)||Pi,il;l.!,.a„,,v liilSpiiiilil :': if iiiii&- 4^1 ■;!;';; if;:; THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF SAN FRANCISCO COUNTY MEDICAL SOCIETY ON DISEASES PECTJLIAK TO WOMEN, INCLUDING DISPLACEMENTS OF THE UTERUS. BY HUGH L. HODGE, M.D., EMERITCS PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN IN THE I'SIVERSITT OF PENNSYLVANIA. 'NULLIUS ADDICTUS JURARE IN VERBA MAGISTRI." WITH ILLUSTRATIONS. SECOND EDITION, REVISED AND ENLARGED. PHILADELPHIA: HEIl^RY O. LEA 1868. Entered according to Act of Congress, in the year 1860, by HUGH L. HODGE, M.D., in the Office of the Clerk of the District Court of the United States in and for the Eastern District of the State of Pennsylvania. PHILADELPHIA: COLLINS, PEINTKR, 705 JAYNE STREET Biomedical Uknry WP /?t8 TO THE ALUMNI UNIVERSITY OF PENNSYLVANIA, 598233 PREFACE TO THE SECOND EDITION. The former edition of this work was prepared main]j for the use of the Alumni of the University of Pennsylvania. The ob- ject of the author was to present more at length and in detail those views on the nervous diseases of women which he had for many years taught in the halls of the University. His opinions were formed chiefly from his own observations and reflections during an extensive practice of many years. They were detailed without much reference to the opinions of others, under the im- pression that thus the views of the author might be more dis- tinctly stated, and that their value could be more readily compre- hended. This plan has been maintained in the present edition, although there have been many additions made to the original text, the result of further observation and reflection, and of the study of many of those excellent works which have been so rapidly issued from the press by authors whose opinions and practice are held in deserved estimation. As the subject of metritis in its various modifications and com- plications has given rise to numerous discrepancies, both in theory and practice, the chapter on uterine inflammation has been greatly altered and enlarged. The object of the author was not merely to present what he deems a more correct theory and practice in inflammatory diseases of the uterus, but also to insist that a very largQ proportion of the so-called cases of metritis are in reality but examples of irritation, where inflammation has subsided, or where it has actually never existed. Indeed, the chief object of this whole work is to exemplify the nature, consequences, and treatment of nervous irritation as distinct from inflammation. In carrying out this idea, the author has endeavored to show that the nervous diseases of women, often grouped under the word VI PREFACE TO THE SECOND EDITION. " hysteria," can be generally traced to the pelvic viscera, and espe- cially to the uterus. The causes of such disturbances, whether centric or eccentric, are exceedingly diversified — the nervous sus- ceptibility of women being easily disturbed by innumerable moral and physical excitements. Experience has convinced the author that not only is the uterus involved in most of these complaints, but that its disturbances are very frequently dependent upon dis- placements of the organ, however induced. Hence, special atten- tion has been given to this subject of displacements of the uterus, the more so, as in the opinion of the author, these displacements of the uterus are of great importance, and have, as he must think, been seldom treated on scientific principles. One part of this work is therefore devoted to this subject. The third part is occupied with sedation, a condition of the tissues in perfect contrast with that of nervous excitement or irritation. Prefixed to the present edition of this work is an introductory chapter, in which the author has endeavored to portray the opinions of many high authorities on the various subjects of ir- ritation, congestion, and inflammation, with their sequelae and treatment, in contrast to those here advocated. In this manner the difference of opinion and practice may be more distinctly ob- served, and it is hoped some valuable truths may be elicited. An enlargement in the size of the page has admitted of these various additions without unduly increasing the bulk of the volume. Numerous illustrations from the skilful pencil of Mr. Baxter, respecting the character and treatment of displacements of the uterus will, it is trusted, greatly assist the student in comprehend- ing the nature of such deviations and their proper management. The drawings represent the organs of one-half their natural size. Tbey have been arranged and lettered upon the supposition that the patient is recumbent, on the back. By turning the book, the relative position of the tissues and organs, in the erect pos- ture, can be perceived. PUILADELPHIA, August, 1868. To CHARLES D. MEIGS, M. D., PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN IN THE JEFFERSON MEDICAL COLLEGE. Deae Doctor: — I embrace the first public opportunity of acknow- ledging the affectionate and complimentary letter, pre- fixed to your work on the Diseases of Women. Be assured that I fully reciprocate your kind feelings. It could not be otherwise, as we were indeed instructed by the same Alma Mater, and have toiled together for upwards of forty years in the arduous and responsible duties of our profession. The chain of our friendship has never been broken, or even sullied. You politely urged me to make a "s^'^/^" for posterity; I have at last ventured to make one — in the form of the work now sent to you. I could not, dear Doctor, write as you have done, not having your peculiar spirit ; and I may, perhaps, fall under the lash of your criticism upon our fathers in medicine, whose " dulness and jargon" you assign as a reason why they are not more studied and appreciated. I have at least, however, followed your examj^le of writing, currente calamo, in my own manner — simple and dull it may be — but with a sincere desire to contribute the results of my observations and reflections towards the improvement of medicine. I know well that our productions — each characteristic of its author — difter exceedingly in theory and in practice ; but, nevertheless, Vlll TO CHAKLES D. MEIGS, M.D. the student who examines each book may discover the truth more clearly, and be prepared to render such truth more efficient. The very opposition, which may be per- ceived in the vicAVS of experienced men in the profession, is often beneficial — ex coUisione scintilla. Should this be the result, we shall both rejoice. Truth is our object — that truth which is practical, and which will increase the efficiency of our beloved science in alleviating the sufferings of our fellow-beings. Priiicipia non homines is our motto. That you, dear friend, may be long spared in health and strength, to carry on your philanthropic labors, is the prayer of Yours, most truly and respectfully, HUGH L. HODGE. November 1, 1860. CONTENTS. Dedication . Preface Letter to Dr. Meigs Introdoction PAGE iii V vii 33 PART I. DISEASES OF IRRITATION. CHAPTER I. NERVOUS IRRITATION AND ITS CONSEQUENCES. Definitions and illustrations ...... . 69 Irritability- . 70 Organic and nervous irritation . 75 Congestion . . 76 Passive . . 76 Active . . 77 Inflammatory or organic 77 Simple or nervous . 77 Neuralgia 84 Vital power . 88 Ansemia 93 Toxicaemia . 95 General conclusions 96 CHAPTER II IRRITABLE UTERUS. Definition .... Opinions of pathologists Supposed diflBculty of treatment Neuralgia, hysteralgia, etc. . Irritable diseases really physical ailments All pain is nervous irritation 99 100 101 101 101 104 CONTENTS. CHAPTER III, LOCAL SYMPTOMS OF IRRITABLE UTERUS. PAGE Pain and distressing sensations ...... 105 Aggravated by motion . 107 Aggravated by menstruation, etc. . 109 Simple dysmenorrbcea . . 109 Congestion .... . 113 Hypertrophy . . 115 Menorrhagia and hsemorrhagia . 117 Leucorrhcea . . 118 Functional leucorrhcea . . 119 Inflammatory leucorrhcea . 122 Dysmenorrhoea . 122 Congestive dysmenorrhoea . 122 Mechanical dysmenorrhoea . 123 Membranous dysmenorrhoea. . 126 CHAPTER lY LOCAL SYMPTOMS OF IRRITABLE UTERUS — COnt imied. COMPLICATIO NS. Inflammation .... ... 130 Metritis ..... 130 Cervical endometritis . 133 Cervico-metritis 137 Strictures of the cervix . 138 Corporeal endometritis 139 Corporeal metritis 140 Pelvic peritonitis 147 Irritability after inflammation 151 Errors in theory and practice 151 Tractability of these inflammations . 154 Treatment of metritis and its varieties 156 General conclusions . 165 Tumors and other complications . 166 CHAPTER V GENERAL SYMPTOMS OF IRRITABLE UTERUS. Cerebro-spinal irritations Spinal irritation Cerebral irritation Languor 168 168 169 171 CONTENTS. XI Irritations along particular nerves .... Hyperesthesia of the skin .... Symptoms vary, and may be confined to one side of the body Cerebral disturbances ..... Convulsions ...... Delirium ...... Intellectual and moral disorders PAliE . 172 . 173 . 174 . 174 . 175 . 175 . 176 CHAPTER VI. GENERAL SYMPTOMS OP IRRITABLE UTERUS — COntimied. REFLEX INFLUENCES OF CEREBRAL AND SPINAL IRRITATION. Sympathy and reflex action External organs Internal organs Pharynx Larynx Organs of the chest . Respiratory function Coughs Aphonia Heart Mammae Viscera of the abdomen Liver Stomach Tympanites . Intestines Kidneys . Organic life sometimes involved 181 182 183 183 184 184 184 185 186 187 188 189 189 190 191 196 199 200 CHAPTER VII progress and results of irritable uterus. Irritable rectum .... Irritable vulva and vagina (vaginismus) Irritable bladder and urethra Irritations and enlargements of the ovaries Irritations of lymphatic glands Irritations of the pelvic nerves Conclusions .... 206 208 211 215 219 221 222 Xll CONTENTS. CHAPTER YIII CAUSES AND PATHOLOGY OF IRRITABLE DISEASES. Predisposing causes Nervous temperament Rheumatism and gout The parturient state Displacements of the uterus Climate General conclusions Exciting causes Inflammatory congestion Parturition Over-lactation . . . Nimia Venus Mental and moral excitements Cold .... Great muscular effort Pressure Diseases of the uterus Obstructions, partial or complete, of Irritations of other organs . General conclusions Pathology Diagnosis .... Prognosis .... the cervix uteri CHAPTER IX TREATMENT OF IRRITABLE UTERUS Removal or Palliation of the cause Congestions of the uterus Acute inflammation Chronic inflammation Enlargements Hypertrophy Induration General conclusions . Rheumatic or gouty irritations Parturient state Lactation CONTEXTS. XI 11 Indulgence of the appetites Excitement of the mind Cold Displacements of the uterus Sj'mpathetic Disturbances General remarks PAGE 255 257 257 257 258 258 CHAPTER X. TREATMENT OF IRRITABLE UTERUS — continued. Hygienic measures . 263 Food . . . . . 263 Laxatives . 264 Tonics . 264 Fresh and pure air . . 266 Water . 266 Warm water baths . 267 Cold water baths . 268 Exercise and rest . 270 Conclusions . . 274 Medicinal agents . • 275 Acute cases . . 275 Loss of blood . 275 Revulsives . 276 Narcotics . 276 Chronic cases . 277 Loss of bipod . 277 Warm water . 277 Cold water . 278 Narcotic applications . 279 Applications of nitrate of silvei . 280 Mechanical measures . 281 General remarks . . 281 CHAPTER XI TREATMENT OF THK UUMJr'LlUAXiUi.Na uj; itiriiiAisuEj Menstrual disturbances ..... Ui.£itVU>3. . 284 Dysmenorrhoea . . . • . . 284 During the interval .... . 284 During the paroxysm .... . 288 Menorrhagia ...... . 289 Removal of the local irritation . . 290 Palliative measures .... . 294 XIV CONTENTS, Leacorrhcea • . . . Removal of the irritation Palliative measures Infi^mmation .... Acute inflammatioa Chronic inflammatioa General measures and local applications Eemoval of the irritation Rheumatic and gouty affections . PA consistent witli the welfare and comfort of the individual ; any material departure from it must be regarded as unnatural, and may sooner or later cause discomfort, or positive mischief. Such deviations are usually termed disijlacements of the uterus. VARIETIES. There are several varieties of displacements, which have been well and systematically arranged under four general heads or divisions, viz.. Prolapsus, Anteversio, Retroversio, and Procidentia Uteri. Each variety, with its complications, should be well de- fined and clearly comprehended. No allusion is here made to lateral and upward displacements, as they will be noticed among the complications arising from pelvic tumors. Prolapsus. — By prolapsus uteri should be understood the simple descent of the organ, so that the extremity of the neck of the uterus impinges unnaturally on the posterior wall of the vagina, and yet the axis of the uterus does not materially depart from its parallelism with the axis of the superior strait. It em- braces, therefore, merely those cases of displacement where the fundus continues to point towards the linea alba. If the top or fundus be anywhere between the bones of the pubis and the pro- montory of the sacrum, without pointing against the os pubis in front or the sacrum posteriorly, and the neck presses firmly on the bottom of the pelvis, it is a case of prolapsus. The uterus may be near to the pubis, or, far back, near to the sacrum ; but PROLAPSUS OF THE UTERUS, 331 PROLAPSUS. PROLAPSUS WITH FLEXION, 332 VARIETIES OF DISPLACEMENTS OF THE UTERUS. the top still points upwards, and the small intestines fall in front and also behind the organ, maintaining essentially its parallelism with the axis of the superior strait. "We have known some cases of " falling of the womb," in which the orifice of the vagina seemed to be obstructed by the neck of the uterus — so near was it to the body of the pubis, with the anterior part of the neck opposite the orifice of the vagina, and the OS uteri resting on the internal surface of the perineum. In other cases of prolapsus, the anterior wall is so far removed from the symphysis pubis, as to demand the whole length of the index finger, to reach the front of the uterus. Comjjlications. — The degree of prolapsus must vary according to the degree of relaxation, or yielding of the ligaments, and the weight and pressure from above. Not unfrequently, therefore, some change is effected in the form of the uterus, although its tissue is naturally very firm, by the force with which it is pressed against the rectum and perineum. Sometimes, the extremity of the cervix is flattened; more generally, the anterior lip of the os uteri seems to be prolonged, and the posterior lip flattened. Still more frequently, there is a bending of the neck of the uterus, so that, while the proper direction of the body is still maintained, there is an alteration in that of the inferior portion of the cervix, the OS uteri looking forward to the orifice of the vagina, instead of towards the coccyx. This is now termed " flexion" of the womb, " flexio uteri," or more strictly, it \q prolapsus with flexion. Hence, the simple word " flexion," should always be associated with the idea of descent of the womb, so great as to cause a bending of its tissue. It is a decided case of prolapsus, with this complication. AXTEVEESION. — Anteversio uteri is the falling forward of the fundus to such a degree, that it impinges against the bladder and pubis; while the os uteri points toward the lower or middle portion of the sacrum, in proportion to the descent of the fundus behind the symphysis. If this description be correct, this variety of displacement is comparatively rare; for, although the fundus is often found inclining forward to a considerable degree, yet, as far as we have observed, no morbid symptoms have resulted, unless it points towards the pubis. Hence, to these last cases the word should be restricted. In anteversion of the uterus, the ANTEVERSION OF THE UTERUS. •N, 383 AXTEVEKSION, ANTEVERSION WITH FLEXMON, 334 VARIETIES OF DISPL A CEMEXTS OF THE UTERUS. pressure of the small intestines seems to be, almost exclusively, on the posterior surface of the organ; and hence every muscular effort in standing, straining, etc., must serve to depress the fundus more and more, and thus aggravate the distress of the patient. Complication. — These cases are often complicated with flexion of the neck of the uterus, so that while the fundus and body are far forward, as in common cases of anteversion, the neck may be ' in situ naturali,\hQ os uteri pointing towards the coccyx, or even, if the flexion be still greater, towards the anterior portion of the perineum. This is " anteversion with flexion^'''' or more shortly, "anteflexion of the uterus." To form a correct diagnosis requires attention, as on a careless j examination, the neck being found in its proper position, the' practitioner may not notice the displacement of the fundus, and the flexion in the neck. Anteflexion must arise from great pressure on the posterior part of the body of the uterus, while the ascent of the lower ex- tremity, towards the hollow of the sacrum is resisted by the weight of the intestines behind, by the attachments of the cervix to the vagina, and to the pelvic fascia. Retroversion. — Retroversio uteri is the turning back of the fundus into the concavity of the sacrum, and therefore includes all those cases in which the fundus is below, or underneath the promontory of the sacrum. There may be, therefore, various degrees or stages of retroversion, according to the position of the fundus, whether pointing towards the upper, middle, or lower portions of the sacrum, or pressing on the os coccygis, or peri- neum. In these last it is " complete" retroversion ; in the former, "partial" or "incomplete" retroversion. Of course, in uncompli- cated cases, the degree of displacement of the os uteri corre- sponds to that of the fundus, pointing either towards the peri- neum or the OS vaginae, in partial retroversions, and towards the pubis, in complete retroversions of the organ. The great peculiarity of retroversion is, that the weight of the intestines, and the pressure, therefore, from the contraction of the muscular walls of the abdomen, are received directly on the ante- rior surface of the uterus ; and this gradually, but almost certainly, increases the displacement on every exertion of the patient. It is thus distinguished from prolapsus, in which the intestines fall EETROVEESION OF THE UTERUS. 335 RETROVEKSIOX. PARTIAL RETROVERSION. 336 VARIETIES OF DISPLACEMENTS OF THE UTERUS. around the uterus, posteriorly and anteriorly, serving to maintain the parallelism of its axis with that of the superior strait. It also differs, in this respect, from anteversion, in which the intestines press on the posterior surface of the organ, and tend to push the fundus still further forward. In anteversion and retroversion, there is a displacement of the longitudinal axis of the womb, which is no longer parallel to the axis of the superior strait, bat becomes oblique to this axis, crossing it at an angle, which varies according to the degree of displacement. In retroversion, there- fore, the long axis of the womb may be sometimes coincident with the axis of the inferior strait; sometimes with that of the vagina; and sometimes even with that of a line from the lower part of the sacrum to the bodies of the pubis, that is, nearly parallel with the coccy-pubic or antero-posterior diameter of the inferior strait. Com} )li cat ion. — Eetroversion of the uterus is, however, very frequently complicated with "flexion" at the cervix. This is retroversion with flexion^ or "retroflexion" of the uterus. Some- times, the bending of the neck is very regular; but, not unfre- quently, it is abrupt, well marked, and usually towards the upper third of the cervix. In these cases of retroflexion, the womb is so nearly of the form of the chemist's retort, that we formerly called it " the retort-uterus." Flexion of the neck often renders the diagnosis of retroversion difficult. For example, the os and cervix may be perfectly in situ, yet the fundus be below the promontory, and perhaps even at the lower extremity, of the sacrum, according to the degree of flexion which exists in the neck. There may be great displacement of the body of the uterus, with all its bad consequences, and yet no displacement of the cervix. If, however, the fundus be low down, at or near the perineum, there is usually also some devia- tion of the neck ; so that the os uteri will generally point towards the orifice of the vagina, instead of towards the coccyx — its nor- mal direction — or towards the symphysis pubis, as in simple cases of retroversion. The causes of flexion in cases of retroverted uterus, are analo- gous to those of anteflexion, namely, the resistance offered by the attachments of the vagina, and the pelvic fascia, at the cervix, and by the pressure of the intestines and of the bladder. All these have a tendency to prevent the ascent of the neck behind -RETROVERSION WITH FLEXION, 337 KETKOVERSION WITH FLEXION. PARTIAL KETKOVEKSION, WITH FLEXION. 22 338 VARIETIES OF DISPLACEMENTS OF THE UTERUS. the pubis, while the fundus is forced down along the concavity of the sacrum. Procidentia. — "Bj procidentia uteri is to be understood, the pro- jection of the organ out of the orifice of the vagina. It may be partial or complete ; it is partial when only a portion of the uterus protrudes, and complete when the whole organ is exterior to the pudendum. In all cases, the womb, excepting the extremity of the neck, is necessarily entirely covered — and of course con- cealed from sight — by the vagina. The vagina may be said to be inverted ; instead of forming a canal to the womb, with the mu- PEOCIDENTIA. 839 cons membrane inside, it presents the appearance of a conical or globular body outside the vulva, and with the mucous surface on the exterior. It may contain not merely the uterus, but fre- quently the ovaries, with large portions of the round and broad ligaments, of the small intestines, of the bladder, and sometimes of the rectum. The degree of procidentia, and of course the size of this tumor, depend on the degree of relaxation of the tissues. Authors mention cases in which it was of an enormous size. Under these circumstances, exposed as the vagina and os uteri must be to external irritation, the whole tissue, occasionally, becomes altered by inflammatory action. Hence, thickening and indurations may result to such an extent that the procidentia, especially when complicated with enlargements of the uterus, may become " irre- ducible." We have seen many cases of this displacement, but they have all been " reducible." The occurrence of procidentia necessarily presupposes great relaxation of all the tissues; this is true, not merely of those composing the ligaments, fasciae, and vagina, but also of those belonging to the perineum and vulva. Hence, it is observed chiefly in aged women who have borne many children. It is generally stated that procidentia follows a prolapsus. Yet, strictly, it is not prolapsus — mere descent in the normal direction of the axis of the uterus— but retroversion, that must precede a procidentia. The fundus must fall into the hollow of the sacrum, and even descend to the inferior portion of this bone, before the axis of the uterus can become coincident with that of the vagina, A prolapsus may precede a retroversion ; but there must be a retroversion before there can be a procidentia uteri. CAUSES. If we consider merely the apparent delicacy of the ligaments of the uterus, a displacement of this organ would seem almost inevi- table, even under the ordinary motions of the body ; but when we remember the obliquity of its position, maintained, as has been explained, by the harmonious co-operation of the lateral, anterior, and posterior ligaments, and also by the pressure of the bladder and intestines in front and behind, we would infer that 3-iO CAUSES OF DISPLACEMENTS OF THE UTERUS. displacements should be of rare occurrence. This idea is con- firmed by the acknowledged fact, that a very large proportion of "women have no suffering from this source, and that multitudes are engaged in the most active and laborious occupations with perfect impunity. Nevertheless, displacements do at times occur, existing, it may be, without any perceptible injury, but frequently producing or maintaining the most severe suffering, mental and corporeal, to which the human system is liable. An investigation of the causes becomes, therefore, all import- ant. They may be divided advantageously under the two general heads of predisposing and exciting causes. The former should be considered separately, although operating also very constantly as exciting, as well as predisposing causes. Predisposing Causes. Relaxation of the Ligaments and of the reflected Pelvic Fascia. — The actual condition of these tissues is not perhaps a subject of positive demonstration, as they are situated within the body, and can neither be seen nor felt. We may safely conclude, however, that in states of great general weakness, languor, and relaxation of the system, the ligaments, which are partially of a muscular character, partake of the gene- ral exhaustion.. We know, moreover, that during pregnancy all these ligaments are exceedingly elongated, as well as developed. Of course, for some time after parturition they remain long, and much relaxed. Hence, most married women date the commencement of their sufferings from a particular abortion, or confinement at term. On this account, pregnancy is to be regarded as predisposing to displacements of the uterus. Increased Size and Weight of the Uterus. — The action of this cause is obvious, for the larger size necessarily presents a broader surface to the superincumbent viscera, and the heavier the organ the greater the strain upon its supports. The frequency and the great influence of this cause have not been sufficiently regarded. Although the ligaments may be as short and firm as natural, yet, in the early stages of pregnancy, every one considers some displacement of the organ as almost inevitable for a few weeks. Also, there is a strong predisposition to displacement after de- livery, especially about the tenth day, when the organ is large PREDISPOSING CAUSES. . 341 and heavy, and has descended completely into the pelvis. This, in addition to the relaxation of the natural supports of the uterus, is another and a very powerful explanation why females do look upon their confinements as the original cause of their troubles. There are various other sources of enlargement of this organ, all of which, therefore, directly or indirectly, facilitate its displace- ment. Such are hypertrophies, indurations from inflammatory action, cancerous or other malignant diseases, physometra or hydrometra, intra- and extra-uterine tumors, or tumors in the substance of the organ. In many of these cases, there is a con- stant displacement ; but in others it takes place only while the woman is in the erect position, and then excites such sensations of weight and pressure as to prevent her from taking much exer- cise. Under this division, a very large proportion of modern authorities would place congestions and inflammations of the uterus, even insisting that the kind of displacement often depends on the part of the uterus which is inflamed. We have never been able to perceive any ground for this assertion. Congestions of the uterus are of every-day occurrence, arising not only from the periodical menstrual nisus, but from all those mental, moral, and physical irritations peculiar to women. Inflammations also are not unfrequently observed in the cervix, and sometimes in the body, but especially in the appendages of the uterus, without any displacement at the time or subsequently. That congestions and sometimes inflammation coexist witb displacements, there can be no doubt, but that they are the cause demands much more positive proof, than has hitherto been presented. Distension of the Abdomen. — A predisposition to displacement often arises from pressure made on the uterus by distension of the abdomen, due, for example, to constipation, to intestinal or peri- toneal tympanites, to ascites, to a distended bladder, to enlarge- ments of the ovaries, of the glands of the mesentery or of the pelvis, to increased size of the liver, spleen, kidneys, omentum, etc., and to extra -uterine pregnancy. Pressure on the Abdomen. — This cause operates virtually in the same manner as the last mentioned, and is dependent on all those circumstances which diminish, or have a tendency to dimi- nish, the size of the abdomen. The peritoneal "cavity," so called, is in reality a plenum. Every agent which tends to diminish the size of the abdomen acts as a compressor to the viscera. Hence 842 CAUSES OF DISPLACEMENTS OF THE UTERUS. all pressure, from the tight dresses and corsets to which women are so strangely devoted, from the weight of the garments tightly secured around the waist, from abdominal or " utero-abdominal" supporters, must act as a depressing force on the body of the uterus, and constitute at least a predisposing cause of uterine mal-positions. Menorrhagia^ etc. — Much has been written of menorrhagia and leucorrhoea, of relaxation of the vagina, perineum, etc., as facili- tating displacements of the womb. These are of no consequence, except as they may evince a corresponding relaxation of the internal tissues. For the uterus is maintained in situ by its ligaments, etc., as above shown, and not by the vagina ; so that relaxation of this canal may be, and often is, very great, with- out any departure of the uterus from its natural position. This declaration is at variance with that expressed by almost all authors, but we have had so many examples of great suffering from displacement of the uterus, where the vagina was small, presenting no evidence of relaxation, in married women, and especially in virgins, that we express our opinion with the greatest confidence. Moreover, it is very common to find the uterus in situ and no bad symptoms present, where the vagina is large and its tonicity has disappeared. The only apparent exception, in these remarks, is in cases of procidentia uteri, with or without cystocele or rectocele. In such cases relaxation of the vagina and vulva facilitates greatly the descent of the uterus and other pelvic viscera. But such descent is the result of a previous relaxation and elongation of the liga- ments of the uterus. Exciting Causes. — The predisposing causes, now enumerated, may exist for a long time, in many individuals, without the occur- rence of any decided displacement. This is especially the case when the individual lives a quiet life, without the necessity of much muscular exertion. Nevertheless, these predisposing causes are often adequate, of themselves, to effect a displacement. If there be a relaxation of the ligaments, the natural weight of the organ and the usual pressure from the intestines will force the uterus out of its posi- tion. This will more readily occur if motion be resorted to soon EXCITING CAUSES. 3i3 after parturition, when the organ is larger and heavier than usual, and its ligaments are elongated. Also, even when the ligaments are of their proper length and X — :_:x_ — • J _: r xt u -f-^jji q^^j cause, an aug- or a diminution of its ^ately or conjointly, by 3r week, or even year Doubtless this is often r, generally occur more [y, in consequence of a the abdominal viscera, 3ular effort. This may 5, but much more rea- ommencement of their )r defecation, especially fatiguing walk, to run- t dancing, to an effort 3ns, to ascending stairs )r vomiting; indeed, to ominal rmiscles and dia- era are simultaneously The uterus, situated in eive all such impulses, ports often yield under e organ to recede from n, with or without pro- )y the development of jterior portions of the the fundus will be in- urface it will generally „ „_placement are often in- curable, the cause being permanent, although they may be greatly palliated. Displacements are also often determined by other developments, as by osseous growths from the puhis or the sacrum, by enlarged glands, hy the cysts of an extra-uterine pregnancy, hy abscesses, and other tume- 842 CAUSES OF DISPLACEMENTS OF THE UTERUS. all pressure, from tlie tight dresses and corsets to which women are so strangely devoted, from the weight of the garments tightly secured around the waist, from abdominal or " utero-abdominal" supporters, must act ?^ ^ r^o,^vocc.iv,rv fr^-n^^ ^^ -t-i^- ■k^.i„ ^.c ^.-u^ uterus, and constitute mal-positions, Menorrhagia, etc. — !N^ leucorrhoea, of relaxai tating displacements o except as they may ( internal tissues. For ligaments, etc., as aho- relaxation of this can out any departure of t This declaration is all authors, but we ha^ from displacement of presenting no evidenc especially in virgins, tl confidence. Moreover situ and no bad sympt its tonicity has disappe The only apparent ( procidentia uteri, with cases relaxation of th descent of the uterus a is the result of a prev ments of the uterus. Exciting Causes.— may exist for a long tii rence of any decided ' when the individual ] much muscular exertic Nevertheless, these ^ ^ ^ ^^ , ^. themselves, to effect a displacement. If there be a relaxation of the ligaments, the natural weight of the organ and the usual pressure from the intestines will force the uterus out of its posi- tion. This will more readily occur if motion be resorted to soon EXCITING CAUSES. 313 after parturition, when the organ is larger and heavier than usual, and its ligaments are elongated. Also, even when the ligaments are of their proper length and tonicity, an increased size of the womb from any cause, an aug- mentation of the contents of the abdomen, or a diminution of its cavity from pressure externally, may, separately or conjointly, by their steady, constant influence week after week, or even year after year, gradually effect a displacement. Doubtless this is often the case. Muscular Effort. — Displacements, however, generally occur more rapidly, and sometimes even instantaneously, in consequence of a fall, a severe blow, a concussion affecting the abdominal viscera, or more frequently from some violent muscular effort. This may happen even when no predisposition exists, but much more rea- dily when there is such a predisposition. Many individuals, therefore, trace the commencement of their sufferings to straining efforts in micturition or defecation, especially when made soon after parturition. Others attribute the accident to a long, fatiguing walk, to run- ning, or jumping, to prolonged or violent dancing, to an effort made in raising weights or carrying burdens, to ascending stairs or heights, to violent sneezing, coughing, or vomiting; indeed, to any sudden or powerful contraction of the abdominal muscles and dia- phragm. For by each of these, all the viscera are simultaneously compressed, and often with great force. The uterus, situated in the inferior portion of the body, must receive all such impulses. No wonder, then, that its ligaments and supports often yield under these reiterated impressions, and permit the organ to recede from its proper position. Tumors^ etc. — Anteversion or retroversion, with or without pro- lapsus, may not unfrequently be caused by the development of heterologue tumors, on the anterior or posterior portions of the uterus. "When on the posterior surface the fundus will be in- clined forward, and when on the anterior surface it will generally be inclined backward. Such cases of displacement are often in- curable, the cause being permanent, although they may be greatly palliated. Displacements are also often determined by other developments, as by osseous growths from the pubis or the sacrum, by enlarged glands, by the cysts of an extra-uterine pregnancy, by abscesses, and other tume- 844 CAUSES OF DISPLACEMENTS OF THE UTERUS. factions in the pelvis. They are still more frequently the result of ovarian enlargements. A small ovarian tumor in the pelvis may cause a " lateral displacement" of the uterus, noticed by some authors, but of no great importance, as the symptoms resulting belong rather to the displaced or enlarged ovary than to the womb. But, of course, anteversion and retroversion also are not unfrequently the consequence of such ovarian enlargements when they press on the anterior or posterior surface of the uterus. The character of the displacement must depend on a com- bination of circumstances not to be easily understood. Some speculations on this subject may, however, be broached. If the bladder or the rectam be not much distended, the small intestines will be driven, by the muscular exertions, so equably behind and before the uterus, that retroversion or anteversion will probably not occur ; but prolapsus or descent of the uterus will result, the axis of the organ not materially departing from its parallelism with that of the superior strait. If the bladder should be empty, and the sigmoid flexure of the colon and the rectum be much distended, the fundus may be pre- cipitated against the pubis, and anteversion result. Should, however, the bladder be distended, and the rectum empty, then any sudden impression would almost inevitably force the fundus of the uterus under the promontory of the sacrum, so that a partial, and eventually a complete, retroversion would be produced. In cases of great relaxation of the tissues of the pelvis and of the perineum, continued succussions from the abdominal pa- rietes would eventually cause a partial or complete procidentia uteri, with the consequent displacements of the bladder, intes- tines, etc. Procidentia will be, as already shown, the immediate result not of a prolapsed, but of a retroverted womb. Some practitioners have attempted to account for the occurrence of anteversion or retroversion of the uterus by the hypothesis that in congestion, inflammation, or induration of the anterior half of the organ its size and weight are so increased that it falls forward, thence anteversion ; but if the posterior half be similarly affected, then its greater size and weight cause retroversion / Hence, partial inflammation or induration of the uterus is the cause of such displacements; and being removed, the displacements disappear! SPECIAL CAUSES. 3l5 It would certainly be very difficult for an educated pathologist to imagine that during life any congestion or inflammation could be confined to one-half of an organ so vascular as the womb ; and perhaps it would be more difficult for an accurate and experienced anatomist to demonstrate, upon a post-mortem examination, an induration from inflammation affecting merely the anterior or the posterior segment of the uterus. If, however, these hypotheses, or anatomical researches be confirmed, would the laws of mecha- nics justify the supposition that ante version in the one case, or retroversion in the other, would result? We trow not. The increased weight, if it had any influence as regards these dis- placements, would, owing to the natural obliquity of the uterus, be always in an anterior direction, where it would be received by a packet of the small intestines, and by the often distended bladder. But it should be remembered that in these supposed cases there is an increase of size also, which would actually necessitate a directly opposite result to that maintained by these authorities. It is evident, upon a little thought, that if the anterior portion of the uterus be augmented in size, the fundus uteri must neces- sarily approximate the sacrum more and more as the swelling of this surface increases, and presses upon the bladder and pubis, thus predisposing to, or actually causing, not an anteversion, which was anticipated, but a retroversion of the organ. So also, if the posterior portion be enlarged, the fundus will as inevitably be pushed forward, so that a tendency to anteversion^ not to retrover- sion, would ensue. If this view needed confirmation, we have a demonstration of its truth in preternatural conditions of the uterus ; for example, in cases where a tumor or tumors of larger or smaller growth are developed on the anterior part of the organ, the fundus is found tending to the sacrum in proportion to the size of the tumor. But if the tumor be on the posterior surface the fundus as necessarily inclines forwards, towards the pubis. The supposition, then, that anteversion or retroversion is the result of simple weight, may be considered as altogether gratuitous. 346 SYMPTOMS OF DISPLACEMENTS OF THE UTERUS. CHAPTER III. SYMPTOMS OF DISPLACEMENTS OF THE UTERUS. The symptoms of displacements of the uterus constitute a difficult subject of investigation, if we may judge from the various and dis- crepant opinions of scientific and experienced pathologists. Many ignore all these malpositions, regarding them of no importance in theory or in practice. They say that if the disease be cured, the displacement will disappear or excite no trouble. Others are dis- posed to refer every morbid phenomenon simply to the malposi- tion, intimating that a woman cannot feel well when the organ is not in its normal position. Between these extremes there is every modification of opinion, and, of course, of practice. These will not be examined in detail, but the author will merely state the results of his analysis of the symptoms. This will be done with the more confidence as the views and principles enunciated were not formed "a priori," but have been derived from careful clinical observations, made during a laborious practice extending through many years. The principles thus practically deduced, have been tested therapeutically so frequently, that the author feels at liberty to 'record them positively, as general facts, of great im- portance as guides for the practitioner, but of course modified by the innumerable circumstances and idiosyncrasies of individual patients. DISPLACEMENTS MAY EXIST WITH IMPUNITY. The first general declaration to be made is, that displacements of the uterus exist in innumerable cases, with apparent impunity. There may be no decided symptoms to intimate that the accident has occurred. The woman may feel well, and all her functions may be easily and comfortably executed. In various tempera- ments, and in all classes of society, such cases may be met with ; DISPLACEMENTS WITHOUT SUFFERING. 347 but, they occur cTiieflj in the strong and laborious, in those of a cold, phlegmatic temperament, and in northern countries. In all such, the nervous system is not very sensitive. It is strong, but not excitable. Since suffering may exist without displacement, and the dis- placement frequently without suffering ; many pathologists have concluded that there is no mutual dependence of the one upon the other, and have attempted to relieve the suffering, while they allowed the displacement to remain. Experience — at least our experience — is, however, so directly in opposition to this practical deduction, that it is impossible to admit it. It is very difficult to relieve the suffering, if the dis- placement continue. It can be usually palliated, even to such a degree, sometimes, that the patient is perfectly comfortable in the recumbent position, or even while she takes moderate exercise ; but " relapses," as Dr. Gooch has observed, are frequent on the least motion, sometimes even by walking across the room, or by a drive in a carriage. In other cases, no palliation can be secured; the patient becomes a martyr to constant and occasionally increas- ing agony, involving the functions of mind and body. Case. — We have lately taken charge of an unmarried lady, with a retroverted uterus, but who was treated for " spinal neuralgia," of long duration. She was forced, a long time since, to resort to crutches ; she has now been confined to her bed for nearly ten months, but the pain, nausea, and vomiting constantly increased, so that for the last month nothing was retained on the stomach but brandy, and the retching so constant and distressing as to forbid sleep night or day. She became greatly exhausted ; in de- spite of the best efforts to palliate, from as excellent a medical practitioner as our city can afford. Such cases are by no means unfrequent. Ladies often suffer five, ten, fifteen, twenty years, or even longer, under any and every treatment, if the displacement be permitted to remain unrelieved. The reverse, according to our observation, is also true, that if the displacement be completely relieved, the suffering disappears with the most marvellous rapidity. The practical difficulty is the perfect restoration of the displaced organ. When, however, this is accomplished, the relief to suffering follows very universally. Indeed, the mitigation of suffering is, generally, in proportion to the degree in which the displacement has been moderated. In 348 SYMPTOMS OF DISPLACEMENTS OF THE UTERUS. the case above mentioned, upon the removal of the displacement, the nausea and retching disappeared at once ; sleep followed ; and the ability to receive food, good digestion, increase of color, of flesh, and of strength, succeeded each other with wonderful ra- pidity. The alcoholic potations, and the narcotics, were entirely abandoned in a short time, although the retroversion was far from being completely obviated. The whole of the daily expe- rience of the author for many years confirms this opinion. Numerous exceptions — apparent and real — will of course be found ; but they, by no means, invalidate the general proposition. Hence, although displacements may exist with more or less impunity in the strong, and in the cold and phlegmatic tempera- ments, whose nerves seldom vibrate even to powerful impressions ; yet, in the delicate, luxurious, sensitive woman, whose mind and body feelingly respond to every transient im.pression, such mal- positions become the source of every kind and variety of nervous irritation. Even in the non-irritable woman, if morbid irritation exists, conjoined with displacements, it will be exceedingly diffi- cult to relieve the former, without paying attention to the latter ; but, it becomes very easy if the malposition be first obviated. This proposition, that displacements are frequently the causes, original or secondary, of uterine suffering, and not mere nullities, will be continually illustrated in the course of these observations. DISPLACEMENTS GENERALLY CAUSE INCONVENIENCE. The second general deduction to be made is, that in a large number of women in civilized life, who have displacements, more or less inconvenience results, even where the uterus is by no means very sensitive. These symptoms of displaced uterus are generally quite positive ; some are local, and relate to the pelvis and its contents ; others are more general, and disturb distant tis- sues and organs. Local Symptoms. — The most frequent and characteristic of the local disturbances are sensations of fulness, of pressure, and of weight at the lower portion of the pelvis. They are often refera- ble to the rectum, as if it were distended, and as if the bowels must be moved, even when the rectum is empty. This sensation has DISPLACEMENTS WITH SUFFERING. 349 often been attributed to internal lisemorrhoids, when they do not exist. In many, there is a feeling of great relaxation of the peri- neum and vulva, an " open feeling," as if all the viscera must im- mediately escape. Often there are analogous sensations about the urethra, with frequent inclination to micturate. In the hypogastrium, there is also a sensation of emptiness, of sinking, of weight, of bearing down, and of inability to stand, or even to walk. There are sensations of weakness, of aching, or of positive pain, in "the small of the back" — the upper portion of the sacrum — and extending to the coccyx, down the limbs, and around to the groin or iliac regions. These and analogous disturbances are aggravated by standing, walking, or any muscular effort, and generally disappear when the patient is at rest, especially in the recumbent position. Sometimes the uterine functions are not disturbed; but not unfrequently there is dysmenorrhoea, which is often very severe and at every menstrual period, even when during the intervals the patient feels comfortable, and able to take her usual exercise. In other instances we have leucorrhoea, menorrhagia, or both. In some cases these functional disturbances are almost the sole indications of a displaced uterus, and remain indomitable till the displacement is relieved. General Symptoms. — The general disturbances have reference chiefly to the nervous system. The vascular system is not much involved. The most frequent of these general symptoms is a sense of lan- guor, lassitude, and "weakness." It is an effort to make any exertion ; a short walk produces great fatigue. There is a great indisposition to rise in the morning, with a strong inclination to sit or lie down on every occasion. If on a journey, such patients, after making a slight exertion, often feel as if it were impossible to move any further ; and they must rest for some twelve, twenty- four, or forty-eight hours, to recover strength. With this lassi- tude, there are often uneasy sensations, not unfrequently pain in the dorsal or cervical portions of the spinal column. Sensations of lightness in the head, and a disposition to headache at all times, are generally experienced : frequently severe pain is felt 350 SYMPTOMS OF DISPLACEMENTS OF THE UTERUS. in the temples, eyes, face, top of the head, and also towards the base of the cranium. The mind is often indifferent, and cannot be interested; the memory fails ; and the patient's interest in the common business of life, and in her relations and friends, is much diminished. Sometimes she is peevish, irritable, restless, and excitable. These miserable disturbances are perfectly consistent with not only good, but excellent, organic health. The patient may be well supplied with good blood, may have an excellent circulation, free secretions, perfect nutrition and development. In other instances, from confinement, loss of appetite, etc., there is more or less anaemia, but still no actual disturbance of the organic func- tions. Often the hands and feet are cold and pallid ; the face and head are frequently hot and flushed. These alternations of tem- perature are often very rapid, appearing and disappearing at short intervals ; but they can always easily be distinguished from fever, to which, indeed, they have but few points of resemblance. The disposition to languor, to coldness or chilliness, generally occurs in the mornings, while the vascular excitement is usually in the evenings; so that such patients, although perhaps most miserable in the early part of the day, are often bright and happy in the evening. Conclusions. — That these local and general symptoms, and many others of a similar character, are indeed the result of a dis- placed uterus, even when there is little or no increased sensi- bility of this organ, is proved by the facts, that they are often coexistent with the displacement ; that there is generally no other local disturbance; and especially that, the displacement being removed, the symptoms disappear. When this is accom- plished, the patient feels light, can stand erect, can move with ease and freedom, can take even long walks, becomes interested in her books and friends, is cheerful and amiable, and is pre^ pared for the performance of the duties and the enjoyment of the pleasures of life. AGGRAVATION OF SYMPTOMS. 351 SYMPTOMS AGGRAVATED TF THE UTERUS BE SENSITIVE. The third observation in this process of analysis is, that when from displacements of the uterus alone, or from other causes, physical, intellectual, or moral, the uterus becomes morbidly sensitive, we then have a great aggravation of the above detailed symptoms, and a more or less full development of those local and genera] phenomena of pelvic and cerebro-spinal irritation, which, have been detailed in, the first part of this work, as the evidences of uterine and sacral irritation. These, therefore, with all the severe reflex influences on the various organs of the economy, need not be repeated. They may, to be sure, exist in men as well as in women; but in the former they are exceedingly rare, while in the latter they are very frequent. Although sometimes, of course, unconnected with displacements, yet they are so frequently coex- istent and inseparable, as to defy the best ordered and most sys tematic treatment as long as such displacements are allowed to remain ; but they rapidly vanish even under very simple treat- ment, when the malpositions are corrected. Practical Deductions. — l^h.Q practical deductions, as confirmed by long-continued experience, seem to the author inevitable, that malpositions of the uterus are so intimately connected with all the phenomena of irritable uterus, as original or aggravating causes, as to make their removal generally absolutely necessary for the return of the organ, and of the cerebro-spinal system to its nor- mal state; that dysmenorrhcea, menorrhagia, and leucofrhcea, the pelvic sufferings, the inability to walk or stand, the spinal and cerebral irritations, with all the occasional but terrible disturb- ances of the larynx, lungs, heart, stomach, liver, kidneys, and bowels — especially the rectum — can hardly be completely relieved, and sometimes not even palliated, if the displacement be per- mitted to remain ; but, on the contrary, if this be removed, re- covery will generally quickly follow. There are, perhaps, many cases of cerebro-spinal irritation, of "hysteria," as sucb complaints are usually named, in which no displacement exists; and that many possibly may be found, even where there is no uterine irritation of any kind — inflammatory 352 SYMPTOMS OF DISPLACEMENTS OF THE UTERUS. or otherwise — no one will deny. Besides these cases, there have occurred to the author, and doubtless to others, those in which the displacement had been completely relieved, yet the local and general symptoms, although palliated, still persisted. This per- sistence is very often due to our ignorance of the sources of sacral irritation ; as, from pessaries in the vagina, from irritable, enlarged, or displaced ovaries or other pelvic tumors, from some state of the rectum, of the tissues in the region of the sacrum, or of the bone itself. There must be a local irritation to disturb the nerve centres ; it is generally in the pelvis, although it may exist in any tissue or organ of the body. A case of the kind has been detailed to the author by a "resident physician" at the Pennsylvania Hospital, where hysteria had evidently been excited by the irri- tation of a diseased knee-joint. It seems impossible, at least for the author, to conceive of spinal or cerebral irritation without a local cause. There must be an irritant acting on the irritability of a tissue to produce irritation. DIAGNOSIS. The diagnosis of displacements of the uterus cannot be satis- factorily determined merely from the symptoms, however accu- rately studied. There are so many morbid sensations in nervous women, so much exaggeration in their description of their feel- ings, and, withal, so many other causes of pelvic irritation, espe- cially perhaps in young females, that a physical examination becomes positively necessary either to verify or to contradict our suspicions. The same difficulty of forming a diagnosis from symptoms alone, every obstetrician knows, exists in the case of pregnancy. The mere sensations of the patient often deceive her even to the supposed full period of utero-gestation ; or the symptoms, even when carefully examined, frequently mislead the practitioner. Dropsies and other swellings have been mistaken for pregnancy ; and on the other hand, pregnancy has often been the sole cause of disturbance, when the woman had been treated for months on account of other developments. In both cases, some approximation to the truth can occasionally be made by a careful analysis of the symptoms ; but vaginal exa- SPECIAL SYMPTOMS. 353 minations are still more imperative to detect the presence and to determine the variety of displacement, than to ascertain the exist- ence of pregnancy. Special Symptoms. — Anteversmi of the uterus might be anti- cipated when, with other intimations, there is a great sensation of pressure in the pubic region, with almost constant uneasy sensa- tions in the bladder, and a frequent disposition to pass urine, which is usually done without much pain or difficulty, and with temporary relief. There is generally also a sensation of fulness about the vulva. Similar disturbance of the functions of the bladder exist frequently, also, in retroversion of the uterus. In Prolajjsiis uteri, the symptoms of sacral irritation are trifling, or altogether absent. There is a sensation of weight at the peri- neum or rectum, as if a stool was demanded, or as if hgemorrhoids Avere present. The patient often cannot bear to sit down, and suffers while riding, especially over a rough road. The character of this displacement is to be determined, however, rather by negative than by positive signs, by the absence of the indications of anteversion or retroversion. The diagnosis of Retroversion of the organ is generally more positive. It is usually indicated by decided symptoms of sacral irritation ; pain in the small of the back ; uneasiness in the rec- tum ; apparent and sometimes partial obstruction to defecation ; a flattened condition of the feeces; severe sufferings while at stool, in the sacrum and posterior perineum, with subsequent prostration; long-continued uneasiness in the bladder, with pain- ful, often repeated efforts to urinate ; the necessity, seemingly absolute, to continue these efforts for a long time, or to repeat them every few minutes ; inability often to lie on one side or the other, and a disposition, in many cases, to lie on the abdomen. Generally, in retroversion, there are also more decided symptoms of spinal and cerebral irritation, of disturbances of the stomach,, heart, and lungs, and a more complete inability to stand or walk, than in the other displacements. Nevertheless, even here, verifi- cation by vaginal examination, is necessary. Flexion of the neck or body, also, can only be established by a tactile examination. "We may suspect it, however, in all those displacements where there is the complication of dysmenorrhoea,. 23 354: SYMPTOMS OF DISPLACEMENTS OF THE UTERUS. which SO often depends on the obstruction arising from the bend- iug of the neck.' ' The subject of flexions of the uterus has attracted very little attention until within the last few years, and its proper role, or relative value in uterine com- plaints, has not yet been fixed. Thus, the distinguished German teacher Scan- zoni, regards flexions as of little importance ; but, at the same time, as quite incur- able, whether by medicinal or surgical measures. Dr. West does not materially difler from this opinion. Mr. Tilt does not refer dysmenorrhcea nor sterility to flexions. M. Goupil, while acknowledging the existence of flexions, ascribes the supposed consequences to congestion and inflammations, and treats liis patients not for flexions or displacement, but for such congestion. Dr. Wright attributes bad symptoms, on the contrary, to displacements, whether with or without flexion ; insisting, therefore, that a reposition is absolutely necessary, as much so as the reduction of a bone which has been thrown out of its socket, instead of trusting to antiphlogistics. These citations are sufficient to exhibit the discrepancy of opinion on the sub- ject. Some authors affirm also that flexions seldom occur in the virgin condition, being chiefly a consequence of the parturient state ; others, on the contrary, state that it is seldom found in women who have had children. Dr. Wright inclines to the opinion that flexion cannot occur in a healthy uterus ; its tissues are too firm. He supposes, therefore, that there is always a predisposition arising from a morbid laxity or softness of this body ; while some authors think that there must be a congenital deformity, or, at any rate, a degeneration of tissue at the point of flexion. The causes of flexion are, therefore, regarded as exceedingly obscure. To us this seems very surprising, and also the idea too frequently inculcated that flexion is a distinct or peculiar kind of displacement, instead of regarding it as a mere addition or complication to an existing malposition of the uterus. The view as presented in the text, and which has guided the author's practice for very many years — and, as he thinks, with great success — is, that the essential cause is pres- sure from above. Under the steady influence of a superincumbent weight, pro- lapsus of the uterus ensues, the os impinges against the posterior wall of the vagina, preventing further descent, while day after day the pressure is being exerted so constantly that the flrm tissues of the cervix gradually yield, so that not only flexion ensues, but various deformities even are produced as described in the text. Hence, flexions of the cervix are very common in the early stages of pregnancy, and very often in the virgin, being with her one of the most frequent causes of dysmenorrhcea ; or, if marriage has ensued, preventing conception. In parturient women it is not so common. Flexions, therefore, are a frequent and by no means an unimportant complication of displacement. The proof is based on the fact constantly observed in the practice of the author, that such flexions are not incurable, as so frequently asserted by high authorities ; that they can be easily rectified by the measures already detailed; and that in a large number of oases the bad consequences, especially dysmenorrhcea and sterility, will be ob- viated. We are the more anxious to press this subject upon professional atten- tion, not merely that we feel confident that pressure is the real source of mischief which can be readily relieved, but because so many influential gynecologists de- clare that flexions are innocuous, or that they are incurable, while the bolder and SPECIAL SYMPTOMS. 355 The symptoms of Procidentia, as described by the patient, would seem generally to be very positive; but, certainly, no practitioner would trust, in pronouncing an opinion, to any such description, without having confirmed it by his own senses. There are many sources of deception to the woman, or to the uninstructed, as, for example, the partial or complete prolapsus or procidentia of the vagina, the uterus being within the vulva; the descent of a portion of the bladder or rectum ; the swelling of the hard or "prostatic" portion of the urethra; the formation of tumors in this tissue, or in the sides of the vulva, the vagina, or the uterus itself, as in cases of polypi, which protrude exter- nally ; or more rarely, it may be not a simple case of procidentia, but complicated with a previous inversion of the organ. In all cases of procidentia of the uterus, the bladder is neces- sarily disturbed in its functions. There is often difficulty in urinating ; sometimes it is so great that no excretion can occur until the whole tumor be restored within the vulva. As regards the nervous symptoms, it is perhaps inexplicable, but in accordance with the uniform experience of the author, that they are comparatively very moderate. The uterus itself does not become very irritable or sensitive, and the sympathetic affections of the pelvic nerves, of the spinal marrow, and of the brain are often trifling, and sometimes hardly recognizable. The explanation is not very evident, but may possibly be referable to the fact that when the uterus is extruded it is no longer under the influence of the abdominal muscles, is no longer impinging more decided spirits of the profession are exercising their science and manual dexterity in devising and executing surgical operations for the removal of obstruc- tions in the cervical canal, or of supposed deformities in the neck of the uterus. We do believe that a large proportion of the supposed strictures are dependent upon flexions, and, with few exceptions, there are no deformities of the cervix which will not, with slight assistance, disappear gradually after pressure from these tissues has been removed. Hence it results that the frequent employment of the uterotome, with all its proposed modifications of the scissors and tlie ampu- tating scalpel, is not only tedious, painful, and dangerous, but unscientific and unnecessary. These observations apply not simply to "prolapsus with flexion," but with equal, indeed with still more force to anteflexion and retroflexion of the uterus. The cause of such accidents not having been investigated, the treatment has been conducted upon improper principles, and has proved often ineffectual, and, in some instances, fatal. This is true even as regards the "intra-uterine stem pessary." 356 SYMPTOMS OF DISPLACEMENTS OF THE UTERUS. against solid substances, and cannot directly irritate the pelvic nerves, but hangs in a soft cavity formed by the inversion of the vagina. Vaginal Examinations must be made in all cases of sup- posed displacement, in order that the diagnosis may be accurately established, and a rational treatment be instituted, A decided Procidentia is easily detected. The whole organ, and sometimes also its tubes and round ligaments, can readily be felt, and its form and size recognized through its vaginal covering. A finger in the rectum, or a curved sound in the bladder, will indicate that one or both of these viscera, occasion- ally, are partially drawn down with the uterus. The os uteri can readily be seen and felt, as well as the insertion of the vagina near its margin. Very generally, in procidentia of a chronic character, the whole tissue of the mucous membrane of the vagina is altered by inflam- mation, brought on by the innumerable sources of irritation due to its exposure, out of the vulva between the limbs of the patient. Hence result patches of inflammation ; mucoid and purulent, and even bloody discharges from this surface ; hence also ulcerations, indurations, and, it may be, gangrene, and sphacelus. Sometimes, after long exposure, the peculiar soft character of the vagina is so altered, as to resemble in appearance and to the touch, the character of the dermoid tissue, with its epithelial scales. Cases have been recorded where, in consequence of inflammation, that portion of the peritoneal sac containing the uterus and its ap- pendages had been obliterated by adhesions, thus shutting the uterus out from the general cavity of the peritoneum, and ren- dering reduction difficult, if not inpossible. The diagnosis, therefore, of procidentia uteri can be easily determined by an ocular and digital examination. It can thus be readily distinguished from a prolapsus of the vagina, of the bladder, or of the rectum, from inversion of the uterus, from polypi of the womb, and from steatomatous, fibrous, or other tumors projecting from the vulva. In the other m,al-positions of the womb even less reliance should be placed on the symptoms. The innumerable varieties of morbid sensation may arise from so many sources, that no careful patho- logist would venture to give a positive opinion, from the history VAGINAL EXAMINATIONS. 357 of the case, as to the existence of displacement, and of course still less as to the kind of displacement. However frequently, or even constantly, these nervous or hysterical sensations are associated with displacements, they may exist without any alteration in the position of the organ, and, as has been observed, may remain, even when they have been coincident with a mal-position, after such mal-position has been rectified. Nevertheless, they are so intimately connected as cause and effect, that, in all protracted nervous complaints, it will be advisable to ascertain, by examina- tion, the position as well as other morbid states of the uterus. Such examination, and the treatment which may be founded on its results, are often, indeed, essential for the recovery of the patient — a " sine qua non." By the " touch" the instructed anatomist and the experienced practitioner will have no real difficulty in determining not merely the existence of a displacement, but also its character and its various complications. Nevertheless, so little attention has been directed to this subject; so many egregious mistakes have been and are so constantly made as to what is or what is not the natu- ral position of the uterus; and, in some cases, there are so many real difl&culties, that it becomes requisite to illustrate the manner in which such examinations should be made, and some of the difficulties which may exist. Anatomical Facts. — Let reference be made, therefore, to the anatomical facts already enumerated in the chapter on the natural position of the uterus : especially the obliquity of the pelvis, as regards the axis of the body ; the parallelism of the axis of the uterus with that of the superior strait of the pelvis; the conse- quent oblique position of this organ as regards the axis of the body; the coccygeal region constituting the floor or bottom of the pelvis, while the orifice of the vagina is at the anterior por- tion ; the axis of the vagina forming an acute angle with the axis of the uterus, and running from below the symphysis pubis towards the lower part of the sacrum ; the uterus a movable organ, and supported in its central position in the cavity of the pelvis, not by the vagina, but by its ligaments, which, in their natural state, as to length and tonicity, assisted by the attach- ments and reflections of the pelvic fascia, and by the position and pressure of the small intestines and the bladder, are fully able to maintain it in situ, and yet allow its pendulum-like motion in the 358 SYMPTOMS OF DISPLACEMENTS OF THE UTERUS, cavity of the pelvis. A practical acquaintance witli these facts will render the diagnosis very easy, with perhaps a few exceptions. Mode of making the Examination. — Undoubtedly the best posi- tion of the woman, for these examinations in cases of displacements of the uterus and tumors of the abdomen, is directly on the back, with the knees drawn up and separated, the pelvis approximating the edge of the bed, and a little elevated, with the shoulders un- supported by a pillow. Thus the practitioner can easily make an external as well as an internal examination. If an examination be made, as is too often done, with the patient upon the side, the intestines will gravitate to that side of the body, the uterus will usually rise higher in the pelvis, and incline laterally, so that its mal position will often not be appa- rent. Occasionally, however, this method is important to examine the upper parts of the rectum, the vagina, etc. The erect posture may, in a few instances, be advantageous, especially in those cases where the organ is displaced only when the woman is erect. In this position, the exploration is inconvenient, for the practitioner is necessarily much restricted, and cannot, from the tension of the abdominal muscles, make any satisfactory investigation through the parietes of the abdomen. It is always desirable that the blad- der and the rectum should have been previously emptied. If the j)arts be in situ naturally the index finger, after entering the vagina, should come in contact with the anterior surface of the uterus, felt distinctly through the parietes of the vagina and blad- der. The OS uteri will be found below the level (the patient being on her back) of the os vagina3, and pointing towards the region of the coccyx, and making no firm pressure on the posterior wall of the vagina. The cervix and body should be perfectly straight, free from flexion. If the woman be not cor- pulent, the fundus of the uterus may with some attention be recognized by the fingers of the other hand placed on the hypo- gastric region, when the uterus is slightly elevated by the finger in the vagina. f In Prolapsus uteri, as already defined, the chief indications [ arise from the position and state of the os and cervix uteri. The body may be found sometimes very near the pubis ; sometimes, however, there is a slight inclination of its axis, so that the fun- dus approximates the sacrum, though it has not fallen below the promontory ; but the os impinges firmly upon the posterior wall MODE OF MAKING EXAMINATIONS. 359 of the vagina and upon the rectum. If it be a chronic case, the form of the os uteri is often altered ; the anterior lip usually projects, and sometimes is tumid, while the posterior lip is flat- tened ; so that together they closely resemble the mouth of a hog, the orifice appearing to be nearer the posterior than the anterior surface^ When there is flexion^ it varies much as to degree. If mode- rate, a bend is noticed by passing the finger along the anterior surface of the cervix, but the os is still in contact with the peri- neum. In decided cases, the os is found pointing towards the orifice of the vagina ; the end of the finger, passing directly in the axis of the vagina, meets the os uteri. The first idea would be, that the uterus was retroverted ; for, if the organ were straight, the fundus would then necessarily be towards the sac- rum; but in these cases of flexion, the anterior surface of the organ will be detected behind the bladder and the pubis. It is a case of prolapsus with flexion. It might be termed a simple case of flexion. Flexion very generally exists in the cervix uteri, about its middle or upper third; occasionally at the internal os; some- times in the lower portion ; very seldom in the body of the uterus, although such cases are met with. The degree of flexion varies from slight curvature to that where the cervix bends at an acute angle. Dr. states a case where the curvature of the lower extremity was so great that the os externum appeared to be upon the anterior surface of the neck. ^When flexions exist for a long time, thinness and even fatty degeneration of the tissues are said to occur on the concave surface. J) Hence, care should be always taken not to penetrate these degenerated tissues, when an examination is made by means of a sound. In Anteversion, which is comparatively a rare displacement, the fundus will be found opposite to the body of the pubis, while the index finger must be extended along the anterior surface of the v uterus, deep into the vagina, so as to reach the extremity of the cervix, pointing towards the hollow of the sacrum, far from the OS coccygis. To effect this the patient, particularly if a virgin, niust often be placed on the side, especially if it be desirable to • examine the lips and the mouth of the womb. Very generally, however, in anteversion there is also flexion, varying, of course, as to degree. Owing to this, the cervix and c 360 SYMPTOMS OF DISPLACEMENTS OF THE UTERUS. OS uteri are often found in their natural position, towards the coccyx ; while the fundus is opposite to the pubis. In similar positions of the body of the uterus, the neck is sometimes so bent, that the os approximates the perineum, and even may be almost parallel with the ostium vaginte. The only mode of diagnosis, therefore, between such cases and those of prolapsus of the uterus, is by careful attention to the position of the fundus. i'ln Retroversion of the uterus, when complete, the finger will detect a tumor through the upper portion of the vagina, behind the cervix, resting upon the rectum.^ That this is the uterus, may be rendered evident, by carefully tracing the continuity of tissue to the os ; this is found pointing towards the body of the pubis, but not close to it, for in the normal state, the organ is too short to extend from the coccyx to the pubis. ( The diag- nosis is strengthened by pressing against the bladder, in front of the OS uteri, and finding no firm resistance ; and by examining per rectum, where a tumor will be distinctly felt through the anterior walls of this tube, of the regular uterine formp This exploration is rendered more complete if the index finger of the other hand be at the same time inserted into the vagina, so that the continuity of tissue between the cervix and body can be more fully determined.^ Very generally this rectal examination gives much pain, indeed, often much more than the vaginal; sometimes it is almost intolerable, the patient screaming when the least pressure is made on the tumor. This will confirm the idea that the uterus constitutes the tumor, as new or adventitious growths have seldom any great sensibility. The diagnosis, if still doubtful, may be positively confirmed by passing a curved uterine probe, with its convexity towards the pubis, into the cavity of the neck and body of the uterus; a finger in the rectum will re- cognize without difiiculty, the point of the probe, through the parietes of the uterus and rectum. Care, however, is always demanded in order to avoid mistakes. A collection of fasces in the upper part of the rectum, an ovarian tumor, an abnormal uterine tumor, an enlarged lymphatic gland, a fibrous or other heterologous formation in the pelvis, an osseous enlargement, a scirrhous or cancerous degeneration of the rectum, have all been mistaken for the fundus or bod}"- of the uterus. In all cases in which the fundus is not displaced, the uterine surface can be recognized anteriorly, behind the bladder, and the EXAMINATION OF RETKO VERSION. 361 point of the uterine probe now introduced with the concavity toward the pubis will be felt, if the patient be not too corpulent, not through the rectum, but through the parietes of the abdomen and uterus, in the hypogastric region. A case may illustrate this fact. Case. — Our unbiassed opinion was requested in the case of the wife of an officer in the army, in which two distinguished accouch- eurs had given very positive declarations as to the condition of the pelvic contents. One stated that he was fully convinced that the uterus was in situ naturali^ and that an enlarged ovary had fallen behind the uterus, namely, between it and the rectum. The other was even more positive that it was a case of retroverted uterus with flexion, and that there was no unnatural development in the pelvis; in order that there might be no misunderstanding, he made a drawing to exhibit his views of the nature and charac- ter of the affection. The lady was about thirty years of age, had been married, but had never become pregnant. She had suffered much from nervous affections, which frequently amounted even to violent spasms. After a careful investigation, we were forced to conclude that it was a case of anteflexion of the uterus, with a fibrous tumor developed on its posterior wall. Our reasons for this opinion were — a tumor could be felt posteriorly, and one also anteriorly through the walls of the bladder ; a finger in the rectum recognized a hard swelling, and a sound in the bladder impinged against a firm body ; the uterus and the tumor poste- riorly were continuous ; no distinct sulcus could be felt between the organ and the tumor, as would probably be the case if the tumor was ovarian, and besides, it was movable with the organ, the whole seeming to form one mass. The decisive mode of diagnosis, however, the " experimentum crucis," was made by passing the probe into the uterus with its concavity towards the pubis ; its point could then be distinctly felt behind the pubis in the hypogastric region, while a finger in the rectum still recog- nized the posterior tumor. The diagnosis in cases o^ partial retroversion of the organ is often very difl&cult, and will in many instances prove incorrect, unless the examination has been very carefully conducted. In partial retroversion the fundus, in accordance with the definition given above, may be found pointing to any portion of the sacrum below 362 SYMPTOMS OF DISPLACEMENTS OF THE UTERUS. the promontory. Sometimes, therefore, the axis of the uterus is but slightly oblique, differing very little from its direction in pro- lapsus. In other cases, it corresponds with the axis of the infe- rior strait of the pelvis, and in others even to that of the vagina. "When the os uteri is low down in the vagina, or when the uterus from any cause, as pregnancy, is enlarged, the diagnosis is com- paratively easy, for the finger per vaginam or per rectum may recognize the posterior surface of the uterus, while the anterior cannot, in any way be felt. (But many cases will be met with in an extensive practice, especially among virgins, or those married women who have never been pregnant, where the vagina is long and its walls dense, and where the os uteri is so high up as to require the whole length of the index finger to reach it ; in these, the diagnosis of the existence or non-existence of a partial retro- version becomes exceedingly difl&cult.) Case. — Some fifteen years ago, a young lady, of excellent health and a good constitution, was married in Virginia. Up to this time, with the exception of some suffering at her menstrual periods, she had no indication of pelvic disease, could walk, and ride on horse- back ad libitum. Not many weeks after marriage the symptoms of irritable uterus were developed, her dysmenorrhoea became in- tense, and then followed irritations about the bladder and rectum, inability to walk with comfort, etc. The usual palliative treatment was adopted ; but the symptoms gradually became more intense. She came to Philadelphia, and applied to an eminent practitioner, who offered no decided opinion, but, after a few visits, directed a course of medicines and sent her home, with a favorable progno- sis. Nearly a year after, she returned, and consulted another experienced physician. At this time she had become confined to her bed ; she was very pallid, although still fleshy, and was ex- cessively nervous, mentally and corporeally; she had frequent attacks of menorrhagia, and experienced great trouble on urinat- ing, while defecation was attended with the most agonizing suf- fering at the time, and followed by the greatest prostration for hours. She constantly affirmed that martyrdom would be pre- ferable to the pain excited by the opening of the bowels. Her new physician treated her, for some six months, for fissure of the anus and for nervous diseases, with all the assiduity and skill imaginable. She was not benefited, and was conveyed home in the spring ; but, when the autumn came, with the symptoms rather CASE OF PARTIAL RETROVERSION". 363 aggravated than otherwise, she was brought to our care. A vagi- nal or rectal examination gave her intense pain, as these passages and their orifices had become excessively sensitive. The vagina was exceedingly long and narrow, and would sometimes spasmo- dically contract on a finger or an instrument with great force. The OS uteri was found small, excessively sensitive, and pointing to the OS vaginas, but so high up as not to be easily reached, especially as the patient was by no means emaciated, notwithstanding her prolonged suffering. No other portion of the uterus was to be felt, either anteriorly through the bladder, or posteriorly through the rectum. No swelling or tumor could be recognized in the pelvis, and, by an external examination, no indication of unna- tural development in the hypogastric or iliac regions could be found. The logical inferences were, that there existed an ex- cessively irritable condition of all the pelvic organs; that the uterus was of a small size ; that its axis was coincident with that of the vagina ; that its fundus was pointing towards the hollow of the sacrum and resting upon the sacral portion of the rectum ; that the pain excited by the passage of the ftBceg was dependent on the pressure thus necessarily made upon the sensitive uterus; that this irritable and displaced condition of the organ was the " radix malorum," the true source of the nervous distress of this otherwise healthy young woman, who, with all the appliances for a happy and useful life, had been prostrated by unremitting suf- fering for years. She was accordingly treated immediately for displacement of the uterus. Much trouble was- of course expe- rienced, but soon her symptoms ameliorated ; in a few weeks she was moving about again, and within four months was able to attend some large parties with much pleasure, and returned home, ready to resume the ordinary avocations of life. Since then, we have seen her several times, and still oftener have heard of her welfare. She has never had any return of her severe complaints, and has become a very useful and ornamental member of society. The diagnosis in all such cases of partial retroversion will be facilitated by the use of the uterine probe ; it should, however, be straightened, for if the attempt be made to pass it while bent, it either could not be introduced, or would rectify the uterus by the very act of introduction. The diagnosis in cases of retroversion becomes complicated when there is a bending of the cervix or body of the uterus. 364 SYMPTOMS OF DISPLACEMENTS OF THE UTERUS. Perhaps still more care is required in these cases of imrtial retroflexion of the uterus. A vaginal examination proves the OS and cervix to be in a natural position, for example, and the practitioner may hastily conclude that there is no displacement ; while a little more careful examination, by the finger or by the probe, would reveal the important fact that the fundus rested in the hollow of the sacrum. In other cases, the os will be found in the direction of the axis of the vagina, while the fundus is low down upon the coccyx, or even on the perineum. These facts exemplify the necessity of careful and minute exa- mination in all cases of suspected displacement of this important organ of the female economy. IMPORTANCE OF DISPLACEMENTS. The importance or non-importance of these displacements of the uterus is by no means a settled point. Extreme opinions are entertained by ^nany. Certain it is, that deviations often exist to a great extent, with no apparent disturbance of the system; and certainly, on the other hand, the most severe forms of nerv- ous irritation, cerebral and spinal, have been rapidly relieved by those mechanical means which have been effectual in rectifying the position of the uterus. This paradox seems to depend on the peculiar temperament of the patients, 'and the various moral and physical excitements to which they have been exposed. In many instances, girls, having few symptoms of displaced uterus, become, after marriage, mar- tyrs to nervous affections. In others, the development of nervous symptoms can be traced to a long walk, a fatiguing dance, or a violent strain, as in vomiting, defecation, coughing, jumping, etc. Or, the whole nervous system becomes preternaturally sensitive from anxiety of mind, disappointments in life, or great fatigue, exhaustion, etc. In all such cases, the displacement becomes more and more a cause of mischief, aggravating and maintaining the nervous affec- tions, in opposition to the best devised remedial measures. Ee- lieve the displacement, and these patients will often recover entirely by a persistence in the same course of remedies which had before proved ineffectual, or sometimes even by mere hygie- PROGNOSIS. 365 nic attentions. The argument is not invalidated by the acknow- ledged fact, that such hysterical affections, of a severe character, will sometimes continue after the displacement has been relieved, and are, not unfrequently, excited originally without any accom- panying displacement. These constitute but the exceptions to the rule, that displacements are usually connected with nervous excitements in the female econom3^ There can be no doubt that there are various other causes of hysteria, especially when the excitement is acute and transitorj^, such as mental and moral affections, sexual feelings, irritations in the teeth, stomach, bowels, etc., and even severe pain from any'^ accidental cause; but in tedious chronic cases, the principle is true, that neuralgic, nervous excitations, spasms, convulsions, i and the whole train of morbid sensations; are dependent on some local cause, the removal of which is all-important for recovery. Most unhappily, physicians cannot always detect, or, if detected, ! cannot always remove such causes; and the patient wears away her tedious life in pain and anguish. Fortunately, however, in a large majority of cases, the cause can be detected and removed. The author's experience is very favorable as to the rapid recovery of such patients; and such recoveries are often accomplished by rectifying deviated positions of the uterus. PROGNOSIS. As to the ■prognosis^ therefore, in irritable or nervous diseases, -(. everything — radical — depends on removing the cause of the irri- tation. Displacements of the uterus are, as already stated, by far the most frequent cause. The prognosis as regards displacements of the uterus is exceed- ingly favorable. The physician ought to succeed in all uncom- plicated cases, even in retroversion and retroflexion, which are the most difficult to manage, and often require much time and perseverance. C In deviations of the uterus, where the organ is hypertrophied, indurated, or loaded with heterologue tumors, or where its dis- placement is maintained by tumors of the pelvis, of the ovaries, of the mesentery, etc., or by adhesions to surrounding organs, great difl&culty is necessarily experienced. -) So, also, in contrac- 866 SYMPTOMS OF DISPLACEMENTS OF THE UTERUS. tions, or other unnatural states of the vagina, it may be almost impossible to rectify the position of the uterus. Yet, there are but few cases in which a partial, if not a complete relief, cannot be afforded. Patience and perseverance in the judicious use of mechanical aids, will, under the direction of science and expe- rience, afford prospect of great success. There are, of course, cases in which other causes of pain and irritation exist, independently of the displacement. This last, therefore, may sometimes be completely relieved, and 3^et, the irritation be kept up by the other causes in a greater or less degree. These causes are often inscrutable ; they sometimes cannot be detected ; and hence, these patients are sufferers for life, or at least until there is a revolution in the nervous system, such as occurs at the cessation of the menstrual secretion; or, until, from natural, unassisted efforts, the local irritation has dis- appeared. Almost any practitioner is familiar with cases of neuralgia which he and perhaps many others have treated by every available method, it may be, for years, ineffectually ; yet suddenly, perhaps, when no measures were resorted to, the pain ceased, and the patient returned to the full enjoyment of health and strength. Such cases have often given a meretricious repu- tation to infinitesimal doses and innumerable empirical remedies, which might have been accidentally emploj^ed at the time. We have had many cases of these irritable diseases of females, in which the symptoms have been greatly palliated by a partial removal of the cause ; yet, complete recoveries have not been effected, as a displacement or other cause was but partially obviated. The principle is true, therefore, however difficult it may some- times be of practical application, through our ignorance or the inefficiency of our means, that nervous diseases are kept up by the continuance or the return of exciting causes, and that these causes being removed, nervous affections, which are by many considered so indomitable, will be readily relieved. We must believe, also, that the most frequent exciting causes of these com- plaints are displacements of the uterus, and that the scientific treatment of uterine deviations is one of the most important elements in the management of cerebro-spinal diseases. TEEATMENT OF DISPLACEMENTS OF THE UTERUS. 367 CHAPTER IV. TREATMENT OF DISPLACEMENTS OF THE UTERUS. In the treatment of the various displacements of the uterus, there are four indications to be fulfilled. First. To remove or palliate any existing causes. Second. To replace the organ. Third. To maintain it at all times in situ naiurali, and to allow of its natural motions. Fourth. To strengthen the natural supports of the uteras. TO REMOVE OR PALLIATE ANY EXISTING CAUSES. This first indication is of great importance, and can in many instances be readily carried out. Teansitory Causes. — Many of the causes are transitory, such as jumping, straining, etc., and therefore disappear at once ; besides these, there are many of daily recurrence which can, however, readily be obviated, such as all compression of the abdomen by tight dresses, corsets, ligatures, and abdominal supporters. Again, all distensions of the abdominal viscera, from too full a diet, from flatulency, constipation, or distension of the bladder, can usually be prevented by judicious attention to diet, drinks, carminatives, laxatives, and other appropriate measures, hygienic or medical. Persistent Causes. — The more permanent causes, such as hypertrophies, can be removed or palliated according to their origin. Hypertrophy arising fropi Polypi can be obviated by removing these tumors. When from Pregnancy, the increased size may be palliated by 368 TREATMENT OF DISPLACEMENTS OF THE UTERUS. constant rest in bed, or by the use of an internal supporter, until the end of the third or fourth month of gestation, when there can be no longer any pelvic displacement. Hypertrophies of the organ, from tumors in its suhstance or on its surfaces which cannot be eradicated ; as well all enlargements and indurations of the organ from inflammation, or other dis- eased states, remain permanent, and can merely be palliated by a proper internal support. The same observation applies to all ovarian, mesenteric, and other tumors in the abdominal cavity ; to enlargements of the liver, sjjleen, kidneys, etc., which might, directly or indirectly, influence the position of the uterus ; also to the pressure arising from peritoneal tympanites, from peritoneal or encysted dropsies, etc. In all such cases, great relief may often be afforded, although the cause cannot be obviated by the usual mechanical treatment for the displacement. When symptoms of displacement arise suddenly from active engorgement of the uterus, and especially from acute inflammation, such vascular excitements must be removed by suitable revulsive, alterative, and evacuating remedies, which will often be effectual in removing all symptoms of displacement. In chvnic inflam- mation of the body of the uterus, medicinal measures should be employed until inflammatory symptoms are removed. When the inflammation is confined to the cervix, and is of a strictly chronic character, the use of antiphlogistic measures may be greatly assisted by suitable pessaries of a ring shape. The modus operandi of such supports is twofold : flrst, they relieve the neuralgic pains, and the spinal and cerebral irritations arising from the displacement; and second, they remove a constant, un- ceasing source of irritation to the cervix from pressure of this inflamed tissue on the walls of the vagina and rectum. This point has already been dwelt upon, and we feel well assured that a large number of the chronic inflammations of the os uteri, espe- cially of the so-called ulcerations of the os and cervix, are kept up by this cause, and are aggravated by constant and repeated caustic and irritating applications. The simple preventing of the pressure on the cervix by a ring pessary will, by removing the cause, original or aggravating, wonderfully facilitate the efficacy of the most simple washes in destroying^ superficial inflammations, and in discussing even the deep-seated inflammations of the cervix uteri. Such cases are numerous, and we can bear testimony that, TO REPLACE THE UTERUS. 369 except in cases of preternatural growths and malignant diseases of the cervix, we have never found the employment of power- ful caustics useful in inflammatory affections. The occasional application of the solid nitrate is sometimes advantageous in diminishing the irritability of the cervix, at least for the time ; but solutions -of this salt, of alum, of borax, of sulphate of zinc, of sulphate of copper, and other analogous preparations, are, in our hands, sufficient for the resolution of such inflammatory affections, when assisted by a suitable ring pessary, properly adjusted.^ Remarks. — But the fulfilment of the first indication is seldom sufficient. For if the ligaments of the uterus have once been elongated to such a degree that their natural elasticity and con- tractility have been lost, the mere removal of the original cause will not be sufficient for the restitution of this organ ; inasmuch as the mere weight of the intestines and the contraction of the abdominal muscles must keep it depressed. TO REPL^JE THE UTERUS IN ITS NATURAL POSITION. This second indication is sometimes a very easy operation, but occasionally difficult, and at times impracticable. In anteversion and simple prolapsus^ pressure with the finger will for the time accomplish the object. In almost all cases of procidentia^ unless very unusual enlargement exists, the uterus can be readily reduced, so as, at least, to re-enter the pelvis. In cases of retroversion^ and especially of retroflexion^ it is more difficult, for the fundus has to be raised from the hollow of the sacrum, so as to approximate the pubis. In some instances this can be accomplished by the finger alone, in the vagina or in the rectum, assisted by a proper position of the patient, generally on the knees and elbows; but this restoration is seldom practicable, especially in women who have not borne children. ' Dr. J. T. Sliarpless, of this city, in a small pamplilet on the " Use and Abuse of Pessaries," published in 1837, inculcates similar views on the utility of pes- saries during inflammatory irritations of the cer-vix. He advises the use of a ring pessary, where there is a slight cervical endometritis in conjunction with astrin- gent washes ; and also where cicatrices had formed after the healing of ulcers similar protection to the cervix is valuable, as preventing the irritations resulting from friction, and the return of the disease. 24 M- 370 TREATMENT OF DISPLACEMENTS OF THE UTERUS. Elevators. — Dr. Bond's elevators, the colpeurjnter, or gum elas- tic bag, and other instruments, acting per rectum or per vaginam, have been used as a substitute for the finger in restoring the ute- rus to its position. If the organ be easily movable, they may sometimes be effectual. The uterine prohe or sound, of a suitable curvature, and a pro- perly shaped pessary, are the only ef&cient instruments for restor- ing the uterus to its normal position ; and they will always answer, provided, of course, there be no adhesions, no large tumors, and no contractions of the vagina, to mechanically resist their safe operation, -f Simpson's uterine sound, with its convexity towards the pubis, may be slowly and carefully introduced into the retroverted uterus by directing its point backwards towards the sacrum. Then, by slowly revolving the probe, so that its concavity shall be turned t owar ds the pubis, the instrument, acting on the interior of the uterus, will gradually elevate the fundus from the sacram to its natural position. This, however, is a very painful opera- tion to some patients, sometimes almost insupportable, and gene- rally followed by an effusion of blood and by some soreness of the womb. An ingenious modification of the sound as an eleva- tor, suggested by Dr. J. Marion Sims, of a joint at the junction of the uterine and vaginal portions of the probe, may obviate some of these difficulties, but is too complicated for common practice. A curved pessary, such as will hereafter be described, may as readily accomplish the same object when the vagina is relaxed, with comparatively little pain, and no subsequent irritation ; and, if allowed to remain, it will preserve what has been gained. In other cases it accomplishes the object more gradually but cer- tainly, operating day after day till the indication is fulfilled. The curved pessary is the best elevator, for it is permanent in its in- fluences. The modus operandi of pessaries, in this and other respects, will be hereafter detailed. , Eemarks. — In very few cases, however, will any advantage . result from the mere replacement of the organ, when no measures are adopted to keep it in situ. As the natural supports, the ligaments, etc., have become inefficient; and as the uterus, even in the recumbent position of the patient, has always to sustain a TO MAINTAIN THE UTERUS. 37L pressure from the intestines, and from the contraction of the abdo- minal muscles, aggravated by a deep inspiration, by every motion in bed, by coughing, by sneezing, by the evacuation of the urine, of the faeces, etc.: elevators of whatever kind are scarcely removed before the displacement recurs. Such, at least, is the result of the author's reiterated observation, although other practitioners have given different reports. Certainly, however, there will be a return of the displacement on every attempt at locomotion. So that the mere replacement of the uterus may be regarded as worse than useless, as it gives the patient the pain and irritation of a disagreeable operation, which cannot be permanently effectual. The only exceptions to these remarks are in cases of pregnancy, at the third or fourth month, and in enlargements of the organ from other causes ; then, owing to the size of the uterus, it may be supported sufficiently by the parietes of the pelvis, and its sub- sequent developments will insure the permanency of its rectifica- tion. After delivery also, the replacing of the organ, if deviated from its position, keeping the patient strictly in the recumbent position, and avoiding most carefully all straining efforts at stool, etc., may be effectual ; inasmuch as there is a natural disposition of the ligaments el ongate d during gestation to contract, which disposition would be resisted by the displacement, and, of course, be facilitated by frequently replacing the organ. Nevertheless, we have been so frequently mortified by the failure of this plan, and by our patient's chagrin at the return of the symptoms of displacement, even after a protracted wearisome confinement in a horizontal position, that we have abandoned it altogether. To maintain as w^ell as replace is the proper indication in such cases ; this, if fulfilled, gives no discomfort and allows the patient to desert her bed at pleasure. TO MAINTAIN THE UTERUS IN ITS NATURAL POSITION. This is the third and important, indeed essential, indication in the management of displacements of this influential organ. To fulfil this indication is a problem of great difficulty, yet perhaps to be completely solved ; for, after all the attention and ingenuity, and even science, which have been directed to this point in times past and present, no suggestion has received the general 872 TREATMENT OF DISPLACEMENTS OF THE UTERUS. sanction of the profession. Innumerable as liave been these suggestions, each has but a limited number of supporters. Many physicians have avoided such cases entirely, surrendering them to every variety of empirical experiments ; so that women remain too often wretched sufferers, spending days, months, and years, a prey to disorders which disturb every corporeal function, and which often pervert the whole intellectual and spiritual being. There have been no lack of ingenuity, and no want of experi- ments with more or less success, but these efforts have not been generally well directed ; the proper position of the organ in health, its means of support, and the suitable scientific indications to be kept in view for the relief of displacements, have not been suf&ciently developed. There are, however, intrinsic difficulties in all mechanical arrangements operating on vital tissues endowed with sensibility, which, in these cases, is often terribly exalted ; in addition to this there is always present the opposition from the weight of the superincumbent viscera and the great pressure from the abdominal parietes, under the ever varying positions and motions to which the body is constantly subjected. These difficulties will be fully presented in the review of the most important suggestions which have been made for the sus- tentation of the uterus in situ naturali. The criticisms ventured on, in these suggestions, will be found presented, it is hoped, in a just and candid manner, as the result of personal experience or observation in the numerous cases at home and from abroad, which have passed under the author's supervision. Eest in Bed. — In order to fulfil this indication of maintaining the uterus in situ, rest in hed^ with a careful avoidance of all straining efforts, has been much insisted upon, theoretically and practically. Often, the patient has been constantly kept for many months, without the least intermission, on her back, with merely a low pillow for the head. In other cases, when retro- version was suspected, the woman has been forced to lie upon the abdomen, and often to spend. much time on her knees and elbows. Many patients have passed months on the back, with the pelvis bolstered up by pillows, and the head dependent, so that gravity should be enabled to remove the intestines from the uterus; the practitioner forgot that the cavity of the abdomen was a plenum, and that the contraction of the abdominal muscles and diaphragm REST IN BED. 373 acted in opposition to tlie ascent of the intestines towards the chest. Rest diminishes, but does not by any means remove the pres- sure from the uterus. In many patients, perfect ease and freedom from paia are experienced on recumbency ; yet, although the organ may, by some diminution of pressure, be partially restored, it is not completely reinstated, the ligaments are still on the stretch, and the moment the patient rises, her bad feelings return. How often do women affirm, that before rising in the morning, they feel perfectly well and able to do anything; but a few moments' experience out of bed brings bitter disappointment. There is no restorative power in rest ; it palliates, but does not cure, because the ligaments are kept elongated by the unceasing pressure from above, continually increased by every muscular effort of the abdominal tissues. As a preventive to displacements, rest is often of great value, particularly after abortions and delivery at term, when the uterus is large, and there is a natural disposition to contraction on the part of the uterus and the ligaments. Hence, there is some truth in the popular notion, that pregnancy is the best cure for a dis- placed uterus. Displacement disappears when the uterus rises out of the pelvis at the sixteenth week of gestation ; and after delivery, perfect rest, conjoined with proper attention, for some four or six weeks, may insure a complete recovery. The reverse, however, is the usual experience, as most patients date the occur- rence of pelvic trouble from one of their confinements. In what may be called acute cases of displacement, as when some deviation has been suddenly caused by a severe strain, a muscular effort, or great distension of the abdomen, then by rest in bed, by keeping the bladder empty, and the bowels free, the contractility of the ligaments may be sufficient for a restoration. These are rare and exceptionable cases. Rest, as a cure for displacement, has been advocated on another principle, namely, that displacements are owing to congestion, or inflammation of the uterus. By perfect quietude the vascular fulness is overcome, and the displacement relieved. The answer to this is twofold: if the assertion be true, the disease to be cured is not displacement, but congestion; the symptoms depend on the fulness of the vessels, and not on a change of position of the organ ; just as there are few women who have not some of these 374 TREATMENT OF DISPLACEMENTS OF THE UTERUS. so-called symptoms of displacement at their catamenial periods, which disappear either daring or after the flow of the menses. The second answer to this view of the case is, that the conges- tion is not the cause of the displacement, but its consequence, as has been proved in all chronic cases, and even in most of the acute forms. The facts in support of this opinion have already- been detailed at length ; suffice it at present to say, that the treat- ment by rest and evacuants, both general and local, we have often known carried on for months and years, not only without permanent relief, but even with great aggravation of all the symptoms, especially of those dependent on irritation of the cerebro-spinal nervous system ; while, on the contrary, by re- lieving the displacement — the cause of the irritation — the con- gestion has disappeared, and also the nervous s3Tnptoms resulting from pain, confinement, and exhaustion. Eest conjoined WITH ASTRINGENTS. — Most practiiioners, however, do not trust to rest alone, but conjoin with perfect quietude of the body the rise of astringents of every variety and by every means of application, to effect the contraction of the vaginal tube so as to aftbrd a support to the uterus. It is useless to specify the details of this treatment. Its entire insufficiency has been demonstrated in thousands of cases; and the reason of its failure has already been exhibited sufficiently when describing the natural supports of the uterus. It seems impossible for any mechanician to conceive that a soft, flexible, and distensible tube, some three or four inches in length, having the uterus attached to its upper extremity, and running at an acute angle to this organ, could give any adequate support to it even in a state of health. The uterus may descend or ascend ; the fundus may be turned forwards, or backwards to any extent ; flexion, anteriorly or posteriorly, may occur ; yet the natural contraction and tonicity of the vagina, in the young virgin, may at the same time exist in all its original integrity. Even the tube may be pre- ternaturally contracted by spasms, by deformities, by adhesions, and by obliteration of its cavity, and yet painful displacements of the uterus may exist. Surely, therefore, any temporary contrac- tion of this vulvo-uterine canal, by the most powerful astringents (for, after all, the contraction is temporary), must be unavailing in replacing or maintaining a uterus, which has been for any length OPERATIONS UPON THE VAGINA. 375 of time displaced. The unvarying experience of the author veri- fies these opinions, and confirms the facts now stated. Cold and astringent washes have, of course, their own appropriate advan- tages in diminishing irritations, checking discharges, removing inflammations, clearing the passage, preventing acrid accumula- tions, facilitating natural secretions and excretions, and giving tone to the tissues, but are altogether uniuflueutial upon the position of the uterus in the pelvis. Operations upon the Vagina. — The theory that the con- traction of the vagina is requisite to the support of the uterus, has been carried to a much more serious and even dangerous practice. Dieffenbach, Gerardin, Berard, and many others in Europe and America, have resorted to the knife to fulfil this false indication. Strips of the mucous membrane of the vagina, sometimes oval or crescentic, but more frequently of a triangular form, and ex- tending longitudinally from the vulva to the uterus, have been elaborately dissected off, and the edges of the wound brought into contact, so that, after adhesion has ensued, there may be a permanent contraction of the passage. Others have closed the whole orifice of the vagina by causing adhesions to occur so ex- tensively as merely to leave a fistulous opening for the exit of the menstrual excretion. Like all novelties, these operations upon their introduction received much attention, and many favorable results were reported ; but they have not obtained the general confidence of the profession. Certainly, in all the usual displacements of the uterus, they are unnecessary, and, according to the views above presented, would generally be ineffectual. In cases of procidentia uteri, at first sight the suggestion ap- pears to be valuable, and it has been chiefly confined to cases of this character. In such instances there will be a partial success, and perhaps, to some patients, complete relief. But even here the operation is not defensible, for it is often difficult of execution, and, as in all cases of operations with the knife, especially upon the internal tissues of the body, involves many dangers from hemor- rhage and inflammation — simple, erysipelatous, or even gangren- ous, especially as the patients are frequently in a bad state of health from the long continuance of their sufferings and confine- ment. There is danger, also, of injuring the important tissues 376 TREATMENT OF DISPLACEMENTS OP THE UTERUS. of the peritoneum and of the bladder or rectum, either by the scalpel of the operator, or bj subsequent sloughing, so that a vesico-vaginal or a vagino-rectal fistula, with all its disgusting consequences, may ensue. Of course, in some instances, even fatal results may follow.^ Another argument, in addition to the above is, that, at best, the operation can be but partially successful. It may sometimes prevent procidentia very effectually by shutting up the uterus within the vulva ; but it can have no effect, as shown by the facts already adduced, in preventing the continuance of a prolapsus, anteversion, or retroversion of the uterus. Indeed, a retroversion will generally be found to exist in such instances, inasmuch as, as has already been demonstrated, retroversion precedes necessarily a procidentia uteri ; and the contraction of the vagina by adhe- sions, even to perfect atresia vaginae, will not only allow a retro- version to exist, but may maintain the organ in this mal-position. Another suggestion for contracting the vagina is by "serre- fines," or short double spring hooks. A few of these can be easily arranged in the vagina, so as to pinch up and thus retain portions of the mucous membrane until some inflammation has taken place, and the tissues become adherent and somewhat thickened. The operation may be occasionally repeated. We have observed no special reports, either as to the frequency or success of this plan. Another suggestion is to excite inflammation or even ulceration by caustics, more or less severe. This plan has generally been ' Comparatively little success has followed this operation. Our countryman, Dr. J. Marion Sims, and his colleague, Dr. T. A. Emmet, of New York, have somewhat modified the operation by removing strips of the mucous membrane of a V or sometimes of a triangular shape, and drawing the denuded surfaces together by silver sutures. They give encouraging accounts of their success, although they acknowledge some cases of failure. Certainly the operation demands nice and delicate manipulation, and cannot, at any time, be considered free from danger ; neither can it have any effect in relieving ante or retroversion of the uterus which may coexist with the procidentia ; for as Mr. Wright says, the movenaents of the body of the uterus, anteriorly or posteriorly, are above and outside of the vagina. Dr. Emmet has published in pamphlet form (from the New York Medical Jour- nal, January, 1865) an account of his modified triangular operation, reporting seventeen cases as being apparently perfectly cured. He says that similar ope- rations may be performed for cyslocele and rectocele. Nevertheless, he regards it as a formidable operation, by no means easy of execution, and as occasionally failing. He wduld restrict it to old cases of procidentia. EXTERNAL BANDAG-ES, 377 condemned as very uncertain, and always dangerous, as the extent of the ulceration or sloughing cannot be previously estimated. The subjacent tissues might be seriously involved. The strongest argument, however, against such operations is, that they are altogether unnecessary. In all cases, in the expe- rience of the author, of reducible procidentia uteri, this organ and the vagina, however relaxed, can be maintained perfectly in their normal positions by means of suitable pessaries ; and this is true even in cases where the perineum has been lacerated so as to involve the sphincter ani. BxTERisrAL Bandages, — No permanent relief being obtained by rest, position, and astringents, the use of external landages under the various names of braces, abdominal or utero-abdominal supporters, abdominal corsets, spinal supporters, etc., has been resorted to by patients, by empirics, and even by the mass of the profession. This is probably a most ancient practice; it may have been contemporaneous with the first woman who seriously suffered from a displaced uterus. The wretched sensation of weakness in the loins, the feeling of emptiness or vacuity in the abdomen, the bearing-down, and the sensation of " openness" at the vulva, as if everything would escape, almost unconsciously induce the poor suffferer to press her hand on the abdomen or on the perineum for relief, and thus a temporary mitigation of suffering is expe- rienced. A more permanent effect is soon obtained by a towel pinned around the abdomen, or by napkins bound against the perineum. These feminine suggestions have stimulated the ingenuity of empirics and of physicians ; so that almost every imaginable form of compresses and braces, non-elastic and elastic, for the support of the uterus and the parietes of the abdomen, have been succes- sively introduced. The apparent success has been so great, that not only have the supporters crept into general use ; but the principle of avarice has conjoined with the love of doing good, so that every trifling modification of the material, of the size and form of the compress, or the particular part on which it is to operate, has been magnified, as if of the greatest importance, and physicians, graduates in medicine, have disgraced themselves and the profession which tolerates them, by obtaining "patents" for 878 TREATMENT OF DISPLACEMENTS OF THE UTERUS. the exclusive sale of their own trifling, if not ridiculous varieties of a feminine girdle. It would, be interminable, as well as useless to describe the innumerable forms of these supporters, with or without the perineal strap — which renders them a modification of the old and useful T bandage of the surgeons — as thej all act on the same principle, and are productive of the same results. The strong and almost the sole argument for their employment, is the experience of the patient. A very large number find imme- diate relief to many of their symptoms, on applying a bandage ; many say they can walk distances with these supports, and are confined to the house when without them ; many cannot move or even stand without their assistance. We have had patients who declared that if the house were on fire, or their child in convul- sions, they could not stir without previously arranging their girdle. This is strong testimony, and fully justifies a bedridden patient in resorting to this simple apparatus, that she may attend to the duties of her household. It would seem, also, to justify the profession in the recommendation of these bandages to their miserable patients. Ohjections. — Enlarged experience and careful observation falsify most of these fair prognostications. There are innumerable cases in which these bandages cannot be tolerated even for a short period. The sensitiveness of the parietes of the abdomen, of the internal tissues and of the pelvic viscera, renders the pressure of the pads or of the girdle intolerable. Many, who can wear them, find no relief; and in those more favorable cases, where they have been worn for years, their beneficial influences decline and often dis- appear. Even in these cases the relief is but partial, as generally some of the old symptoms pertinaciously remain. We have had many patients who have worn these supporters for years, and could not, on an emergency, cross a room without them ; yet during the whole time they had never walked, even with their assistance, in a continuous path, a distance of one hundred yards, and were tormented with leucorrhoea, dysmenorrhoea, dyspepsia, cephalalgia, or other variety of local or sympathetic irritation. Abdominal supporters should, therefore, be regarded at best as but palliatives to some of the urgent symptoms, but often ineffi- cient even in this respect, and in many cases intolerable. Minor Ohjections. — Even when patients can wear these sup- porters with impunity and apparent advantage, there are nume- OBJECTIONS TO BANDAGES. 379 rous inconveniences wliicli render them often very objectionable and onerous ; for example, the necessity of constantly removing and replacing the bandage ; their friction on delicate and irritable parts; their absorption of the perspiration and other excretions; the frequent necessity of renovating them ; the aggravation of these effects in warm weather, in corpulent females, and in labo- rious women. The perineal band or pad will give special trouble, being liable to many sources of uncleanliness and consequent irritation. Hypotheses of their Action. — Prepossessed in their favor, physi- cians have made so-called scientific attempts to justify their em- ployment of these external supports for a displaced uterus. No one but the most grossly ignorant could imagine that the uterus could be raised up by the compress above the pubis — seeing that all such pressure is above^ not below the womb. But it has been very universally maintained by these professional advocates, that the pressure on the hypogastric region elevated the intestines so that they distended the upper part of the abdomen, and thus pressure was removed from the uterus, alloAving its natural sup- ports to regain their strength and contractility. This is a strange hypothesis for an anatomist or a mechanician to make, and still more strange for the natural philosopher and physiologist ! Is not the so-called cavity of the abdomen a "plenum"? Are not the small intestines movable in every direction, to the extent of the mesentery ? Do they not readily glide wherever there is a tendency to vacuity? Is there not always a steady pressure on the viscera from the walls of the abdomen, and must not great pressure be made to bring even the central portion of the mus- cular walls of the abdomen in contact with the spinal column ? Even if this could be kept up, would there not be an abundance of space for the intestines to glide, each side of the lumbar vertebrae, from the iliac fossae into the pelvis ? This space no external pres- sure could possibly obliterate. If the lower or any other part of the abdomen be subjected to pressure, would not all the viscera be proportionally compressed, and the reaction be in every direction, not merely upwards to distend the epigastric and hypochondriac regions, but also downwards into the pelvis, thus increasing the pressure on the pelvic viscera ? Is not all this supposed upward pressure of the intestines resisted by the liver, spleen, stomach, 880 TREATMENT OF DISPLACEMENTS OF THE UTERUS. and diaphragm, by tlie non-contractile as well as by the powerful contractile tissues of the abdomen ? Is not this resistance, from above, constantly increased, and sometimes forcibly augmented by standing, walking, dancing, straining, coughing, and every conceivable variety of muscular exertion, not excepting the sim- ple natural action of the muscles of respiration ? Do not those women who wear these supporters very universally counteract also this supposed elevation of the intestines from the uterus, by tight ligatures around the epigastric and lumbar regions to which are appended some eight to fifteen pounds weight of under-gar- ments? Is not this counteracting influence generally augmented by corsets, laced more or less tightly, and by fashionable dresses, which demand the strong fingers of the maid-in-waiting, or, it may chance be, little pulleys and strings, to insure the hooking of the dress ? Is it possible to conceive that any pressure, how- ever great it can be made, at the lower part of the body, will prevent all these influences, in addition to the gravity of the intestines, and the continually varying size of the alimentary canal from food, gas, and feculent accumulations? " Credat alter, non ego." As regards the perineal pad or supporter, perhaps more can be said in its favor, inasmuch as, in cases of procidentia uteri, the organ may be kept within the vulva, to the great comfort of the patient ; and in many cases the upward pressure affords compara- tive relief to the sensations. It has, however, and can have, no effect in relieving any of the internal displacements. If the perineum be firmly pressed up- wards in cases oi prolapsus, the os uteri will impinge more firmly on the posterior wall of the vagina, by which any flexion of the uterus will be actually increased, and the symptoms dependent thereon be augmented, while in anteversion or retroversion no change of position can possibly result from this upward pressure. Mere Palliatives. — From what has been said, the conclusion may fairly be made, that external supports are, at best, but pal- liative as regards some of the symptoms of displacement, and that they have no tendency to restore the organ to its proper position ; but, on the contrary, that the whole tendency of the abdominal brace is to aggravate the pressure on the uterus, and increase its deviations. Hence such supporters should be ena- ACTION OF BANDAGES. 381 merated among the causes, original or aggravating, of uterine displacements, and not among the remedies. This view is confirmed by the constant experience of the author. Few patients, for some years, have come under his care in which these bandages have not been used for a longer or shorter time ; yet, in all cases, the displacement was found still existing, and in some to a great degree. Cases. — In one patient, a supporter had been in use for three years, palliating, to be sure, many symptoms ; bat the uterus was so completely retroverted that its posterior surface was parallel to the internal plane of the perineum. In another lady, who had suffered excessively from dyspeptic and cephalalgic symptoms for nine years, and was regarded as a confirmed invalid, a decidedly retroverted and hypertrophied uterus was found existing in spite of the constant use of a sup- porter for the whole of this long period. Hoio they afford relief. — In answer to all these facts and reason- ing, the question is urged : if these supporters do not elevate the intestines, and if they so decidedly augment the downward pres- sure on the pelvic viscera, how can so many patients wear them with so much relief, and be so dependent on them for their com- fort and power of locomotion? There is a twofold answer to this question, and to the mind of the author perfectly satisfactory, as well as in unison with the daily experience of patients and their physicians. Certain varieties of pain and morbid sensations are relieved hy pressure. The pain of a bruised finger is often diminished by even a firm grasp ; aching sensations in the back and limbs are relieved by frictions and pressure. What woman, liable to nerv- ous headaches, who has not found relief by a bandage firmly tied over the forehead and temples ? What woman, in the agonies of childbirth, has not called for a powerful support to her aching back? A young lady, when suffering from what she called universal neuralgia, expressed great delight from a firm grasp of a hand around her arm. Many years ago, we attended a lady sub- ject to the most intense paroxysms of pain in the chest, lasting for a few minutes, and often alternating with a similar pain in the forehead. During the paroxysm of pain, she would call for the most powerful pressure to be made on the sternum by the hands of one or two attendants. As soon as the pain ceased, the skin 382 TREATMENT OF DISPLACEMENTS OF THE UTERUS. became so sensitive, that the weight even of her garments was disagreeable ; but, in a few moments, on the return of pain, the attendants were again earnestly called upon to renew the pressure. The same operation was also required when the neuralgic suffer- ing invaded the forehead. Thus it is, in cases of irritable uterus, the miserable sensations and pain in the back and abdomen are relieved by pressure from the hands or the brace. And it will be found that the relief is often greater from pressure over the sacral region, by which, of course, no support can be given to the internal viscera. In one patient, we remember, who. although she could not tolerate on the hypogastrium the pad of a brace, as the tenderness was so great, lamented she could not have the pressure continued over the sacrum. Even while in bed, many patients must have their hand or some hard body pressed upon the sacral region to give partial relief. This affords one solution of the apparent enigma we are explaining. The second answer is perhaps still more satisfactory. External pressure increases the efficiency of muscular action. Every reader of the Bible is familiar with the ancient practice of girding up the loins for the race. The athletes of Greece, the runners in the Olympic games, following the example of their predecessors, are, in turn, universally imitated by the ambitious ones of modern times, who aspire for victory in the race or the combat. The huntsman's girdle is but a counterpart of the most recherche of utero-abdominal supporters. Many a young, luxurious, fashionable woman, who affirms she cannot walk a step or even maintain herself in a sitting posture, without her corsets, or her tight dresses, will, with them, dance the night through, without acknowledging the least sensation of fatigue. The physiologist knows the importance of the dense fasciae of the limbs in giving efficiency to the muscles which they cover; and the surgeon, wisely taking the hint from nature's arrangements, often resorts to bandages and other measures to sustain the debilitated muscles of an exhausted patient. It is very evident, therefore, that abdominal supporters, by their pressure on the muscles of the loins and abdomen, will often enable weak and enervated females to make much more exertion than they otherwise could do. Hence, a uniform regular pressure over the whole parietes of the abdomen, of a moderate character. ACTION OF BANDAGES, 383 is advantageous in cases of great relaxation and debility of these tissues. Most accoucheurs, therefore, recommend the " binder" to women after delivery, until the tissues have recovered their elastic and contractile powers. Many mothers pursue this plan to preserve the symmetry of their figure, after parturition. The surgeon also applies his bandages to the abdomen after the ope- ration of paracentesis, where there has been great distension from dropsical effusions. So, in many cases of debility of these mus- cular tissues, a moderate compression will prove useful, not only in enabling the weak to endure the fatigue of long walking, dancing, etc., but also the orator to exert his lungs, or the vocalist her voice to the greatest extent. No wonder, then, women often are anxious to wear these braces, and praise them highly, as relieving nervous distresses, and enabling them to take moderate exercise. Let it never, however, be forgotten, that all such pressure is at the risk of depressing the uterus ; and that the idea of replacing or support- ing a displaced uterus by pressure above the pubis, must be regarded as an absurdity in physics, and deceptive in thera- peutics. 8S4 TKEATMENT — INTERNAL SUPPORTERS. CHAPTER V. TREATMENT OF D ISPL A C EMENTS — Continued. INTERNAL SUPPORTERS. TiiEfou7-th mode of treating deviations of the uterus, deserving of consideration, is tlie employment of internal supporters; that is, of foreign bodies to be introduced into the vagina, and so arranged as to replace the uterus, and to maintain it in its natural position. Such bodies have been universally termed pessaries. Value of Pessaries. — Few subjects have occupied profes- sional attention more than these instruments, and in few instances have the opinions of practitioners been prone to more vacillation. The pessary has been highly extolled at one time or by one set of physicians ; while at another period, or by another set, the most severe criticisms have been poured out on their use, as inefficient and dangerous. Whence these extremes? Doubtless it is owing to a want of attention, to a limited experience, and especially to an absence of proper scientific principles in guiding and regulating the practitioner in their employment. The long experience of the author in the use of pessaries will perhaps justify the expression of his opinion, that the mechanical treatment of uterine displacements by intra- vaginal supports is essential, a "sine qua non," for their perfect relief; that by pes- saries of suitable material, size, and form, the uterus may very generally be replaced and be maintained in situ ; that the local symptoms of weight, pain, etc., the leucorrhoea, the monorrhagia, the dysmenorrhoea, and all the innumerable direct and indirect symptoms of spinal and cerebral irritation, including neuralgia, nervous headache, nervous affections of the larynx, lungs, heart, stomach, bowels, etc., as also spasms, cramps, and convulsions, may often thus be dissipated ; that the intellectual and spiritual being may be elevated from the lowest states of depression, bor- dering on melancholy, or be delivered from the highest degree TEUE VALUE OF PESSARIES. 885 of maniacal excitement ; and that the whole economy may thus be revolutionized. Patients often are amazed at their own altered sensations ; they can hardly realize their identity — feeling as if they were either renovated, or that they had been transported to a " new world." This will doubtless be regarded as very extravagant — as the language of an enthusiast ; but the author has merely recorded the expressions of many of his patients who have been relieved ; but he would by no means wish to convey the idea that sucli ecstatic feelings are universal. He is, by painful experience, fully aware that here, as in all other cases, disappointments will occur; that partial relief only is sometimes afforded; and that great patience, with often long perseverance in the scientific use of appropriate measures, may be requisite. Yet, he feels per- fectly confident that when, by mechanical measures, displacements of the uterus are completely relieved, and when the agents them- selves excite no irritation, such results may be anticipated. The difiiculties arise from the improper character of the instruments employed, the mechanical obstructions to a replacement of the organ, the great sensibility of the vital tissues involved, the timidity and nervousness of the patient, and too frequently the want of proper indications in carrying out the treatment. Ex- perience proves that these obstacles are great : they have hitherto defied the efforts of physicians, as proved by the discrepancies of opinion on all these points, and by the numerous varieties and modifications of pessaries suggested by the ingenuity of their advocates, who have not even yet satisfied themselves. Much, doubtless, is to be done, but science and ingenuity, with careful attention and perseverance, may soon render recoveries rapid and easy where difficulties now seem to be almost insur- mountable. Objections to Pessaeies. — Great objections, however, exist and are urged against the use of all these internal supports, which must be carefully examined, so as to present the subject fully before the mind of the practitioner. Pessaries are condemned by many as exciting pain, irritation, and inflammation, followed by increased watery or mucoid secre- tions, and purulent discharges, often of a bad and putrid charac- ter, by ulcerations of the os uteri and of the vagina, which 25 386 TREATMENT — INTERNAL SUPPORTERS. ulcerations are said to have penetrated the bladder, the rectum, and even the cavity of the peritoneum. Of course, in such cases, the pain and sufferings of the patient are augmented, emaciation and fever may be excited, and even the life of the patient in- volved. Such is the language of the opponents of pessaries; but certainly these bad consequences must be numbered among the abuses of the instrument, rather than its legitimate results. If the same mode of reasoning be applied to any of the powerful articles of the Materia Medica, such as mercury, arsenic, prussio acid, opium, ether, or chloroform, the mischievous influences of these valuable agents for alleviating human suffering would appear to be well established. "We cannot argue against the use of a thing from its abuse. The evils attributed to these instruments arise chiefly from three sources, namely, from the material, form, and size of the instrument. The improper character of the material employed in their con- struction is a frequent source of trouble. Any article capable of decomposition should not be allowed to remain in the vagina, where there is always heat, moisture, and atmospheric air, so that disintegration of such a pessary speedily ensues; whence acrid and putrid discharges and inflammation necessarily follow. These natural results are often enhanced by the vaginal and ute- rine secretions, which seem to have, to some extent, a corroding power. The second source of mischief is the form of the instruments. Frequently they are constructed with thin edges, angular projec- tions, points, or other inequalities; also some have perforations, into which the neck of the uterus or the mucous membrane of the vagina projects; or they are furnished with a stem, which, projecting out of the body, not merely renders the instrument fixed with an unyielding pressure on the tissues, but aggravates the irritation, especially at the orifice of the vagina and the vulva. A third source of discomfort, and a very frequent one, arises from inordinate pressure, either from the too great size or power of the instrument, or from its pressing, in an improper direction, too firmly on particular portions of the uterus or vagina; whence, of course, inflammation, ulceration, etc., follow. In all cases it has been a matter of surprise to the author to find with what rapidity fetid discharges, inflammations, and even OBJECTIONS TO PESSARIES. 387 ulcerations of the uterus and vagina, vanish on the removal of the cause, and the use of detergent and astringent washes. In a few days their bad effects are usually dissipated. There can be little doubt but that, by care and attention, all these objections to the pessary can be obviated. The important declaration may be safely made, that pessaries can be worn for many months, not merely with impunity, but with great advan- tage, keeping the organ in its natural position, relieving the symptoms of displaced and irritable uterus, the terrible irritations of the cerebro-spinal system, and allowing the bedridden and nerv- ous patient to exert again her powers of locomotion and resume the duties of her social position, without any local disturbance or uneasiness. She finds herself relieved without being conscious of the presence of the agent by which she is benefited. A vagi- nal injection of pure water every day is almost the only attention required. We are abundantly satisfied that these bright hopes may be realized by the scientific employment of suitable pessaries. The difficulties may be great, and the means of success perhaps imperfect ; but there is no doubt in the author's mind that proper indications can be established, and that human ingenuity, in unison with skill and patient perseverance, will insure a success which, to the minds of many, may now be deemed Utopian. IxDiCATioxs TO BE FULFILLED. — More particularly it may be urged that a pessary should be made of incorruptible materials. It should restore and maintain the uterus in its normal position at all times, under the ever-varying pressure from above. It should be movable with the uterus, allowing of the natural mo- tions of this organ, yet effectually preventing any displacement. It should be one with the uterus. It should be worn without pain, uneasiness, or discomfort, indeed, without any consciousness on the part of the patient. It should relieve, and not increase, nervous irritations. It should excite no organic or vascular dis- turbance, no engorgement, no inflammation; and, therefore, it should be influential, not in increasing leucorrhoeal and menor- rhagic discharges, but, under proper restrictions, as will be demon- strated, in contributing to the resolution of chronic inflammations of the OS and cervix uteri. Material. — The first requisite, therefore, in a suitable internal supporter, is incornqjtihi'ity of the material of which it is made. 388 TREATMENT — INTERNAL SUPPORTERS. The instrument ought to be worn for months, and even for years. The decomposition of the material would, of course, be incom- patible with this necessity, as the frequent removal and replacing of a pessary is a subject of annoyance and irritation, mental as well as physical, and as the discharges, becoming unpleasant, fetid, and irritating, produce internal and external inflammation. The numerous suggestions of employing wood^ cork, wax, sponge, hair, ivory, horn, cotton, and even the preparations of gum-elastic or of gutta-percha, that have been ordinarily employed, should be entirely disregarded. Many of these vegetable and animal sub- stances imbibe and retain the natural secretions, which then in a few hours or days become excessively fetid and irritating ; while all these materials, if retained, are liable to decompose in a longer or shorter period, and thus become intolerable. This observation is true of gutta-percha, which has been highly extolled and extensively employed; some of the most offen- sive pessaries we have ever removed have been of this material, too offensive to be tolerated in the room after their extraction from the vagina. Occasionally this decomposition has been so great as to injure, to a destructive extent, the steel spring and its envelop of cotton thread, which gave firmness to the instrument. This is the fact ; the explanation of it was not at first apparent, for gutta-percha is considered to be one of the most incorruptible of materials. Yet it should be remembered that though it resists the action of the strong acids, it softens at once in warm water. In the vagina we have heat and moisture always present ; these, with the pressure to which the pessary is subjected, no doubt soften and attenuate the gutta-percha, so that the secretions pene- trate to the steel spring, corrode it, percolate between it and the gutta-percha, and putrefy. Perhaps, also, some chemical change, besides mere solution, is produced in the gutta-percha by the chloroform employed in the manufacture of these instruments, or by the acid secretion of the vagina. Iron, steel, silver, and German silver oxidize rapidly in the vagina. Pure tin oxidizes slowly, and can be worn for a long time without alteration. Mr. John Warner, our instrument-maker, employs a cheap material of tin, zinc, and lead, which answers for a time, but should not be trusted in patients who cannot be frequently seen. Perhaps one of the best articles is glass, which has been very MATERIAL. 389 commonly used in the form of globular and disk, or concavo- convex pessaries ; yet, in many instances, the polished surface of the glass has been entirely destroyed, so that it has become opaque and rough like ground glass. Glass, however, cannot be moulded so as to be safely employed in the various shapes that are requisite, and women are generally timid as to its use. Be- sides, globe pessaries of this material, unless very thick, cannot always be removed from the vagina without risk of a fracture. Porcelain pessaries would prove equally indestructible, but are too heavy when spherical or elliptical ; and as regards the most desirable form, the artisans, that we have employed, have failed in their manufacture. Platina and gold are perhaps the only metals suitable for prac- tical purposes. The former, from its weight and expensive cha- racter, has been seldom used ; but gold has been, at least in this country, very extensively used, especially as a covering for silver. The expense has been too great for the employment of the pure metal, and even the silver-gilt pessary costs too much for general use. It is almost the only material, till lately, that we have de- pended upon. AYe have had patients who have worn silver-gilt pessaries for five and occasionally for nine years, without any bad consequences. Nevertheless, the gold will wear off; in some instances, after a long time, it will be acted on by the acridity of the menstrual and leucorrhoeal discharges ; and not unfrequently it becomes tarnished, even when the coat of gold is intact. There can be no doubt that, with some patients, owing to peculiarities of their secretions, the gold disappears with comparative rapidity, while in others, after the lapse of years, no alteration has ensued. The remark may be here made, that instruments are often said to be corroded, when no injury has been sustained; deposits of mucus and of m.enstrual fluids accumulate, particularly where daily vaginal washes have not been employed, dry, incrust the instru- ment, and make it rough and even irritating. In some instances, particularly in bedridden patients, calcareous deposit has been found on the pessary, as if the urine had settled into the vagina, and its salts deposited. There is, however, another substance of great value; it is a comparatively new preparation of caoutchouc, brought into use and patented by Goodyear, the celebrated manufacturer of this 390 TREATMEXT — IXTERXAL SUPPORTERS. article. It is commonly termed '■''hard hvlla-riLbher^'' or '■^hard vulcanite^'''' and has been worked up into many useful articles, such as syringes, combs, pencils, fountain-pens, rings for harness, etc., and is represented as being incapable of decomposition, and able to resist the action of concentrated acids and the most power- ful chemical reagents. The experiments that we have made with this article for pessaries have been very favorable; no perceptible change has been manifested in the integrity of the ring after being worn for years, even in cases where leucorrhoea existed. The smooth, polished surface has not been altered even when it has been covered with diYj mucoid deposits. It is, therefore, a cheap and excellent material for such agents.* f Form of the Instrument. — Many of the various shapes ' suggested for these instruments have proved so inefficient and objectionable, that they have been successively discarded by large numbers of the profession ; and many practitioners have even entirely abandoned the use of pessaries. Let it be observed, however, that different patients, from peculiar modifications of the displacement, or certain complications, may demand not merely supporters of various power, but of diverse shapes, to fulfil the indications. A very mistaken idea is prevalent, that a pessary is merely to be pushed into the vagina by the physician, the nurse, or the patient, and left to fix its own position, to replace the organ, and to afford permanent relief. Hence, physicians sometimes, without even a vaginal examination, have handed an instrument to the sufferer, and requested her to operate on herself, altogether regardless of the kind of displacement, the proper form or even the size of the pessary employed. No wonder that such practice has been ineflEicient, and that bad consequences have followed ! I The introduction of the instrument should be made with care, and its adjustment often requires much time and patience ; indeed, the complete reposition of the organ in cases of long standing, where the tissues are accommodated to their unnatural position, or when tumors, adhesions, or other impediments exist, may be ' Eight sizes of our closed-lever pessaries have been made of this material. They may be obtained from the American Hard-Rubber Co., or the surgical instrument- makers, J. H. Gemrig, No. 109 S. Eighth Street, D. W. Kolbe, No. 15 S. Ninth Street, and others. GLOBULAR. 391 the work of weeks or even months, requiring pessaries of varied forms and power. Eeplacement can thus be gradually accom- plished, even in cases apparently desperate. In many cases of chronic retroversion of the uterus, even without but especially with flexion, time is demanded to fulfil the important indication to move the fundus uteri from its depression near the coccyx, along the cavity of the sacrum, to its legitimate position behind the bladder, and among the small intestines. , All pessaries should be perfectly smooth and even polished, so as to facilitate their introduction, and not allow any adhesion of the mucoid fluids to their surface. They should not be very thin, as they would press too much into the tissues and be apt to induce inflammation. They should always be free from irregu- larities and angular projections, lest they should produce u.ndue pressure. It will be profitable to review the most important forms, which have been proposed for the relief of displacements of the uterus, and to present, with all candor, their respective advantages and disadvantages. The object of the writer is truth and the relief of human suffering; hence, the objections and dangers of the varieties suggested by the author, as well as those proposed by others, will be detailed, even while recommending their trial to his professional brethren. Globular Pessaries. — The globular or spherical pessary has apparently much to recommend it, as being perfectly smooth, without angles and edges, and as demanding no special adjust- ment after introduction. It has been highly spoken of by dis- tinguished men, and at one time was regarded by many as perfect in its influences. Now, however, it has greatly fallen into disuse, and apparently, justly. A small ball is perfectly useless, while one large enough to be retained requires considerable force and pain to introduce, and even then is seldom of sufficient size to be useful. If retained, a globular pessary almost always rests at the lower extremity of the vagina, under the urethra, and in front of the inferior portion of the rectum. It keeps up a disposition to urinate, and frequently a tenesmus, particularly after the bowels are moved. The support that it affords to the uterus in anteversion, is sometimes very good, indeed, all that is required, and to such 392 TEEATMENT — INTERNAL SUPPORTERS. cases, it is best adapted. In prolapsus uteri, it cannot be de- pended upon. In one case only have we ever found it to answer, and then the ball had fortunately made a lodgment at the side of the cervix uteri. But ordinarily, in prolapsus, it lies in front of the uterus, and therefore can give it no support ; and the organ descends behind the pessary on the posterior wall of the vagina. In some cases, we have found the lower part of the cervix uteri pressed under the globe, so that the anterior surface of the organ was rendered concave by the convexity of the pessary, consti- tuting a prolapsus with flexion ; the pessary had actually aggra- vated all the symptoms of uterine irritation. In retroversion of the uterus, the globular pessary, so far from being useful, is posi- tively injurious. It unavoidably gets behind and beneath the cervix, which is thus turned more and more upwards, while the fundus necessarily sinks lower in the cavity of the sacrum, in- creasing the pain and aggravating all the symptoms of irritable Titerus. In procidentia uteri, the ball, if very large, may possibly be retained, and prevent the external projection of the organ, although it will not ever return it to its proper position. But very universally, the ball, owing to the laxity of the vulva and vagina, will even fall out almost as rapidly as it is introduced. The introduction of ball pessaries is easy to the practitioner, but generally painful to the patient ; because an instrument comparatively large as respects the orifice of the vagina, is re- quisite that it may be retained and give sufficient support to the uterus. The patient should be placed directly on her back; then the vulva and the pessary being anointed, and the labia separated, the ball is to be pressed slowly and steadily into the orifice of the vagina in the direction of the axis of that canal, so as to stretch the posterior margin of the vulva, and make as little pressure as possible on the urethra. The removal of the instrument can often be accomplished by the bearing-down efforts of the patient, more readily than by the practitioner. "When, however, from the large size of the globe, this is impracticable, the removal can be accomplished hj suitable instruments ; a pair of placental forceps may sometimes be requi- site, but the most simple and ef&cient instrument is a small curved lever, a drawing of which is given, diminished to half its size. The practitioner can now extract the ball by introducing GLOBULAR. 393 tlie lever behind the pessary, and supporting its opposite side with his finger. Similar observations apply with more or less truth against every modification of the spherical pessary, such as the hemi- sjyherical, the egg-shaped^ the barrel- shaved, the conical, and the cylindrical, whether short or long cylinders. They all may be occasionally useful in special cases ; but in the usual forms of displacement, they are useless or injurious. They occasionally prove useful, as adjuncts, to increase the power of other forms of these instruments. We have found them advantageous in ele- vating the womb, whether simply enlai'ged or complicated with tumors, which occupied the cavity of the pelvis, pressing on the bladder, rectum, or nerves of the pelvis, and thus exciting the severe symptoms of irritation. We have succeeded in elevating these masses out of the cavity of the pelvis to the great and per- manent relief of the patient, by gradually distending and enlarg- ing the vagina by one cylindrical or globular pessary after another. This object being accomplished, the pessaries were removed, and the enlarged uterus remained suspended on the brim of the pelvis, like the uterus after "quickening," in gesta- tion. The introduction and removal of these pessaries can be accom- plished in the manner already described for the globe. In the use of the lever, for the removal of cylindrical pessaries, however, some care will be necessary in fixing the lever upon one ex- tremity of the cylinder, so that the instrument shall not become transverse, and thus interfere with its easy removal. Concavo- Convex Pessaries. — The concavo-convex pessary with a central opening — the flat circular disk — the saucer-like pessary — or perhaps best known in this country as Dewees' pessary, having been strongly recommended and employed by the late Prof. Dewees, of this city, has been very extensively resorted to in the United States, and so successfully that its supremacy for many years was undoubted. There were but few practitioners who did not depend on this disk. 394 TREATMENT — INTERNAL SUPPORTERS. It answers very well in anteversion and prolapsus of the uterus ; and in procidentia uteri it is perhaps still superior to any other pessary, as in this respect it has the advantage even over the varieties of the ring in distending and supporting the relaxed vagina, so as to prevent its descent, as well as that of the uterus. In such cases, we still often employ it. In retroversion of the uterus, it can at best merely palliate. It diminishes the degree of retroversion, but cannot, unless perhaps when very large, restore the fundus to its natural position. The reason is evident. The convex portion of the pessary rests on the perineum, an inclined plane from the vulva to the coccyx. The edge of the pessary will always be felt at the orifice of the vagina during all the straining efforts of the patient, and, of course, the upper edge or opposite portion of the circumference does not rise so as to elevate the depressed fundus uteri. This margin of the disk and the fundus of the uterus remain in the hollow of the sacrum. A partial retroversion will still exist to torment the patient. Although these pessaries may be so frequently useful, and have been so extensively employed, yet they have deservedly fallen into much disuse. Their inefficiency in the common case of retroversion has greatly contributed to this result, but there are other serious objections to their general use. Much inconvenience results from the complete occupation of the vagina, and still greater from the retention of fluids chiefly between the uterus and the concave or saucer- like surface, where they putrefy and become irritating and offensive. The idea that these fluids would be discharged through the circular foramen in the centre proved fallacious ; the posterior surface of the vagina pushes into and acts as a perfect stopper to this opening. The extremity of the cervix always rests firmly on the concave or superior surface of the pessary, so that flexion is augmented, the mucous membrane of the os is irritated, or inflamed, and some- times a fungoils growth, by the pressure of a lip of the os uteri into the orifice of the pessary, is generated. Such fungous gra- nulations we have known project also from the posterior vaginal surface into the opening. The uncleanliness of the instrument, and these inflammatory effects frequently resulting, conjoined with its inadequacy to relieve retroverted or retroflexed uteri, justify its almost entire abandonment. The introduction of concavo-convex pessaries is easily accora- CONCAVO-COXVEX — PLANO-CONVEX, 895 plished by separating the labia and pressing the instrument ob- liquely, so that one edge is to the left of the urethra, and the oppo- site side to the posterior margin of the vulva a little on the right. The pessary must now be pushed downwards and backwards, the patient being on her back, in the direction of the axis of the vagina, taking care that it assumes the transverse position after its introduction, so that the concavity shall be towards the uterus. The removal is effected by placing the finger on the concave surface of the disk, thus making firm pressure against the walls of the vagina, and taking care that the instrument passes ob- liquely through the orifice of the vagina. If any difiiculty be experienced from the size of the pessary, or the contraction of the orifice of the vagina, a hook, as repre- sented in the diagram at the extremity of the small lever,' may be passed into the opening in the centre of the pessary, by which traction can be efficiently made. Piano- Convex Pessaries. — "We have made some experiments with a plano-convex pessary, and find it adapted to some cases of greatly relaxed vagina with or without procidentia, to displace- ments of the ovaries, as well as of the uterus, where there is much enlargement, etc. Its only advantage, however, over Dewees' pessary is, that it is more cleanly, as the fluids are not so much retained, and there is less irritation to the os uteri; but otherwise it is liable to most of the objections of the concavo-convex pes- sary. The modifications of this form, with surfaces more or less flat, and edges varying in thickness, have been very numerous ; hence we have i\\Q flat oval pessary, the ellij^tical^ the long plano-convex (a longitudinal cylindrical section), also the flattened cylinder (a long- pessary, say three inches, with the extremities and transverse sec- tion elliptical), which is said to be an exact mould of the vagina, and so also the spoon-shape pessary, the extremity being straight or even a little concave. In practice, all these are very ineffi- cient ; and are not comparable to the circular disk, which, always presenting the same diameters, cannot be displaced ; while the others press irregularly, and their long diameter will never remain parallel to the length of the vagina, but becomes either oblique or directly transverse, doing little or no good. Indeed, those ' See diagram, p. 393. 396 TREATMENT — INTERNAL SUPPORTERS. who have patronized them seem to hav^e had no other jdea than merely to push the orifice of the uterus away from the vulva and perineum, regardless of the position of the fundus, or the direction of the axis of the organ. The transverse position of the pessary must, it would seem, have been considered desirable, as in some of these elliptical or long pessaries, the sides have been made concave to accommodate the urethra and the rectum. Many of them also are perforated in the centre ; the flat cylindrical one has a canal through its whole length, under the vain notion of facilitating the discharge of fluids, but really proving a source of irritation, as the tissues press into the openings, and the dis- charges accumulating become putrid. Many other modifications have been suggested ; but all are liable to the same objections, and especially on account of the constant pressure they make on the delicate, irritable, and sensitive tissues of the os and cervix uteri. " Zwanc'ke'' s''' or the " Butterfly Pessary ^^'' which is much used in Germany and also in Britain, has also attracted some attention on this side of the Atlantic. It consists of two wings, fenestrated, representing the section of an oval, being comparatively large at one end, and tapering to the other ; very analogous, although much smaller, to the blades of Smellie's forceps. The small ex- tremities are connected with a hinge, and are prolonged into short handles, which decussate each other ; so that when they are ap- proximated, the wings are separated ; and when the handles are separated the wings are approximated. This movement in the handles is ingeniously determined by a screw in the form of a small button, and perfectly smooth. The alie, or wings, being brought together, are introduced deeply into the vagina, and by turning the button are made to separate, so as to distend the vagina laterally, making no pressure against the uterus. The removal is effected by causing the wings to approach each other by reversing the action of the screw. The whole operation is so simple, that it is said women can execute it at pleasure. We have. had no personal experience with this instrument, but good practitioners speak of it favorably in cases of great relaxa- tion of the vagina, with procidentia uteri, etc. The objections which suggest themselves to our miud are the constant irritation which must arise from the presence of the bulb at the orifice of the vagina, and also the occupation of this opening by the lower THE RING IN CHRONIC INFLAMMATIONS. 897 portions of the instrument, as interfering with the natural func- tions. Air Pessaries. — Many practitioners are so apprehensive of mis- chief from hard bodies in the vagina, that they have recommended such substances as sponge, wool, cotton, etc., as pessaries. A more feasible suggestion is that of employing gum-elastic sacks filled with air. Hence, globular pessaries of caoutchouc have been, by some, much employed ; while others have resorted to the disk-shaped with a central perforation, to be inflated with air. As regards these peculiar /o?'7?2s, the same advantages and dis- advantages ensue as have been pointed out respecting the disk and globular pessary. The objection to the material, gum-elastic, is, that decomposition will sooner or later take place, necessitat- ing their removal. No advantage is to be gained by the softness or elasticity of the pessarj^, which, on the contrary, may prove too yielding to resist the tendency to displacements. Ring Pessaries. — The ring pessary has been, of late more espe- cially, substituted for all these varieties. There are several modi- fications of this form, but they all have the strong recommendation of affording protection to the cervix uteri. The vagina, on their introduction, is made more or less tense, so that the whole uterus is supported by the tent-like expansion of the superior surface of this tube, with very little pressure against the body of the organ ; while the cervix is entirely free from pressure of the instrument, and even from resting on the posterior wall of the vagina. This great recommendation of the ring pessary in all its varie- ties has never been sufficiently exhibited. All the usual accu- sations against other pessaries of producing inflammation of the cervix, are not applicable to the ring. It produces no pressure on the cervix, and therefore cannot irritate or inflame it. Much more, however, is accomplished than this negative effect. It re- moves irritation ; it obviates, immediately, all the bad effects of the superincumbent pressure on the uterus, which produces pro- lapsus, flexion of the cervix, organic irritation, inflammation, ulceration, and other irritating consequences from friction against the posterior wall of the vagina and the feculent accumulations in the rectum, as formerly detailed. They thus also assist the antiphlogistic remedies for chronic inflammation of the os uteri, to which so much attention has of late been directed in Europe in America. 898 TREATMENT — INTERNAL SUPPORTERS. As has formerly been mentioned, the supposed indomitable character of these inflammatory disturbances of the cervix is often kept up by the pressure and friction of the os against the perineum. This pressure being obviated by means of a ring pessary, resolution of the inflammation may occur almost spon- taneously ; as the congestion and irritation of the conjunctiva disappear on the removal of a mote from the eye. Or, it will rapidly disappear under the usual astringent or detergent washes, occasionally assisted by solutions of the nitrate of silver. At least such has been the author's experience after the lapse of many years, in which he has acted on this principle; during which long period, he has never found it requisite to apply any powerful caustic for the eradication of such inflammations. That such caustics, even not excepting the actual cautery, may be sometimes valuable, when judiciously employed in syphilitic, fungous, cauliflower, cancerous, and other specific degenerations of the cervix, need not now be debated. The magnitude of the danger may justify the heroic character of the agent; but let no surgical treatment be resorted to in cases of phlogosed states of the neck of the womb, which a respectable surgeon would con- sider unjustifiable in analogous cases, upon the skin, eye, or throat of his patient. We have carried this principle to a still greater extent with most satisfactory results. In chronic inflammations, where the whole cervix has been indurated; where there is "ectropion" of the edges of the os from turgescence and thickening of the lining membrane of the canal; where this has become so tender and vascular that the touch of the finger or instruments, or pressure from walking about the room, produced sanguineous discharges with pain and bearing-down sensations, giving anxious suspicion of some malignancy being present : in such cases, the use of the ring has not merely given great temporary relief, but has facili- tated the subsequent recovery without the necessity of confining the patient to bed, with all its enervating results. Although inflammation of the uterus is seldom if ever induced by the ring, yet vaginitis, with its usual consequences, may ensue from inordinate pressure due to the size, or any irregular portion of the ring ; hence leucorrhcea, purulent discharges, ulcerations, and adhesions, may by inattention or carelessness be excited as by other pessaries. FLAT KING. 899 A caution perhaps may be useful as regards the thickness of the pessary. Very thin ones indent the vagina, and are apt to irritate ; while very wide ones — we have used them an inch in thickness and of course proportionally small in diameter — prove injurious to the cervix, not only by confining the fluids, but by acting as a suction power facilitating the engorgement of the cer- vix, and its consequent enlargement. This bad effect we have witnessed so frequently that its occurrence should be appre- hended. The fiat ring pessary as a uterine supporter has similar influ- ences with the Dewees pessary, but perhaps is not so efficient. It often answers very well in procidentia uteri, when there is great relaxation of the vagina ; but it does not so well retain the vagina within the vulva as the concavo-convex, or the plano-con- vex instruments. In the other forms of displacement, it also seems inferior to the disk, as the convexity of the disk towards the rectum renders it more movable with the uterus, and allows the upper margin under the uterus to rise higher on the face of the rectum and sacrum. As intimated, the inefficiency of this form of the ring arises from its flatness. Under the pressure from above, it will, indeed must, remain parallel to the plane of the perineum. Hence, one part of the circumference may be felt towards the orifice of the vagina, while the opposite segment necessarily presses against the rectum. As the patient walks and strains, this pressure, if the pessary be large, may become very inconvenient and sometimes intolerable ; it keeps up, in such cases, a tenesmus, a sense of weight and pressure, and in some instances partially or completely obstructs, like a valve, the feculent evacuations, while under the straining efforts of the patient the closure of the intestine becomes more perfect. The anterior segment of the ring often rises against the urethra, causing dysuria, or even retention of the urine, de- manding the removal of the instrument. In retroversion of the womb, very trifling advantage is gained, in most cases, by the use of this flat ring, as the fundus is pushed up by it only a short distance from the coccyx, while pressure of the body of the uterus against the ring but aggravates the obstruc- tion to the faeces in the rectum with its bad consequences. To obviate these effects, it has been suggested to increase the 400 TREATMENT — INTERNAL SUPPORTERS, diameter of the instrument, that it might rise higher on the sacrum, and through the medium of the vagina acting on the posterior lip of the cervix might draw the neck backwards towards the sacrum, and thus facilitate the ascent of the fundus from the surface of the rectum and sacrum. Practice does not confirm these expectations, the pessary remains flat on the perineum, and the location of the cervix is not much affected THE FLAT KING IN POSITION, through the medium of the vagina ; the neck either does not move, or if somewhat drawn back, flexion is produced, or in- creased, if already existing, while the fundus still rests in the hol- low of the sacrum. At least this is our constant experience, of which we have had a great deal in the use of this form of the in- strument, as after abandoning the circular disk, it was chiefly with the flat ring that most of our observations were originally made. These facts are represented in the diagram. The ordinary flat rings are to be introduced and removed in the same manner as the disk pessary. When in proper position the posterior margin of the ring should be behind the neck of the uterus. STEM-PESSARIES. 401 To introduce a large sized ring, especially in cases of a con- tracted orifice of the vagina, two suggestions have been made. The first by the author consisted in removing a segment of the circumference from an inch to an inch and a half, so as to have an interrupted or imperfect ring.' One extremity of this segment was first introduced through the orifice, and the whole ring was made to revolve as it was pressed into the vagina, so that the other extremity of the segment was the last part to enter. When the vulvo-uterine canal was relaxed, a very large ring could thus be emjjloyed with very little pain or difficulty. The other suggestion has been strongly recommended by Dr. Meigs, of the Jefi'erson Medical College. It consists of a watch spring of delicate steel well covered with thread, and afterwards frequently dipped in a solution of gutta percha in chloroform, until it has received a coating of the requisite thickness. This ring is very elastic, and can therefore be readily compressed into an elliptical shape, and thus easily pushed into the vagina, where it resumes its circular form. Whatever ingenuity may be thus manifested, as regards the in- troduction and removal of a large pessary, yet no beneficial change is effected in the operation of the ring by its increased size. Lately we removed a large ring pessary of fu'll three and a half inches in diameter, from a lady with a retroflexed uterus, which still allowed the fundus to remain in the hollow of the sacrum. Stem- Pessaries. — The inefficiency of all the pessaries above alluded to, in cases of retroversion, has been practically found so great, that numerous modifications of the ball, conical, ring and other forms, have been made and connected with stems or handles, projecting out of the orifice of the vagina, so as to maintain the pessary in situ. By most operators, these stems have been at- tached to a framework and bandages outside of the body. Fail- ing in various efforts to rectify the position of the uterus, by means of the circular or elliptical ring, we also endeavored to increase the efficiency of the instrument by the addition of stems, but found that they were productive of too much irritation. Without going into details as to the varieties of stem-pes- saries, used extensively in Europe and America, the following serious objections may be urged against their employment. The ' See diagram, p. 415. 26- 402 TEEATMENT — INTERNAL SUPPORTERS. external framework and bandages are all productive of incon- venience, and frequently of positive mischief, as already men- tioned, when speaking of external supporters. They must be frequently removed, sometimes even to allow of the natural evacuations, and, of course, they have to be readjusted by the pa- tient herself, ignorant of the indications to be fulfilled. The stem, however smoothly made, and of whatever size, proves a powerful irritant by the pressure and frictions against the very sensitive tissues at the orifice of the vagina, and, to many patients, is actually intolerable. Few persons can bear its constant use for any length of time ; indeed, the instrument is very universally removed upon retiring to bed. Hence, the little advantage to the displacement gained during the day, will be lost at night. Perhaps the most serious objection to stem-pessaries has not been sufficiently regarded, namely, their immobility. The pessary in the vagina becomes a fixed point by means of the stem. It yields naught to the natural motions of the uterus ; it affords a firm re- sistance to any part of the vagina, and of the neck or body of the uterus, against which it may impinge during every effort of the patient, in standing, walking, straining, etc. Pain and irritation must necessarily result to the detriment, if not serious injury, of the tissues. The reason, doubtless, that no more bad effects have resulted, is that such supporters are used only for the occasion. They are removed when the patient is at rest, whether by day or night. Finally, stem pessaries are universally, with one exception, hereafter to be mentioned, incapable of sustaining the uterus in the direction of the axis of the superior strait. All these arrange- ments are predicated, it would seem, on the simple idea of keep- ing the uterus, within and at a certain distance from the orifice of the vagina, without any attention being paid to the natural posi- tion of the OS and fundus. Should these reasons be found valid by others, as they are con- firmed by the observations of the author, stems will be univer- sally abandoned, not only as useless, but as injurious. Notwithstanding these and other analogous objections to stem- pessaries, they are still much employed ; as patients suppose that they can thus be independent of their medical attendant. Simpson's Intra-uierine Pessaries. — Numerous other varieties of pessaries have been proposed, which, perhaps, universally fail in INTRA-UTERINE. 403 the essential point of giving proper direction to tlie body of the uterus, and, therefore, need not even be described. To this ob- servation there is one important exception as regards a compara- tively new instrument, combining the external framework, the vaginal stem and pessary, with a stem or style to project into the cavity of the neck and of the body of the uterus. Professional attention has been turned to this "intra- uterine pessary," as it is termed, by the talented but enthusiastic Professor in the Univer- sity of Edinburgh, now Sir James Y. Simpson, with whose valua- ble suggestions on many subjects the profession are familiar. His course is, however, to be followed like that of most pioneers, "cum magna prudentia longo intervallo:" especially in the em- ployment of this instrument, very efficient in restoring or fixing the uterus in its normal position, but fraught with many dangers. Dr. Simpson having found that although the uterus could be restored to its proper position by the uterine sound, yet, upon the removal of this instrument, the displacement immediately re- curred, however often the operation had been repeated, conceived the idea of retaining a short sound for a certain time in the cavity of the uterus by a suitable apparatus. After various attempts, he succeeded to his own satisfaction, and has presented us with three modifications of his " intra-uterine pessary." The first and second consist of the extremity of a uterine probe, perfectly straight, two inches and one-third in length, and connected with a flat cir- cular disk at its lower extremity, which in the first was solid, smooth, and small ; in the second this disk was larger, of an ovoid shape, in the centre of which was again a smaller disk, with its upright probe. This central portion was ingeniously connected with the larger by a " spring catch," so adjusted that the angle of the stem could be altered in order to allow of its ready intro- duction, and then readjusted and " locked" so as to maintain it in its proper position, and unlocked when it became necessary to remove it. These two varieties need not again be alluded to, as Dr. Simpson reports that the larger as well as the smaller could not be relied upon in the treatment of retroversion, though they answered in cases of anteversion, which can be easily relieved by almost any form of pessary, certairfly more safe and manageable than the intra-uterine. The third form, on which he places great reliance, has, as in the first, the central disk or vaginal portion, and the probe or 404 TREATMENT — INTERNAL SUPPORTERS. uterine portion. From the anterior part of the disk projects a curvilinear flat tube. There is also a framework, to be arranged outside of the body, and extends from the orifice of the vagina five inches upwards to and over the symphysis pubis, is half an inch in breadth below, but over the pubis enlarges to the width of three inches. To the lower or perineal portion of this frame is attached another tubular stem, closed at the outer extremity and smaller than the former, so that it can be readily made to slide into the tube attached to the circular disk. The intra-uterine stem, with its vaginal disk, is to be first introduced, and by them the retroverted organ is to be restored; then the flat stem of the external frame is to be pushed into the flat tube of the vaginal disk, so as to form, as it were, but one solid stem, two and a half inches long, from the internal disk to the external frame. The framework being composed of a flexible metal, can be bent at pleasure, and is to pass in front of the vulva, and the spreading portion to be moulded over the mons veneris, so as to prevent motion and give a fixed character to the framework, to the vaginal stem, and of course to the intra-uterine probe or pessary. This arrangement is generally suf&cient; but tapes and bandages around the loins, and more frequently a napkin over the vulva, with the usual arrangements for its support, are sometimes de- manded. This apparatus is to be worn from one week to some six or eight months at all times, even during the flow of the menses. It is said that after some alterations, to adapt it to the sensations of the patient, it can be often worn without inconvenience, supporting the organ in situ, allowing the patient to take exercise, and ab- solving her from the sufferings of uterine irritation ; and that, after being worn for a few months, the uterus will, of itself, remain in situ, and the patient continue well. Such are the favorable reports of the operation of this instru- ment by its inventor, who, however, frankly acknowledges that there are cases to which it is inapplicable, and that symptoms are sometimes produced which necessitate its abandonment. There are, we think, so many serious objections — theoretical and practical — to be urged against this apparatus, that it would seem to be impossible that it should come into general use. Its em- ployment will probably be confined to special cases, or restricted to those few individuals who are so exact in their diagnosis as to OBJECTIONS TO THE INTRA- UTERINE. 405 estimate aright the peculiar cases to which it is adapted, and so cautious in their practice, as to watch their patient day after day, not to say hour after hour. One important objection to the instrument, as proposed, is the oxidizable character of the metals employed — German silver, or a mixture of silver and nickel. Dr. Simpson has also employed lead, and copper, for the vaginal disk. These metals, from the moisture, atmospheric air and heat in the vagina, will oxidize with more or less rapidity, and thus be corroded ; and their oxides, combining with the acid secretions of the tissues, may become more or less irritating. The effect, if any, in preserving the metals in their natural state which may arise from any galvanic influence due to the combination of different metals, must be de- cided by the chemist and by observation. The second objection is from the frequent necessity of employ- ing napkins, tapes, and bandages, with all their uncleanliness and frictions, especially in warm weather, with the absolute neces- sity of repeatedly changing them, as have been specified when speaking of external supporters. The external framework itself is a great objection, rising up in front of the sensitive tissues of the nymphs, clitoris, and labia, and liable to produce more or less friction and pressure; its mo- bility is, with all care, often so great that it cannot be worn with- out additional applications, as tapes or bandages. The vaginal stem must excite more or less irritation against the urethra, nymphae, and other sensitive tissues, which few patients will bear. The fixed character which all vaginal stems give to pessaries has already been pointed out as a most serious objection. They never yield to pressure from above. The internal irritable tissues are pressed against them forcibly at all times when the patient is erect, and often violently in coughing, vomiting, sneezing, etc. In the case of an intra-uterine pessary, this objection is stronger than in all others, as the points of internal resistance are, first, the mouth of the uterus ; secondly, its internal surface ; and thirdly, in some cases, the upper or transverse side of the triangular cavity of the uterus, directly against the point of the intra-uterine stem. The chief pressure is received against the orifice of the uterus, and the lower extremity of the cervix, which rests on the vaginal 406 TEEATMENT — INTERNAL SUPPORTERS. disk — a fixed point. In all tlie impulses from above, the impres- sion is made on these delicate and irritable tissues, so that some- times the orifice is even dilated by the pressure against the disk. It has already been pointed out in detail, that the results of such pressure in neglected cases of prolapsus uteri, against even the soft parietes of the vagina, are flexion, soreness, nervous disturb- ance, pain, inflammation, continuing for years, with the granular, and sometimes, it is said, even with the ulcerated condition of the mucous membrane. It was also shown that such inflammations of the OS were aggravated by the ball, the concave disk, the double and plano-convex pessaries, even though they were mova- ble in the vagina. The theoretical conclusion, therefore, is clear, that more irritation would ensue when the disk is held immova- ble, as in the intra-uterine pessary, against the orifice by means of the stem. We experimented several times with the intra-uterine stem and disk, generally in women whose catamenia had ceased, and where no marked sensitiveness existed in the uterus. In each, after a few days, leucorrhoeal and bloody discharges ensued, with ..con- siderable pain and irritation, sufiicient to indicate the propriety of discontinuing the instrument. The intra-uterine probe is said to be worn with impunity. This testimony should not be received without great caution, if we reflect upon the sensibility of the internal tissues of the uterus, so great indeed that a uterine sound can seldom be introduced, especially through the internal os uteri, without causing severe pain, sometimes agonizing, if we may judge from the exclama- tions of the patient, and from the intolerance of the uterine cavity to fluids, simple as well as stimulating. The vascularity and delicacy of the lining membrane are so great, that probing the uterus is generally followed by the eft'usion of blood ; and the slightest mental, as well as physical excitement, will often pro- duce leucorrhoeal and menorrhagic discharges. In the case of the intra-uterine pessary, the internal stem is not merely always in contact with these sensitive vascular tissues, . but presses upon them more or less firmly during every motion of the body, as this stem constitutes the means by which the organ is kept in position. It is not, therefore, to be wondered at that in irritable and congestive, as well as inflammatory, states of the uterus this instrument, as is acknowledged, cannot be borne, DANGERS OF THE INTRA - UTE RINE. 407 or that it has sometimes to be removed because leucorrhoeal or hemorrhagic discharges are excited or increased. The greater wonder is that such irritations and discharges are not the con- stant and unavoidable result in all cases. That such is not the uniform effect can only be explained by that law of vital tissues by which, under constant pressure, if not too severe, parts be- come gradually more insensible to irritations. The most serious pressure is, however, to be apprehended from the point of the instrument against the internal and superior sur- face of the cavity. Dr. Simpson has attempted to obviate this danger by making the instrument shorter than the long axis of the cavity. The internal stem measures two inches and one- third, while two inches and a half is the usual length of the uterine axis internally. The difference is merely two lines, or one-sixth of an inch ! What possible security can be given that, in the various motions, this small space of one-sixth of an inch will not be obliterated, and that the fundus will not impinge against the point of the probe? If the uterus were perfectly firm — as if made of metal, of bone, or even of cartilage — such an accident could not perhaps occur ; but the tissue of the uterus, although firm, is flexible, and bending of the organ is a fact of daily observation. With an intra-uterine supporter there can be, it is true, no marked lateral, anterior, or posterior flexion, the metallic rod within resists such changes ; but the whole superin- cumbent pressure must free the fundus downwards, and as the opposite extremity of the organ is fixed by the vaginal disk, the yielding of the uterus will, therefore, be from above downwards, in the direction of its length : all such yielding will endanger the forcible impinging of the uterus against the point of the internal stem. This danger is aggravated by the gradual dilatation of the OS, and the eversion of its lips, so that the stile penetrates still deeper into the organ. Either of these circumstances — and, of course, still more when both are in unison — can readily shorten the perpendicular diameter of the uterus one-sixth of an inch, when mischief of a serious character would inevitably ensue — inflammation, ulceration, even, it may be, perforation of the uterus, and peritonitis with its dire consequences. Such results are said to have occurred, and certainly are to be apprehended, especially as few are expert enough to measure and arrange the safe proportions which ought to exist between the length of the 408 TREATMENT — INTERNAL SUPPORTERS. stile and that of any individual uterus. Dr. Simpson speaks of using one some three and a half inches long in a hypertrophied organ with impunity; but one of our western physicians, less skilled in diagnosis, inserted an intra- uterine pessary, with a stem five inches in length, into a uterus whose length was found to be but three inches when measured by the uterine sound. The in- strument is in our possession. This particular danger can easily be lessened in a great degree by diminishing the length of the stem, so as to allow half an inch or six lines between the internal surface of the fundus and the point of the stem. Nevertheless, the strong objections that the uterus is firmly fixed by an immovable pessary, and the irritation arising from the intra-uterine stem, etc., must be regarded as of serious import. Minor objections may be alluded to, such as the occupation of the vulva and vagina so as to prevent the natural uses of this canal ; and the irritations and discharges which the vaginal stem would usually produce. That the instrument is to be worn but a few months at farthest, and that then it may be removed without a return of the dis- placement, is one of those assertions of an experienced physician which to most other persons is altogether incomprehensible. That a recent case of retroversion may disappear by rest and quietness, after reposition — that a displacement, occurring soon after deli- very, may, if restored, be permanently relieved by the contrac- tion of the ligaments which then quickly occurs — can be under- stood. But that a chronic retroversion, where the ligaments and other supports have been for a long time inef&cient, will usually disappear if the organ be retained in position for a few weeks or months, cannot be so readily comprehended. Dr. Simpson makes no explanation, but simply enunciates the fact, as he regards it. The author's experience is altogether at variance with this idea. The displacement is apt to return, even if the uterus for one or more years may have been steadily, night and day, kept in situ ; and although, in some cases, a support may be removed, as the writer has done, in three and six months, with impunity, yet. such are always to be regarded as exceptionable cases, and not as the rule. The intra-uterine pessary with its external appendages must, however, be regarded as the most efficient instrument for main- taining a uterus, after its restoration to its natural position, that MODIFICATION OF THE INTRA- UTERINE. 409 lias yet been presented to the profession. It is impossible, with the external framework and intra-uterine stile duly con- nected and located, that the displacement should return. The pessary is immovable, and so is therefore the uterus itself. Must it not, however, for these very reasons, be regarded as peculiarly dangerous ; and, although perhaps to be occasionally employed in special cases by the careful and instructed surgeon, it ought not to come into general use. Certainly there are numerous cases to which it is, in the eyes of all, inapplicable, as where there are great irritability and tenderness of the vulva, the orifice of the vao-ina and the uterus ; where there is congestion of the uterus, or inflammation of the os and cervix uteri ; under all circumstances, in virgins ; and where the uterus is from some cause fixed, as by tumors, adhesions, etc., and cannot be at once elevated to its normal position. The answer, of course, given by the friends of this instrument is that experience is in its favor. If so, the question is decided ; our best reasoning and all our fears must yield to stubborn facts. The question is, however, still to be determined, for it would seem that even with the originator, experience has been limited to non- irritable, non-congested, and movable states of the uterus ; and yet it is well known that in a large proportion of retroverted uteri there is much sensibility and often much engorgement. The ex- perience of physicians even in the British isles, and on the conti- nent of Europe, has not yet presented any decided testimony in its favor ; and there certainly has been much opposition to its use, especially if we may judge from the debates in the French Impe- rial Academy of Medicine, and the report of M. le Dr. Depaul. In America we have seen no favorable reports of any importance. The writer has heard of its employment in some cases, but with no permanent advantage. He has had patients who had worn it, but with great suffering, giving rise to constant irritation, pain, and hemorrhage, necessitating its abandonment. Even in the cases in which he ventured to use an intra-uterine pessary — with the probe half an inch shorter than the long diameter of the uterus, and the vaginal disk attached to an elliptical ring pessary as a substitute for the external framework and stem, so as to allow mobility to the uterus, and have the whole instrument within the pelvis — the occurrence of irritation and hemorrhage from the os and labia of the uterus, induced him to abandon the 410 TREATMEN'T — INTERlSrAL SUPPORTERS. experiment, alfhougli made in women after " a change of life" had occurred.^ Simpsonh Intra- Uterine Pessary modified. — We venture to present a drawing^ of the modification, just alluded to, of Dr. Simpson's intra-uterine pessary. As will be observed, a vaginal elliptical ring was substituted for the external framework, and the intra- uterine stem made shorter. The experiment, as regarded the maintenance of the uterus in position, was a perfect success, and at the same time more mobility was allowed to the organ under the muscular efforts of the patient, and all the irritation and annoyance due to an external apparatus were done away with. The intra-uterine stem was made but two inches in length for a uterus measuring two and a half inches internally. The vagi- nal disk had attached to a point in its circumference a short stile four lines in length, with a small foramen at its outer extremity. The disk with its stile should make, with the intra-uterine stem, an acute angle, about 40° to 50°, corresponding somewhat to that made by the axis of the uterus with that of the vagina. An elliptical ring was then made, slightly curved in its length, and two inches and a half long by two inches broad (but of course the size must vary with the size of the vagina), and with a per- foration in a longitudinal direction, through the bar at one ex- tremity to receive the stile. Before introduction^ a strong thread or a fine flexible wire is to be passed through the eye in the vaginal stile. The pessary is then passed into the vagina, the stem carefully introduced into the cavity of the uterus, and the organ may be partially elevated. The string, hanging out of the vagina, should now be carried through the opening in the extremity of the ring. The ring is then introduced into the vagina, with its convexity toward the bladder, and the string being made somewhat tense, acts as a di- ' Although more than eight years have elapsed since the above observations were written, we read of but little favorable testimony respecting this intra-uterine pessary. It seems to be very universally abandoned on the Continent of ilurope, and few writers of repute iu the British Isles or in America have ventured to commend it. All acknowledge that it is a dangerous instrument; many speak of fatal results from its employment, although in some very peculiar and unman- ageable cases, some might countenance a cautious experiment with this pessary, carefully watching the progress of the symptoms. 2 See diagram, p. 415. MODIFICATION OF THE INTRA- UTERINE. 411 rector, hj wliicTi the ring can be pushed so as to cause the vaginal stile to enter the foramen in the ring. The string is now to be withdrawn ; the pressure of the vagina, etc., will keep the ring firmly fixed on the stile, so that the direction of the intra-uterine MODIFIED INTRA-UTERINE PESSARY IN POSITION. probe represents that of the axis of the uterus, and the pessary that of the vagina. If the uterus be not perfectly restored, a little pressure on the ring will accomplish this purpose ; and the ante- rior wall of the vagina under the influence of the superincumbent weight of the viscera, increased by muscular effort, will constantly depress the pubic extremity of the ring towards the perineum, and thus compel the uterus under the command of the stem to follow its motions. All these tissues being pliable and elastic will allow a certain degree of yielding of the uterus to the distension of the bladder, bowels, etc., and thus the instrument does not materially interfere with the mobility of the womb. The removal of this instrument is very readily accomplished by drawing the elliptical ring towards the orifice of the vagina, which detaches it from the stile, after which the vaginal disk, with 412 TEEATMENT — INTERNAL SUPPORTERS. the intra-uterine stem, can readily be removed. If by any arrange- ment of tliis kind too much lateral motion should be allowed to the uterus from the cylindrical form of the stile in the vaginal disk, this can readily be prevented by making it and its sheath in the extremity of the ring flat, so as to prevent rotation. Whatever modifications, however, may be suggested, by which the evils are moderated, yet the intra-uterine pessary ought to be regarded with great suspicion, and be very cautiously employed, even in the very limited number of cases to which it is at all applicable. LEVER PESSARIES, ETC. 413 CHAPTER VI. TREATMENT OF D I S P L A C E M E N T S — Contimjed. LEVER PESSARIES. In his anxiety to fulfil tlie important indication of keeping the uterus in situ, especially when retroversion existed, the author has made innumerable trials through a long series of years, with almost every form of pessary, but finding himself disappointed, instituted a series of experiments, which eventually resulted in a modification of the ring pessary, to which, from its modus ope- randi, he has afl&xed the name of the "Lever Pessary." The im- portant modification consists in making a ring oblong, instead of circular, and curved so as to correspond to the curvatures of the vagina and rectum. Great advantages result from this form ; the convexity of the curve being in contact with the posterior wall of the vagina, corresponds, with more or less accuracy, to the curve of the rectum, perineum, and sacrum. Hence, when properly arranged, there is no pressure against the rectum ; and the higher the instrument rises, the superior extremity, instead of impinging against the rectum, passes upwards and behind the uterus — 'between this organ and the intestine — giving, as will be presently seen, a proper position to the womb, and yet allowing its natural pendulum-like motion to remain unrestrained. The oblong form and the curvature are the two essential pecu- liarities of the lever pessary ; they may be increased or dimi- nished indefinitely according to the views of the practitioner, or the peculiarities of the case. In practice, the author often modi- fies them in various ways ; he would, however, present chiefly two varieties for the consideration and trial of his professional brethren, namely, the oj^en and closed " Lever Pessaries." 414 TREATMENT — LEVER PESSARIES. VARIETIES. Open Lever.' — This is a single-curved parallelogram, with one of its sides deficient. It varies in length from two to two and three-quarter inches, and in breadth from one to two and a half inches, according to the size of the vagina; the sides should be from three to four lines in thickness. The curvature is not that of a segment of a circle, but is rather represented by the longitudinal section of an egg, the curve being greater towards the closed extremity than the opposite. The degree of curvature must always be accommodated to the emergencies of the case, being very moderate in the commencement of the treatment with a rigid and short vagina, and augmenting as the vagina is relaxed and elongated. "When viewed anteriorly, its general aspect is somewhat like a magnet, a horseshoe, or the letter U. It may be distinguished by the name of the " open lever^ The two long and curved sides may be termed the horns, and their terminations the points or the ^^ extremities^^ of the horns; the remaining short or transverse side connecting the two horns, and always to be placed under and behind the uterus, may be called the bar or upper portion of the lever. The two horns may be distinguished by the words right and left, as when the instrument is properly adjusted, one bar always corresponds to the right, and the other to the left si'de of the pelvis. Modus Operandi. — To illustrate the operation of the lever, we shall suppose an irritable retroveried uterus, with a vagina long and relaxed, so as to afford little resistance, and where an open single-curved pessary has been carefully introduced, according to the directions hereafter to be given. The bar of the instrument will now be found behind the cervix uteri, and the extremities of the horns underneath the cystic portion of the vagina. The first object is to press the bar of the instrument as high as possible between the posterior surface of the displaced uterus and the rectum. If the upper portion of the vagina readily yields, this can easily be accomplished, by placing the index finger on the extremity of one (say the left) horn, and pushing the whole ' See diagram, p. 415. LEVER PESSARIES, ETC. 415 OPEN LEVER VARIETIES OF OPEN LEVERS SIDE VIEW OF CLOSED LEVER. 416 TREATMENT — LEVER PESSARIES. instrument directly upwards towards fhe sacrum, in tlie cul-de- sac or pocket of the vagina. Great caution is, however, required, especially when the organs and tissues of the pelvis are morbidly sensitive, so that the bar should not impinge against the uterus anteriorly, or against the rectum or sacral nerves posteriorly ; in either case severe pain may be excited. Let pressure be made slowly and steadily, so that the bar shall elongate the vagina and follow the course of the rectum without striking against this intestine ; in this way little or no pain will be excited. As the vagina yields and the bar ascends, the finger should depress the extremity of the horn gradually from the bladder OPEN LEVE R 1 N POSITION. towards the rectum, by which the bar will ascend posteriorly, ele- vating the fundus of the uterus, while the os uteri, by means of its attachment to the vagina, is drawn more and more backwards. In a short time it will be found that the os will point towards the lower part of the sacrum, and the fundus towards the inferior part of the linea alba in front and above the pubis. The anterior surface of the uterus can now be readily felt behind the bladder. MODUS OPERANDI. 417 and supported by the concavity of the horns of the pessary. The uterus is therefore replaced, and at an acute angle with the va- gina. (It is desirable, as represented in the diagram,' that the fun- dus be t hrown f orward as far as practicable, to insure the descent of the intestines behind the uterus, and also to relax the ligaments as much as possible so as to favor their subsequent contraction. ; The bar of the instrument in its location behind the uterus, can be with difficulty reached by the finger ; while the extremities of the horns can be readily recognized, one on the right, the other on the left side of the uterus, not pressing on the walls of the vagina at any spot, but rather receding when a bearing-down effort is made. The pessary performs the part of an elevator. It operates as a lever in elevating the fundus from its mal-position against the sacrum to its normal position behind the bladder; that portion of the pessary which is posterior to the neck of the organ being the " short arm," while all anterior to the neck is the " long arm," and the " fulcrum," or support, is the posterior surface of the vagina. As the long arm or horn is depressed by the finger of the practitioner, the short arm rises and carries with it the body and fundus of the uterus. This elevation being accomplished, the pessary maintains the organ in this position. It acts as a supporter^ for the intestines now fall once more on the posterior surface of the uterus, and press this organ against the long arm of the lever, that is, against the horns of the pessary ; so that when the woman strains, the horns are depressed towards the rectum, and the bar of course rises behind the uterus. (The condition of the patient is entirely changed ; for, standing and walking, which were before painful and distressing from the pressure of the intestines on the anterior surface of the uterus, increasing the displacement, is now useful as this pressure of the intestines is transferred to the posterior por- tion of the organ, impelling the fundus forward towards the pubis. ^ The woman immediately realizes the change ; she feels relieved of the pressure, the weight, the dragging, the pain, the soreness, the spinal and cerebral distress, and walks forth, con- sidering the transformation as wonderful, and hardly believing in its reality. Such is the most favorable account of the influence of a pessary in cases of relaxed vagina. ' See diagram, p. 416. 27 418 TREATMENT — LEVER PESSARIES. / In a large majority of retroverted uteri, the same bright antici- pations may be indulged, excepting that time, even a long time, may be demanded for the fulfilment of the important indications of replacing the uterus, and maintaining it in its proper position. Many difficulties will be met with, such as shortness and rigidity of the vagina, immobility of the uterus, and its strong tendency to retroversion, its large size, the presence of tumors, of adhe- sions, etc. In many of such cases, patience must be exercised by the physician and his interesting sufferer; but by employing at first small instruments with moderate curvature, slowly and carefully working them up, day after day, between the rectum and the uterus, then gradually augmenting their power by in- creasing their size, and especially their curvature (for the power mainly depends on the degree of curvature), the displaced fun- dus gradually yields, and in a few weeks or months, the patient finds herself relieved. The relief is generally in proportion to the ascent of the fundus. In all these efforts, great caution is required. " Festina lent^" must be the motto of the practitioner, and he should be guided very much by the sensations of his patient, remembering the ob- ject in view is to diminish, not to increase, irritation. He should encourage the patient to move about as much as her strength and pains will permit. If there be an increase of pain, the pes- sary presses in some wrong direction, which should be rectified by a change of instrument, or an alteration in its position. Fre- quent examinations are necessary to ascertain whether improper pressure is made against the uterus or sacral nerves, increasing the pain, or against the rectum, rendering the transit of feculent matters difficult, or whether the points of the horns impinge forci- bly against the bladder or the bones of the pelvis — all of which would be dangerous, as inflammation and ulceration might ensue. The pessary must not, therefore, be permittted to excite organic irritations, or inflammations from its size or too great pressure. It should never be allowed to, twist and occupy a transverse direc- tion, as then it gives pain, and affords no support to the uterus. The pessary should always be borne without pain or inflamma- tion. The patient should feel relieved without any consciousness of the presence of the agent, by which this great blessing has been bestowed. This open lever is equally advantageous in prolapsus ; it keeps CLOSED LEVER. 419 the organ elevated, removes all pressure from the os and cervix, and prevents any tendency to flexion by transferring the super- incumbent pressure from the extremity of the cervix to the iufe- rior portion of the body of the uterus, and to the tent-like expan- sion of the anterior wall of the vagina as it is extended over the pessary. In miteversion it operates as favorably ; for, the horns of the in- strument resting on the perineal portion of the vagina, prevent the descent of the fundus uteri against the pubis, while, in proportion as the upper extremity of the vagina yields to the pressure of the bar, the uterus and pessary, as one body, descend on the plane of the vagina and perineum towards the sacrum. In procidentia we have also completely succeeded with the open lever ; but, as intimated, the relaxed vagina will often descend even externally in folds between the horns of the pessary ; the four-sided lever, or even Dewees' pessary may, in such cases, be preferable. The incidental advantages of the open lever are of considerable importance. Pessaries thus formed, even when of large size, can be much more readily and less painfully introduced and removed than the four-sided instrument, as will be presently detailed. They allow of the free exit of the menstrual, leucorrhoeal, and other vaginal discharges, and of the ready access to the os and cervix uteri of all cleansing and medicated lotions. Moreover, in coitu nulla obstructio est, a circumstance occasionally of no minor importance. Thus, by its use, the comfort and the health of the patient can be promoted, and the instrument can often be worn for a long time without the necessity of removal for purifi- cation. Closed Lever.' — For the general practitioner, this modification of the lever pessary is more safe; it has some decided advantages, and some disadvantages when compared with the open lever. It is four-sided, and its curvature may be single, as in the open lever, or double, as in the one presently to be described. The former, like the open lever, may be very advantageously em- ployed in all the varieties of displacements. The douhle-curved'' ' See diagram, p. 415. 2 Dr. Holmes, from Soutli Carolina, one of our former pupils, is under the im- pression that he first suggested this additional curve. « 420 TREATMENT — LEVER PESSARIES. closed lever is equally advantageous, and is preferable, as being less liable to press injuriously on the bladder or urethra. Its leverage is more powerful, as it is longer, and as the tissues ante- rior to the uterus do not sink so much between the sides of the pessary as in the open lever. Hence, the author, for some time past, has given it the preference. Its curves may be named the greater and the less ; the former may be regarded as perfectly similar to that of the open pessary, but the other extremity is slightly bent in the opposite direction, so that when the instru- ment is viewed laterally its curves resemble somewhat those of the letter S; and, for the purpose of distinction from the open or U pessary, this may be termed the closed or the S pessary. It has also been termed by instrument makers the " hoiv''' pessary. AVhen introduced, it acts similarly to the open lever, as an ele- vator and a supporter.^ In most cases, at the commencement of the treatment, especially when there is a rigid and short vagina, and the uterus not very movable, the extremity iviih the smcdl curve should be placed under the uterus, with its convexity towards the posterior surface of the ' Since the first publication of tliis work in 1860, several modifications of the " lever" or " bow" jiessary have been made iu Europe and America. Dr. Churchill, of Dublin, in cases of relaxation of the vagina, has had a pessary constructed with two bars instead of one in front of the uterus, in order to support the vagina. Dr. Priestley, of London, has also modified it, but in what exact manner we are unin- formed. In this country one modification, which we have seen, consists in having the anterior and the posterior bar curved, instead of straight, so as to accommodate, it is said, the convexities of the urethra, the rectum, or the uterus, while the whole instrument is comparatively long. This last proceeds upon an erroneous principle that pressure must be made on the above named tissues. A good lever pessary, when properly arranged, makes no pressure upon the urethra, rectum, or uterus ; it rests on the posterior wall of the vagina, is movable with the uterus, and at the same time allows of its natural motions. Its extremities do not impinge uncom- fortably on any tissue. The lever pessary is not a " prop." Dr. Scattergood has also proposed a modification, which acts on the same im- proper principle. This consists in making the instrument longer and less curved, while the sides are made, each of two pieces ; the anterior or lower portions being solid, the posterior or upper portions being hollow cylinders, into which the lower or solid cylinders can be readily i-eceived. These hollow cylinders contain springs, so that the length of the instrument will be diminished or increased in proportion to the degree of pressure on the extremities of the instrument. The idea is in- genious, but the principle on which the modification is founded is erroneous. We repeat, there should be no pressure of any consequence on the extremities of the instrument, whether tlie lever be open or closed. CLOSED LEVER. 421 CLOSED LEVER WITH THE SMALL C0KVE BEHIND IN POSITION, CLOSED LEVEE WITH THE SMALL CURVE BEFORE IN POSITION. 422 TREATMENT — LEVER PESSARIES. retroverted uterus, and its concavity towards the rectum; tlie concavity of the greater curvature will be in front towards the uterus, and the convexity towards the j)erineum. Then the index-finger, pressing on the lower portion of the pessary, should cause the instrument to glide slowly between the rectum and the uterus ; and afterwards, by depressing the lower extremity towards the perineum and rectum, the fundus and body will be raised as when the open lever is employed. The advantage in this case is, that the convexity of the small curve presents a broader surface towards the irritable tissue of the uterus, and is therefore less likely to give pain ; on the contrary, however, rather more pressure is made towards the sacrum, which may occasion- ally be an inconvenience. After some days, when the uterus has yielded to this pressure, the pessary may be removed, and reintroduced, so that the con- cavity of the large curve shall be towards the uterus behind, and the convexity of the small curve in front of the uterus and under the bladder. Cit now acts much more powerfully as a lever, and care must be taken that it does not press against the uterus be- hind.' Under these circumstances, the lever-like action is greater, in proportion to its size, than the open pessary ; as, the small cur- vature and the bar in front of the uterus present a larger surface to the superincumbent pressure, depressing the anterior or long arm of the lever more forcibly towards the perineum, and, of course, elevating proportionably the upper extremity or short arm of the lever. This increase of power, and the comparative safety of the closed lever, there being no points by which dangerous pressure might carelessly be made on the tissues, are its chief advantages. The objections, as compared with the open lever, are, that it is more painful to introduce and to remove, more liable to press on the bladder and urethra, giving rise to dysuria, or even obstruc- tion, and does not allow of such ready egress and entrance of fluids, etc., to the uterus. Notwithstanding these minor objec- tions, it is the most valuable instrument, from its great power as a lever, especially when there is much resistance to the replacing of the uterus. In virgins, also, the closed lever is preferable, as a narrow open lever is not easily introduced, owing to the thick- ness of the perineum and the tonicity of the vagina. INTRODUCTION OF OPEN LEVER. 423 INTRODUCTION AND REMOVAL. Introduction of Open Lever. — The introduction of tlie open lever is comparatively very easy, and seldom painful, in women who have had children, if two or three rules be observed. Let the woman be placed on her back, with her limbs flexed and her feet near the edge of the bed ; this is the best, and almost the only, suit- able position for all examinations and operations in displacements. The instrument being anointed, the practitioner should hold it in his right hand, with the points downwards towards the bed, the convex part of the instrument being towards the left thigh of the patient, and the concave towards the right. The labia being now cautiously separated, the extremity of the right horn, which is. now also the upper one, should be passed into the orifice of the. IXTRODUCTION OF OPEN LEVER. vagina,^ and be pushed downward on the plane of the perineum, a little to the right of the median line, until the whole right horn ' Of course, the orifice of the urethra should be avoided. This caution seems to be necessary, as Dr. Horatio R. Storer, of Boston, has reported in the Medical Record of July 15th, 1868, a case in which an open lever pessary had been intro- duced into the bladder. At the expiration of five days, Dr. Storer succeeded in removing it without incision, by his finger, after dilating the urethra. The blunt hook represented (p. 393) at one extremity in the diagram of the small extractor, would be a valuable assistant on such an occasion. 424 TREATMENT — LEVER PESSARIES, disappears in the vagina ; tlie bar is thus brought to the top of the arch of the pubis, and on the left side of the urethra. The left horn will be found extending externally along the perineum towards or beyond the anus, and some care is occasionally re- quired to see that it does not pass through this orifice into the rectum. The bar of the instrument is now to be pushed directly into the vagina till the whole has entered, so that the right horn of the pessary is within and the other without the vagina, and the bar against the left ramus of the pubis. A combined opera- tion is now demanded, in order to depress the bar on the left side of the vagina until it gets under the cervix uteri. This combined manoeuvre consists in placing the index finger of the right hand on the bar, now at the orifice, and pressing it firmly but steadily downwards, on the left wall of the vagina, and within the rami of the pubis and ischium. At the same moment, within the thumb of the right hand (or the fingers of the left), the extremity of the left horn is to be slowly elevated from the perineum near the anus, over the right labia and nyraphse to the right ramus of the pubis, where it will now readily enter the orifice, being of course preceded by the whole left horn of the instrument. By this movement the whole pessary is made to revolve, so that one extremity (that of the right horn) is the first, and the other extremity (that of the left horn) is the last portion that enters the vagina. The bar will now generally be found against the posterior part of the retroverted uterus, and may give pain. This is to be obviated by the index-finger depressing the bar against the rectum, as much as is convenient, and allowing the extremities of the horns to rise in front, close to the bladder. This finishes the introduction of the pessary ; it will be accom- plished most readily when, with sufficient breadth of the instru- ment, the length of the horns is comparatively short. Removal of Open Lever. — Its removal is to be accomplished by reversing the manoeuvre by which it was introduced. The woman being placed in the same position as formerly described, the index-finger of the right hand, well anointed, is to be passed into the vagina to the left horn, and carefully insinuated between it and the side of the pelvis. This horn can be slowly pressed, so as to get the whole instrument into an oblique position. The finger, passed over this horn, can now draw it downward until its extremity comes to the orifice of the vagina, and as soon as it completely emerges, it should be made to ascend in front of the REMOVAL OF OPEN LEVER. 425 pubis, passing over in succession tlie riglit nympha and labium externum. The traction may now be continued by moving the finger along the horn to the bar, and stretching the posterior margin of the vagina, so that the bar, and subsequently the right horn, successively emerge. The extremity of the right horn is, by this evolution, the last portion delivered. REMOVAL OF OPEN LEVER. Large pessaries can thus be introduced and removed with com- paratively little pain, in cases where the vaginal orifice is so con- tracted, that a closed lever of the same breadth could not be employed. These open levers are also as easy of introduction as the spring pessary. We have often introduced an open lever, and allowed patients to wear it for days, without their having been conscious of its introduction or subsequent presence, and they were much surprised when informed of the circumstance. Introduction of Closed Lever, — The introduction of the closed lever is much more painful in proportion to its magnitude, as it must enter presenting the whole of its transverse diameter. If it be desirable that the extremity, with the small curve, should be first introduced, it should be directed to the orifice of the vagina, somewhat obliquely, so that the convexity of the small curve should be anterior, and the concavity posterior ; the labia and nymphse being carefully separated, the bar of the pessary should be pressed into the orifice so that one edge of the instru- ment is anterior and to the left of the urethra, while the other is 426 TKEATMENT — LEVER PESSARIES. posterior and to the right of the raphe of the perineum. The whole instrument must be so elevated that the extremity may enter perpendicularly to the opening of the vagina. By firm pressure downwards against the perineum, the pessary enters the vagina ; but the upper extremity, instead of passing under the uterus, ■ necessarily, owing to the large curve, rises up in front of the organ and against the bladder. Pressure, often quite painful, is for the time made on the neck of the uterus; the practitioner, therefore, hastens to introduce his finger through the opening of the pessary, and to press down the upper extremity under the uterus as soon as possible, thus affording immediate relief to the pain. When the large curve is to be introduced first, the whole ope- ration should be conducted in a similar manner, excepting that the concavity of this curve should be directed anteriorly, and the convexity, posteriorly. The bar should be directed perpendicu- larly against the orifice of the vagina, and the whole be thus gradually introduced, great care being taken, by a finger in the vagina, to direct the upper bar under the uterus. Fixing the Instrument. — Much attention' should be paid to adjust the instrument properly after its introduction into the vagina, and its location under the uterus. If it be thus left, especially in cases of retroversion, the bar would often impinge painfully against the irritable organ, which could not be tolerated. Hence, the practitioner should take time to gradually work the upper or superior bar between the uterus and the rectum, not pressing upon either of these viscera, and therefore giving no pain, the vagina gradually elongating, so as to allow the pessary to ascend posteriorly. This object cannot always be attained immediately; where the vagina is rigid, unusually short, or thickened, time is required, and the form of the pessary is gradually varied from a lesser to a greater curvature. Many fail in the use of the pessary from the want of attention to this rule of gradually elongating the vagina, so that the pessary may ascend behind the uterus. Removal of Closed Lever, — Its removal is easily effected by the practitioner, but with more or less pain to the patient. Since a portion of the instrument is behind the uterus, the instrument should be first turned obliquely, and then the traction effort being made, one edge comes out of the vagina towards the ramus of the pubis, and the other towards the perineum. As the curves successively pass, the instrument should be allowed to rise in front of the pubis. GENERAL EEMARKS. 427 GENERAL REMARKS. The description just given of the good influences of the lever pessary, has been founded on the supposition that the uterus is movable, and the vagina relaxed, so as to be readily elongated. It has been stated also that one and, perhaps, the great difficulty of treating retroversion, is often the shortness of the vagina, and its close connection with the posterior lip of the as uteri, so that no pessary can immediately ascend high on the posterior surface of the uterus; this is especially true in the unmarried and those who have not borne children. The practitioner must not, how- ever, be discouraged by this resistance of the vagina. The vagina is an extensile tube, and admits of enormous distension with impunity, provided such distension be slowly and judiciously made, so as not to excite organic irritation or inflammation. The vagina may be elongated in a case of retroversion by beginning with comparatively a small pessary, and of slight curvature — even a flat ring is often valuable to begin the treatment. By steady pressure between the uterus and rectum, and by allowing the instrument to be worn for a few days, something is gained. It may then be removed, and there may be substituted a larger instrument or one of greater curvature, that is, of more power, for the power of these levers depends more on their curvature than on their dimensions; then a third, still more powerful, may be employed, and so on in gradual or rapid succession, in propor- tion as the vagina yields and the fundus rises, or the comfort and sensibilities of the patient will allow. These sensations should always be regarded; there must be too much pressure, or in a wrong direction, when there is pain. The tissues in some patients are so irritable that every advance must be slow, while in others great pressure will be borne with impunity. Let it be observed, however, that, even in cases of irritable and engorged uterus, pessaries can, with care and pru- dence, be almost universally tolerated. "We have so often, by means of pessaries, afforded partial or even complete relief to patients who had been bedridden from irritable uterus — even to those with whom mere motion in bed was impracticable, and any touching of the vulva and vagina seemed intolerable, in whom spasms of the vagina and the pelvic muscles were often intense, 428 TREATMEN-T — LEVER PESSARIES. and where tbe sympathetic irritations were so great as to result in spasms and convulsions — that we speak and write with confi- dence. The irritability of the orifice and the canal of the vagina will gradually diminish ; operations at first painful are soon not dreaded, and the uterus replaced and sustained, eventually loses its abnormal sensibility. Even in many cases where the vagina has been contracted by inflammation, and where bridles or cica- trices have formed, steady pressure, beginning with a small instrument followed by a larger, will be effectual in overcoming these difficulties, so that the uterus may be properly supported. By steady perseverance in elevating the uterus by means of frequent changes in the form and size of the instruments, as the tissues yield before their influence, even more poioerful obstacles than the resistance of the vagina may be overcome. As exam- ples of these obstacles, we may mention those arising from hypertrophy; from induration; from tumors in the interior, in the substance, or on the exterior of the uterus; from the pressure of tumors of the ovaries, or the mesentery; from tympanites and dropsies ; and from the connecting tissues of the uterus having become rigid and fixed in their unnatural position in consequence of the lapse of years, or it may be from firm adhesions having occurred between the opposing peritoneal surfaces. Even in such cases, " nil desperandum" should be the motto of the practitioner. The principle being correct, perseverance is demanded, and the reward will be proportionate to our endeavors. Such are the happy results which may be expected from the use of the lever pessaries, when cautiously and judiciously employed. The principle of their action being borne in mind, there may and frequently must be made many modifications of the form and size of these curved pessaries, that they may be suited for the peculiarities of the individual cases. Drawings of two of these varieties^ have been exhibited, one rectangular, the other circu- lar, and both furnished with flat circular disks from six to eight lines in diameter. It should always be remembered that, as no physician is qualified to prescribe powerful medicines, such as calomel and opium, without exercising his judgment in adapting them, as to their doses, time, and manner of exhibition to the ever varying condition of his patient ; so no one ought to under- ' See diagrams, p. 415. SHORTNESS OF VAGIN"A, ETC. 429 take the surgical treatment of displacements of tlie uterus, with- out constantly exercising much discrimination in the use of his powerful and even dangerous instruments. If the knife of the surgeon can do mischief, so may his bougies, his bandages, or even his fingers ; and he is equally bound to be careful in the employment of all of them. And besides, the idea that the mere introduction of a pessary within the vulva is "per se," of itself, sufiicient for the elevation and sustentation of the uterus is ab- surd, the indulgence of which has wrought mischief to the patients and discredit to the profession. If the lever pessary be very valuable, it can also he very injurious. Perhaps whatever is most efficient for good may the more readily be perverted to evil. All the objections, formerly detailed against pessaries in gene- ral, may be predicated of lever pessaries. They have been made of perishable materials, too large, too much or too little curved, and have thus originated pain, inflammation, and their conse- quences. Moreover, it may be freely confessed, that the dangers from the lever are rather greater than from many other pessaries, even when the material is unexceptionable. Their power is greater, and of course more care is demanded. A flat disk, a flat ring, or a ball pessary introduced into the vagina, may not excite irritation, while a curved supporter of no larger size may press painfully on the uterus or the walls of the vagina. In retrover- sion, it may turn up against the body of the uterus too suddenly, indeed will generally do so, to the discouragement of all, if care be not taken to elongate the vagina and press the instrument steadily between the uterus and the rectum, so as not to impinge anteriorly against the uterus, or posteriorly against the rectum or the nerves of the pelvis. If the instrument makes pressure against the sacral nerves, it often excites severe neuralgia in various parts of the body, usually N^ so quick and transitory as to be called by patients " lightning- pains." They resemble the pain produced by biting on a dis- eased tooth, or striking the ulnar nerve at the elbow. Facts of this kind have been so numerous and so wonderful in the author's experience as to justify a little detail, advantageous perhaps to the physiologist and anatomist, as well as to the practitioner. In various operations, especially in cases of retroversion, while endeavoring to avoid the uterus in pressing the pessary between 430 TREATMENT — LEVER PESSARIES. it and the sacrum, some nervous twig or larger branch has per- haps been touched, and is followed bj an instantaneous exclama- tion from the patient, indicating the severity and suddenness of the pain. It is as transitory as it is sudden. The exclamation is as speedily followed by the smile of astonishment at the complete suspension of the suffering. (■' The location of these pains, as indicated by the sensation, is various, and may give rise to interesting and productive specula- tions to the anatomist and physiologist. They are most fre- quently, perhaps, referred to the back or the hip — sometimes to the left hip when the pressure, apparently, is made on the right of the rectum, and the reverse — not unfrequently to the iliac fossa, to the groin, to the inside of the thigh; very frequently to the knee, the calf of the leg, the instep, and the heel, especially directly under the os calcis. The reflex influence is sometimes in the opposite direction, evidently through the spinal marrow ; and the pain is often referred to the neck, the shoulder, the hypo- chondriac region, &c. "Oh, doctor," exclaimed a cheerful, and intelligent lady, "you hurt my neck — my shoulder — my side — my knee;" and all this in rapid succession, each spot being re- lieved before the other was involved. Another exclaimed, on the removing of an instrument, "Doctor, you hurt me." — " Where?" — "At the top of my head.'^ Indeed, it would seem that there is hardly a portion of the economy which is not represented by a sacral nerve, an irrita- tion of which may have a response from a distant tissue or organ. So, also, disturbances of the viscera, spasmodic croup, nervous coughs, asthmatic symptoms and oppression in breathing, often arise from the same cause, as also palpitation of the heart, nausea, etc. The reverse of these observations also confirms the truth of the statement. When some of these morbid sensations have existed, they occasionally disappear instantaneously during the elevation of the uterus. The pain in the head, the shortness of breath, the stricture around the chest, and the nausea, have thus disappeared ; or the neuralgia in the neck, in the shoulder, in the hypochondriac, the umbilical, or the iliac region, in the knee, or in the foot, has thus quickly vanished. These and innumerable analogous facts are interesting, and the general explanation is easy from the known unity of the cerebro- spinal apparatus. But, why a pain at the top of the foot or at NEURALGIA FROM PRESSURE OX SACRAL NERVES. 431 the base of the heel, at the apex of the shoulder or in the region of the liver (so often and injuriously considered as the certain representative of " liver disease"), or in the region of the spleen, should exist from uterine and sacral irritation, while other por- tions of the body are perfectly exempt from uneasiness, demands a more accurate anatomy and physiology than has even yet been evolved. The three-sided or open pessary has been objected to from the danger of the horns pressing on the tissues, and producing in- flammation and ulceration. The danger exists, and should be guarded against by taking care that the instrument be not too long, and that the extremities of the horn make no pressure, for then this pessary would have all the disadvantage of a fixed pes- sary — it would no longer be movable, or even allow motion to the uterus. Neither should the practitioner allow the instrument to twist so that the points press laterally, for then the instrument is out of position, and does no good ; nor should they press against the anterior walls of the vagina, for then inflammation and ulcera- tion might arise and penetrate the bladder. Of course, also, the points of the horns should never be allowed to turn posteriorly, as the inflammation and ulceration then excited might penetrate the peritoneum, endangering even the life of the patient. All these dangers may be easily prevented by a little care. The extremities of the horns, when the instrument is in proper position, ought not to advance towards the bladder, but rather should recede on the bearing down efforts of the patient. The practitioner, after the adjustment of the instrument, should place his finger on one extremity, and request his patient to bear down : if it recedes, or remains stationary, he may be satisfied ; if, on the contrary, it advances, and presses on his finger or the bladder, an alteration becomes necessary. This arises because the pressure downwards of the body and fundus uteri is too power- ful for the pessary, or, what amounts mechanically to the same thing, the resistance, whatever be the cause, is not overcome. The short arm of the lever descends, and the long arm, or that in front of the uterus, ascends. A change, in such cases, should be made to a shorter or a less curved pessary, until the vagina or the uterus yield sufficiently to allow of a more powerful in- strument. In other words, the rule, that the pessary is to be 432 TREATMEXT — LEVER PESSARIES. worn without nervous or organic irritation, should always be re- membered.,. The supposed danger from the extremities may be diminished by the addition of the flat disks, on their concave surface, by which the pressure is transferred to these disks, rather than to the extremities of the horns, and by which also the power of the instrument as a lever is increased ; so that a comparatively smaller one will answer. Another objection presented is, that pressure will he made against the bladder and the rectum^ so as to excite dysuria or tenes- mus, or to cause obstruction. This arises from the same cause, namely, too much resistance to the ascent of the fundus, and de- mands, therefore, an alteration in the size or especially in the curvature, so as to elevate the uterus and relieve the viscera, whether in front or behind. The great difficulty in managing the lever pessary is, its tend- ency to rotate^ so as to become more, or less transverse in the vagina. This accident, when it occurs, is unfortunate, as the pressure becomes uncomfortable, or even painful, and the symp- toms of displacement return, inasmuch as the uterus now will have but a trifling support, and the fundus falls down at once into the hollow of the side of the pessary. A globular, a flat circular ring, or disk pessary, may, of course, rotate in any direction with impunity ; they always present the same diameters and the same surfaces to the vagina and the uterus. Not so with the lever, on account of the peculiarity of its shape, its usefulness depends on its not rotating ; the bar must be posterior and behind the uterus, for comfort and efi'ect. The cause of the rotation is evident, being not merely from the resistance of the vagina posteriorly, but from the pressure of the uterus, which is by no means always in the middle line ; for very frequently the fundus is found towards the right, sometimes towards the left ischiatic foramen. The chief cause is, however, the unequal pressure of the rectum, which always lies to the left of the median line of the sacrum, and is constantly and sometimes greatly distended by feculent accumulations. The bearing-down efforts of the patient when such distension exists, as well in standing and walking as in the act of defecation, will sufficiently explain why rotation should sometimes occur. Indeed, it is wonderful, that the pessary should ever remain permanent, under all the irregular pressure to which it is subjected. OBJECTIONS MADE TO LEVER PESSARIES. 433 This predispoeition to rotation may be counteracted sometimes by increasing, to a certain extent, the breadth or the length of the pessary, or by augmenting its curvature, and occasionally by employing instruments furnished with the flat disks on the horns, which also will contribute to prevent rotation. Much may also be accomplished by simple pressure against the instrument, so as to imbed it more completely in the vagina and behind the uterus. Indeed, when the fundus uteri completely yields to the pessary, there is comparatively little danger of displacement of the instru- ment. Similar objections, although in a minor degree, may be made against the closed lever ; its too great size or curvature may produce pain ; pressure against the walls of the vagina may be so inordinate as to excite inflammation, followed by seroid, or mucoid, or purulent discharges, also by ulceration, which, if neglected, will penetrate the surrounding tissues. Sometimes the vagina will grow over the pessary, partly or completely imbed- ding the instrument. All these accidents are owing either to the neglect of the patient or the inattention of the practitioner. The pressure should never be so great as to excite the least degree of vaginitis. Another danger arises from the false idea that the lower part of the pessary should press against the bones of the pubis, and, of course, pain and inflammation would follow. The instrument should never impinge firmly against any tissue, especially where such tissues are near the bones; this is the real fault of the modi- fication of the lever pessary by Mr. Scattergood, who places a spring in each arm of the pessary, that its length may be accommodated to that of the vagina. The pessary should always be movable with the uterus. Of course, in all cases of displacement of the uterus, complicated toith uterine^ ovarian^ or other tumors^ peculiar difficulties may be experienced. Patience and perseverance, perhaps aided by some modification in the form of the instrument, will almost univer- sally overcome such obstacles. The patient should be hept for some time under the supervision of the physician, even after all the symptoms of displacement have entirely disappeared. It is generally found that if the woman can walk two or three miles a day for ten consecutive days with- out any uneasiness or difficulty, and without displacement of the 28 434 TREATMENT — LEVER PESSARIES. Uterus or pessary, she may be regarded as quite independent. Sometimes even after this test, some partial displacement of the instrument may ensue ; but we continually examine patients who have worn these supporters from one to five years, without any change of location in the pessary. Conclusions. — The author has thus endeavored to present fairly the importance of pessaries in the treatment of displacements, the objections against their employment in general, and the peculiar advantages and disadvantages of the more important varieties. He has striven to demonstrate the failure of all the forms, except- ing the intra-uterine and the lever pessary, in fully replacing and sustaining the fundus of the uterus. He has attempted to prove that although the intra-uterine pessary may, mechanically con- sidered, be more directly efficient than the lever, yet the objec- tions against its use are insuperable ; that its temporary employ- ment, even if the patient be at rest, is fraught with danger ; that it cannot be tolerated in cases of inflammation of the cervix and OS uteri, or in cases of irritable and sensitive uterus, especially when attended by leucorrhoea or menorrhagia ; that it must be occasionally removed, when, of course, the displacement .will re- turn ; that its employment is incompatible with connubial rites ; and finally, that its use for a few weeks, or a few months, will very rarely be adequate for a radical cure, as it does not allow sufficient time for the contraction of the elongated ligaments. The lever pessary will more slowly accomplish the restoration of the displaced organ, but, eventually, with equal certainty. It does not necessarily produce any irritation, organic or nervous, or any leucorrhoea, menorrhagia, inflammation, etc. It can be worn at all times, night and day; it interferes with no motion, and no function; the patient has no attentions to pay to it, excepting a daily vaginal wash ; she may, and often does forget its presence, can enjoy her connubial pleasures, can move about in society without anxiety, is free from local and general nervous irritation, from corporeal, intellectual, and spiritual disturbance ; and her physician may hope that, the uterus being perfectly sustained, the ligaments, now free from every counteracting influ- ence, will continue to contract to their normal length, and acquire their original tonicity, so that a permanent cure may be eJffected, or that pregnancy ensuing, the continued use of the pessary will preserve his patient from those irritations so frequently excited by displacements, and so apt to result in abortions. PROLAPSUS — ANTEVEKSION. 435 CHAPTER VII. TREATMENT OF THE VARIETIES OF DISPLACEMENTS. In the preceding pages, many directions and allusions have been made to the treatment of the different forms of displacement, and especially to the modifications occasionally requisite to fulfil particular indications. In the author's experience, the lever pes- sary has, with few exceptions, answered for every displacement ; even" in retroversion and retroflexion of the uterus, it has satis- fictorilj fulfilled the indication of restoring and keeping the fundus in position. VARIETIES. Prolapsus. — In prolapsus^ it is an easy matter to elevate the organ in the direction of the axis, which, according to the definition already given, nearly corresponds in such cases to the axis of the superior strait. To accomplish this, and to support it when thus elevated, some form of a ring pessary is essential. Every other variety would make pressure on the cervix, increasing or causing flexion, and producing or augmenting irritation or inflammation at the mouth of the womb. For these reasons, the disk pessary of Dewees, as already remarked, is decidedly injurious in these cases of prolapsus, and so also the ball, the cylinders, etc. The curved ring or lever seems to be preferable even to the flat ring, as it is accommodated to the natural curves of the vagina, allows mobility, and makes no pressure on the rectum or bladder, while it well supports the uterus, and takes away all pressure from its cervix. Anteversion. — In anteversion, the lever pessaries answer very well ; for, in this case, the uterus resting on the convex surface of the lower, or the long arm of the instrument, is thereby elevated 436 TREATMENT OF VARIETIES OF DISPLACEMENTS. from the pubis, and, by tbe pressure from above, tlie pessary and the uterus glide down the inclined plane of the perineum, and thus the fundus is carried still further from the pubis. As in all ring pessaries, the neck is protected from pressure against the walls of the vagina. However, almost any variety of pessary may, with proper atten- tion, answer in anteversion, such as the spherical, the conical, the cylindrical, the flat oval, the flat disk, the flat ring, the double or plano-convex, etc., as they all have the effect of elevating the fun- dus of the uterus from its position behind the pubis. Generally, in the spherical pessary also no injurious pressure is made in such cases on the os and labia of the cervix. Some modification of the ring, however, is preferable, as securing the safety of the cer- vix from all pressure. In our experience, few bad consequences result from simple anteversion of the uterus, and it is so manage- able, that we are much surprised that some late authors speak of its being so intractable, or even incurable, that no measures are adequate to its relief, especially that any should consider it justi- fiable to contract the anterior portion of the vagina between the uterus and the urethra by scarifications, sutures, etc., so as to draw the cervix uteri forward. We can hardly conceive that such an operation, requiring much dexterity, and involving many dangers, can be demanded, or that it could usually be successful. In anteversion with flexion of the uterus, a ring pessary is all- important, as it alone supports the uterus at the base of the neck ; while, in the use of other varieties, the superincumbent pressure is still received by the extremity of the neck, increasing rather than diminishing its curvature. The cause of flexion, namely, the weight of the viscera received on the cervix, must be removed as formerly shown, to insure a radical relief. The bad conse- quences of flexion, especially as producing dysmenorrhoea, steri- lity, etc., are so serious, that this idea should never be forgotten. If the uterus therefore be restored by means of a lever or other variety of a ring pessary, and an uterine sound be occasionally passed, say once or twice a week, into the cavity of the uterus, thus straightening the neck, the curvature will gradually dis- appear, and often dysmenorrhoea or sterility will vanish. Cer- tainly, this measure should be faithfully tried for a long time, before resort be had to the intra-uterine stem, to the uterotome, or to the elaborate operation, proposed by Dr. Emmet, of New RETROVERSION. 437 York, demanding much dexterity, involving great danger from hemorrhage and inflammation, a tedious confinement, resulting in more or less deformity of the cervix, and, we must imagine, with uncertain benefit. Eetroversioist. — In retroversion and retroflexion of the uterus, all the usual pessaries fail in maintaining the fundus in situ, even when assisted by stems passing out of the vagina ; indeed, they not merely fail, but are decidedly injurious. The intra-uterine and lever pessaries, however, well fulfil the important indication of restoring the axis of the uterus to its parallelism with that of the superior strait, and of maintaining this position under all the motions of the patient. Their advantages and disadvan- tages, the beneficial effects and the difficulties and dangers which may result from resorting to the one or to the other form pro- posed, have been so fully detailed, with, we hope, candor and love of truth, that the question of their relative importance must now be left to the judgment and experience of others. If both should fall short of public expectation, doubtless the ingenuity and science of others will substitute something more safe and prac- tical, to support the uterus in its proper position without exciting nervous or organic irritation, and thus relieve its local and functional disturbances, with the distressing and horrible influ- ences of cerebro- spinal irritations, involving, as they do, the whole corporeal, intellectual, and spiritual being.^ 1 This subject of retroversion of the uterus has greatly engrossed professional attention since the time of Dr. William Hunter ; first, as it existed in the pregnant condition, and second, in the unimpregnated state. It seems wonderful, at the present day, that very little advance has been made towards unity in sentiment and especially towards uniformity in practice. A very large proportion of modern observers are disposed to consider the fact of retroversion as of minor importance, attributing the alleged symptoms to complications. Most practitioners affirm that partial inflammations, or congestions, or tumors in the posterior part of the uterus are the real cause of the accident ; and these being removed, the displacement will disappear, or be innocuous. Hence, antiphlogistic remedies are much trusted to, or, if the cause cannot be removed, the displacement with all its attendant evils is deemed intractable. Few put confidence in pessaries, dreading bad influences, or cautiously employ them as palliatives. Sir James Y. Simpson still has confi- dence in the intra-uterine stem, but most good authorities, perhaps all, condemn it as dangerous. Our own views are so diametrically opposed, both thoeretieally and practically, to the above sentiments, and they have been so sustained by our clinical expe- rience, that we cannot but hope that much may be achieved by others in relieving 438 TREATMENT OF VARIETIES OF DISPLACEMENTS. The following account, as drawn up by a former patient, has been received since the preceding pages have been in type. It is interesting as presenting some very peculiar and singular phe- nomena, developed first during pregnancy, continued after deli- very in connection with a retroverted uterus, and disappeared when this displacement was relieved. The patient now no longer wears a support, and is entirely free from pelvic and uterine irri- tation. Case. — " About two months previous to the birth of my fifth child, while walking across the room, I was suddenly checked in my progress by the seeming dislocation of (the pubic) bones, which in my ignorance of anatomy I believed to be jointed, causing intense agony, accompanied with a sound like a pistol- shot : leaning on something near by, for support, the movement of the body caused the bone to slip in place again, when I was enabled to take a few steps, with great suffering, as the soreness and stiffness were almost unendurable. Such painful sensations and sounds recurred over and over, when attempting to get up or lie down, to the birth of a fine large child, which it may be proper to state caused less pain (though quite enough) than I had ever experienced on any previous occasion — leaving me, how- ever, with prolapsus of the womb, and all the miserable feelings incident to such diseases, until eighteen months after, when, finding I was to become a mother again ; then my health ap- peared almost restored, up to the two or three last months before confinement, when I suffered exactly as before mentioned — which, contrary to expectation, brought no relief — my troubles were steadily increasing. The pain in the bones seemed permanent ; numbness and stiffness in the left hip, which also gave way with a noise, and pain when I would lift my foot. Then I learnt to drag it, as if paralyzed. This continued for six months, when I was taken to Philadelphia, where I was speedily relieved of retroversion of the uterus, and that the profession will regard it, in most instances, as the cause and not the consequence of morbid complications. We trust also that the idea will be received, that flexions in general, and hence, also, retroflexion, are but the result of pressure. Hence, the pressure being removed from the cervix, and the body of the uterus being reinstated in its natural position ; the severe and dangerous operations of the bilateral section of the canal of the cervix, the slit- ting up its sides by scissors, the dividing the neck posteriorly, the amputating one of the lips or the whole cylinder of the cervix now so rife, will, if not entirely abandoned, be at least restricted to some few extraordinary cases. PROCIDENTIA. 439 mucli tliat had distressed me, thougli four montlis elapsed before I was sensible of a decided improvement in the aching bones. I continued to wear an internal support, for several years ; believing it to be the first cause of relief. I had a morbid fear that with- out it I should relapse into mj former wretched condition ; such, however, has not been the case, as, save for bronchial difficulties (which is foreign to our subject), I might be pronounced well. And filled with gratitude," etc. etc. Procidentia. — In procidentia uteris the great relaxation of the vagina and perineum is almost universally a complication de- manding special attention. When this complication is absent, no special difficulty exists in most cases ; for, the uterus being by a little pressure returned into the pelvis, is found, as formerly demonstrated, in a state of retroversion, and should be treated, therefore, for reasons frequently stated, by the " lever pessary." ISTevertheless, since the vagina is usually much relaxed and dis- tended, and also since procidentia occurs most frequently in elderly females, past the change of life, when the uterus has often dwindled in size, and is comparatively free from irritation ; several of the varieties of pessaries above enumerated will prove useful. The author has therefore succeeded, with the flat ring, especially when the circumference of the ring has been compara- tively thick, and also with a large disk pessary, the plano-convex and the double convex pessary. In cases of procidentia uteri with great relaxation of the vagina, the disk or the convex pessaries are often demanded to support the vagina within the vulva; for with the lever or other varieties of the ring pessary the coats of the vagina fall over the margin or through the opening of the instrument, and may protrude from the vulva sufficiently to annoy the patient. In such cases, when the disk or convex pessary is employed, more than ordinary attention will be demanded to prevent the accumulation of fluids, and an increase of leucorrhoeal discharges, fetid excretions, etc. Occasionally the instrument riiust be re- moved for a few days, and astringent washes employed to the vagina, while the patient is kept in bed until the discharges have ceased and the instrument been cleansed. The modus operandi of pessaries in great relaxation of the vagina is first to carry the whole tube completely within the 440 TREATMENT OF VARIETIES OF DISPLACEMENTS. bones of the pelvis. Hence, a large size is generally requisite. If the lever be used, the suggestion of Dr. Churchill of an addi- tional bar on the lower portion of the instrument will be benefi- cial. This pessary also should be as long and as much curved as suits the comfort of the patient, so as to carry the upper part of the vagina as high as possible behind the uterus. A second advantage of the pessary is, by its pressure, to stimulate the muscular and organic actions of the coats of the vagina, so as to facilitate its contraction, or as Dr. Sharpless would express it, to increase its tonicity and condensation. Third, this pressure may be sometimes so great as to excite a moderate degree of vaginitis; hence, as above intimated, increasing the mucoid and seroid dis- charges. Such inflammation, if moderate, serves still more to condense and thicken the coats of the vagina, so that a smaller pessary will be required. Of course, the effect of the instrument must be watched that no severe inflammation or ulceration be excited ; in which case it should be removed and the patient kept at rest under the free use of emollient and astringent washes, until the parts will again tolerate a support. In this way, a per- fect cure may be occasionally anticipated; and although the treatment is tedious, yet, during the whole time, the patient can be allowed to move about, and attend to her ordinary labors, with little or no discomfort. The plan is simple, efficient, and void of danger, and should, we think, be tried by those who abandon such cases as intractable, or resort to perineorrhaphy or elytrorrhaphy, accompanied, as these operations are, with many difficulties and dangers. DISPLACEMENTS OF THE VAGINA, etc. Prolapsus of the Vagina, etc. — There are cases oi prolapsus of the vagina^ described by authors as distinct and independent of displacements of the womb ; but practically they require no dif- ferent treatment from procidentia uteri with relaxed vagina, and they are seldom disconnected from some degree of prolapsus or retroversion of the uterus. These cases of prolapsus of the vagina are often designated as cases of cystocele, or reciocele, or " hernia of the bladder or rectum ;" because in bad cases the bladder or rectum, as they are closely CYSTOCELE — RECTOCELE. 441 adherent to the walls of the vagina, will descend and protrude externally. If it be a cystocele, mere tactile examination, when the bladder is empty, will not usually detect this complication ; but by care it will be found that there is a greater prominence than is natural at the anterior portion of the orifice of the vagina, that there is an increase of this swelling when the urine has been retained for some hours, that there is evident fluctuation, and sometimes ten- sion, and that there is a sudden disappearance of these symptoms after micturition. The diagnosis is confirmed by passing a ute- rine sound, or a curved catheter, with its convexity towards the pubis, into the bladder, when the point will easily be felt through the parietes of the tumor outside of the vulva. The patient com- plains of sensations of fulness, pressure, and weight, especially when the urine accumulates, or when she stands or walks ; and local irritations from exposure, sometimes amounting to inflam- mation, not unfrequently occur. There is generally frequent inclination to micturate, to dysuria, and sometimes inability to empty the bladder until by pressure the tumor is reinstated. In other instances, which are comparatively rare, the posterior wall of the vagina is more relaxed, and protrudes, bringing" with it the anterior wall of the rectum, thus constituting a rectocele. If this should be suspected, its existence may be confirmed very readily, by passing a finger into the rectum, and curving it for- wards, when it is readily perceived outside of the vulva, covered by the combined coats of the vagina and rectum. In addition to the usual symptoms of fulness, weight, etc., in such cases, there is apt to be tenesmus, distension of the pouch from gas, fluids, and sometimes solid faeces, on the evacuation of which the tumor collapses. In one case that we recall, cystocele and rectocele both existed in the same patient, and were readily detected by the catheter in the bladder and the finger in the rectum. The treatment in all such cases is comparatively very easy. Empty the bladder and the rectum, and then introduce a large disk or convex pessary into the vagina, so as to render it suffi- ciently tense. By this means, the symptoms will be immediately relieved. Astringent washes must be daily employed. After a few weeks or months from the combined influence of the astrin- gents, and the pressure of the pessary, such condensation of the 442 TREATMENT OF VARIETIES OF DISPLACEMENTS. tissues may be expected, that a smaller pessary will answer, and subsequently tbe support may be entirely pretermitted. In the use of the pessary, attention should always be paid to the condition and position of the uterus, so that its displacement may be relieved as well as that of the vagina. From our own experience, we cannot conceive of any cases in which such treat- ment should be so ineffectual as to j ustify an attempt to diminish the size of the vulva, or the vulvo-uterine canal, by resort to the knife, or perhaps the more dangerous employment of caustics.^ HERNIA OF THE BLADDER. Although the above mentioned cases of protrusion of the blad- der or the rectum are usually termed hernia^ yet strictly this name is not applicable to them, as there is no opening or foramen through which either viscus has been forced, but there is simply great yielding of the coats of the bladder or rectum and the vagina. Hence there is no danger of inflammation or strangula- tion as in inguinal or crural hernia, whether the intestines or bladder protrude. Case. — The following history of a unique variety of hernia of the bladder to which the name more strictly belongs, may not prove uninteresting. Many years ago, an unmarried lady very imprudently attempted to raise a heavy weight. She felt imme- diately that something had given way internally. She com- plained of a weakness, a feeling of protrusion at the vulva, as if something must escape if she continued in the erect posture. Soon afterwards, she recognized a decided swelling at the orifice of the vagina. No professional examination of the part was allowed. She was requested to remain continually in bed, and persevere in the use of cold and astringent washes, with suitable attention to her bowels. Some months expired and no permanent benefit resulted ; the patient was perfectly well in the recumbent position, but uncom- fortable when erect. An examination was now permitted, and a slight prolapsus of the uterus was detected, with such a degree of apparent relaxation of the anterior wall of the vagina as to allow ' See note on page 376. HERNIA OF THE BLADDER. 443 a vaginal, but not a uterine protrusion at tlie vulva. A pessary was employed with trifling relief; its sliape and size were vari- ously modified, but still, tlie fulness at the vulva continued trou- blesome. This was, of course, very surprising in a virgin, the tissues being tense, and the hymen existing. A more careful investigation was now instituted. The uterus had been sufficiently elevated by the pessaries, but it was found that a portion only of the vagina was relaxed ; this was situated not on the anterior, but on the right and lower portion within the rami of the pubis and ischium. When the swelling was reduced, a longitudinal opening could be recognized by the finger, apparently in the pelvic fascia. The point of a curved catheter passed into the bladder could be felt in the vaginal tumor, coming through this lateral opening. Here, indeed, was detected a regular cystic vaginal hernia, penetrating between separated fibres of the pelvic fascia near the foramen thyroideum, and on the inner surface of the levator ani muscle of the right side. The whole was reducible by steady pressure with the finger, but partially returned as soon as this was intermitted ; and the tumor reappeared at the orifice of the vagina as soon as the patient stood erect. No other portion of the vagina was implicated. The nature of the case, and the indications to be fulfilled, were now evident ; but the means at command proved very inefficient. Innumerable varieties of pes- saries, with and without springs, were tried, but the tumor would press around or over them ; no firm, unyielding pressure could be made on the opening, so as to prevent the egress of the bladder. Success, however, eventually was gained by means of what might be termed a T pessary, that is, a large cylinder, about the length of the vagina, to the middle of which a smaller cylinder was attached at right angles. This was introduced and so arranged, that the large cylinder extended from the foramen thyroideum to the upper part of the vagina, which space it completely occupied ; the small cylinder was then placed across the vagina, its ex- tremity pressing against the left side, so as to keep the larger or longitudinal portion so firmly in position, under all the varying motions of the patient, that the hernia did not escape. The instrument was worn for many months, without any special trouble, and was then removed. Some twenty-five years have since elapsed ; the lady is still living, at an advanced age, but without having had any return of this old enemy. 4-44 TREATMENT OF VARIETIES OF DISPLACEMENTS. STRENGTHENING THE NATURAL SUPPORTS. l!:\iQ fourth indication in the treatment of displacements of the uterus is so to strengthen the natural supports of the uterus that artificial assistance may no longer be required. Our means are here, however, very limited. We must trust merely to the usual recuperative powers of nature. Those who imagine that the uterus is supported merely by the tonicity and contraction of the vagina depend, of course, upon astringents, tonics, and cold applications to this canal ; and, these failing, they have been bold enough to resort to surgical opera- tions to diminish mechanically the size of the vagina, or, it may be, of the vulva, for a radical cure. We have already noticed the falsity of the theory on which this practice is founded, and its inefficiency, except, perhaps, in some cases of procidentia uteri. When displacements of the uterus arise from increased weight or size of the organ, or from increased pressure from above — the natural supports remaining good, or biit slightly impaired — then, if such increased size, weight, or pressure can by any means be obviated, the ligaments may resume their duties, and the organ be supported by them without artificial assistance. This is often observed in cases of hypertrophy from pregnancy, from polypous tumors, from fluid collections in the cavity of the uterus, or even from simple irritable uterus; the causes disappearing, the size of the uterus diminishes, and the ligaments will then be adequate for the sustentation of the organ. The same favorable results may be anticipated, in some cases, when constipation, tympanites, ascites, or other temporary sources of pressure, such as tight dresses, braces, etc., have vanished. In most instances, however, there is such an elongation, want of tonicity, or relaxation of the ligaments, either prior to or after the displacement, that they are inadequate to retain the womb in situ. However frequently the organ may be artificially elevated, it again falls under the weight of the intestines and the contraction of the abdominal muscles. Artificial supports or pessaries are, therefore," demanded for the restoration and maintenance of the uterus. These means will usually prove not merely palliative, but radical. This anticipa- tion is founded on the general physiological fact that there is a natural disposition of all the tissues of the body, especially of CONTRACTION OF THE LIGAMENTS. 4J:5 the muscular, to contract, when there is no counteracting cause. The skin and areolar tissue are continually accommodating them- selves to the size of the subjacent tissues ; the heart, stomach, bowels, bladder, uterus, etc., to the size of their contents. If a limb be kept uniformly in one position for a sufficient length of time, the muscles, ligaments, and other tissues will contract so as to render it inflexible and useless. When the uterus is fully supported by a pessary, and especially if the fundus be tilted well towards the pubis, all the ligaments previously elongated and atonic are thrown into folds; and the organ being constantly sustained in the above position, there exists no counteracting influence to prevent the shortening of the liga- ments. Their contraction may therefore be always expected after a longer or shorter period. The time for its full accomplishment must exceedingly vary, according to the vigor of the patient, whether she has never been pregnant or been frequently a mo- ther, according to the degree of elongation and atony of the liga- ments, the size of the womb, the degree of pressure from the viscera, etc. No definite time can, therefore, be fixed at which a patient can dispense with an artificial support after there has been a chronic displacement, especially a retroversion, where the ligaments are always elongated. We have removed a pessary even after three months, and our patient has remained well ; others have worn them for years, and yet do not feel comfortable without the sup- port. Our general rule is, that at the end of a year the instru- ment may be removed ; but if symptoms reappear, and especially if, on successive examinations, the uterus is found gradually re- turning to its mal-position, then to replace the pessary. The inconvenience of wearing a support is trifling, as it should cause no pain or irritation ; and the miserable consequences of displace- ment are so great, that the propriety of continuing its use can hardly be doubted. Of course, particular circumstances interfere with the execution of this general rule — as, general or local diseases from accidental causes, but especially the occurrence of pregnancy. In this last case, the pessary will continue, for a time, to be useful, as has been maintained, in preventing any displacement in the early stages, and in diminishing any predisposition to abortion. After the third or fourth month it can do no good, as the uterus becomes 446 TREATMENT OF VARIETIES OF DISPLACEMENTS. SO large as to rise out of the pelvis, and it might be injurious, from the enlarged size of the organ, to which it is not adapted. This natural disposition of the ligaments to contract is our chief reliance ; but, as they are muscular tissues, we may conclude that all those hygienic and medicinal measures which increase the tone and energy of the general muscular system will greatly assist recovery, by imparting activity and strength to these hitherto atonic and relaxed ligaments. Even the injections of cold water, astringents, and tonics into the vagina may have a sympathetic tonic influence on these supports. As, however, the ligaments are internal, among the intestines, no one but the empiric would speak of making direct applications to these tissues to strengthen them. FLEXION OF THE NECK OF THE UTERUS. 447 CHAPTER VIII. TREATMENT OF COMPLICATIONS OF DISPLACEMENTS OF THE UTERUS. Many allusions have been made to tlie complications of the usual forms of displacement, the treatment of which has now been presented. FLEXION. With prolapsus, anteversion, or retroversion, flexions of the neck of the uterus demand very little special treatment. The passage of a uterine probe two or three times, with the use of a ring pessary, is almost always successful. The annexed drawing of the uterine sound or probe represents that degree of curvature, required when the uterus is in situ. The influence of the probe IS temporary, that of the ring permanent ; the latter transfers the superincumbent pressure, which is the cause of the flexion, from the extremity of the cervix to the body of the uterus, at its junc- tion with the neck. The vagina attached to the lower extremity of the neck, is stretched out by the pessary, like a tent, and receives also part of the pressure ; so that, the balance being borne, as just mentioned, by the lower part of the body of the womb, the neck is entirely liberated. The cause of flexion is no longer 448 TREATMENT — COMPLICATIONS OF DISPLACEMENTS. operative, and this complication, so fruitful of functional uterine distress, disappears.^ The ring not only delivers the cervix from this complication, but, preventing all firm contact with the posterior portion of the vagina, it liberates the extremity of the neck from that attrition which so often induces and keeps up inflammatory affections of the OS uteri. Hence, not only are dysmenorrhoea and sterility frequently obviated by the ring, as formerly mentioned, but it becomes also an important, if not an essential, adjuvant in the treatment of inflammations of the cervix. MENSTRUAL DISTURBANCE. Frequent notice has already been given of the great benefit to be experienced from a proper support to the uterus, in cases of displacements complicated with leucorrhcea, menorrhaijia, and even hemorrhages from the uterus. By relieving the irritation from the displacement, they usually prevent the congestion of the uterine, vessels, which is the cause of such discharges. Hence leucorrhcea and monorrhagia, which have, from time immemorial, been so indomitable as to be ranked among the "opprobria medicorum," will, often, by these means, become very manageable. They should no longer be regarded as " weaknesses," but as the results of irritation ; and let it be remarked, also, that, in a large majority of cases, these vaginal evacuations of mucus, serum, menses, and blood, are the sequeloe not of inflammatory or organic, but of nervous irritation. Hence in such cases the use of leeches, cups, and blisters, of astringent and stimulating washes, and the employ- ment of nitrate of silver, of caustic potash, of the acid nitrate of mercury, and other analogous measures, will not reach the root of the evil. The congestion may be relieved for the time, but it will certainly return, even when, as we have often known, this- course of practice had been pursued for many years. On the contrary, if the nervous irritation of the uterus be relieved, the congestion will disappear and not return, no matter whether such irritations arise from displacements of the uterus, or from sym- pathy with the bladder, the rectum, the stomach, or the cerebro- ■ Vide Treatment of Anteversion with Flexion, p. 436. HYPERTROPHY. 449 spinal centres. If there be no irritation, there is no congestion, and if there he no congestion, there will be no preternatural evacuations. Thus the uterus, free from irritation, resumes its normal functions. ENLARGEMENTS AND TUMORS OF THE UTERUS. Hypertrophy. — Displacements are also complicated with hypertrophy of the uterus, a natural growth of tissue without disorganization. Many such cases are met with, where there are no tumors, or other permanent sources of irritation. The cause may be often traced to the continued state of irrita- tion and engorgement, kept up by a disiilaced uterus. Such cases of hypertrophy are too often treated, and certainly with doubtful success, by evacuants, by the local and general use of iodine, or of mercurials carried to the extent even of salivation ; by the use of such topical remedies as astringents, stimulants in the form of washes, powders, and ointments; by scarifications, incisions, and leeches ; and by caustics of every variety. If, however, the dis- placement be relieved, especially by some form of the ring pes- sary, the irritation is removed ; the troublesome and distressing pains and nervous symptoms disappear, and the congestion vanishes ; there is no increase of the enlargement, as the pabu- lum is destroyed; and, gradually, the uterus diminishes by the process of interstitial absorption to its natural size, precisely as the uterus of an aged female shrivels, after the normal excite- ments of her menstrual life have terminated. Thus, we have often known hypertrophies disappear, and females who, from this cause, have been sterile for years, again become mothers. Moreover, hypertrophies of course are often dependent upon polypi. In these cases, prolapsus or retroversion may, and gene- rally does exist, from the increased size and weight of the organ, and thus aggravates the symptoms. The polypus usually can be, and of course ought to be, removed. Then, the irritation, as in other cases, being relieved, the congestion ceases, and the uterus gradually diminishes to its normal size, and may thus possibly regain its natural position. Should this however not be the case, the usual treatment for displacements will be demanded. In a few instances of intra-uterine polypi with displacement, the poly- 29 450 TREATMENT — COMPLICATION'S OF DISPLACEMENTS. pus cannot be immediately removed, from occlusion of the os uteri, from adhesions of the tumor, or from other causes. In such cases, more or less palliation may be given to the symp- toms by pessaries, relieving the displacement; but, no radical relief can of course be effected, so long as the polypus remains. It has been asserted by some pathologists that apparent dis- placements of the uterus exist where the body is in its natural position, but the cervix so elongated that it presses upon the floor of the pelvis. Others regard this elongation of the neck as a cause of displacements, especially of procidentia uteri; still, a large number consider it as a cause often of dysmenorrhoea, and , more frequently of sterility. This elongation is sometimes inappropriately regarded as con- genital, but certainly should be considered as merely an inordi- nate development of the cervix, without any prior irritation or disease, the tissues being quite natural. It should be termed spontaneous or natural hypertrophy. The cervix is usually de- scribed as being of a conical form, tapering towards the os ex- ternum, and varying from two inches to, it is said, four inches in length. Of course, it must sometimes be very far back, presenting towards the sacrum, qr occasionally forwards, and has a tendency to appear, or even to protrude at the os externum vaginae. A more frequent cause of this elongation is hypertrophy, or actual induration of the cervix, by which not only the volume, but the length of the neck is increased. In all such cases, symptoms of prolapsus, usually with flexions, dysmenorrhoea, sterility, etc. exist. It is frequently complicated with the various displacements of the uterus, especially retrover- sion. Practitioners have been so much puzzled in the manage- ment of these uterine displacements, especially of these cases of natural or accidental hypertrophy of the cervix, that the ordinary measures failing, they have become more bold, and resorted to amputation of the cervix^ an operation which has always been con- sidered dangerous, and which has certainly, even in the most skilful hands, sometimes proved fatal. It has been often employed in cases of malignant diseases of the neck, certainly with very little success. M. Huguier, of Paris, has, of late years, recommended it in cases of hypertrophy, sometimes dissecting up a portion of the vaginal mucous membrane from the cervix, so as to remove a larger portion of this body. Sir James Y. Simpson, Drs. Tilt UTERINE TUMORS. 451 and Aslawell, in Britain, and Drs. J. Marion Sims, Emmet, and F. Gaillard Thomas, of New York, have also recommended it. That there are some cases, especial! j in non-malignant fungous growths from the cervix, or in decided cases of natural hyper- trophy where this operation is advisable, may be admitted ; but "we can hardly conceive it possible that it would ever be neces- sary in cases of acquired hypertrophy ; inasmuch as such enlarge- ments may be gradually dissipated, and their present inconveni- ences relieved by means of ring pessaries. This, at least, is the con- stant result of our experience. We must consider, also, that all such operations upon morbid tissues must be hazardous. As for so-called " congenital" or natural hypertrophy, we should deem it very rare, having in the course of a practice of half a century met with but one single example. Respecting the mode of operation, a difference among prac- titioners exists ; perhaps the knife has been generally preferred, and Dr. J. Marion Sims, with his usual dexterity, has dissected up the mucous membrane of the stump of each lip, so as to draw it as a flap over each extremity of the lips, as in amputation of the extremities. The hemorrhage, however, primary or second- ary, has been generally so profuse that a constant tampon has to be worn for a week or ten days after the operation. To avoid this difficulty, the " serre-noeud" or the "ecraseur" has been preferred. Tumors. — Enlargements of the uterus may also be dependent on mural tumors, and then almost universally produce displace- ments. The principles have already in these essays been incul- cated, that the symptoms of pain and nervous distress, of leucor- rhoeal and hemorrhagic discharges, which so often attend these cases, are referable, not entirely to the presence of these tumors, but mainly to the displacement, caused by the enlarged size and weight of the organ; that the bad effects arise, therefore, not directly, but indirectly, from these heterologue or abnormal growths; and that the tumors are generally quiescent, not active, often existing for a lifetime, without any serious or troublesome symptoms, if there be no displacement. Of course, there are many exceptions, as these tumors may become inflamed, or may have been originally scrofulous, cancer- ous, or otherwise malignant. These are, the author believes, 452 TREATMENT — COMPLICATIONS OF DISPLACEMENTS, judging from his own experience, very generally the exceptions. So many instances have occurred to him, of uterine tumors with displacements, leucorrhoea and menorrhagia, and the consequent injury of the patient's general health, in which, by simply treat- ing the displacement by pessaries, all the local symptoms have been dissipated ; and the patients have so often, under the influ- ence of fresh air, exercise, tonics, bathing, etc., wonderfully reco- vered, that he must urge upon others a similar practice in suitable cases, founded upon the often-repeated principle, of removing the local irritations due to the displacement. His observation now, for a long series of years, in public and private practice, is directly opposed to the opinion, that those abnormal tumors are often either originally, or secondarily, of a malignant character; or that they are often subject to inflammatory irritation. Although post-mortem examinations occasionally reveal peri- tonitis, or abscesses connected with these tumors, yet this does not invalidate the opinion just given; for, the cases are innumer- able of uterine tumors existing for many years, and yet not affect- ing the patient's general health, or at least not producing any serious disease. In such individuals, death generally arises from other and distinct causes. Cases are reported of death merely from the enormous size of the masses, so great as to interfere with the functions of the thoracic or abdominal viscera, or of the arterial or venous circulation. Such instances are still less fre- quently to be observed than those which terminate by inflamma- tion and abscesses. The law of increment is not yet known, or that of arrest and decrease. There can be no doubt, however, that these growths often remain stationary for years, that some- times after increasing, even rapidly for a time, their development is arrested by some hidden influences, and not unfrequently they diminish and disappear. The following case will be interesting, as illustrating the facts stated, and the principle which should regulate the practice which is to be pursued. Case. — A lady, when about thirty -five years of age, was mar- ried, believing herself in perfect health, as she felt quite well and was not conscious of any unnatural condition of her organs. Mar- riage revealed a complete vaginal obstruction. Her physician. Dr. Marshall Paul, submitted the case to our investigation and subsequent treatment. We found the whole cavity of the pelvis UTERINE TUMORS. 453 occupied hj a very hard tumor, situated behind the vagina, and in front of the rectum, extending from the orifice of the vagina to the sacrum, and from one side of the pelvis to the other. The impaction was so complete, that the tumor was nearly in contact with the fourchette or fr^enum perinaei. The displaced vagina was turned upwards, and behind the pubis to the hypogastric region, where with difficulty the os uteri could be touched by the index finger forced upwards, between the symphysis pubis and the tumor. Per rectum, a regular spherical mass was recognized. The urethra was drawn up behind the symphysis, as in the last stage of pregnancy. By a hand upon the abdomen the uterus could be detected larger than natural, and the whole hypogastric and iliac regions were as tumid as at the fifth month of gestation. Irritability had gradually increased, and was manifested chiefly by inability to retain her urine for more than an hour, by night or day, depriving her of sleep, of the comforts of social inter- course, and often proving very distressing. She suffered also from constant fatigue, with sensations of pressure and weight after slight exercise. The catamenia were regular. To relieve these symptoms the indication was clear to elevate, if practicable, this abnormal mass from the cavity of the pelvis, and to keep it above its brim. As this could not be immediately accomplished by any direct pressure with the fingers, we employed first a cylindrical pessary two inches in length and half an inch in diameter. This could with some difficulty be introduced into the vagina, so as to lie transversely from«the crus of one ischium to the other, and close to the perineum in front. To retain it in this position, a short stem or small cylinder was attached to its centre, and allowed to project at the vulva. The whole instru- ment was of a T shape. By pressing the instrument downwards and backwards, the vagina was elongated underneath the tumor. Soon a larger cylinder was tolerated, the tumor yielded a little ; by the gradual introduction of larger cylinders or balls, and afterwards by the use of more than one at a time, the whole mass was elevated above the superior strait, where owing to its great size it remained supported. Then the instruments were removed, and the patient required no further attention. The frequent in- clination to urinate disappeared. She could remain in bed all night, and during the day could attend to her social duties. Her 45-1: TREATMENT — COMPLICATIONS OF DISPLACEMENTS. health was good, but her abdomen was greatly enlarged, as if at the seventh month of gestation. At the usual period of life her menses disappeared, and she then reported herself as becoming smaller, and after the change was established the diminution was marked. On asking this lady, now about fifty-five years of age, not long since, respecting her tumors, she exclaimed, " I have no tumors," certainly none of which she is conscious, or which a casual observer would notice. This and various other cases would confirm the opinion of the innocuous character of these abnormal growths as they usually present themselves ; that the irritations and congestions, with their consequences, leucorrhoea, menorrhagia, etc., often existing, are owing to the weight of the uterus and to pressure on the bladder, rectum, or nerves, and not to the character of the adven- titious growth; that such pressure being relieved, the symptoms of irritation will often disappear and the patient enjoy excellent health, though the presence of the tumors continues ; and finally, that there is strong reason to believe that the disposition to en- large will eventually lessen and entirely cease, and that in some rare cases the tumors may gradually disappear. The diminution or entire relief of the symptoms by means of pessaries probably facilitates this tendency to spontaneous arrest and disappearance, by lessening the irritation and consequent congestions, while it is extremely doubtful whether anything can be accomplished by medicinal agents. Medicines, in these cases, are of no further use than to main- tain the healthfal functions of the organs of the economy, and to impart tone to the system ; as resolvents, they are not to be trusted. In a large proportion of these uterine tumors which have occurred in our practice, the enlargement has not been suffi- ciently great to retain them above the superior strait of the pelvis; so that the continuance of pessaries, even for years, is generally necessary. Nevertheless, the irritations from the displacement are relieved by the support they give to a greater or less degree ; indeed, very generally, perfect comfort is afforded to the patient. The form given to the pessary must vary according to circum- stances, the kind or degree of complication, etc.; but generally the " lever," from its bent form accommodated to the curve of the perineum and sacrum, will best fulfil the indications. But PESSARIES — COLPEURYNTERS. 455 frequently, however, the disk, conical, globe, cylindrical, or other pessaries may be very important. As a substitute for these instruments, it has been suggested to elevate such tumors and enlargements of the uterus by means of caoutchouc bags intro- duced into the vagina, in a collapsed state, and then gradually distended by air or water, as the sensations of the patient will allow. These colpeurynters, as they have been called, are now much employed, and doubtless with great advantage, in many cases. Care, however, should be taken not to increase the irri- tations, and the sensations of weight and pressure on the bladder, rectum, perinaeum, etc., and also that a right direction be given to their pressure. They are to be regarded merely as temporary assistants, from the perishable character of the material employed. Hence, if any constant support be demanded, the pessaries already recommended must be resorted to. The important practical rule — avoid pain and local irritation from the pessaries — is, of course, never to be forgotten. Much time and perseverance are often demanded, and much attention must be paid to avoid pressure on prominent or sensitive spots, by altering the size, form, and curvature of the instrument, es- pecially as these uterine tumors are very irregular in their shape; and sometimes are very numerous, and situated upon different portions of the uterus, and occasionally render the organ appa- rently immovable. It is very rarely, however, that all these diffi- culties may not be readily overcome, and the patient be relieved. Every encouragement may be presented ; that the support being accomplished without pain or irritation, the symptoms of uterine trouble will entirely disappear, however large may be the uterus and its parasitic growths. Like warts on the fingers, or sarcoma- tous or fibrous tumors elsewhere in the body, they may be tole- rated for years, if the bad effects of pressure or other irritations be removed. In their own nature, they are neither painful nor destructive. This point has been dwelt upon more than might seem to be requisite, but this general principle is of immense importance, as the following summary of facts within the author's cognizance will prove, Antiphlogisiics. — In a great number of cases such uterine tumors have been treated as the result of inflammation, by rest, leeches, scarifications, low diet, purgatives, mercurial cathartics, and ptyal- 456 TREATMENT — COMPLICATIONS OF DISPLACEMENTS ism, to the injury and sometimes to the permanent destruction of the general health. Alteratives. — In other cases, where the tumors have been dis- tinctly recognized, they have been designated as scirrhous and cancerous, and the patient been abandoned to hopeless misery with the continual anticipation of a dreadful death; or, by some enthusiastic heroic practitioner, they have been submitted to repeated salivations and to the most powerful narcotics, etc., to arrest the progress or to alter the nature of such indurations. The health and happiness have often been sacrificed in vain attempts to cure. Many such patients often perish by the still more deleterious efforts of empirics. Occasionally they recover by the operation of natural causes, as already detailed, to the disgrace of the profession which had abandoned the case, and the exaltation of any accidental treatment to which, at the time, the patient may have been subjected. In other instances, where the diagnosis has been correctly made, and no malignant character is regarded as being present, still many severe remedies are continually applied to ameliorate the distress and pain, supposing them to be the result, not of nervous, but of organic irritation. If experience should have demonstrated the perfect inefficiency of this system, the patient is often aban- doned to the miserable influences of alcoholic or narcotic stimuli, to the injury of mind, heart, and body. Excision. — Under the influence of disappointment or the ineffi- ciency of medicinal agents on the one hand, and under fear, on the other, that the patient will be exhausted by pain, by leucor- rhoea, by hemorrhage, or that the tumors will inflame and suppu- rate or eventually assume a malignant character. Dr. Washington L. Atlee, of this city, has boldly resorted to the scalpel, with all its immediate and remote dangers, to effect, if possible, a radical cure. Two locations have been chosen for the operation — one, for distinction, may be termed vaginal ; the other, abdominal. The first is regarded as preferable in all cases where the tumors are towards the lower part of the uterus, or intra-uterine; the second is resorted to, when they are on the external surface sessile or pedunculated. In the vaginal operation, sometimes the tumor can be directly reached; but in most cases the canal of the neck is to be enlarged EXCISION OF UTERINE TUMORS. 457 by bougies, by sponge tents, by incisions with a bistoury or the "hysterotoine." Then, a division of the cyst or capsule being made, the tumor is to be enucleated by the fingers, by scoops, knives, or forceps, as completely as possible. These vaginal operations have, during the last few years, been frequently repeated, and often modified. Mr. Baker Brown, for example, has maintained that simple division of the sides of the cervix by the scissors, is often sufiicient to arrest the hemorrhage. In other instances, he contents himself with a simple division of the cyst inclosing the tumor, stating that the bleeding will then often cease, and in some cases the tumor will be gradually dissipated. In other cases, disintegration of the mass of the tumor being accom- plished, a sloughing process ensues. The mass may be discharged spontaneously, or the process of evulsion by hooked forceps in- stituted. The success of this operation, although still countenanced by some distinguished names, does not appear to be so great as was anticipated. Many good authorities condemn it as being danger- ous, occasionally fatal, and often useless. Without dwelling upon the usual dangers of surgical opera- tions, arising from pain, hemorrhage, inordinate inflammation, abscesses, and exhaustion — without fixing attention on the pecu- liar difficulty of successfully operating deep in the interior of the body, where vision can afford no effectual assistance, and the sense of touch can alone enable the surgeon to distinguish healthy from morbid tissues — and without alluding to the danger of injuring the bladder in front, and the rectum and peritonasum, as they are in contact with the vagina and uterus, posteriorly — -the objections to this operation, perhaps under any circumstances, are radical. The operation, although sometimes easily performed, and with- out any unpleasant succedanea, must always be regarded as serious, and frequently dangerous, from the importance and mor- bid state of the tissues concerned, and their proximity to the bladder, the rectum, and especially to the peritonaeum. A dangerous operation should never be performed until there is some imperative necessity. Does such a necessity exist? This question we have already answered when we explained how the pain, hemorrhage, inability to walk, the nervous and wretched condition of the patient, depended, not on the nature and charac- ter of the tumor, but mainly on the weight and pressure of the 458 TREATMEISTT — COMPLICATION'S OF DISPLACEMENTS. enlarged mass upon the perinaeum, rectum, nerves of the sacrum, etc. Therefore, by removing such pressure, the irritation may be relieved, and its consequences be dissipated. This is our theory, suggested as well as confirmed by much experience. It is not invalidated by the assertion that such tumors may increase, and may destroy life ; for the answer is conclusive, that often no increase occurs ; that if they do augment, the whole mass will then rise above the brim of the pelvis, by which it will be sup- ported without the intervention of even a pessary. The patient is very comfortable, and ought not to be terrified by the assertion that the tumor may grow sufficiently to destroy life by its enor- mous size ; for, such cases are so rare that few practitioners have ever met with them, and are far counterbalanced in number by those in which these tumors have remained quiescent for years, or have spontaneously diminished or disappeared. Neither should the fears of the unfortunate patient be disturbed by anxieties of the possible occurrence of inflammation or malig- nancy in such tumors. These are very unusual occurrences ; in- deed, we are disposed to say, even more infrequent than the occur- rence of inflammation and malignancy in the uterus itself, in the mammas, or other original tissues. Certainly it is a fundamental error to suppose that hard fibrous or steatomatous tumors are either originally or subsequently prone to assume a cancerous action. Their natures are distinct ah initio. Cancer has its own origin and its own progress ; and although morbid tissues may occasionally suffer from a cancerous diathesis, so may healthy tissues also, and this possibility affords therefore no just founda- tion for surgical operations. The far greater probability is, that no such malignancy will ensue ; that the tumors will remain quiescent, and may even vanish. Another, and perhaps, it may be, a more conclusive and radical argument against these surgical operations on uterine tumors, is the general fact that they can seldom, if ever, be satisfactorily ' completed. Without discussing the question whether any sur- geon has sufficient skill, tact, and delicacy of touch, to rerrfove all the diseased tissues; yet, the general truth is, we believe, conceded, that these uterine tumors are very rarely isolated. If there be one, there are generally several, in various stages of development. Thence, if one, two, or more be completely de- stroyed, what security can be honestly given that the patient is EXCISION OF UTERINE TUMORS. 459 safe, and that the apprehended dangers from hemorrhage, inflam- mation, or cancer no longer exist ? Certainly none ; for so long as a single minute tumor exists, the patient is, of course, in the same danger. It, according to these views, is liable to the same development and the same results. Such remaining tumors cannot be always, or indeed usually, detected, as they are often entirely beyond reach, in the substance or on the exterior of the uterus. These vaginal operations, therefore, to remove uterine tumors, must, very frequently, be altogether useless, even in cases of apparent or reputed success. They are, however, not simply useless, but often injurious not merely from the pain and irrita- tion, the inflammation and abscesses, which may be their conse- quences, but from the danger of aggravating the supposed bad character of these morbid growths. If a blow upon a tumor in the breast will hasten its development, why should not the excitement of the uterus and its morbid growths be disturbed by the incomplete efforts for their relief? The nervous and vas- cular irritations thus generated, must facilitate the development of any tumors which remain, and any morbid predisposition to which they may be liable. Eecoveries are said to have resulted from these operations ; and drawings are presented of the supposed condition of the uterus, before and after the extirpation of the excrescence. That patients very generally recover from these vaginal opera- tions may be readily conceded, notwithstanding the forced dilata- tion and incision of the cervical canal, the enucleating of the tumor by the fingers and scoop of the surgeon, and the dragging with forceps, as this organ is wonderfully tolerant of all such severe irritations. It will however require a vast amount of most careful investi- gation, and of reiterated and prolonged experience, to determine how far the distressing symptoms, which had existed prior to the operation, have been destroyed, and how far the patient's general health has been improved; how far such improvement is attri- butable to the spontaneous disappearance which is sometimes observable, or to the greater development by which the whole mass is elevated above the superior strait of the pelvis, and thus the symptoms of displacement relieved ; and, finally, how far such reported recoveries are permanent, or how soon the patient falls 460 TREATMENT — COMPLICATIONS OF DISPLACEMENTS. again into the same miserable state from' the development of the untouched tumors in other parts of the organ. In review of the facts and observations already detailed — in support of the opinion that the urgent symptoms depend on the pressure downward or backward (prolapsus or retroversion) of the .enlarged organ, and not upon the character of these adventi- tious growths — the operation does not appear to be justifiable, perhaps in no case, certainly not until a scientific and judicious trial with pessaries has entirely failed to relieve the neuralgic, menorrhagic, and hemorrhagic symptoms. Several such cases the author has watched for years, the patients partaking of the ordinary business and pleasures of life, until the climacteric period, when hemorrhages have ceased, and general health has been quite restored, and the tumor has become more or less atro- phied, old age being passed in comfort. The abdominal operation also has been proposed, and been boldly if not rashly executed. The cavity of the abdomen being exposed by suitable incisions, and the omentum and intestines being sufficiently displaced, the operator removes all the pedun- culated tumors, or incises and enucleates the sessile. If two or three tumors exist, the operation, as just described, is comparatively simple ; but in a great number of instances the tumors are very numerous, some in the walls of the uterus, and often the whole organ is completely enveloped with adventitious growths, even of larger size than the uterus itself. Moreover, close peritoneal adhesions often exist, converting the uterus, the tumors, and the surrounding tissues into one mass. In other varieties, the whole abnormal growth involves the proper tissue of the womb, as in the case of Mrs. H., already detailed, which, although sometimes free, is not unfrequently bound down by close adhesions. Diagnosis, in such cases, must always be very limited, nothing but actual exploration can evolve all their complications. Never- theless surgeons, encouraged by some partial successes, and by the advantages derived from ani»sthesia, boldly make their inci- sions, have no hesitation in breaking up the adhesions, and when confronted with the terrible fact that these tumors cannot be re- moved without the ablation of the uterus, at once resolve to throw the ligature or the chain of the ecraseur over the cervix uteri, to enable them to remove the whole conglomerated mass. EXCISIOX OF UTERINE TUMORS. 461 Strange to Sc\y, some such patients have escaped. Perhaps the most remarkable case on record is one given by Dr. H. E. Storer, of Boston, Massachusetts, in which a woman recovered after having had the uterus, the Fallopian tubes, and the tumor weighing thirty-seven pounds, all of which was closely connected with the surrounding tissues, removed. How far the success, in this instance, will be productive of good or evil, time must de- velop ; many have already perished under similar attempts both in Europe and America ; perhaps some might have lived for many years with much comfort and even health, if the operation had not been performed. Mr. I. Spencer Wells, the celebrated ovariotomist of London, on a visit to this country in the autumn of 1867, declared that he had performed gastrotomy several times for fibrous tumors, but with very little success. He concludes, therefore, it had better be hft alone, except in extreme cases of hemorrhage, or pressure on a vital organ. This operation is one of no great difficulty in the execution, but one certainly pregnant with dire consequences. It is liable to most of the objections detailed, in regard to the vaginal operation, which need not be repeated, and to peculiar dangers arising from the tissues involved, and the cavity exposed. If wounds of the vagina and uterus can be made with impunity, this is rarely true of wounds of the peritoneum, a serous mem- brane of immense extent, covering very important viscera, and prone to rapid and diffused inflammation. The danger of peri- tonitis is, in such cases, aggravated by more or less effusion of blood among the intestines, where it may putrefy from the pre- sence of atmospheric air ; by the wounds made in. removing the pendent tumors ; by the contusions and lacerations, caused by the process of enucleation ; by the sloughing of any undetached portions of the tumors. That any patient should escape death, would, ci priori, be regarded as wonderful in view of the well- known dangers of acute peritonitis. Should extensive inflam- mation not occur at once, the patient may be exhausted from continuous chronic inflammation and fistulous abscesses. It also should be remembered, that patients who might thus be .destroyed by these bold operations, would probably never have suffered from the presence of such growths; and that many such have actually passed through a long life with perfect impunity. 462 TEEATMENT — COMPLICATIONS OF DISPLACEMENTS. It is therefore dilBcult to conceive how a practitioner, in foro scientiae vel conscientise, can be justified in subjecting his patient to these imminent perils. The introduction of anaesthetics may have done much to diminish these dangers; but they still remain, and naught but extreme necessity, which in these cases, we be- lieve, does not exist, will justify the risk. Another collateral objection is very important, namely, the difliculty of diagnosis, not merely as to the number of tumors and their location, but even as to their existence. In all abdominal tumors the diagnosis is uncertain. This general declaration may seem singular to the inexperienced, or even to the experienced practitioner, who has acquired much confidence in his own skill. Yet, in a long professional life, we have heard so many discordant opinions from men of undoubted science and experience, and so much unavailing and sometimes dangeroas practice, resulting from a false diagnosis as regards the various forms of abdominal swellings, as to justify the declaration, just made, of the uncer- tainty of diagnosis in cases of tumors within the abdomen. Pregnancy has been mistaken for encysted or peritoneal dropsy, so that upon performing paracentesis abdominis, the puncture has been made into a pregnant uterus. Gastrotomy has been per- formed for ovarian tumors, which proved to be uterine, or even where no tumor of any kind existed, "veotus et praeterea nihil." Cases. — In a consultation held some twenty years ago, positive opinions were offered by three out of four experienced surgeons and accoucheurs, in a case of an abdominal swelling of some twelve years' duration, according to the account of the patient. By one it was regarded as an extra- uterine pregnancy; by a second as a uterine growth; by a third as an ovarian tumor; while the fourth would not unite with any of his colleagues. Again, we were consulted by Mrs. H., a widow lady of some thirty-five years of age, who had sufl'ered from nervous affections for many years, and her general health had been injured by almost every variety of regular and empirical practice. We found a hard abdominal swelling, chiefly on the left side; but having passed a long flexible metallic probe for some eight inches into the uterus, we satisfied ourselves that the tumor was uterine. Our advice — to attend carefully to her general health, and to abandon all attempts to destroy the tumor — was neglected. She placed herself for some six months under the care of an empiric, EXCISION OF UTERINE TUMORS. 463 and became mucli exhausted bj his treatment and by the con- tinued development of the tumor. She now consulted an expe- rienced surgeon, and also an accoucheur of a neighboring city. They decided that the tumor was ovarian. Six months after- wards she died in convulsions. A necropsy revealed an immense solid tumor developed from the left half of the uterus, and occu- pying chiefly the left portion of the abdomen ; the upper part of the tumor formed two prominences, as if it were bilobed. The other half of the uterus was greatly attenuated ; the cavity was at least ten inches in the longitudinal diameter, and the whole mass was estimated to weigh twenty pounds, and was of a fibrous character. We are now in attendance upon a lady, who for some ten years has been a martyr to nervous diseases, and who has been succes- sively attended by several of the leading physicians in Philadel- phia, for uterine irritations, and abdominal and pelvic tumors; and here, also, a similar discrepancy of opinion has existed as to the presence, or as to the location or character of the morbid growths. As doubtless sucli facts are familiar to every practitioner, it is useless to multiply examples; for, certainly, every prudent and conscientious man should, however positive might be his own opinion, choose to have his diagnosis confirmed by some expe- rienced co-laborer in the field of human suffering, before resort- ing to this abdominal operation. If the views we have presented be correct, that the symptoms resulting from these heterologue growths chiefly arise, not from their nature, but from pressure on the pelvic tissues, and hence, that intra-vaginal supports are very generally not only adequate to their relief, even during a long life, but are far more certain and safe than a resort to such dangerous operations as proposed, and that, too, on a doubtful diagnosis ; it may be hoped the cause of suffering humanity will be promoted, although less eclat may redound to the profession in the eyes of the public, than is ob- tained by dazzling heroic achievements with the scalpel. The progress of science should diminish the frequency of surgical operations. This is true "Conservative Surgery," 404 TREATMENT — DISPLACEMENTS OF THE OVARIES. CHAPTER IX. TREATMENT OF ENLARGEMENTS AND DISPLACEMENTS OF THE OVARIES, ETC. The importance of vaginal supporters has not yet been fully detailed, altliough, perhaps, many will believe that it has already been unduly magnified. ENLARGEMENTS OF THE OVARIES. Displacements of enlarged ovaries are occasionally observed with or without displacements of the uterus. Ovarian tumors often cause descent or version of the uterus, from their pressure on this organ in various directions. They induce, not unfre- quently, a lateral displacement which has not been here noticed, as by itself it seems to be of no importance; the trouble in such cases is not from the uterus, but from the ovary. Diagnosis. — The diagnosis of ovarian tumors is sometimes easy, but is often surrounded w:ith difficulties; for, an enlarge- ment of an ovary must have attained considerable size before it can be detected by any physical examination. It has been sug- gested, that if it could not be felt per vaginam on the side of the uterus, it might be reached per rectum, by a finger distending the anterior wall of the rectum, and bent up behind the uterus and broad ligament, so as to reach the natural location of the ovary. This the author believes to be impracticable ; certainly all his attempts have entirely failed. The distance from the anus, along the rectum, to the upper portion of the broad ligament, greatly exceeds that of the index-finger, whatever allowance may be made for the yielding of the perineal tissues. In addition, great resistance is made by the contraction — often spasmodic — of the muscles^ at the outlet of the body, and of the muscular fibres DIAGN"OSIS OF OVARIAN TUMORS. 465 of the rectum ; moreover, a displacement of the uterus, and the involuntary bearing-down efforts of the patient, often increase the difficulty. These obstacles are excessively enhanced by the sen- sibility of the tissues, especially of the rectum and the uterus, so that rectal examinations are usually very painful. When, however, the tumor is larger, by a digital vaginal examination it can, with proper attention, be recognized on the side of the uterus, or at the upper extremity of the vagina on the side of and behind the cervix uteri. Of course, also, in such cases it is recognizable per rectum, but not so satisfactorily as per vaginam. The weight of the enlarged ovary, and the super- incumbent pressure from the intestines and abdominal muscles, cause its displacement, usually downwards and backwards, so as to press upon the pyriform muscle and the great ischiatic plexus of nerves. In very many of such cases the tumor cannot be detected by any external or abdominal examination. When of great size, it can usually be felt not only per vaginam, but also through the hypogastric walls ; and when the enlargement is still greater, the tumor is chiefly felt in the abdomen, lying above the superior strait, and not interfering, at least materially, with the tissues and organs of the pelvis. In all cases, however, much care is demanded in determinino- the true character of abdominal swellings, as has already been maintained when speaking of uterine tumors. Mistakes have been so frequently made, by even scientific and experienced men, as to the nature of pelvic and abdominal tumors, that it becomes every one to be very careful in his investigations, and very modest in uttering a positive opinion. Still, by the history of the case, by the external and internal examinations, by the judi- cious use of a uterine probe, and by the existing symptoms, a prudent physician will not often commit any practical error. Pathology, — The nature of these ovarian enlargements need not now be discussed ; it may be left to the morbid anatomist or the pathologist. Suffice it to say, that allusion is now made to those comparatively solid tumors of the ovaries, where there is no inflammation, no abscesses, no dropsical or gelatinous collec- tions, and no malignant disorganization. Such cases are by no means uncommon, and usually remain in a very quiescent state, not perceptibly enlarging even for years, and sometimes actually 80 466 TREATMENT — DISPLACEMENTS OF THE OVARIES. decreasing in size. They usually possess no sensibility, espe- cially when so large as to be above the superior strait ; but sometimes, when low in the pelvis, they are very sensitive and irritable, so that the least pressure on them gives acute pain. This morbid sensibility we have known to exist even for years, without further increase of size or induration, and no inflamma- tion or suppuration occurring. When these ovarian tumors in the abdominal cavity are very large, some trouble may arise from their weight and pressure ; but, great allowance must be made for the nervous apprehension of females when they know that they have a tumor. The ima- gination and fears of the patient are excited, and ready credence is given to idle tales, or to any account of accidents and opera- tions connected with such swellings. The mere idea of a " tumor" is sufficient to destroy their peace of mind. It is a difficult task to allay their apprehensions, and to make such women believe what their daily experience for years should have taught them, that such enlargements are innocuous. Exceptions to these remarks of course exist. Such tumors may inflame, may suppurate, may excite peritonitis, and perhaps may become malignant. These results are comparatively rare, certainly in our experience, and may be predicated of healthy as well as diseased tissues, of a normal as well as an abnormal con- dition of the ovaries. It is possible — and such cases are said to have occurred — that ovarian tumors, unconnected with deposits of water, gelatinous matters, pus, or other analogous substances, may continue to enlarge, so as to interfere with the functions of the arteries, veins, and of the abdominal and thoracic viscera, and thus destroy life. Few practitioners have met with such cases, and they ought not therefore to be anticipated. Ovarian tumors of every size often remain for years, without apparent enlargement or decrease. The process of development is always very slow, and that also of diminution. Besides, cases are reported in which these swellings, after a lapse of years, have greatly diminished or even disap- peared. If practicable, it would be interesting and useful to establish the law of increment and decrement, or what would probably be more within a reasonable expectation, the causes of the development and of the subsidence of ovarian degenerations. PATHOLOGY OF OVARIAX TUMORS. 467 Displacements. — An increase of the size and weiglit of these ovarian tumors necessarily causes displacement ; in the early stages the}^ sink into the cavity of the pelvis, but when large they rise above the superior strait, into the abdomen, precisely as the uterus ascends after the fourth month of utero -gestation. The latter, or what has been termed the upper displacement of ovarian tumors, is, according to our experience, a matter of comparatively small importance. The tumor in itself is quiescent, neither in- flamed nor sensitive, and not even perceptible to the conscious- ness of the patient, by its pressure or weight. She knows of its existence, merely by her increase of size, and by feeling the swelling with her hands. It may indeed have existed for years without her knowledge. Perhaps every practitioner of much experience has met with such cases. The writer has often de- tected these ovarian tumors in patients, whose physicians, as well as themselves, had no suspicion of their existence. The patient feels well and attends to her usual occupation without distress. It would be unnecessary to detail cases of the kind. We will merely allude to a preparation in our obstetric museum, sent by Dr. Thornton, of Mississippi ; it is an enlarged ovary, which had been gradually converted into a solid calcareous mass, of an elliptical shape, six inches and a half in length, by four inches in its transverse or conjugate diameter, and one pound and twelve ounces in weight. It was taken from the body of a negro woman, who had never complained of any inconvenience from its presence during life. The other class of cases are those where, from the small size of the enlarged ovaries, they do not rise out of the cavity of the pelvis. In this circumscribed cavity, containing the bladder, the uterus, and the rectum, and having its internal parietes covered by innumerable ramifications of bloodvessels and nerves, origin- ating from some of the largest trunks, vascular and nervous, in the economy, very various effects are frequently observed. These effects may be slight symptoms, hardly recognizable, or alBfections often exceedingly distressing, and sometimes it may be serious ; they depend on various conditions of the tumor, of the pelvic viscera, and the general temperament or state of the patient. As an ovary enlarges, gravity, in addition to the superincum- bent pressure, causes its descent on the posterior and lateral por- tions of the pelvis ; sometimes it falls, even as far as the lower 468 TEEATMENT — DISPLACEMENTS OF THE OVARIES. portion of the sacro-sciatic foramen, that is, to the floor of the pel- vis. This constitutes the downward displacement of an ovarj. By this displacement of an enlarged ovary, pressure is neces- sarily made on the broad ligament, pushing it forward, so that an anteversion, or, more frequently, a lateral displacement of the uterus, is produced ; on the veins of the pelvis, causing a passive congestion of their radices, especially in the uterus and extremity of the rectum ; finally, and this is the most important fact, pressure is made on the nerves of the pelvis, on the obtu- rator nerve, and on that wonderful plexus of nerves, at the ischi- atic opening, the largest plexus in the body, connected below with every tissue of the pelvis and lower extremity, and above with the spinal and cerebral centres, and thus, with the whole animal economy. Complications. — These displaced ovaries are not unfrequently complicated with displacements of the uterus, with anteversion, or anteflexion, as above mentioned, and with prolapsus or retrover- sion, without or with flexion ; all of which render the diagnosis, but especially the symptoms and treatment, more obscure and difl&cult. Another complication is not very unfrequently observed, an irritable condition of the ovary, thus enlarged and displaced, arising, doubtless, from the continual pressure against the walls of the pel- vis, the uterus, etc. The word irritable, or morbidly sensitive is used, because great pain is often excited by a touch from the finger, or a pessary, and yet no other phenomena of inflamma- tion is developed, even after the lapse of many years. Case. — A lady from New Orleans presented herself to our care, with a displaced uterus, which proved to be, unexpectedly, difiicult to manage. She complained of much soreness and pain in the left side of the pelvis. It was not relieved, but often aggravated by the presence of a pessary. A careful examination detected a body nearly flat, and apparently about one and a half inches in diameter, sensitive on pressure, hard, very movable, and lying on the plane of the left ischium. The patient was relieved of all suffering by modifying the form of the pessary, so as not to press against, but under, this swelling, and thus to elevate it. Years afterwards, we had an opportunity of examining this patient, and found the same tumor, rather less in size, but still somewhat sensitive on pressure. CASES OF OVARIAN TUMORS. 469 The symptoms of irritable ovaries are so analogous to those of irritable and displaced uterus, and the two accidents are so fre- quently coincident, that a diagnosis can only be made by a careful pelvic examination ; even then it will be often difficult to deter- mine what degree of sympathetic disturbance is dependent on the ovarian and what on uterine irritation. Perhaps the symptoms will be best illustrated therefore by allusion to a few cases in which the displaced ovary was involved, with less or more of uterine disturbance. Cases. — A lady from the South, the wife of a physician, came to Philadelphia complaining of feelings of languor and debility, with uncomfortable sensations of pressure. Her husband sus- pected scirrhus of the womb, as he had detected an enlargement in the pelvis. The uterus was in a proper position, though slightly hypertrophied ; but there was a hard ovarian tumor on the right side, pressing forward the broad ligament. A pessary placed under the uterus and tumor relieved her disagreeable sen- sations. She was thus enabled to exercise with impunity. Some ten years afterwards, we had an opportunity of examining this case, and found the ovary had rather decreased in size, and had never given any sensible trouble. The lady is still living and enjoying comfortable health. A far more deplorable case afterwards came under our notice. The whole nervous system of this lady was broken down by pain, morbid sensations, and confinement — chiefly to her bed — for some ten years, so that her organic life had also suffered. She was pale, feeble, ansemic, and much emaciated ; it was with difficulty that she could sit up or move across the room; she experienced pain throughout the spine, chiefly in the right sacral region, together with weight, pressure, bearing-down sensations, and pain on having the bowels moved. Her muscular energies were prostrated; her sensations were all morbid, especially as regarded her brain ; she was troubled with neuralgic pains about the head and eyes, frequent headaches, and confusion of thought ; she could not read or think, and could not sleep, except for short periods ; when awake, especially if excited or in much pain, she would have spectral illusions, " persons appearing before her for hours at- a time, talking, and usually upon disagreeable sub- jects." The slightest mental or moral exertion would be mani- fested by an effusion of tears. 470 TREATMENT — DISPLACEMENTS OF THE OVARIES. She was by nature and education a remarkably delicate and refined woman, and with strong religious feelings. She had been the mother of three living children ; the youngest was then about five years of age. Many of her friends regarded her as more diseased mentally than bodily. She had leucorrhoea, occasional menorrhagia, and a hypertrophy of the uterus. We were sur- prised to find very little displacement of this organ ; it was slightly prolapsed, and deviated somewhat towards the left side ; but deep in the right sacro-sciatic notch over the pyriform muscle there was an enlarged and displaced ovary. No swelling could be detected by an external examination. She was ordered a nutritious and digestible diet, laxatives, tonics, sponging with cold water, and frictions, with cool and astringent vaginal injections. Pessaries of varied forms and power were employed, so as gradually to elevate the tumor from its bed on the sacro-sciatic plexus of nerves. The patient was encouraged to make as much muscular effort as consistent with her weakness and morbid sensations. Her improvement was soon manifested, so that at the first ensuing catamenial period she was surprised and delighted to find that the spectral illusions had entirely vanished. The case was of course tedious ; great atten- tion had to be paid to the mechanical arrangements of the pessa- ries, so as to accomplish the desired object without pain or irrita- tion. General comfort and the ability to move about were obtained, and although circumstances have prevented her, sometimes for two years at a time, from having proper medical attention, yet she mentally and corporeally has enjoyed good health, and is now regularly pursuing her important duties with trifling mental or physical disturbance. In the last examination, the tumor was not nearly so perceptible ; whether from a diminution in size, or because more elevated, could not well be determined. The ex- periment of abandoning the internal support has been several times tried, but ineffectually. Uncomfortable sensations, pains, and mental disturbances have soon called for its restoration. Another lady, whose children were numerous and had arrived at maturity, resigned to them the family domicile, under the feel- ing that her days were soon to terminate. She was weak, pale, and unable to move about without pain in the left iliac fossa, near the spine of the ischium, and over the left gluteal muscles and down the limb, so that the difficulty of walking was very great. CASES OF OVARIAN TUMORS. 471 The catamenia had not appeared for years, but there was some leucorrhoea. She had lost flesh, but was still corpulent. There was found a slightly prolapsed uterus of rather a large size, and also a hard swelling behind the left broad ligament, which could by careful manipulation externally be perceived in the left por- tion of the hypogastric region. This patient immediately began to improve upon the use of pessaries, and under the influence of tonics, fresh air, and after- wards of sea bathing. Exercise, which could not be borne before the mechanical support was employed, now was taken, not only with impunity, but with great comfort and advantage. At this date she continues very well, and able to travel about at pleasure. Occasionally, the old pains in her side, nates, and limb, with some lameness, returns ; but by changing or readjusting the pessary these pains disappear, so that, although corpulent and some sixty years of age, she takes considerable exercise. The ovarian swelling is no longer to be recognized by either an external or an internal examination. This may be explained partly by its being smaller, and partly from the increased obesity of the abdominal region, as well as by the elevation of the tumor in the pelvis by the constant use of a pessary for years. The actual disappearance of the tumor can hardly be suspected ; inas- much as pain and lameness, from irritation of the sacro-ischiatic nerves, return when no adequate support is given. A delicate emaciated lady from the far south, some time since, presented herself in Philadelphia. For years she had been the subject of pelvic irritations, and for many months of menorrhagia. She was nervous and anaemic. She had been treated by leading physicians, north and south, for inflammation and ulceration of the OS and cervix uteri, by nitrate of silver. This caustic plan was carried further than was intended, and to such an extent that the OS, originally quite patulous, was diminished so as hardly to admit a small sized probe. The uterus, upon examination, was found to be about the natural size, slightly anteflexed ; but a hard and sensitive enlargement of the ovary was detected on the right side, and behind the neck of the uterus. The case was treated by means of a pessary, during the use of which, with the occa- sional assistance of a tampon, the menorrhagia was checked, and a steady improvement was manifested. The menses soon were delayed till their regular period, and lasted but seven days. At 472 TREATMENT — DISPLACEMENTS OF THE OVARIES. the end of three months the patient returned home, too soon to judge what would be the final result, but better than she had been for years under difierent treatment. A patient who had been an invalid for two years, and consi- dered as the subject of acute ovaritis, wbicb terminated in an abscess, and had left her very weak and nervous, came to Phila- delphia, and placed herself under our care in February. She was liable to diarrhoea, had some dyspepsia, and the least pain or agitation produced great sensations of debility with hysteric symptoms. There was a slight prolapsus uteri, a trifling leucor- rhoea ; and an irritable tumor was found on the right of the uterus, projecting towards the horizontal ramus of the pubis. The anterior portion of this tumor can be felt, by an external examination, behind and above the insertion of Poupart's liga- ment. Some six weeks have elapsed, and this patient regards herself as quite well, being able to walk about at pleasure, and without inconvenience; she has few or no nervous symptoms, and has gained strength, color, and flesh. A pessary is worn w^ithout discomfort, and the tumor remains as yet without appa- rent change. The following case will illustrate the symptoms of a very acute and severe character, in which there was a retroversion of the uterus with an irritable and displaced ovary on the right side. How far the symptoms were referable to the uterus or the ovary, or to their conjoint influences, must be doubtful ; but that much depended upon the ovary seems to be proved by its analogy with cases already detailed, and by the great disability of the right limb ; but especially, because, long after the retroversion was re- lieved, the nervous and muscular irritation of the right limb in some degree continued, with much irritation of the brain, eyes, etc. A lady, about thirty-five years of age, of healthy aspect, good color, flesh, and muscle, who had always enjo3'ed fine health, and great activity, with the exception of dysmenorrhoea and nervous headaches from early life, began in the winter of 1857-8 to suffer from dyspepsia and symptoms of spinal irritation. In the ensuing spring they rapidly increased, so that by the month of May she was disabled and prostrated. For ten months her sufferings gradually augmented. At first she could move about for short distances on crutches, but the sitting posture could not be tolerated. Afterwards, she was confined constantly to bed CASES OF OVARIAN TUMORS. 473 from severe neuralgic and spasmodic affections of the lower extremities, particularly of the right ; this last was drawn up towards the body, and had to be supported by pillows ; the least attempt to extend it was intolerable. There was great pain in the sacral region, in the right nates, in the right and left iliac fossae, with great soreness on pressure, and utter inability to turn in bed from the severe suffering which was felt on every attempt even to move her. There was great dysuria, intense suffering and faintness on every evacuation from the rectum ; much of this pain in defecation was referred to the left side of the umbilical region near the navel. Great pain was experienced in the dorsal and the upper portion of the cervical regions of the spine, with consequential neuralgia in the arms, and inability to use them even to feed herself. There was also tenderness on pressure over various parts of the spine. The brain suffered exceedingly, as exhibited by intense nerv- ous, "crazy" headaches, by confusion of thought, morbid percep- tions, inability to read, and often incapability of understanding or attending to what was read. There were so much neuralgia and sensibility in the eyes that they could not be used ; and the sense of smell, often acute, was sometimes so perverted that she insisted that her clean, luxurious apartments were surrounded with putrefying bodies. This morbid disturbance of the olfactory nerves was sometimes very transitory, existing for a few hours, and then disappearing. Shortness of breathing, asthmatic symp- toms, and aphonia, were often present, and sometimes so great that her whispers were heard with difficulty. There was much cardiac disturbance ; but some of the most intense suffering was produced, or perhaps rather aggravated, by the state of the sto- mach. There was nausea, loss of appetite, frequent retchings, occasional vomiting of any food that might be taken, but chiefly of watery and glairy mucus, though the quantity was not great. Occasionally, after much straining, some bilious matters appeared, and not unfrequently the fluids were acid. Her nervous energy was much prostrated, and as the gastric, spinal, and leucorrhoeal distress gradually increased, fears were entertained that her life was endangered. At the catamenial periods the agony was in- tense, and the nervous exhaustion excessive. Nevertheless, the patient did not lose much flesh, had no fever, and maintained even a good condition of her blood and circulation ; she had, to 474 TREATMENT — DISPLACEMENTS OF THE OVARIES. be sure, a frequent and irritable pulse, but sufficiently strong and full. She was considered and treated, by most experienced and ex- cellent physicians, as a case of spinal neuralgia, or spinal irrita- tion ; and the diagnosis seemed to be confirmed by a great sensi- tiveness over particular spots in this region. At these places the least pressure gave exquisite pain. Her able physician resorted with perseverance to all the usual remedies of local bleeding, counter-irritation, poultices, liniments, bathing, and internally he employed laxatives, alteratives, tonics, stimuli, narcotics, and antispasmodics. Few of the narcotic articles could be tolerated. The cannabis Indica proved to be the most comforting and effectual in producing sleep and some repose. In February, 1859, the symptoms had become so aggravated — there was so much pain, and the nausea and retching were so constant by night and day — that no continued sleep could be produced, and it was not thought by her friends that she could live from one day to another. Her physician now suspected that there was some pelvic irri- tation, and being confirmed in his opinion by an examination, he committed the case to our care. The sensibility of the pelvic tissues was exceedingly great, without any unnatural or super- abundant secretions; the fundus of the uterus was low down towards the inferior portion of the sacrum, the os nteri pointing to the OS vaginae, and the cervix slightly flexed. After some days of treatment by a pessary, great mechanical resistance was detected behind and to the right of the womb, where there was then discovered the enlarged ovary as a hard body, rounded, slipping under the finger, and exquisitely sensitive. Believing that the displacement of this enlarged ovary on the right side of the uterus was the real cause of the irritations of the pelvic viscera, of the sacral, spinal, and cerebral disturb- ances, with all the reflex influences on the nerves of the senses, lungs, heart, stomach, and extremities, the indication was clear to remove such displacement, and the consequent pressure on sensitive tissues, notwithstanding the great tenderness of the vagina, uterus, etc. This idea was at once cautiously acted upon, to the abandonment of all other treatment — as the organic actions of the patient were good — except the occasional exhibition of a pill of cannabis Indica, and some moderate stimuli. Very small CASES OF OVARIAN TUMORS. 475 instruments were at first employed, and afterwards those wlncli were larger and more powerful, as the tissues yielded to pressure. It was soon found, however, that a great mechanical resistance existed, especially from the ovary, which, in conjunction with the extreme irritability of all the tissues, and the difficulty of avoiding undue pressure on the rectum and nerves below, and the ovary and uterus in front, afforded a combination of diffi- culties seldom to be encountered. The result, however, has been most gratifying, not merely in the relief of the patient, but in confirming the great practical principle, that by relieving sensi- tive tissues from pressure, local and general nervous irritations will subside. The stomach, in a few days after the use of a pessary, was greatly relieved ; food could be readily taken and retained, and sleep, hitherto interrupted by the constant retching, was enjoyed, very generally without an anodyne. All the miserable sensa- tions of the brain, with the reflex influences on other organs, were moderated. The recovery has been steadily progressing, with, of course, alternations from various causes, especially at the catamenial periods, which still bring much pain, and occa- sionally some of the old symptoms, such as aphonia, perverted smell, cephalalgia, etc. It would, perhaps, be interesting to the physiologist to point out, with precision, the regular succession of improvement ; but here we can merely say that the distress in the spine rapidly diminished; the tenderness over the vertebrae, and the pain soon followed ; and then she obtained some com- mand of the right lower extremity, with more ability to turn in bed ; a very gradual increase of capability to extend this limb, and afterwards to move it in bed ; then the power to have her head elevated, and more activity of her mind, so that she could enjoy being read to. In about three months she could move about her room on crutches, and once more take pleasure in the society of her friends. Several troublesome symptoms were long in disappearing ; the pain near the umbilicus in defecation con- tinued for some six months, but has entirely disappeared ; the pain in the eyes, especially that irritability of the nerve which prevented her reading or using her needle, was very persevering, as, indeed, is quite common in these uterine troubles, it would occasionally disappear for days, and even weeks, and then would return. An analogous and usually simultaneous disturbance of 476 TREATMENT — DISPLACEMENTS OF THE OVARIES. the brain, with distress of various kinds, was also very persistent, and even still occasionally returns, and is to her the most dis- tressing symptom. The inability to sit comfortably was also slow in disappearing, and even this spring a peculiar cushion is often required. In September, 1859, her powers of progression began decidedly to improve, at first by means of crutches; but by the end of Oc- tober she could readily walk about her room without any artificial support. In January of this year, she walked out of doors, and soon was able to walk a mile, or even further ; but a soreness, or rather weakness, in the right ankle, forced her to walk very slowly ; of late, however, her ability to walk rapidly is continually increasing. Occasionally there is uneasiness in sitting down, and some trouble about the brain and eyes. All of which symptoms are gradually diminishing, both in frequency and intensity. At the present time, October, 1860, she is able to walk from two to three miles a day, with ease and rapidity; the right ankle has gained strength ; very little uneasiness is produced by the sitting posture, and with the exception of some disturbances of the head and eyes, and some suffering at her catamenial periods, she ap- pears to be well, and has resumed her usual domestic and social duties. All the phenomena, from the beginning of her suffering, have been manifestly dependent on the pressure of the ovarian tum.or, the uterus or the pessary, one or all, upon the pelvic tissues. Just in proportion as such pressure was moderated, changed or removed, has been the diminution, the alteration, or disappear- ance of special symptoms. Sometimes the pain in the right limb would be increased or diminished; sometimes there would be more of the umbilical pain from the act of defecation, then it would diminish ; frequently the head and eyes would be relieved, then become a source of annoyance. Vaginal examinations and operations were, therefore, continually demanded, to alter the form or the size of the pessary, or to change the points of pres- sure so as to alleviate or destroy the suffering. The slow progress of the case has been entirely due to a fixed position of the ovary — whether from adhesions or other cause, cannot, of course, be positively ascertained — so that it yielded very slowly to the pressure of the pessary ; frequently it over- came this pressure, and made the instrument impinge against ANOMALOUS CASES. 477 other tissues, causing irritations. This difficulty not unfrequently exists, even in ordinary cases of retroversions of the uterus, from the fundus being firmly fixed in its unnatural positions. In all such cases great patience and perseverance are demanded. No force can be employed, as the pain and inflammation excited would be intolerable and dangerous ; but by careful and frequent attention, any sign of inflammation may be avoided, until all pressure from the tumors is gradually and often entirely removed, to the great happiness of the poor sujfferer, whose mind and spirit are even more relieved than her body. The principle, that the pessary should be worn without exciting nervous or organic irri- tation is never to be forgotten. ANOMALOUS CASES. Anomalous cases will of course occur in an extensive practice. Some of them may be very analogous to those of common occur- rence, and others not readily to be explained, or completely relieved. Of this character, are enlargements probably of lymphatic glands in different portions of the pelvic cavity, which not only maintain the symptoms of irritation, but becoming excessively irritable themselves, render the treatment by pessaries more diffi- cult. Instances of this character have already been detailed.^ There are other cases in which after a retroverted or other displacement of the uterus, ovary, etc., has been relieved, or where no displacement originally existed ; yet, the symptoms of sacral irritation from pressure were present, in more or less intensity, and, perhaps, no cause could be detected by investiga- tion per vaginam, per rectum, or through the abdominal walls ; and where no examination of the spinal column threw light oft the source of irritation. Such cases we can imagine depend on various causes, such as scybalous collections in the colon ; mesenteric, ovarian, or osseous tumors, too high up from the floor of the pelvis, or too deep- seated in the abdomen, to be recognized. Most of such patients remain great sufferers for years ; any treatment has but a pallia- > See page 219. 473 TREATMENT — DISPLACEMENTS OF THE OVARIES. tive influence Their general liealtli is often very good ; and not unfrequentlj there is a spontaneous disappearance of symptoms, especially at the cessation of the catamenia. 'Death very seldom ensues, as the organic life is often very good ; but, occasionally, from nervous dyspepsia, and the consequent nausea, vomitings, diarrhoeas, etc., secondary symptoms may become so severe, that a life of suffering at length finds relief in the grave. TREATMENT. From the remarks on the cases above presented, it appears that all displacements of ovarian and other tumors in the cavity of the pelvis, producing nervous irritation, should be managed on the same principles as already indicated for the treatment of uterine tumors. Mechanical measures must be so arranged, as to remove all pressure from the nerves of the pelvis or other sensi- tive tissues. In the upward displacements, however, of enlarged ovaries into the cavity of the abdomen, no other attention is ordinarily re- quired than is demanded for the general health and strength of the patient. All attempts to discuss such tumors, by evacuating measures and by alteratives of any kind, prove useless as regards the tumors and positively injurious as respects the health and strength of the patient. The terrible operation of gastrotomy for the removal of such solid tumors is, we think, indefensible: inasmuch as in itself, it is very dangerous and often fatal ; more- over, the diagnosis is necessarily very difficult, it is sometimes impossible to determine whether the swelling be ovarian, uterine, mesenteric, or even whether there be any actual tumor present. If an ovarian enlargement could be positively recognized, who can determine whether there be not such universal adhesions, as to render the operation altogether nugatory ? On the other hand, most of these patients, as has been mentioned, will enjoy health and strength, free from irritation and pain even for a long life, when not subjected to inefficient drugs, or to the knife of the surgeon.^ The question respecting ovariotomy is dijQferent when there are ' Vide p. 460, Observations on Gastrotomy. TREATMENT. 479 collections of watery, gelatinous, purulent, or other fluids in the ovaries; as such cases, after the lapse of months or years, are generally fatal. The difficulties of diagnosis and the dangers of the operation may then be carefully contrasted with the dangers to which the patient is exposed by her disease ; and the decision may occasionally be in favor of the operation. Let it, however, be remembered that some of these ovarian dropsies have disap- peared, either spontaneously or under the effect of remedial agents. A very interesting case of the kind has occurred to the author in the person of a lady, who had an ovarian tumor in the left iliac fossa; pregnancy supervening, this tumor became dropsical, so that when delivery occurred at term, the abdomen remained exceedingly distended, with decided fluctuation over its whole extent. Under the careful attention of our friend and former pupil. Dr. Ludlow, to whom the case was committed, the dropsy entirely disappeared, and she now enjoys excellent health and activity. The chief means employed were tonics, preparations of iodine internally and externally, and moderate compression by means of bandages. "We regret to add, that since the publication of the first edition of this work, and at the end of two years after her apparent re- covery, the dropsical effusion returned, and proved fatal. This whole subject of encysted dropsy has occupied much of professional attention for some years. Experience seems to prove that very generally it is a fatal disease in the course of a few years at the farthest, notwithstanding, there are some re- coveries recorded. Such recoveries have resulted, occasionally, where no remedial agents have been employed; in other instances, where various alteratives, so called, especially iodine, have been freely given. Some few patients have escaped in consequence of an accidental fistulous opening, insuring the evacuation of the cyst, and its subsequent contraction. Surgeons have imitated this process by establishing an artificial fistula, and by making pres- sure over the parietes of the abdomen. Professor Kiwisch has operated in this way per vaginam. Dr. Bainbrigge, of Liverpool, states that in thirty-eight cases, where an orifice was formed, either artificially or spontaneously, thirty-five patients recovered. This is a wonderful success, although we do not learn that this procedure has been extensively imitated. Many successful results have attended the use of iodine injec- 480 TREATMENT — DISPLACEMENTS OF THE OVARIES. tions into tlie cyst. Public attention is much engrossed, however, by the brilliant operation of ovariotomy ; and certainly the results in which the recoveries are said to have reached from 70 to 80 per cent, are far more favorable than could have been reasonably anticipated from the well-known dangers of the operation. Still, ovariotomy has been confined to selected cases, and very often shortens a life, which might have been protracted for months or years. The operation has also been attempted, in very many instances, where it could not be completed, owing to various com- plications, strong adhesions, etc. Let it be remembered also that many patients have recovered by medical and surgical measures, far less dangerous in their character ; and may we not hope that some safer, although less splendid, mode of relief may be devised ? PART III. DISEASES OF SEDATION, CHAPTER I. SEDATION AND ITS CONSEQUENCES. Perhaps the design of this work will not be fully accomplished without noticing the state of a part or of the whole system, di- rectly opposed to excitement or irritation. Inertia or sedation may exist: as irritation is an increase of the vital phenomena or actions of a part or of the whole, sedation is a decrease of those phenomena. In a moderate or normal state, we may say, it is inertia, or torpidity ; in a more severe or morbid state, it is seda- tion. This, when extreme, is termed " collapse." As irritation is the result of an irritant acting on the irritability of a part, so sedation is the result of a sedative acting on the same irritability. It is a depression of the organic or animal actions, or of both. The torpor of the extremities, of the surface, or of the whole body, from exposure to cold, is a very pure and common example of both organic and nervous sedation; as well as the pallor and coldness of the feet and hands, so frequent in nervous people, who, with great irritation, it may be, of the brain, have sedation in the extremities. Sedation does not necessarily imply a loss of power or debility, with which it is too often confounded. Vital power is the capa- bility of resisting injurious influences, or of enduring action. De- bility is the diminution of poAver, sedation a diminution of action or excitement. The. reaction which follows the exposure to cold air or water manifests an abundance of vital power, often, indeed, an increase of power. Hence sedation is generally very transi- tory, rapidly appearing and disappearing, alternating speedily with states of irritation. In excitable temperaments, there is 31 482 SEDATION AND ITS CONSEQUENCES. sucli a sense frequently of depression and exhaustion, that patients and even their friends are terrified, by the so-called " weakness" of the sufferer ; but in a few minutes, perhaps, all these sensa- tions vanish, and the ordinary manifestations of activity and power are observed. Eeaction may rapidly ensue, although not unfrequently it occurs more slowly, but still without any real diminution of strength. Of course, sedation may and often does coexist with debility. Hence, in very weak persons sedation is more serious, and may be followed by prostration or collapse, that is, by a loss of power as well as by a loss of action. This is a sinking or dying condition, or as regards a portion of the tissues, it is a gangrenous state. The proper designation is a loss of power or of strength, in which sedation is a consequence; but generally sedation implies merely a diminution of action or func- tion without loss of vital tone or vigor. Oeganic Sedation. — Every one is familiar with examples of sedation in the organic or circulatory system. Whenever there is pallor of the skin or mucous membranes, there is, for the time, a diminution of the activity of organic life, of the circulation, and of the secreting and nutritive functions. The pallid, contracted condition of the skin, its dryness and harshness, are evidences of sedation. Often also the mucous membranes of the eyes, nose, mouth, vulva, rectum, etc., exhibit the same pallor and the same diminution in the size of their capillary vessels. All direct evi- dence that can be collected, and all analogy indicate the same condition of the internal organs in many cases ; hence we speak of torpor of the brain, heart, lungs, liver, stomach, bowels, uterus, kidneys, etc. This is organic sedation ; whether the cause arise directly or indirectly; whether it be primary or secondary. Neevous Sedation. — Examples of sedation or inertia in the organs of animal life are equally numerous; but such is the inti- mate connection between the nerves and the bloodvessels, that it is not easy to present pure examples of nervous sedation, i. e., of diminution of nervous influence when the. circulation remains undisturbed. Hence cold feet and hands from uterine or cerebral excitements, although primarily and essentially dependent on the nerves, indicate necessarily torpor of the circulation, so that less blood goes to the part. ORGANIC AND NERVOUS SEDATION — CAUSES. 483 There are, however, examples of pure nervous sedation, in many cases of functional amaurosis, where the optic nerve is compara- tively or completely inefficient, when there is no organic disease ; so also there are analogous states of the nerves of hearing, smell- ing and tasting, etc., sometimes transitory, sometimes persistent, from the sedation of the nerves appropriate to these senses. In early life, the organs of generation in both sexes are inert, and the same torpor or inefficiency returns in old age with the decline of nervous excitement. All are conversant with the languor, lassitude, " sensations of weakness," characteristic of certain individuals from natural or acquired temperament, or resulting from inordinate exercise. An increase of this muscular languor may render motion very diffi- cult, requiring a powerful exercise of the will to rouse up the nervous energies. In other cases there is a suspension of nervous influence altogether, as respects the nerves of sensation, of motion, or of both, as from injuries of the brain, spinal marrow, or of the nerves going to a part or organ. This is " paralysis." The mus- cular tissue may be perfect in its texture and organic action, but the nervous influence is absent ; the muscle therefore does not contract, it is in a state of perfect sedation. Physicians and sur- geons are familiar with cases of local paralysis of the eyelids, of the face, of the extremities, of the oesophagus, stomach, bowels, bladder, rectum, etc. Sometimes there is still sensation, but as in injuries of the spinal marrow, there is often loss of sensation as well as of motion. In all such cases there is sedation in the parts involved, even though the remote or essential cause be of an irritant character. The sedations of a portion or of the whole of the nervous system caused by various poisons, narcotics, alcoholic stimuli, antispasmodics, etc., are well known, and are generally exemplars of nervous sedation, whether resulting directly or indirectly, pri- marily or secondarily, from the operation of these agents. CAUSES. These examples of organic and nervous sedation indicate per- haps sufficiently its causes. 484 SEDATION AND ITS CONSEQUENCES. Indirect. — Thej are very frequently indirect^ as from irrita- tions in one part producing sedation in another tissue or organ. Sedation is often the result of previous inordinate excitement, and is thus indirectly caused by the feelings of exhaustion from great muscular effort, the indulgence of animal passions, or the relaxing effects of heat, either with or without moisture. Direct. — Sedation may result directly from mechanical causes, as severe contusions — as in the " asphyxiated" conditions of cer- tain tissues from blows, or of the brain in cases of concussion. Sedation also arises directly from the abstraction of natural .stimuli — for example, caloric, as it influences a portion or the whole of the body ; or oxygen, as regards the lungs ; or the ab- sence of food from the stomach, of bile from the intestines, of mental and moral excitements from the brain, etc. Again, direct sedation may be produced by certain medicinal agents, such as sedatives, narcotics, and antispasmodics. Many of these articles act frequently indirectly, as primarily there is some previous excitement of the nerves, and eventually of the blood- vessels. This state of sedation is of late very much resorted to by sur- geons to lessen the pain and the irritations which arise from surgical operations, usually termed " local anaesthesia," and is effected by the application of ice, or by the " spray" of ether or rhigolene, or by the carbonic acid gas, the vapor of chloro- form, etc. CONSEQUENCES OF SEDATION. The consequences of sedation vary from innumerable circum- stances, especially from the character and the intensity of the cause, the nature of the tissues concerned, whether vascular or nervous, and whether the influence exerted be on a part or on the whole system. Generally, it may be said, there is a diminution or suspension of the secretions, excretions, and other functions of organic life, when the capillary tissue is involved. Thus, when cold is applied to a part, the circulation and the organic actions diminish gradu- ally, until, in extreme cases, the part is frozen or even spliace- PASSIVE CONGESTION. 485 lated. "When the whole economy is involved, there is sedation of the general nervous and vascular tissues, as indicated by the diminished excitement of the pulse, heart, muscles, and spinal and cerebral centres, until universal torpor and eventually death ensue. Influence of Nervous Sedation on Organic Actions. — As regards the nervous sj^stem, every degree of torpor may often exist with apparent impunity ; but, as the nerves have physio- logically some control over the organic actions, there is some- times a disturbance of these actions in cases of nervous sedation. This may perhaps be exemplified by the diminished size of para-, lytic limbs, but more especially by the state of the uterus, ovaries, and mammge before puberty, and their atrophied condition in old age, when the peculiar nervous excitement and passions have dis- appeared. Influence of Organic Sedation on Nervous Actions. — Sedation in organic actions has a much more distinct influence, however, on nervous functions, inasmuch as the bloodvessels per- meate all the organs of animal life for their nutrition and suste- nance. Hence any variation of circulation must influence directly the organ, which these vessels penetrate. The cerebrum, the centre of animal life, is of course dependent on the organic life for its nourishment, development, and integrity. Hence, although the increased flow of blood to the brain may cause mental excite- ment, delirium, etc. ; yet, it is equally true that a decrease of vascular determination will be followed by a diminution of cere- bral activity, by faintness, complete syncope, or even collapse. Passive Congestion. — In the sedation of organic life the activity of the circulation in a part is diminished ; but it does not neces- sarily follow that the quantity of blood in the part is lessened. Frequently this is the case, as already exemplified in the skin, especially of the extremities after long exposure to cold. The arterial circulation is diminished, and the veins are for a short time slightly turgid, and give a purplish hue to the surface, but they gradually empty themselves, so that a general pallor ensues. Facts from observation and experiment, which need not now be detailed, prove that the fluids thus excluded from the extremi- ties and surface gradually accumulate in the large venous vessels 486 SEDATION AND ITS CONSEQUENCES. of the interior, in tlie brain, lungs, heart, liver, spleen, etc. ; and, to some extent, even in their extreme radicals, on the mucous surfaces. At the same time there is, internally as well as exter- nally, a deficiency of the quantity of blood in the arterial system, namely, in the left side of the heart, aorta, and its ramifications. The collection of venous blood in the tissues is termed " passive congestion" — the accumulation of blood in a part, but not an increase of the flow to the part. Such passive congestions seldom exist from pure sedation, except in the large cavities of the head, chest, and abdomen ; but they may often be observed externally, from a different class of causes, as when a ligature is thrown around the arm, in the turgescence of the veins of the lower extremities, in varices or from the pres- sure of the gravid uterus. Owing to the functions, and still more to the peculiarities of the venous circulation in the head, chest, and abdomen, passive congestions of the brain, heart, lungs, and the chylopoietic viscera, are by no means unfrequent. Facts and illustrations might be easily adduced ; but perhaps they occur in the minds of all. When oxygen is excluded from the lungs, asphyxia results, which always implies passive con- gestion of the pulmonary artery and right side of the heart, with a comparative emptiness of the pulmonary veins, and the left side of the heart. The effects of this congestion are, by reason of the pressure on the organs involved, to increase the sedation, and to cripple still further the activity of their functions ; this pres- sure is often augmented by the effusion of seroid, mucoid, or bloody fluids. These consequences of venous or passive conges- tion are familiar to all, from the effects of ligatures to a limb ; there is, first, venous turgescence, then effusions of serum, then of blood, and eventually, mortification. So, in the brain, passive congestions are followed by effusions of serum or blood, consti- tuting " venous or passive apoplexy." Similar results are observed in the lungs, liver, etc. The functions of the organs at times are so much diminished, that death frequently is the consequence. In the viscera of the chest and abdomen, spontaneous relief is more frequently experienced, as the effusions may have taken place on exposed surfaces, as the mucous membrane of the bron- chial tubes or of the alimentary canal. Large discharges of sero- mucoid fluids, or of pure blood, escape through these canals, to the relief, it may be, to the recovery of the patient, as is often REACTION. 487 seen in haemoptysis, hgematemesis, and -mekena ; or in some mode- rate cases, free expectoration, or profuse emesis or catharsis of watery fluids is followed by marked improvement. Eeaction. — Eeaction often, however, relieves sedation. In the nervous system, all the varieties of pure nervous irritation and sedation are continually and often with great rapidity, alter- nating with each other, as has been frequently exemplified; — nervous chills followed by flushes of heat ; coldness or torpor of the extremities appearing and disappearing, with nervous head- achesj etc. So also in organic life, the cause being removed, or stimuli, natural or artificial, being employed, reaction follows, sometimes moderate, sometimes so severe that other dangerous accidents occur. After exposure to cold air, or to cold water, the reaction is moderate, and beneficial. The individual feels better and stronger ; hence, the " tonic effects of cold" — directly " sedative," indirectly "tonic." If the reaction be more severe, then morbid influences, inflam- matory and febrile, are apt to follow. If, again, the reaction be still more sudden and severe, active congestions, apoplectic effu- sions, ensue with fatal results to a part or to the whole. So also in idiopathic fevers, patients often die in the cold stage, from great sedation and passive congestion ; but often reaction occurs, developing the hot stage, sometimes so severely, that death results from violent excitement, and active congestion.^ TREATMENT. The treatment of sedation from this general summary of its nature and consequences, may be easily deduced, so far at least as the general principles are involved. The details are, however, often difficult of execution, and require great judgment and much experience. Stimulation. — The important principle or indication is, to stimulate appropriately the depressed action of the tissues or organs. ' A more extended account of sedation and passive congestion, with their consequences, was published by the author in the American Journal of the Medical Sciences, May, 1832. 488 SEDATION AND ITS CONSEQUENCES. In local sedations, direct and indirect measures are perhaps equally important. Direct Stimulation is demanded in cases of pallor, coldness, and other evidences of diminished circulation in the extremities or on the surface of the body; by dry and moist heat; by frictions, especially with stimulating liniments, rubefacients, etc. When there is much numbness, diminution of sensibility, sensations of muscular weakness, or paralytic symptoms, in addition to fric- tions and rubefacients, passive and active motion should be enjoined, and perhaps direct or indirect electric or galvanic cur- rents may be advantageous. In sedations of the brain, mental and moral stimuli may be conjoined with physical agents. In sedation of the lungs, the free access of pure air is essential ; in torpor of the stomach, liver, and bowels, the judicious administration of suitable food is required; in all of these cases much is gained by the use of mer- curial and other alteratives, to revive the activity of the organic actions, functions, etc. Indirect Stimulation. — As sedation so frequently arises, however, from indirect causes — as from irritations in other organs — indi- rect measures are all important in its treatment. The cause being removed, the sedation disappears; there is a natural disposition to this reaction, to an equalization of excitement, which is often very readily evinced. In irritations of the brain, sedative mea- sures, such as leeches, cups, cold, etc., to the head, are not merely advantageous in diminishing cerebral excitation, but also in relieving the sedation of the extremities. Cold water to the head is as essential for cold extremities, as heat to the feet. This prin- ciple is equally true, whether the cerebral excitement be nervous or organic, whether neuralgic or inflammatory. This general truth, of course, applies to all other analogous cases, in all parts of the body, cseteris paribus. While acting on this principle, discretion should be exercised to prevent a too sudden or an excessive reaction. In cerebro- spinal affections, if the reaction be violent, subsequent collapse - even of a serious character may be the consequence. While in organic life, inflammation, gangrene, and death may be the result of inordinate reaction. In general sedation, all the varieties of stimulants are usually demanded, not merely the external — as rubefacients, etc. — but STIMULATION. 489 the internal, as alcohol, camphor, ether, ginger, capsicum, etc., assisted by alteratives to promote the capillary actions, the secre- tions, and functions of the various tissues. The danger of such cases is often very great, not merely from the fact that all the vital organs are simultaneously involved, but that a passive or venous congestion exists, increasing the sedation, and interfering with all attempts at reaction. If, therefore, the case be severe, no reaction ensues ; all stimuli, however powerful or freely exhibited, prove inefl&cient; collapse and death follow, as is con- stantly observed in the bad forms of venous congestions of the brain, lungs, heart, and even of the chylopoietic viscera ; or in the cold stage of fevers — in " congestive fevers," so called. When the congestion is moderate, reaction, whether spontaneous or artificially excited in the heart and arteries, is rapidly followed by the relief of the venous engorgement of the internal viscera. Thus, in the mild cases of asphyxia in new-born children, or in adults from breathing impure air or immersion in water, a few slight inspirations, assisted by frictions, hot applications, and the internal exhibitions of stimuli, are very efficient in resuscitating the unfortunate patient. In other cases there are often evident but ineffectual attempts at reaction, even when assisted by powerful stimulation. There is so much pressure on the brain, so much distension of the right side of the heart, so much contraction of the bronchial tubes and cells from venous congestion of the lungs, that all efforts are in vain. The organs are oppressed by the quantity of fluid in their tissues. In such apoplectic cases, experience has proved that great good is obtained by general bleeding. When a vein is opened in the arm, if the vital power be not too far exhausted, dark venous blood flows, at first very slowly, but then more and more freely ; until, especially with the help of the usual internal and external stimuli, the pulse rises, and the vital viscera, being re- lieved of their enormous load, act freely, and the danger is, at least temporarily, obviated. Perhaps all have witnessed the de- lightful effects of this combination of evacuating and stimulating measures in venous or passive apoplectic conditions of the brain and lungs. Many of the practitioners in Philadelphia, and else- where, were very successful in the sinking stage of cholera maligna by resorting to the lancet; they found that the loss of blood facili- tated reaction, with the consequent disappearance of the watery 490 SEDATION AND ITS CONSEQUENCES. effusions into tlie alimentary canal, and the muscular pains and spasms. The same practice has been tried in the cold or conges- tive stage of fevers, but by no means with such favorable results. If reaction be dangerous in cases of local sedation, it is, of course, much more to be apprehended in general sedation for reasons now evident, and demands the best exercise of the facul- ties of the most experienced and judicious physician, to prevent effusions, inflammations, etc., in vital organs; or, if such lesions have ensued, to prevent fatal results. Febrile reaction may fre- quently be anticipated, with or without local inflammation, after sedation, and becomes more dangerous when with the sedation there is a real loss of power, as in the cases of fever, severe hemor- rhages or long abstinence. In all such cases, the delicate task of the medical attendant is to moderate irritation, without increasing the exhaustion ; to sustain power even by tonic medicines and nutritious diet, while action is restrained by those anti-febrile and inflammatory remedies, which the exigencies of the case may demand. AMENORKHCEA. 491 CHAPTER II. SEDATION OF THE UTERU S. — A M ENO R R H (E A . From these observations on sedation, tlie role which it exerts in the peculiar diseases of women must be very evident. It is comparatively rare, if irritation exists in one organ, that sedation is not present in other organs. If there be great cerebral excite- ment, as in violent passions, nervous headaches, etc., there is gene- rally coldness and even pallor of the extremities. If puerperal convulsions ensue during labor, there is a comparative cessation of the pains and contractions of the uterus. Hence the important practical principle of "counter-irritation" is as true in regard to the cerebro-spinal as the vascular system. To "equalize" the ex- citement of the nervous system, is as important an indication as to equalize the distribution of blood throughout the economy. This is true, notwithstanding the acknowledged fact that sedation or irritation usually involves a disturbance of the organic as well as of the animal life. For, there can be no doubt that, in numer- ous cases, the primary and important irritative disturbance is located in the nerves. This nervous irritation or sedation occurs, and is then followed by organic irritation or sedation. In a large majority of the diseases of women, irritation of the nerves is primary, sedation secondary and of minor importance, especially as it usually exists in the external surface, in the ex- tremities, and not in the internal or vital organs. Hence, under such circumstances, there is very seldom passive congestion in the external tissues ; as the blood, carried to the exterior in di- minished quantities, gradually returns by the veins with little delay to the interior — leaving the surface pallid, cold, or some- times with a bluish tint. When reaction occurs spontaneously or by excitants, the nervous excitement of the surface is soon succeeded by a renewed activity and development of the capillary circulation and functions. 492 SEDATION" OF THE UTERUS. — AMENORRHCEA. There are, however, cases of general sedation of the nervous system which demand some attention, and occasionally an analo- gous state of some important viscus, as the uterus, for example. SEDATION FROM MORAL CAUSES. Certain moral affections, as disappointment, anxiety, grief, fear, etc., depress the excitements of the brain and nervous system. Hence, there arises inactivity not merely of the mental and moral being, but also of the physical. There is languor, lassitude, weakness, exhaustion, indisposition and inaptitude to muscular effort ; there are feelings of dulness, of fulness or vertigo about the head, of oppression, stricture, or even of distension about the heart and lungs; of similar sensations about the prsecordia; of loss of appetite, with flatulency and other dyspeptic symptoms ; torpor of the liver, stomach, bowels, etc., with the usual indica- tions of diminished external excitement. There is general sedation in such cases, the inactivity of the heart, arteries, and capillaries exists, as well as of the brain; although this latter, being the organ of the mental and moral feelings, was the original source of mischief. This diminution of the external and internal circulation, although much more moderate than in those cases arising from cold, is accompanied by venous conges- tion, which increases the sensations of uneasiness and fulness in the head, chest, and abdomen, and depresses still more the activity of the vital actions. Eeaction may and sometimes does ensue from change of the thoughts or feelings; but should grief or anxiety be continued, the inaction will be followed by serious consequences in important viscera. From a trifling or depressed appetite and bad digestion follows deterioration of the blood. It becomes, therefore, light-colored, less nutritive and stimulating. This deterioration is increased by the torpor of the liver, lungs, skin, etc. The patient becomes " ansemic," so called, or even " chlo- rotic," names given to this cachectic state, from the pallid, bluish, bronze, or greenish tinge given to the tissues. The confinement to the house, and the want of fresh air and exercise aggravate the symptoms ; so that the patient, from this state of melancholy, hypochondriasis, and despair, sinks sooner or later into those chronic organic ailments, varying with different temperaments, MORAL AND PHYSICAL CAUSES. 493 termed scrofulous, tubercular, drojDsical, etc. In many cases the congestions of tlie heart are so great, that hypertrophy and other chronic affections ensue. The patient may, indeed, be said almost literally to die of a "broken heart." SEDATION FROM PHYSICAL CAUSES. These cases of sedation with its consequences, anaemia, chloro- sis, etc., may arise from physical as well as moral causes. They often depend on hereditary predispositions ; on bad phy- sical education, as regards especially diet, air, and exercise; on all those causes which indirectly or directly exhaust power, as from premature or powerful exertion of the mind, from excite- ment of the passions, from great muscular efforts, from febrile, inflammatory, or persistent nervous affections. From this ex- haustion of power, of course, there follow sedation, congestion, and their results. These sedative and atonic states at least pre- dispose, to disease, and are too often followed by a miserable train of functional and organic complaints. If this asthenia exists, as is not unfrequently the case, in early life, there is no natural development of the economy; at least such developments are slow. The usual age of puberty arrives without there being proper development of the skeleton, of the adipose tissue, of the mammae, uterus, ovaries, etc. The peculiar secretion from the womb does not appear. Puberty is deferred, sometimes for years. This condition has unfortunately been termed emansio mensium^ as if the failure of the catamenia was of itself a disease, and not merely one of the signs of general asthenia or sedation. This non-appearance and also the disappearance of the menses, both of which so universally treated of in books as a disease, cwienorrhoea, are, like dysmenorrhoea, leucorrhoea, menorrhagia, etc., but indications of a pathological condition of the uterus or its appendages, or else of a want of development of these organs or of their non-existence. There is often, in cases of non-appearance of the menses, atrophy of the uterus, of the ovaries, and of all the genitals. The age of adolescence or womanhood has arrived; but there is no propor- tionate development of the organs or functions. It is the con- .494 SEDATIOX OF THE UTERUS. — AMEXORRH(EA. tinuance of childhood, a delay of puberty, and not merely tardy menstruation; for, all the other characteristic phenomena of "womanhood are also absent. If these views be correct, it results, necessarily, that the popular notion — no doubt originally a professional axiom, and perhaps still maintained in some quarters — is unfounded, namely, that the non-appearance of the menses is the cause of all this asthenic or anaemic state of the system, leading to the mischievous idea and injurious practice, that the flow is to be brought on, in order that the health may be restored. The reverse is the true pathological and practical view; the health must be restored, then the organs will be developed, and their functions will be executed ; the ova- rian vesicles will maturate, the uterus will respond, and men- struation will appear as a sign, very significant, among others of puberty, as well as of restored health. If amenorrhoea, the non-appearance and the disappearance of the menses, is, therefore, not a disease, but a symptom or sign of an abnormal or morbid state of the uterus or its appendages ; then all attempts to induce the flow of the catamenia, without a careful investigation of the condition of the pelvic viscera, are unscientific. They are but little elevated above the efforts of the empiric, which may or may not be successful, may be useful or injurious, instead of being founded on scientific principles deduced from the pathological state of the organs involved. This view is powerfully enforced by the fact, that girls may be healthy and strong, in whom there is not only no appearance of the menses, but in whom there is no uterus. Cases of this kind are upon record. Cases. — During our practice, we have met with four cases in which no uterus could be discovered. The first was a tall, thin, pallid young woman, of eighteen years, who had been treated for "obstruction." She felt well, with the exception of languor; her organic actions were good, the external genitals and mammse moderately developed ; but no uterus could be detected. The vagina was apparently normal.; it was about two inches in length when stretched, but abruptly terminated as a pocket or "cul-de-sac." No solid body could be felt beyond it, by a finger in the vagina or in the rectum, or by a sound in the bladder. The extremity of the sound in the bladder could readily be felt by the finger in the rectum, the tissues of ABSENCE OF THE UTERUS. — OBSTRUCTIONS. 495 these organs "being thus brought into close contact above the vaginal sac. Several years afterwards we learned that this lady had married; but neither menstruation nor pregnancy occurred. A second case was under the notice of many physicians in Philadelphia, and none could detect a uterus in her pelvis. She was a stout, healthy, well-developed young woman, of about twenty-six years of age, and of a fine ruddy complexion. The third case was a married woman, of the same age, in whom neither menstruation nor conception had ever occurred. A fourth case we examined in 1860. She was a young woman, who had been married six years, with good developments and health, but had never menstruated or conceived. The physical examination gave no evidence of the existence of a uterus; the vagina was about one inch and a half long. Atrophy of the uterus has often been detected by examinations during life, in cases of emansio mensium. In post-mortem exa- minations, not only atrophy of the uterus has been seen, but also of the ovaries. Sometimes no uterus or ovaries could be dis- covered. A further confirmation of the impropriety of treating amenor- rhoea without a proper investigation of the condition of the pelvic cavity, is found in cases of obstruction of the vagina or of the neck of the uterus. In such instances there is, at the age of puberty, an apparent failure of the menses, but there is no real failure. The menses are secreted, but not excreted; they are retained in the body, from the hymen, for example, being imperforate. All the signs of puberty and of the menstrual nisus exist, but there is no flow; month after month, even year after year, the symp- toms return without any discharge. The fluid accumulates in the vagina, or perhaps in the uterus, until a tumor, every month enlarging, is observed in the abdomen to the discomforture and alarm of the patient and her attendants. Case. — The only case we have seen was that of a thin and deli- cate young girl, fourteen years of age. The fluid seemed entirely confined to the enlarged vagina, as through the delicate parietes of the abdomen a small body, apparently the uterus, was felt near the umbilicus, appended to an elliptical swelling rising out of the cavity of the pelvis. On perforating the hymen, a dis- charge of some thirty ounces of a very thick dark-purplish fluid, without any signs of putrefaction, followed, the tumor imme- 496 SEDATION OF THE UTEEUS. — A MENORRHCE A. diately disappeared, and the supposed uterus could no longer be detected through the abdominal walls. When the obstruction from natural deformity or disease exists in the upper part of the vagina or in the neck of the uterus, the fluid is necessarily confined to the uterus, and causes its hyper- trophy, as in pregnancy, for which it has unfortunately been mis- taken. Such collections have also been classed under the general head of " hydrometra," dropsy of the uterus, from which it must be carefully distinguished. It is manifest how vain, and how injurious even, must be all medicinal treatment of such apparent cases of amxenorrhoea or emansio mensium. They are really not medical, but surgical cases. They demand the perforation, or perhaps even the exci- sion, of the hymen, the removal of the strictures or adhesions of the vagina, a puncture, by means of a suitable canula and trocar, in the direction of the canal of the cervix, or, it may be, in some very extraordinary cases, into the body of the uterus, per vaginam or per rectum. If this important principle be established — that amenorrhoea is a symptom, and not a disease — the actual pathological condition of the patient's general system, or of the uterus and its append- ages, must be examined, in order to prescribe, conscientiously as well as scientifically, for her relief. These pathological states are innumerable, but perhaps some general arrangement may be made under a few heads, and a few facts and illustrations given to assist in the diagnosis and thera- peutics of affections often obscure and troublesome. Asthenia. — Amenorrhoea may depend on asthenia, a want of vital power, a state of general atony attended by sedation, and often by anaemia, emaciation, or even chlorosis, according to its degree, persistence, or original and acquired complications. This state has perhaps been sufficiently alluded to. In minor degrees there is merely tardy development, or debility resulting from bad air, confinement, want of good food, or of sufficient exercise. In a few months or years, especially under favorable hygienic treatment, such as good, simple, nutritious food, exercise in the country, bathing, etc., the strength is increased; nutrition is more rapid ; the secretions and excretions become abundant ; the ASTHENIA. 497 uterus, in common with other organs, becomes developed: and its functions, in conjunction with those of the ovaries, are evolved, so that menstruation follows and conception may ensue. In more decided cases of anaemia and chlorosis, medicinal agents may be required, in addition to simple hygienic measures, to give tone to the economy, to facilitate the actions of the nervous and vascular systems, the establishment of the proper digestive and secretory functions ; and thus to purify and enrich the circulating fluid, and to assist nutrition and development. These seem to be the successive links of this physiological chain. To produce these desirable results, much can be done in addi- tion to pure hygienic measures. To excite an appetite, and give tone and activity to the digestive functions, so that food may be readily taken, and, when taken, be digested ; tonics^ from the mild, bitter infusions and extracts, to the strong preparations of cin- chona, iron, zinc, copper, arsenic, etc., become very valuable. Moreover, all that class of remedies, which, with or without a tonic influence, facilitate the gradual development of the secre- tory and nutritive functions, and known by the name of altera- tives^ are often of great importance, such as the alkalies, ipecacu- anha, mercurial preparations, the mineral acids, iodine, and cod- liver oil. This will also include diaphoretics, diuretics, and even laxatives. These laxatives are all-important, if judiciously em- ployed; they should be used, not as cathartics or purgatives, or direct evacuants, which would be positively injurious, but as " peristaltic persuaders," simply to obviate the sedation or torpor of the muscular coat of the bowels. Constipation, with all its direct and indirect consequences, may thus be obviated, and no positive exhaustion or debility ensue. Such articles as rhubarb, aloes, senna, sulphur, colocynth, etc. which have a tonic as well as a laxative influence, are therefore to be employed. They may be advantageously combined with tonics and alteratives, and thus augment their direct and indirect advantages in restoring action and strength to the delicate asthenic girl. This treatment for asthenia is equally important in such states of the econoni}^, whether the emansio be complete or partial. At the age of puberty, some menstrual efforts without any secretion are often manifested ; in some, a leucorrhoeal discharge ensues ; in others, it is pinkish or more or less elaborated. These are 82 498 SEDATION OF THE UTERUS. — A MENO RRHCE A . favorable indications; but the treatment must still be continued unremittingly. Asthenia and ansemia, hoAvever, are not necessarily connected with amenorrhoea, in some cases, as from premature excitation of the nervous system, menstruation may be established or even become profuse. This, M. Virey well calls "precocious menstrua- tion." The precursory and attendant indications of puberty are absent ; but, there is a full development of the genitals, from a premature excitement of the nervous system, the mental, moral, and animal sentiments, passions, etc. This is nervous irritation in a debilitated system ; it increases exhaustion directly by the discharges, and indirectly from the depression which succeeds excitement. Hence, the sedation or debility in precocious men- struation, demands as much if not more, than in ordinary cases of asthenia, the same hygienic and invigorating regimen. Moreover, the condition of the patient is not altered by the fact that the catamenia, although once established, had, from any cause, disappeared. This is a case of '■'■ suppression of the menses,^^ as termed by systematic writers ; but in no essential respect, does it differ from the already described cases of emansio mensium in asthenic individuals. The debility may be so great, that no secretion occurs ; but in other cases after secretion has been esta- blished, exhaustion supervenes, and then the patient is reduced to the same condition as if the menses had not originally appeared. In all such cases of partial, irregular menstruation, or complete amenorrhoea, great hope may exist that the patient, if favorably situated, and properly treated, may recover. Organic Diseases. — There are cases where either originally as a cause, or secondarily as an effect of these cachectic states, positive inflammatory, or organic disease exists in some tissue or organ of the economy. The imperfect digestion, the irritating character of the unas- similated food, the acid and putrefactive character of the ingesta of the stomach and bowels, the bad, illy elaborated state of the various secretions from the liver, stomach, pancreas, bowels, etc., arising from the impure state of the blood, as well as from the want of power in the secreting tissues; all prove more or less irritating to the mucous membranes of the alimentary canal. Hence gastritis, enteritis, and colitis, not unfrequently ensue, ORGANIC DISEASES — RHEUMATISM AND GOUT. 499 with their reflex influences on the oesophagus, pharynx, mouth, etc., aggravating as well as complicating the original disturb- ances. Under such circumstances, any of the many forms of organic chronic disease may be induced. Irritations often remain fixed on particular tissues or organs, until changes of structure, softening of the tissues, suppurations, ulcerations, etc., result to the destruction of the organ and the life of the sufferers. Thus tuberculous, or scrofulous affections of the brain, lungs, heart, liver, intestines, etc., arise. Hence, also, may result albuminuria, Bright's disease of the kidneys, or even uraemia, which some authors have regarded not always as the consequence, but some- times as the cause of amenorrhoea. Indeed, there may be induced any variety of disease, even of a malignant type, followed by colli- quative diarrhoea, vomitings, and dropsical effusions prior to complete prostration, from which there is no reaction. Such cachexia may be hereditary, and may appear at or soon after birth, during childhood, or after adolescence; but, in all cases, it either prevents the appearance of the catamenia, or causes its dis- appearance. The amenorrhoea is not the cause, but the result ; and, therefore, should never be treated as the disease — ipse mor- bus — but as a secondary, and often an unimportant symptom. If, by any fortunate circumstance, the chronic disease and the asthenia be relieved, then the uterine discharge may ensue; its appearance may indeed be hailed, not as the removal of the cause, but as a strong indication of returning health. In phthisis pul- monalis, all are familiar with the gradual disappearance of the menses, as the organic disease becomes more and more decided, and even in less terrible affections of the pleura, lungs, liver, etc., amenorrhoea may ensue. Although there should be a partial return of the menses, encouraging the patient and her friends, yet, in all instances, the treatment ought to be founded on the condition of the diseased organ and general system, and not on the condition of the uterus and its appendages. Eheumatism and Gout. — Amenorrhoea follows also in the train of rheumatism, gout, cutaneous and other metastatic dis- eases. Dysmenorrhoea, monorrhagia, haemorrhagia, and other forms of uterine irritation have been already mentioned as dependent on the translation of the morbid excitement to the uterus. The 500 SEDATION OF THE UTERUS. — AMEXORRHCEA. reverse is also true. The translation may be from tlie uterus to other tissues or organs — the latter being in a state of irritation, the former of sedation. Hence, occasionally we have amenor- rhoea either under the denomination of emansio mensium, or of suppressio mensium. Case. — We attended a very interesting young lady, of eighteen years of age, who for some two or three years had suffered severely from acute rheumatism. The irritation had fixed itself chiefly in the right hand and forearm, producing some deformity of the hand, from which she never fully recovered. She had never menstruated. Her rheumatic complaints were relieved after a few months; the catamenia then appeared. She after- wards married, and became the mother of children. The same result from metastasis to other organs may also follow after the appearance of the menses. There is also a close connection between amenorrhoea and some of the varieties of emtjjtive and cutaneous diseases. The TREATMENT is to be founded on these pathological facts, so. that the usual means, by diet, medicine, etc., are requisite for the original affection. While inordinate irritation is moderated in the suffering tissues, measures should be instituted to deter- mine nervous and vascular excitement once more to the uterine organs, precisely on the same principle, as, when gout affects the brain, heart, or lungs, "derivation" should be made to the sur- face of the body and to the extremities. In acute attacks of rheumatism, gout, etc., derivation to the pelvic viscera should be made by mild, but still very efficient measures ; such as pediluvia, hip-baths, local vapor-baths, fomen- tations, poultices, warm vaginal and rectal injections, and occa- sionally stimulating enemata of senna, aloes, turpentine, etc., to the bowels. In chronic cases, such means may be assisted by rubefacients, blisters to hypogastrium, to the sacrum, to the thighs, etc. In such instances, also, resort may be had to internal remedies, especially to purgatives; as senna, colocynth, rhubarb, aloes, which have their chief influence on the large intestines, and it is supposed sympathetically on the uterus. The treatment of such chronic cases may demand the employment of all those means which are supposed to have a direct or even a specific influence RHEUMATISM, FEVERS, ETC. 501 over tbe uterine functions, known by the expression Emmena- gogues, wliicli will hereafter be noticed. Fevers and Phlegmasia. — A suspension of uterine secretion, partial or complete, is the result sometimes of acute fevers and of the phlegmasise. In the former, such is the universal disturbance of the economy, that perhaps there is no function but is partially disturbed, and many are completely suspended, from the deficiency of nervous action, from congestions, etc. The stomach, liver, and uterus suffer alike in this prostration of their peculiar functions. In the same manner, in the phlegmasise of important organs there may be a suspension of uterine secretion, or transference of irri- tation to the affected organ. In all such vascular disturbances, amenorrhoea is a secondary circumstance. Every practitioner addresses himself almost ex- clusively to the organic disease, and looks for a return of the menses on the patient's restoration to health. Such return will generally be manifested ; but sometimes the injury sustained is more permanent, and the usual course of derivative means, and perhaps occasionally of emmenagogues, may be demanded to re- lieve the sedation of the uterus. Nervous Irritations. — In other cases of amenorrhoea this transference of irritation from the uterus to other organs involves not chiefly, as in the last mentioned cases, the organic life, but mainly the nervous system. There is nervous sedation of the uterus, but nervous irritation of other organs, a diminution or suspension of the menstrual secretion, but increased congestion and consequent effusion or secretion from other tissues or organs. The type of this morbid state is observed in the physiological condition of the uterus and mammas during lactation, there being sedation of the uterus and suspension of its secretion, while in the mammee there is excitement with an abundant excretion. The causes of such normal and abnormal states of the uterus and mammae are entirely obscure ; but that such conditions do exist, and that there is a close connection with the nervous sys- tem, there can be little doubt. It seems hardly requisite to present facts confirmatory of the domain of the cerebro-spinal system over the uterine functions, especially as so much has already been detailed in the former 502 SEDATIO?f OF THE UTERUS. — A MENOREHCE A. parts of this work. Attention, however, may be fixed on the fact, that when certain peculiar changes occur in the brain and its appendages, there follow the development of the genital organs, and the establishment of their wonderful functions at the age of puberty. When, however, another inscrutable change occurs at the climacteric of woman's life ; the ovaries, uterus, and mammae fall into a state of sedation and of atrophy. Again, there is a special nervous excitement and consequent congestion at every menstrual period, in the non -parturient and healthy female. Dur- ing the intervals of the regular periods, the menstrual discharge is often re-excited by any excitation arising from the influences of the mind, of the emotions, feelings, and sentiments. The essential influences of the nervous system in the erections and congestions during fecundation are universally acknowledged. Allusion has already been made to the sedation of the uterus and its functions b}^ the depressing influences of anxiety, melancholy, fear, etc. A young lady fell down a flight of stairs while menstruating ; there was an immediate cessation of the discharge, which did not return for two years. During lactation, also, there is a suspension of the uterine functions. In such cases the mammse are the irritable organs ; the mental and moral emotions, whether exciting or de- pressing, then influence their actions, congestions, and secretions even more, apparently, than the same emotions, under other cir- cumstances, affect the uterine functions. The transient thought of her bright and healthy infant will instantaneously augment the turgescence of the breasts of a lactescent mother, and her supply of nutriment ; while the sickness or death of the child will rapidly cause their collapse, and the diminution, vitiation, and arrest of their secretion. As, in health, peculiar conditions, therefore, of the nerves have such wonderful influences on the uterus, surprise need not be experienced, if morbid states of the nervous system produce disturbances of the uterine functions ; although the true nature of these peculiar states of the nerves may be, in no degree, under- stood. Thus amenorrhoea occasionally occurs in girls who iare appa- rently healthy. The phenomena of puberty are decided ; the skeleton, the muscles, the organs of generation, the mammae, the adipose tissue, are all well developed, under the influence of good rich blood, which distends the capillaries, and gives the NERVOUS IRRITATION. 503 ruddy tinge of health to the whole surface. The brain is active ; the muscular, mental, and moral powers are all indicative of perfect adolescence. Nevertheless, there is no menstruation. It is a case of emansio mensium in a strong girl, arising, therefore, not from asthenia, but from some peculiar state of the nervous system ; there is a sedation, that is, a want of that peculiar excita- tion which gives origin to menstruation. In some such supposed cases, there may be an absence or an alteration in the structure of the uterus or of the ovaries, etc., or an obstruction in the vagina, or some other cause, explanatory of the non-appearance of the menses. But in many cases no such cause of amenorrhoea can be detected, and indeed does not exist; for, eventually, the menses appear and return regularly. This same state may also be observed in cases of suppression of the menses, from any accidental cause, as mental disturbances, exposure to cold, etc. The menses stop, but the organic life con- tinues very good. The cases are numerous of young women whose menses have thus disappeared, and yet they have enjoyed good health for a longer or shorter time, or even for the rest of their lives. In these cases of amenorrhoea, where the irritation is located in the nervous centres, the consequences may be severe, although seldom dangerous. The symptoms of cerebro spinal irritation are often developed. Usually the patient appears perfectly well, is cheerful, happy, and actively devoted to her ordinary pursuits, but with a nervous system so susceptible, that the least impression disturbs it. A disagreeable object, an unpleasant odor, a transi- tory mental or moral emotion, will sometimes produce sensations of exhaustion, giddiness, languor, and even complete syncope ; and if the cause be more powerful, as fear, joy, auger, or severe pain in any portion of the body, we have manifested the various forms of hysteria, such as headaches, a sense of suffocation, globus hystericus, spasms, and convulsions. Often with or with- out severe nervous irritation, there is more or less congestion of particular organs, followed by increased excretions, secretions, and, it may be, effusions of blood from the nose, lungs, stomach, bowels, etc., generally to the partial or complete relief of the symptoms. These hysterical phenomena sometimes vanish speedily, and the ordinary appearance of health is soon manifested. But this 504 SEDATION OF THE UTERUS. — AMENORRHGEA. hysterical state may continue for years, with varying intensity ; however, if there should be an appearance of the menses — that is, if the proper uterine nervous irritation should occur — there is a decided relief; the catamenia being established, the patient is better. Nevertheless the relief, even then, is not always com- plete ; hysterical symptoms often continue, probably from causes formerly noticed under the head of nervous irritation. The return of the menses is often partial ; they are pallid, or even white, and then afford less relief to the economy. Such patients often enjoy excellent health, but occasionally in chronic cases they lose their healthy aspect, and assume a pallid and sallow condition of the surface, a want of activity and excite- ment not only of the vascular system, but of the thoughts and feelings, with much muscular languor and weakness; a kind of premature senescence, instead of the ruddy glow, the sprightliness and buoyancy, the activity and hilarity so associated with our ideas of a healthful and well-developed girl. When the absence of the menses continues, the patient may, as detailed under the first and second of these pathological states, fall gradually, not merely into this condition of general sedation or premature de- cline of vital actions, but into the positively morbid conditions arising from asthenia, with or without organic disease. The instances, therefore, of failure of the menses in girls whose systems are well developed, and whose organic health is excellent, seem to depend on some peculiar inscrutable state of the nervous system. This system has, as we have seen, a predominating in- fluence over woman, on her generative system, the appearance of the menses at puberty, and the disappearance at the change of life ; hence, it may safely be inferred that it has a similar influ- ence on the morbid and irregular condition of this function. When a peculiar nervous excitement is fixed on the pelvic viscera at puberty, the menses occur ; when this excitement is deficient, they do not appear, or appear in an imperfect state. The general cerebro-spinal symptoms, the hysteria, are present, therefore, frequently when there is no menstrual effort. These hysterical symptoms may be partially relieved by the removal of the excit- ing causes, by the occurrence of secretions from the skin, bowels, and the kidneys, or by the establishment of the catamenia; but even in this last event, the relief is seldom complete. More or less nervous irritation often remains and is slowly dissipated, as HYSTERICAL PHENOMENA. 505 changes in the nervous system occur from the alterations in the modes of living, the influence of marriage, gestation, etc. The same state of things prevails in cases of suppression of the menses. There will be found the same condition of the general nervous and vascular systems, whether sthenic or asthenic or cachectic. In the sanguine temperament, with the usual hysteric pheno- mena, there will, in the disappearance as in the failure of the menses, be evidences of plethora, with determinations to particu- lar tissues, occasionally followed by effusions of serous or bloody fluids, or actual hemorrhage, to relieve the engorgements. In the more chronic cases, where there is less plethora, and generally not so much activity and strength, the hysterical and nervous symptoms will be less violent, it may be, and the evidences of congestion comparatively trifling. Still, in many cases, as in the non-appearance, of the menses, there may be partial congestions of one or more tissues, followed by discharges of blood, etc., at intervals more or less regular — " vicarious, ' or metastatic men- struation" — but these afford only partial relief to the nervous symptoms. There may, also, be an incomplete return of the menses, the discharge being imperfect in quantity or quality, sometimes it is mere leucorrhoea. In a few cases the menses may return, but the original injury to the nervous and vascular systems may not be obviated, even for a long time, perhaps not until other influences than the mere condition of the menstrual function are exerted to rectify the economy. Cold. — Exposure to cold is another common cause of amenor- rhoea. The modus operandi of cold, or the abstraction of caloric, has already been alluded to. It has a direct sedative influence, first on the nerves, and secondly, on the circulation in diminishing its rapidity, and in producing passive congestions of the great viscera of the head and body. Also, when the reaction is rapid and severe, apoplectic congestion may be induced, or, in more moderate cases, inflammatory or febrile diseases ; although in most instances, of strong, healthy individuals, where the degree of cold has not been severe, the reaction is beneficial, tonic, and even stimulating in its influences. Great good often results, therefore, from the judicious 506 SEDATION OF THE UTERUS.--'AMEXORRH(E A. local or general use of cold air or cold water. Tlie whole sj'-stem is invigorated, and particular functions stimulated and strengtli- ened. A good appetite, for example, and a good digestion, which imply good secretions from the stomach, pancreas, liver, etc., are induced. The same is true as regards the uterine functions. Thousands of women, especially in savage life and among the strong and laborious in civilized countries, plunge into the river or ocean, even when the menses are flowing, not merely with impunity, but sometimes with advantage. The discharge is not checked, but may even become more profuse. Such hardy persons will for hours stand in damp and wet places, frequently without any protection to their feet, or even immerse their limbs in cold water, during the catamenia, with perfect impunity. Seldom, however, can such exposure be ventured on by the delicate, refined, and sensitive child of civilization, whose physi- cal education has been neglected, and whose mental and moral sentiments have been developed at the expense of the health and strength of her corporeal system. In such, a general or local cold bath, standing in cold and wet places, or even getting the shoes or stockings accidentally damp, may cause a disappearance of the menses for the time, and occa- sionally prevent their return. A young friend and patient of much talent and mental culture, anxious to be present at an eve- ning party, immersed her feet in cold spring water for an hour during her period ; she effectually arrested the flow for the time, but so greatly injured her health, that she remains an invalid, although her menses afterwards returned, and she has become a wife and a mother. The reaction which ensues after exposure to cold may be fol- lowed by catarrhal or other inflammatory symptoms, but usually these are transitory. In some cases there are no evidences of fever or inflammation, yet certain bad effects of the exposure remain. These are manifested not simply by the sedation of the uterine functions, but of other organs — as of the chylopoietic viscera, in the loss of appetite, the imperfect digestion, the torpor, of the liver, of the bowels, etc. The brain, lungs, and heart, with their dependencies, suffer more or less, with the consequent de- terioration of their functions, and of the purity and richness of the blood, etc. A premature senescence is manifested, almost pre- cisely as when such suppressions are caused by mental and moral COLD. 507 impressions. This state of depression from cold may remain, ap- parently stationary, for years, the patient having "feeble health;" or, under unfavorable circumstances, and when additional causes are operative, she may gradually sink into a complete state of asthenia or cachexia, with their miserable and even fatal results — diseased viscera, dropsies, etc. In many instances, partial reac- tions of the nervous system occur, showing themselves in the from of headaches, neuralgia, or other varieties of nervous irrita- tions, perhaps with partial congestions of organs or tissues, when effusions, secretions, and hemorrhages — passive or active — " vica- rious menstruation," may follow. CONCLUSIONS. All these pathological states connected with amenorrhoea are generally regarded simply as owing to the arrest of the men- strual flow, and therefore to re-establish the discharge is, to the masses, the only indication : they suppose if the flow be absent, the patient is sick; if it be excited, the patient will be well. If the history presented be true, the incorrectness of this opinion is evident. The suspension of the menses is doubtless very injurious; it is an arrest of an excretion; it implies the diminution of nervous and vascular excitements of the uterus, a morbid state or sometimes a want of a proper development of the ovarian vesicles, of the iiterus, etc., and probably the non-elimi- nation of elements of a noxious character from the blood, and the consequent depravity of the circulating fluid. All this, and even more,' may be true; but, the mental or physical phenomena that caused this suppression had not a mere local effect on the uterus and its appendages, but also a similar influence on other organs — • as the brain, heart, and their dependencies. Hence arises the trouble to other functions, as well as to that of the uterus ; hence, the want of proper activity of other organs; hence, congestions; hence the want of proper elimination of noxious elements from the lungs, from the liver, etc., as well as from the uterus ; and hence, of course, the general deterioration of the animal economy. This view is enforced by the fact that the restoration of the menstrual function, although a most valuable phenomenon or sign of improvement, does not necessarily re-establish the health 508 SEDATION OF THE UTERUS. — AMENORRHCEA. of the patient. The catameuia, more or less elaborated, may flow, conception may ensue, and even healthy children may be born, but the patient may continue an invalid for years. ■ The results of treatment confirm this view. "Whatever confi- dence may be placed in specific remedies — " emmenagogues," as they are termed — to re-excite the uterus, almost every practi- tioner, elevated above the level of the empiric, has found himself compelled to institute a general course of treatment, having no direct, but merely an indirect and secondary influence upon the pelvic viscera. As, therefore, emansio mensium exists from certain peculiar inscrutable changes of the system, nervous and vascular, although there has been no apparent exciting cause, such as cold, inflam- mations, mental and moral influences ; so, also, the same states exist in suppressio mensium, where such exciting causes have been operative. Practically as well as theoretically, the differ- ences, if any, are not appreciable. Amenorrhoea, in all cases, is a sign, a symptom, therefore, of abnormal states of the uterus, of the ovaries, of the secretory organs, or of the general nervous and vascular systems. DIAGNOSIS. 509 CHAPTER III. DIAGNOSIS AND TREATMENT OF SEDATION OF THE UTERUS. DIAGNOSIS. The Diagnosis of araenorrhoea is of course generally without difficulty. Nevertheless, in some cases, much knowledge and experience are required to decide the nature of the case. The most frequent mistake is to regard cases of delayed puberty as a diseased state. Mothers, nurses, and empirics, often commit this fundamental error, and resort to the so-called emmenagogues, often with positive injury. Care should be taken to examine strictly as to the developments of the economy, and as to the symptoms of approaching menstruation, whether any indications of uterine irritation have been manifested. If no evidence exists of these changes and efforts, it is not a case of "failure of the menses," but one of tardy development. Again, if development has occurred, but no discharge has fol- lowed, and the patient enjoys good health, it is possibly merely a state of tardy menstruation^ which demands no interference ; or, it may possibly be, that there is an absence or at least an atrophy of the ovaries or uterus, or of both. If all the symptoms of menstruation have occurred, not merely once, but several times without any evacuation, a careful exami- nation will be requisite to determine whether there be no ohstruc- tion from an imperforate hymen, contractions of the vagina, or cervix uteri. Especially are such examinations demanded, when the abdomen begins to swell, and the moral as well as the phy- sical character of the maiden is involved in the decision of her medical attendant. The diagnosis between amenorrhoea and pregnancy is generally easy, after the fourth month, in healthy women; but, during the first four months, and even afterwards, especially when complica- 510 TREATMENT OF SEDATION OP THE UTERUS. tions from obesity, from dropsical or other collections exist, the diagnosis is often exceedingly difl&cult, and will sometimes tax all the powers of the physician. The difficulty is often increased, as in many instances the patient will not, or cannot offer any essential assistance. She throws all the responsibility upon her physician. Ladies often deceive themselves and their attendants. Anxious, when married, to have a family, they usually take it for granted that if there be no menstruation, there must be pregnancy ; so that not merely a few weeks, but perhaps months elapse, before their doubts are excited, and the mistake is revealed. Such mistakes are sometimes made, even when there has been almost every mouth some sanguineous discharge. We have known a delicate, emaciated young woman, under her mother's advice, during ten months of this supposed gestation, make all the usual prepara- tions for herself and child ; of course, she was perfectly amazed when informed of her error. In another case, a delicate married lady, sustained by the opinion of her husband, committed the same error, although she had been the mother of four children. In females married late in life, where cessation of the catamenia occurs not very long after marriage, and where there has been an enlargement of the abdomen, such false suppositions are not unfrequent. The diagnosis is the more difficult when there is any great development of the abdominal tissues, preventing satis- factory external examination. The physician must be very cau- tious in venturing to destroy hope, and to pronounce the swelling of the abdomen " ventus seu adeps et prgeterea nihil." Physicians are occasionally called to cases of pregnancy in girls who, unfortunately, have never been married. They insist that they have an obstruction, and nothing else ; and very universally they deny not merely the existence, but the possibility of preg- nancy. Such cases are extremely delicate, involving in the result of his examination the character, perhaps the reputation of the physician, as well as that of his patient. No decision ought to be made unless four months are supposed to have elapsed ; and even after quickening, the expression of opinion should be giveri with as much reserve as is consistent with truth and justice. We have heard women deny the possibility of such an event, even after labor had actually commenced. It is well known that pregnancy has been mistaken for dropsy; PROGNOSIS. — TREATMENT. 511 and, on the other hand, paracentesis abdominis has been per- formed where there was no peritoneal effusion. Amenorrhoea, coexisting with hypertrophy of the uterus, sim- ple or complicated with tumors of the uterus, or with tumors of the ovaries, or of the mesenteric glands, requires often great care to distinguish it from pregnancy. C((se. — A young lady had an abdominal swelling, and no men- struation. A most experienced physician, in a neighboring city, was called in consultation, and pronounced it a case of pregnancy. The young lady and her friends, of high position and religious character, repelled the suggestion with virtuous indignation. Subsequently, a post-mortem examination revealed an enormous collection of gelatinous matter, vindicating the character of the lady, and injuring the reputation of her physician. In all cases, the greatest caution and care should be exercised when abdominal tumors exist in conjunction with amenorrhoea, as perhaps there are few practitioners of extensive experience, who have not cause to regret that they trusted too much to a hasty examination, and to the character and assurances of his patient, in making a diagnosis of such delicate and complicated cases. Prognosis. — The prognosis in amenorrhoea must be necessarily very uncertain, depending, as the history now given shows, on the ever-varying condition of the tissues and organs of the body, and on the general health. It can merely be said, that if the health be restored, the prognosis is favorable, that is, if the general disease be cured, this symptom, amenorrhoea, will usually disappear. TREATMENT. If the views presented be correct, there is, perhaps, no treat- ment for amenorrhoea, which can be called direct, that is, having a positive immediate influence to re-establish the flow of the menses ; no confidence can, therefore, be placed in specific medi- cines for this purpose, in the so-called " Emmenagogues." The almost universal experience of the profession confirms this view. The employment of such specifics is a last resort, a kind of for- lorn hope to the experienced physician; while it becomes a fruit- 512 TREATMENT OF SEDATION OF THE UTERUS. ful source of deception and consequent mischief to the sufferer, and of profit to the empiric, who, in public and private, lauds his "infallible remedy." Nevertheless, there are general and also local measures which are all important in the management of the various pathological states connected with amenorrhoea. Eemoval of THE Cause. — The first general indication is the removal of the cause, so far as this is still operative, or to pal- liate it, if not remediable. This is the essential, the all-important principle in^ the management of amenorrhcea, regarding, as we have done, the non secretory state of the uterus as a sign or con- sequence of various unnatural or morbid states of the pelvic viscera, and of other organs. Asthenia. — In all cases, therefore, of asthenia where there is a failure or suppression of the menses, partial or complete, the whole effort of the judicious practitioner, addressing himself to the mental and corporeal being, should be to invigorate the economy, and to give tone to the nervous and vascular systems by all the direct and indirect means he can employ. The regu- lation of the exercise of the mental and moral powers, the incul- cation of the importance of suitable food, pure air, exercise, bathing, and all other indispensable hygienic measures, are the foundations of his practice, and are to be assisted by alteratives, tonics, and occasionally by stimulants. Organic Disease's. — Where this asthenia is complicated with organic diseases, the latter must, of course, receive sj)ecial atten- tion, secundum artem. Bhenmatism, Gout, etc. — Where gout, rheumatism, or other metastatic diseases coexist with amenorrhoea, they demand pri- mary attention for their removal or palliation, while suitable measures are employed to determine the nervous and vascular excitements again to the uterus and its appendages. Fevers and Injlammations. — The same principle should regulate the physician in all the febrile and inflammatory complaints of an acute or active character. When the inflammation is located in the ovaries or the uterus, the local evacuants, necessary to affect resolution, act on the principle of removing the cause, which, in this case, is the phlogosis. Mental and Moral Disturbances; Exposure to Cold, d'c. — When amenorrhoea exists from mental or moral disturbances, from ex- REMOVAL OF THE CAUSE. 613 posure to cold, or other causes usually transitory, tlie injury sus- tained by tlie nervous and vascular systems often remains long after the exciting cause has disappeared. This deserves constant and scientific attention, that the function of the uterus may be • resuscitated. All these truths are practically acknowledged by any regular practitioner, who, whatever may be his confidence in specifics, never neglects what is termed general treatment. Local measures are often important when there is organic irri- tation, such as inflammatory disturbances of the pelvic 'viscera, and also in cases of nervous irritations and congestions. They are more efficient, if any indication of the menstrual nisus be present. Cups and Leeches, — The employment of cups to the sacral region, or to the hypogastrium ; of leeches to the abdomen, to the groins, to the upper part of the thighs, to the pudendum, to the vagina, and to the uterus, have often been very efiicient in reliev- ing excitement and congestion, and thus promoting secretion. There are but few who have not found such practice useful. Two observations may, however, be made. First. It is remarkable that the relief, afforded by the artificial discharge of blood, is by no means proportionate to that which ensues from the natural secretion. For six or eight ounces of blood really do not relieve a patient as much as half an ounce or an ounce of menstrual discharge. Second, Judging from our own experience, direct loss of blood from the vagina or the uterus is not as efficient in any degree as from the adjacent external tissues — "a derivative leeching," as it has been termed. Whether this comparative inefficiency of the loss of blood from the organ involved arises from the mental and physical suffering attendant, more or less, on the operation, efi'ected by means of a speculum, or on the soreness and inflam- mation ensuing from the leech-bites, or some other cause, may not be clear ; but, in many instances, the irritation has been but partially relieved, and in some positively augmented. Scarifications to the neck of the uterus have been proposed ; but these also require the use of a speculum, with its mental and physical objections ; and the loss of blood is comparatively trifling, while the subsequent irritation is sometimes considerable. 33 514 TREATMENT OF SEDATION OF THE UTERUS. It has been suggested to draw blood from tlie interior of the uterus by suction. A perforated bent tube, resembling a silver catheter, is introduced into the uterus, and to the other extremity an exhausting apparatus is affixed. Some blood can doubtless be obtained in this way from the delicate and vascular lining mem- brane of the uterus ; but, it cannot be easily imagined how such loss will counterbalance the pain and irritation of the intra-uterine operation, severe even in the passive states of the organ, and, of course, much more so, where congestion or inflammation exists. Fomentations, etc. — Under the head of local measures in morbid excitements of the uterus, with no secretion, must be placed all those agents termed relaxing, operating by promoting secretion — such as fomentations, poultices, warm vaginal and rectal enemata. They are very soothing, and although they determine blood to the part, they favor secretion and relaxation — just as the application of a warm poultice to an external phlegmon. Cases of amenorrhoea dependent on great local congestion, or on metritis or ovaritis, are comparatively very rare. In the large majority of cases there is sedation in every sense — organic as well as nervous — of the uterus and its appendages, demanding in many instances remedies of a different character. Eevulsives or Derivatives. — These all act by determining excitement from a tissue or tissues where it is inordinate, to those where it is deficient. They equalize excitement so far as they are operative. They are exceedingly valuable, and perhaps the most reliable in the estimation of the modern therapeutist. If, therefore, general remedies, whether tonics or evacuants, have in any degree rectified the system, if local inflammatory or organic changes be subdued, and especially if there be any premonitions of returning uterine action, means should be adopted to relieve the sedation of the nervous and vascular tissues of the womb. We should revulse from the organs unduly excited, to the uterus. These measures are familiar to every one, but some of the more important may be noticed, as many have been relied upon, in popular as well as professional practice, as if specific — as being really emmenagogues — while they act merely as revulsives. In states, therefore, of debility or sedation, not only of the LAXATIVES — EUBEFACIENTS. 515 uterus, but of other organs, great good is obtained, pro tempore^ by stimulating diapboretic measures, to be resorted to especially at the expected period. They not only determine from the large congested viscera to the cutaneous and muQOus surfaces ; but they favor secretion. Thus, hot baths^ general and local, hot drinhs^ hot fomentations^ alcoholic and vegetable, are greatly relied upon. With women, and even physicians, this practice having been often successful, peculiar specific virtues have been attributed to hot toddies of gin, rum, etc., to hot infusions of peppermint, spearmint, catnip, parsley, pennyroyal, madder, tansy, rosemary, etc. They all, however, are advantageous in equalizing the circulation, and facilitating the secretions from the skin, the mucous membranes, and of course from that of the uterus. Their operation is greatly facilitated by those medicines termed diaphoretics, exhibited with or without anodynes, as the occasion indicates. Laxatives, but not cathartics or active purgatives, have been always much depended on. They act perhaps universally as revulsives, from the head, lungs, or other organs, to the stomach, and intestines. They not only relieve constipation, but restore the secretions of the liver, stomach, intestines, etc. In this point of view they are more efficient when combined with alteratives, in minate doses — as of mercury, ipecacuanha, antimony, etc. Some aperients, such as sulphur, rhubarb, senna, and especially aloes, act mainly on the large intestines, and thence sympatheti- cally on the uterus. Hence, aloes and some other laxatives have been universally regarded as specifics in amenorrhoea. Stimulating enemata operate also as revulsives to the intestines and secondarily to the uterus. They are really useful in hasten- ing any disposition to menstrual secretion. Enemata of senna, aloes, and turpentine, have had much effect, and are often re- garded as specifics. Simple or stimulating diuretics, such as balsam copaiba, spirits of turpentine, tincture of cantharides, sweet spirits of nitre, infu- sions of juniper berries, gin, etc., act as revulsives to the kidneys and the pelvic organs, but have no real pretensions to peculiar influences on the uterus. EuBEFACiENTS are not to be neglected when premonitory symptoms of menstruation are present, in cases of amenorrhoea. 516 TREATMEXT OF SEDATION OF THE UTERUS. Altliougli they are not very influential, they are useful in assist- ing other revulsive measures, and when applied in the neighbor- hood of the uterus, assist in determining excitement to its tissues. Perhaps the most important are cantharidal blisters, as they not only favor secretion, but have much direct or indirect influence on the bladder, the rectum, and perhaps, on the vulva, uterus, etc. They may be applied to the region of the sacrum, to the hypo- gastrium, or to the upper, and especially to the inner portion of the thighs. The mammse sympathize so directly with the uterus, that prac- titioners have hoped, that by irritations applied to these glands, the uterus would sympathetically respond. Dry and moist heat, mustard plasters, blisters, and dry and wet cups, have been ap- plied to the breasts ; and stimulating liniments and plasters have been employed, but with very doubtful benefit. Any success attending this revulsive treatment in the re-esta- blishment of uterine action, will of course be equally efficient, where vicarious discharges have occurred from other organs. As the natural function returns, the local congestions and unna- tural discharges from other organs will probably disappear, at least they will demand no positive treatment. All direct attempts to check vicarious menstruation, from the nose, ears, stomach, rectum, etc., are exceedingly dangerous, as the irritation and con- gestion might be transferred to vital viscera, and with even fatal results. Should it unfortunately happen that the brain, heart, or lungs be the seat of congestion, with or without seroid or bloody effusions, the treatment should be chiefly revulsive. Powerful agents of this character may occasionally be demanded, and, if the congestion of the brain, heart, or lungs assumes a decided apoplectic character, general or local bleeding may be temporarily employed, as in cases of passive congestion, to relieve the oppressed viscera, while the bad eftects of such evacuations may be obviated by stimuli, tonics, nutritious diet, etc. Local Stimuli have had their advocates, and in the form of warm water or vapor directed to the cervix uteri, have already ■ been favorably mentioned as adjuvants. Stimulating washes, particularly the aqua ammonite, in the proportion of ten drops to the ounce of water or milk, have been recommended ; but the success has been but trifling. Injections LOCAL STIMULI. 517 of ammonia and also of the nitrate of silver have been thrown into the cavity of the uterus with reputed success ; but certainly this may be termed rash practice, as the presence of the instru- ment itself gives pain, which will be aggravated by the injection of even simple water, and much more, of such powerful or almost caustic stimuli. Irritations are excited which may QOt be con- fined to the uterus, but extend through the Fallopian tubes to the peritonaeum, with probably fatal results. Besides, these fluids may possibly at once pass through the Fallopian tubes, and thus directly excite peritonitis. Mechanical stimuli have not been neglected. The occasional pas- sage of bougies, or the metallic uterine sound or probe, has often been employed. More lately, in cases of amenorrhoea, the intra- uterine pessary has been recommended, as affording a permanent irritation. But few successful cases have been reported of these measures. Our own experience is, that they are altogether futile. We have frequently been called upon to pass the probe in cases of delayed menstruation ; and, even where dysmenorrhcea had pre- viously existed, there has not been any hastening of the menstrual discharge. We are now in attendance on a young lady who has come to our city, for relief, if possible, from a dysmenorrhcea of many years' duration. "We have passed the uterine sound once before, and twice since the time for the regular period — now delayed for two weeks — and jQt, excepting the pain of the opera- tion, and a slight reddish discharge for a few hours, she has no indication of her catamenia. On the contrary, she feels better than usual, and has not as yet had her usual premonitory symptoms. This result might, a priori^ have been anticipated by the phy- siologist and j)athologist. Such mechanical operations excite pain and contraction of the uterus, that is, " nervous or animal irrita- tion ;" hence, by condensation of the walls of the uterus, blood would be excluded, not invited to its vessels. The trifling san- guineous " show," from the disturbance of the delicate epithelium of the lining membrane, is no proof to the contrary. Hence bougies, as formerly mentioned, are occasionally useful, in chronic menorrhagia, and therefore would probably be inefficient in amenorrhoea. If a probe or an intra-uterine pessary be left in the uterus, the result is practically the same, but the cause entirely different. 518 TEEATMEXT OF SEDATIOX OF THE UTERUS. The continued irritation produces organic disturbance, it may be inflammation ; this is a state also opposed to menstruation, as Ave have already seen, metritis as well as ovaritis is a cause of araen- orrhoea. That bloody discharges are produced by intra-uterine pessaries, there can be no doubt ; but hemorrhages from the uterus are not the catamenia : they afford but partial relief; they are not the results of that peculiar inscrutable excitement of the uterus, of the ovaries, and of the nerves, necessary for the formation of a true menstrual evacuation, which relieves the system, depurates the blood, and is indicative of restored health, and of an aptitude for conception. That after the use of intra-uterine pessaries, the regular return may sometimes be observed is very probable ; but this ought, we think, to be regarded as an accident, as a mere sequence, not an effect. This possibility ought not to establish a principle or to sanction the use of a disagreeable, painful instru- ment, which is liable, as formerly mentioned, to very serious, if not fatal results. These observations are applicable, equallj^ if not more forcibly, to the employment of suction by an apparatus already mentioned, to the internal surface of the uterus. What effect ought reason- ably to be anticipated from the abstraction of a small quantity of blood mechanically from the internal surface of the uterus, either as a substitute for the important menstrual evacuation, or, as an irritant to that peculiar nervous excitement and active congestion of the uterus, ovaries, and all the pelvic and adjacent viscera re- quisite for the uterine function ? The mechanical injury from the passage of the intra-uterine probe in this instance will be aggra- vated by the suction power emplo}- ed on the delicate mucous membrane of the uterus, Emmenagogues are medicines which are reported to have a peculiar physiological influence on the uterus and its appendages, so as to excite them to perform the menstrual actions or function. Are there such remedies ? It is possible, but the experience of the profession, up to the present hour, renders it exceedingly doubtful. We have already characterized them as the "forlorn hope" of the scientific ph3^sician, who, finding all his science and experience inefficient, falls back on such supposed specifics, and continues his warfare with some lingering expectation of an even- tual victory. EMMEXAGOGUES. 519 In his choice of such measures, the practitioner must be guided by the knowledge of the actual state of his patient, as to her general system, and the pelvic viscera, by the known modus operandi of the articles suggested, and by the reputation which may have been accorded to them by good authorities. His prac- tice must be somewhat empirical or tentative, but still under the guidance of science. Many of the supposed specifics have already been noticed, under the head of tonics, diuretics, cathartics, and other revulsives, and the list could easily be extended. Many of them belong to the class of alteratives. Mercury, so universally useful as an alterati\ e, is perhaps as important in amenorrhoea, as any single remedy. Iodine has been also hailed as an emmenagogue, but has failed as such ; it ma^'", however, be advantageously employed, either by itself or in combination, in various states complicated with amenorrhoea. Senerja jjolygala has certainly no specific effect, although strongly recommended by the late Professor Chapman, whose practical acumen was almost unrivalled. The excellent authority of Dewees is pledged to the utility of guaiacum, especially the ammoniated tincture of the gum; but his successors cannot indorse it. "When useful, it acts, indeed, as a tonic stimulating diaphoretic, Sabina, as a powder, an oil, or an extract, has long been regarded as having a special influence on the uterus, and has been employed, out of the profession, with much reputed success, not merely as an emmenagogue, but as an excitant of the uterus to produce contraction during pregnancy. Nevertheless, professional confidence in its virtues is at present by no means great. Ilellehorus, in sufficient doses, will nauseate and purge, and this may facilitate uterine excretion ; but, in some cases, in our expe- rience as well as in that of other practitioners, it appears to have favored the return of the menses when no perceptible influence was exerted on the stomach or bowels. The Secale cornutum, or Urgot, has strangely • been added, by many, to the list of emmenagogues. Experience, however, has condemned it, and theory sanctions the sentence. Under peculiar circumstances, it has a wonderful or , specific ■ influence on the uterine nerves and muscles, in exciting painful contraction ; but 520 TREATMENT OF SEDATION OF THE UTERUS. the suggestion is very crude, that hence it is calculated to excite organic actions, congestion, and secretion. In the former case, as a peculiar stimulant to the uterine nerves, it produces, in the par- turient state, contraction of the muscular fibres, condensation of the substance of the uterus, and diminution therefore of the size of the bloodvessels, relieving congestion and arresting hemor- rhage ; and, in the unimpregnated condition, may arrest menor- rhagia and htemorrhagia of the uterus, in cases of laxity of its tissues. Of course, this is far from indicating any tendency to promote congestion or secretion from the womb, when they are deficient. Nux vomica and Faba St. Ignatii, with their various preparations, have been proposed as emmenagogues. As tonics, in small and repeated doses, they are very useful ; but in larger doses they are dangerous ; and, since they operate chiefly on the nervous and muscular systems, it is not probable that experience will confirm the suggestion, that they have specific influence on the organic actions of the uterus; at least, there is as yet no general testi- mony in their favor. Extract of the Chenopodium olidum has been lately recom- mended; the Lauro-cerasus, as a strong decoction, and, indeed, many other articles at present attract attention, some of which may possibly prove successful as adjuvants, under the direction of the enlightened physician. Matrimony has been recommended in amenorrhoea. The sexual excitements have doubtless the most direct influence on the deve- lopment of the ovaries and the uterus, and the establishment of their functions. They may give origin, as formerly mentioned, even to precocious menstruation; they thus confirm the argument as to a controlling, if not an original, influence of the nervous system over the functions of generation. The excitement, there- fore, of these feelings by marriage, and the additional specific stimulus of the semen masculinum, promote, in favorable cases, the catamenial function. Girls, thin, pallid, and with but few of the signs of womanhood at the time of marriage, often develop very rapidly after its consummation ; the nervous system and the organic life are equally excited, the blood becoming richer and nutrition more active, even when no conception has ensued. In such cases, partial or complete amenorrhoea often disappears, and hopes of maternity may be entertained. EMMENAGOGUES. 521 Nevertlieless, great caution sTiould be exercised by a physician in giving sanction to matrimony in cases of amenorrh(jea, there are so many ethical, and legal, as well as physical questions involved. His approbation should always be withheld, unless he is satisfied that there be no deficiency of the ovaries or uterus, no fixed organic disease, and no incurable mal-condition of the patient's general system or of any special organ. He should be convinced that it is a mere uncomplicated state of sedation of the uterine tissues. Electricity^ galvanism^ electro- galvanism., and electro-magnetism, have, in succession, been suggested as important therapeutical agents, in various forms of disease, especially in those dependent on the nervous system. Fashion has, unfortunately, had its influence in the scientific as well as in the gay world. After the discovery of galvanism, in 1786, and especially of the Voltaic pile, in 1800, great expectations were entertained of their thera- peutical effects, but these were found to be illusory. In 1825, these hopes were revived, by the suggestion of em- ploying them in conjunction with acupuncture, so that the course of the electric or galvanic influence could be accurately directed, or localized. This was also attempted by denuding two separate portions of the surface of the body, to each of which plates were affixed, connected with the opposite poles of a battery. Nume- rous as were the experiments made in this city, and elsewhere, with bright anticipations and reputed success, the practice soon fell into disuse. During the last few years, the hopes of the learned and the enthusiastic have been resuscitated, especially since the discovery, by Faraday, of "electricity by induction-currents," in 1831, and the suggestion, by Duchenne, that the physiological influences of direct electricity and that by induction are diff*erent. Dr. Du- chenne has ingeniously arranged an apparatus to localize the influence of this inductive electricity, and to direct it upon an organ or tissue involved. Some reports are very favorable, and great attention is now paid by regular and irregular practitioners to this subject, especially in the treatment of cerebro-spinal dis- eases, such as neuralgia, paralysis, etc. Analogous effects have been anticipated, perhaps too readily, as regards organic life, its actions and functions; but, as yet, there have been no decided 622 TKEATMENT OF SEDATION OF THE UTERUS. results. Inflammatory affections of the skin, and of tlie mucous membranes, have been induced by this agent, as well as an increased flow of saliva and other secretions ; but how far thera- peutical advantages may result in organic diseases, is very doubtful. As an emmenagogue, electricity has been recommended for very many years, but, almost universally, without decided suc- cess. It is now again brought prominently before the profession under the form of " Faradization," or " electricity by induction- currents," by means of Duchenne's and other apparatus, for locali- zation. The results are yet to be determined ; one practitioner, M. Becquerel, declaring, after repeated trials, that it uniformly failed. Another, Dr. Althaus, states, that in twenty-four cases of amenorrhoea, twenty were cured by this means. Another mode of employing galvanism, which ingenuity has suggested, is by the galvanic pessary. Upwards of twenty years ago, Dr. Rose, formerly a regular physician in this city, employed a vaginal flat disk pessary, with the upper or uterine surface made of silver, and the loAver of zinc, but probably with no suc- cess, as no favorable reports have been given of its influence. Dr. Simpson has suggested that his intra-uterine pessary, when constructed with the style or uterine portion of zinc, and the vaginal portion of copper, will be beneficial in amenorrhoea ; and cases are given by himself and others of success from their employment. The stem of this pessary is sometimes made of zinc one-half, and copper the remainder ; or, as Dr. Noeggeratli has advised, making two equal and parallel pieces of copper and zinc. Dr. T. Gaillard Thomas proposes, in order to give some elasticity to the stem, that it should be made of alternate beads of copper and zinc, strung on a copper wire, secured at each extremity. We have already noticed the dangers attending the use of these intra-uterine supports, in their mechanical effects on the tissues of the uterus ; and such influences will probably not be lessened by the decomposition of such metals as zinc and copper, under any galvanic process, which might be induced by the fluids of the uterus or vagina. The question also is in abey- ance whether the bloody discharge, which may result, is a pure hemorrhage from physical or galvanic excitement, or a proper menstrual excretion. GENERAL REMARKS. 523 We will venture the following general conclusions, and express a few cautions on the subject of Electricity in its various forms. First. No specific or peculiar virtues are to be expected from it as an Emmenagogue. It is a mere stimulus at best, and should be placed among the class of local stimuli. Second. Its effects on organic actions are trifling, uncertain, and very generally indirect, and of course not reliable. Third. In cases of neuralgia, spasms, paralysis, etc., it may sometimes prove advantageous, but merely in those instances where the general or local irritation has, spontaneously or by therapeutical means, been entirely relieved, and a simple stimu- lus is demanded. Fourth. Much science and judgment are required to regulate the proper direction of its influence, as well as the choice of the kind of electricity, direct or indirect, which the peculiarities of the case demand ; and, especially, it is necessary to control the intensity of the current. Not only spasms and convulsions have resulted from injudicious employment of electricity ; but, in sen- sitive women, the whole nervous system has remained morbidly irritable for many years after its application. GENERAL REMARKS. From the history of amenorrhoea, it is manifest that the patient should be constantly under the supervision of the practitioner. During the supposed intervals of the menstrual nisus, every effort must be made to rectify the system, and to relieve local diseases, so as to favor the developments and functions of the whole economy. When the return of the period is expected, the cir- culation must be determined to the pelvic viscera, as much as practicable, by equalizing the general excitement ; by promoting secretion from the cutaneous and mucous membranes, univer- sally ; by revulsive remedies, internal and external ; by direct stimuli to the uterus; and, sometimes, by the employment of medicines, supposed to act specifically on the uterine function. The scientific and judicious physician will know how to assist his hygienic by his medicinal measures ; how to combine laxa- tives, alteratives, tonics, stimuli, and specifics, so as to facilitate 52-4 TREATMENT OF SEDATION OF THE UTERUS. tlie establishment of tlie general health, and, secondarily, the de- velopment and secretions of all the organs of the economy. Dis- appointment must, however, often ensue, as the causes of amenor- rhoea are frequently irremovable ; but, in other cases, he may anticipate as much success as in the treatment of other functional diseases. INDEX. A. Abdominal operation for excision of uterine tumors, 4(j0 tumors, difficulty of diagnosis, 462 Abscess of uterus, 140 Amenorrlioea, description of, 491 diagnosis of, 509 prognosis of, 511 treatment of, 511 Amputation of cervix uteri, 450 Ansemia, definition of, 93 Anteflexion of the uterus, description of, 334 treatment of, 436 Anteversion of uterus, description of, 332 diagram of, 333 treatment of, 435 with flexion, 334 diagram of, 333 treatment of, 436 Aphonia, reflex influence of irritable uterus, 186 Asthenia, cause of amenorrlioea, 496 Axes of body and pelvis, diagram of, 316 B. Bandages, treatment of displacements of uterus, 377 Baths, treatment of irritable uterus, 267 Bladder, hernia of, 440, 442 irritable, 211 Bougies, treatment of dysmenorrhoea, 285 treatment of menorrhagia, 295 " Bow" pessary, 420 Broad ligaments of uterus, 322 " Butterfly pessary," 396 C. Case of a mother inclined to destroy her children, 178 of amenorrhcea from a fall, 502 of an overtaxed clergyman, 270 of anteflexion of the iiterus com* plicated with a tumor, 361 Case of atresia of the vagina with dig- jilacement of the uterus, 321 of bad temper due to uterine irri- tation, 177 of caries of the sacrum, 310 of convulsions from uterine irrita- tion, 183 of convulsions when a foot was lifted, yet the patient could move about the room, 272 of convulsive movement of tlie arm from uterine irritation, 182 of cystocele and rectocele existing together, 441 of diarrhoea, acting as a substitute for the catamenia, 203 complicating endometritis and irritable uterus, 203 from uterine irritation, 203 of dysmenorrhoea, uterine sound employed, menses delayed, 517 of dysuria from a retroverted ute- rus, 306 with a pulsatile pain, 212 of gangrenous chancre of the penis, 248 of hernia of the bladder, 442 of hysteria from a diseased knee- joint, 352 of hysteric convulsions which had been treated for inflammation of the brain, etc., 237 of imperforate hymen, 495 of irritability of the uterus after inflammation, 291 of irritable ovary, 468 of irritable rectum treated for fis- sure of the anus, 207 of irritable uterus, with great lan- guor and no pain, 171 of irritation of the anterior crural nerve, 222 of loss of amiability due to uterine irritation, 177 of membrane from the uterus, 125, 127 from the vagina, 125 of membranous dysmeuorrhosa, 126 526 INDEX. Case of nervous irritation relieved while inflammation still existed, 155 of ovarian dropsy, 479 of partial retroversion, 362 of peculiar cough, 185 of "phthisis incipiens" complicated by prolapsus of the uterus, 299 of precocity, being injurious, 257 of retention of urine in irritable bladder and urethra, 212 of retroflexed uterus continuing while a large fiat ring was in po- sition, 401 of retroversion of the uterus with peculiar sounds, 438 -r of retroversion treated for " spinal neuralgia," 347 — of rheumatism causing amenorrhoca, 500 of salivation in the treatment of irritable uterus, 247 of severe symptoms in a nervous temperament from a slight pro- lapsus, 229 of simulative apoplexy 176 of spasm of the pharynx, 183 of spectral illusions, 178 of successive pains in various parts of the body from pressure on the sacral nerves, 430 of torpor of the bowels in attacks of menorrhagia, 196 of tympanites from a prolapsus uteri, 195 of uterine tumor giving rise to symptoms of hepatitis, 173 of uterine tumors, 452 of vicarious menstruation, 203 Cases of abdominal tumors, difficulty of diagnosis in, 462, 463 of absence of the uterus, 494 of alleged ulcer in an irritable ute- rus due to retroversion, 136 during the seventh mouth of pregnancy, 135 of amenorrhcea mistaken for preg- nancy, 510, 511 of cough caused by pressure from a pessary, 186 of exhaustion upon speaking, 184 of intra-uteriue pessaries employed, 409 of irregular development of the glandular structure of the breast, 188 of irritable lymphatic glands, 219, 220 of irritable rectum with spasm, 207 of irritation of the bladder, 212 of irritation of the pelvic nerves, 309 of neuralgic pain relieved by pres- sure, 381 Cases of ovarian tumors, 218, 219, 469 of pain in the top of the head, etc., on removing a pessary, 430 of prostration from general bleed- ing in the treatment of irritable uterus, 246 of " utero-abdominal supporters'' worn for retroversion of the ute- rus, 381 Cauterization, treatment of irritable ute- rus, 248 Cellulitis, pelvic, 63 . Cephalalgia, symptom of irritable ute- rus, 174 Cerebral irritation, symptom of irritable uterus, 169 Cerebro-spinal irritations, symptoms of irritable uterus, 168 Cervico-metritis, 137 Cervix uteri, elongation of, 450 hypertrophy of, 137 strictures of, 138 ulcers of, 134 Chlorosis, 492 Climate, cause of irritable diseases, 228 Closed lever pessary, description of, 419 diagrams of, 415 introduction of, 425 removal of, 426 with the small curve before — in position, 421 with the small curve behind — in position, 421 Cold, cause of irritable diseases, 233 Colpeurynter, as a uterine elevator, 455 Complications of displacements of ute- rus, treatment of, 447 of irritable uterus, treatment of, 284 Congestion, active, 77 cause of irritable diseases, 230 definition of, 76 opinion of authors, 37 passive, 76, 485 symptom of irritable uterus, 113 of uterus, 37, 113 treatment of, 244 Congestive dysmenorrhoja, 122 Constipation, reflex influence of kritable uterus, 196 Corporeal endometritis, 139 hypertrophy, 140 metritis, 140 Coughs, reflex influence of irritable ute- rus, 185 Cystocele, 440 D. Dewees' pessary, 393 Diabetes serosa, reflex influence of irri- table uterus, 199 INDEX. 527 Diagram of anteversion of the uterus, 333 with flexion, 333 of axes of the body and pelvis, 316 of closed lever pessary, 415 with the small curve before — in position, 421 with the small curve behind — in position, 421 of flat ring — in position, 400 of interrupted ring pessary, 415 of introduction of open lever pes- sary, 423 of lever for the removal of globular pessaries, etc., 393 of modified intra-uteriue pessary — in position, 411 of natural position of the pelvic viscera, 317 of open lever pessary, 415 — in position, 416 of partial retroversion of the ute- rus, 335 with flexion, 337 of pelvic nerves, 315 of posterior view of the uterus and its ligaments, 322 of procidentia of the uterus, 338 of prolapsus of the uterus, 331 with flexion, 331 of removal of open lever pessary, 425 of retroversion of the uterus, 335 with flexion, 337 of side view of closed lever pessary, 415 of Simpson's intra-uterine pessary, modified, 415 of uterine sound or probe, 447 of varieties of open lever pessary, 415 of view of the uterus and its liga- ments in the direction of tlie axis of the superior strait. 323 Digital vaginal examinations, 112 Diseases, irritable, 69 neurotic, 71 of irritation, 67 of sedation, 481 Displacements of ovaries, diagnosis of, 464 treatment of, 478 of uterus, 313 causes, 339 diagnosis, 352 prognosis, 365 symptoms, 346 treatment of, 367 treatment of complications of, 447 of vagina, 440 Diuresis, reflex influence of irritable uterus, 199 Dropsy of the ovaries, 478 Dysmenorrhoea, congestive, 122 mechanical, 123 membranous, 126 pessaries in the treatment of, 287 symptom of irritable uterus, 109 treatment of, 284 E. Ectropion of os uteri, 137 Electricity, treatment of amenorrhoea, 521 Electro-galvanism, treatment of amenor- rhoea, 521 Electro-magnetism, treatment of amen- orrhoea, 521 " Emansio mensium," description of, 493 Emmenagogues, treatment of amenor- rhoea, 518 Endometritis, cervical, 133 corporeal, 139 pessaries in the treatment of, 297 symptoms of, 141 treatment of, 157, 297 Engorgement, definition of, 76 opinion of authors, 37 Enlargements of lymphatic glands, 477 of ovaries, diagnosis of, 464 symptoms of, 215 treatment of, 478 of uterus, treatment of, 449 Examinations, vaginal, 111 Excision of tumors of uterus, 456 Excitability, definition of, 69 Excitants, definition of, 69 Excitation, definition of, 69 Excitement, definition of, 69 Exercise and rest, treatment of irritable uterus, 270 Faradization, treatment of amenorrhona, 522 Fascia of the pelvis, 326 Flat ring in position, diagram of, 400 Flatulence, reflex influence of irritable uterus, 191 Flexion of uterus, 332, 334, 336 treatment of, 447 Fluor albus, symptom of irritable ute- rus, 118 Food, treatment of irritable uterus, 263 Galvanism, treatment of amenorrhosa, 521 528 IXDEX. Gastrotomy, treatment of ovarian tu- mors, 478 ti-eatmeut of uterine tumors, 460 Gout, cause of amenorrhoea, 499 cause of irritable diseases, 228 of uterus, treatment of, 253 H. Hsemorrhagia, symptom of irritable ute- rus, 117 Hard India-rubber, material for pessa- ries, 390 Hemorrhage, witli displacement of ute- rus, 448 Hernia of bladder, 440, 442 of rectum, 440 "Horse-slioe" pessary, 414 Hymen, imperforate, 495 Hypersestliesia of the skin, symptom of irritable uterus, 173 Hypertrophy corporeal, 51, 140 of the cervix, 137 of uterus, symptom of irritable ute- rus, 115 treatment of, 164, 250, 367, 449 opinion of authors, 51 Hysteralgia, meaning of, 101 Hysteria, meaning of, 168 Hysterotome, treatment of dysmenor- rhoea, 285 treatment of tumors of uterus, 457 I. Induration of uterus, treatment of, 251 Inflammation, cause of irritable diseases, 230 followed by irritability, 151 of ovaries, 61 of uterus, 57, 130 treatment of, 156, 244, 296 Interrupted ring pessary, diagram of, 415 Intestines, relation to uterus, 327 lutra-uterine pessaries, 402 treatment of amenorrha3a, 517, 522 treatment of dysmenorrhoea, 285 Introduction of open lever pessary, dia- gram of, 423 Iodine injections, treatment of ovarian dropsy, 479 Irritability, after inflammation, 151 deflnition of, 69 modifications of, 70 opinion of authors, 34 Irritable bladder and urethra, symptoms of, 211 treatment of, 304 diseases, 69 Irritable diseases, causes of, 225 diagnosis of, 240 pathology of, 225, 238 prognosis of, 241 lymphatic glands, treatment of, 309, 477 rectum, symptoms of, 206 treatment of, 301 uterus, definition of, 99 general symptoms of, 167 local symptoms of. 105 progress and results of, 205 treatment of, 243 vulva and vagina, symptoms of, 208 treatment of, 302 Irritants, definition of, 69 Irritation and enlargements of ovaries, symptoms of, 215 cerebral, 169 cerebro-spinal, 168 definition of, 69 diseases of, 67 nervous, 75, 81 of lymphatic glands, symptoms of, 219 of pelvic nerves, symptoms of, 221 treatment of, 309 organic, 75 spinal, 168 K. Kidneys, reflex influences of irritable uterus, 199 L. Lactation, cause of irritable diseases, 232 Leucorrhoea, opinion of authors, 47 pessaries in the treatment of, 296, 448 symptom of irritable uterus, 118 treatment of, 295 •with displacements of uterus, treat- ment of, 448 Levatores ani muscles, 326 Lever for removal of globular and other pessaries, diagram of, 393 pessaries, closed, 419 description of, 413 diagrams of, 415 open, 414 Ligaments of uterus, 321 Local symptoms of irritable uterus, 105 Lymphatic glands, irritations of, 219 treatment of enlargements of, 477 INDEX. 529 M. Material of pessaries, 387 Mechanical dysmenorrhoea, 123 Meigs' spring ring pessary, 401 Membranous dysmenorrhoea, 126 Menorrhagia, opinion of authors, 42 pessaries in the treatment of, 290, 448 symptom of irritable uterus, 117 treatment of, 289 with displacements of uterus, treat- ment of, 448 Menstrual disturbances, treatment of, 284 Menstruation, tardy, 509 Mental excitements, cause of irritable diseases, 233 Metritis, 130 cervical, 137 corporeal, 140 opinion of authors, 57 treatment of, 15(j Modification of Simpson's intra-uterine pessary, diagram of, 415 Modified intra-uterine pessary in posi- tion, diagram of, 411 Moral excitements, cause of irritable diseases, 233 Muscular effort, cause of irritable dis- ease, 234 N. Natural position of pelvic viscera, dia- gram of, 317 Nerves of pelvis, 314 Nervous irritation, 75, 81 consequences of, 67 Nervous, definition of, 71 sedation, 482 temperament, cause of irritable dis- eases, 226 Neuralgia, definition of, 84, 101 Neurotic diseases, definition of, 71 " Nimia Venus," cause of irritable dis- eases, 233 0. Obliquity of pelvis, 328 Open lever pessary, description of, 414 diagrams of, 415 in position, diagram of, 416 introduction of, 423 removal of, 424 Operations on vagina, treatment of dis- placements of uterus, 375 Organic irritation, 75 sedation, 482 Os uteri, ectropion of, 137 34 Ovarian dropsy, treatment of, 478 tumors, cases of, 469 diagnosis of, 464 treatment of, 292, 308, 478 Ovaries, diagnosis of enlargements and displacements of, 464 enlargements of, 215 inflammation of, 61 irritations of, 215 treatment of enlargements and dis- placements of, 478 tumors of, 464 Ovariotomy, treatment of dropsy of the ovaries, 478 treatment of ovarian tumors, 478 Ovaritis, opinion of authors, 61 "Packing system," treatment of irritable uterus, 269 Pain and distressing sensations, symp- toms of irritable uterus, 105 Palpitations of heart, reflex influence of irritable uterus, 187 Partial retroversion, with flexion, dia- gram of, 337 Parturient state, cause of irritable dis- eases, 228 Parturition, cause of irritable diseases, 232 Passive congestion, 76 consequence of sedation, 485 Pathology of irritable diseases, 225, 238 Pelvic cellulitis, 63 fascia 326 nerves, 314 diagram of, 315 irritations of, 221 peritonitis, 147 Peritonitis, pelvic, 147 peri -uterine, 147 Peri-uterine peritonitis, 147 Pessaries, air, 397 "bow," 420 concavo-convex, 393 forms of, 390 globular, 391 "horse-shoe," 414 lever, 413 material of, 387 objections to, 385 plano-convex, 395 ring, 397 "S,"420 stem, 401 treatment of displacements of uterus, 384 treatment of dysmenorrhoea, 287 treatment of hypertrophy of uterus, 449 580 INDEX. Pessaries, treatment of inflammation of uterus, 158, 297 treatment of leueorrhoea, 296, 448 treatment of menorrhagia, 290, 448 treatment of sterility, 288 treatment of uterine tumors, 454 "U," 414 value of, 384 Physometra, 192 Polypus causing hypertrophy of uterns, treatment of, 449 Pregnancy, diagnosis from amenorrhcea, 509 Pressure, cause of irritable diseases, 235 Probe, uterine, 447 Procidentia of uterus, 338 diagram of, 338 treatment of, 439 Prognosis of displacements of uterus, 365 of irritable diseases, 241 Progress and results of irritable uterus, 205 Prolapsus of uterus, 330 diagram of, 331 treatment of, 435 with flexion, 332 diagram of, 331 R. Rectocele, 440 Rectum, hernia of, 440 irritable, 206 Reflex influences of cerebral and spinal irritations, 180 Removal of open lever pessary, 424 Retroflexion of uterus, 336 treatment of, 437 Retroversion of uterus, 334 diagram of, 335 treatment of, 437 with flexion, 336 diagram of, 337 Rheumatism, cause of amenorrhcea, 499 cause of irritable diseases, 228 of the uterus, treatment of, 253 Round ligaments of uterus, 322 " S" pessary, 420 Sedation and its consequences, 481 definition of, 69 diseases of, 481 of the uterus, description of, 491 treatment of, 487 Simple dysmenorrhoea, 109 Simpson's intra-uterine pessary, 402 modified, diagram of, 415 modification of, 410 Sims' uterine elevator, 370 Small intestines, relation to uterus, 327 Small lever, diagram of, 393 Sound, uterine, 447 Spinal irritations, symptoms of irritable uterus, 168 Speculum examinations, 113 Sterility, pessaries in the treatment of, 288 Strictures of cervix uteri, 138 cause of irritable diseases, 236 Supports of uterus, 319 " Suppressio mensium," 498 Symptoms of displacements of uterus, 346 of irritable uterus, local, 105 general, 167 Temperament, nervous, 226 Toxicsemia, definition of, 95 Treatment of complications of displace- ments of uterus, 447 of displacements of uterus, 367 of enlargements and displacements of ovaries, 478 of irritable uterus, 243 of sedation, 487 of tumors of uterus, 451 Tumors of ovaries, cases of, 469 diagnosis of, 464 treatment of, 292, 308, 478 of uterus, causes of displacements, 343 excision of, 456 pessaries in the treatment of, 454 treatment of, 292, 451 Tympanites, reflex influence of irritable uterus, 191 U, " U" pessary, 414 Ulcers of cervix uteri, 134 Urethra, irritable, 211 Uterine probe or sound, diagram of, 447 tumors, treatment of, 292, 451 Utero-sacral ligaments, 324 Utero-vesical ligaments, 324 Uterus, absence of, 494 abscess of, 140 and its ligaments (posterior view), diagram of, 322 (view from above), diagram of, 323 anteversion of, 332 congestion of, 37, 113 flexion of, 332, 334, 336 INDEX. 531 Uterus, hypertrophy of, 51, 115, 140 inflammation of, 57, 130 irritability of, 34, 99 irritable, 99 ligaments of, 321 prolapsus of, 330 position of, 314 procidentia of uterus, 338 retroversion of, 334 supports of, 319 treatment of tumors of, 292, 451 V. Vagina, direction of, 318 displacements, 440 irritable, 208 Vagina, operations upon, 375 support of uterus, 320 Vaginal examinations. 111 diagnosis of displacements of uterus, 356 operations for excision of uterine tumors, 456 Vaginismus, symptoms of, 208 treatment of, 302 Venesection, treatment of irritable ute- rus, 275 Vulcanite, material for pessaries, 390 Vulva, irritable, 208 Z. Zwancke's pessary, 396 HENRY C. LEA'S SON & CO.'S (late henry c. lea) OF MEDICAL AND SURGICAL PUBLICATIONS. In asking the attention of the profession to the -works advertised in the following pages, the publishers would state that no pains are spared to secure a continuance of the confidence earned for the publications of the house by their carci'ul selection and accuracy and finish of execution. 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We quite agree with the critic, that this i Journal of the Medical Sciences, a periodical of journal is second to none in the language, and cheer- 1 world-wide reputation; the ablest and one of the I'ullv accord to it the first place, for nowhere shall oldest periodicals in the world — a journal which has we iind more able and more impartial criticism, and 1 an unsullied record. — Gross's History of American nowhere such a repertory of able original articles. \ Med. Literature, 1S76. Indeed, now that the "British and Foreign Medico- rpj^g bestmedical journal everpuhlished in Europe Chirurgical Review has terminated its career, the ^j America.— Ka. Mtd. Monthly, May, 1879. American Journal stands without a rival. — London \ ,^. . ,, , , .i_"j i.%l_iv. Med. Times and Gazette, Nov. 24, 1877 The best medical journal on the continent. — Bos- ton Med. and Surg. Journal, April, 1879. The present number of the American Journal is an exceedingly good one, and gives every promise of maintaining the well-earned reputation of the review. Our venerable contemporary has our best wishes, and we can only express the hope that it may continue its work with as much vigor and ex- cellence for the next fifty years as it has exhibited in the past.— iondow Lancet, Nov. 24, 1877. It is universally acknowledged to be the leading American medical journal, and, in our opinion, is second to none in the language. — Boston Med. and Surg. Journal, Oct. 1877. This is the medical Journal of our country to which the American physician abroad will point with the greatest satisfaction, as reflecting the state of medi- cal culture in his country. For a great many years it has been the medium throuj-'h which our ablest writers have made known their discoveries and observations.— .4drfr#s.9 of L. P. YntidM, M.D., be- fore International Med. Congress, Sept. 1876. And that it was specifically included in the award of a medal of merit to the Pub- lishers in the Vienna Exliibition in 1873. The subscription price of the "American Journal of the Medical Sciences" has never been raised during its long career. It is still Five Dollars per annum 5 and when paid for in advance, the subscriber receives in addition the "Medical News and Abstract," making In all nearly 2000 large octavo pages per annum, free of postage. THE MEDICAL NEWS AND ABSTRACT. Thirty-seven years ago the "Medical News" was commenced as a monthly to convey to the subscribers of the "American Journal" the clinical instruction and * C(linmnaicationB are invited from gentlemen in all parts of the country. Elaborate articles inserted l»y the\Er. Richard J. Dunjiilison, having assisted his father in the revision of several edition.s of the work, and having been, therefore, trained in the methods and imbued with the spirit of the book, has been able to edit it, not In the patchwork manner .so dear to the heart of book editors, so repulsive to the taste of intel- ligent book readers, but to edit it as a work of the kind should be edited — to carry it on steadily, without jar or interruption, along the grooves of thought it has travelled during its lifetime. To show the magnitude of the task which Dr. Dunglison has assumed and car- ried throui;h,it is only nece.ssary to state that more than six thousand new subjects have been added in the present edition. — Flnla. Med. Times, Jan. 3, 18T4. About the first book purchased by the medical stu- dent is the Medical Dictionary. The lexicon explana- tory of technical terms is simply a sine qua non. In a science so e.^: tensive, and with such collaterals as medi cine, it is a.'* much a necessity also to the practising physician. To meet the wants of students and most physicians, the dictionary must be condensed while comprehensive, and practical while perspicacious. It was because Uunglison's met these indications that it became at once the dictionary of general use wherever medicine was studied in the English language. In no former revision have thealterations and additions been 80 great. Mjre than six thousand new subjects and terms have been added. The chief terms have been set in black letter, while the derivatives follow in small caps; an arrangement which greatly facilitates reference. We may safely confirm the hope ventured by the editor " that the work, which possesses for him a filial as well IS an individual interest, t»ill be found worthy a con- tinuance of the po.sition so long ac(;orded to it as a standard authority ."^ — Oincinnau Clinic. Jan. 10, 1874. It has the rare merit that it certainly has n* rival in the English language for accuracy and extent of references. — London Medical Onzette As a standard work of reference, as one of the best, if not the very best, medical dictionary in the Eng- lish language, Dunglison's work has been well known for about forty years, and needs no words of praise on our part to recommend it to the meniliers of the medical, and, likewise, of the pharmaceutical pro fe.ssiou. The latter especially are in need of such a work, which gives ready and reliable information ou thousands of subjects and terms which they are liable to encounter in pursuing their daily avoca- tions, but with which they cannot be expected to be familiar. The work before us fully supplies this want. — Am. Journ. of Pharm., Feb. 1S74. A valuable dictionary of the terms employed in medicine and the allied sciences, and of the rela- tions of the subjects treated under each head. It re- Uectg great credit on its able American author, and well deserves the authority and popularity it has obtained.— JSnVuvA Med. Journ., Oct. M, 1S74. Few works of this class exhibit a grander monu- ment of patient research and of scientific lore. The extent of the sale of this lexicon is sufficient to tes- tify to its use'nluess, and to the greai service con- ferred by Dr. Kobley Dunglison ou the profession, and indeed on others, by its issue. — London Ldna-t , May 13, 1K75. fJOBLYN [RICHARD D.), M.D. ^A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE collateral SCIENCES. Revised, with numerous additions, by Lsaac Hays, M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 12mo. volume of over 500 double-columned pages ; cloth, $1 60; leather, $2 00 It is thii best bodk of definitions we have, and ought always to be upon the student's l&hle.— Southern Med. and Surg. Journal. pODWELL [G. F.), F.R.A.S., §t. A DICTIONARY OF SCIENCE: Comprising Astronomy, Chem- istry, Dynamics, Electricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, Mechanics, Meteorology, Pneumatics, Sound, and Statics. Preceded by an Essay on the History of the Physical Sciences. In one handsome octavo volume of 694 pages, and many illustrations : cloth, $6. Henky C. Lea's Son & Co.'s Publications — {3Ianuals). 5 A CENTURY OF AMERICAN MEDICINE, ril6-lS16. By Doctors E. H. -^^ Clarke, H. J. Bigelow, S. D. Gross, T. G. Thomas, and J. S. Billings. Inone very hand- some 12mo. volume of about 350 pages : cloth, $2 26. (Lately Issued.) This work appeared in the pages of the American Journal of the Medical iSciencesduring the year 1876. As a detaileti account of the development of medical science in America, by gentle- men of the highest authority in their respective departments, the profession will no doubt wel come it in a form adapted for preservation and reference. l^EILL {JOHN), M.D., and OMITH {FRANCIS G.), M.D., Prof, of the Institutes of Medicine inthe Univ. of Penna AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12m(). volume, of about one thousand pages, with 374 wood-cuts, cloth, $4 ; strongly bound in leather, with raised bands, $4 75. TJARTSHORNE {HENRY), M.D., Professor of Hygiene in the University of Pennsylvania. A CONSPECTUS OF THE MEDICAL SCIENCES; containing Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one large royal 12mo. volume of more than 1000 closely printed pages, with 477 illustrations on wood. Cloth, $4 25 ; leather, $5 00. {Lately Issued.) We can say with the strictest truth (hat it is the best work of the kind with which wf art acquainted. It embodies ina condensed form ail recent coutribu- tions to practical medicine, and is therefore useful to every busy practitioner throughout our country, besides being admirably adapted to the use of stu- dents of medicine. The book is faithfully and ably executed.— C'/taWe.ston Med. Journ., April, 187.5. The work is Intended as an aid to the medical stulent, and as such appears to admirably fulfil its object by itsexcellent arrangement, the full compi- lation of facts, the perspicuity aud terseues.s of lan- guage, and the clear and instructive illustrations in some parts of the work. — American Journ. of Phai'macy , Philadelphia, July, 187-t. The volume will be found useful, not only to stu- dents, but to many otherswhomay desire torefresh their memories with the smallest possible expendi- ture of time. — N. Y. Med. Journal, Sept. 1874. The student will find this the most convenient and useful book of the kind on which he can lay his hand. — Pacific Med. and Surg. Journ., Aug. 1874. This is the best book of its kind that we have ever examined. It is an honest, accurate, and concise compend of medical sciences, as fairly as possible representing their present condition. The changes and the additions have been so judicious and tho- rough as to render it, so far as it goes, entirely trust- worthy. If students must have a conspectus, they will be wise to procure that of Dr. Hartshorne.— Detroit Rev. of Med. and Pharm., Aug. 1874. The work before us, however, has many redeem- ing features not possessed by others, and is the best wehaveseen. Dr. Hartshorne exhibits much skill in condensation. It is well adapted to the physician in active practice, who can give but limited time to the familiarizing of himself with the important changes which have been made since he attended lectures. The manual of physiology has also been improved and gives the most comprehensive view of the latest advances in the science po.ssible in the space devoted to the subject. The mechanical es'Bcution of the book leaves nothing to be wished for. — Peninsular Journal of Medicine, Sept. 1874. After carefully looking through this conspectus, we are constrained to say that it is the most com- plete work, especially in its illustrations, of its kind that we have seen. — Cincinnati Lancet, Sept. 1874. The favor with which the first edition of this Compendium was received, was an evidence of its various excellences. The present edition bears evi- dence of a careful and thorough revision. Dr. Harts- horne possesses a liappy faculty of seizing upon the salient points of each subject, and of presenting them in a concise and yet perspicuous manner. — Leaven- worth Med. Herald, Oct. 1.S74 r UDLOW {J.L.), M.D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended and enhirged. With 370 illustrations. In one handsome royal 12mo. volume of 816 large pages, cloth, $3 25 ; leather, $3 75. The arrangement of this volume in the form of question and answer renders it especially suit- able for the office examination of students, and for those preparing for graduation. rPANNER {THOMAS HA WKES), M.D., 8fc. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- NOSIS. Third American from the Second London Edition. Revised and Enlarged by Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, as seemed neces- sary to the completeness of the work. Tables of weights and measures, and a good alphabetical in- dex end the volume. — Drugyists' Circular and Chemical Gazette, June, 1S79. It is a pleasure to think that the rapidity with which a second edition is demanded may be taken as an indication that the sen.se of appreciation of the value of reliable information regarding the use of remedies!^ notentirelj overwhelmed in the cultiva- tion of pathological ."tudies, cliarac I eristic of the pre- sent day. This work certainly merits the success it has so quickly achieved. — New Remedies, July, '79. The appearance of a new edition of this conve- nient and handy book in less than two years may certainly be taken as an indication of its nsefnl ness. Its convenient arrangement, and its terse- ness, and, at the same time, comoleteness of the information given, make it a handy book of refer- ence. — Am. Journ. of Pharmaty, June, 1879. This work contains in moderate compass such well-digested fact? concerning the physiologiral and therapeutical action of remedies as are reason- ably established up to the present time. By a con- venient arrangement the corresponding effects of each article in health and disease are presented in parallel columns, not only rendering reference easier, but also impressing the facts more strongly upon the mind of the reader. The book has been adapted to the wants of the American student, and (^TILLE {ALFRED), M.D., Professor of Theory and Practice of Medicine in the University of Penna . THERAPEUTICS AND MATERIA MEDICA ; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Fourth edition, revised and enlarged. In two large and handsome 8vo . vols, of about 2000 pages. Cloth, $10; leather, $12; half Russia, $13. (Lately Issued.) It is unnecessary to do much more than to an- nounce the appearance of the fourth edition of this well known and exc«llent work. — Brit, and For. Med.-Chir. Review, Oct 187.5. For all who desire a complete work on therapeutics and materia medicafor reference, iu ca.se^iuvulving medico-legal questions, as well as for information concerning remedial agents, Dr. Still6"s is "par ex- cellence'' the work. The work being out of print, by the exhaustion of former editions, the author has laid the profe.-^sion under renewed obligations, by the careful revision, Important additions, nnd timely re issuing a work not exactly supplemented by any other in the English language, if in any language. The mechanical execution handsomely sustains the well-known skill and good taste of the publi.sher. — St. Louis Med. and Surg. Journal, Dec 1874. From the publication of the first edition "Stmt's Therapeutics" has been one of the classics; its ab- sence from our librariex would create a vacuum which could be filled by no other work in the lan- guage, and its presence supplies, in the two volumes of the present edition, a whole cyclopsedia of thera- peutics. — Chicago Medical Joxci-nal, Feb. 1S75. The rapid exhaustion ofthree editions and the uni- ver-sal favor with which the work has been received by the medical profession, are sufiicient proof of its excellence as a repertory of practical and useful in- formation for the physician. The edition before ue fully sustains this verdict, as the work has been care- fully revised and in some portions rewritten, brrng- ing it up to the present time by the admission of chloral and croton-chloral, nitrite of amyl, bichlo- ride of methylene, methylic ether, lithium com- pounds, gelsemiuum, and other remedies. — Am. Journ. of Pharmacy, Feb. 1S75. We can hardly admit that it has a rival in the multitade of its citiitinns and the fulness of its re- search into clinical histories, and we must assign it a )>lace in the physician's library; not, indeed, as fully representing the present siate of knowledge in pharmacodynamics, but as by far the most complete treatise upon the clinical and practical side of the question. — Boston Med. and. Surg. Journal, Nov. 5, 1874. /GRIFFITH {ROBERT E.), M.D. A UNIVERSAL FORMULARY, Containing the Methods ofPrepar- ing and Administering Officinal and other Medicines. The whole adapted to Phy&iciars and Pharmaceutists. Third edition, thoroughly revised, with numerous additions, b) John M. Maisch, Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large andhandsome octavovolumeof aboutSOOpp., cl., $450; leather, $5 50. {Lately Issued.) To the druggist a good formulary is simply indis- pensable, and perhaps no formulary has been more extensively used than the well-known work before as. Many physicians have toofllciate, also, as drug- gists. This is true especially of the country pliysi« cian, and a work which shall teach him the inenn.'^ by which to administer or combine hi>* remedies in the most efficacious and pleasant manner, will al- ways hold its place upon his shelf A formulary of this kind is of benefit also to the city physician in largest practice.— Oinefnnnrti Olinic, Feb. 21. 1874. A more complete formulary than it is in its pres- ent form the pharmacist or physician could hardfy desire. To the first some such work is indispeni-a- ble, and it is hardly les.s essential to the [iractilioner who compounds his own medicines. Much of what is contained in the introduction ought to be com- mitted to memory by every student of medicine. As a help to physicians it will be found invaluable, and doubtless will make its way into libraries not already supplied with a standard work of the kind. — The American Practitioner, Louisville, July, '74. CHKISTISON'S DISPENSATORY. With copions ad- ditions, and '213 large wood engravings By R. EoLERFiRiD Griffith, M.D. One vol. 8vo., pp. 1000, cloth. $4 00. CARPENTER'S PRIZE ESSAY ON THE USE OF Alcoholic Liquors in Health and Disease. New edition, with a Preface by D. F. Condib. M.D.,and explanationsof scientiflcwords. In oneneat]2mo. volume, pp. 178, cloth. 60 cents. Henry C. Lea's Son & Co.'s Publications — {Mat. Med.and Therap.). 13 liJTILLE {ALFRED), 31. D., LL.D., and JlfAISCH (JOHN M.). Ph.D., A3 Prof of Theory and Praotic of Medicine J-f-L Prof, of Mat. Med. and Bot. in Phila and of Clinical Med. in Univ. of Pa. Coll. Phnrmricy. Si-cy to the American Pharmaceutica I Ax-^ocialion. THE NATIONAL DISPENSATORY: Containitifr the Natural History, Chemistry, Pharmacy, Actions and Uses of Medicines, including those recoofnized in the Pharmacopoeias of the United States, Great Britain, and Germany, with numer- ous references to the French Codex. Second edition, thoroughly revised, with numerous additions. In one very handsome octavo volume of 1692 pastes, with 2.39 illustrations. E.Klra cloth, $6 75; leather, raised bands, $7 50; half Russia, raised bands and open back, $8 25. {Now Ready ) Preface to the Second Edition. The demand which has exhausted in a few months an unusually large edition of the National Dispensatory is doubly gratifying to the nuthors, as showing that they were correct in th'nking that the want of such a work was felt by the medical and pharmaceutical professions, and that their efforts to supply that want have been acceptable. This appreciation of their labors has stimulated them in the revision to render the volume more worthy of the very marked favor with which it has been received. The first edition of a work of vueh magnitude mu«t necessarily be more or less imperfect ; and thouijh but litt'e that is new and important has been brought to light in the short interval since its publication, yet the length of time during which it was passing through the press rendered the earlier portions more in arrears than the la'er. The opportunity for a revision has enabled thp authors to scrutinize the work as a whole, and to introduce alterations .-ind additions whereve • there has seemed to be occasion for improve- ment or greater completeness. The principal changes to be noted are the introduction of seve- ral drugs under separate headings, and of a large number of drugs, chemioaJs, and pharma- ceutical preparations classified as allied drugs and preparations under the heading of more important or better known articles : these additions comprise in part nearly the entire German Pharmacopoeia and numerous articles from the French Codex. All new investigations which came to the authors' notice up to the time of publication have received due coosideration. The series of illustrations has undergone a corresponding thorough revision. A number have been added, and still more have been substituted for such as were deemed less satisfactory. The new matter embraced in the text is equal to nearly one h mdred pages of the first edition. Considerable as are these changes as a whole, they have been accommodated by an enlargement of the page without increasing unduly the size of the volume. While numerous additions have been ma(?e to the sections which relate to the physiological action of medicines and their use in the treatment of dista^e, great care has been taktn to make them as concise as was possible without rendering them incomplete or obscure. The doses have been expressed in the terms both of troy weight and of the metrical system, for the purpose of mak'ng those who employ the Dispensatory familiar with the latter, and paving the way for its introduction into general use. The Therapeutical Index has been extended by about 2250 new references, making the total number in the present edition ab ut 6000. The articles there enumerated as remedies for particular diseases are not only those which, in the authors' opinion, are curative, or even beneficial, but those also which have at any time been employed on the ground of popular belief or professional authority. It is often of as much consequence to be acquainted with the worthlessness of certain medicines or with the narrow limits of their power, as to know the we'l attested virtues of others and the conditions under which they are displayed. An additional value posse'sed by such an Index is, that it contains the elements of a natural classification of medicines, founded upon an analysis of the results of experience, which is the only safe guide in the treatment of disease. This evidence of success, seldom paralleled, ! intend to let the giass grow uader tbeir feet, but to shows clearly how well the authors have met the existing needs of the pharmaceutical and medical professions. Gratifying as it must be to them, they have embraced the opportunity offered for a thor- ough levision of the whole work, striving to em- brace within ir all that might have been omitted in the former edition, and all that has newly appeared of sufBcient importance during the time of its col- laboration, and the short interval elapsed since the previous publication. After hiving gone carefully through the volume we must admit that the authors have labored faithfully, and with success, in main- taining the high character of their work as a com- pendium meeting the requirements of the day, to which one can safely turn in quest of the latest in- formation concerning everything worthy of notice in connection with Pharmacy, JIateria Medica, and Therapeutics. — Am. Jour, of Pharmacy, Nov. 1879. It is with great pleasure that we announce to onr readers the appearance of a .second edition of the National Dispensaiory. The total exhaustion of the first edition in the short space of six months, is a sufficient testimony to the value placed upon the work by the profession. It appears that the rapid sale of the first edition must have induced both the editors and the publisher to make preparations for a new edition immediately after the first had been Issued, for we find a large amount of new matter added and a good deal of the previous text altered and improved, which proves that the authors do not keep the work up to the time. — New Remedies, Nov. 1879. This is a gr^at work by two of the ablest writers on materia medica in Amerira The authors lisve pro- duced a work which, for accuracy and comprehen.sive- ness, is unsurpassed by any work on th-^ s ibject. There is no book in the English language which contains so much valuable information ou the various articles of the materia medica. The work has cost the authors ye irs of laborious study, but they have succeeded in producing a dispensatory which is not only natimial, hut will be a lastinp; memorial of the learning and ability of the authors who produced it. — Edinburyh Medical Journal, Nov. 1879. It is by far more international or universal than any other book of the kind in onr languag?, and more comprehensive in every sense. — Pacific Med. and Stirg. J own., Oct. 1879. The National Dispensatory is beyond dispute the very best authority. It is throughout complete in all the necessary details, clear and lucid in its ex- planations, and replete with references to the most recent writings, where further particulars can be obtained, if desired. Its value is greatly enhanced by the extensive indices — a general in ex of materia medica, etc., and also an index of theiajientics It would be a work of supererogation to say uior^ about this well-known work. No practising physician can afford to be without the National Dispen-atory. — Canada Med. and Surg. Journ.. Feb isan 14 Henry C. Lea's Son & Co.'s Publications — (Pathologt/, &c.). flORNIL (F.). ^ Frnf. in the Fa pANVIER [L.]. -*•*' Prof in the College of fS-ance. AND nf. in the Faculty of Med , Paris. MANUAL OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by E. 0. Shakespeare, M.D., Pnthologist and Ophthalmic Surgeon to Philada. Hospital, Lecturer on Refr?ction and Operative Ophthalmic Surgery in Univ. of Penna., and by Hekrv C. Simes, M D., Demonstratrr of Pathological Histology in the Univ. of Pa. In one very handsome octavo volume of over 700 pages, with over 350 illustrations. Cloth, $5 50; leather, $6 50; half Russia, $7. {Just Ready.) The work of Cornil and Ranvier is so well known as a lucid and accurate te.\t-book on its important subject, *hat no apology is needed in presenting a translation of it to the American profession. It is only necessary to say that the labors of Drs. Shakespeare and Simes have been by no means confined to the task of rendering the work into English. As it appeared in Prance, in successive po'"tions, between 1868 and 1876, a part of it, at least, was soniewhit in arrears of the present state of science, while the dilfuseness of other portions rendered conden- sation desirable. The translators have, therefore, sought to bring the work up to the day, and, at the same time, to reduce it in size, aj far as practicable, without inrairing its com- pleteneps These changes will be found throughout the volume, the most extensive being in the sections devoted to Sarcoma, Carcinoma, Tuberculosis, the Bloodvessels, the Mnmmae, and the classification of tutr.ors Corresponding modifications have been made in the very exten sive and beautiful series of illustrations, and every care has been taken in the typographical execution to render it one of the most attractive volumes which have issued from the American press. The translators have done their work very well j with unusual interest. The illustrations are by no indeed, rendering it into smooth and excellent Eng- | means the lea.st valuable part of the work. Indis- lish, and in their selection of new material they j peu.sable as they are to any work of this nature, have in the main used good discrimination. We heartily commend the book as one of the best works on the subject. — Boston Med. and Surg. Journal, March 11, ISSO. Their book is not a collection of the work of others, but has been written in the laboratory beside the microscope. It bears the niovks > f personal knowl- edge and investigitiou upon every puge, controlled by and controlling the work of others. ... In short, its tr,\nsIatiou has made it the best work in pathology attainable in our langnage, one that every student, certainly, ought to have. — Archives of Med- icine, April, 1860. This work, in the original, has for years past ocenpied a prominent place in the library of French | by the authors them.selves in their own laboratories pathologists, as we should naturally be led to be- j assisted by their pupils. As an aid to microscopists lieve from the reputation of the distinguished au- j in iheir investigations it will be found invaluable — thors. Now that it has been presented to the Eng- i^n fact, the very best with which we are acquainted, lish student for the first time, it will be perused ' — Cincinnati Med. iV«M*, February, 18S0. in the work before us the artist has sncceeiled in producing cuts which will prove unusually valuable to the reader. The translation is well done, and gives evidence throughout the volnme that it was made by a person thoroughly conversant with the subject.— ivr. r. Med. Gazette, Feb. 2S, 1880, This will be found an exceedingly interesting and valuable work by all who are engaged in the study of. or take an interest in, histology — normal or morbid. The material which was utilized in its preparation was del ived from autopsies and opera- tions in the hospitals of Paris, which are so very rich in it. Nothing was taken for granted, but everything verified by microscopical investigation F G 'EN WICK (SAMUEL), M.D., A.isistnnt Phy.'dcian ta the London Hoxpitah THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the Third Revised and Enlarged English Edition. With eighty-four illustrations on wood. In one very handsome volume, royal 12mo., cloth, $2 25. {Just Issued.) RE EN [T. HENRY), M.D., Lecturer on Pn.tholngy and Morbid Anatomy at Oharing-Cross Hospital Medical School, etc. PATHOLOGY AND MORBID ANATOMY. Third American, from the Fourth and Enlarged and Revised English Edition. In one very handsome octavo volume of 332 pages, with 132 illustrations; cloth, $2 25. {Now Ready.) ciently numerous, and usually well made. In the p-esent edition, such new matter has been added as WHS necessary to embrace the later results in patho- logical research. No doubt it will continue to enjoy the favor it has received at the hands of the profes- .sion. — Med and Surg. Reporter, Feb. 1, 1879. For practical, ordinary daily U'e, this is undoubt- edly the best treatise that is offered to students of Cincinnati Lan- Thia is unquestionably one of the best manuals on the subject of patholog.v and morbid anatomy that can be plnced in the sliid»ut's hands, and we are glad to see it kept up to the times by new editions. Each edition is enrefully revii^ed by the author, with the view of making it include the most recent ad- vances in pathology, and of omitting whatever may have become obsolete. — N. Y. Mf.d. Jour., Feb. 1879 The treatiiio of Dr. Green i< compact, clearly ex- j pathology and morbid anatomy pressfd, up to the times, and popular as a text-book, cet and Clinic, Feb. S, 1S79. both in Bugland and America. The cuts are suffi- I GLUGB'8 ATLAS OF PATHOLOGICAL HISTOLOGY Translatei, with Notes and Additions, by Josbph Lbivy, M. D. In one volume, very large imperial quarto, with .^20 copper-plate figures, plain and colored, cloth. $A 00. PAVT'S TREATISE ON THE FUNCTION OF DI- GESTION : its Disorders and their Treatment. Prom the second London edition. In one band- some volums, fmall octavo, cloth, 1^1 00. LA EOCHE ON YBLLOW FEVBR. considered in its Historical, Pathological, Etiological, and Thera peutical Relations. In two large and handsome octavo volumes of nearly 1300 pp., cloth. $7 00. HOLLAND'S MEDICAL NOTES AND REFLEC- TIONS. 1 vol. Svo., pp. 500, cloth. ilS.S .^0. BARLOW'S MANUAL OF THE PRACTICE OF MEDICINE. With Additions by D. F. Conbie M D. lvol.8vo.,pp 600, cloth. '«!2 .50 TODD'SCLINICAL LECTURES on CERTAIN ACUTE Diseases. In one neat octavo volume, of 320 pp., cloth. *2 so STOKES' LECTURES ON FEVER. Edited by John W 11,1,1 AM MooRR, M. n., Assistant Physician to the Cork Street Fever Hospital. In one neat 8vo. volume cloth, $2 00. Henry C. Lea's Son & Co.'s Publications — {Practice of Medicine). 15 f^LINT {AUSTIN), M.D., -*• Professor of the Principles and Practice of Medicine in Bellevue Med. College, zV. T. A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourth edition, revised and enlarged. In one large and closely printed octavo volume of about 1100 pp.; cloth, $6 00 ; orstrongly bound in leather, with raised bands, $7 00. iLately Issued. ) This excellent treatise on medicine has acquired : His own clinical studies and the latest contribn- for itself iu the United States a reputation similar to tions to medical literature both in this country and that enjoyed in England by the admirable lectures , in Europe, have received careful attention, so that of Sir Thomas Watson. We have referred to many some portions have been entirely rewritten, and of the most important chapters, and find the revi- i about seventypages of new matter have been ad- sion spoken of in the preface is a genuine one, and I ded. — Chicago Mi-d Jorir., June, 1873. that the author has very fairly brought up hism alter to the level of the knowledge of the present day. The work has thisgreat recommendation, that it i.s in one volume, and therefore will not be so terrifying to the Has never been surpassed as a text-book for stu- dents and a book of ready reference for practition- ers. Theforce of its logic, its simple and practical student' as the bulky volumes which several of our i teachings, have left it without a rival in the field - - - - I JV. y.—lfed. .Record, Sept. 15, 1874. It isgiven to veryfew men to tread in the steps of English text-books of medicine have developed in to. — British and Foreign Med.-Chir. Rev., Jan. 1875 Itisofcourseunnecessary tointroduce oreulogize ! Austin Flint, whose single volume on medicine, thi8 now standard treatise. The present edition j though hereand there defective, isa masterpiece of has been enlarged and revised to bring it up to the lucid condensatioa and of general grasp of an enor- author's present level of experience and reading.! mously wide^ubject. — Land. Practitio7ier,Dec.'T3. B' >r THE SAME AUTHOR. CLINICAL MEDICINE; a Systematic Treatise on tlie Diagnosis and Treatment of Diseases. Designed for Students and Practitioners of Medicine. In one large and handsome octavo volume of 795 pages; cloth, $4 50 ; leather, $5 50; half Russia, $6. (Now Ready.) It is here that the skill and learniog of the great j clearly, and at the same time so concisely as to clinician are displayed He ha-> given us a store- enable the searcher to traverse the entire ground house of medical knowledge, excellent for the stu- j of his search, and at the same time obtain all that dent, convenient for the praciitiouer, the lesult of a I is essential, without phidding through au interml- long life of the most faithful clinical work, collect- j nab'e space. — N. T. Med. Jour., Nov. 1879 ed by an energy as vigilant and systematic as un. tiring, and weighed by a ju'fgment no less clear than his observation is close. — Archives of Medi- cine, Dec. li-79. The author of the above work has anticipated a want long felt by those for whom it was especially written— the clinical student during his pupilage, and the busy practitioner. He has given to the medical profession a very necessary and u.seful work, complete in detail, accurate in observation, brief in statement. — St. Louis Courier of Med., Oct. 1S79. There is every reason to believe that this book will be well received. The active practitioner is The eminent teacher who has written the volume under consileration has recognized the needs of the American profession, and the result is all that we could wish. The style in which it it written is peculiarly tue author's; it is clear and forcible, and marked by those characteristies which have ren- dered him one of the best writers and teachers this country has ever produced. We have not space for so full a consideration of this remarkable work as we would desire. — S. Louis Clin. Record, Oct. 1879. It is venturing little to say that there are few mea so well fitted as Dr. Flint to impart information oa these last mentioned subjects, and the present work is a timely one as relates both to the author's ca- frequently in need of some work that will enable ' pacity to undertake it and the need for it as an him to obtain information in the diaguo-sis and accompaniment to the multitude now issued, in treatment of cases with comparatively little labor. ' which the subject of treatment is but little consid- Dr. Flint has the faculty of expressing himtelf ' ered. — A^eio Remedies, Hov. 1S7 9. ^Y THE SAME AUTHOR. ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED TOPICS. In one very handsome royal 12rao. volume. Cloth, $1 38. {Just Issued.) TTZ-ATSON (THOMAS), M.D., §-c. LECTIJRES ON THE PRINCIPLES AND PRACTICE OP PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- vised and enlarged English edition. Edited, with additions, and several hundred illustra- tions, by Henry Hartshorne, M.D., Professor of Hygiene in the University of Penn- sylvania. In two large and handsome 8vo. vols. Cloth, $9 00 ; leather, $11 00. {Lately Published.) H ARTSHORNE {HENRY), M.D., Professor of Hygiene in the Univer.tity of Pennsylvania ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDL CINE. A handy-book forStudents and Practitioners. Fourth edition, revised and im- proved. With about one hundred illustrations. In one handsome royal 12mo. volume, of about 550 pages, cloth, $2 6,3; half bound, $2 88. {Lately Issued.) DAVIS'S CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES; being a collection of the Clinical Lectures delivered in the Medicnl Wards of Marcy Hospi al, Chicago. Edited by Frank H Davis, M.D. Second edition, enlarged. In one handsome royal 12ino. volume. Cloth, $1 75. THE CYCLOPiEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica and Therapeutics, Dis- eases of Women and Children, Medical Jurispru- dence, etc. etc. By Dunqi.ison, Forbids, Tweedie, and CoNOLLT. In four large super royal octavo volumes, of .'V2.94 donble-colnraned p ;ige>, strongly and handsomely bound in leather, $15; cloth, $11. STURGES'S INTRODUCTION TO THE STUDY OF CLINICAL MEDICINE. Being a Guide to the In- vestigation of Disease. In one handsome 12mo. volume, cloth, $1 25. {Lately Issued.) 16 PIenry C. Lea's Son & Co".'s Publications — (Pt-acHce of Medicine). DRISrO WK {JOHN SYER), M.D., F.R.C.F., J-J Physician niid Joint Lecturer on Medicine, St . ThoTnox' .1 Hospital. A TREATISE ON THE PRACTICE OF MEDICINE. Second American edition, revised by the Author. Edited, with Additions, by James H. Hutch- inson, M.D., Physiciiin to the Pennn. Hospital. In one handsome octavo volume of nearly 1200 pages. With illustrations. Cloth, $5 00; leather, $6 00; half Russia, $6 60. {Nuw Ready.) In reprinting this work from the recent thoroughly revised second English edition, the author has made such corrections ns seemed ad-, isable, and has added a chapter on Insanity. The Editor has likewise revised his additions in the light of the latest experience, and the work is presented as rt fleeting in every way the most modern aspect of medical science, and as fully entitled to miiintain the distinguished position accorded to it on both sides of the Atlantic as an authoritative guide for the student, and a complete though concise book of reference for the practitioner. Notwithstiinding the author's earnest efi'ort at compression, the additions have amounted to iibout one-tenth of the previous edition ; but by the use of an enlarged page these have been accommodated without increasing the size of the volume, while a reduction in the price renders it one of the cheapest works accessible to the profession. The second edition of tliis excellent work, like the first, has received the benefit of Dr. Hiitehiii.«()a's annotHtions, by which the plia.ses of di.^ease which are peculiar to thi.s country are indicated, and thus a treatise which was intended for •British practi- tioners and students is made more practically ustful on this side of the water. We see no reason to modify the high opinion previously expressed with regard to Dr. Bristowe's work, except by adding our appreciation of the careful labors of the author in following the lateral growth of medical science. The chapter on diseases of the skin and of the nerv- ous system, with a new one on insanity compiled from the best sources outside of the KUtlor's own long experience, and the valuable portion relating to general patholoijy, aid greatly in completing an exceptionally good book for purposes of reference and ins ruction — Boston Medical and Surgical Journal, February, 1S80. The popularity of the work depends, no doubt, upon the clear and incisive way in which it is written, and the attention to details likely to occur in practice, rather than the discusision ot questions of theory. — iVtzt) Remedies, Jan, 1S80. What we said of the first edition, we can, with increased emphasis, repeat concerning this: " Every page is chn rHCterized by the utterances of a thought- ful man. Wtiat has been said, has heeu well said, and the book is a fair reflex of all that is certainly km. ion on the subjects considered." — Ohio Med. Recorder, Jan. 7, ISSO. This is not only one of (he latest and most com- prehensive works out on the general subject of Theory and Practice of Medicine, but it is unques- t'ouablv one of the best.— iS'o Med. Practiti-'ner, Jan. 18S0. piCHARDSON [BENJ. W.), M.D., F.R.S., M.A., LL.D., F.S.A., Fellow n/the R'>yal Qollege of Physicians, London. PREVENTATIVE MEDICINE. In one octavo volume of over 400 pages. {Ill Press.) yrOODBURY {FRAiVK), M.D., ' i- Physician to the German Uotpital, Philadelphia, late Chief Assist, to Med. Clinic, Je.ff. College Hospital, etc. A HANDBOOK OF THE PRINCIPLES AND PRACTICE OF Medicine ; for the use of Students and Practitioners. Based upon Husband's Handbook of Practice. In one neat volume, royal 12mo. (Prejiariug.) H ABERSHON {S. 0.) 31. D. Senior Phy.H'k fully up to the times, and making it a volume of interest to the practitioner in every field of inedicine and surgery. Perverted nutrition is in some form associated with all diseases we have to combat, and we need all the light that can he obtained on a subject so broad and general. Dr Habershon'.s work is one that every practitioner should read and study for himself. — X^. Y. Med. .four It., April, 1879. This valuable treatise on diseases of the stomach and alidon en has been out of print for several years, and is therefore not so well known to the profession as it desnrvfK to be. It will be found a cyclopjedia of information, systematically arranged, on all dis- eases of the alimenttry tract, from the mouth to the rectum A fiiir proportion of each chapter is dovit- ed to symptoms, pathology, and therapeutics. The present ^dition is fuller than former ones in many particulars, and has been thoroughly revised and F 'OTHERGILL {J. MILNER),M.D. Ediv., M.R.C.P. Lend., Asst. Phys. to the West T.ond Hosp. : Asst. PIn/s. to the Oily of Lond. Hosp..e.tc. THE PRACTITIONER'S HANDBOOK OF TREATMENT; Or, the Principles of Therapeutics. Second edition, revised and enlarged. In one very neat octavo volume of about 700 pages. (In Press.) -DY THE SAME AUTHOR. THK ANTAGONISM OF THERAPEUTIC AGENTS, AND WHAT IT TEACHES. Being the Fothergillian Prize Essay for 1878. In one neat volume, royal I2ino. of 166 pages; cloth, $1 00. {Just Ready.) Henry C. Lea's Son & Co.'s Publications — {Practice of Medicine). 17 'OEYNOLDS [J. RUSSELL). M.D., -*-•' Prnf. of the Principles and Practice of Medicine in Univ. College, London. A SYSTEM OF MEDICINE wtth Notbs and Additions by Hii-NRY Harts- HORNE, M.D., late Professor of Hygiene in the University of Penna. In three large and handsome octavo volumes, containing 3052 closely printed double-columneil pages, with numerous illustrations. Sold only hy subscription. Price per vol., in cloth, %^ 00 ; in sheep, $fi.OO: half Russia, raised bands, $6.50. Per set in cloth, $15; sheep, $18; half Russiii, $19.50 Volume I. (just ready) contains General Diseases and Diseases of the Nervous Svstem. Volume II. (jnst rendy) cont;iins Diseases of Respiratory and Circulatoiiv Systems. Volume III. (just ready) contnins Diseases of the Digestive and Blood Glandular Systems, op the Urinary Organs, of the Female Reproductive System, and of the Cutaneous System. Reynolds's System op Medicine, recently completed, has acquired, since the first appearance of the first volume, the well-deserved reputntinn of being the work in which modern British medicine is presented in its fullest and most pr.TCticnl form. This could .'^earce be otherwi.se in view of the fact that it is the result of the collaboration of the leading minds of the profession, each subject being treated by some gentleman who is regarded as its highest authority — as for instance. Diseases of the Bladder by Sir Henry Thompson, Malpositions of the Uterus by Graily Hewitt, Insanity by Henry Maudsley, Consumption by J. Hughes Bennet, Dis- eases of the Spine by CHARt^ES Bl.\nd Radcliffe, Pericarditis by Francis Sibson. Alcoholism by Francis E. Anstie, Renal Afiections by William Roberts, Asthma by Hyde Salter, Cerebral Affections by fc[. Charlton Bastian, Gout and Rheumatism by Alfred Baring Gar- rod, Constitutional Syphilis by Jonathan Hutchinson, Diseases of the Stomach by Wilson Fox, Diseases of the Skin by Balmanno Squire, Affections of the Larynx by Morell Mac- kenzie, Diseases of the Rectum by Blizard Citrling, Diabetes by Lauder Brunton, Intes- tinal Diseases by John Syer Bristowe, Catalepsy and Somnambulism by Thomas King Cham- bers, Apople.xy by J. Hughlings Jackson, Angina Pectoris by Professor Gairdner, Emphy- sema of the Lungs by Sir William Jenner, etc etc. All the leading schools in Great Britain have contributed their best men in generous rivalry, to build up this monument of medical sci- ence. St. Bartholomew's, Guy's, St Thomas's, University College, St Mary's in London, while the Edinburgh, Glasgow, and Manchester schools are equally well represented, the Array Medical School at Netley, the military and naval services, and the public health boards. That a work conceived in such a spirit, and carried out under ruch auspices should prove an indispensable treasury of facts and experience, suited to the daily wants of the practitioner, was inevitable, and the success which it has enjoyed in England, and the reputation which it has acquired on this side of the Atlantic, have sealed it with the approbation of the two pre-eminently practical nations. Its large size and high price having kept it beyond the reach of many practitioners in this country who desire to possess it, a demand has arisen for an edition at a price which shall ren- der it accessible to all. To meet this demand the present edition has been undertaken. The five volumes and five thousand pages of the original have, by the use of a smaller type and double columns, been compressed into three vnhunes of over three thousand pages, clearly and hand- somely printed, and offered at a price which renders it one of the cheapest works ever presented to the American profession. But not only is the American edition more convenient and lower priced than the English; it is also better and more complete. Some years having elapsed since the appearance of a portion of the work, additions are required to bring up the subjects to the exi.^ting condition of science. Some diseases, also, which are comparatively unimportant in England, require more elaborate treatment to adapt the articles devoted to them to the wants of the American physi- cian ; and there are points on which the received practice in this country difters from that adopted abroad. The supplying of these deficiencies has been undertaken by Henry Harts - horne, M.D.,late Professor of H3-giene in the University of Pennsylvania, who has endeavored to render the work fully up to the day, and as useful to the American physician as it has proved to be to his English brethren. The number of illustrations has also been largely increased, and no effort spared to render the typographical execution unexceptionable in every respect. house of information, in regard to so many of the ub.jects with which he slioald be familiar. — Gail- Really too much praise can scarcely be given to this noble book. It is a cyclopicdia of medicine written by some of the best men of Europe. It is fall of useful information snch as one finds frequent need of in one's daily work ; for no one head can possibly carry all the knowledge one needs in gen- eral practice, and one mnst refer sometimes to one's library. As a book of reference it is invaluable. It Is up with the times. It is clear and concentrated in style, and its form is worthy of its famous pub- lisher. — Louisoille Med. News, Jan. 31, 1880. "Reynolds' System of Medicine" is ju-tly con- sidered tlie most popular work on the principles and practice of medicine in the English language The contributors to this work are gentlemen of well- known reputation on both sides of the Atlantic. Each gentleman has striven to make his part of the work as practical as possible, and the information contained is such as Is needed by the busy pracli- ti.>ner. — St. Louin Med. and iiurg. Journ., Jan. 20, 1880. Dr. Hartshome has made ample additions and revisions, all of which give increased value to the volume, and render it more useful to the Ameri- ean practitioner. There is no volume in English medical lite-ature more valuable, and every pur- chaser will, on becoming familiar with it, congrat- ulate himself on the possession of this vaat store- lard's Med. Journ., Feb. ISSO. There is no medical work which we have in times past more frequently and fully consulted wlien per- plexed by doubts as to treatment, or by having un- usual or apparently inexplicable symptoms pre- sented to us thaa "Reynolds' System of Medicine." Among its contributors are gentlenieu who are as well known by reputation upon this side of the Atlantic as in Great Britain, and whose right to speak with authority upon the subjects about which they have written, is recognized the world over. They have evidently striven to make their essays as practical as possible, and while these are sufficiently full lo entitle them to the n«me of monographs, they are not loaded down with such an amount of detail as (o render them wearisome to the general reader. In a word , they contain just that kind of information which the bu.«y practitioner frequently finds himself in need of. In order that any deficiencies may be supplied, ihe publishers have committed the preparation of the book for the press to Dr. Henry Hartshome, who-e judicious notesdistributed throughout the volume afford abun- dant evidence of the thoroughness of ihe revision to which he has subjected it. — Am. Jour. Med. Sciences, Jan. 1880. 18 Henry C. Lea's Son & Co.'s Publications— (Prac. of Med. ^ &c.). B >ARTHOLO W (ROBERTS), AM., M.D., LL.D. Prof, of Materia Medica and General Therapeutics in the Jeff. Med. Coll. of Phila etc A PRACTICAL TREATISE OX ELECTRICITY IN ITS 4PPLL CATION TO MEDICINE. In one very handsome octavo volume of about 450 pages, with illustrations. {Preparing.) piNLAYSON [JAMES), M.D., Phiisician ar.d Lecturer on Olinical Medicine in the Glasgow We.Hern Infirmary, etc. CLINICAL DIAGNOSIS; A Handbook for Students and Prac- titioners of Medicine. In one handsome 12mo. volume, of 546 pages, with 86 illustra- tions. Cloth, $2 63. (Jnst Issued.) live from preface to the final page, and ought to be given a place on every oftice table, been use it contains inacoiideusedform all that is valuable in seraeiology and diagnostics to be found in bulkier volumes, and because in its arrangement and complete index, it is unusually convenient for quick releience in any emergency that may come upon the busy practitioner. — 2f. 0. Med. Juurn., Jan. 1S79. The book is an excellent one, clear, concise, con ve- nieut, practical. It is replete with the very know- ledge the student needs when he quits thelecture- room and the laboratory for the ward and sick-room, and does not lack in information that will meet the wants of experienced and older mea.— Phila. Med. Times, Jan. 4, 1879. This is one of the really useful books. It is attrac- H AMILTOS {ALLAN McLANE), M.D., Attending Phmician at the Hospital for Epileptics and Paralytics. SlackwelPs Island, N. T., and at the Out- Patients' Department of the New York Hospital NERYOUSDISEASES;THEIR DESCRIPTION AND TREATMENT. In one handsome octavo volume of 512 pa This is unque.«tionably the best and most com- plete text-book of nervous diseases that has yet ap- peared, and were international jealousy in scientific affairs at all possible, we might be excused for a feeling of chagrin that it should be of American parentage. This work, however, has been performed in New York, and has been so well performed that no room is left for anything but commendation. With great skill, Dr. Hamilton has presented to ^jis ;es, with 53 illua. ; cloth, $3 50. (Just Issued.) readers a succinct and lucid survey of all that is known of the pathology of the nervou.s system, viewed in the light of the most recent researches. From the preliminary description of the metfcoda of examination and study, and of the instruments of precision employed in the investigation of nervous diseases, up till the final collection of formula, the book is eminently practical. —.BraiTi, London, Oct. 1S7S. M. fJHARCOT {J. Professor to the Fnattltyof Med. Paris, Phys. to La Salpetriire, etc. LECTURES ON DISEASES OF THE NERVOUS SYSTEM. Trans- lated from the Second Edition by George Sigerson, M.D,, M.Ch., Lecturer on Biology, etc., Cath. Univ. of Ireland. With illustrations. 1 vol. 8vo. of 288 pages. Cloth, $1 75. (Just Ready.) CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS Bv C. Handpield Jones, M.D., Physician to St. Mary's Hospital, &c. Sec- ond American Edition. In one handsome octavo volume of 348 pages,cloth, ijiS 25. MORRLS (MALCOLM). M.D., ■'-''*- Joint Lecturer on Dermatology, St. Mary's ffo.ipital Med. School. SKIN DISEASES, Including their Definitions, Symptoms, Diaa^nosis, Prognosis, Morbid Anatomy, and Treatment. A Manual for Students and Practitioners. In one 12mo. volume of over 300 pages. With illustrations. Cloth, $1 75. (NowReady.) To^ihysicians who would like to know something appliances of cutaneous medicine. He has produced about sInn diseases, so that when a patient presents a plain, practical book, by aid of which, who so himself for relief they can make a correct diagnosis chooses may tr^in his eve to the recoguiiion of andprescribearationaltreatment, we unhesitatingly light but significant difference*. The descriptions recommend this little book of Dr. Morris. The afl'ec- are neither too vasue nor over-refined ; the direc- tions of the skin are described in a terse, lucid man- tions for treatment are clear and succinct.— iowdon ner. and their several characteristics so plainly set Brain, April, 1880. forth that diagno'^is will be easy. The treatment i ti .u i u j, j , • , . in each case i's such as the expeHencrof he ^0° ' ^.^.^..^^L'^l'^^'rin I '"^ his subject in a clear and eminent dermatologists advise.-Cinciu«a« Medi- THZZ^^Xl\.^\ f f '"t°",^ to students his cat News, April, ISSO. manual w II be found useful.-JJfs^icaZ and Surgi- ' "^ ' j cal Reporter, March 27, 1880. This is emphatically a learner's book ; for we can The author's task has been well done and has pro- safely say, so far as our judgment goes, that in the \ daced one of the best recent works upon the difficult whole range of mpdical lileralnre of a like scope, subject of which ittreats ; thereis no work published there is no hook which for clearness of expression which gives a better view of the elementary facts and methodical arrangement is better adapted to and principles of dermatology.— A'^ejo Orleans ilfet/i- promole a rational conception of dermatology, a cal and Surgicaljournal, k\>v\],\6&n. t^l^ll^T-irtllifolnL^^^^ An'n" i 'r'"« excellent little book is the first work of a 1890 Ooxcrxer of Medicine, April, ^i,^i„g^,i,,,3j p,ipi| of .lonathan Hutchinson; it re- ' commends it.^elf above all by its clearness, method. The author of this manual has evidently a full and an I precision -Prtr?* Annates de Derrtiatologie et intimate acquaintance with the literature of derma- de Syphiligraphie, 25 April, ISSO. tology, and with the most recent developments and ' 'OX ( T2LBURF), M.D., F.R.C.R.mid T. C. FOX. B.A., M.R.C.S., PInjsieian to the Department for Skin D'.-Y THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate, cloth, $4. Dr. Flint chose a difficult subject for hisrese.n, cloth $2 .'50. DEWEES'S TREATISE ON THE DISEASES OF FE- MALES. With illustrations. Eleventh Edition, with the Author's lastimprovementsand correc- tions. In one octavo volume of 536 pages, with plates, cloth. $.3 00. MEIGS ON THE NATURE, SIGNS, AND TREAT- MENT OF CHILDBED FEVER. 1 vol. Svo., pp. Se.'i. cloth. .$2 00. ASH WELL'S PRACTICAL TREATISE ON THE DIS- EASES PECULIAR TO WOMEN. Third American, from the Third and revised London edition. 1 vol. Svo. , pp. 528, cloth. $3 50. H O ODGE [HUGH L.), M.D., Emeritus Professor of Obstetrics , &e., in the University of Pennsylvania. ON DISEASES PECULIAR TO WOMEN ; including Displacements of the Uterus. With original illustrations. Second edition, revised and enlc^rged. In one beautifully printed octavo volume of 531 pages, cloth, $4 50. 'HURCHILL [FLEETWOOD), M.D., M.R.I.A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With notes and additions by D. Francis Condie, M.D., author of a "Practical Treatise on the Diseases of Chil- dren," itc. With one hundred and ninety four illustrations. In one very handsome octavo volume of nearly 700 large pages. Cloth, $4 00 ; leather, $5 00. MONTGOMERY'S EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREGNANCY. With two exqnisitecolored plates, and numerous wood-cnts. Tn 1 ^ol.Rvo..nfnearlvfinnpp..cloth,«.3 7.'). CONDTE'S PRACTICAL TREATISE ON THE DIS- EASES OF CHILDREN. Sixth edition, revised and ausmented. In one large octavo volume of 80 closely- printed pages, cloth, $5 25; RIGBY'S SYSTEM OF MIDWIFERY. With notes and Additional Illnstrations. Second American edition. One volnme octavo, cloth 422 pages, *2 .W. SMITH'S PRACTICAL TREATISE ON THE WAST- ING DISEASES OF INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged Eaelish edition. In one handsome octa- ■^^^nt.-.ma /.Inlh 4fO I^O 22 Henry C. Lea's Son & -Cc's Publications — (Dis. of Women). rpHOMAS {T.GAILLARD),M.D., I- Profcxsor of Obstetrics, Sec, in the College of Physicians and Surgeons, N. T., Ac A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth edition, enlarged and thoroughly revised 800 pages, with 191 illustrations. Cloth A work which h,H? reached a fourth edition, and that. too. in the short space of five years, has achieved a reputation whicli place? it almost beyond the reach ' of criticism, and the favorable opinions which we have already expressed of the former editions seem to re- quire that we should do little more than announce this new issue. We cannot refrain from saying that, as a practical work, this is second to none in the Knq^ lish, or, indeed, in any other language. The arransre- ment of the contents, the admirably clear manner in which the subject of the differential diacno.sis of several of the diseases is handled, leave nothinj to be desired by the practitioner who wants a thoroughly clinical work, one to which he can re<"er in diflficult cases of doubtful diagnosis with the certainty of gain- ing light and instruction. Dr. Thomas is a man with a very clear head and decided views, and there seems to ' be nothing which he so much dislikes as hazy notions of diagnosis and blind routine and unreasonable thera- peutics. The student who will thoroughly study this • book and test its principles by clinical observation, will '• certainly not be guilty of these faults. — London Lancet, Feb. 13, 1S75. 1 Reluctantly we are obliged to close this unsatis- factory no tic eof so excellent a work, and in concl u- sioa'would remark th»t, as a teacher of gynecology, both didactic and clinical, Prof. Thorn as has certainly taken the lead far ahead of his eonfriren, and as an author he certainly has met with uniisnal and mer- ited saccBfs.— ^TO Journ. of Obstetric.1, Nov. 1874. This volnme of Prof. Thomas in its revised form In one large and handsome octavo volume of , $5 00; leather, $6 00. (Just Tssited.) is classical without beingpedaaticfuU in the details of anatomy and pathology, without ponderous translation of pagesof German literature, describes distinctly the details and difflcnlties of each opera- tion, without wearying and useless minutije, and is in all respects a work worthy of con fide nee. justify- ing the high regard in which its distingui-shed au- thor is held by the profession. — Am. Supplement, Obstet. Jonrn., Oct. 1874. ProfessorThomasfairly took the Profession of the United States by storrn when his book first made its appearance early in 1S6S. Its reception was simply enthusiastic, notwithstanding a few adverse criti- cisms from our transatlantic brethren, the first large edition was rapidly exhausted, and in six months a second one was issued, and in two years athird one was announced and published, and we are now pro- mised the fourth. The popularity of this work was not ephemeral, and its success was unprecedented in the annalsof American medical literature. Six years is a long period in medical scientific research, but Thomas's work on " Diseases of Women" is still the leading native production of the United States. The order, the matter, the absenceoftheoretical disputa tiveness, the fairness ofstatement, and the elegance of diction, preserved throughout the entire range of the book, indicate that Professor Thomas did not overestimate his powers when he conceived the idea and executed the work of producing a new treatise upon diseases of women. — Prop. Pallen, in Louis- ville Med. Journal, Sept. 1874. jyARNES [ROBERT), M.D.. F.R.C.P., ■^-^ Ob.itidric Physieian to St. Thnmo.'i'K Hotpitvl, d-e. A CLINICAL EXPOSITION OF .THE MEDICAL AND SUROI- CAL DISEASES OF WOMEN. Second American, from the Second Enlarged and Revi.sed English Edition. In one hnndsomfl ri(>tavo volnnip, of 7,S4 pages, with 181 illustrations. Cloth, $4 50 ; leather, $5 50 ; half Rus>.«ia, $6. iJi,st Ready") The call for a new edition of Dr. Barnes's work on the Disea,=e.^ of Females has encouraged the author to make it even more worthy of the favor of the profe.ssion than before By a rear- rangement ,Tnd careful pruning space has been found for a new chapter on the Gynsecological Relations of the Bladder and Bowel Disorders, without increasing the size of the book, while many new illustrations have been introduced where experience has shown them to be needed. It is therefore hoped that the volume will be found to reflect thoroughly and accurately the present condition of gynaecological science. Dr Barnes stands at the head of his profession in the work is a vilaable one, and should be largely the old country, and it requires but scant scrutiny i consulted by the profession. — Am. S-'pp Obstetrical erf his book to show that it has been sketched by a | Journ. (ft. Britain and Ireland, Oct. 1S78. master. It is plain, practical eommon sense ; shows very deep research without being pedantic; is emi- nently calculated to inspire enthusiasm without in- culcating rashness; points out the dangers to be avoided as well as the suceess to be achieved in the various operations connected with this hranch of medicine; and will do much to smooth the rngged path of the young gynjecoljgist and relieve the per- plexity of the man of mature years. — Canadian Journ. of Med. Science, Nov. 1878. No other gynajcological work holds a higher posi- tion, having become an authority everywhere in diseases of women. The work has been brought fully abreast of present knowledge. Every practi- tioner of medicine should have it upon the shelves of his library, and the student will find it a superior text-book. — Oincinnnti Med. New.s, Oct. 1S7S. This second revised edition, of course, deserves all the commendation given to its predecessor, with the additional one that it appears to include all or nearly We pity the doctor who, having any consider- ; all the additions to our knowledge of its subject that able practice in diseases of women, has no copy of have been made since the appearance of the first edi- " Barnes" for dailv consultation and instruction. It tion The American references are, for an English is at once a book of great learning, research, and work, especially full and appreciative, and we can individual experience, and at the same time etai- cordially recommend the volume to American read- nently practical. That it has been appreciated by ers. — Journ. of Nervous and Mental Disease, Oct. the profession, both in Great Britain and in this ' 1878. country, is shown by tke second edition following This second edition of Dr. Barnes's great work 80 soon upon the flr8t.-,im. Practitioner. Nov. , jo^es to us containing many additions and improve- meats which bring it up to date in every feature. Df. Barnes's work is one of a practical character, i The excellences of the work are too well known to lairgely illustrated from cases in his own experience, require enumeration, and we hazard the prophecy but by no means confined to such, as will be learned that they will for many years maintain its high jjo- from the fact that he quotes from no les-s than 628 sltion as a standard text-book and guide book for medical authors in numerous countries. Coming i students and praetitiouers. — N. C. Med. Journ., from such an author, it is not necessary to say that ; Oct. 1878 QfTADWJCK {JAMES R.), A.M., M.D. A MANUAL OF THE DTSE.\SES PECULIAR TO WOMEN. neat volume, royal 12mo,, with illustrations. {Preparing.) In one Henry C. Lea's Son & Co.'s Publications — (Dis.of Women). 23 JPMMET ( THOMA S A DDLS), M. D. -^-^ Snrffeon to thf. Woman^/s Hnspilal, New Torlc, etc. THE PRINCIPLES AND PRACTICE OF GYNJECOLOGY, for the use of Students and Practitioners of Medicine. Second Edition. Thorougly Revised, ' In one large and very handsome octavo volume of 875 pages, with 133 illustrations. Cloth, $5; leather, $6"; half Russia, $6 50. {Just Ready.) Preface to the Second Edition. The unusually rapid exhaustion of a large edition of this work, while flattering to the author as an evidence that his labors have proved acceptable, h.ns in a great measure heightened his sense of responsibility. He has therefore endeavored to take full advantage of the opportunity afforded to him for its revision. Every page has received his earnest scrutiny; the criticisms of his reviewers have been carefully weighed ; and while no marked increase has been made in the size of the volume, several portions have been rewritten, and much new matter has been added. In this minute and thorough revision, the labor involved has been much greater than is perhaps apparent in the results, but it has been cheerfully expended in the hope of rendering the work more worthy of the favor which has been accorded to it by the profession. not careles.s reading but profound study. Its value In no country of the world has gynjccology re- ceived moreattt*ntion th^n in America. It is, th^n, with a feeling of pleasure that we welcome a work on diseases of women from so eminent a gyusecolo gist as Dr. Emmet, and the work is essentially clini- cal, and leaves a strong impress of the author's iu- dividuality. To criticize, with the care it mei-its, the book throughout, would demand far more space than is at our command. In pariing, we can say that the work teems with original ideas, fresh and valuable methods of practice, and is written in a clear and elegant style, worthy of the litem ry repu- tation of the country of Longfellow and Oliver Wen- dell Holmes.— 5ri<. Med. Journ., Feb 21, ISSO. No gyuiccologlcal treatise has appeared which contains au equal amount of oiiginiil and useful matter; n(ir does the medical and surgical history of America include a book mom novel and useful. The tabular and statistical information which it contains is mari^pllons, both in quantity and accu- racy, and cannot be otherwise than invaluable to future invest'gators. It is a work which demands as a contribution lo gynaecology is, perhaps, greater than that of all previous literature on the subject combined. — Chicago Med. Gaz., April t, ISSO The wide reputation of the author makes its pub- lication an event in the gynaecological world ; and a gUnce through its pages shows tbat it is a work to be studied with cave. ... It must always be a work to be carefully studied and frequently con- sulted by those who practise this branch of our pro- fession. — Lnnd. Med. Times and Gaz , Jan. 10, 1880. The character of the work is too well known to require extended notice — suffice it to say that no recent work upon any subject has attained such great popularity so rapidly. As a work of general reference upon the subject of Diseases of Women it is invnlnable. As a record of the largest clinical experieuce and observation it has no equal. No physician who pretends to keep up with the ad- vaaces of this department of medicine can afiford to be without it. — Nashville Journ. of Medicine and Sttrgery, May, 1S80. B UNCAN {J. MATTHEWS), M.D., LL.D., F.R.S.E., etc. CLINICAL LECTURES ON THE DISEASES OF WOMEN, Delivered in Saint Bartholomew's Hospital. In one very neat octavo volume of 173 pages. Cloth, $1 50. (Jvst Ready.) The author is a remarkably clear lecturer, and his discussion of symptoms and treatment is full aad sugge.'tive. If will be a work which will not 1 to be read with benefit by practitioners as well They are in every way worthy of their author ; indeed, we look upon them as among the most valu- a;t)ie of his contribu:ions They are all np^n mat- ters of great interest to the general practitioner Some of th^m deal w\>h subjects tliat are not, as a 1 a.s by students. — P^»7a. Med. and Surg. Reporter, rule, adequately hfindled in the text-books ; others I Feb. 7,1880. of them, while bearing upon topics that are usually I yVe have read this book with a great deal of t<"eated of at length in such works, yet bear such a stamp of individuality that, if widely read, as they certainly deserve to bo, they cannot fail to exert a wholesome restraint upon tlie undue eagerness with which many young physicians seem bent upon fol- lowing the wild teachings which so infest the gynae- cology of the present day. — N. X. Med. Journ., March, ISSO. pleasure. It is fall of good things. The hints on pathology and treatment scattered through the book are sound, trustworthy, and of great value. A healthy scepticism, a large expeiience, and a clear judgment are everywhere manifest. Instead of bristling with advice of doubtful value and nn- souod character, the book is in every respect a safe guide. — The London, Lancet, Jan. 21, 18&0. JDAMSBOTHAM [FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- CINE AND SURQERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., Professor of Obstetrics, &c., in the Jefferson Medical College, Philadelphia. In one large and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in all nearly 200 large and beautiful figures. $7 00 '^'INCKEL (F.), ' ' Professor and Director of the Gynacological Clinic in the University of Rostoch. A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- MENT op CHILDBED, for Students and Practitioners. Translated, with the consent of the author, from the Second German Edition, by James Read Chadwick, M.D. In one octavo volume. Cloth, $4 00. (Lately Issued.) rpANNER {THOMAS H.), M.D. ON THE SIGNS AND DISEASES OF PREGNANCY. First American from the Second and Enlarged English Edition. With four colored plates and illustra- tions on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. 24 Henry C. Lea's Son & Co.'s Publications — {Midwifery). PLAYFAIR ( W. S.), M.D., F.R.C.F.. Prn/ef8or of Obstetric Medicine in King's College, etc. etc. ATRKATTSKONTHESCTRNCP] AND PRACTICE OF MIDWIFERY. Third American edition, revised by the author. Edited, with additions, by Robert P. Harris, M D. In one handsome octavo volume of about 700 pages, with nearly 2C0. illustrations. Cloth, $4; leather, $5; half Russin, $5 60. (Just Ready ) EXTRACT FROM THE AUTHOR'S PREFACE. The second American edition of my work on Midwifery being exhausted before the corre- sponding English edition, I cannot better show my appreciation of the kind reception my book has received in the United States than by acceding to the publisher's request that I should myself undertake the issue of a third edicion. As little more than a year has elapsed since the second edition was issued, there are naturally not many changes to make, but I have, nevertheless, subjected the entire work to careful revision, and introduced into it a notice of most of the more import.ant recent additions to obstetric science. To the operation of gastro- elytrotomy — formerly described along with the Csesarean section — I have now devoted a sepa- rate chapter. The editor of the Second American edition, Dr. Harris, enriched it with many valuable notes, of which, it will be observed, I have freely availed myself. The medical profes.-ii>n has now the opportunity i a very intfilligeat idea of them, yet all details not of adding to theT stock of standard medical works necessary for t full understanding of the subject are one of th*- best volume.-* on midwifery ever pablishfd. ' omitted. — Cinciiinati Med. Netcs, Jan. ISSO. The subject is taken up with a ma-ster hand. The [ The rapiditv with which one edition of this work part devoted to laborin all it.s various presentations, follows another is proof alike of irs excellence and the management and result.?, is admirably arranged and the views entertained will be found essentially modern, and the opinions expressed trustworthy The work abounds with plates, illustrating various obtitelrical positions ; they are admirably wrought, and afford great assistance to the student. — N. 0. Med. and Surg. Journ., March, ISSO. If inquired of by a medical student what work on obstetrics we .should recommend for him, as pnr exnellen- e. we would u doubtedly advise him to choose Play fair's. It is of convenient size, but what is of chief importance, i'.s treatment of the various subjects is concise and plain. While the discussions and descriptions are sufficiently elaborate to render of the es'imate that the profesr-iun has lormed of it. Ft is indeed so well known and so highly valued that nothing need be said of it as a whole. All things considered, we regard tliis treatise as the very best on Midwifery in the English language.— .y. ¥. Medical Jo'irnrtl, May, 18SU It certainly is an admirable exposition of the Scienc • aud Practice of Midwifery. Of course the additions made hy the American editor, I'r. R. P. Harris, who never utters an idle word, and whose studious re.-e^rches in tome special departments of obstetrics are so well known to the profession, are of great value — The American Praaticioner, April, 1880 'DARNES {FANCOURT), M.D., -*-' Physician to the General Lying-in Hospital, London. A MANUAL OF MIDWIFERY FOR MIDWIYES AND MEDICAL STUDENTS. With 60 illustrations. In one neat royal 12mo. volume of 200 pages; cloth, $1 25. {Now Ready.) The book is written in plain, and as far as pos- sible in uniechnicrtl language, .-^ny intelligent mid- wile or medical student can easily comprehend the directions. It will undoubtedly fill a want, and will be popular with those for whom it has been prepared. The exam ning questions at the back will be found very useful. — Cincinnati Med. News, Aug 1P79. In Monthly Summary, Qynbcic 28 Articles " " Pediatric 4 " News 9 " rPHE OBSTETRICAL JOURNAL. [Free of postage for 1880.) THE OBSTETRICAL JOURNAL of Great Britain and Ireland; Including Midwifery, and the Diseases op Women and Infants. A monthly of 64 octavo pages, very handsomely printed. Subscription, Three Dollars per annum Single Numbers. 25 cents each. With the January number will terminale Vol. VII. of the Obstetrical Journal. The first No. of Vol. VIII. will be issued about Feb. 1st; the "American Supplement" of 16 pages per No. will be discontinued, and the periodical will thenceforth consist of 64 pages per number, at the exeeedinglj' low price of Three Doll\ps per annum, free of postage. For this trifling turn the subscriber will thus obtain more than 760 pages per annum, contnining an e.xtent and variet3' of information which may be estimated from the fact that Vol. VI. of the "Obstbtri- cal Journal" contains in Original Communications . . 44Articles Hospital Phactice .... 4 " General Correspondence . . 5 " Reviews of Books 9 " Proceedings of Societies . . 101 " 241 In Monthly Summary, Obstetric 73 ' and that it numbers among it? contributors the distinguished names of Limbe Atthill, J. H. Aveli.ng, Robert Barnes, J. Henry Bennet, Nathan Bozeman, Thomas Chambers, Fleet- wood Churchill, Charles Clay, John Clay, J. Matthews Duncan, Arthur Farke, Robert Gkeenhalgh, W. M. Graily Hewitt, J. Braxton Hicks, William Leishman, Angus Mac- DONALD, Alfred Meadow,*!, Alex. Simpso.s, J. G. Swayne, Lawson Tait, Edward J. Tilt, E. H. Trbnholme, T. Spencer Wells, Arthur Wigglesworth, and many other distin- guished pr.'ictitioners Under such auspices it has amply fulfilled its object of presenting to the physician all that is new and interesting in the rapid development of obstetrical and gynae- cological science. As a very large increase in the subscription list is anticipated under this reduction in price, gentlemen who propose to subscribe, and subscribers intending to renew their subscriptions, are recommended to lose no time in making their remittances, us the limited number printed may at any time be exhausted. Henry C. Lea's Son & Co.'s Publications — {Midwifery^ Surgery). 25 TEISHMAN {WILLIAM), M.D., Regius Professor of Midwifery in the University of Glasgow, &c. A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF PREGNANCY AND THE PUERPERAL STATE. Third American edition, revised by the Author, with additions by John S. PARRy, M.D., Obstetrician to the Philadelphia Hospital, Ac. In one large and very handsome octavo volume, of 733 pages, with over two hundred illustrations. Cloth, $4 50; leather, $5 50 ; half Russia, $6. (Just Ready.) Few works on this subject have met with af grant I rior in the English language. — Canada Lancet, Jan. a demand at this one appears to have. To judge | ISSO. by the frequency with which its author's views aie; quoted, and its statements referred to in obstetrical ' literature, one would judge that there are few phy- Tbe book is greatly improv«d, and as such will be welcomed by those who are trying to keep posted in the rapid advances which are being made in the sicians devitiug much attention to obMetrics who study of obstetrics.— .Bos<(-» J/ed. a7i«trated.-iV^ ervations aud discoveries of others, has pro- V"''' &a«ei/«, Oct lo, IS/ / . duced a work, which as a text-book, stands /«ci7e princeps \u our language. We had marked several pa-sages as well worthy of quotation and Ihe atten- Dr. Burnett is to be coin mended for having written the best book on the subject in the English language, and especially for ihe care and altfutiou he has tion of the general practitioner, but theirnumber and given to the scientific side of the subject. — N. 1 the space at our command forbid. Perhaps it is bet- Med. Journ.,l)6c. Ib77. ter, as the book ought to be in the hands of every i rrAYLOR [ALFRED S.),M.D., J- Lectrtrer on Med. Jurisp. and Chemistry in Ouy's Hospital. POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Third American, from the Third and Revised English Edition. In one large octavo volume of 850 pages ; cloth, $5 50 ; leather, $6 50. (Just Issued.) The present is based upon the two previous edi- tions • "but the complete] evision rendered necessaiy by time has converted it iuto a new work." This statement from the preface contains all that it is de- sired to know in reference to the new edition. The works of this author are already in (he library of every physician who is liable to be called upon for medico-legal testimony (and what one is not?), so that all that is required to be known about the present book is that the author has kept it abreast with the times. What makes it now, as always, especially valuable to the praciitiouer is its conciseness and practical character, only those poisonous substances T>T THE SAME AUTHOR. MEDICAL JURISPRUDENCE. by John J. Reese, M.D., Prcf. of Med. octavo volume of nearly 900 pages. Clo To the members ul the legal and medical profes- sion, tt is unnecessary to say anything commenda- | tory'of Taylor's Medical .lurisprudeuce. We might as well undertake lo speak of the merit ofChitty's Pleadings. — Chicago Legal News, Oct. Iti, 187:^. It is beyondquestion the most attractive as well as most reliable maaual of medical jurisprudence published in the English language.— JTrt../oMj-na/ nf Syphilography, Oct. 1873. It i s al toget her su peril uous for us to offer anything in behalf ol a work on medical j urisprudence by an aut h or who isal most universally esteemed to be the being described which give rise lo legal investiga- tions.— TAe Clinic, ^uv. 6, lS7o. Dr. Taylor hat brought to bear on the compilation of this Volume, stores of learning, experience, and practical acquaintance with his subject, probably far beyond what any other living authority on toxicol- ogy could have amassed or utilized. He has fully sustained his reputation by the consummate skill and legal acumen he has displayed iu the arrange- ment ol the subject-matter, and the result is a work on Poisons which will be indispensable to every stu- dent or practitionerin lawand medicine. — Tlie Dub- lin Journ. of Med. Set., Oct. lS7o. Seventh American Edition. Edited Jurisp. in the Univ. of Penn. In one large th, $5 00; leather, $6 00. {Lately Issued.) best authority on this specialty in our language. On this point, however, we will say that weconsider Dr. Taylor to be the safenl medioo-legal authority to fol- low, in general, with whioh we are acquainted in any language. — Va. Clin. Record, Nov. 1873. ThislasteditionoftheManHal is probably the best ofall, as it contains more material aud is worked up to the latest views of the author as expressed in the last edition of the Principles. Dr. Keese, the editor of the Manual, has done everything to make his workacoeptable to his medical countrymen. — if. Y. Med. Record, Jan. 15, 1874. or THE SAME AUTHOR. THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- DENCE. Second Edition, Revised, with numerous Illustrations. In two large ootavo volumes, cloth, $10 00; leather, $12 00 This great work is now recognized in England as the fullest and most authoritative treatise on every department of itn important subject. In laying it, in its improved form, before the Amer- ican profession, the publisheis trust that it will assume the same position in this country. Henry C. Lea's Son & Co.'s Publications — (Miscellaneous). 31 -DO BERTS ( WILLIAM), M.D., -*■•' Lecturer on Medicine in the Mnnehester School of Medicine, etc. A PRACTICAL TREATISE ON URINARY AND RENAL DIS EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Third American, from the ThirdRevised and Enlarged London Edition. In one largt and handsome octavo volume of over 600 pages. Cloth, $4. (Jvst Ready.) THOMPSON {SIR HENRY), ■^ Surgeon and Prnfe.9f.or of Clinical Surgery to University College Bo,spital . LECTURES ON DISEASES OF THE URINARY ORGANS. With illustrations on wood. Second American from the Third English Edition. In one neat octavo volume. Cloth, $2 25. (Just Is.iued.) T>Y THE SAME AUTHOR. ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF THE URETHRA AND URINARY FISTULyE. With plates and wood-cuts. From the third and revised English edition. In one very handsome octavo volume, cloth, $3 60. { Lately Published.) rrUKE {DANIEL HACK), M.D., ■*■ Joint author of " The Manual of Psychological Medicine,'" &c. ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the Imagination. Inonehandsome octavo volume of 416 pages, cloth, $3 26. {Lately Issued.) ■DLANDFORD {G. FIELDING), M.D., F.R.C.P., J-^ Lecturer on P.iyehological Medicine at the School of St. George's Hospital, &c. INSANITY AND ITS TREATMENT: Lectures on the Treatment, Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very handsome octavo volume of 471 pages ; cloth, $3 25. It satisfies a want which mnst have beeii sorely actually seen in practice and the appropriate treat feltby the busy general practitioners of this country It takes the form of a manual of clinical description of the various forms of insanity, with a description of the mode of examining persons suspected of in- sanity. We call particnlarattention to this feature of the book, as givingit a unique value to the gene- ral practitioner. Ifwe pass from theoretical conside- rations to descriptions of the varietiesof insanity as ment for them, we find in Dr. Blandford's work considerable advance over previous writings on the subject. His pictures of the various forms of mental disease are so clear and good that no readercan fail to be struck with their superiority to those given in Jidinary manuals in the English language or (so far as our own reading extends )in any other. — Londot- Practitioner, Feb. 1871. FEA {HENRY C). SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Third Revised and Enlarged Edition. In one handsome royal 12mo. volume of 662 pages. Cloth, $2 50. (Just Ready.) This valuable work is in reality a history of civi- i more accurate than either of the preceding, but. lization as interpreted by the pri.gress of jnrispru dence. ... In " Soperslitiou and Force" we have I a philosophic survey of the long period intervening between primitive barbarity and civilized enlight- enment. There is not a chapter in the work that should not be most carefully studied, and however well ver.^ed the reader may be in the scieace of jurisprud-'nce, he will find much in Mr. Lea's vol- ume of which he was previously ignorant. The book is a valuable addition to the literature of social science. — Westminster Review, Jan. 18S0. The appearance of a new edition of Mr. Henry C. Lea's "Superstition and Force" is a sgn that our highest scholarf hip is not without honor in its na- tive country. Mr. Lea has met every fresh demand for his work with a careful rerision of it, and the present edition is not only fuller and, if possible, from the thorough elaboration is more like a har- monious concert and less like a batch of studies. — The Nation, Aug. 1, 1S7S. Many will be tempted to say that this, like the "Declineaud Fall,"isune of the uncriticizable books Its facts are in numerable, its deductions simple and inevitable, and its chevanx-de-frise of references bristling and dense enough to make the keenest, stoutest, and be.st equipped assailant think twice before advancing. Nor is there anything contro- versial in it to provoke assault. The author is no polemic. Though he obviously feels and thinks strongly, he succeeds in attaining impartiality. Whether looked on as a picture or a mirror, a work such as this has a lasting value. — Lippineott's Magazine, Oct. 1S7S. B' > Y THE SAME A UTHOR. (Lately Publi.-thed.) STUDIES IN CHURCH HISTORY— THE RISE OF THE TEM- PORAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. In one large royal 12mo. volume of 616 pp.; cloth, $2 76. The story was never told more calmly or with , iasapeculiarimportanoefortheEnglish student, and greater learning or wiser thought. We doubt, indeed, | is a chapter on Ancient Law likely to be regarded as if any other study of this field can be compared with i final. We can hardly pass from our mention of snch this for clearness, accuracy, and power. — CWcap'o I works as these — with which that on "Sacerdotal E.t;a'/ni»er, Dec. 1870. Celib?«cv' ' should be included — without noting the Mr. Lea's latest work, " Studiesin Church History." literary phenomenon that the head of one of the first fully sustains the promise of the first. It deals with American housesisalso the writer ofsomeofitsmost three subjects— the Temporal Power, Benefit of original books.-iondo?! ^i/ieneeum, Jan. 7, 1 871. Clergy, and Excommunication, the record of which I 32 Henry C. Lea-'s Son & Co.'s Publications. INDEX TO CATALOGUE. American Joarnal of the Medical Sciences Allen's Aoaloiuy ..... Anatomical Atlas, by Smith and Horner Ashton on the Kectum and Anns Attfield's Chemistry .... Ashwell on Diseases of Females *A.shhnrst's Surgery .... Browne on Ophtliahuoscope . Browne on tlie Throat .... *Burnett on the Ear .... *3arnesou Diseases of Women . Barnes' Midwifery .... Bellamy's Surgical Anatomy Bryant's Practice of Surgery Bloxam's Chemistry .... Blandford on Insanity .... Basham on Renal Diseases . Bartholow on Electricity B 'AUg'b'6"*8Ei ^Wfi20l985 Form L9-42to-8,'49(B5573)444 THE LIBRARY UNIVERSITY OF CALIFORNU LOS ANGELES ■[/' • •>;,::'.''.-:i^^|!!1I!;SF mmm0m ' '■.' :;r'' '!',*'. 'lijij ", I wiJlfjM ■■ S- .'i; ' . I;.!' I ■■' il " ' :'^-;;'::;! iiii! I ! ii I li'iiiiiii! ii