffer more or less from engorgement of the mammae; and it is also proved that the application of the child to the breast in a young woman will frequently determine a secretion of milk. Predicating, therefore, his suggestion on these facts, Marshall Hall argues that when sterility is traceable to a congested condition of the uterus, an efficient mode of removing the congestion is derivation to the breasts by the suction of the infant; and again when sterility is due to an atonic or flaccid state of the uterus, the application of the infant to the mammae, through the reflex action it produces, secures a con- traction of the uterus, and in this way removes the flaccidity of the organ. These suggestions are not without force; they are founded upon a truthful physiology, and one worthy of consideration. Upon this same principle, authors have recommended, as a means of preventing uterine hemorrhage after the birth of the child, the immediate application of an infant to the breast. This is a favorite practice- of Rigby. There can be no objection to it in cases of moderate bleeding; but when the flow is such as to endanger life, more prompt and energetic measures must be adopted, such as we have spoken of in former Cliniques. The following I may cite as an interesting case of sterility, which came under my pro- fessional care, in March, 1852, and which so completely yielded to treat- ment that, in May, 1854, the lady was delivered of a healthy and vigor- ous son: RETENTION OF URINE. 541 Mrs. W., aged thirty-one years, married fourteen years, had always enjoyed good health except during her menstrual turns, when she was uniformly compelled to keep her bed until the catamenial period had passed over, such was the intensity of her suffering. This lady was a native and resident of Ohio, and consulted me through the advice of Dr. Winslow, who had not been her medical attendant, but who had become much interested in her case through family connection. I first saw her in March, 1852, and after a very careful examination, I formed the opinion that her sufferings during the menstrual crisis were altogether due to a stricture of the neck of the uterus, this giving rise to the pecu- liar form of dysmenorrhoea to which I have already alluded. This lady was most anxious to have offspring; she was surrounded by all the com- forts that wealth could bring her, and it seemed that the consummation of her own happiness and that of her husband depended on the birth of a child, which might inherit the name, and supply the only vacancy in their earthly bliss. I told her very confidently that, in my opinion, the cause of her sterility was altogether a mechanical one, and that, with its removal, I could see no reason why she should not bear children. She consented to abide by my advice, and on the 27th day of March I commenced my treatment, which consisted exclusively in dilating the cervix uteri by means of graduated bougies. At first, I had much difficulty in introduc- ing the smallest size instrument. The necessary dilatation, or, in other words, the complete removal of the stricture was accomplished after the introduction of the bougie ten times, at an interval of from five to seven days. The pain, which had previously accompanied each menstrual evacuation had entirely subsided; and on the 10th of the following July, the lady left the city, for her home in Ohio. On the 15th day of May, 1854, she was delivered of a son, being about fourteen months from the time she had first applied to me for advice. This case is interesting in more than one particular, and should point out to you the necessity of a full and proper survey of the circumstances as they exist before giving an opinion as to the possibility or impossibility of removing a condition so full of unhappiness to the female as that of sterility. Retention of Urine in an Infant, three Days old.* Joseph A., aged three days, is brought to the Clinique by his mother, who says she merely came to return thanks for the restoration of her child. " Is that the little sufferer brought here some three weeks since by your friend ?" " Yes, indeed, it is the same, sir ; and he is now quite well." Do you remember this infant, gentlemen? He is the little fellow who was brought here when he was only three days old. Your note-books will remind you of all the circumstances connected with his case. He had not, you will recollect, passed his water since his birth; he was extremely * Page 438. 542 CLINICAL LECTURES. restless, refused the breast, and was constantly moaning. The old woman who came with him here said he had taken parsley-tea, sweet spirits of nitre, etc., but, to use her own language, " these remedies did it no good." This was a case of retention, and not of suppression of the urine. To the important difference between these two affections, and the absolute necessity of a just distinction, your attention was emphatic- ally directed. I remarked to you at the time, that the administration of diuretics to this infant was not only bad practice, based on the wildest ignorance, or the most scandalous carelessness, but that it was calculated, by increasing the secretion of urine, to aggravate its sufferings, and add greatly to the danger of death. I introduced before you a small catheter into the bladder, and drew off four ounces of urine. The child was then ordered to be taken home, to be put into a warm bath, and have 3 j of castor oil given it. One of my staff (Dr. Garvin) was intrusted with the future management of the case, and, if necessary, requested again to introduce the catheter. This, he informs me, was not needed, as the infant experienced no further difficulty. Tumefaction of the Glands of the Neck in a little Boy, aged four Years, resulting from Scarlet Fever—What is Scarlet Fever? —Its Varieties, Causes, Diagnosis, and Treatment—Rules to be OBSERVED DURING CONVALESCENCE FROM SCARLET FeVER.--James L., aged four years, is suffering from a swelling in the glands of his neck. " How long, my good woman, has your child had these swellings ?" " Ever since he recovered from the scarlet fever, sir." " How do you know he had the scarlet fever ?" " Why, sir, he was all red, like a lob- ster, and he had a sore throat, which nearly killed him." " Well, my good woman, that is not a bad description of scarlet fever. How long was he sick with the disease ?" " He was very ill, sir, for ten weeks, but he has been pretty well for the last month, with the exception of these lumps, which give him a good deal of pain." The little boy before you^gentlemen, presents one of the not unusual results of the disease with which he has been affected. I have before directed your attention to the sequelae of scarlet fever, and you will recollect that they sometimes present themselves in the form of dropsy, anasarca, tumefaction of the cervical glands, enlarged tonsils, deafness, etc. The case of this little patient will afford me an opportunity of making some general remarks on an affection which may be said to be the terror of parents, and sometimes, from its rebellious character and sudden fatality, deeply humiliating to the practitioner. Scarlet fever may present itself in one of three forms, and hence its division into simplex, anginosa, and maligna. In the first, the simplex, tne disease assumes its mildest character, and scarcely needs medication. The cutaneous surface of the body presents a slight blush, a mere erythe- ma, with comparatively little constitutional disturbance, and in a few WHAT IS SCARLET FEVER? 543 days the disease passes off, requiring little more than confinement to the house, and an occasional aperient, together with simple diet. The second variety, the scarlatina anginosa, is characterized by more or less febrile excitement, a deeper blush of the integuments, exhibiting the appear- ance of a boiled lobster, and especially sore throat, which oftentimes constitutes the important, if not the perilous feature of the affection. The scarlatina maligna is that form which is most destructive to life. A child, previously in good health, attacked with this virulent variety of the disease, will sometimes be a corpse in two hours after the inception of the malady. Scarlet fever, like other eruptive diseases, consists essentially in a poison, but what that poison is, or what the circumstances are which modify it, so that at one time it is marked by comparative mildness, and at another assumes such virulence as to destroy life in one or two hours, is, as yet, a matter about which we may speculate, but nothing more. The true nature of the poison is concealed from us, and all we know positively is, that when full and undiluted, it constitutes not only a deadly shaft, but one of the most unerring and prompt in its effects to which human life is exposed. It is the scarlatina maligna in which this poison becomes so concentrated as suddenly to depress, through its effects on the nervous system, the vital forces, that has generated in the public mind such apprehension when the disease prevails as an epidemic. I have known parents to become almost maniacal upon this subject. losing all self-control, closing their houses, and rushing to the country in the hope of saving their children from the touch of this fatal upas. This is all wrong. Scarlet fever is one of the diseases incident to childhood, and, except in its malignant form, it can not be considered, if properly treated, one of great danger. I see but little philosophy in attempting to avoid it by change of place, unless some unearthly and all-wise spirit should point out the very locality which, par excellence, enjoys an immunity from its approach. Where, under the afflicting dis- pensations of Providence in the way of disease, is a parent so likely to have her child properly cared for, as at her own home, with all the com- forts of her own fireside, and the devoted attention of her own faithful and well-tried physician, to whom in the hour of danger she has been accustomed to look, and not in vain, for both consolation and safety ! I have just told you that scarlet fever is one of the ordinary affections of childhood—but it will sometimes attack the adult. It is a curious and interesting fact, in a professional sense, that this disease occasionally develops itself in the lying-in woman, and, under these circumstances, it is generally fatal, exhibiting in full force all the marked characters of the poison. Why is this ? May it be because in the puerperal woman the vital forces have become measurably depressed by the process of child-birth, and that, therefore, the poison of scarlet fever meets with so much less resistance than it would encounter in good health ? This hy- 544 CLINICAL LECTURES. pothesis is inconsistent, however, with what we know to occur when the disease in its most malignant form attacks the child, viz., that children in exuberant health, under the invasion of the malignant form of scarlet fever, die in two or three hours from the time of attack. I am rather inclined to the opinion that the disease is usually fatal in the puerperal woman, for the reason that the natural processes of child-birth, viz., the milk secretion, and the lochial discharge, are more or less interfered with, that is, they become arrested under the invasion of the scarlet fever, and these secretions being locked up in the economy, become ad- ditional disturbing agents of the nervous system. It would seem from the researches of Guersant and Blache, that scar- let fever is the least frequent of what may be properly termed the erupt- ive fevers; of four hundred and twenty-seven of these latter cases col- lected by them, two hundred and thirteen were varioloid or small-pox, two hundred and sixty-seven measles, and only one hundred and fifty- seven scarlatina. This disease is both sporadic and epidemic, and it is now conceded that it spreads frightfully through contagion. It may, in- deed, be called fitful, both in its advent, progress, and fatality. In some seasons, without any ostensible cause, it prevails to an alarming extent, and is severely fatal; at other times, on the contrary, its fatality is com- paratively slight. I do not know but what in some respects this affec- tion is to a certain extent entitled to be termed periodical, for observation proves that we often pass several seasons with but a trifling visitation of the malady, while, again, at certain periods, at an interval of from three to five years, it breaks forth with full violence, and from its fatality infuses general terror into the popular mind. Such I have known to be the case in the city of New York, and such, too, is in accordance with facts as noted in other places. Scarlet fever is often complicated with other affections, and it rarely happens in severe attacks of this disease that the brain, thoracic and ab- dominal viscera are not more or less complicated. Sometimes, also, it supervenes during the progress of other maladies, and in such case it has been called by Rilliet secondary scarlatina. The disease with which scarlet fever is most likely to be confounded is measles, but ordinary care will enable the practitioner to avoid all error of diagnosis between the two affections. In measles, the precursory symptoms are peculiar, such, for example, as sneezing, weeping of the eyes, coryza or a discharge of mucus from the nose, an absence of serious inflammation of the throat which is always the accompaniment of the anginose and malignant forms of scarlet fever; the eruption in measles usually presents itself' not until the fourth day after the premonitory symptoms, while in scar- let fever it appears on the second day of the febrile symptoms. The eruption, although it appears earlier, continues for a longer period than in the measles; in the latter affection it passes off generally about the eighth day after its appearance, while in scarlatina it continues from the ITS VARIETIES. 545 tenth to the fifteenth day, but there are exceptions to this, for in some cases it will disappear before the tenth day, and occasionally the disease will be present without the slightest sign of eruption. Another important distinction between the two affections is in the char- acter of the eruption itself. The efflorescence of scarlatina, if closely observed, consists of numerous small points spread out in patches of various forms and size, presenting the aspect of a diffused scarlet surface. In rubeola, on the contrary, the eruption is made up of irregular patches, with ah elevated surface, the spots being less red at their circumference than in the center, and what is particularly observable are the spaces be- tween the spots, in which the skin presents its natural pale color. There is a marked difference in the two affections in regard to the after effects. In scarlet fever, we look for dropsy, either of the chest, abdomen, or an- asarca, more or less derangement of the glandular system, etc., while in measles, the pulmonary organs are extremely apt to become affected, giving rise to bronchitis, pneumonia, etc. Indeed, as a general principle, it may, I think, be conceded that the true danger of measles is not in the disease itself, but in some of its sequelae, more especially the pnuemonia, which often assumes a formidable type. Convulsions will sometimes pre- sent themselves as a complication of scarlet fever, and this is very apt to occur when the efflorescence is either partially developed or, after having appeared, suddenly recedes; you can have no difficulty in understanding why, under these circumstances, the convulsive movement should ensue. Nature is contravened in her attempt to throw upon the surface the poison, which constitutes the essence of the disease; this poison as a consequence accumulates in the blood, becomes an irritant of the spinal cord, and hence the convulsions. The only safety to the patient in such case is re- course to prompt and effective measures to determine to the surface, and thus aid in the full development of the eruption. This remark applies not only to scarlet fever, but also to measles, small-pox, etc. The symptoms of scarlatina are not always the same; they change according to the variety of the disease, and become modified, also, by other influences, such as the virulence of the epidemic, the season of the year, individual idiosyncracy, etc. In scarlatina simplex, there is usually headache, rigors, nausea and vomiting, with more or less febrile excite- ment, and these symptoms, ordinarily in two days, sometimes earlier, are followed by an efflorescence. The pulse in scarlet fever is characterized by extraordinary rapidity; and it is asserted by Trousseau, that he has known the pulse of the adult in this disease to range at one hundred and sixty per minute. In the anginose variety, all these symptoms become aggravated, and in addition there is more or less stiffness about the jaws, painful deglutition, and sore throat, which, as I have already remarked, is characteristic of this form of the malady. In scarlatina maligna, all the above symptoms again undergo an aggravation, and a prominent feature of this variety is great depression of the vital forces, with a strong ten- 35 546 CLINICAL LECTURES. dency, in many cases, to sinking. The tongue at first is partially covered in the center with a whitish paste, but its extremity and borders are red even from the commencement, and this scarlet redness in a day or two pervades the entire tongue, and continues even after the efflorescence has disappeared. The red tongue is peculiar to all the varieties of the dis- ease. In the anginose and malignant forms, the fauces, mouth, and nose are more or less filled with an offensive secretion, and both respiration and deglutition are rendered difficult. I might, indeed, enter into a more minute detail of the symptoms, but sufficient, I apprehend, has been said to enable you, without hesitation, to recognize the disease in all its varie- ties when it exists. Let us now proceed to a most important consideration, viz., the treat- ment, for, after all, this is the material part of the whole subject. You will find much difference of opinion with regard to the therapeutic man- agement of scarlet fever; and I regret to believe that prejudice has some- times sadly interposed between judgment and duty. I have heard prac- titioners affirm in the most emphatic manner that under no circumstances would they abstract blood in this disease; while others, on the opposite extreme, declare that the sheet-anchor of hope in this affection is the lancet. There is, gentlemen, more temerity than good sense in either of these absolute opinions, and you will find nothing in either of them to call for your acquiescence. Bleeding in scarlet fever, like bleeding in any other disease, is good and it is evil—good when indicated by the surrounding circumstances of the case, bad when these justifying circumstances are absent. I shall now briefly tell you the treatment to which I usually have recourse, and which, I am happy to say, has proved highly successful. When called to a case of scarlatina, my first object is to ascertain its variety; if it be the mild or scarlatina simplex, unless, as sometimes happens, un- usual symptoms should develop themselves, I enjoin upon the patient, quiet in the chamber, administer a gentle aperient, and restrict him to an antiphlogistic diet; should there be much heat of surface, I have the entire body four or five times during the day freely sponged with cold water, or vinegar and water. This sponging will be found not only grateful, but very efficient in diminishing the unnatural heat of the sys- tem. There is usually in scarlatina an annoying sensation of burning in the skin, of which the patient is apt to complain; nothing will cause this so rapidly to subside as the cold affusion or sponging, and the pulse also, under its influence, becomes lowered, and the patient falls into a refresh- ing sleep. The cold affusion was first introduced to the attention of the profession by Dr. Currie; and oftentimes is of signal value in this disease. In France it'is employed with great benefit in the most unpromising cases of scarlet fever, such, for instance, as when delirium, coma, subsultus tendinum, etc., supervene. The mode of using the cold affusion is as follows: Let the child be placed naked in a tub, and then let cold water TREATMENT. 547 be poured on the head and entire body for twenty seconds; the child should afterward be wrapped up in a soft quilt, and put to bed. This may be repeated every four or five hours, according to the urgency of the symptoms. Those of you who have not witnessed the effects of the cold affusion in scarlet fever, can scarcely appreciate its magic influence in the general mitigation of the distressing symptoms; and though a priori you might judge the contrary to be the result, yet the eruption under its operation assumes a brighter color. In all the varieties of this affection, acidulated drinks will be beneficial; lemonade, currant-jelly water, barley-water, with a few drops of muriatic acid, tamarind-water, etc. The following combination is a good one, and may be administered in any of the forms of the disease: R Acid Muriatic, dilut. . . .' . . 3 j Syrup Aurantii......§ ss Aquae........§ viij M. A table-spoonful several times during the day. Now for the anginose form; in this case, if there be a full pulse, and much tumefaction of the sub-maxillary and sub-lingual glands, together with active febrile excitement, I do not hesitate to apply from two to four leeches to the throat, depending upon the age of the patient; the leech- ing, I am sure, in these cases, is of essential benefit; it not only diminishes the local congestion setting toward the throat, but it discharges a very acceptable and necessary office in protecting the brain from engorgement and subsequent effusion. Children, I am confident, often die in this dis- ease from effusion on the brain. When death ensues in scarlatina, how often do we notice it preceded by coma. What is this coma ? Some- times, I admit, it may be the result of the poisoned blood on the cere- bral mass, and this is not unusual in the malignant form ; but, again, it sometimes is the effect of effusion. It would be an interesting fact to know the relative proportion of deaths from effusion on the brain in scarlet fever. The leeching must be renewed according to the circumstances of the case; and these circumstances are to be determined by the discretion of the practitioner. But in this connection remember two facts. 1st. Blood-letting in acute diseases, to be efficacious, must be prompt. 2d. The child has not the same ability to sustain the abstraction of blood as is possessed by the adult. Allow me here to give you a caution in the use of leeches in scarlatina; the cutaneous circulation is extremely active in this disease, and, perhaps, in no other malady will the bleeding be so profuse under the application of leeches. Therefore, for this reason, you must exercise much judgment as to the number of leeches to be applied, and watch carefully, especially in very young children, that the bleeding is not carried too far. Many children are sacrificed from carelessness on this point. In addition to the blood-letting, a brisk cathartic should be adminis- sered, say ij grains of calomel, iv of Jalap, and one sixth of antimonial 548 CLINICAL LECTURES. powder; and in six hours afterward a table-spoonful of the following draught may be given every hour until free purgation is produced: R Sulphat. Magnesia?......3j Infus. Sennae.......§ iij Mannse........3ss M The bowels should subsequently be kept in a soluble state, either by enemata of molasses, oil, and soap suds, or simply warm water, as may be indicated. I have found much benefit, especially when there is deter- mination to the head, in the use of two tea-spoonsful of table salt in § iv of tepid water thrown up the rectum. It proves, in these cases, a capital revulsive on the intestinal mucous surface of the lower bowel, and is worthy of being remembered. Small doses of calomel occasionally, say one grain, should the bowels not properly respond to the above reme- dies, will be of special service. I have great faith in the judicious use of this medicine in scarlet fever. The throat, both in the malignant and aginose forms of this disease, will require local applications; in most cases, detergent gargles are all that will be required, and these may consist of alum and barley-water, a few drops of muriatic acid and barley-water. The following, known as Labarraque's solution, is in good favor, and may be used with great benefit in these cases: Solution of the chloride of soda, 3 xij; water, % vss; honey, 3 iv. This is a gargle highly recommended by Dr. A. T. Thomp- son, and is one of much value. Equal parts of lemon-juice and honey, is also a good combination. The ulcers in the throat are usually marked by great sluggishness, and require the stimulus of some of the above ap- plications. But how are these to be made ? It is almost impossible to prevail on the child to use them as gargles. The best plan is to open the mouth with a spatula, and then with a small piece of sponge, satu- rated with whatever material may be selected, the ulcers should be freely touched three or four times a day as may be necessary. Occasionally, it will be found useful to throw some of these remedies into the nose, and this may be done without difficulty by means of an India-rubber bag, with a small ivory pipe. This process of syringing the nostrils is valu- able on two accounts; it not only removes the morbid secretions which collect there, and consequently impede respiration, but it also tends to cleanse the ulcers in the throat. Sometimes a membrane forms in the throat, the result of the inflammatory action, and this has been called the angina membranacea. When this exists, it will be necessary to change the inflammatory action by the application of the nitrate of silver, either in solution or in the solid stick; if the former, 3j of the nitrate to f j of water; the throat may be freely touched with this latter by means of a camel's hair pencil. I have not spoken of emetics, though we have high authority for their administration in this disease. They were much resorted to by Dr. Rush, and he was in the habit of combining calomel with them in order that a TREATMENT. 549 purgative effect might also be insured. There can be no doubt of the value of emetics in certain conditions of this affection ; for example, at the very onset, when the eruption is tardy in its development, and the system becomes oppressed as a consequence, what can act more efficiently than an emetic ? It seems to give a new impulse to the sluggish forces, and by its determination to the skin, produces what is most desired, a fully developed eruption. Again, when the throat is more or less filled up by the morbid secretions, vomiting will be attended by the happiest results; it removes the secretions, and cleanses the throat. A combina- tion of ipecacuanha and tartar emetic will prove efficient for either of the above purposes: R Pulv. Ipecac........gr. iv Emet. Tart........gr. \ M. The above may be given in two table-spoonsful of tepid water to a child from two to three years of age. In the malignant form of scarlatina, when the system becomes sud- denly oppressed by the poison of the disease, and there is every indica- tion of sinking, what is to be done ? These are the cases of desperate hope; they oftentimes defy science, and resist every effort to arrest the work of death. The only indication is, as far as may be, to fortify the system by the prompt employment of wine, quinine, ammonia, etc. Dr. Watson speaks highly, in this typhoid condition of the system, of a solu- tion of the chlorate of potash. He puts 3 j of the potash into a pint of water, and this is to be given during the day as a drink. In the manage- ment of scarlet fever, there is one element so essential to success that it never must be lost sight of—I mean ventilation. And why so ? For the simple reason, that the disease consists in a poison, and the want of fresh air will only tend to the concentration of this poison, and conse- quently the defeat of the best directed treatment. The air of the cham- ber should be constantly purified, and nothing will do this so effectu- ally as the introduction of atmospheric air from without. Let the win. dow and door be opened several times during the day; you need have no apprehension of the patient taking cold—fresh air will harm no one— the only precaution to be observed is not to allow the invalid to be ex- posed to a draft. Tubs of hot water placed in the room are good purifiers, but nothing is so effectual as a healthy atmosphere from without. One word, gentlemen, as to the alleged prophylactic properties of bel- ladonna in scarlet fever. The idea was first suggested by Hahnemann, predicated upon the basis of the homoeopathic school " similia similibus curantur." Hahnemann observed that the administration of this narcotic is often followed by dry tongue, more or less tumefaction of the glands of the throat, a sort of miliary eruption, etc., and hence, consistently with his theory, " like cures like," he strongly advocated the administration of belladonna as a preventive remedy; he also claimed for it the merit of 550 CLINICAL LECTURES. mitigating the severity of the symptoms, even when it failed in prevent- ing the appearance of the disease. Respecting the efficacy of this medi- cine, there is great variety of opinion; I have employed it with a view of its prophylactic virtues, but I must confess without any marked suc- cess. Practitioners are very much divided with regard to this question; and some extraordinary statistical tables have been recorded by Dr. Stievenart, of Valenciennes, which, if they be really accurate, go far to establish the virtues of this drug. The circumstances under which Dr. Stievenart was induced.to have recourse to the belladonna, were these: An epidemic of scarlet fever had prevailed, marked by a sad fatality; thirty had died out of ninety-six attacked. In a village in which this epidemic displayed itself, of two hundred and fifty persons, two hundred took the belladonna, all of whom escaped the disease. He gave the medi- cine, both in solution and powder. Two grains of the alcoholic extract of belladonna were dissolved in % j of water, or aromatic infusion; of this two drops were ordered for a child one year old daily, for a period of nine or ten days, and for every additional year one drop was added to the dose. If the powder were used, one half a grain of the pulverized root mixed with sugar, was divided into ten papers, one of which was given twice a day to children from one to two years of age, four powders to children from three to five years of age, etc. There can be no objec- tion to the use of belladonna in alarming epidemics; as a prophylactic remedy, it may do good; it can not, in the above doses, do harm. But when the disease appears, my advice is to let the narcotic alone, and have recourse to less doubtful remedies, to which we have already alluded. I can not too earnestly enjoin upon you the necessity of careful vigil- ance during the time of convalescence from scarlet fever; many of the formidable sequelae of this affection, I am confident, originate at this pe- riod, not necessarily so, but from some indiscretion on the part of the patient. Cold and over-feeding are two of the prominent exciting causes of these sequelae; therefore, let every caution be observed in reference to these two points. 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 in the Vomiting of Pregnancy ?—Idiopathic and Symptomatic Vomiting; how Distinguished.—Is the Vomiting of Pregnancy Conservative, or otherwise ?—Connection between an absence of Vomiting during Gestation, and Miscarriage.—Miscarriage, how prevented.—Treatment of Nausea and Vomiting.— Vaginal-Rectocele in a married Woman aged thirty-six Tears.—Varieties of Vaginal Hernia.—Excessive pain in the left Mamma in a young girl eighteen Years of age. —Mastodynia Neuralgica.—Irritable Tumor; Pudendal Hernia in the right Labium Externum in a married "Woman aged forty-two Years.—Spasm of the Vagina in a married Woman aged twenty-two Years.—The difference between Spasm and Neu- ralgia of the Vagina. Gentlemen :—You will occasionally meet in practice with cases of ex- cessive vomiting connected with pregnancy, and you will sometimes, too, find such cases rebellious to every medicine which sound judgment can suggest. Allow me, therefore, to call your attention to a few general considerations touching the gastric irritability usually consequent upon gestation. You are aware that nausea and vomiting may be either idio- pathic or symptomatic—that is, they may proceed from primary disease of the stomach, or they may be simply the results of a disturbing in- fluence in some remote organ. The vomiting of pregnancy properly be- longs to this latter class, and it is, therefore, always enumerated as one of the ordinary symptoms of gestation. The uterus, under the numerous modifications produced in its tissues by impregnation, displays various sympathies with distant portions of the economy—hence enlargement of the breasts, head-ache, depraved appetite, nausea and vomiting, con- stipation, etc., etc., are among the usual accompaniments of this condi- tion, and are unequivocally but so many indications of the remarkable changes going on in the uterine organs. It appears to me that the true explanation of these phenomena, and their direct and almost necessary connection with pregnancy, are questions about which there should not be much doubt. These sympathetic influences, it will be conceded, are conveyed through the ganglionic system of nerves,* and to understand * M. Negrier of Angers has recently suggested that the cause of vomiting in preg- nancy is owing to an inflammatory condition of the neck of the uterus, and hence, with this hypothesis, he suggests the application of leeches to the cervix as the most efficient remedy. I do not pretend to deny that, under some oircumstances, the 552 CLINICAL LECTURES. why these nerves should be so modified by pregnancy as to induce im- pressions, not belonging to the ordinary phenomena of life, it is only necessary, it seems to me, to compare the uterus in a state of gestation* ^with that organ in its unimpregnated condition, and free from all the disturbing influences of organic or functional derangement.f Fecundation^ I have told you, consists in the vivification, through the spermatic fluid of the male, of the egg or ovule secreted by the ovary of the female, and as soon as this act of imparting life to the ovule is con- summated, the internal surface of the uterus becomes the seat of an ex- traordinary congestion—this surface presenting, as it were, the aspect of a blaze of fire, and as a consequence of this determination of blood there is poured out on the cavity of the organ a coagulable lymph, not unlike what occurs on the internal surface of the larynx in a severe attack of croup, except that, in the latter case, the exudation is a pathological re- sult, while, in the former, it is simply one of the processes instituted by nature to enable her to carry out in completion that interesting and won- derful work—reproduction. This coagulable lymph, which lines the cavity of the uterus, assumes the shape of the organ, and forms a closed sac, and this sac, the product of an extraordinary congestion, is what is known as the membrana decidua, or membrana caduca. There are three openings in the uterus—one is represented by the os cervix uteri may become the seat of inflammation during gestation—but to say that this is the uniform rule would be at once to declare that pregnancy is essentially a pathological condition, and this certainly can not be said with truth. * Page 136. f It is one of the fundamental principles in uterine pathology, never to be lost sight of, that the various sympathies which the uterus is capable of evoking in a state of pregnancy, are oftentimes brought into active operation when gestation does not exist; these sympathies being called into display in consequence of disease of the uterine organs, whether functional or organic. In amenorrhcea, dysmenorrhoea, etc., how often will you observe the patient to complain of sick stomach, palpitation of the heart, head-ache, fullness of the breasts, etc., not to speak of the numerous fugi- tive pains, partaking oftentimes of a neuralgic character, in various portions of the system, sometimes in the side, at others in the back or limbs. Again in carcinoma of the uterus, one of the most distressing symptoms is frequently excessive gastric disturbance. Attention has been directed so often to these points in the clinic, when speaking of the diagnosis and treatment of affections of the uterine organs, that it can not be necessary to allude more particularly to them at this time. It may, however, not be out of place to state that intercostal neuralgia is far more frequent in the female than in the male, and it is alleged that its most fruitful causes in the former are ancemia and hysteria. It assumes numerous types, and sometimes great judgment is necessary to distinguish its true character. It is not unusual in an aggravated attack of intercostal neuralgia, for the patient to complain of increased pain while coughing, or at the time of a full inspiration, thus causing the unguarded practitioner to imagine that there is inflammation of some of the respiratory organs. The diagnosis is simple—the respiration is natural, no excitement of pulse, and pressure usually palliates the pain. % Page 535. NAUSEA AND VOMITING IN PREGNANCY. 553 uteri, and the other two by the lateral and superior angles, which are con- tinuous with the fallopian tubes. You see, therefore, that, after the for- mation of the membrana decidua, representing as it does an imperforate sac, nothing can enter the uterus, except it penetrate the sac or push it forward. The membrana decidua, it must be recollected, is formed before the germ passes into the uterus, so that, when the impregnated ovule, brought by the successive contractions of the fallopian tube to one or other of the su- perior and lateral angles of the organ, enters the cavity of the uterus, it is not by perforating the sac, but by pushing it before it, and the portion thus pushed forward is the membrana reflexa. So you see, gentlemen, the first change which occurs in the uterus prior to the entrance of the germ is an extraordinary congestion, resulting in the formation of the membrana decidua, while the membrana reflexa has no existence until the fecundated ovule has found its way into the organ. But as soon as the germ has reached its place of sojourn—for the uterus is merely a temporary domicile to be occupied by the embryo until sufficiently de- veloped for an external or independent existence—the organ still con- tinues to be the center of an afflux of fluids, necessary in the first place for the formation of the placenta, and secondly for the continued nutri- tion and development of the foetus. In this way, I might proceed to show you the successive increase in the various structures of the uterus, how their growths are the result of new formations, etc.—these questions, however, I have already fully discussed in my lectures on midwifery. Sufficient, I think, has been said to show you that the uterine organs, at the very earliest period of impregnation, are thrown, if I may so speak, into extraordinary commotion ; not only are there notable modi- fications in their anatomical structure, but there are, also, most remarka- ble and important changes in their physiological functions. I can not too earnestly impress upon you the fact—that the physiology of the im- pregnated uterus is not the physiology of the unimpregnated organ in a state of health. In pregnancy, as a general rule, one of the most inter- esting physiological offices of the uterus and its annexae Ceases—I mean menstruation. And we find as a substitute for this monthly disgorgement an extraordinary increase of fluids setting toward these organs. We need proceed no further to be satisfied of the complete change effected in the uterus and its appendages, under the influence of gestation ; nor, with these facts in view, can wc encounter much difficulty in understand- ing the various sympathies evoked in the economy. One of the first of these sympathies is disturbance of the stomach, as is shown by the nausea and vomiting, which are usually such uniform accompaniments of pregnancy. You will observe in practice great dif- ferences as regards the particular period at which these symptoms mani- fest themselves for the first time after impregnation, and also as regards their duration and intensity. Some women are nauseated almost simul- 554 CLINICAL LECTURES. taneously with the act of fecundation, others again complain of no dis- turbance of the stomach for two or three months after impregnation. But I think you will find, as a general rule, that nausea and vomiting occur during the first month of gestation, and continue with more or less annoyance to the patient until the expiration of the fourth or fourth and a half month, when they gradually begin to subside. Again, in some instances, the vomiting will reach a fearful point, causing great emacia- tion and debility, thus placing the lives of both mother and child in serious peril, the former from the exhaustion superinduced, or the rup- ture of some important organ, the latter from the danger of premature expulsion. There is no difficulty in accounting for the shades of differ- ence in these symptoms—they are due to the differences observed in individual organization, temperament, and also to idiosyncrasy. Varia- tions in the effect of like causes on the human constitution, can not be too closely analyzed by the practitioner; oftentimes they are the surest guides to the correct application of remedies, and to omit a due con- sideration of them is frequently to deprive the patient of an element essential to the successful treatment of disease. The subject of excessive vomiting in pregnancy, involving the safety of the mother, has recently attracted much attention, and, in 1852, there was a remarkable discussion in the French Academy of Medicine, em- bracing more especially the question—Is it ever justifiable to induce abor- tion in cases of excessive vomiting ? The discussion grew out of a re- port made to the Academy by Cazeaux, and there was much conflict of opinion on the subject, the ultimate decision being one of a mixed character. There is no doubt that pregnant women have succumbed from the ef- fects of vomiting—there are some striking instances recorded, and I am sure the unrecorded experience of practitioners could furnish many more examples. Without entering into a prolix discussion of the question whether abortion is ever justifiable in these cases, it seems to me to be more a question of sound judgment than one of controversy; and in this case, as in all others in which doubts may arise as to the proper course to be pursued in the treatment of disease, it is the duty of the medical man to fortify himself in every possible way by an appeal to judicious and experienced counsel, and by a careful and thorough review of all the surrounding circumstances of each individual case. In this way, with no preconceived theory to sustain, with no prejudice to cloud his judgment, no false light to lead him into error, the sound physician will, I think, be enabled, under circumstances like these, to arrive at a just decision; and, at all events, whatever he may do, under the influence of such antecedents, will have been done with good and justifiable intent, and, therefore, will deserve, and must receive the sanction of all good men. I can not for myself recognize any difference between the decision of this question and multitudes of others that are more or less constantly presenting themselves to the practitioner, while engaged in his daily NAUSEA AND VOMITING IN PREGNANCY. 555 rounds of duty. Where is the physician who has not, at times, been al- most bewildered in his desire to decide the nice question, further deple- tion or stimulation, in a case, for example, of pneumonia, pleurisy, or typhus, knowing, at the same time, that on the correctness of his decis- ion must depend the life of the patient! In a case like this, after the proper exercise of his honest judgment, looking merely at the safety of his patient, whatever that judgment may indicate, and whatever the issue may be, I hold that the medical man has performed his duty. So, gen- tlemen, is it in symptomatic vomiting, endangering, if not checked, the safety of the mother. Look carefully at all the circumstances, and if, with the aid of additional counsel, you should be impressed with the conviction that the greatest, if not the only safety of your patient is in premature delivery, then, in my opinion, you would deserve rebuke if you withheld this means of relief, for, after all, the question which you are to determine is the simple but grave one, of life or death,* and the decision has nothing to rest upon but human judgment.f Is it possible to confound the vomiting of pregnancy with idiopathic vomiting ? Under ordinary circumstances, nothing is easier than to dis- tinguish between these two forms of gastric disturbance. The vomiting consequent upon gestation usually occurs at stated intervals ; as soon as the stomach is relieved, the patient is cheerful and well; there is no fever, nor any other indication of ill-health. In idiopathic vomiting, on the contrary, there will be, to a greater or less extent, the usual accompaniments of disease. When it is remembered that almost every pregnant woman, during a period of her gestation, suffers more or less from vomiting, and that this is one of the most uniform attend- * Page 45. f The two chief arguments employed by those who oppose the induction of pre- mature delivery, are: 1. That, in some instances, women who have been supposed to be almost in a moribund state from the exhaustion of vomiting, have recovered and brought forth living children. 2. That the physician is not justified in the perform- ance of an operation, which necessarily leads to the death of the child. I do not see much force in this reasoning, except in the abstract—and when taken in connection with all the circumstances presented by each case, it loses, in my opinion, all strength as a guide in practice. To the first argument, I reply that if a woman, apparently moribund from long con- tinued and excessive vomiting, should recover, it is a rare exception to a general rule, and, as an exception, worthless as a principle of guidance. Again, it is well known that women have succumbed from the operation of this cause who would in all probability have survived, if premature delivery had been resorted to. The second argument, it seems to me, is readily disposed of. The chances of saving the life of the mother, in these cases, by causing the uterus to throw off its contents, are very much increased; and without the operation, should the mother die, the life of the child is also sacrificed. But, I repeat, the whole question resolves itself into one of expediency, the word expediency in this case meaning—the interpretation which conscience and a high morality may place on the necessity for action. 556 CLINICAL LECTURES. ants upon this condition, it can not be regarded as a coincidence, but must be accepted as bearing the relation of effect and cause. I believe, indeed, it is as much a necessary result of impregnation as is the en- largement of the mammae, or the secretion of milk; and it needs but little reflection, I think, to comprehend the particular bearing of this gastric derangement upon the final issue of gestation. I have often re- marked to you that nature, in her arrangements, usually displays con- summate skill, and is remarkable for the adaptation of means to the accomplishment of her ends. Now, if you will recall to mind, for a moment, the extraordinary changes occurring in the uterine system im- mediately after impregnation, and remember, also, that the principal of these changes is characterized by congestion, you will, I think, not fail to perceive that the nausea and vomiting are intended to perform a sub- stantial good. Under the general relaxation produced by this disturbance of the stomach, the engorgement of the uterus is held in salutary check; extreme local plethora is thus prevented, and nature in this way is pro- tected against any contravention of her purpose. We have seen that congestion of the uterus is an ordinary and essential result of gestation; but, in order that it may not do harm, it must be circumscribed within certain limits. If you wish to comprehend thoroughly the effects of relaxation on local congestions, you have only to look at the operation of those two powerful agents, the lancet and tartar emetic. No one, I imagine, will deny, that it is through their directly relaxing effects, if employed opportunely, that the first and most efficient impression is made on active inflammatory disease. I maintain, therefore, that the nausea and vomiting of pregnancy are not ordinarily morbid conditions, but should be classed among those processes instituted by nature for the purpose of carrying out more perfectly her scheme of reproduc- tion. This brings me to the consideration of a most important question, and one to which, for a few moments, I desire especially to direct your attention. It occasionally happens, though an exception to a very gen- eral rule, that some women become impregnated, and are neither nause- ated nor do they vomit; and what is perfectly in accordance with my observation is—that such women are very apt to miscarry. That there is a striking connection between the absence of all gastric irritation and miscarriage, is a fact about which I do not entertain the slightest doubt; and on this assumption I have predicated a treatment which, I am happy to inform you, has proved invariably successful. I could cite to you more than one instance in which miscarriage has occurred under these circumstances, and having been consulted in a subsequent pregnancy, in which the absence of nausea, etc., still persisted, I have been enabled to carry the lady to her full term, and deliver her of a healthy child. The treatment is extremely simple, and it is nothing more than an effort to assist nature, and relieve the uterus from the effects of extreme conges- TREATMENT. 557 tion. I order the patient to take from one quarter to half a grain of ipecacuanha, once, twice, or thrice a day, as circumstances may indi- cate, for the purpose of producing nausea, thus simulating as nearly as possible the course pursued by nature, when not contravened by influ- ences which she can not control. This course of treatment is continued until about the fourth month of gestation, at which time the nausea and vomiting usually attendant upon pregnancy, as a general rule, cease. If, therefore, you should be consulted by a patient who may have had one or more miscarriages, without any assignable cause, and if, on inter- rogating her, you discover that she has not had any gastric disturbance, you may very reasonably conclude that the absence of this irritation has been the cause of her miscarriage ; and it may happen that the rec- ollection of the simple remedy I have suggested will enable you to be of essential service to your patient, and add no little to your own repu- tation. The following case bears so directly on the point under consideration, that I can not forbear citing it: In November, 1851,1 was consulted by a lady from the State of Georgia, who imagined that she was labor- ing under some disease of the uterus, which, as she supposed, had pre- vented her from having a living child, having miscarried twice success- ively at the third month of her gestation. After a very careful examin- ation, I could detect no disease of the uterus, nor could I ascertain, on inquiry, that any of the ordinary special causes had operated in the pro- duction of the miscarriages. In questioning her particularly as to the state of her health while pregnant, she laughingly observed—" Why, sir, my health was in both instances most remarkable; my appetite was surprisingly good, and I did not know what it was to have a moment's sick stomach." Judging that this was a case of miscarriage from the absence of the two usual phenomena of gestation, nausea and vomiting, I so expressed myself to the lady, and enjoined upon her, as soon as she again discovered herself to be pregnant, to commence with the ipecacu- anha, as above directed. She returned home, and in twelve months afterward I received a letter from her physician, Dr. Raymond, in which he remarked : " Your remedy has been attended by the happiest result. Two weeks since I delivered Mrs. W. of a fine son." Treatment of the Vomiting of Pregnancy.—Although, as we have re- marked, the vomiting consequent upon gestation is to be regarded as a natural process, yet, in some instances, it may become necessary to re- sort to remedies, with a view of keeping it within reasonable bounds. Various medicines have been suggested for this purpose, and, unfortu- nately, it too often happens that, in many instances, they are of but little avail. I have occasionally derived much benefit from the applica- tion to the epigastrium of a cloth saturated with laudanum ; chloroform employed in the same way has proved useful. Dr. Simpson speaks favorably of the inhalation of laudanum from a small ether inhaler, hot 558 CLINICAL LECTURES. water being used to promote evaporation. Opium, in its various preparations, may be given internally, a quarter or half a grain at a dose; or two or three drops of the solution of morphia, in a tea-spoon- ful of cold water; equal parts of lemon-juice and cold water, say a table-spoonful of each; a table-spoonful of lime water and milk ; small pieces of ice, internally; or a piece of ice laid on the epigastric region. The tincture of nux vomica, two or three drops every two hours, is a remedy much extolled by Lobach; but he observes that, after the arrest of the vomiting, severe cramps are apt to ensue, which, however, readily yield to the tincture of the acetate of copper, one drop each hour, gradually increasing to six drops an hour. The extract of belladonna in ointment, applied to the cervix uteri, first suggested, I believe, by Brettoneau and Cazeaux, is sometimes very efficacious. I employed it on two occasions with very striking benefit. Its strength should be 3 j of the belladonna to § j of adeps; a small portion to be smeared on the cervix once or twice a-day, as circumstances may require. It should be applied with the finger, and not through the speculum, for the reason that this instrument may, especially in sensitive women, induce premature action of the uterus. The following, which is known as the potion of Riviere, has been in great repute, and may be employed oftentimes with advantage: R Acid Citric......gr. xxxvj Syrup Sacchar......3 viij Potassa? Bicarbonat. .... gr. xxxvj Aquae distillat......§iv The citric acid to be dissolved in one half of the water, and then add the syrup ; the bicarbonate of potash to be dissolved in the remaining portion of water, and a table-spoonful of each to be administered suc- cessively. The vomiting of pregnancy is, I am quite confident, frequently aggra- vated by a constipated condition of the bowels, and it is proper, there- fore, to exercise a due degree of vigilance on this point. The following combination will be well adapted, by its laxative action, to prevent torpor of the system during gestation : R Pil. Colocynth Comp.....3i ss Extract Hyoscyam . . . . 3j Pil. Hydrarg.......gr. xij Ft. pil. xij One or two pills, as occasion may require. Vaginal-Rectocele in a married Woman, aged thirty-six Years, the Mother of four Children, the Youngest three Months old ; Varieties of Vaginal Hernia.—Mrs. S., aged thirty-six years, mar- ried, says her womb is down, and she is almost beside herself with the pain and suffering she has endured from constipation of her bowels. She says she has lost more than twenty pounds of flesh within the last VAGLNAL-RECTOCELE. 559 two months, has no appetite, and complains of dragging pains about her back and hip*. " How long, my good woman, since you first experi- enced these disagreeable feelings of which you speak ?" " I have had them, sir, ever since the birth of my last child, which is now three months old." " Do you know what caused them in the first instance ?" " About two weeks, sir, before my last confinement, I was lifting a heavy tub of water, and I felt as if something gave way, and ever since that time my womb has been down, and I have been a great sufferer from constipation, and bearing-down pains." It does not follow, gentlemen, because this poor woman says her " womb is down," that she is really affected with prolapsion of this organ; and, therefore, in order that we may know her true condition, it will be necessary to make a critical examination of her case. [The patient was placed upon the bed, and the professor proceeded with the investi- gation.] There is, as you perceive, a tumor projecting beyond the vulva, equaling in volume the ordinary fist. It projects from the posterior portion of the vulva, and is increased in size by any effort of the patient, such as coughing, straining, etc. Now, the interesting question for us to determine is, What is this tumor ? In carrying my finger into the vagina, and directing it toward the uterus, I find this latter organ in its proper position ; therefore, I know that the tumor is not a prolapsed womb. It is not a polypus, nor an ordinary fibrous tumor, nor is it an abscess, for it does not possess the characteristics of these various mor- bid conditions. What, then, is it? Is it a prolapsion simply of the vaginal mucous membrane, or is it a prolapsion into the vagina of the rectum itself? In order to ascertain whether there is really a prolapsion of the rectum into the vagina, constituting the tumor now before us, there is a very certain method of diagnosis. I introduce my index finger into the rectum; then, carrying it forward, direct it toward the vagina, and, as you now see, pursuing this direction, the finger passes into the vagina, the only intervening substance between it and the vagina being the anterior wall of the rectum, which is thrown forward, forming the tumor of which this woman complains, and which she has supposed to be " falling of the womb." This is an extremely interest- ing case, and one of more than ordinary importance. The trouble with which this patient is affected is what has been termed by Mal- gaigne a vaginal-rectocele, which means literally a tumor of the rectum in the vagina. This clever French surgeon* was, I believe, the first to describe accurately this particular form of tumor. The vagina may become the seat of various protrusions, forming, in a word, so many vaginal herniae: for example, there may be prolapsus and procidentia of the uterus ; prolapsus and inversion of the mucous mem brane of the vagina ;f prolapsus of the ovary or intestine into the tri- * Memoires de l'Academie Royale de Medecine, tome vii. p. 506. f See pages 166, 462. 560 CLINICAL LECTURES. angular fossa, between the rectum and uterus ;* prolapsus of the bladder known as vaginal-cystocele ;f and, lastly, as in the instance now before us, vaginal-rectocele. It is quite necessary not only that you should know the various displacements occurring in the vagina, but it is also absolutely essential that you should be enabled to make just distinctions as to the real nature of these displacements. I have elsewhere called your attention particularly to the anatomical relations of the vaginaj and rectum; and here allow me to remind you that the adhesions be- tween these two organs are rather feeble, so that it is not at all un- usual for one of them to become displaced without necessarily involv- ing the position of the other; for example, you will see the rectum pro- lapsed, and the vagina quite in situ ; and, again, the vagina will be pro- lapsed, and even inverted, while the rectum suffers no displacement. The rectum itself is maintained in position by cellular and fibrous ad- hesions, by which it is united to the pelvic aponeuroses, and also to the sacrum; and, in vaginal rectocele, it must be remembered that it is the anterior wall of the intestine only which falls into the vagina. Again, the rectum has two coats, which are quite distinct, from which it follows that there may be simple relaxation, or inversion of the mu- cous membrane alone, or there may be inversion of the two tunics at the same time. In the vagina, on the contrary, the spongy and cellu- lar tissues are more intimately connected with the mucous coat, so that when the latter is relaxed and projects beyond the vulva, it is almost always at the same time accompanied with inversion. The firmest ad- hesions of the vagina are in front, between the urethra and bladder; and for this reason it is said that simple relaxation of the anterior wall of the vagina does not take place; but, on the contrary, in displace- ment of this wall, there will necessarily be displacement also of the bladder, giving rise to vaginal-cystocele. Malgaigne forcibly observes that simple prolapsion of the posterior wall of the vagina is a very dif- ferent thing from displacement of the rectum through the vulva; and that prolapsion of the vagina, consecutive to prolapsion of the uterus, does not necessarily cause prolapsion of the rectum. Vaginal-Bectocele has oftentimes been mistaken for simple prolap- sion of the mucous membrane of the vagina, and even for prolapsion of the uterus itself; and hence, under this erroneous diagnosis, it has not generally been alluded to, in systematic treatises, as a distinct affection. Causes.—Pregnancy, child-birth, falls, a relaxed vagina, repeated labors, constipation, may all be enumerated among the influences capa- ble of producing this displacement. Symptoms.—A projection will be observed from the posterior portion of the vulva, varying in volume from a simple fold to the size of the fist; the patient is much annoyed with dragging pains about the hips * Page 224. t PaSe ™- X Page 203. VAGINAL-RECTOCELE. 561 and back; the digestion becomes much deranged; there is loss of appe- tite, and also loss of flesh, and these latter symptoms are the direct results of one of the prominent and most distressing accompaniments of this affection—constipation. With the constipation, there is more or less irritation about the anus, together with tenesmus. Diagnosis.— Vaginal-rectocele may be mistaken for prolapsion of the uterus, prolapsion and inversion of the mucous membrane of the vagina, polypoid and other growths of the uterus and vagina, abscess, etc. The exercise, however, of a proper discrimination will enable you to arrive at a correct diagnosis. The infallible evidence that this affection exists will be derived from the introduction of the index finger into the rectum, directing it in a curved position toward the vagina: if the finger, thus fixed, passes into the cul-de-sac formed in the vulva, you then have positive testimony that the tumor is the result of a prolapsion of the rectum into the vagina, constituting the displacement in question —a vaginal-rectocele. You will remember, when calling your atten- tion to the diagnosis of a case of falling of the bladder,* vaginal-cysto- cele, I remarked to you that all doubt would be removed if, in intro- ducing the catheter into the bladder, and pressing it downward and forward, you should feel the end of the instrument, with the finger of the other hand introduced into the vagina, pressing against the lower portion of the tumor. It is proper that I should say to you that vaginal- rectocele will sometimes exist simultaneously with vaginal-cystocele, or with prolapsion of the uterus ; and even these three forms of displace- ment may be present at the same time. Prognosis.—In a confirmed and long standing case of vaginal-rectocele, the hope of permanent relief will be slight; temporary palliation is all that may reasonably be expected. Treatment.—The treatment of this affection is divided into curative and palliative—the former consists in an operation, the object of which is to remove the relaxed portion of the mucous membrane of the vagina. It has also been proposed to remove a portion of the coats of the rectum, and afterward induce adhesion between the intestine and vagina, but it is quite evident, as Malgaigne observes, that such a course is not with- out danger—at least its beneficial result is more than doubtful. The palliative treatment consists in relieving the prominent symptom, the constipation—and afterward supporting the prolapsed intestine by means of a pessary. The bowels should be kept soluble by the frequent use of enemata; and if found necessary §j of castor-oil may be administered occasionally with advantage. The prolapsed intestine must be supported by the introduction of a pessary, the form of which must depend upon the circumstances of the case. Great benefit will sometimes be derived from the use of a piece of soft sponge, enveloped in oil-silk, carefully in- troduced into the vagina, and kept in place by a bandage. Whether a * Page 279. 562 CLINICAL LECTURES. sponge or pessary be used, you must not forget the importance of having it withdrawn daily for the purpose of ablution. Excessive pain in the left Mamma in a young Girl eighteen Years of age—Mastodynia Neuralgica—Irritable Tumor.—Mrs. L. brings her daughter to the Clinic for advice in consequence of a severe pain in the left breast, which has annoyed her extremely at times for the last year. " Is the pain of which your daughter complains constant, or is she some- times free from it ?" " It is not constant, sir, but it is very bad just be- fore her courses come on." " How is the pain after the courses have ceased ?" " It then leaves her, sir, and she is quite comfortable." [The Professor examined the breast, there was no change of color in the integ- uments, nor was there the slightest evidence of inflammation—there was, however, a small movable tumor the size of a pea, exquisitely sensi- tive to the touch.] " You say, madam, the pain is always increased just before the courses." "Yes, sir." "Does the pain subside during the period of the menses ?" " Yes, sir." " Are your daughter's monthly turns as they should be ?" " No, sir, she only has them on her about two days." " How long has this been the case ?" " Only for the last year, sir ; and ever since that she has complained more or less of the pain in the breast." You will occasionally, gentlemen, meet with this form of disease, and it is especially worthy of your attention. It is a painful affection of the mamma first brought to the notice of the profes- sion by Sir Astley Cooper, and called Mastodynia neuralgica, sometimes known as irritable tumor. It consists in exquisite sensibility in one or more portions of one, and sometimes of both mammae. The pain is described by the patient as piercing, a species of tic douloureux, com- mencing in the breast and passing on to the shoulder and inner side of the elbow, extending sometimes to the fingers, and occasionally to the hip. The disease is very apt to develop itself between the ages of fif- teen and thirty years, and is not observed before the period of puberty. The integuments preserve their natural appearance, there being no evi- dence of inflammation. The pain is oftentimes much increased by at- tempting to sleep on the affected side. The maximum of suffering is just before the menstrual evacuation, and it becomes very much dimin- ished as the catamenia ceases to flow. In the case of this young woman I discover a small movable tumor in the breast, the size of a pea, giving rise on the slightest touch to exqui- site suffering. As a general rule, there is only one tumor, although occa- sionally there may be several, and they will sometimes present the vol- ume of a marble. One remarkable feature about these tumors is, that, continuing as they may for years, they neither increase in size, nor do they pass to suppuration. This peculiar irritable condition of the breast is not always accompanied with tumor—sometimes there will be no appearance of any thing extraneous, the only morbid feature being the PUDENDAL HERNIA. 563 excessive sensibility of the mamma. Irritability ;>f the breast is not, in my opinion, of rare occurrence. On the contrary, you will often meet with it, and it is important that you should not mistake it for other conditions of the organ. When accompanied by tumor, it may possibly be confounded with eysts, hydatids, etc., which occasionally develop themselves in the mammary glands ; but a due degree of attention will enable you to form a correct opinion. In hydatids and cysts, there is neither pain nor tenderness—but there is tension, and subsequently, fluc- tuation. In scirrhus, the tumor is of extraordinary hardness, slightly tender, and characterized by a lancinating pain, usually limited to the breast itself-—the skin covering the tumor becomes adherent, and of a tuberculated character. Mastodynia neuralgica, whether accompanied by a tumor or not, may be considered as especially connected with undue irritability of constitu- tion, and is in more or less alliance with some abnormal state of the menstrual function, either menorrhagia, dysmenorrhoea, or defective menstruation. The treatment should be both general and local, the former being in- tended to fortify the constitution, and break up, if I may so term it, the irritable diathesis; the object of the latter, the local treatment, being the temporary mitigation of pain. The system, in these cases, will usually improve under a judicious ad- ministration of the ferruginous preparations, sea-bathing, exercise in the open air, nutritious diet, etc. Sir Astley Cooper recommended, as a local application, a plaster consisting of equal parts of the ceratum sapo- nis and extractum belladonna, or a poultice of bread crumbs and tincture of belladonna. As the girl before us is laboring under a deficiency of the menstrual function, and as she is evidently chlorotic, I shall order for her the fol- lowing pills, two of which are to be taken daily : R Ferri Sesquioxydi Pil. Galban. c. ) Pil. Colo. c. ) Theriaci The diet should be nutritious—and the painful breast may be rubbed with equal parts of sweet-oil and laudanum. Pudendal Hernia in the Right Labium Externum, in a married Woman, aged forty-two Years, the Mother of five Children.— Mrs. O. says she has a swelling in the lower portion of her person, which increases when she walks, and sometimes causes her much pain. " How long, Mrs. O., have you been troubled with the swelling of which you speak ?" " About two months, sir." " Do you know what . gr. xn . aa 3j . q. s. M. ft. pil xij 564 CLINICAL LECTURES. caused it, my good woman?" " Indeed I do not, sir, except it was hard work." It is impossible, gentlemen to arrive at any accurate opinion touching the nature of this swelling without an examination ; for swelling in the lower part of the person, like swelling in any other portion of the sys- tem, may result from various causes, and assume various phases. [Here the patient was placed on the bed, and the Professor commenced a care- ful examination of the tumor.] You perceive, in looking at the parts, that the tumefaction is seated in the right labium externum; it is coni- cal in shape, and its long axis is from above downward. In gently grasping the tumor, there is no pain, nor is there any evidence, from the aspect it presents, of inflammatory action. There is an entire absence of fluctuation, and the swelling is evidently movable ; for, as you see, I can make it ascend, and now it has completely disappeared. What, then, is this tumor; what its nature; in one word, what has produced it ? This is the question for us to determine, and on a proper decision must depend the hopes of this woman for relief. Again, as I remove my finger, which acts as a sort of support, the tumor descends, and causes a protrusion into the labium externum. " Madam, will you be kind enough to cough ?" You perceive, gentle- men, the effect of the effort at coughing on the swelling ; its volume is increased by the cough, and there is an impulse imparted to the finger, as it grasps the base of the tumor. From this latter circumstance, to- gether with the important fact that the tumor can be made to disappear by properly-directed pressure upward, it is very evident to my mind that the swelling in the labium externum is occasioned by a hernial pro- trusion into that part. I have already spoken to you of the various morbid conditions capable of giving rise to enlargement of the labia ex- terna, and shall not refer to them again, except simply, to remind you of the great necessity of accurate diagnosis in these cases.* But in the present instance, the enlargement is unquestionably due to a hernia, and this is a subject of too much interest to be passed by in silence. Hernia into the labium externum was first described by Sir A. Cooper, and he gave it the name of pudendal hernia: it is of extremely rare occurrence, and, therefore, the case before us is of more than ordinary import. It is sometimes called, when the protruding body consists of intestine, vulvar-enterocele, and when the bladder is thrust into the labium, as is alleged has taken place, it is known as vulvar-cystocele. In pudendal hernia, the displaced mass descends between the vagina and ramus of the ischium, and forms in one or other of the labia an ob- long tumor, which can be recognized by the touch within the vagina, as high up as the os uteri. In carrying my finger along the vagina, I can very distinctly trace the tumor on its internal wall as far as the neck of * See pages 340-406 PUDENDAL HERNIA. 565 the uterus ; and, with the other hand applied to the external surface of the labium, I feel that I grasp the protruding mass between the two hands. The bladder I find perfectly in position; and hence it is not this organ which has descended into the labium. The protrusion, on the contrary, consists of a portion of intestine, and may properly be termed a vulvar-enterocele. Causes.—Pudendal Hernia may be induced by strains, carrying heavy burdens, a relaxed vagina, obstinate constipation, falls, etc. Symptoms.—A tumor in one or other of the^ labia, the volume of which is increased in the standing position, or in coughing. More or less pain in taking exercise, or when the patient is constipated. Diagnosis.—Attention has already been drawn to this subject at pages 340-406. Prognosis.—Under ordinary circumstances, there is no danger attend- ing this form of hernia; but it may become strangulated, requiring a surgical operation ; and, as in all cases of strangulated hernia, there is of necessity more or less danger. Treatment.—The treatment consists, in the first place, in the reduction of the tumor by the taxis; and, secondly, in the prevention of its re- turn by the application of an instrument. I will here proceed to the reduction of the hernia. The patient, as you perceive, is on her back, the shoulders and hips are gently raised by pillows, with a view of re- laxing the abdominal muscles. I introduce into the vagina the index finger of the right hand, for the reason that the hernia is in the right labium, and with this finger the tumor is gently pressed against the side of the vagina, while, with the finger of the other hand, I seize the lower portion of the tumor in the labium, and push it cautiously backward and upward in a direction parallel to the vagina. The evidence that the hernia is reduced is the fact that there is no longer any swelling in the labium. After the reduction, in order to prevent a recurrence of the hernia, it will be necessary to have recourse to some mechanical sup- port. For this purpose, a cylindrical pessary may be used, taking care to introduce it so that the base will be upward, the object being to exert pressure on that portion of the vagina which has allowed the intestine to escape and make its way between its external wall and the ramus of the ischium. With a view of retaining the pessary in position, an ordi- nary T bandage will be found useful But, gentlemen, there is one point in connection with the treatment to which I have not yet adverted, and which, if neglected, will not only cause the patient much annoyance, but will be a constantly exciting cause to a renewed prolapsion of the intestine. I allude to the consti- pation to which this woman informs me she has been subject. In all cases of displacement of the uterus and adjoining organs, as well as in diseases of these viscera, whether organic or functional, the affection will always be aggravated more or less by constipation; the very at- 566 CLINICAL LECTURES. tempt at defecation causing a straining which can not be otherwise than prejudicial. This is an important fact for you to remember. As the patient before us is feeble and requires tone, I will recommend the following pills, one of which may be taken twice a day, as occasion may require : R Quinffl Sulphat.......3 j PiL Gambog. c.......3 isa M. ft. pil. xxx. Spasm of the Vagina in a married Woman, aged twenty-two Years —What is the difference between Spasm and Neuralgia of the Vagina ?—Mrs. M., aged twenty-two years, married, complains of ex- treme suffering in the vagina, at times, and begs that something may be done for her. The case of this patient, gentlemen, embodies several points of more than usual interest. I have had a very full conversation with her, and she informs me that she has been married only four months, and is quite unhappy because she can not perform the duties of wife—in a word, in every attempt at intercourse she says she is thrown nearly into convulsions. This condition of things, she fears, has tended to estrange her husband, and she is most anxious to obtain relief. I need not speak to you of the necessity of just discrimination in cases like these, involving as they do not only the health but the happiness of the patient. I have subjected this woman to a thorough examination, and have discovered that she is affected with spasm of the vagina, a peculiar morbid condition characterized by a convulsive contraction of this canal. The first question, which naturally arises in the mind is, what has produced this unnatural state of things ? Spasm of the vagina may pre- sent itself to your observation in one of two forms—either idiopathic or symptomatic. When idiopathic or primary, it will generally be found that the spasmodic contraction assumes an intermittent character, with an entire absence of all inflammatory symptoms, and develops itself only under the influence of certain exciting causes, such as coition, or a vaginal examination with the speculum or finger; the spasm, in these cases, being due to a morbidly sensitive condition of the nervous system. In the patient before us, we have an example of the idiopathic form of this affection, and I am quite confident we shall be enabled to afford her relief. But you may very naturally ask the grounds of my diagnosis. They are as follow: 1. There is an entire absence of redness, heat or swelling in the vagina, and as far as mere appearances avail, the part is in a perfectly healthy condition. The only abnormal feature in the case —and this is characteristic of the idiopathic form of the disease—is the exquisite sensibility to the touch, immediately causing an irregular or spasmodic contraction of the organ. The degree of contraction will de- pend upon the violence of the affection ; sometimes, during the spasm, SPASM OF THE VAGINA. 567 the cavity of the vagina becomes only partially obliterated, while again, as is the case in the present instance, the walls of the canal closely ap- proach each other, so that it is with great difficulty the finger can be in- troduced. In symptomatic spasm of the vagina, you will find disease of the uterus or vagina itself-—sometimes, too, it will result from an affec- tion of the rectum. I have known it to be occasioned by hemorrhoidal tumors, and prolapsion of the mucous membrane of the intestine. The diagnosis of the symptomatic form is quite simple—you will always, by a careful examination, be able to recognize the evidences of the disease, to which it is to be traced, whether the disease be in the uterus, vagina, or rectum. A fact worthy of recollection is, that, in the symptomatic form, the contraction is not intermittent, but continuous, depending upon the duration of the disease of which it is but a symptom. Treatment.—This patient has an earnest claim upon us. Her situa- tion is strikingly peculiar, and whether she receives relief or not may be the turning point on which her peace of mind and happiness are to de- pend. It is, therefore, the duty of the physician, under circumstances like these, to exercise a full measure of vigilance, and by a just apprecia- tion of the true cause of disease, to afford the necessary relief. The remedies for the patient before us must be both local and general. The former should consist of the warm hip bath, together with injections into the vagina of twenty drops of laudanum in a wine-glass of tepid water twice a day—but what I most prefer in these cases, and which I regard as one of the most effective remedies is the belladonna ointment: R Extract Belladonnas......3j Adipis.........3j Ft. Ungt. Let a small portion be applied to the vagina once or twice a day, or the following suppository may be introduced into the vagina every night for several successive nights: R Extract Belladonnas......gr. ij Sapon. Castil.......gr. iv Misce. ft. suppos. The above suppository may be used with advantage in cases of nervous dysmenorrhoea. The constitutional or general treatment should consist of remedies cal- culated to fortify, and change the morbid condition of the nervous sys- tem ; and for this purpose the sulphate of zinc will be found a useful agent: R Zinci Sulphat........gr. xxiv Extract Gentianae......3 ij 01. Anthemis.......gtt. xij Divide in pil. xxxvj. 568 CLINICAL LECTURES. Two pills three times a day, together with nutritious diet, and exercise in the open air. The treatment of the symptomatic form of vaginal spasm will consist in remedies appropriate to the disease producing it. Allow me here, for the moment, to call your attention to another af- fection of the vagina—neuralgia—with which it is possible that spasm of this canal may be confounded. Both of these affections have some symptoms in common, and each will occasionally assume the idiopathic and symptomatic classification. In the former, vaginal neuralgia, like vaginal spasm, will exhibit no trace of disease, the only feature being exquisite sensibility to the touch. It is also intermittent. In the sympto- matic form, it will sometimes be traced to disease of the uterus, vagina, or rectum—and not unfrequently to spinal irritation. You will some- times meet with neuralgia of the vagina at the final cessation of the menses, and, in this case, it will often be connected with disease of the uterus. But there is one constant and striking characteristic circum- stance which will enable you to distinguish the two affections, it is this —in neuralgia of the vagina there is no spasm. This affection will usu- ally yield to the belladonna ointment; and sea-bathing is particularly efficacious. In some cases, it will be necessary to cauterize lightly the surface of the vagina. If it be due to spinal irritation, an issue on the side of the spine will be indicated. APPENDIX. The following are among some of the more interesting cases, taken from the record, showing the satisfactory results of treatment. In addition to these, there will be found numerous others mentioned throughout the volume. It will be noticed that, at the end of each case reported cured, the page is given, so that reference may be made to the case, and its history learned, when first presented at the Clinic. Profuse Menstruation from Debility.—Passive Menorrhagia.—Mrs. P., aged twenty-seven years, married, who has been greatly prostrated by profuse menstrual discharge, says her courses are now quite regular, and her health is gradually improving. The treatment ordered was the following: R Acid Sulph. dilut.....• . 3 ij Syrup Aurantii.......fivM. A table-spoonful three times a day. Half a pint of cold water was also directed to be thrown up the rectum night and morning; diet gener- ous. " Did you follow the directions, madam ?" " Yes, sir, strictly." " How often did you find it necessary to renew the medicine in the phial ?" " Three times, sir." The principal difficulty in this case is re- lieved—the profuse menstruation; and I shall now order for this patient a table-spoonful of the following tonic twice a day : R- Sulphat. Quinae......gr. xij Acid Sulph. dilut......gtt. xij Aquae distillatae......§ iij Ft. sol In these cases of passive menorrhagia, it is essential first to arrest the bleeding, and afterward, by the judicious use of tonic remedies, to repair the waste.—Page 10. Gonorrhaal Ophthalmia.—William J., aged three years, was returned to the Clinic to-day, with his left eye, which had been the seat of severe gonorrhceal inflammation, quite restored to health.—Page 15. Chlorosis, with suppression of the Menses.—Susan M., aged eighteen years, has undergone a remarkable improvement in her general health. 570 APPENDIX. Her tongue has lost its white coat, her bowels have become regular, with a good appetite; her menstrual evacuation is restored, and she no longer complains of vertigo, palpitation of the heart, neuralgia, etc. The cough, to which particular attention was directed when this girl first ap- plied for advice, has also disappeared. You will remember, gentlemen, when speaking of the case, I impressed upon you the importance, among other things, of making a just distinction between tho cough of chlorosis and the cough of phthisis pulmonalis. The treatment ordered for her, and which has resulted in the restora- tion of her health, was the following: R Sub. Mur. Hydrarg. . • . . . gr. viij Pulv. Rhei ......gr. xij Ft. pulv. To be followed in the morning by %] of castor-oil; and, with a view of exciting a healthy action of the liver, she was directed to take for three successive times every fourth night ij grains of the Hydrarg. c. creta, with half a pint of tepid water thrown into the rectum night and morning, to promote the regular peristaltic movement of the bowels. After the bowels had been freely evacuated, a table-spoonful of the following mixture was taken twice a-day : gr. xv gtt. XV . aa 3 hj §vj M. When this was completed, she took twice a-day 1 gr. of sulphate of iron, and 2 of Barbadoes aloes. " How many pills, Susan, did you take before your courses came on ?" " Just twenty, sir." " And are you now quite well ?" " Yes, sir."—Page 22. Pruritus Pudendi from Final Cessation of the Menses.—Mrs. 0., aged forty-six years, says she is altogether relieved from the annoying irritation of the external organs, from which she had suffered so severely for two months before applying for advice. This was a case of pruritus pudendi, attributable to the final cessation of the menstrual function. She was ordered to lose I viij of blood from her arm, and to be freely purged, with exclusively vegetable diet. The parts to be washed twice a-day with Castile soap and water, and the following lotion to be freely used: R Sulphat. Aluminis......3 ij Aquae Purae.......§ xvj Ft sol —Page 31. Amenorrhaafrom imperfect Physical Development, in a Girl, aged seven- teen Years.—Sarah H. is reported by her mother as much improved in R Quinae Sulphat. . Acid Sulph. dilut. Tinct. Card. c. ) Tinct. Humuli, ) Infus. Rosae, c. . APPENDIX. 571 her general health, but her menstrual function has not yet appeared. " I should judge, my good woman, from the change in the appearance of your daughter, that her health is very much better than it was when you first brought her here." " Yes! indeed it is, sir, but I am very un- easy because her turns have not come on." " You need give yourself no uneasiness; she will be all right in due time." The case of this young girl, gentlemen, is one full of practical interest. You will remem- ber that when she first applied for advice, I called your attention partic- ularly to the fact that, although seventeen years of age, yet she was a mere child as regarded her physical development. The treatment sug- gested for her consisted in remedies calculated to invigorate her general health, and to develop her physical forces. The amenorrhcea, although the chief object in the mother's mind, causing her much anxiety, was for us a trivial circumstance. You perceive now, from the general ap- pearance of the girl, that her health is much improved. For the pres- ent, I shall direct a pill twice a-day of the following combination: R Sulphat. Ferri ....... 3j Extract Gentianae......3ij Divide in pil. xx. In referring to this case, you will be reminded of the treatment orig- inally suggested; and I feel every confidence that as soon as her physical system is sufficiently developed, this girl's menstrual function will be- come established.—Page 33. Undue Lactation in a married Woman, aged thirty-eight Years.—Mrs. P., who, it will be remembered, was extremely exhausted from the effects of suckling her infant, and whose general health was much impaired, reports herself relieved, and says her health is now much better than it has been for the past six months. Her menstrual turns have become regular. The subject of undue lactation is one of extreme interest to the prac- titioner, and of no little consequence to the patient. If suffered to con- tinue, its effects on the general health are insidious, but most positive, and oftentimes destructive. It would be an interesting disclosure, if the fact could be ascertained, how many deaths have ensued from this cause, not directly, but indirectly. For instance, the first effect of over- suckling is exhaustion ; but we are not to forget that the results of this exhaustion are multiplied, and frequently fatal. Not to speak of the numerous nervous disturbances, such as mania, epilepsy, convulsions, etc., so apt to ensue from the operation of this cause, we must take into account the organic and functional derangements of the uterus, phthisis pulmonalis, etc., which, it is now conceded, will occasionally be produced by the dilapidated health consequent upon protracted or undue lactation. It is, therefore, the duty of the practitioner promptly to distinguish be- tween the healthy and morbid effects of suckling; for the early recog- 572 APPENDIX nition of the latter influence will frequently enable him to protect both mother and child against serious disease.—Page 34. Irritation from Teething—Constipation.—J. W., aged nine months, had suffered much irritation from teething; he was feverish and restless; and his bowels constipated. " How is your child now, madam ?" " It has got quite well, sir, since I gave it the medicine, and put it in the warm bath."—Page 36. Anasarca and Ascites following Scarlatina.—I am happy, gentlemen, to be enabled to show you this little fellow, who now exhibits a very different appearance from what he did when he was first brought here, three months ago. You will recollect that this boy was affected with ascites and anasarca of the extremities, together with albuminous urine. He is now quite recovered. It was a case of sthenic dropsy, requir- ing prompt and active depletion.—Page 37. Mucous discharge from the Vagina—Warty Excrescences on the Vesti- bulum.—Sarah W., aged thirty-eight years, married, says she has no longer any discharge from her vagina. This case is one well worth attention. The patient before us had suffered for eighteen months from a vaginal mucous discharge, for which her physicians had prescribed astringent washes, but without the least effect. When she came here, I examined her very particularly, and discovered several warty excrescences studding the vestibulum; and these, as was explained at the time, constituted the only cause of the mucous secretion. The excrescences were re- moved with a pair of curved scissors, and the cut surface freely touched with the nitrate of silver. Before introducing the patient here to-day, I examined the vagina. There is no vestige of the excrescences, and she is entirely free from the discharge.—Page 58. Vascular Tumor of the Meatus Urinarius.—Mrs. S., aged twenty-six years, married, reports herself entirely relieved from the distressing pain which she suffered during micturition. I am quite sure, gentlemen, you have a lively recollection of this case. The patient before us was affected with an interesting form of disease—the vascular or bloody tumor of the meatus urinarius, the only remedy for which is removal, either by the scissors, ligature, knife, or caustic. We employed, you will re- member, the scissors, and you will not have forgotten the free hemor- rhage which followed the excision of the tumor. This, as I told you at the time, is not at all unusual, and constitutes one of the important fea- tures of the affection. The hemorrhage was readily arrested by the ap- plication of nitric acid to the cut surface.—Page 64. Suppression of the Menses from Fright.—Nancy H., aged twenty years, unmarried, whose courses had been suppressed for three months, in con- APPENDIX. 573 sequence of having been alarmed by a fire in a house adjoining the one in which she resided, and whose system had been greatly disturbed by the plethora resulting from the suppression, as was evinced by the head- ache, dizziness, sense of suffocation, etc., is now in the enjoyment of good health. Her menses have returned, and she says she is no longer troubled in any way. The treatment of this case consisted in measures intended to remove the plethoric condition of system—and this, in cer- tain forms of suppression, is one of the surest means of restoring the function. " Did you find it necessary, Nancy, to take the pills ?" " No, sir—my courses came on in ten days after I was bled, and took the pow- der you ordered ; but I continued for two weeks to take a wine-glass of the cremor tartar and salts, which you told me to do every morning be- fore breakfast."—Page 70. Injury from introduction of the Catheter during Pregnancy— Ulcer on lower surface of the Urethra.—Mrs. J., aged twenty-four years, married, applied for advice some time since in consequence of pain in passing water, etc. On examination, it was discovered that' the source of her difficulty was an ulcer on the lower surface of the urethra, which had been occasioned by rude attempts to introduce the catheter in the seventh month of her gestation. The treatment consisted in the injection into the urethra of a solution of the nitrate of silver 3j to § iv of water, to- gether with the free use of flax-seed tea as a drink. " How is your health now, madam?" "I am quite well, I thank you, sir. I have no longer any trouble with my water."—Page 76. Vicarious Menstruation in a Girl, aged nineteen Years—Epistaxis.— Emma J., unmarried, had labored under suppression of the menses for two years. A substitute or vicarious menstruation, from the Schneide- rian membrane of the nose, had commenced about six months before she applied for advice at the Clinic, occurring every three or four weeks. She now says her menses have become restored, and the bleeding from the nose has ceased.—Page 80. Vomiting in an Infant aged five Months, immediately after taking the Breast—Can a nursing Woman become pregnant before the re-appearance of the Menses ?—Margaret McD., returns to the Clinic with her child, and says the child is quite well, has not vomited since she weaned it, and that she herself is near her confinement. You will remember, gentle- men, that when this woman was first presented to you, she was anxious about her infant, then five months old, because of its vomiting imme- diately after taking the breast. After a thorough exammation of the child, I could see no cause for the vomiting except the deranged condi- tion of the mother's milk, which I supposed was due to the fact that she was pregnant, although she did not imagine herself to be in that state. 574 APPENDIX. The future has shown that I was right in my judgment, for she is now before you, and within a few weeks of her confinement.—Page 92. Defective Menstruation in a Girl,aged twenty Years.—Maria G., whose menstrual evacuation had been deficient in quantity for six months be- fore applying at the Clinic, and who, as a consequence, suffered from headache, flushed countenance, etc., reports herself quite well—her men- strual function is regular as to time and quantity. " How often were you bled, Maria ?" " Four times, sir."—Page 96. Final cessation of the Menses in a Widow, aged forty-nine Years.— Mrs. B. says she is no longer annoyed with vertigo, a feeling of suffoca- tion, palpitation of the heart, etc.—Page 101. Induration of the Neck of the Uterus in a married Woman aged twenty- nine Years.—Mrs. R. reports herself free from the bearing-down pain in the region of the womb, and says she is not troubled with the white creamy discharge from her vagina. This case, gentlemen, was one of simple induration of the cervix uteri, the result of chronic inflammation. When this patient was first reported, I called your attention to the ne- cessity of a proper distinction between the induration of schirrus, and the induration of ordinary inflammation. I prescribed for this patient a combination of the prot. iod. hydrarg. and extract conii, one-quarter of a grain of the former to two of the latter, to be taken every night until the gums were slightly touched, followed, with a view of invigorat- ing the strength, with a bitter infusion of gentian, etc., with nutritious diet. " Did your gums become sore, madam ?" " Yes, sir, after I had taken fourteen pills, and then I did not take any more." " That was right, my good woman. Has your health gradually improved ?" " Yes, sir, about two months after I commenced the medicine I began to feel better, and I am now quite well." This is an interesting case, and shows plainly the good effects of the discreet use of mercury in simple induration. Before introducing this patient here to-day, one of my staff, Dr. Martin, and myself have both examined her, and there is nothing abnormal about the cervix, nor is there any discharge from the vagina.—Page 106. Palpitation of the Heart in a Girl thirteen Years of age.—Catherine R., aged thirteen years, is returned to the Clinic by her mother, who says she is very happy to state that her daughter has recovered her health. " Well, my good woman, I am glad to see this change in your little daughter. Did you find it necessary to give her the pills after she had taken the other medicine ?" " Yes, she took twenty of the tonic pills you ordered, and she is now, as you see, sir, in excellent health." This case, gentlemen, is one of more than usual interest, and in referring to it, you will be reminded of what we said when it first came before us.— Page 111. APPENDIX. 575 Purulent Ophthalmia in an Infant, four Weeks old.—Jme M., aged four weeks, who had been affected with purulent ophthalmia, has re- covered, and, as you see, there is no appearance of inflammation about the eyes. The treatment ordered was faithfully carried out by one of my staff, Dr. Steves.—Page 114. Chorea in a Girl aged ten Years, from intestinal Irritation.—Hannah D., aged ten years, had been affected with chorea for eight months. You will remember, gentlemen, we could perceive no other cause for the disease than intestinal irritation from worms. The child was treated in accordance with this diagnosis. She is now before you, and is entirely relieved. " Did your child pass any worms, my good woman, after she took the medicine ?" " Yes, sir, she passed five long worms." " After the operation of the medicine, did you give her the iron powders ?" "Yes, sir."—Page 115. Retention of the Menses in a Girl seventeen Years of age, with Habitual Constipation.—Eliza M., aged seventeen years, is reported by her mother as much improved in health. Her menstrual function has become es- tablished, and is now quite regular. This case, gentlemen, is full of pratical importance. The girl had labored under habitual constipation, was nervous and irritable, and presented a chlorotic appearance. The treatment consisted in measures calculated to relieve the constipation, and she was ordered to take twice a day, as circumstances might indi- cate, a pill of two grains of Barbadoes aloes and one of sulphate of iron. The result you now have before you in the improved condition of this patient.—Page 118. Ulceration of the Neck of the Uterus in a married Woman, twenty-two Years of age.—Mrs. P., had been affected since the birth of her child, five months old when she first applied for advice, with pain in her hips and back, pressure on the upper part of the head, a muco-purulent dis- charge from the vagina, lithates in the urine, etc. On examination, it was ascertained that she labored under chronic ulceration of the cervix uteri. Attention was given to the ulceration. Applications were made to the ulcerated surface with the nitrat. argenti, six times, which, to- gether with tonics, constituted the whole treatment. " What, madam, is the state of your health at present." " I am very much better, I thank you, sir. I have no pain about my womb or hips, and my head is quite relieved from the distressing pressure." "How is your digestion." " That is good, sir ; my bowels are regular and my appetite is good." " Have you any deposit in your urine now ?" " No, sir." This case, gentlemen, is an instructive one. I have examined the uterus and find it quite free from disease.—Page 124. 576 APPENDIX. Ante-version of the Uterus from a collection ofhardfacal matter in the Rectum—Removal of the accumulated Faces by the introduction of a small Spatula.—Mrs. W., aged twenty-five years, the mother of one child, one month old, reports herself entirely relieved from the disagreeable symp: toms of which she complained when she first presented herself at the Clinic. This patient, you will not have forgotten, gentlemen, was much annoyed with ante-version of the uterus produced by a collection of faecal matter in the rectum. The faeces, you will remember, I removed with a spatula, or- dered medicine to keep the bowels soluble, and the result, you see, is the restoration of the uterus to its normal position, and entire freedom from all the distressing effects of the displacement.—Page 143. Epilepsy in a Girl, aged twenty Years, from suppression of the Menses for the last twelve Months.—Ann T., whose case you will, I am sure, re- member with interest, is now before you, and, as her mother informs us, restored to health. Her menses have become re-established, and she has not had an epileptic convulsion since that time. " How often was your daughter leeched, my good woman ?" " She was leeched three times, sir, and after the third leeching her turns came on, and since that she has been like a different girl." This is one of the most interesting cases we have had before us for some time, and is particularly gratifying in its results.—Page 152. Convulsions from Teething in an Infant, eleven Months old—Danger of Opiates in Infancy.—Wm. N., aged eleven months, is reported by his mother as having recovered, and is now a buxom, healthy-looking little fellow. This is the child who incurred such danger from convul- sions, which had been no doubt provoked by the imprudent administra- tion of paregoric.—Page 172. Dropsy in a Girl eleven Years of age, with Albuminous Urine.—Ra- chel M., is reported by her mother as much improved in health. This little girl, when first presented here, gave us but poor hope. Her abdo- men was greatly distended with fluids, and there was general infiltration of the lower extremities. It is gratifying to see the manifest amendment in her condition; although she is yet feeble, and will need careful atten- tion. The abdomen, you perceive, is very much diminished in size, and the anasarcous condition of the limbs has subsided. " How are your child's bowels, madam ?" " Quite regular, sir." " Does she pass her water regularly ?" " Yes, sir—and when she took the powders she per- spired so freely that I think they gave her great relief." " Do you give her the quinine mixture, now ?" " Yes, sir—and it seems to give her a fine appetite." " Very well—continue with the quinine a few days longer—give your child nutritious diet, and be sure she is not exposed to cold."—Page 175. APPENDIX. 577 Pruritus Pudendi in a married Woman, aged twenty Years.—Mrs. B., was a great sufferer when she first came to the Clinic, from pruritus. " How is your health, my good woman ?" " Thank you, sir, I have no more trouble now." You will remember, gentlemen, that I made three applications to the ulcers on the internal surface of the labia majora, etc., of this woman which, together with the other remedies, have restored her to health.—Page 180. Warty Excrescences in the Vagina of a little Girl, accompanied with Mu- cous discharge.—Julia S., aged three years, had suffered greatly from irritation and a discharge of mucus from the vagina, which occasioned the mother much anxiety. On examination it was ascertained that the vestibulum, lateral and outer portions of the vagina were studded with warty excrescences. These constituted the source of the irritation and discharge. The only remedy ordered was an application to the excres- cences of equal parts of the acetate of copper and powdered savin. " How many times, madam, did you apply the powder ?" " Once every day for four days, sir." " How is your child now ?" " She is quite well, sir—she has no more tumors, and the discharge has left her."—Page 188. Convulsions in an Infant five Weeks old, from Constipation.—Julia E., is reported by her mother as having recovered. This little infant, gentlemen, was in much danger from several attacks of convulsions, traceable to a constipated condition of its bowels. " Well, madam, you must be careful in future not to neglect your child's bowels." " Indeed I shall, sir."—Page 195. Falling of the Womb from engorgement of its Cervix, in a married Woman aged forty-three Years.—Mrs. B. had been affected for nearly two years with falling of the womb from engorgement of the cervix. Your attention, gentlemen, was called very particularly to the various causes of prolapsion, and you were told that the remedy must be adapted to the cause, etc. The patient before you I examined to-day before in- troducing here, and am gratified to find that her uterus is now in its natural position, the engorgement having yielded to the remedies pre- scribed when she first came to the Clinic.—Page 202. Retention of the Menses, with Hamatemesis, in a Girl aged seventeen Years—Vicarious Menstruation.—Margaret M., says her courses have come on, and are now quite regular; she has not vomited any blood since her menses have appeared. " Were you bled, Margaret, as directed ?" " Yes, sir—and I did every thing just as you ordered." " How many times were you leeched ?" " Four times, sir, and after the last leeching my turns came on; and since that I have felt very comfortable."—Page 206. 578 APPENDIX. Threatened Paralysis of the lower Extremities in a married Woman, aged twenty-one Years, from defective Menstruation.—Caroline W., re- ports that her monthly turns have become more abundant. She is no longer troubled with dizziness, etc.—Page 208. Meteorism with Globus Hystericus in a young Girl,aged nineteen Years, the result of Hysteria.—Lucy R., whose case was one of much interest from the fact that she was attacked with hysteria, etc., in consequence of the suppression of her courses from fright, returns to-day, and says she is now in better health than she has been for the past ten months. " Have your courses returned, Lucy ?" " Yes, sir ; and I have no more fits." On referring to this case, gentlemen, you will have your recollections refreshed respecting its various points. In looking at the record as taken down at the time, I find this girl returned here one week after she first presented herself, and in addition to what had previously been or- dered she was directed to take, for two nights successively, just before the expected return of the catamenia, two aloetic and myrrh pills of five grains each—and, should it be necessary, to have four more leeches ap- plied, together with the styptic pediluvium. " How often were you leeched, Lucy?" "Twice, sir, and then my courses returned." This case, gentlemen, is one of much practical moment.—Page 236. Paraplegia in a Child, twelve Months old.—Rachel L., aged twelve months, is returned to the Clinic by her mother, who is very happy be- cause her little child has recovered the use of its limbs. This case, gen- tlemen, is but a type of what you will often meet in practice ; and if we had looked at the shadow instead of the substance in our diagnosis, we should not only have employed absurd treatment, but we should have failed in restoring to this child the use of its limbs. The shadow was the paraplegia, the substance the constipation, which, through the spinal irritation it occasioned, had so far impaired the motive power as to in- duce the paraplegic condition of the extremities.—Page 270. Incontinence of Urine in a married Woman, eighteen Years of age.—Mrs. T«, reports herself entirely relieved from all difficulty with her water, and says she can retain it now as well as ever she did. This patient, you will remember, was directed to take in a wine-glass of flax-seed tea, ten drops of the tincture of cantharides, and to apply a blister over the sacrum. " How long, imidam, did you take the drops?" "I took them four days, sir; and put on the blister as you ordered. For the first few days after- ward I felt a smarting about my bladder, and ever since that I have had no trouble whatever with my water." " I am glad to hear it, madam." —Page 274. Palpitation of the Heart in a married Woman, aged thirty-two Years, from Dyspepsia.—Mrs. B., whose case was an interesting one of func- APPENDIX. 579 tional disturbance of the heart, and who had been much distressed in mind for fear she would die suddenly, reports herself quite recovered.— Page 280. Suppression of the Menses from Cold in a young Woman, twenty-two Years of age.—Mary J., whose menstrual function had been suppressed for three months from cold, reports that her turns have been restored, and that she is now quite free from headache, etc.—Page 293. Amenorrhaa, with imperforate Os Tinea, and encysted Dropsy of tk right Ovary, in a Girl aged nineteen Years.—Mary R., the poor girl oi. whom I performed the operation of vaginal-hysterotomy, thus removing three quarts of a tenacious dark-colored fluid, and who had been a great sufferer for four years, died one month after the operation. This event does not at all surprise me; and you will not have forgotten, gentlemen, when this case was first brought before you, I expressed very emphatic- ally my doubts that we could do any thing more than afford her tem- porary palliation.—Page 297. Atrophy in an Infant, aged twelve Months.—John R., aged twelve months, is returned by his mother, who reports his health much improved. You will, gentlemen, scarcely recognize in the cheerful countenance of this little fellow, the emaciated and suffering infant which was presented to your observation some months since. It was a case of extreme atrophy, and one which certainly, from the general condition of the child, did not exhibit any strong hopes of relief. When this child was first brought here I took occasion to call your attention to the subject of atrophy, and I ventured to express to you what I imagined to be the true explanation of this affection ; the treatment suggested was based on the hypothesis which I then submitted. One of my staff, Dr. Thomas A. Gregory, was intrusted with the care of this case—and he, I am sure, feels no little pleasure in the result of the treatment. The doctor, who is now present, states that he carried out the directions most faith- fully. This little child is now rapidly recovering its health, and I think he is more in need of good care and appropriate diet than he is of medi- cine. Therefore, for the present at least, I would advise that all medica- tion be suspended, which, on inquiry, I find has been done by Dr. Greg- ory for the last two weeks.—Page 303. Retro-version of the Fundus of the Womb in a married Woman, aged twenty-four Years—Amussafs operation.—Mrs. L., you will remember, gentlemen, had been affected since the birth of her last child, with a painful pressure on her rectum, and a sensation of numbness in her lower limbs, etc., after an examination of the case, I discovered that all her diffi- culties were occasioned by a retro-version of the uterus. In turning to 580 APPENDIX. the record you will recollect that I performed the operation, in your presence, suggested by Amussat for this character of uterine displace- ment—which consists in cauterizing with the potassa cum cake the pos- terior surface of the posterior lip of the os tincse, and also the upper and posterior portion of the vagina—an eschar is thus formed, adhesion is the consequence between the upper portion of the vagina and posterior lip—and when this adhesion takes place, the cervix uteri is drawn back- ward, while the fundus resumes its natural position. In the case before us, the operation has been completely successful—there is no longer any retro-version, and the patient informs us that she is quite free from disagreeable pressure in her back passage, nor is she any longer troubled with numbness in her lower extremities. " Now, my good woman, you do not regret having submitted to the operation, do you?" " Indeed, I do not, sir."—Page 341. Profuse Menstruation in a married Woman, aged thirty-nine years, from chronic sanguineous Engorgement of the Uterus.—Mrs. M., whose case, gentlemen, you will remember with much interest, reports herself relieved from the menorrhagia, and in improved health. The treatment consisted in the administration of a tea-spoonful of the tincture of ergot in a wine-glass of cold water twice a-day, as circumstances might indi- cate, and half a pint of water cold from the pump to be thrown every morning into the rectum. This, together with the regulation of the bowels, constituted the entire treatment, and you see the patient before you restored to health. Turn to the record, and you will note what we said touching this interesting case when it first presented itself here.— Page 355. Utero Lumbar-Neuralgia in a married Woman, aged twenty-six Years. —Mrs. S. reports herself relieved from all pain about the uterus, and says she is not any longer troubled with a discharge of mucus from the vagina. This case, gentlemen, is one of extreme interest in a prac- tical sense, and I am much gratified in having an opportunity of testing the value of the remedy we recommended. It was simply a nitric acid issue on the side of the lumbar vertebrae ; the issue was kept discharg- ing for two months, the result of which is the restoration of this woman to health.*—Page 361. Deep Ulceration of the Cervix Uteri in a married Woman, aged thirty- one Years.—Mrs. McD., when she first came to the Clinic, was affected with deep ulceration of the neck of the womb, and was annoyed with pain in the back and hips, constipation, a purulent discharge from the * At pages 443 and 495 there will be found a case of neuralgia of the right labium externum, somewhat kindred to this, which also yielded to the continued use of the issue. APPENDIX. 5gl vagina, headache, and a deposit of lithates in the urine. I made in your presence five applications, at an interval of six days, to the ulcerated surface with the potassa cum calce. Her bowels were regulated, and she was placed upon a tonic course. She states that she is now quite well; there is no purulent discharge from the vagina; the pain in her head', back, and hips has left her, and her urine is natural. I have examined the uterus, and find the ulceration has entirely disappeared, and the organ in a normal state. This case is an extremely interesting one, showing, as it does, the dependence of the several general symptoms upon lesion of the uterus.—Page 383. Anamia in a married Woman, aged thirty Years, with Incipient Anasarca, the result of profuse Flooding during a Miscarriage.—Mrs. R., whose case was one of much interest, exhibiting the constitutional effects of excessive losses of blood, is much improved in health. There is now no appearance of anasarca, and she is quite free from vertigo and palpitation of the heart, etc. The treatment was altogether tonic, in- tended to repair the waste which her system had sustained, and the re- sult, as you see in the improved appearance of this woman, has been most satisfactory.—Page 397. Frequent desire to pass Water in a married Woman, twenty-seven Years of age.—Mrs. O. says the difficulty with her water is entirely re- lieved. The treatment here consisted of an injection into the urethra of one syringeful of the solution of the nitrate of silver, 3J to % iv of water. The injection was repeated three times, at an interval of two days; and the patient was, in addition, directed to take during the day half a pint of the decoction of buchu.—Page 401. Sympathetic Cough from Intestinal Worms in a little Girl, seven Years of age.—Ann McD. is returned to the Clinic by her mother, who says she is well of her cough. This is the little girl, gentlemen, about whom the mother felt so much anxiety, fearing that she was in con- sumption. Your attention was particularly drawn to the subject of the cough when speaking of this case, and you were especially admonished to distinguish between the cough of inflammation, and the cough of mere sympathetic action. We assured the mother, you will recollect, that there was not the slightest cause for anxiety ; and we referred the cough to the presence of worms. The child was treated upon this as- sumption. " Did you follow the directions given you, madam ?" " Yes, sir." " Did you notice any worms pass from your child after it took the medicine ?" " I gave it the powder, sir, at night, and in the morning the draught, and when the medicine operated it brought away four long worms. Four days after the worms came away, sir, the cough left it." This case is worth a thought, gentlemen, for you will often meet with 582 APPENDIX similar ones in practice, and it is essentially important that your diag- nosis should be correct.—Page 402. Inversion of the Mucous Membrane of the Urethra in a married Wo- man, aged forty Years.—Mrs. P., aged forty years, returned to the Clinic to-day, and says she still has difficulty with her water. This case, you will remember, was one of inversion of the mucous membrane of the urethra. The outer surface of the protruding membrane was ulcerated. This I touched with a solution of the nitrate of silver; and I find now, upon examination, that the ulcer is completely healed. This woman, however, needs relief; and if she will permit me, I will remove with the curved scissors the projecting fold of membrane, and in the course of a few days she will be quite free from all annoy- ance. "Madam, will you allow me to do what I think right for you?" " Yes, sir." [The patient was placed on the bed; the Professor grasped, with a pair of small forceps, the inverted membrane, and excised it with the curved scissors; and then applied to the cut surface the solid nitrat argenti.] It will be necessary for this woman to keep her bed for a few days, and to drink freely of diluents ; this is all that will be required. —Page 403. Congestive Dysmenorrhaa in a Girl, twenty Years of age.—Jane L., who had suffered seriously from dysmenorrhoea for the past fourteen months, reports that her courses are quite regular, and the pain during the cata- menia is very slight. This girl, gentlemen, when she first came here, to use her mother's language, " almost lost her senses from excessive suffer- ing," during her monthly sickness. It was a case of congestive dysmen- orrhoea, which was treated by the local abstraction of blood from over the sacrum, purgation, and a strictly vegetable diet. The result has been most gratifying.—Page 412. Granular Vaginitis in a married Woman, aged twenty-six Years.—Mrs. A. reports herself entirely relieved. This was an interesting case of disease, to which your attention was particularly directed when this pa- tient first presented herself here. On an examination, I find the vagina quite natural, free from both granulations and discharge. The treatment consisted in painting with a solution of the nitrate of silver the granu- lated surface, 3j of the nitrate to I j of water, together with the daily use of the tepid hip bath. The cauterization was employed five times at an interval of two days.—Page 421. Dysmenorrhaa in a married Woman, aged twenty-four Years, from Stricture of the Neck of the Womb.—Mrs. H., who had suffered for the last eight years from painful menstruation, and who had taken a great variety of remedies, as she informed us, without any relief, re- A.PPENDIX. 583 ports hersef quite natural in her turns, and says she is now in excellent health. This case is well worthy of your attention. This poor woman s distress was owing to stricture of the neck of the uterus, and to nothing else. I introduced into the cervix, in your presence, on seven different occasions, at an interval of a week each, an instrument for the purpose of dilating the stricture. The result is the relief of the patient.—Page 428. Ascites, together with general Anasarca, in a Boy, five Years old, the effects of Scarlet Fever.—Michael M. is reported to be much improved in his health. You perceive, gentlemen, from the appearance of this little fellow, a remarkable change in his condition. The anasarcous in- filtration has entirely subsided, nor can I detect any fluid in the abdo- minal cavity. The treatment suggested for the child has been most faithfully carried out by one of my staff, Dr. Martin, and the result has been, as you see, most satisfactory.—Page 433. Ascites in a Boy, three Years old, from protracted Dysentery.— Arthur J., who was laboring under atonic ascites from dysentery when first brought here, is returned to-day with improved health, and an evi- dent diminution of fluid in the abdomen. The same treatment, which was essentially tonic, to be continued.—Page 434. Prolapsus Uteri from hard Engorgement of the Cervix, in a married Woman, aged thirty-two Years.—Mrs. S. is relieved from the bearing- down pains and frequent desire to pass water of which she complained when she first came to the Clinic. This was a case of prolapsion of the womb from hard engorgement of the cervix. The treatment was revuls- ive bleeding from the arm once in ten days, occasional use of saline cathartics, and rest in the recumbent position. I have examined this patient to-day. The engorgement has disappeared, and the uterus is in situ. " How many times, madam, were you bled ?" " Five times, sir."—Page 441. Laryngismus Stridulus in an Infant, seven Months old.—Mary H., the little infant who was brought here some time since, laboring under laryngismus stridulus, is reported by her mother as quite well, and free from the peculiar crowing respiration with which it was affected at the time. The treatment in this case consisted in the regulation of the bowels, and change of diet. " Did you wean your child, or procure another nurse for it ?" " I weaned it, sir, and have fed it upon cow's milk, as you directed; and it is now, sir, in perfect health." "If you wish to keep it in good health, madam, be careful, and do not allow its bowels to become neglected."—Page 454. 584 APPENDIX. Neumlgia of the Cervix Uteri in a married Woman, aged twenty- three Years.—Mrs. S., who had suffered intense pain in the uterus, more or less, for four months before applying here for advice, reports herself well, and says she has not had any pains since the last application was made to the womb. This is quite an instructive case, and is well worth recollection. The patient before us had been much annoyed with idio- pathic neuralgia of the cervix uteri. I made three applications with the solid nitrate of silver to the painful surface, at an interval of five days ; and the result is entire relief.—Page 477. Retro- Uterine Hamatocele in a married Woman, aged thirty four Years —Exploring Needle.—Mrs. L. returned to-day, and informs us that the pain of which she complained in her back passage, and the frequent de- sire to have an evacuation from her bowels, have entirely subsided. You have had no case before you, gentlemen, of more practical interest than this. You will not have forgotten the diagnosis we formed touch- ing the cause of this woman's distress. We pronounced the cause of her suffering to be an extravasation of blood in the triangular fossa, be- tween the uterus and rectum, constituting a retro-uterine hamatocele. This opinion was amply confirmed by the introduction into the tumor of the exploring needle. I remarked to you at the time that the occa- sional introduction of the needle, permitting the partial escape of blood, together with the action of the absorbents, would probably suffice to dissipate the tumor. In this view I have not been disappointed, for you see the patient now before you quite relieved from suffering. This pa- tient has been before us five different times, and on each occasion I in- troduced the exploring needle, and caused a small discharge of blood.— Page 480. Amenorrhaa in a Girl, sixteen Years of age, from an Atonic Condition of System.—Mary W. is reported by her mother as much improved in health. Her bowels are now regular, her appetite is good, she sleeps well, and she has had her courses twice; they have been sufficiently abundant; and she is altogether, her mother says, a different girl. This case, gentlemen, is an instructive one. There were no emmenagogues given here ; the treatment consisted in the invigoration of the general health.—Page 483. Chorea in a Girl, six Years of age, from Fright.—Elizabeth H. has undergone a decided improvement since she was last here. She is much less nervous, and there is every prospect that she will soon entirely re- cover her usual health. This was a case of chorea from fright, and it is yielding very satisfactorily to a combination of zinc and extract of gen- tian. Let the same treatment be continued.—Page 515. FORMULA OF REMEDIES. THE FOLLOWING PRESCRIPTIONS, SELECTED FROM VARIOUS SOURCES WILL NO DOUBT PROVE USEFUL. ANTHELMINTICS. B. Semin. Santonici . . 3 vj. Aquae bullient . . § xij. Ft. Infus. One third to be thrown up the rectum for three successive nights; Or, B • Syrup Alii Sativi . . § ss. Olei Terebinthinae . . 3 ij. Decoct. Hordei . . § iij. The whole of this to be injected into the rectum at night, followed in the morning by a dose of Castor oil. Either of the above enemeta useful in ascarides. IJ. Pulv. Spigelian Mariland. " Senna? . aagr. xviij. " Sabinae . . . gr. vj. Divide in chartulas iij. One every night, followed when all are taken by Castor oil $. Hydrarg Biniodid . . gr. \. Potass. Iodid . . gr. ij. Aquae distillatae . . § iij. A good enema for Ascarides. Pulv. Stanni Mel. Alb. 3j 3x. M. A tea-spoonful three times a day for children afflicted with lumbricoides. B. Pulv. Spigelian Mariland. " Stanni . Syrup. Zingiberi Mellis ... Fiat Bolus. Taken at a dose in lumbrici. gr.x. 3 ij- 3 ss. q. S. B. 3]J- §iss. aa 3 ij. Infus. Absinthii " Gigartinae Tinct. Valerianae ) Syrup Zingiberi ) Ft. mistura. One third part taken every fourth hour in lumbrici. B. Infusi Spigeliae ) Infusi Allii J ' Confect. Terebinthinae Fiat haustus. Very effectual in lumbrici. aasj. 3y. B. Hydrarg. c creta ) Pulveris Scammonii J Carb. Sodae Siccat. Pulveris Aromatici Divide in chartulas iij. One powder each morning—very good in lumbrici. aa gr. vj. • gr. iij. CATHARTICS. B. Pulv. Bhei. . . . 3ij. Ferri Sulphatis . . gr. xv. Saponis . . . 3j. Aquae distillatae . . q. s. Fiat massa in pil. xx dividenda. Two or three at bed-time, in constipa- tion in debilitated habits. a&3i B • Pulv. Ehei. ) " Zingiber ) * Extract Anthemidis . 3 j- Fiat massa in pil. xxx. dividenda. Three pills at a time in such cases as above. B. Olei Amydal. ) aa gij. Syrup Gummi Croton Tiglii . ' . . gtt. ij. A table-spoonful every thirty minutes in obstinate constipation. £. Pulv. Rhei ) Carbonat. Sodae Siccat. > aa gr. xx. Extract Gentianae . ) Sub. Mur. Hydrarg. . . gr. iij. Divide in pil. xx. Two occasionally as a mild aperient. B Manna? . . . '. Aquae Menthse piperit Ft. haustus. A gentle aperient for children. 3ss. Iss. 586 FORMULA OF REMEDIES. B. Hydrarg. c creta J Pulv. Scammonii > Carb. Soda? Siccat. ) Pulv. Aromatici Divide in chartulas vj, One powder a day. An excellent al- terative for children, and efficient in worms. gr.xij. gr. vj. R Submur. Hydrarg. Pulv. Jalapae . " Antimonialis . gr.x. . gr. xv. ■ gr-j- M. Followed in the morning by Castor oil. aa gr. v. Submur. Hydrarg. ) Pulv. Jalapae ) Olei cSuamon \ ™***• * M. R Extract Colocynth comp. . 3j. Submur. Hydrarg. . . 3ss. Pulv. Antimonial . . gr.j. Divide in pil. x. Two, as circumstances may require. PULVIS PURGANS. $. Pulv. Rhei , , . gr. xxxvj Sodae Sulphat. . • 3j- Pulv. Zingiber . . gr. xviij. OL Cassiae . . gttvj. Divide in chartulas vj. One powder in Iij. of warm water ■ight and morning. R. Pulv. Rhei . . . 3j- Sodae Carbonat. ) ss ,., Pulv. Columbae J a 61J" Aquae Mentha? piperit. ) a5 z • use purae . ) ° Two table-spoonsful three times a day. 3j- 3iss. R. Massa? Hydrarg. Pulv. Aloes Divide in piL xx. One pill three times a day in defective biliary secretion. R. Pulv. Aloes. " Rhei \- . aa 3j Saponis - gr X. Divide in pil. X. One or two pills at night. R. Pulv. Aloes 1 " Rhei J " Saponis Ipecac. Divide in pil. xxx. Two or three at night. aa 3S8. gr.x. gr.uj. R. Nitrat Argenti . . gr. vj. Extract Colocynth comp. . gr. lxviij. Divide in pil. xxiv. One pill twice or thrice a day in nervous headaches of young women. A favorite remedy of Dr. Graves. },. Pulv. Rhei . . . Sii. " Ipecac. . . . gr. xij. Saponis . . . . vj. Divide in pil. xii. One pill three times a day in pilea R. Pil. Colocynth comp. ) a- xxy Saponis Jalapina? ) & • • Ft. massa? in pil. xij. dividenda. Two pills as occasion may require in torpidity of the bowels. R. Infusi Senna? comp. . . § iss. Syrup Rhei . • 1 ij. Spiritus Nucis Moschata? . | ss. Ft. mistura. Two table-spoonsful every three hours until an operation—an excellent purgative for the debilitated. R. Resina? Jalapa? Submur. Hydrarg. J- . aa gr. xv. Saponis Hispanici. Olei Caryophyli Divide in pil. xij. One pill every half hour until it operates, in obstinate constipation. gtt. vj. EMMENAGOGUES. R. Aloes Barbadens. . . 3ij. Ferri Sulphat. . . 3j. Divide in pil. xx. One pill twice a day in chlorotic amen- orrhoea. R. Aloes Barbadens ) Ferri Sulphat. J ' Pulv. Rhei Divide in piL xxx. One or two pins at night in defective menstruation. aa 3j- 3 88. FORMULAE OF REMEDIES. 587 R. Aloes Barbadens Saponis. Theriaca? Ext. Glycyrrhizae. # Divide in pil. xxiv. One pill at night in atonic amenorrhcea. -I: aa 3ss. R. Decoct. Aloes comp. Syrup Croci. ) Rhei 3VJ. aa § iss. M. _ A table-spoonful twice a day, in chloro- tic amenorrhcea. !■ aa 3j. R. Pulv. Myrrhae. Ferri Sulphatis Potassa? Carbonat. Saponis . . . aa gr. xv. Ft. massa in pil. xx. dividenda. One pill three times a day in amen- orrhcea. R. Pulv. Sabina? . . . 3j. " Cantharid. . . gr. ij. Divide in chartulas iv. One powder at night In amenorrhoea. R. Tinct. Ergota? . . . 3 iss. Syrupi Croci. . . . % ij. Decoct. Aloes comp. . § yj. Fiat mistura. A table-spoonful three times a day in atonic amenorrhcea. R. Ergotina? . . . gr.xij. Syrupi Croci . * . 1 ss. Aqua? Mentha? Piperitae . § iijss. Fiat mistura. Two table-spoonsful every fifteen min- utes in inertia of the uterus during partu- rition. R. Ferri Sulphat. . . . Bj- Pilulae Aloes c Myrrha . gr.lx. Olei Rutee . . . . gtt. vj. Ft. massa in piL xxiv. dividenda Two pills twice a day in chlorotic amenorrhcea. gr. xlviij. q. s. gtt. xij. R. Ergota? Theriaca? Olei Sabinae Fiat electuarium. One sixth part to be taken three times a day in an atonic condition of the uterine organs. R. Infus. Quassia? . . • §vj. Tinct. Sabina? comp. . | j. Aqua? Pimentae . . | ij. Syrup Zingiber. . . § j. M. A table-spoonful three times a day in amenorrhoea. R. Pulv. Aloes " Rhei 01. Carui Saponis . Syrup Rhei Divide in pil. xx. One or two pills at night in dofective menstruation. gr. xv. XXX. gtt. vj. gr. iv. q. s. R. Tinct. Aloes . . . fiij.i " Myrrha?. . . 1 iv. " Croci . . . § iij. Fiat mistura. Known as Elixir proprietatis. A tear spoonful two or three times a day. R. 3 33. 5j- Ergota? Extract Gentianae Divide in pil. xxx. Two pills three times a day in atonic amenorrhoea R. Decoct. Aloes comp. . § vj. Two table-spoonsful at a dose—-cathar- tic, tonic and emmenagogue. Tinct. Myrrhae " Hellebori nigri " Cantharid Iss. 3 ij- M. Thirty drops three times a day in sweet- ened water, in amenorrhcea. TONICS. J. Zinci Sulphat. Extract Gentianae 01. Anthemidis Divide in pil. xxx vj. Two pills three times a day. gr. xxiv. 3ij- gtt. xij. TONIC APERIENT. Ferri Sulphat. . Magnesia? Sulphat. Acid. Sulph. diL Infus. Gentiana? C. Infus. Rosar C. . 3j. . Iss. . 3ij aa 3 viij. A wine-glassful three times a day. 588 FORMULAE OF REMEDIES. R. Quinia? Sulphat. . . gr. xij. Acid. Sulph. diL . .3 ij. Tinct. Cardam. . . 3 vj. Aqua? Cinnam. . . 3 x. M. Table-spoonful three times a day. R Quinia? Sulphat. Extract Gentiana? Divide in pil. xx. One pill three times a day. 3j. 3ij. R. Ferri Valerianat . . gr. xxiv. Olei Sabina? . . gtt. xij. Manna? dura? . . . q. s. Ut. fiat massa in pil. xij. dividenda One pill three times a day, in chorea and other nervous affections of young girls at the age of puberty. R. Ferri Pulveris . . . gr.xviij. Pil. Aloes c Myrrha . • 3 ss. ' Olei Juniperi . . . gtt. vj. Fiat massa in pil. xij. dividenda. Two pills twice a day, in chlorotic amenorrhoea. R. Argenti Nitratis . . gr. ij. Fellis Bovini inspissati ) .. Extracti Anthemidis f ^g1"-33*- Divide in pil. xij. One pill twice a day, in gostrodynia, without organic disease of the stomach. aa 3 iss. MISCELLANEOUS R. Acid Nitric ) Acid Muriatic . j" Tinct. Gentiana? comp. . § j. Infus. Gentiana? comp. . f v. A table-spoonful three times a day, in dyspepsia with urinary deposit of oxalate oflime(GoldingBird). aa3j. R. Tinct. Capsici " Cubebae " Cantharid Mucil. Acacia? . . § iij. Table-spoonful twice a day in menorr- hagia from debility. J. Gum Camphora?. ) .. .. Extract Hyosciam J ' ^S^*"- Divide in pil. xij. One pill every hour in strangury. R. Potassa? Liq. . . . 3 ij. Tinct. Cardam. comp . §j. Infus. Quassia? . . | vij. Table-spoonful twice a day in urinary lithates. Potassa? Carbonat. . Tinct. Gentiana? comp. Infus. Gentiana? comp. 3y- M. A table-spooDful three times daily, with regulated diet, in acidity of stomach. CROUP DRAUGHT. R. Emet. Tart. . . . gr.ij. Syrup Ipecac. . . . f j. OxymeL Scilla? . . 3 ijss. Infus. Polygal . . . § iv. A spoonful repeated as occasion may require in membranous croup. A favor- ite remedy in the Hopital des Enfans of Paris. I. Tinct. Buchu . . . § ss. Decoct. Uva? Ursi . . f vijss. M. A table-spoonful three times a day in chronic catarrh of the bladder, and in chronic mucous discharges from the vagina INDEX, A. .Abdomino-Rectal Hernia.........................................211 Action Reflex..................................7.7.7.7......... .7 .' 154 Abortion, causes of......................................".. .7.7.7 *. *. .7! 520 in early pregnancy........................................... 521 from Anasmia............................................... 520 in excessive vomiting........................................ 554 injury from................................................. 254 ABSCESS in the Neck...................................................418 of Labium Externum......................................340, 380 Mammary.................................................185 445 Of the Vulva................................................. 56 after weaning, prevention of....................................422 After-birth, management of.........................................46, 308 Action Muscular, what dependent upon................................. 153 Agalaxt...........................................................445 Albuminuria, cause of................................................. 524 and Puerperal Convulsions, relations of..................4*76, 524 is it always followed by Uraemia?........................... 523 Amenorrhea, divided into Retention and Suppression..................... 119 from atony of system.....................................483 from imperfect physical development........................ 33 from encysted dropsy of the right Ovary.................... 297 from Imperforate Os Tinea?................................297 Anasarca following Scarlatina.......................................37, 433 incipient, from flooding....................................... 397 Anemia from flooding in Miscarriage.................................... 397 two forms of.................................................. 397 Ante-version of Uterus............................................... 143 Anus, Fistula of......................................................442 Occlusion of.................................................295, 325 operation for Occlusion of......................................... 297 Prolapsus of....................................................395 Artificial Premature Delivery...................................... 352 Ascaris Vermicularis................................................ 61 Ascarides, mucous discharge from...................................... 164 Ascites from Dysentery................................................434 from Scarlet Fever.............................................433 Asphyxia, its meaning, causes, and treatment.............................456 Atrophy. 303 Attentions to the New-born Infant.................................... 470 B. 276 Bladder, falling of....................................................*' ° paralysis of.................................................. ^'* ulceration of.......... •..................................• • • • ,„ Bleeding, periodical Hemorrhoidal................................... Km Blood of the Fcetus, how elaborated.................................... «01 590 INDEX. PAOB Blood-letting, excessive, effect of...................................... 24 excessive, Convulsions from...............................493 Bofareira, galactagogue properties of................................... 445 Breast, application of the infant to...................................... 186 pain in the Uterus whenever the child is put to..................... 316 Milk deteriorates by being retained in............................. 501 c. Calculus Forceps.................................................... 201 Carcinoma, ulcerative, of the Uterus.................................... 467 Uteri, treatment of.......................................... 69 Catalepsy from engorgement of the "Womb...........................331, 378 Catheter, injury from the introduction of, in pregnancy..........:.......... 76 manner of introducing....................................... 77 Cephalhematoma.................................................... 189 Cervix of the "Womb, deep ulceration of.................................. 383 engorgement of.................................... 205 neuralgia of....................................... 477 Cessation of the Menses..........................................101, 374 Chancres, Venereal..................................................419 Changes, physical and moral, at Puberty............................. 228 Child, Sick, examination of............................................511 Chlorosis, causes of..........,........................................ 24 diagnosis of................................................. 26 pathology of................................................ 23 prognosis of................................................ 26 treatment of................................................ 26 not always dependent upon Amenorrhoea....................... 23 with suppression of the Menses................................ 22 Eisenman's views of......................................... 23 Sounds of the heart in....................................... 25 Cholera Morbus..................................................... 71 Chorea and Rheumatism, connection between............................ 515 Gymnastic exercises in......................................... 519 from fright.................................................... 515 from intestinal irritation......................................... 115 treatment of................................................... 518 Circulation, Fcetal................................................... 503 Cleanliness of Infant................................................ 473 Clinical Observation, importance of.................................... 9 Clinique, Obstetric................................................... 8 Colchicum promotes secretion of Urea...................................534 Colostrum, its properties.......................................423, 472, 481 Concealed Pregnancy................................................ 48 Condylomata of the Vagina.......................................... 339 Congestive Dysmenorrhea........................................256, 412 Connection between Retro-version of the Fundus Uteri and Paraplegia 341 Profuse losses of Blood and intense Headache.....397 Constipation followed by Convulsions................................... 195 Convulsions......................................................... 306 caused by Mother's Milk.................................423, 481 and suppressed Exanthemata, connection between..............435 Epileptic..................................................365 from Constipation.......................................... 195 from suppressed eruptive disease..........................435, 466 from Teething............................................. 172 Puerperal and Albuminuria, relations of...................475, 481 Puerperal.................................................503 from excessive blood-letting.................................493 from excessive purging.....................................481 Cord, Umbilical, how many Ligatures should be applied f.................. 199 tying and cutting the...................................470 Cough, Hooping...................................................... 19 sympathetic................................................... 104 symptomatic...................................................402 INDEX. 591 Cough, in pregnancy.......... p*°! of Chlorosis................................................• x™ of Phthisis..................'.".7."............................... o« Credulity, human................ ............................ „ ................................... 67 D. Defective Menstruation............ -ioooao Hysteria from................... 36g Deafness, with enlarged Tonsils, from Scarlet Fever....................... 82 Debility, profuse Menstruation from............. " *" 10 Delivery with Forceps................................................ 94 with Forceps after Vaginal Hysterotomy.. 7.7'.'.7'.'.'.'.'.'.....'.'.7 300 instrumental, partial, Paraplegia from............7 .7.7 7.7 7.7 .* 326 Vesico-Vaginal Fistula from.............7 7 7.7 77. 346 premature, artificial................................... # 352 Depletion, general and local, comparative safety of.___77 77 7 7. 7 7.'.'.'.'.' 493 direct, utility of......................................\ [ 152 Development, imperfect, Amenorrhcea from..........................777* 33 Diagnosis, importance of, between diseases of the Uterus and Rectum': 77.'.'.'. 343 Diarracea Ablactatorum............................................... 53 and Ulcerative Stomatitis from Teething........................212 Difficult Parturition, Abscess in right Labium Externum from............340 Discharges, causes of Sanguineous Vaginal.............................. 83 muco-purulent, from the Vagina.............................. 29 mucous, from the Vagina, caused by Ascarides in the Rectum___164 non-sanguineous Vaginal....................................408 periodical watery, per Vaginam, from Hydatids................. 41 purulent, from the Vagina, caused by ulceration of Bladder......174 suppressed Lochia]......................................... 73 Vaginal, generally.......................................... 59 watery Vaginal, from Hydatids.............................. 42 Displacements, Uterine................................................488 Disease, Hereditary, transmission of.................................... 501 Diseases of the Nervous System in Infancy............................... 450 of the Uterus, organic and functional............................ 5 " " their importance................................ 5 " " more frequent now than of old. "Why?........... 6 of the Uterus and Rectum, importance of correct diagnosis between.. 343 Dropsical Effusions, are they common in early life ?....................... 430 their causes and treatment.......................... 432 Dropsy, double Encysted Ovarian....................................... 166 Encysted Ovarian, Patient tapped thrice for, during pregnancy....... 260 Ovarian, pregnancy complicated with............................. 258 with albuminous Urine......................................... 175 Peritoneal.................................................... 118 Dysentery, Ascites from............................................*.. 434 Dysmenorrhoea....................................................... 485 Congestive..........................................256, 412 varieties of............................................. 412 connection with Uterine displacements...................... 485 from Stricture of the Neck of the Womb.................... 428 Dyspepsia, palpitation of the Heart from................................. 280 E. Early Infancy, mortality of—its causes.................................212 Education, physical, among the Ancients.............................. 99 Effects of Matrimony on the Uterine Organs..........................331 Effusions, Dropsical.................................................~0 Element, Fecundating............................................... °^° Eisenman, his Views of Chlorosis...................................• • • • 2i Emmenagogue properties of Mercury..............................*"*, *&& Emmenagogue Medicines, when indicated............•................... s^' danger of indiscriminate use of................... 483 Encysted Dropsy, tapping for.......................................... 263 592 INDEX. PACJH Encysted Tumor in the Posterior "Wall of the Vagina...................283, 325 Engorgement of the"Womb............................................ 205 chronic, profuse Menstruation from.............. 355 from suppression resulting in Catalepsy.......331, 378 Epilepsy in deranged Menstruation...................................... 155 at each menstrual period....................................... 327 from sanguineous engorgement of the Uterus: the utility of direct de- pletion in.............................•.................... 152 treatment of.................................................. 367 Tracheotomy in.............................................. 367 Cauterization in, Cotyledon Umbilicus in......................... 367 Epileptic Convulsions............................................... 365 Ergot and Strychnia, action of.......................................... 355 rupture of the "Womb from rash administration of..................... 96 when to be employed in Childbirth................................. 95 Eruptive Disease, Convulsions from suppressed........................435, 466 Examination of the Sick Child.......................................... 511 Exanthematous Affections, Convulsions in..............................435 Excessive Exhaustion from Flooding after Delivery.......................449 Excrescences, "Warty, in the Vagina, with Mucous Discharge............... 188 Exercises, Gymnastic, in Chorea........................................ 519 F. Facial Hemiplegia...................................................418 Faecal Matter, removal of, with Spatula................................. 143 Falling of the "Womb................................................. 202 Falling of the Bladder mistaken for.................. 276 Fecundation, what is it ?.............................................. 535 Female Life, critical period of.......................................... 101 Female Urethra, stricture of........................................... 79 Female, Puberty in................................................... 228 " its Signs..............................................228 " changes, physical and moral, at.......................... 228 Females, indifference of, to their health................................... 9 Fever Intermittent and Hooping Cough................................. 19 has it any influence over the menstrual function ?........440 Fibrous Tumor, submucous, of the Uterus................................ 217 Final Cessation of the Menses........................................ 374 Fistula in Ano—operation............................................. 442 Vesico-Vaginal...........................................190, 346 Flatus, Dr. O'Beirne's mode of extracting from the Intestines............... 514 escape of, from -the "Womb, on the introduction of a Tube............ 322 Flooding after Delivery, excessive exhaustion from...................... 449 incipient Anasarca from........................ 397 remedial properties of Opium in................. 449 Fcetal Circulation................................................... 503 Forceps, Calculus..................................................... 201 delivery with, after Vaginal Hysterotomy......................... 300 delivery..................................................... 94 Fright, Chorea from................................................... 515 suppression of the Menses from.................................. 236 Function, Perspiratory, importance of.................................. 433 Fundus of the Womb, retro-version of................................... 341 retro-version of, and Paraplegia, connection between.... 341 G. Guiacum, its influence over the secretion of Urea..........................534 Galactagogue Properties of the Bofareira (Ricinus Communis).............445 Germ, Female....................................................... 535 Gestation, five months advanced....................................... 171 with Phthisis Pulmonalis.....................................419 influence of, on milk......................................... 93 Globus Hystericus, with Meteorism, from Hysteria....................... 236 INDEX. 593 Gonorrhoea................................... 29g Granular Vaginitis, with discharge.......'.___7.7. '.'. 7.7...'.'.'.'.'.'.'.'.'. 421 Glands Cervical, tumefaction of....................7.7.7 . 77.7 '.'.'. 542 H. Hematemesis, with retention of the Menses........................ # 206 Hematocele Retro-uterine.................................77777! 480 Hemostatic properties of the Per-chloride of Iron...........7777777 467 Headache, intense, and profuse Losses of Blood, connection between......... 397 Health, indifference of Females to..................................... ! 9 melancholy death from trifling with.............................. 293 Heart, palpitation of................................................... Ill palpitation of, from Dyspepsia.................................... 280 palpitation of, from temporary Disappointed Love.................... 113 sounds of, in Chlorosis........................................... 25 Hemiplegia, Facial................................................... 418 Hemorrhage from ulcerated Carcinoma of the Cervix Uteri, mistaken for Men- orrhagia.............................................. 161 Uterine, treatment of....................................... 313 source of, in Uterine Polypus................................ 84 Hemorrhoids, internal, intense pain during Coition, from...................344 Hereditary Disease, transmission of.................................... 501 Hernia, Abdomino-rectal............................................... 211 Pudendal.................................................... 563 Vaginal—varieties of........................................... 559 Hippocrates and his School........................................... 5 Hooping-cough....................................................... 19 Hydatids Uterine.................................................... 41 and Vomiting................................................ 45 causing enlargement of the Uterus.............................. 41 Hydro-rachitis....................................................... 132 Hypertrophy of the Nymphe, from Syphilitic disease.....................426 Hypochoxdrium, right, pain in, from pregnancy........................... 179 Hysteria, cause of.................................................... 369 from defective menstruation................................368, 402 Meteorism, with Globus Hystericus, from........................ 236 in a Boy.................................................... 371 Hysterotomy Vaginal................................................ 252 and delivery with Forceps.......................... 300 I. Ignorance of Mid wives....................• •«........................ 359 Imperforate Os Tinge, with retention of the Menses...................... ^ retention of the Menses from, mistaken for pregnancy. 251 Importance of Correct Diagnosis between diseases of the Uterus and Rectum 343 Importance of the Perspiratory Function..............................433 Incontinence of Urine................................................ Induration of Uterus................................................ *87 Infancy, diseases of................."■•;.■............................ no* their importance and fatality........................... £»« is this fatality unavoidable?............................ 2°7 diseases of the Nervous System in—their frequency and unportance... 450 early, mortality of, its causes................................." ' 510 Pulse in, how influenced....................................... gl2 Pulse, rate of, in.........................................." " ' g03 Infant, Atrophy in............................................7.7.7.7. 306 Convulsions in.........• • • • • • • • • • •...................... "4.73 cleanliness necessary to the health of.............................. ^ new-born, dressing of....../•" 7 '::'•"; \l\ Ll^ita................ 472 dosing and drugging of—their fatal results................ 47 i " examination of.................................. * . * ^ « washing of................................. "" ^q " attentions to......................................... 594 INDEX. PAOl Infant, new-born, Mother's Milk best Medicine and Food for................47 2 peculiarities, anatomical and physiological, of....................... 288 rules for bringing up by hand....................................498 Vomiting in...............................................290, 338 when it should be Weaned...................................... 499 Infants, neglect of.................................................... 500 why do they cry.............................................. 395 Infantile Therapeutics............................................... 493 Infiltration, Serous, of the Labia Externa............................... 406 Inflammation, Chronic, of the Uterus, Suppression from.................... 403 Instrumental Delivery, partial Paraplegia from.......................... 407 Vesico-vaginal, Fistula from...................... 346 Lnstruments, abuse of................................................. 191 unjustifiable use of......................................... 190 Intense Pain during Sexual Intercourse from internal Hemorrhoids___344 Intermittent Fever, has it any influence over the menstrual function ?.......440 Introduction of the Uterine Sound.................................... 224 Introductory Remarks to Lecture V.................................... 72 to Lecture VII.................................. 98 to Lecture XVI................................. 264 Inversion of the Mucous Membrane of the Urethra....................404 Iron, Per-chloride of, Haemostatic properties of.............................467 J. Jaundice, why dangerous to the Foetus.................................. 501 K. Kiestine, why found in the Urine of pregnant "Women......................474 L. Labium Externum, abscess of........................................... 340 hernia of............................................ 563 neuralgia of.....................................443, 495 sanguineous Tumor................................... 463 Labia Externa, serous infiltration....................................... 406 Labor, Natural, management of the Placenta in.........................46, 308 Lactation, abortion during............................................. 519 undue.................................................... 266 undue, with passive Menorrhagia............................. 34 Menorrhagia during......................................... 109 Pregnancy during.......................................... 93 Lady, Young, melancholy death of....................................... 294 Laryngismus Stridulus............................................... 454 Leucorrhcea, what does it mean ?.......................................408 Ligatures, how many should be applied to the cord ?...................... 199 Light, intolerance of, from Losses of Blood............................... 398 Lochial Discharge, suppressed......................................... 73 M. Mammary Abscess................................................l85> 445 Mamma, excessive pain in.............................................. 562 Mamm^; and Uterus, sympathies between................................ 540 Management of the Placenta in natural labor........................46, 308 Mastodynia Neuralgica.............................................. 562 Matrimony, its effect on the Uterine Organs.............................. 331 Matrons, vaginal examinations by....................................... 6 Meatus Urinarius, complete occlusion of............................346, 379 how found.......................................... 77 Vascular Tumor of.................................. 64 Meconium......................................----•.............425, 472 Medicines, Emmenagogue, not always indicated in Suppression.............. 337 Membrana Decidua................................................... 553 INDEX. 595 Membrana Reflexa............................ 553 Menorrhagia......................". 77.77 .'.'.'. ..................... 1] Menses, final cessation of................7.7.7.7.7. ! 374 retention of.............................. ! 118 retention of, with Haematemesis................. 206 suppression of............................7 "7.77.".7.7 7. 70 440 suppression of, from Chronic Inflammation of the Uterus......7 ! .403,' 482 from Cold....................................166'( 293 " from Fright......................................236 from Imperforate Os Tinea?.....................318, 376 from periodical Hemorrhoidal Bleedings..........337, 380 with submucous fibrous Tumor of the Uterus......... 217 Menstrual Blood, the source of........................................ 234 Menstrual Function, has Intermittent Fever any influence over ?...........440 Menstrual Molimen.................................................241 Menstrual Period, Epilepsy at each.................................... 327 Menstruation during Pregnancy........................................ 171 can a Nursing Woman become pregnant before the reappearance of?.................................................. 93 defective............................................183, 208 defective, what is it?...................................96, 97 essential to Health, but not to Life.......................... 236 final cessation of......................................101, 374 its Causes. Symptoms, and Periodicity....................232, 234 Hysteria from defective................................368, 402 profuse, during Lactation.................................. 109 " from sanguineous engorgement of the Uterus......... 355 " from Debility..................................... 10 retention of, with Constipation.............................. 118 suppression of............................................ 70 " following Scurvy............................. 148 " from Cold................................... 169 " from Cold, with Phthisis....................... 17 uninterrupted, during Pregnancy........................... 171 vicarious, from the Umbilicus.............................. 81 vicarious.....................................80, 207, 337, 380 " what is it ?...................................... 81 when does it commence ?.................................. 230 Mercury, the emmenagogue properties of.............................403, 482 Meteorism, with Globus Hystericus..................................... 236 Metrorrhagia . 11 Midwifery, conservative...............................................191 Midwives, ignorance of................................................359 Milk, Abscess after weaning, prevention of................................ 423 absence of the secretion of.........................................445 Convulsions caused by the Mother's.................................423 deterioration of................................................. 501 excessive purging caused by....................................... £-3 Human, analysis of...............................................*»«> Mother's, best Medicine and Food for the Infant......................4'j* " proper nourishment for the Infant..........................496 influence of Gestation on.......................................... |J3 Mindererus, Spirits of................................................. Miscarriage, causes of........................................ • \ _ treatment of............................................. ~ absence of vomiting.......................................°™ Molimen, Menstrual.................................................. „.„ Mortality of Early Infancy, its causes................................ *** Mother, causes disqualifying for Nursing................................. danger to the, who does not nurse her Chdd....................... *^ fashionable.......................•........................... . fi„ Mucous Membrane of the Vagina, prolapsus of............................ «£ Urethra, inversion of........................... *"* Muguet....................•......................................... 153 Muscular Action, what dependent upon............ .................... 596 INDEX. N. PAOK Natural Labor, management of the Placenta in........................46, 308 Nausea in pregnancy.................................................. 551 Neck, Abscess in the.................................................. 418 Neck of the Womb, stricture ol] Dysmenorrhoea from...................... 428 dilatation of........................................428 Neglect of the young Infant........................................... 500 Nervous System, the Diseases of, in Infancy—their frequency and importance. 450 Neuralgia of the Cervix Uteri......................................... 477 of the right Labium Externum............................443, 495 of the Vagina.............................................. 568 Utero Lumbar.............................................. 361 Nipples, sore in a Primapara............................................ 491 Nurse,"Wet, cramming of............................................... 497 choice of.......................................=.......... 497 Nymphjs, congenital enlargement of among the Boschisman Women..........426 Hypertrophy of. from Syphilitic Disease.......................... 426 0. Occlusion of the Anus.............................................295, 325 " operation for..................................... 297 complete, of the Meatus Urinarius..........................346, 379 Ophthalmia, Gonorrhceal.............................................. 15 Neonatorum.............................................. 114 Opiates, in Infancy, danger of........................................... 173 Opium, remedial properties of............................................449 Os Tinge, imperforate, with retention of the Menses....................... 248 perforation of imperforate, and escape of menstrual Blood......... 248 retention of the Menses from imperforate, mistaken for Pregnancy... 251 suppression of the Menses from imperforate, the result of Inflamma- tion—operation for........................................ 318 Otitis, acute external.................................................. 13 Otorrhcea........................................................... 14 Ovarian Dropsy...................................................... 387 is it curable?........................................... 387 Pregnancy complicated with.............................. 258 double encysted........................................ 166 Ovarian Tumor, Steatomatous.......................................... 156 projecting into the triangular Fossa—its diagnosis from retro- version of the fundus Uteri............................ 224 with Pregnancy........................................ 193 Ovary, prolapsed into triangular Fossa................................... 297 Ozcena............................................................... 200 p. Pain in the right Hypochondrium, with Cough, from Pregnancy.............. 179 in the Uterus, whenever the Child is put to the Breast................. 316 Palpitation of the Heart............................................. Ill from Dyspepsia................................ 280 from temporary disappointed Love................ 113 Paralysis of the Neck of the Bladder................................... 274 threatened, of the Lower Extremities........................... 208 Paraplegia from intestinal Irritation..................................... 270 partial, from instrumental Delivery.........................326, 407 Parturition, difficult, abscess of the right Labium Externum from........... 340 Peculiarities, physiological and anatomical, of the Infant................... 288 Perforation of an occluded Os Tinea?................................... 248 Per-Chloride of Iron, Hasmostatic properties of.......................... 467 Period, Menstrual, Epilepsy at each..................................... 327 Periodical Hemorrhoidal Bleedings, and Suppression of the Menses....... 337 Periostitis, Venereal, with Condylomata of the Vagina.................... 339 index. 597 Peritoneal Dropsy, with Phthisis Pulmonalis... 'ttl Perspiratory Function, importance of ................Aqo Pessary, abuse of........................777.7.7...................... 441 intra-uterine........................!'' .................. .«« Phlegmasia Alba Dolens..........7777777!..................... 89 Phosphate of Lime in Rachitis.....!!! 7 7. 7 !...........................4|76 Phthisis Pulmonalis.................7 .77.7.7 ! .7 7. .77!!.............. 18 complicated with Peritoneal Dropsy.777". 7777777 122 does Pregnancy exercise any influence over?"" ' 419 Physometra......................................... .....321 what is it ?................................ ......323 Pityriasis Capitis.......................7 7 7 7! 7.7 7.! 7.7......... 88 Placenta, Blood of the Foetus elaborated in, how ?..." .777'.'. 7 7.7'.'.!!'.'.!!!! 501 management of, in Natural Labor........................7.7.46" 308 Praevia..................................................* ' 330 Polypus of the "Womb..........................................".... 83* 201 diagnosis of....................................... 86 removal of......................................86 87 treatment of....................................... 86 profuse sanguineous discharge from Vagina in.......... 83 Poison, is Urea a ?..................................................... 529 Pregnancy complicated with Ovarian Dropsy............................. 258 concealed.................................................. 48 Constipation and Diarrhoea in................................. 146 does it exercise any influence on Phthisis ?...................... 419 during Lactation..... ...................................... 93 fibrous Tumor of the Uterus mistaken for....................... 50 injury from introduction of Catheter during..................... 76 introduction of Catheter during............................... 77 Pain in the right Hypochondriac Region, and Cough from......... 179 retention of the Menses mistaken for........................... 251 supposed................................................... 512 with Menstruation.......................................... 171 with Ovarian Tumor.......................................... 193 vomiting in................................................551 Premature Artificial Delivery....................................... 352 Procidentia of the Womb............................................. 393 with Venereal Ulcerations...................271, 316 Profuse Menstruation from chronic engorgement of the Uterus............ 355 Prolapsus Ani........................................................ 395 of the Mucous Membrane of the Vagina....................... 462 Uteri..................................................... 441 Pruritus Pudendi, with cessation of the Menses........................81, 180 Puberty in the Female............................................... 228 its signs........................................ 228 changes, physical and moral....................... 228 Pudendal Hernia..................................................... 563 Puerperal Convulsions....................- - - - •...................• • • • 503 and Albuminuria, relations between.............475, bli Pulsations in the Infant, rate of....................................... 512 Pulse of Disease and of Momentary Excitement........................... w± in Infancy, how influenced........................................ 510 " rate of................................................ Purging, excessive, caused by the Mother's Milk.......................423, 481 a. 67 Quack, heartless exactions of........................................... R. 476 Bachitis, how produced in the Infant........................ ......^Q Phosphate of Lime in..........................•............. g Becamier..........................................................558 Eectocele Vaginal............................................. 598 INDEX. PAOS Rectum, diseases of................................................... 343 Remarks introductory to Lecture V...................................... 72 to Lecture VII.................................... 98 " to Lecture XVI................................... 264 Remedial effects of Strychnine.......................................... 326 properties of Opium in Flooding................................449 Reproduction, how accomplished in the Female........................... 535 Requisites for a "Wet Nurse............................................. 497 Retention of the Menses.............................................. 206 from imperforate Os Tinea?....................... 248 from imperforate Os Tinea? mistaken for Pregnancy.. 251 Retention of Urine...................................................438 difference between, and suppression.................... 438 Retro-version of the Fundus of the "Womb............................. 841 and Paraplegia, connection between........... 341 Retro-uterine Hematocele............................................480 exploring Needle in..........................480 Re-vaccination, is it necessary ?........................................ 505 Ricinus Communis, galactagogue properties of.............♦...............445 Rules for bringing up an Infant by Hand.................................498 s. Sarcomatous Tumor.................................................. 157 Scalp, bloody Tumor of................................................. 189 Scarlet Fever, Anasarca and Ascites following........................37, 433 enlarged Tonsils With Deafness following................... 82 is Albuminuria the constant accompaniment of?............. 37 tumefaction of Cervical Glands in......................... 542 its Varieties, Causes, Diagnosis and Treatment............... 542 Convalescence from..................................... 550 Scrofula, vaginal discharge from......................................,.. 29 Scurvy, has it any influence over the Menstrual Function ?.................. 148 suppression of the Menses following.............................. 148 what is the true cause of?...................................... 148 Sexual Intercourse, intense Pain during, from Hemorrhoids................ 344 Serous Infiltration of the Labia Externa...............................406 Sick Child, examination of............................................. 511 Signs of Puberty in the Female........................................ 228 Sore Nipples......................................................... 491 Sound, Uterine, introduction of.......................................... 224 Source of the Menstrual Blood....................................... 234 Spasmodic Movements of the Limbs, involuntary and constant............... 91 Speculum...........................................................6, 126 mode of introducing it......................................... 127 varieties of................................................... 127 Spermatic Fluid..................................................... 536 Spina Bifida......................................................... 131 Spinal Cord of Marshall Hall.......... ................................ 154 Spirits of Mindererus................................................ 256 Steatomatous Ovarian Tumor......................................... 156 Strictures of the Female Urethra....................................... 79 of the Neck of the "Womb, Dysmenorrhoea from................. 428 " " dilation of.......................... 428 Sterility............................................................ 535 from Stricture of the Cervix Uteri............................... 541 causes of..................................................... 537 treatment of.................................................. 539 Stomatitis. Follicular.................................................. 75 Gangrenous................................................ 75 Mercurial.................................................. 75 Ulcerative, and Diarrhcea from Teething....................... 212 Strangury........................................................... 495 Strychnia........................................................... 407 and Ergot, action of........................................... 355 INDEX. 599 Strychnia, remedial effects of.. . p£°" Suffocation and enlarged Tonsils from Scarlet Fever....................... lo Suppression of the Menses.....................\...................Vn' 440 Emmenagogues not always indicated in....... '337 engorgement of the Uterus from, and Catalepsy '! 331 from Chronic Inflammation of the Uterus___ 403 from Cold......................... ' 293 from Fright................7.7.7.7.7!!! ! 236 from imperforate Os Tinea?..............!! ! 318 from periodical Hemorrhoidal Bleedings! 7777 337 ., „ with submucous fibrous Tumor of the Uterus'* ' 217 Sympathetic Cough.............................. ..... fil Symptomatic Cough.............!..!........!...!.................402 Syphilitic Disease, Hypertrophy of the Nymphae from.7.77.7.77.7777!.' 426 T. Tampon in Uterine Hemorrhage.....................................314 Teeth, order of production......................7 7.7 77.7. 37 Teething, with Convulsions..............! 77 77. .7.777777!! 7!! 7 7 172 irritation from, with Constipation............................... 36 Ulcerative Stomatitis and Diarrhoea from................ 212 Therapeutics, Infantile...............................................493 Thrombus....................................7. ..77. " 463 Toucher.............................7 .......... 7' .77 6 Tonsils, enlarged, with Deafness, from Scarlet Fever........77.77777 82 Transmission of Hereditary Disease..................................... 501 Treatment of Miscarriage.............................................. 245 of Uterine Hemorrhage......................................313 Trismus Nascentium.................................................. 358 Tubes, Fallopian, Catheterization of...........................!........539 Tumor, bloody, of the Scalp............................................ 189 Encysted, in the Posterior Wall of the Vagina...................283, 325 Fibrous, of the Uterus........................................... 50 Irritable, of the Breast........................................... 562 Ovarian, with Pregnancy......................................... 193 Ovarian, projecting into the triangular Fossa, and its Diagnosis from retro- version of the Fundus Uteri................................... 224 Sanguineous, of the right Labium Externum........................463 Sarcomatous................................................... 157 Steatomatous Ovarian........................................... 156 Submucous Fibrous of the Uterus................................. 217 Vascular, of the Meatus Urinarius................................. 64 Twins, with Placenta Praevia............................................ 380 with one Placenta............................................... 380 Tympanites Intestinalis............................................... 512 U. Ulceration, deep, of the Cervix Uteri................................... 383 Venereal, with Procidentia Uteri.........................271, 316 of the Uterus, conflicting opinions concerning.................. 128 Umbilical Cord, Ligature of............................................ 199 tying and cutting of....................................470 Umbilicus, inflamed................................................... '9 Undue Lactation..................................................34, 266 Uremia.............................................................. 522 is Albuminuria always followed by ?............................... 523 Thoughts on...................................................522 Treatment of.................................................... 533 Conclusions Concerning.......................................... 534 Colchicum and Guiacum in...................................... 534 , is it a Poison?...................................................531 influence of Colchicum and Guiacum over the secretion of.............. 534 600 INDEX. Urethra, Female, peculiarities of the ..................................PA7 7 inversion of the Mucous Membrane of................... 404 purulent discharge from............................... 174 Stricture of.......................................... 79 Urine, Albuminous, with Dropsy.....................777777" 77 175 pioody................................777777777777 si Healthy, has no Albumen........................................ 176 Incontinence of............................. . 274 Miiky............................. .777.7.7.7.7.7.7. .7!!!!!!!!! si Betention of.................................... 438 Retention of, and suppression, difference between....................438 frequent desire to pass................................... ... 401 Uterine Hemorrhage, treatment of.......................7. .77 ! .77 ! .777" 313 Uterine Organs, effects of Matrimony on...............".!!!!!!!!!'.!". .7 !'. 331 Uterine Sound..........................................!!!!!'.!!.". 7 490 introduction of........................................... 224 Uterine Displacements.....................................77777 488 Utero-lumbar Neuralgia.................................77.7___! 361 Uterus and its appendages—their Structure..........................77 135 ante-version of, from Faecal Matter in the Rectum.................. 143 diseases of, organic and functional............................... 5 " their importance................................... 5 " not understood by the Ancients........................ 5 " true knowledge of, recent.............................. 6 " circumstances modifying.............................. 6 more frequent now than of old. Why ?................. 6 does it enjoy much mobility ?.................................... 141 excessive Pain in, while Nursing................................. 316 enlargement of, by Hydatids, with periodical Watery Discharge....... 41 engorgement of, from suppression of the Menses, resulting in Cata- lepsy...................................................331, 378 falling of, in a Woman three Months Pregnant..................... 149 falling of, inability to pass water from.............................149 in health and disease........................................... 138 in Pregnancy............................................!..... 135 its Physiological Action......................................... 135 introduction of a Tube into, with escape of Flatus.................. 322 mobility of.................................................... 142 Nerves of... ................................................. 141 Physiology of................................................. 135 Neuralgia of the Cervix of...................................... 477 induration of the Neck of....................................... 106 normal position of.............................................. 141 Procidentia of................................................. 46 with Venereal Ulceration........................271, 316 Prolapsus of, from engorgement..................................441 Prolapsus of, from jumping from a Carriage........................ 108 Retro-version of...............................................485 Structure of................................................... 135 Submucous Fibrous Tumor of, with suppression..................... 217 Chronic Inflammation of, suppression from.........................403 Ulceration of the Cervix of..................................124, 383 Ulcerations of, are they frequent ?................................ 129 conflicting opinions respecting....................... 128 how divided ? Causes, Symptoms.................... 130 diagnosis and treatment............................ 131 Ulcerative Carcinoma of........................................467 the modification of structure of, in Pregnancy...................... 136 V. Vaccination......................................................... 504 origin of................................................... 504 age for.................................................... 506 does it lose its efficacy by transmission ?....................... 506 INDEX. 601 PAGB Vaccination, is re-vaccination necessary ?................................. 505 mode of.................................................. 506 signs of genuine........................................... 508 spurious.................................................. 508 during existence of Cutaneous Disease........................ 507 Vagina, adhesion of the Walls of....................................346, 379 Anatomical relations of......................................... 203 Condylomata of, with Venereal Periostitis......................... 339 discharges from, generally....................................... 58 importance of acourate diagnosis of................. 60 Encysted Tumor in the Posterior Wall of......................283, 325 mucous discharge from, caused by Ascarides in the Rectum..........164 muoous discharge from, and Pruritus of the Vulva.................. 133 mucous discharge from, caused by Warty Excrescences on the Vestibu- lum........................................................ 58 muco-purulent discharge from, in a young Girl..................... 29 neuralgia of................................................... 568 purulent discharge from, caused by Ulceration of the Neck of the Bladder.................................................... 174 Prolapsus of the Mucous Membrane of.........................166, 462 Spasm of..................................................... 566 "Warty Excrescence in, with mucous discharge...................... 188 Vaginal Discharge, generally.......................................... 59 Non-sanguineous....................................408 in young Girls...................................... 29 in Scarlet Fever..................................... 29 "Watery, from Hydatids.............................. 42 Vaginal Hernia...................................................... 559 Becto-cele.................................................. 558 Hysterotomy................................................ 252 and subsequent delivery with Forceps............... 300 Vaginitis, Granular................................................. 421 Varieties of Congestive Dysmenorrhoea.................................. 412 Venereal Chancres..................................................419 Ulcerations on the Womb, with Procidentia Uteri................. 271 Periostitis, with Condylomata of the Vagina..................... 339 Version of the Foetus in Uterine Displacement............................ 144 Vesico-Vaginal Fistula from Instrumental Delivery...................346, 379 Vicarious Menstruation...................................80, 207, 337, 380 Vomiting and Hydatids..........................................•...... 45 in an Infant..........,...................................290, 338 in an Infant immediately after Nursing........................... 92 in Pregnancy................................................ 551 Idiopathic................................................... 555 Symptomatic................................................. 555 Vulva, Abscess of.................................................... 56 Pruritus of..................................................... ld3 w. Walls of the Vagina, adhesion of...................................346, 379 Warty Excrescences in the Vagina................................... ±°° Weaning, prevention of Mammary Abscess after...........................4/fa time for.....................................................^ Wet Nurse, Cramming of............................................... *j" requisites for..............................................4j|' Whites, what is meant by the term......;•■•••'.....................VaV J?a Womb, engorgement of, from suppression of the Menses..................sm, a(» Falling of.......................-•■••";........................ f« " Falling of the Bladder mistaken for....................... ^ «o Induration of................................................''" Polypus of...................................................83- 201 Polypus of, diagnosis of.......................................... °° Polypus of, treatment of.......................................... *jjj Polypus of, removal of........................................... 602 INDEX. PAOB Womb, Dysmenorrhoea from Stricture of the Neck of........................ 428 Procidentia of.................................................. 393 " with Venereal Ulcerations........................271, 316 Betro-version of the Fundus of.................................... 341 " and Paraplegia, connection between................... 341 Prolapsus of.................................................... 1°8 Women, Pregnant, Kiestine, why found in the Urine of...................474 Worms, how generated................................................. 62 Intestinal, in a Girl aged four years............................... 61 Pathognomonic sign of.......................................... 62 the variety and origin of, in the Human System.................... 61 t SECOND EDITION, REVISED AND IMPROVED THE GRAMMAR ENGLISH GRAMMARS, BY GOOLD BROWN. One Volume, large 8vo.;—1048 pages. PUBLISHED BY SAMUEL S. A WILLIAM WOOD, No. 389 BROADWAY, N. Y TESTIMONIALS, FROM NOTICES OF THE PRESS, &c " potior to tnhom honor." 1. "We are gratified to learn that the great work on English Grammar, of our fellow-citizen, Goold Brown, is everywhere received with the highest approbation. Erudite scholars, sagacious and discriminating critics, able teachers and professors in our seminaries of learning, unite in pronouncing the work a profound, complete, and eminently satisfactory exhibition of the grammar of our language."—The Lynn News, May 28, 1852. 2. " We have just been favored with the examination of a part of a forth- coming work—' The Grammar of English Grammars'—by Goold Brown. If we were not afraid of being charged with committing a blunder in terms, we would say, that he has well-nigh exhausted the exhaustless subject of grammatical bibliography. We commend the work to all the teachers of the Grammar of our vernacular tongue."—New York Journal of Education, Feb. 1, 1851. 3. "' The Grammar of English Grammars' has all the severe accuracy of which the ' Institutes,' [the author's first work,] is so remarkable an example. The same doctrines, mainly, are here reaffirmed, and copiously illustrated. Indeed the book abounds in illustration, and is a happy instance of what the French philologers term a ' grammaire raisonnee? Its expositions are so fe- licitously wrought up, that it would be an interesting book for reading by persons not conversant with grammar."—A Correspondent oftht N. Y. Jour- nal of Education. 4. " We are very glad to learn that the ' Grammar of English Grammars' is soon to be published. It will be eagerly sought by teachers, who know the author's high reputation."—L. Wkthbrkll : Rural New Yorkir, Feb. 18, 1851. 5. " Throughout more than a thousand large and compact octavo pages of fine type, the most critical acumen is displayed, and the true principles of the English language are inculcated with admirable clearness and foroe. Prob- 8 RECOMMENDATIONS. ably nothing important that has ever appeared in print, on the subject of our philology, has escaped the attention of Mr. Brown ; and he has wrought into his great work such annotations on all his predecessors as will be quite likely to remedy the varying, and establish the unsettled, usages of English grammarians, in a great degree."—Boston Weekly Museum, July 19, 1852. 6. " It is a work of most elaborate finish, and of surprising extent and co- piousness. It presents, in a form of much originality, and in a style terse and beautiful, all the principles of our language, and develops almost every pecu- liarity of idiom or of construction. Nothing escapes our acute author; he defines, analyzes, discusses and settles disputed points, lays down definite pre- cepts and rules, and illustrates all his teachings by apt and plentiful exam- ples. The most singular thing is, that his 'code of false syntax1 is derived mostly from the writings of antecedent English grammarians /"—Norton's Literary Gazette. New York, Jan. 15, 1852. 7. "It was a.magnificent enterprise, which has been well earned out by the able author. * * * The Grammar of English Grammars will stand among other books of its class, as the large Dictionary of Noah Webster does among other works of that kind. * * * A copy of it should be in the hands of every teacher in the country."—The Lynn News, Jan. 16, 1852. 8. " I have looked it over page by page in detail. It is admirable—it is all it should be—it is a monument of learning, patience, and toil." S. U. Ber- rian, Principal of a Classical Academy at Rye, Westchester Co., N. Y. 9. " I regard it as the most valuable of all the works upon the subject of which it treats. It is a cyclopedia, repositing rich treasures of historical and critical knowledge. It is, throughout, eminently practical in its character. No teacher of English Grammar should fail to procure a copy of this mas- terly work."—J. F. Schroeder, Rector of St. Ann's Hall, Brooklyn. 10. " The author has produced a work, which must exert a material influ- ence in systematizing the laws and assimilating the principles of our lan- guage, and which will surely reflect honor upon himself and credit upon the country. It is learned without being pedantic, discriminating without being hypercritical, copious without being prolix, and independent without being presumptuous."—New York Courier and Enquirer, Jan. 15, 1852. 11. "This great work—great in more senses of the word than one—has at length made its appearance ; and we hail it with a welcome and warm ap- probation. It is emphatically, as its title imports, the ' Grammar of English Grammars,'—a splendid octavo volume, of more than one thousand pages, comprising matter enough to satisfy the most insatiable admirer of grammar, and information sufficient thoroughly to enlighten the ignorant, and to ac- complish the student in every branch of this important science. It will form a valuable, an indispensable book of reference; and may with justice be re- garded as the standard work of the grammar of the English language, accord- ing to the most approved and established usage. We commend the work to all teachers and students who wish to become critically conversant with all the minutiae of the subject; and especially we recommend to our school com- mittee, to cause a copy to be placed in the library of every ward school, fo? the convenience of reference and consultation by teachers and pupils."—The Bay State, Lynn, Jan. 22, 1852. 12. " We think this is a work from which none will feel willing to depart, till a further change takes place in our language. It is a sort of Doctor Johnson amongst grammarians, to whom our tages will look for authority RECOMMENDATIONS. 3 when they have doubts, and for instruction when they have none. * * * Ine specimens of the language in different ages, the notice of the schemes of foreign grammars, and, above all, the prosody—the whole work, in fact, for completeness and excellence, deserves the title of Grammar of Grammars." —lite Christian Intelligencer, Feb. 5, 1852. 13. " It is a work obviously the fruit of much reflection on the part of ita author, and as obviously deserving of the attention of all whose duty it is to discover the most advantageous system of inculcating the rules of English Grammar."—Notes and Queries, London, Feb. 14, 1852. 14. " Brown's Grammar of English Grammars.—We may fairly say, in reference to this great work, that it is the book of the age, so far as concerns the philology of the language. It leaves, at an immeasurable distance be- hind, all the antecedent works in this department. If Webster has more suc- cessfully and learnedly labored than any of his predecessors in perfecting a lexicographical exhibition of English, we may accord to our distinguished au- thor, in his line, an equal meed of praise. Nay, we are not certain that the latter has not paramount claims to distinction. There is a wide chasm indeed between Dr. Johnson's Dictionary and Dr. Webster's, but by no means so wide a one as that between Lindley Murray, who has been called ' the prince of grammarians,' and Goold Brown, of Lynn, Massachusetts." " In the ' Grammar of English Grammars,' we see the true principles of our noble language, according to its present usage, justly and methodically set forth ; these principles learnedly and elaborately commented on; and the whole subject of our grammar redeemed from the mass of irrelevancy, error, confusion, and absurdity, which had so strangely become incorporated with it * * * To the laborious and faithful teacher of youth, we cannot conceive of a pleasanter and more efficient adjuvant of his toil in grammatical institution than that which is presented in this book."—The Westchester Herald, Feb. 17, 1852. 15. " It well deserves a place by the side of the great American Dictionary of our language, and the two are equally glorious trophies of what American energy has been able to accomplish in the difficult field of English Philology.' —The Honesdale Democrat. 16. "A more admirable exhibit of the grammar of a language, certainly that of the English language, we have never seen,—so copious and compre- hensive,—so philosophical in definition, exposition, and arrangement,—so se- verely and elaborately exact. In comparison with the ' Grammar of English Grammars,' our extant works in this department, shrink, in a measure, into insignificance—whether the object be an ascertainment of the authentic norms of speech in our language, or of the divergent, and often contradictory, views of antecedent writers, who have speculated in this department."—A Corres- pondent of the Westchester Herald. 17. " The Grammar of English Grammars.—This is the title of the greatest work upon the English language that has appeared since the publi- cation of Webster's Dictionary. In opening the volume, of more than a thou- sand royal octavo pages, most of which is in small type, the first sensation is that of wonder at the amount of labor that must have been expended upoB iU— The Dedham Gazette, March 6, 1852. 18 "A most comprehensive and invaluable volume, which we have no hes- itancy in pronouncing to be, by far, the most valuable acquisition that has ever been made to this branch of the science of Philology."—The Northern Lancet. i RECOMMENDATIONS. 19. "Mr. Brown is a teacher of great practical excellence, a fine classic scholar, a thorough-bred grammarian, and a critic of great discernment, lucid judgment, and admirable acumen. He has devoted by far the larger portion of his useful life to the compilation of a work greatly and universal^ needed. He has succeeded in producing a book superior in almost every respect to any production of the kind by any preceding author or compiler. * * * The ' Grammar of English Grammars' must stand on our shelves beside Webster, Worcester, and Anthon, as a book of standard reference. No scholar should regard his library of scholastic works as complete without it; every teacher should be in possession of this comprehensive vade mecum ; and we earnestly recommend all school-committees, without delay, to furnish each school-dis- trict with a copy."—The Boston Daily Journal. 20. " No work of the sort has yet been produced which will at all com- pare with it. That it is destined to take the place among grammars which Webster's Dictionary has already taken among works of that sort,—greatly in advance of all,—there can be, it seems to us, no doubt. We think that our State could in no better way promote the cause of education, than by making an appropriation to supply every public school in the State with a copy of this valuable work."—The Bay State, Feb. 26, 1852. 21. " We have carefully examined its pages, and feel bound to acknowl- edge it a standard work—settling numerous and vexatious disputes among teachers and scholars, and rendering plain and interesting what has heretofore appeared difficult and uninviting, and even unprofitable to those who aimed at certainty."—The American Artisan, Feb. 28, 1852. 22. " It is a monument of constant industry and profound study,—embra ting a complete summary and shrewd analysis of the works of previous gram- marians."—New York Daily Times, Feb. 28, 1852. 23. " This great work has at length appeared ; nor is it likely, in any re- spect, to disappoint the high expectations which were entertained respecting it, from the well-known ability of the author as an English grammarian. It leaves far, very far behind it, everything which has hitherto appeared under the denomination of an English Grammar. * * * It is in the amazing ex- tent and compass of the ' critica sylva^—the topics, definitions, rules, and il- lustrations ; in the acute investigation which is everywhere displayed; and in the minuteness and perfect finish with which every particular is wrought up, that the distinguishing features of the work most manifestly appear. It may, in this view, par eminence, be termed the ' Grammar of English Grammars :' but we suppose the author intended the term to have another application. One thousand pages and over, of large octavo, would seem to have given the learned author ' ample room and verge enough' to have traced out all the frammatical peculiarities of our vernacular : but the effort has made manifest ow much remained to be done by the author, and how wide a field he had to traverse. * * * We see, as the result of all that has been done by our author, a noble and most important book,—ample, critical, and symmetrical in a high degree—and, what is a most remarkable feature, an original work— the work of one head and one pen."—The District School Journal of Edu- cation, Albany, March, 1762. 24. *' It cannot be denied that his work everywhere bears the marks of earnest and discriminating labor,—that it takes up all the moot points ©' English philology with freedom and intelligence,—that it presents an extei sive body of principles and rules which are of standard authority in question* RECOMMENDATIONS. 5 concerning good English usage—aud that, as it is the most comprehensive,* is also the most satisfactory treatise on the subject to which the zeal of gram- marians has given birth."—New York Daily Tribune, March 20, 1852. 25. " The work should be in the hands of every student, and in the library of every school-district."— The Waverly Magazine, Boston. 26. "One of the best treatises on grammar that we have seen"—The United States'1 Gazette. 27. " This is a handsome octavo volume, of 1,048 large and closely printed pages; a terse and finished monument of the diligent toil of half a lifetime; a work said to contain more matter, according to the printers' estimate, than any other ever printed in Boston. It is, doubtless, the most complete, accu- rate, and reliable grammar ever produced in English ;—in our opinion,' a truly national work,' and worthy to be put, as Dr. Webster's great American Dic- tionary has so acceptably been, into all the principal schools of the common- wealth."—Petition of the Public Teachers, the School-Committee, the Mayor, and others, of Lynn, Mass., 1852. 28. "It contains all the learning on the subject, and may be regarded as the most complete work, in this respect, that has been or will veiy soon be published. It has consumed a large portion of twenty years of the author's life, and is a monument of industry and perseverance. Those who wish te pursue investigations in the grammatical construction of our language; or who wish to possess in a portable form all that has been said or determined by writers, on mooted points in the language; or who wish, in addition, to possess the independent and original views of an active and strong mind that has been devoted to the subject, will find in these pages all they desire."— Hunt's Merchant's Magazine. 29. "A most lucid, systematic, and beautiful digest of the grammatical principles of our language. • • • We have had, of late years, many works on the subject of English Grammar: some more recently, of considerable merit But in vain, either at home or in England, have we sought for a Gram- mar worthy of the subject, or of being received as an accredited standard whereby to judge what is pure English, and what is not. The work before us seems amply to fill the hitherto existing void."—Eastern State Journal, April 2, 1852. 30. "The author, already widely known as a grammatical teacher and writer, has devoted to this, his magnum opus, the labor of twenty-seven years, and every page bears witness to his faithful industry, care, and enthusiasm. With his diversified experience as a teacher, he has combined the results of a careful analysis of the best authors from Chaucer to our own times, and to both he has added a comparison of the opinions of several hundred writers on English grammar. The principles of the language are clearly exhibited, and its practice is illustrated by a multitude of examples, such as cannot be found elsewhere."—Louisville Journal, April 10, 1862. 31. " The acknowledged void which has long been felt, of an able, critical, and comprehensive grammar of English, has at length been supplied, in a splendid work of that distinguished grammarian Goold Brown, bearing as its title, * The Grammar of English Grammars. This work is a perfect the- saurus of critical detail,—complete in all its parts,—philosophical yet practi- cal —abounding in illustration,—suited alike to the advanced student, to the teacher, and to the general scholar as a work of reference.—Here we have a work as profound as Webster's great Dictionary, at original, as truly Amer- 6 RECOMMENDATIONS. ican and National, as much needed : and should not this noble work be at accessible in our school-districts as Webster!"—George W. Smith, to an Educational Convention at Whiteplains, April 20, 1852. 32. "It discusses with good critical judgment all the topics usually em braced in a work on English grammar, and, moreover, introduces some new and important facts and principles. Its examples of erroneous grammar are also very full, and happily illustrate the principles discussed. A grammar of this size and cost cannot be readily introduced as a text-book into our com- mon schools. It might be used by the higher classes in our academies and norma] schools. And we think that every teacher s>f grammar would find this work a thesaurus to which on doubtful questions he might refer with profit to himself and his classes. This work may be said to sustain the same rela- tion to other grammars of the English language that Webster's Unabridged Dictionary does to other dictionaries, and is perhaps nearly or quite as neces- sary as a work of reference in the school-room for the teacher and the more advanced scholars. And your committee would recommend that the book be procured by the several towns or districts in this Commonwealth, and that one copy be kept for general use in each school. We think the book merits this distinction and place."—Report of the Committee on Education to the House of Representatives, Massachusetts, April 20, 1852. 33. " All that has been said worthy of record, on the orthography, etymol- ogy, syntax, and prosody of the English language, is here methodically ar- ranged and amply illustrated. * * * In the historical and critical introduc- tion, much knowledge and ingenuity are displayed, and all parts of the volume attest the author's learning and diligence. * * * We congratulate the author on the completion of his work, which is a monument of industry and research, and which will be a standard book of reference on the subject of which it treats. The introductory dissertations on the Science of Grammar, the Power of Language, the Origin, History, and Changes of the English Language, and other subjects, contain much that will interest the general reader, while mem- bers of the scholastic profession will find Mr. Brown's book a storehouse of important and curious information."—The London Literary Gazette, and Journal of Belles-Lettres, Science and Arts, April 24, 1852. 34. " This volume must be for all future time, at least, such we think it ought to be considered, judging from the laborious pains, the unwearied re search, and the enormous amount of grammatical knowledge here accumu kted."—M'Makirts American Courier, Philadelphia. 35. " At a meeting of the School Committee of Lynn, held May 18, 1852, the following order, introduced by Mr. Haines, was passed :— "' Ordered, That the School Committee authorize Goold Brown's Gram- mar of English Grammars to be placed in each of the Grammar Schools, and in the High Schools, for the benefit of the scholars and teachers; and that the expense of the same be paid by the city.' "TnEouoRB Atwill, Secretary." 36. "A copious cyclopedia of English Grammar, designed for the guidance of teachers, and the instruction of advanced students. More than three hun- dred writers on the subject have been consulted, and the opinions of the most important of them are cited upon every debatable point. This feature ren- ders the work a sort of library of grammarians, and will give it great value m the estimation of scholars generally."—New York Commercial Advertiser. 87. " The Grammar of English Grammars, by Mr. Brown, of Lynn, Mas- RECOMMENDATIONS. 7 sachusetts, receives warm commendation."—Paris Correspondent : K. Y Journal of Commerce, May 19, 1852. • 38" " Th® work before us> b7 Mr- Brown, is the ne plus ultra in the prov- ince of English grammar. It is an octavo volume of over 1000 pages, a com- plete encyclopedia, comprising everything which other grammarians have written that the scholar or teacher would desire to use either for information or authority. The subject is admirably treated, and the immense amount of information brought together in the work is so analyzed and arranged as to render the treatise most useful and inviting, both as a text-book and as a book of reference. It is the work of a master, and the result of labors ex- tended through a period of over twenty years, with the most triumphant suo- cess. Few, we think, have ever attained to as perfect a knowledge of the English language as Mr. Brown. And none, we are sure, have ever turned their knowledge to better account, in promoting the study of this language. He is critical without being pedantic, and philosophical without speculating on vague theories. His work combines precision with the highest degree of perspicuity; it is complete and comprehensive without being unnecessarily prolix. It is, in its department, the great work of the age, and must be the standard work for ages to come. We have no doubt it will soon be found in general use, wherever the English language is spoken and written."—The Nete York Chronicle. 39 " The work is one which should be in every school-house, public li- brary, or private office, where an immediate decision is needed on the sim- plest or the most abstruse questions on the properties of the English language The contents of the work are methodically arranged and amply illustrated." —New Orleans Daily Picayune. 40. " For the research Mr. Brown has exhibited in this volume, and the thoroughness with which he has prosecuted his investigations, and illustrated his positions by extracts from our classics, he deserves all commendation. The soundness and completeness of his work, can hardry fail to procure for it the foremost place among our standards of philology and criticism."—IJlut- trattd Family Friend, Columbia, S. C. 41. "' The Grammar of English Grammars,' by Goold Brown, is quite a philological curiosity; it bears the same relation to English Grammars that ' Cobbin's Condensed Commentary' bears to Biblical Annotators. A cata- logue is given of about 400 Grammars, which have been dissected and dis- tributed into their appropriate places in this encyclopaedic work. The author has been twenty-seven years employed in packing his materials, and on finish- ing his Johnsonian labors, expresses ' reverent gratitude to God for the signal mercy,' which has enabled him to get through the task."—Westminster Review. 42. " Goold Brown's Grammar of English Grammars, is a very valua- ble book of reference, to the teacher or scholar who takes an interest in the subject, and who wishes to have, in a compact form, all that the several wri- ters on English Grammar have said in regard to the points in dispute. We advise all who love our language to procure a copy of this comprehensive commentary upon it."—The Common School Journal, Botton, June 1,1852. 43. " We consider the ' Institutes,' as here improved, one of the most com- plete and systematic courses of grammar that we have, and, in regard to defi- nitions, superior to all other English grammars."— The Englith Journal of Education, London, June, 1862. 3 RECOMMENDATIONS. 44. "The author has given a 4 Digested Catalogue* of nearly five hundred grammars, that are cited in the Grammar of English Grammars,—a work which, in our opinion, is worth more to the student and scholar, than the whole catalogue of English grammars besides. It is the work of a well-dis- ciplined mind, richly stored with philosophical lore, and trained to thorough and deep thought and investigation. Every teacher and author should have this book lying on his table, to guide whenever syntactical or idiomatical doubte arise. What Webster is to the etymology of words, Brown is to syntax."—Moore't Rural New-Yorker, July 15, 1852. 45. "This production stands out, in bold relief, as the book of the age, on the lubject of English Grammar. No scholar can regard his library complete with- out this book. It is destined to be the standard authority in its department, and will, therefore, be found an indispensable requisite in the office of every rofessional man, and on the table of every teacher. It must have a place y the side of Webster and Worcester, as a book of reference. We confess that we take pride in claiming this as the production of an American, and, what is more, an American schoolmaster. It will reflect honor upon the country and the profession. The name of Goold Brown is destined to be known and mentioned with respect, wherever the English language is spoken in purity."—The Massachusetts Teacher, August, 1852. 46. " Having devoted no inconsiderable amount of time to an examina- tion of the subject to which your work relates, I have no hesitation in saying that you have done more for the Grammar of our language than any other writer, either English or American. W. H. Wells." Letter to the Author, February 3, 1854. 47. Dr. Felix Flugel, in an article entitled " English Philology in North America," and published in Gersdorfs Repertorium, at Leipzic, September, 1862, says :—"This work of Mr. Goold Brown—' The Grammar of English Grammars'—is absolutely indispensable to any one who would know what is the present state of English grammatical science. With unexampled dili- gence the author has briefly adduced the opinions of the best grammarians upon all the difficult points, and he has shown himself to be so thoroughly versed in these, and has brought together such a mass of authorities, that his book deserves to be called a great step in advance in English Grammar. . . . . Upon the whole, it is a most important improvement upon all other English Grammars, and it holds in grammatical science the same place as Webster's great work in lexicography. In respect to style and expression, Mr. Brown's book may be regarded as a model." THE GRAMMAR OF ENGLISH GRAMMARS IS PUBIJBHXD BT B. 8. k W. WOOD, No. 389 BROADWAY, NEW-YORK. THET ALSO PUBLISH THX FIRST LINES OF ENGLISH GRAMMAR, designed fot young learners ; and THF. INSTITUTES OF ENGLISH GRAMMAR, BT THE SAME AUTHOR, u Brown's Grammar is used as our standing text-book in the Normal School." Ji*>a»y, is July, im«. D. P. Pagi, Principal. These Grammars have been adopted as text-books in many of the District and Public Schools and Academies, throughout the country. Sold by the booksellers generally. HOW TO NURSE SICK CHILDREN. Intended especially as a help to the Nurses at the Hospital for Sick Children; but containing directions which may be found of service to all who have the charg* of the young. "The young mother, or the still younger nurse, is commonlv suuDosed to under stand the child's wants and habits intuitively, and the con^quLceTsuch intotive tZt^l "VE ^ ^ 5°W °ften' the S0UrCe of a &SS& oSBtitatiofor aeatn to the child, anguish, and a murmuring spirit to the parent Nor is the blame to be laid solely at the door of the young mother or the child, but rather at the door of those who, with knowledge at their command, have failed to communicate it The author brings to his task the two great qualifications—a thorough love of children and a thorough knowledge of their habits in health and disease It is a ample but feeling account of the wants of the sick child, and of the duties required of its attendant."—Brit. & For. Med. Chir. Review. ON RHEUMATISM, RHEUMATIC GOUT, AND SCIATICA; Their Pathology, Symptoms, and Treatment. BY HENRY WILLIAM FULLER, M.D., CANTAB., Fellow of the Royal College of Physicians, London; Assistant Physician to St George's Hospital, etc, etc. " One of the best practical works of modern times."— Winslow's Journal of Psycho- logical Medicine. DISEASES OF MENSTRUATION AND OVARIAN INFLAMMATION, In connection with Sterility, Pelvic Tumors, and Affections of the Womb. BY EDWARD JOHN TILT, M.D., Physician to the Harrington General Dispensary, and to the Paddington Free 1 pensary for the Diseases of Women and Children. " The best publication on the subject."—Boston Med. and Surg. Journal. MICROSCOPIC ANATOMY OF THE HUMAN BODY, IN HEALTH AND DISEASE. Illustrated with numerous drawings in color, by Arthur Hill Hassal, M.B., Mem- ber of Royal College of Surgeons of England, etc., eta With additions to the Text and Plates, and an Introduction, containing Instructions in Microscopic Manipula- tion, by HENRY VAN ARSDALE, M.D. 2 vols. 8vo. 79 plates. MANUAL OF DISEASES OF THE SKIN. BY MM. CAZENAVE AND SCHEDEL. Translated from the French, with Notes and Additions, by T. H. Burgess, M.D. Re- vised and corrected, with additional Notes, by H. D. Bulklet, M.D., Physician of the New York Hospital, etc., etc. Second American Edition. " One of the most concise, complete, and practical treatises with which We are acquainted."—Northern Lancet. "It is direct, full, and explicit in its descriptions."—N. H. Journal of Medicine. YOUNG LADIES' FRIEND. bt a lady, (mrs. farrar.) Price $1 25. This work was written with care; it enters with great plainness, faithfulness, and sound judgment into the details of every -day life, and commends itself to all who desire to see the peculiar grace of female character called into the most efficient action. The following testimonials are extracts from letters recently received. From Joseph M. Smith, M. D. Nero-York. " I know of no work treating of the same subject, which equals it in merit. The authoress displays a practical familiarity with the subjects which at once inspires entire confidence." From John B. Beck{ M. D. New-York. " I have read with much satisfaction the Young Ladies' Friend, and cannot but wish for it an extensive circulation." From John R. Rhinelemder, M. D. New- York. " I have read the Young Ladies' Friend, and believe its circulation must be beneficial to the community." From Edward Delafield, M. D. New-York. " It contains much advice of great value; a vast amount of the feeble health, so constantly observed among our young females, might be prevented." From Rev. J. F. Schroeder, New- York. " I think the general circulation of it will do much to promote the happiness of those for whose benefit it is designed." From Rev. Thomas M'Auley, New York. " I have found the style chaste, sentiments correct, and the advice generally marked with strong common sense, and a fine perception of propriety." From Rev. Lot Jones, New-York. " I cordially unite in the above view of Rev. Dr. M'Auley." From the Register and Observer. " We hardly know a more useful work; it deserves commendation among other things, for the right views it gives young women of their true relation to their fellow-beings—it addresses them as component parts of society, who are to be useful and not merely ornamental—it considers them as young women as well as young ladies." From Abbot's Magazine. " No one, we believe, who has read this book, will be surprised at its popularity. It is precisely such a book as the wants of a large portion of the young ladies of this country, (and not a few of the older ones also,) had long since called for." From N. P. Willis, Esq. " I have never seen so sensible and so useful a book. It ought to be an indispensable addition to every family library. It would save parents a great deal of trouble, and young people (of all ages) a gr«*> deal of mortification. This book is invaluable." Also from Mrs. L. H. Sigourney. " It is truly an excellent work, and I think the accomplished au- thor must be gratified by its decided popularity." i NLM032061464