LETTER XXXVIII.

GENTLEMEN :—There are not a few persons, who, in the pregnant state, become affected with seeming diseases of the heart, characterized by irregular action of that organ, such as palpitation, great augmentation of the superficies of pulsation, dyspnoea, orthopnoea, paleness, convulsions, sudden loss of sight and hearing, followed in the long run by cedema and true anasarca. I am speaking of persons who seem to labor under disease of the heart, and I speak, having in my mind a vivid recollection of divers cases that I have had the charge of in the course of my practice. A pregnant woman ought to pass through the whole of her gestation without any feeling of disease; and many women do, in fact, conceive, develop, and bear their children without any apparent change of their health or comfort. I have seen young women not far from term, skip up and down stairs as if they had not been married, preserving all their activity, agility, and appetite, their good spirits, their color, and their temperature, enjoying food, sleeping, and waking, as if nothing was the matter with them. But there are some constitutions on which the influence of pregnancy is disastrous in the extreme, constitutions in which the gestation seems to be a direful effort of the life forces that they can scarcely carry out, which they are often unable to perfect, and which, in some instances, is perfected at the expense of the woman's health and life.

A woman who develops her child requires an augmentation of her hæmatosic power; indeed, it is but fair to say that she requires an augmentation of the hæmatosic power for the uses of her own constitution, applying it to the maintenance of her own developments, which demand considerable reinforcements when the life force is exerted with a preternatural energy. The reaper in a harvest field requires more drink and more food than the idler; the woman who maintains not only her own development, but also furnishes the materials for the development of the child, may in respect to her wants be compared to the reaper in the harvest field.

But, an augmented development power is a power augmented at the expense of the nervous constitution or matter. There are some nervous constitutions that can furnish it without detriment, whereas others suffer the greatest detriment in doing so.

If the nervous system becomes affected by these efforts, it may show the affection in some diminution of its power, and the diminution of its power will be most likely to manifest itself as to the specific tissues, that are most immediately subservient to the supererogatory demands of the occasion. Inasmuch as all development takes place at the expense of the blood, of which the consumption and loss are very great in gestation, it is not, I think, unphilosophical to suppose, that the specific tissue most likely to suffer under these circumstances, is the tissue which in former letters I have repeatedly mentioned under the title of the endangium, of Mr. Burdach, or blood-membrane, as I prefer to call it. But, if the blood-membrane, in consequence of exertion of its faculties, becomes weakened, becomes diminished as to functional force, then we shall have an imperfect blood, imperfect in regard to the proportion of its solid constituents, which are diminished while the watery part is abnormally increased, which would constitute a state of anæmia. But a condition of anæmia in a constitution

bound to carry on the great operations of gestation, is one likely to be attended with faulty innervation; faulty innervation, not only of the cerebellar and cerebral and spinal nerves, but of the whole ganglionic system of nervous supply.

The patient will become emaciated more or less, while her cellular tissue is infiltrated with serum or halitus, giving her the appearance of an embonpoint which is likely to deceive the incautious diagnosticator. The increased proportion of water in her blood will give to her superficies a character of pallor or chlorosis, and the diminution of the universal tone will extend even to the heart itself, which may become so flabby as apparently to increase in magnitude and give rise to a great increase of its pulsative superficies on auscultation, misleading the inquirer, and causing him to believe in the existence of a disease of the heart, whereas the disease is essentially an anæmia, or an endangial malady only. These are most distressing cases; they generally become aggravated in proportion to the advance of the pregnancy; and not unfrequently admit of such extensive dropsical infiltrations, not only of the cellular tissues, but even of the serous cavities,

particularly the thorax, as to bring the patient's life into the extremest peril. Yet these maladies are not diseases of the heart; they are samples of anæmia, from which, often, the patient recovers with surprising rapidity, when the cause--videlicet, the gestation has been brought to its term by the birth of the child.

In cases of organic disease of the heart, I mean vast dilatation of its cavities, there is no reason to expect a rapid recovery, or perhaps a recovery under any circumstances. But the anæmical dilatation, or, if you permit me to use the term, the anæmical laxity of the heart's fibre, might well, and in fact does, for the most part, disappear under an appropriate treatment, when its provoking cause, to wit, the anæmia, has been removed. I am very desirous that you should give attention to this theory of the case, and that you should endeavor, whenever you shall come to take charge of a pregnant woman, affected with disease of the heart, to make a careful discrimination between the incurable organic lesions of that important organ, and the modifications of its density and contractility, that may be superinduced by a too feeble innervation of its tissues.

The most extravagant deviations in the heart's action that can be produced by the anæmical state, are for the most part found to be lessened and even to disappear wholly, when the patient is placed in a recumbent posture, and has had time enough to allow the accidental hurry and excitement which have been produced by exertion, motion, or emotion, to subside, and the rate of all the functional forces to come down to a condition conformable to the wants of the economy in a state of profound repose. The anæmical disorder, under a supposed condition of perfect repose, disappears in so far, at least, as it can be manifested by the respiration or by the circulation. This is not the case in the true organic disease of the heart, where, though the derangements of the heart's action, aggravated by exertion, are frightful, indeed, yet they do not wholly disappear even in a state of the most profound repose, but leave their physical signs so plainly discernible to the practised inquirer, that he cannot be misled by them. The hypertrophic throb of a thickened ventricle, and the feeble imperfect action of a coincidently dilated auricle, can be detected by the ear, even after a long night's repose. But the irregular, disordered, anomalous, feeble beat of the anæmic heart,

give place to a perfect rhythm, impulse, and superficies, after such a repose has been had.

I am very desirous that you should make a careful discrimination in the cases supposed, and that you should not mistake the quick but feeble impulse of the anæmical heart, for the stern, resolute and dangerous injective force of the hypertrophied ventricle. In the one, you will be prompted to use the lancet as a means of diminishing the excessive general momentum of the arterial pulse; in the other, you would prescribe profound recumbent rest to save the constitution from the effects of the disordered and convulsive beat which follows every effort. You would direct a nutritious and light diet, you would give wine and iron, you would direct well ventilated rooms, you would prescribe the use of moderate anodynes and antispasmodics, to obtund the exaggerated sensibilities of a debilitated constitution; and in so doing, you would conduct the patient wisely, if not safely, to the term of her utero-gestation, which, being completed, and the cause being removed, leave you afterwards nothing to do, but contend against the pathological causes of the simplest anæmia.

But I have already said so much in these letters upon that subject, that I shall not offer any further observations here, and I refer you to those letters, in the confident belief, that the pathological principles there explained, are founded in sober views of important truths.

In the treatment of these anæmical cases, you will meet with prejudices against the employment of ferruginous articles; for the public in general, who believe that iron is endowed with what are called forcing properties, as regards the menstrua, are timorous as to the use of such therapeutical agents during gestation. They suppose that forcing articles have the power to produce abortion or premature labor, because they thoroughly believe that such forcing articles are capable of bringing on menstruation, in season or out of season. To you who have adopted the doctrines of the periodical ovulation and deposit, I need not say, that the chalybeates have no such forcing power as is supposed, and that the use of them during gestation is not less prudent and safe, than that of any other tonic medicine whatever, and I have not the least misgiving as to the propriety and safety of employing them for the cure of these endangial maladies in women pregnant, whether in the early or in the advanced stages of gestation.

I attended here a few years since, a young woman during the latter half of her utero-gestation, and during the labor in which it terminated; a case which was put in my hands by the advice of her medical attendant, on the ground that it was a very dangerous one, with which he was not disposed to charge himself.

She presented all the appearances of great dilatation of both the auricles and ventricles of the heart-the impulse of which was perceptible to the right of the middle of the sternum. The pulse, except when she was in a state of recumbent rest, was large, gaseous, unsteady and very sudden. The face and whole surface were pale and flabby, the cornea nearly uncovered of the upper palpebra. The respiration was troubled, and on the least motion or emotion, precipitate and difficult. At the end of the seventh month, the lower limbs became considerably infiltrated, and the power of muscular motion much curtailed in consequence of its being always attended with violent beating of the heart, breathlessness, and uneasy sensations in the head, as pain, vertigo, noises and dimness of sight.

The progress of the pregnancy was accompanied with aggravation of all these appearances.

On different occasions she had attempted to walk in her house, and had fallen on the floor in a state of insensibility. I, being hurriedly notified of such an accident, arrived on one of the occasions, at the house, soon after she was taken up from the floor and laid upon the bed.

I found her absolutely pale, scarcely able to speak, and completely blind when I arrived. She knew my voice, and opened her eyes to look at me as I spoke :-the eyes were bright, the pupils natural, but she was wholly without sight. She complained of some degree of fulness of the head. The pulse was still agitated. In a short time the sight returned and was perfect as before. I do not recollect how many times she actually fell in this manner, and with such following phenomena, but the accident was repeated several times. In nearing the term, the swelling of the limbs from œdema was greatly augmented, so as to affect the thighs, and the buttocks, and labia; the pericardium became also the seat of a dropsical effusion, so that a complete orthopnoea soon declared itself.

My patient could not lie down day nor night. If she sat up with a pillow against her back and shoulders, the oppression be