£-**■ mi mi.' w*^* :tj»'.'sj!';>< ■' "^ * '■•- aw* j»j»i;-:;?ii*ii S\. INFLAMMATION OF THE UTERUS: ITS CERVIX, AND APPENDAGES. / PRACTICAL TREATISE INFLAMMATION OF THE UTERUS, tot* aitir 3$pkpst AND ON ITS CONNECTION WITH UTERINE DISEASE. BY JAMES HENRY .RENNET, M. D., MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS ; LATE PHYSICIAN-ACCOUCHEUR TO THE WESTERN GENERAL DISPENSARY ; FORMERLY HOUSE PHYSICIAN (BY COXCOURS) TO THE HOSPITALS SAINT LOUIS, NOTRE DAME DE LA PITIE, AND LA SALPETRIERE, PARIS, ETC. FOURTH AMERICAN, FROM THE THIRD AND REVISED LONDON EDITION. TO WHICH IS ADDED A REVIEW OF THE PRESENT STATE OF UTERINE rATHOLOGY. o\\\\ »: PHILADELPHIA: BLANCHARD AND LEA. 1856. IA/P 3 4 7/p PUBLISHER'S NOTICE. At the suggestion of Dr. Bennet, the publishers have appended to the present volume his " Review of the Present State of Uterine Pathology," from proof-sheets kindly furnished by him. In so doing, they entertain no doubt that the numerous readers of Dr. Bennet's writings in this country will be gratified to have the opportunity of learning his latest views on the important questions which constitute the subject of his remarks. To prevent misconception, the publishers would add that in no other respect do the copies containing this addition differ from those bearing the date of 1853. Philadelphia, July, 1856. PREFACE. In preparing the Third Edition of this work for publication, I have carefully revised it, and have made various additions, which will, I trust, render it more complete. I have also slightly altered the arrangement of the chapters, with a view to improve the general plan. Within the last few years, the doctrines which I have advocated in the previous editions have made great progress, and have been adopted by a large, intellectual, and influential section of the medical profession at home, as also by many practitioners in our colonies. I have, indeed, received the most gratifying and satisfactory testimonies of adhesion and approbation from the most disiant parts of the globe, the result of actual investigation of the subject. I may likewise add, as evidence of the growing importance which is everywhere attached to this department of pathology, that both editions of the work have been republished in America, that the first has been translated into German, and the second into French. Under such circumstances, I may certainly be allowed to pass unnoticed the "opposition" which I have met with. Believing thoroughly in the correctness of the facts and doctrines which I have advanced, I shall henceforth leave them in the hands of the profes- sion, under the conviction that eventually they must and will be adopted and acted upon by the entire medical community. 60, Grosvenor Street, November, 1852. PREFACE TO THE FIRST EDITION. During my connexion with the Paris hospitals, which lasted seven years, (three as a pupil, and four as a resident medical functionary), owing partly to choice, and partly to fortuitous circumstances, I was the assistant of several of the physicians and surgeons of that capital who have paid the greatest attention to uterine pathology, and my attention was thus early directed to this interesting department of medical knowledge. As I generally availed myself of the privilege granted to Paris "internes" by the hospital authorities, to take pri- vate clinical pupils with them on visiting the patients entrusted to their care, I was compelled to analyze carefully the morbid phenomena of every case, so as to satisfy the inquiring disposition of men of mature age and understanding, whom alone I could take with me, owing to the peculiar nature of uterine maladies. I was thus soon led to perceive, that however carefully the field of uterine pathology had been investigated, there still remained much to be elucidated. One point more especially attracted my attention—viz., the nature, causes, and therapeutics of ulceration and induration of the neck of the uterus, the commonest of all uterine lesions. On referring to the most esteemed works on uterine diseases, both French and English, I found that the data which the former contained respecting this malady, were insufficient to account for the numerous modification which I daily witnessed, whilst the latter were nearly completely barren on the subject. After much doubt and uncertainty, I at length arrived at views which appeared to me to explain much of that which had heretofore been obscure. It was not, however, until the experience of one year and of one hospital had been corrected by that of other years and of other hospitals, that my ideas took the direction which is presented in the present work. Till PREFACE TO THE FIRST EDITION. To render this statement intelligible to those who are unacquainted with the medical institutions of Paris, I may mention that that city is remarkable for the extent and number of its special hospitals. There are immense separate establishments for the young, the adult, and the aged, as also for the syphilitic, the scrofulous, and those affected with skin diseases. Into these the house physicians and the house sur- geons (who hold their appointments for four years) are successively draughted, so that, in the six or seven years during which the Paris "interne's" connexion with the hospitals lasts, at first as a pupil, and subsequently as a resident functionary, disease is studied on a large scale, in very varied fields. These successive changes of the point of view from which pathology is seen, I found of the greatest possible use. Uterine disease is not the same at St. Lazare, where five hun- dred prostitutes, affected principally with primary syphilis, are treated, as it is at the Hopital St. Louis, the receptacle for cutaneous syphilis and scrofula, or as at the general hospitals, where non-syphilitie patients are received. Even in the latter, great differences exist; some—such as La Pitie—being near La Maternity where several thousand women are delivered annually, receive many patients recently discharged from* that hospital; others—such as La Charite and the Hotel Dieu—depend more on the general population; whilst in the Salpetriere, which contains three thousand five hundred women above sixty years of age, and several hundred incurable cancerous patients, the uterine field again changes. I do not mean to say that the same forms of disease are not met with in these various establishments,—for such an assertion would be erroneous,—but that the proportions in which they show themselves, and often the modes of their manifesta- tion, differ considerably. An outline of my views on the subject of which I am about to treat, was hastily sketched and presented to the Faculty of Medicine of Paris, in the form of a thesis, on my graduating at that university. The present more elaborate essay was published in parts, in the "Lancet" of this year; and as I think the facts and views which it contains are of importance, I now reproduce them in a more extended and complete form. Under such circumstances, I cannot, certainly, be reproached with not having matured my opinions. In the first instance, they were formed after I had long enjoyed very great oppor- tunities for seeing uterine disease. They have since been considered over and over again, and have stood the test of several years' addi- tional experience. PREFACE TO THE FIRST EDITION. IX Some of the views which I bring forward will, I believe, be found original,—at least, if I can trust the results of my bibliographical researches. I have also many details of great interest and importance to present, with reference to the various modes of treatment in inflam- mation, ulceration, and induration of the uterine neck adopted by the Paris physicians and surgeons—details which will, I believe, be new to most of my readers. Having carefully watched, during a great length of time, the effects of the treatment followed by the eminent Parisian practitioners, with whom the knowledge of this form of disease recently originated, and that under the most favourable circumstances —as their pupil or assistant—I have been able, I hope, to form a cor- rect estimate of the comparative value of the different agents which they employ. I have thus, I am also inclined to think, learnt how to avoid the exclusiveness which most of them show in the choice of their therapeutic agents. In Paris hospital practice, the objections which exist in England to examination by the touch or by the speculum, either are not met with, or are not allowed by those physicians and surgeons who pay special attention to uterine disease; consequently, little more difficulty is experienced in appreciating, by their means, the symptoms furnished by the uterine organs, than in resorting to any usual means of inves- tigation in diseases of other parts of the economy. This being the case, the opportunities for investigating the state of the internal organs of generation in females presenting uterine symp- toms must necessarily be much greater than in England, where no examination, even of a married person, is attempted by the most expe- rienced practitioners, unless there be very serious reason for such a step, and very frequently not even then. That this laudable sense of propriety is, however, often carried much too far by the members of the medical profession with us, is well known to all who specially study uterine pathology. I might mention numerous illustrations of this fact. One alone, however, will suffice to show how frequently exami- nation is neglected by well-informed practitioners, from false delicacy on their part, and not on that of their patients. A few months ago, I was consulted by an unmarried female, who had presented for eight years, not a few only, but all the symptoms of uterine polypus. During this period she had been attended, for weeks and months at a time, by five or six different medical gentlemen, of undoubted talent and ability, not one of whom ever proposed an examination, although, from the intensity of the symptoms, they must X PREFACE TO THE FIRST EDITION. have suspected the nature of her disease. This person has repeatedly told me that she would at any time have submitted to an examination had she been requested, so great were her sufferings. Delicacy carried to such an extent becomes absolutely criminal, and, moreover, reflects discredit on the profession, the patients attributing to ignorance, as in the case alluded to, the excessive scruples of their medical attendants. I have been often told that females in this country will not submit to treatment when afflicted with uterine disease. I can only say that I have not found this to be the case in my own practice. I have met with many objections, but never with a decided refusal, when I have stated that an examination was imperatively necessary. I am, indeed, convinced that our countrywomen, when suffering under these distressing diseases, would always submit to an examination—con- ducted with a due regard to their feelings—were the absolute necessity of such a step properly enforced by their medical attendant. Health and life are too valuable for every possible sacrifice not to be made when they are endangered. It may be as well to mention here, that the cases which are inter- spersed throughout this work, are not given to substantiate my opi- nions, but merely to illustrate them. There is nothing more tedious to a reader than the perusal of a long series of cases, all reproducing the same phenomena; and when the doctrinal points brought forward are deduced from plain every-day facts,—which are not generally appreciated, merely because they are not sought for,—it is quite unne- cessary to parade a long array of cases in order to substantiate them. Lonson, June 18, 1845 PREFACE TO THE SECOND EDITION. The present treatise has been for some time out of print, owing to the favourable reception which it received from the profession. The delay in the publication of the second edition, originated in my wish to give a complete history of inflammation in all the organs and tissues which constitute the uterine system, as elucidated by the application of physical investigation to the study of uterine diseases. This I have at length accomplished; and although nominally a second edition, the present is in reality a new work. It will be found to contain, not only a faithful history of the various pathological changes produced by inflammation in the uterus and its annexed, organs in the different phases of female life, but also an accurate analysis of the influence exercised by inflammation in the production of the various morbid conditions of the uterine system, hitherto described and treated as functional. Guided by the clinical observation of the last twelve years,—during which period I have constantly studied uterine disease in wide fields, and with the advantage of more accurate means of investigation than those generally employed,—I have endeavoured to demonstrate the important fact, that inflammation is the keystone to uterine pathology, and that unless the phenomena which it occasions be recognised and taken into consideration, all is doubt, obscurity, and deception. The results at which I have arrived, and which are embodied in the following pages, are so diametrically opposed to the opinions current in the profession, as reproduced by the most recent and the most classical writers on uterine pathology, that they must appear startling, even to practitioners acquainted with the researches of Continental inquiry in this important branch of medical science. So thoroughly subversive, indeed, are they of all existing views respecting uterine disease, that nothing but the facility with which they can be tested Xll PREFACE TO THE SECOND EDITION. could inspire me with the hope that they will, ere long, be universally acknowledged and adopted. The diseases in question are amongst those to which females are most commonly exposed; and proofs of this fact may be found by any practitioner in the daily routine of his professional duties. To test the value of my assertions, he has merely to examine his patients. It must, at the same time, be borne in mind, that no one who does not set aside for the moment all previously formed pathological opinions, and impartially examine the cases in which the symptoms I have described are present, is competent to offer even an opinion on the subject. Since the first publication of my researches in uterine pathology, above four years ago, a marked change has taken place in the opinions of a large portion of the profession—a change which may fairly be attributed, in a great measure, to the influence exercised by my writ- ings. Several of the most eminent uterine pathologists of the present day—amongst whom I may name Dr. Montgomery1 and Dr. Evory Kennedy2—have since then openly advocated views similar to those which I entertain respecting the frequency of inflammatory affections of the neck of the uterus. Moreover, I am able to state, from positive knowledge, that the practice of nearly all the eminent consulting prac- titioners in this department of pathology has been greatly modified within that period, and it is but rational to infer that their theoretical opinions have undergone a similar change. In the present work there is much that is original, and new to the profession, both abroad and at home. I would more especially direct attention to the history:—of chronic metritis and of the displacements which it occasions, of late years so erroneously viewed—of internal metritis, hitherto confounded with disease of the cervical cavity—of inflammation and abscess of the lateral ligaments in the non-puerperal state, never, as yet described by any author—of inflammation and ulceration in the cavity of the cervix—of inflammation and ulceration in the virgin,—in the pregnant and puerperal condition,—in the ao-ed —and in connexion with polypus and with uterine tumours;—and to the section on the diagnosis of cancer. As the facts detailed in the chapters in which these subjects are discussed are, like those formerly advanced, solely deduced from clinical observation, I firmly believe 1 The Dublin Quarterly Journal, August, 1846. 2 Ibid., February, 1847. PREFACE TO THE SECOND EDITION. xiii that their accuracy will be likewise substantiated, in the course of time, by the unanimous verdict of the profession. It may be considered an axiom, that when once a discovery in science or art has been clearly pointed out and demonstrated, it ought to be susceptible of easy confirmation, wherever and by whomsoever the attempt be made, provided the inquirer possess sufficient knowledge and skill to qualify him for the task which he undertakes, and pro- vided, also, he carefully and conscientiously follow the rules and direc- tions laid down by the discoverer. No alleged discovery that will not bear this test can be accepted as such; and no person who claims the merit of a discovery ought to object to its being applied to his asser- tions. I can have no hesitation in submitting the views and opinions which I entertain respecting the pathology of uterine disease, to the above test. If others, employing conscientiously, in similar cases, the same means of investigation as I have done, and as carefully as I have done, do not arrive at the same results,—however contrary those results may be to the recognised opinions of ages,—I will submit willingly to their repudiation of the doctrines advanced. I have, however, no fear on this score, for they are the expression of facts truly observed and faithfully reproduced, and will hold good alike in all climes, in all lands, and in all grades of social life. London, March 26, 1845. CONTENTS. CHAPTER I. Preliminary remarks —A new field opened to the study of uterine disease, by the adoption of physical means of investigation.—The facts brought to light partially known to the ancients.—The state of medical science and practice in the middle ages, the cause of modern ignorance of uterine pathology............................... 33 CHAPTER II. Anatomy and physiology of the uterine organs.—The uterus, ovaries, broad liga- ments, vagina, vulva, and pelvic fascia....................................................... 39 PART THE FIRST. CHAPTER III. The frequency and importance of inflammation in uterine pathology..................... 56 CHAPTER IV. Metritis.—Inflammation of the body of the uterus in the non-puerperal state.— Acute metritis.—Chronic metritis.—Internal metritis.................................... 61 CHAPTER V. Inflammation of the neck of the uterus.—Inflammation, ulceration, and hypertrophy of the cervix uteri considered generally.—Anatomical, local, functional, and sym- pathetic or constitutional symptoms........................................................... 80 CHAPTER VI. Inflammation and ulceration of the neck of the uterus in the virgin female.—Its connexion with leucorrhea, dysmenorrhea, amenorrhea, irregular menstruation, partial prolapsus, abscess of the vulva........................................................ 127 CHAPTER VII. Inflammation and ulceration of the neck of the uterus during pregnancy.—Its in- fluence as a cause of laborious pregnancy, hemorrhage, obstinate sickness, death of the foetus, moles, and abortion............................................................... 147 CHAPTER VIII. Inflammation and ulceration of the neck of the uterus during and after abortion and parturition.—Its connexion with rigidity of the os during labour, with lacera- tion and abrasion of the cervix, wiih flooding, and with the morbid symptoms that follow natural and difficult labour........................................................ 166 CHAPTER IX. Inflammation and ulceration of the neck of the uterus in advanced life, after the cessation of menstruation......................................................................... 176 CHAPTER X. Inflammation of the vulva, of the vulvo-vaginal gland, and of the vagina.—Acute and chronic vulvitis.—Acute and chronic vaginitis......................................... 181 CHAPTER XL Ovaritis.—Subacute and chronic ovaritis.—Acute ovaritis.—Inflammation and ab- scess of the uterine lateral ligaments and uterine appendages in the puerperal state.—Inflammation and abscess of the appendages in the non-puerperal state... 192 xvi CONTENTS. CHAPTER XII. Treatment of inflammation of the uterus and the uterine organs.—Of inflammation of the neck of the uterus without ulceration or hypertrophy............................ 216 Treatment of inflammation of the neck of the uterus accompanied by ulceration and hypertrophy.......................................................................................... '-'-" The employment of caustics......................................................................... 231 Treatment of displacement of the neck of the uterus......................................... ~°j General treatment...................................................................................... -,,;j Constitutional treatment............................................................................. 266 Treatment of inflammation of the neck of the uterus considered generally............. 276 Treatment of inflammation of the uterine neck in the virgin—during and after preg- nancy—and in advanced life.................................................................... 278 Treatment of acute, chronic, and internal metritis....................................•.■■;•;" Treatment of inflammation of the vulva, of the vulvo-vaginal gland, of vaginitis, acute and sub-acute ovaritis, and of inflammation and abscess of the uterine appendages........................................................................................... 288 PART THE SECOND. Connexion between uterine inflammation and other morbid states.—Morbid men- strual states.......................................................................................... 293 CHAPTER XIII. Dysmenorrhea: constitutional, accidental, inflammatory; physical treatment of.... 294 Amenorrhea ; the constitutional and accidental forms of the malady ; treatment of them!.................................................................................................... 302 Menorrhagia; accidental, inflammatory, from ovaritis—at the dawn and close of menstruation—during pregnancy—after delivery—treatment of various forms... 310 Leucorrhea.............................................................................................. 317 Sterility.................................................................................................. 318 Abortion................................................................................................. 321 CHAPTER XIV. Displacements of the uterus, and their connexion with inflammation—prolapsus— anteversion—retroversion—retroflexion...................................................... 323 CHAPTER XV. Polypi and fibrous tumours of the uterus, and their connexion with uterine inflam- mation.—Fibrous and vascular tumours ; cases illustrating the effects and modes of treatment of....................................................................................... 337 CHAPTER XVI. Syphilitic ulceration of the neck of the uterus.—Real chancres of the cervix uteri. Cases illustrative of this form of disease.—Chronic chancre, with extreme indu- ration.—Non-chancrous-looking ulcerations, complicating various forms of sy- philis.—Propositions respecting chancre..................................................... 349 CHAPTER XVII. Diagnosis of cancer of the uterus.—Definition of cancer, cancerous and cancroid growths.—Sir C. Clarke, Dr. Ashwell, and Dr. Montgomery on cancer.—M. Mal- gaigne on mortality from various cases of supposed cancer.............................. 360 APPENDIX. On the physical examination of the uterus and uterine organs.—Importance of sight in diagnosis.—Accounts of various forms of specula.—Mode of using the speculum and uterine sound................................................................................... ggg Synopsis of three hundred cases presenting uterine symptoms, treated at the Wes- tern General Dispensary:......................................................................... gog INDEX................................................................................................... 423 A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, ITS CERVIX AND ITS APPENDAGES; AND ON ITS CONNEXION WITH OTHER UTERINE DISEASES. CHAPTER I. PRELIMINARY REMARKS. A NEW FIELD OPENED TO THE STUDY OF UTERINE DISEASE BY THE ADOPTION OF PHYSICAL MEANS OF INVESTIGATION--THE FACTS RECENTLY BROUGHT TO LIGHT PARTIALLY KNOWN TO THE ANCIENTS—THE STATE OF MEDICAL SCIENCE AND PRACTICE IN THE MIDDLE AGES THE CAUSE OF MODERN IGNORANCE OF UTERINE PATHOLOGY. Among the various branches of the healing art over which light has latterly been thrown, by the application of physical means of exami- nation to the appreciation of local symptoms and of morbid changes, uterine pathology stands pre-eminent. The recent adoption, by some leading continental practitioners, of careful instrumental examination in the diagnosis and treatment of diseases of the uterus, has opened an entirely new field to practice, and must lead to a complete transforma- tion of uterine pathology, as it is now presented in the medical litera- ture of this country. The discovery of percussion and auscultation, by Avenbrugger and Laennec, has not, indeed, produced as great a change in thoracic pathology as the application of physical examination in uterine disease is destined to produce in this important and extensive department of medical science. That I am not attributing too much weight to the results attainable in uterine pathology by the discovery of improved means of diagnosis, will, I feel certain, be admitted by all who carefully 34 PRELIMINARY REMARKS. peruse the following pages, and who recollect that the views which they unfold, although contrary to generally received opinions, are the scrupulous deduction of clinical observation alone, and not the offspring of theoretical reasoning. To those who have studied uterine disease in the most recent and most esteemed works that have appeared in this country, the views and assertions contained in the present treatise will probably appear exag- gerated ; but all who take the trouble practically to test their correct- ness, will most certainly find that I have neither exaggerated nor mis-stated. The great errror committed by all who have hitherto written on uterine affections, with the exception of some recent French authors, consists in their looking upon and describing inflammation of the uterus as a rare disease in the non-puerperal state, whereas, in reality, inflammation is the commonest of all the morbid manifestations of that organ, as it is of all other organs of the animal economy. As a necessary result of this error, not only is the existence of inflamma- tion itself unsuspected and overlooked, but many morbid states which it gives rise to are also misunderstood, and generally, if not always, studied independently of their origin: among these 1 may mention, leucorrhea, dysmenorrhea, menorrhagia, partial prolapsus of the uterus, general debility, &c. At first sight, it certainly does appear singular, to say the least, that a class of diseases of such every-day occurrence as uterine inflam- mations in reality are, should have been almost totally overlooked until within the last few years, and that the symptoms which they occasion should for ages have been made the foundation for false pathological superstructures. Such, however, is the case; successive centuries have perpetuated the same errors, and that owing to causes which *are easily explained, if we revert to the past history of medicine. The uterus is an organ to which is entrusted the preservation of the species, and not of the individual of whose organization it forms a part. It has, consequently, no hourly, daily, function to perform, like the brain, the lungs, the liver, the interference with which, by inflammation, neces- sarily gives rise to a class of decided, unmistakable symptoms. More- over, inflammation of the non-impregnated uterus, owing to anatomical data, into which I shall presently enter at length, is generally peripheric, if I may use the term ; it is principally confined, at its origin, to the mucous membrane covering the cervix and lining the cavity of the cervix, to the cervix itself,—which is much less sensitive than the body of the uterus,—to the cellular tissue lying between the peritoneal folds that constitute the lateral ligaments, and to the ovaries. It is, likewise, generally chronic when affecting the mucous surfaces mentioned, its most frequent seat. The operation of these physiological and patholo- gical facts, combined with the concealed and central anatomical situation of the uterus itself, gives to the symptoms of the vast majority of uterine inflammatory affections a degree of obscurity which those of few other diseases present. Hence the necessity of calling to our aid, in order to form a true diagnosis, every possible means of PRELIMINARY REMARKS. 35 assistance; and certainly, no mode of investigation is so likely to enable us to arrive at a correct knowledge of the morbid changes which are taking place in a concealed organ as the ocular inspection of the organ itself. That such an inspection is not only possible, but in most cases perfectly easy, was, no doubt, discovered in a very early period of medical history. We continually see the uterus falling, by its own weight, or by the laxity of its means of support, to such an extent as to merely require the separation of the labia to be seen, or as even to protrude externally. From the examination of the womb thus prolapsed to the use of some mechanical means of opening the vulva and vagina, so as to allow the eye to reach the lower segment of the uterus when the organ is not prolapsed, there is but a step. That step was made probably more than two thousand years ago. Although the fact is not generally known, it is nevertheless quite certain, that ocular inspection of the cervix uteri by instrumental means was known to the ancients, perhaps from the earliest times ; and its having subsequently fallen into complete abeyance, along with the information obtained through its means, is a singular circumstance in the history of medicine, which can only be explained by the peculiar social conditions through which medical science has since passed. Paulus iEgineta alludes to the Siontpa, or dioptra, in several parts of his work, as to an instrument in general use. In the section on ulcer- ation of the uterus,1 he states that the ulceration is to be detected by the dioptra; and in that on the treatment of abscesses of the womb,2 there is a long account of the way in which the instrument, evidently a kind of bivalve speculum, is to be used. This well-known author lived in the seventh century, but he was more a compiler than an original writer; and, according to Mr. Adams, the learned translator and commentator of his works, this part of his description of uterine diseases is mostly taken from Aetius, who, in his turn, professes to have copied from writers who lived at a much earlier period, such as Archigenes and Asclepiades. Not only was instrumental examination of the uterine neck known to the ancients, but they were evidently familiar with this mode of investigation. This fact is satisfactorily proved by the practical information respecting diseases of the cervix uteri which they pos- sessed—information which they could only have acquired by the ocular demonstration afforded by the use of the speculum. Thus, in the section of Paulus iEgineta's work on " Ulceration of the Womb," to which I have alluded,3 we find inflammatory ulceration of the cervix 1 The Sydenham's Society's edition of the works of Paulus iEgineta, vol. i., p. 624. a Ibid., vol. ii. pp. 385, 6. 3 Ibid., vol. i. pp. 624, 5:—" The uterus is often ulcerated from difficult labour, extraction of the foetus, or forced abortion or injury of the same, occasioned by acrid medicines, or by a defluxion, or from abscesses which have burst. If, therefore, the ulceration be within reach, it is detected by the dioptra, but if deep-seated, by the dis- charges ; for the fluid which is discharged varies in its qualities. When the ulcer is inflamed, the discharge is small, bloody, or feculent, with great pain; but when the 36 PRELIMINARY REMARKS. uteri, its causes, varieties, and treatment, described at some length. The description is rather confused, it is true, but it is impossible not to recognise in it the various pathological facts which have been resusci- tated these last few years. The writers were clearly acquainted with the various inflammatory lesions of the cervix uteri, which in reality constitute, as I have stated, the commonest forms of uterine disease, and must have been in the habit of guiding their treatment by the state of the cervix as revealed by the dioptra. It is thus that we find different agents recommended according as the ulceration is " clean or foul; spreading or not spreading ; attended or not with inflammation." It does not appear that caustics were used, the treatment enjoined being that resorted to by the ancients in the treatment of ulcers gene- rally, and consisting, rationally enough, in two classes of agents, emollients and astringents. The assertion has recently been made, that the dioptra was only used to separate the parts at the vulvar orifice of the vagina, and that the passages of Paulus JEgineta to which I refer, merely apply to disease in that region. Such an opinion, however, will not stand the test of a careful perusal. The neck of the uterus itself is evidently referred to in the first quotation, and abscesses in the upper part of the vagina, near the cervix, in the other. That the real cervix uteri was known to the physicians, not only of that age, but of an age many centuries antecedent, is evident from the Hippocratic writings. The latter afford evidence of a very considerable amount of knowledge respecting the morbid condition of the neck of the uterus itself. (See Aphorisms 51 and 54, section v., and the special treatises on the Diseases of Women.) Indeed, I cannot do better than quote the words of Mr. Adams, to whom the profession is also indebted for a very valuable edition of the works of Hippocrates. After giving an analysis of these treatises, he adds, " They furnish the most indubitable proof that the obstetrical art had been cultivated with most extraordinary ability at an early period. Beyond all doubt, the complaints of women, and the accidents attending parturition, must at that time have come under the jurisdiction of the male practitioner." It is impossible for any one acquainted with the modern state of medical literature on this subject, to read without surprise the descrip- tion of ulceration of the womb which I have extracted from Paulus iEgineta. The important facts which it sets forth, although of every day occurrence, appear to have fallen into complete oblivion for cen- ulcer is foul, the discharge is in greater quantity, and ichorous, with less pain ; when the ulcer is spreading, the discharge is fetid, black, attended with great pains, and other symptoms of inflammation ; irritation is produced by relaxing medicines, and relief by the opposite class. When the ulcer is clean, the fluid is small in quantity, consistent, without smell, thick, white, with an agreeable sensation. When the ulcer is inflamed' we must use those things recommended for inflammations. When it is foul . the Egyptian ointment without the verdigris answers admirably for the cure of' ulcera- tion .......when the ulcer is spreading and attended with inflammation . . when the ulcer spreads and is without inflammation.......when the ulcer has become clean."....... PRELIMINARY REMARKS. 37 turies, until M. Recamier, (one of the present physicians to the Hotel Dieu in Paris,) about the year 1818, fortunately for humanity, revived the use of the speculum, and by its means resuscitated the knowledge so long dormant. The late celebrated surgeon, Lisfranc, at once adopted the speculum as a means of diagnosis and treatment, and by his lectures, writings, and practice, contributed more than any other of his countrymen to establish uterine pathology on a sound practical basis. I cannot better illustrate how totally, in this country, the important pathological data, which it will be my aim to elucidate, had been lost sight of, than by recalling the very striking fact, that inflammatory ulceration of the uterine neck and its sequelae are not even alluded to in the work which for the last thirty years has been considered the standard authority on uterine diseases, and the talented author of which occupies the very first rank among our uterine pathologists. I allude to Sir Charles Clarke's Treatise on Female Discharges, the third edition of which was published in 1831. Various forms of cancerous ulceration are carefully described, but the very existence of inflamma- tory ulceration is not mentioned. Now when we reflect that, as I shall hereafter show, in nearly five cases out of six of uterine disease, in which chronic discharges, mucous, puriform, or sanguinolent, or other well-marked uterine symptoms, are present, there is inflammatory ulceration of the cervix, it is easy to conceive how erroneous must be the views respecting uterine pathology, of a medical school ignorant of so vitally important a circumstance. The surprise which we must feel on learning that so much valuable information respecting female diseases was lost to humanity for so lengthened a period, diminishes, however, when we reflect on the channels through which the knowledge of the ancients has been con- veyed to us. When Europe was plunged in the intellectual darkness that followed the overthrow of the Roman empire by the barbarians, Science found a refuge among the Arabs, and it was through their labours, principally, that the Greek and Roman medical classics were preserved, and became known to their successors in science, the Roman catholic priesthood. On the revival of letters taking place, several centuries after the overthrow of the Arabian caliphs, all the knowledge of the day, of medicine as well as of the other arts and sciences which constituted the Quadriviura, was confined to priests and monks. Both the Arabian physicians and the Roman catholic priests were placed in a position of peculiar delicacy towards their female patients; the former, owing to the seclusion of the female enforced by Moham- medan customs, and the latter, owing to their vows of celibacy. It is not, therefore, extraordinary that the Arabians should merely have transmitted to us in their works the information respecting uterine diseases and midwifery contained in the Greek and Latin authors whom they translated or copied ; nor is it extraordinary that the Roman catholic priesthood should have abandoned midwifery to midwives, and have allowed the practical knowledge of uterine diseases contained in 38 PREIJMINAUV REMARKS. the works of the ancients and of the Arabians to fall into abeyance. Neither the Mohammedan nor the monkish physicians were so situated socially as to be able to prosecute these branches of medical knowledge. Thence it is that midwifery was utterly neglected, and remained a dead letter so far as science is concerned, until a comparatively recent period, that of Ambrose Pare', Guillemeau, &c. Thence it is, also, that a cloud of ignorance has, from the same cause, overshadowed uterine pathology until our own day. That results directly produced by the existence of a peculiar state of society, should have remained in operation for several centuries after the social condition which created them has itself ceased to prevail, is certainly rather singular ; but this is not unfrequently the case, as might be variously exemplified. It would be difficult, however, to meet with a more striking illustration of the fact than is presented by the history of midwifery and uterine diseases. Up to the middle of the fourteenth century, the practice of medicine being in the hands of the priesthood only, the neglect into which they fell can be easily understood. It is also easy to understand that these branches of medical knowledge should have continued to be neglected for some time afterwards, a certain connexion long continuing between the practice of medicine and the clerical profession ; although Pope Honorius the Fourth, at the close of the fourteenth century, prohibited priests from actually practising medicine, yet in various countries, physicians were bound by oath to celibacy, as was the case until the year 1420 in the University of Paris. It does, however, appear most marvellous that the influence of these former social conditions should still be felt in the medical pro- fession, should still exercise an evident control over medical science in England—a country which has now for three centuries professed Pro- testantism. And yet, unless we admit that such is the case, how can we account for the existing state of uterine pathology, or explain the opprobrium thrown, until within the last few years, by the governing bodies of our leading medical corporations, upon those who devote their attention to midwifery, and to the diseases of females, inseparably connected with midwifery ? CHAPTER II. ANATOMY AND PHYSIOLOGY OF THE UTERINE ORGANS. UTERUS—OVARIES—BROAD LIGAMENTS—VAGINA—VULVA—AND PELVIC FASCIA. The uterus occupies the median region of the pelvic cavity, lying between the bladder anteriorly and the rectum posteriorly, with both of which it has important connexions. It is contained, as also the ovaries, Fallopian tubes, and round ligaments, in the folds of the peritoneum, which constitute the lateral or broad ligaments. Fig. 1. The Uterus and the Lateral Ligaments, {reduced from Quairis Plates.) The anterior wall of the uterus adheres to the bladder inferiorly, for about half an inch. The limits of this adhesion are : from the inser- tion of the vagina on the cervix to the cul de sac formed by the peri- toneum, as it is reflected from the posterior wall of the bladder to the anterior surface of the uterus. The posterior surface of the uterus is connected with the rectum, but indirectly, through the medium of the peritoneum, which, after covering it and the superior region of the vagina, is reflected on the rectum, so as to form the posterior or utero- rectal pouch. The form of the uterus is that of a hollow conoid, with its large extremity, the body, directed upwards, and its small extremity, the cervix, downwards. The neck of the uterus is divided externally into two regions, by the insertion of the vagina : the intra-vaginal, the portion of the neck which protrudes into the vagina, and the supra-vaginal, that which is above, and which, as we have seen, is the region of the uterus in contact with the lowest portion of the posterior wall of the bladder. The relative length of these two regions of the neck of the uterus 40 ANATOMY AND PHYSIOLOGY OF THE UTERINE ORGANS. varies greatly in different individuals, with some the insertion of the vagina being very low on the cervix uteri, with others very high. In Fig. 2. 1. The Virgin Uterus. 2. The Post-Partum Uterus. {Dubois' Traiti des Accouchements.) the former case, the portion that protrudes into the vagina is necessa- rily small, and maybe rudimentary: in the latter case, on the contrary, it is long and voluminous. Independently of this natural cause of elongation, the cervix may be exceptionably elongated to nearly any extent. I have seen it three inches in length, protruding from the vulva like a thick finger ; and there are many instances of this kind on record. The vaginal cervix (fig. 1) in the virgin female represents the upper portion of a small cone directed rather below and behind. At the summit of the cone is the orifice of the os uteri, a small circular opening, the anterior lip of which is rather fuller and thicker than the posterior. The diameter of this opening varies considerably, but it ought never, in a healthy state, to be sufficiently great to give to the finger the sensation of a cavity. Such a condition of the os uteri is generally the result of disease, as we shall see hereafter; the sensation imparted to the finger in health being merely that of a depression. After marriage, the cervix is generally flattened and retroverted, especially when naturally long and voluminous. After parturition, the cone formed by the vaginal cervix (fig. 2) remains, as does the entire uterus, rather more voluminous, and the orifice of the os uteri assumes a transversal form. The uterus occupies the median line in the pelvis. Its axis follows the direction of that of the brim of the pelvis, so that in a woman standing, the fundus of the uterus would be slightly inclined upwards and forwards, and the neck downwards and backwards. Not unfrequently, however, the uterus naturally occupies a diagonal ANATOMY AND PHYSIOLOGY OF THE UTERINE ORGANS. 41 position, lying from right to left, so that the fundus is directed towards the right ilium, and the cervix towards the left groin. This fact, which I am continually observing, is not mentioned by anatomists, but should be borne in mind, as ignorance of it may lead to error in the diagnosis of disease. Most of the lateral deviations of the uterus described by pathologists are merely exaggerations, in a diseased and hypertrophied organ, of this natural position or direction. The weight of the nulliparous uterus is from an ounce to an ounce and a half, and that of the uterus of a woman who has borne children from one ounce and a half to two ounces. The interior of the uterus does not present, as is generally supposed, a single cavity, reached by a channel or passage through the neck, but a double cavity, one belonging to the body of the uterus, and the other to the neck itself. Each of these cavities is dissimilar to the other. That of the uterus is triangular, and its parietes form curves, the convexities of which are internal, and which are all but in contact, being merely separated by a little mucus. The cavity of the uterine neck is, on the contrary, fusiform, and its lateral parietes constitute regular curves, the convexities of which are external. Fig. 3. 1. The Cavities of the Uterus and Cervix, 2. The Uterine Cavities, as repre- as they are during life. sented in Quain's Plates. At the union of the two cavities there is, during life, a natural stric- ture or coarctation, which closes the cavity of the uterus. This coarc- tation, which is not mentioned or described by anatomists, nearly 42 ANATOMY AND PHYSIOLOGY OF THE UTERINE ORGANS. always exists in the absence of disease, and is sufficiently great, (except soon after parturition, and sometimes for a few days after menstrua- tion,) to prevent even a small sound penetrating into the uterus, unless considerable force be used. From its universality, and occasional persistence after death, it must be the result of the anatomical structure of the parts, and probably of the presence of a kind of muscular sphincter. When the mucous membrane of these cavities is inflamed, and under various other conditions hereafter to be enumerated, this sphincter becomes relaxed, and the sound passes easily into the uterine cavity. The surface of the cavity of the uterine neck presents a well-known peculiarity, which, as we shall see elsewhere, is important in a patho- logical point of view. Along the median line both of the anterior and posterior walls there is a longitudinal prominence, or crista, from which radiate on each side numerous thick folds, placed regularly one above the other, and constituting what has been called by anatomists the arbor vitse, or tree of life. A trace of this median longitudinal crista is also found on the anterior and posterior walls of the cavity of the body of the uterus. The capacity of the latter cavity, in the healthy state, is very limited. It will not contain more than from nine to twelve minims of fluid. The depth or length of the two uterine cavities from the os externum to the upper limit of the cavity of the body of the uterus is from two inches and a quarter to two and a half. The uterine cavities are both pretty nearly of the same length—that is, about an inch and a quar- ter. The contraction of the os internum, which arrests the probe, is, however, often found, during life, to be an inch and a half from the os externum, which would give only one inch for the depth of the uterine' cavity. In the nulliparous uterus this natural contraction not unfre- quently begins at about three quarters of an inch from the os. Pregnancy and parturition impress decided modifications on the size and form of the uterus, which deserve special notice. The uterus becomes more voluminous, and its longitudinal and transverse diameters are both increased. (See fig. 2, page 10.) The cavity of the uterus is slightly enlarged at the expense of that of the cervix, the limit between the two being often rather lower, and its form is changed. Instead of representing a triangle with curvilinear borders, the convexity directed inwards, it represents an ovular surface, the margins of which are regularly curved and concave. The infundibuliform angles, also, in which the orifice of the Fallopian tubes are placed in the nulliparous uterus, disappear, to a great extent, in women who have had several children, the Fallopian tubes opening into the superior and lateral region of the ovular cavity. The external form of the uterus also under- goes a change; the anterior and posterior walls becomes more convex and the superior margin rises above the insertion of the Fallopian tubes instead of being all but rectilinear. (Dubois.) Structure.—The uterus is formed by an external peritoneal or serous investment, a proper or muscular tissue, an internal mucous membrane ANATOMY AND PHYSIOLOGY OF THE UTERINE ORGANS. 43 bloodvessels, lymphatics, and nerves. The external peritoneal invest- ment of the uterus is intimately connected with the proper tissue of that organ by dense cellular tissue, according to most anatomists; and by short muscular fibres, according to M. Jobert de Lamballe, except in the lower region, near the cervix and vagina, where he also admits the presence of cellular tissue.* The muscular tissue of the uterus is of a very peculiar nature. In the impregnated state its structure is easily demonstrable, the muscular fibres lying in bands, circles, and ellipses, which the eye perceives without difficulty. It is then highly vascular; the arteries and veins being large, and filled with blood. Its vitality is consequently great, and, as a necessary result, its pathology is that of a highly-vitalized organ. Thence it is, partly, that in the puerperal state we find inflam- mation severe, and rapid in its development and progress.—In the non- impregnated state, on the contrary, the uterus is in a very different condition. Instead of weighing several pounds, it weighs little more than one ounce. Its muscular tissue is in a completely rudimentary state, the fibres being so closely agglomerated and interwoven, that at first sight it appears more like a mass of fibrous tissue than the muscular and highly vascular organ previously examined. The fibro- musculur structure contains but very little cellular tissue; indeed, its presence has been altogether denied by some anatomists. With the assistance of the microscope, however, it may be easily recognised in the diseased urerus ; we may therefore conclude that it is also present in a rudimentary form in the healthy organ. In the uterus of a woman who had died of uterine cancer, presented to the London Medical Society by Dr. S. Beck, the existence of cellular tissue in the healthy structure surrounding the diseased regions was very evident, as also in a uterus half destroyed by corroding ulceration, which I myself subse- quently presented to the same Society.2 The structure of the cervix uteri is fundamentally the same as that of the body of the organ, but it differs by the presence of a greater amount of cellular tissue and by a greater degree of vascularity. The muscular fibres, according to M. Jobert, are circular, decussatory, and longitudinal in the entire animal creation. The circular fibres are the most numerous, the longitudinal being only found in the posterior region of the cervix. The circular fibres are distinct from those of the body of the uterus ; the longitudinal ones, which occupy the middle posterior region of the cervix, are, on the contrary, the continuation of the posterior longitudinal layer of the uterus. Hence, probably, it is, that chronic inflammation of the cervix uteri has a much greater tendency to pass on to the posterior wall of the uterus than to the anterior, the latter region of the cervix being less intimately connected with the body of the uterus. The uterine cavities are lined by an internal or mucous membrane, 1 M. Jobert de Lamballe on Structure of the Uterus, Lancet, Sept. 7th, 1844. 2 Lancet, vol. i. 1851, page 295. 44 ANATOMY AND PHYSIOLOGY OF THE UTERINE ORGANS. the nature of which has much occupied anatomists. It is only, how- ever, within the last few years that its true nature has been satisfac- torily made out, through the labours of M. Coste, of M. Robin, and of Baron Dubois of Paris. In the following brief account of this membrane I have adopted the views of these authors.1 The lining membrane of the uterine cavity, although evidently a mucous membrane, differs considerably from all other mucous struc- tures. It does not merely line the cavity of the uterus, as mucous membranes generally do, but forms a part of the uterine walls, being continuous with the proper tissue of the organ, without the interposi- tion of any sub-mucous cellular tissue. Its thickness is very considerable, representing a fifth, or even a quarter, of the entire thickness of the uterine wall. The adherent surface, as we have seen, is intimately connected with the proper tissue of the uterus ; the free surface, which constitutes the interior of the uterus, is smooth, and presents a great number of small openings, which are the orifices of mucous follicles. On dividing this membrane by a section of the uterus, it is found to be formed by a number of parallel filaments, perpendicular to the uterine cavity, and closely superposed; thence a smooth homogeneous appearance, which contrasts with that of the proper tissue, the fibres of which are irregularly interwoven in every sense, and which presents a number of vascular openings. Fig. 4. p p, the proper tissue ; m m, the mucous layer or membrane ; o t, a tubular gland. 1M. Coste—Histoire Generate du DeVeloppement des Corps Organises, 1847- M. Robin—Archives G6n6rales de Medecine, Juillet, Aout, 1848. Baron Dubois__Traite" des Accouchements, vol. i. 1849. ANATOMY AND PHYSIOLOGY OF THE UTERINE ORGANS. 45 The uterine mucous membrane is formed by glands, vessels, and an epithelium, united by fibro-plastic tissue, dartoic tissue, cellular tissue, and an amorphous matter. The glands are remarkable by their form, which is tubular, long, and sinuous, or vermiform. Numerous vessels penetrate it, but in a state of capillary division. Of the various tissues enumerated, the fibro-plastic is the most abundant, forming about half the mucous membrane. It differs from cellular tissue, properly so called, by its microscopic characters, and also by the fact that it belongs exclusively to anormal tissues, or to those in process of renova- tion. Its presence, therefore, in the uterine mucous membrane, in the normal state, is a remarkable fact, and the only example of the kind in the economy. The epithelium is vibratil$, inasmuch as it presents ciliary corpuscles, which are incessantly agitated by a vibratory move- ment. The mucous membrane of the cervical canal presents the same struc- ture and characteristics, but it is very much thinner. The glands, also, instead of being long and tortuous, are short, and of a utricular form. They are numerous, and many of them present an important peculia- rity, that of being imbedded, hidden between the folds and radiations of the arbor vitse. Thence, as we shall see, the extreme difficulty, in many cases, of curing chronic inflammation of the mucous membrane of the cervical canal. The arteries which supply the uterus, are the ovarian, from the aorta; and the uterine, from the hypogastric. The uterine branches of the ovarian arteries are principally distributed to the body of the organ, but their smaller divisions reach the cervix, and freely ramify in it. The uterine arteries, by far the larger of the two, after passing along the vagina, give off their largest branches to the neck of the uterus, in their course to the body of the uterus. Thus, in the non- pregnant state, the cervix is more freely supplied with bloodvessels than the body of the organ, which may account for its greater liability to inflammatory disease. M. Recamier has described, as existing around and near the os uteri, a vascular network, which forms a sort of erectile tissue : and his views have been confirmed by the researches of M. Forget and Dr. Tilt. This anatomical condition would tend to account for the extreme turgescence so often observed around the os when it is attacked by inflammation. The veins of the uterus accompany the arteries. The ovarian empty themselves on the right side into the inferior vena cava; on the left into the corresponding renal vein. The uterine veins empty themselves into the hypogastric veins, and anastomose freely with the ovarian. These veins are remarkable for their great size, which is much greater than that of the arteries, for their frequent anastomoses, and for their anatomical structure. The external membrane being absent, the internal membrane is in immediate contact with the proper tissue of the uterus, so that the walls of the veins are contractile. With reference to the veins, therefore, the uterus may be considered an erectile tissue, with muscular parietes. The above anatomical facts explain the great 46 ANATOMY AND PHYSIOLOGY OF THE UTERINE ORGANS. tendency to venous congestion which the uterus presents in disease, especially when the vital contractility of the organ has been diminished by the lengthened persistence of morbid changes. The lymphatic vessels are numerous, and may be divided into super- ficial, situated at the surface, underneath the peritoneal covering, and the deep-seated, which are distributed in the walls of the uterus. Those of the body of the uterus follow the course of the ovarian vessels, and uniting with the lymphatics of the ovaries, and broad ligaments, terminate in the lumbar lymphatic ganglia. Those of the cervix uteri terminate principally in the pelvic ganglia. The nerves of the uterus are derived from the renal and hypogastric plexuses. Those from the first source follow the course of the ovarian arteries, and are distributed to the fundus and superior region of the uterus. Those from the second follow that of the uterine arteries, and present pretty nearly the same distribution, dividing into superficial deep-seated branches. (Dubois.)—The hypogastric plexuses are prin- cipally formed by branches of the sympathetic, but they also contain nerves issuing from the sacral plexuses. The uterus is thus connected both with the ganglionic and cerebro-spinal system—a fact which accounts for the sympathetic influence which it exercises when diseased on the various functions of organic life, as also on those of the cerebro- spinal system. The researches of the numerous anatomists who have of late years investigated the nerves of the uterus, have proved satisfactorily that the neck of that organ receives nerves, as well as the body; but they do not clearly prove that these nerves reach the lower, or vaginal portion of the cervix. M. Jobert, indeed, states positively that his dissections show they do not. The marked insensibility of the vagi- nal portion of the cervix, in the great majority of cases,.would tend, a priori, to prove that nerves are deficient in this region, or, which is more probable, present to a very limited extent. In no other region of the uterus do we see the same absence of pain, when serious disease is present, or when painful therapeutic agents are resorted to. This is not always the case, however, for occasionally the cervix is found acutely sensitive to every kind of impression. According to Dr. Robert Lee, the nerves of the uterus enlarge greatly during pregnancy, so as to cover the uterus with a stratum of nervous plexuses and ganglia. Dr. S. Beck, on the contrary, states that the nerves do not alter in their thickness during pregnancy; at least, that no alteration occurs before they enter the tissue of the uterus, while that organ itself, and the vessels which supply it, enlarge in size to an extreme extent. (Quain.)—Both these contradictory state- ments are illustrated and supported by careful dissections, and have both received the sanction of the Royal Academy. The questions which they involve, however, although very important to the anatomist and physiologist, are much less so to the pathologist, to whom it is sufficient to know that the uterus is freely supplied with nerves which connect it primarily and principally with the ganglionic system and secondarily, with the cerebro-spinal system. Thus are explained the ANATOMY AND PHYSIOLOGY OF THE UTERINE ORGANS. 47 numerous sympathetic reactions on the various functions of organic life, and on the brain and spinal cord, which are exhibited in uterine disease. Ovaries, Fallopian tubes, round ligaments, and broad ligaments.— The ovaries are situated in the posterior folds of the broad ligaments, behind the Fallopian tubes, in front of the rectum, from which they are often separated by some folds of the small intestine. They occupy the superior margin of the lateral ligaments, and are consequently on a level with the fundus of the uterus. The external extremity is fixed to the pavilion of the Fallopian tube, and the internal extremity is connected with the uterus by the ovarian ligament. The ovaries are constituted by a peritoneal and a fibrous investment, and by a paren- chyma or proper tissue. The latter is formed by small, densely aggre- gated cellular fibres, between which are spaces filled with a yellow fluid. It is very vascular, and is supplied by the ovarian arteries which enter the ovary by the lower margin. Interspersed in this spongious tissue we find the Graafian vesicles. Between the folds of the lateral ligaments we also find the Fallopian . tubes, constituted by a fibro-muscular sheath, investing a canal lined by alimentary mucous membrane ; and the round ligaments, which are composed of muscular fibres emanating from the uterus. The lateral ligaments, formed, as we have seen, by the reflection of the peritoneum from the anterior to the posterior surface of the uterus, contain between their folds, in addition to the ovaries, Fallopian tubes, and round ligaments, a layer of filamentous tissue, which separates them one from the other, and surrounds the various organs enumerated. The principal use of this intervening dellular tissue appears to be to allow the peritoneal folds to separate and accommodate themselves to the progressive ampliation of the pregnant uterus. Vagina and Vulva.—The vagina is a membranous canal, the length of which varies greatly in different individuals, according to their size and to individual peculiarity. In the healthy female, when not relaxed by disease, or distended beyond measure by repeated child-bearing, the vagina represents a very extensible but closed canal, the walls of which are in contact, so as to embrace and support the neck of the uterus. The posterior wall is longer than the anterior, owing to its rather con- vex form and to its insertion at a higher region of the cervix. It is in contact in its superior fourth with the peritoneum, and in its inferior three-fourths it lies over the rectum, with which it is connected by a layer of fatty cellular tissue of variable thickness. The anterior wall is slightly concave, and is in relation superiorly with the trigone of the bladder, and inferiorly with the urethra. It is connected with these organs by filamentous cellular tissue of a dartoic nature. At the sides the vagina is inclosed between the levator ani muscles. It is partially closed inferiorly by a small sphincter-like muscle—the constrictor vaginae. The vagina is constituted by a proper membrane or tube presenting the characters of erectile tissue, and contained between two fibrous layers. Externally it is surrounded by a loose dartoic or con- 48 ANATOMY AND PHYSIOLOGY OF THE UTERTNE ORGANS. tractile cellular tissue; internally it is lined by a mucous membrane covered by a squamous epithelium, and presenting numerous transverse rugoe, which radiate from a median raphe or columna. These rugic are numerous in the losver part of the canal, and become less marked and less numerous as we reach the upper region. Repeated pregnan- cies, by dilating the vagina, render the rugre less characteristic. Hence the opinion that they are principally destined to facilitate the ampliation of the vagina. M. Cruveilhier, however, in common with some of the older physiologists, considers them to be formed principally by large papillae, lineally arranged, and to be organs of sensation. The vaginal mucous membrane is freely supplied with mucous follicles. The arteries of the vagina are branches of the internal iliac—viz., the vaginal, internal pudic, vesical, and uterine. The corresponding veins are large, and form at each side a large plexus. The nerves are derived from the hypogastric plexus of the sympathetic and from the fourth sacral nerve and the pudic nerve of the spinal system. The vulva is formed by the mons veneris, the labia majora and minora, the hymen, and the clitoris. The mons veneris is merely the integument on the fore-part of the pubic symphysis, elevated by a quantity of cellular and adipose tissue, and covered with hair. The labia majora are two rounded elliptic folds of integument, which descend from the mons downwards and backwards, gradually becoming thinner as they descend. Inferiorly their union limits the perineum in front; superiorly, they conceal between their commissure the clitoris. The external surface of the labia majora is cutaneous; the internal, mucous; and between the two are found fat, vessels, nerves, glands, and dartoic tissue. From the upper surface of the clitoris descend the narrow folds of mucous membrane, the labia minora, or nymphse, which directly inclose the external orifice of the vagina, and are very freely supplied with mucous follicles and sebaceous glands. It is covered by a scaly epithelium. Sometimes the nymphse, instead of being concealed by the labia majora, are elongated, and protrude beyond them, in which case they generally become thicker, and assume a darkish hue. With the women of some parts of Africa and Asia, as is well known, this peculiarity of structure becomes so marked as to consti- tute an inconvenience and a deformity, and has even led to the adop- tion of a kind of circumcision. Between the two layers of mucous membrane which constitute the nymphae is found a cellular tissue of an erectile nature, which may be said to constitute its proper tissue, and a great number of small sebaceous follicles. The vessels and nerves are the same as those of the labia majora; derived from the internal and external pudic and obturator arteries ; and from the inguinal branches of the lumbar plexus and the internal pudic nerve. The clitoris is a spongious vascular erectile organ, placed before the symphysis pubis, and below the upper commissure of the nymphie, which presents a great identity of structure with the parallel organ in the male. Its free extremity or gland is covered by an external mem- ANATOMY AND PHYSIOLOGY OF THE UTERINE ORGANS. 49 brane, on which ramify a vast number of small nerves,1 branches of the internal pudic, the presence of which ^accounts for its extreme sen- sibility and delicacy. This structure constitutes the clitoris an erectile organ, but its erectibility, in the healthy and normal state, is confined within narrow limits, only slightly increasing its length and volume, so that it never depasses the labia majora. Under the influence of dis- ease or irritation, however, and sometimes as a natural condition, it may attain a considerable size. The hymen, a duplication of mucous membrane placed at the entrance of the vagina, is constant in its presence, but varies greatly in thickness and development in different females. In some it is thin, largely open, and elastic, so as to admit of easy dilatation; in others, on the contrary, it is fleshy, presents a small opening, and its resist- ance can only be overcome by considerable force. When lacerated, the divisions retreat and form small tubercles, and sometimes elongated tongues, to which the name of carunculse myrtiformes is usually given. The various vulgar organs which we have described, all present numerous mucous follicles, destined to lubricate them, and to protect them from injury. At the union of the two upper thirds of the vagi- nal orifice with the lower third, at the side of the vagina, are two large mucous glands, the glands of Bartholine, or the vulvo-vaginal glands, which, although known and described by the older anatomists, had been all but forgotten until the recent researches of M. Huguier2 demonstrated their constant existence and their importance as organs of lubrication. The duct by which they empty themselves is about half an inch in length, and opens at the side of the hymen. These glands are frequently the seat of disease, as we shall see hereafter. The mucus secreted by the vulvo-vaginal glands, and by the follicles of the vulva, is transparent and viscid ; that of the vagina is white, creamy, and fluid; whilst that of the cervical canal, uterus, and Fallo- pian tubes, again presents the transparency and viscosity which usually characterize mucus. In the cervical canal it is peculiarly viscid and tenacious, adhering to the surface so as to be extracted with diffi- culty. The mucus of the uterus is alkaline, brings back the blue colour of red turmeric paper, and contains in abundance small corpus- cles,, which appear to be suspended in it.3 The mucus of the vagina is acid, reddens blue turmeric paper, and nearly always contains numerous lamelliform corpuscles, the result of a kind of exfoliation of the epithelium. It will thus be seen, as M. Donne judiciously remarks, that the mucous membrane of the vagina presents characteristics that constitute it a mere modification of the skin, of which it is the contin- uation : it is covered with an epithelium very analogous to the epider- mis, and is, to a certain extent, an organ of tactile sensation, secreting mucus, which, like the cutaneous secretion, contains a multitude of 1 See a very interesting monograph on the structure of the clitoris by Kobelt of Fri- bourg. Paris, 1851. (Translation.) z Memoires de l'Academie de Medecine, 14th volume. 3Donn6, Cours de Microscopie, 1844, p. 155. 4 x 50 ANATOMY AND PHYSIOLOGY OF THE UTERINE ORGANS. epidermic detritus, and no mucous globules. The mucous membrane of the cervix and body of the uterus, on the contrary, more deeply seated, loses completely all analogy with the skin; its epithelium is vibratile, it is not an organ of tact, and its mucus is characterized by the presence of mucous globules, and by the absence of epithelial detritus. The various organs constituting the vulva, which we have rapidly examined, present a feature in common which deserves special notice— their erectile structure. They are all supplied with numerous vessels, which anastomose so freely as to assume the spongious or cavernous character, thus constituting tissues, in which the rapid flow of blood produces erectile phenomena. The multiplicity of nerves, and the presence of dartoic tissue, contribute greatly, no doubt, to the develop- ment of the above conditions. This structural peculiarity of the vulvar organs impresses on their inflammatory diseases peculiar features. The Pelvic Fascia.—The pelvic fascia are constituted by the supe- rior pelvic aponeurosis, and by the perineal aponeuroses.^ The superior pelvic aponeurosis closes the abdomen inferiorly. It represents a concave veil, or diaphragm, extended over the pelvic cavity, and inserted posteriorly on the anterior surface of the sacrum coccyx, anteriorly on the internal surface of the pubis, and lining late- rally the sides of the pelvic excavation. This aponeurosis is traversed by the rectum, the vagina, and the bladder; but the aponeurotic fibres being reflected on each of these organs, there is no positive perforation of the aponeurosis. This disposition is more especially remarkable on the bladder and vagina, and contributes considerably to strengthen these organs. The rectum, vagina, and bladder, thus divide the fas- ciae pelvis into two lateral halves. Between the rectum and the vagina the fascia presents a transversal septum, which divides it also into two very unequal antero-posterior halves ; the smaller one, the posterior, containing the rectum, and the larger, the anterior, containing the vagina and bladder. The existence of this fascia adds greatly to the strength of the floor of the pelvis, which it partly forms; contributes powerfully to retain in situ the pelvic organs, and exercises consi- derable influence in limiting and directing morbid manifestations, and especially fluid collections. The perineal aponeuroses are three in number, and occupy that part of the pelvic outlet which is formed by the pubic arcade. Their form is consequently triangular, and their limits are, laterally, the ascending branches of the ischion, and posteriorly, a line drawn from one tube- rosity of the ischion to the other. They all three adhere to the body and symphysis of the pubis_ superiorly, and to the ascending branches of the ischion laterally, uniting posteriorly so as to form, as it were, closed cavities, traversed by the urethra and the vagina, but not by the rectum, which is posterior. The superficial aponeurosis is inserted on the anterior surface of the pubis and ischion, covers the roots of the clitoris, the ischo-cavernous muscles, and is inserted in the skin of the labia majora. The middle ANATOMY AND PHYSIOLOGY OF THE UTERINE ORGANS. 51 aponeurosis is inserted on the pubis, behind the clitoris, and covers the bulb of the vagina, and the constrictor-vaginae. The deep-seated aponeurosis is separated from the former by cellular and vascular tissue only. It is inserted on the posterior surface of the pubis, and on the internal surface of the ischion. These aponeuroses greatly add to the solidity and power of resistance of the external orifice of the genito-urinary organs. Physiology.—Throughout its entire period of vital activity, the non-pregnant uterus has an important function to perform, that of menstruation. The function of menstruation has been much elucidated during the last ten years by the labors of the numerous physiologists who have investigated the phenomena of generation, amongst whom stand promi- nent, Pouchet, Gendrin, Negrier, Barry, Wharton Jones, Bischoff, and Raciborski, &c. I would, however, more especially refer to the elaborate work on Spontaneous Ovulation, by M. Pouchet,1 in which will be found a full and complete account of his own important researches, as also of those of nearly all the ancient and modern writers on the subject. To M. Pouchet, whose life appears to have been partly devoted to the study of this interesting and important physiological point, belongs the credit of having been one of the first to broach the doctrine of spon- taneous ovulation as a law in the females of all mammiferae, and also of having established this law in the most irrefutable manner by numerous experiments, and by a close and powerful analysis of all that had been done by his fellow-laborers in the field of observation. The researches to which I refer prove, in the most satisfactory and conclusive manner, that menstruation is intimately connected with the evolution from the ovary of matured ova, which takes place periodically in the virgin as well as in the married female. In the human female the maturation and evolution of ova occur at frequent intervals, and are remarked by the exudation from the uterine cavity of a greater or less quantity of blood. In the lower animals, the interval is generally longer, and the menstrual phenomena are less marked, consisting merely in congestion of the sexual organs, accompanied by the exudation of mucus, mingled with a few blood-corpuscles. But in both the pheno- menon is the same; in both, nature directs a tide of blood to the uterine organs, as the ova contained in the ovary arrive at maturity, in order that the uterus may be in a fit state to receive and nourish them should they be fecundated after their emission from the Graafian vesicle. A decided physiological connexion exists between the different organs which constitute the sexual apparatus in the female—viz., the ovaries, the uterus, the external sexual parts, and the breasts. All are dormant, as it were, until the advent of puberty, the great and essential charac- teristic of which is the development of the Graafian vesicles or ova. Previously deeply imbedded in the tissue of the ovaries, small, and 1 Th^orie Positive de l'Ovulation Spontanea, par F. A. Pouchet, Professor of Zoology to the Museum of Natural History of Rouen. Paris: Bailliere. 1847. 52 ANATOMY AND TnYSIOLOGY OF THE UTERINE ORGANS rudimentary, as puberty approaches, some of their number begin to enlarge, and gradually to approach the surface. The installation ot puberty and the first menstrual show coincide, and are evidently con- nected with the arrival of one or more of these vesicles at the full period of development. A few red streaks formed by capillary vessels are first observed on the surface of the Graafian vesicles, which pro- trude from the surface of the ovaries. These capillaries gradually increase in number and intensity of colour, giving the membrane on which they ramify the appearance of being the seat of acute inflam- mation, until at last, in the centre of the vascularized surface, an opening shows itself, the result of a tear or rent, or of absorptive inflammation; the ovule is expelled, and having been grasped by the fringed extremity of the Fallopian tube, passes down its canal, to be lost, no doubt, in the uterus, if not fecundated. According to M. Pouchet, the opening of the Graafian vesicle and the evolution of the ovule take place either at the epoch when men- struation ceases, or one or two days later. If this view be correct, the progressive vascularization of the proper membrane of the ovum or Graafian vesicle would coincide with, and to a certain extent occasion, the uterine congestion that precedes and accompanies menstruation; as also the sympathetic irritation and swelling of the breasts which so frequently precede and accompany the menstrual flux. I have qualified the above statement by the words " to a certain extent," because it appears to me that the uterus is not merely a passive organ, receiving and corresponding only to impressions origin- ating in ovarian phenomena, but that it exercises a marked influence over their development. Thus we find that its diseases very frequently arrest and modify in various ways the function of menstruation, and also diminish, and annihilate, or increase sexual feelings and appetites. We may therefore fairly presume that they exercise the same unfa- vorable influence over the maturation and evolution of the ova. In other words, the attentive consideration of the reciprocal influence of the uterus and of the ovaries on each other in disease, must lead all impartial observers to the conclusion, that in health they constitute one system of organs, the integrity of which in its component parts is necessary for the normal accomplishments of the functions of ovulation and menstruation. The above, I am firmly convinced, is the only true and rational view that can be taken of the uterine system, both in health and in disease. To attribute both the healthy and the morbid conditions of menstrua- tion all but exclusively to ovarian influence, as has been c]one by some pathologists, is to take much too narrow a view of uterine pathology, and is as far from the truth as would be the negation of all ovarian influence on uterine phenomena. The ovaries, it is true, preside over the function of menstruation, as we have seen, but the uterus cannot certainly be considered a "mere reservoir," or bladder, destined only to receive and nourish the ovum after impregnation. The more accurate knowledge which we now possess of the cause, ANATOMY AND PHYSIOLOGY OF THE UTERINE ORGANS. 53 seat, and mode of manifestation of the menstrual function, tends greatly to corroborate the view at which I have long arrived, from clinical experience, respecting irregular or morbid menstruation—viz., that it is nearly always, when strongly marked and inveterate, the result of positive disease of some portion of the uterine system, and, generally speaking, of the uterus. That such is the case must be admitted as probable, when we consider that the function, although presided over by the ovaries, is accomplished by the uterus, which contains an exten- sive mucous surface. Those who have hitherto written professionally on menstruation are, however, so totally unaware of this important fact, that their works, even the most recent, are replete with cases the true nature of which they do not even suspect—cases in which it is most evident to me that menstruation was modified by positive disease, but which they view as physiological, or as the result of constitutional causes. When treating of the morbid conditions of the menstrual functions I shall endeavor to point out the data by which mere physi- ological modifications, the result of constitutional or accidental causes, may be distinguished from modifications the result of actual disease. Although a difficult task, I hope to be able to accomplish it by bringing to bear on the question the facts respecting uterine inflammation which will be previously developed. From what precedes, it is evident that the term menstruation ought in reality to be applied to the totality of the conditions that co-exist with the maturation and evolution of ovarian vesicles. Until recently, however, the exudation of blood from the uterine organs in the human female, the all but invariable concomitant of this periodical function, having been alone observed, it has been to it only that the term menstruation has been given. The necessary connexion between the ovarian and uterine phenomena having only been discovered and established of late years, it is not surprising that the meaning of the word menstruation should have been thus limited. Henceforth, however, it will have to be taken theoretically in its more extended and truer sense, although, practically, we may still be obliged to limit the term menstruation to the uterine element, or the exudation of blood, as it is the ostensible indication and evidence of the changes that are taking place in the ovaries. It is now universally admitted that the menstrual secretion takes place from the mucous membrane lining the uterine cavity. For one or two days before it commences, in the healthy uterus, a tide of blood sets in towards the uterine organs ; and if the cervix uteri is then brought into view, its mucous surface is found greatly congested, and of a deep red hue. When the secretion has commenced, the blood may be seen to ooze guttatim from the os uteri. After it has ceased, the tide of blood gradually recedes, and in the course of one, two, or three days, the uterus is restored to its normal condition, the cervix assuming its naturally pale, rosy hue. If the uterus is the seat of disease, the flux to it begins earlier—often a week previous. After menstruation has ceased, there is also, in disease, a great tendency to the perpetua- 54 ANATOMY AND PHYSIOLOGY OF TIIF, UTERINE ORGANS. tion of the menstrual congestion, the uterus frequently not appearing to have the power to expel the menstrual blood. Menstruation in the human female oscillates physiologically between great extremes, or, in other words, it may vary to an extreme extent in its mode of manifestation, and yet these variations may be com- patible with health, and with the perfect integrity of the uterine organs. Indeed, there is not a greater difference between the human female and the female of the lower mammiferae, in Avhich the menstrual function only shows its presence by a congested state of the genital organs and a slight mucous secretion, than there is between different females. Thus, in some, the menstrual flux only shows itself for a day or two, or even for a few hours, throughout life, and is very scanty; whereas, in others, it lasts seven or eight days, and is always so profuse as to be all but hemorrhagic. The physiological variations of menstruation may be referred to its epoch of first manifestation, to its duration, to the quantity of blood lost, to the amount of pain experienced, and to the periodicity of its return. The epoch at which menstruation first sets in, is very variable, but may be said to range between eleven and nineteen or twenty, the cases in which it occurs before or after these ages being rare. The medium age, in temperate climates, according to Raciborski, who deduced it from the analysis of a large number of cases, is about fourteen—a state- ment which my own experience completely corroborates. There are cases on record, in which menstruation has set in as early even as the third or fourth year, but they can merely be considered freaks of nature. Climate was formerly considered to exercise great influence over the epoch at which menstruation appears, but this influence appears to have been greatly exaggerated. So far from cold greatly retarding, and heat greatly accelerating, its appearance, it would seem, from the valuable researches of Dr. Robinson,1 of Manchester, that the medium age is pretty nearly the same all over the world. Raciborski finds a difference in the medium age of the cases he investigated for the north and south of France, but that difference only amounts to a few months, and would be required to be deduced from a larger number of persons, to be definitively accepted. Menstruation generally ceases between forty- five and fifty, but the menopause may occur much earlier or much later. The duration of the menstrual flux, and the quantity of blood lost, vary very considerably in different females. The average duration may be said to be about four or five days, but many are only unwell two or three, and with many, again, it lasts six or seven. When menstruation is of short duration, the loss of blood is generally scanty, whereas it is greater when it lasts a long period, not only on account of its longer duration, but also because it generally flows more freely. The influence of climate in this respect also appears to have been much exaggerated. The fact of menstruation being constitutionally of long duration and profuse, I have found to be a powerful predisposing cause of uterine inflammation, owing, probably, to the intensity of the mollimen hemorr- 1 Essay and Notes on the Physiology and Diseases of Woman. 1851. ANATOMY AND PHYSIOLOGY OF THE UTERINE ORGANS. 55 hagicum, and to the length of time it persists, during which the patient is exposed to many perturbing causes. The intensity of the physiolo- gical congestion is evidenced by the fact, that for one, two, or three days before and after menstruation, these females often have a slight white or leucorrheal discharge, even when in perfect health. With many females the first manifestation of the menses is unac- companied by pain. The menstrual flux makes its appearance with scarcely any previous admonition of its advent, and continues to appear without pain or uneasiness; or if pain is present, it is slight, and limited to the first few hours. This is the most favorable mode in which the menstrual function can take place, and the one which affords the greatest guarantee of future immunity from inflammatory disease. It is, how- ever, by no means the rule; with many women, the first advent and the subsequent appearance of the menses, are attended, physiologically, throughout life, with great uterine pain. With some the pain is limited to the first few hours, with others it exists for a shorter or a longer period before, and lasts throughout, the period. The periodicity of menstruation also varies physiologically to a great extent. I have found that four weeks or twenty-eight days, the lunar month, is the most general term ; but the periodical return of the menses may take place at any time between the third and the fifth week. Most authors allow even a greater latitude : but I believe that the constant return of the menses at an earlier or later period will nearly always be found, on a careful inquiry, to be a pathological symptom, and to be connected with local disease. From what precedes, it will be perceived that the physiological varia- tions of menstruation—variations quite compatible with health—are so numerous and so great, that it is impossible to lay down any standard by which the integrity of the function can be generally tested. The above fact would much diminish the importance of the changes that occur in the menstrual function in disease, as an element of diagnosis, were it not that this irregularity is not observed, physiologically, in each individual case. In other words, every female has her own indi- vidual standard, to which she generally remains true throughout her life, unless the uterine organs be the seat of disease, or general health be deeply modified by some other cause. Once therefore we have ascertained the mode in which menstruation occurs in any other par- ticular female, at an epoch when it may be fairly presumed that she was in good uterine health, we are authorized to surmise the presence of uterine or ovarian disease—and, generally speaking, the former— if any marked and permanent change takes place. It is the ignorance of this important fact that has filled with errors, as I have already stated, all existing treatises on menstruation, at nearly every page of which cases are narrated as physiological, which I at once recognise as most decidedly pathological. This circumstance, therefore, must greatly invalidate the value of the conclusions at which these authors have arrived, whether statistical or otherwise, with respect to the physiology of menstruation. PART I. INFLAMMATION OF THE UTERUS AND OF THE UTERINE ORGANS. CHAPTER III. THE FREQUENCY AND IMPORTANCE OF INFLAMMATION IN UTERINE PATHOLOGY. Inflammation of the body of the uterus in the acute or subacute state, is not of very frequent occurrence, but inflammation of the cervix, and especially of the mucous membrane which covers it and lines its cavity, is so common as in reality to form the prominent feature of uterine pathology. That such should be the case, is a necessary consequence of the anatomical and physiological condition in which the uterus is placed. On reviewing these conditions, we find that the body of the uterus presents a very dense and non-vascular structure in the non-pregnant state, and contains cellular tissue in an elementary form only; that the uterine neck is of a less dense structure, is more vascular, indeed all but erectile around the os, and has a cavity distinct from that of the body of the uterus, the mucous membrane of which is studded by numerous mucous follicles. Physiologically we find that, throughout its entire period of vital activity, the non-pregnant uterus has an impor- tant function to perform—that of menstruation—which consists, as we have seen, in the periodical secretion or excretion of a certain quan- tity of blood from the uterine cavity, this excretion of blood coinciding with the separation of a mature ovum from the ovary. This act of menstruation is preceded, accompanied, and followed, by determination of blood to the uterine organs, by a kind of molimen hemorrhagicum; so that if a healthy female is examined instrumentally a day or two before the appearance of the menses, whilst they are present, or a day or two after, the vaginal mucous membranes, and more especially that which covers the cervix, are found turgid, and of a deep red colour; thus presenting incontrovertible evidence of a considerable degree of passive congestion. When uterine inflammation exists, this congested condition of the uterine organs often extends over a much more length- ened period, both before and after menstruation, and is necessarily INFLAMATION OF THE UTERUS. 57 greatest in the most vascular part of the uterus, that is, in the cervix, and its lining mucous membrane. The periodical return of menstruation taking place, in the great majority of women, about every fourth week, and the menses generally continuing four or five days, we find that the menstrual molimen hemor- rhagicum must last with most women from seven to ten or twelve days. It thus appears, that during one-third or one-fourth of each month the uterus of a menstruated female, and especially the cervix, the mOst vitalized region, is physiologically in that condition which, throughout the economy, immediately precedes inflammation—viz., a state of con- gestion. When, on the other hand, we consider that the arrest of a secretion from a congested organ is one of the most frequent causes of inflammation, and how very many causes there are that can arrest or modify the menstrual flux, it need not be a source of surprise that inflammation should occur in the uterus and its neck apart from physi- cal lesions, but rather a source of astonishment that it should not occur more frequently than it actually does. With some females, moreover, the uterus seems to be naturally a weak organ. This peculiar delicacy of the uterine system is indicated by the difficulty with which menstruation is at first established, by its irregularity during the first years, by its scantiness or abundance, by the frequent presence of leucorrhea before and after menstruation—an indication of congestion of the uterine system—and by the existence of pain either for the first few days, or for the entire period. These peculiarities of menstruation, although apparently morbid, are evidently natural with some females, as I have already stated, and quite com- patible with the absence of disease of any kind. They characterize a tribe, as it were, of the human race; a class of females who are more liable than others, in the course of their uterine life, to inflammatory diseases of the uterus, and to all the accidents to which these diseases give rise. It would seem as if, with them, either the menstrual "molimen hemorrhagicum" was so great as to distend beyond measure the uterine tissues, thus giving rise to extreme congestion and pain, or as if the uterus was so peculiarly sensitive, that even the physiological menstrual congestion could not take place without its sensibility being anomalously raised. These anatomical and physiological considerations explain how it is that inflammation of the neck of the uterus, as I have stated above, is a frequent instead of a rare disease, as it is supposed to be by our most eminent uterine pathologists. Inflammation of the body of the uterus in the unimpregnated state is, in truth, a rare disease; but inflamma- tion of the neck of the uterus, on the contrary, is an exceedingly common one; so common, indeed, that the very great majority of the females who apply for relief when laboring under uterine symptoms, physical or functional, will be found, on careful examination, to be suffering from its existence. Leucorrhea, dysmenorrhea, menorrhagia, irritable uterus, prolapsus, &c, are generally studied independently of 5S INFLAMMATION OF THE UTERUS. any such origin ; but, in reality, in nineteen cases out of twenty, when confirmed, they are the immediate result of inflammatory disease of the cervix, and only to be effectually treated by attacking the primary disease to which they owe their existence. Leucorrhea, more especially when chronic, and persisting during the entire interval of menstrua- tion, is nearly always the result of inflammation and ulceration of the uterine neck; but a large proportion of the generally-reputed functional diseases of the uterus will also be found, if submitted to severe scrutiny, assignable to the same cause. Most of the more intractable cases of dysmenorrhea, monorrhagia, irritable uterus, and amenorrhea, that are met with in practice, are the result of local inflammation. I do not include chlorosis and hysteria, because they are not diseases of the uterine system. Chlorosis is a disease of the blood, and the modifi- cations which occur in menstruation are merely the result of debility and disordered sanguinification. Hysteria is a disease of the nervous system, which is very often occasioned by disease of the uterus, but which is not necessarily connected with it. Irritable uterus is merely another name, in most instances, for uterine inflammation. All the symptoms which Gooch, and the writers who have copied him, give as characterizing irritable uterus, may generally be referred, without hesitation, to such disease. I am in a position to prove, by statistical data, that inflammation of the lower segment of the uterus is really as frequent, and plays as important a part, in uterine pathology, as I assert. During the last few years, I have kept a careful register of all the cases of uterine disease which I have treated at the Western General Dispensary, with which Institution I am connected as physician-accoucheur. The Western Dispensary is one of the largest institutions of the kind in London, nearly ten thousand patients being annually treated by its medical officers. My patients consist of those who present uterine symptoms, and are either addressed to me by my colleagues or by the house- surgeon on registration. The cases, therefore, present the same origin, and must be of the same nature, as those that fall under the notice of the physician-accoucheur at other similar institutions—at Guy's Hos- pital, for instance—where only one case of inflammation of the cervix in fifty (twenty in a thousand!) is stated by Dr. Ashwell to occur.1 Nothing can be more dissimilar than the results at which I arrive on analyzing my cases, three hundred in number. I find that two hundred and forty-three were suffering from decided inflammatory disease of the cervix or of its cavity, and that in two hundred and twenty-two ulcera- tion was present. As the thousand cases of so distinguised a physician as Dr. Ashwell were taken from exactly the samo class of patients as my own, the extraordinary discrepancy of the results obtained by direct observation cannot fail to arrest the attention of practitioners, more especially as the question at issue is not one of secondary importance, but really 1 Dr. Ashwell's Treatise on the Diseases Peculiar to Women. Second Edition, p. 184. INFLAMMATION OF THE UTERUS. 59 involves the whole truth of the doctrines which I have submitted to the profession. These three hundred cases were all attended by me at the Dispensary between the 1st of July, 1844, and December, 1848. The details of each case were carefully taken down by myself, in the presence of the patient, and the description of the local state of the uterine organs was always written immediately after examination—the examination being invariably carried out before any note of the local state of the patient was made. As the results at which I have thus arrived, with reference to the comparative frequency of the various forms of uterine disease, are quite novel, and perfectly subversive of all existing ideas respecting uterine pathology, I have given a brief tabular summary of these cases in an Appendix. The analysis of the cases which I have seen and attended in private practice, leads to precisely the same conclusion. But as it might be urged, from the nature of my writings, that I am most likely to be consulted on this particular form of uterine disease, I have thought it better not to refer to them for statistical purposes. The most cursory survey of the cases contained in the Appendix will show, that although the real cause of the morbid symptoms was the existence of local inflammation, yet that the apparent nature of the disease was most varied. Some patients complained of leucorrhea, some of dysmenorrhea, some of irregular menstruation, some of flooding, some of backache, some of bearing down and prolapsus, and some merely of debility and anemia. The true nature of the case had to be sifted out—as generally occurs ; what was only a symptom being considered the disease. Although the doctrine which I bring forward—that inflammation of the uterus and inflammation and ulceration of the neck of the uterus are, in the majority of cases, the real causes of morbid uterine changes and symptoms—may at first appear singular to those whose knowledge of uterine pathology is derived from the classical treatises of the day, a little reflection will show that such must be the case. By admitting this important pathological fact, we are only bringing the uterus within the pale of the laws that regulate disease in the rest of the human economy. In the history of the diseases of all the animal structures and organs, we find inflammation playing the principal part. Thus it is with the brain, the lungs, the liver, the kidneys, &c. Take away from a treatise on the diseases of any of these organs all that relates to inflammation and its sequelae, and how small a space, comparatively, would the remainder occupy. How is it, then, that in our modern treatises on the diseases of the non-pregnant uterus,—an organ exposed to so many morbific causes,—inflammation is considered a rare malady, and discussed and dismissed in a few pages ; whilst nineteen-twentieths of the work are taken up with the history of presumed functional affec- tions of tumors, of cancers, &c. ? To this question only one answer can be made. It is because the true pathology of the uterus has been completely overlooked. In reality, inflammation is, comparatively, GO INFLAMMATION OF THE UTERUS. quite as frequent in the uterine system, at least in its peripheric region, as in other organs; its existence has been overlooked only because its symptoms are obscure, and because its diagnosis has been impeded by various causes, social and moral, the more important of which I have already attempted to elucidate. Having by these observations prepared my readers for the facts which I have to bring forward, I shall at once enter into the investiga- tion of the phenomena presented by inflammation in the non-pregnant uterus. As my descriptions are drawn from the actual observation of disease, I may safely assert that those who, following my example, study nature, will find that I am a faithful interpreter of her morbid manifestations. From the great difference which exists between the anatomical and physiological condition of the body and the neck of the uterus, it will be at once understood that it is impossible to unite in the same descrip- tion the history of inflammation in the two regions. I intend, there- fore, firstly, to examine inflammation in the body of the non-pregnant uterus ; and subsequently to study the same disease in the cervix uteri, together with its numerous and important sequelae. After giving a careful and complete description of uterine inflamma- tion, considered generally, I shall briefly examine inflammation of the uterine neck in each of the different epochs of female life—viz., in virgins; in pregnant women, in the puerperal state; and in women who have ceased to menstruate. I shall then give the history of vulvitis and vaginitis; of inflammation of the ovaries ; and of abscess of the lateral ligaments; concluding this part of the work with the treatment of these various forms of inflammatory disease. CHAPTER IV. ACUTE METRITIS—CHRONIC METRITIS—INTERNAL METRITIS. Acute inflammation of the non-impregnated, non-developed uterus, is a rare disease. This is a fact which is generally admitted by uterine pathologists. I believe, however, that acute metritis will be found of even less frequent occurrence than it is now supposed to be, when it is no longer confounded with inflammation of the lateral ligaments—a mistake at present frequently made, even by experienced practitioners. The rarity of acute metritis is the natural result of the peculiar dense, fibro-muscular, non-cellular structure of the body of the uterus. Tissues of this nature being but slightly susceptible to inflammation as a necessary consequence of their peculiar structure, if_ the uterine system is exposed to the causes of inflammation, its periphery,—the mucous surfaces, the cervix, or lateral ligaments,—which are so much more highly vitalized, are generally the regions attacked. When the state of the uterus is modified by the extraordinary development and vitalization that occur during pregnancy, or during the increase of a large fibrous tumour, we remark a very different state of things. If the°uterine system is then exposed to the causes of inflammation, espe- cially after parturition, the body of the organ is frequently attacked; and metritis observed under these circumstances manifests a degree of intensity and a virulence unknown in the unimpregnated condition of the uterus, but quite consistent with its modified structure. In reality, the uterus is anatomically a perfectly _ different organ when unimpregnated and when developed by impregnation ; and its pathology is as different in the two conditions as its anatomical condition. ^ The numerous and.wonderful changes which the uterus undergoes during its physiological life are, indeed, a subject for admiration, and impart extreme interest to the study of its diseases. Seat.—Acute metritis generally appears to affect the entire body-of the uterus, although, no doubt, it may attack a portion only of its tissue. Paulus JEgineta and other ancient writers describe metritis as occupying sometimes the anterior uterine wall, and sometimes the pos- terior, sometimes the sides, and sometimes the fundus or apex, the symptoms varying in each case; and nearly all subsequent authors have copied their description. The distinction is perfectly correct if applied to chronic metritis, in which each of these regions may be separately affected; but it is not, I think, altogether applicable to acute metritis. In all, or nearly all the cases of acute metritis that I have seen, the entire uterus, including the cervix, was apparently affected. The inflammation might perhaps be more intense in one 02 ACUTE METRITIS. region than in another, but this is a point rather difficult to determine, as I shall presently explain, and, moreover, of little practical import- ance. Acute inflammation in the unimpregnated uterus seldom extends to the peritoneal investing membrane, as so often occurs in puerperal inflammation. Indeed, I only recollect having seen two or three instances in which the symptoms of peritoneal inflammation were so decidedly marked as to render the existence of peritonitis certain, although cases of the kind are mentioned by authors as not uncommon. I have, however, repeatedly been called to see cases in which the peritoneum was erroneously supposed to be compromised. The fre- quent participation of the peritoneum in the inflammation that attacks the womb after parturition, is probably owing to changes in its texture and nutrition consequent on the development of the gravid uterus. Like that organ, in all probability, it then becomes more vitalized, and more liable to inflammation. As predisposing causes to acute metritis, and to inflammation of the uterine system generally, we may mention youth, a plethoric tempera- ment, but more especially the peculiar susceptibility of the uterine system which I have mentioned as characterizing from the first so many of the females who are attacked in after-life with uterine inflammation in some of its varied forms. This physiological condition, which may exist, as we have seen, independently of any physical imperfection, lesion, or disease, is evidently one of the principal predisposing causes of uterine inflammation. The chief causes that tend immediately to induce acute metritis, are arrested menstruation, sexual excesses, and the extension of chronic inflammation from the neck of the organ. To these I would also add, as occasionally causing acute inflammation, all kinds of surgical inter- ference with the uterine organs, such as the cauterization of ulcerations of the cervix, the use of vaginal injections, of pessaries, &c. Any influence that suddenly arrests menstruation, especially in its incipient stage, such as exposure to cold or damp, wet feet, or mental emotions, may give rise to acute metritis. These latter causes are generally considered to be capable of occasioning acute inflammation, even in the interval of menstruation. I have very seldom, however, observed it in the unimpregnated uterus apart from the menstrual period, except as the result of some physical injury; of a blow, of a severe fall, or of cauterization of the cervix. This latter cause of inflammation acts, it must be remembered, on an organ, the vitality of which has been raised by the existence of inflammatory disease, generally of a chronic nature. Although of rare occurrence, acute metritis having this origin is occa- sionally met with by those who have great opportunities for obser- vation. Symptoms.—The symptoms of acute metritis are local, and general or sympathetic. The most prominent local symptom is severe pain situated deeply in the hypogastric region, above and behind the pubis! irradiating into the ovarian region, and sometimes down the thighs accompanied by a very disagreeable sensation of pelvic weight and ACUTE METRITIS. 63 uneasiness. There is also, generally speaking, severe pain in the lower lumbar, or lumbo-dorsal region. The cutaneous surface of the inferior abdominal region, from the umbilicus to the groin, is very sensitive to the touch, but slight pressure on the abdominal parietes does not very much exacerbate the deep-seated pain, even when made immediately above the pubis. On examining digitally, the vagina is generally found hot and dry, from arrested secretion ; the cervix is swollen, and often, but not always, sensitive to the touch. The body of the uterus is no doubt always enlarged, but any attempt to appreciate its size, by raising or displacing it, through the medium of the cervix, is generally attended with too much pain to be persisted in. The inflamed uterus is, indeed, so exquisitely painful, that the slightest pressure exercised directly upon it through the vagina, occasions severe pain, often giving rise, instantaneously, to a sensation of nausea. Notwithstanding this excessive sensitiveness of the uterus, it is possible, in every case, to ascertain, without putting the patient to any great amount of pain, that it is the uterus itself which is the seat of inflammation, and not the adjoining tissues. The sensitive tumour is the immediate continua- tion of the cervix, occupying the median line, and is equally painful and evident on the right and on the left of that line; unless, however, the uterus be naturally lying transversely from right to left, as is sometimes the case, when the inflamed organ will extend more to the right than to the left side. This is an important practical point to determine, as in inflammation of the lateral ligaments the tumour formed by the inflamed tissues is generally applied, annexed as it were, to the side of the uterus, so as only to form one mass with it. Owing to the great sensitiveness of the uterus, if moved, directly or indirectly, the patient is unable to walk, or even to stand ; and when sitting up in bed, (a very painful position,) the body is generally so inclined as to take off all strain from the abdominal region. When lying down, the patient remains on her back, that being the position in which the uterus presses least on the surrounding organs. The passage of the faeces through the rectum is often attended with very great pain, owing to its position immediately behind the uterus. This is more especially the case when the motions are constipated. They are then sometimes coated with mucus, showing an irritable state of the rectal mucous membrane. There is also, frequently, considerable irritation and pain about the bladder, accompanied by dysuria, more or less marked. The vascular and nervous connexion between the uterus, the rectum, and the bladder, is too intimate for these organs not all to suffer when one of them is severely inflamed. In acute metritis there is, generally speaking, no discharge at first, • the vaginal secretion being arrested, as well as that from the uterine cavity. Sometimes, however, when the inflammation extends to the lining membrane of the uterus, there is a more or less abundant sero- sanguinolent secretion. On the decline of the inflammation, a copious discharge, of variable nature, will often take place. Acute metritis is always accompanied by considerable febrile reac- 64 ACUTE METRITIS. tion. The skin is hot, the pulse quick, but not small and thready, as when the peritoneum is compromised. The tongue is covered with a white fur, and continued nausea is almost invariably experienced, but it is seldom carried so far as to produce vomiting, as in metro-peri- tonitis. Thirst, headache, and want of rest, are also present, as in all febrile diseases ; and the bowels are constipated. The breasts are often sympathetically affected, one or both becoming swollen and painful. Acute inflammation of the uterus is stated, by, most authors, fre- quently to give rise to hysterical symptoms. I have seldom, however, found this to be the case; and when they are present, I have generally observed them to occur in young females previously subject to hysteria. All the symptoms above enumerated are not met with in every case, nor do they always manifest themselves with equal intensity. Some- times obscure pain in the lower hypogastric region, with slight febrile reaction, alone is experienced ; and it is only by careful digital exami- nation that we ascertain that the body of the uterus is the seat of acute inflammatory action. Progress and Termination.—Generally speaking, the inflammation gives way to treatment in from five to ten days, resolution taking place. Owing to the elementary nature of the cellular tissue contained in the body of the uterus, there is seldom any formation of pus in the sub- stance of the uterus, although it sometimes occurs. If the purulent collection is near the uterine cavity, it empties itself therein, and is evacuated through the cervix. When the matter forms near the outer parietes, the inflammation appears to be generally propagated to the cellular tissue contained between the lateral ligaments, and the pus finds its way out of the pelvis, as when the inflammation and .suppura- tion have primitively existed in those ligaments. The propagation of acute inflammation from the uterus to the lateral ligaments is so often observed, as we shall hereafter see, that it may be considered one of the natural terminations of acute metritis. When acute metritis does not terminate by resolution, or by exten- sion to the lateral ligaments, it passes into the chronic state, and then generally becomes partial, or confined to one region. I have never seen acute metritis in the unimpregnated uterus terminate fatally, and there appear to be but few cases on record in which such has been the case. This is no doubt owing to the inflammation seldom extending to the peritoneum, and to the uterus not having functions to perform necessary to the preservation of the individual. A vast amount of uterine disease may consequently exist without life being directly endangered. Prognosis.—Acute metritis, apart from the puerperal state, being very rarely a fatal disease, there is but little to fear for the life of the patient, provided proper remedial measures be adopted to subdue the inflammation. It may, however, especially if not treated with sufficient energy and promptitude, by passing into the chronic stage, prove the source of very serious and very prolonged evils. There are few diseases ACUTE METRITIS. 65 that occasion more suffering than chronic metritis, and chronic inflam- matory disease of the lateral ligaments. Diagnosis.—Although it is by no means difficult to recognise acute metritis, even if present in a subdued form, its existence is not unfre- quently passed over unperceived. Many practitioners are satisfied with the mere knowledge that there is inflammation existing in the lower abdominal region, and treat the disease on general antiphlogistic principles, calling it " inflammation of the bowels." Treatment, how- ever, which is based on such obscure notions of the real state of the patient, is apt to fall short of the necessities of the case, to partially subdue the morbid symptoms only, and to leave behind the seeds of future and more intractable disease. It is of the greatest importance in pelvic inflammation, as in inflammation of other regions, that the precise seat of the morbid action should be determined, and that no means of diag- nosis should be neglected which can give the necessary information. The diseases with which acute metritis is most likely to be con- founded, are inflammation of the bladder and inflammation of the lateral ligaments, as they both give rise to the same local pains and to the same general reaction. In addition, however, to the symptoms peculiar to each, which differ considerably, the seat of the disease may be at once ascer- tained by a careful digital examination. By passing the fore finger of the right hand into the vagina, upwards, behind and above the pubis, and pressing with the fingers of the left hand over the lower abdominal region, the state of the bladder previously emptied may be directly ascertained. The bladder is then merely separated from the fingers by the abdominal and vaginal parietes. If it is inflamed, pressure will occasion great pain, whereas, if there is merely sympathetic irritation, the pain on pressure will be but slight. I have thus ascertained, in several obscure cases, that acute symptoms, supposed to be the result of uterine inflammation, were really occasioned by cystitis. In one instance, a young unmarried lady had fallen on some stones whilst bathing. The urethra was bruised; retention of urine followed the swelling of the contused parts, and the bladder not being relieved for above twenty-four hours, owing to the patient concealing her sufferings, cystitis ensued. The inflammatory symptoms, which were very intense, irradiating all over the pelvic region, threw considerable obscurity over the case. But all doubt as to the nature and limits of the disease was cleared up by a careful vaginal examination : the uterus was small, free from sensibility, and readily moveable, whilst the bladder was inflamed, and acutely sensitive. In inflammation of the lateral liga- ments, the pain lies more to one side of the median line, and the finger passed upwards by the cervix, detects the inflammatory tumour lying on one side of the uterus. Pathological Anatomy.—Acute metritis in the unimpregnated uterus is, as we have seen, so seldom fatal, that there are scarcely any elements to be found for a description of its pathological anatomy. Thus Boivin and Duges, in their treatise on the diseases of the Uterus (vol. ii. p. 240), say that the state of the uterus of a female who had 66 CHRONIC METRITIS. died of acute non-puerperal metritis, would probably be pretty much the same as in fatal puerperal metritis. As I have not seen a case of the kind, I can only repeat this assertion, and say that the uterus would probably be found tumefied and softened, more vascularized than in the normal "state, and of a reddish-white hue, with limited infiltra- tions of pus. CHRONIC METRITIS. In describing chronic metritis, I shall likewise confine myself to the consideration of the disease in the body of the uterus. Although the distinction is not made by writers on uterine diseases, it is of extreme practical importance. It is in a great measure because it has not been adopted, that there is not to be found a correct description of this form of uterine inflammation. Some of the leading symptoms of chronic metritis are erroneously attributed by many uterine pathologists to the displacements of the uterus which it occasions ; and this has likewise much contributed to obscure its history, especially of late years. Seat.—Chronic inflammation of the body of the uterus, in contra- distinction to acute metritis, is more frequently partial than general; that is, it generally occupies a limited extent only of the uterine tissue. In its partial form, it is observed, in nine cases out of ten, in the posterior wall of the uterus, in its inferior region, immediately adjoin- ing the base of the cervix. The predilection of chronic metritis for this particular region is probably partly accounted for by the band of longitudinal muscular fibres which pass into the posterior region of the cervix, from the posterior wall of the body of the uterus, chronic metritis being generally the result of extension to the uterus of chronic inflammation of the cervix. It may, however, exist in the anterior uterine wall, or laterally. Causes.—Chronic metritis sometimes occurs as the termination of acute metritis, whether puerperal or non-puerperal; but it is, generally speaking, as I have just stated, the result of the gradual extension of chronic inflammation of the neck to the body of the uterus, and the product of years of uterine disease. Symptoms.—Chronic metritis is a malady the symptoms of which vary considerably in intensity, according as the patient is examined during the quiescent state of the uterus—that is, in the interval of menstruation, or during the presence of the menstrual flux, and for a few days before and after. Although a most distressing and wearing affection, it is not altogether incompatible with what a superficial observer might consider tolerable health, especially during the interval of menstruation. At that time, indeed, there is scarcely ever any febrile reaction, and the local uterine symptoms are much mitigated. The general symptoms are then not unfrequently confined to functional derangement of the stomach, of the nervous system, and of the general nutrition, the result of the sympathetic reaction of the diseased uterus CHRONIC METRITIS. 07 on the economy at large. A very different state of things, however, is generally observed when the molimen hemorrhagicum that precedes menstruation sets in. The uterine inflammation, previously latent, again becomes evident, both the local and general indications of its existence reappearing with renewed intensity. When the uterus or any part of it is chronically inflamed, the patient experiences a constant, dull, aching, deep-seated pain in the lower hypogastric region, just above and behind the pubis, and in the right or left ovarian region, oftener in the left than in the right. There is also a dull, aching pain in the lumbo-sacral region, which is even more universal and more constant than the abdominal and pelvic pains. These pains extend, irregularly, round the hips and down the inside of the thighs ; and are generally accompanied by a deep-seated sensation of pelvic weight and heaviness. Walking, and, indeed, every kind of motion, is attended with an exacerbation in the pain, owing to the shocks which are conveyed to the inflamed uterus. Going up and down stairs is more especially painful; and to some even the motion of the most gentle vehicle is insupportable. These pains and aches are more especially marked before, during, and after menstruation. They are then often quite agonizing, and render any motion unbearable. On examining the womb digitally, in addition to the evidence of co-existing disease of the cervix which is usually detected, if the inflammation is general, the entire uterus is found enlarged and sensitive on pressure. When it is partial only, the finger passed care- fully behind, before, and on the sides of the uterus, carrying the cul-de-sac of the vagina before it, so as to explore its walls, readily discovers the seat of the disease. Instead of the finger passing from the base of the uterine neck on to a smooth, insensible surface, a con- tinuation of the plane formed by the cervix, it meets with an exceedingly sensitive elevation or protuberance, sometimes quite regular, sometimes irregular and knotty. In the latter case, however, the nodosities that diversify the tumefied surface are all perfectly spherical; there are no knife-back ridges or sharp irregularities. Pressure on this tumefied surface is exceedingly painful. Occasionally there is no perceptible tumefaction, but merely an exquisite sensitiveness in a limited region of the uterus ; pressure giving rise to the sensation of sickness. The womb is, in most instances, quite moveable, but the attempt to move it is attended with great pain. The uterus is not bound down and fixed in a certain position, like the liver or the kidneys. In order, no doubt, that it may be able to enlarge during pregnancy, it is loosely suspended in the pelvic cavity, and is kept in its normal position as much by the contractility of the vagina and the pressure of the surrounding organs, as by its ligaments. As a necessary consequence, the partial tumefaction of the walls of the uterus that follows chronic inflammation, is invariably attended with greater or less displacement of the body of the organ, the nature of the displacement varying according to the seat of the tumefaction. If the posterior wall is the seat of inflammation and enlargement, as is 68 CHRONIC METRITIS. generally the case, the additional weight in this region causes the body of the uterus to fall backwards, towards the cavity of the sacrum. The uterus, in a word, is retroverted, and the cervix is generally anteverted, that is, directed upwards, towards the pubis ; the finger having to be passed deeply into the pelvic cavity, towards the sacrum, to find the root of the cervix, and the tumefied posterior uterine wall which is lying on the rectum. In the form of uterine retroversion that occurs during pregnancy, the anteverted cervix approximates more and more to the pubis as pregnancy advances, until it presses on the urethra, and impedes the flow of urine. This is not observed in retroversion from inflammation, the increase in volume of the body of the uterus being comparatively slight. Moreover, in the latter form of retroversion, the cervix often remains in its usual position, and is not anteverted, notwithstanding the displacement of the uterus. In that case, it forms an angle with the body of the uterus, which is said to be retroflexed. When it is the anterior uterine wall that is inflamed and tumefied, the uterus may fall forwards, especially in married females, and there is anteversion of the body of the organ, which, instead of gravitating backwards into the sacral cavity, falls forwards towards the pubis, the cervix being retroverted. If this is the case, the anterior vaginal parietes are often so stretched by the extreme retroversion of the cervix, that it is difficult to examine digitally through it the anteverted uterus, so as to ascertain satisfactorily the presence of tumefaction and enlargement. This, however, may be accomplished with care and atten- tion, the bladder being previously emptied, or at least the existence of a limited painful region may be ascertained, which, coupled with the displacement and the other symptoms, is conclusive as to the existence of chronic inflammation and enlargement. When the uterus is retroverted and much enlarged, it generally rests directly on the rectum, and constitutes a mechanical obstacle to the pas- sage of its contents. Thence the accumulation of faeces above the uterus, and obstinate constipation, accompanied by severe bearing-down. Thence also, as in acute inflammation, extreme uterine pain, along with sickness, when the bowels are moved, either spontaneously or from puro-a- tives, owing to the faeces lifting up the womb as they pass. From the same cause, even the injection of a little water into the bowel is often attended with extreme pain. This state of things is likewise accom- panied, in a great number of cases, by congestion, or even sub-acute inflammation of the mucous membrane lining the rectum or colon as evidenced by the secretion of large quantities of muco-pus, and of pseudo-membranous shreds and casts, that are passed along with the faeces. Muco-pus thus passed, however, must not be confounded with thatwhich escapes from the vagina at the time the bowels are moved__ a mistake which the patient frequently makes. There is also very often, considerable irritation of the bladder, of its neck, and of the urethra. This irritation i s partly the result of the uterine displacement, which acts more or less on the bladder, owing to the anatomical con- CHRONIC METRITIS. 69 nexion between that organ and the uterus, partly of. the irradiation of irritation or inflammation from the uterus to the surrounding organs, and partly of a morbid state of the urinary secretion. Partial chronic metritis may, no doubt, be confined to the lateral regions of the uterus, apart from disease of the lateral ligaments, but I scarcely recollect having met with a clear instance of the kind. Were chronic inflammation to be thus localized, the symptoms would be the same, although the displacement of the uterus would pro- bably be more or less modified, according to the laws of gravity. In chronic metritis there is not, necessarily, any vaginal discharge. Nevertheless, a muco-purulent or sanguinous secretion is very frequently observed, owing to the usual co-existence of inflammation of the vagina and cervix. But even in the absence of such a complication, there is generally a white or transparent leucorrheal discharge. In some cases, for one or more days before and after menstruation, there is a very peculiar dark-brown discharge, evidently composed of a combination of mucus and blood. The white mucus is secreted by the mucous mem- brane covering the cervix and upper portion of the vagina, owing to the state of congestion in which the uterine inflammation keeps these tissues. The transparent mucus is secreted by the mucous follicles which line the cavity of the cervix, from a similar cause. The dark mucoso-sanguinolent secretion is evidently thrown off by the lining membrane of the uterine cavity, and possibly from the inflamed portion only, on the approach of or after menstruation, when the uterus is turgid with blood. Cteneral Symptoms.—The countenance of a person suffering from chronic uterine inflammation is generally pale and sallow, and nearly always offers a very marked expression of pain and languor. It has long been remarked that patients labouring under chronic uterine disease present a peculiar cast of features, to which the term uterine has been applied; but in none is the u fades uterina" more indelibly impressed than in those labouring under chronic metritis. It is more especially during the periodical exacerbations of the inflammatory symptoms which menstruation occasions, that this peculiar expression is remarked. Although scarcely ever entirely absent, even in the most quiescent state of the inflamed uterus, it then becomes so obvious as to strike the most indifferent. With nearly all my patients thus affected, I can tell, the moment I enter the room, by the physiognomy alone, if menstruation is impending or has commenced. The pallidness of the countenance in chronic metritis is often modi- fied, on the slightest emotion or excitement, by intense flushing, which gives to'the patient's countenance for the time the hue of health, and deceives a superficial observer as to the state of the sufferer. There is generally considerable emaciation. This, however, is not always the case ; or the emaciation may be only comparative, so as not to be perceived by those who have not known the patient in better health; An exceedingly general, and, in a diagnostic point of view, valuable symptom, is nausea. When inflammation is severe, nausea will exist 70 CHRONIC METRITIS. continually, presenting, however, a decided exacerbation at the monthly period. If, on the contrary, the disease is not so severe, or has been mitigated by treatment, the nausea may only be present during the periodical exacerbation of the disease. It is seldom carried so far as to produce sickness, but is sufficiently great to be attended with loathing of food. Nausea appears to me to be peculiarly characteristic o! chronic inflammation of the body of the uterus, which it nearly always accompanies, whilst in chronic inflammation of the cervix it is often absent. This I find to be so generally the case, that when nausea is present in chronic inflammatory disease of the cervix, I conclude that the body of the uterus is probably more or less compromised, even if I cannot satisfy myself, by digital examination, of the extension of inflammation to that region. In addition to the above symptoms, patients suffering under chronic inflammation of the uterus present, to a greater or lesser degree, the symptoms which are observed when the health is broken down under the influence of all chronic affections. Thus they complain of intense headache, disordered vision, or partial deafness, want of sleep, and dis- agreeable dreams ; foul tongue, loss of appetite, flatulence, heartburn, constipation ; palpitations, flushing of the face, and occasional feverish- ness. The urine is nearly always loaded with lithates, and sometimes with other morbid products. In a word, all the functions which are under the influence of the organic system of nerves, and nutrition gen- erally, appear sympathetically to suffer. The most marked sympathetic reaction, however, is that which the stomach evinces. The intimate connexion between the stomach and the body of the uterus is shown, as we have seen, by the all but constant appearance of nausea when the latter is inflamed. It is also demon- strated physiologically by the general existence of sickness during pregnancy; and experimentally, by the frequent manifestation of nausea on the uterine probe being passed into the healthy uterine cavity. Hence it is that uterine inflammation seldom exists for any length of time without the functions of digestion becoming impaired, and without the symptoms which characterise dyspepsia and imperfect assimilation and nutrition making their appearance. The mutual dependence of the uterus and stomach on the same system of nerves, the sympathetic, affords a ready explanation of this important fact. The same train of reasoning must lead us to the conclusion that chronic uterine disease reacts directly also on the functions of the liver and of all the chylo- poietic and other organs, with which it is similarly connected. These sympathetic reactions will be carefully investigated when we are treating of inflammation of the neck of the uterus. Progress.—Chronic inflammation of the uterus has a decided tendency to perpetuate indefinitely its existence, as is the case with inflammation in all tissues of rather a low vitality; such as the bones, for instance. This tendency, however, is greater in the uterus than in the osseous and other similar structures, owing to the periodical exacerbations to which the peculiar functions of the uterine system give rise. There is CHRONIC METRITIS. 71 also a much greater reaction on the health and integrity of the entire economy, owing to the intimate connexion existing between the uterus and the sympathetic nervous system which presides over the functions of organic life. The disease does not, however, present itself at first, or in all cases, with such severity. Both the local and general symp- toms may be slight and obscure, especially during the interval of men- struation; but as time progresses, they generally become more and more decided, and the patient at last gradually sinks into the state which I have described. Termination.—The periodical exacerbations that occur under the influence of the menstrual uterine congestion appear to prevent chronic metritis from terminating spontaneously by resolution. I cannot, indeed, recall to mind a single instance in which I have satisfactorily ascertained the disease to have thus terminated, during the persistence of menstruation. When menstruation finally ceases, spontaneous res- olution, no doubt, not unfrequently takes place. Resolution, on the contrary, is one of the ordinary terminations of chronic metritis under the influence of appropriate treatment. Sometimes the enlargement of the uterine tissue gradually melts and disappears ; in other instances the disease terminates by induration; the general enlargement of the uterus, or its local hard tumefaction remaining, in part, but all anoma- lous sensibility disappearing. This is, perhaps, a more common result of treatment than complete resolution. Under the influence of the menstrual exacerbation, or of other accidental causes, the chronic inflammation may become acute, and extend to the lateral ligaments, or even to the peritoneal membrane. This, however, is very rarely the case. Cancerous degenerescence is also one of the possible termina- tions of chronic inflammation of the uterine tissue; I believe, however, that it is very rarely observed. When it does occur, we must admit the previous existence of the cancerous diathesis; such a diathesis existing, the presence of chronic disease in the uterus would certainly be very likely to localize its action in that organ. Prognosis.—From what precedes, it is evident, that although our prognosis in a case of chronic metritis may be favourable as regards the life of the patient, which is scarcely ever directly endangered, yet it cannot be said to be favourable with reference to the probability of a speedy recovery. Chronic metritis may also terminate unfavourably, through the casual development of acute inflammation in the surround- ing tissues, or through cancerous degenerescence. We ought always to be guarded, therefore, in giving an opinion as to the future. This is the more imperative, as a still more probable source of danger exists in the extreme sympathetic depression of all the powers of the economy. A female who has been suffering for years from chronic metritis is generally in so weak and enfeebled a condition, from disordered diges- tion and nutrition, and from the numerous other functional derange- ments which the disease occasions, that she has but little vital power to resist the attacks of intercurrent diseases, or to ward off the develop- ment of any cachexia to which she may be constitutionally disposed. CHRONIC METRITIS. Thus, we find such persons becoming consumptive, or succumbing under the influence of acute inflammatory affections, the action of which they would certainly have resisted had their constitution not been weakened by the existence of a chronic depressing disease. Notwithstanding all these drawbacks and perils, we may, generally speaking, take a favourable view of the case, provided the patient be willing and able to submit to a judicious, energetic, and sufficiently prolonged course of treatment; and provided the disease have not existed too long to be susceptible of eradication. Unfortunately this is not always the case. Social circumstances may render it impossible for the patient to obtain proper advice, or, even if obtained, to follow the rules laid down for her guidance. The disease may, also, in some exceptionable cases, in the course of years of undisturbed possession, obtain so firm a hold on the economy as to resist every means employed to entirely eradicate it, at least during the existence of menstruation. I have met with few instances of the kind, in which I have been able to limit and favourably modify the disease, but not entirely to eradicate it. Obstinate chronicity is, indeed, a characteristic of this disease. In most of the cases of chronic metritis which I meet with, the inflam- matory action has existed for many years unrecognised and untreated, when I discover its presence ; and the disease has become, as it were, an integral part of the economy of the patient. When this occurs with chronic inflammation in any of the tissue, it is always exceedingly difficult to subdue it radically. Diagnosis.—Most of the patients affected with chronic metritis whom I see are considered to be merely suffering from uterine irritation, from displacement of the uterus, retroversion or retroflexion, or from functional dysmenorrhea. A careful digital examination, however, at once reveals the true nature of the case. The. general symptoms which I have enumerated are of themselves sufficient, especially when at all severe, to indicate the existence of chronic metritis. Should they not, however, carry conviction with them, their presence is at least suffi- ciently significative to render a further examination indispensable. Once digital investigation is resorted to, if the local symptoms of chronic metritis are borne in mind, it is by no means difficult to discover the real nature of the disease. The limited tenderness, increased by pressure, and generally situated on the posterior uterine wall, the local tumefaction and subsequent displacement of the uterus, are too characteristic not to be recognised. There are, however, morbid non-inflammatory conditions of the uterus which may be mistaken for this form of inflammation. Thus, I have not unfrequently found the uterus present, for some time after the complete cure of the inflammatory disease, a peculiar state of exaggerated sensibility. The slightest touch occasions pain, some- times in every region, and sometimes in a limited spot only; but the sensibility is not inflammatory, for if the contact is renewed, or pressure is continued, pain is no longer experienced. Again, small fibrous tumours often form in the walls of the uterus, increasing their size and CHRONIC METRITIS. 73 weight, and causing displacements; so that tumefaction and displace- ment alone cannot be considered symptoms of inflammation. Indeed, if the uterine enlargement is great, it is most probably the result of a fibrous tumour, the existence of which, at the same time, does not preclude inflammation of the uterine walls. I have repeatedly met with this complication of the two diseases. Lastly, an inflammatory tumour of the broad ligaments may be mistaken for chronic metritis, occupying the lateral region of the womb, more especially if the tumour is lying on the uterus, as is often the case. The symptoms that characterise the latter affection, which I shall hereafter describe, will enable us to establish the distinction when it really exists. In some cases, however, the two diseases whether it be confined to the cavity of the cervix or not. When, how- ever, the ulceration is extensive, and often when it is slight, there is generally a train of symptoms present, which enables the practitioner to form a tolerably accurate surmise as to the existence of the uterine disease. Although very decided and significative, these symptoms have been hitherto overlooked, partly by Continental, and entirely by British accoucheurs. The most prominent of all the symptoms occasioned by the presence of inflammatory ulceration of the cervix during the puerperal state and after abortion, is hemorrhage. Under ordinary circumstances the san- guinolent discharge which follows parturition soon becomes modified, and ceases in the course of a few days, being replaced by the ordinary lochial secretion. When there is ulceration, the flow of blood often continues, in greater or less quantity, for three, four, six, eight, or more Weeks. The blood thus excreted may be pure, or it may be mixed with muco-pus. This hemorrhage generally resists the action of all the usual anti-hemorrhagic remedies, its continuance frequently pro- ducing excessive debility and amenia. When the hemorrhage ceases, OF THE UTERUS DURING AND AFTER PARTURITION. 169 it is sometimes replaced by a profuse purulent discharge; or there may be no hemorrhage, the flow of blood from the uterus stopping at the usual time, and the purulent discharge immediately following. This is sometimes the case even when there is an extensive ulcerated surface. The pain experienced in the lower dorsal, lower hypogastric, and ovarian regions, is often very acute from the time of the confinement, much more so than after an ordinary labour, as the patient perceives if she has had other children. These pains are at first general, but they gradually become localized, and assume more and more the character which they usually present in this disease. When the patient first attempts to rise and walk she feels a sensation of weight and bearing-down, which, instead of diminishing, gradually increases. If the hemorrhage and purulent discharge are continued and abundant, and the uterine pains are very severe, several weeks often elapse before she is able to leave her bed; and when she does, she remains weak, languid, and is unable to make the slightest exertion. These facts are of extreme importance in connexion with the patho- logical history of the puerperal state, and will, I trust, be borne in mind by all who read these pages. If so, a great amount of suffering will be spared to the unfortunate patients whose state I describe. The symptoms I have enumerated are very frequently met with after partu- rition and abortion, and as their true cause has not hitherto been recognized, the means of treatment at present adopted are totally inefficient. Thus, after months of suffering, chronic disease of the neck of the wromb of a severe character is allowed to establish itself, and the health and constitution of the female is deeply injured. I have no hesitation in saying, that when hemorrhage continues after parturition for weeks beyond the usual time, there will nearly always be found some inflammatory and ulcerative lesion of the cervix, and that an instrumental examination is indispensable. When once the real nature of the disease is ascertained, the hemorrhage may, generally speaking, be immediately stopped by the cauterization of the ulcerated surface, from which it appears in these cases principally to proceed. In the course of from four to ten weeks, when the inflammatory disease is left to itself, the hemorrhage seems to cease spontaneously, and the case lapses into one of an ordinary character. The cessation of the hemorrhage is generally supposed to be the result of the remedies used, but is probaly to be accounted for by the changes which have occurred in the anatomical state of the uterus. Rapid absorption has taken place, and the organ having gradually regained, at least to a certain extent, the condition which it presented before impregnation, it has become less liable to hemorrhagic action. It is more especially in these cases that the inflammation of the cervix propagates itself to the body of the uterus, and that the latter is found tender on pressure, larger than in the normal condition, and retroverted. The presence of inflammatory disease of the cervix in many cases, appears to arrest, independently of any diseased state of the body of the uterus, the natural process of absorption which occurs after 170 INFLAMMATION AND INDURATION OF THE NECK parturition, before the uterus has regained its natural size and weight. Thus, instead of diminishing in weight until it has reached an ounce and a half or two ounces, as it would do under normal circumstances, the uterus remains at three, four, or six ounces. This morbid size and weight of the organ is generally attended with displacement, mostly retroversive, and often keeps up hemorrhage. It may exist in a pas- sive state, independently of any inflammatory condition of the body of the uterus itself, and be merely kept up by the presence of disease in the cervix. When the latter is removed, nature will often renew the interrupted process of absorption, and slowly restore the uterus to its natural size and position, without any special treatment being resorted to. As I have elsewhere stated, the presence of inflammatory ulceration of the cervix during the first stage of the puerperal period, has appeared to me powerfully to predispose the patient to puerperal fever, and to abscess of the lateral ligaments. The uterus seems to retain a predisposition to inflammation in the puerperal state, even in the cases in which ulceration, having existed during pregnancy, has been cured before parturition occurred. I have met with repeated instances of puerperal fever under these circumstances, one of which, a fatal one, is narrated at page 157. Inflammatory ulceration of the cervix is so commonly developed after abortion, that I always look for it when the patient does not rally, but presents the symptoms which 1 have above described. Indeed, I may safely say, that this form of uterine disease exists unsuspected in nine cases out of ten, in which are observed the hemorrhagic, febrile, and inflammatory accidents that so frequently follow abortion, and that often occasion so much anxiety and trouble to the medical attendant, as well as to the patient and her family. It is easy to understand, that in the first months of pregnancy, the cervix uteri, not having time to soften and expand, is more exposed to contusion, and even to laceration, than at a later stage. In the preceding pages abortion has been principally alluded to as the cause of inflammatory disease of the cervix. We must not, however, forget that abortion itself is very frequently caused by the existence of inflammation and ulceration of the cervix, developed spontaneously, or under the influence of other causes. This, indeed, is so much the case, that, as we have seen, when abortion occurs without any adequate reason, and especially if several successive abortions take place, we are quite authorized in suspecting the existence of ulcerative disease of the cervix uteri. The two following cases will illustrate the effects produced in the puerperal state by the existence of inflammatory ulceration of the uterine neck. OF THE UTERUS DURING AND AFTER PARTURITION. 171 Case IX. Abortion at an early period, preceded for some months by symptoms indicating Ulceration of the Uterine Neck, and followed for two months by uncontrollable Flooding ; extensive ulcerative Inflamma- tion recognized and treated ; rapid Recovery. On the 6th of June, 1846, I was consulted, at the request of her ordinary medical attendant, by Mrs. L----, a young married lady, aged twenty-two, who had been suffering from continued flooding ever since a miscarriage which had occurred two months previously. On inquiry, I elicited the following particulars:—Of strong and robust constitution, she had enjoyed excellent health until her marriage, which took place at the age of nineteen; menstruated at fifteen, the catamenia had always appeared regularly and easily. She soon beeame pregnant, but miscarried, without any known cause, at three months ; and again, shortly afterwards, at two months. She then became pregnant for the third time, and was delivered of a full-grown child eight months ago. During her pregnancy she was very well; the labour was easy. She nursed her child for two months, when it died. The menses subse- quently returned, but were attended with a great deal of pain, and this continued to be the case; she had also yellow leucorrheal discharge, and slight pain in the back and ovarian regions. Four months ago she again became pregnant, and miscarried two months afterwards, without any assignable cause. This miscarriage was much more pain- ful and tedious than the previous ones, and the flooding greater. She remained nearly a month in bed under medical care, constantly losing blood, more or less, notwithstanding the most varied and energetic treatment. On the slightest exertion, the quantity of blood lost became considerable. When I saw her, she was very thin, pale, and weak; pulse small and quick, tongue white, no appetite, great cephalal- gia, bowels constipated, rest bad. She had severe pain in the lower part of the back, in the left inguinal and in the hypogastric regions. These pains were but slightly increased by pressure, and the abdomen was indolent to the hand, except just over the pubis, where pressure was attended with a little pain. On examining digitally I found the vagina lax, and very moist; the cervix low, voluminous, soft, and pre- senting a spongy surface in nearly its entire extent: the os uteri was open, so as to admit half the first phalanx of the index. The body of the uterus appeared rather larger than normal, and slightly sensitive on pressure. The speculum disclosed the vagina livid, and filled with blood, or a mixture of blood and pus. . On wiping the blood and sanies off the cervix, which was not effected without difficulty, I discovered a fungous ulcerated surface, of the size of a half-crown, from which blood oozed on the slightest touch. This state of the cervix at once explained the inefficacy of the treatment that had been resorted to in order to 172 INFLAMMATION AND INDURATION OF THE NECK restrain the flooding, viz., opiates, ergot of rye, mineral acids, acetate of lead, administered internally, and cold applied externally. Treatment.—The following day I freely cauterized the entire ulce- rated surface with the solid nitrate of silver, carrying the causter into the cavity of the os, and prescribed tepid milk-and-water vaginal injec- tions, tepid hip-baths, rest in bed, light diet, no stimulants, a saline mixture, and a mild aperient. 10th.—There has been no return of hemorrhage since the cauteriza- tion, but there is still an abundant sanious discharge. The cauterization was followed by a little pain, which almost entirely disappeared in the course of the day. The local pains are nearly the same, as also the general state; she feels, however, a little better since the hemorrhage has stopped.—On again using the speculum, I found no blood in the vagina, and I was consequently able to get a better view of the ulcera- tion of the cervix. It appeared rather less fungous and livid than before, but was still unhealthy, bleeding at the slightest touch. After wiping its surface, I cauterized it freely with the pernitrate of mercury. Little pain was felt at the time, or for several hours after; but towards evening, most intense pains set in, principally in the back and in the left side, and also, but with less intensity, in the hypogastric region. They were, the patient stated, as bad as those of labour. I had recommended a warm hip-bath and warm water vaginal injections to be used, in case severe pains should come on. This was done, but without any mitigation in their intensity; and I was sent for. I found the patient in a state of extreme suffering, but without any febrile symptoms; the abdomen was indolent, and pressure on the hypogas- trium not more painful than previous to the cauterization. I ordered a linseed poultice to be applied to the hypogastric region, and fifteen minims of laudanum to be taken in camphor julep. Under the influence of these measures, the pains gradually subsided, and she was able to sleep during the latter part of the night. The following morning they had become very bearable, the pulse and skin were natural, and the abdomen indolent on pressure. The patient was told to resume the vaginal injections, the hip-baths, &c. 17th.—There has been no return of the severe suffering which fol- lowed the cauterization; but she still experiences the old pains in the back, hypogastrium, and ovarian regions. For the last two or three days, the vaginal discharge has ceased to be sanguinolent, and is merely purulent. She has been allowed latterly to sit up on the sofa, and feels much better since the continued discharge of blood has ceased. The cervix appears rather less voluminous to the touch ; the vagina has lost the very congested hue which it presented at first; the ulceration of the cervix is of a florid red hue, and covered with healthy pus. Cauterization with the nitrate of silver ; same general and local treatment.—This time the cauterization was not followed by any unusual degree of pain. The discharge was sanguinolent for a few- days, and then again became purulent. The hemorrhage was arrested by the cauterizations, and at my next OF THE UTERUS DURING AND AFTER PARTURITION. 173 examination I found that cicatrization had fairly commenced. It con- tinued to progress rapidly under the influence of periodical cauteriza- tion, and of appropriate local and general treatment. The external ulceration—that which existed on the surface of the cervix and around the os—was healed within a month from its first discovery ; and in the course of a few weeks more, that which penetrated within the cavity of the os was also well. At the beginning of August, within two months from the commencement of the treatment, the ulceration was perfectly healed, both inside and outside the os. The cervix had nearly regained its natural volume and softness, and the uterus had risen to its normal position in the pelvis. The vagina was healthy. There was no leucor- rheal discharge, and all the local pains had disappeared. The general condition of the patient had improved as rapidly as the local disease. She could walk easily, and without bearing-down or fatigue. The lips and cheeks had again assumed the hue of health ; the head was free from pain; in a word, she was rapidly recovering her former health and spirits. I ordered her to the sea-side ; and a month later, I heard that she had had no return whatever of the uterine symptoms, and that she had much benefited by the change of air. Remarks.—This case presents several points of interest, which we will successively examine. The cause of the first two miscarriages cannot be even presumed, in the absence of any data on the subject. The first time the attention of the patient was directed to the existence of symptoms indicating uterine disease, was a month or two after the death of a child, of which she had been naturally delivered at the full time. This child died two months after her confinement. From that period, until she again became pregnant, some months later, she pre- sented the symptoms which almost invariably indicate inflammatory ulceration of the uterine neck—a yellow leucorrheal discharge, painful menstruation, and permanent ovarian and lumbar pains. She was very unwell during the first two months of this pregnancy, and then miscarried, the abortion being followed by obstinate and repeated flooding, and by a very marked increase in all the uterine symptoms. When I saw her, the flooding and other symptoms had resisted every therapeutic means previously employed. On examining the state of the uterine organs, I found a fungous ulceration of the cervix, freely pouring out blood from its surface, which was clearly the source of the hemorrhage, and the cause of the other uterine symptoms. From the previous history of the case, I consider it most evident, that the inflam- matory ulceration had existed since the last confinement, and that it was the cause of the abortion, although only discovered two months after the latter had taken place. The inefficacy of the therapeutic agents resorted to in this and in similar cases is at once explained, when we know their true nature. What can opium, mineral acids, ergot of rye, &c, do to arrest hemorrhage originating in an unhealthy fungous sore ? The immediate cessation of the hemorrhage under the influence of cauterization is worthy of notice. The application of the 174 INFLAMMATION AND INDURATION OF THE NECK caustic to the ulcer was followed by very intense pain—a rather unusual circumstance, which may be attributed, in this instance, to the congestion that followed the sudden stoppage of the hemorrhage. The recovery of this patient was very rapid and complete, consider- ing the extent of the local disease. This we must attribute, in a great measure, to her youth, and to natural vigour of constitution. Very much depends in the treatment of these forms of uterine disease, as in that of all chronic affections, on the constitution and vital energy of the patients. Some seem merely to want the appropriate treatment to recover rapidly and thoroughly. Others, less favourably endowed by Nature, or weakened by long-continued suffering, and by sympa- thetic reaction, scarcely respond to the most diligent and enlightened treatment, get well with the greatest difficulty, and seem peculiarly exposed to relapse. Case X. Abortion at three months, preceded and followed by severe Uterine symptoms. March 2, 1846, I was consulted by Mrs. H-----, a young married lady, aged twenty-three, residing in the south of England. Her his- tory was as follows :— Of rather delicate constitution, although generally enjoying good health, she menstruated at fourteen. She continued to be regularly and easily unwell every month, during four or five days, until she married, at one-and-twenty. She then immediately became pregnant, and was confined at the full time, of a stillborn child. The labour was exceedingly tedious and difficult, and she was a long time in rallying, having been confined to her room four or five weeks. From that time she has never been well, and has always had a leucorrheal discharge, and lumbar, ovarian, and hypogastric pains. The menses did not appear for three months, and then less freely than formerly, and accompanied by great pain. This afterwards continued to be the case. Nine or ten months after her confinement she again became pregnant, and miscarried, at the end of three months, about ten weeks previous to my being consulted. During the time she was pregnant she was very ill, all the uterine symptoms enumerated being exacerbated. The miscarriage was preceded and followed by flooding, and she was obliged to keep her bed for several weeks. From that time forward, notwith- standing the most careful and continued medical management, she had been, she stated, in a most wretched state. She had not been examined locally, but her medical attendant suspecting the existence of some serious uterine disease advised her to consult me. Although of rather a full habit, she appeared very weak and debilitated; the lips were pale, the skin sallow, the tongue white; she complained of insomnia, headache, palpitations, cardialgia, and constipation; she had a profuse OF THE UTERUS DURING AND AFTER PARTURITION. 175 yellow leucorrheal discharge, often tinged with blood, severe lumbar, hypogastric, and ovarian pains, and a distressing sensation of bearing- down. On examining digitally, I found the vagina moist and relaxed, the cervix low, voluminous, and hypertrophied, but not much indurated; the os open, so as to admit the end of the finger, and surrounded by a soft, velvety surface, which extended over the entire cervix. The uterus itself was enlarged, and painful on pressure. The perineum was deeply torn. The lower half of the vulva, the perineum, and the nates adjoining the perineum, were red, and painful to the touch, and the seat of severe erythematous inflammation, evidently produced by the acrid nature of the vaginal discharge, the vagina was congested, and contained a great quantity of bloody muco-pus. The cervix, of a deep florid hue, presented a large, irritable-looking ulceration, the size of a half crown. The treatment consisted in tepid hip-baths night and morning; emollient, and subsequently astringent, vaginal injections, periodical cauterization of the ulcerated surface, mild saline aperients, and subse- quently tonics, light diet, and rest in the horizontal position. Under the influence of these means she gradually but slowly improved. The emollient agents resorted to, the hip-baths and injections, soon subdued all external inflammation; the case then progressed like that first re- lated, without anything unusual occurring. The general health of this patient, however, rallied much slower than that of the former one; it had been much more deeply affected, and the constitution was evidently weaker. On the 24th of May, nearly three months after I began to attend her, although immeasurably better, she was still weak and delicate. The uterine disease was, however, altogether subdued; the leucorrheal discharge had disappeared, the vagina was healthy, the cervix had nearly recovered its natural volume, and had quite ascended into its normal position in the pelvis, the ulceration was healed, the lumbar and ovarian pains, and the sensation of bearing-down, were no longer experienced, or at least only in a very trifling degree after fatigue, and she could walk with ease and without pain. The general health had also vastly improved; the dyspeptic symptoms had almost entirely dis- appeared; she could sleep and eat well; the bowels acted regularly; and the skin had lost its sallow hue, although it did not yet present the colour of health. Mrs. H---- then returned home. I afterwards heard that her health had become more and more consolidated, and that she had experienced no return whatever of the uterine symptoms. The menses were easy and natural, as before her first pregnancy. CHAPTER IX. INFLAMMATION AND ULCERATION OF THE NECK OF THE UTERUS IN ADVANCED LIFE, AFTER THE CESSATION OF MENSTRUATION. Inflammation of the uterus is occasionally met with in women advanced in life, who have long ceased to menstruate, notwithstanding the low vitality of the uterine system at this stage of female existence. Uterine inflammation at this period of life, however, almost invariably assumes the shape of ulcerative inflammation of the mucous membrane covering the lower segment or neck of the organ, and appears generally speaking, to be the lingering remains of inflammatory disease present at the time the menses ceased. In some cases, however, I have known it evidently to originate spontaneously, and in others it has occurred as the result of blennorrhagia, contracted late in life. The atrophy of the uterine system, which physiologically follows the cessation of menstruation, exercises unquestionably a very salutary influence over any uterine inflammation which may then exist, many females recovering gradually, without treatment, under its influence, from the unrecognised uterine inflammation, which had for many years inexplicably rendered life a burden to them. Hence, I believe, the origin of the popular opinion, that if a female, previously in bad health, passes safely over the critical period of life, she may rally, and enjoy good health for the remainder of her existence. The forms of uterine disease which I have described not having hitherto been recognised and treated, there must have been at all times a large floating population of females thus rendered confirmed invalids, confined to sofas and couches, stranded, as it were, on the shores of the stream of life, some of whom would reach this age, and be spontaneously cured in the way I describe. Indeed, it stands to reason, that if women so situated escape the dangers of accidental disease, and of cancerous degeneres- cence, the absence of the menstrual flux must materially change the pathological condition. The uterus being no longer subject to the periodical congestions which render its inflammations so difficult and so tedious to subdue, the disease in many cases gradually wears itself out, and thus a natural cure is obtained. In some instances, this desirable process of natural cure only takes place partially. The gradual atrophy of the uterus, now become a useless organ in the economy, is still called into action; it limits the morbid action, diminishes the size of the hypertrophied tissues, and partly heals the ulceration, but it has not the power completely to cure the disease. The latter still lingers on, giving rise to more or less of the symptoms which are usually observed in this form of inflammation. INFLAMMATION AND ULCERATION IN ADVANCED LIFE. 177 The most constant and the most prominent, in many cases, is the pain in the sacrum, or lower part of the back;—pains in the ovarian regions, and in the hypogastrium, are occasionally complained of, but by no means so universally. The peculiar backache of uterine diseases has indeed appeared to me frequently more intense in women thus advanced in life than in younger persons, although the latter generally present much more extensive disease. Sometimes a leucorrheal discharge is experienced by the patient, but not alwTays; the ulceration being often small, and there being but little vaginitis, there is no great amount of muco-pus formed, and what little is secreted, is absorbed by the parietes of the vagina. As might be anticipated, the patient seldom experiences much bearing-down. The inflamed cervix, as well as the uterus itself, being more or less atrophied, the latter generally retains nearly its normal position in the pelvis, not falling so much as in younger women when the neck of the uterus is hypertrophied. On examining digitally and instrumentally, the cervix is found small, indurated, sometimes lobular, but in that case the lobules are regular and their divisions radiate towards the centre; the os is slightly open, and presents sometimes, but not always, within its con- tour, the velvety sensation of ulceration. The vagina is in some cases rather rosy and congested, whilst in others it presents a blanched appearance, peculiar to it in advanced life. To the eye, the cervix appears of a vivid red hue, and the ulcerated surface generally seems irritable and angry; the granulations are small; and there is scarcely ever any appearance of luxuriance or of fungosity about them. The cavity of the cervix is closed at a short distance from the external orifice. These, the physical characters of inflammatory ulceration of the cervix at an advanced period of life, are the same, however the disease may have originated. They are often accompanied by consi- derable sympathetic disorder of the general health, especially when the backache is very continued and severe. I have found this form of ulcerative inflammation much more intract- able, and much more difficult to cure, than that which is met with in younger females. It may be that the very circumstance of the disease having withstood the influence of the changes that take place in the uterine system on the cessation of the menses, stamp it as of an intractable nature; or it may be, that chronic inflammation once established in a mucous membrane in a person advanced in life has a greater tendency to resist treatment and to perpetuate itself, than it would have in a younger subject. Whatever the interpretation, the fact is certain. A small ulceration, the size of a fourpenny piece, resting on an atrophied cervix, will resist the most energetic treatment for several months, giving rise, at the same time, in some patients, to extreme pain in the back and sides. The following cases will illustrate the peculiarities of this disease in advanced life. I have, however, frequently met with it in much older females than those whose histories are recorded. At the commence- ment of the present year I was consulted respecting a lady, from the 178 INFLAMMATION AND ULCERATION OF THE country, sixty-five years of age, who had ceased to menstruate twenty years before. She was deaf and very infirm, and those around her only suspected the existence of something wrong from the presence of a yellow vaginal discharge. The family medical attendant, being in doubt as to the nature of the case, brought her up to town to see me. On examination, I found the cervix extensively ulcerated, the ulcera- tion being evidently of a purely inflammatory nature. This lady had had a large family thirty or forty years before, but her faculties were so obscured, that we could obtain little or no information from her respecting her uterine health since that time. I have recently had under my care another lady, above sixty, who presented extensive inflammatory ulceration of the cervix, which evi- dently dated from a miscarriage that occurred above thirty years previous to my seeing her. She had ceased to menstruate for very many years. The ulceration only gave way, after several months' treatment, to the use of the solidified potassa cum calce. In this case there was no backache or local pain. Case XL Slight Ulceration of the Cervix in a person advanced in life, healing after five months' treatment. April 3d, 1846.—Louisa L----, a tall, stout, robust woman, aged fifty-four, was addressed to me, at the Western Dispensary, by one of my colleagues, under whose care she had been for a short time. Men- struated at thirteen, she continued to do so regularly and easily until she married at twenty-three. She subsequently had eight children, the last at the age of forty-three, without ever suffering from any uterine symptom. Two years after her last confinement, and fourteen months after weaning her child, the catamenia stopped for five months, during which time she was very unwell. They returned, and she con- tinued to menstruate as usual, until about eighteen months ago. The show then became scanty, and she was seized with pains in the back and in the hypogastric and inguinal regions. Shortly afterwards the menstrual functions ceased entirely, and the inguinal, hypogastric, and lumbar pains increased; she likewise experienced slight bearing-down and pain in congress. From that time, the symptoms gradually became more severe, until the pain in the lumbar region was so great that she could scarcely sleep or lie ; and this it was that induced her to apply for relief. She stated that she had never had any leucorrheal discharge whatever; her general health had been much impaired during the previous twelve months; she had lost strength, and felt very ill; appetite bad, and bowels costive. On examining digitally, I found the cervix rather high up, not volu- minous, but hard; the os was open, and presented the velvety sensation of ulceration. On using the speculum, the vagina appeared of a natural NECK OF THE UTERUS IN ADVANCED LIFE. 179 healthy hue; the cervix was not large, but of a vivid red colour, and presented around the os an ulceration not larger than a fourpenny piece, which penetrated slightly into the cavity of the cervix. The redness of the surrounding tissues terminated rather abruptly before it reached the vagina, and appeared to be the vestige of a former more extensive ulceration. The ulcerated surface was acutely sensible when touched with the forceps or probe; there was but little purulent secre- tion. On the sore being touched with the nitrate of silver, the agony became so great as to bring on nausea, and every pain she had before suffered became instantly perceptible, with exaggerated intensity. Astringent injections and a saline mixture were prescribed, and rest enjoined. 10th.—The pain of the cauterization, after persisting for the entire day, although much less intense, gradually subsided. Since then all the pains have been less severe, and the bearing down sensation has quite disappeared. The ulceration is less irritable, and the cauteriza- tion is by no means so painful as on the first occasion. From this time the treatment was pursued on the same principle. The ulceration was cauterized every five or eight days, either with the nitrate of silver or the acid nitrate of mercury, according to the appearance it presented, and to the effect produced. Astringent injec- tions of various descriptions were also used, rest enjoined, and the general health attended to. It was nearly five months, however, before the small ulceration was healed. It soon lost all irritability of surface, and the inflammation of the surrounding surface subsided, the lumbar and hypogastric pains nearly entirely disappearing, but z small portion of the primitive ulceration long remained red and abraded, secreting pus, and refusing to heal. Remarks.—In this case, a slight ulceration, unaccompanied by much adjoining irritation, resting on a cervix rather small than otherwise, occasioned severe pain and great constitutional reaction. Notwith- standing these apparently favourable features, it was only after the remedial measures resorted to had been persevered in for several months that the ulceration cicatrized, the inflammatory action having been at last subdued. It is impossible to fix the origin of the disease, as during a long "uterine life," she only recollected having once had uterine symptoms before the cessation of the menses, and that was nine years previously. There may, however, have been some obscure chronic inflammatory action of the cervix in existence ever since that time, but which only became apparent at the change of life. The application of the potassa fusa might have healed it sooner, but I was unwilling to resort to this agent, on account of the absence of hyper- trophy and the very small size of the cervix. 180 INFLAMMATION AND ULCERATION IN ADVANCED LIFE. Case XII. Inflammation and Ulceration of the Cervix in a person aged sixty-one, the result of Blennorrhagia. On the 7th July, 1846, I was consulted by a lady, Mrs. M------, aged sixty-one, for a vaginal discharge, from which she had suffered, she stated, for two years. On inquiry, I ascertained that she was married early in life, had had several children, and had ceased to men- struate nine years previously. She had never laboured under any uterine disease to her knowledge, or presented any uterine symptom, until two years ago, when her husband communicated to her a dis- charge under which he himself laboured at the time. She retained the discharge for several months, without mentioning it to her medical attendant; when she did so, he merely ordered her medicinal agents. Under the influence of this treatment, the leucorrhea diminished, and the heat and scalding on passing water, which she had at first expe- rienced, disappeared. The vaginal discharge, however, although less, persisted, and great and continued pain in the lower part of the back set in, gradually becoming worse. Her general health, which had previously been very good, also failed her. On examining digitally, I found the vagina healthy, the cervix small, very hard, and divided into three small radiated lobules; the uterus appeared also very small, and perfectly moveable. The speculum snowed the vagina to present the white blanched appearance which I have noticed as peculiar to age, except at its upper fifth, which was rather injected. The small lobular cervix was of a livid red, and was ulcerated over the greater part of its surface. The cavity of the os appeared quite obliterated. The tongue was white, appetite and rest bad, bowels costive. The disease in this patient was treated, as in the former one, by periodical cauterization, astringent injections, rest, and attention to the general health; but it was not until six months afterwards that I could pronounce her quite cured. The cervix was then cicatrized, and had assumed the same blanched appearance as the surrounding tissues; all pains and discharge had disappeared, and the general health was very much improved. Remarks.—The decided manner in which so limited an amount of local disease will react on the functions of digestion, even in persons advanced in life, is worthy of notice. In the above case, the patient evidently contracted gonorrheal inflammation of the vagina, which not being subdued, became localized on the mucous membrane covering the cervix, and thus gave rise to the diseased state which I found. The disease was purely inflammatory, and consequently, although obstinate, eventually gave way to treatment. CHAPTER X. INFLAMMATION OF THE VULVA, OF THE VULVO-VAGINAL GLAND, AND OF THE VAGINA. Although inflammation of the vulva and of the vagina mostly co-exist, the difference which their anatomical structure presents considerably modifies their morbid manifestations; we shall therefore examine the disease separately in each of these regions. Both vulvitis and vaginitis are generally considered to present themselves under two distinct forms: a purely inflammatory or non- specific form, and a specific or blennorrhagic form. The propriety of this distinction has been questioned by some modern authors ; but whether a virulent contagious form of inflammation, distinct from simple inflammation, exist or not, it is certain that it is impossible to establish the distinction from a consideration of symptoms alone. After many years' careful study and investigation, I am yet unable to point out any certain data by which the difference can be recognised. I shall, therefore, first describe the disease as it occurs in the cases in which there is no suspicion of contagion, the inflammation being evidently spontaneous, and then briefly discuss the question at issue. VULVITIS. Causes.—As predisposing causes of inflammation of the vulva may be mentioned the peculiar delicacy and tenuity of the skin and mucous membrane that cover the organs which enter into its formation ; their extreme vascularity and erectile character; the great number of sebaceous, mucous, and hair follicles which it contains; its liability to physiological congestions under the influence of menstruation, of mental emotions, and of other causes, favoured as they are by the vasculo- erectile structure already alluded to, and the existence of pregnancy and obesity. The influence of these various predisposing causes of disease has been very lucidly pointed out by M. Huguier, the learned Paris surgeon, in an admirable memoir on disease of the vulva, read a few years ago before the Academy of Medicine.1 In this valuable monograph, M. Huguier very correctly compares the vulva to the face, which presents nearly the same anatomical and physiological 1 M6moire sur les appareils secateurs des organes genitaux externes de la femme, lu a l'Academie Nationale de Medecine. Mars. 1846. Paris. Bailliere. 1850. 1S2 INFLAMMATION OF TnE VULVA AND VAGINA. conditions, and points out, as a necessary corollary, the fact that the disease of the vulva presents the greatest similarity to those of the face. As exciting causes of inflammation may be named all those agencies which are calculated to arrest the menstrual function, or to morbidly increase the molimen hemorrhagicum that precedes, accompanies, and follows menstruation; acrid secretions from the uterus or vagina; marriage and parturition; over-exertion in walking in warm weather, especially in pregnant females, or in stout women, in whom the labia are loaded with fat and the follicular secretions abundant; and all local irritations from whatever cause. Inflammation of the vulva is met with at all periods of female life. It is not unfrequently observed in infants and children, as the result of . cold; and occasionally with the latter as the result of onanism; or it is developed spontaneously, owing to the morbid influence of a scro- fulous cachectic constitution which predisposes to mucous membrane inflammation. My friend Dr. Cormack, has seen it complicate or follow scarlet fever, and no doubt this occurs much more frequently than is generally supposed. The symptoms of vulvitis vary according to the anatomical seat of the inflammation. It may occupy only the proper tissue of the cutaneous and mucous membranes, or the mucous, sebaceous, or hair follicles, or all these structures simultaneously; and it may extend or not to the subjacent tissues. Moreover, the various forms of inflam- mation which are peculiar to the skin may be also met with at the vulva. When the inflammation occupies the muco-cutaneous surfaces, we find the vulva red, hot, congested, swollen, tender to the touch, and bathed with mucus at first, and subsequently with muco-pus. If it has extended to the cellulo-erectile tissue underneath, the labia and nymphae often become enormously swollen, so as to present the form of large masses on each side of the vulvar orifice, which appears greatly enlarged. When this is the case, purulent collections may form either in the free cellular tissue or in the larger mucous follicles, and especially in the vulvo-vaginal gland. The numerous mucous follicles of the vulva are sometimes inflamed separately, or at least their inflammation becomes the prominent feature, that of the tissues in which they are embedded being secondary. At first they present the appearance of numerous small hard specks of coarse sand disseminated over the muco-cutaneous surface. As inflam- mation progresses they often ulcerate, and the parts are dotted over with small aphthous-looking sores, secreting muco-pus in abundance. This state of things is generally attended with considerable inflammation and swelling of the surrounding parts, which are matted together by the purulent secretions, and present a very repulsive appearance. < Dr. Oldham has well described a chronic form of follicular inflamma- tion occasionally met with, in which the inflammation principally attacks the mucous follicles of the nymphae and of the vaginal orifice extending from the meatus to the lower commissure of the nymphae, and seldom involving, to any extent, the external labia. The small aphthous INFLAMMATION OF THE VULVA AND VAGINA. 183 ulcerations which they form, at first sight rather resemble venereal sores. On a closer inspection, however, their purely inflammatory nature becomes evident. The presence of this chronic follicular inflammation is often attended with spasm of the constrictor vaginae, and consequent occlusion of the vaginal orifice. Thence extreme pain on any attempt at congress. This form of the disease is generally most intractable to treatment. It may exist independently of any vaginal or uterine inflammation, but has proved in my practice mostly connected with such disease. Owing to the spasmodically constricted state of the vaginal orifice, it is very difficult satisfactorily to examine the vagina and neck of the uterus, either digitally or instrumentally. Vulvar inflammation, especially in the chronic form, is frequently accompanied by intense irritation and itching. It may be general in the vulvar region, involving or not the clitoris, or it may be confined to the clitoric region alone. This symptom is a most distressing one, often destroying entirely the rest of the patient, and when carried to an extreme degree rendering her nearly frantic. She is induced, in spite of the strongest determination to the contrary, to rub the part affected, in order to allay the itching, and thus the inflammation is increased, while the local irritation is but temporarily relieved. I am convinced, indeed, that in a large proportion of the children and females in whom onanism exists as a habit, it has originated in this manner. The inflammation and irritation, if unchecked, gradually extend to the outer surface of the labia majora, and when they have reached this region, the irritation becomes more intolerable than ever. The patient often rubs the part with a sort of rage, until it is quite excoriated and covered with blood. When the inflammation has become chronic, and has reached this extent, the mucous folds of the labia majora and the nymphae, and those which cover and surround the clitoris and the vestibule, assume a whitish or greyish colour, and become thick and hypertrophied. The labia majora themselves may be several times their usual size, and present a very peculiar mottled appearance. On a careful examination, these chronic forms of vulvar inflammation will generally be found connected with extensive disease of the cervix uteri, and this partly accounts for their extreme intractability to treat- ment, especially when this is directed to the vulvar element of the disease only, as is usually the case, the disease of the uterine neck, which keeps up the external inflammation, being unrecognised and unchecked. The vulva especially at its lower commissure in the vicinity of the nymphae, is sometimes the seat of most obstinate indolent inflammatory ulcerations the size of a shilling or half-crown; the patient suffering but little pain, being sometimes scarcely cognisant of their presence. They have been well described by M. Boys de Loury and M. Laure's, the only authors, so far as I am aware, who have alluded to them. When I first met with an ulceration of this kind, I thought it a degen- erated chancre. But I afterwards concluded that it was not venereal, from its resisting a course of mercury combined with local cauterization. 184 INFLAMMATION OF THE VULVA AND VAGINA. I now believe, with M. Boys de Loury, that these ulcers are purely inflammatory. They are certainly most rebellious to treatment. Tho authors I have mentioned have met with cases at St. Lazare which neither the red-hot cautery, nor potassa fusa, nor any other agent, local or general, could modify or heal. I had a case at the Western Dispensary, in which the sore resisted all these active means for four months, and then suddenly healed in a week, after having been for some time left to itself, whilst the patient was under general treatment. The sebaceous and hair follicles are generally inflamed simultaneously with the mucous follicles, but they may be affected separately._ The inflammation usually attacks one region only of the vulva, but it may be general. They also form hard red elevations or papilhe, only to be distinguished from inflamed mucous follicles by their being rather larger and harder, and by the presence of the hair in the centre, when it is the hair follicles that are diseased; and by the fact, that, the in- flammation having a greater tendency to assume a chronic character, they do not ulcerate either so readily or so soon. In the course of a few days, if the inflammation does not assume an entirely chronic form, a drop of pus forms at the apex of the small papilla, and on its bursting spontaneously or through the patient's abrading it, a small sore is formed, which may heal immediately or remain open. In the early stage of inflammation a copious secretion of sebaceous matter often takes place, giving rise to a white, creamy, oily film, which forms over the diseased surfaces, and is rapidly reproduced if wiped off. This sebaceous secretion is sometimes poured out in great abundance. As in inflammation of the mucous follicles, if many are simultaneously inflamed, the proper tissue of the vulva is generally inflamed simulta- neously, and then presents the characteristics already described. The inflammatory action may pass into the chronic form, or be chronic from the first. When this is the case, the diseased sebaceous follicle may assume the same character, and pass through the same phases as occur in the face. One or more chronically inflamed follicles, presenting a red tubercular appearance, are found disseminated over the vulva, remain some weeks in an indolent state, suppurating or not, and then gradually disappear to be succeeded by others. Owing to the extreme sensibility of the vulva, they often occasion considerable distress to the patient. They are generally looked upon as small boils, or furunculi. Occasionally, under the influence of inflammation, or from some other cause, the duct of one or more sebaceous follicles becomes obli- terated, and the sebaceous matter collecting behind, a steatomatous cyst, or tan, is formed, varying from the size of a millet seed to that of a nut, or even larger. The proper tissue of the sebaceous follicle may also become hypertrophied, so as to form a small tumour, pro- truding from the surface. M. Huguier has very accurately described this condition, and has given to it the name of exdermoptosis. Generally speaking, several hypertrophied follicles are observed in the same patient. They are found on the cutaneous surfaces only, appear to be INFLAMMATION OF THE VULVA AND VAGINA. 185 formed by the deep-seated follicles, and are covered by the superficial layers of the skin which they push before them. As they enlarge, they form a small indolent tumour, of the colour of the skin, at first the size of a pin's head, but which may increase to that of a pea. When it has attained this size, it sometimes becomes pedunculated, so as to adhere to the skin by a pedule only, of variable thickness; in the centre of the small tumour may always be seen a slight depression, the orifice of the follicle from which a certain amount of sebaceous matter may generally be_expressed. These characters distinguish it from syphili- tica! vegetations and mucous pustules, with which the hypertrophied follicles are occasionally confounded. They may remain indolent for any length of time, or become inflamed, soften, ulcerate, and thus be wholly or partially destroyed, leaving a small depression in the skin, or they may wither, so that a minute wrinkled tumour alone remains, as evidence of the disease. The vulva may present all the special forms of cutaneous inflamma- tion, such as erythema, herpes, ecthyma, psoriasis, &c, offering the usual characters of such affections. M. Huguier has also described at considerable length (Memoires de l'Academie, vol. xiv., 1849) a fortunately rare form of disease, which he has only met with in hospital practice, to which he gives the name of esthiomene, and which he assimilates to lupus in the face. As in the face, this fearful malady presents itself under several forms. It may be serpiginous or extend in surface, perforating or extending in depth, or hypertrophic, that is, be attended with hypertrophy of the surrounding tissues. These three varieties of the disease often exist in the same individual. It generally commences on the cutaneous surface of the labia majora, and is principally observed in adult females, although M. Huguier has met with an instance of it in a scrofulous girl only twelve years of age, who had also lupus of the face. The superficialor serpiginous form is characterized by small livid tubercles, or indurations, lying on.thickened integument, and presenting at their base, or in their vicinity, where the skin is exposed to the air, greyish epidemic scales, as on the face. These tubercles generally accompany or surround the other more serious forms of the disease. They soften and ulcerate, forming small ulcerations, which may extend, destroy the entire thickness of the skin, healing on one side, as they progress on the other, and leaving thin, uneven, shining cicatrices, of a whitish or reddish colour. The course of the disease is essentially chronic; it may last for years; is attended with little or no pain or constitutional disturbance in its early stages, and does not then interfere with the accomplishment of the functions of the organs. In the perforating form, the ulceration extends in depth, so as to produce a frightful destruction of parts, sometimes passing between the urethra and the pubis, or the rectum and the pubis, so as to partially separate the vagina from its attachments, and extending to the vagina, anus, and rectum. When this is the case, the parietes of these organs become thickened, and form folds and duplicatures, separated by deep sulci, 1^6 INFLAMMATION OF TnE VULVA AND VAGINA. ulcerated or not. When the hypertrophic element is added, the parts attacked, and the surrounding tissues, become enormously enlarged, and give to the external organs of generation, and to the entire vulvo- anal region a most frightful appearance. It then constitutes a mass of hypertrophied tissues, thrown irregularly into thick folds, covered with tubercles and ulcerations, in which all trace of the natural con- formation, of the parts, or of the natural outlets of these organs, is lost. When disease is carried to this extent, a very considerable amount of local distress is necessarily experienced; the patient falls into a state of marasmus, and sinks exhausted by diarrhea and constitutional irrita- tion. This disease, as in the face, is very rebellious to treatment. The characters given above will distinguish it from the various forms of vulvar inflammation, and from cancer, with which it has no doubt hitherto been confounded. Inflammation of the Vulvo-vaginal Gland.—It is also to M. Huguier that we are indebted for the first full and complete account of inflam- mation of this gland. It is contained in the work to which I have already so repeatedly alluded, and is an important contribution to the pathology of the uterine organs. Inflammation of the vulvo-vaginal gland is principally met with between the ages of eighteen and thirty. This we might naturally conclude would be the case, as the gland is physiologically destined to secrete mucus for the purpose of lubrication, with reference to the sexual functions, which are most developed at that period of female life. Women of a nervous or lymphatic temperament, in whom sexual feelings appear as a rule, more intense than in those of a robust and plethoric, or sanguinous temperament, are the most liable to be attacked by this form of glandular disease. Menstruation may also be con- sidered a powerful predisposing cause, and sedentary occupations of all kinds, from their tending to occasion local congestion. The attack of inflammation itself, however, is mostly induced by positive local irritation. The influence of these causes, both predisposing and immediate, sometimes produces a state of exaggerated vitality of the gland, followed by hypersecretion of mucus, which can scarcely be considered a diseased condition, although it verges on it, and is often the immediate precur- sor of inflammation. This state is characterized by the constant flow, under the influence of the slightest exciting cause, of so large a quan- tity of glairy mucus, as to prove a source of annoyance to the patient. Pressure exercised on the gland, enlarged, distended, and easily per- ceptible to the touch, will itself expel a certain amount of mucus, either transparent or turpid. Sometimes, under the influence of dreams, the glandular fluid will be secreted in great quantity during sleep in the night, thus stimulating nocturnal seminal emissions in the male. This state of hypersecretion of the vulvo-vaginal gland, may exist as a com- plication of uterine disease, or it may be present for months, or even for years, without inflammation setting in. Inflammation of the vulvo-vaginal gland may exist on one or both INFLAMMATION OF THE VULVA AND VAGINA. 187 sides. It may occupy the mucous membrane lining the duct, and present itself under a catarrhal, and generally chronic form ; or it may attack the substance of the gland, in which case it is generally acute and attended with the formation of abscess. In the catarrhal form of inflammation, which M. Huguier designates purulent hypersecre- tion, the gland secretes a greyish, yellowish white, or semi-purulent fluid, and may or may not be swollen, and tender to the touch. There is generally slight pain and itching in the region of the gland, but there may be no uneasy sensation whatever. The mucous purulent discharge may last for months, and when recognised is generally sup- posed to proceed from the fistulous opening of a vulvar abscess. The anatomical position of the orifice of the inflamed duct from which the pus issues is sufficient to establish its origin. When it thus persists, it is generally kept up by the presence of blennorrhagic or other in- flammatory disease of the vulva, or by the continued action of the local irritations which so generally give rise to it. Should the orifice of the duct become obliterated, the muco-pus collects and forms a small, soft, fluctuating tumour, varying from the size of a pea to that of a small walnut, and situated superficially at the lower orifice of the vagina. It is felt immediately underneath the mucous membrane, which it distends visibly to the eye. The muco-pus may dilate the obliterated duct, and force its way out by the natural channel; but it more usually escapes by an artificial opening. All trace of tumefac- tion then disappears, and it is often difficult at first to say whence the matter has escaped. When it is the substance of the gland itself that is the seat of inflammation and suppuration, the tumour which it forms is found lying deeper, between the ascending branch of the ischium and the orifice of the vagina. It is generally painful, the pain irradiating into the surrounding tissues and organs, and may become as large as a walnut. When this is the case, the tumefaction distends the labium, and becomes very evident to the eye. Matter forms rapidly in the course of three or four days, and by the tenth or twelfth the purulent collection, if left to itself, has generally opened an artificial passage externally. The pus once evacuated, cicatrization mostly takes place in the course of four or five days. Sometimes the matter forces its way through the duct, and then the evacuation of the pus is slower, often continuing in an interrupted manner for some weeks. The duct may be involved in the inflammation, and be also distended by pus. When this is the case, and an artificial opening occurs, and sometimes when the inflammatron is confined to the duct, the latter may ulcerate freely, and, on cauterization, be diminished in length, a very evident oval depression marking its new orifice. Whether the duct, or the gland, or both, have been the seat of inflammation, the cicatrization of the artificial opening is not always definitive. Muco-pus or pus will accumulate again and again; each time an exacerbation, or return of inflammatory action, taking place, and continuing until it has again found a vent. The same circum- 1S8 INFLAMMATION OF THE VULVA AND VAGINA. stance occurs with abscesses found in the substance of the labia, but much less frequently. In the latter affection, it is the adventitious pyogenic membrane lining the abscess which remains inflamed, and reproduces pus. In the former, it is the mucous membrane that natu- rally lines the ducts of the gland that remains the seat of disease. In either instance, the only means to prevent these abscesses continually forming, is to open them freely, and to make them heal, as it were, by the second intention, as we shall see when speaking of the treatment of vulvar inflammation. VAGINITIS. Inflammation of the vagina, considered apart from contagion, may be occasioned by all the causes which have been enumerated as pro- ducing vulvitis. It is, moreover, very frequently found to complicate inflammatory disease of the body or neck of the uterus, and especially of the latter. Indeed, I should say that it is principally in connexion with inflammatory and ulcerative conditions of the cervix uteri, that simple non-contagious vaginitis is met with in the chronic form. Vaginitis, like vulvitis, both acute and chronic, is met with at all ages. It not unfrequently attacks very young children, and when existing in them as a result of a scrofulous constitution, and of a ten- dency to inflammation of the mucous membrane, may be very difficult to effectually subdue. Like vulvitis, it sometimes attacks young children during, or after, eruptive fevers. Acute vaginitis is attended with pain, swelling, and redness of the vaginal canal. The patient feels a sensation of heat and fulness in the vagina; and if a digital examination be made, the canal is found swollen and tender to the touch. On bringing the vaginal mucous membrane into view by means of the speculum, should the pain and swelling not be too great to admit of its use, it is found of a vivid red colour, and the rugae appear more developed and prominent than in the normal state. At first there is an arrest of secretion, as in the first stage of inflammation in mucous membranes generally, but after a day or two a more or less abundant secretion sets in, at first serous, and then purulent, and of a yellowish or greenish colour. As soon as this secretion is fairly established, the heat, swelling, fulness, and pain, diminish considerably. The development of these local symptoms is seldom accompanied by much general febrile reaction, unless the tissues underneath the mucous membrane be involved; in that case, the inflammation may assume a phlegmonous form, and purulent collections from which empty into the vagina, or at the vulva; considerable febrile reaction being experi- enced. Fortunately, however, this is a very rare form of vaginitis, and is seldom met with except in cases in which the vagina has been contused, lacerated, or otherwise injured, in severe, prolonged, or instrumental labour. INFLAMMATION OF THE VULVA AND VAGINA. 189 The inflammation in vaginitis may be general, or it may be limited to one region, either to the upper or the lower part of the vagina. When it is thus limited to a portion of the vagina only, it is nearly always chronic, and connected with disease of the cervix or vulva, of which it is only a symptom and the extension. The amount of fluid secreted by the inflamed surfaces varies greatly; in some it is slight, and formed by a mixture of the white mucus secreted in the upper part of the vagina, and of the yellow matter, the product of the acute inflammatory action; in others it is very abund- ant, thick, and of a yellow or greenish colour. Acute vaginitis appears to run its course in from ten to twenty or thirty days, according to the intensity of the inflammation, and to the treatment employed. If, in addition to general treatment, local means are carefully used, an attack of acute vaginitis may generally be sub- dued in from a few days to a fortnight; but if general treatment alone is resorted to, or the local treatment be inefficient, several weeks may elapse before the inflammation subsides, or it may pass into the chronic stage, extending to the mucous membrane which covers the cervix. Inflammation of the vagina, like inflammation of the uterus and vulva, is very liable to be periodically aggravated by the men- strual congestion ; thence a tendency to its perpetuation, if it does not at once subside, or give way to the means of treatment resorted to. If the slightest amount of inflammation is left previous to menstrua- tion, the molimen hemorrhagicum which then exists seems to fan it into a flame, developing anew the inflammatory action. This unfavourable influence of menstruation on the course of vagi- nitis is more especially observed in the chronic form of the disease, and constitutes one of the great difficulties of its treatment—not only does menstruation exaggerate existing inflammation, but it often reproduces it after each menstrual epoch, when all evidence of inflammatory action had so far disappeared that the most careful ocular investigation could detect no evidence of disease beyond a slightly congested state of the vaginal mucous membrane. Chronic vaginitis, as I have stated, is generally connected with disease of the cervix uteri, of which it may either be the cause or the symptom. In the former case, the vaginitis is mostly general; in the latter it is mostly confined to the upper third or half of the vagina, and is evidently the result of the extension of the inflammatory atmosphere from the neck or body of the uterus to the vagina. In this case, the non-inflamed part of the vagina is nearly always more or less congested. Chronic vaginitis, general or partial, may last indefinitely, for years, like chronic inflammation of all other mucous surfaces, giving rise to a constant secretion of muco-pus, and varying in intensity according to the epoch of the month and to the state of the health, and social and hygienic position of the patient. In the course of time, it often passes into a mere mucoso-purulent flux. Its existence in this chronic form is a source of general debility and weakness, but by no means to the extent that is supposed by most authors; the sympathetic connexion 190 INFLAMMATION OF THE VULVA AND VAGINA. between the vagina and the rest of the economy being slight, when com- pared with that which exists between the uterus and the system in general. When the health of a patient labouring under chronic vaginitis suffers greatly, it will generally be found, on examination, that there is also disease of the neck or body of the uterus, or of the ovaries. Inflammation of the vagina may assume the follicular form, that "is, the mucous follicles may inflame and ulcerate, forming small aphthous sores. This species of inflammation, however, is rare, and when met with, is generally limited to the lower portion of the vagina. It is seldom, also, that more than a few isolated follicles are ulcerated. A form of follicular disease has latterly been described on the continent as peculiar to pregnancy, and as characterized by enlargement, or hypertrophy, of the mucous follicles of the vaginal mucous membrane. I do not think the disease described is of frequent occurrence, and am inclined to look upon the conditions described as often physiological, and merely the result of the natural development of the follicular organs, owing to the existence of pregnancy. Pseudo membranes may form on the inflamed vagina, but their presence is of very rare occurrence. They may present the same characters as on the cervix and on other mucous membranes. It is a singular pathological fact that, although the existence of a specific and contagious form of vaginitis is generally admitted; yet that it is difficult, if not impossible, as we have seen, to point out any decided characteristic by which it may be distinguished from simple vaginitis. Like those who have preceded me, I am unable to indicate satisfactorily any absolute means of distinguishing between simple inflammation of the vagina and blennorrhagic inflammation, although I believe that the difference does exist. This seems proved to me by the fact that simple inflammation of the vulva and vagina, the form which is so constantly found co-existing with disease of the neck of the uterus, and the origin of which is evidently inflammatory, does not appear, as a rule, to communicate gonorrhea to the male. I not unfrequently hear of the husbands of my patients suffering from slight irritation, but seldom of their having positive urethral inflamma- tion with purulent discharge. The instances of the kind which I meet with—instances in which, although the wife's disease appears to be of a purely inflammatory nature, yet the husband is obliged to live separate, under penalty of being himself attacked by urethritis—are, indeed, so rare, that I can only look upon them as exceptional. For many years my opportunities of observing uterine disease have been principally confined to the moral classes of society; for even when physician to a dispensary, my patients were mostly the wives of respectable artisans , and I have been greatly struck to find, as a rule, the husbands of my uterine patients living with their wives in apparent immunity, although nearly all of them are, and have been suffering for months or years, when I first see them, from vaginitis of a more or less severe character. It may be that they become acclimatized, as it were, to their wives' local state of health, or it may be that I do not hear INFLAMMATION OF THE VULVA AND VAGINA. 191 what takes place; but it is even more probable that the immunity is real, and the result of the non-contagion of purely inflammatory vaginal discharge under ordinary circumstancee. I say under ordinary circumstances, because, even admitting that such is the case, we can easily understand that a morbid secretion, innocuous when brought into contact with a healthy frame, may, on the other hand produce violent inflammation, if the economy is below par, or if any urethral irritation, caused by lithatic urine or any other cause, previously exist; or if the patient is debilitated by excesses of any kind. To appreciate all the bearings of the question, the above facts must be compared with the results furnished by the medical history of the non-moral part of the population. Do we not find that the young and unmarried who associate casually with women of loose character, with women who do not offer moral guarantees, are continually attacked with gonorrheal inflammation; a fact which tends to prove that they are often exposed to a contagious element in the one case that does not obtain in the other, although the physical evidence of inflammation are identically the same to the eye in both instances ? Although, thus believing in the existence of a contagious and specific form of vaginitis, I am bound to confess that the only difference that I can see ^between the two is, that vaginitis contracted by contagion, or blennorrhagia, appears to me to be more acute than ordinary vaginitis, that there is a greater quantity of pus secreted, greater redness, congestion, and swelling of the mucous membrane, and that the inflammatory action has a greater tendency to spread to the urethra, and is very much more intractable to treatment. These conditions, merely implying degrees of inflammatory violence, do not evidently constitute a distinction as to morbific characteristics. CHAPTER XL OVARITIS — SUB-ACUTE AND CHRONIC —ACUTE INFLAMMATION AND ABSCESS OF THE OVARIES AND UTERINE APPENDAGES. The pathology of the ovaries, after being long much neglected has of late attracted considerable attention, and a great deal has been written on ovaritis in all its forms. It is a well established fact that in puerperal metritis the ovaries are often involved, and that pus disseminated throughout their tissue, or forming collections, is often found after death. It is also probable that the phlegmonous inflammations and purulent collections which not unfrequently occur in the lateral ligaments in the non-puerperal state, and which will be described at length in this chapter, often originate in acute inflammation of the ovary. But the history of ovaritis in its subacute and chronic condition is by no means, as yet, so clearly made out. SUB-ACUTE AND CHRONIC OVARITIS. The term subacute ovaritis has been adopted by Dr. Tilt,1 and other recent writers, to indicate conditions of low inflammatory action in the ovaries, essentially chronic in their mode of manifestation, which they consider both of frequent occurrence and of great importance, as exercising great influence on the functions over which the ovaries preside, those of menstruation and impregnation, and on the health generally. That subacute ovaritis exists as" a decided and distinct form of ovarian inflammation is undeniable, but I think that its frequency has been greatly exaggerated, and consequently, that its importance in the production of deranged menstrual conditions, of dysmenorrhea, mo- norrhagia, and amenorrhea, as also of sterility and abortion, considered generally, has been much overrated. I find the explanation of this circumstance in the fact that the symptoms given as indicating the positive existence of subacute ovaritis may be, and very frequently are, met with as mere sympathetic conditions, depending on the presence of disease in the uterus or its neck, and not on its existence in the ovaries themselves. This opinion is founded on clinical experience, and is supported by reasoning and analogy. If we consider the structure of the ovary apart from the pregnant 1 See Dr. Tilt's work on Diseases of Menstruation and Ovarian Inflammation (Churchill, 1850), in which the doctrines alluded to are very ably and fully exposed. INFLAMMATION OF THE OVARIES. 193 condition, when, like the uterus, it is exceptionally vitalized, we find that it's formed by a dense fibro-cellular parenchyma or structure, which is not likely, pathologically speaking, to very frequently become the seat of subacute or chronic inflammation. Throughout the economy it is the mucous and serous membranes which are most frequently attacked by inflammation, especially by subacute and chronic inflam- mation ; parenchymatous organs, especially those of a dense non- vascular structure, enjoying comparative immunity. This is certainly the case with the uterus itself, the mucous membrane of which is the seat of uterine inflammatory action, as I have most frequently pointed out throughout the course of this work. The ovaries have no mucous membrane, and their structure, in the non-puerperal state, as I have stated, is dense, fibro-cellular, and non-vascular. If we turn to clinical experience we arrive at similar results. Subacute ovaritis is said to be characterized by pains in the ovarian regions, extending round the loins or down the thighs; by a sense of fulness, of swelling, and of heat in the same regions; by enlargement of the ovary, as detected by the actual digital examination of the patient through the vagina or rectum; by the disturbance of the uterine functions, and by the general sympathetic constitutional derangement of health, which has so often been described in the previous chapters as depending on uterine disease considered generally. That these symptoms, taken together, necessarily indicate subacute or chronic ovaritis; as do also those furnished by the actual digital exam- ination of the patient, even when they alone are present, is undeniable. That the functional and rational symptoms may also be the result of such disease, even when there is no attainable physical evidence of its existence, is also certain. Nevertheless, I am fully prepared to state, that in nineteen cases out of twenty in which the ovarian regions are the seat of deep, dull, aching, continuous pain, and appear tender and rather swollen, there is no actual ovarian disease whatever, and that these symptoms merely indicate a state of sympathetic irritation, the result of some uterine lesion. Why it should be so, it is difficult to say ; why an inflammatory ulceration, or any other inflammatory lesion of the body or neck of the uterus, should give rise to pain and tender- ness, not so much in the region where the disease actually exists, as in the right or left ovary, sometimes in both, but generally in the left, I am unable satisfactorily to explain. But the fact is a clinical one, which my daily experience confirms. What proves that the ovarian pains, &c, are, in the immense majority of these cases, merely symp- tomatic, and not the result of actual ovarian disease, is, that if you leave the ovaries entirely alone, and only treat the uterine affection, which is nearly always found on examination to co-exist, they give way as soon as the latter is cured; whereas, if you merely treat the patient for ovaritis, and neither examine nor treat the womb, they either continue indefinitely, or return in a short time, even if modified temporarily by the means resorted to. I so much look upon ovarian pain and tenderness as a mere routine symptom of uterine disease, 194 INFLAMMATION OF TnE OVARIES. that when once I have ascertained by a careful examination that there is no perceptible ovarian enlargement, and that there is uterine disease, I give myself no more concern about the ovarian symptoms than I should about the tongue of a patient suffering from stomach derange- ment ; depending upon their subsiding with the uterine complaint, of which they are merely the indication. I am frequently able also to test, clinically, the correctness of these views. Many young females for whom I am consulted, who present confirmed functional uterine symptoms, which in my own mind I from the first attribute to uterine disease, offer the ovarian pains and tenderness in a very marked manner. Inasmuch, however, as I fully admit that with them all the symptoms may be the result of subacute ovaritis, I seldom consider myself warranted, unless under peculiar circumstances, in making any exploration of the uterine organs until I have resorted to the treat- ment indicated for ovaritis. All but invariably, after blistering and leeching the ovarian regions, and treating the patient generally for some months, I find myself compelled to ascertain the condition of the uterus, owing to the persistence of the symptoms, both ovarian and other, and find uterine disease, the cure of which at once removes the ovarian symptoms. Although thus professing that a large proportion of the cases in which the symptoms attributed to subacute and chronic ovaritis are cases of other disease, in which the ovary is merely sympathetically irritated, merely the seat of neuralgic pain and tenderness, I fully admit, as I have above stated, that these same symptoms are occa- sionally produced by the diseased states in question. That such is the case becomes certain when the symptoms enumerated are present, in the absence of uterine lesions, or if enlargement and tenderness of the ovary can be ascertained to exist by careful vaginal or rectal digital examination, or by the combination of the two, the double touch of M. Recamier. The forefinger of the right hand passed carefully by the side of the cervix uteri, so as to press up the vaginal cul de sac in the direction of the lateral ligament and ovary, or passed into the -rectum, along the side of the uterus, whilst the fingers of the left hand are pressed over the ovarian region externally, will often detect very trifling enlargement of the ovary, especially if it has prolapsed into the pelvic cavity, as it sometimes does, and is tender to the touch. The general symptoms occasioned by chronic inflammation of the ovary thus inflamed and enlarged, are pretty nearly the same as those to which uterine inflammatory disease gives rise, only they are more obscure and chronic. It is, therefore, unnecessary to enumerate them. We have also the same tendency to monthly exacerbations under the influence of menstruation. I am persuaded that considerable ovarian disease, of a low inflammatory nature, may take place without much local pain or tenderness being present, merely reacting on the men- strual function, giving rise most frequently to amenorrhea, or to irregular, scanty, and inefficient menstruation, and deteriorating imperceptibly the. general health. The continued existence of such INFLAMMATION OF THE OVARIES. 195 disease is no doubt, likewise, the explanation of the occasional non- recovery of patients who have been cured of uterine affections from which they had been long suffering, but who do not afterwards rally, as anticipated, and thus falsify the expectations entertained of their restoration to health. That chronic inflammatory morbid conditions of the ovaries, giving rise to thickening, induration, enlargement, &c, are often so obscure during life as not to be recognised, is proved by the frequency with which they are found in patients who die of other diseases in the general hospitals. This fact ought to induce the practitioner to scrutinize very minutely the state of these organs, in obscure forms of ill health, in which, in the absence of uterine or evident ovarian symp- toms the menstrual functions are deficient, and the general health out of order, or in which sterility exists without any apparent cause. ACUTE OVARITUS. Acute ovaritis in the non-puerperal state, although more frequently met with than acute metritis, is not a complaint of very common occurrence, owing probably to the dense structure of the ovary. It is Occasioned by the same causes as metritis, and occurs under the same circumstances. The symptoms of acute ovaritis, are great pain in the ovarian region, accompanied by perceptible swelling and heat, and great tenderness on pressure. The swelling and tenderness becomes still more evident, if the ovarian region be examined per vaginam. There is generally a certain amount of febrile action, which exists from the onset, and may be preceded by lassitude, headache, and even rigors. These symptoms may, after increasing in intensity for from three to five or six days, gradually subside, the inflammation terminating by resolution, or they may persist, becoming modified in intensity and character, owing to suppuration taking place. When this is the case, the inflammatory action generally extends itself to the cellular tissue contained between the folds of the lateral ligament, which envelopes the ovary, and the ovarian abscess thus becomes lost in the more extensive phlegmonous tumour which is formed. As the history of the ovarian abscess is from that moment identical with that of phleg- monous inflammation of the lateral ligaments generally, I shall include it in the general description of this disease which I now purpose giving, and of which it is no doubt frequently the origin or point of departure. 196 INFLAMMATION AND ABSCESS OF THE INFLAMMATION AND ABSCESS OF TnE UTERINE LATERAL LIGAMENTS AND UTERINE APPENDAGES IN THE PUERPERAL STATE. From the writings of Paulus JEgineta, and others, it is evident that pelvic inflammation and abscess in the female, their symptoms^ and sequelae, were known to the ancients. Not only does Paulus iEgineta distinctly mention the manner in which pus formed in the pelvic cavity finds its way to the exterior by the perforation of the rectum, vagina, or bladder, but he also enters into many curious details respecting treatment, describing the process for opening the abscess by the vagina—an operation which has only latterly been revived. The ancients do not appear, however, to have had a correct idea of the origin and nature of these abscesses, which they describe as abscesses of the uterus. They evidently thought that the uterus itself was the seat of inflammation, and consequently the source whence the pus came. The Arabians merely copied the classical writers on this as on most other subjects connected with uterine pathology, making no addition to the information contained in the works of the latter. In the seventeenth and eighteenth centuries, when a revival of mid- wifery and of uterine pathology began to take place, the attention of practitioners was directed to this important class of diseases by Guillemeau, Mauriceau, and more especially by Puzos. The two former thought, with the ancients, that the abscesses proceeded from the uterus, but Puzos recognised the fact of their generally originating in the lateral ligaments of that organ. His more correct views respecting pelvic inflammation in the female were, however, disfigured by a fanciful theory as to its origin, which he attributed to the "metas- tatic deposit of milk." This singular theory was, for a long period, adopted by all who wrote on the subject, amongst whom may be named Planchon, Van-Swieten Levret, Raulin, Antoine Petit, Gastelier, &c, and was only dispelled by the accurate anatomical investigations which characterize the commencement of the present century. Pelvic inflammation, both in the male and female, has attracted much attention in France during the last thirty years, and its history has been elucidated by various writers, and more especially by Dance, Husson, Boivin, Baudelocque, Meniere, Andral, Dupuytren, Grisolle, Velpeau, Bourdon, and M. Marechal de Calvi. This last writer pub- lished, in 1844, an interesting monograph, which contains a good analysis of the existing state of knowledge on the Continent, with reference to pelvic inflammation generally. In our own country, pelvic inflammation—especially that form of the disease which developes itself in the uterine appendages, and which has hitherto been universally connected with the puerperal state—has attracted much less notice. It is scarcely, if at all, alluded to in the principal monographs on the diseases of females, those, for instance, OVARIES AND UTERINE APPENDAGES. 197 of Gooch, Sir Charles Clarke, Churchill, Lever, Ashwell, &c, although isolated cases of inflammation and abscess of the ovaries and Fallopian tubes are described and referred to. Nor does our periodical literature contain much information on the subject, with the exception, however, of the interesting articles of Dr. Doherty and Dr. Churchill, in the Dublin Medical Journal 1843-44, on " Inflammation and Abscess of the Uteiine Appendages," and the paper published in 1844 by Dr. Lever, in Guy's Hospital Reports, under the head of " Cases of Pelvic Inflammation occurring after Delivery." Although of late years so much has been written abroad by French pathologists on phlegmonous inflammation of the uterine appendages, there is still an ample field for investigation. Indeed, I may safely say, that notwithstanding all the efforts that have been made to eluci- date it, the disease is as yet but very partially understood. This I believe is to be attributed to the circumstance, that up to the present time it has only been studied in relation to the puerperal condition, with which it is supposed, by the authors I have named, to be nearly always connected; whereas, in reality, it not unfrequently occurs apart from that state. It is now more than ten years since this fact was pointed out to me by M. Gendrin, the eminent Parisian pathologist; and I have since satisfactorily ascertained the correctness of his state- ment. A careful analysis of all the cases of pelvic inflammation in the female that I have met with, in a rather wide field of observation, enables me to state most positively, from my own experience, that the disease is by no means uncommon in the non-puerperal state, although generally unrecognised and confounded with acute metritis, or iliac abscess. I am not aware that thjs important fact has hitherto been recognised by any author who has written on the subject in question, the most recent essays on inflammation of the lateral ligaments treat- ing of it as a disease all but peculiar to the puerperal state. Thus out of fifty cases collected from various sources, and published by M. Marechal de Calvi, whose work represents the present state of science abroad, forty-nine are puerperal; out of twenty-three cases quoted by Dr. Churchill, twenty-one are puerperal; the case of Dr. Doherty is puerperal; so also are the nine cases of Dr. Lever. Owing to inflammation of the uterine appendages having thus been studied only in its severest form,—as it occurs in connexion with the puerperal state,—the peculiar features which the disease presents in its milder or non-puerperal shape have not yet been described. Thus it is that this form passes unrecognised. Nor can we be surprised when we consider how peculiar is the stamp which the puerperal state impresses on all inflammatory diseases. Under its influence they pre- sent, as we have seen, an unusual intensity; owing, in a great measure, it is supposed, to the increased quantity of fibrine contained in the blood. This increased intensity has been more particularly noticed with reference to inflammation of the uterus, and is equally observable in the organs connected with it. Thence inflammation of the uterine appendages occurring after parturition presents as great a 198 INFLAMMATION AND ABSCESS OF THE UTERINE AFPENDAOES. difference from the same disease in the ordinary state of the system, as puerperal metritis offers to the non-puerperal form of that complaint. In the puerperal form of the disease, the uterus itself is nearly always considerably implicated; the inflammation of the ovaries, Fal- lopian tubes, or cellular tissue, has a tendency to extend to the perito- neum, and to the cellular tissue lining the pelvic cavity ; adhesions to the abdominal parietes, abdominal perforations, and even death, not unfrequently taking place. In the non-puerperal form, on the contrary, the disease has a tendency to limit itself to the tissues primarily attacked; peritonitis, abdominal perforations, and a fatal termination, very rarely occurring. The non-recognition of the milder form of this disease has been attended with another evil. The less severe cases of puerperal inflam- mation are often passed over, and extreme cases only observed and recorded, the result being, that erroneous impressions become preva- lent even with respect to the puerperal form. Thus we find M. Marechal de Calvi giving it as an ascertained fact, that the disease is very often fatal, because he finds thirteen fatal cases amongst the fifty,—in reality exceptional cases,—which he has collected. Reason- ing on the same fallacious data, he also comes to the conclusion that these abscesses open as often by the abdominal walls as by the rectum or vagina. In both these assertions there can be no doubt that he is quite in the wrong. It is my intention, first, to treat of inflammation and abscess of the uterine appendages in the non-puerperal state. By studying this affection in a form in which it is infinitely more simple, and much less complicated with diseases of the surrounding tissues, than when it follows parturition, I hope to be able to throw some additional light on the disease in all its forms. Before, however, we proceed any farther, I must briefly recall to mind the anatomy of the region in which the disease of which I am treating occurs. The peritoneum in the female, after covering the posterior surface of the bladder, is reflected on to the uterus, covers the anterior surface of the body of that organ, also its posterior surface, and is then again reflected on to the rectum. As it passes from the anterior to the posterior wall of the uterus, the peritoneum forms two wide folds, which contain the Fallopian tubes, the ovaries, and the round ligaments. {See fig. 3, p. 15.) The two folds of the peritoneum, which thus, by their juxtaposition, constitute the lateral ligaments, are separated one from the other, and also from the organs which they contain, by a certain amount of filamentous cellular tissue. This cellular tissue is connected with the extra-peritoneal cellular tissue of the pelvis, although in a great measure distinct from it, and deserves more atten- tion both from anatomists and pathologists than it has hitherto received. From its cellular nature, it is prone to inflammation, and consequently it plays a most important part in inflammatory disease of this region. Its physiological use, no doubt, is to allow the folds of peritoneal NON-PUERPERAL INFLAMMATION OF THE UTERINE APPENDAGES. 199 membrane to separate and glide one over the other, when the uterus increases during pregnancy. The structure of the ovaries is fibro-cellular, whilst the Fallopian tubes presents a central mucous canal, and a cellular investment. Both these organs, therefore, as well as the cellular tissue which sur- rounds them, are liable to be attacked by inflammation. We have thus in the cavity of the pelvis, immediately adjoining the uterus, above the pelvic fascia, between two peritoneal folds, but external to the peritoneum, in contact with the bladder anteriorly and the rectum posteriorly, a space containing a mass of filamentous cellular tissue—a tissue peculiarly liable to inflammation—and various other organs, also, which from their structure are more or less exposed to inflammatory disease. The history of inflammation in the space thus limited flows so regularly from the laws of pathology, as applied to these anatomical data, that it is a matter of surprise to me that it should not hitherto have been elucidated. In puerperal peritonitis, the lateral ligaments are frequently more or less implicated. It is by no means uncommon, in fatal cases of this form of the disease, to find one or both the ovaries in a state of sup- puration, or to meet with abscesses more or less voluminous in the lateral ligaments themselves, or in the walls or cavity of the Fallopian tubes. But in these cases the extension of the inflammation from the peritoneum to the organs contained between the lateral ligaments is merely an epiphenomenon of the peritonitis, and is not, generally speaking, attended with any symptoms deserving attention. The complication only becomes important if, as sometimes occurs, after the peritonitis has been subdued by treatment, abscesses remain within the lateral ligaments. Such a case, however, would then fall under the category of those which I shall have to describe, in which the inflam- matory disease exists between the folds of the lateral ligaments, without the peritoneal folds being compromised, or at least without the peritoneal inflammation ceasing to be completely local. INFLAMMATION AND ABSCESS OF THE UTERINE APPENDAGES IN THE NON- PUERPERAL STATE. Seat.—Inflammation occurring in the region which I have described may attack the cellular tissue alone, in which case it is a purely phleg- monous inflammation, or the ovaries alone, or the Fallopian tubes alone, or it may attack all together; in either case the peritoneum may or may not be compromised. Owing to the localization of these organs, to their lying in the same regions, and to their having the same anatomical relations, the symptoms and history of inflammation in them are so similar, that it would be difficult, if not impossible, and certainly useless, to attempt to describe them separately. I shall therefore treat of inflammation of the lateral ligaments generally, 200 N ON -PUERPERAL INFLAMMATION AND ABSCESS pointing out, as I proceed, any difference which may exist, and which is really susceptible of being appreciated. The peritoneal fold themselves are seldom compromised in non-puer- peral inflammation of the uterine appendages. When inflammation occurs in this region after parturition, there is a great tendency in the peritoneal membrane to take on the inflammatory action, as is the case when the uterus itself is the seat of inflammation. In the unimpreg- nated non-puerperal condition, on the contrary, there is very little tendency to inflammation in the peritoneum, and the organs contained between its folds may remain inflamed during months or years without the membrane itself being much affected. This is a singular patholo- gical fact, but one which is equally true when applied to inflammatory affections, external to the peritoneum in other parts of the pelvic cavity. Even when peritonitis does complicate the attack in the non- puerperal state, it seems to have a greater tendency to localize than to extend its action—the contrary of what obtains in the puerperal condition. In non-puerperal inflammation of the lateral ligaments the disease, in most cases, is very evidently limited to the cellular tissue, and to the organs contained between them, and does not extend to the free cellular tissue of the pelvic cavity. This circumstance induces me to think that in the puerperal form the disease is, generally speaking, similarly limited at first; although such is not the prevailing opinion. Causes.—The causes of inflammation of the lateral ligaments, in the non-puerperal state, are the same as those of acute metritis. . Any physiological or pathological action which is calculated to exaggerate the vitality, or to arrest the functions of the uterine system, may be followed by this form of inflammation. Inflammation may attack the lateral ligaments directly or indirectly; directly, when they are primarily affected; indirectly, when the uterus is first inflamed, and the inflammation extends from it to the ligaments. Owing to the tendency of the causes which produce uterine inflammation to act on the periphery of the uterine system—a tendency which I have already noticed—inflammation of the lateral ligaments not unfrequently occurs without being preceded or accompanied by metritis. It then originates, as we have seen, sometimes in the cellular tissue, sometimes in the ovaries, and sometimes in the Fallopian tubes, the probable order of their relative frequency. The cause which in the very great majority of cases gives rise to the inflammatory attack, is arrested menstruation. When menstruation is suddenly suppressed, the uterine system being no longer able to relieve itself of the blood that fills it, inflammation may supervene, generally attacking those regions which are endowed with the highest degree of vitality, and which are consequently the most liable to inflammatory action. I have repeatedly seen this form of uterine inflammation manifest itself in persons labouring under chronic inflammation, or inflammatory ulceration of the cervix.1 The I*published aU iaterestinS case of this description in the Lancet for Feb. 14, 1846, OF THE OVARIES AND UTERINE APPENDAGES. 201 disease of the cervix is then evidently the point of departure of the inflammatory action, which thence extends to the lateral ligaments. In several instances I have known it follow a severe fall. Even in these cases, however, the inflammation of the uterine appendages generally takes place in connexion with menstruation. Symptoms.—The symptoms of inflammation of the uterine appendages are at first sight similar to those of acute metritis. There are the same general febrile symptoms, the same severe pains in the lower hypogastric region ; and on attempting to walk or to stretch the body in the erect posture, the same abdominal tenderness and sensation of weight deep in the pelvis, the same vesical irritation and difficulty in defecation. On a closer inspection, however, we may appreciate some dissimilarities. The pain is greatest at a little distance from the median line, in the right or left ovarian region ; more frequently in the latter. Sometimes the tumefaction is perceptible to the eye from the first. If the patient can bear pressure, and the abdominal parietes are not too thick, or too rigid, a deep-seated swelling is frequently per- ceived in the ovarian region. The presence, however, of these symptoms is seldom sufficiently conclusive to enable the practitioner to distinguish by them alone, inflammation of the lateral ligaments from acute metritis. In order to clear up the doubt that otherwise must necessarily remain respecting the true nature of the disease, it is indispensable that a careful digital examination should be made. This is, in my opinion, effected most satisfactorily by placing the patient on her back, the knees being elevated or flexed: the forefinger being introduced into the vagina, the elbow should be depressed, so that in penetrating it may adapt itself to the axis of the pelvis. The pulp of the finger may thus be carried underneath and round the cervix, which should be carefully and accurately examined ; then by pushing before the finger the cul de sac of the vagina, where it is inserted on the cervix, the state of the body of the uterus, of the adjoining pelvic organs, and of the pelvic cavity generally, may be ascertained with extreme accuracy, especially if the left hand is at the same time epplied over the lower hypogastric region, above the pubis. When this mode of examination is adopted in the healthy female, the bladder being previously emptied, the finger may push the vaginal cul de sac before it on the side of the uterus for an inch or two, and can be made to approximate within a very slight distance of the hand applied externally, and that without giving the slightest pain. The practioner feels with the greatest distinctness that his fingers are only separated from each other by the thickness of the abdominal parietes, and by tissues (the lateral ligaments) which present no great density or resistance. When, however, the structure contained between these ligaments—cellular tissue, ovaries, and Fallo- pian tubes—are inflamed, thickened, and indurated, the state of things is very different. On attempting to push back the vagina on the side of the uterus, we find an unusual resistance. The vaginal cul de sac has disappeared, and resting on the side of the cervix and body^of 202 NON-PUERPERAL INFLAMMATION AND ABSCESS the uterus, there is an indurated swelling; very different from the normal condition, and very different, also, from what obtains on the other or healthy side, supposing disease to exist on one side only, as is most frequently the case. Pressure on the indurated parts is attended with very great pain, and there is a marked increase in the_ natural heat of the region. On carrying the finger behind the inflamed structures, whilst the abdomen is greatly depressed with the left hand, we can ascertain that the inflammatory tumour situated between the hands is moveable, and quite distinct from the parietes of the pelvic cavity. This tumour being generally attached, as it were, to the side of the uterus, only constitutes one mass with that organ. Thence it is, no doubt, that inflammation in the lateral ligaments is^ generally confounded with metritis, even when a digital examination is resorted to, and the presence of an inflammatory swelling recognised. If, notwithstanding a careful vaginal examination, there are doubts as to the nature and extent of the swelling, the uterus and annexed organs should be digitally examined through the rectum. The tumour formed by the inflamed lateral ligaments is, I believe, more intimately connected with the uterus when it is a purely phleg- monous one—that is, when it is merely the result of inflammation of the cellular tissue—than when it is formed by the inflamed ovary. I would not, however, assert that this is always the case. Under all circumstances, the connexion between the inflammatory tumour and the side of the uterus is so intimate, that it must require some expe- rience of these cases to enable a practitioner to distinguish between an enlargement of this description and that caused by acute or chronic metritis. Acute metritis in the non-puerperal state, as we have seen, generally ends by resolution, or by passing into the chronic stage, suppuration being a rare event, owing to the absence of cellular tissue in the structure of the uterus. Inflammation in the lateral ligaments, on the contrary, generally ends in suppuration. It is, in reality, in most cases, a purely phlegmonous inflammation; and the great tendency of this form of disease to terminate by suppuration is an axiom in pathology. Although much less liable to end in suppuration than in inflammation of the cellular structure, ovaritis is more frequently followed by suppuration than acute metritis. Suppuration may consequently be looked for in the course of a few days from the onset of the inflammation, unless the latter has been checked by early and energetic treatment. An experienced and atten- tive observer may determine when suppuration has taken place by the rigors and other symptoms that accompany internal suppuration, by the lull of the general and local symptoms that follows, and some- times by a sensation of deep-seated fluctuation perceptible to the touch through the vagina, or even through the abdominal parietes. When once pus has formed, being closely confined in the region described, if it is not absorbed, as is sometimes, though rarely, the case, it endeavours to find a vent. Adhesive inflammation connects OF THE OVARIES AND UTERINE APPENDAGES. 203 the phlegmonous tumour with the vagina, rectum, abdominal parietes, or bladder, and in the course of a variable period, but generally before the acute inflammatory symptoms have subsided, the pus finds an exit in one or more of these directions. It is nearly invariably by the upper portion of the vagina, or by the rectum, that the pus escapes, in the non-puerperal form of inflammation. I can scarcely recall to mind an instance in which I have seen the pus make its way through the abdominal parietes in this form of inflammation, except in a case or two in which there was a serious and permanent cause of disease, such as suppurated tubercle, in the uterine appendages. When, how- ever, this is the case, it is only after the inflammatory action has lasted for weeks, or even months, that the pus reaches and perforates the abdominal walls; and, nearly always, long before the external perforation takes place, it has also found its wTay out of the pelvis, through the vagina or rectum. The emptying of the abscess into the bladder is of still less frequent occurrence, and is likewise generally preceded by the formation of a vaginal or rectal opening. Sometimes the abscess will open in all these directions successively. These may be termed the ordinary directions by which the pus escapes from the pelvis. In some instances, the peritoneal folds of the lateral ligament ulcerate in the direction of the peritoneal cavity, and the contents of the abscess are evacuated in the peritoneum, giving rise to acute general peritonitis. Sometimes the pus passes along the round ligaments and appears in the labia externa, or, escaping from the pelvis along with the large femoral vessels, follows their course, and points in the thigh. These, however, are quite exceptional cases, and very rarely met with, especially in the non- puerperal form of the disease. In some instances, the pus appears to escape from the neck of the uterus, as if the abscess had emptied itself into the cavity of that organ. I think, however, that when this is the case, the real explanation is that the phlegmonous tumour of the uterine appendages is complicated with metritis, and that an abscess formed in the walls of the uterus has opened into the cavity of the organ. An abscess primarily formed in the lateral ligaments would scarcely be likely to work its way through the thick unyielding walls of the uterus, at least not unless the uterus participated in the inflam- matory action. Generally speaking, as I have stated, the abscess opens, into the vagina or rectum, or into both. That such should be the case is at once accounted for when we consider the position of the phlegmonous tumour with reference to these organs, with which it is in immediate contact. The perforation mostly occurs during some exertion, such as a fit of coughing, or the act of defecation, and in so insidious a manner that it is not perceived or mentioned by the patient, unless her attention be previously directed to the point by her medical attendant. This, however, seldom occurs in non-puerperal abscesses, as he himself is not aware of the nature of the disease, and believes his patient to be merely labouring under metritis. The passage of 204 NON-PUERPERAL INFLAMMATION AND ABSCESS even a considerable quantity of pus from the vagina is thought by the patient to be only an increased flow of the whites, and the escape of pus along with the faeces is still less likely to attract her attention. Women, from a natural feeling of delicacy, require to be closely ques- tioned with regard to uterine symptoms, seldom giving any information respecting themselves spontaneously. This circumstance, and their ignorance of the importance of the fact, will tend to account for their not mentioning, unless asked, the escape of pus from the rectum or vagina, even in the few instances in which they are aware that it has taken place. Sometimes the perforation is accompanied by a bursting sensation. It may take place within a few days of the onset of the inflammation, or it may be weeks before it occurs. The quantity of pus passed varies from a few drachms to half a pint, or more.^ It is owing, no doubt, to the escape of the purulent collection from the cavity of the pelvis thus taking place in so insidious and latent a manner, that unless carefully looked for it is not perceived by the patient or her medical attendant, that the most severe forms only of the disease have hitherto been recognized and recorded. The escape of the pus through the vagina is the most favourable point at which it can make its way out of the pelvis. Its presence occasions a certain amount of irritation of the mucous surface over which it passes, but that irritation is scarcely ever considerable. The next most favourable termination is the penetration of the pus into the rectum. When this occurs, there is generally great irritation of the intestinal mucous membrane. Either the ulcerative inflammation of the coats of the rectum, or the presence of the pus, seems to be gene- rally attended by a considerable degree of dysenteric irritability of the lower bowel, which often lasts several days. Repeated motions take place, accompanied by pain and tenesmus. In both cases, the openings by which the pus penetrates into the rectum and vagina are small. In the vagina, the finger frequently fails to detect the precise spot at which the pus has perforated the parietes, nor is it easier to discover it with the speculum. An instru- mental examination, however, is scarcely ever necessary, or even admissible, in the acute stage of this disease, owing to the tenderness of the vagina and internal tissues. Even in a more advanced stage, it is only necessary if there is coexisting disease of the cervix that requires local examination and treatment. Sometimes, however, there is a slight depression or induration where the opening exists, which indicates its presence to the finger. The faeces and intestinal gases do not appear to escape by these perforations from the rectum, owing, probably, as Dupuytren supposes, to their orifices being closed by the pressure of the abdominal organs. The escape of the pus by the parietes of the abdomen is always preceded and accompanied by great inflammatory swelling and indu- ration of the surrounding tissues and of the abdominal walls. The phlegmonous tumour is a long time in reaching the exterior, and gradually involves all the tissues which separate it from the skin, OF THE OVARIES AND UTERINE APPENDAGES. 205 thus giving rise to an extensive inflammatory tumour of a very painful and distressing nature. The opening generally takes place above the crural arcade, in the neighbourhood of the ovarian region. The sym- pathetic and reactional symptoms are necessarily severe in these cases; but the entire series of symptoms, both general and local, which are observed when abdominal perforations occur, may be con- sidered as more especially characteristic of the puerperal form of the disease, since they are scarcely ever met with apart from its presence. The penetration of the pus into the bladder is a very rare circum- stance; and before it takes place, it has nearly always found some other vent. In one case—a puerperal one, however—which I had under my care in 1840, at the Hospital St. Louis, Paris, the pus made its way successively into the> rectum, through the abdominal walls, and into the bladder. The presence of the pus in the bladder is always attended by very considerable cystic irritability; but the urine does not appear to escape from the ulcerated opening, at least I have neither seen nor read of any instance in which there was reason to suppose that such a serious accident had taken place. When the pus has fairly escaped from the pelvic cavity, a marked change is observed in the state of the patient. There is a decided lull in all the symptoms. The deep-seated pelvic pains diminish, as do also the abdominal tenderness and swelling, and the febrile symptoms quickly subside. In very many cases the improvement is so rapid, especially when the abscess has opened by the vagina, that the patient is considered quite convalescent, and in hospital practice is discharged as cured. This improvement, however, although real, is very deceptive with reference to the future. On making a careful digital examination of a patient so situated, we find that the tumour on one side of the uterus is much diminished in size, that it is no longer so sensitive to the touch, and that there is less heat and tenderness in the upper part of the vagina, and on the side which is in contact with the phleg- monous swelling. But although thus less in size, and less inflamed, the inflammatory tumour is nearly always still perceptible. Part of it has melted and suppurated, but part remains in a state of semi-chronic inflammation and induration, as is generally the case with suppurated phlegmonous tumours. The symptoms which indicate chronic uterine inflammation will con- sequently, on a close examination, be found still to exist. Pain, heavi- ness, and bearing-down, deep in the pelvis; tenderness, pain, and often swelling in one or both the ovarian regions; pain in the lower part of the back; and inability to stand or walk for any time, and more espe- cially to go up and down stairs. These symptoms may be more or less apparent. The orifices by which the pus has escaped into the vagina or rectum generally remain open, and thus allow the pus to discharge itself as it is formed. Sometimes, however, they close in the course of a few days. When this is the case, if pus ceases to be secreted and the remains of the phlegmonous tumour are rapidly resolved, as sometimes occurs, the 206 NON-PUERPERAL INFLAMMATION AND ABSCESS disease is soon brought to a close and the patient completely recovers in the course of a few weeks or of a month or two. But if pus con- tinues to be secreted, it collects, again forms an abscess, and, before it escapes by ulcerative inflammation, may reproduce, though generally in a mitigated form, the acute inflammatory symptoms previously experienced. Were these inflammatory tumours not exposed to the influence of any perturbing causes, they would no doubt, in most instances, gradu- ally become absorbed, and the relapses just described would be slight and unfrequent. Such, however, unfortunately, is not the case; at least in a large proportion of the instances met with. The molimen hemorrhagicum which accompanies menstruation, or functional excite- ment, generally rouses the dormant inflammatory action repeatedly in the still indurated and tumefied tissues. The acute symptoms of the disease reappear, and matter again forms, which forces its way into the vagina or rectum; in the latter case, giving rise to-dysenteric symptoms. These exacerbations or returns of acute disease become less and less frequent as the inflammatory tumefaction of the uterine appendages diminishes, and as the diseased tissues return to their natural con- dition. The malady, however, is essentially a chronic one. A female who has suffered from inflammation and suppuration of the lateral ligaments, even in its mildest form, may be from several months to one or more years before all trace of local inflammation has disap- peared, and before she can be said to be radically well. During this lengthened period, she is never quite free from symptoms of uterine irritation, and remains subject at intervals to the acute exacerbations which I have described. Whilst thus suffering, menstruation is always more or less modified. Sometimes it is absent for months, sometimes its appearance is only delayed for a few days or weeks. Generally speaking, the menstrual period is curtailed, the quantity of blood lost is diminished, and great pain is experienced during the entire period of the menstrual secretion. In some rare instances, however, the quantity of blood lost is increased, and the periods are approximated. Finding, as we thus do, that the physiological congestion which accom- panies menstruation is so much increased and disturbed by the pre- sence of disease in the annexed uterine organs, we cannot be surprised that it should in its turn exercise a prejudicial influence over the inflammatory affection, and be the most frequent cause of the exacer- bations that we have noticed. Nor is it surprising that there should be always a leucorrheal discharge present, the entire uterine system remaining in a state of permanent congestion even when not under the influence of the menstrual flux. Long before the local tenderness gives way, and before the patient can be pronounced well, all trace of induration or swelling, as appre- ciable by the touch, either through the vagina or through the abdominal parietes, will be found to have disappeared. The formation and escape of matter often comes to a close at even a much earlier period; before OF THE OVARIES AND UTERINE APPENDAGES. 207 the induration has melted and ceased to be recognizable on a digital examination. Such is the succession of morbid symptoms observable in the milder or non-puerperal forms of inflammation of the uterine appendages. Although often overlooked, owing to ignorance of the pathological facts of which these symptoms are the result, this disease is in reality as easy to recognize and to follow in the evolution of its phenomena as many better known affections. Progress and Termination.—In the acute stage, inflammation of the lateral ligaments is accompanied by the train of general febrile symp- toms that accompany acute diseases generally. As it passes into the chronic form, it gives rise to the host of sympathetic morbid symptoms which characterize chronic uterine disease generally—dyspepsia, cardi- algia, constipation, cephalalgia, palpitation, insomnia, general debility, defective nutrition, &c. It may terminate, as we have seen, by resolution in the first stage under prompt and energetic treatment. More generally, however, suppuration takes place, and the tedious succession of morbid pheno- mena which I have described are observed. The duration of the secondary stage of the disease, pending which the patient is gradually but slowly rallying from the effects of the first attack of acute inflammation and its immediate results, vary according to the state of the constitution and of the general health, to the social circumstances of the patient, and to the treatment resorted to. When all the circumstances are favourable, the exacerbations and relapses are few in number, and the patient recovers with comparative rapidity. When such is not the case, and sometimes under the most favourable circumstances, the return to health is very slow and tedious. Generally speaking, however, in the form of the disease which I am now more especially describing, that which is unconnected with parturition, the pus escaping internally and the abdominal walls not being involved, the secondary symptoms are not very severe, except during the exacer- bations and relapses. The patient is able to get about, and to follow more or less her usual avocations. She is merely in delicate or bad health, has unusual pelvic pains and sensations, and menstruation is disturbed and laborious; the real cause of this condition being nearly always a mystery both to herself and her medical attendant. Prognosis.—The prognosis of this disease, either under its puerperal or non-puerperal form, cannot be considered imminent as regards the life of the patient, but may be always looked upon as serious with reference to her health for a lengthened period. When it occurs apart from the puerperal state, it very seldom terminates fatally ; although, as we have seen, it nearly always entails suffering upon the patient for months, and sometimes even for years. Hence the very great impor- tance of distinguishing between it and acute metritis, with which it is most frequently confounded. Acute metritis generally terminates by resolution under judicious treatment, without giving rise to suppuration, and without leaving behind it any traces of its existence. Inflammation 208 NON-PUERPERAL INFLAMMATION AND ABSCESS of the lateral ligaments, on the contrary, although apparently not a more severe disease in its invasion and period of acuity, gives rise to lesions and changes of structure which time only can remove, and which are sometimes never completely remedied. The reason that inflammation and abscess of the lateral ligaments have hitherto been considered so serious a disease, and described as very frequently fatal, is, as I have stated, that attention has only been directed to exceptional cases, to those which follow parturition, and in which very extensive pelvic suppurations take place, giving rise to external perforations. In this form of the disease, death occasionally occurs; but even under such circumstances it is rare, unless the inflammation assume an extreme and exceptional degree of intensity. Diagnosis.—No one who has carefully read the above description of inflammation of the lateral ligaments can doubt the extreme impor- tance of an early and accurate diagnosis. When recognised in the first stage of its existence, we may by active treatment produce complete resolution, in which case the disease is at once brought to a close ; and even when unsuccessful in preventing suppuration, the extent of the surrounding inflammation, and the quantity of pus formed, may be limited, and much future suffering spared to the patient. Nor is it a matter of small importance that, being aware from the first of the serious nature and of the peculiar features of the disease in its secondary stage, we are prepared to give a guarded prognosis, or even to predict to the patient and her friends the long train of morbid symptoms that generally follows when suppuration has once taken place, If, on the contrary, we slur over the diagnosis, omitting to resort to those means of examination by which alone we are enabled to recognise the true nature of the disease—if we satisfy ourselves with the presumption of its being a case of metritis or of " inflammation of the bowels"—the vague appellation under which various pelvic and visceral inflammations are so often confounded—the health of the patient and the reputation of the practitioner alike suffer. The symptoms of inflammation of the lateral ligaments in the acute state are often, as we have seen, so similar to those of acute metritis, that unless there be from the first a deep-seated tumour of an inflam- matory nature perceptible in one or both ovarian regions on external pressure, it is next to impossible to distinguish one disease from the other by any means except a careful digital examination. Such an examination is the more necessary, as, even were a tumour found evidently developed externally to the uterus, it would yet be impos- sible, without a digital exploration, to say positively whether the disease was a phlegmonous inflammation of the lateral ligaments, or a similar inflammation developed in the iliac fossa. This latter affection is still universally confounded with the one we are studying, notwith- standing the attention which it has recently attracted. ^ The proximity of the region in which the lateral ligaments are situated to the iliac fossa is so great, that phlegmonous tumours developed in either locality must encroach more or less on the other, OF THE OVARIES AND UTERINE APPENDAGES. 209 thus rendering the distinction by palpation through the walls of the abdomen in most cases difficult, if not impossible. We must not, also, forget to take into consideration, as increasing the difficulty of diagnosis by external examination, the extreme sensibility of the abdominal parietes in these inflammatory diseases, and their consequent spasmodic rigidity, and the frequent presence of a considerable amount of adipose tissue. These various obstacles may, however, be overcome in the very great majority of instances, by a careful digital exploration per vaginam of the pelvic cavity. It is a singular circumstance, and one worthy of notice, that none of the authors who have written on iliac abscess in the female, have given due weight to this very important and rational mode of establishing a corrrect diagnosis. Many writers do not' even attempt to separate the two diseases, unintentionally confounding them in the same description; and those who try to establish the distinction rely on the external examination of the abdominal parietes, and on other symptoms, such as the site of the disease, which is generally on the right side in iliac abcess, retraction of the thigh being often present in that affection, and generally absent in the other disease, &c. If the phlegmonous tumour is situated in the iliac fossa, and in cases of lumbar or psoas abscess, the finger finds the uterus, the region imme- diately adjoining it, and the vaginal cul de sac, nearly free from tumefaction, heat, or pain; although the presence of an inflammatory affection in the neighbourhood sometimes imparts considerable sensi- tiveness to these organs. On pushing back the vagina towards the side of the pelvis, the phlegmonous tumour may be felt, but evidently connected with the side of the pelvis; over the edge of which it protrudes more or less internally. When the appendages of the uterus, on the contrary, are affected, with the assistance of the finger we at once perceive that the disease is seated in the pelvic cavity itself, where all the changes previously described are detected. In some rare instances, inflammation may pass from the lateral ligaments to the iliac fossa, and vice versa, in which case the symptoms of the two affections would be united. Acute metritis and iliac abscess are the two diseases with which inflammation of the lateral ligaments is most likely to be confounded. It presents, however, some features in common with other pelvic affections. In chronic partial metritis, there is a limited tumefaction of the uterus which might be mistaken for a small inflammatory tumour of the lateral ligaments in juxtaposition with the uterus ; but in chronic metritis the enlargement is nearly always situated at the posterior and inferior portion of that organ, not at the side, and it is decidedly a part of the uterus; there is no trace of suppuration, and the antecedents are different. Tumours of the ovaries or of the Fallopian tubes, a tumour formed by extra-uterine pregnancy, or by a collection of faeces in the large intestines, may all occupy the same position, but there is the entire absence of inflammatory symptoms, and the completely different nature of the antecedents and symptoms of the disease to guide us. 210 PUERPERAL INFLAMMATION AND ABSCESS Inflammation of the lateral ligament is not only met with in the acute stage; it frequently presents itself to our notice for the first time in a chronic state, having existed unrecognised for a lengthened period. When this is the case, the abdominal tenderness, the external swelling, and all the acute symptoms may have disappeared. The symptoms may be merely those of chronic uterine disease, more or less marked, with disturbed menstruation, and occasional inflammatory exacerbations. At this stage of the disease an accurate digital exami- nation is the only means of arriving at a correct diagnosis. If we find the remains of a phlegmonous tumour in contact with the uterus, and the antecedents of the case are such as I have described, the nature of the disease may be at once presumed. In some instances I have even clearly recognised the disease by the history which the patient gave me of her sufferings, when all traces of inflammatory induration had disappeared from the pelvis, and there was only slight tenderness in the region previously affected. When the phlegmonous inflammation spreads throughout the entire pelvis, and purulent collections form in various directions, the pelvic cavity becoming, as it were, a mass of disease, it is difficult to say where or how the malady began, if we have not had an opportunity of following its course. But these cases belong more especially to the severe inflammation of the lateral ligaments, that which I shall briefly describe under the head of INFLAMMATION AND ABSCESS OF THE UTERINE APPENDAGES IN THE PUERPERAL STATE. The puerperal state, which may be said to extend from the time of parturition to the end of the fourth, fifth, or sixth week, is one of considerable danger. Whilst it lasts, as I have stated, all inflam- matory diseases present peculiar severity, and more especially those of the prgans that have been directly or indirectly concerned in the function of parturition. If inflammation occurs in the lateral ligaments immediately after delivery, it is frequently complicated with metro-peritonitis, appearing merely as an epiphenomenon of that formidable malady. Most recent writers on puerperal fever have noticed the frequent occurrence of suppuration in the ovaries and lateral ligaments in fatal cases of metro-peritonitis. But even when the lateral ligaments are attacked with inflammation several weeks after parturition, the general symp- toms run higher, the local tumefaction is greater, and there is from the first a greater disposition in the phlegmonous inflammation to extend and to compromise the adjoining tissues, than in the non-puerperal form of inflammation. There is also much greater difficulty expe- rienced in arresting the progress of the disease; the inflammatory and the suppurative process often continue to extend long after the first purulent collection has escaped from the pelvis; and at last give rise in OF THE OVARIES AND UTERINE APPENDAGES. 211 many cases to abdominal adhesions and perforations. This, the severe form of the disease, is the exception in the non-puerperal state; whereas in the puerperal condition, it is so frequently met with, that it has hitherto been considered the only form under which the malady manifests itself. When connected with metro-peritonitis, it is all but impossible to distinguish the symptoms peculiar to the inflammation of the lateral ligaments in the midst of those of the metro-peritoneal inflammation ; but on the latter subsiding, a phlegmonous tumour will be found in the pelvis, recognisable by the symptoms which I have pointed out. Sometimes, in the recovery from metro-peritonitis, false membranes imprison or limit, on one or both sides of the uterus, collections of pus, which are internal to the peritoneum and external to the lateral ligaments, but which, lying in contact with the lateral ligaments, simulate phlegmonous tumours of these organs, and are not to be distinguished from them. In these cases, the lateral ligaments them- selves may or may not be diseased. Even when the disease is a bona fide phlegmonous inflammation of the organs contained within the lateral ligaments, if it has originated in an attack of metro- peritonitis, it is nearly always subsequently complicated by more or less chronic inflammation of the uterus and neighbouring peritoneum, Inflammation of the lateral ligaments may, however, appear prima- rily, at any period of the puerperal condition, apart from metro- peritonitis. The symptoms are those which I have already described, but in a more violent form; the degree of violence depending, to a great extent, on the proximity to the date of the delivery. In these cases there is often a certain amount of metritis and peritonitis present; the peritoneum not having yet lost its liability to take on inflammatory action. I have often seen this form of the disease in the Paris hospitals in young women who, after passing over their confinement safely in the maternity hospitals, had been sent out on the eight or tenth day, and had been exposed to cold and over-exertion on their return home. One of the most frequent causes is the sudden arrest of lactation, however it may originate. In the puerperal form of the disease, the inflammation being more extensive than in the non-puerperal condition, occupying nearly always the uterus and the peritoneum, as well as the cellular tissue and organs contained between the peritoneal folds, not only are the primary symptoms very much more acute and more serious, but we do not observe that complete remission of the febrile symptoms which takes place in the milder form, when the pus has escaped externally. Relief is certainly experienced by the escape of pus through the rectum, vagina, or bladder, but the relief is only partial. The abdominal tumefaction remains, and is hard and painful to the touch; the pulse is quick, the skin hot, the tongue white, or furred ; the patient does not sleep, loathes food, and is unable to move without pain. On examin- ing digitally, we find a hard sensitive tumour lying on one side of the uterus, but it is impossible to limit it as before. It has evidently 212 PUERPERAL INFLAMMATION AND ABSCESS contracted adhesions with all the surrounding organs, with the abdo- minal walls, and with the pelvic parietes, and often resists all efforts to move it with the finger. At the same time, pressure thus exercised is so extremely painful, that it is very difficult, if not impossible, to make a satisfactory examination. Generally speaking, the opening naturally formed into the rectum or vagnia for the escape of pus, remains patent, and allows the pus to ooze out as it is formed. This does not, however, in many case, seem to prevent the inflammatory action extending in various directions, and the pus making its way to the exterior of the pelvis by other outlets. Softening of the abdominal muscles, and perforation of the abdom- inal walls, are frequently observed in this form of the disease; and the efforts of nature thus to evacuate the contents of the inflammatory tumour by fresh outlets are always accompanied by a recrudescence in the general febrile symptoms. Sometimes oedema of one or both limbs takes place, owing to inflammation and obliteration of the large pelvic veins. The danger of extensive pelvic adhesions and of subsequent abdominal perforations, decreases as the patient recedes from the epoch of her confinement, until, after five or six weeks, she falls into the non- puerperal state, and if she is then attacked, the malady assumes the milder form. The unfortunate patient thus suffering, often remains in a very deplorable condition for several months, and becomes reduced to such an extreme state of marasmus, that a practitioner who is not accustomed to see these cases would think it nearly impossible for a recovery to occur, especially if he is aware of the extensive amount of pelvic inflammation that exists. In some instances death does take place, the patient becoming reduced so low by pain, continued fever, and extensive suppuration, as not to be able to rally. Death may also occur from the manifestation of general peritonitis,—the result of extension of the inflammation or of perforation of the peritoneum, and of the escape of pus into its cavity,—or from some intercurrent disease, which the debilitated patient cannot withstand. * I firmly believe, however, that even in this, the severest form of the disease, the mortality has been much exaggerated by M. Marechal de Calvi, and other recent writers, owing to the source of error which I have pointed out—viz., their opinions being formed from the statistical comparison of the cases hitherto published, these cases being in reality extreme and exceptional illustrations of the disease, which have attracted attention from that very circumstance. To these statistical calculations I am not able, is is true, to oppose any figures of my own, for I have noted down but a few of the many cases of puerperal inflammation of the uterine appendages that I have seen. My recollec- tion, however, enables me to assert, most positively, that even in the puerperal form of the disease, death is not of frequent occurrence, if we except the cases to which I have alluded, in which the inflammation of the organs contained within the lateral ligaments is merely an OF THE OVARIES AND UTERINE APPENDAGES. 213 epiphenomenon of a much more dangerous disease, acute metro- peritonitis. The same source of error has also led M. Marechal de Calvi astray with reference to the frequency of abdominal perforations, which, on the same statistical grounds, he supposes to be as great as that of perforation of the rectum or vagina. Nothing, according to my experience, can be farther from the truth. Consecutive perforation of the abdominal parietes is not unfrequently met with in the puerperal form of the disease, but still it is exceptional as compared with the great majority of cases in which it does not take place. This fact of itself proves how erroneous must necessarily be the discription of a disease founded, not on personal experience, but on the analysis of a limited number of exceptional cases recorded in medical literature. Although a female may be reduced to the most extreme state of marasmus and debility by this disease, death, as I have stated, does not frequently follow. It is, indeed, most extraordinary how tenacious of life females thus suffering appear. I have known them recover, after seeming, for weeks, as if they could scarcely live four-and-twenty hours. This tenacity of life is no doubt to be explained by the circum- stance of no vital organ being attacked the functions of which are necessary for the preservation of the individual. It is well known that in cases of uterine cancer life will persist long after the pelvic cavity has become a complete mass of disease, owing to the same cause. In these severe cases, however, the recovery is always very slow, especially when fistulous openings exist in the abdominal walls. The first indication of a favourable change is the subsidence of the febrile action, which is generally accompanied by a marked remission in the local inflammatory symptoms. The appetite and sleep return and the patient gradually enters the period of convalescence. So many morbid changes, however, have taken place; there is so much thickening and inflamma- tory incuration of the pelvic tissues and organs, and such extensive deposits of lymph ; the sinuses that communicate with the exterior or with the internal cavities are so indirect and so firmly organized, that months and even years may elapse before all traces of disease have disappeared, and before the pelvic organs are restored to a state of integrity. The chronic inflammation of the uterus, which as we have seen, generally co-exists in these cases, renders the recovery still more tedious and difficult, and sometimes the patients never thoroughly rally. Even when a complete restoration to health has taken place, and all traces of pelvic inflammation have disappeared, there often remain adhesions between the various pelvic organs, which are permanently united one to another; thence various displacements of the uterus, Fallopian tubes, or ovaries, uneasy sensations, and in some instances incurable sterility, as the result of these changes. Pathological Anatomy.—It is by no means easy to give a clear and faithful description of the pathological anatomy of inflammation of the lateral ligaments, since, as we have seen, it is only followed by 214 PUERPERAL INFLAMMATION AND ABSCESS death when such extensive changes have taken place in the surrounding organs, that it is next to impossible to distinguish the primary from the secondary morbid phenomena, and to say whether the disease commenced in the lateral ligaments or elsewhere. If the disease of the lateral ligaments exists as a complication of acute metro-peritonitis, in addition to the changes usually found in acute metro-peritonitis in the uterus and peritoneum, to the sero- albuminous effusion, and to the pseudo-membranes agglutinating the injected intestinal circumvolutions, we find the cellular tissue contained between the lateral ligaments and the ovaries swollen and congested, or infiltrated with pus ; or there may be pus in greater or less quantity collected between the peritoneal folds, in the ovaries, or in the Fallopian tubes. These are, also, no doubt, the pathological changes that take place in the non-puerperal and more simple form of the disease— changes which, as I have said, we have scarcely ever the opportunity of observing, the disease not being a fatal one in this, its primary and simple form. When the patient dies from extension of the inflamma- tion to the peritoneum, or from acute peritonitis, the result of the escape of pus by perforation into the peritoneal cavity, we have also the combined changes produced by the inflammatory disease of the uterine appendages, and by the general peritoneal affection. In these cases, as in the former, it is not unfrequent to find circumscribed purulent collections, limited by false membranes, existing in the cavity of the peritoneum in the neighbourhood of the pelvic organs. When death occurs from exhaustion, the result of long continued inflammatory action and suppuration, a vast amount of disease is generally revealed. On exposing the pelvis, it is found to present a suppurating cavity of greater or less extent, containing more or less pus, and circumscribed, sometimes by a well marked pyogenic mem- brane, from one to two or three lines in thickness, sometimes by the pelvic organs and the intestines thickened and lined with pseudo- membranes. I have seen this suppurating cavity occupy nearly the entire pelvis, its walls being formed by the rectum posteriorly, the bladder and abdominal parietes anteriorly, and the intestines superiorly. The ovaries and Fallopian tubes were thickened and enlarged, and were lying macerating in pus, on the side of the uterus, which was itself inflamed and much increased in size. When this is the case, all trace of the peritoneal element in the lateral ligaments seems to have disappeared, or, at least, is no longer recognisable. The rectum, vagina, and bladder, are generally thickened and inflamed, especially if they have been perforated by the pus. The abdominal walls are also thickened and indurated where they are in contact with the purulent collection. If a perforation has taken place, the muscular fibres are transformed into a dense homogeneous tissue, streaked with yellow lines. In addition to these changes in the pelvic cavity there may be also various evidences of disorganization in the iliac fossae, and in the OF THE OVARIES AND UTERINE APPENDAGES 215 lumbar region, &c, the result of the extension of the disease to these regions, or of its simultaneous manifestation therein. Thus under- neath the iliac or lumbar fascia we may find purulent collections macerating and dissociating the iliac psoas and quadratus muscles. I need scarcely add, that when the latter evidences of morbid action alone are found, the disease is no longer the one I am describing, but a totally different one in its seat and symptoms—viz., iliac abcess: this latter malady not unfrequently occurs after parturition. The large veins of the pelvis and abdomen, the iliac and femoral veins, and even the vena porta, have been found obliterated by MM. Melier, Tardieu, and other observers, and the lymphatics of the uterus and pelvic region have also been found filled with pus. CHAPTER XII. TREATMENT. ON THE TREATMENT OF INFLAMMATION OF THE UTERUS AND OF THE UTERINE ORGANS. The neck of the uterus being the region most frequently attacked by inflammation, I shall intervert the order which I have adopted in the first part of the work, and commence the study of the treatment of inflammation of that region. Another peremptory reason for follow ing this course is, that the neck of the uterus and its cavity being the most accessible parts of the uterus, and, consequently, those to which local means of treatment are principally addressed, it is but natural that the effect of such remedies should be first studied in inflammation of the tissues to which they are more immediately applied. After I have fully described the treatment of inflammation in the neck of the uterus, and its sequelae, I shall be able, in a few pages, to state in what manner it should be modified when the disease occupies other regions of the uterine system. I may here remark, that in describing the treatment of inflammatory affections of the uterus, I shall merely have to apply to these diseases, as elucidated in the preceding pages, the laws which regulate the treatment of inflammation, when it occurs in other regions of the body. The intimate nature of disease is the same in all similar tissues, although its modes of manifestation are varied; and when once the real nature of the morbid processes which take place in the uterus is brought clearly to light, the appropriate treatment may, to a great extent, be deduced by analogy and reasoning from the general laws of therapeutics. THE TREATMENT OF INFLAMMATION OF THE NECK OF THE UTERUS. Inflammation of the Neck of the Uterus, without Ulceration or Hypertrophy. Simple inflammation of the neck of the uterus, limited to the mucous membrane covering the cervix and lining its cavity, in its incipient stage, and unaccompanied by ulceration or hypertrophy, may generally be subdued by the use of emollient or astringent injections, tepid baths, and rest, combined with attention to the state of the bowels, and to the general health. TREATMENT OF INFLAMMATION OF THE UTERINE ORGANS. 217 It is seldom, however, that the disease is seen in practice in this, its elementary state. The discomfort experienced by the patient is so slight, that she is scarcely ever aware that anything is wrong, and con- sequently does not complain. Even were she to seek advice, the absence of any marked uterine symptom would probably prevent the existence of disease being detected. When inflammation has extended to the deepest tissues of the cervix, symptoms supervene, as we have seen, which more imperatively call the attention of the patient to the uterus; and the existence of the morbid condition is thus often recognised in an early period of its development. If the cervix has become even slightly hypertrophied and enlarged, the means above mentioned are scarcely sufficient to overcome the inflam- mation, and the application of leeches to the organ affected generally becomes advisable, or even necessary. The use of the nitrate of silver, in solution or solid, to the mucous membrane covering the cervix, or lining its cavity, is also often very beneficial. When the cavity of the cervix and the mucous follicles concealed between the rugas of the arbor vitae have -been long inflamed, and an abundant transparent or purulent mucus issues from the os uteri, it is generally necessary to carry the remedies into the cervical cavity itself. The inflammation may subside without this being necessary, under the influence of the means used to subdue the inflammation of the cervix; but in chronic cases, this is rather the exception than the rule. Not unfrequently the disease seems to take refuge, as it were, in this region, nothing short of strong cauterization of the inflamed surface being ( sufficient to overcome its tenacity; owing probably to the deep-seated and concealed position of the mucous follicles. On glancing over the above enumeration of the local means of treat- ment in simple inflammation of the neck of the uterus and of its cavity, it will be seen that they consist principally in vaginal injections, hip-baths, local depletion, and the use of caustics. I will now enter into a few details respecting each of these various therapeutic agents. Injections.—Vaginal injections, properly used, constitute a very valuable means of treatment in uterine disease. They may consist of water only, or of water containing some medicinal substance in solution. Water alone as an injection to the vagina is very beneficial. Its repeated use washes away the morbid secretions from the inflamed surface, and keeps the entire mucous membrane of the cervix and vagina in a clean and cool state. The vagina being a contractile canal, a kind of longitudinal sphincter, when healthy, and when its natural tonicity has not been impaired by disease or by frequent child-bearing, closes on itself in its entire extent; thus embracing the uterine neck by its upper portion. As a necessary result of this structural condition, when the neck of the uterus is inflamed, the mucus secreted, unless very abundant,—which it is not in slight affections,—stagnates round the cervix, where it is always found in greater or less quantity on the introduction of the speculum, and where it tends to keep up irritation. This is, no doubt, one of the reasons why a slight inflammation—which, 218 TREATMENT OF INFLAMMATION OF THE UTERUS on an exposed surface, or on one that could cleanse itself of the morbid secretion, would run through its phases in the course of a few days—- is often perpetuated, and gives rise to ulceration. Cold water not only acts as a wash or lotion, but has a decided the- rapeutic effect. It is a powerful tonic and astringent, and may be used with great benefit when inflammation has been subdued, in order to give strength to the relaxed mucous membrane. When it is employed with this view, a large quantity, two or three pints, should be injected once or twice in the twenty-four hours, so as to keep up a continued stream for several minutes. The water may be either quite cold, or with the chill taken off, according to the feelings of the patient, the time of the year, and the external temperature. As a general rule, the colder the water, the more decidedly are its tonic effects obtained. I do not think that cold water alone can be depended upon to subdue actual inflammation, especially if it has existed some time, and has assumed a chronic character. I have repeatedly known patients to use the cold douche for months without subduing the inflammatory disease for which it was recommended. Medicated injections may be either emollient, anodyne, or astrin- gent. The emollient injections I generally employ are, milk-and-water, linseed tea, or the decoction of marsh mallows, used tepid or cold. They frequently have a very soothing effect, and are principally useful when there is a considerable amount of irritation or inflammation about the vulva and vagina, which astringents do not allay, but even increase. The effects of the decoction of poppy-heads are the same, only it has, in addition, a slight anodyne property. Plain water may be rendered anodyne by the addition of a few minims of laudanum, or of a drachm or two of tincture of hyoscyamus. I seldom, however, resort to the vaginal injection of fluids containing opium, in order to allay uterine pain, as a much more powerful sedative result is obtained by their injection into the rectum. Astringent injections are most valuable remedies in the treatment of inflammation of the lower segment of the uterus, and of the vagina and vulva. Those which I principally employ are, sulphate of alumen, sulphate of zinc, acetate of lead, solution of nitrate of silver, decoction of oak bark, and solution of tannin. The first three I generally use in the proportion of a drachm to a pint of water, increasing or diminishing the strength according to circumstances. After many experimental essays, I have arrived at the conclusion that alum is by far the most efficacious of all these agents, with the exception of nitrate of silver; and as it is the cheapest and most easily met with, it is the one I now most frequently resort to in public practice. Inflammation of the mucous membrane of the vagina, even when of a blennorhagic nature, very rarely resists its use, continued during two or three weeks, pro- vided the injections be properly employed. At the same time it is worthy of remark, that the patients who use it are liable to sudden recrudescences of inflammatory action, or to sudden outbursts of irri- tation of the vulva, which are seldom met with when other astringents AND OF THE UTERINE ORGANS. 219 are employed. These exacerbations, however, always give way, in the course of a few days, to the use of emollients, generally leaving the patient in a much improved state. I do not often employ the solution of nitrate of silver, in consequence of its having to be injected with a glass syringe, which may break, and injure the patient; moreover, it discolours and destroys the linen. It is, indeed, a very energetic and safe therapeutic agent; but as the same result can be obtained by alum and the other astringents which I have mentioned, I reserve it for exceptional cases. As a topical application to the vulva, when the seat of inflammation, and of the irritation which so often accompanies it, the solution of nitrate of silver, in various gradations of strength, is invaluable. Injections, although of such great importance as a means of cleansing the vagina from all morbid secretions, of diminishing uterine irritation, and of removing vaginal and vulvar inflammation, are generally power- less to subdue confirmed inflammation of the substance of the cervix, or of the mucous membrane by which its cavity is lined. Their ineffi- ciency in inflammation of the cervical cavity is no doubt owing to the fluid not reaching the region affected. In inflammation of the substance of the cervix, a remedy which is only applied to the surface can scarcely be expected to subdue deep-seated disease. Not only is it possible to treat successfully non-ulcerated inflamma- tion of the cervix, when slight, and of recent date, merely by emollient and astringent injections, rest, and attention to general health, without having recourse to instrumental examination, or to means of treatment requiring instrumental interference, but even slight ulcerations, unac- companied by general inflammatory hypertrophy, and unattended with disease of the urinary canal, will sometimes give way under the influ- ence of these means. In order to establish this fact, after ascertaining with the speculum the presence of a superficial ulceration of this description, I have repeatedly thus treated the patient, without using any other local application to the ulcerated surface, and have found the inflammation diminish, the ulceration decrease, and at last cicatrize. It is only, however, in cases of slight ulceration, unaccompanied by general hypertrophy, or by cervical disease, a rare condition, that emollient and astringent injections alone succeed; and even in these exceptional cases the treatment cannot be depended upon. Moreover, the recovery, when it does take place, is so much more tedious than when cauterization of the ulcerated surface is resorted to, that I never feel authorized to recommend its adoption, if the existence of ulceration has once been instrumentally recognised ; as long as it is only suspected, and there does not seem sufficient grounds to warrant an examination, the employment of these local means of treatment, is, however, the rational course. The knowledge of the fact that it is not impossible to cure the slighter forms of ^inflammation and ulceration of the uterine neck by vaginal injections, by rest, and by general medication, without the use of the speculum, must be our guide as to the course we ought to follow in 220 TREATMENT OF INFLAMMATION OF THE UTERUS these cases. If 'the symptoms are so obscure and so slight as not to warrant an immediate examination, digital or instrumental, we must have recourse at first to the means above enumerated. Should they fail, the scruples of the patient should be overcome, and a digital, and, if possible, instrumental examination made. We must bear in mind that however careful and minute the examination made with the finger may be, it can only enable us to form a conjecture as to the precise nature and extent of the disease; and that, consequently, unless we bring the speculum to our assistance, we must treat the patient, in a great measure, in the dark. When once the speculum has been em- ployed for the purpose of diagnosis, its further use, as a means of treatment, is not likely to meet with any obstacle on the part of the patient, and still less on that of her friends. In order to obtain the full benefit derivable from vaginal injections, they should be properly and efficiently used; and this is never the case unless the patient be previously instructed howT to proceed. When a fluid is injected into the vagina, the patient being in a stooping position, not only does it at once escape from the passage, but it rarely reaches the cervix, or the upper part of the vagina. For this to be insured, she should lie horizontally on her back, on the bed, the sofa, or the floor, with the pelvis slightly elevated, so that the fluid may gravitate towards the internal structures. The natural contractility of the vagina expels the water, it is true, but not until it has well washed its entire surface. A small quantity of the injection often remains imprisoned, as it were, in the superior cul de sac of the vagina, in the vicinity of the cervix, until the patient rise, when its own weight brings it away. To prevent the fluid, as it escapes, moistening the dress of the patient, I generally advise a flat bed-pan to be placed under the pelvis. It is by far the most effectual plan, although the female's own ingenuity will often find a substitute. This mode of using vaginal injections almost necessarily requires the assistance of a second person, which forms the great objection. If the difficulty cannot be overcome, and the patient cannot manage the injec- tion herself, it must be used in any position which is found practicable. The therapeutic effects will not be so decided, but still a great amount of local benefit will be obtained if the tube be passed as high as possible. The best instrument for vaginal injections is a pump syringe, with a six-inch elastic vaginal tube, adapted to the longer tube, and presenting at its extremity four or six small holes, on the sides as well as at the end. The vaginal tube can, after introduction, be directed to the region of the vagina where the cervix lies, and any quantity of fluid can be injected without its being withdrawn. I seldom use less than a pint when the injection is a medicated one; and when it is merely water, I generally advise the patient to keep injecting for several minutes, irrespective of quantity. The ivory and metal syringes in general use are ridiculously small, and contain so little, that the effect produced on a large surface like the vagina must be insignificant, unless they are withdrawn and reintroduced many times. This, however, AND OF THE UTERINE ORGANS. 221 cannot be done without occasioning great external pain and irritation ; moreover, these syringes have not the power to carry the fluid into the upper part of the vagina. It is entirely owing to the use of these inefficient syringes, and to no precaution being taken to insure the injection reaching the parts affected, that they have fallen into discredit with some practitioners, who assert that vaginal injections are of little use in the treatment of uterine inflammation. With the poorer class of patients who cannot afford the expense of the pump syringe, I employ a large-sized four-ounce metal syringe, with a long curved extremity, similar to the one known by instrument-makers as Clarke's syringe. As injections are inefficient unless they reach the entire extent of the vaginal cavity, it is very important to ascertain whether such is the case, especially if their employment does not appear to be attended with the usual benefit. This can easily be ascertained by telling the patient to use an astringent injection—the aluminous one is the best for this purpose—an hour or two before the time of examination. Unless the vaginal secretion be most profuse, all that part of the vaginal cavity which the injection has reached will be found contracted so as to admit with difficulty the introduction of the finger. If, how- ever, it has only washed the lower part of the vagina, the finger, after passing the contracted region, finds the upper part moist and lax. I seldom recommend vaginal injections to be used oftener than twice in the twenty-four hours, except in blennorrhagic inflammation; and generally find, that in the course of one, two, or three weeks, the vaginal inflammation is so modified that it is no longer necessary to employ them more than once in that period. When injections are resorted to in order to assist in subduing inflammation of the cervix, they may be continued twice a day for a much longer period, together with the other more powerful and more efficacious means that are employed. In these cases, the injection is merely an adjuvant to the treatment, which carries away all morbid secretions, prevents congestion and inflamma- tion from again extending to the vagina, and assists the action of the remedies directed against the disease of the cervix. Hip-baths—Entire Baths—Shower Baths.—Decided benefit is often derived in the treatment of uterine inflammation in general from the use of hip-baths, provided they are neither too warm nor too cold. The temperature at which they should generally be taken is from 65° to 85° Fah., according to the season of the year, and to the feelings of the patient. At this temperature, their effect seems to be sedative ; as they appear to moderate the rapidity of the pelvic circulation, and often to subdue pain. At a higher temperature they do harm, when habitually used, by drawing blood to the pelvis. As an occasional remedy against pain, however, especially at the beginning of menstrua- tion, a warm hip-bath at 94° or 96° often affords great relief. When the temperature is lower than 60°, the momentary sedative effect is very decided, but the local depression is apt to be followed by violent reaction, and thus, in the end, more harm than good is done. The 222 TREATMENT OF INFLAMMATION OF THE UTERUS duration of the hip-bath may vary from five to twenty minutes, accord- ing to the season of the year, and to the patient's sensations. Entire Baths are often beneficial, but more as general than as local therapeutic agents. Warm baths may be occasionally taken with benefit, but their frequent repetition is weakening, and shouW be avoided. Cold or tepid baths are more useful in summer than in winter. In the latter season, a cold bath, and, indeed, to many, a tepid bath, is too disagree- able to be willingly borne. In the summer, on the contrary, a cold or tepid bath at 65° or 75° is generally very grateful, and may be resorted to every third or fourth day, with great advantage, if it can be obtained without inconvenience or fatigue. Shower Baths constitute a valuable means of invigorating the general health, and are nearly equally applicable winter and summer, as the temperature of the water can be easily raised so as to meet the exigen- cies of the season. Many females, however, when reduced to a state of debility and weakness, by uterine disease, cannot bear their effects, however modified. Proper reaction not taking place, the use of the shower-bath is followed by headache, chills, and languor. At the same time, these very patients may, as they gain strength under treatment, subsequently derive benefit from its employment, the system having recovered its vital power. Cold or tepid sponging often agrees when the shower-bath cannot be borne. Local Depletion—Leeches—Scarification.—Local depletion, by which I mean the abstraction of blood from the neck of the uterus itself, is as efficacious a means of subduing inflammatory disease in that organ, as in the external region of the body. Not only can we, by the application of leeches to the cervix uteri, or by scarification, moderate the intensity of inflammatory action, but we can also, by their assistance, diminish or remove those congested conditions of the uterus, and of the pelvic viscera generally, which so frequently precede, accompany, or follow menstruation, when the cervix or the body of the uterus is the seat of inflammation. Leeches take easily, and fill well, when applied to the congested or inflamed neck of the uterus, and their application is generally followed by a considerable flow of blood. The same dependence cannot be placed on scarification, the incisions often affording but a few drops of blood. I have generally found that scarification only succeeds in oc- casioning a sufficient flow of blood to relieve congestion or inflammation when the cervix presents dilated or varicose veins which can be divided. The incisions of the lancet, as also the bites of the leeches, always heal very readily. The amount of blood lost from the application of a moderate number of leeches—four to eight is the number I generally employ—may be said, in most cases, to depend on the degree of "the congestion or inflammation. In some instances, however, they bleed so freely, that too much blood would be lost if the bleeding were not arrested, which may always be easily accomplished by injecting into the vagina a solution of alum in cold water, of the strength usually used for vaginal injections, or AND OF THE UTERINE ORGANS. 223 stronger. I generally leave instructions with my patients thus to arrest the bleeding, should it not stop spontaneously, as soon as they feel faint or weak, or even earlier, if the flow of blood is very considerable. For want of these precautions, too much may certainly be lost from a very limited number of leeches, without any commensurate local benefit being derived. I always consider that more than is desirable has been abstracted, should the patient remain low, faint, and languid for several days. The object of applying the leeches is to reduce uterine inflam- mation, or to remove uterine congestion, but not to drain the rest of the system through the womb. Although, after the application of leeches to the cervix, more blood may be lost than is desirable, when the patient is left to herself, it is very seldom that a really alarming hermorrhage takes place. I have, however, on several ^occasions, known this to occur, and have in two instances, been obliged to plug the vagina. In one of these cases, the patient, a lady, aged fifty-two, had ceased to menstruate for five years, but had been labouring during all that time under inflammatory ulcer- ation of the cervix. This disease had evidently occasioned and kept up great congestion, not only of the uterus, but also of the liver and other abdominal viscera. One of the leech-bites bled profusely for more than twenty-four hours, notwithstanding the repeated use of cold astringent injections. At the expiration of that time, I examined the cervix with the speculum, and found blood escaping freely from two leech-bites. I cauterized them with the nitrate of silver, and left two or three small pieces of sponge in contact with the neck of the uterus, which effectually stopped the bleeding. It is worthy of remark, that in nearly all the cases in which I have seen hermorrhagic bleeding follow the application of leeches, there has been congestion of the liver. This fact I have already noticed at p. 115. I have been able, during the last few years, to test on a large scale the use of local depletion in uterine inflammation. At the Western General Dispensary, I am all but obliged to attend to my patients without resorting to this means of treatment, as I cannot command that assistance which is necessary for the local application of leeches ; and but very little blood can be drawn, as I have stated, in the gener- ality of cases, by scarification. I have therefore availed myself of this circumstance, to test how far uterine inflammation is susceptible of being treated and cured by other means. All the cases of inflammation given in the Appendix were so treated; and I have thus arrived at the con- clusion, that local depletion, although a great adjuvant, is by no means indispensable to the successful treatment of inflammation of" the uterus and of its cervix. My dispensary patients got well, as do those I attend in private life, and with whom I resort to depletion. Only the latter get well sooner, and with less suffering ; because, by the local abstraction of blood, the inflammation is sooner favourably modified, and the mor- bid congestions connected with menstruation, which so much aggravate the sufferings of patients, and so greatly retard their recovery, are prevented or removed. 224 TREATMENT OF INFLAMMATION OF THE UTERUS At the same time, I have become convinced, through the experience thus acquired, that if the general strength of the patient is permanently reduced, by frequent leeching, or by a too copious abstraction of blood from occasional leeching, she is placed in even a more unfavourable condition than the one with whom depletion is never employed. To derive that benefit from leeches which they really can give, a medium course must be followed. They should only be applied once or twice at the commencement of the treatment, when inflammation is acute. They may then be considered, generally speaking, as having done all the good toward reducing the inflammation of which they are capable, except in connexion with the exacerbations occasioned by menstruation. Immediately before menstruation, the moderate local abstraction of blood often removes a degree of congestion that would otherwise prevent or retard its appearance, and thus ensures an easy period. Even during menstruation, when the pain is agonizingly great, or hysterical convulsions are produced, if sedatives fail in giving relief, the application of leeches may be resorted to with all but certainty of immediate relief. But it is more especially after menstruation that their application to the cervix uteri is valuable. In inflammation of the neck of the uterus and of the uterine system generally, as we have elsewhere seen, after the menstrual flux has ceased, the uterus often seems incapable of expelling the blood which physiologically fills it during menstruation, and thus the organ remains throughout the mens- trual interval in a state of morbid congestion, which is very unfavour- able to the subsidence of inflammatory disease. This morbid congestion is removed by the application of leeches, which may be repeated every month until the inflammation be subdued, should the case seem to require their use. Care, however, must be taken that too much blood be not lost at these periodical bleedings. In some instances, uterine congestion persists subsequently to mens- truation, even after the entire subdual of all disease, gives rise to uterine irritation, and to a host of disagreeable general symptoms, and would no doubt reproduce inflammatory action were it not removed. I have under my care a lady who has been quite well locally for several years, and who still presents this uterine congestion after menstruation, and in so marked a manner as imperatively to require assistance every two or three months. If not relieved by leeches, the tide of uterine congestion seems to increase after each menstruation, which is always insufficient, and gradually to extend to the abdominal viscera, but more especially to the liver, until at last an explosion takes place in the shape of intense bilious vomiting and diarrhea. Even in these cases, however, the action of leeches may be replaced, but not with advantage, by saline purgatives and other means of depletion. These I am compelled to resort to in dispensary practice. When the leeches are applied to remove congestion, I generally use astringent injections for two days after the cessation of .the menses, and apply them about the third day. I thus allow the patient the benefit of the physiological effort which nature makes to expel the surplus AND OF THE UTERINE ORGANS. £25 blood from the womb after menstruation, before I come to her as- sistance. From what precedes, it is evident that although local depletion in uterine inflammation is a most valuable means of treatment, it may, however, be omitted. That such is the case is satisfactorily proved by my experience at the Western Dispensary, where I have treated and cured, without its assistance, several hundred patients, many of whom were labouring under the severest forms of chronic uterine inflammation. Local depletion is, indeed, much more easily dispensed with in the treatment of actual inflammation of the uterus and its cervix than in that of the congestive condition of the uterus and abdominal viscera which so frequently follow its long continued existence. There is, however, much greater reason to fear that local depletion will be abused, now that it is becoming generally adopted in the treat- ment of these diseases, than that it will be neglected. I am continu- ally seeing cases in which, in my opinion, it is or has been carried very much too far, and in which the constitution of the patient has been greatly weakened by the repeated abstraction of blood. This is an error the more to be guarded against, as the frequent repetition of local depletion does not remove nutritive hypertrophy of the neck of the uterus, or cure ulceration. I am now attending a lady, aged thirty- nine, who had leeches applied to the cervix twice a week for above five years, without the ulceration or hypertrophy being removed—at least I found both these morbid conditions existing to a very decided extent when I examined her; and by the symptoms which had been present from the first, their origin could clearly be traced back many years, probably fifteen or twenty. She was reduced by this treatment to a complete state of anemia, the blood being in a perfectly serous condition. I have frequently seen the same state of the general sys- tem induced by the repeated internal application of leeches, blindly followed up, for many weeks, on theoretical grounds only, and irre- spective of the effects produced, the local disease remaining unmodified. The application of leeches every week, or twice a week, for a lengthened period, as they are sometimes prescribed, appears to me rather to keep up local congestion than to diminish it, and consequently to tend to increase the nutritive hypertrophy of the cervix and uterus, to which chronic inflammation gives rise. Leeches, when applied to the neck of the uterus, not only remove the blood which it contains, but appear to establish a flow to that organ from the abdominal viscera, as seems indicated by the patient generally feeling a dragging sensation all over the lower abdominal region when the leeches begin to fill. This drawing of blood from the pelvic organs is in no degree prejudicial when there is subacute inflammation, or even congestion of the uterine system, because the surrounding viscera are also more or less congested, as we have seen, and the subtraction of blood from them, as well as from the uterus, relieves the entire abdominal circulation. But this is no longer the case when all acute inflammation has been subdued, and chronic inflammatory hypertrophy, and induration, with atonic ulcera- 226 TREATMENT OF INFLAMMATION OF THE UTERUS tion, remain. These are conditions which must be remedied by other means of treatment—repeated local bleeding, irrespective of menstrual congestion, merely keeps up a flow of blood to the uterus, and_debili- tates the system, not only without benefit, but with positive injury to the patient. The tendency to abuse the use of leeches, shown by some practi- tioners, who have adopted it as an ordinary means of treatment, is promoted by their generally entrusting the application of them to mid- wives, who are unable to judge of the effect produced. It is too much the custom with them to prescribe a "course of leeching" as they would a "course of medicine," giving directions for leeches to be applied once or twice a week, for one, two, or more months, without ascertaining whether the continuance of depletion is necessary or not. In reality, it is very desirable that the practitioner should apply the leeches himself, if he can possibly afford the leisure; and the time employed need not be long. He is thereby enabled to form an opinion on various points which will afford him useful information, and guide him as to their repetition, besides having an opportunity of making a very careful examination of the uterine organs. Thus I often remark, that when there is great passive congestion of the uterine circulation, and the blood stagnates, as it were in the organ, that which is drawn by the two or three first leeches is black and venous. The abstraction of this blood, re-establishing the freedom of the uterine circulation, that which flows subsequently, and which fills the leeches that fall off last, is more florid and arterial, a satisfactory proof of their being required on the one hand, and of their giving relief, on the other. The rapidity with which the leeches fill, and the extent to which both the enlarged cervix and uterus diminish immediately after the depletion, give important hints for subsequent treatment, which can only be obtained by the personal application. There is another reason why the leeches should, if possible, be applied by the medical attendant—to avoid pain. The external surface of the cervix has very little sensibility, and when the leeches fix on it, the patient experiences little or no pain. Generally speaking, indeed, she is only aware of their presence from the dragging sensation to which, in the course of a few minutes, suction gives rise. The cavity of the cervix, on the contrary, is acutely sensitive, and if a leech fixes in it, the patient may experience the most agonizing pain. I think I have scarcely ever seen more acute pain than that which has been experienced by several of my patients under these circumstances. It comes on as an acute aching pain in the uterine region, gradually increases, and- at last gives rise to uterine tormina of the most severe description, which return every one, two, or three minutes, like labor- pains, as is the case with all uterine spasms. The most efficacious treatment that can be adopted is the inhalation of chloroform, or the injection of laudanum into the rectum. Twenty or twenty-five minims injected, in a tea-cupful of warm water, if retained, generally lull the spasms in the course of fifteen or twenty minutes. When no remedial AND OF THE UTERINE ORGANS. 227 means are adopted, they may last for several hours before they gradu- ally die away. As the orifice of the cervical cavity, when inflamed and ulcerated, is open, this accident not unfrequently occurs in such cases if no means are adopted to prevent the leeches fixing in this region; and this whether a closed or an open leech tube be employed, although it is less likely to occur with the former. The only effectual precaution that can be taken consists in the introduction of a small cone of sponge or cotton into the open os. The plug should be introduced as firmly as possible without giving pain, and tied to a piece of thread, by means of which it may subsequently be extracted with ease. If this is effi- ciently done, no fear of pain need be entertained; but although trifling, it is too delicate an operation to be entrusted to midwives, for if leeches are applied by them, the patient must inevitably run the risk of its occurrence. Leeches may be applied to the cervix uteri by means of open tubes, or of tubes closed at their extremity so as to prevent the possibility of their escape. In the latter case, the closed end has several small holes, of sufficient size to allow the leeches fixing on the part with which the tube is placed in contact. In the former, the ordinary conical or cylindrical speculum is the best instrument that can be used. The application of leeches by means of the closed leech-tube is gene- rally tedious, and the leeches do not fill by any means so promptly as when an open tube is used; moreover, it does not always prevent their fixing in the cavity of the cervix, if the tube is in contact with the open os uteri. An open tube is certainly much to be preferred. When the cervix has been brought within the field of the instrument, and the os, if open, has been closed as above directed, the leeches should be put into the speculum and pushed close up to the cervix by a plug of sponge or cotton ; they are thus imprisoned in the instrument between the cervix and the plug. All that are inclined to bite do so immediately, whilst those that are not, generally work their way out in the course of two or three minutes, between the vagina and the specu- lum. When leeches have thus come away, it is of very little use to reintroduce them, as they seldom take. The plug may be left in about fifteen minutes, and on being withdrawn it will generally be found that they have filled, and that some have already come away. If the plug is allowed to remain longer, those that have filled often escape by the side of the instrument. If they have got between the vagina and the speculum, and have not appeared externally, they fall into the instru- ment as it is slowly withdrawn. The entire operation need not last more than half an hour. Cupping from the loins was formerly much resorted to, if inflamma- tion or congestion of the uterus was suspected. It certainly gives relief, but not so surely, nor with so much benefit to the local disease, as the direct abstraction of blood from the uterus. The application of leeches to the sacro-lumbar region is as efficacious as cupping, and less painful, and I should often resort to this means of depletion, were it 228 TREATMENT OF INFLAMMATION OF THE UTERUS not that I wish the patient, generally a debilitated female, to derive as much benefit as possible from every ounce of blood she loses. I conse- quently prefer, when feasible, applying the leeches to the neck of the uterus itself. Lisfranc used to resort very frequently to the monthly abstraction from the arm of a small quantity of blood, about three or four ounces, at the period of menstruation, in the treatment of chronic inflammation of the uterine organs. His object was to establish a derivative action, which he thought prevented the exacerbations so often observed at this time. His treatment, however, has not been generally^ adopted. I cannot say that I have seen sufficient benefit accrue from it to counter- balance the weakening effect which it produces on the system. Cauterization.—The only caustic that can be used with advantage in inflammation of the cervix without ulceration or hypertrophy, is the nitrate of silver, which acts, however, more as an astringent than as a caustic. The solid nitrate of silver, or a strong solution of it, should be applied every three, four, or five days, to the inflamed mucous membrane covering the cervix. This is also the mode of treatment to which principally I have recourse, in the first instance, in inflammation of the cavity of the uterine neck, carrying the caustic into the cervical cavity as far as it will pass. When pseudo-membranous patches exist on the cervix, more powerful caustics, however, may be necessary to modify the vitality of the diseased surface. This is a most intractable form of inflammation. In some cases of inflammation of the cervical cavity, owing, no doubt, to the disease lurking in the mucous follicles, concealed between the rugae of the arbor vitae, although the mucous membrane be not ulcerated, nothing but the application of the most powerful caustics, the acid nitrate of mercury, or the potassa cum calce, so modifies the vitality of the part as radically to cure the inflammation. It may appear cured before menstruation sets in—the os being closed, and there being no discharge—but if an examination be made a few days after the menses have ceased, the os is again found open, and a stream of muco-pus issuing from it. Inflammation of the Neck of the Uterus accompanied by Ulceration and Hypertrophy. When ulceration and hypertrophy of the neck of the uterus are present, in addition to the local means of treatment above enumerated, others become necessary. Very slight and^ recent ulcerations of the neck of the uterus, unaccompanied by disease of the cervical canal, may, as I have already stated, be treated and cured merely by emollient and medicated vaginal injections, rest, and attention to general health. This result, however, is so rarely obtained that it would be irrational to depend on such means aloro, when once the existence of ulcerative disease has been AND OF THE UTERINE ORGANS. 229 instrumentality ascertained. They can only rationally be resorted to a3 the sole means of treatment when there is doubt as to the presence of ulceration, and in order to avoid, if possible, the necessity of instrumental examination. The general inefficiency of medicinal injections to cure ulceration in these cases is no doubt, in a great measure, owing to its almost invariably penetrating into the cavity of the os, where the injection cannot reach. Consequently, although great improvement may be experienced by the patient, from the treatment adopted modifying to a great extent the local inflammatory symptoms, the disease is not cured, and on the suspension of the means used she soon relapses into her former state. This is one reason why, if the uterine symptoms are decided, and the patient can make up her mind to submit to an exami- nation, I nearly always advise it, except with unmarried females, as a preliminary to any treatment. By endeavoring to treat the disease with- out an examination, generally speaking, the case is only rendered more obscure, and the day of trial but deferred. The patient often improves for a time, and thinks she shall get well, but after continual relapses, she is at last obliged to allow her state to be thoroughly investigated; and if, as generally happens, a morbid condition is found that can only be removed by local treatment, nearly all the time previously spent in attempting to cure the disease may be considered as in a great measure lost. This frequently occurs with the unmarried females presenting symptoms of inflammatory uterine disease, respecting whom I am consulted. If I am the first practitioner applied to, I generally com- mence with the means above enumerated, with a view to avoid the painful necessity of instrumental examination; but, after losing more or less time, I am often at last obliged to insist on an examination, and then find that my want of success is owing to the existence of lesions which require more energetic and efficient treatment. Cauterization.—Ulceration existing on the cervix uteri, or within the cervical cavity, has a remarkable tendency to perpetuate itself indefinitely, notwithstanding the subdual of all acute and subacute inflammatory action. This tendency is, no doubt, increased by the periodical sanguineous congestions to which menstruation physiologi- cally exposes the inflamed tissues. Should it not yield, and it seldom does, to antiphlogistic means directed as above, the most efficacious treatment, indeed the only one that can be depended upon, is the direct stimulation of the diseased and ulcerated surface, so as to modify its vitality in such a manner as to induce a healthy action, and, finally, cicatrization. This end is obtained by the use of caustics of varied strength, according to the nature and extent of the disease, its chronicity, and the effects obtained. In the application of these two principles resides the entire theory of the treatment of ulcerative inflammation, not only in the neck of the uterus, but in any other part of the economy. We must first subdue acute or subacute inflammatory action by emollients, depletion, and astringents; and then modify by direct stimulation the diseased 230 TREATMENT OF INFLAMMATION OF THE UTERUS surface, so as to substitute healthy reparative inflammation for morbid ulcerative inflammation. Although, as I have stated, these principles apply to_ ulcerative inflammation in any region of the body, it is more especially in the treatment of ulceration existing on the mucous surfaces at the various epenings of the body, that they are exemplified. Thus it is that we find cauterization to be the principal resource in all ulcerations of the nares, mouth, fauces, and anus, as well as in those of the external genital organs, both of the male and the female. In all these situations, cauterization presents an additional advantage to those which it offers on a free ulcerated surface. The eschar which forms on the ulceration protects it efficiently from the contact of the various fluids excreted through, and secreted by, the organ, the mucous membrane of which is attacked, and thus allows the process of reparation to take place undisturbed. The progress of inflammation and ulceration is, generally speaking, at once arrested by cauterization. The congestion and redness of the cervix diminish visibly, the granulations become smaller and healthier, the escape of blood is stopped, and the purulent secretion assumes the character of laudable pus, if it has not presented it before. When cauterization is suspended, the ulceration generally remains stationary for a time ; but if left entirely to itself, it is all but certain to relapse, after a variable period, however advanced the healing process may have previously been. The first evidence of cicatrization takes place at the circumference. The margin of the ulcerated surface loses its well-defined character, and mingles imperceptibly with the red, inflamed, but not ulcerated, mucous membrane. As the latter returns to its natural.pale color, a film of white cicatrical tissue appears around the ulceration, and gradually progresses to the centre. Towards the end of the treatment, points of cicatrization will occasionally appear in the centre of the ulcerated surface, and by their gradual extension abridge the process. When the ulceration is cicatrized, it presents a pale rosy, or ash- colored hue, which is pretty nearly the natural color of the healthy cervix, and soon becomes so much like the surrounding tissues, that in the course of time it is impossible to say where the ulceration existed. The fibrous framework of the mucous membrane covering the cervix is so slight, that the healing of an ulceration, however deep, is never followed by the formation of hard cicatrices, as in the healing of ulcerations of the skin when they involve its fibrous structure. The mucous membrane of the cervix, indeed, seems, as it were, to be renewed. Evenwhen a deep slough has been formed by the action of a powerful caustic, such as potassa fusa, or the actual cautery, in the course of a few months, or even weeks, all trace of the cicatrix dis- appears, and the cervix again becomes soft and supple. The last part to heal in an ulceration of the neck of the uterus, is that which dips into the cervical cavity, inside the os. Thence the AND OF THE UTERINE ORGANS. 231 absolute necessity of separating the lips of the os with a bivalve specu- lum in a good light, and of carefully exploring the state of the cavity of the cervix before the disease be pronounced cured. Unless this precaution be adopted, in a very considerable proportion of the cases treated, the ulceration will only be partially cured, and what is erro- neously considered a relapse will occur in* the course of a few months. In reality, the relapse in such cases is nothing more than the disease creeping out of the cavity of the cervix, where it had been lurking from the first. A few years ago, in this country, ulcerative disease of the uterine neck was seldom detected, even by the most eminent uterine prac- titioners of the day. In a large proportion of the chronic cases of this description, for which I was then consulted in private practice, the very existence of the inflammatory ulceration from which the patient had been suffering for many years had not been even suspected, not- withstanding many valued opinions had been taken. Since the atten- tion of the profession was directed, in the first edition of this work, to the frequency of this form of disease, and since the doctrines therein promulgated have been adopted and acted upon by many leading prac- titioners, I have observed fewer instances of non-detection of ulcerative disease. I am still, however, continually witnessing cases in which ulceration has thus been imperfectly recognized and treated, the exter- nal or cervical ulceration only having been attended to, and the internal ulcerative element remaining unperceived. This error is committed in Paris as well as in this country. I never recollect seeing the cervical cavity examined, as I now invariably examine it, when I held office in the Paris hospitals ; and in what has been written by French patholo- gists on uterine diseases, there is no evidence of their being acquainted with the fact of ulceration so frequently penetrating and lurking in the cavity of the cervix. On the contrary, they mistake for indications of internal metritis the discharges which exist when the cervical cavity is inflamed or ulcerated. The agents which may be used for cauterization of the cervix are varied. The principal are the nitrate of silver, the mineral acids, and more especially the acid nitrate of mercury, potassa fusa and potassa cum calce, and the actual cautery. We will successively examine each of these agents. The most generally employed, and at the same time the least energetic caustic, is the nitrate of silver. Indeed, it scarcely deserves the name of caustic, so superficial is its action. When freely applied in substance to the granulations which cover the ulcerated surface, it forms a white film or eschar, the thickness of which, when it falls, is seldom greater than that of a piece of drawing-paper. This eschar is thrown off either entire or piece-meal, about the third or fourth day. On the latter day, the surface to which the solid nitrate of silver has been applied, is generally found red, irritable, and bleeding. On the fifth day, however, all apparent irritability and tendency to bleed dis- appear, and by this or the following day, the amount of benefit to be 232 TREATMENT OF INFLAMMATION OF THE UTERUS obtained from the application is generally ascertained, the ulceration seldom improving subsequently. If left to itself, indeed, it soon again becomes morbidly irritable, and occasions pain and sympathetic reaction on the general system. When a solution of nitrate of silver is used, these effects are obtained in a shorter space of time, and it may conse- quently be applied at shorter intervals than every fifth or sixth day, the period which should be allowed to elapse between the applications of the solid nitrate. In some cases, a strong solution thus employed may be more beneficial than the solid nitrate, but as it entails a more frequent use of instrumental means, the great drawback in the treat- ment of these diseases, I generally confine myself to the use of the solid caustic. The periodical application of the nitrate of silver to the ulceration often suffices to bring on healthy action, and to cause the ulceration, if small and recent, to heal in a few weeks. Even when it is covered with fungous, livid granulations, and secretes an abundant sanguineo- muco-purulent discharge, the solid caustic, freely applied, generally arrests the exudation of blood, and brings the ulcer to a clean, healthy, and comparatively dry state after two or three applications; although it is seldom sufficiently powerful to modify the vitality of such a diseased surface, so as to produce cicatrization. In these cases, however, the solid nitrate of silver is a most valuable agent, as it is applicable in a stage of the disease when other and more powerful remedies can scarcely be used. Owing to the very limited cauterizing powers of the nitrate of silver, it may be employed without the precautions which the more powerful caustics imperatively require. Its being dissolved to a considerable extent by the blood and muco-pus which freely exude from these ulcerations, is of no consequence ; so far from doing harm to the surrounding tissues, if it runs on and touches them, it acts, on the contrary, beneficially, as a powerful astringent, if they are at all inflamed, which they generally are. When applied to a non-ulcerated, mucous surface, it merely seems to produce a white film or epithelial eschar, the falling of which is never followed by ulceration or excoria- tion, all evidence of its having been applied disappearing in a few days. If the ulceration penetrates into the cervical cavity, the solid nitrate of silver may be pushed into it as far as it will enter, or a camel-hair pencil^ loaded with a saturated solution, may be used in the same way. There is no fear, aswe have seen, of penetrating too far, as the cervical canal is only sufficiently dilated to admit the brush, or the caustic cylinder, in the region to which inflammatory action extends. Beyond the point where inflammation ceases, the natural and healthy coarcta- tion of the cervical canal will prevent their passing. I prefer the brush when the inflammation penetrates very far, lest the stick of caustic should break. This has occurred to me more than once, but I have never had any difficulty in extracting the fragment, either by means of the speculum forceps, the end of which I have had purposely AND OF THE UTERINE ORGANS. 233 made small,1 or of the uterine sound. Thence the necessity of examining the piece of caustic that has been used, when it is withdrawn, in order to see that it is entire. On one occasion, when I had omitted this precaution, I only per- ceived a couple of minutes after I had withdrawn the speculum, that a small piece of the solid nitrate, a couple of lines in length, had broken of, and remained within the cervical cavity. Although not in the least alarmed at the circumstance, for I knew that it could do no harm, that the nitrate of silver would merely dissolve, and spread in width and not in depth, I endeavoured, but in vain, to reapply the speculum. The caustic, in dissolving, had acted as an astringent on the mucous membrane of the upper part of the vagina with which it came in con- tact, and so corrugated it, that I found it would be impossible to reintroduce the instrument without giving great pain. I therefore, merely requested my patient to inject at once several pints of cold water. There was more blood lost than usual for three or four days subsequently, but on examining her on the sixth day, I could find no evidence whatever of what had occurred. There was no loss of sub- stance in the cervical cavity, which appeared rosy and healthy; and the mucous membrane of the upper vaginal region was in a less inflamed and in a more healthy state than on my previous examination. The application of the nitrate of silver to the cervix, externally, whether it be ulcerated or not, is attended and followed by very little pain. This is also the case when much more powerful caustics are resorted to ; but it is not so, when the caustic is applied to the cervical cavity. This region, on the contrary, is sensitive with most females, although much less so than the external integument, or than the mucous membrane lining the external orifices of the natural cavities. Some patients always suffer considerable pain when it is cauterized; but the pain is never so severe as that which, as we have seen, may follow the biting of a leech. This is rather a singular fact, as it is difficult to explain how the mere fixing of a leech on a mucous membrane should occasionally give rise to agonizing uterine tormina, whereas the same region may be irritated by the most powerful caustics with comparative immunity from suffering. The pain which follows the application of caustic to these regions is sometimes very prolonged ; but its duration is very variable in different persons, and even in the same persons at different times. It may last from half an hour to two, three, or four days. Generally speaking, it is merely an exacerbation of former pains in the back, the ovarian regions, or lower hypogastrium, and shows at once to the patient the connexion which exists between the local disease and the sensations formerly experienced. Sometimes the principal pain is felt chiefly in the lower hypogastric region behind the pubis, in the region where the 1 This instrument, as also all those which I shall have to mention hereafter, has been made for me by Mr. Coxeter, of Grafton-street East, who has shown great patience, inge- nuity, and skill in conforming to my wishes and designs. 234 TREATMENT OF INFLAMMATION OF THE UTERUS neck of the uterus is situated, and in the very spot where the caustic has been applied. But this is the exception ; in the majority of instances, although a smarting sensation is felt in this region, that of which the patient principally complains, is the exacerbation of the ordinary ovarian and lumbar pains. The application of caustic frequently gives no pain, in the first stage of the treatment, when the sore is indolent; whereas, when the vitality of the ulceration has been modified by treatment, its use be- comes acutely painful. The change is rather trying to the patient, who is apt to think herself worse on this account, unless, from the first, apprized of the possibility of its occurrence. This takes place more especially with those females who, although suffering from a consider- able amount of uterine disease, present little or no local evidence of its existence. For the first day or two after the application of the solid nitrate of silver, there is generally a more or less abundant sanguinolent or muco-purulent discharge, which ceases or diminishes on the third, fourth, or fifth day. This discharge is sometimes so very abundant as percep- tibly to debilitate the patient. When this is the case, it may be expedient to cauterize half only of the diseased surface at a time, or to use some other more powerful caustic which has not the same effect. With some patients the nitrate of silver is absolutely inapplicable from this cause. It is more especially when the ulceration is very luxuriant, and with pregnant women that I have noticed this result. With the latter the application of the nitrate of silver is occasionally followed by a very copious flow of blood. When this occurs also I do not use it. After the pain occasioned by the application of caustic has abated, there is generally a lull in the local symptoms; the patient feeling easier than before the interference. This is owing, no doubt, to the irritability of the ulcerated surface having beea modified, by the cau- terization, as we see photophobia and pain in ulceration of the cornea temporarily removed, or greatly modified, by the same means. If nothing more is done, the ulceration again becomes irritable in the course of a few days, and a revival of pain takes place. The patient herself is thus made aware of the necessity for a repetition of the cauterization, and will often spontaneously urge its being resorted to again. Even when recourse is had to other caustics, the nitrate of silver, solidor in solution, is a most useful agent as a topical application in the interval of their application. The more powerful caustics should be used only at lengthened intervals, to rouse or modify energetically the vitality of the diseased surface; and it is by the nitrate of silver that the new action thus created should be moderated and guided. Its occasional employment serves as a dressing to the ulcerated surface, prevents its becoming irritable and unhealthy, keeps down the granu- lations, and thus powerfully assists in bringing about cicatrization. The mineral acids which may be employed when a more energetic caustic than the nitrate of silver is required, are, the acid nitrate of AND OF THE UTERINE ORGANS. 235 mercury, nitric acid, hydrochloric acid, and sulphuric acid. I have given each of these preparations in succession several months' trial, employing it in all cases in which the form of caustic appeared indica- ted, and see no reason for modifying the opinion which I have long entertained,—viz., that the acid nitrate of mercury is more efficacious in its action than the other acids. It appears to bring the ulceration more rapidly into a healthy, healing state. After that, I prefer pure nitric acid, although the extent to which it fumes on being applied is a slight disadvantage. Any of these acids, however, may be employed in the absence of the others. The acid nitrate of mercury is a caustic much used by French prac- titioners in the treatment of syphilitic ulcerations, and of unhealthy ulceration generally. It is prepared in the following manner:—To 100 parts of mercury add 200 parts of nitric acid; dissolve the mercury in the acid with the aid of heat, and evaporate to 225 parts. This pre- paration is a dense solution of deuto-nitrate of mercury, in an excess of acid, and contains 71 per 100 of the deuto-nitrate. The acid nitrate of mercury is a much more powerful caustic than the nitrate of silver. It gives rise to a white eschar, which falls piece- meal about the sixth day, and sometimes not until later. I generally use it pure, but sometimes diluted with a little water. In the former case, the beneficial effect is only obtained by the seventh or eighth day, and it should not, consequently, be reapplied sooner. It is seldom, however, advisable to reapply the acid nitrate several weeks in suc- cession. Generally speaking, twelve or fourteen days should be allowed to elapse between two cauterizations, the nitrate of silver, solid or in solution, being used in the interim. When the ulceration is large, and the granulations are redundant and unhealthy, this caustic exercises a very prompt and beneficial influence, often cleansing and modifying the sore in one application, even when the nitrate of silver has failed. In slight ulcerations, however, it is too powerful a remedy, and may aggravate the inflammation if injudiciously employed. The mineral acids being energetic agents, great care should be taken in their application. Wherever they touch, they produce a sore, although a superficial one, therefore great attention should be paid to circumscribe the action of the acid to the part on which it has to be applied. I use for the purpose small dossils of cotton, placed between the cleft of a very small and narrow platinum fork, fixed at one end of a long silver caustic-holder. A common stilet or piece of wire to which the cotton can.be tied, will also answer the purpose. The cotton being firmly fixed, it should be dipped in the fluid caustic, care being taken, by pressing it against the sides of the bottle, or on a dry piece of cotton, that there be no superfluity of acid. This precaution is even more necessary when the acid has to be introduced into the cavity of the cervix, as often occurs. If the cotton contains too much of the caustic, the pressure of the parietes of the cervical canal squeezes it out, and it runs on the lower lip of the cervix, which is thus injured by its action. When the acid has been applied, the surface of the cauterized tissues 236 TREATMENT OF INFLAMMATION OF THE UTERUS should be wiped quite dry before the speculum be withdrawn. If a bivalve speculum has been used to separate the lips of the cervix, and the cavity of the cervix has been cauterized, the valves should first be allowed to close, and the fluid which exudes from the os should be wiped away before the instrument is extracted. If this is carefully done, it is not necessary to inject water into the vagina to neutralize the effect of any uncombined acid, a precaution otherwise desirable. Owing to the neglect of these minute precautions, I have repeatedly seen considerable temporary mischief occasioned by practitioners who were acting under my directions, the caustic having been allowed to run on the cervix and vagina, and thus to produce extensive inflamma- tion and ulceration. The lesions thus created are not dangerous, as they are superficial, and readily heal, but they often give rise to great pain, and to a very abundant discharge, which alarms the patient. A slight amount of inflammation and ulceration of the cervix and vagina thus produced, will give much more pain than the most energetic cauterization by potassa fusa or the actual cautery. In the majority of cases, judicious general treatment, the use of injections, and local depletion, combined with the persevering and careful application of the caustics above enumerated, suffice to subdue inflammation, and to induce cicatrization of the ulcerated surface, both outside and inside the os uteri, in the course of from six weeks to three months, according to the extent of the disease, its chronicity, and the constitution of the patient. If she has always suffered from dys- menorrhea, and if menstruation exacerbates the local inflammatory symptoms, and gives rise to uterine congestion, the treatment is nearly always tedious. In these cases, the disease, so far from progressing during menstruation, absolutely retrogrades ; and it is often only a week or ten days after the menses have ceased that the patient is as well as she was before they began. In some instances, however, all the means enumerated fail; the ulceration heals to a certain point, and then cicatrization seems to come to a stand; or, the ulceration healing, the healed surface remains red and angry, having become the seat of chronic inflammation. Generally speaking, it is in the cavity of the os uteri that the disease thus proves rebellious. When this is the case, the only means by which we can ensure cicatrization, or restore the cervix to a healthy state, is by modifying the vitality of the diseased surface still more profoundly than is possible by the mineral acids. The agents by which this may be accomplished are potassa fusa, and the actual cautery. The application of potassa fusa to the treatment of intractable ulcera- tions of the neck of the uterus, and of chronic inflammatory hypertrophy of the cervix, is due to M. Gendrin, the eminent Paris physician. It was in his wards that I first learned the value of this very important addition to our means of treating inflammatory affections of the neck of the uterus. Although by means of this agent, and of the actual cautery, cases otherwise all but incurable are susceptible of easy and radical cure, both these means of treatment, when I left Paris in 1843, were AND OF THE UTERINE ORGANS. 237 all but confined to M. Gendrin and M. Jobert de Lamballe, the practi- tioners who first introduced them. In the first edition of this work, I gave, at considerable length, the results of my experience as to the vast practical importance of potassa fusa as a cauterizing agent in these diseases, but I believe that Dr. Simpson, of Edinburgh, is the only practitioner of eminence who has since then given it a trial, and adopted my opinions. I am happy to say, however, that Dr. Simpson's testi- mony is altogether in favour of its efficacy, and that, from his pub- lished statements on the subject, I may consider him as a complete convert to my views. Within the last few years I have been endeavouring to simplify the application of potassa fusa, and to divest it of the dangers which, unless the very greatest care be taken, must necessarily be connected with the use of so potent an escharotic, and I think I am able to state that I have fully succeeded in so doing. Potassa fusa, or the hydrate of potassa, is, as is generally known, one of the most powerful caustics with which we are acquainted, destroy- ing in a few seconds the living animal tissues with which it is brought in contact. Moreover, it is a caustic which not only acts superfiicially, like those whose action we have studied, but which may be made to destroy the parts to which it is applied, to nearly any depth, by merely prolonging its contact with them. These are the properties which have induced surgeons to choose potassa fusa for the establishing of issues, the entire thickness of the skin being destroyed by its agency in an extremely short space of time—a few minutes. The hydrate of potassa, however, is so very fusible, and consequently so liable to run on the adjoining parts, that it can scarcely be employed in its uncombined state, at least not where it is necessary to limit very exactly the extent of the tissues to be destroyed; it has therefore long been combined in practice with quick-lime, which, without impairing to any extent its cauterizing power, prevents its deliquescence, and renders it possible to apply it in the shape of a paste to a circumscribed surface. The potassa cum calce of the London Pharmacopeia is a combination of this descrip- tion, being composed of equal parts of hydrate of potassa and quick- lime. The same preparation, under the appellation of Vienna paste, is in general use on the Continent for establishing issues. Not liking to use pure potassa fusa to the neck of the uterus in the cases in which he saw that a more powerful escharotic than those which we have described was necessary, M. Gendrin fixed upon the potassa cum calce made into a paste, with a few drops of alcohol, which he applied in the following manner:—A large conical speculum being first introduced, the uterine neck is1 made to enter its orifice; or should the cervix be too voluminous, the speculum is firmly pressed on the part which it is intended to cauterize, great care being taken not to enclose a fold of the vagina between the rim of the speculum and the cervix. About as much of the paste as would cover a fourpenny-piece, a line in thickness, is placed on a triangular piece of diachylon plaster, one end of which is inserted in the cleft extremity of a common bougie. 238 TREATMENT OF INFLAMMATION OF THE UTERUS The caustic paste is then carried, by means of the bougie, to the cervix, and applied to the centre of the part comprised within the speculum. With the long forceps, cotton is placed carefully all round the spot on which the caustic paste is applied, so as completely to protect the neighbouring parts ; and the bougie having been withdrawn, the specu- lum is two-thirds filled with cotton or lint, which is firmly pressed against the uterine neck. The speculum is then slowly extracted, the cotton which fills it being at the same time forcibly pushed back in the vagina with the forceps, as the speculum is withdrawn, so that the vagina remains thoroughly plugged. If this is carefully done, the caustic cannot fuse, and injure the parietes of the vagina. In about fifteen or twenty minutes, the cotton or lint must be carefully withdrawn by means of a bivalve speculum gradually introduced, and an eschar, of the size of a shilling, or rather larger, will be found where the caustic was applied. The vagina should then be washed out with a little tepid wTater, complete rest in bed enjoined, and emollient injections employed until the separation of the eschar, which takes place from the fifth to the eighth day. Enlightened by subsequent experience, I should now reject this mode of applying the Vienna paste, even did I employ it, which, however, I have long ceased to do, having discovered a more safe and efficacious way of using the potassa cum calce. Although I have for years seen M. Gendrin follow this mode of operation, and have myself often adapted it, without once witnessing the extension of the eschar to the vagina, still I think it demands too much caution and instrumental experience to be retained, especially as it is possible to apply potassa fusa, either combined with lime or alone, with equal efficacy and greater safety, in a more simple manner. The extraction of the speculum after the application of the caustic paste evidently depriving the vagina of the protection which the instru- ment affords it, I first determined to leave the speculum in situ until the process of cauterization was entirely accomplished. With this view, after getting the cervix well into the field of the large conical speculum, I introduced pledgets of cotton, steeped in acetic acid and water, between the speculum and the cervix in its entire circumference, so as completely to isolate the organ. I then, as before, applied the paste to the surface to be cauterized, and when the desired effect was obtained, carefully wiped it away, washed the eschar with the diluted acetic acid, and, placing on the latter, as a dressing to prevent its coming in contact with the surrounding parts, a large pledget of cotton soaked in the vinegar-and-water, and tied to a piece of strong silk, withdrew the speculum. * Ths plan succeeded so well, and appeared so thoroughly to isolate the cervix, and to prevent the possibility of the surrounding parts being compromised, that I determined to use the pure potassa fusa instead of the potassa cum calce, on account of the greater intensity of its action. As an additional precaution, however, I first applied the nitrate of silver freely to the lower lip of the cervix, in order more effectually to gua- AND OF THE UTERINE ORGANS. 239 rantee it from the liquefied potassa, which invariably runs on the most depending part when the pure hydrate is used. The eschar formed by the nitrate of silver, superficial as it is, prevents the part which it covers from being acted upon. The lower lip of the neck of the uterus being protected by the nitrate-of-silver eschar, and the vagina by the pledgets of lint soaked in dilute acetic acid and pushed carefully in between the lower valve or circumference of the speculum and the cervix, there can be no risk of the potassa, although so very fusible, extending to parts which it is not intended to cauterize. I long used it exclusively, in this manner, and in a great number of cases, without its action once extending to the vagina. When thus applied, however, it is always advisable to leave for a few hours a pledget of lint soaked in dilute acetic acid in contact with the eschar, as uncombined particles of caustic lying on it might otherwise slightly cauterize the vagina. This has happened to me in one or two instances in which I had omitted to take the precaution I recommend. The pledget or dressing may be with- drawn in the course of a few hours, and a pint or two of tepid water, or of poppy-head decoction, injected. In giving the above directions, I have supposed the patient to be lying on her back when examined, and the pelvis to be elevated so as to admit of easy and thorough inspection. In this case the cervix is, necessarily, the most depending part of the canal represented by the speculum and the vagina, and consequently any fluid which runs off from the cervix has a tendency to gravitate on to the vaginal cul de sac. Hence the necessity of taking the above precautions. The pelvis might, it is true, be elevated to such an extent as to render the vaginal canal dependent, especially if the patient were lying on her side ; and this position would diminish the danger of the potassa running on the vaginal cul de sac ; but as it renders the inspection of the cervix uteri and all surgical manipulations difficult, I advise the dorsal position to be enforced. When about to use so powerful an agent as potassa fusa, we cannot see too clearly and satisfactorily the state of the parts on which we have to operate. Otherwise, all is doubt and danger. For the last year or two, however, I have not once used either the Vienna paste or the pure hydrate of potass. I now always substitute cylinders of potassa cum calce, which, with the assistance of Mr. Squire, of Oxford-street, I have succeeded in obtaining similar to those of nitrate of silver in ordinary use. M. Filhos, of Paris, appears to have been the first to discover, some ten or twelve years ago, that it was possible to fuse potassa'and lime in variable proportions, and to run the preparation into solid lead tubes. Not finding M. Filhos' first tubes of fused potassa cum calce by any means as energetic or as efficacious as the Vienna paste or the hydrate of potassa, I long only used them for superficial cauterization. Some time ago, however, having received several from Paris, which were much more powerful, the proportions of potassa being greater,—two of potassa to one of lime,— I requested Mr. Squire to fuse these substances for me in the above proportions, and to run them into soft metal tubes. The fluid potassa 240 TREATMENT OF INFLAMMATION OF THE UTERUS cum calce invariably melting the tubes, we determined to have iron moulds of various sizes made, and to run it into these. I have thus succeeded in obtaining cylinders of potassa cum calce, which can be used with the greatest ease, and with perfect freedom from risk, owing to their not fusing as pure potassa does, although nearly as powerful in the effects they produce as the latter substance itself. They are not free from a tendency to deliquesce, soon becoming spongy if left exposed to the atmosphere, but if applied to a dry or nearly dry surface, the action of the caustic does not extend beyond the part touched. This action is nearly as prompt and as deep as that of uncombined potassa, owing to their not fusing the cylinders. The cylinders may be used without all the precautions which are absolutely requisite when the Vienna paste or potassa fusa are employed. All that is necessary is to see the cervix well isolated in the speculum, to Avipe off the sanies that oozes from the surface cauterized, and then to apply a cotton pledget, moistened with vinegar and water, and tied to a piece of thread, which is to remain as a dressing on the withdrawal of the speculum, and which the patient can herself remove in the course of a few hours. These precautions are necessary, as, for two or three minutes after the application of the caustic, a straw-coloured fluid exudes,—especially if it has been carried into the cervical cavity— which may slightly cauterize the parts with which it comes in contact. I use cylinders of three different sizes. The middle size is that of the nitrate-of-silver cylinder, the largest is about twice as large, and the smallest considerably smaller. This latter size I principally employ to cauterize the cavity of the cervix. It may be fixed in the fluid caustic-holder; the two larger sizes in the nitrate-of-silver holder. When the potassa fusa, or its combinations with lime, are only used to modify the vitality of an ulcerated or inflamed surface, they need not be allowed to remain in contact with the diseased region more than a few seconds. If, on the contrary, the intention is to give rise to a slough, as when they are employed with a view to reduce hypertrophy, they must be kept in contact longer. The eschar produced by potassa fusa is of a greyish-black colour. It does not fall off at any given time, but melts away, as it were, revealing a healthy granulating surface, from which it has gradually been thrown off. This gradual disintegra- tion of the eschar is accomplished in from five to ten days, according to the depth to which the tissues have been destroyed. When the eschar is deep, if the patient is examined about the third day, the presence of the eliminatory inflammation is very clearly indicated at the margin of the eschar, which is separated from the adjoining tissues by a superficial sulcus or groove. The surrounding parts are then the seat of considerable inflammatory reaction, and the cervix and the upper part of the vagina will generally be found considerably con- gested and inflamed. The elimination of the eschar may be attended by hemorrhage about the fifth day. I have, however, never known it AND OF THE UTERINE ORGANS. 241 to be alarming, and have found cold astringent vaginal injections always to arrest the flow of blood. In the course of from seven to fourteen days, the cervix and adjacent tissues return to the state in which they Avere before the application of the potassa, the artificial inflammation produced by the caustic gradu- ally subsiding. If an ulceration previously existed, it is generally found larger on the final elimination of the eschar; the granulations are more florid, and more developed, and appear endowed with more vitality. If no ulceration existed, there is one left, presenting the above characters. For the ten or fourteen days that follow, there is little or no change in the state of the ulcerated surface, which con- tinues to secrete healthy pus; but about the twenty-fifth day from the date of the cauterization, a decided progression towards cicatrization commences. This' tendency to heal in the ulceration continues to be very marked from about the twenty-fifth to the fortieth day,, when it ceases. Very frequently the ulceration heals before the fortieth day; but if it does not, the influence of the strong potassa cauterization being exhausted, it must either be repeated, or the treatment must be carried on with the milder caustics, if it is thought that they alone will suffice. Severe cauterization should never be resorted to within less than twelve or fourteen days of the menstrual epoch, which it often slightly accelerates. During the time that elapses from the falling of the eschar to that when the improvement to be expected from the severe cauterization has fully taken place, the ulceration must not be left to itself, other- wise it may become too luxuriant and irritable, and not heal. The reparative inflammation set up must be controlled by the periodical application of the nitrate of silver in substance, or in solution. The vitality of the ulcerated surface is so much increased by severe cauteri- zation, that I find the eschar of the nitrate of silver is generally thrown off in three or four days. I consequently sometimes diminish the interval I usually allow to elapse between the " dressings" of the ulceration, using a solution of the solid nitrate of silver, instead of the solid caustic. Although it be thus advisable, in order to insure the full benefit of severe cauterization, that the ulceration should subsequently be care- fully watched and treated, there is more probability of its healing with- out further interference on the part of the practitioner, than under any other form of treatment. I have repeatedly applied potassa, or potassa cum calce, to patients whom I have subsequently lost sight of for five or six weeks, OAving to unavoidable circumstances, and on examination have found the ulceration nearly or quite well, no examination or local treatment, except vaginal injections, having been used in the interim. This is, no doubt, owing to the profound modification which severe cauterization impresses on the vitality of the diseased tissues, and to its substituting a healthy ulceration with a natural tendency to heal, for a morbid one, with a tendency to indefinitely perpetuate its exist- ence. It would be unwise, however, to depend on this tendency after 242 TREATMENT OF INFLAMMATION OF THE UTERUS deep cauterization, and to forego the subsequent periodical dressing of the sore, the success of the treatment being thereby very much com- promised. I have in many cases tried to ensure the continued improve- ment of patients who could not remain long with me, by resorting to severe caterization, and then allowing them to suspend local treatment for a few weeks, as soon as they had recovered from its immediate effects, but have most frequently found that the diseased condition did not improve after a short time, for want of the subsequent treatment. The pain occasioned by the application of potassa fusa is not, gene- rally speaking, very much more severe than that which follows the use of the ordinary caustics; when, at least, its application is limited to the exterior of the cervix. Indeed, the degree of pain occasioned by cauterization of the cervix does not seem in any wray to be proportioned to the extent of the cauterization, but to depend more on variable individual susceptibility. With some, the formation of a deeper eschar on the cervix only occasions smarting; whilst with others, the mere use of nitrate of silver is attended with very severe pain. That which follows the employment of the more severe escharotics is not unfre- quently less than that Avhich is occasioned by the milder ones; owing, probably, to the complete destruction of the tissues acted upon. When the potassa-cum-calce cylinder is introduced into the cervical cavity, the pain is often very intense, sometimes giving rise to nausea, and even sickness; as we have also seen to be the case with the milder caustics. The more highly-developed vitality and nervous sensibility of this region—the cervical cavity—accounts for this difference, as also for the fact that a very slight amount of disease in this region often deeply affects the general health. When applying potassa fusa or potassa cum calce to the cavity of the neck of the uterus, I never leave it more than a few seconds in contact with the diseased surface, as the object is not to create a slough, but merely to profoundly modify its vitality. I generally use the smallest cylinder, which, from its size, moves freely in the enlarged cavity, only applying it where there is evident morbid dilatation ; and never beyond half or three quarters of an inch in depth, even when the disease appears to penetrate farther. Owing to the smallness of the cylinder, it may break unless great precaution be used ; but even were this to occur, nothing is easier than to seize hold of the fragment with the speculum forceps, or to extract it with the uterine sound. For the first three weeks, the discharge of muco-pus and of transparent mucus from the os uteri is much increased. It then diminishes, the cervical cavity begins to close, if it has not done so already, and by the end of the fifth or sixth week, generally speaking, all trace of internal inflammation has disappeared, and the diameter of the os is reduced to its natural size. The tendency to contraction which is observed during the healing process,^ when thepotassa cum calce is carried into the cavity of the cervix, is an additional and very powerful reason for watching over the patient at that time. Indeed, I have seen so many cases within the AND OF THE UTERINE ORGANS. 243 last few years, since the publication of the second edition of this work, in which, for want of such care and attention, the os and cervical canal have become contracted to such an extent as nearly to obliterate them, and as to prove a serious obstacle to menstruation, that I feel obliged to lay down as a rule, that the potassa cum calce should never be used in this region unless the practitioner have the opportunity either of following up the case, or at least of seeing his patient a few weeks afterwards, and of counteracting any tendency to contraction which he may then remark. This may be easily done by merely passing a moderate sized bougie through the cervical canal each time the nitrate of silver is used, that is every four, five, or six days. In the cases in which I have thus seen the os and cervical canal all but obliterated by the action of the potassa cum calce, it must evidently have been too freely applied, inasmuch as in my own practice such results do not occur. In a few instances I have had, it is true, a greater degree of contraction than was desirable, but it has never been to the extent I have seen it in some of the cases treated by other practitioners under the idea of carrying out my views. The secretions of the uterine cavity and of the cervical canal have generally sufficed to keep the passage free, when I have not had an opportunity of regularly attending to the patient. It should be recollected that the principal reason for the employment of so potent an agent as caustic potash in the treatment of intractable inflammation of the cervical canal is, that part of the inflamed mucous membrane, and of the mucous follicles that stud it, are concealed between the rugae of the arbor vitse, Avhich have to be partly destroyed before they can be reached by the caustic. When this is accomplished, all that is required has been effected, and any further destruction of the parietes of the cervical canal can only be productive of mischief, by giving rise not only to general contraction, but to adhesions which, if they all but obliterate the passage, must interfere both with menstruation and with impregnation. In a patient of my own, with whom I had used the potassa cum calce five years previous to her dying from cancer of the caecum and ascending colon, I found adhesions throughout all that portion of the cervical canal that had been acted upon. The canal was, however, quite free in its centre. When the cervical canal has been only moderately narrowed by the action of caustics, for the use of the milder caustics may also be followed by contraction in a minor degree, its artificial dilatation is easily accomplished. The passage of a few bougies of graduated sizes, is, generally speaking, all that is required. When, however, the os externum is nearly obliterated, and firm adhesions have taken place throughout nearly the entire cervical passage, the difficulty may be extreme. In a case which I recently had to attend, I could not for some weeks find the orifice of the os; not, indeed, until an effort at menstruation revealed it. The menses had been retarded and even arrested for some time with this lady, and severe hysterical convulsions appeared to have followed as a consequence. With the assistance of 244 TREATMENT OF INFLAMMATION OF THE UTERUS stilets, bougies, and prepared sponge, however, I have always hitlierto succeeded in obtaining a tolerably free passage.^ In two or three instances I have had to make a small preliminary incision with a gum lancet. The use of the potassa cum calce in the cervical canal, exposing the patient to such accidents as these, it is evident that too much care and caution cannot be taken by those who resort to it. It is infinitely better to apply it lightly and to repeat the application two or three times if necessary, than to run the risk of permanent injury by using it too energetically. In recommending its use, I certainly never con- templated its being applied in such a manner as to give rise to results like those aboA'e detailed, and regret that I did not lay more stress on this point in the previous editions of this work. When inflammation of the cervical cavity has been treated and cured by the potassa cum calce, there is not so great a liability to relapse after menstruation as is observed when the disease has been apparently cured by milder applications. This remark applies to the treatment of chronic inflammation of the cervix generally by potassa fusa. The vitality of the diseased tissues is more profoundly modified, and con- sequently not only does the ulceration heal or the chronic inflammatory action subside, but the parts underneath and around become quite healthy and free from disease. When ulceration is cured by other treatment, this is not ahvays the case—the cicatrized surface some- times remaining red, irritable, and inflamed. Even when the application of the stronger caustics does not occasion much pain, it often gives rise to extreme exhaustion and mental depression, and sometimes to syncope, thereby showing the connexion between the uterus and the general languor and debility which so frequently characterize these inflammatory disease. I occasionally see patients so prostrated by its action, although scarcely in any pain, as to be unable to rise from the bed or sofa for several days. One of the principal properties of potassa fusa, when energetically applied, is that of melting inflammatory induration and hypertrophy. This effect is also produced by the actual cautery, the action of which we have now to examine. I shall, however, enter more fully into the consideration of the action of these remedies as solvents, when treating specially of hypertrophy of the cervix. The Actual Cautery.—It is possible to obtain by the actual cautery the same results as those furnished by potassa and its combinations with lime. The effect produced by the actual cautery are in every respect identical with those of the hydrate of potassa. An eschar is created, the elimination of which is attended with subacute inflammation of the tissues on which it rests. Under the influeuce of this subacute inflammation, the induration and hypertrophy subside, and the vitality of the ulcerated surface being deeply modified, cicatrization rapidly follows. _ Celsus recommends ulcers of the prolapsed uterus to be cauterized with the actual cautery, and other modern surgeons have proposed the AND OF THE UTERINE ORGANS. 245 same means of treatment, as, for instance, Percy and Baron Larrey. It does not, however, appear that these suggestions were acted upon until adopted by M. Jobert de Lamballe, the talented Paris surgeon, who has for many years resorted, with great success, to this mode of treating ulceration and inflammatory induration of the neck of the uterus. Indeed he adopts the actual cautery as a general means of treatment, using it in cases of simple ulceration, as well as in severe inflammatory hypertrophy. In order to protect the vagina from the heat which radiates from the cautery, especially if the one employed is large, an ivory conical speculum may be used, ivory being a bad conductor of caloric. This precaution, although always adopted by M. Jobert, is not, however, indispensable. One, two, or three olive-shaped cauteries, heated to whiteness, may then be extinguished on the part of the cervix which has to be cauterized. An eschar, more or less deep, is thus formed, as by cauterization witi. potassa fusa. It is necessary that the cautery should be brought to a white heat, as otherwise it adheres to the tissues on being withdrawn. . But little pain is experienced by the patient, either at the time, or subsequently, the eschar falling off from the sixth to the tenth day, according to the depth of the cauterrization. When the actual cautery is used to remove inflammatory hypertrophy, two or more cauterizations may be necessary to restore the neck of the uterus to its natural size. The actual cautery, as a means of treatment in uterine disease, has met with but little encouragement from the Paris surgeons, and is stated by many to be inefficient and unsafe. I can, however, confi- dently assert, from what I saw of M. Jobert's practice when I was his house-surgeon at the Hopital Saint Louis, in 1840, and from the results which I have myself since obtained, that these objections are perfectly unfounded. I have never known any serious symptoms to follow its use, whereas I can testify to its efficacy in very many instances of severe disease. I must, however, admit, that in two or three of the cases in which I have used the actual cautery to cauterize the orifice of the cervical caATity, the result has not been quite satisfactory. The local inflammation produced by the elimination of the eschar lasted too long, and the parts assumed a rather unhealthy character. This I do not recollect having observed after using potassa fusa. M. Jobert thinks that cauterization with the actual cautery possesses peculiar advantages as compared with potassa fusa. I believe, how- ever, that he is mistaken in this respect, and that the two methods are identical in their effects. My friend, M. Laure's, who was for three years M. Jobert's house-surgeon, and during that time saw most of his uterine cases, has Avritten an interesting thesis on the use of the actual cautery, which may be considered faithfully to represent M. Jobert's opinions. M. Laure's states that it is difficult to appreciate rigorously the depth to which the Vienna paste will disorganize the tissues of the uterine neck : that instead of exciting in the neighbouring parts a favourable reaction, it weakens the vital force and exercises a stupi- 246 TREATMENT OF INFLAMMATION OF THE UTERUS fying influence ; that it is difficult to apply, and, in liquefying, runs on to the parietes of the vagina, thus giving rise to extensive loss of substance, which, on filling up, contracts the parts. To these propositions I can give the most decided negative, from lengthened experience. A practitioner who is accustomed to the use of the caustic, may measure to a nicety the extent of the eschar which he wishes to form by means of potassa fusa, and if great care and caution be shown at first, he will gradually and safely acquire the necessary knowledge, even if previously ignorant of its effects. So far, on the other hand, from the action of the caustic on the surrounding parts being a stupifying one, I have always seen reaction take place most freely, and with all the characters of healthy inflammation: whereas, as I have above remarked, I have, in some feAV instances, seen the actual cautery followed by unhealthy reaction. As to the caustic running on to the adjoining parts, such an accident is certainly possible in unskilful hands, and I have indeed known it to occur, but it need never take place with a prudent, cautious, practitioner, who knows what he does, and carefully attends to the rules and precautions which I have laid down. I have used it myself, for nearly ten years, and have never known the vagina even touched by the caustic. The same objection applies with equal force to the actual cautery,—which I should be very sorry to see used for the cauterization of the cervix by any but a skilful and prudent practitioner,—and also to all surgical operations. I am at a loss to discover how my former colleague can have adopted such unfounded notions respecting this mode of cauteri- zation, and should not have reproduced these statements, were it not that they constitute the chief objections that have been urged in France against cauterization with potassa fusa in the shape of Vienna paste. For some years, • I frequently resorted to the actual cautery, principally in cases in which I wished to modify the vitality of intractable ulcerations persisting within the os uteri. For that purpose I used olive-shaped cauteries, sufficiently small to pass within the morbidly dilated os, and with very gratifying results. Since I have succeeded, however, in rendering the application of potassa cum calce so very simple and safe, I have all but ceased to employ this mode of treatment, on account of the dread which it occasions to the patient. There is certainly something rather alarming to the imagination in the application of the actual cautery to any part of the body ; and the fear it occasions is increased by the noise and odour which the combus- tion occasions. In. reality, the operation is a trivial one, although the patient cannot easily be made to look upon it in this light. I there- fore prefer the potassa cum calce, which is quite as efficacious, and is unattended with this drawback ; the patient not being able to tell the difference between an application of the nitrate of silver, which is a mere dressing, and that of potassa fusa, which is an operation. Both the actual cautery, and potassa fusa alone or combined with lime, have always proved free from any risk or danger in my hands ; more so, indeed, than could possibly have been supposed, d priori, from AND OF THE UTERINE ORGANS. 247 the energy of all their effects. The reactional inflammation which is thus intentionally set up for therapeutic purposes, seems all but invariably to limit its action to the neck of the uterus, not extending to the body of the organ. Indeed, if the patient keeps perfectly at rest, on a couch or sofa, during the six or eight days this inflammation lasts,—a very desirable, and even necessary precaution,—she is often perfectly unconscious of any more severe application than usual having been made, or of the existence of the eliminatory inflammation. On moving, however, she generally feels that the womb is painful and sensitive. Although it is now many years (1837) since I first witnessed this mode of treatment, and although I have myself subsequently employed it in a very large number of cases, I have only once seen serious inflammation occuring as a sequela ; and even in this instance I am far from certain that what occurred can be fairly attributed to the treatment adopted. The patient, a young married lady, without family, twenty-four years of age, had bean under my care, at intervals, for nearly two years, for inflammatory disease of the cervix, which appeared, from the antecedents of her case, to have been in existence even before she married, at twenty-one. The peculiarity of the case consisted in a most obstinate tendency to relapse. When I was first consulted, there was extensive ulceration of the cervix and its cavity. This disease was perfectly subdued after a few months' treatment, and she left me apparently well. In the course of the eighteen months that followed, however, she had several relapses of cervical inflammation,—these relapses always occurring after menstruation, which was attended with great pain, which had been the case all her life. Thinking they might be owing to extreme menstrual congestion, the result of an evidently constricted state of the cervical canal, I dilated it by means of sponge tents. Finding that this was of no avail, I thought that the cause of the relapses might be a very limited amount of inflammation, apparently existing in the mucous follicles just within the os uteri, which appeared never to have thoroughly subsided. I had generally found a few drops of pus exuding from the os, on examining shortly after menstruation; and when the relapses of general cervical inflammation took place, muco-pus invariably issued from the os, in large quantities. With a view to modify effectually the vitality of the chronically inflamed mucous membrane, I touched it very lightly with a small cylinder of potassa cum calce, which merely gave rise to a very superficial eschar. The usual reaction took place, without presenting any marked intensity, and ten or twelve days afterwards the menses appeared. This time, however, they Avere followed by cold shivering, and fever; and when I saw the patient a few days later, I found that an abscess had formed on the left lateral ligament, and had opened into the rectum. I had abstained from calling for a week or ten days, owing to the menses, and was not sent for, my patient being so much accustomed to pain as not to attach much importance to what she suffered. Had I seen her from the first, and treated her energetically, it is possible that 24s1 TREATMENT OF INFLAMMATION OF THE UTERUS suppuration might have been prevented. She slowly recovered from the effects of this attack of inflammation. Pus long passed in the motions, and tumefaction was long perceptible on internal examination with the finger on the left side of the uterus, becoming, however, gradually less and less marked. It was, indeed, aboA'e eighteen months before all traces of the abscess of the lateral ligaments disappeared, and before she regained her health; this she eventually did completely. The attack of inflammation in the appendages of the uterus has been apparently attended with one beneficial result; there has been no relapse of uterine or cervical inflammation since its existence. It would seem as if the local irritation in the lateral ligaments acting by counter- irritation on the uterus, prevented any return of acute inflammation in that organ, and allowed the disease at last to die away. The chronic inflammation of the cervical cavity, for which the potassa cum calce was used, entirely gave way within a few weeks after its application. Although I have given the above case as an illustration of inflamma- tion and abscess of the lateral ligaments occasioned by the extension of the reactional inflammation following severe cauterization, it is by no means certain that its occurrence was not merely a coincidence. Generally speaking, the inflammation caused by a much more severe cauterization than the one in question subsides by the eighth or tenth day ; and, in this instance, it was not until the twelfth that the menses appeared, and only subsequently that the fever and shivering manifested themselves. Might not this attack have been of a similar nature to those which had so repeatedly occurred before at the menstrual period, only this time located in the lateral ligaments, instead of in the neck or body of the uterus ? When I reflect that I have seen the cervix deeply cauterized, or have myself cauterized it in hundreds of patients, in the treatment of inflammatory disease, it is a subject of surprise to me, that this should be the only serious accident that I can call to mind. This fact alone proves the correctness of the assertion I made in the first edition of this work—namely, that deep cauterization of the cervix uteri, even when carried to a great extent, does not entail more risk to the patient, indeed scarcely as much, as the minor operations of surgery. It cannot, however, be denied, that cauterization of the cervix, as above described, and especially deep cauterization, is an operation, and, like all operations, surrounded with danger. It must not, therefore, be either injudiciously resorted to, or carelessly carried out. Although my own practice has hitherto been free or all but free from serious accidents, the same immunity does not appear to have attended that of others. Various cases in which serious accidents have followed the use of the caustic potash, have been narrated as arguments against its use, since the last edition of this work was published ; and M. Gendrin himself, within the last few years, has had several cases of acute metritis, and of abscess in the lateral ligaments, the evident and immediate result of deep cauterization. He has, however, seen the same results follow the use of the nitrate of silver, and of injections ; and I may mention that AND OF THE UTERINE ORGANS. 249 the two most severe instances of acute metritis that I have myself witnessed for some time, in the unimpregnated womb, occurred after the use of weak astringent vaginal injections. It is clear, from Avhat precedes, that no surgical interference with the womb, however simple, is absolutely free from risk. No such means of treatment, therefore, should be resorted to unless rendered necessary by the state of the patient; but, at the same time, we should not shrink—owing to the existence of a slight risk—from having recourse to the remedial agencies which experience teaches us to be efficacious, if they become necessary for the cure of the patient. We must bear in mind that, in order to restore to health a person suffering from any disease, which can only be removed by surgical treatment, generally speaking there is considerable risk and danger to be encountered ; whereas in the surgical treatment of uterine inflammation, the risk is so slight, that it scarcely deserves to be taken into consideration. Hypertrophy and Induration.—In giving the history of the local treatment of inflammation and ulceration of the neck of the uterus, and of its cavity, I have also, to a great extent, given that of the hypertrophy and induration which so usually accompany these morbid conditions. Hypertrophy of the uterine neck is generally the result of the combination of two pathological conditions—inflammatory congestion and nutritive hypertrophy. The presence of inflammation gives rise to an unusual developement of the vessels and capillaries of the entire cervix, thereby more or less increasing its size and density. On the other hand, the continued existence of this morbid state, in the course of time gives rise to cellular hypertrophy and induration. The plastic lymph exuded becomes organized, new vessels are formed, and the cervix uteri may thus become enormously increased in size. This nutritive hypertrophy is often connected with deep-seated chronic inflammation. The antiphlogistic measures which have been enumerated, injections, hip-baths, local depletion, and superficial cauterization, always very considerably diminish hypertrophy of the cervix, by subduing the con- gestive and inflammatory element; and if it exist alone, they generally remove it entirely. When both deep-seated and superficial inflammation are thoroughly subdued, eAren if a slight amount of nutritive hypertrophy remains, it is not absolutely necessary to carry treatment farther, as Nature alone, in the absence of actual disease, will generally melt and diminish by degrees the hypertrophy. I am continually witnessing cases of this description—cases in which the cervix and body of the uterus regain their natural size, without any special treatment in patients whom I have left to the restorative powers of Nature, after the entire removal of actual disease ; the nutritive hypertrophy Avhich they still presented on the suspension of local treatment, gradually melting and disappearing. In many instances, hoAvever, the therapeutic means enumerated only partly subdue the deep-seated chronic inflammation which is connected 250 TREATMENT OF INFLAMMATION OF THE UTERUS with the hyertrophy, or, overcoming diseased action, lea\re behind a very considerable amount of hypertrophy, sufficient to drag down the uterus, and to occasion serious inconvenience. In the first case, even if the ulceration is quite cured, there is no safety for the patient. The healed surface remains red and congested, and is nearly certain again to become ulcerated, under the influence of the slightest cause. More- over, the local and general symptoms of uterine inflammation persist, although in a mitigated shape. In the latter case, if the hypertrophy is very considerable, it is too serious a condition to be allowed to remain, more especially as there is scarcely any probability of Nature unassisted removing such extensive enlargement. The principal therapeutic means recommended by the most recent writers for the treatment of inflammatory hypertrophy of the cervix uteri, are those which we shall hereafter see extolled in the treatment of presumed cancer: local depletion, the local application of iodine and mercurials, and their internal administration. I have not myself derived sufficient benefit from the use of iodine and mercurials, either external or internal, in the treatment of hyper- trophy,—whether connected with deep-seated intractable chronic inflam- mation, or existing merely as nutritive hypertrophy, the remains of a former disease,—to induce me to employ them. Indeed, I am inclined to believe that the benefit that other practitioners think they obtain from their use in cases of inflammatory hypertrophy, is more to be attributed to the simultaneous use of local antiphlogistic treatment, than to the action of the mercury or iodine. The internal administration of iodine or mercury, moreover, can scarcely be carried to such an extent as to react on the nutrition of a cellular hypertrophy, like that of the cervix uteri, without some slight peril to the general health. Nothing, therefore, but necessity ought, in my opinion, to warrant our having recourse to the long continued use of such powerful medicinal agents in these cases—females present- ing this morbid condition being generally in a weak, debilitated, cachectic condition, from the effects of long-continued disease. With them the hypertrophy is not the result of a general disease, that can be neutralized by medicinal agency, but solely the consequence of chronic local irritation and inflammation, similar in every respect to the hypertrophy of the tonsils, so often observed as the sequela of repeated attacks of amygdalitis, or even of common sore throat. I should myself as soon think of giving mercury and iodine to remove this chronic enlargement of the tonsils, as to" remove hypertrophy confined to the neck of the uterus. Surgical treatment is as much indicated in one form of enlargement as in the other, unless, indeed, there be some general indication in the economy which renders the administration of these medicinal agents desirable, and likely to be exceptionally efficacious. Were there, indeed, no possibility of removing hypertrophy of the neck of the uterus by local treatment, it would be perfectly rational to try these, or any other medicinal agents, however powerful; especially AND OF THE UTERINE ORGANS. 251 in the cases in which the hypertrophy is connected with deep-seated chronic inflammation, which keeps up the whole train of local and general symptoms observed in uterine inflammation. Such, hoAvever, is not the case. If hypertrophy resists the action of the ordinary antiphlogistic means of treatment, it never withstands the melting influence of deep cauterization with potassa or the actual cautery. This assertion is so generally true, that I do not even find it necessary to resort to the internal administration of medicinal agents, to assist the action of cauterization, and reserve them exclusively to meet general symptoms ; or for those cases in which the hypertrophy extends to the body of the uterus, and resists local treatment. This mode of treating hypertrophy is so prompt and efficacious, that it must eventually be universally adopted. Of the two, potassa and the actual cautery, I infinitely prefer the former, for the purpose of making a deep eschar on the hypertrophied cervix. If the actual cautery is resorted to, a large-sized olive must be used, and it must generally be heated and re-applied two or three times, or fresh ones used. As the cautery acts by combustion, the noise and fumes are considerable, and generally alarm the most cour- ageous patients, although, as I haA7e stated, the pain is not very great. The retraction of the surrounding tissues, which accompanies a burn, is felt likewise rather painfully. When, on the contrary, potassa fusa or the potassa-cum-calce cylinders are used, the patient is in complete ignorance respecting the extent to which the cauterization is carried, neither her own sensations nor the concomitants of the operation being different from what she is accustomed to feel or witness in the habitual treatment of the disease under which she is suffering. In either case the subsequent result, as I have already stated, is the same. Nature sets up eliminatory inflammation in order to throw off the eschar. This inflammation extends, more or less, to the hypertro- phied tissues, according to the size of the eschar, and to the nature and extent of the hypertrophy; and, as it gradually subsides, these tissues melt and are absorbed. Under the influence, of this very simple process, the effects of which persist during two or three weeks from the date of the cauterization, any amount of hypertrophy of the uterine neck may be gradually and safely removed, and that without much suffering to the patient. As I have already explained at length the manner in which the cauterization should be made, the precautions to be taken, and the immediate and subsequent results, I have but little further to add on the subject. I must, however, most emphatically guard practitioners against an error into which there would appear to be some danger of their falling, from misinterpretation of my views. I wish it to be most distinctly understood that I do not propose to destroy the hypertrophied cervix by cauterization, but merely to set up an artificial eliminatory inflammation, by means of an eschar or issue, of limited extent, estab- lished in the centre of the hypertrophied region. I do not calculate, in the remotest degree, on the destruction of tissue to which the caustic 252 TREATMENT OF INFLAMMATION OF TnE UTERUS or cautery gives rise, for diminishing the size of the hypertrophied cervix, but solely and entirely on the inflammation subsequently set up, Any attempt actually to destroy the hypertrophy, by direct cauteriza- tion, appears to me both dangerous and unnecessary; dangerous, because I should be afraid that the intensity of the reactional inflam- mation would be so great as often to extend to the uterus or to the lateral ligaments, and because I consider it next to impossible always to limit the action of the caustic when applied with such profusion; unnecessary, because a mere eschar, of the size of a shilling, will answer the purpose of reducing the hypertrophy equally well. It may perhaps be necessary to apply it several times ; but of what consequence is prolonging for a few weeks the treatment of a disease which must ha\re existed for years to require treating at all by such agents, com- pared with the danger of perforating the vagina, and causing peritonitis, or of giving rise to intense metritis? The ulcerations occasioned by the deep application of potassa heal very rapidly, even when left to themselves. It is better, however, to touch them at intervals with the nitrate of silver, to prevent the granu- lations becoming too luxuriant, and to favour the cicatrization Avhich usually takes place in from three to four or five weeks. This fact shows how very different the morbid ulcerations of the uterine neck (described throughout this work) are from ulcerations produced artificially; the latter having a direct tendency to heal, whereas the former have an equal tendency to perpetuate their existence. It also demonstrates the rationale of the treatment of morbid ulceration by cauterization, which substitutes healthy for unhealthy action. Indeed, I may here remark that the theory of the treatment of inflammatory ulceration of the uterine neck, as I have expounded it in the preceding pages, might, with great benefit, be more thoroughly applied by surgeons to intractable ulcerations in other parts of the body. I have in several instances succeeded experimentally, in curing, by the same means, chronic ulcers of the leg, which had resisted for years all preAdous attempts at treatment. In speaking of the surgical treatment of hypertrophy of the cervix uteri, I have not hitherto even alluded to amputation of the enlarged neck, as I consider it an unjustifiable operation in these cases. Ampu- tation of the hypertrophied cervix is difficult to perform, and is attended with great danger from hemorrhage, as is shown by M. Lisfranc's cases, many of which, no doubt, were mere instances of inflammatory enlargement. Moreover, it is next to impossible to remove the entire extent of the hypertrophy, which is usually con- nected with the uterus by a large base; and what remains, generally speaking, soon assumes as great a development as before. I have seen several cases, in which amputation of the hypertrophied cervix has been resorted to, probably under the impression that the disease was cancerous; but on close examination it was clear that a portion of the hypertrophied tissues only had been removed, and that the condition of the patient was but little improved by the operation. Amputation of AND OF THE UTERINE ORGANS. 253 the cervix is, in my opinion, an operation to be discarded from practice, except when cancerous or cancroid pedunculated tumours, growing from the cervix, are recognised in a sufficiently early period of their existence to render their entire removal possible, along with that of the portion of the cervix from which they proceed. It has been objected to deep cauterization of the cervix, that it occasions cicatrices, which must interfere with the dilatation of the uterine neck in subsequent confinements. This, however, is an objec- tion which could only be raised by those Avho have never seen deep cauterization resorted to, and who have not reflected on the structure of the cervix uteri, or on the results furnished by their own obstetric experience. The fact is, that a hard, fibrous cicatrix is never observed on the cervix, under any circumstances, and that because there is no tissue therein, the cicatrization of which could furnish one. The hard cicatrices, which are seen after the healing of wounds, burns, or ulcers, involving the entire thickness of the external skin, are owing to the existence of a thick, fibrous frame-work, or skeleton, in which the vessels and nerves of the skin ramify. This fibrous tissue—nearly all that remains of the skin of animals in leather—is but very partially repaired by nature after any loss of substance. There is, it is true, an abundant exudation of plastic lymph, Avhich subsequently becomes organized; but the loss is principally made good by a puckering and drawing together of the surrounding cutaneous fibrous tissue; and it is the definitive point of union of this contraction that constitutes the ' hard cicatrix. In the neck of the uterus, nothing of the kind can occur. In mucous membranes the fibrous network exists, but in so rudimentary a condition as scarcely to require taking into account. Mucous mem- branes are nearly entirely composed of vessels and nerves; and the former when destroyed are very easily reproduced. There is, conse- quently, little or no puckering in the healing of even a deep ulceration, —and no hard cicatrix being formed, all evidence of cicatrization soon disappears, as we may daily observe on the lips, cheeks, and other mucous membranes accessible to the eye. Even when an ulceration on a mucous membrane has recently healed, the cicatrix is scarcely perceptible to the touch ; and the eye itself soon ceases to detect its existence. It must also be borne in mind, that in hypertrophy and induration of the cervix uteri, it is not the muscular structure of the organ,— which, in the normal state, we have seen to be excessively scanty,— but the cellular structure, that is the seat of chronic enlargement. An eschar, therefore, even when apparently of considerable size and depth, in reality does not, generally speaking, attack the proper tissue of the organ. In confirmation of these facts, I may also add the practical results of experience, as I have frequently confined females whom I had previously treated by deep cauterization, without any difficulty or accident. M. Gendrin's experience on this point is the same as my 254 TREATMENT OF INFLAMMATION OF THE UTERUS own. Indeed, the removal of inflammatory hypertrophy of the cervix by this means, so far from proving an impediment to delivery, absolutely assists it, by doing away with the indurated state of the cervix. As I have ^elsewhere stated, it appears evident to me that almost all the cases of rigidity of the cervix in labour that are met with in practice are the result of inflammatory hypertrophy, and that rigidity of the cervix during labour would be much more common than it is, were not the indurated and hypertrophied cervix gradually to melt as pregnancy progresses. I may here remark, that there is a great similarity betAveen the physiological softening and melting of the indurated cervix that occurs during pregnancy, and the softening that takes place under the influence of the reactional inflammation which follows deep cauter- ization. In the above account of hypertrophy, I have merely considered it as existing in an isolated state, and not extending to the body of the womb. Hypertrophy is not unfrequently met with in both regions simultaneously, but we shall discuss its treatment in the body of the organ when speaking of that of chronic metritis. Displacements of the Neck of the Uterus.—The neck of the uterus, when inflamed and enlarged, is generally displaced, as we have seen; being either prolapsed, retroverted, or anteverted. Prolapsus of the cervix, as I have fully explained in former chapters, is nearly always the result of its inflammation and enlargement, and not, as generally supposed, of laxity of the lateral ligaments. As a natural result, therefore, all attempts to remedy the prolapsus, and to keep the uterus in its natural position, by pessaries and other mechan- ical contrivances, are not only irrational, but injurious, as long as the inflammatory cause persists. Pessaries, it is true, whilst applied, keep up the womb ; but in so doing they aggravate the disease which occasions the prolapsus, their presence greatly irritating the inflamed tissues. The continued dilatation of the vagina, also, with which the retention of a pessary is attended, by dilating the vaginal canal, and destroying what little of its natural contractility inflammation has left, deprives the neck of the uterus of a very powerful and important natural support. In a word, I have no hesitation in asserting, that in forty-nine cases out of fifty in which pessaries are now employed, the patient is absolutely injured instead of benefitted by them. The rational treatment of partial prolapsus is, after ascertaining the real nature and extent of the inflammatory disease which occasions it, to treat that disease by the means which I have enumerated. Prolapsus exists, to a greater or less extent, in the great majority of the cases of inflammation of the cervix that are met with in practice; the uterus being so delicately poised, that the slightest increase in its weight modifies its position. As the cervix returns to a natural size, and as the vagina regains its contractility, under the influence of appropriate treatment, the prolapsed cervix gradually rises in the pelvis, and eventually, when all disease has been subdued, regains its natural position. AND OF THE UTERINE ORGANS. 255 This gradual elevation of the cervix, as the inflammatory enlarge- ment subsides, is all but universal, although, in some rare instances, it only partially takes place, even Avhen the diseased state of the cervix has been removed. When this is the case, the vagina is either naturally very lax, or it has been rendered so by frequent parturition. Even Avhen the uterus does remain slightly prolapsed, after the removal of all inflammatory disease, I seldom find the patient complain of dragging or pain, unless after fatigue or over exertion ; and care, with rest, and the use of astringent or of cold water injections, are the only remedies required. In such cases I never think of introducing pessaries, the presence of which is only a source of distress to the patient, and calculated to irritate and inflame the internal tissues. Almost the only cases, in my opinion, in which the use of pessaries is occasionally justifiable, are those in which complete procidentia has taken place, and does not give way to the removal of inflammatory disease, to rest, and to the subsequent use of astringent injections, exhibited with a view to restore the tone and contractility of the vagina. Even in these cases, however, pessaries may frequently be dispensed Avith; the womb often recovering its position in patients in whom it has appeared at the vulva, or has protruded externally, by merely following the above treatment. In complete and incurable procidentia, when some artificial means of support is imperatively demanded, I generally find that a bandage, with a vulvo-perineal pad, is the most easily borne by the patient. As, however, these bandages only prevent the uterus protruding, and do not obviate its falling in the vagina, vaginal pessaries ought to be preferred, although inconvenient and painful, if they exercised, in the course of time, a curative influence on the prolapsus, as commonly asserted, by allowing the ligaments to regain their tone. But I have not, in my own practice, or in that of others, found this to be the case, even in these extreme instances. Pessaries have always appeared to me a'mere artificial means of sustentation, like a crutch to a lame man, exercising no beneficial influence whatever on the prolapsus, and allowing it to return to the full extent as soon as subtracted. On the other hand, I have seen, and still continually see, a great deal of harm result from their blind and indiscriminate use. Nor can it be otherwise, when we consider that pessaries are commonly employed to remedy what is, in almost every instance, merely a symptom of inflammatory disease of the uterine neck. Thus it is that such eases occur as the one I have narrated at page 141, in Avhich a Avooden pessary was forced up the vagina of a young, unmarried female, suffering from ulcerative inflammation of the cervix uteri, and that by an experienced uterine practitioner, in the face of the most conclusive evidence as to the existence of the disease. Abdominal bandages and supporters have been much recommended and used by most practitioners in the treatment of prolapsus of the uterus. Their advantage is limited to taking off the pressure of the intestines from the womb, by the support afforded to the lower part of 256 TREATMENT OF INFLAMMATION OF THE UTERUS the abdomen. The uterus, in the non-pregnant state, being concealed within the pelvis, an abdominal bandage clearly cannot give it any direct support. It may really afford, however, considerable relief to women in whom the uterus is enlarged, sensitive and prolapsed; but can only be considered a palliative remedy, principally valuable to females in whom the real nature of the inflammatory disease under which they are suffering has not been recognised, and who, being left to take their chance, are glad to adopt any means that can give the slightest relief. As soon as all inflammatory enlargement of the uterus has been subdued, and it has regained its normal position, it loses its morbid sensitiveness, and the pressue of the abdominal organs is borne without being perceived. I therefore seldom recommend bandages to my patients, and generally find that those who have previously Avorn them, leave them off spontaneously long before the uterine disease is quite cured, no longer deriving any relief from their use. There are cases, however, in which the abdomen is large or loose, and in which a bandage gives great relief, appearing to contribute indirectly to keep the uterus in its position, both before and after treatment. Retroversion of the neck of the uterus, with or without anteversion of the body, is a very common displacement in married females, as we have seen, and is by no means confined to persons suffering from inflammatory disease of the cervix. Attempts have been made, of late years, to treat this displacement instrumentally, although no such means can possibly remedy its existence. It is a mere delusion to endeavour to restore^the^cervix and the uterus to their proper position, when thus displaced, by introducing the uterine sound into the cervical cavity, and bringing the cervix forward, even if the operation be repeated daily for several weeks. Such a treatment only inflicts pain on the patient who is made to submit to it, without being of the slightest benefit to her. It does not remove, in any respect, the cause of the displacement, and the consequence is, that as soon as the instrument is withdrawn, the cervix falls back into its original position. Retroversion of the cervix, it will be recollected, is partly the result of gravity, acting on an enlarged and indurated cervix, and partly of long-continued intercourse, taking place under the same circumstances; and the only chance there is of remedying it is to restore the enlarged and indurated organ to a natural size and consistency by judicious antiphlogistic treatment. When this has been effectually accomplished, the uterus rises in the pelvic cavity, and the cervix, ceasing to press upon the rectum, gradually reassumes, to a certain extent, its normal position. ^ I say, to a certain extent, for it very seldom happens that the cervix thoroughly regains a normal direction, when it has once been much retroverted. This circumstance, however, is not of the least importance, as a slight deviation of the cervix posteriorly, and of the uterus anteriorly, gives rise to no morbid symptoms, in the absence of inflammatory disease, and requires no treatment, a fortunate circum- stance, as it is the usual position of the organ in many married women perfectly free from any kind of uterine disease. AND OF THE UTERINE ORGANS. 257 The above remarks apply, in every respect, to anteversion of the uterus, which is nearly always connected with, and apparently the result of, extreme retroversion of the cervix. Anteversion of the cervix is scarcely ever observed, except in connexion with retroversion of the body of the uterus. We shall examine its treatment when describing that for chronic metritis. Pain.—The various local pains that have been elsewhere described constitute one of the prominent symptoms of inflammation and ulcera- tion of the cervix, and vary considerably during the course of treatment. Generally speaking, they do not require any particular medication ; they are, however, subject to exacerbations after cauterization, the application of leeches, over exertion, and the approach or presence of the menses, which may imperatively require relief. The most prompt and efficacious remedy for uterine pain, and for pain in the uterine regions,—the lower part of the back, and the vicinity of the ovaria,— is the injection of laudanum, or of any preparation of opium, into the rectum, in a small quantity of warm water, to be retained. The effect is much more decided than if the opiate were taken by the mouth. From fifteen to thirty minims of laudanum may be used at a time, and repeated in the course of an hour, if the desired effect is not obtained. A preparation of Mr. Squire's, to which he has given the name of solution of bimeconate of morphia, has appeared to me to occasion less sickness and headache than any preparation of opium I have ever used, and I generally give it the preference on this account. The dose is the same as that of laudanum. To the opiate injection may be added, sedative vaginal injections, the warm hip-bath, rest in bed, large poultices to the abdomen, leeches at the menstrual epoch, sulphuric ether administered internally, chloro- form, and Indian hemp as a tincture or an extract. Chloroform is a very valuable addition to our means of allaying severe uterine pain, in whatever shape it manifests itself, whether as an exacerbation of the ordinary aching pains, as an occasional attack of uterine spasm, or as^a periodical neuralgic affection. In all these forms of pain I have often given it with great benefit. It may be administered by inhalation, or internally as a medicine, or by rectal injection. The inhalation of chloroform, carried so far as to produce insensi- bility, but not muscular paralysis, has often, in my hands, allayed the most violent pain, and subsequently procured the patient several hours refreshing sleep. The same effect has been produced in many of my patients, by giving internally from thirty to forty minims beaten up with the yolk of an egg, or in a little thick gruel. I have obtained a like sedative effect from the use of the same quantity injected into the bowels. As chloroform does not mix with water, it is necessary to beat it up with mucilage, the yolk of an egg, or thick gruel, in order that it should remain in suspension. Very frequently, however, the rectum cannot retain it, owing, apparently, to its irritating effect on the mucous membrane. 17 258 TREATMENT OF INFLAMMATION OF THE UTERUS Generally speaking all uterine pains vanish when the disease of the cervix is cured. This is not, however, invariably the case. The pain in the back, more especially, may remain long after all trace of disease has disappeared from the uterus, varying in intensity without any tangible reason. The treatment which I have found the most beneficial in this neuralgic form of backache is, the repeated application of large blisters. Blisters generally relieving it, even when uterine disease is still in existence ; but I seldom resort to them during treatment, as the relief is only temporary, and a blister in this region is rather a pain- ful and annoying remedy. When the uterine disease is quite subdued, on the contrary, one, tAvo, or three blisters, applied successively, will often permanently remove the pain. If not at first successful, their application will generally be found to be so a few months later. Opiate and belladonna plasters, cupping and leeching, are frequently useful, although by no means so efficacious as blisters. When uterine or vesical pain is very constant, and only temporary relief is obtained by the above means, I have repeatedly derived great benefit from the formation of an issue in the cellular tissue, just above the pubis, near the symphysis pubis. This issue should be kept up for several months. It also exercises a beneficial influence on the chronic uterine inflammation itself. 1 The pains in the left and right ovarian regions, which so generally accompany inflammation, and especially ulceration of the uterine neck, do not require any particular treatment. In the very great majority of cases in which they are met with, as we have seen, they are merely sympathetic pains of the nerves distributed to the ovary, and do not indicate the existence of ovaritis, either acute or chronic. Their almost invariable presence in the ovarian regions, however, when the cervix uteri is ulcerated, is a remarkable circumstance, which leads to nume- rous errors. In practice, I continually meet with patients who are supposed to be suffering from chronic ovaritis, because they present these pains along Avith tenderness in the ovarian region, and with Avhom the inflammatory disease of the cervix is in reality, the only decidedly morbid condition, the ovaries being free from all inflammatory action and merely sympathetically irritable. Dilatation of the cervical cavity.—Menstruation appears occasionally to remain painful, after the subdual of inflammatory action in the cervix, from contraction either of the region of the cervical canal Avhich has not been inflamed, or of that in which inflammation existed and has been cured. In the former case, the contraction is probably the result of the morbid thickening and enlargement of the cervix, diminishing the calibre of that part of the cervical canal that does not participate in the inflammation ; for it will be remembered that inflammation of the cervical canal itself has invariably a contrary or dilating effect. In the latter case, the contraction is probably owing to the narrowing of the previously inflamed and dilated region which occurs from the treatment having been carried a little too far. Even when narrowing of the cavity of the cervix does exist under AND OF THE UTERINE ORGANS. 259 the influence of either of these causes, as a sequela of inflammation, it is often only temporary, and is gradually removed by nature without the necessity of any particular treatment. In the course of a few months, in the absence of inflammation, the remaining induration of the neck of the uterus may be gradually absorbed, and all pressure thus taken off the upper cervical region, whilst the lower region almost generally relaxes in time, however contracted it may be when the cure is first effected. This being the case, it is clear that no remedial treatment for narrowing of the cervical canal is required, under ordinary circum- stances, within the few first months of the cure of inflammatory disease. Should, however, menstruation, after a reasonable lapse of time, con- tinue to be anomalously painful, all inflammatory action, both inside and outside the cervix, having been subdued, artificial dilatation of the cervical canal may be reasonably recommended. In deciding on the adoption of dilatation, the state of menstruation is with me the principal criterion. The condition of the cervical canal, as appreciated by the uterine sound, I do not look upon as a guide that can be entirely depended upon. I continually see instances in which the cervical canal is so narrowed, especially after treatment, as not to admit the uterine sound at all, and yet menstruation is easy, free from pain, and suffi- ciently abundant. In such cases I should never dream of resorting to dilatation, unless it were with a view to remove a possible cause of sterility. I am constrained, however, to confess that I do not believe that narrowing of the cervical canal is a frequent cause of sterility. The removal of this structural condition has proved of no avail in the majority of the cases in which I have resorted to it; and in those in which] it has been followed by success, I am not certain whether the favourable result ought not to be attributed to the previous cure of the inflammation. The following case will, illustrate the difficulty of forming an opinion on the subject. In the spring of 1848 I was consulted by a young lady, aged twenty-five, married nearly two years. Of delicate constitution, she had for years suffered from dyspepsia and from dysmenorrhea, but had been much worse since her marriage. She also presented various uterine symptoms, and, on examination, I found the neck of the uterus and the upper region of the vagina slightly inflamed, but not ulcerated. The local disease gave way, the general health improved under appropriate treatment, and in the course of about two months, I was able to pronounce her well, and to state that an important cause of sterility having been removed, it was not at all improbable that conception would subsequently take place. The uterus was then perfectly healthy, but the cervical passage was too small to admit the uterine sound in its entire extent, and I could not pass the smallest bougie through the os internum. Both the lady and her husband being anxious for a family, I mentioned this condition, and stated that it might be desirable at some subsequent period to remove the contraction, 260 TREATMENT OF INFLAMMATION OF THE UTERUS if it did not spontaneously disappear, and if the sterility persisted. A few months later I again saw ber ; her health had still further improATed, and the uterus was, as before, free from disease, but the cervical contraction Avas not in any sense diminished. It was therefore decided that the dilatation should be effectually carried out on her return from the seaside, where she was about to spend a couple of months. Before she had been there a fortnight, however, she became pregnant. Had dilatation been effected when I last saw this lady in town, previous to her journey to the seaside, the inevitable conclusion would have been that it was the result of the dilatation only. The sequence between cause and effect would have appeared undeniable, and it would have received the entire credit of having removed the sterility. Such instances as these show how difficult it is to arrive at the truth in the estimation of the value of remedial agents, and also that indi- vidual cases, however apparently conclusive, prove nothing. No medi- cinal or surgical agent can be considered the cause of a subsequent result, unless that result generally follow its administration or use. Judged by this test, dilatation of the cervical cavity has not proved in my hands a remedy for sterility that can in any respect be depended upon. Still, as contraction may possibly be the cause of sterility, I do not hesitate to advise it, and to resort to it, when inflammation,has been thoroughly removed, and conception does not take place after a reasonable lapse of time—that is, after three, six, or twelve months, according to circumstances, or when contraction exists in sterile females, independently of inflammation. There are various means by which the cervical canal may be dilated. Dr. Mackintosh, of Edinburgh, to whom the idea appears to have first occurred, used metal bougies of different sizes, which he introduced into the cervix, allowing them to remain for a few minutes, and gradu- ally increasing their size; thus applying to the dilatation of the cervical passage the principles which regulate that of the urethra in the male. Dr. Simpson has made several ingenious modifications and improAre- ments in the dilatation of the cervical canal. Instead of long bougies, which can only be retained a short time, he uses small ones, only two and a half inches in length, terminated by a bulbous disc or extremity. The vagina closing round this disc prevents the bougie being expelled frorn the cervical canal by its contraction. A small-sized bougie is at first introduced and allowed to remain four-and-twenty hours, or longer, and the size is gradually increased as the canal dilates, until the os internum itself is opened, and the sound passes freely into the uterine cavity. Dr. Simpson also uses for the purpose of dilatation, cones of prepared and compressed sponge, which are introduced into the cer- vical canal by means of a stilet; as far as they will pass, and which by their gradual expansion under the influence of the moisture and heat of the parts, gently dilate and open the cavity of the uterine neck. An instrumental dilator has long been used, formed of two blades, the length of the cervical canal, which open by the action of the handle, AND OF THE UTERINE ORGANS. 261 and when closed merely represent a conical staff. The blades are introduced closed, and on being opened, forcibly dilate the cervical canal. Dr. Simpson has likewise invented a very ingenious instru- ment, Avhich he calls the uterotome, for dividing the os internum or the cervical canal. It presents a long narrow blade concealed in a bougie- like extremity, which also opens by the action of the handle. Dilatation by means of the ordinary metallic sounds is tedious and inefficient. Owing to the great thickness of the walls of the cervical canal, and to the considerable amount of contractile power which they possess, the mere gentle introduction of a metal bougie for a feAV minutes every two or three days, is powerless to efficiently dilate a contracted cervix: at least, it has always appeared so to me when I have tried it. On the other hand, if force is used, the space gained is more likely to be obtained at the expense of contusion of the tissues Avhich form the immediate parietes of the cervical canal, than by the dilatation of the walls of the cervix, which it must not be forgotten are half an inch in thickness. This latter objection applies with even greater force to the metallic dilator. Such an instrument might rationally be used to dilate a mere membranous canal, but in the cervical cavity it must act to a very great extent by bruising and crushing the tissues which it is meant to expand. It should therefore be entirely discarded. The small, bulb-ended metal bougies of Dr. Simpson are free from these objections, and, if carefully used, are safe and effectual. No force need be employed, as we depend for dilatation on their gradually tiring out, as it were, the contraction of the part of the cervical canal into which they are introduced. A size is chosen which just passes, and which is sufficiently small to be grasped by the cavity of the cervix. Its sojourn in the cervical canal, if there is no inflammation present, is unattended with irritation or inconvenience, and in the course of a period varying from a few hours to four-and-twenty, the cervix relaxes around it, and becomes sufficiently open to admit of a larger-sized bougie. The great difficulty, however, with these bougies is their introduction, on account of the bulb. If the vulva is relaxed and open, nothing is easier; but if, on the contrary, as is very often the case, the vulva is small and contracted, it becomes extremely diffi- cult to introduce the bulb, and subsequently to guide the other extre- mity to the os uteri, even with the assistance of the director used by Dr. Simpson, which fixes in the bulb. I endeavoured to obviate this difficulty by having small bougies made without a bulb, keeping them in situ by a small piece of sponge, introduced into the vagina as a pessary. This plan, however, does not answer, as the bougie, not having the support of the bulb, is easily expelled; moreover, the retention of the sponge is often attended with vaginal irritation. The above objections and difficulties have induced me to resort nearly exclusively to the use of compressed sponge, as suggested by Dr. Simpson, for the purpose of dilatation. I use very small cones, from an inch to an inch and three quarters in length, tapering down 262 TREATMENT OF INFLAMMATION OF THE UTERUS to a small blunt point, and covered with a thin coating of wax. One of these cones—a small one—is introduced into the cervical canal, by means of the stilet, as far as it will go, and there left for four-and- twenty hours. The wax as it melts forms a coating to the sponge, and protects the tissues which it imperceptibly dilates; the slow dila- tation of the sponge, under the influence of capillary expansion, thus overcoming the resistance of the cervix, and effectually opening the region in which it is introduced without irritating the mucous mem- brane. This, however, is only the case when the sponge is well covered with wax; if left bare, it irritates the mucous surface and makes it bleed. The sponge should be allowed to remain for twenty- four hours, when the patient herself can easily withdraw it, by means of a small piece of silk or thread, which should be fixed to it, and should be sufficiently long to protrude externally. The expansion of the sponge is seldom attended with any pain, or, indeed, with any sensation. Sometimes, however, the patient will say, that she feels as if something were being forcibly opened about the womb. If the sponge is alloAved to remain more than twenty-four hours, it is generally expelled spontaneously into the vagina, apparently by the pressure of the mucus naturally secreted above the point where it lies. If imper- fectly introduced, it may fall out long before, and be found lying in the vagina. It is generally easy to tell which part of the tent has expanded in the cervical canal, as it is much less swollen than that which has not entered, and which has freely expanded in the vagina. A decided contraction indicates the line of demarcation. If the entire tent is uniformly and fully developed, as if it had been soaked in water, the probability is, that it either never was really introduced into the cervical cavity, or that it was expelled before it had time to dilate. When the os uteri is much closed, and very small tents are intro- duced, the use of a speculum cannot wTell be avoided, as the warmth of the vagina softens the tent or its point, before it can be passed into the os. When the os is more open, and a larger tent can be employed, the speculum is not required, as it can then be easily introduced with the assistance of the director or of a stilet, the patient lying on her left side. The first will probably only pass a quarter or half an inch; but each time a new tent is inserted it penetrates further, until the entire cervical canal can be dilated. As I only introduce the tent every third or fourth day, in order to prevent irritation, the interval between two menstrual periods is generally required in order thoroughly to dilate the canal. The day the tent is withdrawn, as there is gene- rally a certain amount of mucous discharge, I recommend a quantity of cold water, or an astringent solution, to be injected into the vagina, to allay any slight irritation which the interference may have occa- sioned. By thus progressing carefully, ascertaining occasionally the state of the parts by instrumental examination, and suspending the dilatation if any irritation of the mucous surface is produced, in the course of two AND OF THE UTERINE ORGANS. 263 or three weeks the cervical canal may be efficiently dilated without any local injury whatever. This is certainly not always the case when more violent means are used. I have met with repeated instances in which much mischief had been produced by forcible dilatation, and by blind attempts to dilate the cervical cavity when in a state of inflam- mation. At one time I used Dr. Simpson's uterotome frequently, in order to divide the os internum, and found it a very efficient means of removing the apparent constriction at that region. A mere slit laterally, on each side, not more than a line in depth, which is scarcely felt by the patient, is all that is required to establish a free communication between the tAvo cavities. In order, however, to make this slight incision, the instrument must pass through the os internum, as otherwise the blade could not be made to bear on the spot which it has to incise; and since I have carefully analyzed the state of this region, when free from disease, I have ascertained that a degree of openness, that admits the passage of the uterotome through the os internum, is in reality more than is generally met with in the healthy female; and that, conse- quently, there can be no sound reason for increasing it still farther. When, therefore, by means of the sponge tents, the cervical cavity has been dilated, and the os internum relaxed, so as to admit the passage of a moderate-sized bougie, or of the extremity of the uterotome, I now consider that the dilatation has been carried quite as far as is neces- sary or desirable, and consequently very seldom resort to the uterotome. After the os internum has been divided by the uterotome, there is generally a slight oozing of blood for a few minutes. Were no means adopted to prevent union, the incised surfaces would probably heal by the first intention, in twenty-four hours; it becomes necessary, there- fore, to introduce a moderate-sized metallic bougie, taking care that it be pushed sufficiently far to pass the os internum. This bougie should be retained four or five days, if its presence is unattended with pain or discomfort; if otherwise, it may be withdrawn for a few hours, or eAren a day, and then re-introduced. By the above means the incisions may be prevented healing, but in the course of a few weeks or months the os internum invariably closes again. I have never examined a patient on Avhom I had performed this operation, after a lapse of some time, without finding the os internum as much closed as at first. Nor is it surprising that this should be the case, the os internum being naturally closed, as I have elsewhere explained; so that any attempt to establish a permanently free communication betAveen the two cavities of the cervix and uterus, is merely an attempt to establish what is not a natural condition. Rest, Exercise.—A patient suffering from inflammation and ulcera- tion of the neck of the uterus should remain, as much as possible, in a reclining posture, on a couch or easy chair. In this position there is no pressure on the uterus, and its graA'ity is not called into action; in the erect posture, on the contrary, the weight of the uterus drags it down, and in walking it is thrown against the adjoining tissues, which 264 TREATMENT OF INFLAMMATION OF THE UTERUS gives rise to pain. Complete rest is more especially advisable after any surgical interference, when the vitality of the inflamed tissues has been raised by local applications, and AYhen the uterus is consequently more sensitive than usual. I do not, however, consider it necessary for the generality of patients suffering from inflammatory disease of the uterine neck, to remain per- petually on a sofa or on an easy chair. Unnecessary exertion, standing, and going up and down stairs, should be avoided as much as possible; but if the motion of a carriage can be borne, it will, generally speaking, do no harm, and the fresh air will improve the general health. Even a gentle walk, taken for air more than for exercise, may be allowed, if there is npt much hypertrophy and displacement, and if it does not bring on pain or uneasiness. In a word, we must be guided by the nature of the symptoms, the amount of disease, and the sensations of the patient, always bearing in mind that absolute confinement is an evil which we cannot avoid in some cases, but which should never be enforced without necessity. It is scarcely necessary to add, that during the treatment of this form of disease, separation of the husband and wife should be strictly enforced. The Bladder and the Rectum.—We have seen that the bladder and the rectum generally participate more or less, in the congestion which accompanies inflammation of the neck of the uterus, and that sometimes inflammation extends from the uterus to these organs. When this is the case, the means employed to mitigate the uterine disease—leeches, abdominal poltices, hip baths, and vaginal injections—are equally efficacious in allaying the vesical or rectal irritation—all the morbid symptoms which the pelvic viscera present subsiding at the same time. Irritability of the bladder, the result of extension of inflammatory action, must not be confounded with that which is produced by the contact of morbid urine. I shall revert to this form of vesical irritability, when speaking of the treatment of depraved digestion and assimilation. I am in the habit of treating the irritable state of the mucous membrane of the lower bowel, and the kind of paralysis of its action which is so frequently met with, by a very simple means—the daily injection of a small quantity of cold water into the rectum. Injections of warm water relax the bowel, and appear, if preserved in for any length of time, to increase, or even to occasion, constipation. But this is not the^ case with cold water, or cold linseed tea, when it can be borne, as is generally the case. It restores the contractility of the muscular fibres, and allays irritation of the mucous membrane. If injected in a small quantity only, not more than half a pint at the utmost, its presence is seldom attended with any uncomfortable sensation whatever. Indeed, it is not even necessary to take off the chill, unless the Aveather be cold, or the feeling of the patient requires it; for in some exceptional cases, the impression of cold on the bowel produces spasm. When th« rectum is perfectly inactive, and allows hardened faeces to AND OF THE UTERINE ORGANS. 265 remain for days in its lower regions, without giving any intimation to the patient of their presence, or without having power to contract and expel them, as generally occurs in chronic uterine disease, the daily use of the cold injection after breakfast is invaluable. It clears the lower part of the bowel, without the patient being obliged to have recourse to aperient medicines, otherwise indispensable, and may be continued for months, or even years, Avithout the slightest inconveni- ence or injurious effect. If the constipation is situated higher up in the intestinal canal, and the faeces do not reach the rectum, injections of all kinds are, of course, inefficacious. But even then, I often advise my patients to persevere in the use of the cold injection, merely as an additional means of applying cold to the pelvic viscera, in the anticipa- tion of its gradually restoring the contractility of the rectum, and thus preparing it for its duty, when other causes of constipation have been removed. General Treatment. Although of the most vital importance, the general medical treat- ment of a patient suffering from inflammatory disease of the neck of the uterus may be considered accessory to the local means employed. That such is the case, is proved by the fact that general medication alone is totaly powerless to subdue the disease; whereas, by local means, with attention to dietetic and hygienic rules only, the uterine inflammation may, generally speaking, be entirely subdued, and its sympathetic reactions removed. The various symptoms indicating disordered digestion, assimilation, nutrition, circulation, and enervation, being entirely sympathetic— that is, the result of the reaction of a diseased organ on the functions of organic and animal life, with which it is connected by its nervous system,—it stands to reason, that when the cause of all the mischief is removed, the economy must rally, even unassisted, unless too far depressed by disease. Fertunately, this is seldom the case, the system appearing almost always to retain the power of rallying, even when it has been lowered by a long life of disease. Thus I have frequently known females recover from the all but unassisted energy and vitality of their constitution, although for twenty years or more the existence of chronic uterine inflammation had rendered them confirmed invalids. We may therefore hope much from the latent strength of the economy, when local disease has been removed, independently of what we can do by medicinal and hygienic means, to assist the restorative efforts of Nature. Although I thus give by far the greatest share to Nature in the restoration of the general health, when the uterine disease has been removed, I must not be thought to depreciate the powers of medicinal and hygienic means of treatment. Much may, no doubt, be done through their agency to hasten the recovery of the health and strength of the patient, as I shall endeavour to show. 266 TREATMENT OF INFLAMMATION OF THE UTERUS The principal characteristic of the disordered state of the digestive system, which almost invariably accompanies chronic inflammatory disease of the neck of the uterus, is weakness. The stomach evidently participates in the general debility, and in the depression of the ner\*ous system, and loses the power of transforming the food ingested into healthy chyle—digestion being either rapid and imperfect, or sIoav, laborious, and painful. Such being the case, it evidently follows that the plan generally pursued with patients thus suffering, who, because they are Aveak and debilitated, are gorged with meat and stimulants, and drenched with steel and quinine, must be injurious, instead of beneficial. That it is injurious, my daily experience demonstrates. I constantly meet with patients who have been thus treated for months and years, and who, instead of deriving any benefit from the good living and tonics which were to build them up, have gradually become more and more debilitated, emaciated, and feverish. The fact is, that in such cases a large proportion of the food that is taken passes away undigested; whilst that which is digested with difficulty gives rise to such imperfect chyle, that, as soon as the lymphatics pour it into the blood, it is eliminated by the kidneys, as we have seen, in the shape of urate of ammonia, oxalate of lime, &c, giving rise, at the same time, to headache, palpitation, heartburn, restlessness, nightmare, and other similar symptoms. It should never be forgotten that loading the stomach of a debilitated invalid with nourishing food is not nourishing to him, and that tem- porarily raising the circulation and the nervous system by the repeated administration of wine and other stimulants is not strengthening him. It is not what is taken into the stomach that nourishes, but that Avhich, being thoroughly digested, furnishes a healthy chyle, susceptible of being assimilated, and of repairing the wear and tear of the system. Thus it is that a patient may starve and lose flesh on a diet of meat and wine, or ale, three or four times a day, and grow fat on rice and milk, or on any other light article of food, containing the necessary elements of nutrition, which the stomach can really digest. The same remark may be made with reference to the principal tonic medicines, such as iron and quinine, which, although universally administered, irrespective of the state of the digestive system, are, in reality, totally incompatible with a disordered digestion. When given under such circumstances, far from being beneficial, they often posi- tively do harm—occasioning headache, flushing, and general uneasiness, because the debilitated and disordered stomach cannot digest them. We see this fact exemplified in the treatment of intermittent fever. So long as the tongue is loaded, and the stomach out of order, it is of but little avail to give quinine; in order to ensure its being, digested and assimilated, so as to produce its specific influence, it is first necessary to restore the integrity of the digestive system. The only tonics that I have found beneficial in this morbid state of the digestive system, are the mineral acids and vegetable bitters, and AND OF THE UTERINE ORGANS. 267 more especially the former. Stimulants, such as spirits, wine, and malt liquor, are decidedly injurious. They do not rouse the vitality of the stomach, and enable it to digest food, as is generally supposed, but tend, on the contrary, still further to increase the depraved condition of its secretions, and to diminish its power of transforming food into healthy chyle. Although this is invariably the effect of their administration in these cases, they are nevertheless generally adA'ised and taken as a means of restoring strength. The patient is easily induced to believe that such is really the effect produced, as the immediate result of the ingestion of stimulants of this description is to temporarily dispel the sensations of extreme languor, debility, and depression experienced, and to give artificial strength, which conceals the real state of the system. In order, therefore, to appreciate correctly the actual condi- tion of a patient who has been thus taking stimulants, she should be made to forego their use entirely for a few days, and then the debility will be seen as it really is. These observations also apply to diffusible stimulants, such as ammonia and sal volatile, when taken to excess. The habitual use of opium, and of narcotic medicines generally, has the same pernicious effect. Their continued action both injures the patient, and conceals the real state of her health by the false calm or excitement which it occasions. The constant administration of opium in order to soothe pain, in cases in which the real nature of the disease is not understood, and in which, consequently, medical treatment utterly fails to subdue, or even to mitigate, the sympathetic nervous symptoms, is more especially pernicious. It not unfrequently so reduces the patient to the state of the professed opium-eater, that after all uterine disease is subdued, she may have to go through intense mental and physical misery before the habit can be conquered, and the system restored to a natural state. The habit of taking large doses of laudanum as a means of lulling the bodily pains, and of soothing the mental depression and distress so frequently experienced in chronic uterine disease, is much more common than is generally supposed. Laudanum is at first prescribed medically, in small doses, by the medical attendant, and the patient finding relief from it, of her own accord gradually increases the dose, often concealing the fact from those around her, until at last the quantity she takes daily becomes enormous, a wine glassful or more. When once this point has been attained, she may be considered a confirmed opium-eater, and the effects of the opium on the economy are pretty much the same as those Avhich it would produce on a non- diseased person. Not only are the pains of disease obscured whilst the patient is under the immediate influence of the drug, but the nervous system is calmed, and the mind for the time recovers its pristine clear- ness and power. Thence it is that the female opium-eaters I meet Avith, under these circumstances, are principally very intellectual persons, who fly to it as a means of enabling them to accomplish their social duties and obligations, notwithstanding the prostrating influence of the disease under which they are labouring. They cannot resist 268 TREATMENT OF INFLAMMATION OF THE UTERUS the temptation offered to them by a drug Avhich, even for a time, restores to them their former mental energy, and enables them to soar above the frailties of their corporeal frame—and that although perhaps aware that they are sowing the seeds of destruction in their frame, and aggravating the disease from Avhich they suffer. One of the results of the habit of opium eating experienced by some, but not by all, is a tendency to dream whenever sleep closes the eyes. The dreams may be, and often are, for a time, wild, fantastic, but agreeable; later, however, they become horrible and terrifying, assuming the form of a nightmare, which pursue the patient whenever she attempts to sleep. I have met with illustrations of both these conditions. Under the influence of this pernicious and fatal habit, not only does the local uterine disease make rapid strides, but the functional derangements which it occasions increase in the same proportion, and others supervene, more especially the result of the opium. The symp- toms which I would more especially refer to the latter are congestion and irritation of the liver, giving rise to frequent attacks of bilious vomiting and purging, alternating with obstinate constipation. The general nutrition also flags, and in the course of time the emaciation becomes extreme. When I meet with cases of this kind, I merely diminish the quantity of opium taken until the uterine disease be cured, and then oblige the patient to leave it off altogether and at once. The attempt is always a severe trial, and requires great courage on her part and great and constant attention on the part of her medical attendant. The mental prostration and distress, and the bodily rest- lessness and agitation for the first few weeks are often truly deplorable. I have always succeeded, however, hitherto, in ^breaking the habit although often only after great trouble and anxiety. It is a fact that should be borne in mind, that patients are generally very loath to confess to this habit. I have repeatedly attended persons for many months without being made aware of it. From what precedes it must be evident that the strengthening plan of treatment generally pursued in cases of general debility and functional^ derangement, the result of unrecognised chronic uterine inflammation, is essentially wrong. It is adopted under the impression that the languor and debility are idiopathic, the evidence of a low vitality, and to be met by tonics. Nothing, however, as we have seen throughout this work, can be more irrational than these views, which are founded, on the one hand, in ignorance of the existence of local inflammation, and on the other, in being unaware of the injurious effects of the attempt to increase the nutrition of the system, by stimulating and over-taxing the powers of the stomach, when debilitated by disease. Great as these errors are, however, they are daily committed by the most eminent practitioners. I am constantly consulted by anemic females labouring under chronic uterine disease, and great derangement of the digestive and nutritive system, who have for years been plied with animal food, stimulants, and tonics, AND OF THE UTERINE ORGANS. 269 and tortured by exercise, in order to remedy what was erroniously considered to be "idiopathic debility ! " The principles on which the disordered state of the digestive and nutritive functions in these cases should be treated, are twofold. Firstly, the local uterine disease, which, through its sympathetic reaction on the stomach and digestion, occasions these morbid conditions, should be subdued by the local means already enumerated, in order that all morbid reaction may cease ; otherwise general treatment is vain. Secondly, the stomach and digestion should be taxed as little as is consistent with the reparation of the system. The stomach is a muscular organ, which, even in health, like all other muscular structures, requires rest. Even the heart, although apparently in motion, is so constructed, that its muscular elements rest during a considerable part of the twenty-four hours. How much more necessary, therefore, must rest be to the stomach when it is debilitated and diseased, when its secretions are depraved, and when its powers of carrying out the process of digestion are weakened ? And yet this is the very state that is often chosen, as we have just seen, to pour into it, at short intervals throughout the twenty-four hours, animal food and irritating stimulants ; the former requiring, it should be recollected, three, four, or more hours of constant trituration. This system is adopted under the plea of general debility, with a view to invigorate the system by nourishing food. But of what use is it to furnish materials in such abundanco, if the organ which is to transform them into chyle participates in, or even originates, the general weakness, and, being unable to accomplish the duty imposed upon it, either gets rid of the food in an undigested state, or elaborates imperfect chyle, which, when it reaches the circulatory system, merely poisons the economy, and is speedily eliminated and thrown out by its emunctories the kidneys, in the shape of urate of ammonia, oxalate of lime, &c. The more rational course, the one which I invariably follow, is, to alloAV the stomach as much rest as possible, taking into consideration, that by its labours the wants of the system have to be repaired. I treat it as I would a sprained joint. No person in his senses would think of walking all day with a sprained knee, or ankle, in order to strengthen it ; and it appears to me equally absurd to keep the weakened or diseased stomach constantly full and at work, eighteen hours out of the twenty-four, in order to invigorate it. Actuated by these views, I discard, in the treatment of the morbid conditions of the stomach, the precept so generally followed in dyspepsia—" a little substantial food taken often." On the contrary, I only allow animal food once a day, restrict the patient to three light meals, and endeavour to arrange her diet, so that everything taken should be as easily digested, and consequently as soon out of the stomach, as possible. By these means, the " labour" of the stomach may be limited to eight or nine hours in the tAventy-four, and yet a sufficient 270 TREATMENT OF INFLAMMATION OF THE UTERUS quantity of chyle be furnished by digestion to supply the Avants of the economy; better, indeed, than they are supplied by the imperfect digestion of five times the amount of more solid, and, according to the popular idea, more nourishing food. The constant craving for food, and the sinking sensations which are so often present in a disordered state of the digestion, are decidedly morbid symptoms ; the presence of which is owing, probably, either to the food ingested leaving the stomach in a semi-digested state, or to the chyle formed being morbid, and unfit for the_ purposes of assimilation, and to its being eliminated by the kidneys in a short time after it reaches the blood. This fact illustrates the fallacy of the popular opinion, that the stomach should not be allowed to remain empty during the state of wakefulness. If the food taken is thoroughly digested, and affords to the system sufficient reparative elements, hunger is appeased for some time, and the emptiness of the stomach is borne Avithout any uneasy sensation. It is, indeed, a period of rest for that organ, during which it recovers its strength, as it were, and prepares for subsequent exertion. If the food, on the contrary, OAving to weakness or disease, is not so digested as to afford to the economy the elements of nutrition, hunger is again felt within a very short time after its ingestion. This morbid craving is thus more effectually met by a light and rather spare diet, than by an abundance of solid food, which only perpetuates and increases the evil. The form of dietary which I generally recommend is as follows :— For breakfast: thin cocoa, made with part milk, or very weak tea, with stale bread-and-butter, and an egg if desired. For luncheon : an egg, or broth, or a light farinaceous pudding, or merely a little bread and-butter. For dinner : fish, poultry, game or meat alternately; vegetables, if they agree. The dinner to be completed with some light pudding, rice, bread-and-butter, sago, arrow-root, &c. If the digestion is very much disordered, the patient had better confine herself to fish and poultry for some time. When meat is taken, not more than an ordinary-sized mutton-chop should be eaten; when poultry, not more than the wing of an ordinary fowl. In the evening, a little very weak tea may be allowed, without anything solid. If in these three meals the patient takes from eight to ten or twelve ounces of bread, from ten to sixteen ounces of milk, in one shape or another, from two to three or four ounces of animal food, a little butter, vegetables in small quantities, if they agree, and broth, or an egg, as accessories, there need be no fear of the system not being nourished. This amount of food is not, in reality, a very low diet, and is quite sufficient to supply all the wants of the economy, not only in an invalid, but also in most dyspeptic persons, otherwise in health. It is a singular fact, the truth of which is daily more and more demonstrated to me by observation, that those who suffer from dyspepsia extract a sufficient amount of nourishment from a compara- tively small quantity of food. Even when in perfect health, with them the wants of the system are supplied from a less amount of AND OF THE UTERINE ORGANS. 271 nutritive elements than is required by persons who are free from any tendency to dyspepsia, and whose digestion is much stronger. As I have already stated, all kinds of stimulants, including strong tea and coffee, are prejudicial. The patient should therefore be limited to water, or toast-and-water, and very weak tea, as a beverage. A little strong coffee may sometimes be taken in milk, for breakfast, without any injurious effect. When it can be borne, it is an agreeable change ; but the milk should be merely flavoured with coffee. Thus taken, it is the cafe au lait of the Continent. Strong tea to many persons thus suffering is a very pernicious beverage, giving rise, almost immediately, to spasms and cardialgia. Some patients, especially when they are thus made water-drinkers against their inclination, fall into the error of not taking enough fluid. It should, however, be recollected, that fluid is just as necessary to carry on the operations of the animal economy as food, and that not less than about two pints, in one shape or another, should be taken in the twenty-four hours. I have often known the urine to become permanently lithatic merely for want of the necessary quantity of fluid. The regulation of the hours for meals is of great practical importance. As a general rule, I do not approve of breakfast being given to invalids or dyspeptic patients, as soon as they awake, in bed, or immediately on rising. I think it much better to wait a little, and to alloAv the stomach time to recover itself, and thus to prepare for the morning meal ; the more so, as hunger is rarely experienced immediately on awaking in the morning. From nine to ten o'clock, therefore, according to the hour at which the patient rises, is quite early enough. Dinner must be early or late, according to the habits and constitutional peculiarities of the patient. Persons who have dined early all their lives seem to digest their principal meal better in the middle of the day than later; they should therefore dine early, but not sooner than two, if possible; as otherwise the system becomes exhausted before night, and supper is almost imperatively demanded, under the penalty of loss of sleep. When an early dinner is taken, of course luncheon is not necessary, but the tea must be more substantial, and taken late, between six and seven, so as to render supper unnecessary. There are many persons, however, who cannot digest animal food early in the day; it would seem with them as if the stomach required the entire day to rally and collect strength for its digestion. Such persons should merely make a light luncheon in the middle of the day, and dine at five or six at the latest, making that the last meal. I have been thus minute in laying down dietetic rules, because it is principally on their observance that I depend for the recovery of the digestion and nutrition of the patient, when the local uterine disease has been subdued. Great assistance may be derived, it is true, from medicinal agents, but assistance only. If the powers of the stomach are constantly overtaxed, and it is continually irritated by stimulants, 272 TREATMENT OF INFLAMMATION OF THE UTERUS medicinal treatment merely mitigates the intensity of the morbid symp- toms, failing to restore the patient to health, even when all local disease is removed. The above dietetic rules, however, it must be remembered, are for dyspeptic invalids, and not for persons in health taking exercise. As the tone of the stomach returns, as the powers of digestion increase, and more exercise is taken, the diet may be made fuller and more animalized, if the patient finds it really to her advantage. The medicinal preparations which I find of greatest use in these conditions of the digestion, are the alkalies, and principally liquor potassae, the mineral acids, more especially dilute hydrochloric acid, the vegetable bitters, hydrocyanic acid, and the tris-nitrate of bismuth. When administering the alkalies or acids, I generally give them largely diluted with water, about an hour after breakfast and dinner, having remarked that the ingestion of fluid at that time appears to prevent the formation of lithates in the subsequent periods of digestion. At least, if they are formed, they are often retained in solution, so as not to render the urine turbid. This precaution is more especially advisable when the presence of lithates in the urine creates or keeps up irritability of the mucous membrane of the kidneys, ureters, and bladder. When a patient, whose real debility has been long concealed by stimulants and high feeding, is placed on a Ioav diet, and deprived of the accustomed stimulation, she necessarily for some time feels exces- sively prostrated languid, and unwell. Whilst taking rum-and-milk early in the morning—a favourite prescription with some practitioners, porter or ale at luncheon, and two or three glasses of sherry or port at dinner, the system is kept in a state of feverish excitement, which affords artificial strength, and, flushing the countenance, gives to the face, in the eyes of a superficial observer, the hue of health. It is, consequently, often difficult to persuade the patient and her friends that it is better for her to be left to her real weakness, to appear as pale, as languid, and as debilitated as she really is. There can, how- ever, be no doubt that such is the case. If a patient is really debili- tated and anemic, her state should be accepted by herself, her friends, and her medical attendant, and met by therapeutic means directed to the morbid conditions which occasion the anemia. It is infinitely pre- ferable that, until her health be really improved, she should lie languid and exhausted on a sofa, than that she should be performing, with misery to herself, in an imperfect manner, the ordinary duties of life, under the excitement of wine and other stimulants. If the patient has good sense enough to accept the debility as a symptom of the disease for which she is under treatment, and to fol- low these directions, she soon feels the benefit of the change of system ; she ceases to be alternately flushed and excited, or miserably depressed; her sensations gradually become calm and more natural, and as the local disease improves, and the sympathetic re-action decrease, she gradually regains strength, not artificially and temporarily, but really and permanently. AND OF THE UTERINE ORGANS. 273 Some females, however, are so self-willed and so imbued with, the idea that strength can only be regained by feeding and stimulants, or are so much influenced by relations or previous medical attendants, who entertain these opinions, that no reasoning can convince them that they would not die of starvation if they were not to be continually eating meat and taking "support" in the shape of porter, wine, or spirits. With such persons it is in vain to argue; the languor at first felt in the absence of the accustomed stimulation is taken as evidence of its being indispensably requisite, and in order to retain their confidence during the treatment of the local disease—the original and principal cause, after all, of the morbid condition—liberal concessions must be made with regard to diet. When this is the case, the local disease even- tually gets well, although often with much trouble, but a disordered state of the digestion frequently remains. In some rare instance, however, stimulants, medicinal or other, must be given, although injurious, owing to the system being reduced so low by disease as to render temporary stimulation indispensable. The irritability of the mucous membrance of the urinary organs, kidneys, ureters and bladder, but more especially of the latter organ, so frequently observed in these diseases, is, as I have stated, in most cases the result of the mechanical irritation occasioned by the lithatic state of the urine. The anomalous salts which it holds in suspension irritate the mucous surface, and often bring on a state of extreme irritation, bordering on sub-acute inflammation. Such being the real cause of the irritation, no effectual relief can be afforded to the patient until the digestion be restored to a healthy state. As that, again, is under the influence of the uterine disease, we, step by step, revert to the latter, as the affection that must be cured before we can expect to remedy the vesical irritation, of which it is the primary cause. Even when the urine has been restored to a healthy state, owing to improvement in the functions of the stomach, the bladder, unfortu- nately, in many cases, does not at once cease to be irritable. In the natural state, the urine, although an irritating fluid to other surfaces, mucous or cutaneous, is not so to the mucuous membrane of its own reservoir, the bladder, its contact with which occasions no uneasy sen- sation. When, however, the sensibility of the bladder has thus been anomalously raised, even the healthy urine often long remains a source of irritation, giving rise to a frequent desire to pass water, and to pains, on its excretion, in the urethra, and especially at the neck of the bladder. I have tried many medicinal substances, with a view to modify this most distressing state, but with very little immediate suc- cess. It appears to me not to yield so much to the influence of medicinal agents, as gradually to die away, from the absence of the cause that produced it—viz., the morbid state of the urine and the proximity of uterine disease. When this irritability has existed for many years, the bladder may become so permanently contracted as to be unable to retain more than a few ounces of urine, even in the absence of any morbid state. This is a very miserable condition, as 274 TREATMENT OF INFLAMMATION OF TnE UTERUS the urine has to be passed every hour or two, and the probability of its cure becomes very doubtful. The immediate effect of the cure of uterine inflammation and ulcera- tion, as we have seen, is not unfrequently, at first, unfavourable with regard to the irritation of the bladder, which greatly increases, or even appears when previously absent. Under the impression that this may be the result of the absence of the accustomed counter-irritation, I have repeatedly, with benefit, applied an issue in the cellular tissue, just above the pubis, keeping it open for several months. The medi- cinal preparations which have appeared to me the most beneficial in these cases are the alkalies, alone or combined with hyoscyamus or with camphor, balsam copaiba, and other resinous substances. Constipation often exists when the digestive functions are disordered, from inaction of the upper part of the large bowel. In this case, the faeces never reaching the rectum, injections fail to procure an evacua- tion. Should dietetic means, such as brown bread, and fruits, when they agree, not succeed in removing the constipation, aperients must be given. I only have recourse, hoAvever, to their assistance when they are absolutely indispensable. A few grains of compound rhubarb pill, or a pill composed of hyoscyamus and colocynth two grains, aloes one grain, or of some other mild purgative, taken on the night of the second day, if the bowels have not been moved by the cold injection, will generally suffice to open them once, which is all that is required. I always regret to be obliged to have recourse habitually to aperients, as their regular use renders it more difficult to restore the digestion to a state of integrity. They also increase the tendency to hemorrhoids and to prolapsus ani, which is often very marked in patients suffering from inflammatory disease of the uterus. When these latter affections co-exist, they do not, generally speaking, require any particular treatment. It is, however, more than ever necessary to keep the lower bowel free from any accumulation of faeces, the pressure of which, by interfering with the intestinal circulation, materially increases the rectal disease. The cold injection is of the greatest use in these cases, as a topical remedy, to the congested and relaxed mucous membrane. When the uterine affection is finally sub- dued, and health returns, the prolapsus ani often entirely disappears without further treatment. This is also the case, although less fre- quently, with hemorrhoids. When congestion extends to the liver, and bilious symptoms super- vene, or when they manifest themselves independently of congestion, in connexion with the disordered state of the digestive system, it may be necessary to have recourse to the administration of calomel or blue pill. The former is the most efficacious, especially if bilious diarrhea or Aromiting has set in. It is seldom, however, necessary or desirable to continue its use. Leeches alone generally fail to relieve the symp- toms occasioned by a congested state of the liver, whatever the cause; but they may, when timely applied, prevent uterine congestion from extending to it, and thus obviate the periodical explosion of biliary AND OF THE UTERINE ORGANS. 275 attacks, if the tendency exists. It is, indeed, on the occasional appli- cation of leeches after the catamenia that I principally rely, in the cases to which I have elsewhere alluded, in which, after the cure of uterine disease, menstruation remaining scanty, or being finally sup- pressed, a tide of congestion gradually extends from the uterus to the abdominal circulation, giving rise to biliary symptoms when it reaches the liver. The emaciation and defective state of the general nutrition which so frequently accompany chronic inflammatory disease of the uterus, being in a great measure the result of the disordered condition of the diges- tive system, can only be treated by removing the primary cause of the evil. The sympathetic reaction which the diseased uterus exercises on the stomach strikes at the root of the functions of nutrition, as it were, and the only remedy is to annihilate this morbid reaction by curing the uterine disease. Unless this be accomplished, the chyle supplied by digestion continues to be defective, and the general nutrition becomes more and more deteriorated; the uterus no doubt exercising also, directly, a depressing sympathetic action on the functions of assimila- tion and nutrition. Thus it is that the patient loses flesh, and becomes in the course of time thin, pale, sallow, and anemic. What satisfac- torily proves that this anemic state of the economy depends principally on depraved digestion is, that if the stomach resists the action of the local disease, and retains its functional activity, the patient may remain many years a sufferer from the local disease without becoming weak and debilitated, and without losing the outward characteristics of tolerable health. The disordered condition of the special senses, of sight, hearing, and cutaneous sensibility, which is occasionally observed in chronic inflam- matory disease of the cervix uteri, does not call for any particular treatment. These states are merely symptomatic of the general morbid condition of the system, and can only be treated by curing the disease in which they originate. Their increase is thus almost invariably prevented; but even the complete restoration of the patient to health is not always followed by their entire disappearance. Convulsive hysteria occurring under the influence of uterine disease is generally a very formidable complication. The convulsive attacks are often severe and frequent, occurring whenever any exacerbation takes place, and sometimes under the immediate influence of the remedial means employed to subdue the local disease which occasions the hysterical affection. The practitioner may thus be placed in a painful dilemma. If the uterine malady is not treated, the convulsions gradually become worse, and may, as we have seen, threaten the life of the patient. On the other hand, the cauterization of the ulcera- tion Avhich generally exists in these severe cases, is often attended with a repetition of the convulsive attack. Between these two dangers, however, we must choose the least. As the recovery of the patient, both from the uterine disease and from the convulsive affection which it occasions, depends on the subdual of 276 TREATMENT OF INFLAMMATION OF THE UTERUS inflammation and on the healing of ulceration, the means absolutely necessary must be cautiously adopted, irrespective of their immediate effect; but every precaution must be taken to prevent the subsequent convulsive attack, or to mitigate its intensity. The most efficacious means that can be resorted to for this purpose are the injection of preparations of opium into the rectum, and the use of chloroform administered by inhalation, or by the stomach. Generally speaking, the convulsions cease when the uterine disease is cured, or only occur at the menstrual epoch, and that merely for a short time. Whether it be cured or not, the most efficacious remedy for the convulsive attacks produced by the approach or by the existence of menstruation, or following its cessation, is the application of leeches to the neck of the uterus. Leeches, mustard-poultices, or blisters, applied to the sacro- dorsal region, are also often very useful. The want of sleep, or its very disturbed and unrefreshing character, is only remedied by improvement of the local disease, and of the morbid conditions sympathetically produced. Opiates and other sedatives merely increase the mischief which they are given to allay. The return of quiet, refreshing sleep is always a very favourable symptom. Inflammation of the neck of the Uterus considered generally. By the local and general means of treatment which I have described, inflammation, ulceration, and hypertrophy of the neck of the uterus, may always be subdued, and the patient is, generally speaking, restored to health. In most cases, all local symptoms disappear along with the disease which occasioned them. This, however, is not always the case. The pain in the back, the vesical irritation, or the inability to walk may remain, in a more or less marked degree, for a considerable period after the entire removal of the local disease; but they invariably all but disappear eventually, unless the body of the uterus remain chronically inflamed and enlarged, or unless the ovaries be diseased or permanent morbid changes have taken place in the bladder or rectum. The same remark may be applied to the general symptoms, although in a more limited degree. The general health may have received so severe a shock, that a lengthened exemption from uterine disease is necessary to allow the powers of the system to rally and throw off the morbid results which it has produced. Thus digestion and nutrition may remain long impaired, nervous and hysterical symptoms may long continue to hang on the patient; but in the course of time, in the numerous majority of patients, all disappear, unless the morbid conditions above enumerated persist in an incurable form. Generally speaking, except in extreme cases, the general health rallies as the uterine disease progresses towards a cure; and within a comparatively short period of its entire removal, the patient is restored to health. Sometimes, however, even in the absence of any lingering morbid AND OF THE UTERINE ORGANS. 277 condition, the general health does not completely rally, the powers of life appearing to have been too prostrated for a complete recovery to take place; but these cases are fortunately rare exceptions. The duration of treatment necessarily varies, according to the nature, the extent, and the intensity of the disease, to the structural changes which it may have produced, and to the influence exercised by menstruation over its phenomena. When the latter is unfavourable, it is always prolonged. This is also generally the case when ulceration and hypertrophy are both present; it then mostly lasts many months. Since I have made it a rule minutely to investigate the state of the cavity of the cervix, and never to dismiss a patient so long as there is the slightest vestige of disease remaining, I am much longer in curing my patients but when they are once cured, I never have any relapse of the ulcerative disease. The relapses which I formerly used continually to witness in the practice of the French surgeons, were clearly owing to the disease not being followed into the interior of the cervical canal, and thus not being entirely eradicated. On the whole, there are few diseases that give more satisfactory results under treatment than those which I have described in this work, provided their real nature be recognised, and rational means of treatment adopted. I am continually seeing pale, weak and helpless females completely restored to health, whose life had been a misery to them for years, Avho during that time had never been free from the most gloomy, the most depressing feelings and the most painful sen- sations, and who had wandered in vain in search of relief, from physician to physician, from place to place. To them the recovery of health is often a kind of resurrection. Stranded, as it were, on the shores of life, all but devoid of hope, they once more find themselves able to resume their social duties, and to take a part in active occupations. One of the most striking results of the removal of uterine disease is the entire subduction of that fretful, irritable, nervous and hysterical state of the mind which often characterizes it, especially in the higher and more cultivated classes of society. The most intellectual and strong-minded women are not exempt from this reaction of uterine disease on the nervous system. Under its influence they become irritable and capricious, without the slightest suspicion being enter- tained by those around them as to the cause of the change that has taken place in their mental state. They thus meet with blame instead of the pity they deserve, for their feelings are all but uncontrollable. I have, indeed, no hesitation in stating that the very frequent existen:e of uterine disease, modifying the temper and mental state of women, without suspicion being entertained as to the real physical cause of the change, either by friends or by medical attendants, has unfavourably influenced the opinion of moralists respecting the female character. My experience Avould tend to prove that when a female, whatever her rank in society, is perfectly well, she is rarely irritable, nervous, or capricious, and that when these mental conditions are present in a very 278 TREATMENT OF INFLAMMATION OF TnE UTERUS marked degree, they will be too often found referable to the unsuspected existence of chronic uterine disease. INFLAMMATION OF THE UTERINE NECK IN THE VIRGIN—DURING AND AFTER PREGNANCY—AND IN ADVANCED LIFE. The rules which I have laid down for the local and constitutional treatment of inflammation and ulceration of the uterine neck are so generally applicable to the disease, in whatever stage of female existence it may be observed, that I have but little to add that the medical knowledge of a well-informed practitioner will not supply. With unmarried females the entire difficulty of treatment lies in the instrumental part of it. AYhen the disease has Once been reached, the treatment differs in no respect from that of the same affection in married women. The existence of pregnancy, so far from being an obstacle to the local treatment of inflammatory and ulcerative disease of the uterine neck, is a strong reason why it should be adopted and carried out without delay, unless the patient have reached the latter period of her pregnancy. If so, as the child is viable, and it becomes rather difficult to bring the cervix fully into view, owing to the very lax state of the internal mucous surfaces, it is as well, unless the symptoms be urgent, merely to resort to astringent injections, and to reserve all instrumental treatment until after the confinement. During the first six or seven months, on the contrary, it is the absolute duty of the medical attend- ant to treat the disease, as by curing the ulceration, or even by modifying its irritability, not only is much suffering spared to the patient, but abortion is often prevented. The local treatment must con- sist in astringent injections, and cauterization with the nitrate of silver, or the acid nitrate of mercury. I never think of using the potassa cum calce, as the reaction after its use, under such circumstances, would be much too powerful to be safe. Moreover, the pregnancy itself is doing gradually what deep cauterization is partly intended to effect when resorted to—melting the induration. Neither do I find leeches necessary, nor should I knowingly like to have recourse to them, in the more advanced stages of pregnancy. I have, however, repeatedly applied them to patients who were one or two months pregnant with- out my being aware of the circumstance, not only without any bad result, but with positive benefit; and this has emboldened me to apply them in some cases in which abortion had occurred, after the removal of actual disease, in a subsequent pregnancy, with a view to diminish congestion, and carry on gestation. This has been attended with decided success. When there is reason to suppose that ulcerative disease of the cervix exists after parturition or abortion, I never interfere until four or five weeks have elapsed, unless the abortion be a very early one. I then examine the patient, whether the hemorrhage has stopped or not, and AND OF THE UTERINE ORGANS. 279 cauterize at once the ulcerated surface with the nitrate of silver. Whether the blood comes from the ulceration or not, the cauterization almost invariably stops its excretion, and the case then falls into the general category. I may here remark, which I believe I have omitted to do before, that for some time after parturition, and during the entire period of lactation, the mucous membrane of the vagina retains a very vivid congested hue. It is then, evidently, the seat of a sympathetic physiological congestion, which must not be mistaken and treated as a morbid condition. The only special observation that I have to make with respect to the treatment of this disease in the age, is with reference to its intracta- bility. A very minute amount of disease will often resist all mild means of treatment, and only give way, at last, under the influence of the most powerful, the actual cautery, or potassa fusa. When the disease is cured, the natural process of atrophy which usually occurs in the uterus after the definitive cessation of menstruation often takes place with astonishing rapidity, the congestion of the pelvic circulation, previously kept up by the disease, entirely giving way. ACUTE METRITIS. Acute inflammation of the unimpregnated uterus seldom extends to the peritoneum, it is not therefore necessary to resort to antiphlogistic treatment with the same energy as when the disease occurs in the puerperal state. In young plethoric females, in whom the inflammatory symptoms run high, the abstraction of blood from the arm may be advisable or necessary. Generally speaking, however, the external application of leeches to the lower hypogastric or ovarian regions is alone required. From ten to tAventy should be applied, according to the intensity of the attack ; and they should be repeated in the course of about tAventy- four hours if the inflammatory symptoms do not abate. It must be remembered, that although there is very little fear of inflammation extending to the peritoneum, there is great danger of its passing to the lateral ligaments, and giving rise to abscess. Thence the neces- sity for resorting, at an early period, to such means as are likely to arrest the progress of the disease. The application of leeches would, no doubt, be more decidedly beneficial, were it possible to apply them directly to the neck of the uterus ; but in acute metritis, the sensibility of the organ, and of the adjoining parts, is so great, that the introduc- tion of the tube by means of Avhich they are applied cannot possibly be resorted to. Light poultices, large enough to cover the lower part of the abdomen, are beneficial, and when their weight can be borne, generally afford great relief. They appear to act principally by relaxing the abdominal parietes. When the tenderness is too great for the weight of the poul- tice to be endured, warm anodyne fomentations may be substituted. 280 TREATMENT OF INFLAMMATION OF TnE UTERUS The general treatment must consist in absolute rest in bed, absti- nence from all solid food, the administration of purgatives, of diapho- retic saline medicines, and of tartarized antimony in small doses. It is very seldom necessary to give this latter substance in large doses, or to administer calomel and opium, as in puerperal metro-peritonitis. Should, however, the inflammatory symptoms, instead of giving way to the means enumerated, increase in intensity, and there be evidently danger of the extension of the disease to more important structures, these powerful agents for controlling inflammation should not be neglected. Under the judicious use of the above means, acute metritis generally terminates by resolution in the course of from five to ten or twelve days. It may, hoAvever, notwithstanding the resort to early and active treatment, extend to the lateral ligaments, giving rise to abscess, or it may pass into the chronic stage. CHRONIC METRITIS. Chronic metritis is a most intractable disease, wether it occupies the uterus, or is limited, as is usual, to one particular region. It is, how- ever, most obstinate when confined to the posterior wall of the womb, and Avhen the result of the gradual extension of chronic inflammation and induration from the cervix to the body of the organ. When it is the immediate result of acute inflammation, or of inflammation and sup- puration of the lateral ligaments, it is, generally speaking, much easier to subdue. If chronic metritis is occasioned or kept up by ulceration, or by sub- acute inflammation of the neck of the uterus, the first thing to be done is to subdue the local disease by the means already pointed out. This is absolutely necessary, as it acts like a thorn in the part keeping up irritation throughout the entire uterine system. The local depletion, and other antiphlogistic means used for this purpose, combined with the regulation of the general health, by the dietetic rules and the medicinal agents already indicated, as generally applicable in chronic uterine inflammations, not unfrequently remove the disease of the body of the organ simultaneously with that of its neck. In some cases, however, in which the cervix is evidently the part primarily in fault, chronic inflammatory induration of the body of the uterus remains, after the entire removal of all morbid conditions of the cervix. In these cases, as also in those in which chronic inflammation originates in the uterus, apart from any affection of its neck, the tenacity of the disease and the difficulty of removing it are extreme; so much so, indeed, that, as a general rule, it is impossible to form even a surmise as to the length of time that may be required to accomplish this desirable end. A few months may suffice, or it may be years, before the disease is subdued, even Avhen active treatment is persever- ingly resorted to. In some exceptional cases, indeed, the disease is AND OF THE UTERINE ORGANS. 281 never perfectly subdued, proving rebellious to all treatment, however energetic and continuous. The local means of treatment most generally applicable under these circumstances are, rest in the horizontal posture, the use of emollient or astringent vaginal injections, and the occasional application of leeches to the neck of the uterus, before or during, but more especially after, menstruation, according to the period at which they appear most serviceable. It is to a great extent the existence of the menstrual flux that feeds and keeps up the chronic inflammation, and nothing gives such effectual relief in the exacerbations of inflammation and pain that occur at this time, as the abstraction of blood from the womb, by the direct application of a few leeches. During these exacerbations, the injection of opiates into the bowel, or the use of chloroform in the various modes indicated, often afford great relief, and assist in enabling the patient to pass over the catamenial period Avithout the occurrence of any permanent increase of the uterine disease. In extremely obstinate cases, I sometimes apply an issue just above the pubes, keeping it open for some months, and have frequently derived great benefit from this plan of treatment, for which the profession is indebted to M. Gendrin. In addition to the general means of treatment already described, we may resort to the exhibition of iodine or mercury. I must, however, confess that I have not obtained that benefit from the use of these medicines that might be anticipated from the assertions of other prac- titioners. This discrepancy between the results furnished by my practice and that of others admits of explanation ; but the explanation I give, if correct, will go far to prove that the experience of those who attach so much importance to the action of these medicines in the treatment of chronic inflammation and enlargement of the uterus is not to be depended upon. Most of the patients labouring under chronic metritis whom I meet with have been suffering from uterine disease for many years; and the general health has, in consequence, long been completely broken down. With such patients, I do not feel authorized, as I have elsewhere stated, to give such medicines as iodine or mercury, unless the neces- sity be absolute and imperative: the more so, as they must necessarily be administered for a lengthened period if they are destined to act on the nutrition of a chronically inflamed organ, and mercury and iodine, when taken so as thoroughly to saturate the system, produce of them- selves a species of cachexia. Persons already reduced to a state of extreme debility and emaciation by chronic disease, are certainly not those in whom it is desirable to give medicines, which can only add to the evil. Entertaining these views with regard to the administration of mer- cury and iodine, in whatever mode or form they may be given, and never resorting to them until all ordinary means, both local and general, have failed, I have thus ascertained that they are seldom necessary, the chronic inflammation generally giving way without their assistance. 282 TREATMENT OF INFLAMMATION OF THE UTERUS On the other hand, in the few obstinate cases in which I am obliged to resort to their use, I do not find the effect they produce by any means so beneficial as is generally asserted. I am therefore, I consider, warranted in concluding that if they succeed oftener in the hands of other practitioners, it is because they are generally used from the first, in the early stage of treatment, in conjunction with other means, which alone would probably suffice to remove the disease. When all ordinary therapeutic agents, including the internal admin- istration of mercury and iodine, fail to remove the chronic inflammation and induration of the uterus, I have often established, as a counter- irritant, an artificial ulceration or issue on the neck of the uterus itself, with potassa fusa or potassa cum calce, independently of any disease of that region, and with very great benefit to the patient. The first case in which I resorted to this rather severe mode of treatment was that of a lady who had been under my care for nearly two years, without any permanent benefit having been derived from the numerous means employed. There were several very painful nodosities on the posterior wall of the uterus, which was much enlarged and retroverted: the disease had existed many years. Finding that an issue applied over the pubis had done more good than anything else, it occurred to me, that if the issue were applied on the cervix uteri, which was healthy, but rather hypertrophied, the counter-irritation would be much more efficacious. I long hesitated, fearing that the inflammatory reaction might extend to the inflamed uterus, and occa- sion acute metritis ; but I was at last induced to waive all scruples, and to try the application of the issue, OAving to the sufferings of my patient being very great, and to the slight hope that remained of a cure being ever effected by ordinary means. The issue was applied four times, at intervals of about six weeks, and with very decided benefit. The nodosities of the posterior region of the uterus much diminished in size, the enlargement of the organ greatly abated, and the patient became much freer from pain and uneasy sensations. Several years have now elapsed since the last issue was applied, and the patient continues in a greatly improved state, although still an invalid, and suffering considerably at the monthly epochs. The womb remains tender, and enlarged posteriorly. Since then I have often adopted this derivative plan of treatment with equal, and even greater success, and that without the occurrence of any untoward symptom. Although much more pain and much more general sympathetic disturbance is experienced than when potassa fusa is used to the cervix, in the absence of inflammation of the body of the uterus, there does not appear to be much reason to fear too severe an amount of inflammatory reaction; the more so, as we must not forget that a certain amount of uterine reaction is necessary in order that the vitality of the diseased tissues may be deeply modified. At the same time, I should never think of recommending such treatment, except in extreme cases, which have long been under treatment, and against which all other means have failed. AND OF THE UTERINE ORGANS. 283 When the inflammation exists principally in the posterior wall of the uterus, and the latter is retroverted on the rectum, as is usually the case, it becomes difficult to remedy the constipation, which is nearly always a prominent symptom. The injection of cold or tepid water, so useful in other cases, cannot be resorted to, as the dilatation of the lower bowel, raising the retroverted and inflamed womb which lies upon it, generally gives rise to very severe pain. We must, therefore, inevitably have recourse to mild aperients, in as small doses as possible, choosing those that act more especially on the lower bowel. The aperient, however, should not be given oftener than is necessary to prevent a collection of hardened faeces taking place above the retro- verted womb, the passage of which, under such circumstances, is a source of extreme pain. In these cases, the mere fact of the patient becoming able to bear the injection is a proof that great improvement has taken place. It is not only useless, but most pernicious to the patient, to attempt, by mechanical means, to replace the inflamed and retroverted uterus. The organ is retroverted because it is inflamed and enlarged, and the only rational treatment of the displacement is the cure of the disease which occasions it. The uterus as we have seen, is not, like a joint, liable to dislocation, and then susceptible of being reduced by mechanical means; but an organ lightly suspended or poised in the pelvic cavity. It is therefore most irrational to attempt to restore it to its natural position, by means of a sound or a bougie, when it has fallen backwards from inflammatory hypertrophy. The retroverted organ might be twisted round by the uterine sound, if not bound down by adhesion, a hundred times, and a hundred times it would again fall, as soon as the sound were withdrawn; there being nothing to keep the organ in situ when it has been "replaced." The cases of retroversion of the uterus that I meet with may be classed under three heads: either the retroversion is accompanied by the formation of fibrous growths in the posterior wall of the uterus, which carry the uterus backwards by their weight; or, whatever its cause, it is accompanied by inflammatory disease of the body of the uterus, or of its neck; or there is merely the retroversion present, without inflammation. In the first instance, there are usually no morbid symptoms, unless the fibrous tumour should enlarge greatly, and not escaping, as is commonly the case, from the cavity of the pelvis, should, by its pressure, interfere with the passage of the faeces. Unfortunately, whether the tumour and the retroversion be little or great, there is nothing to be done. When small, it is in vain for us to bring the womb forward, it is sure immediately to fall back again; when large, if it does not spontaneously emerge from the pelvis, or cannot be displaced, it generally becomes fixed and immovable. When inflammation of the uterus, of its neck, or of its cavities, accompanies retroversion, whatever the cause of the retroversion, it is principally the inflammatory disease, and not the retroversion, that 284 TREATMENT OF INFLAMMATION OF THE UTERUS occasions the morbid symptoms. It is the inflammatory disease, con- sequently, that requires to be treated. If the contrary opinion prevails now with some practitioners, it is because they are under the influence of erroneous theoretical opinions. Overlooking the real disease, they merely treat the imaginary one, and thus do more harm than good. Not only is their serious error apparent in their writings, but I am con- tinually seeing it illustrated in practice, in cases in which very evident inflammatory disease has thus been overlooked, and left untreated, whilst the patient has been tortured by useless attempts to replace the retroversion—the imaginary cause of her ill health.1 1 Since the above was written, I have been consulted by a lady whose case very aptly illustrates this fact. Her history is as follows: — Menstruated rather late in life, the catamenia were at first irregular, and she always suffered considerably. She married at twenty-two, and six months afterwards accompanied her husband to a tropical climate. Soon after her arrival she began to suffer from whites, pain in the back and ovarian regions, and pain in congress. Her health rapidly gave way, it was supposed under the influence of the climate, and she was ordered home within a year of her arrival. On reaching England, she placed herself under an eminent general physician, and was treated as one whose health has given way from residence in a tropical climate; no sus- picion of the existence of uterine disease being entertained. During the two years that she spent in England, she consulted various physicians, without any further light being thrown on her state, which only slightly improved; the local symptoms persisting, although mitigated. She then rejoined her husband abroad, but immediately became ill again. The uterine symptoms rapidly increased, great debility followed, and she was attacked on two occasions by the fever of the country. The existence of uterine inflam- mation was this time recognised by her attendants, but nothing was done to remedy it, and she was again sent home for medical advice and for change of climate. On her arrival in England she applied to an eminent accoucheur, who had adopted the mechani- cal doctrine of uterine displacement. She was then suffering from severe pain in the lumbo-dorsal, ovarian, and hypogastric region, has a muco-purulent discharge, great bearing-down, and could scarcely walk. She was pale and emaciated, suffered agonizing pain at the menstrual epochs, could not bear congress at all, from the extreme pain it occasioned, and was a victim to dyspepsia, cardialgia, cephalalgia and insomnia. Indeed, she evidently presented all the symptoms, both general and local, of chronic inflam- matory uterine disease. After being carefully examined digitally, she was told that she was merely suffering from displacement of the womb, that the uterus was retroverted, and that if it were once restored to its natural position she would be quite well. In accordance with this view of her case the womb was "replaced," with the uterine sound, at short intervals, during six weeks, and then Dr. Simpson's permanent pessary was introduced and allowed to remain. The replacing of the womb with the sound always gave intense pain, as also did the introduction of the permanent pessary. After much suffering, however, she got accustomed to the latter, and retained it during six months. After that time, it was taken away by the practitioner who had introduced it, who told her that the womb " was in its right place," the displacement having been permanently removed, that all had been done for her that medical art could do, and that she would soon be restored to health. ^ This took place two years before she consulted me, and during that time she con- tinued a confirmed invalid, no better in any respect than when she returned to England, nearly three years ago. Under the impression, however, that all had been done that was possible by medical skill, she did not take any further advice. I found the general and local symptoms exactly as described above, and on examination, ascertained that the body of the uterus was very much enlarged, thoroughly retroverted, so as to lie com- pletely on the rectum, and so exquisitely painful on pressure as scarcely to bear the contact of the finger. The cervix was also inflamed and enlarged, and its os and cavities were open and extensively ulcerated. It is perfectly clear that, in this case, the disease from the first was uterine inflamma- tion, and that the retroversion of the uterus was solely the result of its inflammatory enlargement, and merely a symptom of that condition. To consider the retroversion as AND OF THE UTERINE ORGANS. 285 What proves retroversion of the uterus to be merely an epipheno- menon in the class of cases to which I am now alluding,—those in which it is accompanied by some inflammatory condition,—is, that when the latter is thoroughly cured, all morbid symptoms disappear, without any therapeutic means having been directed to the retroversion, and that, in very many cases, the uterus gradually resumes, partly or entirely, its natural position. But, even if it does not, the circumstance is of little or no consequence. I have noAv restored to the active duties of life a very considerable number of females, in whom the uterus was retroverted when they left me, and is so, probably, to this day; and yet they are totally unconscious, from any symptom which they expe- rience, that the organ is not in its normal position. Nor do I find, as has been asserted, that such displacement subsequently prevents impregnation. The impediment to impregnation, generally speaking is the inflammatory disease that accompanies the retroversion, and not the retroversion itself. When retroversion, not complicated with tumour, is met with, no inflammatory condition being present, I never find any morbid symp- tom of any importance existing as the result of the displacement, and, consequently, never deem treatment of any kind applicable. Dr. Simpson himself admits {Dublin Quarterly Journal, vol. v. 1848, page 394), whilst laying down rules for the treatment of retroversion, that " the restoration of the uterus temporarily, from day to day, with the bougie, is sufficient;" adding, "that some more permanent means of keeping the organ replaced and retained are necessary." These means Dr. Simpson believes he has found in a double-stem pessary, one part of which is introduced into the uterine cavity, whilst the other rests externally on the anterior part of the pubis. He states that he has used this pessary extensively, and with very beneficial results. I can quite understand that this uterine pessary may be worn without any great pain or inconvenience, Avhen the uterus, the cervix and its cavity, are free from inflammatory disease—provided the uterine stem do not pass beyond the os internum of the cervical canal—but when there is inflammation, it must irritate the parts, and do mischief. I have met with several instances in which this had evidently been the case, and in which ulceration of the cervical canal, and great irritation of the uterus and its cervix, were either produced or greatly aggravated by its use. These patients had not been under Dr. Simpson's care, but under practitioners who adopt his views and treatment of the displace- ment in question. Moreover, several cases have been published in which fatal peritonitis has followed the use of this pessary. I am also the disease, as the cause of all this lady's sufferings since her marriage, was most irra- tional, and to treat her by mechanical attempts to "replace the womb," without doing anything to remove the inflammation that occasioned the disease, was an error both of omission and commission. Such treatment could only aggravate the inflammation, and thus, by increasing the enlargement of the uterus, increase the tendency to displacement which it was meant to remedy. This lady rapidly improved under rational antiphlogistic treatment during the time Bhe remained under my care, and has since got quite well. 2S6 TREATMENT OF INFLAMMATION OF THE UTERUS in possession of one of a similar nature, not hitherto published, and communicated to me by Mr. Keyworth, of York. For some years I have been looking for cases in which the use of such a pessary appeared to me really indicated, and have been quite prepared to give it a fair trial, but I must confess that I have not yet met with them. I have seen very many cases of retroversion, both in private and in public practice, for it is a very common displacement, but none in which mechanical treatment appeared to me indicated or even justifiable. Either there were tumours present, which must have rendered any attempts at mechanical replacement irrational and nugatory, or the retroversion was accompanied by inflammatory lesions, the existence of which contra-indicated mechanical interference, and the removal of which dispersed all morbid symptoms—or there were no morbid symptoms to indicate the presence of the retroversion, and under such circumstances I did not feel justified in interfering. I have, on the other hand, repeatedly been called upon to extract the stem pessary from patients in whom it had been introduced by other practitioners, and who could not bear its presence. In two or three instances in which I have tried it myself, against my own judgment, I have also been obliged to withdraw it, owing to the great pain and general disturbance which it created. I must confess, however, that these were cases in which it was not likely to be borne, as the uterus was not only retroverted, but the seat of great vitality. In Paris, Dr. Simpson's pessary has several warm advocates, amongst whom the most enthusiastic is M. Valleix. When I was last there (1841) he showed me a ward full of females wearing it, all, he stated, without inconvenience, and many with decided benefit. INTERNAL METRITIS. Inflammation, existing in the interior of the uterine cavity is generally subdued by the means adopted to cure the inflammation of the cervix or of the cervical canal, which almost invariably accompanies it. Although, therefore, from the first, the fact of the os internum being open, and of the inflammation extending to the uterine cavity may be recognized, it is not necessary at once to carry the local appli- cations beyond the cervical canal. The co-existence of this form of internal uterine inflammation, however, should be considered a sufficient motive for pushing antiphlogistic measures, such as the application of leeches, farther than might otherwise be deemed necessary. Should the internal metritis not give way to these means of treatment, and persist after all subacute inflammation of the uterus, of its cervix, and of the cervical canal, have been subdued, it may be necessary to apply caustics directly to the uterine mucous membrane. The solid nitrate of silver can be easily used by means of an instrument similar to that which is employed to cauterize the urethra. Its application is exceedingly painful, and is generally followed by a copious exudation AND OF THE UTERINE ORGANS. 287 of blood, sometimes quite amounting to flooding. Indeed, the pain produced by the cauterization of the lining membrane of the uterine cavity, under any circumstances, is nearly always so great, and con- tinues so long, and is attended with so much general disturbance of the system, that I can scarcely understand how it can have been proposed as an ordinary therapeutic agent in amenorrhea, to induce menstruation. The remedy is too severe and painful, in my opinion, to be adopted for this latter purpose—the more so, as the flow of blood is not menstrual, but merely blood thrown off under the influence of local irritation. The application of a few leeches to the cervix appears a much more simple and more rational mode of treatment. Solutions of nitrate of silver have been much used on the continent, as injections in what they term internal metritis. As I have shown elsewhere, however, continental practitioners have universally mistaken, described, and treated inflammation of the cervical canal for inflam- mation of the uterine cavity. What they say, therefore, of injections in internal metritis, must be considered to apply merely to their influence in disease of the cervical canal. When disease really exists in the uterine cavity, the injections would, no doubt, do much good, and, were they safe, would be preferable to the solid nitrate of silver, applied with the porte-caustic; but there is reason to believe that uterine injections are not safe, and I consequently never resort to them. Several deaths occurred in Paris, during my residence there, from metro-peritonitis, brought on by their use.- One took place in the female ward of M. Jobert, at the HSpital Saint Louis, and under my own care, as I was then his house-surgeon. The patient, a fine healthy young woman, of twenty-four, was afflicted with a large fibrous tumour of the uterus, which had much developed that organ, and had, no doubt, opened the os internum. M. Jobert was at that time trying the effects of the so-called uterine injections, and injected some astrin- gent solution into the cervical canal of this young female, there being a slight muco-purulent discharge from the os. Shortly after, she was seized with rigors, fever, and severe abdominal pain, and in a few days, died of peritonitis. I performed the post-mortem, and found nothing but the lesions of peritonitis, and the ovarian tumour, embedded in a womb developed to the size Which it presents in the fourth month of pregnancy. The fluid of the injection must have penetrated freely into the uterus, through the open os, and thence have passed along the Fallopian tube into the cavity of the peritoneum, thus causing fatal peritonitis. This accident would probably have occurred much oftener than it has done, in the hands of French practitioners, were it not that the natural coarctation of the os internum must have generally prevented the fluid injected from penetrating into the uterine cavity, where the disease is erroneously thought to exist. Sometimes internal metritis is so obstinate, that even the use of the solid nitrate of silver does not appear to remove the morbid action. I have, in cases of this description, carried the acid nitrate of mercury, 288 TREATMENT OF INFLAMMATION OF THE UTERUS pure or diluted, into the uterine cavity, and thus succeeded in re- establishing healthy action, and curing the disease. In order to pass the caustic through the cervical canal, I first introduce into the cavity of the cervix a small silver tube, or piece of a common sound, through which the caustic may be carried by means of a camel-hair brush. I never have recourse to this means of treatment, however, except as a last resource. The cavity of the uterus bears surgical interference, as we have seen, less than any other uterine region; its cauterization being nearly always attended with extreme pain, nausea, or even sickness, copious hemorrhage, and considerable febrile reaction. Fortunately it is very seldom indeed that the internal application of caustics becomes necessary. Internal metritis, as I have stated, is not a common disease, and when it does exist, usually gives way to ordinary antiphlogistic means, along with the acute metritis, which it often accompanies. If, however, this does not take place within a reasonable time, it is generally most obstinate, and the local means mentioned may become imperatively necessary. The success of the treatment resorted to is shown by the change that takes place in the nature of the uterine discharge. It first ceases to be sanious, or sanguinolent, and assumes a purulent character; it then becomes mucous, and finally ceases. INFLAMMATION OF THE VULVA. The remedial agencies required in the treatment of inflammation of the vulva are general and local. The local means consist in emollient and astringent fomentations and lotions, such as linseed tea, poppy- head or marsh-mallow decoctions, and solutions of acetate of lead, alum, sulphate of zinc, &c, and in the use of tepid or cold hip-baths. If the inflammatory symptoms run very high, a few leeches applied on the outer surface of the labia majora, near the groins, are of great utility. When applied to the inner surface of the labia they are apt to be followed by considerable swelling. If the mucous follicles are extensively ulcerated, a solution of nitrate of silver will be often found more efficacious than any other lotion, especially when pruritus exists. As the inflammation generally passes more or less into the vagina, the medicated lotions should likewise be injected into that canal, so as to act simultaneously on it. The patient should remain lying, and be kept on a low diet, the general treatment consisting in purgatives, salines, and cooling medicines. It is all but needless to add, that the cause that has produced the inflammatory neck should be avoided. If it occurs merely as the extension of disease of the more internal genital organs, as soon as it has been sufficiently subdued to admit of an examination, their state should be carefully investigated, and the disease found at once treated. The above rules for the treatment of acute vulvitis, will also be found to apply, with some slight modification, to the chronic forms of AND OF THE UTERINE ORGANS. 289 inflammation of the sebaceous and hair follicles. In the more con- firmed stage of the disease, when emollients and astringents fail, solvents and stimulants, such as the iodide of potassium, or the iodide of lead, the sulphuret of potassium, applied locally in the form of ointment, or mercurial ointment, will often succeed. Should the vuh'a be attacked by the special forms of cutaneous inflammation, the means of treatment usually resorted to in other parts of the body will also be found applicable. The repulsive disease which has been described under the head df esthiomene, or lupus, requires the same treatment as when it occurs in the face. If it has evidently originated under the influence of a scrofulous or syphilitic constitutional taint, the treatment should be principally directed to the re-establishment of the general health. At the same time, the local agents enumerated as applicable to vulvitis in all its forms must be resorted to. Should both local and general means fail, an attempt may be made, if possible, to extirpate the diseased tissues with the knife. This, however, is often impossible, owing to the extension of the malady to regions with which it is impossible to interfere surgi- cally. Thus it is that, notwithstanding every effort made to restore the patient, death often closes the scene, the disease generally proving much more serious and more frequently fatal than in the face. That this should be the case is easily understood, when we consider that the affected parts are constantly exposed to irritating discharges from the urethra, the vagina, and the anus, and to the periodical congestions connected with menstruation. INFLAMMATION OF THE VULVO-VAGINAL GLAND. Hyper-secretion, simple or purulent, of the vulvo-vaginal gland, generally ceases on the removal of the cause or causes of irritation which produced it, combined merely with simple antiphlogistic means, such as hip-baths, and emollient and astringent injections. When the gland itself is inflamed, swollen, and tender, in addition to these means, "the application of a few leeches, along with purgatives and salines, is often very serviceable, and if resorted to sufficiently early, will frequently prevent the formation of matter. When once pus has formed, whether in the duct or in the gland, it is better to make an artificial opening for its escape, than to allow it to make one for itself. In the latter case, the orifice of the opening is often very small, and soon cicatrizes, when the matter may again collect; whereas, if an artificial opening is formed, it may be made sufficiently large to afford a free escape for the pus, and to be easily kept open until the inflammation of the gland have subsided, when it can be allowed to close without risk. This remark also applies to the abscesses that form in the proper tissue of the labia. It is the absence of this pre- caution that accounts for the constant recurrence of abscesses in this region which has been so frequently noticed by modern surgeons. 290 TREATMENT OF INFLAMMATION OF THE UTERUS The treatment of the cysts that form in the vulvo-vaginal gland, and present, in some respects, such a great similitude to these abscesses, should be conducted on the same principles. They ought to be freely opened, a portion eAren of their walls excised, and the orifice kept free so as to allow of the cavity of the cyst becoming obliterated by the inflammatory process that is set up. VAGINITIS. Simple non-blennorrhagic vaginitis should be treated on exactly the same principles, and in the same manner, as vulvitfs. When compli- cated with, and the result of the extension of, vulvitis, we have merely to carry the agents used beyond the vulva into the vagina, to subdue it along with the more external disease. When it is only a symptom of inflammatory disease of the neck or body of the uterus, and the result of its extension to the A^agina, the uterine affection must be attended to at the same time that emollient and astringent injections are used; otherwise it is in vain that the vaginitis is treated. Any improve- ment obtained is lost as soon as the means resorted to are for a time abandoned Thence the continued recrudescence of vaginal discharge observed in these cases when the uterine disease is not recognized and treated. As I have stated when speaking of the use of vaginal injec- tions in the treatment of inflammation of the neck of the uterus, their success in vaginitis depends principally on the mode in which they are employed. I must refer the reader to that part of the work for a more detailed account of the manner in which these remedial agents should be used in the treatment of vaginitis. OVARITIS, ACUTE AND SUB-ACUTE. • •• ^ Acute ovaritis requires the same treatment as acute metritis, the only difference being, that general blood-letting is seldom demanded, the application of leeches, generally speaking, proving sufficient. These may have to be repeated several times within the first few days of the attack, the aim of the practitioner being, if possible, to prevent suppuration. Acute ovaritis, having a tendency also to pass into the chronic stage, it is well to ascertain that all inflammatory action had subsided before the patient is left to herself as cured. In subacute ovaritis the principal reliance must be placed on the application of leeches to the ovarian region, the repeated use of blis- ters, and on resolutive frictions with ointments containing the iodide of potassium or of lead, or with mercurial ointment. To these local means of treatment must be added such general antiphlogistic agencies as the state of the economy seems to require, or as the strength of the system appears likely to bear. I need scarcely add, that any coexisting disease of the uterus, or of the cervix, should be removed as speedily as possible. AND OF THE UTERINE ORGANS. 291 INFLAMMATION AND ABSCESS OF THE UTERINE APPENDAGES. The treatment of inflammation of the uterine appendages, or lateral ligaments, in the first or acute stage, is the same as that of acute ovaritis and metritis. As, hoAvever, the danger of suppuration, if the inflammation be not speedily subdued, is much greater, it is generally desirable to have recourse, with even greater promptitude and energy, to antiphlogistic measures, and more especially to local and even general blood-letting. When the existence of inflammation in the lateral ligaments is recognized from the first, and it is'energetically treated, the formation of pus is often prevented, or the pus formed is absorbed. Should this not be the case, and the pus, in its efforts to find a vent by one of the natural apertures, becomes perceptible from the vagina, it has long ago been proposed to make an artificial opening, so as to allow of its escape. Paulus iEgineta describes this operation at some length; and in our own days M. Recamier has revived it, and strenuously advocates its adoption. Were the phlegmonous tumour absolutely to point in the vagina, and the fluctuation which it produces to become so evident as to show that it is in immediate contact with the vaginal parietes, I should not hesitate to adopt this course; but this is so rarely the case, that it is very seldom indeed that the operation, thus restricted, becomes appli- cable. To make an incision in the vagina, in the direction of obscure fluctuation, or tumefaction only, would be highly dangerous and repre- hensible. When the inflammation is not subdued by active antiphlogistic treatment, and the pus has found its way to the exterior by the vagina, rectum, abdominal parietes, or bladder, all that can be done is to meet the symptoms as they present themselves, to assist Nature in her efforts gradually to restore the parts compromised by inflamma- tory disease to a healthy state, and to endeavour, by every feasible hygienic and medicinal means, to support the strength of the patient during the tedious process of reparation which has inevitably to take place. In this stage of the disease, the rules laid down for the general treatment of chronic inflammatory disease of the uterus and its neck equally find their application. The periodical exacerbations which occur at the monthly periods, during the first few months, often require mild antiphlogistic treat- ment by leeches, purgatives, and salines. Subsequently, rest in bed for a day or two, and warm poultices applied to the abdomen, alone suffice. The diarrhea occasioned by the opening of the abscess into the rectum soon subsides, generally speaking, under the influence of starch or opium injections. It is then often succeeded by consti- pation, which must be remedied by very mild aperients, or by cold or tepid enemata. 292 TREATMENT OF INFLAMMATION OF THE UTERINE ORGANS. In that more severe form of the disease Avhich is observed during the puerperal state, the pelvic mischief, as we have seen, is often so great as to react most unfavourably on the general health, and to reduce the patient to the greatest state of marasmus. When this is the case, powerful stimulants, such as wine and quinine, may become absolutely necessary to keep her alive. It is more especially in these severe cases that abdominal perforation takes place. As soon as fluctuation is distinctly felt underneath the walls of the abdomen, and the skin reddens, it is best to make an artificial opening, in order to allow the pus to escape. This opening may be made with the lancet, or with potassa fusa, but I prefer the former mode of operating,—it is more prompt, and equally safe. Desperate as the state of these unfortunate patients often appears, they almost invariably rally under judicious treatment, and eventually recover, although the process of recovery may be a very tedious and lengthened one. PAET II. CONNEXION BETWEEN UTERINE INFLAMMATION AND OTHER MORBID UTERINE STATES. In the first part of this work, I pointed out, as I progressed, the great influence that inflammation of the uterus and its annexed organs exercises in developing disordered functional conditions of the uterine system, that is, morbid menstrual states, sterility, abortion, &c, and in producing the various displacements of the uterus. Inflammation may also be complicated with polypi and fibrous tumours of the uterus, and greatly modify their symptoms. In the neck of the womb, syphili- tical ulceration presents peculiar characters, which require elucidation, in order that it may be distinguished from inflammatory sores. It is in the neck of the womb, that cancer also generally first makes its appear- ance ; and although the morbid changes produced by inflammation are in reality easily distinguished from those resulting from cancer, they have been, hitherto, generally confounded with the latter, with which they are erroneously supposed to have great affinity. I now intend carefully to examine these various morbid conditions in their con- nexion with inflammation, to point out in what manner it influences their origin and development, and to establish their diagnosis on full and accurate data. MORBID MENSTRUAL STATES. The history of morbid menstrual states, Dysmenorrhea, Menor- rhagia, and Amenorrhea, is so inextricably mixed up with that of uterine inflammation, that the influence exerted by the latter cannot be duly appreciated unless they be studied generally. I shall there- fore give a brief but complete account of these conditions in all their forms, and of the treatment they require. CHAPTER XIII. DYSMENORRHEA—AMENORRHEA—MENORRHAGIA—UTERINE HEMOR- RHAGE GENERALLY—LEUCORRHEA—STERILITY—ABORTION. DYSMENORRHEA. By the term dysmenorrhea is implied painful and difficult menstrua- tion. Most females experience slight uterine and ovarian pains accompanied by some external tenderness in the hypogastric region, with or without aching pain in the back, for the first few hours pre- vious to and after the advent of menstruation. When these feelings are not usually experienced they will often manifest themselves, accidentally, as the result of over-fatigue or mental emotion, or without any appreciable cause. To such conditions, however, the appellation of dysmenorrhea cannot be applied; it must be reserved for those cases in which a very considerable amount of pain is experienced, either invariably or by exception. Dysmenorrhea may exist—First, Permanently as a constitutional condition, or accidentally and temporarily in connexion with general morbid states. Secondly. It may be the result of the presence of uterine or ovarian disease, or of, a contracted state of the cervical canal. Constitutional Dysmenorrhea.—This form of dysmenorrhea is often observed in females whose uterus appears naturally predisposed to congestion, and with whom menstruation is very abundant and is pre- ceded and followed by a white leucorrheal discharge. It is met with also when this is not the case. It may be limited to the first day or two, or extend throughout the entire period. In such women the dysmenorrhea is evidently functional, the result of the distention produced by over-congestion, or of a peculiar susceptibility of the uterine innervation. The pain is by no means the same in intensity at every period, but varies according to hygienic and moral circum- stances. Under the influence of fatigue, excitement, or anxiety, and frequently without any appreciable cause, the dysmenorrhea will become much more intense than usual, and last a much longer time. In some instances I have known it to come on only at every second period. This form of dysmenorrhea may persist with varying intensity throughout the entire duration of the menstrual function, although occasionally it is modified or even removed by marriage, by parturition, or hjthe mere influence of time. Although verging on disease, con- stitutional dysmenorrhea can scarcely be considered a morbid condition. It may be said to be characterized by its commencing with the men- DYSMENORRHEA. 295 strual function, by the entire and complete absence of all uterine symptoms in the interval of the monthly period, and by the general similarity of the menstrual epochs. Although one period may be, and often is, more painful than another, on comparing menstruation during any two given periods of several months, the amount of pain suffered, and the mode of manifestation of the function, are found to be pretty nearly the same. If a permanent increase of pain occurs, it is a suspicious circumstance, as indicating the possible or even probable existence of some inflammatory condition of the cervix uteri, to which these females, as we have seen, are peculiarly liable, or of some morbid ovarian condition. Accidental Dysmenorrhea.—Dysmenorrhea may occur accidentally in a female who usually menstruates without pain, as the result of over-excitement or fatigue, from exposure to cold, or as the result of some temporary disturbance in the general health. When this is the case, the dysmenorrhea is probably occasioned by a disturbed or con- gested state of the uterine circulation, or by an exaggeration of the nervous susceptibility of the uterine organs. It is characterized by its merely temporary existence, and by the fact of its passing away with the cause that produced it. Inflammatory Dysmenorrhea.—Non-constitutional dysmenorrhea, however, according to my experience, is much more frequently the result of inflammatory disease of the uterine organs, and principally of the cervix, than, as is generally supposed, of functional derangement, or of nervous susceptibility. When menstruation, naturally easy, becomes permanently painful, or when naturally but slightly painful, it becomes extremely so, we are warranted in looking for local disease. Such a change does not take place without a cause, and that cause is, generally speaking, inflammation of the cervix or body of the uterus ; dysmenorrhea being one of the most prominent and most ordinary symptoms of that disease. This fact applies to the virgin as well as to the married female, and is of great importance, as affording a key to those extreme cases of dysmenorrhea, accompanied sometimes by spinal irritation and hyster- ical epileptiform convulsions, which appear to resist every form of treatment, and are alike distressing to the patient, her friends, and her medical attendant. Since I have ascertained that such is the case, nearly all the instances of extreme dysmenorrhea in the unmarried female that have come under my notice, have proved to be of this description, and, hoAvever, intractable before, have yielded as soon as a proper antiphlogistic treatment has been adopted. The history of two patients formerly under my care, strongly illus- trates these facts, and their importance. In the younger female, a young, unmarried lady, dysmenorrhea from the first was the prominent symptom. She had always suffered slightly from painful menstruation, but not to such an extent as to inconvenience her. About two years before I saw her, the dysmenorrhea became much more intense, and at last so agonizing, as to produce hysterical epileptiform convulsions, 296 DYSMENORRHEA. which ended in partial paralysis. In the other lady, who was thirty vears of age, and the mother of a family, the uterine inflammation commenced six years before, with a laborious confinement. The most prominent symptom with her, also, was dysmenorrhea, which increased rapidly, so as at last to bring on intense convulsions at every monthly period, and thus to occasion partial paralysis of the left side, as in the former case. Both these patients were considered to be merely suffering from hysteria, spinal irritation, and functional derangement of the uterus, and had been treated, for several years, solely in accordance with these views ; whereas, in reality, they were labouring under severe inflammatory ulceration of the uterine neck. In these cases the dysmenorrhea is a mere symptom of the inflam- matory condition of the uterine organs, and is only to be removed by their restoration to a healthier state. Generally speaking, it is the neck of the uterus that is found to be the seat of the disease that occa- sions the dysmenorrhea. The latter is nearly always very intense when the body of the uterus is affected. Sub-acute inflammation of the ovaries may also give rise to dysmenorrhea, but I cannot agree with Dr. Tilt that it is a frequent cause. This difference of opinion is connected with that which exists between me and my esteemed friend respecting the frequency of sub-acute inflammation of the ovaries, inas- much as I consider the symptoms which Dr. Tilt supposes to indicate the existence of such inflammation—pain and tenderness in the ovarian regions—to be merely symptomatic of disease of the uterus or of its neck, in nineteen cases out of twenty in which they are observed. We may connect with inflammatory dysmenorrhea that form which has been described under the head of pseudo-membranous, and which is characterized by the expulsion of shreds and casts of plastic lymph from the cavity of the uterus. I believe that the formation of these membranes coincides almost invariably with the present or past exis- tence of uterine inflammation. In other words, I have found, in the great majority of cases of this description that have come under my observation, that there has been at first inflammatory disease, although the removal of this disease has not always freed the patient from the liability to the formation of the pseudo-membranous casts. It would appear as if habit alone sufficed in some instances to perpetuate their formation, or at least their occasional occurrence, even after the re- moval of inflammation, if once they have occurred under its influence. M. Pouchet states, that in all females, even in virgins, a delicate decidual membrane or cast is formed in the cavity of the uterus at every menstruation, and is throAvn out about the tenth day. If so, the deciduous pseudo-membranes of dysmenorrhea may be considered as merely an exaggeration of a natural condition, but occurring, generally speaking, only under the influence of inflammatory disease. The expulsion of these pseudo-membranous shreds is always preceded by an aggravation of the uterine suffering, and not unfrequently by tormina similar to labour-pains, which are evidently occasioned by the efforts of the uterus to get rid of the casts formed in its cavity. That DYSMENORRHEA. 297 the difficulty of expulsion is partly the cause of the uterine tormina, is proved by the fact that I have repeatedly relieved them by dilating the cervical canal in the interval of menstruation, in females who continued to expel pseudo-membranes, and to suffer, after the removal of all uterine disease. Inflammatory dysmenorrhea may be said to be characterized by the development of pain as a permanent menstrual condition, in a female previously free from it, or by the increase of pain experienced consti- tutionally, but in a less marked degree. In other words, as pain during menstruation may exist constitutionally without local lesions, its value as a symptom of disease can only be ascertained by comparing the past with the present state of the patient. Generally speaking, other uterine and general symptoms are present during the interval of menstruation, which tend to assist the diagnosis. This, however, is not always the case. I recently attended a young unmarried lady, only twenty-one, who had suffered ever since the menses appeared, at seventeen, from severe dysmenorrhea. The pain was indeed so severe, that for the first five days she was always obliged to keep her bed, writhing in agony, and for eight days out of every lunar month she was confined to her room. In the interval she had not an uterine symptom, and beyond a certain amount of general languor and anaemia, which the mere physical pain she had to go through at short intervals sufficiently explained, the general health did not appear to have much suffered. Previous to my seeing her, she had been under constant medical treatment, and the total inefficacy of the remedial means usually resorted to in such cases had been over and over again tested. Under such circumstances, after treating her without any result for sub-acute ovaritis, I considered myself warranted in making an exami- nation of the uterine organs, being impressed with the idea that dysmenorrhea of so severe a character, and so rebellious to general treatment, must be occasioned by some local morbid condition, and probably by congenital contraction. To my surprise, I found the cervix the seat of decided inflammatory ulceration. I may also add, that the dysmenorrhea has quite subsided under the influence of appropriate treatment for the local disease. This case, however, is an exceptional one*, even to me, from the entire absence of all uterine symptoms in the interval of menstruation, and shows the difficulties which occasionally surround the diagnosis of these forms of uterine disease. Physical Dysmenorrhea.—Dysmenorrhea may also depend, as demonstrated by Dr. Mackintosh of Edinburgh, on a physical imper- fection of the uterine neck, on contraction of the os internum, or of the canal which constitutes the cavity of the cervix. This contraction may be either congenital, or the result of inflammation. The peculiar character of the dysmenorrhea, when caused by congenital contraction, is the absence of any uterine symptom during the interval of men- struation, and intense agonizing pain for a few hours before the flow of blood appears, either then disappearing,- or lasting throughout the 298 DYSMENORRHEA. period ; these pains commencing with menstruation in early youth. If they are occasioned by inflammation, there are the same symptoms at the time of menstruation, but there is not the same immunity from uterine symptoms in the interval of the catamenia. The cause of the pain experienced under these circumstances is evident. The cavity of the non-pregnant healthy uterus not containing more than about ten or eleven drops of fluid, as soon as the catamenial secretion commences from the lining membrane of the uterine cavity, unless the blood find a free exit through the os internum and the cavity of the cervix, it distends the uterus, and gives rise to great pain. The obstruction may merely be at the os internum, spasmodically con- tracted; in which case, as soon as it has been overcome, the blood escapes freely, and pain disappears. But if the os internum is perma- nently contracted, or the contraction exists in the cervical canal, the pain may continue throughout the catamenial period. A contracted state of the upper part of the cervical canal, or of the os internum, is not, I believe, an unfrequent complication of inflam- mation of the cervix, from the swelling and hypertrophy of the substance of the organ which it occasions. This remark, however, does not apply to the inflamed region of the cervical canal, which is uniformly dilated by the existence of inflammation. I do not, however, think that Dr. Simpson's criterion of the exist- ence of contraction of the os internum is entirely to be depended upon. Dr. Simpson believes, if I am right in my interpretation of his views, that unless the uterine sound pass without effort into the uterine cavity, there is contraction of the os internum. Now the careful examination of many hundred females with the sound, has led me to a different conclusion. There evidently exists at the os internum a kind of muscular sphincter formed by a strong band of the circular muscular fibres of the cervix, and destined to close the uterus during the latter stages of pregnancy. Generally speaking, this sphincter, in the natural state, is sufficiently closed to prevent the uterine sound passing into the cavity of the uterus, unless a considerable amount of pressure be exercised. In nearly all the females I examine, in the interval of menstruation, the sound passes easily along the cervical cavity, but stops at the os internum, and that when there is no reason whatever to suppose the existence of a morbid coarctation. It appears to me, on the contrary, that a free communication between the cervical and uterine cavities, allowing the easy introduction of the uterine sound, is generally an anomalous condition, indicating the existence of disease, unless observed soon after menstruation, when the os internum relaxes, or soon after parturition, when it has not yet had titne to recover its normally contracted state. The principal morbid conditions in which I have observed a free communication between the two cavities, are inflammation and uterine tumors. If the inflammation which exists at the os uteri, and in the loAver part of the cervical cavity, ascends as far as the os internum, it appears to relax the muscular contractility of that region. The os internum is DYSMENORRHEA. 299 always open when the inflammation passes into the uterine cavity, and implicates its lining membrane. The same effect is also produced by the development of the uterine cavity, through the formation of tumors in the substance of the uterus, or from any other cause; the os internum gradually opening as the uterus enlarges, probably by the same mechanism as in pregnacy. This is so generally the case, that the fact of the uterine sound penetrating easily through the os internum into an enlarged uterine cavity, may be considered a valuable symptom of the existence of such tumors, to add to those with Avhich we are already acquainted. Extreme dysmenorrhea from congenital contraction of the cervical canal and os internum, independent of inflammation, is, I believe, of rare occurrence. This is a fortunate circumstance, as it is most embar- rassing to treat, requiring an amount of interference with the uterine organs which it is very painful to have to propose to an unmarried female. Dilatation of the contracted cervical canal is, however, sometimes the only means we have of remedying an amount of suffering at the catamenial period, so extreme as to render life nearly a burden, and as to re-act deeply on the general health. A very strongly marked illustration of this fact occurred to me some time ago, in dispensary practice. A young female, aged twenty-two, was sent to me by a medical practitioner in town for dysmenorrhea. It appeared that she had suffered in the most excruciating manner at every menstrual period, since the menses first appeared, at the age of eighteen. The pain always continued without intermission throughout the three days and nights that the catamenia lasted, and was of so severe a character that she neArer closed her eyes, and was confined to her bed for the whole time. She had generally been under medical treatment, and the usual remedies had been repeatedly tried—anti- spasmodics, anodynes, sedatives, &c. Latterly she had been taking very large doses of opium without the slightest benefit. On inquiry, I found that after the menstruation ceased, the pain gradually subsided, and that during the menstrual interval she was perfectly well, and was then altogether free from any uterine symptom. In appearance she was rather stout and healthy-looking. The hymen was intact, but dilatable, and I was thus enabled carefully to examine the neck of the uterus, which I found perfectly natural in size, colour, texture and density, and free from any tenderness. The cavity of the cervix, how- ever, was evidently very narrow, not even admitting a very small-sized bougie. Thinking this might be the cause of the dysmenorrhea, I at once decided on dilating it. This I effected to a considerable extent in the course of the three weeks which ensued before the next monthly period, by means of small sponge tents. I had not, however^ dilated the os internum sufficiently to admit of the sound penetrating into the cavity of the uterus, and was consequently rather surprised to hear from the patient, after a week's absence, that not only had the cata- menia been more abundant than usual, but that she had been entirely free from pain. The dilatation was continued irregularly, and as the 300 DYSMENORRHEA. next period was equally free from pain, I ceased all treatment, although the os internum was still undilated ; at least, it was only sufficiently open to admit of the entrance of the small extremity of the wax bougie. The dysmenorrhea which accompanies inflammation of the cervix, is evidently increased in some cases by the narrowing of the cervical canal, which the inflammation occasions, inasmuch as it may persist in a mitigated form after the inflammatory disease has subsided, and be readily removed by dilatation. The persistence of dysmenorrhea from this cause after the remoAral of uterine inflammation, is not, however, of itself sufficient to necessitate, or even to warrant, dilatation of the cervical canal being resorted to, except in some special cases, until a few months have been allowed to elapse. After the removal of inflam- matory disease of the uterus and of its cervix, a resolutive action is set up by nature, which will often soften and relax the still swollen and indurated tissues, and thus open the cervical canal, and render mechanical dilatation unnecessary. It is therefore well to give the patient the benefit of this chance of recovery without further surgical treatment. Whatever may be the cause of dysmennorrhea, the mode in which the menstrual secretion takes place is modified by its existence: instead of a flow of bright blood, regular and continuous, although generally incereasing by exercise and diminishing by rest, Ave have a dark, unin- terrupted and clotted discharge. After severe uterine pains, which may last many hours, and are often accompanied by tenderness, and swelling in the ovarian regions, and pain in the back and down the thighs, more or less dark, clotted blood is thrown out. Its expulsion is generally followed by relief, and by a freer flow for a while, when it again diminishes, and the same ordeal again takes place. Sometimes the interruption will be complete for one, two, or three days, the pains subsiding with the menstrual flux, and returning when it again makes its appearance. The venous condition of the menstrual secretion shows plainly that, either from inflammation, congestion, or some other cause, the uterine circulation is defective, the blood stagnating in the vessels of the uterus, remaining in its cavity, and distending it after it has been secreted. Treatment.—The attacks of constitutional dysmenorrhea may be palliated, but can seldom be removed, by medical treatment. A great deal of subsequent uterine disease would, however, be spared to those young females who unfortunately suffer from it, were mothers more generally aware that its existence constitutes throughout life a strong predisposition to uterine inflammation, and that they cannot take too great care of such of their daughters as labour under it. For such young females the discipline of public schools may be said to be nearly always too severe, and often to lay the foundation for much future physical and mental misery. That this must be the case, will be easily understood when we reflect that the domestic treatment of this form of dysmenorrhea consists principally in rest and warmth. Females who suffer habitually from dysmenorrhea, whatever their age, should remain DYSMENORRHEA. 301 quietly at home, taking care to preserve themselves from atmospheric vicissitudes during the first day or two of menstruation, which is the period during which the pain is mostly felt. A warm hip-bath will often be found useful. If the pains are very decided, it is best even to confine the sufferer to bed, and to apply warm linseed poultices to the loAver abdominal region—a valuable and simple mode of soothing pain. In mere constitutional dysmenorrhea, these simple means nearly always suffice to render the pain very bearable. If they do not pro- duce relief, that fact alone constitutes a suspicious circumstance, and should induce the medical attendant to scrutinize narrowly the state of his patient, lest there should be some morbid or physical cause in action. In severe dysmenorrhea, connected with uterine disease, the only efficacious treatment is that directed to the cause of the disease which occasions the dysmenorrhea. As time is required, hoAvever, to effect this, we are often called upon, even in these cases, to treat the dys- menorrhea as a symptom; and, warmth and rest failing, recourse must be had to medicinal agents. By far the most efficacious remedy with which I am acquainted is the ejection of laudanum, or any other pre- paration of opium, into the bowel. From fifteen to thirty minims of laudanum, mixed with a little warm water, should be injected into the rectum, and will generally exercise, if retained, as much influence in soothing the uterine pain as would double the quantity taken by the mouth. Moreover, the nausea and headache which opiates occasion are much less likely to be produced when they are thus administered. If the first opiate injection is not retained, a second, given half an hour later, will generally be more successful. I have also found chloroform of great value in these cases. It may be inhaled, or administered by the mouth in doses of from twenty to forty minims, mixed with mucilage, the yolk of an egg, or with camphor, which favours its sus- pension in water. I have given it by injection, but with less success, as it appears, generally speaking, to irritate the rectal mucous mem- brane, and is consequently not retained. When, however, it is retained, the sedative effect is nearly always effectually produced. Although chloroform may thus often be resorted to with great benefit in dysmenorrhea, I do not find that as much reliance can be placed on it as on opiates. There are various other medicinal agents, principally antispasmodics and narcotics, which may be administered with benefit in dysmenorrhea. We may mention more particularly the various ethers, and especially sulphuric ether, hyoscyamus, belladonna, musk, valerian, and camphor. It must not, however, be forgotten that these remedies are mere tempo- rary palliatives; that dysmenorrhea, when constant and not constitu- tional, nearly invariably depends upon some physical cause, generally speaking, uterine or ovarian inflammation, and that it is this cause which we must find out and remove during the interval of menstruation. It is the fact of dysmenorrhea being so frequently caused by inflam- matory disease, that'explains the success which often attends blood- letting, both general and local, and which has induced so many authors 302 AMENORRHEA. to recommend it, although unaware of the pathological state Avhich it relieves. General bloodletting acts by revulsion ; Avhilst local blood- letting directly relieves the congested and embarrassed abdominal circulation. I seldom, if ever, resort to general bleeding in dysmen- orrhea, because the relief which it gives is obtained at too great a sacrifice of the strength of the patient, and, moreover, cannot be depended upon. A few leeches applied to the groin, or, better still, to the neck of the uterus, when possible, if the discharge is scanty, or temporarily arrested, is much more likely to mitigate the pain, and with less loss to the economy. Purgatives, which are frequently useful, act in the same way as leeches, by depleting the abdominal circulation. Some authors—amongst others, Dr. Gooch—have considered dysmen- orrhea to be frequently akin to rheumatism, and have recommended colchicum, guaiacum, and other medicines usually given in rheumatic affections. That the uterus may be the seat of such an affection is undeniable; but I am persuaded that its frequency has been greatly exaggerated, as has likewise that of irritable uterus. Indeed these tAvo conditions may be said to have been, to a great extent, mere theoretical creations, destined to account for pathological conditions, the real nature and meaning of which have, until recently, been a mystery* to the profession. It will be seen, by what precedes, that dysmenorrhea is by no means so simple a disease, or so easy to treat, as has been generally supposed, involving, as it often does, the question, whether or not local disease requiring local treatment may not exist as the real cause of the morbid state. If it resists all general treatment, it is probably the result of such disease, and the health and happiness of a young female are seriously endangered. Of course the medical practitioner has a duty to perform to his patient, before which all scruples must be made to succumb. I, however, here repeat what I have so often said before, especially with reference to unmarried females, that nothing can war- rant manual or surgical investigation and treatment, but months, or even years of unsuccessful treatment, and the conviction, with the latter, that unless they be resorted to, the case must be abandoned as hopeless. I would also urge, that a consultation should always be held first when the patient is unmarried, to decide the point, whether the examination of the uterine organs be warranted and necessary. AMENORRHEA. We understand by the term amenorrhea, the absence, when physio- logically due, of the sanguineous discharge by which menstruation is externally manifested. The menstrual function consisting as we have seen, not merely of the periodical secretion of blood from the interior of the uterine cavity, but also of the maturation and elimination of ova from the ovary, it is necessary to make Ittie above distinction. Ova may, by exception, be matured and evolved from the ovary in the AMENORRHEA. 303 human female, as well as in the lower animals, without any sanguineous discharge taking place, as is evidenced by the repeatedly recorded fact of the conception of young females who have never menstruated, and by the pregnancies which occur in women Avho are nursing, without menstruation having returned. Thus, the external excretion of blood can no longer, in our present state of knowledge, be considered as comprising the entire function, although, as the rule, its manifestation is an evidence of the existence of those all-important ovarian phenomena Avith which it is generally connected. Amenorrhea may be studied under two principal forms : in the first, which Ave will call "constitutional amenorrhea," menstruation has never taken place; in the second, which may be termed " accidental amen- orrhea," it has manifestsd itself, but has been suddenly or gradually suppressed. Constitutional Amenorrhea.—In order to appreciate this, we must recall to mind some of the principal facts connected with the physiology of menstruation noticed in a former chapter. Thus, we must recollect, that the first appearance of this function follows no strict rule, oscillating, in health, between the ages of eleven and nineteen or twenty, an interval of nine or ten years ; and that the average age of fourteen or fifteen is obtained by the inclusion of the exceptionally extreme cases. We must also bear in mind, that, apart from constitutional and family peculiar- ities, the acceleration or delay of menstruation appears to be more the result of favourable or unfavourable hygienic conditions than of climate, as was formerly taught and believed. Such being the physiological conditions of menstruation, it is evident that its non-appearance after the average age of fourteen or fifteen is not to be considered a morbid state, so long as the delay is unaccom- panied by any symptoms of disease or ill-health. Thus we occasionally meet with young females, non-menstruated, of the age of seventeen or eighteen, or even older, whose frame is well developed and healthy, and who complain of no ailment beyond an occasional headache or backache, and sometimes not even of that. With them, menstruation is merely late in its manifestation: they are not suffering from amenorrhea. In a considerable proportion, however, of the young females who reach the age of eighteen or more without having menstruated, the delay is either attended with great discomfort and distress, apart from any physical deficiency; or is connected with defective general and sexual development; or is occasioned by some local or general morbid condition; or is prevented by some physical impediment. Each of these states may be said to constitute a distinct form of amenorrhea. In those who belong to the first category, we find a well-formed frame, properly developed breasts, as also the other external signs of puberty ; but the patient suffers from constant headache and flushing of the face, severe pains in the back and loins, extending to the lower part of the abdomen and down the thighs, and often from leucorrheal discharge. It is evident that the changes that precede and accompany 304 AMENORRHEA. menstruation, both in the internal and external organs of generation, have taken place, but that the function has a local difficulty is estab- lishing itself: thence an irregular state of circulation, determination of blood to the head and face, congestion of the uterus, vagina, and ovaries, with consequent pain in the uterine regions, and the leucorr- heal discharge. This state is not unfrequently connected with a plethoric condition of the system, and may last from a few months to several years. The advent of the menstrual hemorrhage generally relieves the patient at once, although she may still continue to suffer at times, as above described, if menstruation fails to establish itself regularly. The second division comprises non-menstruated females, who, although they have attained, or even passed, the ordinary age of puberty, do not present that development of the mammae and other external organs of generation, by which this period of life is usually characterized. They remain thin, angular, and flat-chested, and retain all the characteristics of girlhood, mental as well'as bodily. It Avould appear as if in these cases the ovaries remained dormant, and as if the general stimulation which their progressive maturation imparts to the economy were not supplied. We have seen that, physiologically, menstruation is retarded by bad living and unfavourable hygienic conditions; whereas its advent is accelerated by good living and favourable hygienic conditions. From this fact alone, we might conclude that all diseases that debilitate the economy would have a tendency to retard the menstrual flux; and such is really the case. Phthisis, scrofula, chlorosis, fevers, indeed all diseases that weaken, produce this effect. None, however, more frequently occasion amenorrhea than chlorosis, a disease of the blood, in which the solid constituents of the vital fluid are diminished, and the fluid or serous part increased. The delay or suppression of the menses, under the influence of this malady, is so prominent a feature in its history, that many writers have very erroneously connected it with the uterus, and have described it as a uterine disease. In reality, the state of the menses is a mere symptom of the anemia and debility occasioned by the morbid state of the blood. It is only in a few exceptional cases that I have found chlorosis connected with actual uterine disease. Lastly, the menstrual secretion may have taken place, but the excretion may never have occurred, owing to congenital or accidental closure of the genital passages. The os uteri, the vagina, and the hymen, may be all closed together, or they may be each closed sepa- rately. If the closure exists at the os uteri, the menstrual fluid accumulates in the cavity of the uterus, and gradually developes it, so that the enlarged organ rises out of the pelvis, and appears above the pubis, simulating pregnancy. If it is the lower part of the vagina or the hymen that is imperforate, the menstrual fluid first accumulates in the vagina, which it distends to an extreme degree before it enlarges the uterine cavity. If the fluid collection reaches the hymen, it AMENORRHEA. 305 generally pushes it forward, and forms a tumour, which appears between the labia. This distention of the internal uterine organs is generally attended with great suffering, both local and general, and is marked by periodical exacerbations, corresponding to the monthly periods. Accidental Amenorrhea.—The second class of cases comprises those in which menstruation has existed, but has been suddenly or gradually suppressed. The sudden suppression of menstruation is generally the result of exposure of the body, and especially of the feet, to cold or to wet; of a mental shock, from fear, grief, pain, or anxiety, &c.; or of a sudden attack of disease. It not unfrequently occurs, for a time, as the result of a sea-voyage, or of change of climate, without giving rise to much distress, and without requiring medical treatment, the return taking place spontaneously. The sudden suppression of the menses, under the influence of the other causes mentioned, is often followed by the development of inflammation in the uterus, ovaries, or lateral ligaments. Even when suddenly suppressed, however, the suppression may be unattended with any unfavourable symptom, beyond slight pain in the back and hypogastrium, flushing, and headach. Amenorrhea, thus suddenly induced, seldom extends over more than one, two, or three periods, under proper management, although the suspension may be considerably lengthened, and is sometimes indefinite. A gradual suppression of menstruation is sometimes observed in those females in whom the function has set in late and with difficulty, without there being any evident cause, general or local. It would appear as if the ovarian and sexual vitality were anomalously Ioav ; and after making one or more efforts, at irregular periods, to establish itself, menstruation ceases, not to return, except under the influence of treatment. When this occurs, the health is scarcely ever good, the constitution generally remaining delicate and weak. In such cases, however, we are warranted in suspecting ovarian or uterine disease. Generally speaking, in the absence of the chlorotic or tubercular cachexia, the gradual suppression of the menses is con- nected Avith such disease. The development of the various tumours to which the ovaries are liable, frequently causes amenorrhea; and the chronic inflammatory affections which are so often observed in the neck and body of the uterus may have the same result. Menstruation first becomes irregular, being days, weeks, or months, and then ceases completely. I have often been consulted for amenorrhea by females who Avere labouring under these forms of disease, and in whom it had evidently come on subsequently to the uterine affection. When menstruation does not return, the uterus, and especially its cervix, eAren in the absence of positive disease, appear sometimes to be the seat of a kind of permanent congestive irritation, which ultimately may bring on hypertrophy and induration of the latter region. I have seen the cervix become thus enlarged, under my eyes, as it were, in the course of four or five years, although there Avas never any really 306 AMENORRHEA. tangible disease during that time. In one instance, that of a married woman, noAV twenty-eight, the menses, which from the first had been irregular, stopped immediately after marriage at twenty-three. Soon afterwards she began to suffer from uterine symptoms, and when she consulted me, I found the cervix inflamed and ulcerated, but not hypertrophied. The disease was soon subdued, but the menses haAre only returned once or twice. The uterus has appeared to remain in a state of semi-congestion, and the cervix has gradually enlarged. This female remains delicate, although in very tolerable health, free from pain, and not suffering under any other morbid state. Suppressed menstruation, either sudden or gradual, is not unfre- quently followed, even when uterine inflammation is not developed by serious general symptoms, obstinate vomiting, severe hysteria, and, sometimes by the establishment in the economy of a supplementary hemorrhage, to which the name of " vicarious menstruation" has been given. The mucous membrane of the nasal fossae, of the lungs, stomach, and bowels, are the most ordinary seat of this hemorrhage, which takes place in some instances Avith the regularity of normal menstruation, and in others at irregular periods. All the other mucous membranes, as also the skin itself in various regions, have been the seat of vicarious menstruation. It has not unfrequently been observed from the surface of wounds or sores. Such being the case, it is evident that hemorrhage occurring from any of these sources in a young female in Avhom the menses are suppressed, has not that importance which it would haAre under other circumstances. The hemorrhage may be, and probably is, merely an effort of nature to establish a supplementary issue for the menstrual secretion, which has not taken place. Treatment.—The rules which should guide the practitioner in the treatment of amenorrhea must be draAvn from an attentive considera- tion of the causes by which it is occasioned, and must vary as they vary. In a general point of view, hoAvever, the indications are, 1st, to give tone to the economy, if tone be deficient, and to remove general or local disease, if such disease be present; 2ndly, to favour and pro- mote, within reasonable and judicious limits, the menstrual function. We will now briefly see how these indications are best carried out in the various forms of amenorrhea above described. When the advent of the menstrual flux is retarded in well-developed young females, Avho evidently suffer, both generally and locally, from the delay, a little judicious management will often determine its appear- ance. The state of the health should first be carefully scrutinized, and any general or functional derangement remedied by proper treatment. If the patient is weak and delicate, the various preparations of iron, with a generous dietary, are often of great use. If, on the contrary, she is plethoric, and subject to headache and flushing of the face, a light diet, gentle exercise, and alteratiA'e or saline medicines, are indi- cated. A young female, suffering in this way is better at home, under the eye of a devoted and attentive mother, should she be fortunate AMENORRHEA. 307 enough to possess such a parent, than in a public school, where the rigid discipline usually enforced renders it difficult to pay that atten- tion to her state which it requires. Under the influence of these gene- ral means, the menstrual function usually manifests itself, and becomes regularized in the course of a few months. Should they prove ineffi- cient, slight periodical stimulation of the uterine system should be resorted to. The plan I most frequently adopt is, the application of large mustard poultices to the breasts, and to the inner and upper parts of the thighs, alternately, night and morning, during five or six days, every four weeks. The mustard poultices should be allowed to remain on until the skin reddens and begins to feel painful, but not long enough to blister it, as that would prevent their being replaced the fol- lowing day. The feet may also be put in hot water night and morn- ing, for a few minutes, and if there is any pain in the hypogastric or ovarian regions, large warm linseed poultices, sprinkled over with laudanum, may not only afford relief, but also promote the menstrual excretion. When the symptoms of local congestion are very marked, the application to the vulva of a few leeches every month, or about the fifth day of the local treatment, may be of great assistance. The commencement of this local treatment should be made to coincide with the menstrual nisus, when it manifests itself periodically. "When it does not, a certain date should be taken, and adhered to at the interval stated—that is, every twenty-eight days-. In such cases the medicines known as emmenagogues, which exercise a special influence over the uterus, are scarcely, in my opinion, admissible, the object being to gently promote the natural function, and not to violently stimulate, and probably irritate, the uterine organs. In amenorrhea connected with deficient uterine and bodily develop- ment, the local treatment should be conducted on the same principles, only it generally requires to be carried out more perseveringly and for a greater length of time. In addition to the means mentioned, I have also derived great benefit from electricity, the electric current being carried through the pelvis from the hypogastric to the sacro-lumbar region, for an hour night and morning, during the week that local means are resorted to. In these cases it is evident that the non-deve- lopment of the body is often in a great measure the result of the dor- mant condition of the uterine organs, inasmuch as I have repeatedly succeeded in rousing them to action by the local treatment above detailed, when the most judicious and persevering general treatment had failed. In these cases I have invariably seen the bodily struc- tures subsequently develop themselves with great rapidity. At the same time, the knowledge of this fact must not for a moment prevent our employing every possible means of invigorating the general health, of vitalizing the economy, and of promoting the regular play of the various functions. After removing any morbid functional con- dition which a careful scrutiny may detect, recourse should be had to the mineral and vegetable tonics, and especially to ferruginous prepa- rations, to which should be added a generous diet, moderate exercise 308 AMENORRHEA. in Avalking or riding, cold bathing or sponging, early hours for retiring and rising, and, if possible, a residence in the country. When amenorrhea can be traced to a debilitating disease, such as chlorosis, phthisis, scrofula, &c, the best mode of proceeding is the treatment of the disease to which it is referrible. Thus, in chlorosis, the menstrual flux gradually diminishes, and may finally cease alto- gether under the influence of the progressive deterioration of the blood, without there being any uterine disease or any other uterine symptom than the scantiness and final disappearance of the secretion. As under appropriate general treatment the blood becomes healthy, in the immense majority of cases menstruation returns, or again becomes gradually more and more normal, without any local treatment being necessary. The same may be said of scrofulous and other forms of constitutional debility. In pulmonary phthisis, the falling off and final disappearance of menstruation is a symptom of much more seri- ous import, as it is generally connected with the more advanced stages of the disease, and with an amount of tubercular deposit, and of con- sequent marasmus, through defective nutrition, which renders the chance of a recovery very problematical. Amenorrhea from physical obstacles can only be remedied by surgi- cal means. If the hymen is imperforate, or the lips of the vulva are adherent, and the menses have collected behind, a crucial incision in the centre of the bulging hymen, or vulvar protuberance, is all that is required. Care, however, should be taken, when the menstrual fluid has been evacuated, that the divided surfaces do not unite and cicatrize. This is to be prevented by the use of small sponge or cotton tents for a few days, or by the application of the nitrate of silver to the edges of the incisions—a more painful but equally efficacious process. When the vagina is partially or wholly absent, or closed, either congenitally or by adhesion from accidental causes, the case is a much more serious one, and more difficult to remedy. If there is merely adhesion of the walls of the vagina, this adhesion can generally be removed by the dilatation of the vagina, coupled with the gradual and careful division of the adherent surfaces. When the vagina is partially or entirely absent, the symptoms produced by the retention and accumulation of the menses in the uterus may be sufficiently serious to render it impe- rative to attempt to form an artificial passage, by surgical means, to the distended uterus. In such cases the difficulty and risk of the operation depends on the distance that separates the vaginal cul-de-sac or the imperforate vulva from the uterus, the operator having to make his way between the rectum and the bladder. Considerable assistance in diagnosis is derived from a careful rectal examination. It is of great importance to find a vent for these uterine accumulations of menstrual fluid, as, in addition to the suffering endured, there is posi- tive danger to life. Cases are on record in which the distention of the uterus extended to the Fallopian tubes, and in which death occurred from the peritonitis occasioned by their rupture. Occlusion of the os uteri, as a congenital occurrence, is rare; but AMENORRHEA. 309 since I first recommended the use of potassa cum calce as a last resource in obstinate inflammatory disease of the cervical canal, I have seen several cases in which its use had been followed by all but complete occlusion, and by partial retention of the menses, or at least their difficult excretion. This was evidently owing to the want of due caution at the time of application and- during the period of healing afterwards. The tendency of the tissues thus treated to contract being very great, it should be counteracted, if necessary, by the occa- sional use of wax bougies, until the process of repair has been fully accomplished. The possibility of this-accident occurring through want of caution in the operator, does not in the least invalidate the utility of the remedy as an exceptional and ultimate one. I have generally, but not always, found this form of occlusion easy to remove by pro- gressive dilatation. Should occlusion of the os uteri exist congenitally, when it is recognized it is easily remedied by a slight incision in the region of the os, and by subsequent dilatation. When menstruation is accidentally arrested or prevented, by exposure to cold and wet, by illness, or by any other of the causes enumerated, the amenorrhea is seldom of long duration. The condition in which it originated having ceased to obtain, the function generally rights itself; the only treatment usually required being that which ia most calculated to restore the general health of the patient. In some cases it may also be necessary to resort to the local means already detailed, when menstruation appears to have a difficulty in re-estab- lishing itself. The catamenial function appears more especially liable to be arrested, from accidental temporary influences in those females who present the low degree of sexual vitality to which allusion has been before made, and with whom menstruation appears late, and with difficulty. In such constitutions, indeed, it sometimes stops for many months, or even permanently, if no treatment be resorted to, without any apparent cause. Under the influence of decided general and local treatment, the menses will often return for a time, but flag and cease as soon as the treatment is suspended. If there is no positive disease of the uterus or ovaries, the emmenagogues, such as ergot of rye, savine, &c, may- be cautiously tried. I have known also the married state, especially if followed by conception, produce a complete change in the functional activity of the uterine system, and menstruation become regular and natural. It is in these cases that the application of the nitrate of silver to the cavity of the uterus, or the, scarification of its mucous surfaces, has been proposed. I must confess, however, that I do not think we are warranted in thus interfering with so delicate and sensative a region of the uterus for such a purpose. In the unmarried female the application of leeches to the vulva, and in the married to the neck of the uterus, answers every purpose, without being open to the same objection. The development of inflammatory disease in the neck or body of the uterus, or in the ovaries, and of* cystic and scrofulous tumours in 310 MENORRHAGIA. the ovaries, is one of the most frequent causes of amenorrhea in those in whom the function has once been fairly established, and especially of partial amenorrhea. When such lesions exist, they generally give rise to other symptoms which an attentive and well-informed observer may easily recognise. This remark, however, applies more to the uterus than to the ovaries, for important morbid changes are not unfrequently found after death in the latter organs, which during life, have given little other evidence of their existence than the modification or arrest of the catamenial functions. In all these cases, the amenorrhea is merely a symptom of the ovarian or uterine disease. The latter is the condition to be treated, the only indication the amenorrhea itself supplies being the advisability of having recourse to such local means as are calculated to promote menstruation, whenever nature appears to be making the least effort to establish the menstrual flux. In vicarious menstruation, our first effort ought to be directed to the restoration of the integrity of the uterine organs, if it be impaired. We should then, by all the means enumerated, attempt to divert the molimen hemorrhagicum of menstruation from its abnormal to its normal seat. The most important of these means is the abstraction of blood from the vulva or cervix uteri, which should be resorted to every month, a day or two before the vicarious menstruation is expected, and may be repeated after it has begun, should the strength of the patient admit of such a step. By this treatment the menstrual nisus may nearly always be diverted into.its natural channel; whereas, any attempt to stop the morbid hemorrhage, by means applied directly to the organ from which it takes place, might be productive of mischief to the system at large. MENORRHAGIA. Menorrhagia is profuse, prolonged, and too frequent menstruation, and uterine hemorrhage generally, in non-pregnant females, when not occasioned by the existence of uterine tumours, or by malignant disease. From this definition it will be perceived that the forms under which menorrhagia may manifest itself are varied. Thus, it includes men- struation normal as to duration and periodicity, but hemorrhagic in quantity; menstruation normal as to periodicity and the amount of blood lost during a given time, but hemorrhagic from its being pro- longed beyond the physiological duration ; and menstruation normal as to quantity and duration, but too frequent in its return. Again, all these modes of hemorrhagic manifestation may be combined, and men- struation may be too profuse, too prolonged, and too frequent; or the hemorrhage may be continuous, with irregular or periodical exacerba- tions denoting the menstrual nisus. In a word, a marked increase in the quantity of blood usually lost during the menstrual flux by the MENORRHAGIA. 311 individual in question constitutes monorrhagia. It must, however, be borne in mind, that, as we have already seen, there is no general stand- ard by which the menstrual flux can be measured, and by which the normal state can be separated from the abnormal. What is normal in one woman would be hemorrhagic in another, and vice versa. The only standard for each individual female is her own condition, when indisputably in health. Menorrhagia is generally considered to be the result of an active or passive state of congestion of the uterus, existing independently of local disease, and connected with or occasioned by general conditions of the economy. This, the opinion of both ancient and modern pathologists, is founded in ignorance of the facts enunciated in the preceding pages. In reality, the quantity of blood lost during menstruation is seldom increased so as to constitute hemorrhage, and the menstrual periods are seldom morbidly approximated, for a continuance (apart from tumours, polypi, and cancer), unless there exist some chronic inflam- matory disease of the cervix or of the body of the uterus, or unless menstruation be finally disappearing. Idiopathic menorrhagia, except at the change of life, is as rare as hemorrhage from the lung under the influence of mere congestion, apart from any organic disease, tuber- cular or other. In the uterus, as in the lung, there is nearly always some organic lesion which produces the congestion that precedes hemorrhage. This assertion is not the result of theory, but of scrupu- lous observation, and must become equally evident to all practitioners who will accurately investigate the state of the uterine organs of patients so affected. Congestion of the uterus exists, it is true, in confirmed menorrhagia, but it is all but invariably, with the exceptions above made, the result of uterine inflammation, and assumes an active or passive character, according to the natural constitution of the patient, and to the amount of reaction produced by the disease and by the loss of blood on the system at large. If the uterine inflammation is of an active nature, and has not had time sympathetically to debili- tate the patient, the hemorrhage is considered active or sthenic. If, on the contrary, the local disease has long existed, and has produced great anemia, and been attended with great hemorrhage, the hemor- rhage is said to be asthenic. Accidental Menorrhagia.—The above remarks, however, apply only to confirmed menorrhagia, and not to those cases in which menorrhagia appears in a casual and evanescent form, under the influence of some accidental and temporary cause, such as mental emotion or violent exertion. Under such influence the menstrual flux is not unfrequently increased in quantity, prolonged in duration, or morbidly approximated, in the absence of local disease. This is more especially observed in those females who are habitually menstruated profusely, and with whom menstruation presents the extreme physiological duration.— These casual hemorrhagical manifestations, however, very rarely be- come permanent, and cease without treatment; the function, as it were, soon righting itself. 312 MENORRHAGIA. Inflammatory Menorrhagia.—Menorrhagia originating in chronic inflammation of the cervix or body of the uterus, occasionally persists after the removal of the morbid condition which at first occasioned it. When this is the case, its persistence is generally the result of a torpid, languid state of uterine circulation, giving rise to obstinate congestion; a not unfrequcnt sequela, as I have elsewhere stated^ of long-neglected uterine disease. This congested condition of the uterine circulation may or may not be connected with chronic enlargement or hypertrophy of the body of the uterus. I have, however, met with such enlargement in most of the cases of menorrhagia which have obstinately persisted after the subdual of local inflammatory disease. In these cases, the uterine hypertrophy did not appear to be connected with actually existing inflammation of the body of the uterus, but to be traceable to a previously diseased state of the cervix or uterus, which had prevented the latter organ returning to its normal size after par- turition. Indeed I think I may state, as the result of observation, that the actual existence of chronic inflammation in the tissue of the body of the uterus, generally diminishes the menstrual flux, and retards its appearance, whilst inflammation of the cerA'ix renders it more profuse and more frequent than usual. Inflammation of the mucous membrane lining the uterine cavity, on the contrary, is often a cause of hemor- rhage. A congested state of the portal circulation, connected with hyper- trophy and passive congestion of the liver, or with other abdominal lesions, has occasionally, in my experience, given rise to obstinate uterine hemorrhage, especially in cases in which the tone and contrac- tile powers of that organ had been simultaneously weakened by chronic inflammation. Menorrhagia from Ovaritis.—Sub-acute inflammation of the ovaries may no doubt sympathetically re-act on the uterus, and produce menor- rhagia. Notwithstanding, however, the intimate physiological con- nexion between the ovaries and the function of menstruation, I have not often been able to trace, clinically speaking, menorrhagia to such disease, when unaccompanied by uterine lesions. At the same time, it is quite possible that the irritable state of the ovaries, which inflam- matory disease of the uterus so very frequently induces, may re-act on the menstrual function, and contribute to exaggerate and pervert it. In these cases, however, the uterine lesion is generally, according to my experience, the primary and principal cause of the menorrhagia; on its removal the ovarian irritation disappearing along with the menorrhagia. Menorrhagia at the dawn and close of Menstruation.—Menorrhagia is occasionally met Avith at the dawn and close of menstruation, from mere uterine congestion, apart from any local inflammatory disease. Thus, the first manifestation of the menses may be characterized by a severe attack of hemorrhage, the subsequent periods being physiolo- gical ; or the menses may continue to appear hemorrhagically at irregular intervals for several months. This latter type of menor- MENORRHAGIA. 313 rhagia, however, is much less frequently met with than the first. When, also, the menses are about to cease definitively, and become physiologi- cally irregular, profuse menstruation, amounting to flooding, is not unusual, as a result of mere congestion. Thus the menses will disap- pear for two or more months, and then return with excessive abundance. It is very seldom, however, even at this period of life, that hemorrhagic menstrual fluxes occur frequently, and assume a continued character, in the absence of tumours or malignant disease, unless there be inflamma- tory ulceration of the cervix. In nearly all the instances of very obsti- nate hemorrhage at the change of life which I meet with, I find, on ex- amination, that the congestion and hemorrhage are^keptup by inflamma- tory and ulcerative disease. Indeed, some of the very worst instances of protracted and severe hemorrhage that I have ever seen, have been cases of this description ; and what satisfactorily proves that the inflammatory affection is the cause of the continued hemorrhage is, that when it is cured the hemorrhage generally ceases. This is not, however, invariably the case. I have occasionally met with females at the critical period of life, in whom hemorrhage obstinately persisted after the removal of the inflammatory and ulcerative disease of the cervix, which had probably in the first instance given rise to it. In several of these cases, however, time or dilatation of the cervix has subsequently proved that the hemorrhage did not proceed from a sound uterus, but was connected with the presence of a polypus, or of a fibrous tumour, so small and obscurely situated as not to have been recognized at first. Menorrhagia during Pregnancy.—The periodical hemorrhages which occasionally occur during pregnancy, are considered by some writers to be of a menstrual character. Without denying the possi- bility of a true menstrual flux taking place from the cervical canal during pregnancy, I would mention that in nearly all the cases of this form of hemorrhage—not merely temporary, and not proceeding from separation of the ovum—that have come under my observation, I have discovered inflammatory ulceration of the cervix. This fact certainly offers the most natural explanation, at least in the majority of instances, of the presumed menstruation of pregnant women. On examining these patients, I have generally found blood escaping from the ulcerated uterine neck, the ulcerations presenting the peculiarly turgid and luxuriant appearance which I have already described as characteristic of such lesions during pregnancy. When a. pregnant female suffering from ulceration of the cervix is instrumentally examined, the ulcerated surface bleeds freely on the slightest touch, and women in whom abor- tion or premature confinement is brought on by such disease are very frequently found on inquiry, to have experienced repeated hemorrhagic fluxes during the pregnancy, which are often mistaken for menstrual periods. Menorrhagia after parturition.—The continued and obstinate hemor- rhage which is often observed after parturition, both before and after the return of menstruation, is nearly always complicated with and 314 MENORRHAGIA. occasioned by inflammatory ulceration of the neck of the uterus, with or without disease of the body of the uterus. This form of menor- rhagia may be protracted for months after the labour, until the patient be reduced to the last stage of anemia, if the real cause be not dis- covered and efficiently treated. In the various forms of menorrhagia occurring in the non-pregnant female, and accompanied by ulcerative lesions, does the blood escape from the lining membrane of the uterine cavity, as in ordinary men- struation, or from the ulcerated surface ? I believe that both these surfaces are often simultaneously the sources of the hemorrhage, although sometimes it may proceed from one only. I have frequently seen the blood oozing from the diseased surface under all the circum- stances mentioned, and have often checked it instantaneously, by freely cauterizing Avith the solid nitrate of silver the entire ulcerated surface, both internally and externally to the os uteri. Treatment.—The views and facts which I have above developed are of extreme practical importance. Not only do they render unneces- sary, in the immense majority of cases, the hair-drawn distinctions of pathologists with reference to the constitutional state of the patients suffering from menorrhagia, but they also greatly simplify treatment. The hemorrhage being in reality nearly always the result of local disease, the latter is, in most cases, the real element to be attacked and subdued. Instead, therefore, of an intricate and complex system of therapeutics, founded on a host of indications, the practitioner has, generally speaking, merelyto bring to light and treat the disease which causes the mischief. By so doing, he removes the morbid condition which keeps up the hemorrhagic state, and menstruation spontaneously returns to a natural condition. In those forms of menorrhagia in which the absence of any local disease is evident, or at least to be presumed,—at the beginning and termination of the menstrual function, for instance, or when the hemor- rhage occurs in an accidental manner from some easily assignable cause, mental or bodily,—very little medicinal treatment, generally speaking, is required. If the patient is kept at rest in a horizontal posture, and the cause be removed, the hemorrhage will generally sub- side of itself, without leaving any trace on the general health beyond temporary debility, which quiet and a moderately nourishing dietary soon remove. This is not, however, always the case; the hemorrhage may, even under these circumstances, be so severe and so prolonged, that it would be imprudent to trust to the unassisted efforts of nature. When such is the case, the indications are, to moderate the activity of the circula- tion by means of sedatives, such as opium, hyoscyamus, digitalis, hydrocyanic acid, Indian hemp, and other medicinal agents similar in their action; to modify the plasticity of the blood by the administra- tion of vegetable and mineral acids ; and to exercise a revulsive action on the intestinal canal by the means of saline purgatives. The appli- cation of cold to the lower abdominal region, and the injection of cold MENORRHAGIA. 315 astringent lotions into the vagina, may also be resorted to, should these means fail. It is as well, however, to wait, unless the hemor- rhage be excessive, until the normal duration of the menstrual flux in the patient have passed, lest the impression of cold should suddenly arrest the excretion of blood, whilst the physiological flux towards the uterus is still in force, as extreme congestion, and even inflammation, might ensue. This appears to me a desirable precaution, and one which I usually adopt, although the direct impression of cold on the uterine organs during menstruation does not appear to be in reality as dangerous as it is usually considered. In this the most simple form of menorrhagia it is seldom necessary to resort to those medicinal agents which have a direct influence upon the uterus, such as ergot of rye and savine. It must not, however, be forgotten that they are very valuable anti-menorrhagic remedies, and often succeed when all other medicinal means fail to arrest the hemor- rhage. As a last resource, we can resort to plugging the vagina ; but this is a means of treatment which may be said to be scarcely ever necessary in mere accidental menorrhagia, and which may be kept in reserve for the more formidable forms of hemorrhage, of the treatment of which we have yet to speak. Should the antecedents of the patient, carefully scrutinized, reveal the existence of any decided uterine symptoms, or lead to the impres- sion that uterine disease may exist, as soon as the hemorrhage has stopped or has been temporarily arrested by the means above mentioned, the state of the uterus and of its cervix ought to be investigated— firstly, by the touch, and secondly, by the speculum, should the finger detect disease, or a suspicious condition of the uterine neck and of its cavity. In those cases in which the hemorrhage is continuous, or all but continuous, it is not necessary to wait for its entire subsidence to examine the patient. When the exacerbation which corresponds to the menstrual epoch in the patient has passed, and the hemorrhage has abated, the state of the uterine organs should be ascertained without delay. When inflammation, and more especially inflammatory ulceration of the neck of the uterus is discovered, and the absence of cancerous lesions, or of fibrous growths, has been ascertained, the practitioner may consider that, in nineteen cases out of twenty, he has found the key to the menorrhagic state, and that the most efficacious and prompt means of treating it is to treat the disease he has discovered. From that moment he may look upon all medicinal anti-hemorrhagic agents as mere adjuvants—useful, no doubt, but of very secondary importance compared with the treatment of the local disease. Very often the hemorrhage stops as soon as the irritability of the inflamed surface is modified, and long before the disease is cured. The menorrhagia, however, may persist with more or less intensity, notwithstanding the gradual improvement of the local disease. It is with such patients more especially that great advantage may be derived from the administration of ergot of rye in substance or infu- 316 MENORRHAGIA. sion, of saATine in powder, of gallic acid, and of the other medicinal agents mentioned. I generally begin with scruple doses of the ergot or savine tAVO or three times a-day, gradually increasing the dose if required. In those cases in which, as we have seen, the hemorrhage persists after the entire removal of local disease, OAving to enlargement of the uterus, to the presence of a small unrecognized polypus or uterine tumour in the caArity of the uterus and its neck, or from the mere hemorrhagic habit, I have of late resorted, with encouraging success, to plugging the os uteri itself, instead of the vagina. It occurred to me that the usual plan of filling up and distending the vagina by pieces of sponge or a handkerchief, was a very clumsy, painful, and inefficient mode of opposing mechanical resistance to the exit of blood from the undeveloped uterus, when its orifice could be so easily brought into sight. Acting on this idea, I have, in several instances, brought the cervix uteri into view, and passed inside the os two or three small pieces of cotton tied to a piece of thread, which I wedged in firmly, covering the whole cervix with two or three larger pieces left in close contact with it on the withdrawal of the instrument. In most of the cases in which I have resorted to this plan, I have easily arrested the hemorrhage. Indeed, this modification of the ordinary practice appears to me so simple and so consonant with common sense, that I cannot but think it will be often adopted in severe cases. In the ordinary operation of plugging the vagina, that canal has to be distended by a large mass of sponge or linen, soaked with clotted blood, which often interferes with the functions of the bladder and rectum, is invariably a source of great discomfort to the patient, and is not always efficient; whereas, by the plan I describe, the end proposed is much more effec- tually encompassed, with scarcely any annoyance to the patient beyond that Avhich the use of the speculum occasions. Owing to the natural contractility of the cervical canal, and the pressure of fluids from behind, if the cotton is not well pushed in, it is soon forced out. The plug may be left without renewal twenty-four or even thirty-six hours ; but in the latter case it is generally expelled spontaneously. A small piece of sponge may be used, and is more likely to remain in situ, owing to its expansion ; but as it must neces- sarily be very small, it is more likely to be permeated by the blood. If sponge is used, great care should be taken to extract the piece passed into the os, to which a small piece of thread should always be tied, as the os uteri might not be able to expel it alone, owing to its great expansion. In the class of cases which we are now treating, I have occasionally found that a few leeches applied to the cervix uteri after menstruation have arrested the hemorrhage. I need scarcely add, that any disease of the abdominal viscera that appears to favour the hemorrhage should be treated, and that the debi- lity occasioned by menorrhagia must be met, during the intervals of the attacks, by as nourishing a diet as the patient will bear, and by LEUCORRHEA. 317 those tonics which are suited to her state. It must, however, be borne in mind, that when the hemorrhage is accompanied or occasioned by inflammatory uterine lesions, the stomach is generally sympathetically affected, and unable to digest much food, so that a free dietary may be positively injurious, and increase the mischief. I have not spoken of the hemorrhage that is observed in fibrous tumours and polypi of the uterus, and in cancer, because it is so much a symptom of these diseases, that it can only be properly treated of in connexion with them. LEUCORRHEA. The term leucorrhea is applied indistinctly to all vaginal discharges of a non-sanguinolent nature. These discharges may be the result of very varied morbid conditions, it is therefore evident that leucorrhea, thus defined, must include a very wide pathological range. In the course of this work the conditions of circulation and disease which give rise to vaginal discharges, as also their nature and character, have been minutely described: it would, therefore, be useless to again enter into them at length, and I will now merely recall in a few words the princi- pal facts connected with their history. A vaginal non-sanguinolent discharge may consist of natural mucus, of white mucus, of transparent or ropy mucus, and of pus, or of the four combined. The mucous follicles of the vulva, vagina, and uterine neck, when in a perfectly physiological state, free from all congestion or morbid influ- ence, secrete in more or less abundance a slightly glutinous transparent fluid, of the same description as that which is secreted by mucous fol- licles in other parts of the body. This, the natural mucous secretion of the female sexual organs, is best observed for a day or two after menstruation in a healthy female, the vulva and vagina being then, generally speaking, freely lubricated by mucus of this description. This mucous secretion is also increased under the influence of uterine orgasm. In the healthy state, it is never sufficiently abundant to con- stitute a discharge, merely lying on the parts where it is secreted, and moistening them. The white creamy mucus is secreted by the mucous membrane of the cervix, and possibly of the upper part of the vagina when congested; and as congestion of these membranes may exist physiologically, its presence does not necessarily indicate disease. A large portion of the female population of towns present more or less of this white leucor- rheal discharge during the physiological congestion which precedes and follows menstruation, but so long as they are free from local inflamma- tion, its existence is of no importance, as alone it neither gives rise to local nor to general symptoms. When, however, it is very abundant and persists throughout the menstrual interval, the circumstance is a suspicious one, and on examination there will be generally found some inflammatory condition of the cervix Avhich keeps up the congestion. 31S STERILITY. If the white mucus is mixed with the transparent mucus, or with pus, the existence of inflammation is certain. But in that case there are always some local or general symptoms. Such being the case in nine- teen instances out of twenty in which a female seeks professional advice for leucorrhea, she will be found, on examination, to be suffering from some inflammatory disease of the uterine region. Were there not local disease, she would attach no importance to the discharge, feeling no inconvenience from its presence. The ropy transparent discharge is secreted by the numerous mucous follicles of the cavity of the uterine neck, and its existence in any quan- tity is a certain sign of inflammation of that part. This ropy mucus may possibly be merely a hypersecretion of the mucous follicles of the cer- vical cavity, the result of the inflammation of the vascular frameAvork of the mucous membrane in which they are imbedded. Whether or not this be a correct explanation of the fact, it is certain that when- ever an abundant ropy secretion exists, the os and cavity of the cervix are, on careful inspection, found open, red, and inflamed, or ulcerated. The same secretion is observed in inflammation of the nares. In what is popularly called "cold in the head," the discharge is of a similar transparent nature. Pus, as a matter of course, indicates severe inflammation or ulcera- tion, as does also a muco-purulent discharge ; when either are present, there are nearly always some local or general symptoms. A very abundant secretion of pure pus seldom exists in simple inflammatory disease of the cervix and vagina; when pus flows in a stream from the vagina, the disease is almost invariably of a blennorrhagic character. These three forms of vaginal discharge may be combined, as is gene- rally indeed the case when there is ulcerative disease of the cervix. It must not, however, be forgotten, that ulceration not unfrequently exists without any leucorrheal discharge whatever ; at least, AA'ithout any of which the patient is cognisant, the morbid secretions being absorbed in the vagina. When a patient is examined instrumentally, the exact nature of any existing discharge can be at once ascertained, but it is often difficult to obtain by any other means correct information on the subject. Thence the precise determination of the physical characters of a vaginal dis- charge for the purpose of diagnosis, when a physical examination is not made, is not of such importance as might be supposed; the more so, as we have seen that other and more important symptoms exist to guide us in the appreciation of the state of the uterine organs. STERILITY. Chronic inflammation of the body and of the neck of the uterus, and also of the ovaries, is a very frequent, and a generally unsuspected cause of sterility. Chronic inflammation of the body of the womb appears to prevent STERILITY. 319 conception taking place, by modifying the vitality of the uterus, and perhaps, in some instances, by closing the Fallopian tubes. Inflamma- tion and ulceration of the cervix not only occasion sterility by the same morbid reaction on the uterine functions, but also superadd a physical impediment. When the os uteri and the cervical cavity are inflamed and ulcerated, the viscid muco-pus secreted closes the uterine cavity, and probably prevents the spermatozoa reaching that part, where its presence is supposed by physiologists to be necessary for impregna- tion. It is also stated by some French pathologists, as the result of experiment, that the contact of this morbid mucus instantaneously kills the spermatozoa. The hypertrophy of the central tissues of the cervix produced by inflammation, and the spasmodic contraction of the os internum, may also close the uterine cavity. With some females, however, none of these morbid conditions appear to prevent fecundation, owing to their peculiar aptitude to conceive. With them this aptitude to impregnation seems so remarkable, that they conceive under the most adverse circumstances, even when suffer- ing from serious uterine disease. Thus there are cases on record in Avhich the partial destruction of the uterus from cancer did not prevent fecundation. Sterility, as the result of chronic inflammation of the uterus and its neck, may be observed both in females who have never conceived, and in those who have. In a very large proportion of the cases of confirmed sterility from the onset of marriage for which I have been consulted, I have found chronic inflammation, or inflammatory ulceration of the cervix and its cavity, to exist; and, on minute inquiry, I have generally been able to trace the symptoms of the disease to the first weeks of marriage, or even to a period antecedent to marriage. I am therefore fully warranted in looking upon inflammatory disease of the cervix as one of the most frequent causes of this species of sterility. On restoring the uterus to a state of integrity, some of my patients have become pregnant, but as many, as yet, have not. I must, however, remark, that in those cases in which conception has followed the removal of disease, it has generally been only after an interval of a year or more, so that I may eventually prove to have been more successful than is now apparent. It would seem as if time were required for the uterus to recover its physiological powers. In most of the cases in which I have been consulted, the inflammatory disease and the sterility had existed for many years—from three to fifteen. It is possible, therefore, that the long-continued existence of inflammation in such cases, may, with some, modify the physiological powers of the uterus beyond recovery, even when the morbid condition is removed. Or it may be attended, in the course of time, by inflamma- tion, contraction, and obliteration of the Fallopian passages. It has been proposed recently to dilate the Fallopian tubes by means of a sound; but this plan of treatment, useless in case of mere closure of the canal from mucus, and dangerous in more decided stricture, from the risk of perforation, appears to have been abandoned even by its author. 320 STERILITY. In several of the cases successfully treated, I have dilated the cervical canal and divided the os internum subsequently to curing the inflam- matory and ulcerative disease of the cervix. One was a lady, aged thirty-two, who had been married seven years when I first saAV her, during the whole of which time she had presented symptoms of uterine disease. The ulceration was extensive ; and when it was quite cured, I dilated the upper part of the cervical canal, which was contracted. She became pregnant eighteen months after, and went to the full time. The other was a younger lady, aged twenty-four, who had been married four years when she consulted me. Like the former patient, she had presented uterine symptoms ever since her marriage. The inflammatory ulceration was less extensive, and after it was cured, I also dilated the cervical cavity, and divided the os internum with Dr. Simpson's metro- tome. She became pregnant six months after, but miscarried at four months, a year or two ago. I have not since heard of this patient. In the above cases, as both inflammatory disease and contraction of the os internum existed, it is difficult to say whether the dilatation had anything to do with subsequent impregnation. Conception may have been solely the result of the removal of the inflammatory disease, inas- much as I have seen many other cases of sterility from inflammation, in Avhich the patients have become pregnant after treatment, without dilatation being resorted to, although the contraction of the os internum was quite as marked. One case of this description has just occurred to me. A lady, aged thirty, married seven years, sterile, and living in a tropical climate, consulted me last winter, in a very debilitated condi- tion. She was laboring under severe inflammatory ulceration, which gave way under appropriate treatment. She left England to return home at the beginning of the present year, and I have just heard that she became pregnant immediately on her return home, and is noAY expecting her confinement. On the other hand, I have, in at least ten or twelve instances, dilated the cervix, and divided the os internum, in patients cured of inflamma- tion, who have remained sterile. I have never performed this operation on a patient Avho had not previously suffered from inflammation. Indeed, I seldom meet with such cases; and have no doubt that other practi- tioners will say the same, if they scrutinize as carefully as I do, the uterine health of their patients. It will be perceived from what precedes, that I am still rather uncertain as to the influence exercised by contraction of the cervical passage, and of the os internum, in the production of sterility. My own experience has left doubts on my mind, which the researches of Dr. Simpson will, I trust, solve when they are brought before the profession. I am indebted to this talented practitioner for having had my attention turned, a few years ago, to this cause of sterility. I then embraced his views with enthusiasm, and at first lost no opportunity of testing their correctness. Latterly, I have been rather discouraged, I must confess, and have often shrunk from exacting from my patients, ABORTION. 321 on the score of sterility only, submission to so tedious and annoying a treatment as dilatation of the cervical canal. Women ^ who have had families frequently become sterile when affected with inflammatory ulceration of the cervix. Sterility thus occasioned is generally removed by the cure of the disease. I am continually seeing illustrations of this fact. Sometimes they become pregnant before the disease is quite cured, and sometimes after a year or two only. Occasionally, however, the uterus seems to have been morbidly modified, as in the preceding class of patients, and the woman remains permanently sterile. Chronic inflammatory disease of the ovaries is no doubt occasionally a cause of sterility, but not, I believe, as frequently as uterine disease, owing partially to the existence of two ovaries, which can replace each other in function, and which are only simultaneously affected in severe cases. Although I 'thus attach so much importance, in the production of sterility, to local inflammatory lesions of the uterine system, including those of the ovaries, Fallopian tubes, and broad ligaments, which have been described in a former section of this work, it must not be sup- posed that I underrate the physiological causes of sterility. Fecunda- tion is one of the most capricious of all human functions; and there are, no doubt, many physiological causes in operation which may produce sterility, the precise nature and mode of operation of which is concealed, and probably always will remain hidden, from us. It is thus that we see a female conceive with a first husband, and not with a second, and vice versa, although she herself is in the same physiological state, and both husbands may have had children by other women. It is thus, also, that we see healthy females remaining sterile for some years, and then conceiving with the same husband; or females having children at very variable intervals of their married life, although under precisely the same hygienic conditions. I firmly believe, however, that these anomalies and apparent inconsistencies are often merely the result of latent inflammatory disease, and, as such, susceptible of being explained and remedied. ABORTION. I _ have _ elsewhere (page 171, et seq.) entered so fully into the consideration of the connexion which exists between inflammation and ulceration of the uterine neck and abortion, that it only remains for me here to recall, in a few words, what has been previously stated. Abortion is often occasioned by inflammatory ulceration of the cervix, and likewise often occasions it. In the latter case, abortion occurs accidentally, under the influence of some of its generally recognised causes, and leaves behind a morbid state of the cervix and its cavity. Local disease of this nature may follow an abortion of the simplest 21 322 ABORTION. kind, one from Avhich the patient rallies in a few days; although it is more generally the result of those that are accompanied by inflamma- tory and hemorrhagic symptoms. Ulcerated disease of the cervix Avhen once established, from whatever cause, is itself a frequent cause of abortion. When abortion is the result of the actual existence of inflammatory disease of the cervix, it may be produced in various ways. The vitality of the womb may be so modified in the earliest stage of pregnancy, by the existence of the inflammatory disease, that the foetal germ dies; in which case it is either expelled along with the membranes, or it is partly or entirely absorbed, the membranes continuing to enlarge for some months, and being eventually expelled under the form of a mole or false conception. Or the pregnancy may advance to a farther period, until the third or fourth month, when the womb, becoming too irritable, or being unable to develope itself, or the foetus dying, the membranes separate, flooding ensues, and the contents of the uterus are expelled. At a later stage still, when the muscular structure of the womb is more fully developed, the presence of inflammation at its mouth may bring on strong reflex action, and occasion premature confinement, independently of any disease of the child, or of its mem- branes. Abortions, no doubt, frequently occur under the influence of acci- dental causes alone, and of constitutional cachexia, such as scrofula and syphilis, without there being any local disease of the cervix. It may, however, be laid down as a rule, that a great majority of the abortions which are preceded or followed by morbid symptoms, and of those which occur spontaneously without any evident cause, and in the absence of uterine tumour or constitutional cachexiae, are occasioned by inflammatory disease of the cervix. It may also be considered as all but certain, that inflammatory and ulcerative disease of the cervix exists when abortions quickly succeed one another, and when a female does not seem able to carry the product of impregnation to the full time. CHAPTER XIV. DISPLACEMENTS OF THE UTERUS AND THEIR CONNEXION WITH INFLAM- MATION—PROLAPSUS—ANTEVERSION—RETROVERSION—RETROFLEXION. It will have been perceived, in the first part of this work, that, according to my experience, prolapsus and all other displacements are generally the result of increased volume and weight of some part or other of the organ, produced either by inflammatory action or by morbid growths. This view of the origin and nature of uterine dis- placements is, however, so different from that entertained by modern uterine pathologists, and more especially by those who have recently written on the subject in this country, that it requires elucidation. I am the more inclined to enter at some length into this subject, as I believe that the doctrines which have recently been brought forward by several leading authors are fundamentally wrong, and calculated to lead practitioners into serious practical errors. PROLAPSUS OF THE UTERUS. Prolapsus, or falling of the uterus, either partial or complete, is generally attributed to laxity of the uterine ligaments. This opinion I believe to be mistaken, and to be founded on an anatomical error- The uterus is not so much supported and retained in situ by its liga- ments as by the pressure of the surrounding organs and the contraction of the upper part of the vagina on its loAver segment. In a word, it is more poised than suspended in the centre of the pelvic cavity; and that such was the intention of Nature is obvious from the small size and lightness of the virgin and unimpregnated uterus. It is certainly one of the problems of the animal economy that an organ which weighs several pounds when its functions are fully called into action, at the moment of parturition, should, in a state of vacuity, only weigh an ounce and a quarter. A large heavy organ would, however, have required powerful means of sustentation, which would have been incompatible with the enlargement and change of position that takes place in pregnancy. The necessary result of this extreme lightness of the unimpregnated uterus, and of the slight amount of support afforded by its ligaments, is, that it is naturally ATery moveable. In order to test this point, the finger need only be passed per vaginam to the cervix of a healthy female, and it will be found, that by acting on the cervix as a lever. 324 THE CONNEXION BETWEEN INFLAMMATION the body of the uterus may be moved in any direction. This natural mobility of the uterus becomes still more apparent if the left hand is simultaneously placed on the hypogastric region, Avhilst the patient is reclining on her back. The uterus will then be grasped, as it Avere, between the finger of the right hand, carried behind the cervix internally, and the left hand placed externally, and may be moved backAvards and forwards, to the right or to the left, to a considerable extent. This anatomical fact accounts for the displacements which inevitably occur when any one region of the womb increases in weight. Should it be the cervix that becomes enlarged and heavy, as is the case when it is the seat of inflammation, the entire organ falls in the direction of the axis of the pelvic outlet, and approximating to the vulva, constitutes partial prolapsus ; the extent of the prolapsus depending principally on the extent of the hypertrophy of the cervix, and on the contractility of the vagina. The vagina, in the healthy state, is not a mere open pouch, but a contractile closed canal, like the rectum, which closes on and supports the uterine neck, and, in my opinion, has, generally speaking, almost as much to do with the support of the uterus as the uterine ligaments themselves. In virgins, with whom the vagina is very contractile, prolapsus seldom exists to any extent. In married women who have had children, it is often considerable, the cervix Avith them frequently reaching the vulva, occasionally protruding externally, and even drag- ging after it the entire" uterus, so as to constitute complete prolapsus, or procidentia uteri. This latter form of prolapsus is nearly always accompanied by complete relaxation of the vagina and vulva, the former constituting a wide non-contractile pouch, and the latter offering no kind of support to the prolapsed uterus. It is occasionally, also, connected with lacerated perineum. In the great majority of cases of procidentia uteri, the cervix is found inflamed, ulcerated, and enlarged. The frequency of ulceration of the cervix in complete uterine prolapsus has long been generally recognised, and it has always been a source of surprise to me that its existence, under these circumstances, did not lead pathologists to look for inflammatory ulceration in the non- prolapsed uterus. The ulcerations, however, were thought to be merely the result of the friction of the prolapsed cervix against external objects. In these extreme cases, the procidentia is generally the result of the combination of all the causes that give rise to prolapsus—increased weight of the lower segment of the uterus, laxity of the ligaments, and more especially the complete annihilation of all contractile power of the vagina and vulva. Complete prolapsus of the uterus Avould, I am convinced, be much more frequent than it is in married females who have had children, and who are suffering from inflammatory enlargement of the cervix, were it not that in them the hypertrophied cervix is very often retroverted. Being thus lodged, as it were, in the AND DISPLACEMENTS OF THE UTERUS. 325 cavity of the sacrum, on the rectum and perineum, the uterine neck receives an artificial support, which prevents its following the axis of the pelvic outlet, and appearing externally. The partial prolapsus of the uterus is really owing, in the immense majority of cases, solely to increase in the volume and weight of the cervix, and to the relaxed state of the vagina, induced by inflammation and distention, must soon become apparent to any practitioner who gives himself the trouble accurately to ascertain the position of the enlarged and inflamed cervix when a patient first applies to him for advice, and to compare it with that which it occupies when the ulcera- tion is healed, the hypertrophy reduced, and the vagina restored to a healthy state of contractility. He will then almost invariably find the cervix two or three inches higher; the finger, which at first found the cervix low down, just behind the vulva, being often barely able to reach it. The patient herself is generally aware of the change, and will often say, towards the close of such treatment, that she feels the pain of the cauterization in quite a different position, very much higher up than she did at first. Such being the real cause of partial prolapsus in nearly all the cases that are met with in practice, it is evident that the mechanical means of sustentation generally resorted to, such as pessaries, &c, are per- fectly useless as curative agents; that, so far from curing, they actually increase the tendency to prolapsus by irritating the inflamed tissues, and destroying, through distention, the natural contractility of the vagina. RETROVERSION OF THE CERVIX AND ANTEVERSION OF THE UTERUS. Retroversion of the cervix is exceedingly common. In this form of displacement, the cervix lies in the cavity of the sacrum, resting on the rectum, and the body of .the uterus is more or less thrown forward or anteverted. This is one of the forms of uterine displacement which have been misunderstood and misinterpreted by modern writers. By them it is represented as in itself an important morbid condition, the cause of a host of symptoms. In reality, retroversion of the cervix is, in the very great majority of cases, merely one of the ordinary results of inflammation, compara- tively of but little importance, and easily explained. Patients suffer- ing from uterine inflammation, finding that walking and standing are painful, generally lie or recline as much as possible. In this position the uterine neck, if hypertrophied and heavy, not only falls in the vagina, but bears on the posterior vaginal wall, and in the course of time becomes retroverted, especially if the contractility of the vagina has been relaxed by inflammation. in married females, intercourse exaggerates, and may even alone occasion, this displacement of the cervix. As long as the cervix is healthy, it remains small and elastic, and yields easily to pressure; 326 THE CONNEXION BETWEEN INFLAMMATION but when it becomes enlarged and indurated as the result of inflam- matory disease, it offers resistance to pressure, and is gradually thrust more and more backAvards, by intercourse, into the cavity of the sacrum. Indeed, the combined action of these causes operates so powerfully in married women, that it is only an exception to find the hypertrophied cervix in them in any other position. In unmarried females, on the contrary, retroversion of the cervix is rarely observed, even when the cervix is considerably enlarged. This is OAving to the uterine neck not being exposed to physical pressure, and to the vagina being, generally speaking, more contractile, so that it guides the hypertrophied cervix, as it were, toAvards the vulva. The extent to which the retroversion of the uterine neck is carried depends partly on the degree of the hypertrophy, and partly on the length of time that it has existed. When the cervix is very volumi- nous, has been so for years, and the patient has uninterruptedly been living with her husband, it is often thrust so far back towards the sacrum, that it can scarcely be reached with the finger, and the specu- lum has, as it were, to search it out of the sacral region. Some of the most difficult instrumental cases that I have met with have been of this description. If the cervix, not being very voluminous, is only turned backwards, and does not press upon the rectum, so far from the displacement giving rise to serious symptoms, I do not think it occasions any, or that the patient is made aware of its existence by any abnormal sensa- tions. The morbid symptoms which have been described as the result of this displacement are, in reality, the symptoms of the inflammatory and ulcerative disease which occasion it, and which is nearly always in full activity when the displacement is recognized. To regard inflam- mation, ulceration, and the local functional and general symptoms in these cases as the result of the displacement, is an utter delusion; it is simply to substitute cause for effect. According to my experience, displacements of the uterus and of its neck, in whatever direction they occur, when slight, and when they have taken place gradually, do not occasion any symptoms whatever, if there is no inflammation present. The uterine ligaments are organized by nature to give way to gradual traction, without pain or uneasiness, as we daily see in pregnancy; and the pressure of the anteverted uterus and cervix on the bladder, or of the retroverted uterus and cervix on the rectum, unless the organs involved be rendered sensitive by inflammation, only gives rise to marked symptoms when the dis- placement is so great as to interfere with the functions of the organs compressed. Under all other circumstances only, slight sensations of discomfort or bearing-down are experienced, and even these are often absent. The history of fibrous growths permits no room for doubt on this question. These growths almost invariably attain a considerable size, and deeply modify the position of the uterus, giving rise to retrover- sion or anteversion, and exercising considerable pressure on the pelvic AND DISPLACEMENTS OF THE UTERUS. 327 viscera, before they occasion any appreciable symptoms. In fact, my experience shows that patients thus suffering seldom complain at all, unless there be some concomitant inflammatory affection of the cervix or its cavity, until even the external appearance of the abdomen be modified by the size of the tumour, or until hemorrhage supervene; the first period of the existence of the tumour, and the displacement which it occasions, passing unperceived and unnoticed by the patient herself and by her medical attendant. The impunity with which pressure may be exercised on viscera and organs by tumours, the growth of which is very gradual, may be observed in every part of the economy. Even the brain, the most sensitive of all to pressure, will bear it, if very gradually applied. Thus we often see exostosis and tubercular formations greatly compressing the cerebral substance with- out the supervention of any symptom until the growth has reached a considerable size, or until inflammation supervene. It may, indeed, be considered an axiom in pathology, that all organs will largely accom- modate themselves to pressure, provided such pressure be gradually applied, not carried to the extent of seriously interfering with their functions, and be unaccompanied by inflammatory action. My principal reason, however, for thus attaching but little importance to mere displacement of the uterus, when not carried to an extreme degree, is derived from the results obtained in practice. I have now for many years been in the habit of treating inflammatory diseases of the uterus, without directing any particular therapeutic means to the cure of the displacements by which they are almost invariably accom- panied. I have always recognized and taken the displacement into consideration, but considering it merely a symptom of the inflamma- tory affection, or of the morbid growth Avhich accompanied it, I have directed my attention mainly to what I considered the cause of the malposition. That I have not erred in so doing is proved by the fact that I have found the displacement occasioned by the inflammatory enlargement of the body or the neck of the womb, either to entirely disappear, or at least to be very much modified by the removal of the original disease. If the displacement is not entirely remedied, owing to the uterus haA'ing contracted adhesions in its new position, or to its remaining permanently enlarged after the entire subsidence of inflam- mation, there is, generally speaking, a complete absence of all morbid symptoms. When these symptoms, either local or general, persist, I usually find that the uterus remains partially inflamed; sufficiently so to account for the symptoms present, without attributing them to the displacement. The errors which have been and are still made with reference to the pathological importance of retroversion of the cervix and of the body of the uterus, are susceptible of explanation. To a practitioner unac- quainted with the extreme frequency of inflammation and ulceration of the uterine neck, and whose finger has not been educated to recog- nize these lesions, the most prominent feature, on a digital examina- tion, in a case of inflammation of this organ, accompanied by retro- 328 THE CONNEXION BETAVEEN INFLAMMATION version, is undoubtedly the retroversion. He is, therefore, naturally enough, inclined to attribute the sufferings of the patient to the retro- version, not being aAvare of the existence of other lesions Avhich consti- tute the real cause of the morbid symptoms. Even those who resort to instrumental examination of the uterus may thus be led astray. The fact on which I have laid so much stress—namely, the very frequent penetration of inflammatory and ulcerative disease into the cavity of the cervix, and its tendency to lurk therein, and to perpetuate the symptoms of the inflammatory disease, is but little, if at all known. Thus the practitioner may recognize an ulceration of the cervix in a case of inflammatory indu- ration and retroversion, and may, to all appearance, cure the ulcera- tion without the symptoms disappearing. Under such circumstances, he thinks himself warranted in concluding that the retroversion is the cause of the remaining symptoms, whereas, Avere he to evert the lips of the os uteri with a proper bivalve speculum, and carefully examine the state of the cervical canal, he would detect disease still in existence,— the real cause of the persistence of the morbid symptoms. I am con- tinually meeting with cases of this description—cases in which the pains in the back and in the side, the bearing-down, inability to walk, and disordered state of health, persisting after the apparent cure of ulcerative disease of the cervix, are erroneously attributed to retro- version ; whereas, in reality, they are occasioned by latent and unre- cognized inflammatory action in the cavity of the cervix. Patients of my own, thus suffering, have applied to practitioners professing these doctrines, and have been told that these symptoms were owing to retroversion, and were only to be remedied by instrumentally replacing the uterus,—the internal disease of the cervical cavity being entirely overlooked. They have again applied to me; the internal cervical inflammation has been subdued, and they have lost all the morbid symptoms, although the uterus remained more or less displaced. When the cervix is not very voluminous, even if considerably retro- verted, it does not press to any great extent on the rectum. If, on the contrary, it is very much hypertrophied and enlarged, it becomes embedded in the anterior part of the rectum, and may interfere mate- rially with the escape of the faeces. The passage of faeces through the rectum, however, is seldom attended with that excruciating pain which is experienced Avhen it is the inflamed body of the uterus that is retro- verted on to the bowel, and which has to be raised to allow of the escape of its contents. The explanation is obvious; the hypertrophied cervix is scarcely ever very sensitive to pressure, whilst the inflamed uterine body is always acutely so. If the retroversion of the cervix be extreme, the body of the uterus may be thrown considerably forwards, so as to press slightly on the bladder. Whenever this is the case, any irritability of the bladder which may co-exist is at once attributed to the pressure. Although I am quite prepared to admit that pressure of this description may occa- sion vesical irritation, I think it seldom does, and that this painful AND DISPLACEMENTS OF THE UTERUS. 329 symptom is generally the result of that morbid state of the mucous membrane of the urinary system which I have described at length, when speaking of the symptoms of inflammation of the cervix. I am the more inclined to hold the opinion, that in retroversion of the Avomb during pregnancy, in which the cervix may be pressed against the sym- physis pubis to such an extent as entirely to prevent the escape of urine from the bladder, it is not so much irritability that is experienced, as difficulty or even total inability to void urine. Again, when pressure is exercised from above on the body of the bladder by the pregnant uterus, by an ovarian tumour, or by a fibrous growth of the uterus, ascended into the abdomen, the patient does not experience pain and irritation, but a frequent desire to pass water, owing to the bladder being pressed upon, and unable to dilate. Lastly, I continually see patients in whom the anteversion of the uterus is considerable, but Avho present no vesical irritation whatever. I may also remark, that anteversion from inflammatory enlargement and displacement is very rarely carried to such an extent as for the uterus absolutely to rest and press on the bladder. Retroversion of the cervix and anteversion of the uterus being the result of the physical causes which I have described, especially in married females, in whom it is principally observed, the use of pessa- ries and bougies alone can be of little avail in permanently remedying the displacement. The hypertrophied cervix, even after successful treatment, nearly always retains a slight increase in density and volume, which is quite sufficient to oppose resistance to pressure, and to allow of its being thrust back again as soon as marital intercourse is allowed. Indeed, I find retroversion of the cervix existing, to a greater or less extent, in most married females in whom the neck of the uterus is at all elongated naturally, and this in the absence of any morbid • change in its structure. The simple fact of the cervix offering a certain volume, appears sufficient to occasion it to be thrust towards the sacrum in the way I describe. Although, as it will have been perceived, I do not believe in the advantage of the instrumental treatment of this form of displacement by bougies and pessaries, I do not mean to say that the displacement ought not to be taken into consideration in the treatment as one of the morbid elements of the case. I have, however, more fully explained my views on this subject when speaking of the treatment of inflamma- tion of the uterus and of its sequelae. RETROVERSION OF THE UTERUS, AND RETROVERSION OF THE CERVIX. Retroversion of the unimpregnated uterus is a displacement of com- mon occurrence, although it has only laterally been carefully studied. The profession is principally indebted to Dr. Simpson for directing attention to it, the distinguished Edinburgh Professor having published A'arious interesting memoirs on this subject, the first in the "Monthly 330 THE CONNEXION BETAVEEN INFLAMMATION Journal of Medical Science" for July, 1844, the last in the " Dublin Quarterly Journal" for May, 1848. BetAveen the date of these essays, various communications have appeared in the medical journals, the most important of which are by Dr. Rigby, Dr. Protheroe Smith, Mr. Hensley, Mr. Safford Lee, Dr. Beatty, Dr. Joseph Bell, and Dr. Old- ham. All these writers, with the exception of the last three, adopt, without restriction, and amplify, the vieAvs expounded by Dr. Simpson. Retroversion of the uterus consists in the displacement, backAvards, of the body of the uterus, which then rests on the rectum. This dis- placement has been termed retroflexion, or retroversion, according as the body of the uterus forms an angle with its neck or not. If the neck of the uterus is healthy and soft, the body of the uterus, in falling, does not alter the position of the cervix, and a bend or angle takes place between the two, the concavity of which is backwards and down- wards. On the contrary, if the cervix is enlarged and indurated, and the induration extends into the body of the uterus, the cervix is thrown up towards the symphysis pubis, and no curvature is observed. This distinction was first made by Madame Boivin, and has since been gene- rally adopted. It exists in practice. I think, however, with Dr. Simpson, that these conditions are merely degrees of the same displace- ment, and that to retain them would be both theoretically and practi- cally useless. There has been a great tendency, of late years, to exaggerate the importance of this displacement. The essays of Dr. Simpson himself, although highly practical and interesting, are not free, in my opinion, from this reproach. Dr. Simpson, has, however, written on the subject with such caution, lucidity, and completeness, and the profession are so greatly indebted to him for the light he has thrown on the pathology of this displacement, that I feel no less pain than diffidence in being compelled to dissent from his opinions. The views, however, which I novr enunciate being based on observation, must be everywhere equally demonstrable, and by this test I am willing that they should be judged. I am the more disposed to insist on the opinions which I entertain on this subject, as several recent writers, in their attempts to follow out Dr. Simpson's researches, have published such singularly errone- ous statements respecting retroversion of the uterus and its symptoms, that I feel called upon to enter my protest against doctrines calculated greatly to mislead the profession. Thus, it has been repeatedly asserted of late years, not only that retroversion of the uterus is a very com- mon condition, but that it frequently, if not generally, gives rise to all the local, functional, and general symptoms and reactions which I have described as characterizing inflammatory affections of the uterus, to engorgement and ulceration of the uterine neck, to chronic inflamma- tion of the ovaries, sterility, &c. &c. These assertions are stated to be founded on clinical facts; but I firmly believe that they are, to a great extent, deduced from facts misunderstood and misinterpreted. Retroversion of the uterus is, in reality, a common occurrence; and AND DISPLACEMENTS OF THE UTERUS. 331 it is impossible that it should be otherwise, when we reflect how slight is the support afforded to the uterus by its ligaments and the surround- ing organs, and that its continuing in its normal position depends almost entirely on its remaining free from local disease of any descrip- tion. Whenever the body of the uterus is increased in one particular region, it has a tendency to gravitate in that direction, and more espe- cially if the partial increase in size and weight takes place, as usually occurs, in the fundus, or posterior wall. If the uterus increases in its totality, as in pregnancy, or when a tumour is developed in it centri- cally, its capability of remaining poised in the natural position seems, generally speaking, to be retained, and thus it is that the uterus gradu- ally enlarges in pregnancy without being displaced, and that retrover- sion is then rare. There are, hoAvever, many causes which tend morbidly to increase the size and weight of the posterior wall and fundus of the uterus, and which thus occasion retroversion. The uterus, which only weighs ten or twelve drachms in the unimpregnated state, weighs two pounds after parturition, and has to be reduced to its normal state by absorp- tion. The process of absorption may take place imperfectly, and leave the entire uterus, or the posterior wall or fundus of the uterus, enlarged. This not unfrequently occurs when parturition has been followed by uterine inflammation. Local induration and enlargement may also remain in this region as the result of an accidental attack of acute metritis; or inflammatory hypertrophy may extend from the cervix to the posterior wall of the uterus, owing to the anatomical continuity of the tissue, which I have elsewhere noticed. In all these cases, in which inflammation is the cause of the uterine enlargement and of the subsequent retroversion, there may be actual inflammation going on when the retroversion is discovered, or the inflammation may have subsided, leaving only hypertrophy behind. Retroversion may also occur from the temporary existence of inflammatory enlargement, and remain when that enlargement has subsided or been cured, owing to the uterus having contracted adhesions, or to its having taken the bend, as it were, and not being able to resume a normal direction. The size and weight of the posterior region of the uterus may likewise be increased, and retroversion occasioned, by the development of fibrous growths of variable size. Dr. Simpson believes that the healthy womb may be retroverted, owing to the partial yielding and giving way of those parts of the " pelvic fascia that unite the back part of the uterus to the rectum and pelvic cavity behind." Retroversion of the uterus is easily detected by one who is accus- tomed to the examination of the uterine organs. It is only, hoAvever, by a digital examination that the displacement of the uterus can be ascertained, the speculum giving no information, and not being, con- sequently, required. On passing the finger up to the superior extremity of the vagina, the cervix is found either in its usual position or anteverted, but on pushing back the vaginal cul-de-sac between the 332 THE CONNEXION BETWEEN INFLAMMATION cervix and the rectum,—which may be done, as we have seen, to a considerable extent,—instead of feeling a smooth plane surface, con- stituted by the posterior wall of the uterus in its normal position, the finger meets with a rounded globular tumour, formed by the retroverted uterus, lying on the rectum, which limits its range. The continuity between this tumour and the cervix is generally evidentto the_ touch, but Avhen the angle is very great it may be difficult to discern it. In such cases, the valuable sound of Dr. Simpson becomes of great service. By passing it into the cervical cavity and into the uterus, if possible, we at once find that the tumour felt by the finger is really the uterus, the entire tumour being displaced by the sound. An examination per rectum may contribute to throw light on the case, as the finger can generally reach a higher point by the bowel than by the vagina; the globular tumour of the retroverted uterus being thus distinctly felt from the bowel. The uterine sound affords an easy means of distinguishing retro- version of the uterus from ovarian tumours, which are apt, in their early stage, to fall between the rectum and vagina, and thus to simulate retroversion. Retroversion of the uterus may be confounded with stricture of the rectum, with pelvic abscess, with the retroversion of pregnancy, and with extra-uterine conception. Retroversion is not unfrequently mistaken for stricture of the rectum. I have met with several instances of the kind, in Avhich the patients were long treated by dilatation. Such an error can, however, only be made by a surgeon Avho exclusively directs his attention to the rectum, and omits to examine the state of the uterine organs. Retroversion is less frequently mistaken for pelvic abscess; one reason being, the slight attention that the latter disease has hitherto attracted. I have now, however, under my care, a young married lady, suffering from retroversion consequent upon inflammatory enlargement of the posterior wall of the uterus, following parturition, Avho was pro- nounced by an authority in uterine diseases, to be suffering under pel- vic abscess. Indeed, it was debated whether the abscess should not be opened, although I am at a loss to conceive how such a step could have been even contemplated. I saw the young lady a few 'days after- wards, and could find no trace whatever of the existence, present or past, of pelvic inflammation and abscess. There was the globular tume- faction of retroversion lying on the rectum, and nothing else, the pelvic cavity being everywhere perfectly free. In inflammation and abscess of the lateral ligaments, the indurated tumour always exists at the sides of the uterus. It may pass posteriorly, but it is then only by extension from its original seat on the side of the uterus, where its presence is indicated by the symptoms which I have elsewhere pointed out. The retroversion of pregnancy is seldom discovered until the latter has advanced beyond the third month, when the volume of the uterus increasing, the cervix begins to press on the neck of the bladder, and to impede the escape of the urine. It may, however, exist much earlier: AND DISPLACEMENTS OF THE UTERUS. 333 I have recognised it at the seventh week in a patient whom I had treated for retroversion in a previous pregnancy under circumstances which rendered the nature of the uterine enlargement rather obscure.1 She was under treatment for ulceration of the cervix, when the first retroversion occurred, and subsequently miscarried. Soon after the disease of the cervix Avas cured, she again became pregnant, and on my examining her, at her own request, at the end of the seventh week, to see if she remained well, I found the uterus completely retroverted, and lying on the rectum. The patient was not herself conscious of any change in the position of the uterus having taken place, and was perfectly free from all uterine symptoms. This I have found to be the case in the first stage of retroversion during pregnancy. The pressure of the uterus on the rectum does not seem to be attended with any great uneasiness, the patient merely experiencing, at the utmost, slight weight and bearing-down. Generally speaking, therefore, she only complains, when the uterus is developed to such an extent, as seriously to interfere with the escape of the faeces, or when the anteverted cervix reaches, and by its pressure closes, the neck of the bladder. This remark equally applies to retroversion from the presence of a fibrous tumour in the posterior wall of the uterus. This is not an unfre- quent occurrence, and the pressure on the rectum which then takes place seems to be generally unattended by any marked symptoms of local discomfort, the uterus often attaining a considerable size, owing to the development of the morbid growth, before the patient makes any complaint. When she does, it is generally because the menses are disordered, and have become more abundant and more frequent. When this symptom is not present, it is frequently only after the uterus has rightel itself, and ascended into the abdominal cavity, modifying the outward size of the abdomen, that medical assistance is required. These facts throw considerable light on the symptoms of retrover- sion of the uterus ; shoAving as they do, that under the influence of pregnancy or tumours, the uterus may be retroverted to such an extent as to exercise considerable pressure on the rectum, without there being any local or general symptoms, and that when any indications of the displacement do exist, they are confined to the existence of pelvic weight, dragging, and bearing-down, of a more or less decided character. My experience leads me to precisely the same conclusion with refer- ence to retroversion existing independently of pregnancy or uterine tumours. I find that in the absence of acute or chronic disease of the uterus, retroversion, whatever its cause, is a displacement to Avhich the pelvic organs gradually get accustomed, and Avhich occasions very little uneasiness or discomfort. I have attended a very considerable num- ber of females in whom retroversion of the uterus existed as one of the elements of the disease when they first consulted me, and who, although they still retain the displacement, are now well, and com- 1 This case was published in The Lancet of July 25, 1846. 334 THE CONNEXION BETAVEEN INFLAAIMATION pletely free from all uterine symptoms, the inflammatory disease of the cervix, of its cavity, or of the body of the uterus, alone having been treated. In some few of the cases which I have seen, the retroversion of the uterus has evidently been, or is still, a source of great distress. But in the females thus suffering, there is the most irrefragable proof of the continued existence of chronic inflammatory action in the posterior wall of the uterus, which is painful, tumefied, and knotty to the touch. In these patients, the retroversion is a painful complication and symp- tom of the disease which I have described at length, in the first part of this work, as partial chronic metritis. Any mechanical attempt to restore the womb to its natural position is attended with the most ago- nizing pain, and with nausea, carried even to absolute sickness. The uterus appears, in this class of cases, to contract adhesions which firmly connect it to the rectum. For further details on the treatment of this form of displacement I must refer the reader to the section on the treatment of chronic metritis. It will be perceived by the above details, that, in my opinion, retro- version of the uterus, like retroversion of the cervix, is merely a symp- tom of enlargement of the uterus, and that I almost entirely repudiate the symptomatology of recent writers on the subject. I think that in both forms of uterine deviation the great error has been committed of attributing to displacement the symptoms of the inflammatory diseases which accompany and cause it. At the same time I am perfectly will- ing to admit that the question is a difficult one to unravel, and that more extended investigation, both on my own part and on that of others, is necessary, before the question at issue can be considered in every respect definitely settled. It is certainly of great importance that the real value of these uterine displacements be correctly ascertained, as, should the mechanical doctrines—which appear to be gaining ground, and which regard the Avomb as a joint capable of being dislocated backwards and forwards, to the right and to the left—become gene- rally adopted, there seems no limit to the sufferings that will be inflicted on females by the pernicious application of mechanical principles to the treatment of uterine disease. HYSTERIA AND CHLOROSIS. Although hysteria and chlorosis are not, properly speaking, uterine diseases, there is sufficient connexion betAveen them and the uterus to warrant a few special remarks on the subject. Convulsive hysteria is a disease of the spino-cerebral nervous system. which may exist independently of any uterine lesion, or of any evident connexion with the uterus or its functions. I have repeatedly observed it occurring under these circumstances. At the same time it is a mat- ter of universal observation, that it is often occasioned by uterint disease. I have purposely used the term convulsive hysteria, because AND DISPLACEMENTS OF THE UTERUS. 335 there is a great difference between hysteria existing as a disease, and characterized by convulsions, and the symptoms commonly called hys- terical, but which are merely transient manifestations of nervous sus- ceptibility. These slight nervous symptoms are very common in females debilitated by uterine disease ; but they are also frequently met with, in both sexes, when the health is impaired, the strength much reduced, and the nervous system shaken. That convulsive hysteria is not a mere functional disease of the womb, as formerly supposed, is, I think, evident, from the mere inspection of the three hundred cases of uterine disease contained in the Appendix. Not more than one or two presented this form of disease ; whereas, in other dispensary cases which I attended, and which are not reported, hysteria existed alone, independently of any uterine derangement. In the higher classes of life, uterine disease is more frequently complicated by hysteria, owing, no doubt, to the greater susceptibility of the nervous system. Hysteria thus originating generally presents great intensity, and Can only be cured by the removal of the uterine disease which occasions it, through its excito-motor reaction on the spinal cord. I have now under my care, as I have elsewhere stated, two ladies, in whom severe ulcerative disease of the cervix evidently brought on convulsive hys- teria ; in both, the convulsions were so violent as to be followed by partial paralysis of the left side. These cases, however, although so severe, are generally more amenable to treatment than those which occur from less tangible causes; the hysterical convulsions nearly always ceasing when the neck of the uterus is restored to a state of integrity. The convulsions are evidently brought on by the exacer- bation of the uterine pains which menstruation occasions. They are no doubt the result of reflex action coming on with the exacerbation of local pain, and ceasing Avhen it abates. Such is not the history of the convulsive attacks of an ordinary case of hysteria. The connexion between chlorosis and the uterus is much less marked than between hysteria and the uterus. Chlorosis has evidently nothing whatever to do with that organ. It is a disease of the blood, and of the functions of nutrition, and is characterized by decided anatomical characters, ascertainable by chemical and microscopic analysis of that fluid. The erroneous idea that it is connected with the uterus has originated solely in the fact that the menstrual secretion ^ gradually diminishes, and finally ceases, in those who are affected by it. These changes in menstruation, however, are only the result of depraved nutrition, and of the anemic condition and low vitality of the patient, and occur in all diseases characterized by anemia and deficient nutri- tion. Thus, in tubercular consumption, as the anemia and emaciation increase, the menses diminish, generally disappearing entirely for months before death takes place. In chlorotic patients, with the exception of this gradual diminution of the menstrual secretion, there are no uterine symptoms of any description, and there is no evidence of any kind indicating that the uterus is involved; moreover, the health 336 THE CONNEXION AND DISPLACEMENTS OF THE UTERUS. generally rallies, and menstruation returns by the mere administration of iron—that is, by treating the disease of the blood irrespective of the uterus. Although I am continually seeing and treating chlorotic females, both in public and in private practice, I only once recollect meeting with inflammation and ulceration of the uterine neck in a female thus suffering. The patient, a young female, aged twenty-two, recently married, was in a confirmed state of chlorosis. As she presented all the symptoms of ulcerative inflammation, I examined her instru- mentally, and found a well-marked ulceration of the neck of the uterus. The mucous membrane of the vulva and vagina was as blanched as the skin, and the ulceration Avas so pale, that I had some trouble in ascer- taining its existence. As the skin regained its natural coloration under the administration of iron, the internal mucous membrane became of a natural hue, and the granulations of the ulcerated surface, assuming a florid character, became apparent. CHAPTER XV. POLYPI AND FIBROUS TUMOURS OF THE UTERUS, AND THEIR CONNEXION WITH UTERINE INFLAMMATION. The great tendency of the mucous membrane covering the cervix and lining its cavity to take on inflammatory and ulcerative action, under the influence of any cause of irritation, is strongly illustrated by the circumstance that the various species of polypus, and of fibrous tumour of the uterus, are very frequently complicated by this form of disease. This important fact I pointed out in two papers in the Lancet (July 19th, 1845, and June 5th, 1847). Between the appearance of these two papers, Dr. Montgomery, of Dublin, published in the Dublin Quarterly Journal a very interesting memoir, which fully corroborates and sustains my views on this subject, so far, at least, as they relate to uterine polypus. The forms of uterine polypus most commonly met with, as is well known, are the fibrous and the vascular. Fibrous polypi are generally expelled from the cavity of the uterus, and are found lying in the vagina, connected with the body of the uterus by a pedicle, which passes through the cavity of the cervix. Vascular polypi mostly originate at, or within, the os uteri, or from some point of the cervical cavity. The contact of the pedicle and of the narrow extremity of a fibrous polypus lying on the expanded lips of the os uteri, appears often to create irritation, and eventually to produce inflammation and ulceration. In three instances, after extirpating fibrous polypi by ligature, I have found the lips of the open os extensively ulcerated, the ulceration being evidently of a chronic character. It would be illogical to draw any conclusion from so limited a number of cases, but I believe that the existence of ulceration in these instances was not merely the result of coincidence, and that the disease would frequently be met Avith were the state of the neck of the uterus always carefully ascer- tained instrumentally, after the extirpation of polypi, before the patient was pronounced cured. Such a precaution, as far as I know, has never yet been considered necessary, or adopted, either in this country or abroad. My principal reasons for this belief are: the probability that the contact of a morbid growth with so susceptible a mucous membrane would produce inflammation, and the fact that the mere existence of a tumour developed in the substance of the uterus, apart from any local cause of irritation, is frequently attended with the development of inflammation of the cervix. In a large pro- portion of the cases of fibrous growths developed in the substance of 338 POLYPI AND TUMOURS the uterus which I have met with for many years past, in unmarried as well as in married females, I have detected inflammatory ulceration of the cervix. It would seem as if the increased vitality of the uterus, occasioned by its enlargement from the gradual development of the tumour, predisposes powerfully to inflammation of the cervix. What- ever the theoretical explanation, the fact is certain, and is practically important. When inflammatory ulceration of the cervix complicates fibrous polypi, it must necessarily be one of the principal causes of the local pains, of the discharges, and of the sympathetic constitutional reactions that are so often observed in this disease. Moreover, as the ulceration remains after the extirpation of the polypus, the patient does not com- pletely rally after the operation, as is expected, and the symptoms that it occasions, which were attributed to the polypus, remain, although in a mitigated degree, after the removal of the latter. When inflammatory ulceration of the uterine neck complicates fibrous tumours existing in the body of the uterus, its presence not only gives rise to the symptoms, local and general, which have been described, but it tends to keep up a congested, irritable condition of the entire uterine system, highly favourable to the increase of the fibrous tumour, —the development of the latter being necessarily promoted by any cause which adds to the vitality of the uterus. It is therefore very important that the cervix should be restored to a healthy state, and I have always found the very greatest benefit follow the removal of any inflammatory affection of this description existing in the cervical region. The inflammation which complicates fibrous polypi has been charac- terized, in the cases in which I have'observed it, by an open expanded state of the os, hypertrophy of the cervix, and the presence of an ulceration on one or both lips, but more especially on the lower one. When it accompanies fibrous growths, the os is but slightly open, the lips but slightly hypertrophied, and the ulceration small, penetrating more or less into the cavity of the cervix, and scarcely spreding at all on the cervix itself. The ulcerations which are found complicating fibrous polypi may, however, not be the result of the contact of the polypus with Lthe adjoining mucous membrane; they may have existed before the expul- sion of the polypus from the uterus, when the latter was merely a fibrous tumour of that organ. I have a case now under my care which illustrates this fact. A Avoman, forty-nine years of age, who still menstruated, but irregularly, had been under me for some months as a dispensary patient, for ulceration of the uterine neck. The disease appeared to have originated in a confinement seven or eight years previous. From the first I noticed that the uterus was more volumin- ous than was normal, but in the absence of any peculiar symptom, did not attach much importance to the fact. The ulceration Avas nearly cured, and the uterine symptoms had become very much mitigated, when she was seized with expulsive uterine pains, which lasted several IN CONNEXION WITH INFLAMMATION. 339 days; and on examining her subsequently, I found that a small fibrous polypus, the size of a pigeon's egg, had been expelled from the uterus, and was lying in the vagina. I tied the polypus, and the patient recovered rapidly. On examining her subsequently, I found the pervix still slightly ulcerated, just as I had seen it a few days previous to the expulsion of the polypus. There is another form of uterine polypus, the vascular polypus, which is much more common than is generally supposed, and which is usually accompanied by inflammatory ulceration of the uterine neck. Vascular polypi are small, soft growths, varying in size from that of a pea to that of a filbert. They generally originate by a pedicle from the^ vicinity of the os, but may arise from any part of the cervical cavity. Their presence may be recognised by the touch, when they grow from the edge of the os, or when they have escaped from its cavity; but in many instances they lie embedded, as it were, within the lips of the os uteri. When such is the case, the os is always rather open, and this may be the only morbid condition that the finger can detect; unless the contour of the os be ulcerated, or the surface of the vascular growth protrude sufficiently to be felt. Under these circum- stances, the finger detects, not only the patulous state of the os, which, as I have repeatedly stated characterizes inflammation and ulceration of the os and of the cervical cavity, but also the soft velvety sensation which is afforded by the ulcerated surface, and by the protruded portion of the polypus. The possibility of a small vascular polypus lying thus imbedded within the open os uteri is, therefore, an additional reason for using the speculum whenever this open state of the os uteri is detected. By its means only can a polypus thus situated be recognised and removed. It is, however, of the utmost importance, that an instrument should be used which is capable of completely expanding and separating the lips of the uterus. This the ordinary-sized conical and circular specula fail in effecting. The bivalve or quadrivalve speculum should there- fore be used, unless the parts are sufficiently lax to admit of the largest-sized conical one, which may sometimes sufficiently open the parts. This remark is more especially important when the lips are SAvollen and hypertrophied, as they then entirely conceal the os uteri, unless it be fully opened by the instrument which is used. In a remarkable case, related at page 343, a vascular growth of this description, which had escaped detection until the patient applied to me, although she had consulted many accoucheurs, was again over- looked by an experienced physician, who had been apprised of its existence by the patient herself, owing to his having used an instru- ment not adapted to the case. These vascular polypi are almost invariably accompanied by inflammation and ulceration of the surrounding mucous structures, along with more or less congestion and hypertrophy of the cervix and its lips. This is the case both when the polypi lie external to the os, and when they are imbedded within its lips; in the latter case, the 340 POLYPI AND TUMOURS ulcerated surface being sometimes within the cavity of the cervix, it is only after the expiration of the polypus that the ulceration is discovered. These small polypi are easily extirpated by a long pair of scissors, or crushed by means of the speculum forceps; but the patient is by no means cured when this has been effected. The presence of the polypus is merely an element in the case: of importance, inasmuch as it is probably, in most instances, the cause of the irritation and ulceration of the mucous surface, but having in itself little evil reaction over the system. The distressing uterine and general symptoms which usually exist, and direct the attention of the medical attendant and of the patient to the uterus, are the result of the local inflammatory disease secondarily produced, and can only be got rid of by its removal. The importance of the facts above detailed respecting the connexion between local inflammation and ulceration of the neck of the uterus, and uterine tumours and polypi, is daily becoming more and more evident to me. As they have a decided practical bearing on the treat- ment of these diseases, I hope they will meet with the attention they deserve. In the cases in which the tumour can be removed, the patient is only half cured if extensive inflammatory lesions are allowed to remain; whilst in those in which the tumour is beyond the reach of instrumental means, the only chance we have of arresting its increase, and of restoring the patient to tolerable health, is our being able entirely to subdue all inflammatory action in the uterine system, thus bringing it to a state of quiescence. The following cases are interest- ing illustrations of inflammatory ulceration of the cervix, under the circumstances Avhich I have described. Case XIII. Fibrous Polypus of the Uterus adhering to the Neck of the Uterus; and complicated by extensive Inflammatory Ulceration of that region. On the 1st of August, 1844, I was consulted by Miss C----, aged thirty-four, for uterine hemorrhage, from which she had suffered many years. She had menstruated regularly until the age of twenty-seven, when she was seized with severe pains in the loins, and flooding, at each menstrual period. The duration of the menstrual flux increased from three or four days to eight or ten. She lost at each epoch large clots of blood, and experienced great pain in the loins and hypogas- trium. For some time past, indeed, the hemorrhage at each menstrual period had amounted, she said, to more than a washhand-basin-full of blood, and it often continued in the interval of menstruation. Her health had long been very bad, and although generally under medical treatment during the last few years, no local examination had been made, and no local disease had been suspected. Complexion exceed- IN CONNEXION WITH INFLAMMATION. 341 ingly sallow, features bloated, tongue loaded, anorexia, loss of sleep, continued headache, cardialgia, palpitations, great general debility, legs cedematous, pulse quick and small, great pain in the loins and hypogastrium, sensation of Aveight in the pelvis when walking. On examining digitally, the hymen was found intact, but sufficiently dilatable to admit of examination. In the cavity of the vagina was a tumour about the size of a small egg, perfectly regular and smooth, pedunculated, and traceable to the orifice of the os uteri, from the right side of which it appeared to grow. The examination occasioned a considerable discharge of pure blood, devoid of all odour. On the 17th, as a preliminary step, I divided the hymen by a crucial incision, slightly cauterizing, the next day, the edges of the incisions with the nitrate of silver to prevent their reunion. On the 23rd, the incisions having perfectly healed, I proceeded, with the assistance of my friend, Dr. Heming, to apply a ligature of waxed silk. The noose was carried on to the tumour several times, but each time on being tightened slipped off. This led to a more careful examination, when we ascertained that the polypus did not grow from the cervix, with which it appeared connected, but issuing from the cavity of the cervix, had become adherent to the right side of the os uteri. The adhesion preventing the ligature from reaching the stalk of the polypus, it was evidently impossible to apply it effi- ciently until the connexion had been destroyed. This I attempted to effect by means of a pair of scissors, guided on the fore and middle fingers of the left hand. Owing, however, to the insufficient length of the scissors I only partially effected the division, and the remaining adhesions had to be broken down with the finger. There being still some little difficulty in applying the ligature, arising partly from the narrowness of the vagina, a speculum Avas introduced, and the polypus having been exposed, a noose, passed through a single branch of the canula, was carefully placed over it, and pushed on to the stalk by means of the forceps. The ligature was then tightened, and the hemorrhage, which had been considerable during the operation, imme- diately ceased. The ligature was tightened every morning until the fourth day, Avhen it came away with the polypus. After the operation there was no further loss of blood. A few days subsequent to the fall of the polypus, I examined the cervix uteri with the speculum, and found an ulceration existing, not only where the polypus had adhered to it, but over a great part of its surface; and injections and rest were prescribed, in the hope that it would heal spontaneously. Finding, on the contrary, ten days after- wards, that the ulceration had increased in extent, I cauterized it with the nitrate of silver. The cauterization was repeated several times, and in about a month the cicatrization was complete. 342 POLYPI AND TUMOURS Case XIV. Fibrous Polypus of the Uterus, complicated by Inflammatory Ulceration of the Cervix. On the 1st of May, 1845, Mrs. D----, aged fifty, came to town, from Somersetshire, by the advice of her medical attendant, to place herself under my care. During eight years she had suffered from uterine hemorrhage, the intensity of which had gradually increased. She had had several children, the last at the age of forty-two. The two following years she miscarried at three months. After the last miscarriage she was seized with flooding, which returned to such an extent at each menstrual period as greatly to debilitate her; some- times even producing syncope. At the age of forty-five she ceased to lose blood at periodical periods, but since that time the hemorrhage has been nearly continual; seldom a day passing without more or less blood being lost. She has presented for some time all the symptoms of extreme anemia; the skin is sallow, the body emaciated; she suffers from palpitations, headache, want of sleep, and extreme debility; and a bellows-murmur is heard over the heart and along the arteries. The digestive functions do not, however, appear much disordered; the appetite is good, and she takes a great quantity of meat, wine, and porter, in order to keep up her strength. Complains of lumbar and hypogastric pains, and of a bearing-down sensation when walking. On examination per vaginam, a pedunculated tumour, as large as a goose's egg, was found situated in the vagina, issuing from the orifice of the os uteri. The examination occasioned a copious flow of blood. Ligature of the tumour was proposed, and gladly accepted, as she had been told that no operation was possible. On the 3rd, the bowels having been previously well relieved, I passed a whipcord ligature round the neck of the tumour with great ease. The hemorrhage during the process was, however, considerable; the blood evidently exuded from the entire surface of the tumour, which was of a florid red colour, and was exposed by the mere separa- tion of the labia. 11th.—The tumour escaped from the vagina whilst she was making water; the canula and ligature remaining. On exercising traction, I brought down the uterus, but did not bring away the ligature and canula. I was therefore obliged to untie the whipcord, and pull it through one of the branches of the latter. 17th.—Examined the os uteri with the speculum, and found a large ulcerated surface on the anterior and posterior lips. The anterior was much more voluminous than the inferior, and was the principal seat of the ulceration. There was no trace whatever of the pedicle of the tumour. Cauterized the ulceration with the nitrate of silver; ordered IN CONNEXION WITH INFLAMMATION. 343 injections with sulphate of.zinc; sesquioxide of iron half a drachm a day, and a nourishing diet. On the 25th, she Avas absolutely obliged to leave town for family reasons, although the ulceration was not healed. I ordered her to use the sulphate-of-zinc injections carefully for some weeks. The sallowness of complexion was already much modified, and she felt stronger than she had done for some time. I subsequently learnt that her general health had very much im- proved. She_ still felt pain in the back, which might probably be owing to the ulceration not having quite healed. As, however, I have not again heard from her, it is probable that these symptoms gradually subsided, and that the cervix is restored to a state of integrity. Case XV. Inflammatory Ulceration of the Neck of the Uterus, complicating a Vascular Uterine Polypus. In May, 1846, I was requested to see, in consultation, a lady, aged thirty-nine, who had been suffering for many years under obscure uterine disease. From the gentleman in attendance, and from the patient herself, I elicited the following details:—Menstruated rather early in life, about twelve or thirteen, she enjoyed good health as a girl, although always rather delicate. At eighteen she went abroad, and settled in South America, in a tropical climate, where she married, and had two children within the first few years of her marriage. The labours were favourable, and were not followed by any untoward symptoms. About the age of twenty-five, the menses, which had previously only lasted four or five days, began to be more abundant and prolonged. This state of things became gradually more marked, the flow of blood often lasting from fourteen to twenty days, without, however, being excessively abundant, except during the first three or four. She also experienced severe and continued pain in the lower part of the back, and slight pain in the ovarian regions, especially the left, and had a,white vaginal discharge. The uterus was examined per vaginam; the only lesions, however, to be detected, were slight hard- ness and tenderness of the cervix. Every known means of arresting uterine hemorrhage were resorted to, but without avail. As the general health was rapidly giving way under the influence of the continued hemorrhage and uterine irritation, and as it was thought that a tropical climate might be the cause of the obstinate resistance of the morbid symptoms to all remedial agents, she was at length ordered home to Europe. She was then thirty-one years of age. The change of climate, however, brought no alleviation to the hemorrhage and local pains. The former continued to occur at each monthly period, the flow of blood sometimes continuing, from one period to the other. During the eight years that had elapsed when I 344 POLYPI AND TUMOURS saw this lady since her return to this country, she had been almost continually under medical treatment. The uterus was always examined digitally by the various practitioners who attended her, but never Avith the speculum, and different opinions had been given. All who were consulted, however, agreed in considering the Avomb inflamed, and in recommending antiphlogistic treatment. In consequence of the opinions thus entertained she was cupped in the loins some score times, and was quite drained by leeches applied to the hypogastrium and vulva. The antiphlogistic measures thus pursued, d outrance, appeared, however, only still further to debilitate the general health, which became more and more affected. At one time the solid nitrate of silver was, for six weeks, applied daily to the cervix uteri, through a tube, Avithout a speculum being used. This treatment appeared to lessen the duration and amount of the hemorrhage for a few months, as had occasionally been the case with other means, but it then returned as before. A few years ago, the medical gentleman who had attended the lady in America, returned to England, and, on examining digitally, found that the cervix, which was hard and closed when he last saw her, had become open and soft. This change in the state of the cervix had evidently occurred recently, as it had been noticed by the practitioner in attendance, who told the patient he was afraid that it was a fore- runner of cancerous degeneration. Her medical friend, by whom I was called in, said that he then thought the change was the result of the excessive loss of blood under which she had suffered, both from the treatment and the disease. The complexion presented the pale, rather sallow hue, which we find in the ulcerative stage of uterine cancer; but as this cachectic hue is also met with in chronic inflammation of the uterus, and in obstinate flooding, as well as in cancerous disease, its existence cannot be con- sidered as especially indicative of the latter. On examining digitally, I found the vagina lax, and very sensitive ; the cervix low, very retroverted, voluminous, and indurated, but per- fectly smooth and even ; the os so open as freely to admit two-thirds of the first phalanx of the index finger. The kind of small cavity into which the finger thus penetrated was soft and fungous to the touch; the uterus was rather voluminous and sensitive to pressure, but pre- sented no nodosities or inequalities. The hypertrophied state of the cervix, and the patent velvety condition of the os, showing at once that inflammation of the cervix and ulceration around and in the os existed, I explained the necessity of an instrumental examination. This was at once assented to, and with a large bivalve speculum, and in a good light, I raised the retroverted cervix, and expanding the blades to their fullest extent, brought the cervix and open os fairly into view. I then at once saw the cause of the hitherto unexplained uterine sufferings of the patient. Between the separated lips of the enlarged cervix was a small vascular polypus about the size of a hazel nut, occupying the cavity of the os, and merely showing its anterior extremity on the blades of the bivalve speculum being expanded. If they were allowed IN CONNEXION WITH INFLAMMATION. 345 to approximate even partially, the hypertrophied lips of the cervix closed over the os so as to conceal it and the contained polypus. I ascertained, by means of the uterine probe, that the polypus proceeded from the cavity of the neck above an inch from the exterior. It was connected with the point from which it originated by a long pedicle. The cavity of the uterine neck was much dilated, and all that portion of it that was accessible to the eye was ulcerated. The ulceration occu- pied the entire contour of the os for a few lines external to the point reached by the head of the polypus. The latter are very red and vascular, and so soft as to pit deeply under the slightest pressure. The circumstance of its being thus embedded, as it were, in the cavity of the os, and its softness, accounted at once for its not being percep- tible to the touch. The fingers, on examining the uterine neck, merely felt a small, soft, fungous cavity, representing the apex only of the polypus, and the surrounding ulcerated tissues. The cervix itself was much enlarged, red, and inflamed, and so much retroverted as to be brought into view with some difficulty, It was not without trouble that I succeeded in persuading the patient, even with the corroborative evidence of her medical friend, that she really was suffering from the presence of a small uterine tumour, which had probably been there for many years, and had thus occasioned the hemorrhages and uterine inflammation by which her life had been so long embittered. Having family matters to arrange, it was determined that the extirpation of the polypus should be deferred for a few weeks, and that she should then return to town and place herself under my care. Some months elapsed before I again saw this lady. It appears that, after leaving town, her belief in the existence of a hitherto undis- covered cause for her sufferings became staggered, and she began to think that it was next to impossible that the many experienced practi- tioners previously consulted could be wrong. The persistence of all the symptoms, however, again drove her to town towards autumn, and she determined to seek for confirmation of my opinion. She accordingly 'consulted an eminent accoucheur, told him that she had been suffering for many years from uterine hemorrhage—that she had been treated for inflammation, without beneficial results—that she fancied there might be more than had been discovered by her previous attendants— some tumour or ulceration : and that she wished him to examine her with the speculum. This was accordingly done. A careful speculum examination was made, and the patient was told that she had neither tumour nor ulceration, and that her disease was merely retroversion of the uterus. Simpson's probe was introduced into the cervix, and the uterus brought, as it was stated, into its right place. She was likewise told, that if this operation was repeated at proper intervals, for a suffi- cient length of time, the vitiated direction of the organ would be reme- died, and that she would recover her health. A few days afterwards I was sent for, and frankly acquainted with what had occurred, the lady stating that she had no confidence in the opinion last given, because the examination was made in such a man- 346 POLYPI AND TUMOURS ner as to convince her that but little information could have been obtained. She was examined, it appears, on her side, in the usual obstetric position, on a sofa away from the window, a conical or cylin- drical speculum being used, and artificial light resorted to. I had examined her, as I generally do, reclining on the back, in a strong natural light, opposite a window. I was so much surprised to hear that a careful examination had been made by a very competent person, and no tumour found, that I concluded the polypus had fallen off, by ulcer- ation of the pedicle—a circumstance which I have known to occur. To my astonishment, however, on separating the blades of the specu- lum, I found the small vascular tumour lying in the os, surrounded by a ring of ulceration, just as before. It became evident, therefore, that by the use of the conical or cylindrical speculum, the hypertrophied lips of the cervix had been so approximated as to cover the os uteri and conceal the polypus and ulcerated surface. By means of a pair of speculum forceps, with a small serrated extre- mity, I broke down, and brought away, by torsion, the small tumour, and the greater part of its pellicle. A few drops only of blood were lost. I subsequently cauterized the ulcerated surface, which appeared to extend to the entire depth and circumference of the cavity of the uterine neck. From this time the case resolved itself into one of simple inflamma- tion and hypertrophy of the cervix, along with deep-seated ulceration; and was treated by the means which I usually employ—cauterization at variable intervals, emollient or astringent vaginal injections, hip- baths, leeches to the inflamed cervix, and rest in the recumbent posi- tion. Both the inflammation and ulceration, hoAvever, proved very rebellious to treatment. It was only by very slow degrees that the inflammatory hypertrophy of the lips of the cervix subsided. As this change occurred, the cervix, which, as we have seen, was very Ioav and retroverted, gradually rose in the pelvis, and partly assumed a more normal direction, the ulceration likewise cicatrizing. The ulceration external to the cavity of the os healed in the course of a few weeks, but the internal ulceration proved very obstinate, and the more so the deeper it was situated. It was only after an almost uninterrupted treatment of five months that the cavity of the cervix was completely healed. As it cicatrized it closed, until, from being long sufficiently open for an inch in depth, to admit a large-sized draw- ing-pencil, it became so contracted as merely to admit the uterine sound. For the last six weeks of the treatment, the ulceration appeared limited to a small deep-seated surface, probably that from which the polypus sprung, near the inner orifice of the cavity of the uterine neck. At the time the local treatment was brought to a close, the cer- vix was at least two inches higher in the pelvis than when I extirpated the polypus. It was also very much smaller, very much less retro- verted, and presented no evidence of inflammatory induration, although still rather larger and harder than natural. The vagina was quite healthy. All the uterine organs were, however, still very sensitive to IN CONNEXION WITH INFLAMMATION. 347 the touch ; but in this respect they merely participated in the exagge- rated state of nervous sensibility of the entire economy. Ever since the evulsion of the polypus there had been no continued sanguineous discharge after the monthly periods, although the purulent discharge was often streaked with blood, especially after cauterization. The menses flowed rather abundantly for five or six days, and were then replaced by the purulent or sanguineo-purulent discharge from the ulcer. The slowness of the process of cicatrization in this case may be accounted for by two circumstances,—first, by the very lengthened existence which I feel warranted in ascribing to the local disease ; and secondly, to the very debilitated state of the general health, depraved by fifteen years of flooding and suffering. Not only was the patient so reduced by the continued loss of blood, morbid and artificial, that loud anemic murmurs were heard in the heart, and in the large blood- vessels, but the digestive and nervous system had received a severe shock. The stomach could scarcely bear even the lightest foor'J, and that only in very small quantities ; the action of the bowels was irre- gular, they were often relaxed and irritable; and no stimulant, or dietetic or medicinal tonic, could be borne. She had been salivated more than once, and attributed the extreme susceptibility of the diges- tive system partly to this cause. Iron, quinine, iodine, &c, Avere all tried at various periods, but as often suspended from the disturbance they created in the economy. The intercostal, the sciatic, the crural, the dorsal, and other nerves, were all at different times the seat of severe neuralgic pains, which generally proved rebellious to local therapeutic agents. They seemed to change their seat or disappear under the influence of atmospheric variations, or of mental or bodily conditions of a still less tangible nature, and were evidently the result of the general anemic state of the economy. Case XVI. Inflammation and Ulceration of the Neck of the Uterus, camplicating a fibrous Tumour of the Uterus. In March, 1847, I was consulted by Mrs. M.----, aged thirty-nine, married, without family, who had for some years been suffering from severe uterine symptoms. Her disease had been pronounced cancerous. Married rather late in life, she had never been pregnant, enjoying good health until about the age of thirty five when she began to expe- rience bearing-down pains, and menstruation become rather more painful and more abundant than usual. At a later period she suffered from whites and pain in the back. These symptoms gradually increased, her health failed totally, and for some time before I was consulted, she had been confined to bed. When I saw her, she was weak, pale, sallow, and emaciated; and complained greatly of severe 348 POLYPI AND TUMOURS IN CONNEXION WITH INFLAMMATION. dorsal and ovarian pain, of cardialgia and cephalalgia. The digestion was much impaired. On examining the uterus digitally, I found it very much enlarged, and rising considerably above the pubis, but moveable and non- adherent. It was evidently the seat of a large fibrous growth. The os was open, and presented the velvety sensation of ulceration. On using the speculum, the vagina was found red and congested; the cervix more voluminous than natural, and ulcerated, the ulceration passing into the open os. The os internum of the cervical canal Avas relaxed, and the uterine sound passed nearly four inches into the uterine cavity. Being convinced that the ulcerative inflammation of the uterine neck had a great deal to do with the state of the health, more, perhaps, than the fibrous tumour itself, I at once placed the patient under the treatment Avhich I follow in such cases. The ulceration was periodi- cally cauterized, astringent vaginal injections used, the bowels, which Avere very constipated, regulated, and great attention paid to diet. Under the influence of this treatment, seconded by such medicinal means as her state seemed to require, the inflammatory ulceration gradually diminished, and finally healed, all the surrounding inflamma- tion likeAvise disappearing. At the same time the local pains became less, and ultimately all but disappeared, the digestion and general health gradually improving. In the course of a few months from the time I first saw her she was quite convalescent, and has since been restored to a very tolerable state of health. The more severe uterine symptoms have disappeared, the menstrual flux is moderate, the tumour is indolent, and does not appear to increase, and her state, although that of an invalid, is very bearable. In this instance there was no decided hemorrhage at the menstrual periods. Hemorrhage, however, is so often present in fibrous tumours of the uterus, especially when these inflammatory lesions of the cervix exist and the uterine cavity is increased in size. I nearly always find this hemorrhage greatly diminished, if not entirely subdued, by the entire removal of the local inflammatory disease. CHAPTER XVI. SYPHILITIC ULCERATIONS OF THE NECK OF THE UTERUS. But little has been written respecting syphilitic ulceration of the neck of the uterus, and that little is of a very contradictory nature ; some writers thinking syphilitic ulcerations common, whereas others assert that they are extremely rare. When, however, we recollect that, even in Paris, the speculum has only been brought into use, as a means of diagnosis, within the last ten or fifteen years, and when we also bear in mind the great difficulty of determining precisely, in many cases, what is and what is not a syphilitic sore, this discrepancy cannot be a cause of surprise. By most writers on uterine diseases, syphilitic ulcerations of the cervix are not even alluded to. Thus, in Lisfranc's lectures on diseases of the uterus, edited by M. Pauley, not a word is said on the subject; neither are they mentioned, except by Dr. Balbirnie, in the most recent British works on the diseases peculiar to women. M. Duparcque con- siders these ulcerations rare, but evidently confounds them with other diseases (corroding ulcers, &c), under the title of chancrous ulcers, so as to render it difficult to understand what are his real views on the subject. On the other hand, M. Gibert, the learned physician of St. Louis, in a pamphlet on uterine disease, published in 1837, states, that out of five hundred women whom he examined with the speculum at the venereal hospital of Lourcine, one hundred and forty presented granular ulcera- tions, the greater part of which he considered to be syphilitic. None of these ulcerations, however, presented the physical characters of a real chancre. I have myself seen numerous ulcerations of the cervix uteri under similar circumstances, but they had not the appearance of true chancres. I was consequently surprised to read, a short time since, in Dr. Balbirnie's treatise on " Organic Diseases of the Womb," that " during a twelvemonth he had seen many beautiful examples of real Hunterian chancre existing on the os tincae, at the Hopital des Veneriens, in the service of M. Ricord." I was the more surprised to meet with this statement, as M. Ricord has repeatedly told me that he, also, has very rarely met with the Hunterian chancre on the cervix uteri. I have lately ascertained from Mr. Acton, the author of a very able work on venereal disease, who was several years M. Ricord's pupil and friend, that my recollections of that distinguished practitioner's opinion and practice are perfectly correct, and that uterine chancres are scarcely ever met with in his ward or practice. Dr. Balbirnie 350 SYPHILITIC ULCERATIONS OF TnE NECK OF THE UTERUS. must, indeed, have totally misrepresented the pathological meaning of the cases which he saw. All the treatises on syphilis with which I am acquainted, are nearly or quite barren on the subject of syphilitic ulceration of the cervix uteri. In giving the result of my own experience, I shall also avail myself of that of others, and shall endeavour to present a faithful picture of the present state of science, with reference to syphilitic ulcer- ation in this region. The first step to be taken in the study of syphilitic ulcerations of the cervix uteri is their separation into two classes; the first comprising the true classical, Hunterian chancre, the primitive venereal ulceration; and the second, including ulcerations which do not present the charac- ters of the true chancre, but appearing under doubtful circumstances, are believed to be venereal by some writers. REAL CHANCRES OF THE CERVIX UTERI. There can be no doubt that the real Hunterian chancre is very rarely met with on the cervix uteri. I only saw two instances of it during my lengthened connexion with the Paris hospitals, and since then have not seen a case. The late M. Cullerier, who was many years physician to the Paris Venereal Hospital, and habitually used the speculum, only met with three cases during his entire career. M. Gibert, who was several years physician to the Lourcine (a female venereal hospital,) when he wrote the pamphlet already alluded to, had only seen three instances of true chancre. At the Hopital St. Lazare, where many hundred cases of syphilis, in all its forms, are annually treated, only a very small number of real chancres are met with in the course of each year. M. Duparcque admits their extreme rarity; and although he has long enjoyed a very extensive practice in the treatment of uterine disease, he is obliged to borrow from other authors the two or three cases which he gives in his work to illustrate syphilitic chanerous ulcer- ation. The experience of M. Emery, of the HOpital St. Louis, who is also physician to the "Dispensaire,"1 and is intrusted with the weekly visitation of the females who are there examined, furnishes the same result. The extreme rarity of primary -chancres, with their usual physical characters, on the cervix uteri, must therefore, I think, be admitted as a fact. This question, however, at once presents itself: is the apparent rarity of primary chancre to be attributed to the syphilitic virus being seldom deposited on the organ, or to the chanerous ulceration, when it 1 In Paris, all women of the town are registered by the police, and examined weekly, by medical gentlemen appointed for that purpose. The locality where this examination takes place is called the Dispensaire. Those who are found diseased are sent to St. La- zare, a kind of Female hospital prison. Formerly the examination was merely external, but now the speculum is invariably used. This system has much contributed to dimin- ish the frequency of venereal disease in Paris. SYPHILITIC ULCERATIONS OF THE NECK OF THE UTERUS. 351 does occur, soon losing its characteristic appearance, and assuming the aspect of an ordinary ulceration ? M. Gibert seems to adopt the latter opinion, and says that a chancre probably passes into "granular ero- sion,"—which he thinks venereal,—when its duration is prolonged. I am myself disinclined to accept this interpretation. I do not see why a specific chanerous ulceration should lose its characters any sooner when situated on the cervix uteri than on the other mucous surfaces lining the cavities of the body. A syphilitic ulceration retains- its peculiarities in the mouth, in the vulva, and on the parietes of the vagina, and I see no reason why, when left alone, it should rapidly lose its characteristic appearance on the cervix uteri; so rapidly, indeed, as to render it difficult to meet with a chancre on that organ, however great the opportunities afforded for the investigation of syphilitic disease. I think, indeed, that it is much more probable that primary infection seldom takes place on the cervix, the virus of a sore being brushed off before this part is reached, and being thus almost invariably deposited on the mucous surfaces covering the external and inferior regions of the^ female sexual organs. This view is corroborated, also, by the rarity of chancres in the superior part of the vagina, which must proceed from the same cause. Their frequency, indeed, decreases as we recede from the vulva, their ordinary seat. If the views which I now_ advocate are correct, if a real chancre situated on the cervix retains its peculiar appearance, in the same way as when situated in other regions, we must then admit that the very great majority of the ulcerations that are so frequently found on the uterine neck of females labouring under the various forms of syphilis, are not primary syphilitic ulcerations modified by time, but either secondary syphilitic or non- syphilitic ulcerations. The researches of M. Ricord with reference to the inoculation of the secretion from ulcerations of the cervix, corroborate the above views. In his treatise on inoculation, he merely gives one instance of chancre of the cervix. {Case xiii.) The pus from this chancre was inoculated on the thigh, and gave rise to the characteristic ulceration. On the_ other hand, inoculation was unsuccessful in four cases in which ulceration of the cervix accompanied blennorrhagia. In tAvo of these cases the ulceration was the ordinary bleeding granular ulceration; in one, the ulcerated surface was covered Avith a Avhite pseudo-membranous film, which only disappeared with the eschar of the cauterization. In the last there were chancres on the vulva, and the ulceration of the cervix was absolutely like a chancre. The inoculation was only per- formed a week after the ulcerated surface had been cauterized; at that time the eschar had fallen, and the ulceration was rosy, and covered with healthy granulations. Was this a chancre, or not ? I am unable to decide, but am inclined to think, with M. Ricord, that it was not. The patient had been labouring under severe blennorrhagia for many months. When a chancre really does exist, it presents the usual characters. 352 SYPHILITIC ULCERATIONS OF THE NECK OF THE UTERUS. The ulceration is deeply excavated, and its surface is covered by a yellow or greyish film; the edges are elevated, irregular, and indu- rated. This chancre is, no doubt, generally accompanied, except at the onset, by slight partial induration of the cervix, the extent of the induration depending on the uterus haA'ing, or not having, undergone the changes which follow conception; and in the former case, on the length of time that has elapsed since the last labour or abortion. The size of the chancre or chancres, for there may be several, varies. Those which I have seen were small; one Avas not so large as a fourpenny piece, the other was still smaller. M. Duparcque mentions a case in which the chancre was much larger than in either of my patients. If the chancre is allowed to remain untreated, it may heal spontaneously, or it may, according to M. Duparcque, assume a chronic form, and remain unchanged for months. When this occurs, the state of sub- inflammation of the cervix, which the chancre keeps up, is followed by general induration of that organ. This induration may be carried to such an extent as to simulate the stony hardness of ulcerated scirrhus. {See Case xix.) The presence of a well-formed chancre might, possibly, be appre- ciated by the touch. The excavation, with its indurated margin, would lead, at all events, to the conclusion that an ulceration existed, the nature of which the speculum would partly reveal. The local and general symptoms produced by a chancre in the first period of its formation are very obscure. Indeed, they may at first be said scarcely to exist; they are then, at the most, confined to very slight hypogas- tric pain, and to a scarcely perceptible mucoso-purulent secretion. Should, however, the chancre increase in size, and give rise to irrita- tion, inflammation, and induration of the cervix, then all, the symptoms which have been enumerated as the result of these lesions manifest themselves—viz., severe hypogastric and lumbar pains, sensation of weight and bearing-down in the pelvis, leucorrhea, &c. The following cases will illustrate these varieties of chancre of the cervix. CASES ILLUSTRATIVE OF REAL CHANCRE OF THE CERVIX UTERI. Case XVII. Blennorrhagia ; a Chancre appears at the Os Uteri a fortnight after the commencement of treatment. A. M----, housekeeper, aged thirty, entered the HOpital St. Louis, the 1st of May, 1843. Of robust constitution, she habitually enjoys good health, and menstruates regularly. Some few years ago, she had a natural labour ; since then she has not presented any uterine symp- tom, nor suffered from leucorrhea. For the last two years she has lived maritally with an elderly person, to whom, a few weeks before her admission, she communicated a chancre, which was followed by a bubo. SYPHILITIC ULCERATIONS OF THE NECK OF THE UTERUS. 353 She confesses having exposed herself to suspicious communication. She Avas carefully examined in town with the speculum, but no trace of chancre was found. The entire surface of the vagina, I was told, was then the seat of an abundant mucoso-puriform discharge, but there was no other lesion; the cervix and os uteri were perfectly healthy. After her admission, I examined, very carefully, the external and internal genital organs, the case, as presented to my notice, bearing directly on the identity of blennorrhagia and syphilis, and tending to prove that blennorrhagia is susceptible of communicating chancre. I did not, however, find the slightest erosion of any portion of the mucous surface. The cervix was perfectly natural and healthy, merely presenting slight redness of its mucous membrane, in common Avith that of the vagina. Between the lips of the neck of the uterus, however, there was a stream of opaque muco-pus apparently issuing from the cervical cavity. The uterus was slightly sensible on pressure, and rather more voluminous than in the natural state, but as she had men- struated only two days previously, I did not attach much importance to these symptoms. On opening the lips of the os uteri as much as possible with the speculum, and wiping away the muco-pus, I could discover no lesion. Founding my opinion on the data furnished by the above examina- tion, I concluded that the disease was merely blennorrhagia, occupying the entire vagina, and extending into the uterine cavity. The patient was therefore treated accordingly (balsam copaibae, emollient injections, general baths, and light diet.) The inflammatory symptoms and the discharge diminished rapidly. In the ten days which followed, she was tAvice examined with the speculum ; for I Avas most anxious thoroughly to investigate the case, and each time the cervix presented the same appearance, except that the redness gradually diminished, as did likewise that of the vagina; the increased sensibility and the congestion of the uterus had entirely disappeared. On the 16th of May, I again applied the speculum, and saw dis- tinctly a small ulceration issuing from the cavity of the os uteri, and turning over on to the anterior lip. The ulceration presented a greyish surface, and an irregular indurated margin ; it Avas deemed to be a true chancre by M. Emery, as well as by myself and many other persons Avho saw it. Under this impression, it Avas cauterized with the acid nitrate of mercury, and the patient was submitted to mercurial treat- ment—viz., bichloride of mercury, one-seventh of a grain, and sarsa- parilla. In spite of these measures, the ulceration extended itself over a surface as large as a fourpenny piece. It lost, however, its^ charac- teristic appearance after the second cauterization. The increase of the ulceration was attended with gradual induration of the anterior lip of the cervix, which became as large as a small walnut. The cauteri- zation was repeated every Aveek. After the third, the ulceration began to diminish in size, but it was not cicatrized until the end of July. The SYPHILITIC ULCERATIONS OF THE NECK OF THE UTERUS. flow of muco-pus from between the lips of the os ceased a short time after the escape of the chancre from that cavity. The blennorrhagia disappeared during the course of treatment. The administration of mercury was continued during a month, without producing salivation. No other syphilitic symptoms manifested themselves. The patient was discharged cured on the 1st of August. There was still, however, a little hypertrophy of the anterior lip of the cervix. Remarks.—In this woman it is more than probable that the chancre remained concealed within the cavity of the os uteri during several weeks, a very singular and important feature in the case. Had I not persisted in examining her with the speculum, during the treatment of the blennorrhagia, the chancre would never have been discovered, and the case would have been considered an all but unimpeachable proof that blennorhagia in one person can produce chancres in another; and had the uterine chancre healed spontaneously, and secondary symptoms supervened at a later period, they would likewise have been attributed to the blennorrhagia. One carefully observed and well authenticated instance, such as the above, goes a great way to annihilate the value of the exceptionable cases by which some authors endeavour to establish the identity between syphilis and blennorrhagia. In the above female, the muco-pus issuing from the cavity of the os uteri was most likely the product of the concealed chancre. It will be remarked that the characteristic appearance of the chancre ceased to be observed on the falling of the eschar produced by the second cau- terization. Case XVIII. Chancre of the Cervix ; Inoculation; Blennorrhagia. [Abridged from M. Ricord on Inoculation, p. 212.) Catherine H----, entered the hospital on the 4th of April, 1834. Had contracted several chancres seven months previously; had been subjected to no treatment. She presented, on her admission, a chancre on the left labium externum, and another on the corresponding nympha. On examination with the speculum, there Avere found a puriform vaginal secretion, and an excavated greyish ulceration on the anterior lip of the cervix, with irregular elevated margin. Until the 10th, emollient injections only were resorted to, the chancre being dressed with opiated cerate. On the 18th, the acute period of the disease had disappeared; the discharge was white, and less abundant; the ulceration of the cervix had not changed its aspect; pus was taken from its surface, and ino- culated on the right thigh: pus Avas also taken from the peri-uterine cul-de-sac, and inoculated on the left thigh. The uterine ulcerations were then cauterized with the nitrate of silver. On the 19th, the inoculated points Avere red and elevated; on the SYPHILITIC ULCERATIONS OF THE NECK OF THE UTERUS. 355 20th, the vesicles were quite formed on both thighs ; on the 22nd, they Avere full of pus; and on the 1st of May, well-characterized chancres existed on both thighs. These chancres were then cauterized, and dressed with calomel-and-opium ointment. The chancre of the nympha had disappeared under the influence of the cauterization; that of the outer lip Avas cicatrizing, as was also, the chancre of the cervix, which had been repeatedly cauterized.—Injections and plugging of the vagina with lint steeped in a lotion containing acetate of lead. On the 20th, the original chancres were cicatrized, but their bases were indurated. The blennorrhagia had disappeared. Pills of proto- iodide of mercury and sudorific syrup (a preparation containing mer- cury) were given, in order to remove the indurations. On the 30th, the inoculated chancres were also healed, and the indu- ration had nearly disappeared. On the 7th of June, the cure was perfect. Case XIX. Chronic Chancre ; extreme Induration of the Cervix. Cure by mercury. This case occurred to M. Cullerier, and is quoted by M. Lagneau and M. Duparcque. It is said to be the only one that Cullerier ever met with in private practice.—Madame —---, had lived several years with a gentleman, whose bad health was occasioned by frequent returns of an old venereal disease. From the commencement of her cohabitation with this person, she experienced a degree of sensibility in the neck of the uterus, which was not usual to her, but did not attribute it to the real cause. This sensibility gradually increased, until it became an acute, lancinating pain, accompanied by a sanious, abundant discharge. After three years' suffering, she consulted Cullerier, who recognized a considerable scirrhous (?) engorgement of the cervix, which was also the seat of several ulcers with hard indurated margins. It was from these ulcers that the sanious discharge above mentioned came. Being convinced that the disease was venereal, Cullerier treated it with a preparation of mercury, (the bichloride.) In two months the ulcera- tions were cicatrized, the cervix had returned to its normal size, and all the symptoms under which she laboured had disappeared. This case illustrates the extreme (stony) induration of the cervix which sometimes folloAvs chronic ulceration of that organ, whether the ulceration be syphilitic or not. The term scirrhous used by Cullerier, is evidently synonymous with hard, and does not convey the meaning of cancer. The ulceration was certainly syphilitic, but it is impossible to say whether it was a primary sore or not. From the imperfect description given of it, it appears to resemble more those deep, sanious, chancrous-looking sores which are found on the falling of pustular syphilides, than primary chancre. 356 SYPHILITIC ULCERATIONS OF THE NECK OF THE UTERUS. I shall now examine the non-chancrous-looking ulcerations of the cervix, which so frequently complicate blennorrhagia and the various secondary forms of syphilis, and endeavor to ascertain what is their real nature. THE NON-CHANCROUS-LOOKING ULCERATIONS, AVHICH COMPLICATE THE VARIOUS FORMS OF SYPHILIS. As I have already attempted to prove, both by my own experience, and that of other competent judges, the real classical, inoculatable, Hunterian chancre, is very seldom met with on the cervix; and the facts which I have brought forward to establish this proposition are, I think, so satisfactory, that Ave may consider this point as definitely settled. Ulcerations, however, not presenting the above-mentioned characters, are exceedingly common in females labouring either under blennor- rhagic discbarges, or primary, secondary, or tertiary syphilis; much more so, indeed, than could possibly be supposed by practitioners who do not habitually use the speculum, however accustomed they may be to the treatment of syphilitic diseases. The frequency of ulceration of the cervix uteri in women suffering under acute or chronic blennorrhagia, has been pointed out for some years past by the Paris surgeons, but I am not aware that its great frequency as a concomitant of secondary syphilitic symptoms has been insisted upon. In the spring and summer of 1843, whilst in charge of a female skin- ward of seventy-five beds, at the Hopital St. Louis, in which there were always a great number of syphilitic skin diseases, I carefully examined with the speculum all who were so affected, in order to ascertain the state of the internal genital organs. I was led to adopt this course by finding, on inquiry, that several of those patients who presented no syphilitic disease of the external genital organs, except trifling leucor- rhea, were labouring under the symptoms which I have enumerated as indicating slight inflammation and ulceration of the cervix uteri. On examining these latter patients, I found the cervix ulcerated and slightly indurated, and it then occurred to me that the others might be similarly diseased, although they had not directed my attention to any symptoms of uterine disease. To my great surprise, I found that three out of four—perhaps more—also presented ulcerations of the cervix. Most of these patients were young women who had either never borne children, or had been confined several years previously, and were under treatment for syphilitic psoriasis, lichen, rupia, &c, When questioned narroAvly, they all admitted that they experienced slight hypogastric pain; that congress had been rather painful for some time ; and some, that they had likewise a slight leucorrheal discharge. They had not, howeA'er, paid any attention to these symptoms. What was the nature of these ulcerations ? Were they syphilitic, modified chancres, or secondary ulcerations, or were they merely in- SYPHILITIC ULCERATIONS OF THE NECK OF THE UTERUS. 357 flammatory sores ? In their appearance, I could discover little or no difference from the ulcerations observed in non-syphilitic patients, and Avas therefore inclined to deny their general syphilitic nature. Some were large, some small; some had a well-defined margin, others not; some were covered with large unhealthy granulations; others with small, florid, healthy granulations ; whilst some, again, presented a kind of pseudo-membranous film. On referring to M. Gibert's treatise, I found that his experience at the Lourcine Venereal Hospital coincided with what I saAv with reference to the frequency of ulceration of the cervix in persons labouring under syphilis. It did not appear, however, from his statistics, that he had met with it so often as I had—a fact which may easily be explained. The Lourcine is the hospital to which females affected with syphilis, who apply to the central board for admission, are drafted 51 and the slightest suspicion of a woman labouring under blennorrhagia or syphilis is sufficient to ensure her being sent to it, in preference to any other. The consequence is, that women are often admitted who are not affected with blennorrhagia or syphilis, but present some other disease of the genital organs. They are however examined with the speculum. Out of the five hundred patients examined indiscriminately by M. Gibert, the details of whose cases he took down, one hundred and forty- four presented ulceration of the cervix, {erosion granuUe.) Of the latter, fifteen offered no other morbid symptom; eighteen all presented chancres; twenty-four, condylomata, or mucous tubercles; eleven, buboes; ten, consecutive ulcerations of the amygdalae, mouth, or pharynx; ten, rhagades ; six, vegetations; eleven, syphilides; and eight, blennorrhagia. In some cases there was no appreciable leucorrhea; in the majority of the remainder, but little. When describing these "granular erosions" (p. 13), M. Gibert says, "This ulceration, always "rather superficial, generally has a rounded form, and is more or less " plainly limited; it occupies .sometimes the superior lip, sometimes the "inferior, and sometimes the two, and sometimes it even appears 1 The Paris hospitals are all under one common jurisdiction. Every day a board of surgeons, and another of physicians, sit in a central situation, to admit patients into the different hospitals. The director or governor (a non-medical resident functionary) of each hospital is obliged to send every morning, before ten o'clock, to the central board, (bureau central,) a list of the vacant male and female beds. The patients applying for admittance if found, on a superficial examination, to present any symptoms of disease, are at once sent to the different hospitals until all the beds are filled, that hospital be- ing selected which is the best suited for the disease, or which is the nearest to their home. There are nearly always more beds than applicants. Should, this however, not be the case, for some days together, as occurs in time of epidemic disease, supplemen- tary beds are at once put up in the various hospitals to meet the emergency. This truly Samaritan system of relieving the sick poor deserves to be better known and appre- ciated in this country than it is at present. In Paris there is no difficulty whatever placed'in the way of the admission of the poor into the hospitals. In addition to the " bureau central," every morning a physician and surgeon likewise admit applicants at each hospital, and the "interne" on guard, during the absence of the physician or sur- geon, has also power to admit whomsoever he may think proper, day or night. No questions are asked as to means, &c, the very fact of a person applying for admission into a hospital being considered a sufficient guarantee of his or her poverty. The Paris hospitals are therefore the ordinary asylum of the poor, when sick. Indeed, one-third of the population of that city die under their roof. 358 SYPHILITIC ULCERATIONS OF THE NECK OF TnE UTERUS. "to penetrate into the cavity of the cervix uteri; its surface is red and « granular, and contrasts notably with the smooth and polished surface « of the normal neck; and it bleeds easily. Generally speaking, a veil » of viscous semi-transparent mucus, which flows from the orifice of " the neck of the uterus, cov.ers the granular erosion." Foundino- his opinion on the above description, M. Gibert endeavours to establish this form of ulceration as a distinct species of syphilitic ulceration, which he appears to think succeeds m many instances to OnflIlCl*GS In this view of the lesion, as I have already said, I cannot agree with M. Gibert. I do not, I must confess, see in his description of the " o-ranular erosion" the elements of a distinct species of ulceration. The characters which he gives to it are the characters which I have uniformly met with in merely inflammatory ulcerations. The circular form of the ulceration, on which he subsequently lays great stress, is the form which I have hitherto seen all kinds of ulceration of the cervix assume, in forty-nine cases out of fifty. Sometimes an ulceration may be irregular, serpiginous ; indeed, some French practitioners have (very unnecessarily, I think) admitted a serpiginous variety; but this is the exception, not the rule. As to the "granular" appearance of the ulceration, all ulcerated surfaces are covered with granulations of some species or other, and I never could understand why the term "granu- lar" should be applied to any kind of ulceration as a distinctive name. All ulcerations being granular, the addition is altogether unnecessary, and, indeed, implies nothing. For the above reasons, although I accept M. Gibert's experience as substantiating the extreme frequency of ulceration of the cervix in persons labouring under syphilis, primary or secondary, I do not accept his views with regard to the syphilitic nature of these ulcerations. The experiments which M. Ricord has performed, with reference to the inoculation of syphilis, have thrown very great light on this question, as on every other connected with the pathology of syphilis. M. Ricord, as I stated above, has repeatedly inoculated^ the pus from these ulcerations,—that is, from ulcerations of the cervix, not offering the physical characters of true chancre, but existing in women Avho labour under some of the various forms of syphilis,—without giving rise to the formation of chancres. I have also learnt, from Mr. Acton, that he repeated M. Ricord's experiments, some years ago, in Paris, along with M. Vidal de Cassis, then surgeon to the Lourcine, Avith a like result. Inoculation with the pus from the non-chancrous-looking ulcerations of the cervix in syphilitic patients never gave rise to chancres. I must add, as an element in the diagnosis, that these ulcerations generally gave way easily to the usual treatment—viz., slight cauteri- zation, injections, &c. It is, however, scarcely necessary to say, that in those instances in which considerable induration of the cervix exists, it is as troublesome as usual. In all the cases which have come under my notice, the venereal symptoms were treated at the same time as the uterine. SYPHILITIC ULCERATIONS OF THE NECK OF THE UTERUS. 359 From the facts which I have brought forward, and the considerations into which I have entered, I think I am warranted in concluding that the non-chancrous-looking ulcerations observed on syphilitic patients are not, in the immense majority of cases, primary syphilitic sores, or modified chancres; I do not say in all, because it is generally admitted that real primary sores do not always assume the appearance of the classical chancre. Admitting that these ulcerations are not primary syphilitic sores, is it equally true that they are merely inflammatory ? may they not be secondary ? That some may be so, I think is probable; but I do not believe it probable that more than a very small number can possibly have such an origin. On the one hand, affectipns of the mucous membranes are not so very common (as secondary symptoms of syphilis), and on the other, a secondary ulceration of the mucous surface presents peculiar characters, which are not those usually observed. I have, however, seen ulcerations of the cervix, in syphilitic patients, present the grey pseudo-membranous covering which is seen in secondary syphilitic ulceration of mucous membrane, and am quite willing to admit that they may really have been instances of this form of disease. If the ulcerations which we are examining are not syphilitic what is their nature ? To this question I answer that, in my opinion, they are nearly all inflammatory. In vaginitis, be it simple or virulent, as I have elsewhere stated, the inflammation soon extends to the cervix and its cavity, where, owing to the great vitality of the organ, and to the number of its mucous follicles, inflammation easily passes on to ulceration. It has been stated by Ricord and other writers on syphilis, that blennorrhagic inflammation frequently passes into the cavity of the uterus, and attacks its lining membrane. My own observation would lead me to conclude, that in blennorrhagic inflammation and ulceration of the cervix, as in simple inflammation, this is rarely the case. I believe that this opinion is to be attributed in one form of the disease as in the other, to inflammation of the cavity of the cervix being mistaken for inflammation of the cavity of the womb. The prevalence of ulceration in women labouring under the various forms of syphilis without vaginitis is certainly singular; but I am inclined to attribute it, in a great measure, to the abandoned life which they nearly all lead, or have led. I shall conclude this account of syphilitic ulceration by the following propositions:— First.—The real classical chancre, presenting its ordinary physical characters, is excessively rare on the cervix uteri. Secondly.—Ulcerations presenting the characters of the inflam- matory ulceration are, on the contrary, excessively common in patients labouring under blennorrhagia, or primary, secondary, and tertiary syphilis. Thirdly.—Some few of these ulcerations may be primary or second- ary, but the very great majority are merely inflammatory. CHAPTER XVII. ON THE DIAGNOSIS OF CANCER OF THE UTERUS. It is difficult, indeed, perhaps, impossible, in the present state of science, to give a correct and comprehensive definition of cancer. Cancer may, hoAvever, be said, generally, to be a disease characterized by the formation of growths or structures which "have the power of re-development—that is, which once existing, may spread to other tissues or organs, causing in them a disease or growth similar to themselves, by a species of propagation similar to that possessed by animalcules or vegetable fungi." This is the definition given to the term malignant by my namesake, Professor Bennet, of Edinburgh, in a very able work on cancer,1 which he has recently published, and may with equal propriety be applied to the various forms of disease to Avhich the appellation of cancerous has hitherto been given. The researches of modern anatomists and histologists having demonstrated that cancer is not an inflammatory affection, its history does not necessarily form part of a treatise on inflammation of the uterus. As, however, inflammation and cancer of the uterus have been, and are still, confounded by the most classical writers of the present day, a short account of the manner in which cancer manifests itself, and of the appearances which it presents in the uterus, is neces- sary, in order to establish correctly the diagnosis between malignant and inflammatory disease. Previous to modern investigation in the field of pathological anatomy, the most vague notions prevailed respecting the nature of cancerous formation. The first results, however, afforded by pathological anatomy, tended rather to encourage fresh errors than to dispel former ones, as they led to a belief in the identity of cancer and inflammation. Subse- quent researches were more successful, and since the microscope has been applied to the study of the intimate organization of healthy and morbid structures, a very considerable amount of information has been acquired respecting the pathology of these affections. The researches of Professor Bennett, contained in the monograph to which I have above referred, throw great additional light on the nature of maligant disease. 1 0n Cancerous and Cancroid Growths, by John Hughes Bennett, M. D. Edinburgh, »■ I cannot .too strongly recommend Professor Bennett's work to the attention of the profession. It is certainly the most luminous essay on the subject that has yet appeared and if it does not solve all the difficulties of the inquiry, it clearly points out in what direction our investigations should be carried, in order to elucidate the hitherto obscure problem of the real pathological nature of cancer. DIAGNOSIS OF CANCER OF THE UTERUS. 361 The Edinburgh Professor has embodied in it the results of many years' careful microscopical investigation, for which his intimate acquaintance with the labours of continental histologists had peculiarly prepared him, and he has thus been able to produce a more accurate and more philosophical essay than any author who has preceded him- Impressed as I am with the great value and importance of his histolo- gical labours, I shall adopt, in the few remarks I have to make on uterine cancer, his classification of malignant disease, and shall borrow from him his definitions of the various forms under which it is observed. Professor Bennett recognises two divisions of malignant groAvths, the cancerous and the cancroid. Cancerous growths are those which present undoubted anatomical and microscopic characteristics, whilst cancroid growths are structures which, to the naked eye, the feel, and often in their progress, so closely resemble cancerous ones that they are commonly mistaken for them, although they present, on examina- tion, structural differences of a very marked character. Cancerous growths include three forms of cancer properly so called, which comprise the principal forms spoken of by morbid anatomists— scirrhous or hard, encephaloma or soft, and colloid or'gelatinous cancer. These three forms of cancer are merely modifications of an anatomical state characterized by the presence of nucleated cancer cells infiltrated amongst the meshes of a fibrous structure, and swimming in a viscous fluid. It is the presence of these three elements thus associated that constitutes the cancerous growth, and it is the relative amount of each that determines its form. Thus it is that a cancerous growth is at the same time a homologous and a heterologous tissue. The individual elements of which it is composed do not essentially differ from those which are found in healthy tissues; in this sense, therefore, cancer may be said to be homologous to the healthy structures of the economy. But the mode in which these individual elements are aggregated and combined has no parallel in normal structures; in this sense, therefore, it is heterologous. As we have seen, the fibres, the cells, and the viscous fluid which constitute the three essential elements of a can- cerous growth, vary in the relative amount which they present one to the other. If the fibrous element be in excess, it constitutes scirrhous or hard cancer ; if the cells be numerous, encephaloma, or soft cancer; and if the fluid abound, and be collected into loculi, or little cysts, it becomes colloid cancer. All these forms of cancer may fre- quently be observed in the same tumour; in one place it is hard or scirrhous; in another, soft or encephaloid ; and in the third, jelly-like or colloid. Yet although they may pass into or succeed one another, they are not unfrequently distinct from their origin to their termination. The researches of histologists have been less successful in deter- mining the intimate structure of cancroid growths. They have, how- ever, throAvn considerable light on a subject previously involved in darkness, by proving that various growths, which in their appearance, feel, and progress closely resemble cancerous ones, and are commonly mistaken for such, on microscopical examination present structural 362 DIAGNOSIS OF CANCER OF THE UTERUS. differences of a very marked character. As these structural differences profoundly modify the pathological course of such growths, and the results obtainable by treatment, the distinction is most valuable and practical, and deserves to be universally adopted. Under the head of cancroid growths, Professor Bennett describes a variety of formations, some of which are generally considered as mere forms of cancer, 'whilst the others are universally separated from cancerous diseases, from which, however, they are frequently difficult to distinguish. They are— lstly. Fibro-nucleated cancroid growths, which include growths closely resembling scirrhus and cephaloma, but differing from them by the absence of cancer-cells, which are replaced by naked nuclei. This difference of structure is only ascertainable by means of the microscope. In several cases quoted by Professor Bennett, growths of this descrip- tion were removed without a return. 2ndly. Epithelial cancroid growths, Avhich consist essentially of an hypertrophy of the mucous or epidermic layer, and are composed of numerous epithelial cells, more or less compacted together. These growths may occur on all large free surfaces, such as the skin, and the mucous membranes of the internal cavities, as also within follicles, and the minute ramifications of secreting glands, such as the mammae or kidneys. When present in the form of tumours, epithelial growths frequently soften and ulcerate, but they may commence by a mere indurated or warty spot, which thickens, assumes a circular cup-shape, and ulcerates. It is to this form of cancroid growth that belong cauliflower excrescence of the cervix uteri, soft warts, and condylomata, cancer of the lip, chimney-sweeper's cancer, noli me tangere, corroding ulcer of the cervix uteri, &c. 3rdly. Fibrous cancroid growths. Fibrous tumours are constituted wholly of fibrous or filamentous tissue, and so closely resemble cancer that they are often mistaken for it, and especially for the scirrhous form. Nor is this surprising, when we consider that the only anatomi- cal difference between the two growths is the presence of cancer-cells and nuclei in cancer, and their absence in fibrous tumour. This section comprehends, 1st, thickening or hypertrophy of the subareolar tissue of mucous membranes ; 2nd, tumours of different varieties, which may be divided into sarcomatous, dermoid, chondroid, and neuromatous. The other cancroid growths recognised by Professor Bennett are— 4thly, the cartilaginous; 5thly, the fatty; and 6thly, the tubercular. Having thus obtained some little insight into the real nature of cancer, we will endeavour to apply our knowledge to the consideration of malignant^ disease of the uterus, with a view to the elucidation of its diagnosis in that organ. Both cancerous and cancroid growths are observed in the uterus, but the former are mere frequently met with, and principally under the form of scirrhus, or hard cancer. DIAGNOSIS OF CANCER OF THE UTERUS. 363 CANCEROUS GROWTHS OF THE UTERUS. Cancerous growths rarely commence in the body of the uterus, or, at least, are seldom there first recognised, the neck of the organ being the region in which they are usually first observed. In the course of time, however, even when the disease commences in the cervix, it gradually extends from the neck to the body of the uterus, so that after death from uterine cancer, the entire womb, or the greater part of it, is generally found involved. The apparent rarity of cancer in its incipient stage in the body of the uterus has long been recognised. Thus Sennertus says : " Etsi cancer etiam ipsi uteri substantias acci- dere potest tamen hocrarius accidit, et vix tam satis cognoscitur, multo minus curatur ; frequenter vero in cervice uteri generatur quapropter hoc loco de eo agemus : isque nunc est sine ulcere, nunc exulceratus." (Lib. iv. de Morbis Mulierum, cap. 11, quoted by Sir Charles Clarke, in his Observations on the Diseases of Females.) I have used the word "apparent," because I am by no means certain that cancer is as often entirely confined to the neck of the uterus in its first stage as is generally supposed. When females really labouring under uterine cancer draw the attention of their medical attendant to the local symptoms which they present, and a digital examination is made, the disease is, almost invariably, very far advanced, the cervix deeply involved, and the uterus fixed in the pelvis by adhesions ; so that it becomes very difficult, if not impossible, to recognise whether or not it extends to the body of the organ. The opinion which prevails that cancerous disease is nearly always confined at first to the cervix is probably owing" in part to the fact that chronic inflammatory enlargement of the uterine neck has long been, and is still, very generally mistaken for incipient cancer. In these cases, the disease is, in fact, confined to the cervix, the body of the uterus being generally free from enlargement, inequalities, or adhesions. In the very rare instances in Avhich cancerous growths commence in the body of the uterus, the neck remaining free from disease, and in which the patient is seen in this stage, the uterus is increased in size, indurated, and presents irregular nodosities or divisions. The cervix gradually opens, and allows a sanious fluid to escape, having the peculiar offensive odour of cancerous discharges. The uterus is also generally the seat of severe lancinating pains. As the disease pro- gresses, fungous excrescences make their way through the os, the cervix becomes involved, the uterus is fixed in the pelvis, and the case assumes all the characteristics of confirmed uterine cancer. The only forms of disease with which a cancerous growth of this nature is likely to be confounded, are fibrous tumours and polypi, and chronic partial metritis. The size of the uterus is increased by a fibrous growth, Avhich may be irregularly divided into lobes, so as to give a very uneven surface to the uterus. But there is to guide us the absence, in most instances, of the lancinating pains of cancer, the \ 364 DIAGNOSIS OF CANCER OF THE UTERUS. gradual indolent growth of the tumour, and the absence of the offen- sive watery or sanious discharge. I have seen a polypus contained in the cavity of the uterus mistaken for cancer, which that organ had been endeavouring to expel for several weeks by violent contractions. On examining digitally, I found the neck of tbe uterus soft, dilated to the size of a half-crown, and behind it a regular globular surface, like that of an orange. The hemorrhage was abundant, but the blood was perfectly inodorous and pure. These conditions were sufficiently characteristic to leave no doubt as to the nature of the case. In chronic metritis the uterus is partially enlarged, and the enlarged region may present indurated nodosities ; but these nodosities are per- fectly smooth and regular on their surface ; they are also exquisitely sensitive to the touch—unless inflammation has subsided, and has terminated by induration, in which case there is an entire absence of uterine symptoms;—whilst cancerous tumours are indolent or but slightly sensitive to pressure. Moreover, inflammatory indurations of the uterus present the exacerbations at the menstrual periods elsewhere described, which are not observed in cancer, and remain stationary for months and years, whereas all cancerous growths, especially in the uterus, have a tendency to pass through the various stages of their development, and to decay within a limited period. In nearly all the instances of uterine cancer, however, that are met with in practice, the disease is certainly first recognized in the neck of the organ. When thus discovered, it may be either in an incipient or in an advanced and ulcerated condition. Cancer of the Cervix in the Incipient or Non-ulcerated Stage. According to my experience, cancer in the neck of the uterus is almost invariably found in the advanced or ulcerated stage of its, development before a female applies for relief. It would seem as if cancerous growths in this region gave such slight indications of their presence during the first period of their formation, and progressed so insidiously, that the attention of the patient, and of her medical attendant, is scarcely ever directed to the uterus. My opinions on this subject, however, are widely different from those entertained by uterine pathologists, even the most recent; the incipient stage of cancer in the cervix uteri being universally described by them as of common occurrence in practice. This discrepancy, however, in the results of observation, is easily explained. From the descriptions given of the morbid changes, it is evident that the incipient stage of cancer is still confounded with the hypertrophied indurations of the uterine neck, of inflammatory origin, which I have fully described in a former part of this work. Writers on uterine pathology evidently have not yet shaken off the errors to which the Broussaian. doctrines gave rise, especially on the continent, in the early part of the present cen- DIAGNOSIS OF CANCER OF THE UTERUS. 365 tury, and not only still see a connexion between inflammation and cancer—as cause and effect—which does not in reality exist, but even absolutely mistake for cancer the lesions and changes produced by inflammation. The details respecting the intimate anatomical structure of cancerous growths which I gave at the beginning of this chapter, most incontro- vertibly establish the decided and absolute difference in the anatomical characteristics of inflammatory and of carcinomatous formations—that they are, in fact, the result of two totally different morbid processes. Inflammation may, possibly, lead to the subsequent development of cancerous growths,—although even this is a question yet undecided,— but the fact is undeniable, that the two morbid conditions are essen- tially different. I am, indeed, impressed with the belief, founded on clinical observation, that the more our diagnosis improves, the less frequent will be found what is called the "cancerous degenerescence" of chronic inflammatory disease. Clinical experience has thus led me to modify the opinion I formerly entertained, in common with the rest of the profession, respecting the frequency of cancerous degenerescence of chronic inflammatory tumours. During the last ten or twelve years I have followed the progress of many hundred cases of uterine inflammation, and have not seen a single instance of inflammatory disease thus degenerate. In some instances, I have been told in consultation, that the disease respecting which my opinion was required, although then evidently cancerous, had at first been merely inflammatory. In these cases, however, the diagnosis of my informants could not be relied upon, and the antece- dents of the patient were also completely at variance with their view of the evolution of the morbid phenomena. On the other hand, all the cases of cancerous disease that I have myself witnessed during the before-mentioned period, have been evidently such from the time they first came under my observation. It is these three facts:—1st, by the totally different structural origin of the two diseases ; 2ndly, the absence of any tendency in inflammatory disease to degenerate into cancer, as exemplified by my never having seen a single instance of such degenerescence occurring during treat- ment ; and 3rdly, the circumstance of my always finding cancer in an advanced and decided stage of its development—-that makes me doubt the frequency of the connexion of cancer and inflammation in the uterus. That the anatomical characters ascribed to incipient cancer by uterine pathologists do not possess the meaning which is given to them is susceptible of easy demonstration. Thus, Sir Charles Clarke,1 1 Observations on the Diseases of Females attended by Discharges, 3rd edition, vol. i. chapter xiv., on carcinoma uteri. At page 212, the appearances which carcinoma uteri presents in the neck of the uterus, on inspection after death, are described as follows:— " AVhen carcinomatous tumours are cut through with a knife, they offer a good deal of resistance, and appear sometimes as hard as cartilage. The cut surface presents an ap- pearance of white lines, which run pretty regularly with regard to each other; but the 366 DIAGNOSIS OF CANCER OF THE UTERUS. speaking of carcinoma uteri, (p. 215,) as distinguished from ulcerated cancer, says, " Two varieties of this disease are observed in the early " stage, (in the uterine neck.) 1. There is a firm tumour, of a rounded " form, springing from the surface of the cervix uteri, or imbedded in " it, whilst the other parts of the uterus are perfectly healthy, except " that its parietes are thickened as the disease advances, and that its " cavity becomes larger than that of a healthy unimpregnated uterus. " 2. Instead of any distinct tumour, the whole of the cervix of the " uterus becomes larger and harder; and if this thickened part is " examined after death by cutting into it, it puts on the same appcar- " ance which a true carcinomatous tumour possesses. " The two cases proceed differently. In addition to the usual symp- " toms of carcinoma, there will frequently be found in the first variety " of the disease some mechanical symptoms depending on the pres- " sure made by the tumour upon the neighbouring parts; which " symptoms will be more or less severe, according to the size and " situation of the tumour. In the second variety of the disease, these " symptoms seldom exist; because the carcinomatous thickening of " the cervix uteri rarely acquires a sufficient size to produce them. . . " In women Avho live temperately the disease may continue for a " long time, without producing any symptoms, if any judgment can be " formed from the cases of patients who apply for medical aid on " account of symptoms under which they have not long laboured. On " examination, there is often found in such women a considerable " alteration in the structure of the parts, which most probably would " not have happened in a short time. The examination made from " time to time of patients labouring under this disease, who will consent " to follow a proper regimen, perpetually demonstrate the very trifling " change which will take place in the complaint, even in the course of " many years...... " The os uteri (p. 226) will be found also to have undergone a " change. It becomes larger than natural, still, however, retaining " its original shape. This open or gaping state of the os uteri some- " times is sufficient to admit the extremity of a finger, which, when " introduced into it, feels as if surrounded by a firm ring. The parts " will sometimes have undergone all the changes of structure above " related, when no local symptoms have been apparent, and when the " disease has only been ascertained by an examination, suggested by " the failure of remedies in relieving the supposed disease of the " stomach or kidney. It is unusual for patients to be cut off during " the carcinomatous state of the disease; when, however, this does " happen, it is from the excessive discharges of blood bringing on a " dangerous decree of debility...... " Chapter XV.—These symptoms are seldom dangerous, but they " are very distressing to the patient. . . . This local disease may directions of which vary according to the shape of the tumour." This description ap- plies equally well to fibrous growths or even to simple inflammatory hypertrophy of the uterine tissue. DIAGNOSIS OF CANCER OF THE UTERUS. 367 " remain stationary, or it may have its symptoms alleviated, so that " the patient's life may be prolonged, and her comforts increased, " (p. 228.) .... If the system is plethoric, some blood should be " taken from the arm.....Blood may also be taken away from " the hypogastric region or from the loins, by cupping or by leeches; " and from time to time, upon any increase of uneasiness, this opera- " tion should be resorted to.....The relief produced by topical " blood-letting is great, and often immediately felt, (pp. 229, 230.) ".....No attempt should be made to restrain the mucous dis- " charge; but if it should be secreted in,large quantity, it should be " frequently washed away. (p. 235.)..... " In treating this disease, as no cure is known for it, the practitioner " must be satisfied with palliatives, and not be anxious to restore the " vigour of the body, which might aggravate the disease again. Still " let it be recollected, that by a strict attention to management, and " an unwearied perseverance in the means suggested, all the cases of " the complaint may be relieved; in many the further enlargement of " the tumour, or progress of the thickening, may be prevented; and " if the author was not afraid of deceiving himself, or of deceiving " others, he would venture to express a belief that in a few instances " the disease has altogether subsided. This surmise he offers with " great diffidence. Perhaps the enlargement in the cases which have " given rise to it was not of the true carcinomatous kind; perhaps the " tumefaction arose from common inflammation of the part, attended " by serous effusion into the cellular structure surrounding it....... " Certain, however, it is, that some cases have come to the knowledge " of the author, and others have occurred in his own practice, in which " an enlargement of the cervix of the uterus, ascertained by examina- " tion, has disappeared, and together with it the symptoms connected " with it. " If such cases were in truth carcinomatous, {and that they were so " was the opinion of the practitioner,) the knowledge of them must " afford a great consolation to persons suffering under this dreadful " malady, and must act as an incentive to the employment of a mode " of treatment suggested by reason, and confirmed by experience: a " mode of treatment, which, to say the least of it, has a manifest " tendency to retard the progress of the disorder, and to prevent its " conversion into ulceration."—pp. 242—244. Passing over intermediate authors, who all adopt, to a greater or less extent, the views of Sir Charles Clarke, we at once arrive at those, among the more recent writers on the incipient stage of cancer, whose opinions carry with them the greatest weight—Dr. Montgomery and Dr. Ashwell. Dr. Ashwell's views will be found in the third edition of his Treatise on the Diseases of Women, and may be fairly supposed to represent the present state of science on this important subject. In order to deal fairly by Dr. Ashwell, I shall quote his own words as follows, (p. 370.) "Before entering more fully into the history and symptoms (of 368 DIAGNOSIS OF CANCER OF THE UTERUS. " cancer), I shall briefly pursue this interesting inquiry, commencing " my observations by reiterating an opinion formerly expressed by " myself, Guys Hospital Reports, (January, 1806, p. 153;) that hard " tumours of the cervix, and indurated puckering of the^ edges of the " os, (conditions which frequently terminate in ulceration,) may be " melted down and cured by the topical application of iodine, aided " by the recumbent posture, abstinence from sexual intercourse, cup- " ping of the loins, a mild, unstimulating, and often a milk diet, gentle " aperients, narcotic injections into the vagina, and the almost daily " use of the warm hip-bath." " It has been doubted whether I have sufficiently defined the nature " of these hard tumours ; whether in fact, they are to be regarded as " cancerous, or merely as congestions and ulcerations, Avhich not being " malignant, are capable of cure. I believed at the time I made these " observations, and I still adhere to the opinion, that they Avere " malignant tumours; but that their full development was prevented, " at this early period, by the treatment pursued; for I have long been " convinced that cancer of the Avomb may be arrested in its early " stages by the removal of the pathological state of which it is the " consequence. At Ipage 145 of the first volume of the Reports, the " folloAving observations occur—' To suppose or to call these hard " ' tumours scirrhous, cancerous, or malignant, would in some minds " ' instantly excite prejudice. If I am censured, then, for using the " 'term 'hard,' I justify myself by saying, that it is the best and " ' least controvertible expression with which I am acquainted. It is " 'scarcely possible to avoid attaching a precise and perhaps an " ' erroneous idea, to such terms as scirrhous, cancerous, or tubercular " 'induration.' The denomination, 'hard tumour,'has this advantage; " it assumes only, a degree of hardness, or firmness, beyond that which " is healthy and natural, leaving the precise cause or nature of such hard- " ness to be decided by the result of the treatment, or to the further pro- " gross of the disease. Such a condition may be the effect of chronic " inflammation only, or, if of malignant character, it may yet be very " distant from that degree of malignancy which will resist all treatment. " Nevertheless, I am persuaded, if many of these structural changes " (in the os and cervix) were examined without reference to their treat- " ment at all, and especially by iodine, they would be pronounced to " be schirrous or malignant alterations. I am not, however, pertina- " cious on this point: it is not a matter of practical moment; although " my conviction decidedly is, that these changes, whatever may have " been their precise character at the commencement of the iodine " treatment, would, without that treatment, have proceeded on to " ulceration, and thus have left the patient with but slight chance of " recovery.". . . . Dr. Ashwell states (p. 377) " that the os and cervix may present, in " the incipient stage of cancer, three kinds of induration,—1. The " rima or circumference of the uterine aperture may be wholly or " only partially hardened and puckered. 2. The cervix may be hard DIAGNOSIS OF CANCER OF THE UTERUS. 369 " throughout its whole structure; or, 3. Hard tumours may be " deposited in any portion of it. " The practitioner, however, is to remember, that, independently " of disease (cancerous), there may be—1. A large and firm cervix; " 2. A capacious, patulous, and firm os; 3. An os fissured and " unequally hard. " The distinction (pp. 382-83) between malignant affections of the " uterus and those of simple character, is not always easily deter- " mined. There are cases of engorgement, hypertrophy, and indura- " tion, in which the finger introduced into the vagina, discovers an " increase of volume, either in the entire uterus, the cervix, or in the " body only. Now, as there are changes induced by cancer, and as " there may be slight or severe pain in all the affections, it is important " to point out the diagnostic character. " Simple engorgement, hypertrophy, and induration, are less hard, " of more uniform surface, often unnaturally warm and tender on pres- " sure, whatever part may be affected ; while even in the early stages " of cancer, the surface is irregular and rough, free from tenderness, " and there is often a weight, coldness and stony induration. " In cancer, and the simple affections already mentioned, there is a " marked difference in the mucous membrane covering the cervix. In " the former, it is of a dull white or slightly grey colour; in the latter, " it is much redder, and more vascular, and often morbidly sensitive. " Hypertrophy, or common induration, may affect either the body " or cervix separately, or at the same time; but never in so isolated a " form as to give rise to distinct and separated nodules of tuberculous " induration, like carcinoma. Scirrhus developes itself slowly, the " former affections rapidly; frequently reaching a size in six or eight " weeks which scirrhus would require as many months to attain. . . . " Simple enlargements are generally easily cured by the means " already pointed out, while scirrhus, in its earliest formation, requires " a much longer period. Common induration is nearly stationary. " Malignant disease, although slowly, is gradually progressive, and by " affecting neighbouring tissues, transforms them, and sooner or later, by " their consolidation, destroys the natural mobility of the uterus. . . . " The exact prognosis depends very much on the stage of the " disease, and on the belief of its curability.....It is a disease " capable of being arrested, if not cured, in its earliest periods. . . . " The assiduous and early employment of prophylactic measures may, " if it does not entirely arrest the malady, protract it through several "years." The means of treatment recommended by Dr. Ashwell, and con- sidered by him as occasionally curative, are,—" rest in the recumbent " posture, a simple unstimulating diet, sexual abstinence, mercurials, " iodine, and iron, local blood-letting by cupping, leeches, and scarifi " cation ; hip-baths, blisters, setons, the topical use of iodine, and the " nitrate of silver." The above extracts convey a comprehensive summary of Dr. Ash 24 370 DIAGNOSIS OF CANCER OF THE UTERUS. well's views respecting cancer of the neck of the uterus in its incipient stage. It is impossible to read his first paragraphs Avithout being struck with the doubt and hesitation by Avhich they are characterized. Dr. Ashwell at last, however, arrives at the conclusion that " hard tumour"—the same condition which Sir Charles Clarke has described —is really malignant, although susceptible of being arrested, or even cured, by iodine, Sec. He subsequently attributes, without hesitation, to cancerous disease the more decidedly morbid changes which he describes, and also considers them curable by antiphlogistic and alterative treatment. The same views are entertained by Dr. Montgomery, the eminent Regius Professor of Midwifery at Dublin, Avhose opinion on any subject connected with the diseases of females must ahvays be received with the greatest deference. In an essay on the incipient stage of cancerous affections of the womb, Avhich appeared in the Dublin Medical Journal (January, 1842), this distinguished physician asserts the possi- bility of recognizing and curing cancer of the cervix in its incipient stage. The folloAving extracts will show on tyhat data he founds this opinion :— " I am perfectly convinced, from many years' observation, that ' something may be done to stem, at its source, the torrent of agonies ' that will otherwise overwhelm the patient; nay, I firmly believe it ' may, in many instances, be altogether turned aside, and the victim ' be rescued from the sad fate impending OArer her.......I am ' satisfied that there is a stage of cancer uteri which precedes the two ' usually described by authors: a stage in which the nature of the ' disease may be detected, its further progress arrested, and its germs ' arrested ; and the reason why this stage is not more generally recog- ' nised is, that the accompanying symptoms are frequently so slight ' as to attract very little the attention of the patient, and thus are ' suffered to remain without treatment, until a profuse hemorrhage, or ' some violent fit of pain, sounds the-alarm, and then, on examination, ' the disease is found to have passed into its second stage: the sur- ' rounding tissues are indurated and consolidated with the organ ' concerned, and no human means hitherto discovered can do more 'than blunt the thorns thickly strewn across the path, which the ' sufferer must tread to ' the house appointed for all living.' (pp. 433,434.) s vn " The margin of the os uteri is found hard, and often slightly ' fissured^ and projects more than usual, or is natural, into the vagina, ' and is irregular in its form. In the situation of the muciparous ; glands, there are felt several small, hard, and distinctly defined pro- jections, almost like grains of shot or gravel, under the mucous ' membrane. Pressure on these with the point of the finger gives ' pain, and the patient often complains that it makes her stomach feel 1 sick. ^ The cervix is, in most instances, slightly enlarged, and harder ' than it ought to be. The circumference of the os uteri, especially •' between the projecting glandule, feels turgid, and to the eye presents DIAGNOSIS OF CANCER OF THE UTERUS. 371 " a deep crimson colour, while the projecting points have sometimes a " bluish hue. In two cases of women who died, one of fever, and the " other of pneumonia, in a more advanced stage of this condition of " the os uteri, the substance of the uterus was found considerably " increased in size and thickness, and was intensely vascular. There " is no thickening, or other alteration of structure, in any part of the "vagina, at its conjunction with which the cervix uteri moves freely; " nor is there any consolidation of the uterus with the neighbouring "contents of the pelvis; in fact, the morbid change appears to be, " at first, entirely confined to the os uteri, and lower portion of the " cervix. " This stage of the affection is, in many instances, very slow, lasting " sometimes for years,1 before the second and hopeless stage is estab- lished; during this time the patient experiences only comparatively " slight and transient attacks of pain, or perhaps only sensations of " uneasiness, referred often to the situation of one or other of the " ovaries, or about the os uteri, with anomalous tingling along the " front and inside of the thighs; these last for a few hours, or a day " or two, and then disappear, perhaps for weeks, but again and again " return in the same situation, and for a long time are not increased in " severity, (pp. 436, 437.) " Sufficient observation has fully satisfied me that, in the great " majority of instances, the first discoverable morbid change which is " the forerunner of cancerous affections of the uterus, takes place in " and around the muciparous glandulae or vesicles, sometimes called ova " Nabothi, which exist in such numbers in the cervix and margin of " the os uteri; these become indurated by the deposition of scirrhous " matter around them, and by the thickening of their coats; in con- " sequence of which they feel at first almost like grains of shot or " gravel under the mucous membrane; afterwards, when they have " acquired greater volume by further increase of the morbid action, " they give to the part the unequal, bumpy, or knobbed condition, like " the end of one's fingers drawn close together. When this second " stage (usually described by writers as the first) is established, all " means hitherto devised have failed in producing any permanent " beneficial effect." (p. 439.) Speaking of treatment (p. 441), Dr. Montgomery says:—" In almost " every instance the treatment should be begun by the local abstraction " of blood, either by cupping, or by leeches applied directly to the os " uteri, or as near as possible to the organ ; and their application will " in most cases require to be frequently repeated, and should be " accompanied by the free use of anodyne fomentations." To local depletion Dr. Montgomery adds, " mercurials, iodide of iron, arsenic, " counter-irritation, the warm-bath and the hip-bath, emollient vaginal " injections, light diet, and regular living." 1 The italics in both pages are Dr. Montgomery's. 372 DIAGNOSIS OF CANCER OF THE UTERUS. The copious extracts which I have given from the works of Sir Charles Clarke, Dr. Ashwell, and Dr. Montgomery, three of the most esteemed uterine pathologists of the present day, show that cancer of the neck of the uterus, in its incipient stage, is generally considered to be recognisable by its physical characters, and capable of arrest, or even cure, in the majority of instances. Cases are brought forward, by these and other authors, to substantiate this position. Although I feel the greatest respect for the scientific attainments of the physicians whose opinions I have quoted, as likewise for those of other eminent pathologists who support the same views, I am compelled to state my conviction that their opinions are not founded on a true and correct interpretation of the facts which they have observed. I firmly believe that the forms of disease which they have described as the first stage of uterine cancer are merely and solely modifications of inflam- matory action in the neck and mouth of the uterus, totally distinct from cancerous growths, and having little, if any, tendency to malig- nant degeneration. I also believe that the cases brought forward to illustrate the physical diagnosis and the curability of cancer are simple instances of inflammation. My opinions on this subject have not been hastily formed. They are the result of mature deliberation—of a conscientious analysis of all the cases of uterine disease, malignant or non-malignant, which I have seen for many years; and their truth must be acknowledged by all who have attentively perused the description I have given of inflammation and its sequelae—hypertrophy and induration of the neck of the uterus. Setting aside all interpretation of anatomical changes occurring in the cervix uteri, every one conversant with the pathology of cancer must confess, that if the disease described in the extracts which I have given from the before-mentioned distinguished pathologists is really cancer of the neck of the uterus, cancer in that organ must be a totally different malady to what it is in all other parts of the body. Cancer in other regions is not, most certainly, a disease which can be nearly always arrested and often cured by antiphlogistic and alterative treat- ment, even when recognized in its early stages. We will, however, briefly analyze the physical data on which these views are founded; not forgetting that cancer is a morbid condition which it is next to impossible to recognize by its external character- istics alone, as we have seen in the first part of this chapter, and, con- sequently, that unless morbid conditions in the cervix uteri resemble in their progress, treatment, and results, at least in the majority of cases, cancer in other parts of the economy, we cannot rationally attach to them the malignant character. The principal anatomical changes stated to characterize cancer in its incipient, non-ulcerated stage, by the three authors I have quoted, are as follow :—A firm tumour of a rounded form, springing from the sur- face of the cervix, or embedded in it, or general enlargement and hard- ness of the cervix ; an open gaping os, which admits the extremity of DIAGNOSIS OF CANCER OF THE UTERUS. 373 the finger ; perfect freedom of the vagina from thickening or disease. —(Sir Charles Clarke.)----Hard tumour of the entire cervix; puckering and hardening of the edges of the os, and hard tumours deposited in any portion of the cervix; a dull white or slightly grey colour of the mucous membrane covering the cervix.—(Dr. Ashayell.) ----Margin of the os hard, slightly fissured, projecting into the vagina, and irregular; in the situation of the muciparous glands are felt seve- ral small, hard, and distinctly defined projections, like grains of shot, painful on pressure ; cervix slightly enlarged, and harder than natural; circumference of the os turgid, of a deep crimson colour, the project- ing points being bluish; no thickening or disease of vagina, or conso- lidation of the uterus to the pelvic contents.—(Dr. Montgomery.) All these are anatomical conditions which may be produced in the neck of the uterus, and are daily produced, by inflammation and puer- peral laceration of its orifice. > The enlargement of the cervix described by Sir Charles Clarke is evidently that produced by inflammatory hypertrophy, and the two chapters which he devotes to " carcinoma of the uterus, and its treatment" in the non-ulcerated stage, are clearly descriptive, in almost their entire extent, of inflammatory hypertrophy alone. The " form" in which a firm tumour springs from the surface of the cervix is pro- bably hypertrophy limited to one lip, whilst the form in which there is enlargement and general hardness of the cervix is general hypertrophy. If any evidence, beyond the mere description of the state of the neck of the uterus, were wanted to indicate the inflammatory nature of these changes, it would be found in the open, gaping state of the os, admit- ting the end of the finger. This is the characteristic condition of the os uteri in inflammatory hypertrophy. Dr. Ashwell, falling into the same error, admits the malignant nature of simple " hard tumour of the cervix," as he designates the condition described by Sir Charles Clarke. He considers, also, puckering and hardening of the edges of the os, with the presence of hard tumours in any region of the cervix, to be characteristic of cancerous disease. Dr. Montgomery's description of incipient cancer seems limited to the latter changes. Puckering of the edges of the os has always appeared to me to be merely the result of laceration of the os and cervix during labour, and of subsequent inflammation of the lobules into which the margin of the os and cervix is thus accidentally divided, as I have elsewhere explained, (p. 195.) The cervix is, in reality, frequently lacerated; and if Dr. Ashwell has not observed this to be the case, (see p. 433 of his work,) it must be, that, on the one hand, he has not analyzed with sufficient care the results furnished by digital and instrumental examination,_and that, on the other, he has mistaken for incipient cancer the cases in which the lacerations, not having healed, have led to a puckered, indurated state of the edges of the os. When laceration occurs in abortion or labour, if the parts involved do not return to a healthy state, but remain ulcer- 374 diagnosis of cancer of the uterus. ated and inflamed, lobes are formed around the os, being separated from one another by fissures more or less deep. These lobes, although merely inflamed, may become of a stony hardness; and when this occurs, the hardness is very erroneously supposed to characterize scir- rhus, and is cited as an evidence of the malignant nature of the disease. If the lobes thus formed and indurated around the os are considerably hypertrophied, they present exactly the sensation to the touch which Dr. Montgomery compares to the ends of the fingers brought closely together, and whLh he considers to characterize the second stage of cancer. I have now under my care, a lady, forty-five years of age, whose cervix presented exactly this " feel" when I first examined her, nearly a year ago. It seemed as if the finger reached a cluster of hard nodo- sities, just like the ends of the five fingers approximated, and these nodosities were of stony hardness. This lady had been pronounced to be labouring under, scirrhus of the cervix uteri, by two eminent autho- rities, eighteen months previously. I found, however, the vagina per- fectly healthy, and no uterine adhesions; the lobules were all regularly clustered round an axis, which was the open ulcerated os, they were separated one from the other by ulcerated sulci or fissures, which radi- ated regularly from the centre of the os uteri, like the spokes of a wheel. The discharge, although muco-sanguinolent, was not offensive to the smell. On inquiry, I could trace the origin of the uterine symp- toms and depraved health to a bad labour, which had occurred six years previously. The shoulder presented, and she was delivered by turning. All her previous confinements, nine in number, had been favourable. I at once concluded that the disease was purely inflam- matory, and was able to dispel the gloomy anticipations of the patient and her friends. This local hypertrophy is now nearly subdued by cauterization with the potassa cum calce, although the patient has been treated under great disadvantages. Owing to her residing at a distance from town, she has never, until lately, been able to remain under treat- ment for more than two or three weeks at a time. I may observe, with reference to this case, that the regular radiation of the fissures and hypertrophied lobes which constitute the puckering, may be considered positive evidence of their originating in laceration of the cervix. Indeed, I have never observed it, except in women who had children, or have miscarried. Were the puckering the result of cancerous growths, it would evidently be quite irregular, as would also the lobes and nodosities similarly formed; at least, such is the case with cancerous growths in other parts of the body, and in the cervix itself, in the advanced and ulcerated stages of cancerous disease. The isolated nodosities described by Dr. Montgomery may certainly be cancerous nodules, but they may also be merely muciparous glands inflamed and indurated. In fact, their being of a crimson hue would seem to show that such is really the case, inasmuch as cancerous growths in mucous membranes are rather characterized by a bleaching or whitening of the tissues which they attack. DIAGNOSIS OF CANCER OF THE UTERUS. 375 Thus a critical analysis of the anatomical changes ascribed to inci- pient cancer shows that, on the one hand, these changes present nothing special, nothing that can be said to characterize as malignant the case in which they are found, whilst on the other it shoAvs that they are con- stantly met with as the result of inflammation. Let us now see if the malignant nature of the disease can be recognised by its history when admitted on the faith of the above-mentioned data. According to the authors Avhom I have quoted, the form of cancer which they thus describe may exist for years, without giving rise to any other symptoms than those which are produced by the pressure of the tumour on surrounding organs. If symptoms do exist, they are mucous or hemorrhagic discharges, and sympathetic reactions on the stomach, brain, general nutrition, &c. The progress of the disease, even when recognised, is extremely sIoav ; it may continue in this stage of its deAre- lopment for many years, or even be cured completely under judicious treatment. The means of treatment found successful in arresting and curing the disease are principally : local bloodletting by leeches or cup- ping, seconded by alterative and tonic medicines, rest, light diet, absti- nence from stimulants, and from sexual excitement. Can any unprejudiced practitioner recognize the first stage of cancer in a disease, the progress and treatment of which is, generally, indeed nearly always, such as I have just recapitulated? Does not the entire history of these morbid uterine changes, as given above, tally, on the contrary, with that of chronic inflammation generally, in whatever part of the economy located? Chronic inflammation may, as every one knoAvs, remain for years in an indolent state, giving but slight local evidence of its existence, or merely reacting on the general health. Moreover, the influence of local blood-letting, of iodine, mercurials, counter-irritants, on chronic inflammation, wherever situate, in the uterus, breast, or in any other organ or region—has become an axiom in therapeutics. Again, who has ever witnessed incipient cancer in any other part of the body being arrested and cured, not exceptionally, but as the rule, by antiphlogistic and medicinal agents ? And yet there are parts of the body, such as the breast, in Avhich cancerous growths are all but invariably recognised and treated from the first. In this region, however, they almost constantly prove rebellious to medical treatment; generally returning, even after total extirpation. Must we, then, conclude that cancer is a different disease in the neck of the uterus to what it is in other parts of the human economy ? The same in its secondary or ulcerated stage, why should it be different in the incipient or non-ulcerated period? The probability is, that cancer is just as intractable in the uterus as in other organs, and much more rapid in passing through the various stages of its developement. Cancerous growths, as we have seen, are tissues, sui generis, the results of a special form of exudation, having a peculiar vitality of their own, and a tendency to extend and to pass through the various phases of their pathological existence, within a limited period. Indeed, according to Professor Bennett, in no organ 376 DIAGNOSIS OF CANCER OF THE UTERUS. does this tendency to extend, to enlarge, to soften, and to ulcerate, appear more decided than in the womb. Although the intimate structure of cancerous growths has been but recently revealed, yet the tendency of malignant formations to extend, and to destroy life in a limited period, has been known for ages. This tendency has been strikingly illustrated by some researches of, I be- lieve, M. Malgaigne, made a few years ago in order to ascertain the influence of operations on the duration of life. M. Malgaigne collected the details of above five thousand recorded instances of cancerous disease, about half of which had been operated upon. The other half was composed of cases of internal cancer, or cancer not operated on, or situated in regions in which no operation could be performed. From the analysis of these cases, he found that the average duration of life in the patients who had been operated on from the time of the discovery of the disease was twenty-three months ; whereas, in the cases in which no operation has been performed, the average time that had elapsed between the discovery of the disease, and death, was twenty-one months. The results, however, arrived at by Malgaigne, merely em- bodied in figures the generally received doctrines of the profession on this subject. Notwithstanding my lengthened analysis of the opinions of Sir Charles Clarke, Dr. Ashwell, and Dr. Montgomery, on this very important subject, it would be incomplete were I not to reproduce the cases which they bring forward in order to substantiate their assertions. The two following are the principal cases narrated by Sir Charles Clarke:— Case 1.—A married lady, about forty years of age, fell under the care of Mr. Pennington and the author. On examination, a tumour was found at the back part of the cervix of the uterus, of the size of a pullet's egg; it was painful to the touch, and the usual symptoms of carcinoma, in its first stage, were present. The horizontal posture was strictly enjoined, and followed; blood was taken from the sacrum repeatedly by cupping; the bowels were kept open by mild pargatives, and decoction of sarsaparilla was ordered to be taken with small doses of extractum conii. Under a long continued course of such treatment the symptoms all ceased, the patient was enabled to join her family, which she was incapable of doing at first. The author has seen the patient very lately, nearly three years having elapsed since he was first consulted; she reports herself well, and has no reason to believe that any disease exists. Case 2. A widow lady, about forty-eight years of age, who had been a patient of Mr. Bond, at Brighton, was attacked with such symptoms as usually attend disease of the uterus, in the cervix of which a tumour was found, on examination, as large as a French walnut. It was exceedingly tender to the touch, whether the finder was introduced into the vagina, or into the rectum. The means employed in this case were, repeated cupping, abstinence from animal food, the recumbent position, (the upright position or exercise being always attended by considerable pain,) the exhibition of extractum conii, and soda, with the use of the hip-bath, and the occasional employment of mild aperients. After this treatment had been pursued during several months, the uterus was again examined, both by Mr. Bond and myself: this tumour had subsided, and the patient expressed very little pain when the former seat of it was pressed upon (p. 249.) DIAGNOSIS OF CANCER OF THE UTERUS. 377 The wow-cancerous nature of these cases is so clear—they are so evidently mere illustrations of inflammatory induration and hypertrophy of the cervix, subdued by antiphlogistic treatment, that it is quite unnecessary to analyze them. The inflammatory nature of the cases of Dr. Ashwell and Dr Mont- gomery is equally obvious. I will, however, enable my readers to judge for themselves, by reproducing them in a slightly abridged form. Dr. Ashwell's Cases of Incipient Cancer in the Uterine Neck. {Page 394, et seq.) Case 62.—Elizabeth ----, aged forty-nine, married; six children and two miscarriages. In early life menstruation irregular. Her age indicates that the cata- menia are about to cease; and the history of her symptoms during the last year confirms this opinion. The menses have been very irregular, both in quantity, quality, and time of recurrence. A profuse leucorrhea alternates with the catamenial flow. On admission she complained of lumbar pain, central pains in the lower :abdomen, of a pricking and shooting character, which have existed during the last three or four months. An offensive muco-sanguineous discharge (being the cata- menia mixed with leucorrhea) flows from the vagina ; the constitutional symptoms are slight. On examination :—The mucous lining of the upper part of the vagina is relaxed and hot; and above this, a hard body is felt, occupying the superior part of the cervix, and the lower portion of the posterior partes of the uterus. The os is hardened and fissured. After a short preliminary constitutional treatment, and the maintenance of the recumbent position, she was ordered iodine internally and locally. This course was adopted on the 2nd of June, and at the commencement of August all appearance of the tumour and the unhealthy condition of the os had disappeared, and she left the hospital cured. Case 63.—Jane----, aged twenty five, admitted Sept. 5th, 1835. Is the mother of three children, the last of whom was born three months since. Her labours have been undeviatingly easy, and her general health uniformly good. Since her last confinement the abdomen has been considerably distended, and occasions great suffering when pressed. This enlargement is the result of an accumulation of flatus. In addition to this tympanitic condition, which is associated with impaired appetite, occasional nausea, and constipated bowels, she complains of a sense of weight and bearing-down in the lower abdomen, which is aggravated by the erect posture, or by walking. After an examination, Dr. Ashwell reported:—" I find a tumour of scirrhous hardness situated low down, on the posterior part of the cervix of the uterus but not implicating the Up. This growth presses on the rectum, and thus accounts for the constipation." Treatment—assafcetida injections, tonics, iodine. On examina- tion, October the 24th, Dr. Ashwell reported that "no vestige of the tumour was present, and that the os and cervix were perfectly healthy." During the treatment, her symptoms were those arising frem mechanical pressure on the tumour, which gradually subsided with its resolution. Case 64—Sarah----, aged thirty-two, admitted 24th January, 1835. Married five years ago, and has two children. Health in early life good. For some time before marriage, and ever since, has had a leucorrheal discharge. From the same epoch the catamenia have been profuse, frequent in their recurrence and of long duration. Latterly has suffered constantly from languor, and lumbar pains. Her last confinement, thirteen months previous, was followed by passive hemorrhage, which reduced her constitutional power, and engendered debility with loss of flesh. Latterly the menses were suppressed for three months, and she supposed she was pregnant. They reappeared, however, a fortnight ago. Dr. Ashwell, after examin- ation reported:—The uterus is enlarged generally; its lips and cervix are swollen and soft; and there is a considerable quantity of leucorrheal secretion bathing the parts posteriorly. Just above, and encroaching on, the cervix, at the posterior part of the uterus, is a tumour about the size of a hen's egg, scarcely hard enough for scirrhus. 378 DIAGNOSIS OF CANCER OF THE UTERUS. This patient was treated during six weeks by the internal administration of iodine, and its local application to the neck of the uterus. On examination being then instituted, the tumour on the posterior paries of the uterus had disappeared. The use of the iodine was unattended with any deleterious effects. She had assumed a more healthy and robust, rather than an emaciated appearance; and during its exhibition she did not complain of headache, or undue cerebral excitement. Case 65.—Elizabeth----, aged forty-six; admitted under Dr. Ashwell, early in 1830. She has borne several children, and till lately enjoyed good health. For the last few months, however, there has been vaginal discharge of a muco-purulent, and occa- sionally of a sanguineous character. She suffers much from central pains, especially from pain deep down behind the pubes ; her appearance is cachectic and unhealthy; the catamenia are irregular. On examination, the cervix was found excessively hard and enlarged, without any distinct deposit of hard material; the edges of the os puckered and uneven, and their surface slightly broken ; ulceration appears to be just commencing. Iodine treatment. This case continued under treatment for nearly twelve months; but as it was only one out of many similar examples, there was no accurate note preserved of its progress towards cure; nor would it have been reported at all, if the patient had not accidentally presented herself in November, 1835, in the out-patient's room, and thus afforded Mr. Tweedie, who originally had charge of the case, and myself, the opportunity of carefully examining the os and cervix. All vestiges of induration, puckering, irregularity and abrasion of surface? have disappeared: and. with the exception of a leucorrheal discharge, the parts may be pronounced entirely healthy. I have seen this patient very lately, and I can still report the parts to be as sound as they were when the treatment was first discontinued. How a practitioner Avho has seen so much of uterine disease as Dr. Ashwell could possibly publish as illustrations of incipient cancer such cases as the above, is to me matter of astonishment. The most cursory perusal must at once establish them as simple instances of inflamma- tory induration. The first three, more especially, present scarcely any of the symptoms which Dr. Ashwell himself describes as character- izing cancerous disease. Case 62 is an instance of laceration of the os from parturition, followed by inflammatory induration and hypertrophy of the anterior lip, in a woman, mother of a large family. The antecedents and symptoms are purely those of inflammatory disease. In tivo month she was quite well under the influence of rest and iodine. Case 63 is an illustration of chronic inflammatory induration of the posterior region of the cervix and uterine paries, following a natural confinement in a healthy young woman of twenty-five. The symptoms were merely those of local inflammatory hypertrophy, and the general sympathetic reactions which are observed in such cases. She got quite well in six weeks under the influence of rest, general treatment, and iodine. Case 64 is one of inflammatory swelling of the uterine neck, with inflammatory induration of the root of the cervix posteriorly, in a married woman, aged thirty-two, Avho had for some years presented symptoms indicating the existence of inflammatory disease of the cervix. These symptoms had gradually increased since the last con- finement, thirteen months previous. Had she been examined instru- mentally, and the lips of the os opened, inflammatory ulceration would DIAGNOSIS OF CANCER OF TnE UTERUS. 379 probably have been found within. This patient got apparently well in six weeks under the same treatment as the other. Case 65.—This patient presented a condition which at first sight might appear suspicious, but the data which I have laid down for the elucidation of these more obscure cases, at once prove the inflammatory nature of the disease. The cervix was hard and enlarged, the edges of the os puckered and uneven, and ulceration existed. This, however, as I have stated, is the condition in which we find the os and cerA'ix, when the lacerations which often occur after, labour do not heal, and the intervening lobes or lobules, as also the cervix itself, become indurated and hypertrophied. The antecedents and symptoms were purely inflammatory. There is therefore no reason for surprise that she should gradually improve under treatment, and eventually become perfectly free from local disease. The fact of Dr. Ashwell not being able to find any more character- istic cases than these to illustrate the incipient stage of cancer, would alone suffice to invalidate his description of this phase of the disease. It may be remarked that several of these cases present laceration of the cervix, a lesion that I consider of frequent occurrence as the result of labour, an opinion strenuously repudiated by Dr. Ashwell. (p. 433.) Let us now see if Dr. Montgomery's cases are more conclusive. Dr. Montgomery's Cases of Incipient Cancer in the Uterine Neck. {Page 444, et seq.) Case 1.—Mrs. S------; seen 24th August ; 1833. She was in her forty-seventh year, had had six children, and had encountered much domestic anxiety. She was suffering severe pain for the last nine months in the region of the uterus, in the small of the back, and down the thighs, with occasional profuse hemorrhages, alter- nating with sero-mucous discharges. Vaginal examination detected well-marked morbid alterations in the uterus, the orifice of which was irregularly notched, tumid, and with several nodules of scirrhous hardness projecting all round its margin ; and the posterior wall of the cervix was so much thickened, that when felt from the rectum, there was a distinct prominence of the part, with very painful sensibility. She had lost her appetite, was losing her flesh, got little or no sleep, and was in great distress of mind about the state of her health. The treatment was com- menced by leeching, and the use, both internally and externally, of hydriodate of potash and iodine, and of anodynes. Subsequently, the symptoms not yielding, her system was brought moderately under the influence of mercury, and so kept for Bome time. Lastly, she took carbonate of iron, with hyoscyamus and conium. Counter-irritants were used; the leeching was frequently repeated; the hip-bath was tried, but it so decidedly made her worse, that it was given up. After several months of continued treatment, she was perfectly cured of the uterine affection, and has now been well for more than seven years. Case 2.—Mrs. B----, aged thirty-five years, was a member of a family amongst whom there had been a very extraordinary predisposition to cancerous affection. She had had three children, and one 'of her labours was severe. When I first saw her, which was in May, 1837, she complained of lancinating pains in the loins, back and thighs ; dysuria, bearing-down, with irregular sanguineous and other dis- charges; and on examination, the os uteri was tumid, uneven, gaping, a little with its margin irregularly nodulated ; and in one spot there was a deep cleft, as if the part had been torn. There was no discoverable increase in the volume of the 380 DIAGNOSIS OF CANCER OF THE UTERUS. uterus, nor any consolidation of it with the surrounding parts. Treatment: Mercury, iodines, baths subsequently, the symptoms returning after temporary improvement, repeated application of leeches to the os uteri, and externally, iodine, iron, counter-irritants.....The result was, in time, the complete removal of the complaint. I am now informed, by her medical attendant from the country, that she continues perfectly well. Case 3.—Mrs. G----, thirty-five years of age, without children ; seen November, 1838. Complaining of sharp lancinating pains shooting through the centre of th79 29 Married early; Inflammation and several labours.! slight ulceration of cervix. Married at 27; Inflammation and one abortion, j ulceration of cer- vix ; pregnant 6 i months. pains, bearing-down; ill since metritis, soon after marriage. Ill since last labour, 4 years ago; has already been under instrumen- tal treatment, and partly cured. Aborted from a fall a year ago; severe flood- ing ; ill ever since. APPENDIX. 421 No. 1 Age. Menstruation. Social State. Disease. Prominent Symptoms. 1848. Dec. 280 29 Menstruated at Married at 21; Inflammation, ul- Uterine pain, leucor- 19, painfully. two labours. ceration, and hy-pertrophy of cer-vix. rhea, hemorrhagia, extreme debility ; ill since last labour, at 23. 281 48 Menstruated at Married at 18; Inflammation, ul- Uterine pain, leucor- 14, regularly. nine labours ; ceration, and hy- rhea, bearing-down, one abortion. pertrophy of cer-vix; laceration. sickness, great debi-lity ; ill ever since abortion, 5 years ago. 282 22 Menstruated at Virgin ...... Inflammation and Dysmenorrhea, leucor- 18, easily. i ulceration of cer-vix. rhea, uterine pains, debility; ill 18months. 283 29 Menstruated at Married at 20; Inflammation, ul- Dorsal pain, leucor- 18, painfully. two labours. ceration, and hy-pertrophy of cer-vix. rhea, bearing-down, debility ; ill since last labour, 3J years ago. 284 28 Menstruated at Married at 26; Inflammation,slight Uterine pains, bearing- 15, painfully. sterile. ulceration, and hy-pertro'y of cervix. down. 285 16 Menstruated at Married at 17 ; Inflammation,slight Hemorrhage, leucor- 12, painfully. two abortions. ulceration of cer-vix ; pregnant 3 months. rhea, uterine pains, debility; ill since first abortion. 286 30 Menstruated at Married at 27; Inflammation,slight Uterine pains, leucor- 14, painfully. one abortion. ulceration, and hy-pertrophy of cer-vix. rhea; ill since mar-riage ; worse since; abortion. 2S7 16 Menstruated Virgin ...... Inflammation ' and Abscess of left labium, twice, six and ulceration of cer- dorsal pains, leucor- three months vix. rhea, bearing-down : ago. ill nine months. (See 1849. p. 189.) Jan. 288 25 Menstruated at Married at 16; Inflammation, ul- Menorrhagia, uterine 14, painfully. one labour; one ceration, and hy- pains, debilityjill since abortion. pertrophy of cer-vix ; lacerations. tedious labour, at 17 ; worse since abortion, at 20. 289 40 Menstruated at Married at 25; Procidentia uteri, Uterine pains, and ute- 14, painfully. seven labours; ulcerations, and rus prolapsed since one abortion. hypertrophy ol cervix. last labour, 2 years ago, tedious; debility. Feb. 290 33 Menstruated at Married at 23; Inflammation,slighl Uterine pains, leucor- 17, painfully. one labour. ulceration, and hy-pertrophy of cer-vix. rhea, bearing-down, debility since labour, at 24. 291 60 Menstruated at Married at 20 ; Procidentia uteri, Uterus prolapsed many 12. nine labours extensive ulcera- years ; abundant mu- and abortion. tion. co-sanguinolent dis-charge. 292 35 ...... ' Married early; Inflammation, ul- Uterine pains, and 1 five labours. ceration, and hy- spasms ; ill since last pertro'y of cervix. labour, 3 years ago. 422 APPENDIX. No. Age. Menstruation. Social State. Disease. Prominent Symptoms. 1849. Jan. 293 65 Menstruated at 20, regularly, ceased at 50. Married at 25; two labours. Ulcerated cancer of uterus. Last child at 30; no uterino symptoms un-, til a year ago; then leucorrhea, hemor-rhage, dorsal pain. 294 30 Menstruated ai 14, easily. Married at 20; three labours ; three abortions. Inflammation and slight ulceration of cervix. Uterine pains, leucor-rhea, previously flood- j ing ; ill since last la-bour, two years ago, since which, two abor-tions. 295 Mar. 296 50 63 Menses ceasing. Menstruated at 15, painfully. ceased at 48. Married early; several labours. Married at 26; five labours; last at 32. Idiopathic hemor-rhage on cessation of menses. Procidentia uteri, ulceration. Cervix congested ; no lesion; dorsal pain. Uterus prolapsed two years ago, after an effort; leucorrhea. 297 25 Menstruated at 12, easily. Married at 20; three labours. Inflammation ulceration of vix. and cer- Leucorrhea, lumbar pains; ill since first labour, 2 years ago. 298 37 Alenstruated at 15, easily. Married at 21; four labours. Inflammation, ceration, and pertrophy. ul-hy- Flooding every 10 or 15 days; no other ute-rine symptoms since last labour at 29 ; widow since then. 299 20 Menstruated at 15, easily. Married at 18; one labour. Inflammation ulceration of vix. and cer- Severe dorsal and cru-ral pains, leucorrhea; pains soon after la-bour, 7 weeks ago. 300 34 Alenstruated at 14, regularly. Married at 18; six labours; one abortion. Inflammation ulceration of vix. and cer- Uterine pains, dysme-norrhea, bearing-down ; ill since last labour, 14 months ago. The treatment of the above cases was conducted on the principles laid doAvn in the course of the work, and, generally speaking, with the most satisfactory results. I have not, however, thought it advisable to include these results in the tables. The attendance of persons who are treated for chronic disease, as out-patients, at a public institution, must, in many instances, be irregular and interrupted, and often prematurely brought to a close—the physician or surgeon exercising little or no control over their movements. It would, consequently, be injudicious and unfair to attempt to arrive at any statistical deduction as to the length or ultimate success of the therapeutic means employed, by the analysis of such cases. THE END. INDEX. Abortion, cases in which it was prevented, 153,157 ; cases followed by, 160, 163, 171, 174 ; causes of, 321. Abscess, in vulva, case of, 145 ; of uterine appendages in non-puerperal state, 199; causes of, 200; symptoms of, 201; progress and termination of, 207; prognosis of, ib.; diagnosis of, 208; in puerperal state, 210; pathological anatomy of, 213; case of, following cauterization, 247; of uterine appendages, treatment of, 291. Acid nitrate of mercury, application of, 235. Acton, Mr., on syphilitic ulceration of uterine neck, 349. Actual cautery, the effect of, 244; recommended by Celsus, ib. ; M. Jobert on, 245. Advanced life, inflammation of neck of uterus in, 176; case of, 178 ; case of, from blennorrhagia, 180. Amenorrhea, various forms of, 303 ; treatment of, 306. Ashwell, Dr., his experience respecting inflammation of the cervix uteri, 58 ; on cancer of the uterus, 367 ; cases treated by, 377. Backache, a symptom of inflammation of the cervix uteri, 103; in cases of uterine inflammation in advanced life, 177. Bandages, remarks on, 255. Baths, use of, in inflammation of uterine neck, 221. Beck, Dr. Snow, on the nerves of the uterus, 46. Bennett, Dr. Hughes, on various forms of cancer, 362. Biliary derangement, iu cases of inflammation of the uterus, 114. Bladder, extension of inflammation of cervix uteri to, 98 ; case of great irritability of, from inflammation of the cervix uteri, 139; treatment of irritability of, 264. Blennorrhagia, case of inflammation of the uterine neck from, 180; eases of, connected with chancres, 352—354. Blood, deterioration of, a cause of amenorrhea, 308. Bougies, metallic, for dilating the cervical cavity, 260. Boyer, his definition of ulceration, 90. Boys de Loury, M., on inflammation of uterine neck in pregnancy, 147. Breasts, pain and swelling of, a symptom of inflammation of the uterus, 109. 424 INDEX. Cancer, of the uterus, diagnosis of, 360 ; Dr. Hughes Bennett on various form.s of, 362; of the cervix in incipient stage, 364; Sir C. Clarke on cancer of the uterus, 366; Dr. Ashwell on cancer of uterus, 367 ; Dr. Mont- gomery on, 466 ; M. Malgaigne on operations for, 477; cases of supposed, treated by Sir C. Clarke, 474; cases treated by Dr. Ashwell as, 475; Dr. Montgomery's cases of " incipient cancer," 479; ulcerated cancer of os uteri, 486. Cancerous and cancroid growths, mistaken ideas concerning, 360. Cauterization, treatment of inflammation of the cervix uteri by, 228, 229; by nitrate of silver, 231; inflammation and abscess following, 247; metritis following, .249. Celsus, his recommendation of the actual cautery, 244. Cerebral symptoms, in uterine inflammation, 118. Cervix uteri, inflammation of, considered generally, 80; ulceration and hyper- trophy of, ib.; case of congenital elongation of, ib. ; inflammation of, seat, causes, 81; symptoms of, 85; anatomical symptoms of, ib. ; con- gestion and simple inflammation of, ib. ; changes produced by inflamma- tion in cavity of, 86; inflammatory ulceration of, 89; inflammatory hypertrophy of, 94; displacement of, 96; extension of inflammation of, to vagina and vulva, 97; to rectum and bladder, 98; hemorrhoids and prolapsus ani, symptoms of, 99; state of urine in, 101; pain, and its seat in, 102 ; backache a symptom of, 103 ; menstruation, state of, in, 105 ; impregnation in cases of, 107 ; sterility arising from, 108 ; uterine inertia a symptom of, ib.; sexual passion modified by, 109; pain and swelling of breasts a symptom of, ib.; effects of, on digestion, 110; state of urine in, 111; biliary derangement in, 114; state of respiration in, 116; state of circulation in, 117; defect of nutrition in, ib.; cerebral and spinal symptoms in, 118; deafness in, ib.; sleepless- ness in, 119; summary of symptoms of, ib.; progress of, 120; termina- tion of, 121 ; prognosis of, 122 ; diagnosis of, 123 ; pathological anatomy of, 126; inflammation of, in the virgin, 127; case of extensive inflammation of, in virgin, 136 ; remarks on case of, 138 ; dysmenorrhea and irritation of bladder, abortion from, 139 ; inflammation of, during pregnancy, 140; cases in which abortion was prevented, 153, 157 ; cases followed by abortion, 160, 163, 171, 174; inflammation of, during and after parturition, 166; induration of, ib.; case of induration of, 167; laceration of, from parturition, ib.; hemorrhage in cases of, 168; puerperal fever from, after parturition, 170; inflammation of, in advanced life, 176; cases, 178 ; case of, from blennorrhagia, 180; treatment of inflammation of, without ulceration or hypertrophy, 216; treatment of, with ulceration and hypertrophy, 228 ; treatment of hypertrophy and induration of, 249 ; treatment of, by mercurials and iodine, 250; dis- placement of the, 254 ; retroversion of, 256 ; rest and exercise in, 263 ; general treatment of inflammation of, 265 ; treatment of, in virgin, 278 ; amenorrhea from inflammation of, 310 ; menorrhagia from inflammation of, 312; inflammation of, a cause of sterility, 319 ; abortion from, 321; prolapsus connected with, 324; inflammation of, the cause of convulsive hysteria, 334; fibrous tumours in connexion with, 337; syphilitic ulceration of, 349 ; cancer of, 360; ulcerated cancer of, 383. INDEX. 425 Chancres, real, of cervix uteri, 350; their character and appearances, 356; cases illustrative of, 352, 354, 355; inoculation from, 354. Changes produced by inflammation in the cervix uteri, 86. Chloroform in uterine pain, 257. Chlorosis, account of, 335 ; not connected with the uterus, ib. Circulation, state of, in inflammation of the uterus, 117. Clarke, Sir C, on cancer of the uterus, 365; cases treated by, 376. Clitoris, the anatomy of, 48. Congestion, of the cervix uteri, 85. Constipation, a symptom of inflammation of the uterus, 99; treatment of, in uterine inflammation, 274. Convulsive hysteria, description of, 334. Cooper, Samuel, his definition of ulceration, 89. Cupping, in inflammation of uterine neck, 227. Deafness dependent on inflammation of the uterus, 118. Debility, treatment of the, consequent upon inflammation of the neck of the uterus, 272. Diarrhea preceding menstruation, 99. Diet, remarks on, 266. Digestion, effects of inflammation of the uterus On, 110. Dilation, of the cervical cavity, 258 ; cases of dysmenorrhea treated by, with metallic bougies, 259 ; by sounds, 261. Dioptra, the ancient speculum, 35. Discharges in connexion with ulceration of the cervix uteri, 92. Displacements of the cervix uteri, 96 ; of the neck of the uterus, 254; of the uterus, 323. Dysmenorrhea, caused by inflammation of the cervix uteri, 139 ; case of, treated by dilatation of cervical cavity, 258; description of various forms of, 300; treatment of, ib. Dyspnoea in inflammation of the uterus, 117. Dyspepsia a symptom of inflammation of the uterus, 110. Electricity, its value in amenorrhea, 307. Ergot of rye in menorrhagia, 315. Esthiomene, M. Huguier on, 185. Exdermoptosis, account of, 184. Fallopian tubes, the anatomy and physiology of, 47. Flatus, expulsion of, from the uterus, a sign of inflammation, 93. Fibrous growths of the uterus the cause of displacement, 327. Fibrous polypus, of the uterus, 387; case of, 838 ; adhering to the neck, cases of, 340, 342; case of inflammation and ulceration of uterus, complicating, 347. 420 INDEX. Gendrin, M., on inflammation of the uterine appendages, 197; his mode of applying potassa fusa, 236; cases of abscess following severe cauteriza- tion, under, 248. Gibert, M., on syphilitic ulceration of the neck of the uterus, 349, 357. Guy's Hospital, inflammation of the cervix uteri at, 58. Hemorrhage, periodic, during pregnancy, 151; in cases of abortion and par- turition, 168 ; case of obstinate, 171; obstinate case of, from vascular polypus, 343. Hemorrhoids, a symptom of inflammation of the uterus, 99. Hippocrates, his writings on diseases of the womb, 36. Huguier, M., on exdermoptosis, 184; on esthiomene, 185. Hymen, anatomy of the, 49 ; imperforate, a cause of amenorrhea, 308. Hypertrophy of cervix uteri, considered generally, 80. Hysteria, various forms of, 335. Impregnation, in cases of inflammation of cervix uteri, 107. Induration, of the neck of the uterus in connexion with delivery, 166; case of, 167 ; of the cervix uteri following ulceration, 355. Inertia of the Uterus a symptom of inflammation, 108. Inflammation, of the uterine neck—ignorance respecting it, 37 ; its frequeney and importance in uterine pathology, 56; of cervix uteri, considered generally, 80 ; mistaken for cancer, 361. Inflammatory hypertrophy of the uterine neck, symptoms of, 94. Inflammatory ulceration of the cervix uteri, 89. Injections, in inflammation of the cervix uteri, 217; mode of using, 220; uterine, danger of, 287. Inoculation, from chancres of neck of uterus, 354. Iodine, treatment of induration and hypertrophy by, 250. Issue, formation of an, for uterine pain, 258. Issues, use of, in chronic metritis, 282. Jobert, M., on the use of the actual cautery, 245; his trial of uterine injec- tions, 287. Laceration of the uterine neck from parturition, 167. Latham, Dr., on the investigation of disease, 391. Lee, Dr. R., on the nerves of the uterus, 46. Leeches, use of, in inflammation of uterine neck, 222 ; mode of applying, 227. Leucorrhea, description of, 317. Lisfranc, his use of the speculum, 37; on bleeding, in inflammation of neck of uterus, 228. Lobes, cause of, in indurated cervix uteri, 96. INDEX. 427 Macintosh, Dr., his use of metallic bougies, 261; on dysmenorrhea, 297. Malgaigne, M., on duration of life in cancer of the uterus, 376. Marechal de Calvi, M., on pelvic inflammation, 196. Menorrhagia, various forms of, 310. Menstrual states, morbid, 293. Menstruation, physiology of, 53 ; Dr. Robertson on, 54; condition of, in inflammation of cervix uteri, 105; causes of suppression of, 305; menorrhagia in connexion with, 312 ; vicarious, 306. Mercurials, treatment of induration and hypertrophy by, 249. Mercury in cases of chancre of uterine neck, 355. Metritis, acute, description of, 61; seat of, ib.; symptoms of, 62 ; progress and termination of, 64; prognosis and diagnosis of, ib.; pathological anatomy of, 65 ; internal seat of, 74 ; causes, symptoms of, 75; progress, termination, prognosis of, 77; pathological anatomy, diagnosis of, 78; Dr. Hall Davis, his case of ulceration of the uterus, 77 ; chronic, seat of, causes, symptoms of, 66; partial, 69 ; progress of, 70; termination, prognosis of, 71; diagnosis of, 72; pathological anatomy of, 73; acute, cases of, following cauterization, 248 ; acute, treatment of, 280 ; chronic, treatment of, 281; internal, treatment of, 286. Metro-peritonitis, death from, 157. Mineral acids, application of them as caustics, 234. Montgomery, Dr., on cancer of the uterus, 870 ; cases treated by, 379. Narcotics, remarks on the use of, 266. Nerves of the uterus, Dr. R. Lee and Dr. Beck on, 46. Neuralgia of the uterus, symptoms and causes of, 103. Nitrate of silver, cauterization by, 231; mode of applying, ib. Non-chancrous ulcers complicating syphilis, 356. Nutrition, defect of, in uterine inflammation, 117. Occlusion of the os uteri, 309. Opium, remarks on the use of, 267. Os uteri, plugging the, for menorrhagia, 316. Ovaries, anatomy and physiology of the, 47; inflammation and abscess of, 196; Paulus iEgineta on the, ib. Ovarian disease, amenorrhea from, 309. Ovaritis, subacute and chronic, causes and symptoms of, 192; acute, 195; acute and subacute, treatment of, 290; menorrhagia from, 312. Pain, and its seat, in ulceration of the cervix uteri, 102; uterine, treatment of, 257. Paris hospitals, regulations of, 357. Parturition, menorrhagia after, 313. Paulus iE ( cy, inflamed ) Ditto Ditto Ditto Ditto ged by re- pre inflamed Swollen and soft Natural..... Ditto ..... Ditto..... Large and inflamed Natural..... Gravid..... Natural..... Prolapsed . . . . Natural..... Cervix and Os Uteri. Natural..... Os rigid and contracted f Os irregular, a tumor { on one side . Healthy .... f Cervix much inflamed ( os ulcerated . Os and cervix ulcerated Os closed . Fungous tumor Os widely open Ditto .... Sloughing . . . Natural .... Ditto .... Ditto .... Fatty degeneration Natural .... Ditto .... ( Displaced fundus' < adherent! ( turn Natural Ditto Ditto Ditto Ditto Ditto 1 fundus J it to rec- > ( Displaced to ~i < right side, hard > ( and swollen . ) Natural Hard and small . Natural .... Ditto .... Ditto .... f Fibrous tumor of 1 | the fundus J Natural .... Ditto .... Long neck . . Natural .... Inflamed Os ulcerated . . Os scirrhous, deep ulcers Cervix swollen Os ulcerated . . Lacerated ulcers . Cervix inflamed, os ulc'ated Cervix inflamed, os ex- 1 tensively ulcerated) Cervix swollen, soft Not unhealthy Cervix ulcerated, os raw and open . Os irregular, hard . Cancerous uicers . . Cervix and os inflamed Ditto...... Os obliterated . . . Cervix and os ulcerated Tubercles in cervix Natural .... Ovaries and Fallopian Tubes. f Cervix long and large, { bent slightly backward ( Ulcers within the canal ] \ of the cervix ... J Healthy......' Cervix and os congested Healthy...... Ulcers in cervix . . . Healthy...... Fallopian tubes obliterated. Ovaries shrivelled. Left ovary much diseased. Healthy. (Left ovary enlarged and in ( flamed. Fallopian tubes strictured. Both ovaries absorbed. Left Fallopian tube obliterated. Both ovaries healthy. Ovaries, &c. inflamed. Healthy. Ovaries natural. One Fallopian tube obliterated. Natural. General redness. Tubes and ovaries adherent. General inflammation. Ovaries sound. Natural. ( Right Fallopian tube oblite \ rated. Ovaries absorbed. Inflamed. Natural. Ditto.* Ovaries absorbed. Ditto. Ovaries red. Healthy. Natural. Ovaries very hard. Fallopian tubes adherent. Healthy. Hydatids in left ovary. (Ovaries sound, Fallopian tube: \ obliterated. Scirrhus of right ovary. Cervix much ulcerated Natural..... Cervix hard, os small Cervix swollen and red Natural..... Ditto...... Ditto...... Os very red, abraded . Natural..... Large and soft Natural . . Ditto . . • Healthy. . . Ditto....... (Cervix fissured and) (hard; os red, abrasion J Reddish...... Natural...... Ditto....... Extensively ulcerated . f Ovaries congested, Fallopiar [ tubes obliterated. Right ovary atrophied. Ovaries small. Healthy. Ditto. Ditto. Natural. Natural. (Right ovary very hard and ( horny. Healthy. Left ovary corrugated. Natural. Undeveloped. Natural. Inflamed. D. Stewart, M. D., First-Class Staff Surgeon, Late Professor of Midwifery in the Medical College of Calcutta. Calcutta, March, 1S53. G3 APPENDIX. This interesting and valuable document from the far east speaks for itself. In fifteen cases out of the fifty, there was inflammatory ulcera- tion ; and in many the ulceration is noticed as extensive. In various other instances the cervix was also inflamed and indurated. Thus does it bear out all my statements and opinions respecting the frequency of inflammatory and ulcerative lesions of the cervix uteri in the dead as well as the living. It corroborates the results arrived at by Dr. West, and proves, at the same time, the utter fallacy of Dr. Robert Lee's and Dr. Tyler Smith's negative assertions in 1850—assertions founded on the old post-mortem records of St. George's Hospital. It is impos- sible, also, to cast an eye over the list of lesions, uterine and ovarian, which it reveals, and not to feel that the defective nutrition and debility which usually accompany such lesions during life must have exercised a pernicious influence on the individuals in whom they were found, and must have thus contributed to their death, by depriving them of the power of resisting intercurrent disease. II. THE USE AND ABUSE OF THE STRONGER CAUSTICS, AND OF THE ACTUAL CAUTERY, IN THE TREATMENT OF UTERINE DISEASE. In the course of the discussion to which the publication of this Re- view has given rise, it has been stated that I recommend the stronger caustics to be used to destroy the indurated and hypertrophied tissues in chronic inflammatory disease of the neck of the uterus. I can- not better disprove such assertions—which are thoroughly unfounded and untrue—than by giving a few extracts from my own writings. They will show, in the most undeniable manner, not only that I am not open to any such accusation, but that I have been the very first to raise my voice against the abuse of the surgical agents, the discreet use of which I recommend in the treatment of intractable disease of the cervix uteri. They will also tend to place the question in its real light, should it become the subject of further discussion. Extracts from the Third Edition of my Work on "Uterine Inflamma- tion," published 1853. "It cannot, however, be denied that cauterization of the cervix, as above described, and especially deep cauterization, is an operation, and, like all operations, surrounded with danger. It must not, therefore, be either injudiciously resorted to, or carelessly carried out. Although my own practice has hitherto been free, or all but free, from serious accidents, the same immunity does not appear to have attended that of others. Various cases in which serious accidents have followed the use of the caustic potash have been narrated as arguments against its use since the last edition of this work was published; and M. Gendrin has THE USE AND ABUSE OF THE STRONGER CAUSTICS. 69 himself, within the last few years, had several cases of acute metritis, and of abscess in the lateral ligaments, the evident and immediate re- sult of deep cauterization. He has, however, seen the same results follow the use of the nitrate of silver, and of injections; and I may mention, that the two most severe instances of acute metritis that I have myself witnessed for some time in the unimpregnated womb, occurred after the use of weak astringent vaginal injections."—p. 297. " I must, however, most emphatically guard practitioners against an error into which there would appear to be some danger of their falling, from misinterpretation of my views. I wish it to be most distinctly understood that I do not propose to destroy the hypertrophied cervix by cauterization, but merely to set up an artificial eliminatory inflamma- tion, by means of an eschar or issue, of limited extent, established in the centre of the hypertrophied region. I do not calculate, in the re- motest degree, on the destruction of tissue to which the caustic or cautery gives rise, for diminishing the size of the hypertrophied cervix, but solely and entirely on the inflammation subsequently set up. Any attempt actually to destroy the hypertrophy by direct cauterization appears to me both dangerous and unnecessary; dangerous, because I should be afraid that the intensity of the reactional inflammation would be so great as often to extend to the uterus or to the lateral ligaments, and because I consider it next to impossible always to limit the action of the caustic when applied with such profusion; unnecessary, because a mere eschar, of the size of a shilling, will answer the purpose of re- ducing the hypertrophy equally well. It may, perhaps, be necessary to apply it several times; but of what consequence is prolonging for a few weeks the treatment of a disease which must have existed for years to require treating at all by such agents, compared with the danger of perforating the vagina, and causing peritonitis, or of giving rise to acute metritis ?"—p. 302. A Memoir read before the Medical Society of London, July, 1854, On the Use and Abuse of the Stronger Caustics in the Treatment of Uterine Disease, and published in " The Lancet," July and August, 1854. It is now more than nine years since I introduced to the profession, in the first edition of my'work on "Uterine Inflammation," potassa fusa and potassa cum calce as valuable remedies in the treatment of some chronic and intractable forms of uterine inflammation. Since then these agents have been adopted by many practitioners at home and abroad, a fact of which I have ample evidence in my own practice, as I am constantly consulted by patients in whom this means of treatment has been resorted to. In some of these cases I have found that the caustic potash has been incautiously used, so that lesions of the vagina and partial occlusions of the cervical canal have been produced, not- withstanding the careful and minute directions which I have given for its employment. As I cannot but consider myself to a certain extent responsible for the use of a remedy which I have introduced in this country, I am anxious, in the present paper, to lay down precisely the 70 APPENDIX. rules which ought to regulate practitioners when they resort to so powerful an agent. . . Pota«a cum calce was first used in the treatment of chronic inflam- mation of the cervix uteri by M. Gendrin, the enlightened physician to la Pittf Paris. It was in the year 1837, seventeen years ago, that I fir«t «'iw him employ it, and during the three years that I subsequently passed with him, as his pupil and interne, we were scarcely ever with- out cases in process of treatment by this means. Subsequent experi- ence confirmed the results at which I then arrived, and led me to the conviction which I have repeatedly expressed—a conviction that time only strengthens—that the application of caustic potash to the treat- ment of chronic and intractable uterine inflammation is one of the most valuable contributions to uterine pathology that has been made in modern times. At the same time, I am perfectly ready to admit, that in unskilled hands it is a dangerous remedy—a double-edged sword, which indiscreetly used may do positive harm, instead of good. But we must recollect that the same remark equally applies to all surgical means of treating disease in every part of the human economy. What havoc may not the bistoury, the principal agent of the operating sur- geon's ministry, produce, unless guided by skill and prudence ? The fact of a powerful remedy being, in unskilled hands, a dangerous one, is no more a reason why it should be discarded than is the same fact a reason why the health or death-giving instruments of the surgeon should be anathematized. It is, however, a reason why the rules that ought to guide us in the use of this remedy should be carefully elucidated and scrupulously followed. It is owing, no doubt, to the unvarying care with which I use the caustic potash, that I am able to say that, after seventeen years' extensive experience of the remedy, I have not yet had a single serious accident. M. Gendrin always used a paste made of the potassa cum calce of the Pharmacopoeia, moistened with alcohol. I myself followed his ex- ample for some years ; but finding its application difficult, I first tried the caustic potash of Dr. Filhos, and then potassa fusa alone. The former consists of two parts of lime and one of potash, run into lead moulds. I found these tubes convenient for use, but not sufficiently active ; whilst the pure caustic potash in cylinders was so very delique- scent, that it required a troublesome process of packing the surround- ing parts with cotton steeped in vinegar, to limit the action of the caustic to the region on which it was intended to act. This induced me to try if I could not obtain cylinders of potassa cum calce in a more active form : two parts of potash to one of lime, and in a free state— that is, not cased in tubes. In this attempt, with Mr. Squirr's assist- ance, I completely succeeded, by casting it in iron moulds, and obtained sticks of potassa cum calce nearly as active as the pure potassa fusa, and yet having the non-deliquescent properties of the potassa cum calce paste. These cylinders, which are made of various sizes, render the application of this powerful remedy as easy as that of the nitrate of silver, no previous packing of the parts being necessary, and the action being limited to the region to which it is applied. Thus has been at- tained a great desideratum—a valuable agent, which could previously THE USE AND ABUSE OF THE STRONGER CAUSTICS. 71 only be used with some trouble and risk, having been rendered manage- able and safe. The conditions of local uterine disease in which I consider that potassa cum calce may be used with advantage, are—intractable chronic inflammation, or inflammatory ulceration of the mucous membrane covering the cervix uteri, or lining the cervical canal; chronic inflam- matory hypertrophy of the cervix: and lastly, chronic inflammation of the body of the uterus, in which form of disease I merely apply the caustic potash to the cervix, to produce a derivative issue. The principles on which I have endeavored to found the local treat- ment of the chronic inflammatory conditions which are so common about the cervix, its os and cavity, are those which ought to regulate the treatment of all inflammatory diseases of the skin and mucous membrane in explorable regions. If the acute or subacute stage of in- flammation still exists, emollient applications and local depletion are indicated; if that stage has passed, and the disease appears in the chronic form, astringents should be used to directly modify the diseased capillary circulation, and they failing to restore healthy action, caus- tics should be resorted to, especially if ulceration be present, with a view to substitute healthy, reparative, manageable inflammation for that in existence, which is unhealthy, destructive, and unmanageable. This appears to me the true modus operandi of caustics and of the actual cautery, whenever they are used in the treatment of morbid in- flammatory conditions, from a minute ulcer of the cornea to hospital gangrene. The inflammation set up by nature to throw off the eschar artificially produced, is naturally of a healthy, reparative kind, which admits of being controlled, and brought to a favorable termination, provided the stimulation be sufficiently poiverful. Thence it is that if one caustic, the nitrate of silver, for instance, does not produce the desired effect, another more powerful, such as the acid nitrate of mer- cury, may; and that failing, a still more powerful agent, such as the actual cautery or caustic potash, will certainly succeed. This law—for law it may be termed—deserves a more general recognition in surgery than it has hitherto obtained, for it points out the true mode of treat- ment in many intractable forms of chronic inflammatory disease. It will be observed that I speak of the actual cautery in the same para- graph with caustic potash, the rationale of the action of these agents being identically the same. In chronic ulcerative disease, the caustic should only be lightly ap- plied, the object being merely to renew the surface of the sore. In chronic hypertrophy, the object in view is rather different. It is not the destruction of the hypertrophied tissues which is desired ; but the production of a state of increased vitality, bordering on inflammation, in these tissues, under the influence of which they soften and melt. This result is produced by the mere formation and elimination of an eschar the size of a shilling, and a few lines in depth. It is certainly quite unnecessary to destroy any amount of diseased tissue, as has been recommended since I first introduced this plan of treatment; such a course greatly aggravates the importance and risk of the operative pro- cess, without any equivalent benefit accruing to the patient. If the 72 APPENDIX. softening and melting of the indurated and hypertrophied cervix does not take place entirely on the first application, it may be repeated several times on different regions of the cervix, at intervals of four or six weeks. Although a more tedious mode of proceeding, I am con- vinced that it is a more safe one than the extensive destruction at one sitting of the indurated tissues of the cervix uteri, advised by some who have adopted the practice. It is, however, more especially when the caustic cylinder is passed into the cervical canal, in the treatment of inflammation of that region, that caution is necessary, and that I find it is not always observed. Inflammatory ulceration not unfrequently passes into the lower part of the cervical canal, and proves intractable to all ordinary means. Chronic inflammation of the mucous membrane and follicles lining the cervical canal, may obstinately resist all means of treatment, owing, probably, to many of the diseased follicles being concealed between the sulci, or depressions existing between the rugas of the arbor vitse. In both these forms of cervical disease, I have recommended, as a last re- source, a small potassa cum calce cylinder to be applied inside the os, to the diseased surface. Its action being more decided and deeper than that of iodine, the nitrate of silver, &c, it probably produces more energetic vital reaction, and reaches, moreover, the concealed follicles, which the other milder caustics do not. It is certain that I occasionally meet with cases of chronic inflammation of the cervical canal, otherwise incurable, both in my hands and in those of other physicians who have preceded me, which I am able to cure by this means, and this alone. I must, however, be allowed to repeat, that in my practice the use of potassa cum calce, especially in the treatment of inflammation of the cervical canal, is altogether an ultima ratio—a last resource, and not an ordinary mode of treatment. When a small caustic cylinder is merely passed gently inside the cervical canal, and only allowed to remain a few seconds—all that is generally required—the destruction of tissue is very slight, and there is afterwards no very marked tendency to contraction. If a more decided action is produced, however, the subsequent tendency to con- traction is great, and unless counteracted by dilatation during the process of healing, may end in all but complete obliteration of the cervical canal, and that by a cicatricial tissue which it is very difficult to dilate. Several instances of the kind have come under my notice from the country. In one lady, I was a fortnight before I could dis- cover the external orifice of the canal, and then I only found it through the advent of menstruation, the blood bulging behind the mucous membrane, for I had been previously dilating the orifice of a mucous follicle. This lady, aged forty, had scarcely seen any show for months, although the menstrual molimen came periodically ; and she had become liable at those times to severe hysterical attacks bordering on epilepsy. These attacks all but ceased on a free exit being procured for the menstrual discharge. I have now under my care a young lady aged twenty-six, in whom the cervical canal was so narrowed from the same cause, that I was not able to pass the smallest bougie. Men- struation took place with extreme difficulty, and guttatim. Her state THE USE AND ABUSE OF THE STRONGER CAUSTICS. 73 was one which it was very difficult to remedy, for the stricture was high up—half an inch from the os—and extended some distance. That such a cicatricial stricture must be difficult to remove stands to reason, as the union between the walls of the canal is no doubt very intimate. Two years ago I had an opportunity of examining the uterus of a former patient of my own, similarly, but more cautiously treated some years previously, and found the cervical canal, although quite permeable, much diminished in calibre by extensive adhesions. This lady died at the age of thirty-seven, of cancer of the caecum; the uterus was quite healthy. These and other similar cases which I have met with prove that great care should be shown when this plan of treatment is followed, but not that it is one which should not be adopted if imperatively required. If the caustic is not too severely applied, on the one hand, and on the other, the canal is kept open by passing a common bougie once or twice a week regularly, until the surface acted on is healed, and all tendency to contraction have ceased, no morbid diminution of the calibre of the cervical canal can ensue. Many of the cases which I see being extreme ones, I not unfrequently have had to resort to this mode of treatment, and yet I have very seldom had occasion to dilate the cervical canal afterwards; and when I have, it has been because accidental circum- stances have taken the patient out of my reach whilst under treatment. As a rule, I should say that no patient, in whose case the caustic potash has been applied to the cervical canal, should be lost sight of in less than six weeks, and during that time the canal should be kept open by the passage of a moderate-sized bougie once or twice a week. The other accidents which may follow the use of caustic potash are, extension of the caustic to the vagina, and extension of the inflamma- tory reaction produced to the uterus and peritoneum. These acci- dents, like the former, may be avoided by common care and prudence. Potassa fusa itself ought, I think, to be discarded, now that we have in the potassa cum calce cylinders such an admirable and safe substi- tute. All the instances in which I have seen the vagina compromised have been cases in which pure potassa fusa had been used. It is so extremely deliquescent, that it is all but impossible to always avoid its running on to the adjoining parts. As regards the extension of the secondary inflammation, that need not be feared if due precautions are taken both before and after the caustic is applied. All acute or even subacute inflammatory action should be first subdued, and the proper time should be chosen for the operation. Four or five days after men- struation is the best time, as it allows two or three weeks' quiescence from the menstrual molimen. Lastly, the eschar produced should not be too extensive. One of the chief arguments that have been adduced against the use of caustic potash to the neck of the uterus is, that it produces cica- trices that may interfere with the process of parturition. This is merely a theoretical objection, not founded on observation, and devoid of truth. The fact is, that the faintest trace of even a deep eschar produced in this region, either by a caustic or by the actual cautery, ceases to be visible after the lapse of a few months. So far from causing 6 74 APPENDIX. induration, the action of these surgical agents is to melt and soften induration of the cervix when the latter is the result of chronic inflam- mation, as is usually the case, by favorably modifying the morbid nutri- tion of the parts diseased. The idea of hard cicatrices has been taken from the observation of what occurs in the skin, without taking into consideration that the structure of the skin and of mucous membrane is essentially different. In the skin there is a fully developed fibrous framework, which is the principal foundation of the hard cicatrix that follows any loss of substance in which it is involved. This fibrous framework is merely rudimentary in mucous membranes, and thence the facility with which any loss of substance in them is repaired. This we see exemplified in the mouth and intestinal canal, where all traces of ulcerative action are eventually lost. In the cervix uteri we see how nature repairs divisions and losses of substance, by observing what occurs after the lacerations of the substance of the cervix, which are so common in parturition, and which, when no subsequent inflamma- tion sets up, merely leave a soft notch as the trace of their occurrence. Such being the case, it is clear that the application of potassa cum calce to the cervix uteri, so far from hardening the organ, and proving an impediment to future labors, acts in the reverse manner, positively facilitating parturition, by removing chronic inflammatory hypertrophy. Indeed, I may here remark, that the more I progress in life the more I become convinced of the truth of an assertion which I made many years ago, viz : that most of the cases of rigid, undilating os uteri met with in practice are occasioned by chronic inflammatory disease of that organ, and not by constitutional conditions, spasms, &c, an important fact in practical midwifery. In concluding these remarks on the use and abuse of caustic potash in the treatment of inflammatory disease of the uterus, I wish to lay stress on the fact, that I only recommend it, and resort to it, when there is actual disease present, when the cervix is the seat of chronic inflammatory action, intractable to all other agents, general and local, and when the hypertrophy is caused and kept up by such disease. In those cases of hypertrophy in which the cervix is merely passively enlarged, in which inflammatory action either does not exist, or has given way to treatment or time, it ought not to be resorted to. The enlargement may then be safely left to nature and to general treatment. The absorbent powers of the uterus are, perhaps, greater than those of any other organ in the economy, and are generally sufficient, in the course of time, to fine down the enlarged cervix, when all actual disease has been removed. I must be allowed to add, that the potassa cum calce cylinders con- stitute a very valuable and manageable caustic, whenever such an agent is required, for the destruction of cancers, the treatment of indolent sores, &c. I have found it of great use in the treatment of hemor- rhoids, and in some cases, preferable to the nitric acid, which has been of late so much recommended. THE USE AND ABUSE OF THE STRONGER CAUSTICS. 75 Extract from a Communication to " The Lancet" of May 3, 1856. There are morbid conditions of the cervix uteri, chronic inflamma- tory indurations, indolent ulcerations, suspicious sores and tumors, which, like similar morbid conditions in other parts of the economy, occasionally resist mere antiphlogistic remedies, and require for their radical cure more potent surgical agencies, viz: the mineral acids, potassa cum calce, or the actual cautery. In the immense majority of cases, these surgical means need only be used as vitality-modifying agents ; and when so employed with due care and discretion, leave no trace behind them; neither cicatrix nor other evidence of their use, beyond the removal of disease. There are instances, however, in which these agents may be legitimately used, and must be used, to destroy diseased tissue ; as, for instance, in the treatment of cauliflower excrescences, or of other forms of suspicious but removable tumors springing from the cervix. In such cases, we ought not to be satisfied merely with the removal of the tumor, but to destroy, without hesi- tation, but with care, the diseased surface from which it springs. In so doing we may, if successful, leave traces of the operation ; but we have not mutilated the patient; we have simply saved life. Mutilation, in its accepted scientific sense, implies, on the contrary, "the unnecessary, unwarrantable destruction of organic textures." 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By reference to the terms it will be seen that, in addition to this large amount of valuable and practical information on every branch of medical science, the subscriber, by paying in advance, becomes entitled, without further charge, to THE MEDICAL NEWS AND LIBRARY, a monthly periodical of thirty-two large octavo pages. Its "News Department" presents the current information of the day, while the " Library Department" is devoted to presenting stand- ard works on various branches of medicine. Within a few years, subscribers have thus received, without expense, the following works which have passed through its columns :— WATSON'S LECTURES ON THE PRACTICE OF PHYSIC. BRODIE'S CLINICAL LECTURES ON SURGERY. TODD AND BOWMAN'S PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. 72-4 pages, with numerous wood-cuts, being all that has yet appeared in England. WEST'S LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. MALGAIGNE'S OPERATIVE SURGERY, with wood-cuts. SIMON'S LECTURES ON GENERAL PATHOLOGY. BENNETT ON PULMONARY TUBERCULOSIS, with wood-cuts, WEST ON ULCERATION OF THE OS UTERI, and BROWN ON THE SURGICAL DISEASES OF FEMALES, with wood-cuts. While the number for July, 185G, will commence a new and highly important work, WEST'S LECTURES ON THE DISEASES OF WOMEN. Part I.—Diseases of the Uterus. The very favorable reception accorded by the profession to the valuable " Lectures on the Diseases of Children," by the same author, which likewise appeared in this periodical, lias in- duced the publishers to secure the present work for their subscribers, from advance sheets, supplied by the author. The very high reputation of Dr. West, and the unusual clinical advantages which he has enjoyed, sufficiently indicate the practical value of a systematic work from his pen on so important a subject. The publishers, therefore, trust that its appearance in the " News" will afford entire satisfaction to their numerous subscribers, who will thus receive it free of all expense. 133* For a more extended advertisement, see p. 32. It will thus be seen that for the small sum of FIVE DOLLARS, paid in advance, the subscriber will obtain a Quarterly and a Monthly periodical, EMBRACING ABOUT FIFTEEN HUNDRED LARGE OCTAVO PAGES, mailed to any part of the United States, free of postage. These very favorable terms are now presented by the publishers with the view of removing all difficulties and objections to a full and extended circulation of the Medical Journal to the office of every member of the profession throughout the United States. The rapid extension of mail facili- ties will now place the numbers before subscribers with a certainty and dispatch not heretofore attainable; while by the system now proposed, every subscriber throughout the Union is placed upon an equal footing, at the very reasonable price of Five Dollars for two periodicals, without further expense. v ' Those subscribers who do not pay in advance will bear in mind that their subscription of Five Dollars will entitle them to the Journal only, without the News, and that they will be at the expense of their own postage on the receipt of each number. The advantage of a remittance when order- ing the Journal will thus be apparent. As the Medical News and Library is in no case sent without advance payment, its subscribers will always receive it free of postage. ' "3 Remittances of subscriptions can be mailed at our risk, when a certificate is taken from the Pn«t- master that the money is duly inclosed and forwarded. Address BLANCHARD & LEA, Philadelphia. AND SCIENTIFIC PUBLICATIONS. ALLEN (J. M.), M. D., Professor of Anatomy in the Pennsylvania Medical College, &.C. T§Ei PRACTICAL ANATOMIST; or, Tbe Student's Guide iu the Dissecting- ROOM. With over 200 illustrations. In one handsome royal 12mo. volume, of over 500 pages. (I o be ready for the fall sessions.) In the arrangement of this work, the author has endeavored to present a complete and thorough course of dissections in a clearer and more available form for practical use, than has as yet been accomplished. The chapters follow each other in the order in which dissections are usually con- ducted in this country, and as each region is taken up, every detail regarding it is fully described and illustrated, so that the student is not interrupted in his labors, by the necessity of referring from one portion of the volume to another. ANALYTICAL COMPENDIUM OF MEDICAL SCIENCE, containing Anatomy, Physiology, Surgery, Midwifery, Chemistry, Materia Medica, Therapeutics, and Practice of Medicine. Bv John Neill, M. D.. and F. G. Smith, M. D. New and enlarged edition, one thick volume royal 12mo. of over 1000 pages, with 374 illustrations. iSP See Neill, p. 24. ABEL (F. A.), F. C. S. AND C. L. BLOXAM. HANDBOOK OF CHEMISTRY, Theoretical, Practical, and Technical; with a Recommendatory Preface by Dr. Hofmann. In one large octavo volume, extra cloth, of 662 pages, with illustrations. §3 25. It must be understood that this is a work fitted for the earnest student, who resolves to pursue for him- self a steady search into the chemical mysteries of creation. For such a student the ' Handbook' will prove an excellent guide, since he will find in it, nut merely the approved modes of analytical investi- gation, hut most descriptions of the apparatus ne- cessary, with such manipulatory details as rendered Faraday's ' Chemical Manipulations' so valuable at the time of its publication. Beyond this, the im- portance of the work is increased by the introduc- tion of much of the technical chemistry of the manu- factory.—Dr. Ho/mann's Preface. ASHWELL (SAMUEL), M.D., Obstetric Physician and Lecturer to Guv's Hospital, London. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third and revised London edition. In one octavo volume, extra cloth, of 528 pages. (Lately Pub- lished.) $3 00. The most useful practical work on the subject in the English language. — Boston Med. and Surg. Journal. The most able, and certainly the most standard and practical, work on female diseases that we have yet seen.—Medico-Chirurgical Review. The young practitioner will find it invaluable, while those who have had most experience will yet find something to learn, and much to commend, in a hook which shows so much patient observation, practical skill, and sound sense.—British and Fo- reign Med. Review. We commend it to our readers as the best practi- cal treatise on the subject which has yet appeared. —London Lancet. ARNOTT (NEILL), M. D. ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, M. D. Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra- tions. $2 50. _________________ BENNETT (HENRY), M. D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS. ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. Fourth American, from the third and revised London edition. To which is added (July, 1856), a Review of the Present State of Uterine Pathology. In one neat octavo volume, extra cloth, of 500 pages, with wood-cuts. $2 00. The addition of the "Review" presents the most recent aspects of the questions discussed in this well-known work, bringing it down to the latest moment. This edition has been carefully revised and altered,, When, a few years back, the first edition of the and various additions have been made, which render j present work was published, the subject was oneal- it more complete, and, if possible, more worthy of' most entirely unknown to the obstetrical celebrities the hi",h appreciation in which it is held by the | of the day; and even now we have reason to know medical profession throughout the world. A copy that the bulk cf the profession are not fully alive to should be in the possession of every physician.— the importance and frequency of the disease of which Charleston Med Journal and Review. it takes cognizance. The present edition is so much We are firmly of opinion that in proportion as a enlarged, altered, and improved, that it can scarcely knowledge o^uterinePdiseases becomes 'more appre- b«^considered the same work.-2?r. Ranklng>s Ab- ciated, this work will be proportionabiy established siraci. as a text-book in the profession.—The Lancet. Also, just ready, by the same author, and for sale separate, A REVIEW OF THE PRESENT STATE OF UTERINE PATHOLOGY. ~ 1 small vol. 8vo. 50 cents, in flexible cloth. In this little work, which can be had either in connection with the "Practical Treatise," or separate the author presents his latest views with regard to the various doctrines which have re- cently been brought forward on this interesting question, under the following heads i— Chap I Preliminary. II. Sketch of Uterine Pathology. III. Objections. IV. The Leucorrhoea Theory—tbe Syphilis Theory —the Ovarian Theory. V. The Displacement Theory. Vi.. Summary. BLANCHARD & LEA'S MEDICAL BROWN (ISAAC BAKER), Surgeon-Accoucheur to St. Mary's Hospital, Ac. ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT- MENT. With handsome illustrations. One vol. 8vo., extra cloth. (jYow Ready.) SlfiO. Mr Brown has earned for himself a high reputa- ; and merit the careful attention of every surgeon- tioninthe operative treatment of sundry diseases j accoucheur.—Association Journal. r.nd injuries to which females are peculiarly subject. I We ,mve no hesitation ;n recommending this book We c:in truly say of his work that it is an important tf>the careful attention of all surgeons who make addition to obstetrical literature IMie operative fem.l]e c<>rnpiaints a part of their study and practice. suggestions and contrivances which Mr. Brown tie- , __Dublin Quarterly Journal. Bcribes, exhibit much practical sagacity and skill, , BENNETT (J. HUGHES), M.D., F. R. S. E., Professor of Clinical Medicine in the University of Edinburgh, &c. THE PATHOLOGY AND TREATMENT OF PULMONARY TUBERCU- LOSA and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken for or "associated with, Phthisis. In one handsome octavo volume, extra cloth, with beautiful wood-cuts. pp. 130. (LatelyIss2ied.) SI 25. BUDD (GEORGE), M. D., F. R. S., Professor of Medicine in King's College, London. ON DISEASES OF THE LIVER. Second American, from the second and enlarged London edition. In one very handsome octavo volume, extra cloth, with four beauti- fully colored plates, and numerous wood-cuts. pp. 468. S3 00. For manv years, Dr. Build's work must be the I the subject has been taken up by so able and experi- Buthority of the .treat mass of British practitioners enced a physician.—British and Foreign Medico- on the hepatic diseases ; and it is satisfactory that I Chirurgical Review. BY THE same author. (Now Ready.) ON THE ORGANIC DISEASES AND FUNCTIONAL DISORDERS OF THE STOMACH. In one neat octavo volume, extra cloth, $1 50. A new work, 1856. W hile special treatises have been multiplying upon almost all the different classes of diseases, there has long been felt the want of an authoritative work on the disorders of the stomach, which con- stitute, perhaps, a larger proportion of the daily practice of the physician than any other class of maladies. To supply this want has been the object of the author, and his reputation is an ample guarantee of the value of his labors. From the high position occupied by Dr. Budd as style, the subjects are well arranged, and the practi- a teacher, a writer, and a practitioner, it is almost cal precepts, both of diagnosis and treatment, denote needless to state that the present book may be con- the character of a thoughtful and experienced phv- sulted with great advantage. It is written in an easy sician.—London Med. Times and Gazette, Dec. 1855. BIRD (GOLDING), A. M., M. D., &c. URINARY DEPOSITS : THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL INDICATIONS. A new and enlarged American, from the last improved London edition. With over sixty illustrations. In one royal 12mo. vol, extra cloth, pp.372. $130. extension and satisfactory employment of our thera- It can scarcely be necessary for us to say anything of the merits of this well-known Treatise, which so admirably brings into practical application the re- sults of those microscopical and chemical researches regarding the physiology and pathology of the uri- nary secretion, which have contributed so much to the increase of our diagnostic powers, and to the peut.ic resources. In the preparation of this new edition of his work, it is obvious that Dr. Golding Bird has spared no pains to render it a faithful repre- sentation of the present state of scientific knowledge on the subject it embraces.— The British and Foreign Medico-Chirurgical Review. BY THE SAME AUTHOR. ELEMENTS OF NATURAL PHILOSOPHY; being an Experimental Intro- duction to the Physical Sciences. Illustrated with nearly four hundred wood-cuts. From the third London edition. In one neat volume, royal 12mo., extra cloth, pp.402. $125. BILLING'S PRINCIPLES OF MEDICINE.— Second American, from the Fifth and Improved London edition. In one handsome octavo volume, extra cloth. 250 pages. $125. BLAKISTON'S PRACTICAL OBSERVATIONS ON CERTAIN DISEASES OF THE CHEST, and in the Principles of Auscultation. In one vol., cloth, 8vo. pp. 384. $125. BURROWS ON DISORDERS OF THE CERE- BRAL CIRCULATION, and on the Connection between the Affections of the Brain and Diseases of the Heart. In one 8vo. vol., extra cloih, with colored plates, pp. 216. $1 25. BEALE ON THE LAWS OF HEALTH IN RE- LATION TO MIND AND BODY. A Series of Letters from an old Practitioner to a Patient. In one volume, royal 12mo., extra cloth, pp. 296. 80 cents. BUSIINAN'S PHYSIOLOGY OF ANIMAL AND VEGETABLE LIFE; a Popular Treatise on the Functions and Phenomena of Organic Life. In one handsome royal 12mo. volume, extra cloth, with over 100 illustrations, pp.234. 80 cents. BUCKLER ON THE ETIOLOGY. PATHOLOGY, AND TREATMENT OF FIBRO-BRONCHl- TIS AND RHEUMATIC PNEUMONIA. Jn one 8vo. volume, extra cloth, pp. 150. $1 25. BLOOD AND URINE (MANUALS ON). BY JOHN WILLIAM GRIFFITH, G. OWEN REESE, AND ALFRED MARKWICK. One thick volume, royal 12mo., extra cloth, with plates, pp. 460. $1 25. BRODIE'S CLINICAL LECTURES ON SUR- GERY. 1 vol. 8vo., cloth. 350 pp. $125. AND SCIENTIFIC PUBLICATIONS. 5 BARLOW (GEORGE H.), M.D. Physician to Guy's Hospital, London, &c. A MANUAL OF THE PRACTICE OF MEDICINE. With Additions by D. F. Condie, M.D., author of "A Practical Treatise on Diseases of Children," cVc. In one hand- some octavo volume, leather, of over 600 pages. (A new work, just ready, 1806.) $2 75. The position of the author as physician to Guy's Hospital and other large public institutions, is a sufficient guarantee of the extent and value of the experience which is here systematically re- corded and condensed. His aim throughout has been to produce a ■practical work, on which the student can rely as a guide, and to which the practitioner can refer with confidence. The additions by the editor comprise chapters on Cerebro-spinal Meningitis, Cholera Infantum, and Yellow Fever, besides numerous notes wherever the diseases or practice of this country seemed to render them necessary or desirable. "We most emphatically commend it to the attention of the profession, as deserving their confidence—a depository of practical knowledge, from which they may draw wilh great benefit.—Cincinnati Med. Ob- server, Mar. 1856. The student has long been in want of a good ele- mentary work on the Practice of Medicine. In Dr. Barlow's Manual that want is supplied ; and we have no question that it will at once be installed as the favorite text-book in all Medical Schools.— Medical Times and Gazette. We recommend Dr. Barlow'sManualin the warm- est manner as a most valuable vade-mecum. We have had frequent occasion to consult it, and have found it clear, concise, practical, and sound. It is eminently a practical work, containing all that is essential, and avoiding useless theoretical discus- sion. The work supplies what has been for some time wanting, a manual of practice based upon mo- dern discoveries in pathology and rational views of treatment of disease. It is especially intended for the use of students and junior practitioners, but it will be found hardly less useful to the experienced physician. The American editor has added to the work three chapters—on Cholera Infantum, Yellow Fever, and Cerebro-spinal Meningitis. These addi- tions, the two first of which are indispensable to a work on practice destined for the profession in this country, are executed with great judgment and fi- delity, by Dr. Condie, who has also succeeded hap- pily in imitating the conciseness and clearness of style which are such agreeable characteristics of the original book.—Boston Med. and Surg. Journal, Feb. 1856. We have looked through this volume with very great satisfaction: it is written in an easy and plea- sant style, and the short though lucid expositions of disease, clearness of description, and soundness of precept will make it a welcome visitor in the library of every practitioner. It combines the simplicity of old Cullen, with the elegance of Watson, and al- though not so copious as other works we might men- tion, it will, nevertheless, become a standard autho- rity.—American Lancet, Mar. 1856. BARTLETT (ELISHA), M. D. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS OF THE UNITED STATES. A new and revised edition. By Alonzo Clark, M. D., Prof. of Physiology and Pathology in the N. Y. Coll of Physicians and Surgeons, &c. In one octavo volume, of six hundred pages, extra cloth. (Nearly Ready.) The masterly and elegant treatise by Dr. Bartlett is invaluable to the American student and practi- tioner.—Br. Holmes,s Report to the Nat. Med. Asso- ciation. We "regard it, from the examination we have made of it, the best work on fevers extant in our language, and as such cordially recommend it to the medical public.—St. Louis Medical and Surgical Journal. Take it altogether, it is the most complete history of our fevers which has yet been published, and every practitioner should avail himself of its con- tents.—The Western Lancet. BOWMAN (JOHN E.), M.D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Second Ame- rican, from the third and revised English Edition. In one neat volume, royal 12mo., extra cloth, with numerous illustrations, pp. 288. (Now Ready, 1856.) $1 25. Presenting, in a condensed and convenient form, at a very low price, the applications of Chemistry to the practical purposes of Clinical Medicine, this work supplies a want which has long been felt bv the physician. The numerous editions which have been called for both in England and this country, sufficiently attest the success with which the author has carried out his plan. BY THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- LYSIS. With numerous illustrations. In one neat vol., royal 12mo., extra cloth, pp.350. $125. CURLING (T. B.), F.R.S., Surgeon to the London Hospital, President of the Hunterian Society, &c. A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPERMA- TIC CORD AND SCROTUM. Second American, from the second and enlarged English edi- tion. In one handsome octavo volume, extra cloth, with numerous illustrations, pp. 420. (Now Ready, 1856.) $2 00. In the revised English edition, of which this is a reprint, the author, for want of space, omitted the Anatomical Introduction. By a more condensed style of printing, room has been found in the present volume to retain this important portion without rendering the work inconveniently-large. Some of the notes of the former American editor have also been incorporated, and a number of new illustrations introduced. With these improvements, and the thorough revision which it has enjoyed at tne hands of the author, it will be found fully worthy to retain the authoritative position which it has acquired with regard to this class of affections. We now take farewell, for the present, of this ex- cellent treatise, placing it on our book shelves by the side of Cooper on Fractures and Dislocations, and other similar standard and valuable works — Asso. Med. Journal, Jan. 1856. We shall not devote any further space to the work under notice, as it is so well known to the profession already. We can only say that it should be in the library of every practical surgeon. The present edi- tion is much improved, contains numerous wood- cuts, and several accounts of cases illustrating the various diseases of the testicles.—Med. Times and Gazette, Feb. 1856. 6 BLANCHARD & LEA'S CARPENTER (WILLIAM B.), M. D., F. R. S., &c. Examiner in Physiology and Comparative Anatomy in the University of London. large pages, handsomely printec lv'.O.) $4 SO. In the nrenaration of this new edition, the author has spared no labor to render it, as heretofore, •t comnlete and lucid exposition of the most advanced condition of its important subject. Ihe amount of the additions required to effect this object thoroughly, joined to the former large s,ze of the volume presenting objections arising from the unwieldy bulk of the work, he has omi ted all those portions not bearing directly upon Human Physiology, designing to incorporate them in . ^'forthcoming Treatise on General Physiology. As a full and accurate text-book on the Phy- Y>!«~v of Man the work in its present condition therefore presents even greater claims upon tl'.VsTudent and physician than those which have heretofore won for it the very wide and distin- eui-hed favor which it has so long enjoyed. The additions of Prof. Smith will be found to supply whatever may have been wanting to the American student, while the introduction of many new illustrations, and the most careful mechanical execution, render the volume one of the most at- tractive as yet issued. For upwards of thirteen years Dr. Carpenter's To eulogize this great work would be superfluous. vork has been considered by the profession gene- We should observe, however, that in this edition lished author. The present edition (which, like the last American one, was prepared by the author him- belt")- is the result of such extensive revision, that it may almost be considered a new work. We need hardly say, in concluding this brief notice, that while the work is indispensable to every student of medi- cine in this country, it will amply repay the practi- tioner for its perusal by the interest and value of its contents.—Boston Med. and Surg. Journal. This is a standard work—the text-book used by all medical students who read the English language. It has passed through several editions in order to keep pace with the rapidly growing science of Phy- stology. Nothing need be said in its praise, for its merits are universally known ; we have nothing to say of its defects, for they only appear where the science of which it treats is incomplete.— Western Lancet. The most complete exposition of physiology which any language can at present give.—Brit, and For. M'd.-Chirurg. Review. The greatest, the most reliable, and the best book on the subject which we know of in the English language.—Stethoscope. work on Human Physiology in our language.- Southern Med. and Surg. Journal, December, 1855. The most complete work on the science in our language.—Am. Med. Journal. The most complete work now extant in our lan- guage.—N. O. Med. Register. The best text-book in the language on this ex- tensive subject.—London Med. Times. A complete cyclopaedia of this branch of science. —N. Y. Med. Times. The profession of this country, and perhaps also of Europe, have anxiously and for some time awaited the announcement of this new edition of Carpenter's Human Physiology. His former editions have for many years been almost the only text-book on Phy- siology in all our medical schools, and its circula- tion among the profession has been unsurpassed by any work in any department of medical science. It is quite unnecessary for us to speak of this work as its merits would justify. The mere an- nouncement of its appearance will afford the highest pleasure to every student of Physiology, while its perusal will be of infinite service in advancing physiological science.—Ohio Med. and Surg. Journ. by the same author. (Lately Issued.) PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from the Fourth and Revised London edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations, pp. 752. Extra cloth, $4 80 ; leather, raised bands, $5 25. The delay which has existed in the appearance of this work has been caused by the very thorough revision and remodelling which it has undergone at the hands of the author, and the large number of new illustrations which have been prepared for it. It will, therefore, be found almost a new work, and fully up to the day in every department of the subject, rendering it a reliable text-book for all students engaged in this branch of science. Every effort has been made to render its typo- graphical finish and mechanical execution worthy of its exalted reputation, and creditable to the mechanical arts of this country. no man, we believe, could have brought to so suc- cessful an issue as Dr. Carpenter, ft required for its production a physiologist at once deeply read in the labors of others, capable of taking a general, critical, and unprejudiced view of those labors, and of combining the varied, heterogeneous materials at hls disposal, so as to form an harmonious whole. We feel that this abstract can give the reader a very imperfect idea of the fulness of this work, and no idea of its unity, of the admirable manner in which material has been brought, from the most various sources, to conduce to its completeness, of the lucid- ity of the reasoning it contains, or of the clearness of language in which the whole is clothed. Not the profession only, but the scientific world at large, must feel deeply indebted to Dr. Carpenter for this This book should not only be read but thoroughly studied by every member of the profession. None are too wise or old, to be benefited thereby. But especially to the younger class would we cordially commend it as best fitted of any work in the English language to qualify them for the reception and coin- prehension of those truths which are daily being de- veloped in physiology.—Medical Counsellor. Without pretending to it, it is an encyclopedia of the subject, accurate and complete in all respects— a truthful reflection of the advanced state at which the science has now arrived.—Dublin Quarterly Journal of Medical Science. A truly magnificent work—in itself a perfect phy- siological study.—Ranking's Abstract. This work stands without its fellow. It is one few men in Europe could have undertaken; t is one great work. It must, indeed, add largely even to his high reputation.—Medical Times. AND SCIENTIFIC PUBLICATIONS. 7 CARPENTER (WILLIAM B.>, M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. (Now Ready, June, 1856.) THE MICROSCOPE AND ITS REVELATIONS. With an Appendix con- taining the Applications of the Microscope to Clinical Medicine, &c. By F. G. Smith, M. D. Illustrated by four hundred and thirty-four beautiful engravings on wood. In one large and very handsome octavo volume, of 724 pages, extra cloth, $4 00 ; leather, $4 50. Dr. Carpenter's position as a microscopist and physiologist, and his great experience as a teacher, eminently qualify him to produce what has long been wanted—a good text-book on the practical use of the microscope. In the present volume his object has been, as stated in his Preface, " to combine, within a moderate compass, that information with regard to the use of his ' tools,' which is most essential to the working microscopist, with/ such an account of the objects best fitted for his study, as might qualify him to comprehend what he observes, and might thus prepare him to benefit science, whilst expanding and refreshing his own mind " That he has succeeded in accom- plishing this, no one acquainted with his previous labors can doubt. The great importance of the microscope as a means of diagnosis, and the number of microsco- pists who are also physicians, have induced the American publishers, with the author's approval, to add an Appendix, carefully prepared by Professor Smith, on the applications of the instrument to clinical medicine, together with an account of American Microscopes, their modifications and accessories. This portion of the work is illustrated with nearly one hundred wood-cuts, and, it is hoped, will adapt the volume more particularly to the use of the American student. Every care has been taken in the mechanical execution of the work, which is confidently pre- sented as in no respect inferior to the choicest productions of the London press. The mode in which the author has executed his intentions may be gathered from the following condensed synopsis of the qONTENTS. Introduction—History of the Microscope. Chap. I. Optical Principles of the Microscope. Chap. II. Construction of the Microscope. Chap. III. Accessory Apparatus. Chap. IV. Management of the Microscope Chap. V. Preparation, Mounting, and Collection of Objects. Chap. VI. Microscopic Forms of Vegetable Life—Profophytes. Chap. VII. Higher Cryptoga- mia. Chap. VIII. Phanerogamic Plants. Chap. IX. Microscopic Forms of Animal Life—Pro- tozoa—Animalcules. Chap. X. Foraminifera, Polycystina, and Sponges. Chap. XL Zoophytes. Chap. XII. Echinodermata. Chap. XIII. Polyzoa and Compound Tunicata. Chap. XIV. Molluscous Animals Generally. Chap. XV. Annulosa. Chap. XVI. Crustacea. Chap. XVII. Insects and Arachnida. Chap. XVIII. Vertebrated Animals. Chap. XIX. Applications of the Microscope to Geology. Chap. XX. Inorgauic or Mineral Kingdom—Polarization. Appendix. Microscope as a means of Diagnosis—Injections—Microscopes of American Manufacture. and even those who have no previous acquaintance with the construction or uses of this instrument, will find abundance of information conveyed in clear and simple language.—Med. Times and Gazette, May, 1856. Those who are acquainted with Dr. Carpenter's previous writings on Animal and Vegetable Physio- logy, will fully understand how vast a store of know- ledge he is able to bring to bear upon so comprehen- sive a subject as the revelations of the microscope j BY THE SAME AUTHOR. Examiner. The best and most complete expos^ of modern Physiology, in one volume, extant in the English language.—St. Louis Medical Journal. ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- LOGICAL ANATOMY. Second American, from a new and revised London edition. With one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp. 566. $3 00. In publishing the first edition of this work, its title was altered from that of the London volume, bv the substitution of the word " Elements" for that of " Manual," and with the author's sanction the title of " Elements" is still retained as being more expressive of the scope of the treatise. To say that it is the best manual of Physiology Those who have occasion for an elementary trea- now before the public, would not do sufficient justice tise on Physiology, cannot do better than to possess to theauthor.—Buffalo Medical Journal. themselvesof the manual of Dr. Carpenter.-illedtcaJ In his former works it would seem that he had exhausted the subject of Physiology. In the present, he gives the essence, as it were, of the whole.—N. Y. Journal of Medicine. by the same author. (Preparing.) PRINCIPLES OF GENERAL PHYSIOLOGY, INCLUDING ORGANIC rm?MmTT?V AND HISTOLOGY". With a General Sketch of the Vegetable and Animal Km-dom In one large and very handsome octavo volume, with several hundred illustrations. The%ubiect of general physiology having been omitted in the last editions of the author's « Com- naradve Physiofogv" and "Human Physiology," he has undertaken to prepare a volume which shall present* more thoroughly and fully than has yet been attempted, and which may be regarded as an introduction to his other works. BY THE SAME AUTHOR. A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH AND DISEASE New edition, with a Preface by D. F. Condie, M. D., and explanations of fcfentifiowoYd^T'In one neat 12mo. volume, extra cloth, pp.178. (Just Issued.) 50 cents. CHELIUS (J. M.), M. D., Professor of Surgery in the University of Heidelberg, &c. A . should compare it with the other pharmacopoeias extant, which enjoy and merit the confidence of the profession : it is enough to say that it appears to us as perfect as a Dispensa- tory, in the present state of pharmaceutical science, could be made. If it omits any details pertaining to this branch of knowledge which the student has _ right to expect in such a work, we confess the omis- sion has escaped our scrutiny. We cordially recom- mend this work to such of our readers as are in need of a Dispensatory. They cannot make choice of a better.—Western Journ. of Medicine and Surgery. COOPER (BRANSBY BJ, F. R. S. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large octavo volume, extra cloth, of 750 pages. $3 00. COOPER ON DISLOCATIONS AND FRAC- TURES OF THE JOINTS —Edited by Bransbt B. Cooper, F.R.S., &c. With additional Ob- servations by Prof. J. C. Warren. A new Ame- rican edition. In one handsome octavo volume, extra cloth, of about 500 pages, with numerous illustrations on wood. S3 25. COOPER ON THE ANATOMY AND TREAT- MENT OF ABDOMINAL HERNIA. One large volume, imperial Svo., extra cloth, with over 130 lithographic figures. $2 50. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST, with twenty-five Miscellane- ous and Surgical Papers. One large volume, im- perial Svo., extra cloth, with 252 figures, on 36 plates. S2 50. COOPER ON THE STRUCTURE AND DIS- EASES OF THE TESTIS, AND ON THE^ THYMUS GLAND. One vol. imperial Svo., ex- tra cloth, with 177 figures on 29 plates. $2 00. COPLAND ON THE CAUSES, NATURE AND TREATMENT OF PALSY AND APOPLEXY In one volume, royal 12mo., extra cloth, pp. 326. 80 cents. CLYMER ON FEVERS; THEIR DIAGNOSIS PATHOLOGY, AND TREATMENT In "one octavo volume, leather, of 600 pages. $1 50. COLOMBAT DE L'ISERE ON THE DISEASES OF FEMALES, and on the special Hygiene of their Sex. Translated, with many Notes and Ad- ditions, by C. D. Meigs, M. D. Second edition, revised and improved. In one large volume, oc- tavo, leather, with numerous wood-cuts. pp. 720. $3 50. CARSON (JOSEPH), M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA* MEDTPA AND PHARMACY, delivered in the University of Pennsylvania. Second and revised ^1 Hon. In one very neat octavo volume, extra cloth, of 2OS pages. (Now Ready.) $100. AND SCIENTIFIC PUBLICATIONS. 9 CHURCHILL (FLEETWOOD), M. D., M. R. I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American, from the last and improved English edition. Edited, with Notes and Additions, by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Children," &c. With 139 illustrations. In one very handsome octavo volume, leather, pp. 510. S3 00. To bestow praise on a book that has received such marked approbation would be superfluous. We need only say, therefore, that if the first edition was thought worthy of a favorable reception by the medical public, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much in- terest and instruction in everything relating to theo- retical and practical midwifery.—Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obste- tric practitioner.—London Medical Gazette. This is certainly the most perfect system extant. It is the best adapted for the purposes of a text- book, and that which he whose necessities confine him to one book, should select in preference to all others.—Southern Medical and Surgical Journal. The most popular work on midwifery ever issued from the American press.—Charleston Med. Journal. Were we reduced to the necessity of having but one work on midwifery, and permitted to choose, we would unhesitatingly take Churchill.—Western Med. and Surg. Journal. It is impossible to conceive a more useful and elegant manual than Dr. Churchill's Practice of Midwifery.—Provincial Medical Journal. Certainly, in our opinion, the very best work on the subject which exists.—N. Y. Annalist. No work holds a higher position, or is more de- serving of being placed in the hands of the tyro, the advanced student, or the practitioner.—Medical Examiner. Previous editions, under the editorial supervision of Prof R. M. Huston, have been received with marked favor, and they deserved it; but this, re- printed from a very late Dublin edition, carefully revised and brought up by the author to the present time, does present an unusually accurate and able exposition of every important particular embraced in the department of midwifery. * * The clearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, have served to place it already in the foremost rank of works in this department of re- medial science.—N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if not the very best text-book and epitome of obstetric science which we at present possess in the English lan- guage.—Monthly Journal of Medical Science. The clearness and precision of style in which it is written, and the great amount of statistical research which it contains, have served to place it in the first rank of works in this department of medical science. —N. Y. Journal of Medicine. Few treatises will be found better adapted as a text-book for the student, or as a manual for the frequent consultation of the young practitioner.— American Medical Journal. BY the same author. (Now Ready, 1856.) ON THE DISEASES OF INFANTS AND CHILDREN. Second American Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D. In one large and handsome volume, extra cloth, of over 700 pages. $3 00, or in leather, $3 25. In preparing this work a second time for the American profession, the author has spared no labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, while every portion of the volume has been subjected to a severe scrutiny. The efforts of the American editor have been directed to supplying such information relative to matters peculiar to this country as might have escaped the attention of the author, and the whole may, there- fore, be safely pronounced one of the most complete works on the subject accessible to the Ame- rican Profession. By an alteration in the size of the page, these very extensive additions have been accommodated without unduly increasing the size of the work. A few notices of the former edition are subjoined :— The present volume will sustain the reputation We regard this volume as possessing more claims to completeness than any other of the kind with which we are acquainted. Most cordially and ear- nestly, therefore, do we commend it to our profession- al brethren, and we feel assured thut the stamp of their approbation will indue time be impressed upon it. After an attentive perusal of its contents, we hesitate not to say, that it is one of the most com- prehensive ever written upon the diseases of chil- dren, and that, for copiousnessof reference, extent of research, and perspicuity of detail, it is scarcely to be equalled, and not to be excelled, in any lan- guage.—Dublin Quarterly Journal. After this meagre, and we know, very imperfect notice of Dr. Churchill's work, we shall conclude by saying, that it is one that cannot fail from its co- piousness, extensive research, and general accuracy, to exalt still higher the reputation of the author in this country. The American reader will be particu- larly pleased to find that Dr. Churchill has done full justice throughout his work to the various American authors on this subject. The names of Dewees, Eberle, Condie, and Stewart, occur on nearly every page, and these authors are constantly referred toby the author in terms of the highest praise, and with the moat liberal courtesy.—The Medical Examiner. acquired by the author from his previous works. The reader will find in it full and judicious direc- tions for the management of infants at birth, and a compendious, but clear account of the diseases to which children are liable, and the most successful mode of treating them. \Ve must not close this no- tice without calling attention to the author's style, which is perspicuous and polished to a degree, we regret to say, not generally characteristic of medical works. We recommend the work of Dr. Churchill most cordially, both to students and practitioners, as a valuable and reliable guide in the treatment of the diseases of children.—Am. Journ. of the Med. Sciences. AVe know of no work on this department of Prac tical Medicine which presents so candid and unpre- judiced a statement or posting up of our actual knowledge as this.—N. Y. Journal of Medicine. Its claims to merit both as a scientific and practi- cal work, are of the highest order. Whilst we would not elevate it above every other treatise on the same subject, we certainly believe that very few are equal to it, and none superior.—Southern Med. and Surgical Journal. BY THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- CULIAR. TO WOMEN. Selected from the writings of British Authors previous to the close of the Eighteenth Century. In one neat octavo volume, extra cloth, of about 450 pages. $2 50. 10 BLANCHARD & LEA'S MEDICAL CHURCHILL (FLEETWOOD), M. D., M. R. |. A., &.C. ON THE DISEASES OF WOMEN; including those of Pregnancy and Child bed. A new American edition, revised by the Author. With Notes and Additions, by D Fran- cis Condie, M. D., author of "A Practical Treatise on the Diseases of Children." In one large and handsome octavo volume, with wood-cuts, leather, pp. 684. S3 00. larity. This fifth edition, before us, is well calcu- lated to maintain Dr. Churchill's high reputation. It was revised and enlarged by the author, for his American publishers, and it seems to us that there is scarcely any species of desirable information on its We now regretfully take leave of Dr. Churchill's book. Had our typographical limits permitted, we should gladly have borrowed more from its richly stored pages. In conclusion, wc heartily recom- mend it to the profession, and would at the same time express our firm conviction that it will not only add to the reputation of its author, but will prove a work of great and extensive utility to obstetric practitioners.—Dublin Medical Press. Former editions of this work have been noticed in previous numbers of the Journal. The sentiments of high commendation expressed in those notices, have only to be repeated in this; tiot from the fact that the profession at large are not aware of the high merits which this work really possesses, but from a desire to see the principles and doctrines therein contained more generally recognized, and more uni- versally carried out in practice.—N. Y. Journal of Medicine. "We know of no author who deserves that appro- bation, on "the diseases of females," to the same extent that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on the subject; and it may be commended to practitioners and stu- dents as a masterpiece in its particular department. The former editions of this work have been com- mended strongly in this journal, and they have won tiieir way to an extended, and a well-deserved popu- snbjerts that may not be found in this work.—The Western Journal of Medicine and Surgery. We are gratified to announce a new and revised edition of Dr. Churchill's valuable work on the dis- eases of females We have ever regarded it as one of the very best works on the subjects embraced within its scope, in the English language; and the present edition, enlarged and revised by the author, renders it still more entitled to the confidence of the profession. The valuable notes of Prof. Huston have been retained, and contribute, in no small de- gree, to enhance the value of the work. It is a source of congratulation that the publishers have permitted the author to be, in this instance, his own editor, thus securing all the revision which an author alone is capable of making.—The Western Lancet. As a comprehensive manual for students, or a work of reference for practitioners, we only speak with common justice when we say that it surpasses any other that has ever issued on the same sub- ject from the British press.—The Dublin Quarterly Journal. DICKSON (S. HJ, M. D., Professor of Institutes and Practice of Medicine in the Medical College of South Carolina. ELEMENTS OF MEDICINE; a Compendious View of Pathology and Thera- peutic*, or the History and Treatment of Diseases. In one large and handsome octavo volume, of 750 pages, leather (Now Ready.) S3 75. As an American text-book on the Practice of Medicine for the student, and as a condensed work of reference for the practitioner, this volume will have strong claims on the attention of the profession. Few physicians have had wider opportunities than the author for observation and experience, and few perhaps have used them better. As the result of a life of study and practice, therefore, the present volume will doubtless be received with the welcome it deserves. This book is eminently what it professes to be: a distinguished merit in these days. Designed foT " Teachers and Students of Medicine," and admira- bly suited to their wants, we think it will be received, on its own merits, with a hearty welcome.—Boston Med. and Sur^. Journal. Indited by one of the most accomplished writers of our country, as well as by one who has long held n high position among teachers and practitioners of medicine, this work is entitled to patronage and careful study. The learned author has endeavored to condense in this volume most of the practical matter contained in his former productions, so as to adapt it to the use of those who have not time to devote to more extensive works.—Southern Med. and Surg. Journal. We can strongly recommend Dr. Dickson's work to our readers as one of interest and practical utility, well deserving of a place in their libraries as a book of reference ; and we especially commend the first part as presenting an admirable outline of the princi- ples of medicine".—Dublin Quarterly Journal, Feb. 1S56 This volume, while as its title denotes it is a compendious view, is also a comprehensive system of practice, perspicuously and pleasantly written, and admirably suited to engage the interest, and in- struct the reader.—Peninsular Journal of Medicine, Jan. 1856. This volume is designed as a text-book for teachers and students; but its merits extend far beyond its modest dedication; it is a complete treatise upon me- dicine, and one that will stand the test of years. The arrangement is simple, a feature oftentimes obscured in otherwise excellent works. This Treatise is a valuable addition to our medical literature, and in the clear and accurate descriptions, purity, and simpli- city of style, and soundness of precept, the reader will find much to admire and adopt, and not a little that calls for deep reflection. We cordially recom- mend this volume to our readers, whether old prac- titioners or students, for we take it that the physician should always be a student.—American Lancet. Prof. Dickson's work supplies, to a great extent, a desideratum long felt in American medicine.—iV. O. Med. and Surg. Journal. Estimating this work according to the purpose for which it is designed, we must think highly of its merits, and we have no hesitation in predicting for it a favorable reception by both students and teachers. Not professing to be a complete and comprehensive treatise, it will not be found full in detail, nor filled with discussions of theories and opinions, but em- bracing all that is essential in theory and practice, it is admirably adapted to the wants of the American student. Avoiding all that is uncertain, it presents more clearly to the mind of the reader that which is established and verified by experience. The varied and extensive reading of the author is conspicuously apparent, and all the recent improvements and dis- coveries in therapeutics and pathology are chroni- cled in its pages.—Charleston Med. Journal. In the first part of the work the subject of gene- ral pathology is presented in outline, giving a btan- tiful picture of its distinguishing features, and throughout the succeeding chapters we find that he has kept scrupulously within the bounds of sound reasoning and legitimate deduction. Upon the whole, we do not hesitate to pronounce it a superior work in its class, and that Dr. Dickson merits a place in the first rank of American writers.—Western Lancet. DAY S PRACTICAL TREATISE ON THE DO- I DE JONGH ON COD-LIVER OIL, comparatively MESTIC MANAGEMENT AND MORE IM- considered, with its Chemical and Therapeutic PORTAXT DISEASES OF ADVANCED LIFE. I Properties. In one 12mo. vol., ex. cloth. 75 cents. One volume, octavo, cloth, 226 pages. $1 00. AND SCIENTIFIC PUBLICATIONS. 11 DRUITT (ROBERT), M.R. C.S., &.C. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new American, from the improved London edition. Edited by F. W. Sargent, M. D., author of " Minor Surgery," &c. Illustrated with one hundred and' ninety-three wood-engravings. In one very handsomely printed octavo volume, leather, of 576 large pages. S3 00. Dr. Druitt's researches into the literature of his subject have been not only extensive, but well di- rected; the most discordant authors are fairly and impartially quoted, and, while due credit is given to each, their respective merits are weighed with an unprejudiced hand. The grain of wheat is pre- served, and the chaff is unmercifully stripped off. The arrangement is simple and philosophical, and the style, though clear and interesting, is so precise, that the book contains more information condensed into a few words than any other surgical work with which we are acquainted.—London Medical Times and Gazette. No work, in our opinion, equals it in presenting bo much valuable surgical matter in so small a compass.—St. Louis Med. and Surgical Journal. Druitt's Surgery is too well known to the Ameri- can medical profession to require its announcement anywhere. Probably no work of the kind has ever been more cordially received and extensively circu- lated than this. The fact that it comprehends in a comparatively small compass, all the essential ele- ments of theoretical and practical Surgery—that it is found to contain reliable and authentic informa- tion on the nature and treatment of nearly all surgi- cal affections—is a sufficient reason for the liberal patronage it has obtained. The editor, Dr. F. W. Sargent, has contributed much to enhance the value of the work, by such American improvements as are calculated more perfectly to adapt it to our own views and practice in this country. It abounds everywhere with spirited and life-like illustrations, which to the young surgeon, especially, are of no minor consideration. Every medical man frequently needs just such a work as this, for immediate refer- ence in moments of sudden emergency, when he has not time to consult more elaborate treatises.—The Ohio Medical and Surgical Journal. The author has evidently ransacked every stand- ard treatise of ancient and modern times, and all that is really practically useful at the bedside will be found in a form at once clear, distinct, and interest- ing.—Edinburgh Monthly Medical Journal. Druitt's work, condensed, systematic, lucid, and practical as it is, beyond most works on Surgery accessible to the American student, has had much currency in this country, and under its present au- spices promises to rise to yet higher favor.—The Western Journal of Medicine and Surgery. The most accurate and ample resume of the pre- sent state of Surgery that we are acquainted with.— Dublin Medical Journal. A better book on the principles and practice of Surgery as now understood in England and America, has not been given to the profession.—Boston Medi- cal and Surgical Journal. An unsurpassable compendium, not only of Sur- gical, but of Medical Practice.—London Medical Gazette. This work merits our warmest commendations, and we strongly recommend it to young surgeons as an admirable digest of the principles and practice of modern Surgery.—Medical Gazette. It may be said with truth that the work of Mr. Druitt affords a complete, though brief and con- densed view, of the entire field of modern surgery. We know of no work on the same subject having the appearance of a manual, which includes so many topics of interest to the surgeon ; and the terse man- ner in which each has been treated evinces a most enviable quality of mind on the part of the author, who seems to have an innate power of searching out and grasping the leading facts and features of the most elaborate productions of the pen. It is a useful handbook for the practitioner, and we should deem a teacher of surgery unpardonable who did not recommend it to his pupils. In our own opinion, it is admirably adapted to the wants of the student.— Provincial Medical and Surgical Journal. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c. h\ four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound, with raised bands. $12 00. *** This work contains no less than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians, rendering it a complete library of reference for the country practitioner. The most complete work on Practical Medicine extant; or, at least, in our language.—Buffalo Medical and Surgical Journal. For reference, it is above all price to every prac- titioner.—Western Lancet. One of the most valuable medical publications of the day__as a work of reference it is invaluable.— Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English medicine is exhibited in the most advantageous light.—Medical Examiner. We rejoice that this work is to be placed within the reach of the profession in this country, it being unquestionably one of very great value to the prac- titioner. This estimate of it has not been formed from a hasty examination, but after an intimate ac- quaintance derived from frequent consultation of it during the past nine or ten years. The editors are practitioners of established reputation, and the list of contributors embraces many of the most eminent professors and teachers of London, Edinburgh, Dub- lin, and Glasgow. It is, indeed, the great merit of this work that the principal articles have been fur- nished by practitioners who have not only devoted especial attention to the diseases about which they have written, but have also enjoyed opportunities for an extensive practical acquaintance with them, and whose reputation carries the assurance of their competency justly to appreciate the opinions of others, while it stamps their own doctrines with high and just authority.—American Medical Journ. DEWEES'S COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occasional cases and many engravings. Twelfth edition, with the author's last improvements and corrections In one octavo volume, extracloth,of 600pages. $320. DEWEES'S TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILD- REN. Tenth edition. In one volume, octavo, extra cloth, 548 pages. $2 80. DEWEES'S TREATISE ON THE DISEASES OF FEMALES. Tenth edition. In one volume, octavo, extra cloth, 532 pages, with plates. S3 00. DANA ON ZOOPHYTES AND CORALS. In one volume, imperial quarto, extra cloth, with wood- cuts. $15 00. Also, AN ATLAS, in one volume, imperial folio, with sixty-one magnificent colored plates. Bound in half morocco. $30 00. DE LA BECHE'S GEOLOGICAL OBSERVER. In one very large and handsome octavo volume, ex- tra cloth, of 700 pages, with 300 wood-cuts. $4 00. FRICK ON RENAL AFFECTIONS; their Diag- nosis and Pathology. With illustrations. One volume, royal 12mo., extra cloth. 75 cents 12 BLANCHARD & LEA'S MEDICAL DUNGLISON (ROBLEY), M.D., . Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise Explanation of the various Subjects and Terms of Physiology, Pathology, Hygiene, Therapeutics. Pharmacolo<>-v,Obstetrics, Medical Jurisprudence, >.Vc Willi the French and other Synonymes ; Notice* of Climate and of celebrated Mineral Waters; Formulae for various Officinal, Einp'irical, find Dietetic Preparations, etc. Thirteenth edition, revised, is now ready. In one very thick octavo volume, of over nine hundred large double-columned pages, strongly bound in leather, with raised bands. S4 00. Even- successive edition of this work bears the marks of the industry of the author, and of his determination to keep it fully on a level with the most advanced state of medical science. Thus nearlv fifteen thousand words have been added to it within the last few vears. As a complete .Medical Dictionary, therefore, embracing over FIFTY THOUSAND DEFINITIONS, in all the branches of the science, it is presented as meriting a continuance of the great favor and popularity which have carried it, within no very long space of time, to a thirteenth edition. Everv precaution has been taken in the preparation of the present volume, to render its mecha- nical execution and typographical accuuacy worthy of its extended reputation and universal u>e The verv extensive additions have been accommodated, without materially increasing the bulk of the volume by the employment of a small but exceedingly clear type, cast for this purpose. The press has been watched with great care, and every effort used to insure the verbal accuracy so ne- cessary to a work of this nature. The whole is printed on fine white paper ; and, while thus exhi- biting 'in every respect so great an improvement over former issues, it is presented at the original exceedingly low price. Wewelcome it cordially; it is an admirable work, \ readers to its peculiar merits; and we need do and indispensable to all literary medical men. The j little more than state, in reference to the present labor which has been bestowed" upon it is something j reissue, that, notwithstanding the large additions prodigious. The work, however, has now been i previously made to it. no fewer than four thou- done, and we are happy in the thought that no hu- [ sand terms, not to be found in the preceding edi- man being will have again to undertake the same j tion, are contained in the volume before us.— gigantic task. Revised and corrected from time to Whilst it is a wonderful monument of its author's time, Dr. Dunglison's '• Medical Lexicon" will last j erudition und industry, it is also a work of great for centuries.—British and Foreign Med.-Chirurg. practical utility, as we can testify from our own Rww. The fact that this excellent and learned work has passed through eight editions, and that a ninth is rendered necessary by the demands of the public, affords a sufficient evidence of the general apprecia- tion of Dr. Dunglison's labors by the medical pro- fession in England and America. It is a book which will be of great service to the student, in teaching him the meaning of all the technical terms used in medicine, and will be of no less use to the practi- tioner who desires to keep himself on a level with the advance of medical science.—London Medical Times and Gazette. in taking leave of our author, we feel compelled to confess that his work bears evidence of almost ! can only confirm their judgment, by recommending experience; for we keep it constantly within oui reach, and make very frequent reference to it, nearly always finding in it the information we seek. —British and Foreign Med.-Chirurg. Review. It has the rare merit that it certainly has no rival in the English language for accuracy and extent of references. The terms generally include short physiological and pathological descriptions, so that. as the author justly observes, the reader does not possess in this work a mere dictionary, but a book, which, while it instructs him in medical etymo- logy, furnishes him with a large amount of useful information. The author's labors have been pro- perly appreciated by his own countrymen ; and we incredible labor having been bestowed upon its coin position.— Edinburgh Journal of Med. Science. A miracle of labor and industry in one who has written able and voluminous works on nearly every branch of medical science. There could be no more useful book to the student or practitioner, in the present advancing age, than one in which would be found, in addition to the ordinary meaning and deri- vation of medical terms—so many of which are of this most useful volume to the notice of our cisat- lantic readers. No medical library will be complete without it.—London Med. Gazette. It is certainly more complete and comprehensive than any with which we are acquainted in the English language. Few, in fact, could be found belter qualified than Dr. Dunglison for the produc- tion of such a work. Learned, industrious, per- .—...... ... ...\.ui\...i ,,1.11410---o.i ujaii, K.11 Willi;!! die 1M i i i ■ ,, . ., modern introduction—concise descriptions of their : fevennS> .an« accurate, he brings to the task al . . . . . ' . . «..v... ,h. n.nn II. tnlanta ., Ann con i".. fn* if« n.innnnnA.l explanation and employment; and all this and much more is contained in the volume before us. It is therefore almost as indispensable to the other learned professions as to our own. In fact, to all who may have occasion to ascertain the meaning of any word belonging to the many branches of medicine. From a careful examination of the present edition, we can vouch for its accuracy, and for its being brought quite up to thedate of publication ; the author states in his preface that he has added to it about four thou- sand terms, which are not to be found in the prece- ding one. — Dublin Quarterly Journal of Medical ' Journal. Sciences. n„ .„„ „__ r .. , . ,. . „ . T,ie most comprehensive and best English Die- ntahKr r ,fl"1 'tl0n °f this | tionar>-of medical terms extant .-Buffalo MedU-a. valuable work, we directed the attention of our Journal. the peculiar talents necessary for its successful performance; while, at the same time, his fami- liarity with the writings of the ancient and modern '■ masters of our art," renders him skilful to note the exact usage of the several terms of science, and the various modifications which medical term- inology has undergone with the change of theo- ries or the progress of improvement. — American Journal of the Medical Sciences. One of the most complete and copious known to the cultivators of medical science.—Boston Med. BY THE SAME AUTHOR. THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and The- rapeutics. Ihird Edition. In two large octavo volumes, leather, of 1,500 pages. SO 25. Upon every topic embraced in the work the latest information will be found carefully posted up — M'dual Examiner. The student of medicine will find, in these two elegant volumes, a mine of facts, a gathering of precepts and advice from the world of experience, that will nerve him with courage, and faithfully direct him in his efforts to relieve the physical suf- ferings of the race.—Boston Medical and Surgical Journal. It is certainly the most complete treatise of which we have any knowledge.— Western Journal of Midi- cine and Surgery. One of the most elaborate treatises of the kind We hav««—Souther* AT*rf n*d S-urir Invnr.1 AND SCIENTIFIC PUBLICATIONS. 13 DUNGLISON (ROBLEY), M. D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and exten- sively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes, leather, of about 1500 pages. (Just Ready, 185(3.) 87 00. In revising this work for its eighth appearance, the author has spared no labor to render it worthy a continuance of the very great favor which has been extended to it by the profession. The whole contents have been rearranged, and to a great extent remodelled; the investigations which of late years have been so numerous and so important, have been carefully examined and incorporated, and the work in every respect has been brought up to a level with the present state of the subject. The object of the author has been to render it a concise but comprehensive treatise, containing the whole body of physiological science, to which the student and man of science can at all times refer with the certainty of finding whatever they are in search of, fully presented in all its aspects; and on no former edition has the author bestowed more labor to secure this result. A similar improvement will be found in the typographical execution of the volumes, which, in this respect, are superior to their predecessors. A large number of additional wood-cuts have been introduced, and the series of illustrations has been greatly modified by the substitution of many new ones for such as were not deemed satisfactory. By an enlargement of the page, these very considerable additions have been accommodated without increasing the size of the volumes to an extent to render them unwieldy. It has long since taken rank as one of the medi- cal classics of our language. To say that it is by far the best text-book of physiology ever published in this country, is but echoing the general testi- mony of the profession.—iV. Y". Journal of Medicine. There is no single book we would recommend to the student or physician, with greater confidence than the present, because in it will be found a mir- Rhould be without it It is the completes! work on Physiology in the English language, and is highly creditable to the author and publishers.—Canadian Medical Journal. The most complete and satisfactory system of Physiology in the English language.—Amer. Med. Journal. The best work of the kind in the English lan- ror of-'almosT every"stTndard Vhysiol7gicaTwork*of j SuaSe— SUliman's Journal. the day. We most cordially recommend the work ! The most full and complete system of Physiology to every member of the profession, and no student I in our language.—Western Lancet. BY THE SAME AUTHOR. GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-book. Fifth edition, much improved. With one hundred and eighty-seven illus- trations. In two large and handsomely printed octavo vols., leather, of about 1100 pages. S6 00. Asa text-book for students, for whom it is par- ticularly designed, we know of none, superior to it.—St. Louis Medical and Surgical Journal. It purports to be a new edition, but it is rather a new book, so greatly has it been improved, both in the amount and quality of the matter which it contains.—N. O. Medical and Surgical Journal. We bespeak for this edition, from the profession, an increase of patronage over any of its former ones, on account of its increased merit. — Ar. Y. Journal of Medicine. We consider this work unequalled.—Boston Med. and Surg. Journal. In this work of Dr. Dunglison,we recognize the same untiring industry in the collection and em- bodying of facts on the several subjects of which he treats, that has heretofore distinguished him, and we cheerfully point to these volumes, as two of the most interesting that we know of. In noticing the additions to this, the fourth edition, there is very little in the periodical or annual literature of the profession, published in the interval which has elapsed since the issue of the first, that has escaped the careful search of the author. As a book for reference, it is invaluable.—Charleston Med. Jour- nal and Review. It may be said to be the work now upon the sub- jects upon which it treats.— Western Lancet. BY the same author. (A new Edition.) NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARATION AND ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo volume, leather, of 770 pages. (Just Ready, May, 185G.) §3 75. Another edition of the " New Remedies" having been called for, the author has endeavored to add everything of moment that has appeared since the publication of the last edition. The chief remedial means which have obtained a place, for the first time, in this volume, either owin°- to their having been recently introduced into pharmacology, or to their having received novel applications—and which, consequently, belong to the category of " New Remedies"—are the fol- lowing :- nunction Iodide of sodium, Nickel, Permanganate of potassa. Phosphate of lime, Pumpkin, Qmmdia, lennet Saccharine carbonate of iron and manganese, Santonin, Tellurium, and Traumaticine. The articles treated of in the former editions will be found to have undergone considerable ex- nan*ion in thi-s in order that the author might be enabled to introduce, as far as practicable, the results of the subsequent experience of others, as well as of his own observation and reflection; and to make the work still more deserving of the extended circulation with which the precedin editions have been favored by the profession. By an enlargement of the page, the numerous addi tions have been incorporated without greatly increasing the bulk of the volume.—Preface One of the most useful of the author's works.— Southern Medical and Surgical Journal. This elaborate and useful volume should be found in every medical library, for as a book of re- ference, for physicians, it is unsurpassed by any other work in existence, and the double index for diseases and for remedies, will be found greatly to enhance its value.—New York Med. Gazette. The great learning of the author, and his remark- able industry in pushing his researches into every source whence information is derivable, has enabled him to throw together an extensive mass of facts and statements, accompanied by full reference to authorities; which last feature renders the work practically valuable to investigators who desire to examine the original papers.—The American Journal of Pharmacy. 4 BLANCHARD & LEA'S MEDICAL ERICHSEN (JOHN), Professor of Surgery in University College, London, Sec. THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical Injuries, Diseases, and Operations. Edited by John H. Brinton, M. D. Illustrated with three hundred and eleven engravings on wood. In one large and handsome octavo volume, of over nine hundred closely printed pages, leather, raised bands. SI 2i. It is. in our humble judgment, decidedlv the best book of the kind in the English language. Strang that just such books are notofiener produced by pub- lic teuch-rs of surgery in this country and Great Sir.tain Indeed, it is a matlerof great astonishment. hut no less true than astonishing, that of ihe many works on surgery republished in this country wiihin the last fifteen or twenty years a* text-books for medical students, this is the only one that even ap- proximates to ihe fulfilment of the peculiar wants of young men just entering upon the study of this branch of the profession.— Western Jour.of Med. an serviceable guide which he can consult. He .v'll find a fulness of detail leading him through every step of the operation, and not deserting him until the final issue of the case is decided. For the same rea- rarely encounter cases requiring surgical manage- ment.—Stethoscope. Embracing, as will be perceived, the whole surgi- cal domain, and each division of itself almost com- plete and perfect, each chapter full and explicit, each subject faithfully exhibited, we can only express our estimate of it in the aggregate. AVe consider it an excellent contribution to surgery, as probably the best single volume now extant on the subject, and with great pleasure we add it to our textbooks — Nashville Journal of Medicine and Surgery. Prof. Erichsen's work, for its size, has not been surpassed; his nine hundred and eight pages, pro- fusely illustrated, are rich in physiological, patholo- gical, and operative suggestions, doctrines, details, and processes; and will prove a reliable resource for information, both to physician and sunieon, in the hour of peril.— N. 0. Med. and Surg. Journal. We are acquainted with no other work wherein son wh recommend ii to those whose routine of prac- so much good sense, sound principle, and practical tice lies in such parts of the country that they must inferences, stamp every page.— American Lancet. ELLIS (BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Tenth edition, revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one neat octavo volume, extra cloth, of 1296 pages. (Lately Issued.) SI 75. V & l 9 '■) After an examination of the new matter and the alterations, we believe the reputation of the work built up by the author, :md the late distinguished editor, will continue to flourish under the auspices of the present editor, who has the industry and accu- racy, and, we would say, conscientiousness requi- site for the responsible task.—Am. Jour, of Pharm. It will prove particularly useful to students and young practitioners, as the most important prescrip- tions employed in modern practice, which lie scat- tered through our medical literature, are here col- lected and conveniently arranged for reference.__ Charleston Med. Journal and Review. FOWNES (GEORGE), PH. D., &c. ELEMENTARY CHEMISTRY; Theoretical and Practical. With numerous illustrations. A new American, from the last and revised London edition. Edited with Addi- tions, by Robert Bridges, M. D. In one large royal 12mo. volume, of over 550 pa°-es, with 181 wood-cuts. (Lately Issued.) In leather, $1 50; extra cloth, $1 35 AVe know of no better text-book, especially in the difficult department of organic chemistry, upon which it is particularly full and satisfactory. We would recommend it to preceptors as a capital ■'office book" for their students who are beginners in Chemistry. It is copiously illustrated with ex- cellent wood-cuts, and altogether admirably "got up."—iY. J. Medical Reporter. A standard manual, which has long enjoyed the reputation of embodying much knowledge in a small space. The author hasachieved the difficult task of condensation with masterly tact. His book is con- cise without being dry, and brief without bein» too dogmatical or general.— Virginia Med. and Surgical Journal. The work of Dr. Fownes has long been before the public, and its merits have been fully appreci- ated as the best text-book on chemistry now in existence. We do not, of course, place it in a rank superior to the works of Brande, Graham, Turner, Gregory, or Gmelin, but we say that, as a work for students, it is preferable to any of them.—Lon- don Journal of Medicine. A work well adapted to the wants of the student. It is an excellent exposition of the chief doctrines and facts of modern chemistry. The size of the work, and still more the condensed yet perspicuous style in which it is written, absolve it from the charges very properly urged against most manuals termed popular.—Edinburgh Journal of Medical Science. FERGUSSON (WILLIAM), F. R. S Professor of Surgery in King's College, London, &c. A SI STEM OF PRACTICAL SURGERY. Fourth American from the third The most important subjects in connection with practical surgery which have been more recently brought under the notice of, and discussed bv the surgeons of Great Britain, are fully and dispassion- ately considered by Mr. Fergusson, and that which was before wanting has now been supplied, so that we can now look upon it as a work on practical sur- gery instead of one on operative surgery alone Medical Times and Gazette. *.!0 "'orkiTalever written which more nearly comprehended the necessities of the student and practitioner, and was more carefully arranged to that single purpose than this.—N. Y. Med. Journal. The addition of many new pages makes this work more than ever indispensable to the student and prac- titioner.—Ranking's Abstract. -Among the numerous works upon surgery pub- lished of late years, we know of none we value more highly than the one before us. It is perhaps the very best we have for a text-book and for ordi- nary reference, being concise and eminently practi- cal.—Southern Med. and Surg. Journal. AND SCIENTIFIC PUBLICATIONS. 15 FLINT (AUSTIN), M. D., Professor of the Theory and Practice of Medicine in the University of Louisville, &c. (An Important New Work.) PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- ING THE RESPIRATORY ORGANS. In one large and handsome octavo volume, extra cloth, 636 pages. (Now Ready.) S3 00. Tbe author has aimed in the present work to supply a vacancy in medical literature, viz: "a work limited to diseases affecting the respiratory organs, treating inextenso and almost exclusivelv of the principles and practice of physical exploration, as applied to the diagnosis of those affections." The intricacy and importance of the subject demand a fuller and more detailed exoosition than has been accorded to it in any volume as yet accessible to the American profession ; while the high re- putation which the author has acquired by his researches in kindred topics sufficiently manifests his ability to render the present work a text-book of great practical utility for the student, and a source to which the practitioner can at all times refer with certainty. A very condensed summary of the contents is subjoined. INTRODUCTION. Section I. Preliminary points pertaining to the Ana- tomy and Physiology of the Respiratory Appara- tus. Section II. Topographical Divisions of the Chest. PART I. Physical Exploration of the Chest. Chap. I. Definitions—Different Methods of Explora- tions—General Remarks. Chap. II. Percussion. Chap. III. Auscultation. Chap. IV. Inspection. Chap. V. Mensuration. Chap. VI. Palpation. Chap. VII. Succussion. Chap. VIII. Recapitu- latory Enumeration of the Physical Signs fur- nished by the several methods of Exploration. Chap. IX. Correlation of Physical Signs. CONTENTS. PART II. Diagnosis of Diseases Affecting the Respira- tory Organs. Chap. I. Bronchitis, Pulmonary or Bronchial Ca- tarrh. Chap. II. Dilatation and Contraction of the Bronchial Tubes—Pertussis—Asthma. Chap. III. Pneumonitis—Imperfect Expansion (Atelec- tasis) and Collapse. Chap. IV. Emphysema. Chap. V. Pulmonary Tuberculosis — Bronchial Phthisis. Chap. VI. Pulmonary (Edema—Gan- grene of the Lungs—Pulmonary Apoplexy—Can- cer of the Lungs—Cancer in the Mediastinum. Chap. VII. Acute Pleuritis—Chronic Pleuritis— Empyema—Hydrothorax—Pneumothorax—Pneu- mo-hydrothorax—Pleuralgia—Diaphragmatic Her- nia. Chap. VIII. Diseases affecting the Trachea and Larynx—Foreign Bodies in the Air-passages. Appendix. On the Pitch of the Whispering Souille over Pulmonary Excavations. GRAHAM (THOMAS), F. R. S., Professor of Chemistry in University College, London, &c. THE ELEMENTS OF CHEMISTRY. Including the application of the Science to the Arts. With numerous illustrations. "With Notes and Additions, by Robert Bridges. M. D., &c. &c. Second American, from the second and enlarged London edition. PART I. (Lately Issued) large 8vo., 430 pages, 185 illustrations. §1 50. PART II. (Preparing) to match. GRIFFITH (ROBERT E.), M. D., &c. A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- ministering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceu- tists. Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one lars-e and handsome octavo volume, extra cloth, of over 600 pages, double columns. (Just Issued.) S3 00; or bound in sheep, $3 25. It was a work requiring much perseverance, and when published was looked upon as by far the best work of its kind that had issued from the American press. Prof Thomas has certainly "improved," as well as added 'othis Formulary, and has rendered it additionally deserving of the confidence of pharma- ceutists and physicians.—Am. Journal of Pharmacy. We are happy to announce a new and improved edition of this, one of the most valuable and useful works that have emanated from an American pen. It would do credit to any country, and will be found of daily usefulness to practitioners of medicine; itis better adapted to their purposes than the dispensato rles.—Southern Med. and Surg. Journal. A new edition of this well-known work, edited by R P. Thomas, M. D., affords occasion for renewing our commendation of so useful a handbook, which ought to be universally studied by medical men of every class, and made use of by way of reference by office pupils, as a standard authority. It has been much enlarged, and now condenses a vast amount of needful and necessary knowledge in small com- pass The more of such hooks the better for the pro- fession and the public- N. Y. Med. Gazette. It is one of the most useful books a country practi- tioner can possibly have in his possession.—Medical Chronicle. The amount of useful, every-dav matter, for a prac- ticing physician, is really immense.—Boston Med. and Surg. Journal. This is a work of six hundred and fifty one pages, embracing all on the subject of preparing and admi- nistering medicines that can lie desired by the physi- cian and pharmaceutist — Western Lancet. In short, it is a full and complete work of the kind and should be in the hands of every physician and apothecary. O. Med. and Surg. Journal We predict a great sale for this work, and we espe- ciallv recommend it to all medical teachers.—Rich- mond Stethoscope. This edition of Dr Griffith's work has been greatly' improved by the revision and ample additions of Dr. Thomas, and is now. we believe, one of the most complete works of its kind in any language. The additions amount to about seventy pages, and no effort has been spared to include in them all the re- cent improvements which have been published in medical journals, and systematic treatises. A -work of this kind appears to us indispensable to the physi- cian, and there is none we can more cordially recom- mend.—N. Y. Journal of Medicine. BY THE SAME AUTHOR. MEDICAL BOTANY; or, a Description of all the more important Plants used in Medicine, and of their Properties, Uses, and Modes of Administration. In one large octavo volume, extra cloth, of 704 pages, handsomely printed, with nearly 350 illustrations on wood. $3 00. 10 BLANCHARD A; LEA'S MEDICAL GROSS (SAMUEL D.), M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia, &.C. A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE <;LANf), AND THE URETHRA. Second Edition, revised and much enlarged, with one hundred and eiglny- four illustrations. In one large and very handsome octavo volume, of over nine hundred pases. (Just Issued.) In Iealher, raised bands, S-3 25; extra cloth, $4 75. The author has availed himscll of the opportunity afforded by a call for a new edition of 1 his work, to thoroughly revise and render it in every respect worthy, so far as in his power, of ibe very flattering reception which has been accorded to it by the profession. The new matter thus added amounts to almost one-third of the original work, while the number of illustrations has been nearly doubled. These additions pervade every portion of the work, which thus has rather the aspect of a new treatise than a new edition. In its present improved form, therefore, it may confidently be presented as a complete and reliable storehouse of information on this important class of diseases, and as in every way fitted to maintain the position which it has acquired in Europe and in this country, as the standard of authority on the subjects treated of. provements, it will probably remain one of the most valuable works on this subject so long as the science of medicine shall exist.—Boston Med. and Surg. Journal. A volume replete with truths and principles of the utmost value in the investigation of these diseases.— Am. rican Medical Journal. On the appearance of the first edition of this work, the leading English medical review predicted that it would have a " permanent place »n the literature of surgery worthy to rank with the best works of the present age." This prediction h;is been amply ful- filled. Dr. Gross's treatise has been found to sup- ply completely the want which has been felt ever since the elevation of surgery to the rank of a science, of a good practical treatise on the diseases of the bladder and its accessory organs. Philosophical in its design, methodical in its arrangement, ample and sound in its practical details, it may in truth be said to leave scarcely anything to be desired on so im- portant a subject, and with the additions and modi- fications resulting from future discoveries and im- Dr. Gross has brought all his learning, experi- ence, tact, and judgment to the task, and has pro- duced a work worthy of his high reputation. "We feel perfectly safe in recommending it to our rend- ers as a monograph unequalled in interest and practical value by any other on the subject in our language.—Western Journal of Med. and Sitrg. Whoever will peruse the vast amount of valuable practical information it contains, and which we have been unable even to notice, will, v/e think, agree with us, that there is no work in the English language which can make any just pretensions to be its equal.—N. Y. Journal of Medicine. BY THE SAME AUTHOR. (Just IsS7ied). A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PAS- SAGES. In one handsome octavo volume, extra cloth, with illustrations, pp. 408. $2 75. A very elabornte work. It is a complete summary conclude by recommending it to our readers, fullv ul the whole subject, and will be a useful book of j persuaded that its perusal will afford them much reierenee.—British and Foreign Medico-Chirurg. ! practical information well conveyed, evidently de- ■''"'""'• j rived from considerable experience and deduced from A highly valuable book of reference on a most im- an ample collection of facts. — Dublin Quarterly portant subject in the practice of medicine. We I Journal, May, 1855. by the same author. (Preparing.) A SYSTEM" OF SURGERY; Diagnostic, Pathological, Therapeutic, and Opera- live. With very numerous engravings on wood. BY THE SAME AUTHOR. ELEMENTS OF PATHOLOGICAL ANATOMY; illustrated by colored En- prayings, and two hundred and fifty wood-cuts. Second edition, thoroughly revised and greatly 82^13 75 eVer)rgea"d handsoftle i™!*"*1 o^avo volume, leather, raised band! ppy GLUGE (GOTTLIEB), M. D., Professor of Physiology and Pathological Anatomy in the University of Brussels, Ac LaS«-ASw PATHOLOGICAL HISTOLOGY. Translated, with Notes n?a n SieT' Y"™' M" ^\ ^^ °f A"at0my in ,he Univemity of Pennsylva- Tnvc vTcoppe^SeT y£TolmPe"aI qUart°' ^ C'°th' With 32° ^™eS> ^ and col°red> GARDNER'S .MEDICAL CHEMISTRY, for the use of Siiulents and the Profession. In one royal «M)0 V°' ' 6X' Cl0th' PP' 396' WUh i,lustlati0I>s- ^urln.^Sr^^ TOWARDS A CORRECT THL(iR\ OF THE NERVOUS SYSTEM In one octavo volume, leather, 292 pages. SI 50. HE£HES' CLINICAL INTRODUCTION TO ££E PRACTICE OF AUSCULTATION AND OTHER MODES OF PHYSICAL DIAGNOSIS IN DISEASES OF THE LUNGS AND HEART! becond American, from the second London edition. 1 vol. royal 12mo., ex. cloth, pp. 304. $1 00. HAMILTON (FRANK H.), M. D., a mT>Ti,mTOT, « rrofewor of Surgery, in Buffalo Medical College, ice. A TREATISE ON FRACTURES \ND DTST OPxt!(\n% t v i octavo volume, with numerous illustrationst (PrepaHnt) ATI0NS- In °De handsome Ji^AtS^^ of ™*°* ha* -ce'ived "am the .kill systematic onVina^orkon he?artlcuIar.V appropriate and valuable a complete and kindred topics!re aSy widely^and favnrlhh T*V* ^ Professor Hamilton has published on wiH ptoveindL-.j>oaSy^ihVli^}Z?iy .T^' ?nd ^earnest that his forthcoming work ix-u.doie, Dotn as a text-book for Ihe student, and as a guide for the practitioner. AND SCIENTIFIC PUBLICATIONS. 17 HOBLYN (RICHARD D.), M. D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. By Richard D. Hoblyn, A. M., &c A new American from the last London edition. Revised, with numerous Additions, by Isaac Hays, M. D., editor of the "American Journal of the Medical Sciences." In one large royal 12mo. volume, leather, of over 500 double columned pages. (Now Ready, 1856.) SI 50. The great care bestowed on the revision of this work, and the extensive additions made to it by the editor, have caused the delay in its appearance. While carefully excluding obsolete words, it has been his aim to render it a complete manual of definitions, in which the student of medicine or of its allied sciences might feel assured of being able to find concise explanations of all terms occur- ring in his course of reading. The amount of the additions thus made, may be estimated from the fact that the present edition contains fully-one-third more matter than the last, the number of pages having been increased by over one hundred, notwithstanding an enlargement of the size of the page, while at the same time it has been kept at the former exceedingly low price. nor desire to procure a larger work. — American Lancet. Hoblyn has always been a favorite dictionary, and in its present enlarged and improved form will give If the frequency with which we have referred to this volume since its reception from the publisher, two or three weeks ago, be any criterion for the future, the binding will Boon have to be renewed, even with careful handling. We find that. Dr. Hays has done the profession great service by his careful and industrious labors. TheDictionary has thus become eminently suited to our medical brethren in this country. The additions by Dr. Hays are in brackets, and we believe there is not a single page but bears these insignia; in every instance which we have thus far noticed, the additions are really needed and ex- ceedingly valuable. We heartily commend the work to all who wish to be au cnurant in medical termi- nology.— Boston Med. and Surg. Journal. To both practitioner and student, we recommend this dictionary as being convenient in size, accurate in definition, and sufficiently full and complete for ordinary consultation.—Charleston Med. Journ. and Review. Admirably calculated to meet the -wants of the practitioner or student, who has neither the means greater satisfaction than ever. The American editor, Dr. Hays, has made many very valuable additions. —N.J. Med. Reporter. To supply the want of the medical reader arising from this cause, we know of no dictionary better arranged and adapted than the one bearing the above title. It is not encumbered with the obsolete terms of a bygone age, but it contains all that are now in use ; embracing every department of medical science down to the very latest date. The volume is of a convenient size to be used by the medical student, and yet large enough to make a respectable appear- ance in the library of a physician.—Western Lancet. Hoblyn's Dictionary has long been a favorite with us. It is the best book of definitions we have, and ought always to be upon the student's table.— Southern Med. and Surg. Journal. HUNTER (JOHN). TREATISE ON THE VENEREAL DISEASE. With copious Additions, by Dr. Ph. Ricord, Surgeon to the Venereal Hospital of Paris. Edited, with additional Notes, by F. J. Bumstead, M. D. In one octavo volume, with plates. $3 25. 1SF See Ricord. Also, HUNTER'S COMPLETE WORKS, with Memoir, Notes, &c. &c. In four neat octavo volumes, leather, with plates. $10 00. HORNER (WILLIAM E.), M. D., Professor of Anatomy in the University of Pennsylvania. SPECIAL ANATOMY AND HISTOLOGY. Eighth edition. Extensively revised and modified. In two large octavo volumes, extra cloth, of more than one thousand pages, handsomely printed, with over three hundred illustrations. $6 00, This edition enjoyed a thorough and laborious revision on the part of the author shortly before his death with the view of bringing it fully up to the existing state of knowledge on the subject of general and special anatomy, to adapt it more perfectly to the wants of the student, he introduced a large number of additional wood-engravings, illustrative of the objects described, while the pub- lishers have endeavored to render the mechanical execution of the work worthy of its extended reputation. JONES (T. WHARTON), F. R. S., Professor of Ophthalmic Medicine and Surgery in University College, London, &c. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY With one hundred and ten illustrations. Second American from the second and revised London edition, with additions by Edwaed Hartshorne, M. D. Surgeon to Wills' Hospital, &-c. In one large, handsome royal 12mo. volume, extra cloth, of 500 pages. (l\ow Ready.) $1 50. The thorough revisions which this work has undergone at the hands of both author and editor have brought ?t thoroughly up to the present state of the subject, and have rendered it complete, without detracting from its character as a manual, or deviating from its onsrinal object of affording adi-estof the present condition of ophthalmic science for study and reference by those whose leisure does not admit of their perusing the larger works of Mackenzie or Lawrence. By an en- arrrement of the size of the page, the numerous additions to this edition have been accommodated without increa^in- the bulk of the volume, and at the very low price at which it is offered, a con- tinuance of the favor which it has hitherto received is confidently expected. We are confident that the reader will find, on perusal, that the execution of the work amply fulfils the promise of the preface, and sustains, m every point, the already high reputation of the author as an ophthalmic surgeon as well as a physiologist and pathologist. The book is evidently the result of much labor and research, and has been written with the greatest care and attention; it possesses that best quality which a general work, like a sys- tem or manual can show, viz: the quality of having all the materials whencesoever derived, so thorough- ly wrought up, and digested in the author's mind, us to come forth with the freshness and impressive- ness of an original production. We entertain little doubt that this book will become what its author hoped it might become, a manual for daily reference and consultation by the student and the general prac- titioner. The work is marked by that correctness, clearness, and precision of style which distinguish all the productions of the learned author.—British and For. Med. Revieiv. IS BLANCHARD & LEA'S MEDICAL JONES (C. HANDHELD), F. R. S., &. EDWARD H. SIEVEKING, M.D., Assistant Physicians and Lecturers in St. Mary's Hospitnl, London. A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, Kevi-cd. With three hundred and ninety-seven handsome wood engravin-js.^ In one large and beautiful octavo volume of nearly 750 pages, leather. (Lately Issued.) S3 75. As a concise text-book, containing, in a condensed authors have not attempted to intrude new views on form, a complete outline of what is known in the their professional brethren, but simply to Iny before domain of Pathological Anatomy, it is perhaps the them, what has long been wanted, an outline of the best work in the English language. Its great merit present condition of pathological anatomy. In thia consists in its completeness Ind Wvity, and in this they have been completely successful. The work i- it with anv degree of success. The authors of the I you have a synopsis of the views of the mr)st ap present work have sought to corrrct this defect by | proved authors.—Charleston Medical Journal and placing before the reader a summary of ascertained Review. facts, together with the opinions of the most eminent i \ye have no hesitation in recommending it as pathologists both of the Old and New World. As a WOrthy of careful and thorough study by every mem- Bimple work of reference, therefore, it is of great I Der „f tne profession, old or young.—N. W. Med. value to the student of pathological anatomy, and ; and Surg. Journal. should be in every physician's library.—Western, prom the casual examination we have given we Laneet- | are inclined to regard it as a text-book, plain, ra- We urge upon our readers nnd the profession gene- < tional, and intelligible, such a book as the practical rally the importance of informing themselves in re- ] man needs for daily reference. For this reason it gard to modern views of pathology, and recommend wju De likely to be largely useful, as it suits itself to them to procure the work before us as the best ■ t0 those busy men who have little time for minute means of obtaining this information.—Stethoscope. investigation, and prefer a summary to an elaborate In offering the above titled work to the public, the I treatise.—Buffalo Medical Journal. KIRKES (WILLIAM SENHOUSE), M. D., Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c; and JAMES PAGET, F. R. S., Lecturer on General Anatomy and Physiology in St. Bartholomew's Hospital. A MANUAL OF PHYSIOLOGY. Second American, from the second and improved London edition. With one hundred and sixty-five illustrations. In one large and handsome royal 12mo. volume, leather, pp. 550. $2 00. the practitioner who hag but leisure to" refresh his memory, this book is invaluable, as it contains all In the present edition, the Manual of Physiology h is been brought up to the actual condition of the science, and fully sustains the reputation which it has already so deservedly attained. We consider the work of MM. Kirkes and Paget to constitute one of the very best handbooks of Physiology we possess —presenting just such an outline of the science, com- prising an account of its leading facts and generally admitted principles, as the student requires during his attendance upon a course of lectures, or for re- ference whilst preparing for examination.— Am. Medical Journal. We need only say, that, without entering into dis- cussions of unsettled questions, it contains all the recent improvements in this department of medical science. For the student beginning this study, and that it is important to know, without special details, which are read with interest only by those who would make a specialty, or desire to possess a criti- cal knowledge of the subject.—Charleston Medical Journal. One of the best treatises that can be put into the hands of the student.—London Medical Gazette. Particularly adapted to those who desire to pos- sess a concise digest of the facts of Human Physi- ology.—British and Foreign Med.-Chirurg. Review. We conscientiously recommend it as an admira- ble " Handbook of Physiology."—London Journal of Medicine. KNAPP'S TECHNOLOGY ; or, Chemistry applied to the Arts and to Manufactures. Edited, with numerous Notes and Additions, by Dr. Edmund Ronalds and Dr. Thomas Richardson. First American edition, with Notes and Additions, by Prof. Walter R. Johnsow. In two handsome octavo volumes, extra cloth, printed and illus- trated in the highest style of art, with about 500 wood-engravings. $6 00. LALLEMAND ON THE CAUSES, SYMPTOMS. AND TREATMENT OF SPERMATORRHOEA. Translated and edited by Henry J. McDotjgal. In one volume, octavo, extra cloth, 320 pages. Second American edition. SI 75. LUDLOWS MANUAL OF EXAMINATIONS upon Anatomy and Physiology, Surgery, Practice of Medicine, Chemistry, Obstetrics, Materia Me- dica, Pharmacy, and Therapeutics. Designed for Students of Medicine throughout the United States. A new edition, revised and improved. In one large royal 12mo. volume, with several hundred illus- trations. (Preparing.) LEES CLINICAL MIDWIFERY. In one Toyal 12mo. volume, extra cloth, of 238 pages. 75 cents. LISTONS LECTURES ON THE OPERATIONS OF SURGERY. Edited, with numerous Addi- tions and Alterations, by T. D. Mutter, M. D. In one large and handsome octavo volume, leather, of 566 pages, with 216 wood-cuts. $3 00. LARDNER (DIONYSIUS), D. C. L., &c. HANDBOOKS OF NATURAL PHILOSOPHY AND ASTRONOMY. Revised, with numerous Additions, by the American editor. First Course, containing Mecha- nics, Hydrostatics, Hydraulics, Pneumatics, Sound, and Optics. In one large royal 12mo. volume, of 750 pages, with 424 wood-cuts. SI 75. Second Course, containing Heat, Electricity, Magnetism, and Galvanism, one volume, large royal 12mo., of 450 pages, with 250 illustrations. 51 25. Third Course (now ready), containing Meteorology and Astronomy, in one large volume, royal 12mo. of nearly eight hundred pages, with thirty-seven plates and two hundred wood-cuts. $2 00. The whole complete in three volumes, of about two thousand large pages, with over one thousand figures on steel and wood. $5 00. Any volume sold separate, strongly bound in leather. The various sciences treated in this work will be found brought thoroughly up to the latest period. AND SCIENTIFIC PUBLICATIONS. 19 r%„ LEHMANN (C. G.) PHYSIOLOGICAL CHEMISTRY. Translated from the second edition by George E Day, M. D., F. R. S., &c, edited by R. E. Rogers, M. D., Professor of Chemistry m the Medical Department of the University of Pennsylvania, with illustrations selected from Th Sj °f Pnysiol°gical Chemistry, and an Appendix of plates. Complete in two large and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus- trations. (Now Ready.) $6 00. This great work, universally acknowledged as the most complete and authoritative exposition of tne principles and details of Zoochemistry, in its passage through the press, has received from rrotessor Kogers such care as was necessary to pre.-ent it in a correct and reliable form. To such a work additions were deemed superfluous, but several years having elapsed between the appear- ance in Germany of the first and last volume, the latter contained a supplement, embodying nume- rous corrections and additions resulting from the advance of the science. These have all been incor- porated in the text in their appropriate places, while the subjects have been still further elucidated by the insertion of illustrations from the Atlas of Dr. Otto Funke. With the view of supplying the student with the means of convenient comparison, a large number of wood-cuts, from works on kindred subjects, have also been added in the form of an Appendix of Plates. The work is, therefore, pre- sented as in every way worthy the attention of all who desire to be familiar with the modern facts and doctrines of Physiological Science. Already well known and appreciated by the scien- tific world, Professor Lehmann's great -work ic- quires no laudatory sentences, as, under a new garb, it is now presented to us. The little space at our command would ill suffice to set forth even a small portion of its excellences. To all whose studies or professional duties render the revelations of Physio- logical Chemistry at once interesting and essential, these volumes will be indispensable. Highly com- plimented by European reviewers, sought for with avidity by scholars of every nation, and admirably written throughout, it is sure to win a welcome and to be thoroughly studied.—Boston Med. and Surg. Journal, Dec. 1855. The most important contribution as yet made to Physiological Chemistry.—Am. Journal Med. Sci- ences, Jan. 1856. The present volumes belong to the small class of medical literature which comprises elaborate works of the highest order of merit.—Montreal Med. Chron- icle, Jan. 1856. The work of Lehmann stands unrivalled as the most comprehensive book of reference and informa- tion extant on every branch df the subject on which it treats.—Edinburgh Monthly Journal of Medical Science. All teachers must possess it, and every intelligent physician oueht to do likewise.—Southern Med. and Surg. Journal, Dec. 1S55. BY the same author. (Now Ready, 1856.) MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital Force, by Samuel Jackson, M. D., Professor of the Institutes of Medicine in the University of Pennsylvania. With illustrations on wood. In one very handsome octavo volume, extra c'oth, of 336 pages. $2 25. The original of this work, though but lately issued by its distinguished author, has already assumed the highest position, as presenting in their latest development the modern doctrines and discoveries in the chemistry of life. The numerous additions by the translator, and the Introduc- tion by Professor Jackson will render its physiological aspect more complete than designed by tbe author, and will adapt it for use as a text-book of physiology, presenting more thoroughly than has yet been attempted, the modifications arising from the vast impulse which organic chemistry has received within a few years past. From Prof. Jackson's Introductory Essay. In adopting the handbook of Dr. Lehmann as a manual of Organic Chemistry for the use of the students of the University, and in recommending his original work of Physiological Chemistry for their more mature studies, the high value of his researches, and the great weight of his autho- rity in that important department of medical science are fully recognized. The present volume will be a very convenient one I densed form, the positive facts of Physiological for students, as offering a brief epitome of the more Chemistry.—Am. Journal Med. Sciences, April, 185G. elaborate work, and as containing, in a very con- | LAWRENCE (W.), F. R. S., &.c. A TREATISE ON DISEASES OF THE EYE. A new edition, edited, with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi- tal, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound in leather with raised bands. $5 00. This work is so universally recognized as the standard authority on the subject, that the pub- lishers in presenting this new edition have only to remark that in its preparation the editor has carefully revised every portion, introducing additions and illustrations wherever the advance of science has rendered them necessary or desirable, constituting it a complete and thorough exponent of the most advanced state of the subject. This admirable treatise—the safest guide and most j octavo pnges—has enabled both author and editor to comprehensive work of reference, which is within I do justice to all the details of this subject, and con the reach of the profession.—Stethoscope This standard text-book on the department of which it treats, has not been superseded, by any or all of the numerous publications on the subject heretofore issued. Nor with the multiplied improve- ments of Dr. Hays, the American editor, is it at all likely that this great work will cease to merit the dense in this single volume the present state of our knowledge of the whole science in this department, whereby its practical value cannot be excelled. We heartily commend it, especially as a book of refer- ence, indispensable in every medical library. The additions of the American editor very greatly en- hance the value of the work, exhibiting the learning and experience of Dr. Hays, in the light in which he confidence and preference of students or practition- | ought to be held, as a standard authority on all sub- ers. Its ample extent—nearly one thousand large | jects appertaining to this specialty .—N.Y. Med. Gaz. 20 BLANCHARD & LEA'S MEDICAL LA ROCHE (R.), M. D., &c. YELLOW FEVER, considered in its Historical, Pathological, Etiolo-i<:il, and Therapeutical Relations. Including a Sketch of the Disease as it has occurred in i'hiladelphia from 169(J tol8')4, with an examination of the connections between it and the fevers known under the same name in other parts of temperate as well as in tropical regions. In two large and handsome octavo volumes of nearly 1500 pages, extra cloth. (Now Ready.) $7 00. The publishers are happy in being able at length to present to the profession this great work, which they are asMired will be regarded as an honor to the medical literature of the country. As the result of many years of personal observation and study, as embodying an intelligent resume of all that has been written regarding the disease, and as exhausting the subject in all its various aspecls, these volumes must at once take the position of the standard authority and work of refer- ence on the many important questions brought into consideration. erection of this towering monument to his own fame, and to the glory of the medical literature of his own country. It is destined to remain the great autho- From Professor S. IT. Dickson, Charleston, S. C, September 18, 1855. A monument of intelligent and well applied re- search, almost without example. It is, indeed, in itself, a large library, and is destined to constitute the special resort as a book of reference, in the subject of which it treats, ta all future time. We have not time at present, engaged as we are, by day and by night, in the work of combating this very disease, now prevailing in our city, to do more than give this cursory notice of what we consider as undoubtedly the most able and erudite medical publication our country has yet produced But in view of the startling fact, that this, the most malig- nant and unmanageable disease of modern times, has for several years been prevailing in our country to a greater extent than ever before; that it is no longer confined to either large or small cities, but penetrates country villages, plantations, and farm- houses; that it is treated with scarcely better suc- cess now than thirty or forty years ago; that there is vast mischief done by ignorant pretenders to know- ledge in regard to the disease, and in view of the pro- bability that a majority of southern physicians will be called upon to treat the disease, we trust that this able and comprehensive treatise will he very gene- rally read in the south.—Memphis Med. Recorder. This is decidedly the great American medical work of the day—a full, complete, and systematic treatise, unequalled by any other upon the all-important sub- ject of Yellow Fever. The laborious, indefatigable, and learned author has devoted to it many years of arduous research and careful studv, and the result is such as will reflect the highest'honor upon the author and our country.—Southern Med. and Surg. Journal. The genius and scholarship of this great physician could not have been better employed than in the rity upon the subject of Yellow Fever. The student and physician will find in these volumes a rcsumi of the sum total of the knowledge of the world upon the awful scourge which they so elaborately discuss. The style is so soft and so pure as to refresh and in- vigorate the mind while absorbing the thoughts of the gifted author, while the publishers have suc- ceeded in bringing the externals into a most felicitous harmony with the inspiration that dwells within. Take it all in all, it is a book we have often dreamed of, but dreamed not that it would ever meet our waking eye as a tangible reality.—Nashville Journal of Medicine. We deem it fortunate that the splendid work of Dr. La Roche should have been issued from the press at this particular time. The want of a reliable di- gest of all that is known in relation to this frightful malady has long been felt—a want very satisfactorily met in the work before us. We deem it but faint praise to say that Dr. La Rcche has succeeded in presenting the profession with an able and complete monograph, one which will find its way into every well ordered library.— Va. Stethoscope. Although we have no doubt that controversial treatises on the mode of origin and propagation of the fever in question will, as heretofore, occasionally appear, yet it must be some time before another sys- tematic work can arise in the face of so admirable and carefully executed a one as the present. It is a mine of information, quite an encyclopaedia of refer- ences, and risuml of knowledge relative to what has been recorded upon the subject.—London Lancet. A miracle of industry and research, constituting a complete library of reference on the disease of which it treats.—Dublin Quarterly Journal. BY THE SAME AUTHOR. PNEUMONIA ; its Supposed Connection, Pathological and Etiological, with Au- tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one handsome octavo volume, extra cloth, of 500 pages. $3 00. n,^rlr01!,e„H.impIe'C.lear' and/orciMe exposition of I This work should becarefully studied bv Southern n^rtfin noi-h^f ° V6 'T da,n?er<>,us tendency of | physicians, embodying as it does the reflections of S1\P.. g . ,,a.nd etlol"Slcal heresies, has I an original thinker and close observer on a subject ?S3te anlc^raYs^cT"- *' '"^ I %£%1/ »"** — ^™ ""■ — ^glcal MULLER (PROFESSOR J.), M.D. PRINCIPLES OF PHYSICS AND METEOROLOGY. Edited, with Addi- S with V§wo^, Gri"ith' M- D. In one large and handsome octavo volume, extra ciotn, with1 050 wood-cuts, and two colored plates, pp. 636. $3 50. ^e^^Stw^n^^^1^^^1^' ! "°,n to tlle scientific records of this country may be eoSdnothave'beenKr 3i«! ^'hSciei,n" du ^ eStimated b^ the fact that the cost of the origi- of surpas8uigVlnbteerestbetThe vaiuelf t^contrtbu! | ^T^S^^t8' '^ ^ ^^ ^ MAYNE'S DISPENSATORY AND THERA- PEUTICAL REMEMBRANCER Comprising the entire lists ot Materia Medica. with ever? Practical Formula contained in the three British Pharmacopoeias. AVith relative Tables subjoined, illustrating by upwards of six hundred and sixty examples, the Extemporaneous Forms and Com- binations suitable for the different Medicines. Edited .with the addition of the Formula of the fiS 11™ u nh,rmaCOp(Eia' ^' R- Eglesfeld nfWM ' • In "ne 12,no volumei extra cloth, of 300 large pages. 75 cents. MATTEUCCIS LECTURES ON THE PHYSI- CAL PHENOMENA OF LIVING BEINGS. Edited by J. Pkreira, M. D. In one neat royal 12mo. volume, extra cloth, with cuts, 3-8 paees. SI 00. > > i s<=»- MALGAIGNE'S OPERATIVE SURGERY, based on Normal and Pathological Anatomy. Trans- lated from the French by Frederick Brittan A. B.,M.D. Withnumerousillustrationson wood! In one handsome octavo volume, extra cloth, of nearly six hundred pages. S2 25. AND SCIENTIFIC PUBLICATIONS. 21 MEIGS (CHARLES D.), M. D., Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia. OBSTETRICS: THE SCIENCE AND THE ART. Second edition, revised and unproved. With one hundred and thirty-one illustrations. In one beautifully printed octavo volume, leather, of seven hundred and fifty-two large pages. S3 75. The rapid demand for a second edition of this work is a sufficient evidence that it has supplied a desideratum of the profession, notwithstanding the numerous treatises on the same subject which have appeared within the last few years. Adopting a system of his own, the author has combined the leading principles of his interesting and difficult subject, with a thorough exposition of its rules ot practice, presenting the results of long and extensive experience and of familiar acquaintance with all the modern writers on this department of medicine. As an American Treatise on Mid- wifery, which has at once assumed the position of a classic, it possesses peculiar claims to the at- telut,1
    RICORD (P.), M. D. A TREATISE ON THE VENEREAL DISEASE. By John Hunter F R S With copious Additions, by Ph. Ricord, M D Edited with rJ„t"L k i? nUN ,R' * • -K- »• M. D. In one handsome ojtavo volume,' ^'^X^^i^^^^^^^^ ne will recognize the attrartivonp^ *.„,! .„'.__:___y ° . ' wuu Plaies. h.very one will recognize the attractiveness and vdtue which this work derives from thus presenting the opinions of these two masters side by side But it must be admitted, what has made the fortune of the book, is the fact that it contains the "most com- plete embodiment of the veritable doctrines of the Hopital du Midi," which has ever been msde public The doctrinal ideas of M. Ricord, ideas which, if not universally adopted, are incontestably dominant, have herelotore only been interpreted by more or less skilful ILLUSTRATIONS OF SYPHILITIC DISEASE Iranslated by Thomas F. Betton, M.D. \Vith fifty large quarto colored plates. In one lam-e quarto volume, extra cloth. $15 00. ° "KenoiP^'iT16? acc7ediled" a«d sometimes not. Jff t 8l° Hunter, the master substitutes him- self for his interpreters, and gives hisorigiral thoughts ne L,0co„cln,t Udd a"d PCrfeC,ly «*»£«.£ "est'ablv th? h«, ,°n W6 Can Say lhal this is i'1^"- are acLSfntPH -USalI8e on »yP»»« with which we are acquainted, and, as we do not often emnlov the SiatTZt TI be ,eXCU?ed for ^pressing heyhoJe swVn 7 "d a,P,laCe in the libri»y of every phy! 1 &"Mn.-VirginiaMed. and Surg. Journal P BY THE SAME AUTHOR. L|dh(frRo?thfun7P^L,IS',addreSSed t0 the Chief PLnSM Medicale. Translated by W. 1]rn. * ftAv} ' - "■ In one "eat octavo vol- ume, of 270 pages, extra cloth. $-2 00. AND SCIENTIFIC PUBLICATIONS. 27 RAMSBOTHAM (FRANCIS H ) M D TISI,fRr^NCIPfLES ^/fiACTICE OF OBSTETRIC MEDICINE AND imperial octavo volume, of 650 pages, stronHy bound fn lent'hV.' »-«i,n ™e]larSe,and handsome four beautiful Plates, and numerous Wood-cms in the ?«t eonJnlnSr"""!? ^"^ ™h ^ large and beautiful figures. (Lately Is sued,W56) «5 00 COntamin^ ln a11 nearly tw° hundred wSilSlM ST "^ wort, the publishers remarkab,e favor with which it has been rece'ved^e VloZT^^^wTcZfaet bly enlarged has received a further revision from the author, especially for this country It spas Sage through the press here has been supervised by Dr. Keating, who has made numerous addi- tions with a view of presenting more fully whatever was necessary to adapt itTorougldto ^Sund F ^ US mechanical exec«lion' * *** superiority oPver former editions _, t. . ■ ... .From Prof. Hodge, of the University of Pa. To the American public, it is most valuable, from its intrinsic nn,ir.„KtD^ ^___n ,_ • The publishers have shown their appreciation of the merits of this work and secured its success by the truly elegant style in which they have brought it out, excelling themselves in its production, espe- cially in its plates. It is dedicated to Prof. Meigs, and has the emphatic endorsement of Prof. Hodge, as the best exponent of British Midwifery. We cine and Surgery to our library, and confidently recommend it to our readers, with the assurance that it will not disappoint their most sanguine ex- pectations.— Western Lancet. It is unnecessary to say anything in regard to the utility of this work. It is already appreciated in our country for the value of the matter, the clearness of know of no text-book which deserves in all respects I u t 7 0r ,h5uV'V^e of th,e- m!!tter> the clearness of to be more highlv recommended to students, and we I l -y ■' ?n(J..the fulness of its illustrations. To the could wish to see'it in the hands of every practitioners n,ny?ie'an s library it is indispensable, while to the for thev will find it invaluable for reference.— M,,f sixilien},as a text-book, from which to extract the for they will find it invaluable for reference.—Med Gazette. But once in a long time some brilliant genius rears his head above the horizon of science, and illumi- nates and purifies every department that he investi- gutes; and his works become types, by which innu- merable imitators model their feeble productions. Such a genius we rind in the younger Ramsbotham, and such a type we find in the work now before us. The binding, paper, type, the engravings and wood- cuts are all so excellent as to make this book one of the finest specimens of the art of printing that have give» such a world-wide reputation to its enter- prising and liberal publishers. We welcome Rams- botham's Principles and Practice of Obstetric Medi- : . ~ - --"» """«., ....... vvmv-.l LW CALiaUl LUC material for laying the foundation of an education on obstetrical science, it has no superior.—Ohio Med. and Surg. Journal. We will only add that the student will learn from it all he need to know, and the practitioner will find it, as a book of reference, surpassed by none other.— Stethoscope. The character and merits of Dr. Ramsbotham's work are so well known and thoroughly established, that comment is unnecessary and praise, superfluous. The illustrations, which are numerous and accurate, are executed in the highest style of art. We cannot too highly recommend the work to our readers.__St. Louis Med. and Surg. Journal. ROKITANSKY (CARD, M.D., Curator of the Imperial Pathological Museum, and Professor at the University of Vienna &c A MANUAL OF PATHOLOGICAL ANATOMY. Four volumes,' octavo, bound in two, extra cloth, of about 1200 pages. (Now Ready.) $5 50 Vol. I.—Manual of General Pathological Anatomy. Translated by W. E. Swaine, Vol. II.—Pathological Anatomy of the Abdominal Viscera. Translated by Edward Sieveking, M.D. Vol. III.—Pathological Anatomy of the Bones, Cartilages, Muscles, and Skin, Cellular and Fibrous Tissue, Serous and Mucous Membrane, and Nervous System. Translated by C. H. Moore. Vol. IV.—Pathological Anatomy of the Organs of Respiration and Circulation. Translated by G. E. Day. To render this large and important work more easy of reference, and at the same time less cum- brous and costly, the four volumes have been arranged in two, retaining, however, the separate paging, drc. The publishers feel much pleasure in presenting to the profession of the United States the great work of Prof. Rokitansky, which is universally referred to as the standard of authority by the pa- thologists of all nations. Under the auspices of the Sydenham Society of London, the combined labor of four translators has at length overcome the almost insuperable difficulties which have so long prevented the appearance of the work in an English dress, while the additions made from various papers and essays of the author present his views on all the topics embraced, in their latest published form. To a work so widely known, eulogy is unnecessary, and the publishers would merely state that it is said to contain the results of not less than thirty thousand post-mortem examinations made by the author, diligently compared, generalized, and wrought into one com- plete and harmonious system. The profession is too well acquainted with the re- putation of Rokitansky's work to need our assur- ance that this is one of the most profound, thorough, and valuable books ever issued from the medical press. It is sui generis, and has no standard of com- parison. It is only necessary to announce that it is issued in a form as cheap as is compatible with its size and preservation, and its sale follows as a matter of course. No library can be called com- plete without it.—Buffalo Med. Journal. An attempt to give our readers any adequate idea of the vast amount of instruction accumulated in these volumes, would be feeble and hopeless. The effort of the distinguished author to concentrate in a small space his great fund of knowledge, has I Am. Med. Monthly. so charged his text with valuable truths, that any attempt of a reviewer to epitomize is at once para- lyzed, and must end in a failure.—Western Lancet. As this is the highest source of knowledge upon the important subject of which it treats, no real student can afford to be without it. The American publishers have entitled themselves to the thanks of the profession of their country, for this timeous and beautiful edition.—Nashville Journal of Medicine. As a book of reference, therefore, this work must prove of inestimable value, and we cannot too highly recommend it to the profession.—Charleston Med. Journal and Review, Jan. 1856. This book is a necessity to every practitioner.— 2S BLANCHARD & LEA' KIGHY'S SYSTEM OF MIDWIFERY. With Notes and Additional Illustra- \ions. Second American Edition. One volume octavo, extra cloth, 422 pages. l?2 50. ROYLE'S MATERIA MEDICaTaND THERAPEUTICS; including the Preparation* of the Pharmacopoeias of London, Edinburgh Dublin, and of the United States. With many new medicines. Edited by Joseph Carson, M. D. With ninety-eight illustrations. In one large octavo volume, extra cloth, of about 700 pages. 00. SMITH (HENRY H.), Professor of Surgery in the University of Pennsylvania, &c. MINOR SURGERY; or, Hints on the Every-day Duties of the Surgeon. Illus- trated bv two hundred and forty-seven illustrations. Third and enlarged edition. In one haad- some royam.no. volume, pp. 456. In leather, ?2 25; extra cloth, $2 00. A work such as the present is therefore highly useful to the student, and we commend this one to their attention.—American Journal of Medical Sciences. And a capital little book it is. . . Minor Surgery, we repeat, is really Major Surgery, and anything which teaches it is worth having. S>o we cordially recommend this little book of Dr. Smith's.—Med.- CJiir. Review. This beautiful little work has been compiled with a view to the wants of the profession in the matter of bandao-in", &c, and well and ably has the author performed his labors. Well adapted to give the requisite information on the subjects of which it treats.—Medical Examiner. The directions are plain, and illustrated through- out with clear engravings.—London Lancet. One of the best works they can consult on the subject of which it treats.—Southern Journal of Medicine and Pharmacy. BY THE SAME AUTHOR, AND HORNER (WILLIAM E.), M.D., Late Professor of Anatomy in the University of Pennsylvania. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. $3 00. No operator, however eminent, need hesitate to consult this unpretending yet excellent book.^ Those who are young in the business would find Dr. Smith's treatise a necessary companion, after once under- standing its true character.—Boston Med. and Surg. Journal. No young practitioner should be without this little volume; and we venture to assert, that it maybe consulted by the senior members of the profession with more real benefit, than the more voluminous works.— Western Lancet. These figures are well selected, and present a complete and accurate representation of that won- derful fabric, the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its superb artistical execution, have been already pointed out. We must congratu- late the student upon the completion of this Atlas, as it is the most convenient work of the kind that has yet appeared ; and we must add, the very beau- tiful manner in which it is ".got up" is so creditable to the country as to be flattering to our national pride.—American Medical Journal. SARGENT (F. W.), M. D. ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. Second eHition, enlarged. One handsome royal 12mo. vol., of nearly 400 pages, with 182 wood- cuts. (Now Ready, 1856.) Extra cloth, $1 40; leather, $1 50. This very useful little work has long been a favor- ite with practitioners and students. The recent call for a new edition has induced its author to make numerous important additions. A slight alteration in the size of the page has enabled him to introduce the new matter, to the extent of some fifty pages of the former edition, at the same time that his volume is rendered still more compact than its less compre- hensive predecessor. A doublegain in thus effected, which, in a vade-mecum of this kind, is a material improvement.—Am. Medical Journal. Sargent's Minor Surgery has always been popular, and deservedly so. It furnishes that knowledge of the most frequently requisite performances of surgical art which cannot be entirely understood by attend- ing clinical lectures. The art of bandaging, which is regularly taught in Europe, is very frequently overlooked by teachers in this country; the student and junior practitioner, therefore, may often require that knowledge which this little volume so tersely and happily supplies. It is neatly printed and copi- ously illustrated by the enterprising publishers, and should be possessed by all who desire to be thorough- ly conversant with the details of this branch of our art.—Charleston Med. Journ. and Review, March, 1856. A work that has been so long and favorably known to the profession as Dr. Sargent's Minor Surgery, needs no commendation from us. AVe would remark, however, in this connection, that minor surgery sel- dom gets that attention in our schools that its im- portance deserves. Our larger works are also very defective in their teaching on these small practical points. This little book will supply the void which all must feel who have not studied its pages.—West- ern Lancet, March, 1856. We confess our indebtedness to this little volume on many occasions, and can warmly recommend it to our readers, as it is not above the consideration of the oldest and most experienced.—American Lan- cet, March, 1856. SKEY'S OPERATIVE SURGERY. In one very handsome octavo volume, extra cloth, of over 650 pages, with about one hundred wood-cuts. $3 25. STANLEY'S TREATISE ON DISEASES OF THE BONES. In one volume, octavo, extra cloth, 2S6 pages. SI 50. SOLLY ON THE HUMAN BRAIN; its Structure, Physiology, and Diseases. From the Second and much enlarged London edition. In one octavo volume, extra cloth, of 500 pages, with 1-20 wood- cuts. $2 00. SIMON'S GENERAL PATHOLOGY, as conduc- ive to the Establishment of Rational Principles for the prevention and Cure of Disease. In on« neat octavo volume, extra cloth, of 212 pages. $1 25. 6 STILLE (ALFRED), M. D. PRINCIPLES OF GENERAL AND SPECIAL THERAPEUTICS. In handsome octavo. (Preparing.) AND SCIENTIFIC PUBLICATIONS. 29 SHARPEY (WILLIAM1, M. D., JONES QUAIN, M. D., AND RICHARD QUAIN, F. R. S., &c. HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidt, M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo volumes, leal her, of about thirteen hundred pages. Beautifully illustrated with over five hundred engravings on wood. $6 00. It is indeed a work calculated to make an era in anatomical study, by placing before the student every department of his science, with a view to the relative importance of each ; and so skilfully have the different parts been interwoven, that no one who makes this work the basis of his studies, will hereafter have any excuse for neglecting or undervaluing any important particulars connected with the structure of the human frame; and whether the bias of his mind lead him in a more especial manner to surgery, physic, or physiology, he will find here a work at once so comprehensive and practical as to defend him from exclusiveness on the one hand, and pedantry on the other. — Journal and Retrospect of the Medical Sciences. We have no hesitation in recommending this trea- tise on anatomy as the most complete on that sub- ject in the English language; and the only one,, perhaps, in any language, which brings the state of knowledge forward to the most recent disco- veries.—The Edinburgh Med. and Surg. Journal. SMITH (W. TYLER), M. D., Physician Accoucheur to St. Mary's Hospital, &c. ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OF OBSTETRICS. In one royal 12mo. volume, extra cloth, of 400 pages. $1 25. BY THE SAME AUTHOR.—(Just Issued.) A PRACTICAL TREATISE ON THE PATHOLOGY AND TREATMENT OF LEUCORRHCEA. With numerous illustrations. In one very handsome octavo volume, extra cloth, of about 250 pages. $1 50. We decide this book to be one of the most useful monographs which has appeared in this country. What was before unutterable confusion in regard to its subject has now the order, regularity, and har- mony of a most beautiful science. Dr. Smith has placed the whole profession directly, and mankind indirectly, under abiding obligations. — Nashville Journ. of Medicine. We hail the appearance of this practical and in- valuable work, therefore, as a real acquisition to our medical literature.—Medical Gazette. SIBSON (FRANCIS), M.D., Physician to St. Mary's Hospital. MEDICAL ANATOMY. Illustrating the Form, Structure, and Position of the Internal Organs in Health and Disease. In large imperial quarto, with splendid colored plates. To match "Maclise's Surgical Anatomy." Part I. (Preparing.) SCHOEDLER (FRIEDRICH), PH.D., Professor of the Natural Sciences at Worms, &c. THE BOOK OF NATURE; an Elementary Introduction to the Sciences of Physics, Astronomy, Chemistry, Mineralogy, Geology, Botany, Zoology, and Physiology. First American edition, with a Glossary and other Additions and Improvements; from the second English edition. Translated from'the sixth German edition, by Henry Medlock, F. C. S., &c. Li one thick volume,, small octavo, extra cloth, of about seven hundred pages, with 679 illustra- tions on wood. Suitable for the higher Schools and private students. (Now Ready.) $1 80. TANNER (T. H.), M. D., Physician to the Hospital for Women, &c. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS. To which is added The Code of Ethics of the American Medical Association. In one neat volume, small 12mo. Price in extra cloth, 87 £ cents; flexible style, for the pocket, 80 cents. (Lately Publislied.) In this admirable little work the author's object has been to give the young practitioner that kind of information which enables him to make practical application of the knowledge acquired by his studies and which is not to be found in the text-books. Such a manual has been much wanted, as it fills a void which has long been felt, but which there has hitherto been no attempt to supply. That the author has succeeded in his endeavor, is sufficiently shown by the unusually favorable reception which the work has already received, although only just published Dr. Tanner has, in a happy and successful manner, indicated the leading particulars to which, in the clinical study of a case of disease, the attention of the physician is to be directed, the value and import of the various abnormal phenomena detected, and the several instrumental and accessory means, which maybe called into requisition to facilitate diagnosis and increase its certainty.—Am. Journal of Med. Sciences. In this small work is collected a fund of such in- formation as the student at the commencement, and even during the continuance of his studies, is often Badly troubled to know where to look for .—Montreal Med. Chronicle. The work is an honor to its writer, and must ob- tain a wide circulation by its intrinsic merit alone. It seems to us that but slight effort on the part of the publishers will be requisite to exhaust even a large edition. Suited alike to the wants of students and practitioners, it has only to be seen, to win for itself a place upon the shelves of every medical library. Nor will it be " shelved" long at a time; if we. mis- take not, it will be found, in the best sense of the homely but expressive word, " handy." The style is admirably clear, while it is so sententious as not to burden the memory. The arrangement is, to our mind, unexceptionable. The work, in short, de- serves the heartiest commendation.—Boston Med. and Surg. Journal We cordially recommend every young practitioner who wishes to reap the greatest possible benefit from his observation of disease to make this book his daily companion.—New Hampshire Journal of Medi- cine. As a convenient and suggestive book of reference, weaccord it our hearty praise.—Va. Med. and Surg. Journal. 30 BLANCHARD well is this work known to the members both of the medical and legal professions, and so highly is it appreciated by them, that it cannot be necessary for us to say a word in its commendation; its having already reached a fourth edition being the best pos- sible testimony in its favor. The author has ob- viously subjected the entire work to a very careful revision.—Brit, and For,.ign Med. Chirurg. Review. This work of Dr. Taylor's is generally acknow- ledged to be one of the ablest extant on the subject of medical jurisprudence. It is certainly one of the It is not excess of praise to say that the volume before us is the very best treatise extant on Medical Jurisprudence. In saying this, we do not wish to be understood as detracting from the merits of the excellent works of Beck, Ryan, Traill, Guy, and others; but in interest and value we think it must be conceded that Taylor is superior to anything that has preceded it. The author is already well known to the profession by his valuable treatise on Poisons ; and the present volume will add materially to his high reputation for accurate and extensive know- ledge and discriminating judgment.—N. W. Medical ana Surgical Journal. BY THE SAME AUTHOR. ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE Edited with Notes and Additions, by R. E. Griffith, M. D. In one large octavo volume, leather, of 688 pages. S3 00 TODD (R. B.), M. D., AND BOWMAN (WILLIAM!, F. R S PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With numerous handsome wood-cuts Parts I, II, and III, in one octavo volume, 552 pages. $2 50 Fart IV will complete the work. y ° v ThC JLT iP0.rti0n °r V?$F> 7huh numer,ous oriS'nal illustrations, was published in the Medical ill T^ y°r853,i"'1d the completion will be issued immediately on its appearance in London. Those who have subscribed since the appearance of the preceding portion of the work can have the three parts by mail, on remittance of $2 50 to the publishers. WATSON (THOMAS), M. D., &.c. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC Ihird American edition, revised, with Additions, by D. Francis Con™* M n «„,£<• To say that it is the very best work on the sub- ject now extant, is but to echo the sentiment of the medical press throughout the country.__N. O. Medical Journal. Of the text-books recently republished Watson is very justly the principal favorite.—Holmes's Rep to Nat. Med. Assoc. ' By universal consent the work ranks among the very best text-books in our language.—Illinois and Indiana Med. Journal. Regarded on all hands as one of the very best if not the very best, systematic treatise on practical medicine extant—St. Louis Med. Journal. Confessedly one of the very best works on the principles and practice of physic in the English or any other language.—Med. Examiner. nfAn!?^][t'bool£, it; has. n« equal; as a compendium AnnaUsi°gY Practlce n« superior.—New York We know of no work better calculated for bein* placed in the hands of the student, and for a text! book; on every important point the author seems to have posted up his knowledge to the day.— Amer. Med. Journal. 8 y One of the most practically useful books that ever was presented to the student. — N. Y Med Journal. ■«■"<*. WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDTCAT paw Published under the authority of the London Societv for M^i^i nu iU^-UJ-CA-L CASES. from the second and revised London edition In one vJS t» \ Observa,,,on- A new American, cloth. (Just Issued.) SI 00 ery handsome volume, royal 12mo., extra To the observer who prefers accuracy to blunders and precision to carelessness, this little book is in- valuable.— N. H. Journal of Medicine. ha?eevertseenDe8pa^8 *? * 1°™* Petitioner we nave ever seen.—Peninsular Journal of Medicine. AND SCIENTIFIC PUBLICATIONS. 31 WILSON (ERASMUS), M.D., F. R. S., Lecturer on Anatomy, London. A SYSTEM OF HUMAN ANATOMY, General and Special. Fourth Ameri- can, from the last English edition. Edited by Paul B. Goddard, A. M., M. D. With two hun- dred and fifty illustrations. Beautifully printed, in one large octavo volume, leather, of nearly six hundred pages. $3 00. In many, if not all the Colleges of the Union, it has become a standard text-book. This, of itself, is sufficiently expressive of its value. A work very desirable to the student; one, the possession of which will greatly facilitate his progress in the study of Practical Anatomy.—New York Journal of Medicine. Its author ranks with the highest on Anatomy.— Southern Medical and Surgical Journal. It offers to the student all the assistance that can be expected from such a work.—Medical Examiner. The most Complete and convenient manual for the student we possess.—American Journal of Medical Science. In every respect, this work as an anatomical guide for the student and practitioner, merits our warmest and most decided praise.—London Medical Gazette. BY THE same author. (Now Ready.) THE DISSECTOR'S MANUAL; or, Practical and §urgical Anatomy. Third American, from the last revised and enlarged English edition. Modified and rearranged, by William Hunt, M. D., Demonstrator of Anatomy in the University of Pennsylvania. In one large and handsome royal 12mo. volume, leather, of 5S2 pages, with 154 illustrations. $2 00. The modifications and additions which this work has received in passing recently through the author's hands, is sufficiently indicated by the fact that it is enlarged by more than one hundred pages, notwithstanding that it is printed in smaller type, and with a greatly enlarged page. So com- plete has the author rendered it, that the editor has found but little to do, except in rearranging it to suit the mode of dissection practised in this country, and in introducing a large number of additional illustrations. Of these, many new ones have been engraved expressly for the work, and the series throughout will be found greatly enhanced in value. The typographical execution of the volume has undergone a like improvement, and in every respect the work is presented as merit- ing an increase of the favor which it has hitherto enjoyed as a sound practical guide to the study of anatomy. It remains only to add, that after a careful exami- I ing very superior claims, well calculated to facilitate nation, we have no hesitation in recommending this | their studies, and render their labor less irksome, by work to the notice of those for whom it has been I constantly keeping before them definite objects of expressly written—the students—as a guide possess- | interest.—The Lancet. BY THE SAME AUTHOR. ON DISEASES OF THE SKIN. Third American, from the third London edition. In one neat octavo volume, of about five hundred pages, extra cloth. §1 75. The "Diseases of the Skin," by Mr. Erasmus I in that department of medical literature.—Medico- Wilson, may now be regarded as the standard work | Chirurgical Review. BY THE SAME AUTHOR. ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. In one small octavo volume, extra cloth, beautifully printed, with four exquisite colored plates, presenting more than thirty varieties of syphilitic eruptions. $2 it>. BY THE SAME AUTHOR. (Just Issued.) HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- tion and Management. Second American, from the fourth London edition. One neat volume, royal 12mo., extra cloth, of about 300 pages, with numerous illustrations. $1 00; paper cover, 75 cents. WHITEHEAD (JAMES), F. R. C. S., &c. THE CAUSES AND TREATMENT OF ABORTION AND STERILITY; being the Result of an Extended Practical Inquiry into the Physiological and Morbid Conditions of the Uterus. Second American Edition. In one volume, octavo, extra cloth, pp. 368. $1 75. WALSHE (W. H.), M. D., Professor of the Principles and Practice of Medicine in University College, London. DISEASES OF THE HEART, LUNGS, AND APPENDAGES; their Symptoms and Treatment. In one handsome volume, extra cloth, large royal 12mo., 512 pages. $l 50. We consider this as the ablest work in the En- I the author being the first stethoscopist of the day.— (riish language, on the subject of which it treats; | Charleston Medical Journal. WILDE (W. R.), Surgeon to St. Mark's Ophthalmic and Aural Hospital, Dublin. AURAL SURGERY, AND THE NATURE AND TREATMENT OF DIS- EASES OF THE EAR. In one handsome octavo volume, extra cloth, of 476 pages, with illustrations. $2 80. This work certainly contains more information on the subject to which it is devoted than any other with which we are acquainted. We feel grateful to the author for his manful effort to rescue this depart- ment of surgery from the hands of the empirics who nearly monopolize it. We think he has successfully shown that aural diseases are not beyond the re- sources of art; that they are governed by the same laws, and amenable to the same general methods of treatment as other morbid processes. The work is not written to supply the cravings of popular patron- age, but it is wholly addressed to the profession, and bears on every page the impress of the reflection* of a sagacious and practical surgeon.—Fa. Surg, and Med. Journal. 32 BLANCHARD & LEA'S SCIENTIFIC PUBLICATIONS. WEST (CHARLES), M. D., Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for Sick Children, ice. LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. Vecond American, from the Second and Enlarged London edition. In one volume, octavo, itra cloth, ol nearly live hundred pages. (Just Issued.) £2 00. We take leave of Dr. West with great respect for his attainments, a due appreciation of his acute powers of observation, and a deep sense of obliga- tion for this valuable contribution to our profes- sional literature. His book is undoubtedly in many respects the best we possess on diseases of children. Dublin Quarterly Journal of Medical Science. Dr. West has placed the profession under deep ob- ligation by this able, thorough, and finished work upon u subject which almost daily taxes to the ut- most the skill of the general practitioner. He has with singular felicity threaded his way through all the tortuous labyrinths of the difficult subject he has undertaken to elucidate, and has in many of the darkest corners left a light, which will never be extinguished.—Nashville Medical Journal. BY the same author. (Nearly Ready.) Publishing in the "Medical News and Library," for 1856. LECTURES ON THE DISEASES OF WOMEN. In two parts. Part I. Svo. of about 300 pages, comprising the Diseases of the Uterus. Part II. (Preparing), will contain Diseases of the Ovaries, and of all the parts connected with the Uterus; of the Bladder, Vagina, and External Organs. The object of the author in this work is to present a complete but succinct treatise on Female Diseases, embodying the results of his experience during the la on application to the Publishers, 13 inclosing six cents in postage stamps. Mlllljiiiifflfiii ;'I national library of medicine nlm D3nnm 5 •: ' •'• i;^^^k^?^i^£ ,•••&- :; '=■-:!•"':- '■■■ ;-;-;;'.«P J-J'iiiUiiJi . ; ■' irT-tr-' NLM031911145