face, within or near to the margin of the areola, milk is found to escape along with the pus, and a troublesome milk-fistula is generated by it; sometimes these fistulas of milk continue to flow for a great many weeks accompanied with a very small quantity of purulent matter, and a portion of sero-pus or sanies. To shut up the orifice with adhesive plaster is to re-form the abscess, since it reproduces a circumscribed cavity, and the abscess opens again and again—a cause of great vexation. I have found them, I think always, yield upon the daily introduction of a delicate cereole, made of cere-cloth, which should be carried to the bottom of the cavity, and withdrawn from time to time to allow of the escape of the contained fluids, but to be replaced immediately afterwards. It generally happens very soon that the cereole goes less and less deep into the tube, which, filling up with granulations from the bottom, at length precludes the possibility as well as the necessity of its introduction-for the fistula is cured.

In this way, she became so great

In the winter of 1840, I attended a lady confined with her first child. She was so extremely modest that, several days after the birth of the infant, being seized with inflammation of part of the gland of the left breast, she would not allow the nurse to inform me of the accident, lest I should wish to examine the part. continued to bear the pain for several days, until it that my attention was called to it. I advised the use of leeches. Compliance with this order was deferred for two or three days, and when at last yielded it was too late to do any good. The breast suppurated near the posterior surface, almost down on the fascia; the pus was long making its way to the surface, which it did at length, and was evacuated by an incision. The case altogether was rendered a most embarrassing one by the timidity and nervousness of the patient, who became so very ill as to excite in me the most painful solicitude. I was for many days anxious on account of a very wearying short cough, for which I could discover no explanation upon a most careful auscultation of the thorax. The pulse was always above one hundred and ten. Upon going to see her one morning, I found her with the most singular respiration and pulse that I had ever seen connected with any exterior disorder of the breast. Her pulse was not less than one hundred and sixty beats a minute, and the respiration was more than one hundred times a minute. Her hands were covered with moisture, and from her emaciation, I felt the greatest inquietude upon finding so strange a state of her circulation and respiration, which, she told me, had come on shortly before, having been of the same character once or twice some hours previously to my visit.

After looking upon this strange scene for a minute or two, and after repeating the auscultation, I begged permission to examine the breast, which had been more painful. I found a new abscess pointing up under the skin. As soon as I opened it, and with a bistoury cut up a bridge of skin which strongly bound two other orifices, her strange respiration instantly gave place to a very calm and deliberate one, while her pulse also recovered a far more natural rate. This lady, having lost all her milk, took in a wet-nurse, and after some time recovered a very perfect health, after the most distressing and protracted illness brought on by a simple, but neglected, inflammation of the lactiferous gland.

In the second volume of Bright's Medical Reports, p. 459, there is related a case of what he calls hysteric dyspnoea.

"I was passing," says he, "through the wards of George's Hospital one day during last winter, when one of the surgeons requested me to look at a female patient who had a formidable disease of the mamma. She had been seized with alarming dyspnoea: her respiration was performed with most unusual effort, but it was not so much hurried as laborious; and she complained of a constriction across the chest, which was altogether unconquerable. Pulse very quick. It had been believed by some that she suffered an attack of pneumonia; but there was no cough, and the breathing was rather with effort than with pain. or difficulty. Her feet were quite cold; her pulse weak. She was in a state which might have resulted from sudden effusion into the chest, or the bursting of an aneurism. This was hysteria, and assafoetida was its cure."

I wish the Student to compare Bright's case with mine given above; the slowness of the respiration in his with the frightful acceleration in mine, and all coexistent with formidable disease of the mamma; and then observe that my patient was instantly and completely relieved by the bistoury, while Bright's was cured by assafoetida. I should think he would come to the conclusion that neither of the cases was really to be arranged among the hysterical disorders, but was the result of irritation of a gland, having so large a supply of nerves from within the thorax itself.

It is highly advisable to wean the child, when sufficient time has been allowed to ascertain the probable long duration and great severity of a mammary abscess. This ought not to be done too early, because the suction of the breast by the child is a great and curative resource in the management of the disorder: when the inflammation confines itself to only a part of the breast, the other portions of the gland continue to furnish a good abundance of milk, and that milk ought to

be regularly taken away, lest its accumulation should add to the difficulty already too great within the inflamed packets, or even invite the inflammation into the still healthy structures.

For counter-sunk nipple and inverted nipple, I refer the Student to my letter on the Breast, in my work on Woman, her Diseases, &c., p. 673. To the same letter I beg leave to direct his attention for a fuller statement of this subject than I find occasion to present in the present volume.

I shall close this article, by advising every Student who intends to practise Midwifery, to dissect the breast for himself, after having most carefully studied "The Anatomy of the Breast, by Sir Astley Paston Cooper. London, 1840, 4to., with a vol. of Plates." This work is really a legacy to those whom, in his dedication, he calls "My dear brethren." It is prepared with an elegance, and liberality, and profuseness of illustration worthy of that great surgeon. The republication of it in the United States, in a style fully equal to that of the London edition, has conferred a benefit not only on the profession, but on thousands of suffering females, whose disorders of the breast would be more fully understood, as soon as that work should find its way, as assuredly it would, through the country.

PART IV.

THE HISTORY AND DISEASES OF THE YOUNG

CHILD.

CHAPTER XXIII.

THE child in utero, as has already been stated, requires for its complete development a lapse of nine months, or two hundred and eighty days less or more. It becomes viable at seven months, though some children have lived that have been born much earlier than this; yet it is proper to say that viability is attained at the seventh month.

The viability of the foetus depends upon the evolution and perfecting of its organs to such a degree as to enable it to live a respiratory life. This it could not do until its lungs should be sufficiently evolved to enable the air-cells to receive the atmospheric air, and fitted also to make the transfer of oxygen to the blood and of carbon to the expired air. If a child should be expelled while its air-cells were still undeveloped, it would necessarily perish immediately from the atelectasis; new-born children expelled shortly before their time die, not because they have a complete but because they have a partial atelectasis pulmonum. The heart of a child, in the earlier of its embryonal periods, is a straight tube; it soon becomes tortuous, and afterwards makes two cavities, which are its auricle and ventricle. The progress of the uterine life brings the foetal-organs daily nearer and nearer to the condition of those of the breathing mammal; but it does not attain this condition, until the seventh month of gestation. If driven into the world before the completion of the organization of its heart, it could not be deemed viable or liveable, because it could not successfully carry on the work of oxygenating its brain and nervous mass.

The septum ventriculorum of the foetus in utero is early completed: if the septum auricularum should be also completed before the period of its birth, the child would necessarily be born dead, because there is

no route by which the oxygenated blood of its placenta could be submitted to the action of the systemic ventricle, save that by which it traverses the right auricle and the foramen ovale, passing into the systemic ventricle, and that which it performs when driven by the right ventricle into the aorta through the ductus arteriosus. The black blood of its ductus arteriosus enters the aorta below the giving off of the carotids and subclavians: that blood can by no means reach the brain, but goes into the tissues below, where it gives up its oxygen or returns to the placenta to take an additional charge: therefore, none of the oxygeniferous blood of the child can reach the brain, save that which comes into its systemic ventricle through the foramen ovale and the left auricle. A child, therefore, whose foramen ovale should be completely closed in utero-to suppose the case-would necessarily perish with asphyxia, for asphyxia is black blood in the brain; nothing else is asphyxia.

Therefore, the neonatus is necessarily born with an open foramen ovale; but the foramen ovale is covered by a valve that lies on the left surface of the septum, and serves after birth as an operculum or lid to shut the passage. It is probable that the first inspiration of atmospheric air, coinciding with the descent of the diaphragm and the expansion of the thorax in every direction, serves to carry off to the lungs, through the pulmonary artery, a great efflux of blood, which, antecedent to that first act of respiration, chiefly flowed off through the ductus arteriosus. The constantly augmenting facilities of this new pulmonary circulation soon set aside any further necessity for the ductus arteriosus-whose deserted channel becomes a ligamentous band.

The increased amount of blood thus determined to the lungs must have the effect of throwing a greatly augmented quantity of fluid upon the right ventricle; not to say that the right side of the heart carries on a greater circulation after birth than before birth; but the right ventricle cannot but carry on a much greater amount now, because it carries on the whole, whereas, before birth it carried on only a moiety of it, the other half having passed through the foramen ovale.

The passage of the blood from the right ventricle into the pulmonary artery is probably effected with a facility greater than was that of its propulsion into the aorta through the ductus arteriosus; and I can imagine that now, the pressure of the two symmetrical halves of the heart being equalized, the valve of Botalli, instead of floating upwards into the left auricle, by this equalization of the pressure is shut down as the operculum of the foramen ovale; so that, although the child is necessarily born with an open foramen ovale, the equaliza