iii!ii*'iii| HUftf!|ji[[(t!iiM!l!iji!|ij!ijili;nmm |iiiii|ii(i!iiii||ii|l|||iffl iHiii(iU[iti[titt|imi!ii.fpiii!|i!ii|nii[i^ ^?r THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA PRESENTED BY PROF. CHARLES A. KOFOID AND MRS. PRUDENCE W. KOFOID ULCERATION OF THE OS UTERI. AN INQUIEY INTO THE PATHOLOGICAL IMPORTANCE ULCERATION OF THE OS UTERI. BEING THE CROONIAN LECTURES FOR THE YEAR 1854, BY CHARLES WEST, M.D., FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS; PHYSICIAN-ACCOUCHErR TO ST. BARTHOLOMEW'S HOSPITAL; PHYSICIAN TO THE HOSPITAL FOR SICK children; AUTHOR OF "LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD," &C. &C. PHILADELPHIA: BLAN CHARD AND LEA 1854. T. K. PHILADELPHIA: AND P. G, COLLINS, PRINTER CONTENTS. LECTURE I. Knowledge of diseases of women imperfect, and its progress slow Employment of speculum, and disputes as to its value Peculiarities of uterus in health and disease Ulcerations of os uteri described; their alleged Importance Doubts suggested; and plan of inquiry proposed I. Evidence of physiology . . . II. Evidence of morbid anatomy . . • . PAGB 11 21 22 26 29 31 32 LECTURE II. Inquiry continued. III. Results of ulceration of procident uterus 41 ly. Results of clinical observation , . 45 Influence of ulceration on fecundity 49 Comparison of symptoms in absence of, or in connection with ulceration 51 Conclusions from inquiry 60l LECTURE III. Inquiry into causes of uterine ailments Constitutional causes frequent and various . Local causes ; sequelae of abortion and labor Other causes productive of hypertrophy 6a 64- 68 10 M354G59 Vlll CONTENTS. Results of inflammation of uterus; and their independence of ulceration Importance of affections of uterine cavity underrated — ^those of cervix over-estimated Symptoms of ulceration, and of ailments akin to it Local treatment of ulceration .... Objections to indiscriminate local treatment Conclusion 71 75 78 81 85 88 AN INQUIKY INTO THE PATHOLOGICAL IMPORTANCE OP ULCERATION OF THE OS UTERI LECTURE I. Introduction — Imperfection of our knowledge concerning the Diseases of "Women; reasons for it. State of opinion at time of first employment of speculum ; facts which use of that instrument brought to light ; different estimates of its value. Important principles involved in the disputes on this subject — Proposed inquiry into them in these Lectures. Preliminary remarks on some peculiarities of the uterus in health and in disease — Supposed cause of most uterine ailments — Alleged importance of ulceration of the OS uteri — Description of those ulcerations — How they are supposed to react on the uterus ; suggestions for their cure. Doubt as to correctness of these opinions — Plan of proposed inquiry into them — I. Conclusions from anatomy and physiology unfavourable to them. II. Results of examinations after death hitherto unsatisfactory, and why — Observations of lecturer; inferences from them opposed to idea of great importance of ulceration of OS uteri. Mr. President — Sir : I enter on the honourable task which you have assigned to me, with much apprehension and misgiving. It is not merely that I appear in the teacher's garb before those from whom I have learned much, and might still be well content to learn all my life long — nor that I address an audience whose criticism I dread and whose unfavourable censure I would deprecate — which fills me with anxiety ; but it is, that I am here to-day in some sort as the repre- sentative of those who follow a department of medical practice which, till but recently, this College scarcely countenanced — to whom it has but lately extended honourable distinctions — on whom 2 18 IMPERFECTION OF KNOWLEDGE it has now for the first time imposed a still more honourable duty. While I rejoice, Sir, in the full recognition by this College, of the fact that all departments of our profession, by which suffering can be assuaged, disease arrested, or life prolonged, are alike honour- able — that none are alien from the paths of scientific inquiry, nor unfriendly to that culture of the mind which confers distinction more precious far than any worldly honours — I dread lest anything that comes from me should seem unworthy of this body, undeserving of that liberality of sentiment and enlargement of view to which I owe it that I have now the opportunity of addressing you. Never, Sir, have I wished so much as I do now for that insight into Nature's ways, which might enable me- to justify your appoint- ment of me as Croonian Lecturer for this year, by bringing before this assembly some new truth, or by throwing fresh light on some great principle but dimly seen, or partially understood before ; or at least for those rare gifts of speech which can impart interest and freshness even to subjects trite and commonplace. But, while to such endowments I have no pretensions, my need of your indulgence is all the greater, since I have had most to do with small complaints and e very-day diseases ; and if from them I select a subject for these Lectures, though obscure, it still must seem familiar, and, with all the disadvantages of novelty, yet have none of its charms. Frequent as is the occurrence, it must nevertheless be confessed that the Diseases of Women are those concerning which our know- ledge is most defective. And yet there seems, at first sight, to be but little reason for these deficiencies ; so little, indeed, that their existence has been made a constant ground of reproach against those who, having to do with ailments so simple as they are assumed to be, yet have left so much concerning them uncertain or unex- plored. I believe, however, that many of the doubts and uncertain- ties which beset these subjects depend on the difiiculties in the way of arriving at truth concerning them, far more than on any want either of diligence or of honest purpose, on the part of those whose special duty it was to engage in their investigation. If, now, for a few minutes I occupy your time in the endeavour to point out whence those difficulties have arisen which did, and do still, retard the advancement of knowledge concerning uterine dis- ease, you must bear with me, since my object is not only to account for the apparent omissions of obstetric practitioners in general, but also, by showing the uncertainty of much that we seem to know, CONCERNINa DISEASES OF WOMEN. 19 to excuse myself for the choice which I have made of a subject for these Lectures. In wonder, says the ancient writer, all philosophy begins, in wonder it ends ; but wide, indeed, is the distance which separates the marvelling of the ignorant from the admiration of the learned. Processes such as those by which the perpetuation of the species is accomplished, could not but excite in every stage, the wonder of all people, in all times. The principle of life, symbolized under various forms, was in the earliest ages the object of reverence, or of actual worship, while the happy issue of the mysterious process of parturi- tion was sought to be secured by rites and ceremonies, and charms, propitiating the various deities who superintended it. If these failed of their looked-for result, or if some untoward event hap- pened, passing the skill of the attendant women, the aid of the surgeon was sent for, though only to perform some barbarous operation. In the diseases of their own sex, it was natural that women should be first consulted ; and the instances were compara- tively few in which application was made for the assistance of any physician : hence it resulted, from sheer w^ant of opportunity, that the anatomical and physiological discoveries which were made, though slowly and imperfectly, remained long unapplied ; that for ages, all knowledge of the pathology of the female sex continued fragmentary, and all treatment of their diseases empirical. Nor was this state of things as much amended as might have been expected by the general advancement of knowledge in compa- ratively modern times. Anatomists devoted themselves to the task of exploring the mysteries of generation, but passed by without inquiry the scarcely less mysterious process of parturition, and the changes which succeed to it ; while, by their unquestioning adop- tion of many errors which time had rendered venerable, they lent to them a fresh sanction, and gave them, as it were, the stamp of truth. In subjects thought to be beneath the dignity of science, advances must needs be slow ; and the whole history of the obstet- ric art is a most appropriate commentary on this fact. By slow degrees, indeed, and by steps which we cannot now stop to trace, improvement came, though amended practice in this, as in so many other instances, preceded correct theory ; and even now we not infrequently do what experience has taught us to be right, although we are unable to assign a thoroughly satisfactory reason for our proceeding. \ 20 IMPERFECT KNOWLEDGE OF DISEASES OF WOMEN. But if our knowledge be still incomplete concerning a process like that of parturition, which is transf^cted in a few hours, and is con- stantly offering itself to our observation, there is little cause for surprise that it should be still more imperfect with reference to the physiology and pathology of the generative system in the unimpreg- nated state. So recently, indeed, as thirty years ago, neither was the structure nor were the functions of the sexual organs at all cor- rectly understood. The uterus, it is true, was known to be muscu- lar ; but neither the process by which its muscularity becomes so marked during pregnancy, while it ceases to be clearly apparent soon after delivery, nor the intimate nature of its structure in the virgin state, had been the subject of inquiry. The interior of its neck was seen to be invested by a membrane arranged in folds, between which minute glands or follicles were present in great abundance ; but the existence of a distinct lining membrane in its cavity was rather inferred from the results of observation in some forms of disease, than demonstrated by anatomical investigation in a state of health. Though the structure of the ovaries was in the - main understood, yet the ovarian ovule had not been discovered, ■ and the function of the ovaries was supposed to be called into exer- cise only during the stimulus of sexual congress. Hence it resulted that the import of menstruation continued to be a riddle unread ; all that was certainly known about it being that it was a function which bore an important, though undefined relation, to the genera- tive process. To have written, under such disadvantages, a work on the Dis- eases of Women — so full of sound observation — so abounding in practical instruction of the highest kind — that, like Pemberton's Treatise on the Abdominal Viscera, it has not only not been ren- dered obsolete by the lapse of time, but that it still remains, after forty years, our safest guide in the management of these diseases, is certainly not the least among the many honours which its author has won, and wears so well. But, in trying to judge fairly of the labours of our more immediate predecessors, or to estimate what remains for us to do, we must not forget that where the knowledge of healthy structure and of natural function is defective, the know- ledge of diseased structure and of perverted function must be imper- fect too. Very few facts will suffice to illustrate the defective pathology of but a few years ago. It was assumed that an organ of such EMPLOYMENT OF SPECULUM. 21 dense structure as the unimpregnated uterus must be little liable to inflammation, and its kindred processes ; though in some rare cases the neck of the womb was allowed to be their seat. Its lining membrane, supposed to be so rudimentary in the unimpregnated state, was not thought worth consideration among the possible seats of disease ; and leucorrhoeal discharges, supposed to be always furnished by the vagina, were usually regarded as the consequence and the index of constitutional debility. The different morbid growths were not properly discriminated; scirrhus, a disease of extreme rarity, was assumed to be of very frequent occurrence ; and to it were attributed almost all chronic affections of the neck of the womb, attended with induration of its substance and increase of its size. In this state of knowledge, when observation must have been perpetually clashing with preconceived opinions, M. Recamier first thought of employing an instrument — the Speculum — for the more convenient application of local remedies to cancerous ulcerations of the womb. Its use, however, was not long confined to this object ; for practitioners found that by means of it they were enabled to discover yarious morbid conditions of the uterus, with which they were hitherto unacquainted, and to which it w^as but natural to attach importance, as the probable cause of many previously inex- plicable symptoms. In fact, by its means one important question was speedily and decisively set at rest — for leucorrhoeal discharges were ascertained to be derived in great measure, not from the vagina, but from the uterus ; to be associated with various diseased appearances of its orifice, and to be, sometimes at least, removed by different remedies directed to that part and to the neck of the womb. So long as the lining membrane of the uterine cavity was supposed to exist in the unimpregnated state merely in a rudiment- ary condition, it was most natural that an exaggerated importance should be attached to the various morbid appearances of the os and cervix uteri ; and so long as the ovaries were believed to be called into activity only at the time of sexual congress, it was to be expected that their share in the production of diseased phenomena should be rated very low. Ignorance, with reference to these two points, was shared alike by the advocates of the employment of the speculum, and by the opponents of its use ; and under these circum- stances their controversies were not likely to lead to any satisfac- tory result. 2Sf PECULIARITIES OF THE UTERUS We need not, indeed, wonder that the disputants on both sides, thus imperfectly furnished for the debate, should have narrowed the question to one of details touching the expediency of employing an instrument which some pronounced to be all important, while others decried it as useless, mischievous, and even immoral. It must be obvious, however, to us who enjoy the advantage of the additions to physiological knowledge which the past quarter of a century has brought with it, that our decision on this subject in- volves much more than the mere acceptance or rejection of a certain therapeutical proceeding, but that it really concerns the opinions which we entertain with reference to the main principles of uterine pathology. Regarded in this light, what might at first have seemed a trivial inquiry, at once assumes a greater importance, and be- comes, I think, not unworthy the attention even of such an audience as the present. It is not without reluctance that once again I venture to delay you with some further preliminary considerations touching the structure and the functions of the womb ; though my doing so might perhaps be justified on the plea of the desirableness that we should, before entering on an examination of conflicting opinions, ascertain what facts are accepted as true on either side. But there is another reason for this course, in the circumstance that the womb presents peculiarities of situation, structure, and function, such as render it probable that the diseases of the organ may likewise ex- hibit distinctive features, and possible that their cure may call for modes of treatment which otherwise would not be expedient, nor even justifiable. Now, it would not be easy to imagine a state of things more favourable to the occurrence of ailments dependent on venous con- gestion, or in which those ailments would be more difficult to remove, or more apt to return, than is observed in the case of the uterus during the whole period of activity of the generative powers. The return of blood from the organ, which is rendered difficult by its situation at the lowest part of the trunk, is still further impeded by the absence of valves from its veins ; while every month, for several days together, this organ and its appendages are the parts towards which blood flows in superabundant streams. During this period, the natural secretion from the uterus and Fallopian tubes is much increased; the epithelium covering their surface is detached, and reproduced again and again; hemorrhage breaks forth along the IN HEALTH AND IN DISEASE. 28 ■whole tract — and it is not until this has continued for some days, that the congestion ceases and the parts subside once more into their former state of quiescence — the uterus remaining, however, for a short time heavier, and its tissue looser, and more abundantly supplied with blood, than it was before. I need not stop to tell how a slight cause may protract this hemorrhage, or how some accident may check it ; nor need I labour hard to prove that in either case there must be a general disturbance of the function of the organ — a general impairment of the health of the individual : exhausted in the one instance by loss of blood, broken down in the other by the suffering, both general and local, which the return of the periodical excitement of the generative organs, unrelieved by their customary depletion, cannot fail to bring with it. In what organ of the body does one find a parallel to this series of occur- rences ? Again ; the uterus is held in its position by supports which allow to it a large measure of mobility, and whose power is generally diminished by the very causes that increase the weight of the body they have to bear. Hence, it is very apt to become displaced, and to be displaced in a downward direction, or prolapsed. And such prolapsus not only brings with it a variety of painful sensations, due to the womb dragging upon its ligaments, but the moment the organ ceases to be suspended in the pelvic cavity, it becomes ex- posed to shocks of various kinds, to irritation from sources from which it was previously safe. The neck of the womb, even when that descent is not very considerable, becomes a sort of stem on which the organ rests upon the floor of the vagina. In this position it is liable to disturbing causes almost numberless — sitting, riding, exertion of any kind, the very passage of the feces along the rectum, produce pain, keep up congestion, and favour that slow increase of size which seldom fails to occur in parts the seat of long- continued irritation, and which offers one great impediment to the cure of many affections of the womb. Another peculiar and fertile source of disorders of the womb is furnished by the changes that attend upon conception and parturi- tion, and their frequent interruption. With these changes, even in the healthy state, our acquaintance is at present too imperfect for us to appreciate with accuracy the nature of the mischief which may result from their disturbance. We know, indeed, many things concerning these processes of which our predecessors were ignorant ; 24 PECULIARITIES OP THE UTERUS but our increased knowledge is as yet sufficient to show us the dif- ficulties of the problem, not sufficient to furnish its solution. The growth of the pregnant womb is not, as it was once supposed to be, a mere increase in size and unfolding of texture of the muscular fibres already present there, but is as much the result of a new formation as is that of the foetus contained within it ; its tissues going through the same development from a rudimentary condition to a high organization. Cells elongate into caudate bodies ; these unite into fibrillae, while the mucous membrane increases in vascu- larity, grows in thickness, and becomes developed into decidua. The small, dense, lowly organized uterus becomes the large, vascu- lar, powerful muscle which we see it to be at the end of pregnancy ; when having served as the residence of the foetus, and as the medium through which it derived its support, the organ accom- plishes in the act of parturition the last of that wonderful series of processes to which it owed in old time its appellation Miraculum Naturae. But even before this period has arrived, indications of decay have manifested themselves in the changes that have taken place in the decidua ; while no sooner is the child born, than all the tissues of the womb evince the commencement of similar alterations, which go on with a rapidity such as is observed in no other body and under no other circumstances. The muscular fibres undergo fatty degeneration, and to a great extent disappear ; nerve-matter ceases to be apparent within the sheaths which had contained it, while even the fibres of elastic tissue interwoven with the muscular substance of the womb, lose their distinctness or become entirely absorbed. The old uterus has done its work and is removed ; but in the midst of its decaying fibres the elements of a new organ are developed, and the microscopist tells us of a new generation of spindle-shaped cells, which he can discover in its tissue, just like those which existed in the organ before pregnancy began, and which remain stationary at the same low stage of formation, till in their turn excited by impregnation to go through higher phases of development. In these changes, the body of the uterus, and the lining of its cavity, bear a far greater part than either the substance of its cervix or the mucous membrane which lines that canal. The mucous membrane of the body only is developed to the decidua, and it alone is thrown ofi" after delivery ; the lining membrane of the neck undergoes much slighter alterations, and is not deciduous. IN HEALTH AND IN DISEASE. 25 It is in the body of the uterus that its muscularity is most evident ; firm fibro-cellular tissue predominates in the cervix, with which are interwoven here and there bundles of narrow, smooth, muscular fibres ; and the stimulus of pregnancy, which works such changes in the former situation, brings to pass far slighter alterations in the latter. At present, we are too imperfectly acquainted with the nature of those changes which I have thus briefly sketched, to be able to say exactly what influence is produced by accidents which interrupt the course of pregnancy and originate the processes of degradation of the uterine tissue prematurely ; or what results follow from disease succeeding to delivery at the full period. We may confidently hope in time to know more ; at present, we have learned from every-day experience that such occurrences interrupt the ready return of the womb to the size and condition which are natural to it in the unim- pregnated state ; that the organ is apt to remain permanently increased in size ; that this enlargement is often especially marked in the more lowly organized cervix; that under such circumstances the menstrual function is usually in some respect or other ill per- formed, while secretions are likely to be furnished from the organ differing in quantity or quality from those which proceed from it in a state of health ; that the performance of all the sexual functions is very apt to be attended by pain, that impregnation is less likely to occur, and that, if pregnancy should take place, there is very great probability of its coming to a premature termination. This set of symptoms, however, or at least many of them, are met with independent of pregnancy and its consequences ; superven- ing sometimes, indeed, under the influence of causes which evidently, and in a marked manner, interfere with the generative functions, but coming on at other times slowly, and, as far as we can discover, without cause. How are they to be explained ? Do they proceed from an invariable pathological occurrence, which is present in every case, how wide soever may be in other respects the points of difi'erence between them — or are they the indications of disordered function, which may depend on causes as various as those which produce vomiting or occasion dyspnoea ? The inquiry is manifestly an important one ; its elucidation will be the object of these Lec- tures. It has been said that there is an invariable, or almost invariable, cause of these symptoms — that, be the remote occasion of them what it may, inflammation and ulceration of the neck of the lib ALLEGED IMPORTANCE OF ULCERATION. womb is their immediate cause — that the key to the right under- standing of uterine diseases is to be found in the correct appreciation of the importance of this condition ; and the cardinal point in their treatment consists in the adoption of means for its cure. The ulcerations to which such important results are attributed, are for the most part mere superficial abrasions of the epithelium investing the lips of the os uteri, whose abraded surface is of a vivid red colour, and finely granular. In other cases, in which the absence of epithelium is less complete, the surface seems beset by a large number of minute, superficial, aphthous ulcerations, between which the tissue appears healthy, or slightly redder than natural. The ulcerations of the os uteri seldom or never present an exca- vated appearance with raised edges, as ulcers of other parts often do ; but either their surface is smooth or it projects a little beyond the level of the adjacent tissue. They are usually, but not con- stantly, of greater extent on the posterior than on the anterior lip, are sometimes confined to the former, but very rarely indeed limited to the latter. They appear to commence at the inner margin of the OS uteri, whence they extend outwards, and sometimes, though by no means invariably, the short extent of the canal of the cervix uteri which can be brought into view by the speculum, appears denuded of its epithelium. The adjacent parts of the os uteri vary considerably in their appearance ; sometimes their natural pale rose tint is preserved up to the edge of the abrasion, which is marked by a distinct, well-defined line, while at other times the whole surface is of a much more vivid red than natural, and the line of demarca- tion between the abraded and the healthy surface is irregular and indistinct, the one encroaching on the other. The orifice of the uterus is generally more open than in a state of health ; and the disappearance of the abrasion, which always takes place from the periphery towards the centre, is accompanied by the gradual closure of the previously patent orifice. The state of the tissue of the os and cervix varies ; sometimes there is a very marked softness of the parts, the condition resembling that of the uterus soon after abor- tion or delivery, while at other times it is much harder than natural ; but it certainly is not at all a common occurrence for extensive abrasion of the os uteri to coexist with a condition of the organ such as would seem healthy to the touch. The secretion from the surface varies considerably in diff"erent cases, and the chief part of the leucorrhoeal discharge from which patients sufi'er is derived from STATEMENTS IN SUPPORT OF IT. 27 ■within the canal of the cervix, or from the cavity of the womb — not from the abrasion itself. Still, in some instances, those espe- cially in which the ulceration presents a very marked granular character, the discharge derived from this source alone is far from inconsiderable. The degree of sensibility which the ulcerated surface possesses also varies greatly; now and then the slightest touch is extremely painful ; but, in the majority of cases, the ulce- rated surface is not more sensitive than the adjacent parts, nor is the neck of the uterus, whose os is abraded, by any means con- stantly more tender to the touch than the same part of an organ entirely free from that affection. Such, then, are the chief characters of these ulcerations or abra- sions of the OS uteri. I retain the old name of ulceration in spite of the objections which have been raised to it, because it seems to me better, as there is no risk of our being thereby led into error with reference to the appearances to which that name has been applied, to accept for the present the current terminology, and to avoid those disputes about words which are so proverbially fruit- less. The really important question is, whether ulceration of the os uteri is to be regarded as the first in a train of processes which are the direct or indirect occasion of by far the greater number of the ailments of the generative system ; or whether, on the other hand, it is to be considered as a condition of slight pathological import- ance, and of small semeiological value — a casual concomitant, perhaps, of many disorders of the womb, but of itself giving rise to few symptoms, and rarely calling for special treatment ? The former opinion, according to which it would be difficult to overrate the pathological importance of ulceration of the os uteri, is supported by the following allegations, which I will endeavour to state as briefly, but at the same time as correctly as possible. It is stated that the mucous membrane of the cervix uteri, by reason of its vascularity and of the abundance of mucous follicles which are imbedded between its duplicatures, is extremely liable to inflam- mation ; and that this predisposition is still further increased by the abundant afllux of blood towards the neck of the womb, as well as by the position of that part of the organ, and its consequent exposure to irritation and injury from various sources. This in- flammation of the cervix is said to manifest itself by the secretion of an abundant albuminous matter from the cervical glands, and by 28 ALLEGED IMPORTANCE OF ULCERATION. the opening of the otherwise closed os uteri — as also in by far the greater number of cases by abrasion or ulceration of the os uteri, which usually occurs at a very early period. The cervix becomes swollen and congested, and, it increases in size; but, while in some instances it remains soft to the touch, even after years of disease, its substance becomes more frequently the seat of inflammation, lymph is effused into it, and it is not merely enlarged, but indu- rated — a change which takes place to a greater degree in those who have given birth to children than in the unmarried or the sterile. The different extent of the ulceration is the only cause assigned for the presence of induration of the cervix in one case, and its absence in another ; but the relation of the two conditions does not seem to be by any means invariable. The degree to which the ulceration spreads appears also to be uncertain ; in the great majority of cases it passes more or less deeply into the canal of the cervix, and sometimes occupies its whole extent, the internal os uteri, however, forming a barrier to its further progress, and preventing almost invariably its extension into the cavity of the womb. It is then inflammation, with its attendant ulceration of the os and cervix uteri, and usually with consecutive induration of its tissue, to which, according to these views, the sufferings of the patients are due ; and all the varied disorders of the uterine functions, the pain, the leu- corrhoea, the hemorrhages, the irregular menstruation, the sterility, or the frequently occurring abortions, are attributed to the sympa- thies of contiguous parts with that small portion of the womb which is the seat of disease. Ulceration, too, when once it has occurred, is alleged to have scarcely any tendency to heal ; while, so long as it remains, there may perhaps be a lull in the patient's sufferings, and some temporary mitigation of her symptoms ; but there can be no real cure until the time when, the period of sexual vigour having expired, the organs which subserved it pass into a common state of atrophy — while cure, even then, is uncertain, and the consequences of disease outlast, by no means rarely, the uses of the part. This picture (and I have added nothing to its colouring) of all the ills which follow from the seemingly trivial ulceration of the os uteri, must certainly be allowed to warrant those who drew it, if only it be a faithful portraiture, in attaching great importance to this affection — in trying to discover it as early, to cure it as speedily as possible. As uterine pathology is simplified beyond expectation by the dis- CORRECTNESS OF THESE OPINIONS DOUBTED. 29 covery of an almost invariable cause of the most diverse symptoms, so uterine therapeutics also are made easy, according to the writers whose opinions I am relating, by one remedy being found almost always applicable for its cure, be the duration of the disease or its severity what it may. If the evil be slight, its removal will be speedy ; if severe, a longer time will be required ; but to modify the vitality of the part by caustics is the one unfailing indication ; and, this accomplished, the ulceration and the inflammation and its results disappear together, and the sufferings of years are thus almost infallibly got rid of in a few weeks, or, at latest, in a few months. There are, indeed, some cases of slight mischief, which rest, antiphlogistic treatment, and vaginal injections may cure ; but these are rare. There are also some circumstances under which the local abstraction of blood may be of service ; but what caustics to use, how often to repeat their application, how to prevent or to remove those inconveniences which sometimes result from their employment, are questions discussed as of chief importance ; since to these remedies all other local measures, as well as all general treatment, are but secondary and subservient. If I thought that the accuracy of these opinions were beyond a doubt, or, on the other hand, that their entire fallacy had been satisfactorily demonstrated, I would not now venture to occupy your time in conducting you over twice travelled ground. I believe, however, that the profession is much divided, both as to the facts and as to their interpretation ; and that it may, therefore, prove no profitless task to endeavour to bring both to the test of a rigid inquiry, and to ascertain, as far as may be, where an error has been committed in observation, or where wrong inferences have been drawn from right observations. In doing this I must crave your indulgence, and that of all persons from whom I may differ ; for I am fully sensible how often I may need for myself that candid interpretation of my statements, and that lenient judgment of my errors, which I hope always to manifest to others. The evidence by which to try the accuracy of those statements that I have endeavoured fiiithfully to set before you, is very various in its kind, and also of very various worth. It may, however admit of being arranged under four principal heads, to each of which, in succession, our attention must be directed. In the first place, we may inquire how far these statements receive 30 PLAN OF INQUIRY INTO THESE confirmation from what we know of the anatomy and physiology of the uterus in a state of health. Still, what answer soever we may receive to this question, it cannot, from its very nature, be conclusive ; it may render a certain occurrence probable or improbable, may substantiate or disprove the correctness of certain opinions or explanations, but cannot invalidate the evidence of positive facts. In the second place, we may try to ascertain whether examination of the dead body shows the morbid conditions of the os uteri which have been described to be frequent or rare, slight or extensive; and we may also endeavour to make out what connection subsists be- tween ulceration of the mucous membrane of the os and cervix uteri, and other changes in the tissue of the organ. It must, however, be borne in mind that many evidences of dis- ease, such as are very obvious during life, may be greatly obscured, or may even entirely disappear after death : and further, that uterine disorders of the class which we are considering, though exceedingly painful, and seriously interfering with a woman's health and com- fort, are yet not of a kind to prove the direct occasion of her death. Evidence derived from this source will therefore be open to the objection that it understates both the frequency and the importance of these diseases. We may inquire, in the third place, whether there is any condi- tion in which ulceration of the os uteri comes under our notice unconnected with other disease, and with such circumstances as to admit readily of our observing its characters and watching its course and consequences. Such a state of things presents itself to us often in the case of the procident uterus, since the irritation to which the displaced organ is unavoidably exposed has the almost invariable effect of producing ulceration of the surface of the os uteri, and of the immediately adjacent parts of the organ. But, whatever conclusions we may deduce from this source are open to all the objections inseparable from analogical reasoning. The probabilities of certain occurrences taking place in the uterus under other circumstances may be increased or weakened ; but the evidence still falls short of absolute proof, either of the affirmative or of the negative of the question. The fourth and most important inquiry of all concerns the fre- quency of these ulcerations of the os uteri under those circum- stances in which they ordinarily come under our notice, and call, OPINIONS PROPOSED. 31 or are supposed to call, for our interference. This inquiry, how- ever, must include not only the frequency of ulceration, but also the conditions generally associated -with it, and the symptoms to which it commonly gives rise. If the alleged symptoms of ulcera- tion are found to be not rarely present without ulceration, and if ulceration is discovered even where there are no symptoms ; or if, in the same case, the ulceration may vary in extent, with no corre- sponding change in the symptoms ; if an indurated state of the cervix exists without ulceration, and ulceration even of long stand- ing, without induration — the conclusion, especially if supported by the answers obtained to our previous inquiries, seems to me irre- sistible that the importance of inflammation of the cervix and of ulceration of the os uteri has been overstated ; that they are not the cause of all the symptoms which they have been alleged to occasion, and that, in the treatment of uterine disease, many other considerations must influence us more than the mere removal of ulceration of the orifice of the womb. If this were proved, it would still remain for us to consider whether, in any case, we may fairly look upon the ulceration of the OS uteri as a symptom calling for distinct recognition and special treatment. There are, I am aware, some persons of deserved repute who will look upon this inquiry as superfluous ; but, for my own part, I do not conceive that, even if we arrived at a conclusion never so unfavourable to the supposed great importance of ulcera- tion of the OS uteri, we should be thereby entitled to regard its symptoms as a mere delusion, its very existence as little more than a figment of the fancy. I. It was observed that, in the first place, something of additional probability or improbability might be imparted to those views which we propose to investigate by what anatomy and physiology teach us of the uterus and its functions. Now it is alleged, as one reason for the liability of the cervix uteri to affections from which the body of the organ is comparatively free, that it receives a greater amount of blood, that it is endowed with a higher degree of vitality than other parts of the organ. But surely this statement is erroneous-; and it sufiices to examine the healthy uterus for any one to satisfy himself of the smaller vascularity of the neck than of the body of the womb. It is the body which chiefly grows as the period of puberty approaches, it is the body to which the great determination of blood takes place during each menstrual period, and from the 32 PHYSIOLOGICAL FACTS UNFAVOURABLE TO lining membrane of the body that the menstrual flux is poured out. The looser tissue, the large vessels, the congested mucous membrane characteristic of the menstruating uterus, are limited, or nearly so, to the body and fundus of the organ ; and it is the epithelium of its cavity, not that of the neck of the womb, which is abundantly intermixed with the menstrual fluid. When conception takes place, it is the body of the uterus which first and chiefly enlarges, its mucous membrane which becomes developed to the decidua, ita tissue which grows and is metamorphosed into muscular fibre; while the changes in the membrane of the cervix are limited to an increased activity of its mucous follicles, and the alterations in its substance to an increased formation of fibro-cellular tissue, with a comparatively scanty growth of muscular fibre. After delivery, the retrograde processes are much more striking in the body than in the neck of the womb. The mucous membrane of the cervix, stretched during pregnancy till the folds which it presented in the unimpreg- nated condition are obliterated, resumes once more its former pli- cated arrangement, while that of the body is detached and repro- duced again and again before the organ reverts to its former state. The cervix is less sensitive than the body of the uterus : the sound which passes along the canal of the former almost unfelt, generally finds the lining of the uterine cavity acutely sensitive. The cervi- cal canal has been forcibly dilated, it has been incised ; the tissue of the cervix has been burnt with the strongest caustics, or with the actual cautery, or portions of it have been removed by the knife, generally with no injurious consequence ; often with so slight a degree of constitutional disturbance, or even of local sufi'ering, as to surprise those who advocate, little less than those who condemn, such proceedings. But, if structurally so lowly organized — if physiologically of such secondary importance — if so much less subject than the body of the uterus to alterations in its intimate structure — and if so compara- tively insensible even to rude modes of therapeutical interference — it certainly does appear to me that the assumption that some slight abrasion of the mucous membrane covering this part is capable of causing a list of ills so formidable as are attributed to it, ought to rest for its support upon some other and stronger foundation than any inference fairly deducible from anatomical or physiological data. II. We will now, however, inquire, in the second place, into the SUPPOSED IMPORTANCE OF ULCERATION. 33 nature of the evidence on this subject which can be deduced from anatomical investigation. At first sight, indeed, it seems somewhat strange that those who believe in the frequency and importance of ulceration of the os uteri, have made no attempt to demonstrate those facts by examination of the body after death ; while the only persons who have appealed to its results, allege this condition to be very rare and very trivial. It must not be forgotten, however, that appearances, the most striking characters of which consist in increased vascularity, and in that vital turgescence which disap- pears soon after life has departed, cannot be expected to be very marked some days after death. Indeed, no one who has felt the large firm growth of cauliflower excrescence sprouting from the neck of the womb during life, and has contrasted with it the small bundle of collapsed filaments which are all that remains of it after death, but must be prepared to admit that a condition of the os uteri very obvious during life, and the cause of very grave symp- toms, may yet leave but very few traces after death. Besides, it must, I think, be acknowledged that the data on which the negative assertions of morbid anatomists rest are not so fault- less as to command by any means implicit confidence. Neither M. Lair,^ who, in 1828, gave some of the results of the inspection of 500 female subjects, nor M. Pichard,^ who, in 1846, added to them the results of 300 more, gives the least information as to when, where, or how these examinations were made. They do not even state the age of any of the subjects, nor afibrd, either directly or indirectly, the slightest guarantee that these inspections were made with due care ; on the contrary, indeed, the appearances observed are described so loosely that, with reference to many of them, it is by no means easy to determine their exact nature. Of this want of exactness no better proof can be given than the fact that while M. Lair discovered but 12 ulcerations of the os uteri out of 500 examinations, and M. Pichard but 5 out of 300 more, the latter mentions that in 54, or rather more than a sixth of his cases, a granular state of the os uteri was present ; while M. Lair makes no reference to his having ever met with such a condition. But I 1 Nouvelle Methode de Traitement des Ulceres, etc., de I'Uterus, 8vo., Paris, 2d edit. 1828. 2 Des Abus de la Cauterisation, etc., dans les maladies de la matrice, 8vo., Paris,. 1846. 3 34 RESULTS OF need say no more about these two writers, since any attempt to reconcile their statements leaves us in hopeless bewilderment, satis- fied of but one thing, namely, that facts so collected and so arranged are available for no useful purpose. I fear that a very similar statement must be made with reference to the facts bearing on this subject which have been collected in our own country. Not only is there no evidence of their having been observed with that minute care which is needed to render them thoroughly trustworthy ; but, with reference to many hundreds of the cases, if not to all, conclusions have been drawn as to the frequency of certain morbid conditions of the uterus, from the examination alike of the infant of a few weeks old and of the old woman of seventy; an oversight, to call it by the mildest term, which renders any results deduced from such data worse than useless. It is idle to expect to meet with frequent indications of uterine disease before the generative organs have arrived at maturity suf- ficient to commence the performance of their functions; while, after the time of sexual vigour has passed, the only diseases we are likely to find are such as commenced at an earlier period, or such as may be incidental to the mere tissue of the organ, wholly inde- pendently of the function which it once performed. The question then is, with what frequency, and associated with what other changes, do we meet with indications of inflammation and ulceration of the os and cervix uteri, in the bodies of women after puberty, and especially during the period of sexual activity ? My own observations, which amount only to 62, are too few conclusively to settle this inquiry ; though I cannot but hope that the care with which they were made may compensate to some extent for the smallness of their number, and that they may serve at least to indicate the side towards which the weight of evidence inclines. Each examination was recorded according to a printed form, on which were specified for separate notice the dimensions of the uterus, the condition of the os, the length and breadth of the cervix uteri, the size of the uterine cavity, the thickness of the walls of the organ, and so on ; — points some of which were of practical interest, while the enforced attention to others had at least this advantage, that it prevented anything from being overlooked. The uteri were taken from patients who died in the medical wards of St. Bartholomew's Hospital of other than uterine disease. PERSONAL OBSERVATION. 35 Of the total number, 13 were above forty-five years of age, the remaining 49 between the years of fifteen and forty-five. Concern- ing all of the former class, and 30 of the latter, making a total of 43, it was either known with certainty, or concluded with great probability, that they were married, or had had sexual intercourse ; the remaining 19 were believed to be virgins. The subjoined table shows the general results of the examination of the uterus in these cases, and the relations borne to ulceration of the OS uteri by the more important morbid appearances.^ TABLE Showing the chief results of the examination of 62 uteri: Uterus healthy in . '* diseased in . Ulceration of os uteri in . " existed alone in . '* with diseased lining of uterus in " with induration of walls of uterus in Induration of walls of uterus, without ulceration of os Disease of lining of uterus, without ulceration of os . 29 . 17 11 3 3—17 . 6 . 7 Total of diseased uteri, 29 The OS uteri was abraded in 1 of the subjects above 45 years of age ; and the lining of its interior was diseased in 5 of that number. In 11 of the 19 patients, all under 45 years old, who were virgins, the uterus was perfectly healthy ; in 8 it presented some sign or other of disease. This consisted 5 times in slight abrasion of the OS uteri, which existed alone in 3 cases ; but was associated in the other 2 with some morbid state of the interior of the womb. Twice the interior of the uterus was the only part afi'ected ; and once the uterine walls were much harder than natural. There is certainly something at first not a little startling in the result at which we arrive, that the womb was found in a perfectly healthy condition in little more than the half of 62 women, none of whom died of uterine disease, nor were supposed to be suffering from any grave uterine ailment. But it may, it ought indeed to be, asked, what is the value of these appearances? Some of them ' In the above table, and in the general statements of the state of the uterus, no notice is taken of morbid conditions of the uterine appendages, nor of those affections of the womb (such, for instance, as fibrous tumors) which obviously stand in no necessary relation to inflammation of the organ, or to ulceration of its orifice. 86 ULCERATION GENERALLY SLIGHT. may be of little moment, and the very frequency of their occurrence, instead of substantiating the opinion that they are of great import- ance, rather militates against that supposition. When ulceration of the OS uteri was first observed, it was natural enough to attribute to it many symptoms, and to refer to its influence many structural changes. But what if such ulceration be found to be usually very limited in extent, and so superficial as to be unassociated with changes in the basement membrane of the afi'ected surface, and exercising so little influence on the state of the uterus in general, as to be unconnected in a large number of instances with changes either in the interior of the womb, or in its substance ; while indu- ration of the uterine tissue and disease of the lining membrane of the womb are found independently of it, or of each other ? Should such appear to be the case, it will, I think, be rendered in the highest degree probable that this abrasion of the os uteri has not the long train of sequences which have been supposed to follow it, but that it is of comparatively small pathological import; that it may be found to vary under the influence of comparatively trifling causes ; and not unfrequently to be dependent on functional disorder of the uterus, just as the mucous membrane of the tongue and mouth betrays the disturbance of the digestive system ; that it may, in short, be the consequence, and sometimes the index, but rarely the occasion, of the ailments with which it is associated. Abrasion of the os uteri was observed in 11 instances unconnected with any other morbid condition of the womb. In 6 cases it was extremely slight, afi"ecting just the edges of the os uteri, but not extending for more than a line in breadth ; the mucous membrane lining the canal of the cervix was in all of these instances quite pale, but twice the lining of the uterine cavity was of a brighter red than natural. In the other 5 cases, the abrasion, though retaining the same character, was more extensive ; once the abraded surface presented a finely granular aspect, but was quite uniform ; but in the other four cases it had an uneven worm-eaten appearance, probably due to a partial destruction of the papillae which beset the OS uteri. ^ In 4 of these cases the abrasion extended for a short distance up the canal of the cervix, while once it was limited to that exclusively, the lips of the os being perfectly pale and healthy, and ' As in the delineation, by Drs. Hassall and Tyler Smith, in vol. xxxv. of the Medico-Chirurgical Transactions. INDURATION OF CERVIX UTERI. 87 the mucous membrane of the cervix unaltered, except along a strip a third of an inch in breadth by an inch in length, where the pos- terior wall was abraded. In 3 of the above 4 instances there was some increase of vascularity in the mucous membrane of the cervix, which on one occasion extended for nearly half an inch up its canal ; and once this condition was very marked, and the mucous membrane appeared swollen and infiltrated, but in no other case was there any appearance of thickening of the membrane either at the seat or in the immediate neighbourhood of the abrasion. It is alleged, as we have already seen, that in the great majority of instances ulceration of the os uteri gives rise to induration of the cervix, the result of the extension of inflammation to it, and of the efi'usion of plastic lymph into its structure, which lymph comes by degrees to be more and more organized. This description, however, of the manner in which induration of the cervix uteri takes place is purely imaginary ; there are no observations whatever bearing on the subject, and the difficult task of tracing the results of chronic inflammation in any tissue is obstructed by so many special impedi- ments in the case of the uterus, that it will probably be long before we shall be in a position to speak with any measure of certainty concerning it. The account of the process by which induration of the cervix uteri is produced may possibly be correct, but at any rate it is not proven ; and few things have so retarded the advance of medical knowledge as the accepting some plausible hypothesis as if it were a statement of well-ascertained facts, and then proceeding to reason from it as if from some secure basis. Under what circumstances is induration of the uterine tissue met with, and in connection with what other changes in the organ ? It existed in 9 cases ; in 5 of which it was not associated with any other disease of the uterine substance ; in 3 it coexisted with ulcera- tion of the OS ; and in 1 with a morbid state of the interior of the uterus. In an unmarried girl, aged eighteen, who died of capdiac dropsy, the tissue of the fundus, and of the upper half of the body of the uterus, presented its usual characters; but about half-way down the body of the organ there began a strip of a dead yellow colour, and much denser texture, resembling fibro-cartilage or the elastic coat of an artery. The dense tissue lay immediately beneath the lining membrane of the uterus, and being at first only one line in thickness, increased in width till it came to constitute the whole thickness of the cervix uteri. In the case of another patient, aged 38 ' OTHER APPEARANCES DISCOVERED forty-seven, a similar condition was met with in the body of the uterus, but scarcely at all involved the cervix ; and in the three other cases, in all of which the women were under thirty years old, the cervix uteri alone was affected, being white, hard, creaking under the knife, and seeming under the microscope to be composed of an extremely dense fibrous tissue. It appears, then, that most marked induration of the tissue of the cervix, and of part of the body of the womb, may exist where there is no other trace of inflammation, either past or present. It may also occur in connection with inflammation and ulceration of the lining membrane of the uterine cavity. In a woman who died at the age of fifty-six, about a third of the thickness of the wall both of the body and of the neck of the womb was exceedingly firm, and creaked under the knife. Abundant glairy secretion from the cervical glands, and some want of transparency of its lining mem- brane, were the only unusual conditions of the interior of the uterine neck ; but the cavity of the organ Contained a copious purulent secretion mixed with blood ; its mucous membrane was thickened, vascular, and destitute of polish, and about the middle of the pos- terior wall completely destroyed, leaving the substance of the womb beneath uneven, rather soft, and presenting the appearance of a granulating surface. Ulceration of the os uteri, and induration of the uterine walls, were associated together in three instances. On one occasion the ulceration was but slight, and the interior of the cervix extremely pale, though there was great injection of the lining of the uterine cavity. In this instanfce the cervical wall was much indurated, , that of the body of the uterus rather less so. Extreme induration of the cervix existed in one case where there was rather extensive ulceration of the os uteri ; and in this instance the cervix was con- siderably hypertrophied. The patient from whom this uterus was taken had been under my care for some years^ previously, suffering from symptoms such as Gooch describes under the name of irritable uterus ; her sufferings had been most severe, and the enlargement of her womb most considerable at a time when there was no abra- sion of its orifice. In one case only, in which there was consider- able induration of the cervix, there was a distinct line of congestion, about half a line in depth, between the ulcerated surface and the pale tissue of the indurated cervix. In 10 cases, the condition of the lining membrane of the uterine MORE SERIOUS THAN ULCERATION. 39 cavity deviated from that which characterizes it in a state of health. Thrice this state of the interior of the womb coexisted with ulcera- tion of its orifice of moderate extent, and presenting its ordinary appearance ; but in the remaining 7 instances the os uteri was per- fectly healthy. In 7 of the 10 cases the uterine mucous membrane was vividly injected, so as to present a bright rose tint, and was more or less swollen and softened. Once very extensive disease of the lining membrane of the uterine cavity, probably of a tuberculous character, was discovered in the body of a woman fifty-six years old. In a second case, in which the patient was stated to have had a copious leucorrhoeal discharge, and to have complained of pain and of a sense of heat at the lower part of the abdomen, the intensely red mucous membrane of the uterine cavity presented an almost gelatinous appearance, and looked not unlike decidua. In this instance, though there was some ulceration of the os, yet the lining membrane of the cervix was quite pale ; no secretion occupied its canal, and the tissue of the uterus was quite healthy. In a third case a small patch of ecchymosis was present beneath the lining of the uterine cavity ; and in a fourth, where the patient had not menstruated for five months, the lining membrane, though of a pinkish colour, had lost its polish, and looked more like an injected serous membrane than like the mucous lining of the womb. It has not been from want of perception of the hopeless tedious- ness of such details, that I have ventured to take up your time so long with an account of the morbid appearances of the uterus, ob- served in these cases. Many, probably very many, of these condi- tions ought to be classed with pseudo-morbid, rather than with pathological appearances ; but the data at present fail us for dis- tinguishing with accuracy the one from the other. But, be this as it may, it is yet abundantly evident that many of them imply de- viations from a healthy state more considerable than the trifling abrasion or ulceration of the os uteri, -vVhich existed on several occasions. We have seen that, in by far the majority of cases, the ulceration, when present, was not merely trifling in extent, but that it had not given rise to so much irritation of the neighbouring tissues as to produce any appreciable congestion of the mucous membrane in its vicinity ; while the changes in the uterine sub- stance alleged to depend upon it were often er present without than in connection with it ; and, moreover, none of the alterations about 40 CONCLUSION UNFAVOURABLE TO ITS IMPORTANCE. the OS and cervix of the womb were so considerable as those which were apparent in its cavity. Other evidence, indeed, must be adduced than that which ana- logical reasoning from the facts of physiology has suggested, or than that which examinations after death have furnished, before we shall be entitled to reject the opinion that inflammation of the cervix, and ulceration of the os uteri, are occurrences of very serious pathological importance — the occasion of ijearly all the ills which affect the physical well-being of woman. That other evidence must be reserved till the next Lecture ; but yet, unless I have altogether failed in my endeavours, the question is not left to-day quite where it was before ; since, tempting though this hypothesis may be, and numerous the difficulties which it may appear to solve, we yet have found that it is opposed by the facts of physiology, unsupported, to say the least, by the results of anatomical investi- gation. LECTURE II. Inquiry continued. III. Course and consequences of ulceration of the prolapsed uterus; they do not seriously disorder the uterine functions, or alter its struc- ture. IV. Kesults of clinical observation. Examination of prostitutes suffering from gonorrhoea or syphilis shows susceptibility of cervix uteri to have been over-estimated. Question considered with reference to importance of ulceration when present. Three different solutions of it suggested. Tests by which it is proposed to determine it. Nature of materials for this purpose stated. Influence of ulceration of os on fecundity inconsiderable — Its occurrence connected with activity of sexual functions, as shown by patient's age and alleged cause of illness. Similarity in these respects to cases where ulceration is absent shown further by duration of symptoms, by disorder of menstruation, by occurrence of leucorrhoea, by complaints of pain, and in the main by condition of the uterus. Further examination into relation of ulceration of the os uteri to induration of its cervix shows it not to be constant, nor bearing any necessary relation in degree. General inferences from inquiry unfavourable to first two solutions of question con- cerning importance of ulceration of os uteri ; and consequently to opinion that it is a condition of great importance. Mr. President — Sir : The facts and considerations which I had the honour to submit to you in my former Lecture, were, as you will remember, not brought forward as conclusive of the question that they were intended to elucidate. They seemed, however, to raise a presump- tion against rather than in favour of the opinion, that inflammation of the cervix and ulceration of the orifice of the uterus are condi- tions of great pathological importance ; and at any rate to warrant us in scrutinizing very closely such other evidence as may be ad- duced to substantiate its correctness. I purpose to-day to advance further in this investigation ; to abandon for the present physiological reasoning, to lay aside the scalpel of the anatomist, and to learn what we may of this subject from the study of the living. The complex character of disease offers one great impediment to our thoroughly understanding it : the having surmounted this dif- ficulty constitutes the great difference between the experienced 42 CHARACTERS OF ULCERATION OF physician and the novice. In the matter of uterine disease, we are, I fear, all novices ; and it was this consideration which induced me to propose that we should, if possible, study — III. As the third point m this inquiry, ulceration of. the os uteri, under some condition in which it presents itself to our notice unconnected with other disease, and with such circumstances as to admit readily of our observing its characters, and noting its course and consequences. Fortunately, the opportunities for this study abound ; and in almost every woman whose uterus has become prolapsed beyond the external parts, we may observe the effects which ulceration of the OS uteri commonly produces, the symptoms to which it gene- rally gives rise ; we can trace it in its progress, can watch it for weeks or months together, and see what it has led to where it has existed even for years. A previously healthy woman leaves her couch too soon after her delivery, while her vagina is still lax, and its power of supporting the uterus is perhaps still further diminished by laceration of the perineum. The retrograde process by which the bulk of the womb should be eventually reduced to its former dimensions is still in- complete ; while the outstretched uterine ligaments have not had time to contract to their former size, nor to recover their former resiliency. The heavy uterus, thus ill-supported, sinks down in the pelvis, approaches by degrees nearer and nearer to the external parts, and at length occasionally projects beyond them ; and in the course of a few weeks or months the occasional prolapse becomes habitual. At first, it is only a portion of the womb which thus pro- jects ; but often the whole uterus comes in the course of time to hang externally ; while in many instances, a portion of the bladder in front, and of the rectum behind, descends into the sac of the tumor and increases its bulk. The delicate lining of the vagina, dragged down and inverted by the descent of the womb, furnishes an investment to the whole mass, and, assuming by degrees the characters of ordinary integument, becomes adapted to its new condition. The lips of the os uteri, however, and the immediately adjacent portion of the cervix which the vagina does not cover, retain in most cases much of their original delicate structure, while their very position at the most depending part of the tumor exposes them more than any other part to external injury ; so that, with THE PROCIDENT UTERUS. 43 comparatively few exceptions, they are, permanently in a state of abrasion or superficial ulceration. These ulcerations are generally indolent, though by no means so much so as the ulcers of the inverted vagina itself, which are apt to become deep and excavated with raised and callous edges, and exactly to resemble chronic ulcers of the skin of other parts of the body. The abrasions of the os, however, after weeks or months still retain much the same characters as they originally presented. They extend, indeed, at one time over a larger extent of surface than they occupy at another; but they very rarely increase in depth, or extend into the subjacent tissue. The ulcerated surface is denuded of epithelium ; now and then it is partially covered by a thin layer of yellowish lymph, but usually it is of a rather vivid red colour, and of a granular appearance. This granular character is generally more marked in proportion to the age of the ulceration ; while in a few instances the granulations are distinct from each other, rather elongated in form, and look exactly like hypertrophied papillae. A transparent albuminous secretion in general covers the ulcerated surface, and is sometimes poured out freely from it ; but there is seldom any abundant discharge from the interior of the uterus, or even from the canal of the cervix. In almost all cases of procidentia uteri (those alone excepted in which the misplacement of the womb occurs in advanced life, as a consequence of that general wasting of the tissues within the pelvis which takes place when the generative functions have been long extinct), the organ becomes in the course of time more or less con- siderably hypertrophied. This hypertrophy usually affects the neck of the womb more than its body, involving it in all its dimen- sions, though mostly to a greater degree in length than in thickness. It seems to be a simple increase of growth, such as we find occurs in other parts when subjected to constant and long-continued irri- tation ; but nowhere, except perhaps in the female mamma, is it observed so frequently or to so great a degree as in the uterus, since nowhere else does there exist the same store of formative material, which needs but a stimulus to excite it to active develop- ment. To the touch the enlarged cervix presents no remarkable hardness ; but its substance feels generally healthy, and the knife of the anatomist detects no alteration in its tissue. There is over- growth of the part, but nothing more. That such is the case, we have additional proof in the fact that a 44 RESULTS NOT VERY SERIOUS. uterus misplaced, enlarged, with its orifice even abraded, and retained within the pelvis only by some mechanical contrivance, is nevertheless capable of performing all its functions, even its highest ; and this in many instances with a remarkably small degree of dis- turbance. Not only does conception take place readily in spite of the existence of prolapse of the womb, but pregnancy and labour are not seldom passed through with no additional suffering beyond that which attended those processes on former occasions, or, at the worst, the increased discomfort of the patient is obviously due to purely mechanical causes. It can scarcely be necessary to say, that it is not my intention for one moment to assert that misplacement of the womb produces no inconvenience, or that ulceration of its orifice, when it is thus mis- placed, is of no importance. Daily experience yields abundant proof to the contrary ; but a detail of the symptoms of prolapse of the uterus forms no part of our present object. I referred to the accident and its consequences only for the sake of suggesting the reasonable inference, that if inflammation of the neck of the womb were as frequent as has been supposed, or ulceration of its orifice the necessary occasion of such serious disorder of function apd alteration of structure, we ought to meet with some of the most striking illustrations of these facts in cases where the womb, by its misplacement, is exposed to injuries from without, such as it was never intended to encounter. But though it be conceded, as I think it must be by all observers, that the symptoms supposed to characterize inflammation of the neck of the womb, and ulceration of its orifice, are not met with either constantly or in a specially marked degree in cases of pro- lapsus or procidentia uteri; still, we should not be justified in drawing an absolute conclusion from what we observe in the misplaced uterus, as to the effects produced by similar ailments attacking the organ when in its natural position. It may be alleged, and with plausi- bility, that during the gradual process of its misplacement, the sympathies of the womb have been rendered less keen than they were while the organ retained its natural position ; and that thus it comes to bear, with comparative impunity, injuries which might otherwise have produced great disorder of its functions and great alteration of its tissue. Bearing in mind, then, the necessity for care, lest from any facts we draw a wider inference than they really warrant, let us now turn ULCERATION NOT SEVERE IN PROSTITUTES. 45 to the fourth and most important part of this inquiry, and seek to ascertain — IV. What clinical observation generally teaches us concerning ulceration of the os uteri — its course, its symptoms, and its im- portance. Before entering on the general consideration of the subject, how- ever, there is one point specially elucidated by a particular class of patients, and concerning which it may not be inappropriate to say a few words. The peculiar susceptibility of the cervix and os uteri, the extreme readiness with which they become the seat of inflamma- tion and ulceration, are much insisted on by those writers whose opinions we are considering. Now, assuming such views to be correct, we may, I think, expect them to receive full confirmation from the medical history of those wretched women who live by prostitution. In them, more than in any other class of persons, do we meet with the conditions best calculated to inflict local injury on the neck of the uterus. It will therefore be reasonable to expect that they will present, with remarkable frequency and intensity, an ulcerated condition of the os uteri, an indurated and hypertrophied state of its cervix. It is true that the severest forms of these affec- tions must prevent persons labouring under them from exercising their disgraceful calling ; but yet no one who is familiar with the state of wretchedness, suffering, and disease, in spite of which the lower order of prostitutes continue to ply their trade, but would expect to meet among them with many instances of those ailments in their acute stage, if they were in reality very frequent. More- over, as a hypertrophied cervix uteri returns, even under favourable circumstances, extremely slowly to its original size, there would be many occasions in which the chronic effects of bygone inflammation must be evident in those who had devoted themselves for months or years to a vicious life. Observation, however, seems to show that, be the causes of ulcer- ation of the OS uteri, of inflammation, hypertrophy, and induration of its cervix, what they may, sexual excesses, at any rate, have no great share in their production. Four years ago, being anxious to satisfy my mind on this point, I examined, by permission of Mr. Lawrence, forty women on their admission into the venereal wards of St. Bartholomew's Hospital. Of these 40 patients, 18 suffered from gonorrhoea alone, 10 from gonorrhoea and syphilis, and the remaining 12 only from syphilis. The cases were unselected, and 46 THREE DIFFERENT ANSWERS the examinations were made as soon as possible after the admission of the patients into the Hospital. In 27 instances, the os and cervix uteri were absolutely healthy, or presented only, and this but rarely, a slight blush of redness, deepening the natural hue of those parts. In 10 of the remaining thirteen, the ulceration, if indeed it deserved the name, was a mere excoriation not above a line in breadth, partially or completely circumscribing the os uteri, but associated with no other change of its tissue. In the remaining 3 cases, the abrasion was more ex- tensive, surrounding the os uteri for about a third of an inch ; and in the case of one of these three, that of a woman who had given, birth to children, the lips of the os were noted to be elongated: this, however, was the nearest approach to a hypertrophied state of the cervix met with in the whole forty cases ; while in no instance was there any such alteration of the texture of the part as to de- serve the name of induration. These facts, however, after all, prove no more than this — that the susceptibility of the os and cervix uteri to the effects of local injury has probably been over-estimated ; they do not bear, or bear but very slightly, on the more important inquiry as to the value to be attached to ulceration of the os uteri when present. In ap- proaching this question, as we are bound to do with no conscious bias of the mind in one or the other direction, three different pos- sibilities at once suggest themselves to us, of which any one may be correct. 1st. Ulceration of the os uteri may be the cause of all the symp- toms of uterine disease which have been attributed to it ; and con- sequently it may be of no less importance to remove it when present, than to ascertain the fact of its existence. 2d. Though not in itself the cause of the symptoms, or at least of the greater part of them, it may yet be the concomitant of certain forms of uterine disease ; of the state and progress of which its extent and degree may be a trustworthy index. In this case, though of small importance as far as therapeutical proceedings are concerned, it may yet be of great semeiological value. 3d. Neither the one nor the other of these suppositions may be correct ; but either the ulceration may exist alone, giving rise in that case to few symptoms, or to none at all ; or it may, in other instances, complicate different uterine ailments, though not an index of their state, nor varying with their changes. SUGGESTED TO THE INQUIRY. 47 Considering that, in the opinion of some writers, so large a pro- portion as 81 per cent, of all women presenting symptoms of uterine ailment, are suffering from inflammatory disease of the tissue or canal of the cervix uteri, and 70.4 per cent, likewise from ulceration of the OS uteri, this inquiry can scarcely be expected to detain us long. The evidence in support of such a view may fairly be ex- pected to be overwhelming ; and the symptoms of ulceration of the OS uteri to be characteristic, either from their peculiarity or their severity, or from both together ; and to differ in important respects from such as attend upon those uterine ailments which are not associated with that condition. Fortunately, too, the presence or absence of ulceration of the mouth of the womb is a fact easily ascertainable ; so that there can be no difficulty in making this the ground of a division of cases of uterine disease into two grand classes for the purpose of comparison. I purpose, then, to inquire whether sterility is more frequent, whether the rate of fecundity is lower, and whether abortion occurs oftener in the one class of cases than in the other ? Whether men- strual disorder is more common, more severe, or different in kind ; whether leucorrhoea is more abundant, or furnished from a different source ; or whether pain is less tolerable when the os uteri is ulcer- ated, than when that condition is absent ? And lastly, whether similar or different causes produce the uterine affections in the two classes of cases; whether the duration of illness is the same; whether the structural alterations of the womb are alike or diverse ? If this inquiry should discover marked differences between the two classes of cases, it will then be for us to determine whether the ulceration is to be regarded as the cause of the coexisting disease, or only as a constant attendant upon it ? That it must hold one or other of these places, will, I think, be established beyond cavil; and it will follow that, on either supposition, the importance of ascer- taining its existence can scarcely be overrated. If, on the other hand, we find that a very great degree of resem- blance exists between the two classes of cases ; that women of the same age, under similar circumstances, present the same symptoms, leading to the same results, having the same duration, and attended with similar structural changes, whether ulceration of the os uteri be absent or present ; it may then be inferred with equal certainty that ulceration of the womb can neither be regarded as a general cause of uterine disease, nor as a trustworthy index of its progress ; 48 DATA ON WHICH TO FOUND REPLY. but that it is a pathological condition of secondary moment, and this even though there be still some difficulty in assigning to it in every instance its proper value. The materials from which I hope to make some approach to a satisfactory answer to these questions are derived from 1226 cases, of which records were preserved while the patients were under my care, either at the Middlesex or at St. Bartholomew's Hospital. Of these, 300 were in-patients of one or other institution, and the re- maining 926 were out-patients of St. Bartholomew's Hospital, between Jan. 1, 1850, and Oct. 15, 1853. Conclusions as to the results of treatment can of course be drawn only from the in- patients of a hospital ; but the history of out-patients yields, if carefully recorded, trustworthy data with reference to the symp- toms of disease. It has been my custom for the past three years to keep a minute account of the history of my out-patients at St. Bartholomew's Hospital — recording with reference to each one her age, the number of years she has been married ; if a widow, the duration of her widowhood, the number of children to whom she has given birth, as well as that of the abortions which she has expe- rienced, with the date of her last pregnancy. Further, the date of her first menstruation, with the manner in which that function has generally been performed, as also the ordinary presence or absence of leucorrhoeal discharge, have always been noted ; together with the date of the commencement of her present illness, its symptoms, and the result of vaginal examination ; which last I have invariably made, and dictated the account of, myself. These particulars have been taken of all cases without selection — or if any were omitted, they were only some of those cases of trivial ailment which all who have had much experience of hospitals know to be never absent, in certain proportions, from these institutions ; cases sometimes of mere loitering idleness, but oftener of destitution, where the symp- toms are those of want, not of disease, and food, not physic, is the appropriate remedy. In 268 of the 1226 cases, the symptoms appeared to me to justify the use of the speculum ; and in 125 instances, the os uteri was found to be the seat of ulceration ; while in the remaining 143 it showed no sign of that condition. Though for some purposes con- clusions may be drawn from the whole number of patients, yet ob- viously the solution of the questions before us must be attempted INFLUENCE OF ULCERATION ON FECUNDITY. 49 by a comparison of the smaller number of instances in -which exa- mination with the speculum was instituted. Thus much premised as to the grounds on which the different con- clusions rest, to which I now have to crave your attention, we are in a position to take up successively the various points that I have already referred to as likely to elucidate the question of the influ- ence of ulceration of the os uteri in the production of uterine dis- ease, or in occasioning functional disorder of the generative system. The perpetuation of the species being the highest function of the generative apparatus in either sex, it is but natural to expect that any serious disease of the organs which subserve that function shall produce some appreciable effect in interfering with its performance, and that it shall, in the case of women, show its influence either in the production of absolute sterility, in lessening the number of con- ceptions, or in increasing the number of abortions. For our purpose it is not sufiicient as a standard of comparison to know the proportion of children to a marriage generally throughout this country (which is about 4.2) ; but we ought to ascertain the general fecundity of women in the same class of life, and placed under the same general circumstances with those who apply as pa- tients at the hospital. In the subjoined table, therefore, the first division represents the proportion of pregnancies which reached their full term, and also the proportion of abortions to a marriage in 980 married women at different ages who were attended in their confinement by pupils of St. Bartholomew's Hospital. The second division represents the same fact in the case of 980 women married above one year, who applied during the childbearing period of life for relief on account of any ailment of the uterine system, and shows also the proportion of cases in which marriage had proved absolutely sterile. The third division represents the same facts with reference to 125 of the above 980 persons in whom, examination with the speculum having been made, the os uteri was found unaffected by ulceration ; and its results may be compared with those in the fourth division, which refers to 117 of the same number of patients in whom ulceration of the os uteri existed. 50 INFLUENCE OF ULCERATION ON FECUNDITY. PATIENTS WITH UTERINE SYMPTOMS, WITH ULCERATION. To each fruitful marriage. •suoT^jxoqv .84 1.1 1.75 ^ •«»-iPMO 1 rH Cq -^ CO CO Proportion of sterile marriages. lin 1.5 1 in 6.3 1 in 10.7 CO .a •jaqranj^j CO CO CO 00 CO Tj< t^ PATIENTS WITH UTERINE SYMPTOMS WITHOUT ULCERATION. To each fruitful marriage. •suoi'^aoqy .6 1.29 2.47 CO •uaxpnqo lO CO : - rH -"^ lO 1:^ CO CO (M O OO CD 1^ s Abortions to each marriage. q "* ^ "3 «>: Children to each marriage. rH CO t-; CO rH (?q vd l-^ •jaquin^ Rest, tonics, and the cold douche to the uterus, arrested the he- morrhage, greatly checked the discharge, and improved the patient's health. The uterus, however, remained of about the same dimen- sions at the end of a fortnight, when the outbreak of smallpox in the ward necessitated the woman's discharge from the hospital. I saw her again once six weeks afterwards, and the uterus was greatly diminished in size ; but I had not then the opportunity of ascertaining its exact dimensions by means of the uterine sound. Other cases of a similar kind have at different times come under my notice, but I do not remember any in which the uterus remained of so large a size as in the instance just related. In the above-mentioned instance, and in many others of a similar kind, there is no evidence of any other morbid condition than a mere deficient involution of the uterus.^ It must, however, be at once apparent that- such a state is one in which processes akin to inflammation will be very likely to supervene, * See, with reference to this subject, a short but very interesting paper, by Pro- fessor Simpson, on Morbid Deficiency and Morbid Excess, in the Involution of the Uterus after Delivery, in the Monthly Journal for 1852. TENDENCY OF UTERUS TO HYPERTROPHT. 71* and to aggravate the patient's condition ; while, even should that not be the case, the law which connects hypertrophy of an organ with long-continued congestion of its vessels, will, at any rate, not meet with an exception in the case of the uterus. No organ of the body presents naturally conditions so favourable to the occurrence of hypertrophy as the uterus, since nowhere else is there the same store of formative material, only awaiting some stimulus to excite it to development. The presence of an impregnated ovum in its cavity, is the appropriate stimulus which awakens to the full its dormant vital energies. But I need not mention how the development of an extra-uterine ovum, the formation of a polypus in the cavity of the womb, the growth of a fibrous tumour in its wall, even the can- cerous disease which destroys its substance, will also call those energies into activity, and cause the uterus to grow to dimensions far exceeding those which it naturally presents. It may, indeed, be stated that excitement of the uterus of almost any kind during the period of sexual activity tends to increase its size : and further, that this increase of size will be marked in proportion as the stimulus acts upon the cavity of the organ, and not simply upon its cervix. How different is the amount of uterine enlargement produced by a small fibrous tumour imbedded in its walls near to its cavity, from -that which accompanies even a large cancerous growth from its cer- vix ! Enlargement of the neck of the womb may, probably generally does, accompany enlargement of its body ; but that the latter is the consequence of the former appears to me to be, in the majority of instances, not merely not proved, but even opposed to probability. But it may be asked, what does inflammation do if it attacks the uterus in these cases ? If this question be put as to the intimate nature of the changes which it works in the uterine tissue, I must confess that I do not know ; and may add that, to the best of my knowledge, no one competent to attempt the investigation has ap- plied himself to the elucidation of this so difficult problem. If, however, the inquiry be limited to those obvious results apparent to the ordinary observer, I think I may say that it produces pain of a severer kind than is experienced in the other cases; pain present- ing somewhat of a paroxysmal character, and sometimes even being excruciating from its intensity ; while even in its absence there is extreme tenderness of the uterus, with great heat of the vagina, and usually a very abundant purulent leucorrhoea, often, though by no means invariably, tinged with blood. Moreover, these local symp- 72 RESULTS OF INFLAMMATION toms are associated with more or less considerable constitutional disturbance ; while on their subsidence, the uterine tissue, as far as its state can be ascertained, is felt to be harder in texture than before ; and lastly, these symptoms, when once they have occurred, are apt to return at uncertain intervals during a period of many years, presenting on each occasion the same characters, amenable to the same treatment, but in spite of it retaining the same disposition to recur over and over again. In September, 1851, a married woman, aged 41, was admitted into St. Bartholomew's Hospital, and told the following history of her ailments : Having married at sixteen, at which time the menstrual discharge was scanty, and irregular in its return, she at once became pregnant, but miscarried at the third month. A second pregnancy terminated at the full period after a lingering labour of two days and a half duration, in the eighteenth year of her age ; and a third pregnancy soon afterwards likewise terminated prematurely at the fourth month. Her symptoms dated from the time of her lingering abour; and consisted of leucorrhoeal discharge, sometimes very copious, occasionally also very offensive ; constant sense of dis- comfort in the uterine region, with occasional sharp stabbing pain, chiefly referred to the right groin, and always aggravated at a men- strual period ; while the menstrual discharge, which for years had been gradually increasing in quantity, and was now extremely pro- fuse, was always succeeded by temporary relief to the patient's suffer- ings. The pain and the hemorrhage together had worn down her health ; her countenance was anxious, and her pulse 128, and feeble. The uterus was found to be rather low down, but not much enlarged, though very tender; the cervix uteri was indurated, somewhat elon- gated, and very painful; and the os uteri, which was small and circular, presented no trace of abrasion, either affecting its lips or extending into the canal of the cervix, though the congestion of that part was very marked. Rest, frequent local leeching, and sedatives, relieved the patient's sufferings, improved diet restored her strength, and when she left the hospital, in November, she had lost the sense of pain and bearing-down ; there was but little leucorrhoea, the tenderness of the uterus was much diminished, and the congestion of its orifice had entirely disappeared. It may be added that once, during the course of her treatment, superficial abrasion of the os uteri showed itself, but disappeared of its own accord in a few days. Great as the relief was which this poor woman OF ENLARGED UTERUS. T8| had obtained, I did not anticipate that she would continue free from suffering if she returned home to bear a part in the duties, and to submit to the hardships, which are inseparable from poverty. Ac- cordingly, in less than twelve months, she returned to the Hospital, presenting the same symptoms as before, and submitted to a similar plan of treatment with the like result. The os uteri on this occasion «lso presented no abrasion, though frequent examinations were made with the speculum to ascertain this fact. The patient remained this time somewhat longer than before in the Hospital, and took small doses of the bichloride of mercury for several weeks, though never in such quantities as to affect the mouth. For six months after her discharge she continued almost free from suffering; but in September, 1853, her symptoms began to return: menstruation, though not so profuse as before, became once more very painful: and for some days before her admission into the Hospital on October 20, she had pa- roxysms of such intense severity that she rolled about the bed in uncontrollable agony ; which large doses of sedatives were unable to subdue. On her admission, there was the same intense congestion of the OS uteri as on former occasions, with a very abundant, highly offensive, purulent discharge, slightly tinged with blood from its interior ; the womb itself being low down, somewhat larger than natural, and the cervix large, hard, swollen, and intensely tender ; but no trace of abrasion of the os was perceptible. The application of six leeches to the uterus was followed by bleeding so profuse as to cause syncope ; but for several days subsequently the patient con- tinued perfectly free from pain, and though it afterwards returned, yet it never again attained the same degree of intensity. She remained in the Hospital for six weeks ; during which time local leeching was occasionally resorted to, small doses of the bichloride of mercury were again given, together with the syrup of the iodide of iron ; and under this treatment improvement once more took place, and the neck of the womb at the time of the patient's dis- charge was at least a third smaller than it had been at her admis- sion. In this instance, we observe symptoms of the greatest severity recurring again and again without ulceration of the os uteri, or of the canal of the cervix (for the slight abrasion apparent once, and then vanishing spontaneously in the course of a few days, cannot be regarded as of importance) ; and this was observed during three distinct attacks of illness, spread over a period of three years. I 74' ' IMPORTANCE OF AFFECTIONS apprehend that one does not err in connecting the patient's illness ■with some inflammatory affection of the mucous membrane of her uterus, which, supervened upon her delivery, and which, during the many subsequent years, was every now and then lighted up afresh by causes which in the household of the poor are not far to seek. In this instance it is true that the most marked enlargement of the uterus was perceptible in the neck, not in the body of the womb; but I doubt whether a diff"erence from other cases in this respect is a matter of so much importance as at first it may appear. When a woman has frequently given birth to children at the full period, the portio vaginalis of the cervix uteri, or in other words that portion of the neck of the womb which projects into the vagina, becomes greatly shortened, sometimes almost completely disappears, while it commonly remains of considerable length in the case of women who have only aborted, or at most have given birth only to one or two children at the full period. The deficient involution of the uterus after a miscarriage, will in such cases be shared in its measure by the cervix uteri, and by as much of the portio vaginalis as exists ; and to this circumstance, rather than to any essential difference, I am disposed, in a large proportion of instances, to attribute the difference in size of the portio vaginalis. But admitting even that this explanation is not conclusive, and that the condition of the cervix is of more importance than I have just suggested, the fact still remains that all the symptoms of ulceration of the os uteri, and even that enlargement of the cervix which is said to depend upon it, were observed during a period of many months, and observed to be unconnected with any such state during the whole of that period. It would not be difficult to multiply cases of this description if time allowed ; but, in further illustration of the subject, I will just refer to one other of a kindred nature. In some few, h'appily very few cases, the inflammation, which in gonorrhoea is usually limited to the vagina, not only attacks the mucous membrane of the bladder, but affects the lining of the uterus also, and even extends to the peritoneum, sometimes endangering the patient's life. But without causing those most formidable results, acute inflammation of the vagina sometimes extends beyond its original seat, and gives rise to symptoms such as we are now considering. A patient, aged thirty- five, was admitted into St. Bartholomew's Hospital, complaining of dysuria and frequent micturition, of painful and profuse menstrua- tion, and of leucorrhoeal discharge — symptoms which she referred OF UTERINE CAVITY. 75 to a somewliat severe attack of gonorrhoea three months before. Her uterus was found much enlarged, anteverted, and fixed in its unnatural position, while its tissue generally was much harder than natural, and the margins of the os uteri, though free from the slightest trace of abrasion, presented a very marked congestion, and discharge was poured out from the interior abundantly. It is here, I think, no unfair assumption to suppose that all these symptoms, from which the patient had never suffered previous to the gonorrhoea, were excited by it ; that that had affected the interior of the uterus, and had also bound down the organ in its unnatural position by adhesions consequent on peritoneal inflammation. At any rate, here was no ulceration of the orifice of the womb, and yet here were all the symptoms which are usually described as indicative of its presence. It is w^ell, also, to bear in mind, with reference to cases of this and of a similar kind, that the assumption of inflammation affecting the body of the womb is not sufficiently negatived by the absence in the patient's history of any mention of symptoms so grave as we might be inclined to imagine that inflammation of the more import- ant parts of this viscus must of necessity produce. In making* examinations after death, we constantly find adhesions between the uterus and rectum, or matting together of the parts within the fold of one or other broad ligament, although the patient during her lifetime may never have mentioned any attack of uterine or abdomi- nal inflammation. Not unfrequently, too, we find the uterus firmly fixed in the pelvis, with most obvious thickening of the broad liga- ment, or of the pelvic cellular tissue ; while yet the closest inquiry will fail to elicit anything more definite than the statement that a bad confinement or a bad miscarriage some time before was succeeded by a painful and tedious convalescence. Other cases might be mentioned which, I believe, admit of the same interpretation — cases where the symptoms have succeeded to marriage, or where they have followed suppressed menstruation ; nor would I propose a different explanation of those instances in which uterine misplacements, as anteflexion or retroflexion, are succeeded by signs of sexual disorder such as we have been consid- ering, or where they have been associated with misplacement of the ovary. In all of these instances it is, I believe, the interior of the uterine cavity which suffers first — it is thence that the hemorrhages are derived, thence that the greater part of the leucorrhoeal discharge 7d. IMPORTANCE OF AFFECTIONS is furnislied ; and it is the irritation of that part of the organ in which its most important functions are transacted, which leads to the increase of its size so apparent in the great proportion of cases of long- continued uterine ailment. That the ovaries suifer too, constant observation proves ; and facts illustrative of the affection of the neck of the womb are also perpetually coming under our notice ; but that, as a general rule, inflammation of the canal of the cervix is the first step in the disease, and ulceration of the os uteri the second ; and that these two conditions are the two factors pro- ducing all the symptoms we have been studying, is an assumption which I cannot but regard as unsupported by facts, and as opposed to any fair inference from what anatomy, physiology, or analogical reasoning teach us. There are, however, some writers who, while they concede the comparatively small importance of ulceration of the os uteri, yet appear to me (and I trust that these my doubts are always expressed with that respect and deference for the opinions of others which I sincerely entertain) scarcely to attach due weight to the ailments of the uterine cavity. The elaborate secretory apparatus of the cervix uteri, so minutely described and so beautifully delineated by Dr. Hassall and Dr. Tyler Smith, seems indeed to furnish an ample source for almost any conceivable amount of discharge. But it must be remembered that, like many other secreting apparatuses, this is by no means in constant activity. Its full action seems to be called forth only during pregnancy ; and my own observation does not by any means confirm the statement, that in the intervals between the menstrual periods a mucous plug is secreted, hermetically closing, as it were, the canal of the cervix ; for I have observed any such secretion, to say the least, quite as often absent as present in uteri which I have examined. Moreover, at each menstrual period it is the mucous membrane of the body of the uterus which is congested, and from which the mucus and epithelium, as far as we can ascertain, are derived, which form at its commencement and end the greater part of the menstrual flux, and constitute the white discharge that not infrequently continues in the healthy subject for twelve or twenty- four hours after the cessation of all admixture of blood. Nor must it be forgotten that the mucous membrane of the uterine cavity is furnished with appropriate glands to furnish such secretion almost infinite in number, curiously convoluted to increase the extent of their surface, and susceptible of a peculiar hypertrophy more re- OF CERVICAL CANAL EXAGGERATED. 77 markable than any which is observed to take place in the glands of the cervix. Observation also not infrequently discovers the mem- brane of the uterine cavity abundantly moistened with secretion ; while cases are now and then met with in which inflammation having attacked it, it pours out abundance of pus. Such a case sometime since came to my knowledge ; and the uterus, removed from the patient after death, is now in the Museum of St. Bartholomew's Hospital. A fibrous tumour growing in the substance of the posterior uterine wall occasioned an unusual amount of irritation of the pelvic viscera, the cause of which was not detected during the patient's life. After death, this tumour, of the size of a small apple, was seen to be most intensely injected, while the mucous membrane of the uterine cavity, into which, however, the tumour did not at all project, was of the brightest possible rose tint, and looked like red velvet. Pus had been poured out from the ftiflamed mucous membrane, and collecting within the uterine cavity all the more readily from the neck of the womb having become bent upon itself, so as to prevent the ready escape of fluids from the interior, had distended it, as may be seen in the specimen, to the size of a hen's egg. It is true, indeed, that our means of investigation do not enable us, during the lifetime of our patients, to ascertain beyond a doubt whether a discharge poured out from the os uteri is furnished from the cervical canal, or from higher up in the body of the uterus, or from both. Probability appears to me to incline to its being chiefly derived from the uterine cavity ; though I do not doubt but that it is often furnished in a measure by the cervix also. The weight of proof seems to me to lie upon those who see in leucorrhoea only a hypersecretion from the glandular apparatus of the cervix uteri. Moreover, it is not only the excessive mucous or purulent discharge which in these cases attracts our notice and calls for our interference, but menstrual disorder, abdominal and pelvic pain, uterine enlarge- ment — all that category of symptoms, in short, which have been so often dwelt on in these Lectures, that to refer to them again, even in the briefest manner, seems an almost needless tediousness. But it may not unnaturally be asked, whether I then believe that the condition of so-called ulceration of the os uteri is one of abso- lutely no importance, adding nothing to a patient's suff'erings, in no respect protracting her illness, calling for no treatment ? I do not believe this ; though at the same time disease of the os uteri is so "TjS symptoms of ulceration almost invariably associated with other evident ailments of the organ as to render it very difficult to distinguish accurately one set of symptoms from the other. That the existence of an abraded condi- tion of the OS uteri is capable of producing under some circumstances very considerable discomfort, is, however, certain ; and is proved by cases such as the following : — A woman, twenty-seven years of age, who had lived in sterile marriage with two husbands, was admitted into St. Bartholomew's Hospital on account of dysmenorrhoea. The canal of the cervix uteri was extremely narrow ; and, under the impression that the case was one of those comparatively rare instances of menstruation rendered difficult by mechanical causes, sponge tents were introduced to dilate the contracted cervix. The presence of the sponge tent, though causing no other inconvenience, occasioned a very distressing sense of itching referred to the uterus : on the withdrawal of the tent, the edges of the os uteri and the cervical canal, as far as it could be seen, were observed to be very red, and quite denuded of their epithelium, while a rather abundant glairy secretion was poured out from their surface. So long as the abrasion continued, and it did not disappear till three days after the removal of the sponge tent, the sense of itching and the discharge continued, though with gradually diminishing severity. Causes so purely local in their action are of course very rare ; but symptoms such as were here produced by mechanical irritation are sometimes observed in other cases in which disease, as far as can be ascertained, is confined to the os uteri. I will but just allude here, by way of illustration, to cases in which the earliest stage of uterine cancer has been attended with some vague sense of itching, burning, or smarting, referred to the mouth of the womb : to do more than merely mention them would take us away from our more immediate subjects. But, independent of such cases, it happens now and then that without any other, or at any rate with very little other, appreciable evidence of uterine disease, one observes the orifice of the womb present a red, coarsely granular surface, from which a glairy secretion is poured forth abundantly. This surface is somewhat tender to the touch, and bleeds so readily that even the most careful examination with the speculum causes the blood to flow. Much more rarely I have also "Seen what looked more like an ordinary ulcer with sharply cut edges ; its surface apparently a little depressed below the adjacent tissue, partially covered by a thin layer of dirty yellowish lymph, but red, OF OS UTERI. 79 and bleeding on its removal. Both of these conditions I have usually noticed in women whose previous history contained mention of some syphilitic infection only a few months previously ; though I should hesitate to class the appearances among secondary syphilitic symptoms. ,. I apprehend that the marked granular appearance is due to hyper- trophy of those papillae covering the surface of the os uteri, for our acquaintance with which we are indebted to the late Dr. Franz Kilian, of Mayence ; whose early death it may be permitted me here to deplore, since it was' as much too soon for science as for his own fair fame ; while unanswered problems remind one painfully every day of the loss of him who had proved himself so well fitted to attempt their solution. In these cases, the analogy between the state of the os uteri and that granular condition of the palpebral conjunctiva observed in purulent ophthalmia, would seem to be com- plete ; and no one who has observed the abundant secretion poured out from between the lids of the infant affected by that disease, need wonder at the amount of discharge furnished from so comparatively small a surface as the os uteri. That sometimes there is an actual destruction of substance over and above the mere abrasion of epithe- lium, can also not be doubted ; but I believe that this is not generally the case. With reference to the morbid states of the os uteri, how- ever, there is much need of careful microscopic research. We hear of phlebitis of its minute vessels, of herpes and eruptive diseases affecting its surface : terms expressive sometimes of a theory, at other times descriptive of the character of an appearance which presented itself to the observer; but such phraseology cannot at present be accepted as a statement of any well-ascertained patholo- gical fact. One of these conditions I must notice, because it is met with independent of other uterine disease, and presents characters so -marked as to have attracted the notice of Boivin and Dug^s, and to have received from them a distinct name as granular metritis. Under this not very appropriate name, two different conditions at least have been described. In one, numerous small, rather hard, miliary prominences beset both lips of the os uteri, usually, but not invariably, destitute of epithelium, giving exit when pricked to a small drop of mucus or muco-pus, and being probably hypertrophied follicles. The other condition is produced by a number of small, soft, red papulae, similar in size to those just mentioned, very vascu- 80 AFFECTIONS OF OS UTERI AKIN TO ULCERATION. lar, bleeding easily, but solid, and probably identical in structure with the granulations ascertained by M. Robin to be small hyper- trophied points of mucous membrane ; and which, occasionally deve- loped in the uterine cavity, have been the object of a somewhat over-active treatment on the part of M. R^camier and some other practitioners, who, believing them to produce obstinate leucorrhoea, menstrual irregularity, and other ills, scrape out the uterine cavity with a blunt instrument, and find in the blood-stained debris of the mucous membrane the proofs of their diagnostic skill, and the tro- phies of their chirurgical dexterity. These states of the os uteri, however, though by no means common, are unquestionably attended with leucorrhoeal discharge, often very profuse, with a tendency to slight bleeding from their surface ; while they produce uncomfort- able sensations of itching, smarting, and the like, not amounting, indeed, to actual pain, but quite sufficient to keep alive all the patient's anxiety lest they should be the portent of some worse ailment to follow. Affections such as these have seemed to call for local treatment, and when resorted to, I have seen them yield under it, and the patient return rapidly to health. These cases, however, are, I be- lieve, exceptional ones, and, in the majority of instances, the morbid state of the os uteri is but a part of the general disease which has attacked the organ ; the ulceration persisting, now larger, now smaller, presenting different aspects, not as the cause of the symp- toms, but with them dependent on, and expressive of, the influence of another and a common cause. What causes these may be I have already stated. But even in such cases, it has seemed to me that the ulceration has itself sometimes outlasted the graver evils under which it arose, and has remained ; causing discomfort, leucorrhoea, and slight sanguineous discharge, and keeping up a perpetual dispo- sition to uterine congestion, which but for it would subside. That, under such circumstances, a tendency to slow increase in the size of the cervix uteri should exist, is surely no matter for wonder, since the neck of the womb is more exposed to irritation of every kind than any other part of the organ ; while, slight though the morbid state may be, it yet is sufficient to produce some increased afflux of blood thither, whence its return is more difficult than from any other part ; and we have already seen how great is the tendency in the uterine tissue under any stimulus, either natural or morbid, to LOCAL TREATMENT OF ULCERATION. 81 some degree of that hypertrophy which, during thirty years of life, represents its highest physiological condition. It cannot be necessary that I should say a word to point out the difference between these opinions and those which I have ventured to criticize, and according to which inflammation of the cervix and ulceration of the os uteri are the first and the last in uterine patho- logy. It may, however, be asked, how is it that such successful results have followed a course of treatment directed exclusively to the cure of the ulceration — that^ the application of caustics to the OS uteri has been succeeded by the restoration of the patient to health ? Now, I think it should be borne in mind that, in connection with this mode of treatment, various other measures are of necessity adopted, eminently calculated to relieve many of the slighter forms of uterine ailment. The married woman is for a time taken from her husband's bed; the severe exertion to which either a sense of duty urged, or a love of pleasure prompted her, is discontinued ; while rest in the recumbent posture places the uterus and the pelvic viscera in just that position in which the return of blood from them j encounters the smallest difficulties. The condition of the bowels, probably before habitually neglected, is now carefully regulated, and the patient's diet, bland, nutritious, and unstimulating, often differs widely from that with which, while all her functions were overtaxed, she vainly strove to tempt her failing appetite. Add to this, that the occurrence of the menstrual period is carefully watched for ; that all precautions are then redoubled, and each symptom of disorder, such as on former occasions had been borne uncomplain- ingly, though often not without much suffering, is at once encoun- tered by its appropriate remedy ; while generally returning conva- lescence is met in the higher classes of society by a quiet visit to the country, or to some watering-place, in pursuit not of gayety, but of health; and we have assembled just those conditions best fitted^ to remove three out of four of the disorders to which the sexual J system of woman is subject. But the very simplicity of these mea- sures is a bar to their adoption ; for you will bear me out in saying, that the rules which common sense cannot but approve, but which seem to require nothing more than common sense to suggest them, are just those to which our patients least readily submit. The case is altered, however, when these same rules are laid down not as the means of cure themselves, but only as conditions indispensable to the success of that cauterization which, repeated once or oftener in 6 ■ 82 ITS INDISCRIMINATE ADOPTION the week, is the great remedy for the ulceration that the doctor has discovered, and which he assures his patient, and with the most perfect good faith, produces all the symptoms from which she suffers. The caustic used in these milder cases is the nitrate of silver ; the surface to which it is applied is covered by a thin layer of albuminous secretion, which it is not easy to remove completely, and which serves greatly to diminish the power of the agent, while the slightly stimu- lating action that it nevertheless exerts seldom does harm, sometimes, I believe, does real good, though no more than might have been equally attained by vaginal injections, or other similar remedies, which the patient might have employed without the intervention of her medical attendant. There is no more difficult problem in therapeutical inquiry than how to distinguish between the results which really depend on our remedies, and such as only casually follow their employment. The patient had symptoms of uterine ailment ; the orifice of her womb was abraded, caustic was applied, and the healing of the abrasion and the subsidence of the uterine symptoms took place simultaneously. From these facts a formula is framed, which is applied to the manage- ment of uterine ailments generally — to three-fourths or four-fifths of the diseases of the female sex that come under the care of the practitioner. So far, indeed, are these views sometimes carried, that even the utter absence of all signs of uterine disease is not always thought a sufficient reason for doubting its existence ; but examination with the speculum is made, and the detection of some slight speck of abrasion of the os uteri is thought to furnish an explanation of chronic ailments of the most dissimilar kinds ; and a panacea for those ills is sought in the use of the caustic. There are those here who can bear me out in the assurance that this is no overcharged statement ;, but the annals of medicine are full of in- stances of the extent to which preconceived ideas modify the experi- ence of men whose honesty is as much above suspicion as their ability is beyond question ; and no fellow of this college will doubt the integrity or the talent of either of the would-be combatants who, some hundred and twenty years ago, drew their swords in Cheap- side to settle the proper treatment of the smallpox. It would be a matter of comparatively little moment whether the views which I believe to be erroneous really were so or not, if they led to nothing more than an over-estimate, on the part of some practitioners, of the value of a certain kind of therapeutical pro- INJURIOUS TO PATIENT. 83 ceeding. But their evil, if they be erroneous, does not cease here ; they exert an injurious influence, both on the patient and the practitioner. No one engaged in the practice of medicine, but must have been often struck with the important part which the sexual system plays, unconsciously to herself, in almost all the diseases of woman. The frequent sadness and low spirits in celibacy, the grief, the almost shame of childless marriage, depend on causes / more deeply seated than reason can dispel, and are familiar to us as \ often stamping a peculiar character on the diseases of our patients. « To the same cause is due the nervous susceptibility which women often manifest on the least symptom of ailment affecting their uterine system ; to control which, and to prevent the disposition to uncon- scious exaggeration of their symptoms, becomes often one of our ' most important, and at the same time one of our least easy, duties, j Any course of proceeding, then, which, without the most urgent and absolute necessity, directs the patient's attention in the slighter ailments painfully and frequently to her uterine system, is in the highest degree objectionable. The patient recovers from her illness, but with the impression that all the sensations that for weeks or months before she had experienced were exclusively due to the local disease which had called for local remedies. On the first return of any symptoms resembling them, all her apprehensions are revived, lest the same painful investigation, the same distressing manipulations as before, should be again required. The fact that^ it needs but to watch the beatings of one's heart for a few minutes in order notably to quicken its pulsations, and to become painfully conscious of its action, is one of the most familiar illustrations of j that influence of attention upon the functions of the body of which, / both in health and in disease, we see so many instances. Digestion," watched through its diff'erent stages with the not unnatural anxiety of a dyspeptic invalid, often leaves him a hypochondriac, unable to take other than certain articles of diet, and those cooked in some peculiar fashion ; while in many instances, neither in the food itself, nor in its mode of preparation, is there any reason to be found why that alone should be tolerated by his fastidious stomach. More or^ less discomfort — often, indeed, much positive pain — attends in the great majority of women upon the performance of the menstrual function, precedes or follows it. These pains are now thought to be of more importance than before ; their occurrence is watched for, the sufl'ering of one month is weighed against that of the month ) 84 INJURIOUS TO PATIENT AND PRACTITIONER. # before, as the woman thinks she finds in its increase or diminution grounds for hope or for apprehension. But the sensations thus attended to increase in intensity and in persistence ; the slight ail- ment, which, but for the coming evil that it is supposed to portend, would in a few days be forgotten, is noted with anxious vigilance; and the more it is observed, the more it seems to grow ; she fears she never shall be well again, and at length makes up her mind once more to go through the same treatment as before relieved her, though it brought to her the painful revelation of the grave cause on which her suiFerings, once thought so little of, in reality depended. Such persons among the poor come to our hospitals ; and on questioning them as to their ailments, they at once, and without waiting to describe their symptoms, say that they are suffering from ulceration of the womb ; though on examination one finds no trace of it, or at most a little redness of the edges of the os uteri, or it may be even that slight abrasion which I trust that I have shown to be as trivial in importance as it is frequent in occurrence. But though they have no serious disease, they are not the less, or perhaps one might say all the more, real sufferers, and sufferers most difficult to cure. The treatment they perhaps are once more subjected to serves but to confirm the morbid habit of mind which has been gradually increasing upon them, and destroying both their present happiness and their capacity for it in future years. They are the victims, I believe, not of the want of honest purpose or of high motive in those who practise our art, but of an erroneous opinion. This erroneous opinion, however, reacts injuriously upon the practitioner himself. He unlearns what physiology might teach him of the uterus and its functions, and sees in all the varied manifesta- tions of disorder the expression of one fact, and of one alone ; namely, the existence of ulceration of the womb, and its reaction first on the uterine system, then on the general health. For him, indeed, there is little more to learn in uterine pathology ; for when once a case has been ascertained not to be one of fibrous tumour, polypus, or cancer, then ulceration of the os uteri is the almost invariable cause to which the symptoms are referred, and the cure of this ulceration is the one grand object at which he endeavours. All the evils inseparable from the practice of a specialty are thus aggravated, and the natural tendency of such practice to subside into routine, or to degenerate into empiricism (I use the word in no invidious sense), becomes almost unavoidable. OBJECTIONS TO THE USE OF THE STRONGER CAUSTICS. B5 There was a time in a neighbouring country, and not very long since, when the clue to the understanding of all diseases, the essential cause on which they depended, was supposed to be Gastro- Enteritis. It was conceived to be the primary pathological condition, or proximate cause of fevers, to play a most important part in the disorders of the cerebral and respiratory systems; and all that ingenious argument could do was done by M. Broussais to support his new doctrines. For years, France was divided into two schools — the supporters and the opponents of M. Broussais's theories ; and though truth was elicited by the contest, yet medical science ad- vanced during the time much more slowly than, but for these divisions, it doubtless would have done. In the same way, i believe that the progress of uterine pathology has been retarded by the disputes about ulceration of the os uteri ; for while one party has denied its very existence, and another has exaggerated its import- ance, both have allowed numerous important questions to pass "Vv'ithout even an attempt at a reply. But though it is my conviction that, in the great majority of instances in which the nitrate of silver is applied to the os uteri, the proceeding is simply superfluous, it yet would not be right to leave unnoticed other cases in which the neck of the womb beins: more or less enlarged, stronger agents are employed. On these occasions, the caustic potash is generally used, and by some with the view of destroying outright a certain portion of the enlarged cervix, by others with the intention of getting rid of the enlarge- ment by means of the inflammation which it sets up in the uterine tissue. With whichever object resorted to, this proceeding is con- fessedly devoid neither of sufi'ering nor of danger. If the caustic be introduced, as is usually done, within the cervical canal, it is allowed that the pain produced, and which sometimes lasts for two or three days, is very intense, causing nausea or sickness, and sometimes even syncope, or occasioning extreme depression, pros- trating a patient so completely as to render her unable to quit her bed or sofa for several days. Thus much for the present eff'ect of this remedy, for which its strongest advocates can scarcely lay claim to such an epithet as jucunde. But it does not fare much better with it as far as cito is concerned. The application of the pot~assa fusa, so as to produce an eschar, implies a subsequent course of treatment with frequent applications of the nitrate of silver for a period of about forty days, at the end of which time, the action of 86 EXCEPTIONAL CASES the remedy being supposed to be exhausted, unless the patient is cured, it will be necessary to repeat the same treatment again and again. This treatment, too, it will be observed, confines the patient during the whole time that it is in progress to her room, and almost to her couch, and entails upon her the necessity of one or two ex- aminations with the speculum every week during its continuance. But if it can be said to act neither eito nor jucunde, it might be hoped that this mode of proceeding had at least the third merit of tuto ; but it has not. The tendency to contraction or obliteration of the cervical canal after these proceedings is very considerable, and is referred to even as a frequent occurrence, while inflammation, both of the uterus generally, and of its appendages, is a contingency far from uncommon. Of the last of these accidents I have seen several instances among patients at the 'Hospital, who, previous to their coming under my care, had been treated with the stronger caustics for ulceration of the os uteri. I will not attempt to follow the advocates of this puactice through the explanation which they give of its mode of action; and the rather, since where some see a healthy stimulus to the affected tissues, others discern what they consider to be a dulling, stupefying influence, as they term it, weakening the vital force ; while, through- out the language used with reference to this subject, there is a mingling of metaphor with scientific terminology, from which it is extremely difficult to arrive at a clear notion of what is meant. I do not doubt but that, by either mode of applying the caustic potass, the cervix uteri may be reduced in size ; but my dissent from the practice is founded on the fact that it has none of the three recom- mendations of painlessness, speed, or safety ; while my own experience would lead me to believe that, when adopted, it is usually either out of place or superfluous. During the presence of any active symptom of inflammation, such a proceeding as the destruction of a portion of the uterine tissue by caustics cannot but be perilous ; after their removal, the womb will return slowly, often indeed but imperfectly, to its previous size. This return, however, does take place, as far at least as my experience goes, in the immense majority of cases ; and takes place as surely, and not much more slowly, under just those conditions which best promote the general health, as under a course of treatment which, apart from other evils, confines a woman for weeks and months to her chamber and her couch, to the grievous impairment of her general health, and the utter ruin of her cheerful- JUSTIFYING LOCAL TREATMENT. 87 ness, as o» several occasions I have had the opportunity of observ- ing. Moreover, very wide variations in the size of the womb seem to be equally compatible with the healthy performance of its functions; while the special tendency which it exhibits, under any circumstances that produce congestion of its vessels to increase in size, must never be forgotten in estimating the pathological importance of hypertro- phy, either of the whole or of a part of the organ. In this opinion, too, I am further strengthened by the fact that some of the most marked instances of enlargement of the neck of the womb, with increased hardness of its tissue, which have come under my observa- tion, occurred in cases where there was no trace of ulceration either of the OS uteri or of the canal of its cervix. At the same time there are some exceptional cases, which I have already referred to, where ulceration, or some allied morbid condition of the OS uteri, is found to exist independent of any appreciable disease elsewhere ; and others, equally rare, in which, after symp- toms of uterine ailment have been subdued, a morbid state of the OS uteri persists, which is benefited by stimulant applications. In such cases, I use either the nitrate of silver or the acid nitrate of ^mercury, though neither of them frequently ; and for weeks together no case appears among my patients at St. Bartholomew's Hospital in which the employment of either appears to me indicated. In justice to others, it should, I think, be observed, that we have no right to infer that the majority of practitioners, who resort to those agents with much greater frequency than some of us feel warranted in doing, regard them as absolutely the best remedies that could be used, but merely as the best under the peculiar circumstances in which uterine diseases have to be treated. Were it possible to keep any of those milder agents in contact with the abraded os uteri, which can generally be applied to an irritated or ulcerated surface elsewhere, this would doubtless be allowed in many instances to be a preferable proceeding. The problem, however, is to find some agent sufficiently powerful to exert an influence which may continue for several days, and thus to obviate the necessity fo'P that frequent painful interference which would otherwise be required. That lo- tions, batks, and other remedial agents which may be safely intrusted to the patient herself, will answer the desired ends more frequently than some practitioners imagine, is my firm conviction ; but I could not refrain from stating what seems to me to be the candid interpre- tation of their conduct who pursue a different course of proceeding. 88 CONCLUSION. Time forbids that I should enter into further detail — nor, indeed, does my subject need it; for I proposed to myself only " To inquire into the Pathological Importance of Ulceration of the Os Uteri." In doing this, I have had of necessi1:y to refer to opinions from which I diifered. It was no want of respect for many of those who entertain those opinions, and whose talents have done so much to render them popular, which has led me studiously to abstain from referring to them by name ; but I believe, and have high authority for acting on the belief, that " The cause of truth gains much by a course, which not only avoids personal controversy, but confines attention to the real merits of the case, independently of the ex- traneous circumstances which ought not to influence the decision." I have treated this inquiry, Sir, into what is after all but a com- paratively small ailment, as gravely as though it were one of those dire diseases, in the study and the cure of which the highest skill of the greatest votaries of our art has found its fit employment. But you will not blame me, I trust, for this : the thousand smaller ills to which mankind is subject bring, in their frequent repetition, as much suiFering, cause as much sorrow, and therefore are as worthy or our heartiest labour to understand, and of our best efforts to relieve, as those perilous visitants — inflammations, fevers, apoplex- ies, which threaten life only at long intervals or on rare occasions. If, however, it should still seem to any that I have chosen a theme beneath the dignity of this College, may I remind them that Syden- ham himself has told us, he should not deem his life ill-spent if he had contributed to even the least improvement in the very humblest branches of practical medicine ;^ and, taking shelter behind his great name, plead in extenuation of my poor performance, " Quantacum- que fuerint aliorum conamina, semper existimavi mihi vitalis auras usum frustra datum fore, nisi ^t ipse in hoc stadio versatus symbolam aliquam utcunque exiguam in commune medicinse aerarium contri- buerim." ^ <'Etsi nihil magnificentius," says he, "quam odontalgiae, aut clavorum pedibus iunascentium curatio." THE END. CATALOGUE OP BLANCHARD & LEA'S MEDICAL im SURGICAL PUBLICATIONS. TO THE MEDICAL PROFESSION. In submitting the following catalogue of our publications in medicine and the collateral sciences, we beg to remark that no exertions are spared to render the issues of our press worthy a continuance of the confidence which they have thus far enjoyed, both as regards the high character of the works themselves, and in respect to every point of typographical accuracy, and mechanical and artistical execution. Grentlemen desirous of adding to their libraries from our list, can in almost all cases procure the works they wish from the nearest bookseller, who can readily order any which may not be on hand; and who, as well as ourselves, will be happy to answer any inquiries as to price, &c. BLANCHARD & LEA. Philadelphia, November, 1854. TWO MEDICAL PERIODICALS, FREE OF POSTAGE, FOR FIVE BOI^IiARS PER Al^rVlJM. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, subject to postage, when not paid for in advance, $5 00 THE MEDICAL NEWS AND LIBRARY, invariably in advance, - - 1 00 or, BOTH PERIODICALS fumished, free of postage, for Five Dollars remitted in advance. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by ISAAC HAYS, M. D., 18 published Quarterly, on the first of January, April, July, and October. Each number contains at least two hundred and eighty large octavo pages, appropriately illustrated, wherever necessary, by engravings. It has now been issued regularly for a period of thirty- five years, during a quarter of a century of which it has been under the control of the present editor. Throughout this long space of time, it has maintained its position in the highest rank of medical periodicals both at home and abroad, and has received the cordial support of the entire profession in this country. 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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 earrent 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 LECTCJRES ON THE PRACTICE OF PHYSIC. BRODIE'S CLINICAL LECTURES ON SURGERY. TODD AND BOWMAN'S PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. 724 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, and SIMON'S LECTURES OxN GENERAL PATHOLOGY. While the year 1854, presents BENNETT ON PULMONARY TUBERCULOSIS, ' BEAUTIFULLY ILLUSTRATED ON WOOD. AND WEST ON ULCERATION OF THE OS UTERI. To be followed in 1855 by A VALUABLE WORK ON A PRACTICAL DEPARTMENT OF MEDICAL SCIENCE. It will thus be seen that for the small sum of FIVE DOLLARS, paid in advance, the subscriber wttl 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 difficuUies aiid objections to a full and extended circulation of the Medical Journal to the office of every member of the profession throughout the United Slates. 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It should also be borne in mind that the publishers will now take the risk of remittances by mail, «ily requiring, in cases of loss, a certificate from the subscriber's Postmaster, that the money was duly mailed and forwarded I^^ Funds at par at the subscriber's place of residence received in payment of subscriptions. Address, BLANCHARD & LEA, Philadelphia. AND SCIENTIFIC PUBLICATIONS, ANALYTICAL COMPENDIUM OF MEDICAL SCIENCE, containing Anatomy, Physiology, Surgery, Midwifery, Chemistry, Materia Medica, Therapeutics, and Practice of Medicine. By John Neill, M. D., and F. G. Smith, M. D. Second and enlarged edition, one thick volume royal 12mo. of over 1000 pages, with 350 illustrations. 1^ See Neill. ABEL (F. A.), F. C. S. Professor of Chemistry in the Royal Military Academy, Woolwich. C. L. BLOXAM, Formerly First Assistant at the Royal College of Chemistry. HANDBOOK OF CHEMISTRY, Theoretical, Practical, and Technical, with a Recommendatory Preface by Dr. Hofmann. In one large octavo volume of 662 pages, with illustrations. {Now Ready.) There was still wanting some book which should who resolves to pursue for himself a steady search aid the young analytical chemist through all the into the chemical mysteries of creation. For such phases of the science. The " Handbook" of Messrs. ■ a student the 'Handbook' will prove an excellent Abel and Bloxam appears to supply that want. As ' guide, since he will find in it, not merely the most Dr. Hofmann says in his brief Preface, " The pre- approved modes of analytical investigation, but sent volume is a synopsis of their (the authors') ex- ■ descriptions of the apparatus necessary, with such perience in laboratory teaching ; it gives the neces- ; manipulatory details as rendered Faraday's ' Che- sary instruction in chemical manipulation, a concise j mical Manipulations' so valuable at the time of its account of general chemistry as far as it is involved I publication. Beyond this, the importance of the in the operations of the laboratory, and lastly, quali- work is increased by the introduction of much of the tative and quantitative analysis. It must be under- technical chemistry of the manufactory." — Athe- stood that this is a work fitted for the earnest student, ' nceum. ASHWELL (SAMUEL), M. D. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. With Additions by Paul Beck GoDDARD, M. D. Second American edition. la one octavo volume, of 520 pages. 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, of 484 pages, with about two hundred illustrations. 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- LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistakea for or associated with, Phthisis. In one handsome octavo volume, with beaulilul wood-cuts. {Now Ready.) How it may be most effectually carried into prac- tice, our readers will learn from Dr. Bennett's pages, especially from the histories of the valuable and in- teresting cases which he records. Indeed, if the au- thor had only reported these cases he would have benefited his profession, and deserved our thanks. As it is, however, his whole volume is so replete with valuable matter, that we feel bound to recommend our readers, one and all, to peruse it. — Lond. Lancet. The elegant little treatise before us shows how faithfully and intelligently these investigations have been pursued, and how successfully the author's studies have resul ted in clearing up some Qf the most doubtful points and conflicting doctrines hitherto entertained in reference to the history and^reatment of pulmonary tuberculosis. — N. Y. Journal of Medi- cal and Collateral Science, March, 1851. 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. In one neat octavo volume, of 430 pages, with wood-cuts. {Now Ready.) This edition will be found materially improved over its predecessors, the author having carefully revised it, and made considerable additions, amounting to about seventy-five pages. This edition has been carefully revised and altered, that the bulk of the profession are not fully alive to and various additions have been made, which render the importance and frequency of the disease of which it more complete, and, if possible, more w^orthy of -^ '- •"■ the high appreciation in which it is held by the medical profession throughout the world. A copy stiould be in the possession of every physician. — Charleston Med. Journal and Review, March, 1854. We are firmly of opinion that in proportion as a knowledge of uterine diseases becomes more appre- ciated, this work will be proportionably established as a text-book in the profession. — The Lancet. it takes cognizance. The present edition is so much enlarged, altered, and improved, that it can scarcely be considered the same work.— Dr. Ranking^s Ab- stract. Few works issue from the medical press which i are at once original and sound in doctrine ; but such, I we feel assured, is the admirable treatise now before I us. The important practical precepts which the author inculcates are all rigidly deduced from facts. When, a few years back, the first edititm of the 1 . . • Every page of the book is good, and eminently present work was published, the sul)ject was one al- ^ practical. ... So far as we know and believe, it is most entirely unknown to the obstetrical celebrities ! the best work on the subject of which it treats. — of the day ; and even now we have reason to know Monthly Journal of Medical Science. BLANCHARD & LEA'S MEDICAL BEALE (LIONEL JOHN), M. R. C. S., &,c. THE LAWS OF HEALTH IN RELATION TO MIND AND BODY. A Series of Letters from an old Practitioner to a Patient. In one handsome volume, royal 12mo.. extra cloth. BILLING (ARCHIBALD), M. D. THE PRINCIPLES OF MEDICINE. Second American, from the Fifth and Improved London edition. In one handsome octavo volume, extra cloth, 250 pages. BLAKISTON (PEYTON), M. D., F. R. S., &.C. PRACTICAL OBSERVATIONS ON CERTAIN DISEASES OF THE CHEST, and on the Principles of Auscultation. In one volume, 8vo., pp. 384. BURROWS (GEORGE), M. D. ON DISORDERS OF THE CEREBRAL CIRCULATION, and on the Con- nection between the Affections of the Brain and Diseases of the Heart. In one 8vo. vol., with colored plates, pp. 21t). 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, with four beautifully colored plates, and numerous wood-cuts. pp. 468. New edition. {Just Issued.) The reputation which this work has obtained as a full and practical treatise on an important class of diseases will not be diminished by this improved and enlarged edition. It has been carefully and thoroughly revised by the author ; the number of plates has been increased, and the style of its me- chanical execution will be found materially improved. The full digest we have given of the new matter introduced into the present volume, is evidence of the value we place on it. The fact that the profes- sion has required a second edition of a monograph such as that before us, bears honorable testimony to its usefulness. For many years, Dr. Budd's work must be the authority of the great mass of British practitioners on the hepatic diseases ; and it is satisfactory that the subject has been taken up by so able and experienced a physician. — British and Foreign Medic o-Chirurgical Review. BUSHNAN (J. S.), M. D. THE PHYSIOLOGY OF ANIMAL AND VEGETABLE LIFE: a Popular Treatise on the Functions and Phenomena of Organic Life. To which is prefixed a Brief Expo- sition of the great departments of Human Knowledge. In one handsome royal 12mo. volume, with over one hundred illustrations. Though cast in a popular form and manner, this work is the production of a man of science, and presents its subject in its latest development, based on truly scientific and accurate principles. It may therefore be consulted with interest by those who wish to obtain in a concise form, and at a very low price, a resume of the present state of animal and vegetable physiology. BLOOD AND URINE (MANUALS ON). BY JOHN WILLIAM GRIFFITH, G. OWEN REESE, AND ALFRIID MARKWICK. One thick volume, royal 12mb., extra cloth, with plates, pp. 460. BRODIE (SIR BENJAMIN C), M. D., &c. Ca:iD^ICAL LECTURES ON SURGERY. 1 vol. 8vo., cloth. 850 pp. BY THE SAME AUTHOR. SELECT SURGICAL WORKS, 1 vol. 8vo. leather, containing Clinical Lectures on Surgery, Diseases of the Joints, and Diseases of the Urinary Organs. URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND THEllAPEUTICAL INDICATIONS. A new and enlarged American, from the last improved London edition. With over sixty illustrations. In one royal 12ino. volume, extra cloth. The ne. 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 lo physician and surgeon, in the hour of peril.— JV. 0. Med. and Surg. Journal. FERGUSSON (WILLIAM), F. R. S., Professor of Surgery in King's College, London, &c. A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third and enlarged London edition. In one large and beautifully prmted octavo volume, of about seven hundred pages, with three hundred and ninety-three handsome illustrations. (Just Issued.) The most important subjects in connection w^ith practical surge-iy which have been more recently brought under the notice of, and discussed by, 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. And we think the author has shown a wise discretion in making the additions on surgical disease which are to be found in the present volume, and has very much enhanced its value; for, besides tw;o elaborate | Journal. The addition of many new pages makes this work more than ever indispensable to the student and prac- titioner. — Ranking^s Abstract. sively on operative surgery ; but this defect is now removed, and the book is more than ever adapted for the purposes of the practitioner, whether he confines himself more strictly to the operative department, or follows surgery on a more comprehensive scale. — Medical Ti?7ies and Gazette. No work was ever written which more nearly comprehended the necessities of the student and practitioner, and was more carefully arranged to that single purpose than this.— IV. Y. Med. and Surg. chapters on the diseases of bones and joints, which were wanting before, he has headed each chief sec- tion of the work by a general description of the sur- gical disease and injury of that region of the body j which is treated of in each, prior to entering into the I ^ . _ . consideration of the more special morbid conditions I lished of late years, we know of none we value and their treatment. There is also, as in former j more highly than the one before us. It is perhaps editions, a sketch of the anatomy of particular re- the very best we have for a text-book and for ordi- gions. There was some ground formerly for the nary reference, being concise and eminently practi- eoraplaint before alluded to, that it dwelt too exclu- | ca\.— Southern Med. and Surg. Journal. Among the numerous works upon surgery pub- FRICK (CHARLES), M. D. RENAL AFFECTIONS; their Diagnosis and Pathology. One volume, royal 12mo., extra cloth. With illustrations. AND SCIENTIFIC PUBLICATIONS. 1$ FOWNES (GEORGE), PH. D., See. 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 pages, with 181 wood-cuts, sheep, or extra cloth. (Now Ready.) The lamented death of the author has caused the revision of this edition to pass into the hands ot those distinguished chemists, H. Bence Jones and A, W. Hofmann, who have fully sustained its reputation by the additions which they have made, more especially in the portion devoted to Organic Chemistry, considerably increasing the size of the volume. This labor has been so thoroughly performed, that the American Editor has found but little to add, his notes consisting chiefly of suck matters as the rapid advance of the science has rendered necessary, or of investigations which had apparently been overlooked by the author's friends. The volume is therefore again presented as an exponent of the most advanced state of chemical science, and as not unworthy a continuation of the marked favor which it has received as an ele- mentary text-book. We know of no better text-book, especially in the difficult department of organic chemistry, upon w^hich it is particularly fall 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."— iV. J. Medical Reporter, March, 1854. A standard manual, ^vhich 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- cfse without being dry, and brief without being 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, Graliam, 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. Thesizeof the work, and still more the condensed yet perspicuous style in -which it is written, al)solve it from the charges very properly urged against most manuals termed popular. — Edinburgh Monthly Journal of Medical Science. 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., &e. &c. Second American, from the second and enlarged London edition PART I. (Lately Issvsd) large 8vo., 430 pages, 185 illustrations. PART II. (Preparing) to match. The great changes which the science of chemistry has undergone within the last few years, ren- der a new edition of a treatise like the present, almost a new work. The author has devoted several years to the revision of his treatise, and has endeavored to embody in it every fact and inference of importance which has been observed and recorded by the great body of chemical investigators who are so rapidly changing the face of the science. In this manner the work has been greatly increased in size, and the number of illustrations doubled ; while the labors of the editor have been directed towards the introduction of such matters as have escaped the attention of the author, or as have arisen since the publication of the first portion of this edition in London, in 1850. Printed in handsome style, and at a very low price, it is therefore confidently presented to the pro- fession and the student as a very complete and thorough text-book of this important subject. GROSS (SAMUEL D.), M. D., Professor of Surgery in the Louisville Medical Institute, &c. A PRACTICAL TREATISE ON THE DISEASES AND INJURIES OF THE URINARY ORGANS. In one large and beautifully printed octavo volume, of over seven hundred pages. With numerous illustrations. A volume replete with truths and principles of the utmost value in the investigation of these diseases. — American Medical Journal. Dr. Gross has brought all his learning, experi- ence, tact, and judgment to the task, and has pro- duced a w^ork worthy of his high reputation. We feel perfectly safe in recommending it to our read- ers as a monograph unequalled in interest and practical value by any other on the subject in our language. — Western Journal of Med. and Surg. It has remained for an American writer to \vipe away this reproach ; and so completely has the task been fulfilled, that we venture to predict for Dr. Gross's treatise a permanent place in the literature of surgery, worthy to rank with the best works of this department of art. We have, indeed, unfeigned pleasure in congratulating all concerned in this pub- lication, on the result of their labours; and expe- rience a feeling something like what animates a long- expectant husbandman, who, often times disappointed by the produce of a favorite field, is at last agree- ably surprised by a stately crop which may bear comparison -with any of its former rivals. The grounds of our high appreciation of the work\vill be obvious as we proceed; and we doubt not that the present facilities for obtaining American books will induce many of our readers to verify our re- commendation by their own perusal of it. — British and Foreign Medico-C hirurgical Review. AVhoever will peruse the vast amount of valuable the present age. Not merely is the matter good, i practical information it contains, and wliich we but the getting up of the volume is most creditable i have been unable even to notice, will, we think, to transatlantic enterprise; the paper and print ' agree with us, that there is no work in the Knglislv would do credit to a first-rate London establishment; language which can make any jnst pretensions to and the numerous wood-cuts which illustrate it, de- be its equal. — N. Y. Journal of Medicine. monstrale that America is making rapid advances in i BY THE SAME AUTHOR. (NoW Ready.) A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PAS- SAGES. In one handsome octavo volume, with illustrations. BY THE SAME AUTHOR. (Preparing.) A SYSTEM OF SURQERY; Diagnostic, Pathological, Therapeutic, and Opera- tive. With very numerous engravings on wood. 16 . '• y ; > rr A ■ ; T "Z :^ i D ^ ( i ;4 .^ BLANCHARD & LEA'S MEDICAL 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, thoroug-hly revised, with numerous additions, by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large an<3 handsome octavo volume, of over six hundred pages, double columns. {Jiist Issued.) The speedy exhaustion of a large edition, and the demand for a second, sufficiently show the posi- tion which this work has so rapidly attained as an authoritative and convenient work of reference for the physician and pharmaceutist. The opportunity thus afforded for its improvement has not been neglected. In its revision, Professor Thomas (to whom this task has been confided inconsequence of the death of the author), has spared no labor, in the hope of rendering it the most complete and correct work on the subject as yet presented to the profession All the newly introduced articles of the Materia Medica have been inserted, such formulae as had escaped the attention of the author have been added, and the whole has been most carefully read and examined, to insure the absolute correctness, so indispensable in a work of this nature. The amount of these additions maybe esti- mated from the fact that not only has the page been considerably enlarged, but the volume has also Ijeen increased by about fifty pages, while the arrangement of the forraulee and the general typo- graphical execution will be found to have undergone great improvement. To the practitioner, its copious collection of all the forms and combinations of the articles of the Pharmacopoeia render it an invaluable book of reference, while its A'ery complete embodiment of officinal preparations of aUt kinds, derived from all sources, American, English, and Continental, make it an indispensable assisl- tant to the apothecary. 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 t'rom the American press, beinjT free of much of the trashy, and embrac- ing most of the non-officinal formul.'^e used or known in American, English, or French practice, arranged under the heads of the several constituentdrugs, plac- ing the receipt under its more important constituent. Prof Thomas lias certainly "improved," as well as added ;o this Formulary, and has rendered it addition- ally deserving of the confidence of pharmaceutists and physicians. — American 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; it is better adapted to their purposes than the dispensato- ries.— SoitzAern 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 ofiice 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 books the better for the pro- fession and the public— N. Y. Med. Gazette. It is one of the mo«t useful books a country practi- tioner can possibly have in his possession. — Mtdieal Chronicle. The amount of useful, every-day matter, for a prac- ticing physician, is really immense.— jBos^o/i Mtd, and Surg. Journal. This is a work of six hundred and fifty one pages. embracmg all on the subject of preparing and admi- nistering medicines that can be desired by the physi- cian and pharmaceutist. — Wester7i 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. Bled, and Surg. Journal We predict a great sale for this work, and we espe- ciallv recommend it to all tnedical teachers. — Rich- mond Stethoscope. This edition of Dr. Griffith's work has been greatly imoroved 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 sy.slematic treatisas. A work of this kind appears to us indispensable lo the physi- cian, and there is none we can more cordially recom- mend. — iV. 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, of 704 pages, handsomely printed, with nearly 350 illustrations on wood. GLUGE (GOTTLIEB), M. D., Professor of Physiology and Pathological Anatomy in the University of Brussels, &c. AN ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylva- nia. In one volume, very large imperial quarto, with three hundred and twenty figures, plain and colored, on twelve copperplates. This being, as far as we know, the only work in which pathological histology is separately treated of in a comprehensive manner, it will, we think, for this reason, be of infinite service to those who desire to investigate the subject systematically, and -who have felt the difficulty of arranging in their mind the unconnected observations of a great number of authors. The development of the morbid tissues, and the formation of abnormal products, may now be followed and studied with the same ease and satisfaction as the best arranged system of phy- siology. — American Med. Journal. GREGORY (WILLIAM), F. R. S. E., Professor of Chemistry in the University of Edinburgh, &c. LETTERS TO A CANDID INQUIRER ON ANIMAL In one neat volume, royal 12mo., extra cloth. MAGNETISM. GARDNER (D. PEREIRA), M. D. ^ MEDICAL CHEMISTRY, for the use of Students and the Profession: being a Manual of the Science, with its Applications to Toxicology, Physiology, Therapeutics, Hygiene, &c. In one handsome royal i2mo. volume, with illustrations. iiyiO iUOiDUUi AND SCIENTIFIC PUBLICATIONS. 17 HASSE (C. E.), M. D. AN ANATOMICAL DESCllIPTION OF THE DISEASES OP RESPIRA- TION AND CIRCULATION. Translated and Edited by Swaine. In one volume, octavo. HARRISON (JOHN), M. D. AN ESSAY TOWARDS A CORRECT THEORY OF THE NERVOUS Si^STEM. In one octavo volume, 292 pages. HUNTER (JOHN). TREATISE ON THE VENEREAL DISEASE. With copious Additions, by Db. 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 {Now Ready.) ^W See Ricord. Also, HUNTER'S COMPLETE WORKS, with Memoir, Notes, &c. &c. In four neat octavo volumes, with plates. HUGHES (H. M.), M. D., Assistant Physician to Guy's Hospital, tea. A CLINICAL INTRODUCTION TO THE PRACTICE OF AUSCULTA-' TION, and other Modes of Physical Diagnosis, in Diseases of the Lungs and Heart. Second American from the Second and Improved London Edition. In one royal ]2mo. vol. {Now Ready.) It has been carefully revised throughout. Some small portions have been erased ; much has been, I trust, amended; and a great deal of new matter has been added; so that, though funda- mentally it is the same book, it is in many respects a new work. — Preface. 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, of more than one thousand pages, handh somely printed, with over three hundred illustrations. This work has enjoyed a thorough and laborious revision on the part of the author, 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 has introduced a large number of additional wood-engravings, illustrative of the objects described, while the publishers have en- deavored to render the mechanical execution of the work worthy of the extended reputation which it has acquired. The demand which has carried it to an EIGHTH EDITION is a sufficient evi- dence of the value of the work, and of its adaptation to the wants of the student and professional reader. HOBLYN (RICHARD D.), A. M . A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. Second and Improved American Edition. Revised, with nu- merous Additions, from the second London edition, by Isaac Hays, M. D., &c. In one large royal 12mo. volume, of over four hundred pages, double columns. {Nearly Ready.) In passing this work a second time through the press, the editor has subjected it to a very tho- rough revision, making such additions as the progress of science has rendered desirable, and sup- plying any omissions that may have previously existed. As a concise and convenient Dictionary of Medical Terms, at an exceedingly low price, it will therefore be found of great value to the stu- dent and practitioner. HOPE (J.), M. D., F. R. S., &tc. A TREATISE ON THE DISEASES OF THE HEART AND GREAT VESSELS. Edited by Pennock. In one volume, octavo, with plates, 572 pages. JONES (C. HANDFIELD), F. R. S., 8l EDWARD H. SIEVEKING, M.D., Assistant Physicians and Lecturers in St. Mary's Hospital, London. A MANUAL OF PATHOLOGICAL ANATOMY. With 400 engravings on wood. In one large and handsome octavo volume, of about seven hundred pages. {Now Ready.) This work will supply a want which has been felt of a volume which, within a reasonable size, should contain a clear and connected view of the present advanced state of pathological anatomy, embodying the numerous investigations and discoveries of recent observers, who, with the aid of the microscope, have so greatly enlarged the boundaries of pathological science. This has Ijeen the aim of the authors, and their reputation is sufficient guarantee that the object has been attained. The publi?-hers have omitted nothing that is requisite to the full appreciation and understanding of the subject, and the very numerous illustrations with which the volume abounds, will, it is hoped, fully elucidate the details and descriptions. r JONES (T. WHARTON), F. R. S., &ic. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. Edited by Isaac Hays, M. D., &c. In one very neat volume, large royal 12mo., of 529 pages, with four plates, plain or colored, and ninety-eight wood-cuts. migrht become, a manual for daily reference and I The work amply sustains, in every point the al- rejtdy high reputation of the author as an ophthalmic Burgeon 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. We entertain little doubt that tills book will become what its author hoped it consultation by the student and the general practi- tioner. The work is marked by that correctness, clearness, and precision of style which distinguish all the productions of the learned author. — British and Foreign Medical Review, 18 BLANCHARD & LEA'S MEDICAL 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 PHYSIOLOaY. Second American, from the second and improved London edition. Witii one hundred and sixty-five illustration!?. In one larg-e and handsome royal r2mo. volume, pp.550. {Just Issued.) In the present edition, the Manual of Physiology has been brought up to the actual condition of th 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. The text is fully and ably illustrated by a series of very supe- rior wood-engravings, by which a comprehension of some of the more intricate of the subjects treated of is greatly facilitated. — Am. Medical Journal. We need only say, that, without entering into dis- cussions of unsettled questions, it contains all the recent improvements in tliis department of medical science. For the student beginning this study, and the practitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all 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. The general favor with which the first edition of this Avork was received, and its adoption as a favor- ite text-book by many of our colleges, will insure a large circulation to this improved edition. It will fully meet the wants of the student. — Southern Med. and Surg. Journal. 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 (F.), PH. D., &,c. TECHNOLOG-Y ; 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, bj'- Prof. Walter R. Johnson. In two hand- some octavo volumes, printed and illustrated in the highest style of art, with about five hundred wood-engravings. PHYSIOLOGICAL (Preparing.) LEHMANN. CHEMISTRY. Translated by George E. Day, M. D. LEE (ROBERT), M. D., F. R. S., &c. CLINICAL MIDWIFERY; comprising the Histories of Five Hundred and Forty-five Case? of Difficult, Preternatural, and Complicated Labor, with Commentaries. From the second London edition. In one royal 12mo. volume, extra cloth, of 238 pages. LA ROCHE (R.), M. D., &,c. 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. the periodical press, and yet in the work before us he has exhibited an amount of industry and learning, research and ability, beyond what we are accustomed to discover in modern medical writers; while his own extensive opportunities for observation and experience have been improved by the most laudable diligence, and display a familiarity with the whole subject in every aspect, which commands both our respect and confidence. As a corrective of prevalent and mischievous error, sought to be propagated by novices and innovators, we could wish that Dr. La Roche's book could be widely read. — N. Y. Medical Gazette. A more simple, clear, and forcible exposition of the groundless nature and dangerous tendency of certain pathological and etiological heresies, has seldom been presented to our notice. — N. Y. Journal of Medicine and Collateral Science, March, 1854. This work should be carefully studied by Southern physicians, embodying as it does the reflections of an original thinker and close observer on a subject peculiarly their own. — Virginia Med. and Surgical Journal. The author had prepared us to expect a treatise from him, by his brief papers on kindred topics in BY THE SAME AUTHOR. (In PresS.) YELLOW FEVER, considered in its Historical, Pathological, and Etiological Relations. In one very large and handsome octavo volume. LONGET (F. A.) TREATISE ON PHYSIOLOGY. With numerous Illustrations. Translated from the French by F. G. Smith, M. D., Professor of Institutes of Medicine in the Pennsylvania Medical College. {Preparing.) AND SCIENTIFIC PUBLICATIONS. 19 LAWRENCE (W.), F. R. S., Sec. A TREATISE ON DISEASES OF THE EYE. A new edition, edited, with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Wills Hospi- tal, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound in leather with raised bands. {Now Ready.) This work is thoroughly revised and brought up to 1854. This work is so universally recognized as the standard authority on the subject, that the pub- Mshers 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. In this manner it will be found to con- tain over one hundred pages more than the last edition, while the list of wood-engravings has been increased by sixty-seven figures, besides numerous improved illustrations substituted for such as were deemed imperfect or unsatisfactory. The various important contributions to ophthalmological science, recently made by Dalrymple, Jacob, Walton, Wilde, Cooper, &c., both in the form of separate treatises and contributions to periodicals, have been carefully examined by the editor, and, combined with the results of his own experience, have been freely introduced throughout the volume, rendering it a complete and thorough exponent of the most advanced state of the subject. In a future number we shall notice more at length ■ octavo pages- has enabled both author and editor to this admirable treatise— the safest guide and most ' do justice to all the details of this subject, and con- comprehensive work of reference, which is Avithin ! dense in this single volume the present state of our the reach of all classes of the profession. — Sietho- ] knowledge of tlie whole science in this department, scope, March, 1854. I whereby its practical value cannot be excelled. We j heartily commend it, especially as a book of refe- This standard text-book on the department of : renee, indispensable in every medical library. The which it treats, has not been superseded, by any or | additions of the American editor very greatly en- all of the numerous publications on the subject hance the value of the work, exhibiting the learning heretofore issued. Nor with the multiplied improve- ! and experience of Dr. Hays, in the light in which he nients of Dr. Hays, the American editor, is it at all i ought to be held, as a standard authority on all sub- likely that this great work will cease to merit the ; jects appertaining to this specialty, to which he has confidence and preference of students or practition- j rendered so many valuable contributions. — N. Y. ers. Its ample extent — nearly one thousand large j Medical Gazette. BY THE SAME AUTHOR. A TREATISE ON RUPTURES; from the fifth London edition. In one octavo volume, sheep, 480 pages. LUDLOW (J. L.), M. D., Lecturer on Clinical Medicine at the Philadelphia Almshouse, &c. A MANUAL OF EXAMINATIONS upon Anatomy and Physiology, Surgery, Practice of Medicine, Chemistry, Obstetrics, Materia Medica, Pharmacy, and Therapeutics. Designed for Students of Medicine throughout the United States. A new edition, revised and extensively improved. In one large royal 12mo. volume, with several hundred illustrations. {Prepart?ig.) LISTON (ROBERT), F. Fl. S., &c. LECTURES ON THE OPERATIONS OF SURGERY, and on Diseases and Accidents requiring Operations. Edited, with numerous Additions and Alterations, by T. D. MiJTTER, M. D. In one large and handsome octavo volume, of 566 pages, with 216 wood-cuts. LALLEMAND (M.). THE CAUSES, SYMPTOMS, AND TREATMENT OF SPERMATOR- RHCEA. Translated and edited by Henry J. McDougal. In one volume, octavo, 320 pages. Second American edition. {Now Ready.) LARDNER (DIONYSIUS), D. C. L., &c. HANDBOOKS OF NATURAL PHILOSOPHY AND ASTRONOMY. Kevised, with numerous Additions, by the American editor. First Course, containing Mecha- nics, Hydrostatics, Hydraulics, Pneumatics, Sound, and Optics. In one large royal l2rao. volume, of 750 pages, with 424 wood-cuts. Second Course, containing Heat, Electricity, Mag- netism, and Galvanism, one volume, large royal 12mo., of 450 pages, with 250 illustrations. 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. The whole complete in three volumes, of about two thousand large pages, with over one thousand figures on steel and wood. The various sciences treated in this work will be found brought thoroughly up to the latest period. factory manner the information they desire. — The Virginia Med. and Surg. Journal. The work furnishes a very clear and satisfactory account of our knowledge in the important depart- ment of science of which it treats. Although the medical schools of this country do not include the study of physics in their course of instruction, yet no student or practitioner should be ignorant of its laws. Besides being of constant application in prac- tice, such knowledge is of inestimable utility in fa- eilitating the study of other branches of science. To students, then, and to those who, having already en- tered upon the active pursuits of business, are desir- ous to sustain and improve their knowledge of the general truths of natural philosophy, we can recom- mend this work as supplying in a clear and aatis- The present treatise is a most complete digest of all that has been developed in relation to the great forces of nature. Heat, Magnetism, and Electricity. Their laws are elucidated in a manner both pleasing and familiar, and at the same time perfectly intelli- gible to the student. The illustrations are suffi- ciently numerous and appropriate, and altogether we can cordially recommend the work as well-de- serving the notice both of the practising physician and the student of medicine. — The Med. Examiner. BLANCHARD & LEA'S MEDICAL MEIGS (CHARLES D.), M. D., ; Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia. ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume, of three hundred and sixty-five pages. {Now Ready.) BY THE SAME AUTHOR. WOMAN : HER DISEASES AND THEIR REMEDIES. A Series of Lee- tures to his Class. Third and Improved edition. In one large and beautifully printed octavo volume. {Just Issued. Revised and enlarged to 1854.) The gratifying appreciation of his labors, as evmced by the exhaustion of two large impressions ol' this work within a few years, has not been lost upon the author, who has endeavored in eA'ery way to render it worthy of the favor with which it has been received. The opportunity thiw afforded for a second revision has been improved, and the work is now presented as in every way superior to its predecessors, additions and alterations having been made whenever the advance of science has rendered them desirable. The typographical execution of the work will also be found to have undergone a similar improvement and the work is now confidently presented as in every way worthy the position it has acquired as the standard American text-book on the Diseases of Females. It contains a vast amount of practical knowledge. by one who has accurately observed and retained ihe experience of many years, and who tells the re- sult in a free, familiar, and pleasant manner. — Buh- lin Quarterly Journal. Tliere is an off-hand fervor, a glow, and a warm- heartedness infecting the effort of Dr. Meigs, which is entirely captivating, and which absolutely hur- ries the reader through from beginning to end. Be- eides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information "is pre- sented. We know of no better test of one's under- standing a subject than the evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, under the pencil of Prof. Meigs, are isolated and made to stand out in such bold relief, as to produce distinct impressions upon the mind and memory of the reader. — The Charleston Med. Journal. Professor Meigs has enlarged and amended this great work, for such it unquestionably is, havin? passed the ordeal of criticism at home and abroad, but been improved thereby ; for in this new edition the author has introduced real improvements, and increased the value and utility of the book fm- measurably. It presents so many novel, bright, and sparkling thoughts ; such an exuberance of new ideas on almost every page, that we confess our- selves to have become enamored with the book and its author ; and cannot withhold our congratu- lations from our Philadelphia confreres, tliat such a teacher is in their service. We regret that our limits will not allow of a more extended notice of this work, but must content ourselves with thus commending it as worthy of diligent i>erusal by physicians asM'^ell as students, who are seeking Iro be thoroughly instructed in the important practical subjects of which it treats. — N. Y. Med. Gazette. BY THE SAME AUTHOR. OBSTETRICS : THE SCIENCE AND THE ART. Second edition, revised and improved. With one hundred and thirty-one illustrations. In one beautifully printed octavo volume, of seven hundred and fifty-two large pages. {Lately Published.) 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 of 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- tention and study of the practitioner and student, while the numerous alterations and revisions which it has undergone in the present edition are shown by the great enlargement of the work, which is not only increased as to the size of the page, but also in the number. Among other addi- tions may be mentioned A NEW AND IMPORTANT CHAPTER ON "CHILDBED FE7ER." BY THE SAME AUTHOR. {Now Ready.) A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK OF THE UTERUS. With numerous plates, drawn and colored from nature in the higliest style of art. In one handsome octavo volume, extra cloth. The object of the author in this work has been to present in a small compass the practical results of his long experience in this important and distressing class of diseases. The great changes intro- duced into practice, and the accessions to our knowledge on the subject, within the last few years, resulting from the use of the metroscope, brings within the ordinary practice of every physician numerous cases which were formerly regarded as incurable, and renders of great value a work like the present combining practical directions for diagnosis and treatment with an ample series of illus- trations, copied accurately from colored drawings made by the author, after nature. No such accu- rate delineations of the pathology of the neck of the uterus have heretofore been given, requiring, as they do the rare combination of physician and artist, and their paramount importance to life physician in whose practice such cases are frequent, is too evident to be dwelt upon, while in artistic execution they are far in advance of anything of the kind as yet produced in this country. BY THE SAME AUTHOR. OBSERVATIONS ON CERTAIN OF THE DISEASES CHILDREN. In one handsome octavo volume, of 214 pages. OF YOUNG AND gCIENTIFIG PUBLICATIONS. 21 MILLER (JAMES), F. R. S. E., Professor of Surgery in the University of Edinburgh, &c. PRINCIPLES OF SURGERY. Third American, from the second and revised Edinburgh edition. Revised, with Additions, by F. W. Sargent, M. D., author of '< Minor Sur- gery," &c. In one large and very beautiful volume, of seven hundred and fifty-two pages, with two hundred and forty exquisite illustrations on wood. The publishers have endeavored to render the present edition of this work, in every point of me- chanical execution, worthy of its very high reputation, and they confidently present it to the pro- fession as one of the handsomest volumes as yet issued in this country. This edition is far superior, both in the abundance I guage. This opinion, deliberately formed after a and quality of its material, to any of the preceding We hope it will be extensively read, and the sound principles which are herein taught treasured up for future application. The work takes rank with Watson's Practice of Physic ; it certainly does not fall behind that great work in soundness of princi- ple or depth of reasoning and research. No physi- cian who values his reputation, or seeks the interests of his clients, can acquit himself before his God and Hie world without making himself familiar with the sound and philosophical views developed in the fore- 5oing book. — Ntw Orleans Medical and Surgical ournal. Without doubt the ablest exposition of the prin- ciples of that branch of the healing art in any lan- BY THE SAME AUTHOR. {NoW Ready.) THE PRACTICE OF SURGERY. Third American from the second Edin- burgh edition. Edited, with Additions, by F. W. Sargent, M. D , one of the Surgeons to Will's Hospital, &c. Illustrated by three himdred and nineteen engravings on wood. In one large octavo volume, of over seven hundred pages. ' This new edition will be found greatly improved and enlarged, as Avell by the addition of much new matter as by the introduction of a large and complete series of handsome illustrations. An equal improvement exists in the mechanical execution of the work, rendering it in every respect a companion volume to the "Principles." careful study of the first edition, we have iiad no cause -to change on examining the second. This edition has undergone thorough revision by the au- thor ; many expressions have been modified, and a mass of new matter introduced. The book is got up in the finest style, and is an evidence of the progress of typography in our country. — Charleston Medical Journal and Review. We recommend it to both student and practitioner, feeling assured that as it now comes to us, it pre- sents the most satisfactory exposition of the modern doctrines of the principles of surgery to be found in any volume in any language. — N. Y. Journal of Medicine . No encomium of ours could add to the popularity of Miller's Surgery. Its reputation in this country ia unsurpassed by that of any other work, and, when taken in connection with the author's Principles of Surgery, constitutes a whole, without reference to which no conscientious surgeon would be willing to practice his art. The additions, by Dr. Sargent, have materially enhanced the value of the work. — Southern Medical and Surgical Journal. It is seldom that two volumes have ever made so profound an impression in so short a time as the " Principles" and the " Practice" of Surgery by Mr. Miller — or so richly merited the reputation they have acquired. The author is an eminently sensi- ble, practical, and well-informed man, who knows exactly what he is talking about and exactly how to talk it. — Kentucky Medical Recorder. The two volumes together form a complete expose 9f the present state of Surgery, and they ought to be on the shelves of every surgeon. — N. J. Med. Re- porter. By the almost unanimous voice of the profession, his works, both on the principles and practice of surgery have been assigned the highest rank. If we were limited to but one work on surgery, that one should be Miller's, as we regard it superior to aU others. — St. Louis Med. and Surg. Journal. The author distinguished alike as a practitioner and writer, has in this and his " Principles," pre- sented to the profession one of the most compl ete and reliable systems of Surgery extant. His style of writing is original, impressive, and engaging, ener- getic, concise, and lucid. Few have the faculty of condensing so much in small space, and at the same time so persistently holding the attention; indeed, he appears to make the very process of condensation a means of eliminating attractions. Whether as a text-book for students or a book of reference for practitioners, it cannot be too strongly recommend- ed. — Southern Journal of the Medical and Physical Sciences. MALGAIGNE (J. F.). OPERATIVE SURGERY, based on Normal and Pathological Anatomy. Trans- lated from the French, by Frederick Brittan, A. B., M. D. With numerous illustrations on wood. In one handsome octavo volume, of nearly six hundred pages. To express in a few words our opinion of IVTal- gaigne's work, we unhesitatingly pronounce it the We have long been accustomed to refer to it as one of the most valuable text-books in our library. — Buffalo Med. and Surg. Journal. Certainly one of the best books published on ope- rative surgery.— Edinburgh Medical Journal. very best guide in suro^ical operations that has come before the profession in any language. — Charleston Med. and Surg. Journal. MOHR (FRANCIS), PH. D., AND REDWOOD (TH EOPH I LUS). PRACTICAL PHARMACY. Comprising the Arrangements, Apparatus, and Manipulations of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, by Prof. William Procter, of the Philadelphia College of Pharmacy. In one handsomely printed octavo volume, of 570 pages, with over 500 engravings on wood. It is a book, however, which will be in the hands of almost everyone who is much interested in phar- maceutical operations, as we know of no other pub- lication so well calculated to fill a void long felt. — Medical Examiner. The book is strictly practical, and describes only manipulations or methods of performing the nume- rous processes the pharmaceutist has to go through, in the preparation and manufacture of medicines, together with all the apparatus and fixtures necea- sary thereto. On these matters, this work is very full and complete, and details, in a style uncom- monly clear and lucid, not only the more compli- cated and difficult processes, but those not less im- portant ones, the most simple and common. — Buffalo Medical Journal. The country practitioner who is obliged to dis- pense his own medicines, will find it a most valuable assistant. — Monthly Journal and Retrospect. 22 BLANCHARD & LEA'S MEDICAL MACLISE (JOSEPH), SURGEON. SURGICAL ANATOMY. Forming one volume, very large imperial quarto. With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con- taining one hundred and ninety Figures, many of them the size of life. Together with copiou.s and explanatory letter-press. Strongly and handsomely bound in extra cloth, being one of the cheapest and best executed Surgical works as yet issued in this country. Copies can be sent by mail, in five parts, done up in stout covers. ^ This great work being now concluded, the publishers confidently present it to the attention of the profession as worthy in every respect of their approbation and patronage. No complete work of the kind has yet been published in the English language, and it therefore will supply a want long felt in this country of an accurate and comprehensive Atlas of Surgical Anatomy to which the student and practitioner can at all times refer, to ascertain the exact relative position of the various portions of the human frame towards each other and to the surface, as well as their abnormal de- viations. The importance of such a work to the student in the absence of anatomical material, and to the practitioner when about attempting an operation, is evident, while the price of the book, not- withstanding the large size, beauty, and finish of the very numerous illustrations, is so low as to place it within the reach of every member of the profession. The publishers therefore confidently anticipate a very extended circulation for this magnificent work. of keeping up his anatomical knowlecige. — Medical Times. The mechanical execution cannot be excelled. — Transylvania Medical Journal. A work which has no parallel in point of accu- racy and cheapness in the English language. — JV. Y. Journal of Medicine. To all engaged in the study or practice of their profession, such a work is almost indispensable. — Dublin Quarterly Medical Journal. No practitioner whose means will admit should fail to possess it. — Ranking^s Abstract. Country practitioners will find these plates of ini- mense value. — N. Y. Medical Gazette. We are extremely gratified to announce to the profession the completion of this truly magnificeat work, which, as a whole, certainly stands unri- valled, both for accuracy of drawing, beauty of coloring, and all the requisite explanations of the subject in hand. — The New Orleans Medical and Surgical Journal. This is by far the ablest work on Surgical Ana- tomy that has come under our observation. W« know of no other work that would justify a stu- dent, in any degree, for neglect of actual dissec- tion. Jn those sudden emergencies that so often arise, and which require the instantaneous command of minute anatomical knowledge, a work of this kind keeps the details of the dissecting-room perpetually fresh in the memory. — The Western Journal of Medi- cine and Surgery. The very low price at which this work is furnished, and the beauty of its execiition, require an extended sale to compensate the publishers for the heavy expenses incurred. One of the greatest artistic triumphs of the age in Surgical Anatomy. — British American Medical Journal. Too much cannot be said in its praise ; indeed, we have not language to do it justice. — Ohio Medi- cal and Surgical Journal. The most admirable surgical atlas we have seen. To the practitioner deprived of demonstrative dis- sections upon the human subject, it is an invaluable companion. — N. J. Medical Reporter. The most accurately engraved and beautifully colored plates we have ever seen in an American book — one of the best and cheapest surgical works ever published. — Buffalo Medical Journal. It is very rare that so elegantly printed, so well iilustriiied, and so useful a work, is offered at so moderate a price. — Charleston Medical Journal. Its plates can boast a superiority which places khem almost beyond the reach of competition. — Medi- cal Examiner. Every practitioner, we think, should have a work of this kind within reach. — Southern Medical and Surgical Journal. No such lithographic illustrations of surgical re- gions have hitherto, we think, been given. — Boston Medical and Surgical Journal. As a surgical anatomist, Mr. Maclise has proba- bly no superior. — British and Foreign Medico-Chi- rurgical Review. Of great value to the student engaged in dissect- ing, and to the surgeon at a distance from the means MULLER (PROFESSOR J.), M. D. PRINCIPLES OF PHYSICS AND METEOROLOGY. Edited, with Addi- tions, by R. Eglesfeld Griffith, M. D. In one large and handsome octavo volume, extra cloth, with 550 wood-cuts, and two colored plates. The Physics of Mailer is a work superb, complete, I tion to the scientific records of this country may be unique : the greatest want known to English Science [ duly estimated by the fact that the cost of the origi- could not have been better supplied. The work is I nal drawings and engravings alone has exceeded tiie of surpassing interest. The value of this contribu- | sum of £2,000. — Lancet. MAYNE (JOHN), M. D., M. R. G. S. A DISPENSATORY AND THERAPEUTICAL REMEMBRANCER. Com- prising the entire lists of Materia Medica, with every Practical Formula contained in the three Britifih Pharmacopoeias. With relative Tables subjoined, illustrating, by upwards of six hundred and sixty examples, the Extemporaneous Forms and Combinations suitable for the different Medicines. Edited, with the addition of the Formulae of the United States Pharmacoposia, by R. Eglesfeld Griffith, M. D. In one 12mo. volume, extra cloth, of over 300 large pages. MATTEUCCI (CARLO). LECTURES ON THE PHYSICAL PHENOMENA OF LIVINa BEINGS. Edited by J. Pereira, M. D. In one neat royal 12mo. volume, extra cloth, with cuts, 388 pages. AND SCIENTIFIC PUBLICATIONS. 23 NEILL (JOHN), M. D., '•■ Surgeon to the Pennsylvania Hospital, &c.; and FRANCIS GURNEY SMITH, M. D., Professor of Institutes of Medicine in the Pennsylvania Medical College. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. Second edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of over one thorteand pages, with three hundred and fifty illustrations on wood. Strongly bound in leather, with raised bands. The speedy sale of a large impression of this work has afforded to the authors gratifying evidence oi the correctness of the views which actuated them in its preparation. In meeting the demand for a second edition, they have therefore been desirous to render it more worthy of the favor with which it has been received. To accomplish this, they have spared neither time nor labor in embo- dying in it such discoveries and improvements as have been made since its first appearance, and such alterations as have been suggested by its practical use in the class and examination-room. Considerable modifications have thus been introduced throughout all the departments treated of in the volume, but more especially in the portion devoted to the "Practice of Medicine," which has been entirely rearranged and rewritten. The authors therefore again submit their work to the profession, with the hope that their efforts may tend, however humbly, to advance the great cause of medical education. Notwithstanding the enlarged size and improved execution of this work, the price has not been increased, and it is confidently presented as one of the cheapest volumes now before the profession. In the rapid course of lectures, where work for the students is heavy, and review necessary for an examination, a compend is not only valuable, but it is almost a sine qua non. The one before us is, in most of the divisions, the most unexceptionable erf all books of the kind that we know of. The newest and soundest doctrines and the latest im- provements and discoveries are explicitly, though concisely, laid before the student. Of course it is useless for us to recommend it to all last course students, but there is a class to whom we very sincerely commend this cheap book as worth its weight in silver — that class is the graduates in medicine of more than ten years' standing, who have not studied medicine since. They will perhaps find out from it that the science is not exactly now what it was when they left it off. — The Stethoscope Having made free use of this volume in our ex- aminations of pupils, we can speak from experi- ence in recommending it as an admirable compend for students, and as especially useful to preceptors who examine their pupils. It will save the teacher much labor by enabling him readily to recall all of the points upon which his pupils should be ex- amined. A work of this sort should be in the hands of every one who takes pupils into his office with a view of examining them; and this isunquestionablj' the best of its class. Let every practitioner who has pupils provide himself with it, and he will find the labor of refreshing his knowledge so much facilitated that he will be able to do justice to his pupils at very little cost of time or trouble to himself. — TransyU vania Med. Journal. • NELIGAN (J. MOORE), M. D., M. R. I. A., &c. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. In one neat royal 12mo. volume, of 334 pages. .^^j OWEN (PROF. R.), ■'* Author of Lectures on Comparative Anatomy," '* Archetype of the Skeleton," &c. ON THE DIFFERENT FORMS OF THE SKELETON, AND OF THE TEETH. One vol. roj'-al 12mo., with numerous illustrations. {IVow Ready.) The name of the distinguished author is a sufficient guarantee that this little volume will prove a satisfactory manual and guide to all students of Comparative Anatomy and Osteology. The im- portance of this subject in geological investigations will also render this work a most valuable assistant to those interested in that science. PHILLIPS (BENJAMIN), F. R. S., &c. SCROFULA; its Nature, its Prevalence, its Causes, and the Principles of its Treatment. In one volume, octavo, with a plate. PANCOAST (J.), M. D., Professor of Anatomy in the Jefferson Medical College, Philadelphia, &c. OPERATIVE SURGERY; or, A Description and Demonstration of the various Processes of the Art ; including all the New Operations, and exhibiting the State of Surgical Science in its present advanced condition. Complete in one royal 4to. volume, of 380 pages of letter-press description and eighty large 4to. plates, comprising 486 illustrations. Second edition, improved. Blanchard & Lea having become the publishers of this important book, have much pleasure in oflering it to the profession. This excellent work is constructed on the model of the French Surgical Works by Velpeau and Mal- gaigne; and, so far as the English language is con- cerned, we are proud as an American to say that, OF ITS KIND IT HAS NO SUPERIOR. — N. Y. Journal of Medicine. PARKER (LANGSTON), Surgeon to the Queen's Hospital, Birmingham. THE MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRL MARY AND SECONDARY; comprisingtheTreatment of Constitutional and Confirmed Syphi- lis, by a safe and successful method. With numerous Cases, Formulae, and Clinical Observa- tions. From the Third and entirely rewritten London edition. In one neat octavo volume. {Now Ready.) ' j mux ](flLiv«iiii8-'tK>ow \o iiB dfli dsitiv; o) soila»»eq 24 BLANCHARD & LEA'S MEDICAL (Now Complete,) PEREIRA (JONATHAN), M. D., F. R. S., AND L. S. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. Third American edition, enlarged and improved by the author ; including Notices of most of the Medicinal Substances in use in the civilized world, and forming an Encyclopaedia of Materia Medica. Edited, with Additions, by Joseph Cakson, M. D., Professor of Materia Mediea and Pharmacy in the University of Pennsyivania. In two very large octavo volumes of 2100 pages, on small type, with over four hundred and fifty illustrations. Volume I. — Lately issued, containing the Inorganic Materia Medica, over 800 pages, with 144 illustrations. Volume II.— Now ready, embraces the Organic Materia Medica, and forms a very large octavo volume of 1250 pages, with two plates and three hundred handsome wood-cuts. The present edition of this valuable and standard work will enhance in every respect its well- deserved reputation. The care bestowed upon its revision by the author may be estimated by the fact that its size has been inci-eased by about five hundred pages. These additions have extended to every portion of the work, and embrace not only the materials aflbrded by the recent editions of the pharmacopoeias, but also all the important information accessible to the care and industry of the author in treatises, essays, memoirs, monographs, and from correspondents in various parts of the globe. In this manner the work comprises the most recent and reliable information respecting all the articles of the Materia Medica, their natural and commercial history, chemical and thera- peutical properties, preparation, uses, doses, and modes of administration, brought up to the present time, with a completeness not to be met with elsewhere. A considerable portion of the work which preceded the remainder in London, has also enjoyed the advantage of a further revision by the author expressly for this country, and in addition to this the editor, Professor Carson, has made whatever additions appeared desirable to adapt it thoroughly to the U. S. Pharmacopoeia, and to the wants of the American profession. An equal improvement will likewise be observable in every department of its mechanical execution. It is printed from new type, on good white paper, with a greatly extended and improved series of illustrations. Gentlemen who have the first volume are recommended to complete their copies without delay. The first volume will no longer be sold separate. When we remember that Philology, Natural His- tory, Botany, Chemistry, Physics, and the Micro- scope, are all brought forward to elucidate the sub- ject, one cannot fail to see that the reader has here a work worthy of the name of an encyclopedia of Materia Medica. Our own opinion of its merits is that of its editors, and also that of the whole profes- sion, both of this and foreign countries— namely, " that in copiousness of details, in extent, variety, and accuracy of information, and in lucid explana- tion of difficult and recondite subjects, it surpasses all other works on Materia Medica hitherto pub- lished." We cannot close this notice without allud- ing to the special additions uf the American editor, which pertain to the prominent vegetable produc- tions of this country, and to the directions of the United States Pharmacopcsia, in connection with all the articles contained in the volume which are re- ferred to by it. The illustrations have been increased, atid this edition by Dr. Carson cannot well be re- garded in any other light than that of a treasure which should be found in the library of every physi- cian. — New York Journal of Medical and Collateral Science, March, 1854. The third edition of his "Elements of Materia Medica, although completed under the supervision of others, is by far the most elaborate treatise in the English language, and will, while medical literatune is cherished, continue a monument alike honorable to his genius, as to his learning and industry. — American Journal of Pharmacy, March, 1854. The work, in its present shape, and so far as can be judged from the portion before the public, forms the most comprehensive and complete treatise on materia medica extant in the English language.— Dr. Pereira has been at great pains to introduce into his work, not only all the information on the natural, chemical, and commercial history of medi- cines, which might be serviceable to the physician and surgeon, but whatever might enable his read- ers to understand thoroughly the mode of prepar- ing and manufacturing various articles employed? either for preparing medicines, or for certain pur- poses in the arts connected with materia medica and the practice of medicine. The accounts of the physiological and therapeutic eflects of remedies are given with great clearness and accuracy, and in a manner calculated to interest as M^ell as instruct the reader.— TAe Edinburgh Medical and Surgical Journal. AJTT' PEASELEE (E. R.), M. D., Professor of Anatomy and Physiology in Dartmouth College, &c. HUMAN HISTOLOGY, in its applications to Physiology and General Pathology; designed as a Text-Book for Medical Students. With numerous illustrations. In one handsonie royal 12mo. volume. (Preparing.) The subject of this work is one, the growing importance of which, as the basis of Anatomy and, Phvsiology, demands for it a separate volume. The book will therefore supply an acknowledged deficiency in medical text-books, while the name of the author, and his experience as a teacher for the last thirteen years, is a guarantee that it will be thoroughly adapted to the use of the student. PIRRIE (WILLIAM), F. R. S. E., Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D., Demonstrator of Anatomy in the University of Pennsylvania, Surgeon to the Pennsylvania Hospital, &c. Li one very handsome octavo volume, of 780 pages, with 316 illus- (Just Issued.) trations. We know of no other surgical work of a reason- able size, wherein there is so much theory and prac- tice, or where subjects are more soundly or clearly taught. — The Stethoscope. There is scarcely a disease of the bone or soft parts, fracture, or dislocation, that is not illustrated by accurate wood-engravings. Then, again, every instrument employed by the surgeon is thus repre- sented. These engravings are not only correct, but really beautiful, showing the astonishing degree of perfaetion to which the art of wood- engraving has arrived. Prof. Pirrie, in the work before us, has elaborately discussed the principles of surgery, and a safe and effectual practice predicated upon them. Perhaps no work upon this subject heretofore issued is so full upon the science of the art of surgery. — Nashville Journal of Medicine and Surgery. One of the best treatises on surgery in the English language. — Canada Med. Journal. Our impression is, that, as a manual for student*, Pirrie's is the best work extant.— Western Med. and Surg. Journal. AND StJIENTIFia PUBLICATIONS. 25 RAMSBOTHAM (FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY", in reference to the Process of Parturition. Sixth American, from the last London edition. Illustrated with one hundred and forty-eight Figures, on fifty-five Lithographic Plates. In one large and heuidsomely printed volume, imperial octavo, with 520 pages. In this edition, the plates have all been redrawn, and the text carefully read and corrected. It is therefore presented as in every way worthy the favor with which it has so long been received. From Prof. Hodge, of ths University of Pa. To the American public, it is most vahiabie, from its intrinsic undoubted excellence, and as beiny the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout our country. We recommend the student who desires to mas- ter this difficult subject with the least possible trouble, to possess himself at once of a copy of this work. — American Journal of the Med. Sciences. It stands at the head of the long list of excellent obstetric w^orks published in the last few years in Great J3ritiiin, Ireland, and the Continent of Eu- rope. We consider this book indispensable to the library of every physician engaged in the practice of midwifery. — Southern Med. and Surg. Journal. When the whole profession is thus unanimous in placing such a work in the very first rank as regards the extent and correctness of all the details of the theory and practice of so important a branch of learning, our commendation or condemnation would be of little consequence; but regarding it as the most useful of all works of the kind, we think it but an act of justice to urge its claims upon the profession. — N. O. Med. Journal. RICORD (P.), IVl. D., Surgeon to the Hopital du Midi, Paris, &c. ILLUSTRATIONS OF SYPHILITIC DISEASE. Translated from the French, by Thomas F. Betton, M. D. With the addition of a History of Syphilis, and a complete Bib- liography and Formulary of Remedies, collated and arranged, by Paul B. Goddabd, M.D. With fifty large quarto plates, comprising one hundred and seventeen beautifully colored illustrations. In one large and handsome quarto volume. Blanchard & Lea having purchased the remainder of this valuable work, which was originally sold as a subscription book, are now prepared to offer it to the profession. It is universally known as one of the handsomest volumes as yet presented m this country, and as containing the only ex- tended and thorough series of illustrations on the subject. BY THE SAME AUTHOR. (NoW Ready.) A TREATISE ON THE VENEREAL DISEASE. By John Hunter, F. R. S. With copious Additions, by Ph. Ricord, M. D. Edited, with Notes, by Freeman J. Bumstead, M. D. In one handsome octavo volume, with plates. From the Translator's Preface. " M. Ricord's annotations to Hunter^s Treatise on the Venereal Disease were first published at Paris, in 1840, in connection with Dr. G. Richelot's translation of the work, including the contri- butions of Sir Everard Home and Mr. Babington. In a second edition, which has recently ap- peared, M. Ricord has thoroughly revised his part of the work, bringing it up to the knowledge of the present day, and so materially increasing it that it now constitutes full one-third of the volume. " This publication has been received with great favor by the French, both because it has placed within their reach an important work of Hunter, and also because it is the only recent practical work which M. Ricord has published, no edition of his Traite des Maladies vineriennes having appeared for the last fifteen years." Every one will recognize the attractiveness and value which this work derives from ihus presenting ihe 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 made public. The doctrinal ideas of M. Ricord, ideas which, if not universally adopted, are incontestably dominant, have heretofore only been interpreted by more or less skilful secretaries, sometimes accredited and sometimes not. In the notes to Hunter, the master substitutes him- self for his interpreters, and gives his original thoughts to the world, in a summary form it is true, but m a lucid and perfectly intelligible manner. In conclu- sion we can say that this is incontestably the best treatise on syphilis with which we are acquainted, and, as we do not often employ the phrase, we may be excused for expressing the hope that it may find a place in the library of every physician — Virginia Med. and Surg. Journal. BY THE SAME AUTHOR. LETTERS ON SYPHILIS, addressed to the Chief Editor of the Union Medicale. With an Introduction, by Amedee Latour. Translated by W. P. Lattimore, M. D. In one neat octavo volume. Blanchard & Lea are now the publishers of this valuable work. From the Translator's Preface. To those who have listened to the able and interesting lectures of our author at the Hopital da Midi, this volume will need no commendation; while to those who have not had the pleasure to which we allude, the book will commend itself by the truths it contains, told as they are in the same inimitable style in which M. Ricord delivers his clinical lectures. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON VENEREAL DISEASES. With a Thera- peutical Summary and Special Formulary. Translated by Sidney Doane, M. D. Fourth edition. One volume, octavo, 340 pages. 26 BLANCHARD & LEA'S MEDICAL RIGBY (EDWARD), M. D., (T Physician to the General Lying-in Hospital, &c. A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American Edition. One volume octavo, 422 pages. ROYLE (J. FORBES), M. D. MATERIA MEDIC A AND THERAPEUTICS; including the Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. With many new medicines. Edited by Joseph Carson, iVI. D., Professor of Materia Medica and Pharmacy ia the University of Pennsylvania. With ninety-eight illustrations. In one large octavo volume, of about seven hundred pages. This work is, indeed, a most valuable one, and will fill up an important vacancy that existed be- tween Dr. Pereira's most learned and complete system of Materia Medica, and the class of pro- ductions on the other extreme, which are neces- sarily imperfect from their small extent. — British and Foreign Medical Revieiv. SKEY (FREDERICK C), F. R. S., &,c. OPERATIVE SURGERY. In one very handsome octavo volume of over 650 pages with about one hundred wood-cuts. Its literary execution is superior to most surgical treatises. It abounds in excellent moral hints, and is replete with original surgical expedients and sug- gestions. — Buffalo Med. and Surg. Journal. With high talents, extensive practice, and a long experience, Mr. Skey is perhaps competent to the task of writing a complete work on operative sur- gery. — Charleston Med. Journal. We cannot withhold from this work our high com- mendation. Students and practitioners will find it an invaluable teacher and guide upon every topic con- nected with this department. — N. Y. Medical Ga^ zette. A work of the very highest importance — a w#trk by itself.— Loncfon Med. Gazette. SHARPEY (WILLIAM), M. D., JONES QUAIN, M. D., AND RICHARD QUAIN, F. R. S., &c. HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy, M. D. Complete in two large octavo volumes, of about thirteen hundred pages. Beautifully illustrated with over five hundred engravings on wood. 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. — Monthly 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 Engli.sh 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. Admirably calculated to fulfil the object for vvhkh it is intended. — Provincial Medical Journal. The most complete Treatise on Anatomy in the English language. — Edinburgh Medical Journal. There is no work in the English language to be preferred to Dr. Quain's Elements of Anatomy. — London Journal of Medicine. SMITH (HENRY H.), M. D., AND HORNER (WILLIAM E.), M. D. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, with about six hundred and fifty beautiful figures. late the student upon the completion of this Atlas, as it is the most ccmvenient 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 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- to the country as to be flattering to our national pride. — American Medical Journal. In SARGENT (F. W.), M. D. ON BANDAaiNO AND OTHER POINTS OF MINOR SURGERY. one handsome royal 12mo. volume of nearly 400 pages, with 128 wood-cuts. The very best manual of Minor Surgery we have l We have carefully examined this work, and find it Been;an American volume, with nearly four hundred [well executed and admirably adapted to the use of Besides the subjects usually embraced pages of good practical lessons, illustrated by about one hundred and thirty wood-cuts. In these days o( '' trial," when a doctor's reputation hangs upon a clove hitch, or the roll of a bandage, it would be well, perhaps, to carry such a volume as Mr. Sar- gent's always in our coat-pocket, or, at all events, to listen attentively to his instructions a$ home. — Buffalo Med. Journal. the student. in works on Minor Surgery, there is a short chapter on bathing, another on anajsthetic agents, and an appendix of formulae. The author has given an ex- cellent work on this subject, and his publishers have illustrated and printed it in most beautiful style. — The Charleston Medical Journal. STANLEY (EDWARD). A TREATISE ON DISEASES OF THE BONES. extra cloth, 286 pages. In one volume, octavo, AND SCIENTIFIC PUBLICATIONS. 27 STILLE (ALFRED), M. D. PRINCIPLES OF THERAPEUTICS. In one handsome volume. ^Preparing.) SIMON (JOHN), F. R. S. GENERAL PATHOLOGY, as conducive to the Establishment of Rational Principles for the Prevention and Cure of Disease. A Course of Lectures delivered Thomas's Hospital during the summer Session of 1850. In one neat octavo volume. at St SMITH (TYLER W.), M. D., Lecturer on Obstetrics in the Hunterian School of Medicine. ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OP OBSTETKICS. In one large duodecimo volume, of 400 pages. 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, Vf\\h. splendid colored plates. To match "Maclise's Surgical Anatomy." {Preparing.) SOLLY (SAMUEL), F. R. S. THE HUMAN BRAIN; its Structure, Physiology, and Diseases. With a Description of the Typical Forms of the Brain in the Animal Kingdom. From the Second and much enlarged London edition. In one octavo volume, with 120 wood-cuts. 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 Physiolog>\ 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. In one thick volume, small octavo, of about seven hundred pages, with 679 illustrations on wood. Suitable for the higher Schools and private students. {Now Ready.) This volume, as its title shows, covers nearly all the sciences, and embodies a vast amount of informa- tion for instruction. No other work that we have seen presents the reader with so wide a range of ele- mentary knowledge, with so full illustrations, at 90 cheap a rate. — Silliman-s Journal^ Nov. 1853. TAYLOR (ALFRED S.), M. D., F. R. S., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. MEDICAL JURISPRUDENCE. Third American, from the fourth and improved English Edition. With Notes and References to American Decisions, by Edward Hartshorne, M. D. In one large octavo volume, of about seven hundred pages, {Just Issued.) We know of no work on Medical Jurisprudence which contains in the same space anything like the same amount of valuable matter .—JV. Y. Journal of Medicine. The American editor has appended several im- portant facts, the whole constituting by far the best, most reliable, and interesting treatise on Medical Jtrrisprudence, and one that we cannot too strongly recommend to all who desire to become acquainted with the true and correct exposition of this depart- ment of medical literature. — Northern Lancet. No work upon the subject can be put into the hands of students either of law or medicine which will engage them more closely or profitably ; and none could be offered to the busy practitioner of either calling, for the purpose of casual or hasty reference, that would be more likely to afford the aid desired. We tlierefore recommend it as the best and safest manual for daily use. — American Journal of Medical Sciences. We have heretofore had reason to refer to it in terms of commendation, and need now only state that, in the edition before us, the author has com- pletely revised the whole work, making many addi- tions and alterations, and brought it fully up to the present state of knowledge. The task of the Ameri- can editor has been to present all the important facts and cases that have recently occurred in our own country, bearing on the subjects treated of. No better work can be placed in the hands of the physician or jurist. — St. Louis Medical and Surgical Journal. BY THE SAME AUTHOR. ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND JVIEDICINE. Edited, with Notes and Additions, by R. E. Griffith, M. D. In one large octavo volume, of 688 pages. One of the most practical and trustworthy works on Poisons in our language. — Western Journal of Medicine. The most elaborate work on the subject that our literature possesses. — British and Foreign Medico- Chirurgical Review. It contains a vast body of facts, which embrace ail that is important in toxicology, all that is ttecessary to the guidance of the medical jurist, and all that can be desired by the lawyer, — Medico- Chirurgical Review. It is, so far as our knowledge extends, incompa- rably the best upon the subject; in the highest de- gree creditable to the author, entirely trustworthy, and indispensable to the student and practitioner. — JV. Y. Annalist THOMSON (A. T.), M. D., F. R. S., &c. DOMESTIC MANAGEMENT OF THE SICK ROOM, necessary in aid of Medical Treatment for the Cure of Diseases. Edited by R, E. Griffith, M. D. In one large royal 12mo. volume, with wood-outs, 360 pages. (NMMil i,U 3$ B L AN C H A R D & LEA' S Mfel) I C A L TOMES (JOHN), F. R. S. A MANUAL OF DENTAL PRACTICE. Illustrated by numerous engravings on wood. In one handsome volume. {Preparing.) TODD (R. B.), M. D., AND BOWMAN (WILLIAM), F. R. S. PHYSIOLOaiCAL ANATOMY AND PHYSIOLOaY OF MAN. With numerous handsome wood-cuts. Paris I, II, and III, in one octavo volume, 552 pages. Part IV will complete the work. The distinguishing peculiarity of this work is, that the authors investigate for themselves every fact asserted ; and it is the immense labor consequent upon the vast number of observations re- quisite to carry out this plan, which has so long delayed the appearance of its completion. Tlie first portion ot Part IV, with numerous original illustrations, was published in the Medical News and Library for 1853, and the completion will be issued immediately on its appearance in London. Those who have subscribed since the appearance of llie preceding portion of the work can haw the three parts by mail, on remittance of $2 50 to the publishers. TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. VOLUME VI, for 1853, large 8vo., of 870 pages, with numerous colored platea and wood-cuts. Also to be had, a few sets of the Transactions from 1848 to 1853, in six large octavo volumes, price $25. These volumes are all published by and sold on account of the Association. WATSON (THOMAS), M.D., &c. LECTURES ON THE PHINCIPLES AND PRACTICE OF PHYSIC. Third American, from the last London edition. Revised, with Additions, by D. Francis Condie, M. D., author of a "Treatise on the Diseases of Children," &c. In one octavo volume, of nearly eleven hundred large pages, strongly bound with raised bands. 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 vxjry 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. Lxmis Med. Journal. Confessedly one of the very best works on tb« principles and practice of physic in the English or any other language. — Med. Examiner. Asa text-book it has no equal ; as a compendium of pathology and practice no superior.— iVet^" York Annalist. We know of no work better calculated for being 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. One of the most practically useful books that ever was presented to the student. — N. Y. Med. Journal, 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, large royal 12mo., 512 pages. We consider this as the ablest work in the En- 1 the author being the first stethoscopist of the day.— gfieh language, on the subject of which it treats; | Charleston Medical Journal. WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASE,S. published under the authority of the London Society for Medical Observation, handsome volume, royal 12mo , extra cloth. {Just Issued.) In one very We hail the appearance of this book as the grand desideratum. — Charleston Medical Journal. This is truly a very capital book. The whole medical world will reap advantages from its publi- cation. The medical journals will soon show its influence on the character of the " Reports of Cases" which they publish. Drs. Ballard and Walshe have given to the world, through a small but useful medical organization, a cheap but invaluable book. We do advise every reader of this notice to buy it and use it. Unless he is so vain as to imagine him- self superior to the ordinary human capacity, he wiW in six months tee its inestimable advantages.— Stethoscope. WILDE (W. R.), 'OPTm • Surg-eon 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, with illustrations. {Now Ready.) So little is generally known in this country concerning the causes, symptoms, and treatment of aural affections, that a practical and scientific work on that subject, from a practitioner of Mr. Wilde's great experience, cannot fail to be productive of much benefit, by attracting attention lo this obscure class of diseases, which too frequently escape attention until past relief The im- mense number of cases which have come under Mr. Wilde's observation for many years, have afforded him opportunities rarely enjoyed for investigating this branch of medical science, and hia work may therefore be regarded as of the highest authority. 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 \% , not written to supply the cravings of popular patro- nage, but it is wholly addressed to tlie profession, and bears on every page the impress of the reflections of a sagacious and practical surgeon.— Va. Surg, and Med. Journal. AND SCIENTIFIC PUBLICATIONS. f9 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. iM., M. D. With two hun- dred and fifty illustrations. Beautifully printed, in one large octavo volume, of nearly six hun- dred pages. 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 Medittd 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. THE DISSECTOR; or, Practical and Surgical Anatomy. Modified and Re- arranged, by Paul Beck Goddard, M. U. A new edition, with Revisions and Additions. In one large and handsome volume, royal 12mo., with one hundred and fifteen illustrations. In passing this work again through the press, the editor has made such additions and improve- ments as the adv^ance of anatomical knowledge has rendered necessary to maintain the work in the high reputation which it has acquired in the schools of the United States, as a complete and faithftil guide to the student of practical anatomy. A number of new illustrations have been added, espe- cially in the portion relating to the complicated anatomy of Hernia. In mechanical execution tb« work will be found superior to former editions. ON DISEASES OF THE BY THE SAME AUTHOR. SKIN. Third American, from the third London edition. In one neat octavo volume, of about five hundred pages, extra cloth. (J its t Is sited.) Also, to be had done up with fifteen beautiful steel plates, of which eight are exquisitely colored ; representing the Normal and Pathological Anatomy of the Skin, together with accurately colored delineations of more than sixty varieties of disease, most of them the size of nature. The PlatefS are also for sale separate, done up in boards. The increased size of this edition is sufficient evidence that the author has not been content with a mere republication, but has endeavored to maintain the high character of his work as the standard text-book on this interesting and difficult class of diseases. He has thus introduced such new matter as the experience of the last three or four years has suggested, and has made such alterations as the progress of scientific investigation has rendered expedient. The illustrations have also been materially augmented, the number of plates being increased from eight to sixteen. The "Diseases of the Skin," by Mr. Erasmus Of these plates it is impossible to speak too highly. The representations of the various forms of cuta- neous disease are singularly accurate, and the color- ing exceeds almost anything we have met with in ptnnt of delicacy and finish. — British and Foreign Medical Review. by Mr. Wilson, may now be regarded as the standard work in that department of medical literature. The plates by wliich this edition is accompanied leave nothing to be desired, so far as excellence of delinea- tion and perfect accuracy of illustration are con- eorned. — Medico-Chirurgical Review. BY THE SAME AUTHOR. ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. In one small octavo volume, beautifully printed, with four exqui- site colored plates, presenting more than thirty variettes of syphilitic eruptions. Dr. Wilson's views on the general subject of connection with its transmissibility, pathology and Syphilis appear to us in the main sound and judi- sequelae. His facts and references will, we are satis- cious, and we commend the book as an excellent fied, be received as decisive, in regard to many monograph on the subject. Dr. Wilson has pr^- questiones vexata;. They appear to us entitled to sented us a very faithful and lucid description of notice at some length. — Medical Examiner. Syphilis and has cleared up many obscure points in BY THE SAME AUTHOR. (NoW Read?/.) HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- tion and Management. Second American, from the fourth London edition. One neat voluro«, royal 12mo., with numerous illustrations. Copies can be had done up in paper covers for mailing, price 75 cents. WHITEHEAD (JAMES), F. R. C. S THE CAUSES AND TREATMENT being the Result of an Extended Practical Inq Second American Edition. In &-C, of the Uterus. The simple title of this work gives a very imper- fect idea of its contents. The subject of sterility occupies a mere fraction of space, and upwards of one-half of the whole volume is taken up with an elaborate account of menstruation as a physiological process, and of the disorders which its deviations from health are apt to produce. — Medical Chirurg. Review . Such are the adyances made from year to year in OF ABORTION AND STERILITY; uiry into the Physiological and Morbid Conditions one volume, octavo, 368 pages. {Now Ready.) this department of our profession, thnt the practi- tioner who does not consult the recent works on the complaints of females, will soon find himself in tb« rear of his more studious bretiiren. This is one of the works which must be studied by those who would know what the present state of our kmnvledg« is respecting the causes and treatment of abortion and sterility. — The Western Journal of Medicin4 cmd Surgery. 30 BLANCHARD & LEA'S MEDICAL WEST (CHARLES), M. D., Physician to the Hospital for Sick Children, &c. LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. Second American, from the Second and Enlarged London edition. In one volume, octavo, of nearly five hundred pages. {Now Ready.) From the Preface to the Second Edition. In the preparation of the second edition of these Lectures, the whole work has been carefully revised. A few formulae have been introduced and a minute alphabetical index has been appended while additions amounting altogether to fifty pages, have been made, wherever I felt that more extended observation, or more careful reflection had enabled me to supply some of those deficiencies which I am well aware, are still far too numerous. The work now contains the result of 640 observations, and 199 post-mortem examinations, chiefly made among 16,276 children who came under my notice during the ten years of my connection with the Children's Infirmary in Lambeth. 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 manj' respects the best we possess on diseases of children. The extracts we have given will, we hope, satisfy our readers of its value ; and yet in all candor \ve must say that they are even inferior to some other parts, the length of which prohibited our entering upon them. That the book will shortly be in the hands of most of our readers we do not doubt, and it will give us much pleasure if our strong recommend- ation of it may contribute towards the result.— TAe Dtiblin Quarterly Journal of Medical Science. Dr. West has placed the profession under deep ob- ligation by this able, thorough, and finished work upon a 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, for the benefit of suc- ceeding travellers, which will never be extinguished. Not the least captivating feature in this admirable performance is its easy, conversational style, w^hich acquires force from its very simplicity, and leaves an impression upon the memory, of the truths it conveys, as clear and refreshing as its own purity. The author's position secured him extraordinary fa- cilities for the investigation of children's diseases, and his powers of observation and discrimination have enabled him to make the most of these great advantages. — Nashville Medical Journal. BY THE SAME AUTHOR. [NoiV Ready.) AN ENQUIRY INTO THE PATHOLOaiCAL IMPORTANCE OF ULCER- ATION OF THE OS UTERI. Being the Croonian Lectures for the year 1854. In one neat octavo volume, extra cloth. 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