I give similar directions to the monthly nurse, and, if I have the opportunity, I ask the husband of the lady to watch over her, in order that I might receive the earliest information of any indisposition. This course I have pursued for years, and yet, up to this hour, I am unacquainted with a single household or individual in whom I can trust on such occasions. If the lady is taken sick, the nurse, or the grandmother, or she herself, will explain it as after-pains, or as headache, or as rheumatism; and if the curable stage has been gone through before your visit, such signal disobedience of express directions, such enormous stupidity, is apt to be followed by the loss of the patient; a loss so great, that there are no words in which I can set forth the mental distress it occasions. Please to understand, that if you scrupulously adopt the plan which I have above recommended, and should practice midwifery for half a century, you will scarcely find ten occasions in your whole life, in which a prompt information will be communicated to you; and this it is that makes the life of an accoucheur more painful than that of the surgeon or the general practitioner. It is very singular, but it is very true, that physicians are subject to these constant anxieties and mortifications. A woman will send a break-neck message after you, to call you out in night and storm and tempest, because her baby has had a bellyache, or possibly a green stool; but she will not send for you, perhaps, if she is standing on the brink of the grave, as every woman is who is even threatened with this direful disease. She will ask the nurse to do something to cure her. Be not discouraged, however; the fault will not be yours if you should have taken all the precautions in your power; whereas, a heavy charge would lie upon your conscience, should a patient be lost in consequence of inattention, on your part, in issuing the needful directions.

After the death of a charming lady here a few years ago, I sent to her husband a copy of Gordon's treatise. She fell a victim to the imprudence and stupidity of her nurse, who allowed her to pass through the curable stage of an epidemic puerperal fever, declaring that it was only after-pains, which she understood as well as the doctor, and that she would not have the doctor sent for. "Haven't I nursed," said she, "for thirty years and more, and must I have a doctor put on me because you've got an afterpain? Nonsense!" And so, when her physician, who had left her well a few hours before, was at length requested to visit her,

he found her far gone-past all hope of recovery. The gentleman read Gordon, and when he returned me the volume, "Oh, sir!" said he, "why is it that this book is not to be found in every house?—If I had read these pages sooner, I should not, perhaps, now mourn over my irreparable loss."

If

I could relate to you many histories, setting forth the importance of early information in this case. But it is time to close this letter, in which I have endeavored to give you what I regard as sound and wholesome views upon the subject of which it treats. you will take my advice, you will buy Barrington & Haswell's book, and read it with the greatest care. And when you shall have read Gordon, Hey, Armstrong, and Robert Lee, if you will practice with ipecac. and calomel, and nothing else, I cannot be responsible for you, though I shall be very sorry for you.

C. D. M.

LETTER XLII.

PHLEGMASIA DOLENS; CRURAL PHLEBITIS.

GENTLEMEN:-There is a disease of which I have not yet spoken, and which is vulgarly known by the term Milk Leg. It has been called by the writers, phlegmasia alba dolens puerperarum, or the painful white swelling of the lying-in woman. Some of the Frenchmen still call it lait repandu, which is a translation of the English word milk leg; a word employed to express the sense, that the milk of the woman has fallen into her leg, and inflamed and swelled it; and I suppose, indeed, that in this nineteenth century, half gone as it is, you will have plenty of trouble to convince your patients that it will not be your duty always to get the milk out of the leg, or so to regulate your prescriptions, as to provide against the effusion of more milk into the cellular tissue of the limb. I suppose you will laugh, gentlemen, at the idea of having milk in a woman's leg, for you know milk is made in the breast, and not in the leg; it is pretty much like saying, that a

man has a salivation of his liver, or a diarrhoea of his kidney; in fact, it is sheer nonsense.

There are a great many doctors in this country-people who don't read books-who, while they don't suppose that it is milk in the leg, yet persist in believing that it is inflammation of the cellular tissue: though no man ever saw one suppurate, and though every man knows that when cellular tissue inflames, it is almost sure to suppurate. I should like to see a woman get well of an inflammation of the cellular tissue of the whole limb from the crista of the ilium to the os calcis, and from the pubis to the metatarsal bone of the great toe!-one whose thigh is bigger than a man's body, and her leg swollen to the size of that of an elephant! -that is to say, get well without a suppuration, or, indeed, in any

way.

Some persons have supposed that the swelling is produced by a disease of the absorbents of the limb; and, in fact, nothing was known about it, until Robert Lee, the same Robert Lee of whom I have spoken so many times in these letters, made the discovery of it, and clearly demonstrated its true pathological nature; showing that the lesion in the disease, is a lesion of the veins of the limb, for which, he gave to it the name of Crural Phlebitis, the name by which it is called by all physicians who know anything about it: it is called milk-leg only by those who know nothing about it. The old doctrine of milk-leg is still taught by persons in high places.

Dr. Lee, in his Essay on Crural Phlebitis, (Barrington and Haswell's ed., page 314,) after having given a literary history of crural phlebitis in puerperal women, says: "It is a remarkable circumstance in the history of crural phlebitis, that nearly a century and a half should have elapsed, after it was first clearly pointed out by Mauriceau, before an opportunity was presented of ascertaining, by dissection, the precise nature of the disease. There had been opportunities, as I have shown, to determine the accuracy of the different hypotheses that had been advanced, but these were neglected, and the real nature of the disease, and its commencement in the uterus, were imperfectly understood, until I ascertained, by dissection, the true nature of the complaint." Dr. Lee's account of this dissection is in the Medico-Chirurgical Transactions, vol. xv., 1839.

The disease under consideration, commences in the endangium

of the vessels; it is the same malady which most frequently carries off the chirurgical patient who has been subjected to amputation of the limb. It is the same thing that happens to every blood-vessel, whether artery or vein, around which you cast a ligature, and tie it, for the suppression of hemorrhage. Fortunately, the application of your simple ligature develops only a sufficient amount of inflammation to effect the union of the disrupted endangium, and constitute a plug of lymph, fitted to become a bond of union for the opposing walls of the vessel, and thus restrain the hemorrhage after the ligature shall have fallen off.

Crural phlebitis may begin before the termination of the gestation; I have met with several cases in which it occurred six weeks before the child was born. It may commence soon after the ending of the labor, or not until the woman has begun to move about her chamber; she is liable to it at any period within the lying-in month. A man is liable to it; so is a child;—it is by no means peculiar to the gentler sex.

Many of the cases of swollen limbs, that are looked upon by the Doctors, as cedema, coming on at the close of great chronic visceral diseases of the belly, such as enormous enlargements of the liver, or spleen, or great heterologue glands, that are produced there; or cancer of the stomach-many of these swellings, I say, are not œedema, as the Doctors suppose, but they are crural phlebitis. I have known them to be so at the beginning, and have proved them to be so after death; for I have found the great crural veins and internal iliacs filled with lymph, and pus, and coagulated blood, and, in some instances, totally obstructed. Dr. Lee has found some puerperal cases, in which the great crural vein, in returning into the body, has been lost, like an African river in the sands; no trace of the vessels being left by the ravages of disease, which had extended from the endangial lining into the circumvolved tissues within the abdomen.

Now, gentlemen, see a limb supplied by a great femoral artery and profunda, with its anterior and posterior tibials, and all the other branches: imagine these arteries healthy, strong, perfect in structure and volume; and see a current of blood, driven into them by the contraction of the heart under the powerful excitement of a great fever; and then, imagine the femoral vein or the saphena, obstructed by thickening of its endangium; by quantities of plastic lymph which has exuded from the inner wall; by

strong, firm coagula of blood, which have been arrested on its now irregular surfaces; by a quantity of serum exuded between the outer or fibrous coat of the vein and the cellular sheath in which it runs, so as to give you the feeling, when you pass your finger from Poupart's ligament down the limb to where the vessel pierces the triceps muscle, as if the finger were pressing upon a body as large as a man's thumb, and as hard as a stick. Now, tell me, what is to become of all the blood dashed into the limb by the force of an infuriated systemic ventricle; and how is it to get out? How is the woman to avoid the great swelling of the limb, which you call phlegmasia alba, or milk-leg, but which you would better call crural phlebitis?

It is impossible to suppose such a condition of the vessels, without conformable swelling: for the vein which carries blood from the limb, is virtually compressed, as if you had tied it up with a ligature, preparatory to bleeding it. The vein is as if you had. put the pad of Petit's tourniquet upon it, and left the artery perfectly free and unobstructed. But it is not the crural vein alone that suffers in these cases; the inflammation not unfrequently extends into numerous superficial branches, which become extraordinarily sensible to the touch, and hard; evidently containing within their cavities, quantities of coagulated blood.

But, the disease is called phlegmasia alba dolens. What makes the pain? Don't you know that the femoral artery, the crural vein, and the great crural nerve, constitute a fasciculus, and they are bound up in a common sheath or theca, until they reach the point where they perforate the triceps to get into the ham? Well, then, the inflammation of the endangium of the crural vessels dips through the fibrous coat, and causes the infiltration I spoke of in the common sheath of the fasciculus; producing the long, hard, cordlike swelling extending from Poupart's ligament even into the ham. The whole crural nerve is thus compressed, gentlemen; but if you compress the crural nerve, won't the woman have pain? Won't she have neuralgia? Well, the sensibility that the woman has, and the pain that she suffers in crural phlebitis, are essentially a neuralgia from pressure on the crural nerve.

The veins in the interior of the body are, for a long time, compressed by the gravid uterus; and sometimes, compressed with great force, which is increased enormously in the throes of labor. They are not only compressed, so as in some instances absolutely