operation. What is the medicine that doesn't disappoint you? Castor oil. The dose of this medicine ought to be, as a medium, about half a tablespoonful. In ten cases of women just confined, a dessertspoonful of castor oil will be sufficient for nine of them, and the tenth one can repeat it after five or six hours, if she chooses. I advise you to follow this method; and I confidently advise you in this way, because "haud inexpertus loquor." Neither my friend Dr. Samuel Jackson, nor I, would consent to give a woman a tablespoonful of castor oil under such circumstances, because we know that half a tablespoonful is a better dose for her. Dr. Jackson is a good authority in matters of therapeutics. I wish there were more like him in the country. The diet of the woman is worthy of some consideration: many women are left by labor with their blood-vessels in a state of convulsion, so to speak; the tempest and whirlwind of their passion do not subside, for many of them at least, for hours after the provoking cause has been taken away. If the woman has not lost a great quantity of blood by the detachment of the placenta; or if the lochial discharge should prove to be not very abundant, the materials for development left within her blood-vessels ought not to be deemed to require much refection for two or three days. She is about to have a new cause of constitutional disturbance set up within her: both the mammary glands are destined to sudden, I was going to say, bursting development. They are both about to become suddenly instinct with life; an operation attended, in the majority of cases, if not with fever, at least with a quasi febrile paroxysm. These considerations render it expedient that her diet should consist of very light, digestible, and sufficiently nutritious materials. I presume that in different parts of the country there are different modes of treating the lying-in woman as to her diet; but as for us in Philadelphia, a time-honored custom, which is universally adhered to, commands the nurse to provide for her patient a diet of gruel made with oatmeal. Many of the nurses boil it into a thick porridge, and give it to the patient sweetened with sugar, after having made a very slender addition of salt; it is light, aperient, agreeable to the patient, and satisfies well the cravings of the stomach. The woman is also allowed a cup of tea, and some dry toast or baked rusks; or any simple preparation of bread. Tea and toast, oatmeal gruel and cold water are a lying-in woman's allowance, until after the milk comes, in Philadelphia. Hot tiff, or brandy and water; soups, meats, eggs; all animal substances, ought to be proscribed. A woman ought to keep her bed for the first nine or ten days after her accouchement; if she gets up, the womb descends into the excavation, lower than the place it ought to occupy. The womb will get well, notwithstanding such imprudence; but the vagina may be ruined, and the woman's health may be forever after disturbed by a prolapsion, which always coincides with a shortening of the vagina. Prolapsus uteri means, and is nothing else than shortening of the vagina; and you have nothing to cure in prolapsus uteri but a shortening of the vagina; and when it is cured, the woman is cured, and you have nothing else to do with it. There is another motive why a woman should not get up, arising from her extraordinary nervous susceptibility after labor. She may take cold; she may be seized with a rigor; and the rigor may give her an attack of weed in the breast; or the force of the reaction may fall upon the womb, or upon the peritoneum; so that she shall pay for her imprudent early rising with a mammary abscess, or by loss of her life in a child-bed fever. I verily believe, that one half of the vexations I have experienced in the course of my life, from such occurrences, have been the fruit of untimely, imprudent exposure as to diet, or as to too early rising from the bed. I tell my young lady-patients that if they keep the bed until they are cured, child-bearing will not make them break, as it is called. A squaw, with two pappooses, is nothing but a squaw. She might have been a very pretty woman still, if she had had a good nurse, and kept her bed until after the ninth day. She who gets up too soon will have wrinkles, and grow sallow and ugly before she is twenty-five. After the ninth day has elapsed, if nothing has happened, the woman may be taken up for an hour in the morning, and again as long in the afternoon; prolonging from day to day her leave of absence from the couch, until her strength being gradually restored, there shall seem no longer need for any restriction what ever. I shall refrain from offering remarks here on the coming of the milk, and the management of the breast, as I intend to devote a separate letter to that consideration. As to riding out, it will depend upon the state of the patient's health; it is well, however, to have a rule;-my rule is to say, you may ride out on the twenty-first day, if you be well enough and the weather be inviting. An hour's ride is long enough for the first sortie. But, if the lochia are not gone, it is better to stay at home. No woman ought to consider herself recovered from the effects of her accouchement, until after the lapse of an entire month. The Jews, who inhabited a very warm climate, were considered, by their Lawgiver, unclean for forty days after the birth of the child. Christian women are purified in thirty days, and I am afraid that some of them think themselves so earlier than that. I wish that the brethren could lend their influence to reinstate the Mosaic doctrine on this point. But, some people will not believe Moses nor the prophets; nor would they believe, though one should rise from the dead to tell them, they are not well, if they but feel well. Pregnant women ought not to be vaccinated. This is a rule that I advise you to depart from only on the most urgent occasions. If a woman have been once vaccinated, and appeal to you to revaccinate her because there is a present variolous epidemic, I hope you will refuse to accede to her request. Small-pox is exceedingly and peculiarly pernicious to pregnant women.-She who has it, and miscarries-or who is brought to bed at term, generally dies. It is, in my opinion, inexcusable to expose her to so great a risk-a risk far greater than that from accidental contagion, or that of the epidemy. But the vaccine is identical with the variolous animal poison, saving some lessened intensity of its malignant form derived from its having been modified by the nature of another mammal.-To inoculate a cow with small-pox virus, is to give her the vaccine disease, with the lymph of which you can vaccinate, but not reproduce unmodified small-pox. Keep your pregnant patients clear of small-pox in all its forms, whether modified or unmodified.—Do not vaccinate them. I have been the witness of dreadful distress from the operation.-Eschew it, I entreat you. C. D. M. LETTER XLI. GENTLEMEN:-There is a "word of fear" that I shall pronounce when I utter the name of Puerperal fever; for there is almost no acute disease that is more terrible than this-even small-pox, which reduces the fairest form of humanity to a mass of breathing corruption, cannot be looked upon with greater awe, since, like an inexorable Atropos, it cuts off the thread of life for those to whom Clotho and Lachesis would give the longest span. There is something so touching in the death of a woman who has recently given birth to her child; something so mournful in the disappointment of cherished hopes; something so pitiful in the deserted condition of the new-born helpless creature, forever deprived of those tender cares and caresses so necessary for it—that the hardest heart is sensible to the catastrophe. It is a sort of desecration for an accouchée to die. The disease in question, from its liability to assume the character of a devastating epidemic, acquires an importance far greater than would appertain to it, were it limited to the occasional fatalities of its sporadic or accidental formulas-for when it does prevail as an epidemic, it sometimes rages over a great extent of country, or districts, and lays not aside its destroying wrath, not for weeks only, or months, but even for a term of years; carrying in its train fear, expectation of death, and the overthrow and desolation of the domestic altar. The maladies comprised under the denomination of puerperal fever, for there are several of them, are so insidious in their approach, so sudden and violent in the attack, and so rapid in their progress, that the fatal boundaries are not unfrequently passed before assistance is sought for from the hands of the physician. It is, therefore, clearly your duty to make yourselves accurately acquainted with its nature, signs and treatment. I shall accordingly, in the present letter, endeavor to lay before you such views upon the subject as I have been able to obtain from no little clinical observation of cases, from reflection upon what I have myself seen, and from conversation and reading. Puerperal fever, denominated, by the public, child-bed-fever, is also called peritoneal fever, puerperal peritonitis, metritis, metro-peritonitis, uterine phlebitis, and lastly, pyogenic fever: it is a disease consisting of inflammation of the serous coat of the abdomen, or of some portion of it-inflammation of the ovaries—one or both of them; of the womb, with, or without coincident inflammation of the peritoneum; of the veins of the womb; or of the absorbent vessels of that organ. It is probable, that a major part of the cases consist of serous inflammation only,-cases in which the sub-serous textures have little participation in the pathological modifications of the peritoneum proper. Many of these samples of peritonitis, however, coincide with violent inflammation of one or both of the ovaria-of the ligamenta lata, and of the external superficial tissues of the uterus. In pure samples of metritis-or of uterine phlebitis, the inflammatory modification of the tissues may not, on the one hand, or on the other may, extend to, and involve the serous lining of the womb, and spread far and wide throughout the various folds and reflections of the whole peritoneum. Leaving out of consideration the nature of the recondite causes. that operate upon the economy to develop the various puerperal inflammations; such as an epidemic or an endemial influence; or a poison conveyed in the clothing or persons of physicians and nurses, one would seem to perceive sufficient provocatives to the attack of inflammation, in the state of the parturient woman's constitution, and in the events of the labor by which she may have been brought to bed. Indeed, there is room for surprise, that the examples of violent inflammation of the tissues concerned in parturition, are not far more numerous than they are really found to be. In the first place, it is extremely rare to let blood for a patient pregnant and nigh to her term, without discovering the proofs of an inflammatory tendency, in the sizy and cupped appearance of the blood, when allowed to lie in a state of rest. I beg you to take notice, in your subsequent practice, of this point. But if the blood be sizy in nearly all pregnant women, then all such women are, to say the least, in a state of proneness to inflammatory attacks-since that siziness of the blood indicates an excessive predominance of the fibrinous element. I beg you to allow me |