to suffer contusion, but the whole of the veins of the lower extremities are, in many women, for a long time, distended by the pressure of the womb, causing oedema gravidarum, and that very common occurrence, varix gravidæ. Such a constant, long-continued pressure upon the vessels, might well be supposed to have, in many instances, the effect of developing an inflammatory state there; this would be endangitis. But the endangitis is more likely to affect the veins below, than those above, the point of pressure. There are many cases in which inflammation, commencing in the branches of the uterine veins, and spreading along the endangium to the internal iliacs, passes out beneath Poupart's ligament, along the external iliac to the femoral, and thence to all the veins which become subject to it in the leg. It will be first suspected by pain felt at the groin, or in the calf of the leg. I am very sure, that, in many of the cases I have met with, my first detection of the existence of the malady, was made in consequence of complaints as to pain in the calf of the leg. When a woman who has been confined, or who is pregnant, tells me she has a pain in the calf of her leg, I put a thumb upon the spine of the tibia, and the fingers upon the calf, and then suddenly compress the gastrocnemii and soleus against the bone; if the woman shrinks from the pressure, and makes an outcry, I next ask permission to examine the groin; and if I feel the swollen ridge of the theca of the vessels, I know that my patient labors under crural phlebitis. I then examine the external iliac, by putting my hand on the same side of the hypogaster, and pressing the teguments against the brim or strait of the pelvis as far as I can push them; when I am very sure to detect the evidence of inflammation extending up into the body, if it goes so far inwards.

The calf of the leg will be found hard. Let the woman lie upon her back, and be directed to draw both of the knees up in the bed until the tibia become nearly vertical: you now take hold of the calf of the leg, lightly from behind, and endeavor to shake it from side to side. You will find you can't shake it, for the whole mass seems attached to the bone, or packed against it. If you shake the other calf, it will be perfectly flabby and movable in your hand; the result of this comparison will settle the diagnostic.

As you will have to treat the case, you ought to be able to make comparison of its progress from day to day; to which end,

take a piece of broad tape, cast it around the thickest part of the calf of the leg, measure it accurately, making a mark with a pen or pencil upon the tape, to show the exact circumference, with the date inscribed. Let this tape be carefully kept by the nurse for future reference; and let this measurement be repeated from day to day.

If you detect the disease in its formative stage, or in its earlier stages, you will find it before there has been much swelling, particularly of the thigh; and you should announce that the thigh will become enormously swollen, provided your treatment should not succeed in assuaging it. There will also necessarily be fever, or the expression of constitutional distress, from so great and so painful a malady.

And now, gentlemen, as for the treatment. It is, rarely, proper to bleed for this disease; because, the disease is seldom detected, until one of the terminations of inflammation has been reached. I say one of the terminations of inflammation, for the termination of an inflammation is reached, first, by resolution-second, by effusion-third, by suppuration-fourth, by adhesion-fifth, by sphacelation and mortification. But, when you find this great ridge, extending down from the groin, it is because effusion has taken place already; and, therefore, the bleeding stage has passed by. It may be useful to apply some leeches along the course of the swollen theca, because a topical depletion tends to prevent the further exterior or circumferential progress of the malady; it will have very little influence on the essential or endangial disease.

But, perhaps, gentlemen, the best and most efficacious of all remedies, is position, used in the chirurgical sense-I ought, perhaps, to say rest and position. The patient is to be irrecusably confined to the dorsal decubitus; the whole limb to be placed upon pillows, or upon a bolster, so arranged as to incline the leg upwards at an angle, not above 7° or 10°. She should be told : "Now, madam, if you dare to put the foot upon the floor, even after you shall be almost cured of this disease, you will scarce fail to reproduce it with all its intenseness: the peril and the pain will be yours. Look to it, that you incur them not." Is not it very clear, that if she puts her foot to the floor, and stands upon it, she will have to lift the whole column of blood in the veins, from the sole of the foot to the cardiac extremity of the vena cava, at the expense of the most enormous strain upon the sides

of the vessels? It would be the grossest malpractice, to allow the woman even to sit up on a sofa, until the limb is safe.

Our great and learned surgeon, Dr. Physick, used to be proud of the certainty with which he treated cases of phlebitis, by HIS method. Dr. Physick's method was to apply a blister, covering the whole diseased tractus of vein, a little wider than that tractus. If you will take my advice, you will not neglect it; for of Dr. Physick's practice it may be said, "Nil tetigit quod non ornavit."

Well, what is the next thing to be done? The limb is to be stuped, which should be done in this way: procure an old flannel petticoat-there is always a petticoat to be found where there is a woman-cut off the gathers; dip the flannel petticoat-the whole of it into a large basin, filled with equal quantities of vinegar and boiling water; the liquor should be very hot. Let the petticoat be wrung out, as hard as four strong hands can possibly wring it, and with it let the whole member be carefully enveloped. To prevent the moisture of the fomentation from wetting the bedclothes, a piece of blanket, or some oiled silk, should be spread beneath it. A blanket is better, for the blanket can be rolled over the whole stupe, keeping up its temperature and its moisture for a long time.

My custom is to keep up the stuping for six consecutive hours; after which, as the woman becomes tired of it, I cause the member to be gently bathed with a mixture of warm sweet oil and laudanum, carefully wrapping it up afterwards in fine flannel; and after leaving it so, for two or three hours, the stuping is recommenced, and continued for five or six hours; and so, I alternate the stuping, and the inunction with the oil and laudanum, until the swelling has abated, or until I can shake the calf of the leg. After which, I inclose the limb in a common roller bandage, for the purpose of facilitating and hastening absorption.

When the woman has got well, I let her walk about; but, I always make it a rule to tell her, that her vein is reduced in size, and that it is no longer capable of carrying off from the limb, with the same facility as formerly, all the blood thrown into it by the arteries; that if she will throw into it excessive quantities, by walking about too soon, or too much, she will have a swelled leg. Sometimes the leg continues swelled for thirty years; I have seen it so. Why should it not? The calibre of its vein is diminished, and in some instances destroyed. Where it is totally

destroyed, the woman can never expect to have the limb as small as it was before the malady-she should be thankful to God, for her escape with existence.

No prudent man would lay aside the charge of such a case, without directing his patient to wear a gaiter-to come up above the knee-for several months after the cure.

C. D. M.

LETTER XLIII.

GENTLEMEN :—Among the numerous sources of that anxiety to which the practitioner of midwifery is exposed, is the dread that he often feels, lest his pregnant or parturient patient should be attacked with eclampsia, or puerperal convulsions. I say the practitioner of midwifery-for I presume that it will be found, in general, true, that he who has much professional business in the line of those maladies, that are called Diseases of Females, will be also an Obstetrician.

Puerperal convulsions, or eclampsia, from exλɑμяqes, a flash, is a convulsion affecting a woman advanced in pregnancy, or in labor; or one in the first days of the lying-in.

It is a malady that is not met with every day-but it is one so horrible in appearance, so deadly in its tendency, so embarrassing sometimes in its treatment, that, although, as I said, it is not met with every day, it is solicitously expected, and probably obviated in many a case, which, but for such careful supervision, would swell its proportions in the statistical tables.

To show you the relative frequency of the attacks, in a given number of labors, I refer you to Dr. Collins' Midwifery.

Among the whole number, 16,414 labors, under his care, there were thirty cases of puerperal convulsion-of which twentyfive recovered, and five died. This shows you, that one woman out of every 547, was attacked with the disease. How many others were guarded against the threatened attack, cannot be known; since, many of them may have been menaced, whose

cases having ended happily, by being averted, do not appear in the statistical result. Out of 20,357 labors, under the care of the late Madame Boivin, at the Maternité, at Paris, the number of patients affected with eclampsia, was 19. So that, out of every thousand women in the Maternité, one was seized with the disease. Dr. Churchill, (Midwifery, p. 447,) has collected tables of 96,903 labors, in which 159 cases of convulsions occurred; giving one in 609.

These results, if you depend upon them, will mislead you in practice. They do not at all represent the risks that women run from this cause; for in fact, if you become wise, sagacious, and prudent practitioners of midwifery, you will avert the attack in a very large majority of the instances that would, but for the precautions made use of under your administration of them, add to the ratio in the tables. I have met with a good many samples of eclampsia, in the course of my obstetrical practice, but I am very sure that I have prevented a far greater number of attacks. than I have witnessed. Some of those that have fallen under my observation, were wholly unexpected, sudden as a flash. Others came on after a long and anxious expectation of them, or after the careful and persevering employment of all the prophylactic means within my reach. Those means, in a far greater number of cases, have been employed when I had good reason to expect convul sions; but in which no convulsions occurred. I did suppose, that the remedies had hindered the attacks, and I still believe that they did so. Perhaps, however, I have many times indulged vain fears for the safety of my wards, and subjected them to treatment that was unnecessary.

Upon consulting my case books, and taxing my memory, I find that I have observed twenty-four instances of puerperal convulsions; and my colleague Dr. Huston, your Professor of Therapeutics and Materia Medica, informed me in 1844, that he had observed thirteen cases. Of those under my observation, twenty recovered, and four died. Dr. Huston's cases show eleven recoveries, and two deaths.

Primiparous women are most liable to eclampsia; but all parturient women are liable to the invasion.

Of eighty-five cases that are mentioned in the work of Collins, seventy-three were observed in primiparous women.

Women with short necks; those who are fat; those who possess