OF THE. 
 
 U N I VLR.5 ITY 
 Of ILLINOIS 
 
 618 
 
 C7ltEm 
 
The person charging this material is re- 
 sponsible for its return to the library from 
 which it was withdrawn on or before the 
 Latest Date stamped below. 
 
 Theft, mutilation, and underlining of books 
 are reasons for disciplinary action and may 
 result in dismissal from the University. 
 
 UNIVERSITY OF ILLINOIS LIBRARY AT URBANA-CHAMPAIGN 
 
 HAY 17 i!S 7 fh 
 

Digitized by the Internet Archive 
 in 2017 with funding from 
 
 University of Illinois Urbana-Champaign Alternates 
 
 
 
 https://archive.org/details/treatiseondiseas00colo_0 
 

TREATISE 
 
 ON THE 
 
 DISEASES AND SPECIAL HYGIENE 
 
 FEMALES. 
 
 BY COLOMBAT DE L’ISERE. 
 
 TRANSLATED FROM THE FRENCH, WITH ADDITIONS. 
 
 BY CHARLES D. MEIGS, M.D. 
 
 Prof, of Midwifery and the Diseases of Women and Children in Jefferson Med. Col., Philad.; 
 Member of the Amer. Philos. Society; of the Philad. Col. of Physicians; 
 of the Philad. Med. Society; and 
 Physician to the Lying-in Department of the Penn. Hospital. 
 
 WITH WOOD CUT ILLUSTRATIONS. 
 
 PHILADELPHIA: 
 
 LEA AND BLANCHAKD. 
 
 1845. 
 
Us 
 
 V 
 
 Entered according to the Act of Congress, in the year 1845, by 
 LEA AND BLANCHARD, 
 
 in the Clerk’s Office of the District Court of the United States in and for the 
 Eastern District of Pennsylvania. 
 
 T. K. (Sc P. G. COLLINS, Printers, No. 1 Lodge Alley 
 
r~ 
 
 X 
 
 { 
 
 M 
 
 c 
 
 I 
 
 % 
 
 A 
 
 TO R. LA ROCHE, M.D. 
 
 My dear Friend — 
 
 i 
 
 I have translated the very learned work of Mons. Colombat de 
 L’Isere, and have added to it, in the form of notes, printed Avithin 
 brackets in the body of the text, about one hundred pages of original 
 matter, constituting nearly a seventh part of the volume. I dedicate 
 my labour to you ; and I beg you to accept even this small offering 
 to a friendship which is, and has been for many years, a large part 
 of my happiness. 
 
 You, who know what a hurried and toilsome life I lead, will, on that 
 account, perhaps as well as out of your constant grace and goodness to 
 me, be ready to overlook such faults of style, and such typographical 
 errors, as have crept into the pages; the more especially, seeing that 
 I have written them out, corrected the proofs, and revised them, for 
 the most part, after midnight, while engaged in practice, and during 
 my course of Lectures at the college : I say for the most part, since 
 my son, Dr. Meigs, has assisted me in a portion of the translation. 
 These excuses for faults, probably the critical public will not accept ; 
 If you should accept them, however, I shall rest under the hope 
 that they also will admit them, and readily acknowledge the good 
 service I have done in laying before them so excellent a treatise. 
 Mons. Colombat, by his elaborate and judicious collation of authori- 
 ties, of whom more than one thousand are here cited, on topics rela- 
 tive to the objects of the treatise, has produced a complete exposition 
 of the opinions and practical methods of the celebrated practitioners 
 of ancient and modern times; and his work comprises a body of 
 knowledge most important in this country. I cannot, therefore, but 
 hope that I may even be favourably received by our brethren, who 
 now enjoy the benefits of M. C.’s enormous toil. 
 
 I refer you to M. Colombat’s introductory pages for a statement 
 of his motives and his method as to this work — trusting that you 
 will find in it the plan of a capital performance, which, as the 
 perusal of his pages may serve to show, has been fully carried out. 
 
IV 
 
 DEDICATION. 
 
 As a text and table book for the student and practitioner, I do not 
 think it has an equal in its department. 
 
 As to the materials that I have contributed, I hope you will give 
 your approbation to the notices on the Hsematological Disorders, and 
 also to my remarks upon Puerperal J^ever, concerning which many 
 vague, incompetent and unsettled notions seem to prevail on both 
 sides of the Atlantic. I confess myself as wholly belonging to the 
 party of the Gordons and Heys, who have been so strenuous in 
 their advocacy of a sound pathology and therapeia of the terrible dis- 
 ease in question. You will see that in some places I disagree with 
 M. Colombat, and even enter my protest against his views ; but I 
 can never, even under such circumstances, feel other sentiments than 
 those of a profound respect for an author who has effected so much. 
 
 In one of the pages of his Hygiene, M. C. says that women 
 are not, by their nature and position, fitted to shine in the walks of 
 literature, nor to toil for a scientific reputation, which men, even, 
 cannot acquire but at the expense of their health and their happi- 
 ness. Alas! I am grieved to learn that the estimable author of 
 the Treatise presents, in his own person, the confirmation of his 
 assertion ; and that his ruined health may be traced to the untiring 
 zeal with which he has pursued “ the bubble reputation,” and a 
 more solid advantage, to wit, a consciousness of having done a good 
 work for his day and generation. Join with me in sincere wishes 
 that it may please the Divine Providence to restore his health, and 
 that he may again be able to exert his inexhaustible patience, skill 
 and probity, in behalf of an art which such talents are well qualified 
 to illustrate and adorn. 
 
 Farewell, my dear friend, and believe that I am, always, 
 
 Your grateful and affectionate 
 
 CH. D. MEIGS. 
 
INTRODUCTION. 
 
 Medicina non ingenii humani partus est, 
 
 Sed temporis filia. i Baglivi. 
 
 In obedience to the unchangeable law of nature, and in fulfil- 
 ment of the common destiny of organic beings, the female, like the 
 male, lives under subjection to the various revolutions of existence; 
 like him she is born, grows up, becomes feeble and perishes ; like 
 him she passes through all her phases, and attains the fatal term, 
 after having been constantly under the influences of the varied 
 causes that are capable of affecting the health of the body. But 
 although both sexes are alike exposed to a variety of maladies, the 
 number of ills that overwhelm them, is not alike, for to the too 
 numerous evils which woman participates, as a common lot with 
 man, nature has superadded all those that take their rise in the 
 superior excitability of her nervous system, and in those painful and 
 stormy functions which prepare her for the power, or for the act of 
 reproduction. 
 
 If it be true, as Bischat says, that lesions are most frequent in parts 
 where action is greatest, if each organ is liable to be affected in the 
 direct ratio of its degree of activity, there is no occasion for us to be 
 surprised ~at the frequency and variety of the maladies to which the 
 womb is subject. The extreme sensibility of that viscus, its phy- 
 siological importance, its peculiar irritability, and especially its more 
 or less intimate sympathetic connection with other parts of the body, 
 render it a centre of action, which in the sex seems, in a measure, 
 to domineer over the whole economy, and form the principal basis 
 upon which the edifice of the organization rests. It is easy, from 
 what we have just said, to explain why the vital lesions of the womb 
 and its appendages rarely exhibit themselves at the two extremes 
 of existence, but are very frequent at the season of the cessation of 
 the menses, and especially throughout the whole term of years dur- 
 ing which the genital organs are subject to periodical states of exci- 
 tation, as well as to other excitements of various kinds. 
 
VI 
 
 INTRODUCTION. 
 
 All these disorders, the number of which Democritus exaggerated 
 in his letter to Hippocrates, in which he says “ Uterus sexcent arum, 
 aerumnarum in mulieribus causa,” all these disorders are much 
 better understood in modern than they were in ancient times. Our 
 ideas in regard to their nature, causes and treatment, are more pre- 
 cise in the present age, because in their search after truth, the medi- 
 cal men of the present period are guided by a more rigorous analysis 
 of symptoms, and have liberated themselves from the rusty chains 
 of the doctrines of the ancients, by embracing the sources of positive 
 knowledge found in the sciences of physics, chemistry, and patho- 
 logical anatomy. 
 
 Notwithstanding the whole circle of diseased conditions is com- 
 prised within the domain of medicine, and though it is the bounden 
 duty of the physician to consecrate his studies and meditations to the 
 discovery of prophylactic and therapeutical methods that may serve 
 to prevent them all, or conduct them with greater or less celerity to 
 a radical cure, they cannot all be equally the objects of his profound 
 research; they cannot all alike exercise his talent for investigation ; 
 he must direct his attention especially to those which, like most of 
 the diseases of the womb, indeed, have been imperfectly studied, and 
 are in some sort known only by their disastrous effects. 
 
 In spite of the progress of the human mind, and the numerous 
 conquests that have been made in every department of medical 
 science, there is much still to be said, and a great deal to be done, 
 and a brilliant task remains to be fulfilled. Multum rest at adhuc 
 operis, multumque restabit, nee ulli nato post mille saecula, prse- 
 cludetur occasio aliquid adjiciendi. Seneca, lib. i. epist. lxiv. 
 
 If, on the one hand, we reflect upon the real improvements in the 
 medico-chirurgical therapeutics of the diseases of the womb, which 
 have lately been introduced by the new methods of diagnosis ; and, 
 on the other hand, consider that all the treatises upon diseases of 
 women are in several regards incomplete, or, at least, far from being 
 up to the level of the times, we shall be able to appreciate the useful- 
 ness, and even the necessity of a work that may contain,, although 
 within a narrow compass, every thing relating to this interesting sub- 
 ject. It is with the hope of filling up this vacuum, and with the 
 intention of being serviceable, both to practitioners and pupils, that 
 the present treatise is published; a treatise which comprises an 
 account of the physiology, the surgical anatomy, pathology, thera- 
 peutics, operative medicine and hygiene, of the genito-mammary 
 organs of the sex. 
 
INTRODUCTION. 
 
 Vll 
 
 We have been aware of the extent and difficulty of our enterprise. 
 In venturing to undertake it, notwithstanding the numerous diffi- 
 culties in our path, we have been influenced less by any confidence 
 in our own ability, than by the attraction of the powerful interest of 
 a subject, to which we have, during the last ten years, consecrated 
 a major portion of our studies and researches.'* 
 
 The division we have adopted, is founded upon the analogies ob- 
 served between the maladies whose history is comprised within our 
 plan : with a view to facilitate the study of them, and particularly 
 with the design of grouping and approximating them as closely as 
 possible, in the natural order they ought to occupy in any general 
 system of pathology, we have divided them into six sections, to 
 wit: 1. lesions of form ; 2. lesions of situation; 3. -physical lesions; 
 4. vital lesions; 5. lesions of the functions; 6. lesions relative to 
 reproduction. 
 
 In the first section, which comprises all the primitive and the acci- 
 dental deformities, we have entered more into detail than any of our 
 predecessors, and endeavoured more distinctly to point out the various 
 lesions connected with the coherence, imperforation, obliteration, nar- 
 rowness, obturation, and all the different kinds -of genito-urinary 
 occlusion in the female. After relating and criticizing a great number 
 of curious cases, and after having indicated all the diagnostic and the- 
 rapeutical methods appropriate to these different lesions, we pointed 
 out a very simple mode of perforating the membrana hymen , at the 
 same time preserving it as far as possible, on account of the moral 
 importance attached to its existence, and allowing of a gradual dis- 
 charge of the menstrual products accumulated within the womb, and 
 avoiding as completely as possible, the pernicious effects of air, when 
 introduced into the cavity of the viscus. We have also proposed a 
 new method of curing congenital narrowness of the vagina, and 
 have given a figure of a cutting thimble, and a knife with a very 
 convex edge, for separating the coherent sides of the vagina. 
 
 In the second section we have, in considerable detail, treated of the 
 various prolapsions of the womb ; and founding our opinions upon a 
 great number of observed cases, we have pointed out in a more com- 
 plete manner, the advantages and disadvantages of the various kinds 
 
 * Having been resident surgeon of the Maison de Sante, of the Rue de Valois du 
 Roule, specially appropriated to the medico-chirurgical treatment of the diseases of 
 women; and having, for a long time, attended the learned clinics of Dupuytren, and 
 of Messrs. Lisfranc and Recamier, &c., we have enjoyed opportunities of collecting 
 a great number of cases of disorders of the womb, and its appendages, which we 
 made the subjects of a memoir in the year 1828 . 
 
INTRODUCTION. 
 
 viii 
 
 of pessaries in use, and of other palliative and curative measures 
 scarcely treated of by other authors on the diseases of women. We 
 have, likewise, made efforts to omit nothing important relative to the 
 deviations, the incurvations, the inversion, elevation and immobility 
 of the uterus ; the different hernias of the organ, as well as of the 
 ovaria ; the prolapsus of the lining membrane, and the invagination 
 of the vagina; in fine, the prolapsus and thickening of the lining 
 membrane of the urethra; while the vulvar and vaginal cystoceles and 
 enteroceles have been particularly the objects of our close attention. 
 
 In the third section, which comprises all the solutions of continuity, 
 the contusions, the wounds and lacerations ; the ruptures of the 
 vulva, of the perineum* the vagina, and the womb ; the contusions 
 and wounds of the breast, and in fine, the introduction of foreign 
 bodies into the genital cavities, we have proposed various instru- 
 ments to facilitate and ensure the surgical operations required by 
 these lesions, especially the vaginal fistulas. 
 
 In the fourth section, which alone consists of near two hun- 
 dred pages, and in which are collected the different phlegmasias, 
 acute and chronic, superficial or deep-seated ; the transformations, 
 the degenerations and all the morbid productions of the vulva, the 
 vagina, the uterus, the ovaries and the mammae, we have made 
 known several instruments of our own invention, for the surgical 
 treatment of the polypous tumours and cancerous affections of these 
 organs. For the purpose of facilitating a comparison and impar- 
 tial judgment of the measures we have proposed, we have men- 
 tioned and described with equal fidelity, most of those that have 
 been employed by other medical men ; and we were prevented from 
 giving figures along with the descriptions of the operative proceed- 
 ings, merely by the consideration that most of them are already of 
 no recent date, and, therefore, generally known. 
 
 In the fifth section, not only have we endeavoured to forget 
 nothing relating to the functional lesions and the neuroses peculiar to 
 females, but we have advanced some new ideas on the causes, the 
 diagnosis and treatment of uterine haemorrhage, amenorrhoea, chlo- 
 rosis, nymphomania and hysteria. 
 
 We pass in silence by the sixth section, which figures in our 
 synoptical table of the diseases of women, because it comprises those 
 lesions that are relative to reproduction, which do not enter into the 
 plan of the present work, and which, moreover, are of sufficient 
 importance to induce us to consecrate to them a special Treatise, 
 wholly independent of the present one. 
 
INTRODUCTION. 
 
 IX 
 
 To complete our prefatory sketch of the plan of this volume, let 
 us remark, that previously to entering properly upon our task, we 
 have given, 1. Four chapters, comprising the history of the physical, 
 moral and physiological changes that occur in women at different 
 periods of life. 2. The varieties of conformation; the surgical 
 anatomy of the sexual organs, and the sympathies of the womb. 
 3. The different methods of exploration of the genitalia, and the 
 history of the speculum uteri. 4. The general causes and a synop- 
 tical table of the diseases of females. It should be likewise ob- 
 served, that our anatomical and physiological details are confined to 
 considerations applicable directly to pathology and therapeutics. 
 Under the conviction that all epochs and all nations are tributary to 
 medicine, and that to shut up this noble science within the narrow 
 boundaries of an age -or a nation, is to do it injustice, we have 
 neglected none of the materials furnished by antiquity, by the 
 middle ages, and by cotemporary medicine of all countries. It will 
 be perceived, that in stating a variety of opinions, of experiments, 
 and of curious cases, scattered throughout many volumes, numerous 
 collections, and French and foreign journals, we have scrupulously 
 quoted the sources whence they were obtained.* Lastly, in order 
 to render our work as complete as possible, we have brought it to a 
 conclusion by a long chapter on the special hygiene of the female ; 
 and hoping thereby to secure the better attention of the reader, 
 and especially to lessen the dryness of the descriptions, we have 
 intercalated throughout the whole extent of the work, historical facts 
 and many curious and interesting cases. 
 
 Notwithstanding all our efforts to succeed and leave no gap unoc- 
 cupied, we are far from supposing this treatise to be equal to our 
 wishes : that is to say, a *book in which nothing is wanting ; where 
 nothing is in excess ; and where every thing is in its proper place. 
 Should a benevolent criticism point out the errors and omissions of 
 our work, we shall be flattered by it, and shall the more gratefully 
 receive the advice of the learned, especially as we are resolved to 
 profit by any good counsel, even should it be dictated by envy, sup- 
 posing us sufficiently fortunate to awaken such a feeling. 
 
 May our intentions be properly estimated, and may this work 
 obtain the approbation of our readers ! 
 
 “Quebso veniam non laudem.” 
 
 * The extent of our researches will be understood when it is known that we have 
 cited above one thousand authors, an alphabetical list of whom is given, with a view 
 to facilitate the history and literary study of the diseases of women. 
 

 
 
 
 
 -i 
 
 . 
 
 * • . . ■ .• t . \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 . ' • i ' 
 
 
 
 
 
 
 
 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 - *■ ; 
 
 
 
 
 
 
 
 4 
 
 
 
 
 
 
 
 
 
 r<3 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 * 
 
 
 
 
 
 
 
 
 * * « a 
 
 t 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 * 
 
 
 
 
 
 
 
 
 
 
 
 
 ' 
 
 
 
 
 
 
 
 
 
 
 
CONTENTS 
 
 Dedication, - - - - - - - -iii 
 
 Introduction, --------- y 
 
 CHAPTER I. 
 
 HISTORY OF THE PHYSICAL, MORAL AND PHYSIOLOGICAL CHANGES WHICH TAKE 
 
 PLACE IN FEMALES AT THE PRINCIPAL EPOCHS OF LIFE. 17 
 
 Phenomena of Menstruation, -------22 
 
 Phenomena of Gestation, ------ 35 
 
 Of the Cessation of the Menses, ------ 37 
 
 CHAPTER II. 
 
 OF VARIETIES OF CONFORMATION, THE SURGICAL ANATOMY OF THE GENITAL ORGANS, 
 
 AND THE SYMPATHIES OF THE WOMB. 43 
 
 Of the Vagina and certain varieties of Conformation observed in it, - - 46 
 
 Of the Womb; its Surgical relations, and certain Varieties of its situation, - 49 
 Varieties of Conformation, and surgical relations of the Neck of the Womb, 51 
 
 Faulty Conformation, primitive or accidental, of the Female Sexual Organs, - 53 
 Of the Sympathies of the Womb, - - - - - - 56 
 
 CHAPTER III 
 
 EXAMINATION OF THE FEMALE ORGANS OF GENERATION, BY TOUCHING AND BY THE 
 . SPECULUM. 
 
 Of Touching per Vaginam, ------- 60 
 
 Of Touching by the Rectum, -------62 
 
 Of Palpation above the Pubis, or Touching at the Hypogastrium, - - 63 
 
 Of the Speculum Uteri and the manner of using it, - - - - 64 
 
 CHAPTER IV. 
 
 GENERAL CAUSES AND SYNOPTICAL TABLE OF DISEASES OF FEMALES. 71 
 
Xll 
 
 CONTENTS. 
 
 . FIRST SECTION. 
 
 CHAPTER V. 
 
 Lesions of Form and Development, ------ 74 
 
 Occlusion of the Sexual Organs, - - - - - 74 
 
 Of the Union of the Labia and of other faulty Conformations of the Vulva 
 
 and its parts, - - - - - - - - 76 
 
 Of Cohesion of the Nymphee, ------- 79 
 
 Of Excessive Development of the Nvmphse, ----- 80 
 
 Of Unnatural Development of the Clitoris, and of its Excision, - - 82 
 
 Imperforation and Stricture of the Female Urethra, - - - 85 
 
 Faulty Conformation of tfce Vagina, ------ 87 
 
 Imperforation of the Vagina, -------87 
 
 Of Congenital Narrowness of the Vagina, - - - - - 94 
 
 Of Accidental Obliteration and Stricture of the Vagina, ... 100 
 
 Of Obturation of the Vagina and the Means of cure, - - - - 106 
 
 Surgical Treatment of Accidental Cohesion of the Vaginal Parietes; and of 
 
 Congenital Obturation of the Vagina, - - - - - 111 
 
 Occlusion of the Cervix Uteri, - - - - - - -113 
 
 Atresia of the Fallopian Tubes, - - - - - -115 
 
 Of Absence of the Vagina — and of Cases in which the Vagina opens into the 
 
 Rectum or Bladder, - - - - - - - 116 
 
 Absence of the Womb and Means by which it can be ascertained, - - 118 
 
 SECOND SECTION. 
 
 CHAPTER VI. 
 
 Lesions of Situation, - ------ - 121 
 
 Of Hysteroptosis, - - - - - - - -122 
 
 Of Pessaries and their Varieties, - - - - - - 133 
 
 Of the principal Pessaries in use, and the Method of Employing them, - 139 
 
 Of the choice of a Pessary, - - - - - - -145 
 
 Accidents connected with the presence of a Pessary in the Vagina, - - 145 
 
 Complications contra-indicating the use of the Pessary, and Indications in 
 
 certain peculiar cases, - 149 
 
 Cure of Prolapsus Uteri, ------- 150 
 
 Extirpation of the Prolapsed Womb, ------ 152 
 
 Method of Operating, - - - - - ... -152 
 
 Of Anteversion and Retroversion of the Womb, - - - - 154 
 
 Of the Anteflexion and Retroflexion or Curvature of the Uterus, - - 169 
 
 Of Inclination, and Obliquity of the Womb, - 172 
 
 Of Inversion of the Womb, - - - - . . -175 
 
 Of Elevation of the Womb, - - - - . . -190 
 
 Of Abnormal Immobility of the Womb, ----- 191 
 
 Of Hysterocele or Hernia of the Womb, - - - - - 194 
 
 Inguinal Hysterocele, -------- 195 
 
 Crural Hysterocele, - - - . - . - - 195 
 
CONTENTS. Xlll 
 
 Ventral Hysterocele, - - - - - - - -196 
 
 Hernia of the Ovary, - 198 
 
 Vaginal Cystocele, or Hernia of the Bladder in the Vagina, - - - 201 
 
 Prolapsion of the Mucous Membrane of the Urethra, - 204 
 
 Vaginal Enterocele, - 205 
 
 Vulvar Enterocele and Cystocele, - - - - - 208 
 
 Of Inversion and Swelling of the Lining Membrane of the Vagina, - - 209 
 
 Invagination of the Vagina, ------- 214 
 
 THIRD SECTION. 
 
 CHAPTER VII. 
 
 Physical Lesions, - -- -- -- - 215 
 
 Contusion of the Labia Majora, - - - - - - 216 
 
 Of Rupture of the Perineum and the Means of remedying it, - - - 217 
 
 Of Lacerations and of Rupture of the Vagina, .... 224 
 
 Of Contusions and Wounds of the Uterus, ----- 227 
 
 Contusions and Wounds of the Mammae, ----- 229 
 
 Of Rupture of the Uterus, ------- 230 
 
 Of Vaginal Fistulas, - -- -- -- - 238 
 
 Of Vesico-Vaginal and Recto-Vaginal Fistulas, - - - - 238 
 
 Of the Palliative Method, ------- 243 
 
 Temporary Palliative Method, ------- 244 
 
 Of Tamponnement, and of Dessault’s Method, ... - 245 
 
 Of Cauterization, -------- 246 
 
 Of the Suture, 249 
 
 Method of the Author, ------- - 252 
 
 Of the Approximation of the Edges of Vagino-Vesical Fistulas by means of 
 
 peculiar instruments, without the use of the Suture, - - - 257 
 
 Of Recto-Vaginal Fistulas, - - - - - - -261 
 
 A Recto-Vaginal Fistula, cured by J. Rhea Barton, M.D., - - - 264 
 
 Of Foreign Bodies accidentally introduced into the Vagina, the Uterus and 
 
 the Canal of the Urethra, ------ 266 
 
 FOURTH SECTION. 
 
 CHAPTER VIII. 
 
 Vital and Organic Lesions, ------- 268 
 
 Superficial Inflammation of the Vulva, ----- 269 ^ 
 
 Of Prurigo of the Vulva, ------- 269 
 
 Of Phlegmon and deep-seated Inflammation of the Labia Majora, - - 272 
 
 Gangrenous Inflammation of the Labia Majora, - - - 273 
 
 Acute Inflammation of the Vagina, ------ 274 
 
 Inflammation of the Parenchyma and Lining Membrane of the Uterus, - 276 
 
 Treatment of Acute Metritis, ------- 284 
 
 Of Chronic Metritis or Subacute Inflammation of the Proper Tissue of the 
 
 Uterus, - - - - - - - - - 293 
 
 Chronic Metritis without Engorgement, ----- 294 
 
XIV 
 
 CONTENTS. 
 
 Chronic Metritis with Engorgement, ------ 295 
 
 Engorgement of the Uterus without Induration, ... - 297 
 
 Of CEdema of the Neck of the Uterus, ----- 299 
 
 Sanguine Engorgement of the Uterus with or without Haemorrhage, - - 300 
 
 Congestive Engorgement with Haemorrhage, ----- 301 
 
 Of Primary Engorgement with Induration, ----- 303 
 
 Of Scirrhous Engorgement, ------- 304 
 
 Tubercular Induration, - 305 
 
 Of Leucorrhoea, or the Whites, ------ 307 
 
 Of Redness, Simple Ulcerations, and Eruptions upon the Os Tincae, - - 323 
 
 Of Chancres, and Scrofulous Ulcers, etc., upon the Os Tincae, - - 325 
 
 Of Carcinomatous Ulcers, ------- 327 
 
 Of Cancer of the Uterus, ------- 328 
 
 Treatment of Cancer of the Womb, ------ 338 
 
 Surgical Treatment of Cancer, ...... 344 
 
 Amputation of the Neck of the Uterus, ----- 346 
 
 Modifications of the Operation by the Author, ... - 349 
 
 Of Hysterotomy performed without displacing the Uterus, - - - 351 
 
 Description of the Operation, ------- 352 
 
 Advantages of the Author’s Method, ------ 356 
 
 After-Treatment, - 358 
 
 Extirpation of the Cancerous Uterus, ------ 360 
 
 Physometra, or Tympanitis of the Womb, ----- 366 
 
 Of Hydrometra, or Dropsy of the Womb, ----- 374 
 
 Of Hydatids of the Womb, - - - - - - £ - 373 
 
 Of Calculi of the Womb, and other Genital Parts, ... - 381 
 
 Of Polypus of the Womb and Vagina, ----- 385 
 
 Inflammation of the Ovaria and Fallopian Tubes, - - - - 410 
 
 Of Dropsy of the Ovaries, and Fallopian Tubes, ... - 420 
 
 Of Cancer of the Ovarium and other Degenerations of that organ, - - 433 
 
 Cancer of the Vagina and external Organs of Gene r ation, - - - 437 
 
 Of CEdema, Varix, and other Tumours of the Vulva, - - - - 438 
 
 Cancer of the Breast, - - - - - - - -441 
 
 Of Encysted Tumours, and different kinds of Chronic Engorgement of the 
 
 Mammae, -------- 457 
 
 FIFTH SECTION. 
 
 CHAPTER IX. 
 
 Lesions of the Functions, ------ 459 
 
 Of Amenorrhoea, - -- -- -- - 463 
 
 'Of Dysmenorrhcea, -------- 479 
 
 Of Immoderate Flow of the Menses and other Uterine Haemorrhages, - 483 
 
 Of Metrorrhagia, - - - - - - ... 486 
 
 Of Chlorosis or Green Sickness, ------ 495 
 
 Of Nymphomania, or Furor Uterinus, ------ 513 
 
 Of Hysteria and other Spasmodic Diseases of Women, ... 518 
 
 Hysteriform Attacks, - - - - - - - 536 
 
 Of Gastro-Intestinal Spasm, ------- 538 
 
 Of Hysteralgia, -------- 540 
 
CONTENTS. 
 
 XV 
 
 CHAPTER X. 
 
 Special Hygiene of Women, - 542 
 
 Hygienic Rules concerning Puberty and Menstruation, - - - 552 
 
 Hygienic Rules in relation to the Union of the Sexes, ... 546 
 
 Hygienic Rules relative to the Change of Life, - • - 549 
 
 General Hygiene of Women, ------- 552 
 
 SIXTH SECTION. 
 
 CHAPTER XI. 
 
 Lesions relative to Reproduction, ------ 562 
 
 Of Impotence and Sterility, ------- 562 
 
 Of False Pregnancy, -------- 568 
 
 Of Moles, or Depraved Conception, ------ 570 
 
 Of Extra-Uterine Pregnancy, ------- 574 
 
 Of Gastrotomy, --------- 583 
 
 Of Diseases connected with Pregnancy, ----- 584 
 
 Of Abortion or Miscarriage, ------- 585 
 
 Of Nausea and Vomiting, ------- 595 
 
 Of Ptyalism, - -- -- -- -- 597 
 
 Of Odontalgia, -------- - 598 
 
 Of Anorexia, -------- - 599 
 
 Of Boulimia, - -- -- -- -- 599 
 
 Of Dyspepsia and Polydipsia, ------- 600 
 
 Of Capricious Appetite, (Pica, Malacia,) ----- 600 
 
 Of Pyrosis, Dysphagia and Heartburn, - - - - - 601 
 
 Of Gastralgia, --------- 602 
 
 Of Enteralgia, -------- - 604 
 
 Of Constipation, - -- -- -- - 604 
 
 Of Diarrhoea, Dysentery and Tenesmus, ----- 605 
 
 Of Dyspnoea, -------- - 606 
 
 Of Cough, 609 
 
 Of Haemorrhages occurring during Pregnancy, - 610 
 
 Of Haemoptysis, Haernatemesis and Epistaxis, - - - 616 
 
 Disorders of the Circulation during Pregnancy, - - - 61 S 
 
 Of Palpitation, - - - - - - - - - 619 
 
 Of Syncope, --------- 621 
 
 Of Varices, - -- -- -- -- 622 
 
 Of Haemorrhoids, -------- 624 
 
 Of (Edema, - - - - - - - - 625 
 
 Of Cephalalgia and Vertigo, 627 
 
 Insomnia, or Agrypnia, -------- 628 
 
 Lesions of the Sight, the Hearing, the Smell, &c., - 629 
 
 Disorders of the Intelligence and of the Moral Inclinations and Affections, - 631 
 
 Of Eclampsia, or Puerperal Convulsions, ----- 632 
 
 Disposition to Fall, - 646 
 
 Disorders of the Urinary Organs during Gestation, ... - 647 
 
 Pains in different parts during Pregnancy, ----- 648 
 
XVI 
 
 CONTENTS. 
 
 Diseases connected with the Lying-in, - 
 After-Pains, - 
 
 Accidents relative to the Lochia, - 
 Of Milk-Fever, ------ 
 
 Of Puerperal Peritonitis, - 
 
 Of Uterine Phlebitis, - - - - - 
 
 Of other kinds of Puerperal Phlebitis, 
 
 Of Painful (Edema, - - - - 
 
 Puerperal Neuritis, - 
 
 Of Phlegmonous Abscess in Lying-in Women, 
 
 Inertia of the Womb, and Flooding depending thereon, 
 
 Of Miliary Eruption, - - - - - 
 
 Lesions relative to Lactation, - 
 
 Polygalactia, and Milk-Consumption, - 
 
 Diseases of the Mammae, - 
 
 Of Inflammation of the Mammae, or the Weed, 
 
 Hygiene of Pregnant and Lying-In Women, 
 
 List of Authors, - 
 Ihdex, 
 
 649 
 
 649 
 
 651 
 
 652 
 
 654 
 
 661 
 
 665 
 
 682 
 
 684 
 
 684 
 
 685 
 
 687 
 
 688 
 
 689 
 
 692 
 
 693 
 
 696 
 
 705 
 
 715 
 
A 
 
 TREATISE 
 
 OX THE 
 
 DISEASES OF FEMALES. 
 
 CHAPTER I. 
 
 HISTORY OF THE PHYSICAL, MORAL AND PHYSIOLOGICAL CHANGES WHICH TAKE PLACE IX 
 FEMALES AT THE PRINCIPAL EPOCHS OF LIFE* 
 
 Feeble and sensitive at birth, and destined by nature to give us 
 existence and to preserve us afterwards by means of her tender and 
 watchful care, woman, the most faithful companion of man, may be 
 regarded as the very complement of the benefits bestowed upon us 
 by the Divine Being ; as an object fitted to excite our highest inte- 
 rest, and presenting to the philosopher, as well as to the physician, a 
 vast field of contemplation. 
 
 What subject, indeed, is more worthy of our attentive meditation 
 than the ‘series of changes, physical, moral and physiological, that 
 accompany every stage of woman’s existence ! By a long succes- 
 sion of modifications and revolutions, she discloses all the phases of 
 her constitution. In infancy she differs slightly from the male, in 
 whose pleasures and amusements she participates, as well as in his 
 dispositions and tastes, his inconstancy and vivacity. At that early 
 period, ignorant of her own sex, ignorant, so to speak, of her own 
 nature, the blush of modesty does not mantle on her cheek, and her 
 eyes, which reveal no passions, seem to seek only what has reference 
 to her real wants. 
 
 Although at this early epoch her body is but a sketch of the forms 
 it is destined to assume at a later period, she always retains, even 
 after her entire development, some touch of the softness and delicacy 
 peculiar to childhood, and does not depart so widely as her playmate 
 from the idea of her original constitution. 
 
 The reproductive faculty divides the life of the female into three 
 very distinct periods or stages. In the first, this property has no 
 existence*, in the second it is in fpll activity, and in the third it has 
 become null again. The duration of the first commonly decides that 
 2 
 
IS 
 
 PHENOMENA OF PUBERTY. 
 
 of the two last periods; so as to establish the general rule that the 
 old age of woman comes earlier in proportion as her puberty has 
 been more precocious. 
 
 The vital forces that regulate the organic system, and the organs that 
 constitute that system, gradually increase during the first period of 
 life; they attain their perfect development in the second ; and diminish 
 and become extinct at the close of the third, whose term, like that of 
 the others, may be accelerated or retarded by different accidental 
 causes and circumstances, dependent on certain physical and moral 
 conditions. 
 
 Upon setting out in the career of life, the two sexes exhibit nearly 
 the same physiognomical characters and the same delicacy of organi- 
 zation. Their type and their character, as yet indeterminate, differ 
 only by almost imperceptible modifications, and which it is not pos- 
 sible to trace out in full detail. Subject to the same functions and 
 wants, their isolated and individual existence fails, as yet, to reveal 
 the sympathetic relations that are in the end destined to establish 
 between them a state of reciprocal dependence. Subjects of the 
 same kinds of diseases, they are principally liable to the convulsive 
 affections, and especially to inflammation of the brain, because the 
 head, which, in infancy, has a proportional size greater than in any 
 other age, is, in them a vital centre, towards which almost all the 
 efforts of the organisms are directed. 
 
 The shades of difference in the sexes soon assume a more de- 
 cided tone; and their peculiar characters become so much the more 
 marked as the development of each individual is more complete and 
 approaches more nearly to the period when, by a sudden change, 
 nature reveals the completion of those preparations she has been 
 silently making. 
 
 The interval betwixt the tenth year and the age of puberty is a 
 period of transition, a sort of passage from childhood to adolescence, 
 which appears to be the happiest era in the life of the female. Her 
 extreme nervous mobility prevents her being too long impressed by 
 the grave sentiments that might be fitted to interfere with her happi- 
 ness. This being for young women the period of gentle pleasures and 
 of the freest gaiety, it follows that imagination exhibits every object 
 under the most attractive colours, and that the existence of young 
 females is agreeably varied by a piquant freedom of action and a 
 great mobility of tastes and affections. Exempt, at this age, from 
 cares and troubles, they sing, they weep and laugh at the same mo- 
 ment; and, as their joys, so their pleasures and their grief, as well as 
 all their other impressions, are ephemeral; they proceed along a 
 flowery path up to the age when nature calls on them for the tribute 
 which they owe to the species. 
 
 The young girl who, until now, was an equivocal, non-sexual crea- 
 ture, becomes a woman in her countenance and in all the parts of 
 her body, in the elegance of her stature and beauty of her form, the 
 delicacy of her features, in her constitution, in the sonorous and 
 melodious tones of her voice, in her sensibility and affections, in her 
 character, her inclinations, her tastes, her habits and even in her 
 
PHENOMENA OF PUBERTY. 
 
 19 
 
 maladies. Very soon are all the traits of resemblance between the 
 two sexes found to be effaced. The bud newly expanded blossoms 
 amongst the flowers, and this brilliant metamorphosis is signalized 
 by the rosy tints of the cheeks and lips, and the perfect development 
 which discloses the arrival of the age of puberty. 
 
 This important period, this first moment of triumph in which nature 
 seems to renew herself, is announced by a sentiment of necessity to 
 multiply, within, the principle of life, and by various striking and 
 admirable phenomena which put an end to the social inertia in which 
 the young girl had lived from the period of her birth. The sexual 
 organs soon become a centre of fluxion; nature makes great efforts 
 in order to establish the periodical discharge, and the whole machine 
 experiences, in its inmost recesses, a succussion, a violent commotion, 
 a general movement. The new energy of the womb impresses a 
 powerful impulse upon the entire system of organs; their functions 
 become more active; the body grows with rapidity; the various 
 portions of the figure become more expressed, and bring out those 
 graceful contours which belong to the tender sex alone. At the same 
 time other important changes take place ; the pelvis and the sexual 
 organs, which were in a rudimental condition only, now acquire their 
 full proportions ; the throat rises and becomes more sensitive ; the 
 breasts become rounded and full, while they establish their corre- 
 spondence of sympathy with the womb. The mons veneris comes 
 out into complete relief, and clothes itself with a thick down, which, 
 like a veil covering the organs of modesty, seems to announce that 
 they are destined soon to become fitted to act the important part 
 assigned to them by the law of nature. The meshes of the cellular 
 [and adipose] tissue, becoming rapidly dilated under the influence 
 of the uterine irradiations, soon impart to the surface of the body 
 a voluptuous embonpoint which lends the highest splendour to the 
 attractive beauty and freshness of youth. 
 
 The physiognomy of the young woman has now acquired a new 
 expression; her gestures bear the stamp of her feelings; her language 
 has become more touching and pathetic ; her eyes, full of life but 
 languishing, announce a mixture of desires and fears, of modesty 
 and love — in fine, every thing conspires to excite, to caress and to 
 incite. 
 
 Her tastes, her enjoyments and her inclinations are modified like 
 the rest ; her most pressing want is to experience frivolous emotions ; 
 she is passionately given to the dance, shows and company; the 
 curiosity so natural to her sex acquires new force and activity; she 
 devours books of romance, or more than ever fervent in devotion, 
 is excited by the expansive passions, and particularly by religious 
 piety, which is to her a sort of love. 
 
 At this brilliant period of life her moral, which depends upon 
 her physical condition, undergoes great mutations. The young girl 
 becomes more tender-hearted, more sensitive, more compassionate, 
 and appears to attach herself to every thing about her. The new 
 sensations of her soul make her timid in approaching the compa- 
 nions of her childhood; a strange trouble, a sort of restlessness, an 
 
20 
 
 PHENOMENA OF PUBERTY. 
 
 agitation before unknown, are the heralds of a power whose exist- 
 ence she does not even suspect. 
 
 The action of the new forces of vitality established within the 
 sexual organs augments more and more, and reacts with energy 
 upon the whole system. Under the sympathetic irradiations of the 
 uterus the general sensibility becomes changed and even excited in 
 a peculiar manner. A new sentiment soon gives rise to desires 
 which, as yet, have no definite object, and to vague emotions, of 
 an instinct that seeks some object — it knows not what. This rising 
 want produces the impression of a touching melancholy, a charming 
 bashfulness, whose principle is founded in ingenuous love, presaging 
 new dispositions and announcing that the inclinations and habits of 
 childhood are exchanged for other sentiments. The young virgin 
 becomes timid, reserved, abstract and dreamy. She sighs less for 
 pleasure than for happiness ; the necessity of loving makes her seek 
 solitude — and this new want, that troubles her heart and engages 
 it wholly, becomes, if it remain unsatisfied, a source of multiplied 
 disorders and derangements. 
 
 Various causes calculated to render the play of the vital forces 
 more active, have the effect either of retarding or precipitating the 
 age of puberty : thus, abundant. and stimulating food and drinks, man- 
 ners, habits and climate, exercise a marked influence upon this vital 
 phenomenon. Certain moral circumstances may likewise accelerate 
 its arrival ; but the artificial maturity thus resulting always acts inju- 
 riously upon the organization: among these circumstances may be 
 enumerated premature passions and pleasures, the arts of imitation, 
 music, painting, the perusal of obscene romances, the inspection of 
 lascivious pictures, the theatre and the ball-room ; the bad examples 
 and the premature libertinism, of which too many samples are unfor- 
 tunately furnished in great cities. These specimens of premature 
 puberty, the miserable consequence of too great vivacity of the ima- 
 gination, are sometimes met with as early as the eighth or tenth year. 
 
 The normal puberty that is announced by the eruption of the 
 menses, is, in our climate, not generally observed before the fifteenth 
 or sixteenth year; but its period is different according to the region 
 in which the subject lives. In southern countries, for example, as in 
 Greece, Italy and Spain, under the beautiful skies of Provence or 
 Languedoc, young girls are often found to be grown vp at twelve 
 or sixteen years of age ; and in certain Asiatic countries, heated by 
 a burning sun, the young women become marriageable as early as 
 the tenth or eleventh year. In the cold latitudes, on the contrary, as 
 in Sweden, Norway or Lapland, it is not uncommon for the women 
 to be as late as the twentieth or twenty-fifth year before the erup- 
 tion of the menses, or even still later. 
 
 in general, the crisis of puberty is more distressing for females than 
 for males, especially for such as are endowed with a very delicate 
 and nervous constitution, as often happens to such as lead a seden- 
 tary life, and have, acquired the habits and manners appertaining to 
 the opulent and luxurious classes. 
 
 The most important physiological phenomenon of this era con- 
 
PHENOMENA OF PUBERTY. 
 
 21 
 
 sists in the eruption of the catamenia, which depends upon the new 
 mode of vitality established in the sexual organs. When nothing: 
 has occurred to interrupt the operation of the laws of the economy, 
 the uterus, which in the little girl was quiescent and unaroused, 
 acquires a considerable degree of activity, together with an exalted 
 state of sensibility. The full-grown woman very soon becomes the 
 subject of the mensual revolution, which terminates in a real crisis, 
 and by a haemorrhage from the womb more or less considerable, 
 according to circumstances. 
 
 [There are very conflicting statements as to the influence of climate on 
 puberty. In order to have a reliable authority, I addressed a note to Dr. 
 Joseph Maria Vargas, of Caraccas, in Venezuela, requesting information 
 from him on the subject of puberty, and the change of life in that climate. 
 Dr. Vargas is the same gentleman who, some years since, was President of 
 the Republic of Venezuela, and is well known for his devotion to every 
 thing relative to philosophical pursuits: he is the author of a system of 
 surgery in two volumes, published at Caraccas in 1842, and is professor in 
 that university. In his answer to my note, under date of May 2d, 1844, 
 he says: “As to the points you are desirous of ascertaining, regarding the 
 epoch of puberty and the critical age of the women of this country, you will 
 find adjoined my answer, (to your queries,) embodying the information of 
 the most practical physicians of this city,” and he gives the following 
 table : — 
 
 First. — Common epoch of puberty. 
 
 In 70 per cent, menstruation from 13 to 15 
 “ 10 “ “ “ “11 to 12 
 
 in very rare cases at 10 
 “ 20 “ “ “ “ 16 to 18 
 
 very rare cases 19 to 20 
 and even 21 
 
 Second. — Critical age common from 45 to 48 
 
 In a few cases 40 to 44 
 
 In a few cases 49 to 50 
 
 In very rare cases 38 to 40 
 In very rare cases 51 to 53 
 
 Dr. Vargas informs me that precocious menstruation is more common in 
 the white than in the negro race. 
 
 In Lee’s Lectures on Midwifery , p. 44, is a statement of the epoch at 
 Antigua, where Dr. Nicholson never met with it before the fourteenth year. 
 Dr. Lee doubts whether intertropical women menstruate earlier than others. 
 The reader is referred to Lee’s Fourth Lecture for a statement of the con- 
 flicting reports upon the influence of climate in precipitating or procrasti- 
 nating the eruption of the catamenia, and also to Raciborski. 
 
 The period of eruption in 1781 women of England and France, which I 
 
22 
 
 PHENOMENA OF MENSTRUATION. 
 
 have calculated from the tables of Brierre de Boismont (Z?e la Menstruation , 
 &c., Paris, 1842, p. 39,) and Lee’s Lecture, was as follows: — 
 
 At 
 
 11 
 
 years 
 
 in 
 
 110 
 
 
 At 16 
 
 “ “ 284 
 
 t( 
 
 12 
 
 44 
 
 44 
 
 144 
 
 
 “ 18 
 
 44 44 144 
 
 44 
 
 13 
 
 44 
 
 44 
 
 256 
 
 • ♦ 
 
 “ 19 
 
 44 4 4 72 
 
 44 
 
 14 
 
 44 
 
 44 
 
 360 
 
 
 “ 20 
 
 “ “ 40—: 
 
 44 
 
 15 
 
 .44 
 
 44 
 
 366 
 
 
 
 
 PHENOMENA OF MENSTRUATION. 
 
 Menstruation is a distinctive characteristic of the human species, 
 for, except at the coupling season, no other animal is subject to a 
 periodical discharge from the sexual organ. 
 
 In some females the first eruption of the menses takes place sud- 
 denly, and without the least premonitory sign. The blood, by 
 accumulating within the organ destined at some future period to 
 contain the embryo, by its superabundant quantity, opens an easy 
 way of escape by a before unaccustomed route. 
 
 [I do not perceive the necessity or force of this remark, if he refers to 
 the cavity, since it is certain that a drop of fluid, whether of blood or any 
 other liquor, can never have the least difficulty in escaping from the cavity 
 of the fundus and body of the womb, along the canal of the cervix, which 
 is always sufficiently open to admit of the introduction of a medium bougie, 
 even to the fundus uteri. — M.] 
 
 In the major part of the cases, however, the first mensual haemor- 
 rhage is both preceded and accompanied by various inconvenient 
 circumstances. A real febrile movement is set up ; the pulse is full, 
 irregular, bounding ; a considerable heat is felt in the genitalia, 
 which become tumid, painful and sensitive, occurrences which are 
 also observable with regard to the mammary glands. The young 
 girl complains of general plethora, cephalalgia, suffocation, colic and 
 other symptoms, the signs of uterine congestion, such as pain in the 
 loins, with a sense of weight in the thighs and in the pubic region. 
 In some cases spasmodic cough is noticed, and the sleep is disturbed 
 by palpitations and wearisome dreams. At this period, the young 
 adolescent becomes sad and melancholy, and gives herself up to 
 indulgence in reverie, the cause of which she does not understand ; 
 she is now more susceptible, impressionable, and becomes subject to 
 violent emotion from very slight causes. She grows more irascible, 
 often has queer appetites, and is ‘Capricious — her imagination is 
 more elevated, and a secret instinct gives her the presentiment of 
 that important destiny that nature calls her to fulfil. 
 
 At length the flow makes its appearance, preceded and followed 
 by a muco-serous discharge ; it is in inconsiderable quantity, rarely 
 lasts more than two or three days, and at first recurs at irregular 
 periods, but acquires precision after the fourth or fifth return. 
 
PHENOMENA OF MENSTRUATION. 
 
 23 
 
 [There are a great many persons to be met with who become regular at 
 first, and who continue so throughout the whole period of the menstrual 
 life.— M.] 
 
 In women, already regular, the discharge is gentle or moderate, 
 but without any interruption from beginning to end. On the first 
 day it is scarcely a show , but increases progressively until the third ; 
 from which time it gradually lessens until the fifth or sixth, more or 
 less. By this time great relief is obtained, all the precursory symp- 
 toms have vanished, and nothing remains but a feeling of languor, 
 which makes her seek repose, not exercise — the countenance has a 
 languishing look, the cheeks are pale, the eyes are less bright, and 
 have a dark palpebral areola, the breasts continue to be painful, the 
 odour of the breath and perspiration is strong, and there is in the 
 genital parts a sense of heat, and pruritus which provoke the aphro- 
 disiac sense. 
 
 [M. Colombat has, in the above paragraph, painted, in colours, perhaps, a 
 little too strong, the features of a healthful menstruation. I am assured, by 
 many persons in the various classes of society, that the menstrual act is, in 
 them at least, unattended by such very marked signs of constitutional con- 
 sent as M. C. would seem to believe. Many of them have assured me, 
 during more than thirty years, that for them the catamenia have never been 
 the occasion of the least trouble or the smallest modification of their health. 
 The flow begins, continues and ends without sensation or inconvenience, 
 except what arises from the needful cares as to cleanliness of the person. I 
 am very much inclined to think, seeing that so many millions of women 
 exist who never make the least complaint of their menstruae, it is only in 
 particular cases that the reader should adopt M. Colombat’s description, and 
 not in all cases. — M.] 
 
 There are women who, though always very regular, are quite ill 
 at each menstrual revolution — such persons are generally unwell 
 and suffering at the approach of the menses, and some of them 
 suffer from various accidental affections, as colic, headache, vapours, 
 spasms, hysterics, convulsions, and even epilepsy. In others the 
 digestive functions become deranged and painful. The patient feels 
 debilitated, and the memory is weakened : all women at this time 
 readily take cold, are soon fatigued, and as they are generally more 
 sensitive to all sorts of impressions, they become more susceptible, 
 sad, timid, irascible, and subject to caprices that claim not indul- 
 gence only, but the tenderest commiseration. 
 
 The relief that follows the menstrual travail is a sure index of the 
 regularity of this function, which in general recurs, when well esta- 
 blished, at fixed periods of twenty-eight or thirty days, and in this 
 regard, in some females, seems to correspond with the phases of the 
 moon. This opinion, being generally entertained among the vulgar, 
 has been reduced to a proverb by the poet: — 
 
 “Luna vetus vetulas, juvenes nova luna repurgat.” 
 
24 
 
 PHENOMENA OF MENSTRUATION. 
 
 Instead of having any reference to the lunar month, Haller and 
 some other authors suppose rather that the menses coincide with the 
 solar months. Gail, whilst not admitting a sidereal influence, be- 
 lieves that the discharge will be found generally to take place at 
 about the same period of time, and that there are certain weeks in 
 each month in which no women are menstruating. He divides the 
 menstrual epochs into two classes — comprising the first eight days of 
 the first and second fortnights, that is to say, the first and third weeks: 
 if there be women who, from accidental causes, become unwell dur- 
 ing the second and fourth weeks, he pretends that, after some months, 
 they will return under obedience to the general law; but Dr. Gall 
 furnishes no explanation of the cause of her general menstruation 
 at two different epochs. Many women are met with who, in all 
 other respects, are in fine health, yet in whom the periodical re- 
 turns anticipate as regards the lunar months. Thus certain nervous 
 women, especially such as are of an erotic temperament, are found 
 to menstruate every fortnight, while others, of an opposite constitu- 
 tion, are subject to the returns only every six weeks, or even only 
 every two months. Linnaeus says that he saw women in Lapland 
 whose discharges occurred only once a year. In his Treatise on 
 Diseases of the Womb, Dr. Pauly relates that M. Lisfranc has met 
 with women who were regular every fifth or sixth month, or only 
 every fourth and even sixth year. Some of these women were 
 habitually disordered, and others enjoyed perfect health — in the first 
 case the indications would be the same as for persons who had 
 never yet menstruated ; hut we shall return to this subject in treating 
 of the diseases of menstruation. 
 
 [I see no propriety in citing such cases as these as samples of menstrua- 
 tion. I should, in all such instances, be inclined to regard the flow as a 
 malady merely, and not as the result of the regular exercise of a normal 
 physiological function. A lady, for example, informed me yesterday, 
 (March 14, 1844,) that she was regular at thirteen, and, after giving birth 
 to twelve children, lost her catamenia definitively at 35 aetat.; after having 
 seen nothing for seven years, she had a very copious menstruation. She 
 has had uninterrupted health all her life long. I could not regard the case 
 in question otherwise than as an incident in her history having probably no 
 relation to the menstrual function. The case mentioned by M. Colombat 
 below, is, however, of a different character. — M.] 
 
 The Duchess of D., celebrated as much for her wit as for her ad- 
 mirable literary talents, assured me that, having ceased to menstruate 
 at thirty-five, she supposed she had reached her critical age ; the 
 more especially as she became marriageable at an early age ; but at 
 about her forty-fifth year, that is to say, after ten years of menstrual 
 suppression, she again became regular. From that time the duchess, 
 who is at present fifty-three years of age, has been as regular as she 
 was in her youth. 
 
 The menstrual revolution has been attributed to a variety of causes. 
 Aristotle, Mead, Werlhoff, Vanhelmont, Roussel and some other 
 
PHENOMENA OF MENSTRUATION. 
 
 25 
 
 authors supposed it to depend upon lunar influence; Pliny thought 
 it was the excretion of a noxious substance; Galen, Astruc, Simpson 
 and Lobstein could perceive in it nothing more than the expulsion of 
 a superfluous quantity of blood. Frederick Hoffmann supposed the 
 menstrual flux to be the fruit of a mechanical action. He says that 
 women generate more blood than they need, in consequence of the 
 slowness of their circulation and the small amount of their perspira- 
 tion. Hence arise venous congestions and spasms in the extreme 
 vessels. The blood that is refused admittance into the vessels that 
 are affected with spasmodic constriction must escape into the womb, 
 whose particular structure favours this congestion. M. Osiander and 
 some other German physicians allow that menstruation takes place 
 on account of the excess of carbon and azote contained in the blood 
 of the womb. Paracelsus, Silvius and De Graff regarded it as the 
 product of a fermentative principle. Clifton avers that it depends 
 upon the weakness of the venous paries, as related to the perpendi- 
 cular effort of the fluid. Emett regarded it as consequent upon a 
 state of erection ; Lecat as an amorous phlogosis; Stahl and Professor 
 Luges think that it takes place under an irr it ament um, a peculiar 
 molimen ; and, lastly, the position of the uterus and certain arrange- 
 ments of its blood-vessels have been assigned as the causes of the 
 menstrual discharge. 
 
 [I feel compelled, by a sense of duty to the reader, to make some remarks 
 upon the causes of menstruation additional to those cited by M. Colombat, 
 and which, to the merest tyro, must appear unsatisfactory. It seems to be 
 universally admitted that the substantial causes of menstruation ought to 
 be sought for in a condition of the female ovaries, which are regarded as 
 the proper seats of the reproductive faculty, not only as being the points in 
 which the aphrodisiac faculty most essentially dwells, but as influencing the 
 female constitution in the remarkable manner known to be coincident with the 
 development of those bodies and also consequent upon the abstraction of their 
 vital energies after the lapse of years. In the male the full unfolding of the 
 size, form and power of the testes is the sign and guarantee of the repro- 
 ductive force, and the same is true of the ovary of the female, in whom, up 
 to the age of puberty, these organs are known to be incomplete. 
 
 The total absence, by congenital deformity or by ablation or by diseased 
 destruction, of both ovaries, is known to be attended with loss of the men- 
 strual power, as well as of the erotic principle. The atrophy of the same 
 organs, by the progress of age, equally involves the abolition of the men- 
 strual force. If these propositions be true, it follows that the seat of the men- 
 strual force must be conceded to exist in the ovaries. But the question as to 
 how that force comes to be exerted upon the constitution in a manner so sur- 
 prising, in the regular, equable and necessary exercise of it, was unexplained 
 until the simultaneous development of the new theory of menstruation by 
 MM. Negrier and Gendrin in France, and Lee in England. This is not the 
 place to settle, even were it in my power, the claims of the rivals for the 
 
26 
 
 PHENOMENA OF MENSTRUATION. 
 
 honour of originating this new philosophy. The reader who takes interest 
 in that point is referred to M. Negrier’s reclamation against M. Gendrin, in 
 his Recherches Anat. et Physiolog. sur les Ovaires , Paris, 1840, 8vo.; and 
 to Lee’s Midwifery , and Raciborski’s late work, Be la Puberte , &c. M. 
 N., in the preface, shows that so early as November, 1831, he read a paper 
 upon the theory at the Medical Society of Angers, and also made it known, 
 after considerable researches, at Paris, in 1838, to Messrs. P. Dubois, Berard, 
 sen., Cullerier, jun., and Ollivier d’Angers. But, unfortunately for him, 
 M. Gendrin gave a very lucid statement of the theory and of the facts which 
 illustrate and uphold it, in his Traite Philos, de Med. Pratique, 1838. Dr. 
 Robert Lee, of London, whose rising fame seems destined to eclipse all his 
 English brethren, also had perceived the truths of nature upon this point as 
 early as 1831. T. L. G. Bischoff, in his Entwickelungsgeschicte der 
 Saugthierre und des Menschen , Leipzig, 1842, and which has been trans- 
 lated by M. Jourdan and published in the Encyclopedic Anatomique, 1843, 
 speaks of this new doctrine as follows: “At first I opposed this doctrine, 
 for it seemed to me improbable that, after so many researches and discus- 
 sions on the subject of the corpora lutea, it had not been long since examined ; 
 and because, had it been true, there must have been found corpora lutea in 
 the numerous subjects dying during the menstrual act and examined by the 
 anatomists. However, I have since had opportunities of examining the 
 bodies of two women who died while menstruating, and in both of them I 
 not only found the ovaries very turgid and gorged with blood, but I also 
 discovered a well-marked Graafian vesicle, open, and containing a corpus 
 luteum in the process of its development. I have also become satisfied that, 
 if the sexual union is prevented, with animals in heat, the swollen follicles 
 are likewise converted into a sort of corpora lutea. Lastly, since the period 
 referred to, I have carefully examined all the ovaries I have met with of 
 persons dying in puberty: there is always to be found a tuberculated and 
 cicatrized surface, and, at least in many of them, traces of imperfect corpora 
 lutea, even where there had been no antecedent conception. I look upon it 
 as an indubitable fact, that this appearance is the result of antecedent men- 
 struation,” &c. 
 
 The most finished and complete account of the matter, however, is that 
 which is contained in M. Negrier’s work above mentioned, and in Raci- 
 borski, op. cit. M. N.’s is a full-sized octavo of 131 pages, with eleven 
 lithographic plates, which present fifty-three figures, representing the ova- 
 ries and womb in different circumstances. He divides his work into three 
 parts. In Part I., which is divided into four chapters, he commences, Chap- 
 ter I. with an anatomical account of the ovaries, exhibiting their structure at 
 the different periods of life, from birth to puberty. The second chapter 
 exposes the state of the ovaries during the reproductive life of the woman. 
 Chapter III. concerns the anatomy of the ovaries during gestation and lacta- 
 
PHENOMENA OF MENSTRUATION. 
 
 27 
 
 tion. Chapter IV. is assigned to the exposition of their condition in wo- 
 men who have finally ceased to menstruate. 
 
 In Part II. M. N. advances certain physiological considerations and de- 
 ductions from the facts previously cited, — while the third and last part is 
 devoted to points relative to the physiological and pathological anatomy of 
 the organs in question. 
 
 The result of his researches in Part I. is given in a resume , at p. 12, 
 as follows. The parenchyma ( stroma ) of the ovary of a new-born child is 
 homogeneous. In the first year it is found to contain an uncertain number 
 of miliary granulations, as large as poppy seeds, each of which is surrounded 
 by a whitish zone. At the third year and forwards to the sixth, the ovaries 
 increase in size, but undergo no change of shape. A small globule, con- 
 taining a drop of serous fluid, is found glued to one of the granules, whose 
 white zone has sensibly diminished in size. These globules, which are 
 rarely larger than a millet seed, have pretty thick walls, but they may be 
 easily crushed between the fingers. The globule or lodge contains a vesicle 
 comprised in two concentric membranes that are contiguous. At about the 
 tenth year some of the globules enlarge, but a grayish pulpy matter is depo- 
 sited betwixt the outer and inner concentric membranes, so that the vesicle 
 that is innermost is compressed and becomes wrinkled. These vesicles M. 
 Negrier denominates ( bourses grises ) gray pouches. The gray pulp of the 
 pouches gradually changes to a yellowish colour, and it is then the first 
 signs of puberty become manifest in the girl. In infancy and childhood the 
 vesicles are found nearest the adherent margin of the ovary, after which they 
 are found to be nearer to the free margin of the organ, and when they begin 
 to form gray pouches, they are in contact with the indusium of the gland, but 
 there is no sign of cicatrices upon the surface of the ovarium. During this 
 entire period the womb has remained, so to speak, stationary, and its muta- 
 tions of size have no comparison with those that take place in the before- 
 mentioned body. 
 
 In Chapter II. M. Negrier shows that, whenever an opportunity has been 
 enjoyed of examining the condition of the ovaries in women who have died 
 suddenly while menstruating, there has been always observed a point on the 
 ovarian surface which appears to have been ruptured or lacerated. In such 
 as have died a long time after the cessation or suspension of the menses, no 
 trace of recent rupture could be found. 
 
 Dr. Gendrin gives, at p. 18, vol. ii., his first case, which occurred in 
 1828; and Dr. Robert Lee ( London Medical Gazette , 1842-3, p. 165, 
 vide also Lee’s Theory and Practice of Midwifery , p. 47, Phila., 1844), 
 relates a case that he observed on the 11th of March, 1831, with others , 
 subsequently. 
 
 The frequent, if not invariable, occurrence of a rupture of the Graafian 
 vesicle, coincidently with the menstrual act, may be taken, one would think, 
 as tenable grounds for the belief that this development and rupture are suffi- 
 
28 
 
 PHENOMENA OF MENSTRUATION. 
 
 cient causes of the phenomena presented by that great and most important 
 sexual function. The discovery of the vesicle of the bird’s egg, by Pur- 
 kinje, and the elucidation of the nature of the human ovum, by Baer 
 Coste, Wharton Jones, Barry and others, throw new light upon this topic. 
 It is fully understood that De Graaf’s vesicle is but the organ, the ovisac, 
 which contains the egg of the mammal, a microscopic point, consisting of a 
 yolk with its germinal vesicle and germinal spot, which is kept steady in 
 the centre or moved to the surface of the cyst or cell in which it exists, by 
 a granular membrane, like the chalaze of the hen’s egg, and which has 
 received from M. Barry the name of retinacula, the existence of which is 
 denied by Bischoff. 
 
 Barry has shown, and any one who possesses a good microscope can 
 observe for himself, that the ovary contains an immense number of granules, 
 which are the nuclei, or nucleoli, of the germinal cell. They amount to 
 unknown numbers, millions, perhaps, and are of exceeding minuteness ; but, 
 in passing from the state of nucleus to that of ovisac, they cannot fail to com- 
 press the ovarian stroma, and dispart its cellular tela, its vessels and nerves; 
 in like manner as the sac which incloses the rudimental tooth, presses aside 
 and disparts the structure of the gum in a young child, producing upon its 
 constitution various effects, from the very slightest manifest uneasiness to 
 the most fatal spasm, convulsion, cholera, <fcc. &c. 
 
 But it is universally admitted that the human female, unlike the other 
 mammals, has no stated season of reproductiveness; that she is liable to 
 fecundation at any period of her reproductive age. Hence it appears clearly 
 that a necessity exists for her evolving and perfecting the germina of her 
 offspring, throughout the entire series of years from puberty until the arrival 
 of her critical age. Supposing her to be perfectly regular, and never to be- 
 come pregnant, she would, in the course of thirty years, have nearly four 
 hundred menstruations. If, now, each menstruation is to be taken as the 
 sign of her constitutional aptitude for fecundation, it is a just inference that 
 such aptitude must bear a close relation to the perfectness of the germ-cell 
 or ovulum of the Graafian vesicle. Let it be admitted, then, that a vesicle 
 is always found to have been discharged in the cases of women dying sud- 
 denly in the menstrual act, and it does not seem to be a violent wresting of 
 the facts to apply them to the solution of this great problem, the cause of 
 menstruation. MM. Gendrin, Negrier, Lee, Raciborski and Bischoff alf 
 concur in the statement that in menstruation the ovarian vesicle is burst, 
 with loss of the ovula and granules or retinacula — that the ovarian stroma 
 and indusium are highly injected and vascular — that a similar condition 
 exists in the tube and womb, and thus is sufficiently established a hyperce- 
 mic status of the internal genitals, to account for the entire local plethora or 
 uterine hyperffimia, whose result is the menstrual discharge. Here, at last, 
 we see established the doctrine of a local plethora as a cause of menstrua- 
 tion, and that plethora resting on a sure physiological basis — the regular 
 periodical development, to wit, of the Graafian vesicle with its contents. 
 
PHENOMENA OF MENSTRUATION. 
 
 29 
 
 The question as to why it should have so exact a periodical character, is 
 no more difficult of solution than that of the stated periods of eruption of the 
 first and second dentition, the growth and fall of the hair or the beard, &c., 
 or the periodical affections of the sphincters under a regularly operating law 
 in physiology. 
 
 In adopting the 'dews of the writers whose names have been so re- 
 peatedly mentioned, I find abundant explanations of the poverty of our 
 resources in the use of the mere menagoga, and in the efficacy of the treat- 
 ment of menstrual disorders, by a regard fixed upon the constitution, whose 
 disorders are fully sufficient to impair the ovarian travail, by suspending the 
 development of the vesides, under disease of other organs, or of the repro- 
 ductive system itself, or by precipitating and rendering dangerous an irrita- 
 mentum whose gentle and aormal influences ought to produce no pain nor 
 be attended by the least interruption. 
 
 Dr. M. A. Raciborski, of Paris, has put forth, in the present year, 1844, a 
 small volume already mentioned, upon the subject of menstruation, of the very 
 highest interest. It is entitled De la Puberte et de V Jige Critique chcz la Fem- 
 me, au point de Vue Physiologique, Hygienique et Medicate , et de la Ponte 
 Periodique chez la Femme et les Mammiferes. M. R. shows that the deve- 
 lopment of the Graafian vesicle ought to be considered not merely as the cause 
 of menstruation, hut as menstruation itself; and that a woman may regularly 
 develop her ova and be liable to conceive even when she may have never had 
 the outward and visible signs of the catamenia. After having related certain 
 cases of very late occurrence of the catamenia, he says, at p. 89: “ These 
 facts seem only to confirm what we shall, in a subsequent page, fully esta- 
 blish, to wit, that the menstrual haemorrhage is but a secondary phenomenon 
 in menstruation, properly so called, and that the capital phenomenon in this 
 function consists in the maturation and the periodical discharge of the ova 
 or the ‘ ponte, ’ (laying.) There are women in whom it is confined to this 
 act alone, and we have the records of cases in which women have given 
 birth to several children without having ever seen the menses.” 
 
 Such is the short statement I have thought proper to add to M. Colombat’s 
 views of the causes of menstruation. But I should gladly refer the reader 
 to Negrier, to Gendrin, to Robert Lee and Raciborski. — M.] 
 
 The immortal Bichat, in his Anatom. Gen., says that the blood 
 that flows in a menstruation is of the same nature with that which 
 escapes in any other active hasmorrhage. It proceeds principally 
 from the womb and escapes from the capillaries on the mucous sur- 
 face, where, incited by a lively irritation, it is conducted into unac- 
 customed channels and expelled by a process of exhalation. 
 
 In his anatomical researches upon the position of the glands and 
 their action, Theoph. de Bordeu gives out nearly the same opinion. 
 “The womb and the vagina effect an excretion of blood almost as pure 
 in common as that which flows in the vessels. This excretion comes 
 every month or nearly so; it begins about the age of twelve or fifteen 
 years and terminates towards the fortieth or fiftieth, and is generally 
 
30 
 
 PHENOMENA OF MENSTRUATION. 
 
 suspended during suckling and under certain diseases ffiat occasion 
 discharges, whether sanguine or of other character, &c. The excre- 
 tion of the womb takes place as it does in all the other glands — that 
 we have denominated active glands. The organ awakes , ( erigitur ,) 
 and, by the turns ( replis ) which it makes upon itself, it invites the 
 blood and rejects it outwards by the same mechanism we have else- 
 where explained. Each organ acting in its turn, that of the womb 
 recurs only from month to month. Why? This is what we are 
 ignorant of— and what we seek to know.” 
 
 In women the menses may be regarded as the aurora and com- 
 panions of puberty. In fact, though there be samples wherein a 
 sanguine discharge from the vulva may have been noticed in children 
 of from two to six years old, or in women who have attained to an 
 advanced age, true menstruation does not commence until the period 
 when the young girl is fitted to become a mother — and ceases when 
 she loses, together with her charms, the faculty of conceiving in the 
 womb.* This moment of sexual dissolution generally arrives about 
 the fortieth or fiftieth year, earlier or later. 
 
 Menstruation, then, is a physiological function which characterizes 
 the period during which the female is endowed with the reproductive 
 faculty. From the first appearance of the menses until the term when 
 they are to cease by the lapse of years, her health, her freshness and 
 her beauty depend upon the regular return of this sanguine evacua- 
 tion.! Those who experience no menstrual revolution are rarely 
 fruitful, and its sudden suppression in youth and in health is one of 
 the least deceptive signs of conception. 
 
 When the periodical evacuation meets with obstacles, and nature 
 makes vain efforts to establisu it, all the powers of life diminish or 
 become perverted; and trouble and disorder among the functions 
 throw a speedy veil over the brilliancy of the maiden. A crowd of 
 symptoms often comes to aggravate this dull languor, the respiration 
 becomes difficult, the circu/ation languishes, the tastes and appetite 
 are perverted, depraved, the feet and limbs begin to swell, the eye- 
 lids to be tumid, the face is bloated, and acquires a sallow hue, or a 
 greenish or chalky tint : at length painful palpitations, frequent faint- 
 
 * Professor Osiander, of Goettingen, has noted that of 137 women, 9 were regular 
 at 12 aetat., 8 at 13, 21 at 14, 32 at 15, 24 at 16, 11 at 17, 18 at 18, 10 at 19, 8 at 20, 
 and 1 at 21, and one other at 24. From this statistical view of menstruation it is 
 seen that the mean age for the apparition is between fifteen and sixteen years. 
 
 f We know a lady thirty years of age who has never been regulated, and who, 
 nevertheless, enjoys perfect health. She has had no children, notwithstanding that 
 she has been, since her eighteenth year, united to a husband who is young and in 
 vigorous health. The sister of this lady is also married and has never been regulated ; 
 but she has had one child — a healthy one. The annals of the science furnish many 
 similar examples. Rondellet, chancellor of the faculty at Montpellier, speaks of a 
 woman who had twelve children, and Joubert, his pupil and successor, speaks of one 
 who gave birth to eighteen children, though neither of these women had menstruated. 
 Zacchias and Fodere have also related similar observations. We may add that the 
 periodical discharge furnishes, in its history, numerous examples of anomalies and 
 deviations; but all these irregularities and menstrual aberrations do not impair the 
 validity of the general rule, for, being the fruits of some disorder of the womb, they 
 
 constitute real cases of disease. [Madame N 1 informed me tfiat she had given 
 
 birth to ten children, and that she had never menstruated since her marriage, having 
 always become pregnant before the return of her courses after a confinement. — M.j 
 
PHENOMENA OF MENSTRUATION. 31 
 
 ings, a deep-felt anxiety, distress, weakness of the senses, a certain 
 indolency, and a weariness which renders every motion disagreeable 
 — come to obscure this sad and afflicting picture. 
 
 During the entire period of the menstrual life, women are exposed 
 to the attack of a great variety of maladies, to most of which they 
 are not liable antecedently to the age of puberty ; for they draw 
 their sources from irregular menstruation, or from the sympathetic 
 reaction of the womb. Among the disorders of this class, without 
 comprising such as are connected with pregnancy, we must cite the 
 cases of hysteria, catalepsy, convulsions, spasmodic diseases, cardi- 
 algia, dyspnoea, chlorosis and leucorrhoea ; to which may be added 
 consumption, and various forms of haemorrhage, as epistaxis, haemo- 
 ptoe, haematemesis, and a variety of febrile affections unnecessary to 
 detail in this place. 
 
 The nature and properties of the blood of the menses have been, 
 from the remotest antiquity, the object of a crowd of popular preju- 
 dices and scientific errors, the absurdity of which can hardly be con- 
 ceived of. According to Aristotle, this kind of blood is as pure as 
 that which flows from any wound. Hippocrates compares it with 
 that of a slaughtered victim. Sanguis autem....sicut ct victimd, si 
 sana fuerit mulier. Pliny, in speaking of the menstrual fluid, says, 
 * on the other hand, that it is a fatal poison, that it corrupts and decom- 
 poses urine, deprives seeds of their fecundity, destroys insects, that it 
 blasts the garden flowers and grasses, and causes fruits to fall from 
 their branches, &c. Nihil facile reperiatur mulierum profluvio magis 
 monstrificum. Acescunt superventu musta, sterilescunt tactse fruges, 
 moriuntur insita, exuruntur hortorum germina, et fructus arborum, 
 quibus insedere decidunt. (Lib. vii. cap. 15.) 
 
 The Lawgiver of the Hebrews goes still further when he says, 
 “And if a man shall lie with a woman having her sickness, and shall 
 uncover her nakedness, he hath discovered her fountain, and she hath 
 uncovered the fountain of her blood, and both of them shall be cut 
 off from among their people.” (Lev. xx. 18.) 
 
 A number of authors, and amongst others, Columella, [Dr Re rus- 
 tica ,) whose eloquence and style savour so strongly of the Augustan 
 age, Graaf, [Mul. Org. Gener.,) Verheyen, ( Vera Hislor. de Horrend. 
 Sang.,) the Arabians, and even some among the modern writers, 
 have attributed dangerous qualities to the blood of the menstruae. 
 In perusing the histories of various nations, whether savage or civil- 
 ized, we find that most of them have entertained the same preju- 
 dices, and have established customs no less barbarous than injurious 
 to the female. At a crisis in which they ought to be the objects of 
 the highest interest, instead of finding protection and security, they 
 have been compelled to sequester themselves from society, and sub- 
 mit to the most humiliating precautions.* It appears, says Roussel, 
 
 * M. Moreau de la Sarthe, in the Hist. Nat. de la Femme, Tom. II. 261 , also says 
 that the Negroes, the South Sea Islanders, and the Aborigines of South America, 
 send their females into separate huts, and keep them in a state of absolute seques- 
 tration during the whole menstrual period. The Illinois Indians punish with death 
 their women who fail to give notice of their being affected with their periodical flux. 
 History also informs us that by a decree of the Council of Nice, women were forbid- 
 den to enter the church while menstruating. 
 
32 
 
 PHENOMENA OF MENSTRUATION. 
 
 ( Systhne Physique et Moral de la Femme,) that the male feeling him- 
 self more at liberty during this transitory crisis, in which the charms 
 of the female are somewhat obscured by a slight shade, would profit 
 by the interregnum thus left to him, in order to revolt and outrage 
 her, whom, in all other circumstances, he is compelled to adore. 
 
 The opinion of Hippocrates as to the identity of the menstrual and 
 other haemorrhages, finds few opponents at the present day, and 
 although there are still, especially among the common people, some 
 prejudices as to the pernicious qualities of the menstrual fluid, the 
 major part of the medical profession, at the present time, look upon 
 the discharge as being equally pure with the blood of other sanguine 
 effusions. Any differences as to its nature or smell are attributable 
 to the changes it undergoes in the vagina. Such a decomposition of 
 the menses may communicate properties of a more or less dele- 
 terious nature, and cause it to react upon certain fluids easy of 
 decomposition. It is very desirable that researches more careful, and 
 conducted without prejudice, might serve to throw light upon this 
 long-vexed question, and dispel those injurious opinions in regard to 
 a sex whose condition and well-being ought to be a constant care. 
 
 The quantity of blood that escapes at each period varies accord- 
 ing to climate. Hippocrates thought that the Greek women lost 
 twenty ounces or two cotyla at each menstruation. Galen estimated 
 it at eighteen ounces. Haller computed it at six, eight or twelve 
 ounces for the German women. According to Dehaen, it amounts 
 to three ounces in England, but Smellie and Dobson suppose it to be 
 four ounces. Pasta says it is five ounces, and Freind ten ounces. 
 Gorter thinks that in Holland the discharge does not exceed six. 
 Fitzgerald estimates it at fourteen or fifteen ounces for Spanish 
 women. Astruc says that it varies from eight to ten ounces among 
 the French women ; and Baudelocque regards it as amounting only 
 to three or four. Lastly, M. Magendie thinks it is often very great 
 and may amount to several pounds. 
 
 Linnaeus avers, in his Flora Lapponica, that the women of frozen 
 regions, as the Samoiedes, lose but a very small quantity of blood, 
 and that only in the summer season; and that the Greenlanders 
 have scarcely any discharge, on account of the cold, which hinders 
 the development of the generative faculties as it does the flower- 
 ing of plants. From the foregoing, then, it is perceived that, as 
 a general rule, the catamenia are most abundant in those coun- 
 tries where puberty is most early attained. But on this point there 
 will be found considerable differences, according to the different con- 
 stitutions of women ; thus, the Greeks of the Archipelago, who are 
 more precocious than the Italians, and inhabit a warmer climate, 
 rarely lose more than three ounces of blood. It is quite certain that 
 European women, who migrate to a hotter climate, as the West and 
 East Indies, to live particularly at Batavia or in Java, often perish 
 in consequence of excessive menstrual losses, and are, besides, more 
 liable to abortions than under more temperate skies. 
 
 The difficulty of collecting the menstrual blood, and the numerous 
 variations in the amount of the discharge, have necessarily occasioned 
 
PHENOMENA OF MENSTRUATION. 
 
 33 
 
 the differences of reports by the observers whose names we have 
 now cited. All calculations upon this subject must be more or less 
 faulty, and we can, therefore, only expect approximative results in 
 our various estimates. 
 
 [I maybe permitted to remark here, that seeing that all women in health, 
 and not pregnant nor suckling, ought to menstruate regularly, and that they 
 vary in constitution as much as in intellectual and moral character or pro- 
 pensity, we ought not to expect to ascertain a standard quantity as the 
 rule of the sex. What the female requires as such, is to menstruate, and 
 not to discharge just so many ounces, more or less. Indeed, that which is 
 sufficient to maintain the health of a woman in one period of her life, or in 
 one state of society, might be either too little or too much for her constitu- 
 tion under changed circumstances of age or social relations. Each woman 
 is a law unto herself, and provided she obey that law, she is well, if not, 
 by excess or deficiency, by anticipation or procrastination, she falls sick. 
 It is well known, that in a great metropolis like Paris or Philadelphia, there 
 exist multitudes of women who do not take the least precaution to prevent 
 the blood of the menses from soaking through their clothes, and exposing 
 their condition to the public eye, in the street or in the marketplace. I have 
 met with many healthy women who informed me they never put on the 
 napkin, and I doubt not that we daily meet with hundreds of menstruating 
 women who wear no cloth for the purpose of receiving the discharge. 
 Nevertheless, it is an event of the most extreme rarity to find a spot of blood 
 upon the stocking or dress of a woman : in such persons it is not possible 
 to conceive that the loss amounts to more than three or four ounces. But 
 in a great many others the quantity is enormous. For example, when I 
 have desired to obtain information on this point from my patients, I have 
 inquired as to the number of changes used in the whole period of five or 
 seven days, and I have been repeatedly informed that they change twice or 
 thrice, and some even four times in twenty-four hours. Now three changes 
 per diem for seven days, will give twenty-one napkins, on each of which is 
 found at least two tablespoonfuls of blood, or more ; but with the estimate of 
 two spoonfuls to each, we shall have the result of twenty-one ounces for 
 the whole product. I am confident that many healthy women lose fully 
 this quantity as the regular and normal elimination. M. Brierre de Bois- 
 mont, in his work De la Menstruation , p. 172, says, in speaking of the 
 analysis of the fluid, “This task has lately been taken up by M. Bouchar- 
 dat, who had the goodness to analyze the blood of one of my patients, who 
 submitted to experiments for this purpose — one of the most disagreeable and 
 distressing that could be thought of. In order to collect a quantity amount- 
 ing to twenty-two grammes, about one ounce, it was necessary that a specu- 
 lum, embracing the cervix uteri exactly, should be retained in situ for ten 
 consecutive hours,” <fcc. Now, if this woman yielded an ounce in ten 
 hours, she would give more than two ounces in twenty-four hours ; bift at 
 3 
 
34 
 
 PHENOMENA OF MENSTRUATION. 
 
 the same rate for seven days, the sum of the discharge, it is seen, would be 
 not far from fifteen or sixteen ounces. I repeat my opinion, that what it 
 interests us as medical counsel to know is, not what is the usual quantity 
 for women, but what is the rate of the particular woman in her ordinary 
 health: her deviations from her own economic law are the signs and mea- 
 sures of her disorder. — M.] 
 
 Unwilling to extend our observations further upon a topic treated 
 perhaps too much in extenso already, I shall abstain from repeating 
 all that has by authors been stated in regard to the menses and their 
 periodicity. The opinions of the writers who have treated this point 
 are so different and often so contradictory, that we shall content our- 
 selves with adding that the mechanism of the function is always the 
 same, whether the discharge takes place within the body or the 
 cervix uteri, in the vagina or in the appendages. Most modern 
 physiologists regard the menstrual evacuation as an active haemor- 
 rhage, and the effect of a peculiar excitement of the womb, but have 
 not as yet settled the point as to whether the discharge takes place 
 from the arteries of the capillary system or from vessels of the venous 
 system. 
 
 The mystery of menstruation will be for ever covered with a veil 
 which cannot be perfectly removed. Under this conviction, we shall 
 confine ourselves to the statement that the flow takes place when- 
 ever, under the influence of a special law of the organization, the 
 womb acquires a certain intensity of vital force proper to attract the 
 blood towards itself at the periodical epochs. 
 
 We shall also add that the cause of the regular intermittence of 
 this uterine erethism is a physiological problem which will, probably, 
 never be solved. 
 
 [I trust that the exposition of the causes of the function, both as to its 
 regularity and , nature, given in a preceding page, and which has the sanction 
 of MM. Negrier, Gendri.n, Bischoff, Lee, &c., will be found, by most read- 
 ers, sufficient to remove the doubt and uncertainty above expressed upon the 
 subject. — M.l 
 
 In some rare cases the flow never appears, and it may be so with- 
 out any evil consequences. This condition, which in nowise implies 
 the nullity of the venereal appetite, nor even the existence of sterility, 
 is sometimes met with in women whose sexual organs are in a nor- 
 mal condition, and present no physical obstacle nor chronic affection 
 to account for the want of a secretion which appears to be inherent 
 in the nature of marriageable women. 
 
 As the menstrual office is liable to frequent derangement, it may 
 present phenomena requiring both assiduous and intelligent care. 
 These alterations in the discharge are not, properly speaking, dis- 
 eases, but symptoms of lesion of the organs charged with the elimi- 
 nating office. The indications of treatment, therefore, will be drawn 
 from the state of these organs themselves, or that of such as are sym- 
 pathetically involved. As we shall be obliged to occupy the reader’s 
 attention with the disorders, irregularities and deviations of menstrua- 
 
PHENOMENA OF GESTATION. 
 
 35 
 
 tion, we refer him to the future chapters that will be found to treat 
 of the difficulty, the suppression, the immediate discharge or supple- 
 mentary haemorrhage of menstruation, and which are scientifically 
 denominated dysmenorrhcea , arnenorrhcea , menorrhagia, or meno- 
 xenia. 
 
 PHENOMENA OF GESTATION. 
 
 Physical and moral changes that take place in gestation. Diseases to which preg- 
 nant women are liable in the various stages of pregnancy. 
 
 All the phenomena of which we have now given a slight sketch, 
 are but the prelude to the admirable part the uterus is destined to act 
 after the occurrence of conception. 
 
 In this new condition, it would seem to concentrate every thing 
 upon itself. This is the period in which woman is called to the ful- 
 filment of her most important task. The vital forces are concentrated 
 upon a single organ ; the conservative efforts then become less ener- 
 getic, the reaction of the body less powerful, and, consequently, the 
 impression of extrinsic agents becomes more lively and redoubtable. 
 
 Scarcely has conception taken place when the vital forces of the 
 womb assume new strength, and radiate to the rest of the economy 
 the most extraordinary sympathies and the most powerful reactions. 
 The relations of the womb with the brain appear to become more 
 intimate ; the circulatory, the digestive and the respiratory organs 
 are subjected to an unusual stimulation, and their sympathy with the 
 gestative organs, whether greater or less, is announced by syncope, 
 convulsions, faintness, dyspnoea, disgusts, and perverted appetite ; 
 by spasmodic colic and a variety of other appearances which are 
 also signs of pregnancy. The nervous susceptibility is augmented, 
 the inclinations and passions are changed, the sensations become 
 more acute, and the force of the intellectual faculties is sensibly 
 increased on the one hand, or, on the other, lessened ; the imagina- 
 tion is more excitable and the judgment less sound. Women have 
 been found to become insane in pregnancy, some have become musi- 
 cians or poets, and some have acquired a thievish propensity. Their 
 will loses its strength ; their affections are less constant ; antipathies, 
 anger and even cruelty are occasionally met with in the sex, whose 
 natural and inherent inclinations are marked by gentleness, goodness, 
 compassion, tenderness, an exquisite sensibility, and the most eager 
 desire to console the unhappy. 
 
 The womb having acquired, in its new estate, an incomparably 
 greater vitality, there occurs, in the pregnant woman, a considerable 
 number of modifications, both anatomical and physiological. 
 
 Some of these modifications, constituting in themselves the preg- 
 nancy, must be respected ; but others of them, that are merely sym- 
 pathetic or physiological, are divided into three classes. In the first 
 class are placed those that we call nervous , to wit, vomiting, syncope, 
 depraved appetite, nausea, anorexia, vigilance, toothache, ptyalism, 
 headache, palpitations, tinnitus of the ears, deafness, mastodynia, 
 
36 
 
 PHENOMENA OF GESTATION. 
 
 cough, dyspnoea, pains in the limbs and groins, heartburn, diarrhoea, 
 constipation and nervous colic. 
 
 Those of the second class, which we denominate plethoric, are 
 noticed in the second stage of pregnancy, that is, from the end of the 
 third to the fifth month. Among these may be mentioned uterine 
 haemorrhage, epistaxis, piles; sometimes varices and oedema of the 
 inferior extremities; haemoptoe, cough, dyspnoea; and, lastly, abortion. 
 
 The modifications of the third class, which we call mechanical , are 
 met with towards the close of pregnancy: in this list we place ante- 
 version and retroversion of the womb, hernia of the womb, its pro- 
 lapsion, its obliquity, its relaxation, to which must be added moles, 
 abortion, colic, dysury, constipation, dyspnoea, varix, piles and oede- 
 ma, with a number of other atfections which neither can nor ought 
 to be treated, but whose too violent symptoms may be palliated by 
 reasonable methods, at the risk of seeing them reproduced at every 
 step of the gestation. 
 
 [M. Colombat ought not to have included in a list of affections met with 
 near the close of gestation, either the retroversion of the womb, then an 
 impossible occurrence, or abortions, which are always supposed of the 
 embryo and not of the child . — M.] 
 
 After having been for nine months exposed to all the inconveni- 
 ences of pregnancy, the woman at length reaches the term of utero-ges- 
 tation, when the foetus and after-birth are expelled with severe pain. 
 At this moment a complete cessation takes place of the connection 
 of the foetus with its mother ; the womb contracts, the walls of the 
 abdomen shrink back to their pristine form and dimensions, the 
 breasts enlarge, a secretion of milk takes place, and at last all the 
 organs recover their natural estate. 
 
 The diseases of lying-in women are numerous, some of them being 
 chirurgical and some medical. Among the former are found lacera- 
 tions of the womb or perineum, contusions of the vagina and of the 
 vulva, prolapsus of the rectum, vesico and recto-vaginal fistulas, 
 inversion of the womb and other physical lesions, which require the 
 surgical aids which, in a later chapter, will be set forth and explained. 
 
 Among the second, which comprise vital lesions belonging to the 
 province of medical practice properly so called, are observed acute 
 metritis, puerperal peritonitis, the suppression or the immoderate flow 
 of the lochia, milk fever and weed, inflammation of the mammary 
 gland, dysury, strangury, ischury, puerperal engorgement of the infe- 
 rior extremities, and, in fine, the various hagmorrhages that occur 
 before, during and after delivery. 
 
 Notwithstanding it may be difficult to point out a treatment com- 
 mon to all these maladies, as various as they are numerous, it is easy 
 to observe that most of them affect the inflammatory character, de- 
 pending, probably, upon the sudden plethora resulting from the less- 
 ened extent of the sanguine circle immediately consequent to delivery. 
 
 Under such a view, might we not say that the most rational treat- 
 ment, one that will generally suit the case, is an antiphlogistic one, 
 
OF THE CESSATION OF THE MENSES. 
 
 37 
 
 modified according to circumstances, such as the strength of the patient 
 and the losses she may have sustained in labour ? 
 
 When nature’s object has been attained, says Roussel, she seems 
 to neglect the means by which she has fulfilled it, the woman 
 gradually loses her bloom — that delicate flower of the constitution, 
 which buds and blossoms in early youth, vanishes as the morning 
 dew. The expansive force, whence the organisms deduced their 
 tints and their seductive forms, becomes relaxed, and a disagreeable 
 flaccidity would succeed the supple and elastic firmness which marked 
 them were they not sustained by the embonpoint which generally 
 accompanies the adult age and deceives by a certain air of freshness. 
 
 This change in the physical character of the woman does not 
 always take place so suddenly; it frequently happens that the con- 
 jugal union and its consequences make upon the constitution an 
 impression favourable to the beauty of the female. Nevertheless, the 
 frequent reiteration of the erotic spasm, conception, pregnancy and 
 lactation, which are the consequences of marriage, have, on most 
 women, the effect of lessening the bloom of the skin and the resili- 
 ency of the cellular tissue. Those especially who are of an amorous 
 temperament, who have too much sensibility, soon lose their fresh- 
 ness and witness an early loss of the beautiful contour which persists 
 for a long time in such as are of a cold and unexcitable constitution. 
 
 Without ceasing to love, the female arrives at length at a calmer 
 and happier state ; having become both wife and parent, she finds 
 new duties, she experiences new sentiments; thus, the love of off- 
 spring, her conjugal tenderness, the education of her children, the 
 management of her domestics, are the sole objects that attract her 
 regard and fill up her happy existence. It is then that she has come 
 to the possession of the purest happiness, a happiness connected with 
 the love of her family and secured by the moral qualities inherent in 
 her sex. 
 
 OF THE CESSATION OF THE MENSES. 
 
 Physical and moral changes effected by the cessation of the menses in women. 
 Diseases to which they are liable at the critical period and during the subsequent 
 advance of old age. 
 
 Scarcely have the reproductive faculties ceased from their state of 
 active existence, when the expansive forces of her economy become 
 lessened and enfeebled. The woman begins to lose the hue and the 
 blossom of life, which had opened under the expansive age which 
 gives power to the circulation of the blood and juices ; her complex- 
 ion fades and gives way, and the disagreeable impression of wrinkles 
 has taken the place of those enchanting outlines and that elastic firm- 
 ness which characterized the surface of the skin. She now resem- 
 bles a dethroned queen, or rather a goddess whose adorers no longer 
 frequent her shrine. Should she still retain a few courtiers, she can 
 only attract them by the charm of her wit and the force of her talents. 
 Yet women are met with who preserve for a long time a part of the 
 attractiveness of their youthful age, by means of a certain fulness 
 
38 
 
 OF THE CESSATION OF THE MENSES. 
 
 and embonpoint which, while it can have no comparison with the 
 suppleness and freshness of youth, may yet serve to preserve the out- 
 line to a certain extent, and leave them the possession of attractions 
 still capable of inspiring the tender passion of love. 
 
 Old age, always early for women, does not always commence as 
 soon as they become absolved of all obligation as regards the species. 
 She still has left a space, doubtless all too short, in which she may 
 yet interest by the remnants of those charms that serve to recall the 
 memory of those she has lost for ever. 
 
 After having been exposed to a thousand infirmities at the first 
 eruption of the catamenia, during the season of their perfect establish- 
 ment, at every return, during her pregnancies, and in her season of 
 lactation, there remains for the female a period, more or less stormy, 
 of life, to which she always looks forward with dismay, because it is 
 accompanied with certain affections and maladies much more rarely 
 met with during the adult age. 
 
 This period, so cruel for the female, whom it deprives of her beauty 
 and her charms, is called the critical age , the climacteric , the turn 
 of life , the change of life: and is announced by the more or less 
 sudden cessation of the menses, and takes place in this climate be- 
 tween the forty-fifth and fiftieth year of her age. 
 
 Like the first appearance, so the cessation of the periods varies in 
 different subjects, and is in subordination to the temperament, the 
 constitution, the climate and the habit of life of the female. The 
 connection existing between the first and the last menstruation has 
 not escaped the view of the observant physician, and every one is 
 aware that the cessation is at a later period, in proportion as the 
 eruption was less precocious. Indeed, there is as great a difference 
 in regard to the manner of the cessation as there is in that of the first 
 establishment. In our temperate climate, however, it is prolonged 
 to the age of forty-five or fifty years. This correspondent duration 
 of the fertile age is what Rod. a Castro, a Portuguese physician, who 
 practised towards the close of the sixteenth century, referred to in the 
 Tract, de Mulieb. Morb., lib. ii., in these Latin verses: — 
 
 “Adde decern terms, mulierum menstrua cernis 
 Ad quinquaginta durat purgatio tota.” 
 
 Samples, however, have been recorded of a much later fecundity; 
 for example, Pliny, the naturalist, says that Cornelia, of the family of 
 the Scipios, became the mother of Valerius Saturninus at the age of 
 sixty-two. Vallescus de Tarenta, in his Course of Physic , published 
 in 1518, says that he attended a woman in labour who was sixty- 
 seven years old. The great Baron Haller mentions a woman still 
 regular at seventy, and brought to bed at that age. I myself saw in 
 the little town of Walse, department of the Ardeche, a woman who 
 was very regular, and who was confined at sixty-one, aud I may 
 add, that one of my relatives, the mother of ten children, whoresided 
 in the department of Seine and Oise, where she died in 1832, never 
 ceased from the age of eighteen to be subject to a sanguine discharge, 
 which took place regularly every month to the seventy-third year. 
 
OF THE CESSATION OF THE MENSES. 
 
 39 
 
 And lastly, M. Orfila has informed us, in his lectures, of a fact still 
 more extraordinary. A woman, said the leartied professor, who had 
 had seven children, became pregnant of her first child at the age of 
 forty-seven, gave birth to her last at sixty, was regular to her ninety- 
 ninth, and died at 114. 
 
 [M. Brierre de Boismont, at p. 209, says, “ It is generally observed that 
 the cessation takes place in this country (France) at about forty-five, sooner 
 or later.” The fact is true, but I think the appreciation of it would be 
 more perfect in view of a tabular statement, indicating the different periods 
 of the change of life. I have collected 183 cases of women in whom the 
 menses had ceased, and here are the results. 
 
 21 
 
 years 
 
 2 
 
 37 years 
 
 4 
 
 48 
 
 years 
 
 8 
 
 24 
 
 it 
 
 1 
 
 38 
 
 tt 
 
 7 
 
 49 
 
 44 
 
 7 
 
 26 
 
 tt 
 
 1 
 
 39 
 
 tt 
 
 1 
 
 50 
 
 44 
 
 12 
 
 27 
 
 ti 
 
 1 
 
 40 
 
 tt 
 
 18 
 
 51 
 
 
 4 
 
 28 
 
 tt 
 
 1 
 
 41 
 
 tt 
 
 10 
 
 52 
 
 44 
 
 8 
 
 29 
 
 ti 
 
 1 
 
 42 
 
 tt 
 
 7 
 
 53 
 
 44 
 
 2 
 
 31 
 
 ti 
 
 3 
 
 43 
 
 tt 
 
 4 
 
 54 
 
 44 
 
 5 
 
 32 
 
 tt 
 
 2 
 
 44 
 
 tt 
 
 13 
 
 55 
 
 44 
 
 2 
 
 34 
 
 tt 
 
 4 
 
 45 
 
 tt 
 
 13 
 
 56 
 
 44 
 
 2 
 
 35 
 
 tt 
 
 6 
 
 46 
 
 tt 
 
 9 
 
 57 
 
 44 
 
 2 
 
 36 
 
 tt 
 
 7 
 
 47 
 
 tt 
 
 13 
 
 60 
 
 44 
 
 1 
 
 Total 181— M.] 
 
 It often happens that the discharge is suddenly suppressed, but it 
 generally ceases by degrees, and this successive cessation in some 
 cases comprehends the interval of only one, and in others of six 
 months. Certain females are met with, who are two whole years 
 losing the attribute of the sex. If interrogated upon this point, 
 many of them will not give a candid answer, for they desire to dis- 
 pute every inch of ground with the advance of old age. They 
 invariably conceal the ravages of time, and converse with evident 
 disquietude of the close of their spring-time of existence, even when 
 the faded traces of beauty, and the stealing traces of grayness in the 
 hair proclaim the approach of winter. Delivered from the discharge 
 attached to the important functions of the uterus, the woman loses 
 along with it the power of conceiving, and ceases thenceforth to exist 
 as for the species. 
 
 At this period she may be said to exchange her own constitution 
 for that which is appropriate to the male ; but being of a more flexi- 
 ble constitution, she is less exposed than he to the assault of man)?’ 
 maladies, and is more likely to run a long career of existence. 
 Nevertheless, she certainly does undergo very remarkable changes in 
 her nature, which we shall distinguish, like those that occur at the 
 other periods of her life, as either physical or moral. 
 
 The womb having laid aside those vital properties which fitted it 
 for the act of reproduction, gradually ceases to react upon the general 
 
40 
 
 OF THE CESSATION OF THE MENSES. 
 
 economy, and takes its place in class among the other organs whence 
 it emerged at puberty.' It diminishes in size, becomes more dense, 
 its cervix undergoes a sort of atrophy, and little by little, is effaced; 
 its os tineas becomes undistinguishable, or disappears entirely. At 
 this period all the organic functions are performed at a diminished 
 rate. As the blood no longer retains its habitual determination 
 towards the organs of reproduction, it flows more freely towards the 
 superior regions of the body, where it gives rise to vertigo, headache, 
 epistaxis and hot flushings. The face acquires a purplish hue, the 
 eyes are red and injected, to which symptoms are added dizziness 
 and buzzing of the ears. The pulse being full and bounding, indi- 
 cates a plethoric state ; the beatings of the heart are effected with a 
 sort of distress, the respiration is not easy, and the sleep, often broken 
 by frightful dreams, does not serve as usual to repair the wasted 
 strength. In fine, a sort of uneasiness and restlessness of the limbs 
 comes to indicate a state of great irritability, conjoined with extreme 
 exhaustion. The pains that she feels in the loins and in the lower 
 part of the abdomen, are accompanied with intolerable and vexa- 
 tious itching about the vulva and fundament. The skin rapidly 
 loses its colour and suppleness, becomes wrinkled and sallow ; the 
 hair falls off or turns gray, the breasts, which at first become flaccid 
 and pendulous, at length disappear entirely; the perspiration lessens 
 in quantity, the urine increases in abundance, the voice changes and 
 resembles more nearly that of the male, and all the graceful and soft 
 contours of the gentle sex disappear, to be replaced by a wrinkled 
 surface. 
 
 Some women get happily through the change of life, especially 
 such as were always thin and' delicate before, who have the con- 
 stitution completely changed, and so greatly strengthened, that the 
 most perfect health and plumpness seem to restore to them the ele- 
 gance of figure and form they enjoyed in the spring-time of their 
 days, and almost to re-establish the polished and finished air of youth. 
 
 The moral character of the female is sometimes even more affected 
 by the change than her physical constitution. She becomes sad, 
 restless, taciturn, she regrets her lost power to please, the enjoyments 
 that are gone forever, and the future, which she views clothed in the 
 most sombre hues. Some among them, who were always good, sweet- 
 tempered and patient, become sour, excitable, irascible ; often fall- 
 ing into passion without provocation, they become unjust towards 
 every body ; they issue their orders with sharp tones, and treat every 
 body about them with severity. In others, the sensibility increases as 
 it did at puberty, and they are pestered with vapours and hysteri- 
 cal paroxysms, or tyrannized by the memory of past love, seek to 
 extinguish their ardour in new sources of enjoyment. This resur- 
 rection of the desires and passions almost always leads to bitter 
 remorse, and to the most formidable results. 
 
 In spite of the loss of all her physical advantages, the aged woman 
 who is endowed -with sense and wit, and who renounces all vain 
 pretensions, and lays aside all coquetry, finds it in her power, by 
 
OF THE CESSATION OF THE MENSES. 
 
 41 
 
 numerous admirable qualities, to become more worthy than ever of 
 the warmest friendship and confidence of the male, whose lover she 
 is not, but to whom she is a sincere and consolatory friend. At this 
 period the qualities of her soul are greatly perfected ; the passions 
 that long agitated her bosom have purified her heart, which becomes 
 steady, so that her friendship is immovable,, and capable of the 
 greatest sacrifices. Together with a new existence, she regains a 
 new dominion over all that surround her, and her empire, which 
 was previously circumscribed by the narrow circle of a few men, 
 now comprehends within its circumference even the women who 
 have ceased utterly to be classed among her rivals. 
 
 The unhappy victims of a life of celibacy, those whose lives have 
 been agitated by the liveliest passions, by numerous vexations or 
 excess of pleasures, are generally more violently and painfully shaken 
 at the crisis than such as have made a better use of their existence. 
 
 Dr. Moreau de la Sarthe, the elegant and spirited author of the 
 Hist. Natur. de la Femme , justly remarks that two circumstances 
 are worthy of observation, among the numerous differences presented 
 by the change of life in those women who have not passed easily 
 and naturally through the revolution. 
 
 “ The first is that of a stormy suppression, the consequence of an 
 excess of strength and vitality in the womb, which with difficulty 
 renounces its habits of exaltation, and in its last effort to preserve its 
 empire and predominance of action, overthrows the whole living 
 system, and gives rise especially to nervous disorders, and a profound 
 change in the powers of the digestive apparatus. When the cessa- 
 tion takes place in so unfavourable a manner, women observe that 
 their habitual indispositions become more frequent and serious. All 
 their functions are more or less disordered and irregular. The com- 
 plexion acquires an unhealthy tint, or a bilious hue, and transitory 
 flushings of the face are frequently felt, so that the countenance at 
 last becomes permanently reddened all over, or in patches of colour 
 seated on a dark and sallow ground. She also suffers under some 
 other more or less serious ailments. A painful sensation in the loins 
 and in the region of the womb, sadness and depression, rebellious 
 vigils, strange and fatiguing dreams, swelling of the joints, &c. 
 
 “ The other circumstance consists in too prompt a cessation ; one 
 so sudden and unexpected, that she mistakes it for a simple suppres- 
 sion. Such a case is always serious, as are, for the most part, all 
 suppressions of habitual discharges that do not take place gradually, 
 when they are of a kind that exert considerable influence on the 
 constitution. These sudden revolutions commonly lead to a general 
 disorder of the health, whose real cause is apt to be misapprehended, 
 or they lay the foundation of disease in the organ itself, whose weak- 
 ness and unsteady vital rate become the sources of multiplied acci- 
 dents and infirmities. 
 
 “ The haemorrhages that supervene in such cases are mostly accom- 
 panied, or even preceded, by sharp and pungent pains in the region 
 of the womb, and are also followed by the symptoms usually apper- 
 taining to such incidents of disease. Differences in constitution, 
 
42 
 
 OF THE CESSATION OF THE MENSES. 
 
 whether natural or acquired, must effect numerous diversities in the 
 mode in which women come to the complete change of life” 
 
 This picture of the phenomena that accompany the close of men- 
 struation, is but a version of that drawn by Dr. Fothergill, in the first 
 volume of the Trans, of the Med. Soc. of London. The celebrated 
 English physician also thought, and very justly, that the sudden ces- 
 sation produced symptoms the more alarming if the female had 
 habitually made an improper use of pleasure, if she had had but few 
 children, if barren, and lastly, if she had laboured under herpetic 
 affections, or neglected syphilitic disorders. 
 
 There are a great number both of local and general disorders that 
 may help to cast a deeper shade over the picture of the female crisis. 
 Scirrhus, cancer of the womb, vagina or rectum, of the breast and 
 ovary; dropsy of the ovarium, or the Fallopian tube; chronic metri- 
 tis, uterine haemorrhage, fibrous tumours and polypus of the vagina 
 or womb ; ulcerations and catarrhs of these parts; and, in fine, nume- 
 rous other local and general affections, are the mournful appurte- 
 nants of a woman at the change. Considering all the various modi- 
 fications of the economy of the female that take place under the 
 . influence of the womb, might we not venture to say, with Van Hel- 
 mont, Propter uterum mulier id est quod est ; and with Hippo- 
 crates, Propter uterum mulier tota morbus est? 
 
 Notwithstanding the female grows old earlier than the male, a 
 greater number of examples of longevity is found among women 
 than among men, except, indeed, a few very rare cases of extraor- 
 dinary longevity, which are always found to occur in persons of our 
 own sex. The numerous researches that have been made as to the 
 mortality among women, and particularly at the period called change 
 of life, prove that this period, which they look upon as so dangerous, 
 is in fact not more critical for them than for us, and does not show a 
 greater ratio of mortality for females than for meri. Muret, in his 
 work on the Population of the Pays de Vaud , did not find that 
 from forty to fifty was more dangerous to females than from the 
 tenth to the twentieth year of age ; and M. Benoiston de Chateau- 
 neuf, who has also made very elaborate researches on the same sub- 
 ject, read an interesting memoir at the Acad, of Scien., in ISIS, 
 which contains results as follows : 
 
 “ From the fortieth to the sixtieth degree of latitude, on a line 
 extending through Vevay, Paris, Berlin and Stockholm, we can dis- 
 cover at no period of the life of the female, from her thirtieth to her 
 seventieth year, any other increase in the ratio of mortality than that 
 necessarily determined by the progressive advance of age.* At every 
 epoch of the life of the male, from the thirtieth year to the seventieth, 
 the mortality exceeds that of the other sex, but especially from forty 
 to fifty years of age. It follows, then, that the age from forty to fifty 
 is more dangerous for men than for women, and that too without 
 reference to the kind of life they lead, whether in town or country, 
 in the camp or the cloister. But, as it cannot be denied that women 
 do die between the fortieth and fiftieth year of the consequences of 
 their .great physiological change under consideration, and us in spite 
 
OP THE CESSATION OF THE MENSES. 
 
 43 
 
 of this cause of mortality, not to be found in the other sex, their 
 decrease, instead of being greater, is actually less than that of the 
 male, what power and duration of life would be theirs, were it 
 not for this condition which nature has appended to their sexual 
 character ?” 
 
 At Paris, and at all the great cities, where the causes of hygienic 
 perturbations are very abundant, and constantly renewed, the women 
 use up their day of youth and expend their vital power almost with- 
 out perceiving it. They are surrounded by many circumstances cal- 
 culated to hasten the approach of old age and lessen the duration of 
 life. We intend to speak at large on this subject, in that portion of 
 this work that treats on the hygiene of the sex, as applicable to all 
 the periods of their life. 
 
 Having now sketched a picture of the changes that take place in 
 women, and having indicated the peculiar diseases to which they are 
 principally exposed at the different phases of their existence, we shall 
 proceed to say a few words upon the surgical anatomy and the vari- 
 eties of conformation of the genitalia, and upon the sympathies of 
 the womb. 
 
 CHAPTER II. 
 
 OF THE VARIETIES OF CONFORMATION, THE SURGICAL ANATOMY OF THE GENITAL 
 ORGANS, AND THE SYMPATHIES OF THE W(MB. 
 
 As the external genitals of the female present no anatomical cha- 
 racter that is not familiar to all physicians, we shall here confine our- 
 selves to the duty of describing only such varieties of conformation 
 as they may present according to differences of age, climate and 
 constitution, and we shall indicate especially those points in their 
 surgical anatomy, the knowledge of which is important as throwing 
 light upon some points of the diagnosis, as well as simplifying some 
 of the operations that are required in the treatment. 
 
 In southern climes the sexual parts are found a little higher up and 
 more in front than in cold and damp countries. Thus, in the Scot- 
 tish, English and Dutch women, the vulva is not so directly in front, 
 and the womb is lower down than in the French women of the 
 southern departments, the Spaniards and the Italians. The latter 
 are known to have the labia of a more rounded form, and containing 
 a more abundant and elastic cellular tela. 
 
 [This remark has been made by other writers ; but it is difficult to 
 imagine that any other foundation for it can exist than the imagination. 
 The human pelvis is very much alike all the world over, and since the 
 genitalia are founded upon the bones of the ossa pubis, how can it be that 
 such differences as those described by the author are to be reconciled with 
 
44 
 
 VARIETY OF FORM 
 
 the anatomical, or rather the osteological basis of these formations. In all 
 women, except those in whom the external genitalia have been injured and 
 relaxed by repeated acts of parturition, by the relaxation of age, emaciation, 
 debility and accidents, the posterior commissure of the genital fissure, coin- 
 cides with the top of the pubic arch ; but as the symphysis pubis is but an 
 inch and a quarter to an inch and a half long, all the world over, it is clear 
 that the author is under some mistake in making out his point above stated. 
 To suppose him correct is to suppose that the southern women have very 
 deep pubic symphyses, or that the plane of the superior strait dips at a 
 lesser angle under the horizon, which is inadmissible. — M.] 
 
 In young females, the labia are thicker above than below, in which 
 respect they differ from those of women who have borne children. 
 In early life these two folds are not so near together as at a later 
 period, although they are more prominent and of a larger size rela- 
 tively. At the age of puberty they are in mutual contact closing the 
 genital fissure, and are also of a firmer texture than at any other 
 period. In married life, and particularly after parturition, the labia 
 becomes soft and pendent, and lose their original form and even- 
 ness. The mucous membrane that lines the interior surface is of a 
 lively red in the virgin, but acquires a brownish and violaceous hue 
 in such as have been the frequent subjects of the coitus, and who 
 have had many children. 
 
 At birth the nymphae generally project beyond the level of the 
 labia — in young virgins the labia conceal them, but they again 
 become salient in child -bearers. In the commencement, from being 
 firm, erectile and of a rosaceous hue, they grow flaccid, and, like the 
 mucous membrane of the labia, turn soft, brown or violet-coloured, 
 and offer a greater variety of appearances than the labia do in differ- 
 ent races and climates. Among the Turkish and Persian women the 
 nymphae are naturally much more prominent than in our European 
 regions, and in some of them they grow so very large as to obstruct 
 the entrance and constitute a disorder so disgusting that it is removed 
 by means of the excision of the swollen part. Ten-Rhine, Tackard, 
 Sparmann, Banks, Peron, Le Sueur and most of the naturalists have 
 spoken of a very considerable elongation of the nymphae, which is 
 known as the tab tier des Hottentottes, or Hottentot apron , and 
 which seems to be a conformation natural to the Bosjesman women 
 of Southern Africa. Levaillant says that this hideous conforma- 
 tion, this sort of fleshy apron of the Hottentots is not an elongation of 
 the nymphae, but of the labia themselvesj which, according to his 
 account, grow to the length of eight or nine inches. 
 
 The uses of the nymphae are but little understood. The ancients 
 conferred upon them the name of nymphae, in allusion to the fabulous 
 nymphs who presided over springs and fountains. Most of the 
 accoucheurs suppose that their use consists in giving, by their unfold- 
 ing in labour, more material for the distension of the external parts. 
 It has also been said, that as they are endowed with the highest 
 sensibility, they contribute to augment the sexual excitement. The 
 
OF THE EXTERNAL GENITALS. 
 
 45 
 
 learned academician, M. Serres, supposes that during the act of 
 copulation, the nymphse being forced backwards into the vagina, 
 their upper extremity, which surrounds the clitoris as a preputium 
 clitoridis, is drawn forwards and downwards so as to compel the 
 clitoris to toucfy the dorsum penis, which occasions a much more 
 intense erotic sensation. 
 
 Like the other parts of the external genitalia, the clitoris is found 
 to be the subject of differences which are worthy of mention. This 
 exquisitely sensitive point, which has been compared to the uvula, 
 and which is like a miniature penis, is relatively much larger at birth 
 than at any other period. 
 
 [It is difficult, in the early embryonic stages, to detect the difference of the 
 sexes, in consequence of the similitude of the penis and the clitoris. — M.] 
 
 It soon ceases to increase in size, and at puberty is commonly four 
 or five lines in length. But in a few cases, women are to be met 
 with, in whom the clitoris is six inches long, which gives it a con- 
 siderable resemblance to the male organ. This state of the case 
 generally gives rise to a suspicion of hermapbrodism, and is observed 
 in women of a very masculine character, and who prefer the kind of 
 occupations generally devolved upon men alone. Such women com- 
 monly have very small breasts, but the muscular and pilous systems 
 are, on the other hand, greatly developed. The upper lip and chin 
 are bearded, they are of tall stature, and, in fact, they seem to belong 
 really to neither of the sexes, and are said even to be fond of the 
 illicit enjoyment of other females. 
 
 [I do not feel that I have the right to doubt the above remarks, but I can- 
 not refrain from saying, that they can have no other foundation than the 
 imagination of authors by whom they have been reiterated, and need only 
 suggest to the medical reader, that such a clitoris, even if slightly endowed 
 with erectile properties, can by no means be supposed capable of such a 
 state as to admit the possibility of so revolting an act. It is true that there 
 are the corpora cavernosa clitoridis, but as there is no corpus spongiosum, 
 nor glans, and as the clitoris in question is a case of diseased hypertrpohy, 
 the notion repeated by our author must be without real foundation, in the 
 anatomical nature of the part. — M.] 
 
 If, as is generally believed, the frequency of conception is in a 
 direct ratio to the intenseness of the erotic excitement in the sexual 
 combination, it is a consideration of much importance in surgery to 
 respect, as far as possible, both the clitoris and the nymphse, which, 
 in consequence of their sensitive endowments, appear to be the prin- 
 cipal seats of the erotic excitations. 
 
 In its anatomico-chirurgical regards, the vestibulum presents no- 
 thing of interest, excepting that it is the point at which both Celsus 
 and M. Lisfranc have advised us to open the bladder for the extrac- 
 tion of a calculus. 
 
 There are several anatomical varieties of the urethra, especially at 
 its external orifice. This canal has been seen to open into the vagina, 
 
46 
 
 VARIETY OF FORM 
 
 into the rectum, and even on the mons veneris. There are some 
 females with the vulva very small, even though they may have been 
 subject to the coitus, in whom the orifice is far back, behind the 
 symphysis of the pubis. 
 
 In such case it would be impossible to apply the catheter, unless, 
 by introducing the index upwards and backwards, the surgeon should 
 first draw the urethra downwards and forwards to expose its orifice. 
 
 The perineum, that is to say, the space betwixt the anus and the 
 vulva, is smaller than is commonly supposed; when it seems to pos- 
 sess an antero-posterior diameter greater than common, it happens 
 so because its anterior margin is prolonged by means of a sort of 
 transverse band, thin from above downwards, and slightly concave 
 forwards, terminating in a thin membranous edge, beyond which the 
 fossa navicularis is situated. From this anatomical arrangement, it 
 happens that the longer the perineum, the shorter seems to be the 
 genital fissure, and vice versa. The perineum, in reality, is always 
 of the same extent, and it is only this prolongation of its transversal 
 fold that varies, and that sometimes augments its antero-posterior 
 diameter. We have deemed it proper to mention this circumstance, 
 in order to show that whenever, for certain surgical purposes, it 
 might be judged necessary to increase the size of the vulvar opening, 
 we might do so by dividing this anterior transverse band, without 
 any fear of doing injury to the true perineum. 
 
 OF THE VAGINA AND CERTAIN VARIETIES OF CONFORMATION 
 OBSERVED IN IT. 
 
 There are varieties of conformation observable in the vagina, in 
 different women, the knowledge of which is of much importance to 
 the practitioner. In the virgin state the tube is generally partially 
 closed, on its posterior part, by a membrane called the hymen, which 
 although ordinarily very thin, is sometimes found to be several lines 
 in thickness. In childhood this membrane forms a semilunar fold, 
 and it acquires only at puberty, according to Ruysch and Meckel, a 
 circular form in some specimens. The former of these authors, and 
 some modern writers, and among them M. Lisfranc, relate cases in 
 which it has been found double. 
 
 This membranous fold, which is correctly regarded as one of the 
 best signs of virginity, is, nevertheless, sometimes found to exist in 
 young persons who have ceased to be virgins. In such cases it has 
 been preserved by its thickness and elasticity from rupture by the 
 violence offered to it. Examples of this sort are very rare, however, 
 for in an immense majority of cases, the hymen is ruptured at the first 
 sexual approaches, and the fragments into which it is then torn con- 
 stitute certain small fleshy eminences, called carunculae myrtiformes, 
 which it is necessary not to confound with venereal vegetations. 
 Notwithstanding the great moral importance attached to the inte- 
 grity of the hymen, there are cases met with in practice, in which 
 the surgeon is compelled to destroy the membrane, by means of an 
 
OF THE EXTERNAL GENITALS. 
 
 47 
 
 operation to be described when we shall have occasion to speak of 
 the indications that render it indispensably necessary. 
 
 The vulvar orifice of the vagina, which is not very dilatable in 
 young marriageable girls, is much more so in women who have 
 borne children, and its dilatation is almost null in women arrived at 
 the change of life, and especially in such as have long overpassed 
 that critical period. As the sexual organs at this age have no func- 
 tions to fulfil, they become atrophied, the vagina contracts, its mucous 
 coat, which was soft and full of pleats in youth, now becomes smooth, 
 whitish and polished; the vaginal orifice, instead of being a supple and 
 easily dilatable ring, becomes hard and resisting, and is, in many 
 persons, so contracted as scarcely to admit of the introduction of the 
 little finger. 
 
 Instead of being a cylindroid canal, as it is described to be by almost 
 all the anatomists, the upper third part of it exhibits a dilatation so 
 considerable as to admit of the finger pressing it aside in every direc- 
 tion, and even of our examining the very corpus uteri. The author 
 was long ago acquainted with this fact, of the great extensibility of 
 the part of the vagina that is nearest the womb, and it was this 
 knowledge which gave rise to the idea of his speculum brise, as well 
 as of the peculiar mode of operating for amputation of the cervix 
 uteri. The superior region of the vagina, in its posterior and lateral 
 parts, is in direct relation with the peritoneum, so that if the surgeon 
 should make a perforation there, he would inevitably wound the 
 peritoneal membrane and penetrate the abdominal cavity, whilst a 
 perforation made in front and above, would penetrate the bas-fond 
 of the urinary bladder. 
 
 Instead of being inserted horizontally and like a ring upon the 
 cervix of the womb, as we are taught by all the anatomists, the 
 upper end of the vagina is attached obliquely from behind, forwards, 
 that is to say, the anterior surface is nearer to the os tineas than the 
 posterior. This arrangement, the knowledge of which is extremely 
 important as regards the operation for excision of the cervix uteri, 
 affords a more considerable space behind than is found in front of the 
 cervix. M. Lisfranc found, in more than one hundred patients, that 
 the breadth of the vaginal insertion is much more extensive than is 
 generally supposed, and that it may vary from six to fifteen lines. 
 According to that distinguished surgeon, the smallest distance from 
 the os uteri to the peritoneum is nine lines on its anterior and ten 
 lines on its posterior surface. This discovery has, on various occa- 
 sions, enabled him to cut off six or eight lines in length of the cervix, 
 still leaving to this part of the organ a sufficiency of the insertion to 
 support the weight of the viscera. It is easy to conceive of the 
 advantages arising from the anatomical disposition we have just 
 detailed, and to appreciate the value of a correct knowledge of them 
 in performing certain operations upon the neck of the womb. 
 
 We must add, moreover, that the inferior region of the vagina 
 is somewhat depressed in a direction from before backwards, and 
 slightly bent towards the pubis. Its two extremities are cut obliquely 
 or beveled, so that its anterior is shorter than its posterior wall. The 
 
48 
 
 VARIETY OF FORM 
 
 vagina is remarkable for the property it possesses of dilating, and 
 of rapidly and insensibly acquiring very large dimensions in every 
 direction. Tumours are frequently formed in its interior, that distend 
 it more or less both in its longitudinal and transverse diameters; thus 
 a polypus, whether fibrous or carcinomatous, a lipoma, a steatoma, 
 a phlegmon, &c. &c., not unfrequently cause the canal to acquire, by 
 degrees, an enormous dilatation. In these cases, as happens after 
 labour, when the distending cause has been removed, the walls con- 
 tract by degrees and at length recover their natural size. 
 
 [The translator requests the attention of the reader’ to a circumstance in 
 the anatomical character of the vagina that seems to have escaped the 
 observation of the author of the work. It is this, that the posterior and 
 part of the lateral walls of the vagina are inserted in the soft and distensible 
 parts, as the perineum, while the anterior and part of the antero-lateral 
 walls are firmly attached to the pubic arch. Now it is worthy of remark, 
 that when the womb, in labour, is pressing the presenting part of the child 
 through the lower part of the vagina, but dilating and stretching it in length 
 to its utmost capacity, the chief part of the strain must be expended on the 
 anterior column and the antero-lateral walls of the organ. Hence, if the 
 vagina gives way or becomes lacerated, the rupture will be most apt to 
 commence on the anterior or on an antero-lateral surface, which cannot 
 yield in length so freely as the posterior column can do, that being attached 
 to the perineum, and to other soft and distensible parts. 
 
 I have seen two cases of labour in which the vagina was ruptured, and in 
 both, the fracture occurred in the anterior and antero-lateral surface and not 
 behind. Such an accident, implicating the vesico-vaginal septum, could 
 scarcely fail, except by merely detaching the vesical mucous membrane, 
 such an accident, I say, could hardly fail to give rise at least to a very bad 
 case of vesico-vaginal fistula. I avail myself of this opportunity to recur to 
 M. Colombat’s remarks on the great dislensibility of the upper portion of 
 the vagina. This fact is often noticed in the management of early abortions, 
 say of six weeks to two months. In such cases, when attended with great 
 hemorrhage, it is common to find the part of the tube in question enor- 
 mously distended, even when it does not, at the moment, contain but little 
 fluid or coagulated blood. The lower or exterior end of the organ 
 is close, tight and firm, whereas it would seem that the upper two-thirds of 
 the canal are frequently found dilated to a size sufficient to contain a very 
 large pippin or an orange. I have often found it similarly dilated in the 
 mere case of menorrhagia. I have so often had occasion to find the parts in 
 this state, that I have little doubt of its having been as frequently observed 
 by other practitioners, and it is important to dwell upon it for the purpose 
 of indicating the necessity there is, in such instances, of employing, if at all 
 employed, a sufficiently large tampon. A tampon, consisting of a single 
 piece of sponge, is, in my opinion, inefficient, inasmuch as a sponge of 
 sufficient dimensions to fill up this great dilatation, can not feadily be intro- 
 
OF THE EXTERNAL GENITALS. 
 
 49 
 
 duced through the os externum. Hence the tampon that I invariably prefer, 
 consists of portions of linen torn into squares of three or four inches, of 
 which the pieces are successively introduced until the cavity is quite filled. 
 Such a tampon very rarely fails to suppress the hemorrhage of an early 
 or embryonal abortion. — M.] 
 
 We shall close this article by remarking, that there are frequently 
 formed in the vagina, membranous bands or bridles, either circular 
 or lateral, which may interfere with the operation of touching, and 
 prevent us from getting a view of the os uteri on using the speculum. 
 Dr. Pauly, in his work on diseases of the womb, relates from Lis- 
 franc, two cases, in which that learned practitioner met with circular 
 bands of this kind dividing the vagina as by a diaphragm, with a 
 central opening of two or three lines in diameter, and situated about 
 one inch below the os uteri. The uterus was in a diseased state, as 
 was shown by certain well-known symptoms, and by a considerable 
 leucorrhceal discharge. Being unable to reach or see the womb, M. 
 Lisfranc, at all hazards, resolved to cauterize the cervix through the 
 small opening, and had the good fortune to restore the patient to 
 health. 
 
 OF THE WOMB, ITS SURGICAL RELATIONS, AND OF CERTAIN VARIE- 
 TIES OF ITS SITUATION. 
 
 The womb, which is designed for the lodgment of the foetus from 
 the period of conception until delivery, is a hollow, symmetrical 
 organ, shaped like a pear; or of a truncated, conoidal figure; placed 
 in the pelvic excavation, beneath the convolutions of the small intes- 
 tines, behind the bladder, in front of the rectum, and attached infe- 
 riorly to the vagina ; which is inserted obliquely from Jielow and in 
 front, in a direction upwards and backwards, into that part of the 
 womb to which the anatomists have applied the term neck, in order 
 to distinguish it from the rest of the organ called its body. 
 
 The front surface of the womb is slightly convex. Only the upper 
 half of this part of the womb is covered by the peritoneum, all the 
 rest of it being in contact with the bas-fond of the bladder. The 
 posterior surface, which is much more convex than the other, is 
 wholly covered with the peritoneum, and seems to be separated from 
 the rectum by a small space in which an intestine might become 
 strangulated. 
 
 The external surface of the womb presents three margins and three 
 angles. The superior margin, which is convex and smooth, corre- 
 sponds to the fundus ; the two others, which are lateral and convex 
 ill their superior half, but concave in the inferior half, are covered by 
 the broad ligaments. The superior angles of the womb are situated 
 upon the sides, and conjointly with the margins, which are here 
 united, they give rise to the Fallopian tubes, the ligaments of the 
 ovaries and the round ligaments. The third or inferior angle, which 
 it is most important to understand well, forms the os tincae or free 
 extremity of the uterus, which shall be described when we come to 
 speak of this part of the womb. 
 
 4 
 
50 
 
 THE WOMB. 
 
 The cavity of the viscus, of a triangular shape, is lined by a 
 membrane, which we shall denominate a mucous membrane, though 
 it has no epithelium; we denominate it thus because it furnishes 
 mucus in the healthful, and'puriform mucus in the unhealthful state. 
 The internal walls of the womb are very near to each other, and 
 there is a raphe along the median line of this cavity both on the front 
 and on the posterior wall. Upon this raphe are directed other oblique 
 and transverse lines or folds. In virgins, the sides as well as the 
 fundus coincide nearly with right lines, or they are slightly convex 
 inwards, whereas, in women who have had children, they are very 
 concave. The two superior internal angles are continuous with the 
 origin of the Fallopian tubes, and are frequently found more or less 
 dilated like a funnel. The inferior angle, at the base of which is 
 found the superior internal orifice of the cervix, will soon be de- 
 scribed in speaking of the neck of the womb. 
 
 In women who have had no child- 
 ren, the uterus, from the top of the 
 fundus to the most projecting part 
 of the anterior lip of the os tineas, 
 has, in most of our measurements, 
 been found to be from twenty-six 
 to twenty-eight lines in length ; from 
 front to rear, at the thickest part, 
 from nine to eleven lines; and from 
 side to side, measured horizontally, 
 from twenty-three to twenty-four 
 lines — but it ought to be observed 
 that all these measurements are one 
 or two lines larger in women who 
 have had several pregnancies. — 
 (Vide Figure.) 
 
 Being retained in its place by 
 very lax ligaments, the womb, with- 
 out being itself the subject of dis- 
 ease, is readily subject to displace- 
 ment, and yet continues to exercise 
 all its functions. All these vari- 
 ous uterine malpositions, of which 
 notice will be hereafter taken, may be in the direction downwards, 
 upwards, to the right, or the left, and forwards, or backwards. M. 
 Lisfranc justly remarks that they are most commonly the results of 
 uterine engorgement, the weight of the organ being augmented, 
 causing it in that state to put its ligaments on the stretch and thus to 
 lose its natural position. 
 
 The height of the womb in the pelvis may differ according to the 
 stature of different women, their climate, or some peculiarity of con- 
 stitution. Thus, in very tall women, in women in warm latitudes, 
 but especially in virgins, the womb is higher up than in those of cold 
 and moist countries, in such as have had children, or in whom the 
 physical conditions we have stated are absent. In some persons 
 the womb is naturally very low without any assignable cause, and, 
 
NECK OF THE WOMB. 
 
 51 
 
 on the other hand, it is often found to be very high up in the pelvis, 
 either in consequence of its great size, which gives rise to a sort of 
 locking of the organ there, or from the presence of tumours within 
 the pelvis, or even of faecal matters hardened and impacted in the 
 rectum. The last-named cause sometimes has a different effect — 
 forcing the womb down to the bottom of the pelvis by the masses 
 accumulated above it. 
 
 As the ovaries and the ligaments of the womb offer nothing very 
 peculiar in regard to their chirurgico-anatomical relations, we shall 
 proceed to speak of the neck of the womb and its imperfectly under- 
 stood relations to the peritoneum and vagina, and, in fine, all the 
 anatomical points on which are founded most of the operations to be 
 described in this work. 
 
 VARIETIES OF CONFORMATION, AND SURGICAL RELATIONS OF THE 
 NECK OF THE WOMB. 
 
 The contracted part which forms the inferior angle, I mean the 
 neck of the womb, is extremely variable as to its form and the degree 
 of its projection within the vagina. In vertical diameter it is from 
 eleven to thirteen lines long in adult women, and from eight to ten 
 in persons of advanced years, while its antero-posterior diameter is 
 six or eight lines and the transverse eight or ten. On the extreme 
 portion of the neck that projects into the vagina there is a transverse 
 cleft bounded by two rounded lips— the anterior one being thicker 
 and longer than the posterior, which, according to our observations, 
 is more frequently than the other the seat of primitive ulcerations of 
 the os tincae. The posterior lip is, also, the one most frequently 
 eroded by cancerous ulcers, probably from being found in more per- 
 manent and immediate contact with all the secretions of the womb. 
 The projection which these two lips present to the observer, and 
 which constitutes the os tincae, is subject to several differences in dif- 
 ferent people. In general it amounts to four or five lines for the 
 anterior lip, and three or four for the posterior, although the con- 
 trary might be imagined upon carefully performing the operation of 
 touching ; for, as we have already stated, the vagina ascends higher 
 behind than in front. This anatomical arrangement may be easily 
 verified by separating the womb completely from the vagina in the 
 subject. 
 
 In women who have had no children, the lips of the os tincae 
 are found shut; but in those who have conceived they are naturally 
 partly open, soft internally, and sometimes tubercular, more or less 
 tumid, and though in all other respects perfectly sound, they are 
 occasionally found of a grayish, violaceous or deep-red colour. It is 
 easy to conceive the importance of not mistaking for disease all the 
 varieties of shape and appearance we have described, and particu- 
 larly the hard and linear cicatrices which are the consequence of 
 laceration of the os uteri in labour. It ought to be noted, however, 
 that, when the lips of the os uteri are uneven and festooned, it does 
 not invariably follow, as is commonly thought, that there must have 
 
52 
 
 NECK OF THE WOMB. 
 
 been one or more pregnancies, for certain disorders may give rise to 
 such appearances, and women who have conceived again and again 
 have a different condition of the os tineas. 
 
 In most persons the neck of the womb is not placed perpendicu- 
 larly in the centre of the vagina. If it be true that it is sometimes 
 found inclined forwards, it nevertheless is almost always inclined 
 backwards, especially in married women, because, during the copu- 
 lative act, it is forced backwards in that direction. Without being at 
 all diseased it is found to be softer and larger some days before and 
 during the whole period of the catamenial discharge : it is then of 
 about the same size, consistence and sensation as is found in it at the 
 second month of gestation. 
 
 Our own anatomical researches have led us to conclude, that the 
 distance from the os tincae to the peritoneum is really but nine lines 
 in front, and not more than seven or eight behind, for on that side 
 the serous membrane descends quite down upon the vagina, to make 
 the recto-genital excavation. These^ measurements, which are esti- 
 mated to be greater by some surgeons, are not so large as they are 
 in women advanced in years, because both the body and neck of the 
 womb may, in such persons, be said to become atrophied, which is 
 doubtless the real cause of that obliteration of the os tineas, long 
 known to the medical authorities, among whom we may mention 
 the names of Mayer of Bonn, Lisfrane and Velpeau, and whieh, in 
 accordance with M. Breschet’s opinions, we look upon as a real 
 physiological law. 
 
 According to Messrs. Velpeau and Civatte de Siteron, the dimen- 
 sions we have laid down would be found less, particularly behind. 
 The last named author, in his thesis, asserts that the ant’ero-supe- 
 rior part of the cervix touches the bas-fond of the bladder, and 
 adheres to it by means of a loose layer of cellular tissue, which 
 corresponds precisely to the middle of a line drawn from the orifice 
 of one ureter to the other. He adds, that if a horizontal section of 
 the womb should be made, at the distance of four lines above the 
 extremity of the anterior lip of the os tincae, it would just lay open 
 the cellular tissue that unites the bas-fond of the bladder to the neck 
 of the womb. Instead of making the incision at this point, if it should 
 be effected five lines above, it would inevitably open the peritoneum. 
 
 M. Civatte -says, further, that in making an incision at the distance 
 of five lines, if the edge of the bistoury were directed forwards and 
 upwards, it must wound the bladder, particularly if distended with 
 urine. Posteriorly there is a greater space between the extremity of 
 the lip and the terminus of the surgical neck, but in this situation 
 there is no cellular space like that which is found in front, and a sec- 
 tion, even if horizontal, higher up than the limits proposed by M. 
 Mury, would hazard a wound of the peritoneum. Here the rectum is 
 united to the cervix by means of the upper part of the vagina, and 
 by about one line in width of cellular tissue. The upper part of the 
 vagina is inserted into and confounded with the neck, anteriorly, four 
 lines above the end of the lip, and posteriorly, five lines higher up 
 than the top of the posterior lip : the longitudinal and ascending 
 
VICIOUS FORM OF THE WOMB. 
 
 53 
 
 fibres of the vagina thus proceed to form the first muscular layer of 
 the cervix uteri, and to continue upwards with the superficial longi- 
 tudinal fibres of the uterus. 
 
 Before closing our remarks upon the subject of the cervix uteri, it 
 ought to be observed that the degree of its projection into the 
 vagina is not always as great as we have stated, for its varieties are 
 infinite. Women in phthisis, for example, have the neck of the 
 womb remarkably prominent; in little girls, nine or ten years of age, 
 as is the case with the clitoris, the salience of the cervix is pro- 
 portionably greater than it. is in adult women. In the latter it often 
 loses in length, but gains in breadth or thickness. In aged persons, 
 on the contrary, it disappears almost completely, and always seems 
 to become absolutely atrophied. — (Vide figure, which needs no ex- 
 planation.) 
 
 Fig. 2. 
 
 FAULTY CONFORMATION, PRIMITIVE OR ACCIDENTAL, OF THE 
 FEMALE SEXUAL ORGANS. 
 
 The sexual organs of females are subject to vices of form, consist- 
 ing in their absence, occlusion, narrowness, adherence, voluminous- 
 ness, connections and shape. The greater part of these lesions 
 depend upon some fault, arrest or aberration in the laws of their 
 development, or on some disease' affecting the individual either be- 
 fore or after her birth. 
 
 The records of the science contain no sample of complete and 
 simultaneous absence of all the internal genital organs. In some 
 rare cases only a single ovary has been found, with one tube, and 
 half of a womb. There may be absence of the ovaries, while all the 
 other sexual organs are in a natural condition. 
 
 In a post-mortem examination, carefully conducted, M. Jadelot 
 found but a single ovary. They have been by various persons met 
 with, of very minute size, which almost invariably implies sterility, 
 
54 
 
 VICIOUS FORM OF THE WOMB. 
 
 for the Graafian vesicles could not be developed in such ovaria. 
 The Fallopian tubes have been found to have contracted adhesions 
 with the peritoneum, or to be closed in a few instances, in some near 
 the ovary, in others near to the womb. 
 
 Theden, Lieutaud, Bousquet, Engel, Professor Caillot, MM. Re- 
 nauldin, Breschet and others, have related cases of absence of the 
 womb, and have found examples in which the neck alone existed, 
 and others in which it remained in the rudimental state. 
 
 The womb has also been found divided into two equal or unequal 
 portions, either entirely or partially, internally or externally, and that 
 in the same case. Such a case constitutes what is called a double 
 uterus, or two-horned uterus, like the natural uterus of a quadruped. 
 
 It may likewise be perfectly 
 divided into two separate 
 wombs, each of them opening 
 by an os uteri into a separate 
 vagina. Or they may have a 
 single cervix, though the body 
 is divided into two distinct 
 halves. There are cases met 
 with, in which the exterior 
 shape of the womb is not at all 
 changed from the natural ap- 
 pearance, yet its cavity is di- 
 vided into two parts by a ver- 
 tical median septum. 
 
 It has happened, but very rarely, indeed, that the womb has been 
 so very little developed, as to nullify, physiologically speaking, its 
 entire functions. Baron Portal, in his Pathological Anatomy , 
 speaks of two women in whom the womb was not in either of them 
 larger than it is in a child of nine or ten years old. They were both 
 moderately fat, the mons veneris was not covered with hair, and the 
 other external genitals presented the same characters as are observ- 
 able in childhood. M. Renauldin also tells us of a woman who, 
 instead of a womb, exhibited a cord about the size of a writing quill, 
 while M. Pauly cites the example of a lady of sixteen years old, not 
 yet regular, and subject from her ninth year to attacks of hysteria, in 
 whom he found a womb the size of a hazelnut, with a bulb not 
 three lines in diameter. 
 
 Although, in most cases, the orifices of the bilobate womb open 
 with a simple or double vagina, it is shown by Valisnieri, Saisard 
 and Daverney that one of them sometimes opens into the rectum, 
 while the other preserves its true position. But whether the os tincae 
 be single or double, whether it depend upon a bilobate or natural 
 womb, it has not very unfrequently been met with opening into the 
 rectum, the bladder, or the urethra, or even above the symphysis of 
 the pubis. 
 
 The womb is, also, the subject of other anomalies of shape ; for 
 example, the neck or body is obliterated wholly or in part, in conse- 
 quence either of a primary organic vice or of an accident. Bichat, 
 Lallemant, Leroux of Dijon, Buisson, Gardien, M. Lisfranc and 
 
 Fig. 3. 
 
VICIOUS FORM OF THE WOMB AND VAGINA. 
 
 55 
 
 other authors have proved, as we have ourselves done, that the 
 cervix may, in some persons, acquire a very considerable length and 
 volume, and that sometimes, on the contrary, it is so small that its 
 substitute seems to be a mere tubercle. Its position may, likewise, 
 exhibit variations from the natural order of things, and it may be 
 deranged by adhesions which tie one of its surfaces or sides too near 
 the brim of the pelvis. 
 
 Specimens of faulty conformations of the vagina are as frequently 
 met with as those of the womb. It may be wholly or partly wanting. 
 The external orifice may be closed by a membrane that prevents the 
 escape of the menses at the age of puberty, and gives rise to the 
 most serious consequences. It may be absent as to its upper or 
 middle portion, and not communicate with the womb. It has been 
 seen to open into the rectum. But this deformity, which is always 
 complicated with imperforation of the vulva, does not compromise 
 the person affected with it, and it generally remains undiscovered till 
 the menstrual discharge, taking place into the rectum, causes its ex- 
 istence to be discovered. In his Treatise on Midwifery, Barbaut, 
 formerly king’s surgeon at the Chatelet, has given the history of a girl 
 who conceived by this passage, and was brought to bed without any 
 other accident than the rupture of the sphincter-ani muscle. 
 
 In certain equally rare cases the vagina may open into the bladder, 
 or into the bladder and rectum at the same time. This sort of 
 anomaly, which, as well as the one last mentioned, is beyond the re- 
 sources of the art, compromises the patient’s life, and, like it, is rarely 
 discovered until the menstrual period of life, when a monthly dis- 
 charge from the bladder leads to a suspicion of the real nature of the 
 case. It is quite a difficult task to avoid confounding it with the 
 sanguineous exhalation from the interior lining of the urinary blad- 
 der, which is sometimes observed to take place as vicarious to the 
 catamenial office of the womb in instances of absence of the uterus. 
 
 In some specimens the vagina has been found completely divided 
 by a median longitudinal septum, directed vertically from before 
 backwards ; but, in such a state of things, the womb is, also, for the 
 most part, found to be bilobate. Lastly, the canal, which may be 
 wholly wanting in the subject, is found extremely narrow and short, 
 and both of these anomalies may be either co-existent or not. 
 
 The clitoris, the labia and the nymphm, either individually or all 
 alike, do, in certain cases, acquire enormous size, or the external geni- 
 tals may be wholly wanting, or may be coherent either by a single 
 point of contact or throughout. 
 
 If the absence of the womb, the tubes and the ovaries, involves 
 the consequence of barrenness, the absence of the vagina, its want 
 of due length, its constriction and narrowness, are also in the way 
 of the sexual union. Imperforation of the exterior orifice of the 
 canal and cohesion of the labia may occasion serious consequences 
 as to the discharge of the menses. 
 
 [[I do not perceive any foundation for the fear expressed by M. Colombat 
 of the obturator power of coherent labia, because, in all possible cases of such 
 
56 
 
 SYMPATHIES OF THE WOMB. 
 
 cohesion, there must remain an exitus for the urine, which, as it escapes 
 from beneath the triangular ligament of the pubis, it will always keep the 
 labia from cohering to the troublesome extent supposed by the author. — M .3 
 
 The double cavity of the vagina, 
 the tube, being divided by a me- 
 dian septum corresponding with a 
 bilobate uterus divided, each form 
 into a distinct cavity, and, duly 
 provided with its appendages, might 
 consist with the possibility of a su- 
 perfcetation which, without such 
 anomalous form, seems difficult to 
 explain. 
 
 Adhesion of the neck of the 
 womb to the vagina, as well as 
 its occlusion, almost in every case 
 prevents conception; and adhesions of the Fallopian tubes and the 
 ovaries to the peritoneum also promote the formation of extra-uterine 
 pregnancy, but much more commonly lead to barrenness. Lastly, 
 any unnatural opening of the womb into the rectum, openings of the 
 rectum into the vagina, and those of the vagina into the bladder, 
 afford very reasonable explanations of certain anomalies observable 
 in females, whether as regards the discharge of the catamenia, the 
 emission of the urine, or the dejection of the alvine products. 
 
 Inasmuch as the congenital deformities of the female sexual organs 
 are so numerous and varied, and as the principal part of them do not 
 involve her life in any danger, we believe that we have spoken suffi- 
 ciently in extenso upon the subject, the more especially as we shall, 
 in the course of this work, have occasion to speak of them in greater 
 detail, and to point out the surgical processes appropriate to most of 
 them. 
 
 OF THE SYMPATHIES OF THE WOMB. 
 
 In physiology and therapeutics we understand by the word sym - 
 pathiesf the relations of two or more organs, more or less near to or 
 remote from each other, which have established betwixt them an 
 association, by means of which the vitality of the one is modified by 
 that of the other, whether that vitality be in a sound or in an un- 
 healthful state. There is nothing more certain than is the existence 
 of a bond of sympathy which communicates certain modifications of 
 the vital state to one or several remote organs, from an impression 
 received by some other organ. These modifications that are parti- 
 cipated in by the intermediate parts, cannot be referred to the mere 
 mechanical connection or to the common alliance of functions; but 
 they appear to depend upon a certain peculiar organization, which 
 causes all those parts to vibrate in unison, that are so arranged as to 
 irradiate, of themselves, the impressions they receive, whether di- 
 rectly by nervous anastomosis, or indirectly by the intervention of the 
 brain. In explaining the sympathies of the womb with most of these 
 organs, we shall restrict ourselves to the statement of facts, without 
 
 Fig. 4. 
 
SYMPATHIES OF THE WOMB. 
 
 57 
 
 going into an examination of their causes, since they are covered 
 with a veil as impenetrable as that which conceals from us the real 
 nature of the nervous power. 
 
 The ancients, who were ignorant of the sympathies of the uterus 
 with other parts of the body, supposed that it was endowed with a 
 special existence, and a temperament independent of the general 
 constitution. They thought that the body, properly speaking, should 
 be regarded merely as a cage, within which the uterus enjoyed the 
 faculty of moving in any direction, and of affecting any organ to 
 which it might proceed, while the latter could not exert upon it the 
 smallest influence. 
 
 Among others, Plato says, “ that the womb is a wild beast that 
 obeys no reason, but which, when its desires are unsated, wanders 
 about within the body and excites all sort of irregular motions.” — 
 ( Tim. 500.) 
 
 The sympathetic phenomena of the womb, resulting from the or- 
 ganization of the female, are so evident, that it would be worse than 
 absurd to call them in question. It is, therefore, indispensable, espe- 
 cially for the physician who, in his practice, is chiefly conversant with 
 the diseases of women, to have, as far as possible, the most exact 
 information as to the intimate relation of the uterus with the other 
 organs, and with the reaction of these latter upon it. This study is 
 of the highest importance, since the life of the patient may depend 
 upon it. In fact, it sometimes happens that the only clue to a suspi- 
 cion of uterine disease is to be found in the sympathetic phenomena. 
 In all such cases that physician alone can make a sure diagnosis, and 
 order a rational method, who possesses a perfect knowledge of the 
 sympathetic irradiations of the womb. 
 
 It has happened that ulcerations or engorgements of the cervix, 
 or even confirmed cancers of the organ, have been treated as cases 
 of chronic gastro-enteritis, because they exhibited many symptoms 
 of these disorders, which were in reality nothing more than sympa- 
 thetic affections, results of the abnormal and pathological reaction of 
 the womb upon them. It is generally not until they have had fre- 
 quent and considerable haemorrhage, and severe pain in the sexual 
 organs, that women make up their minds to consult a more eminent 
 medical man, who then, but often too late, learns the sad certainty of 
 the nature of the case. 
 
 Many distinguished physicians, M. Lisfranc among others, have 
 been consulted for diseases supposed to be nephritis, gastralgia, gas- 
 tritis, enteritis, palpitation, active aneurism of the left ventricle, lum- 
 bago, sciatic or crural neuralgia, &c., which were, in reality, but the 
 sympathetic reaction, and the symptoms of a disease of the womb, 
 that might be perfectly made known by touching, by the use of the 
 speculum, and especially by the disappearance of all the nervous 
 phenomena, in consequence of the treatment and cure of the uterine 
 affection. 
 
 We have ourselves been often consulted for eases of aphonia, pro- 
 duced by a sympathetic action of the womb, excited by a physical 
 or physiological lesion of the organ. As in aphonias of this sort, 
 
58 
 
 SYMPATHIES OF THE WOMB. 
 
 several cases of which are related in our treatise on diseases of the 
 vocal organs, the larynx is generally found to be perfectly healthy in 
 its appearance, it is only by a knowledge of the uterine sympathies 
 that we are enabled to suspect and detect the cause, and the true seat 
 of the malady. For the establishment of a good diagnosis in all 
 these difficult circumstances, it is indispensable for us to know the 
 nearly invariable connection that exists between certain kinds of pain 
 and the affections of the uterine system. Instead of the sympathetic 
 irradiations of the organ we are liable to combat only the symptoms, 
 and not the disease that gives rise to them ; and frequently allow, in 
 spite of all the therapeutical resources of the art, a disease to become 
 aggravated up to an incurable stage. 
 
 The sympathies and the connection that exist betwixt the womb 
 and all the other organs, may be made manifest by the following 
 described phenomena. 
 
 1. With the breasts: we shall prove it by the decided coincidence 
 observed at puberty in their growth, in the development of the geni- 
 tal organs, and the first eruption of the menses. 
 
 No one is ignorant of the fact, that the sucking and titillation of 
 the nipple by the young child is sometimes accompanied by sensa- 
 tions referred to the reproductive organs. Hippocrates was the first 
 to notice the fact that the breasts of the pregnant woman become 
 flaccid, when the foetus dies, or during a uterine haemorrhage; or 
 that the suppression of the menses and of the lochia, or the distension 
 of the womb by a mole, a polypus, by hydatids or any other foreign 
 body, whose expulsion is effected by the contractions of the womb, 
 are apt to produce a secretion of milk, and a full milk fever, like that 
 which follows an ordinary parturition. 
 
 Women who give suck, and have an abundance of milk, are not 
 commonly regular, have but little lochia, and are rarely subject to 
 leucorrhoea, whereas those who lose their milk, and thus only half 
 fulfil the obligations of the mother, are liable to the whites, to abun- 
 dant lochial discharges, as well as copious menstrual effusions. 
 
 2. The sympathy of the womb with the stomach is rendered suffi- 
 ciently manifest, by the qualms, the strange appetite, the nausea and 
 vomiting, and by certain hysterical affections observable in some 
 pregnant persons, and in others who have irregular menses, or some 
 disease seated in the womb itself. 
 
 Its influence upon the stomach has been acknowledged by almost 
 all the authors, and in particular by Rega, where, in his brilliant dis- 
 sertation De Sympathia, p. 137, he says: Ergo si ab utero labo - 
 rante , plura stomacho contingcmt incommoda non est dubitan- 
 dum quin ventriculo patiente pati debeat et uterus. 
 
 The active sympathies of the womb upon the stomach commonly 
 disappear about midway of the term of gestation, because the organ 
 is at that period occupied with its own condition, and has no longer 
 any excess of vital activity to infuse into other portions of the viscera. 
 
 3. The sympathy with the brain is perfectly evident. Do we not 
 find that pregnant women, on the one hand, lose their memory, or, 
 •on the>o.ther, have it greatly strengthened; that their imagination is 
 
SYMPATHIES OF THE WOMB. 
 
 59 
 
 much more lively, or that they become less intelligent ; that they 
 exhibit symptoms of insanity, that they wish to bite persons whom 
 they really love, are prompted to homicidal acts, lose their reason, 
 become maniacs, cruel, thievish, &c. &c.? 
 
 Has it not often happened that a violent fit of passion, a jealousy, 
 a sudden fright, a violent impression on the mind, have arrested the 
 flow of the menses or lochia, and suspended the secretion of milk, 
 or at least changed the nature of the liquid, while the whites are 
 increased by vexation or great distress of mind. 
 
 4. The cessation of a uterine catarrh, and the appearance of a 
 bronchial catarrh ; the disappearance of the latter following the ap- 
 pearance of the former ; the dyspnoea, syncope, palpitation, oppres- 
 sion, spitting of blood, and, in short, a number of phenomena of this 
 sort noticed in pregnancy, and during the existence of many uterine 
 disorders, sufficiently prove the intimate connection between this 
 viscus and the respiratory organs. 
 
 The change in the voice at puberty and at the close of the menses ; 
 the aphonia and dysphonia sometimes met with in pregnancy, and 
 under some affections of the womb; the sensation often excited in the 
 genitalia when a child or a lover imprints a kiss upon the lips, or 
 merely touches any part of the body; the indigestion, borborygmi, 
 colic, cephalalgia, toothache, tinnitus of the ears, and other symp- 
 toms supervening at different stages of pregnancy ; the tumefaction 
 of the belly before menstruation ; the spontaneous vomiting and all 
 the nervous phenomena that follow rupture of the womb in labour, 
 or an operation performed on the organ ; the cessation of an obsti- 
 nate uterine catarrh from the application of a blister, or an issue to 
 the arm ; the suppression of uterine hasmorrhage by the application 
 of a sinapism, or cup under the breasts, or the immersion of the 
 hands or feet in cold water ; the energy imparted to the womb in 
 labour by the inhalation of acetic acid, by frictions with alcoholic 
 liquors, or the application of cold to the belly; and a variety of other 
 phenomena, both physiological and pathological, compose a group of 
 proofs capable of establishing the reality of the sympathies and con- 
 nections that exist betwixt the womb and all the other organs,* 
 and prove the accuracy of these two aphorisms of Van Helmont — 
 Propter solum uterum,mulier id est quod est...femina omnem bis 
 patitur morbem. 
 
 An attempt here to explain the causes of the great influence of the 
 womb upon the entire economy, would be to enter a labyrinth of 
 theories easier to imagine than to unravel. Any researches made in 
 
 * Those of our readers who may desire fuller and more curious views of the sen- 
 sibility of the womb, would do well to consult the works of Haller, Walter, Wm. 
 Hunter, and especially the important work of Fred. Tiedemann, published in Heidel- 
 burg in 1822 , under the title of Tabulae Nervorum Uteri , fol. He has endeavoured 
 to exhibit an anatomical demonstration of the manifest connections of the uterine 
 nerves with the great ganglionic and encephalic system of nerves, in order to 
 explain the sympathetic irradiations and the different consensus noted, whether during 
 menstruation, conception, pregnancy, labour or suckling; whether in the physical 
 and vital lesions of the uterus, in the hysterical affections and other troubles to which 
 women are liable. 
 
60 
 
 TOUCHING, AND THE SPECULUM. 
 
 this direction would certainly tend only to prove still more conclu- 
 sively, that man may ever seek in vain to lift up the veil that shrouds 
 the impenetrable secrets of nature. 
 
 CHAPTER III. 
 
 EXAMINATION OF THE FEMALE ORGANS OF GENERATION, BT TOUCHING AND BT THE 
 
 SPECULUM. 
 
 OF TOUCHING PER VAGINAM. 
 
 The operation of touching is not so easy a matter as one might at 
 first suppose ; and it requires long practice and repeated trials, both 
 upon the dead subject and upon living persons, to acquire the readi- 
 ness that is desirable in discriminating between the various lesions 
 that are found upon the interior genitalia. 
 
 As most modern writers, and the general treatises upon surgery, 
 are wholly silent on this most important point in the diagnosis of 
 sexual disorders, we conceive it will not be out of place to indicate 
 the rules to be followed in touching, and the different modes of per- 
 forming that operation. 
 
 The bladder and rectum having been emptied, the patient should 
 lie across the bed with a pillow under her head thick enough to 
 raise it a little higher than her hips. She should place herself so 
 that the coccyx should project a few inches over the edge of the 
 mattrass, while the feet rest upon two chairs about a foot apart. The 
 operator, seated upon one of the chairs, carefully introduces the index 
 finger, anointed with oil or dipped in mucilage, into the vagina, 
 directing it backwards and somewhat upwards. The preparation 
 of the finger and a gently rotary movement, render its introduction 
 easier to him and less painful to the patient. If seated upon her 
 right side, he should touch with his right hand, and vice versd. 
 Care should be taken to pare the nail, lest the vagina might be hurt 
 by it. He might, also, if on any account preferable, place the patient 
 lengthways in bed, in a dorsal position, the head and shoulders 
 slightly raised, the feet drawn up near the body and resting on the 
 mattrass, the knees moderately separated, so as to afford no obstruc- 
 tion to the operator’s hand. To render the womb more accessible, 
 and the introduction of the finger easier, and to avoid unnecessary 
 awkwardness, the pelvis should be raised, either by the woman ele- 
 vating it at his request, or by placing under it a cushion or a pillow. 
 Every thing being arranged as now directed, he will place himself 
 by that edge of the bed nearest to which the patient lies, and then 
 turning himself towards her, let him pass his hand under her dress 
 and betwixt the knees. Then let the operation be concluded as 
 above directed. This mode of effecting the touch is particularly 
 
TOUCHING. 
 
 61 
 
 applicable to cases in which it is necessary to examine the region of 
 the hypogastrium by palpation. 
 
 There is a third method, which we prefer to the two now described, 
 whether because it enables us to judge better of the weight, size, 
 direction and elevation of the womb, or because it is less alarming 
 to the delicate feelings of a person subjected for the first time to this 
 trial. This method consists in placing her standing with her back 
 against a partition, with her feet properly separated, and allowing 
 her muscles to be as relaxed as possible. The surgeon kneeling on 
 one knee, and pressing one hand on the hypogaster to force the 
 uterus downwards, introduces the index, anointed with oil, upwards 
 and backwards into the vagina, until he reaches the os tincae, which, 
 if natural, feels like a circular, firm and resisting ring, and giving 
 rise to a sensation, as the elder Dubois judiciously observes, very 
 much like that one experiences when touching the tip of the nose 
 betwixt the cartilages. 
 
 After having fully examined the vagina, the operator should pro- 
 ceed to examine the cervix uteri as to its temperature, its form, its 
 situation, the dilatation of its orifice, its sensibility, its volume, its 
 consistence, and lastly, he should ascertain whether there be any 
 ulceration of it, any erosions* or fissures, roughness, exuberance, 
 excrescences, vegetations, haemorrhoids, varices, or any polypus occu- 
 pying the whole or a portion of its circumference. He ought to be 
 careful not to mistake for actual disease, the rents often met with in 
 women who have had children ; such solutions of continuity are 
 nothing more than the consequences of those lacerations, to which 
 the neck of the womb is liable during labour. 
 
 Having well examined the os tincae, the operator ought to try, by 
 pressing the finger as far as possible upwards betwixt the cervix and 
 the surrounding parts, to ascertain the state of its surface. This 
 information is best obtained by touching first with the one and then 
 with the other hand, as, indeed, ought always to be done. The right 
 hand explores the right side of the vagina, and the left side of the 
 cervix, while the left hand operates in the inverse direction, and 
 explores the opposite sides. When the state of ail the parts has 
 been sufficiently understood, and the successive steps of the inquiry 
 carefully remembered, the hand should be removed as gently and 
 speedily as possible, in order to avoid fatiguing the woman. The 
 index should be seen for the purpose of learning whether it is stained 
 with blood, a sign of organic lesion, provided the patient is not actu- 
 ally under her catamenial period. And lastly, for the purpose of 
 more surely knowing the nature and colour of the blood and other 
 humours brought away by the hand, it should be wiped with a nap- 
 kin before washing the hands. 
 
 In a case where we are chiefly to examine the lower and anterior 
 part of the vagina, the woman ought to be in a horizontal position, 
 resting upon her knees and her hands. The position may be changed 
 by requesting her to lie upon either side, as may be considered de- 
 sirable, and according to the regions to be subjected to the inquiry 
 
62 
 
 TOUCHING BY THE RECTUM. 
 
 or the attitude that would be most likely to bring the deviated womb 
 into a more favourable situation. 
 
 Although the touch is applicable to the vast majority of cases, cir- 
 cumstances arise that render it necessary to defer it, and even wholly 
 to reject this excellent mode of exploring disease. Thus, we should 
 avoid touching for several days before and after the menstrual term, 
 and more especially during their flowing, because the womb, at that 
 time, undergoes changes that might lead to erroneous conclusions. 
 Touching ought not to be done either when the patient is subjected 
 to severe pains, nor when the vagina is highly sensitive and irritated 
 by the slightest friction. In such a case we should imitate the practice 
 of M. Lisfranc, by curing this unnatural irritation by means of small 
 bleedings at the arm to act as revulsives, and by the prolonged use 
 of the bath, and by the semicupium and small anodyne injections. 
 In fine, we ought to abstain from touching, or rather not repeat it, 
 when we are sure that the malady is incurable, as we may know to 
 be the case when we find the uterus large, botryoidal, and with a 
 neck affected with vegetations, lacerations and holes that bleed at 
 the slightest touch, and yield a noisome stench characteristic of the 
 carcinomatous affections. All further search in such cases would be 
 as useless as dangerous, for, in these desperate cases, each examina- 
 tion increases, and that without the least prospect of usefulness, the 
 patient’s sufferings, and often becomes the cause of a violent inflam- 
 mation or a fatal haemorrhage. 
 
 Although, as a general rule, we ought to examine early, we ought 
 to recur to it as seldom as possible, and only in case of absolute neces- 
 sity, and then always observing the utmost caution. This precept 
 will not, however, be carried so far out as to deprive the attendant 
 of all information required to note the progress of the disease, and 
 the changes that may demand some modification of the therapeutical 
 treatment. It is especially in the treatment of sexual disorders that 
 the physician should endeavour to inspire the greatest confidence, for 
 females submit to touching not without the greatest repugnance, and 
 only when pressed by sufferings characterized by increasing violence. 
 
 OF TOUCHING BY THE RECTUM. 
 
 Having completed the operation of touching per vaginam, should 
 there be any remaining doubts as to the state of the womb and its 
 appendages, and especially if any operation is about to be performed 
 upon the parts contained within the cavity of the pelvis, the physi- 
 cian has within his power another excellent mode of exploration — 
 one which throws a great deal of light upon the diagnosis of the dis- 
 eases of women, and which is even better adapted than the vaginal 
 touch for the investigation of the excavation and the organs contain- 
 ed within it. We allude to the mediate touch through the rectum, 
 which ought not to be resorted to, however, when it becomes difficult 
 on account of the presence of painful hmmorrhoidal tumours, spas- 
 modic constriction of the sphincters, or, lastly, from certain diseases 
 of the anus or the bowel. It is proper, however, to say that even 
 
TOUCHING AT THE HYPOGASTRIUM. 
 
 63 
 
 in the most difficult cases, when the examination by the rectum had 
 been supposed in some sort impossible and completely contra-indi- 
 cated, we have always been enabled to effect it with sufficient facility 
 and without producing much pain. This we have brought about 
 by introducing into the anus, an hour or two before the operation, a 
 suppository of beurre de cacao with which had been incorporated 
 half a grain of extract of opium and the same quantity of extract of 
 belladonna. 
 
 But where there is no obstacle to the introduction of the index, 
 the bowel having been first emptied by means of an enema, we 
 proceed as in the vaginal examination, but more gently, so as better 
 to overcome the resistance of the sphincters. Without this precau- 
 tion the patient often suffers from a sort of constriction and a painful 
 tenesmus that will not admit of the operation being long continued. 
 
 One thing ought not to be lost sight of: I mean that we should 
 follow the curve of the rectum until the index has reached the sacro- 
 vertebral angle ; care should also be taken to place one hand on the 
 hypogastrium, for the purpose of pressing the bladder down upon the 
 pubis and the womb towards the lower part of the pelvis. By this 
 mode we are enabled not only to examine the state of the back part 
 of the womb, but even to learn the state of the broad ligaments, the 
 ovaries, the tubes, and, in fact, to ascertain, when it is not to be found 
 in the excavation, the existence of some pathological lesion, some 
 carcinomatous mass, contra-indicating any operation which, in such 
 circumstances, could by no means save the patient’s life. An exam- 
 ple of this sort we witnessed in a patient at La Pitie, on whom M. 
 Lisfranc had operated for amputation of the neck of the womb, 
 eighteen days before. The dissection disclosed a carcinomatous mass, 
 which embraced the lumbar portion of the vertebral column and 
 contained some encephaloid matter. 
 
 The touch by the rectum is the best means of investigation for 
 the volume and the obliquities of the womb, where this organ does 
 not rise above the symphysis of the pubis. It is also the best mode 
 of ascertaining the existence or absence of the womb in cases of 
 imperforation or total absence of the vagina. 
 
 OF PALPATION ABOVE THE PUBIS, OR TOUCHING AT THE HYPO- 
 GASTRIUM. 
 
 If it be desirable to inquire into the condition of all the exterior 
 surfaces of the womb, there yet remains to be performed the sur- 
 pubal or hypogastric touch, which is effected by placing the patient 
 on her back, the head supported, the shoulders slightly raised, the 
 thighs flexed, and the feet resting upon the mattrass, so as to allow 
 to the abdominal muscles the greatest possible relaxation. Except 
 when absolutely necessary to examine the uncovered surface, the 
 chemise should be the only part of the dress left to conceal her skin. 
 The operator’s open hand should be placed upon the hypogastrium, 
 at first transversely and then vertically, so as to press the abdominal 
 parietes, and, by gentle movements in a transverse direction, should 
 
64 
 
 THE SPECULUM. 
 
 be made to push the bladder downwards and the bowels upwards, 
 so as to reach at last the womb itself, which is felt to be a solid and 
 movable body. With the tips of the fingers the womb can now be 
 examined on its anterior surface and a knowledge obtained of its 
 volume, shape, consistence, mobility, and its connections with the 
 surrounding parts; and, lastly, by examining also the iliac fossa we 
 can determine whether the tubes and ovaries are diseased, as by 
 tumour or other malady not otherwise to be ascertained. 
 
 In order to obtain the utmost certainty in the diagnosis of the sex- 
 ual disorders, and to prevent the mistakes and dispel the doubts to 
 which the similarity of their symptoms, notwithstanding the great 
 differences in their real nature, might give occasion, we must not 
 rest contented with the operation of touching alone, though we ought 
 always to begin by that. It is necessary, on many occasions, to add 
 to this excellent means of exploration, the use of the speculum uteri , 
 which allows us to judge of the malady by inspection, and yields an 
 almost mathematical certainty as to the determination of its nature. 
 It is by the aid of this instrument that we are enabled rigorously to 
 appreciate the volume, shape, colour and appearance of the affected 
 parts, and thus being in full possession of the facts as to the actual 
 situation and existence of certain lesions, inappreciable by the touch, 
 we are naturally in the right track as to those therapeutical indica- 
 tions whose efficacy is established on the grounds of experience. 
 
 OF THE SPECULUM UTERI AND THE MANNER OF USING IT. 
 
 If we meet with much difficulty in persuading the patient to sub- 
 mit to the operation of touching, it is easy to conceive what care is 
 necessary to render as little distressing as possible, the sacrifice that 
 a modest woman makes on the score of delicacy, when she is led to 
 expose to the physician parts that she always conceals with the 
 greatest care. 
 
 In cases where the external genitalia are to be examined, the 
 patient should lie across the bed, or be seated in an easy chair or on 
 a sofa, with the knees well separated, and raised upwards in the 
 former case by two chairs, and in the latter by pillows. The surgeon 
 being before her, kneeling on one knee, will examine, in the first 
 place, the perineum and the labia, then separating them, he will ascer- 
 tain the state of the mucous surface, the clitoris, the vestibule, the 
 nymphae, the orifice of the urethra, the anterior and inferior portions 
 of the vagina, and, in fine, all the folds of the vulva, which may 
 conceal small ulcers that it is important that he should discover. 
 
 If it should seem desirable to subject not only the vagina, but also 
 the neck of the womb to the same scrutiny, it will be found, as before 
 remarked, indispensable to make use of the speculum iiteri, by 
 means of which the walls of the vagina may be separated, and the 
 os tineas itself brought into view. 
 
 This vaginal dilater, to which so unfit a name has been given, and 
 which we should prefer to call a hysteroscopc , were it not that we 
 fear the imputation of being neologists, has been subject, since its 
 
SPECULUM UTERI. 
 
 65 
 
 introduction into practice, to numerous changes, an historical sketch 
 of which we propose to give, before pointing out the method of 
 applying it. 
 
 The invention of the speculum is of the highest antiquity, and it 
 would be difficult to give the name of its inventor, or the period at 
 which it was first made use of. According to Aetius,* Archigenes, 
 of Apamea, in Syria, who settled in Rome under the reign of Domi- 
 tian, was the first to make known the instrument in question. In 
 a translation of Paulus iEginetta by Rondelet, the author, in the 
 article phyrnosis in females, says, U instrument appelle 8<,o7tspa,eslant 
 introduit fermeb dedans la vulue , apres soil lourn£ pour Pouvrir , 
 affin que les conjunctions du-dit instrument soient eslargies , et la 
 cauiti de la feme soil distendue. t The speculum that Paulus iBgi- 
 nettaf speaks of was composed of two branches that were made to 
 act by means of a screw. Avicenna,! who died about A. D. 1036, 
 who had received the title of Prince of Physicians, and who, by the 
 Arabs, was considered a second Galen, and Albucasis,§ who died 
 A. D. 1122, have described, under the title of vertigo , two kinds of 
 speculum uteri , with three branches, that were made to separate 
 from and approach each other by means of a screw handle. These 
 instruments are figured in the work of Andreas de la Croce. || Spa- 
 chius,1[ the author of a collection of writers on diseases of women ; 
 Franco,** who first performed lithotomy by the high operation; 
 Pare, ft Scultetus,!! Garengeot,§§ and several other authors of the last 
 century, have likewise published different sorts of jointed speculum, 
 with two or three branches ; but these instruments, which were for 
 the most part inconvenient, had fallen into disuse, when Professor 
 Recamier revived the use of them by demonstrating their utility in 
 the exploration of the genital organs. The instrument that was 
 first used by that excellent practitioner was extremely simple, and 
 consisted of a tin tube, the uterine extremity of which presented a 
 circumference with rounded edges, which admitted of its embracing 
 the neck of the womb, without risk of injuring it. The instrument, 
 which was too long, and conical, and beveled at its vulvar extre- 
 mity, was modified by M. Dupuytren, who shortened it to the length 
 of the vagina, and added a handle, by means of which it could be 
 more firmly held and more readily introduced. Professor A. Dubois, 
 for the purpose of adopting it to the exploration and treatment of 
 vaginal fistulas, added a notch or slit near its superior extremity. 
 
 Since that time the speculum has been modified by Madame Boi- 
 vin, Messrs. Lisfranc, Weis, Deyber, Ricque, Guillon, Bertze, Joubert, 
 Thompson, Ricord, and especially by M. Charriere, the distinguished 
 cutler of Paris, who has invented several different kinds, of which 
 we shall have occasion to speak in the course of this work, and of 
 
 # Lib. iv. cap. 86. f Lib. iii. cap. 66. * Tract, iv. cap. 3. 
 
 § Lib. ii. cap. 77. || Officina Chirurgica, p. 39. ^ Gynaeciorum, 1597. 
 
 ** Traite des Hernies, &c., et autres Maladies, &c., 1651. 
 
 ff Les (Euvres d’Ambroise Pare, Liv. xxiv. chap. 86. Paris, 1585. 
 
 44 Armamentar Chir., Tab. xl. p. 153. Ven. 1668. 
 
 §§ Nouveau Traite des Instruments de Chirurg., tom. i. pi. 28. Paris, 1723. 
 
 5 
 
66 
 
 SPECULUM UTERI. 
 
 which, as well as of the other, we shall give a description and figures 
 in our Diet. Histor., et Iconographique of all the chirurgical instru- 
 ments and operations. 
 
 In our memoir on amputation of the neck of the womb, published 
 in 1828, we gave a description and figure of a speculum with six 
 and eight branches, which we had invented in 1827, and which we 
 again represent in this work. This instrument, of a conical shape, 
 
 Fig. 5. Fig. 6. 
 
 with the base at the handle when closed, and at the other extremity 
 when opened, may be introduced when of a small size, and opens 
 only near the os uteri, when it abundantly separates the parietes of 
 the vagina, so as to afford space to act freely where some operation is 
 required. To use the instrument, it must first be fitted with its end- 
 piece, which is of an oval shape. This end-piece, which is of steel, 
 polished like the rest of the speculum, whose cone it completes, 
 receives the branches of the instrument in its concavity, which facili- 
 tates its introduction and obviates the pain which the inequalities of 
 the point of the speculum might otherwise produce. 
 
 When the speculum has passed through the vulva, and is suffi- 
 ciently deep within the vagina, the end-piece is disengaged by 
 pushing it a little forwards by the handle, and is then withdrawn 
 by slightly opening the instrument so as to give it room to pass out 
 easily. The instrument may be opened by turning the screw which 
 pulls the ring towards the immovable base of the cone formed by 
 the shut speculum. Having laid the end-piece aside, the speculum 
 is completely introduced, opening the branches gradually as it goes 
 forward. 
 
 This speculum is particularly convenient in effecting the excision 
 of the cervix uteri, because in every one of its diameters it produces 
 
SPECULUM UTERI. 
 
 67 
 
 Fisr. 7. 
 
 great dilatation .only near the womb, which greatly facilitates the 
 operation by the methods which we shall explain. M. Velpeau does 
 not do justice to it in saying that it is apt to pinch the vaginal mu- 
 cous membrane, for it is so formed that such an accident can by no 
 means happen. 
 
 In cases where a simple exploration is required, we make use of 
 M. Recamier’s speculum instead of our own, 
 above described. It consists of a conoidal tube 
 of tin or silver, to which I have added a han- 
 dle, with a joint an inchin length, and turning 
 backwards towards the body of the instru- 
 ment. The speculum thus modified is very 
 convenient and portable. To a great sim- 
 plicity of construction it joins the advantage 
 of being easy of application, and of showing 
 better than other instruments the cervix by 
 reflecting the light upon it. Besides, as it is 
 whole, the mucous membrane of the vagina 
 cannot mask the os uteri, as in other appli- 
 ances it is said to do, by intruding itself be- 
 twixt the open branches of other speculums 
 composed of several pieces. Such a difficulty, 
 which really does not exist, since the vagina is stretched when the 
 speculum is in situ , would readily disappear by giving to the instru- 
 ment a few slight rotary motions, first in one direction and then in 
 the other. 
 
 But whatever kind of speculum it may be that is to be used, the 
 following rules ought to be observed in order to proceed properly to 
 its application. The patient should lie upon her back across the bed, 
 with the hips near the edge of it, her feet being supported upon two 
 chairs, the thighs widely separated. The pelvis, somewhat higher 
 than the head, should be firmly supported, and should project a little 
 beyond the margin of the mattrass. Every thing being thus pre- 
 pared, let the surgeon proceed to introduce the speculum, after having 
 warmed it a little and anointed it with oil or mucilage to render its 
 insertion easier and less painful to the patient. Then, having sepa- 
 rated the labia externa and interna with the thumb and index of the 
 left hand, let him direct the point of the instrument to the orifice of 
 the vagina, holding it so as to make with the canal an obtuse angle 
 posteriorly. With gentle efforts and slight rotary motion the specu- 
 lum, which ought to bear most upon the posterior wall of the vagina, 
 will readily pass upwards to the os tineas, pushing before it the mu- 
 cous membrane which forms a sort of circular cushion or fold that 
 very much resembles the neck of the womb. He must take care 
 not to mistake it as such, a^d be cautious in inserting the speculum 
 gently, so as not to bruise the parts he wishes to examine. 
 
 When the os uteri has been brought into view, care should be 
 taken not to press it backwards, because, in that case, the body of 
 the womb would take a position as in a kind of anteversion, which 
 would render it impossible to examine the os tincae ; and the farther 
 
68 
 
 SPECULUM UTERI. 
 
 the speculum should be pushed the more difficult-would it become 
 to examine the parts — and this is the reason why it has been rejected 
 and abandoned by several surgeons as a useless instrument — the fact 
 being that they did not understand the use of it. 
 
 For the purpose of correcting the position of the cervix and com- 
 pelling it to project within the end of the speculum, we invented 
 
 a kind of concave lever, by 
 Fig. 8. means of which the os tincae 
 
 can be drawn forwards. This 
 instrument, which is more easy 
 of application than Madame 
 Boivin’s fenestral spoon, which is too broad, has, at the other end of 
 it, a forceps with a slide for the purpose of holding a bit of sponge, 
 a portion of charpie or a linen tampon, either to cleanse or cauterize 
 the os tincae according as the indication may be. 
 
 Having reached the bottom of the vagina, in order to increase the 
 saliency of the cervix the patient should be told to bear down, with 
 expulsive efforts as if on the close stool. 
 When the cervix is perfectly exposed, it 
 should be cleansed with a bit of sponge or 
 some parcels of lint fixed in the forceps of 
 our lever, or upon our four-branched for- 
 ceps ; all the mucus that has been pressed 
 upwards about the os uteri ought to be care- 
 fully removed, to admit of a perfect inspec- 
 tion. This is obtained by the light of a taper 
 placed betwixt the orifice of the vagina and 
 a metallic mirror, which we invented and 
 denominated the hysteroscope , and which 
 throws an abundant light to the very bot- 
 tom of the speculum. The rays of the taper, 
 being reflected from the mirror, form a luminous cone by their con- 
 vergence, the apex of which falls upon the neck of the womb. In 
 this way we may make sure of a perfect exploration of the diseased 
 organ, and of discovering certain alterations which, but for the re- 
 flection, could never be ascertained. 
 
 It ought here to be remarked that the choice of the metal for the 
 speculum is not a matter of indifference. Those of silver, tin or 
 polished steel are to be preferred. It is especially advisable to avoid 
 such as are composed of two metals, as, for example, the plated ones, 
 for we have observed that the use of such was painful, because the 
 contact of two metals and the acid mucus of the vagina give rise to 
 certain voltaic phenomena that were capable of a considerable reac- 
 tion upon the womb. 
 
 But, whatsoever be the nature of the speculum, the use of it should 
 always be governed by the rules above laid down, observing always 
 that the handle should be upwards, lest it might give trouble by 
 catching against the bed-clothes if turned in a downward direction. 
 
 Although the utility of the speculum is incontestable for a great 
 many kinds of cases, there are, as in the operation of touching, some 
 
 Fig. 9. 
 
SPECULUM UTERI. 
 
 69 
 
 circumstances that ought to induce us to defer or even wholly to 
 reject it. For example, cases of acute inflammation of the vagina; 
 contractions of the passage in elderly persons and in young virgins; 
 membranous bands across the vagina; the hymen; and all the reasons 
 for deferring the touch are equally applicable against the employ- 
 ment of the speculum, until all the counter-indications have been 
 removed by proper precautions or operations. 
 
 The instrument should be absolutely prohibited in all cases of 
 deep ulceration of the cervix and vagina, as endangering the pro- 
 duction of serious lacerations and haemorrhages. It is also useless, 
 and even dangerous, where, by the touch, the existence of extensive 
 carcinomatous vegetations, or a large fungus of the cervix has been 
 ascertained. Lastly, in all cases, before proceeding to the examina- 
 tion of the internal genitalia, the rectum should be emptied by means 
 of an enema, for the purpose of getting rid of all extraneous obsta- 
 cles or sources of error in the examination. 
 
 Notwithstanding the use of the speculum is always, at least for 
 respectable women, a serious sacrifice of their delicacy, such a con- 
 sideration ought not to arrest the medical adviser, when he has rea- 
 son to suspect the existence of some lesion, whether actual or only 
 threatening to become serious. He ought, therefore, to insist upon 
 his purpose, and endeavour to persuade them to submit to the exami- 
 nation, though so repugnant to their feelings. It is in such cases that 
 he ought to inspire the greatest confidence, and by gentleness and 
 good conduct, so perform the operation, as to lessen, as far as practi- 
 cable, the moral and physical distress that are the ordinary accom- 
 paniments of these inquiries. 
 
 We shall not close this chapter without remarking that among 
 the different means of exploring the uterus, reliance is placed upon 
 the stethoscope, which Fodere, Major, and especially Kergaradec, 
 have proposed for the auscultation of the foetal pulsations, and to 
 discriminate thus betwixt pregnancy and a variety of disorders that 
 occasion enlargement of the womb, such as dropsy, tympanitis, &c., 
 of the organ. The instrument which we have rendered more con- 
 venient and portable, by constructing it with tubes that slide one 
 within the other, like a spy-glass, ought to be applied betwixt the 
 anterior margin of the pelvis and the level of the umbilicus, being 
 placed higher as the pregnancy is more advanced. The patient 
 should be examined while lying down. 
 
 The foetal heart, which sounds at each pulsation, beats 100, 140 or 
 150 times a minute, while the mother’s heart beats only from sixty 
 to seventy-five times. These sounds are the certain signs, not only 
 of pregnancy, but of the life and health of the foetus ; the latter being 
 judged of by the force and frequency of the beats. Foetal pulsations, 
 very manifestly perceived, yet coinciding with very little develop- 
 ment of the womb itself, would be in proof of the existence of extra- 
 uterine pregnancy. However, the absence of the pulsations like 
 that of the active and passive motions of the child, are not conclusive 
 proofs as to the life of the child, or even the fact of gestation. As 
 the employment of the stethoscope, in this case, is to be looked upon 
 
70 
 
 SPECULUM UTERI. 
 
 rather as an obstetrical than as a medico-chirurgical exploration, we 
 may properly dispense with more extended observations upon it, 
 merely adding that the metroscope proposed by M. Nauche, for 
 hearing the sounds and appreciating the movements that are to be 
 distinguished in the vagina and womb, is, in our opinion, a much less 
 trustworthy means than the stethoscope, properly so called. 
 
 [M. Colombat appears to me to have passed very hastily over his remarks 
 upon auscultation as an obstetrical resource, and it seems barely justice to the 
 reader and to a distinguished gentleman, Dr. Evory Kennedy, of Dublin, to 
 mention his work on the signs of pregnancy, a little volume that has added 
 much to the facility of acting with prudence as well as knowledge in cer- 
 tain doubtful cases. The use of the stethoscope, or of immediate ausculta- 
 tion, is become a resource of the most indispensable kind in the conduct of 
 labours, and in settling questions of pregnancy. It is not to be doubted 
 that the use of the stethoscope may, in some cases at least, enable us to 
 detect the sensible signs of pregnancy, if the child be alive, as early as the 
 end of the fourth month of gestation. By its use, also, we may be very 
 correctly determined as to our course of action, since it reveals with clearness 
 the state of the child’s circulation. Now, if we find that the pulsations of 
 the child in utero are becoming dangerously disordered, either by excessive 
 precipitation of the heart’s action, or extreme feebleness, irregularity or 
 slowness of the same, it is manifest that we have possession of the means 
 of deciding whether the security of the infant demands our intervention, in 
 the way of some obstetrical operation, as the use of the forceps, &c. So, 
 also, where, in a bad labour, we have repeatedly recognized the situation and 
 activity of the foetal heart, if upon carefully seeking in vain for them in the 
 same place, it being impossible for them to have changed their place, we 
 have the elements of an opinion as to some operation of cephalotomy, &c., 
 which we might have been highly inclined to perform, but from our respect 
 to the rights of the foetus — rights which cease with the cessation of its life. 
 Doubtless, also, by means of auscultation, we may gain great light as to the 
 diagnosis of position, to the saving for the patient much of that distress or 
 pain that an exploration with the w r hole hand could not fail to give; an 
 exploration now often unnecessary, by the gentler intervention of auscultation. 
 
 In the diagnosis of pregnancy from dropsy, and various other forms of 
 disease, which, by their exterior physiognomy, so closely simulate several 
 stages of gestation, the methods by auscultation are invaluable. M.] 
 
CAUSES or DISEASES OF FEMALES. 
 
 71 
 
 CHAPTER IV. 
 
 GENERAL CAUSES AND SYNOPTICAL TABLE OF DISEASES OF FEMALES. 
 
 It would be easy to explain why the sexual organs of the female 
 are more subject to disease than those of men, by reflecting that her 
 share in the act of reproduction, which is vastly greater than that of 
 the male, imposes upon her organs of generation a most painful func- 
 tion, and that in her the different parts of the reproductive functions 
 are numerous and protracted. 
 
 There are a variety of circumstances to be regarded as deviations 
 from the design of nature, and which are the most ordinary causes 
 of various genital affections. Among them we may cite the state of 
 celibacy, continence, abusus coitus , the too frequent provoking of 
 erotic spasms, sterility, laborious labours, abortions, drying up the 
 milk, &c. If it be true that, in the higher classes of society, and 
 especially in the great capitals, we meet with a greater number and 
 variety of the diseases of females than in country places and amongst 
 the less exalted ranks, it is doubtless owing to the latter being less 
 under the influence of the perturbing causes which accumulate in 
 and are perpetually renewed as to the females who live in a state of 
 opulence. 
 
 As the womb is an organ upon which most of the impressions, 
 both physical and moral, made in the female, are reflected, we ought 
 to count among the most common causes of uterine diseases in great 
 capitals, particularly at Paris, the insalubrious nature of the air, dis- 
 regard of the laws of hygieine, protracted vigils, cold and astringent 
 cosmetic lotions for the vulva during or soon after the menses, the use 
 of foot warmers, the abundance of exciting dishes, the immoderate 
 use of ices and sherbet, and of coffee ; great political excitement and 
 commotions, secret manoeuvres, illicit enjoyments, the distracting and 
 oft-repeated emotions excited by theatrical representations and the 
 reading of works of fiction; jealousy, disappointed love, loss of for- 
 tune, domestic chagrin, joy too strongly felt, frequent fits of passion; 
 and, in a word, all the violent passions and every species of mental 
 shock. 
 
 It is easy to perceive how all these causes must be more powerful 
 in their pernicious influence among city women, and especially those 
 of the elevated class, because, as they are in general more nervous, 
 more impressionable, and endowed with the liveliest imagination, 
 they are, by that very circumstance, most prompt to take the alarm, 
 on account of their own families, and sometimes on account of persons 
 who are strangers to them. The consequence of their social position 
 and the modifications resulting from their habits and manners, ren- 
 
72 
 
 CAUSES OF DISEASES OF FEMALES. 
 
 der their sensibility and delicacy very frequent causes of grief and 
 distress. 
 
 In country women and among the common people the affections 
 of the sexual organs often depend upon totally different causes. For 
 example, a residence in marshy countries, a damp and badly-lighted 
 dwelling-house, violent bodily exertion, blows, falls upon the buttocks, 
 atmospherical vicissitudes, cold feet, the continued use of coarse food 
 and alcoholic drinks ; sitting on the grass or on the ground, or a stone 
 bench, immersion of the hands or feet in cold water; the use of 
 emmenagogues taken with criminal design ; meddlesome midwifery, 
 continued employment at sedentary labour in cellars, or in low damp 
 workshops, lifting heavy weights or carrying heavy burthens for a 
 long time for sale in town ; finally, rage, libertinism, drunkenness, 
 filthiness and a variety of other causes, both physical and moral, too 
 tedious to mention here. 
 
 The change of life is also a frequent source of sexual disorders, 
 inasmuch as the cessation of the menstrual discharge determines 
 towards the pelvis a congestion giving rise to uterine haemorrhage 
 and organic alterations which tend to become very serious when left 
 to themselves. It is at this period of life that we may, with Horace, 
 say: — 
 
 Multa ferunt anni venientes comraoda secum, 
 
 Multa recedentes adimunt. 
 
 The first effect of disease of the womb is to produce a prompt 
 reaction upon both the physical and the moral nature of the female. 
 She becomes sad, melancholy, restless and susceptible, and troubled 
 with sinister presentiments. Those who live in a state of opu- 
 lence withdraw from society, or rush into the vortex of company, as 
 if to escape from an evil that they fear without understanding it, and 
 which, from a sentiment of false delicacy, they permit to become so 
 aggravated that it unhappily, too often, gets beyond the reach of 
 art. Those particularly who are attacked with carcinoma of the 
 cervix uteri soon find that their beauty and freshness are gone, and 
 that the malady, which increases pari passu with their sufferings, 
 both wrinkles and fades them 
 
 Comme un fruit dont le coeur est rouge par un ver. 
 
 From this succinct enumeration of the general causes of female 
 diseases we should gather the notion of how much prudence and 
 sagacity are required in governing the health of an organization so 
 delicate and so mobile, and into what depths of the heart the physi- 
 cian ought to seek and detect the principle of so many unnatural 
 shocks, so as to put in motion the springs of a sensibility as inconstant 
 as it is flexible. 
 
 In order to facilitate the study of the lesions of the genitalia, and to 
 group them, as far as practicable, according to the natural order they 
 ought to occupy in a general system of pathology, of which they 
 constitute but a trifling portion, we have made a classification in 
 which we divide them into six sections: — as, 1 . Lesions of form and 
 development, 2. Lesions of situation. 3. Physical lesions . 4. 
 
VICIOUS CONFORMATION OF GENITALS, 
 
 73 
 
 Vital lesions. 5. Lesions of functions. 6. Lesions appertaining 
 to reproduction . 
 
 Although we might be disposed to look upon this classification of 
 female diseases as more rational than those proposed by our prede- 
 cessors, we are far from deeming it perfect and unattackable. But we 
 are somewhat reassured, in regard to its imperfections, by the con- 
 sideration that there is no perfect classification in pathology; and 
 further, that all writers on female disorders have, like ourselves, met 
 with some shoals which it is impossible to avoid. 
 
 I. Section - . 
 
 Lesions of 
 Form and 
 Development. 
 
 II. Section. 
 
 Lesions of 
 Situation. 
 
 III. Section. 
 
 Physical 
 
 Lesions. 
 
 IV. Section. 
 Vital Lesions. 
 
 V. Section. 
 
 Lesions of 
 Functions. 
 
 Synopsis of the Diseases of Females. 
 
 Comprising all cases of vicious conformation, whether congenital or 
 accidental, of the sexual organs and their appendages — among which 
 we enumerate absence of the labia, cohesion of the labia, excessive 
 magnitude of the nymphae, cohesion of the nymphse, excessive deve- 
 lopment of the clitoris, imperforation and stricture of the urethra, 
 < absence of the vagina, contraction of the vagina, narrowness of the 
 vagina, obliteration of the vagina, imperforation of the vagina, obtu- 
 ration of the vagina, congenital opening of the vagina into the rectum 
 or bladder, absence of the womb, bifid womb, incomplete develop- 
 ment of the womb, congenital occlusion of its neck and its accidental 
 ^obliteration, and, lastly, imperforation of the Fallopian tubes. 
 
 Comprising all cases of displacement, and deviation of the geniio-uri- 
 nary organs of the female — among which we arrange hysteroptosis or 
 prolapsus of the womb; anteversion, retroversion, anteflexion, retro- 
 I flexion, inversion, obliquity, elevation and immobility of this organ ; 
 j hysterocele and all the hernias of the womb and ovaries; vaginal 
 cystocele and enterocele ; vulvar enterocele and cystocele ; prolapsus 
 of the urethral mucous membrane; prolapsus of the lining membrane 
 ^of the vagina, and invagination of the canal. 
 
 f Comprising all cases of lesion of continuity, and the accidental intro- 
 | duction of foreign bodies — among which are found wounds, contusions 
 J and lacerations of the vulva, the fourchette, the vagina, the uterus, 
 ] and the rupture of the womb; vesico-vaginal, urethro- vaginal and 
 | recto-vaginal fistula; and, lastly, foreign bodies accidentally intro- 
 kduced into the genital cavities. 
 
 f Comprising the phlegmasia, the transformations, and all the patho- 
 logical products and degenerations of texture, such as phlegmon, carci- 
 noma, oedema, cysts, varix, fibrous and sanguine tumours of the 
 labia. Inflammation and fungus of the nymphas, carcinoma of the 
 clitoris and meatus urinarius, erysipelas, prurigo, venereal chancres 
 and syphilitic excrescences of the vulva, acute vaginitis, chronic 
 vaginitis, and all the white discharges; acute and chronic metritis, 
 uterine phlebitis, ulceration, excoriation, fungous tumours and en- 
 gorgement of the cervix uteri; scirrhus, cancer, carcinoma, putre- 
 scence, softening, dropsy and tympanitis of the womb; metrorrhagia, 
 polypus, fibrous tumours, calculus, hydatids, sanguine and lymphatic 
 concretions formed in the cavity or in the substance of the womb ; 
 scirrhus, cancer, encysted tumours, and dropsy of the ovary; and 
 ^lastly, cancer of the breast. 
 
 
 Comprising the neuroses, neuralgia, and functional derangement of 
 the female organs of generation, such as cessation of the menses and 
 all the sympathetic phenomena of the change of life. Hysteria, 
 J nymphomania, false pregnancy, hysteralgia, anaphrodisia, inertia of 
 the womb, mastodynia, chlorosis, dysmenia, amenia, amenorexia, 
 arnenorrhcea, dysmenorrhea, menorrhagia, raenostasis, and all the 
 ^anomalies of menstruation. 
 
74 
 
 VICIOUS CONFORMATION OF GENITALS. 
 
 VI. Section. 
 
 Lesions apper- 
 taining to 
 Reproduction. 
 
 r Comprising the accidents and all the sympathetic phenomena of con- 
 ception , pregnancy, labour and lactation, among which are false germs 
 or moles, extra-uterine pregnancy, abortion, strange appetite, ano- 
 rexia, odontalgia, ptyalism, convulsions, vomiting, nervous cramps of 
 the stomach, nervous colic, constipation, diarrhoea, tenesmus, dysuria, 
 ischuria; the hernias which sometimes complicate pregnancy; dys- 
 pepsia, cough, haemoptysis, haematemesis, epistaxis, sanguine ple- 
 thora, palpitations, syncope, varices, haemorrhoids, oedema of the 
 limbs, cephalalgia, vigils; neuroses of sight, hearing and smell; neu- 
 ralgia of the loins, kidneys, groins, pubis, labia and thighs; contusions 
 and lacerations of the genital parts ; inversion of the womb and va- 
 gina, puerperal peritonitis, milk fever, phlebitis of the uterine and 
 ovaric veins, of the inferior cava and the crural veins; neuritis of 
 the sciatic, crural and sub-pubal nerves; painful oedema, phlegmo- 
 nous abscess of the mons and labia, of the psoas and iliacus mus- 
 cles; absence, diminution, suppression or excess of the lochia; miliary 
 eruption, polygalactia, agalactia, retention of the milk in the breast, 
 involuntary flow of milk, alterations of the milk; and lastly, mam- 
 mary abscess, mammary fistula, cracks, excoriations, flattening, im- 
 _perforation, absence and multiplicity of the nipple. 
 
 FIRST SECTION. 
 
 CHAPTER V. 
 
 LESIONS OF FORM AND DEVELOPMENT. 
 
 Vicious conformation, congenital or accidental, of the female genitais. 
 
 Though there may exist cases of vicious conformation of the 
 female genitals that are beyond the resources of our art, such as ab- 
 sence of the womb and vagina, opening of the vagina into the blad- 
 der or rectum, imperforation of the Fallopian tubes, absence of the 
 ovaries, &c., &c., there are others susceptible of remedy, and not a 
 few such — as, for example, the complete or partial cohesion of the 
 labia or the nymphas; their excessive length; too great a development 
 of the clitoris; occlusion of the meatus urinarius; imperforation, obli- 
 teration and obturation, and congenital or accidental narrowness or 
 stricture of the vagina; and, lastly, occlusion of the neck of the womb. 
 
 OCCLUSION OF THE SEXUAL ORGANS. 
 
 The occlusion of the female genitals, which has been noticed from 
 the remotest antiquity by the Greek physicians,* was, by the Latins, 
 (Celsus, lib. 7. cap. 28, JEtius, lib. 16. cap. 97.) called clausum , and 
 by the Arabians, (Avicenna, 21. 3. tract. 4. cap. 1, and Albucasis, lib. 
 
 * Girls who exhibit this faulty conformation received from the Greeks the epithet 
 of arptirai — among the Romans they were called imperforatse clausse velatae ; Cicero ( de 
 Divinat., lib. iii.) speaks of a dream in which was seen a woman quae obsigimtam 
 habebat naturaui; and Pliny relates that Cornelia, the mother of the Gracchi, was 
 born with an imperforation of the sexual parts — concreto genitali naia fuit. {Hist. 
 Natural ., lib. 7. cap. 16.) 
 
OCCLUSION OF THE SEXUAL ORGANS. 
 
 75 
 
 2. cap. 72,) alratica; it is the phymosis of Galen and Paulus AEgi- 
 netta, (Paulus iEgin., lib. 3. cap. 73. and lib. 6. cap. 71 and 72;) the 
 phymon of Ambrose Pare, (Ambroise Pare, liv. 4. chap. 59. p. 998,) 
 and, in fine, has, by most of the modern French writers, been desig- 
 nated by the words atretism , atresia ,* imperj oration. 
 
 Although the words union, imperforation, obliteration and obtura- 
 tion are not synonymous, and present totally different ideas to the 
 mind, one of these expressions is often used to designate an occlusion 
 of the genitals, whatsoever may happen to be its seat, nature or 
 causes. 
 
 In order to establish a more exact division, and give to the words 
 union, imperforation, obliteration and obturation the true sense and 
 meaning they ought to express, we shall distinguish them in the fol- 
 lowing manner: 
 
 We shall use the word union to express the congenital and acci- 
 dental coherence of the labia and the nymphse. 
 
 The words imperforation, atretism, atresia imperforatio, atresia, 
 will indicate the occlusion of the inferior and anterior part of the 
 vagina; which may be either complete or incomplete, accidental or 
 congenital; and which may depend either upon the presence of the 
 hymen or any other imperforate membranous fold, or upon cellular or 
 cellulo-fibrous bands situated in various parts and at different heights 
 in the canal of the vagina. 
 
 The word obliteration , from the Latin word obliterare , will ex- 
 press not only the accidental constriction of the vagina, but also the 
 coherence of its walls throughout its entire length, or in its middle, 
 or towards either extremity. The obliteration, which is aliuays 
 accidental , may, therefore, like the imperforation, be either complete 
 or incomplete. 
 
 Lastly, the word obturation , from the Latin obturare , will indicate 
 the more or less complete occlusion of the womb or of the vagina; 
 which may, when it is accidental, be occasioned by excrescences, by 
 polypus, by hydatids, by tumours of different sorts; or, when conge- 
 nital by means of some intermediate substance of a fibrous, cellular 
 or cellulo-fibrous nature. 
 
 The occlusion of the genital organs of the female, whatever be the 
 nature and cause of it, is the more especially deserving of the atten- 
 tion of the practitioner, inasmuch as it obstructs the exercise of several 
 important functions, and may often compromise not only the health 
 but the life and the reputation of the patient. 
 
 As this subject has been but little studied, and mention is scarcely 
 made of it in works treating of female diseases, we shall dwell upon 
 it at greater length than has been done by our predecessors upon 
 the history, etiology, differential signs, diagnosis and treatment of the 
 various primary and accidental occlusions of the sexual organs. 
 We shall also, in the same chapter, treat of all the faulty conforma- 
 tions, whether congenital or whether developed after birth and at all 
 the periods of life. 
 
 From the Greek priv. a, without opening . 
 
76 
 
 UNION OF THE LABIA. 
 
 OF THE UNION OF THE LABIA AND OF OTHER FAULTY CONFORMA- 
 TIONS OF THE VULVA AND ITS PARTS. 
 
 We sometimes find that female children are born with a more or 
 less complete cohesion of the labia, so that these bodies are united in 
 the whole or in a part only of their length. When the cohesion is 
 complete nothing can be seen but a sort of raphe or seam, without 
 any trace of clitoris or vagina, or urethral orifice. The labia, which 
 are prominent, constitute a soft, elastic, fluctuating tumour, and there 
 is found above the pubis a rounded elevation occasioned by the 
 accumulation of the urine in the bladder, and which is very painful 
 upon the least pressure. 
 
 This complete absence of the genital' fissure, the result of aeon- 
 genital deformity, is announced soon after birth by the continual cries 
 of the child, and by all the signs proper to a suppression of urine. In 
 such a case death is the inevitable consequence if measures be not 
 taken to re-establish the natural openings. 
 
 In some cases where the vulva is not imperforate through its 
 whole length, the urethra is sufficiently open to give issue to the 
 urine ; in others, the fluid escapes drop by drop, and with greater 
 difficulty in proportion as the cohesion of the labia is more or less 
 extensive, leaving more or less liberty to the orifice of the meatus 
 urinarius. In the former case, that is, where the urine escapes 
 freely, the infirmity under question does not interfere with the 
 health of the young girl, and it is not until the period of puberty that 
 it gives rise to the disorders caused by retention of the menstrual 
 fluid, concerning which we shall have to treat in a future chapter. 
 
 Where the partial union of the labia affects the lower part of the 
 vulva, there is always a discharge of urine into the vagina, which, 
 by its accumulation there, may produce mischievous effects, such as 
 ulceration of the walls, fistulas of the rectum and perineum, and a 
 multitude of other accidents. 
 
 Schultz, ( Miscel . cur Germ., obs. 3. Decemb. 1. anno. 10,) relates 
 that a little girl, four years old, had been unable, since her birth, to 
 discharge the urine except drop by drop, and that with extreme pain 
 and difficulty. The parents, supposing she had a stone in the blad- 
 der, consulted a surgeon, who discovered an almost complete union 
 of the labia. He destroyed the adhesion and established the free 
 course of the urine by means of an incision with a convex-edged 
 bistoury. 
 
 The lesion, whether complete or partial, of the labia is not always 
 congenital ; it may depend upon certain accidental disorders ; thus it is 
 sometimes occasioned by acute inflammation of the vulva either attack- 
 ing spontaneously, or brought on by the effects of laborious labour,* 
 
 * Marcellus Donatus, De Med. Histor. Mirab., lib. 6. cap. 2; Riolan, sen., art. bene 
 medendi, sec. 4. tract. 2. cap. 1; Felix Plater, Obs., lib. 1. p. 258; Casp. Bauhin, 
 Theat. Anatom., lib. 1. cap. 39, and De Hermaphrodilis , lib. 1. cap. 38; Fabr. Hildan, 
 Obs. centur, lib. 6. obs. 67; Riolan, jun., Enchirid. Anat., lib. ii. cap. 37, and Anthro- 
 pograph. lib. 2. cap. 35. p. 197; Th. Bartholin, Hist. Anatom., centur, ii. histor. 31; 
 Rudolph Jacob Camerarins, Misc. Nov. Curios. German., centur, 9, io. obs. 73; J. 
 Conrad Beckerus, De Inculpata, § 18, and seq.; Roonhuysen, Obs. Chirurg., obs. 2. p. 
 125 ; Heister, Institut. Chirurg n torn. ii. p. 9. 52. 
 
UNION OP THE LABIA. 
 
 77 
 
 of a burn,* of a venereal affection, t a wound or a laceration.^ It 
 may likewise depend upon the long-continued friction of any hard 
 substance;§ upon frequently repeated coitus;|| upon excoriations pro- 
 duced by the acrimony of the urine in children yet wearing the 
 
 * G. de Sorbait, Eph. Curios . Nat. de Cur. 1 . ann. 3. obs. 273, and Chambon, who, 
 in his Traite des Maladies des Femmes, chap. 37. p. 299, cites from this author the case 
 of a young girl eight years of age, who, as she was warming herself by an earthen 
 pot filled with lighted coals and covered over with ashes, by a sudden motion overset 
 the vessel, so as to produce a burn of the vulva and lower part of the vagina. As 
 little attention was paid to the consequences of the accident, the inner surfaces of 
 the labia cohered as they got well, and there was left only a small hole in the middle 
 of the vulva, through which the menses escaped regularly. At a later period, the 
 girl having abandoned herself to the caresses of her lover, she became pregnant, 
 notwithstanding the narrow dimensions of the opening. The adhesions were sepa- 
 rated from the orifice just mentioned to a point below the orifice of the urethra, but 
 the dilatation proving to be insufficient, the incision was prolonged, and the labour 
 terminated happily. 
 
 f Anton- Beneveni, de abditis nonnulis morbis , et san causis, cap. 31; also, La 
 Lancette Fran guise, Gazette des Hopiteaux , No. 31.1. vii. Mar. 1833. 
 
 * The illustrious Dupuytren has given, in his Lectures, the case of a girl who 
 was seduced, and who, in giving birth to a child, was delivered precipitately and 
 with violence; the consequence of which was a deep laceration of the perineum, 
 with severe inflammation of the vulva. The learned professor brought the parts 
 together by means of three sutures. After the lapse of two years, without his having 
 heard from her, she called upon him to request that he would say nothing <on the sub- 
 ject of her misadventure to her husband, who was to call upon him the next day for his 
 advice. In fact, he called in order to consult with M. Dupuytren as to the measures 
 to be taken for overcoming the resistance dependent on the virginity of his wife, in 
 consequence of which the marriage could not be accomplished. A new operation 
 removed the difficulty, without his having the least suspicion of her past history. 
 The medical annals contain a great number of similar cases — I had an opportunity 
 of seeing one not less curious at La Charite, in the wards of Baron Boyer. 
 
 § Arnaud (Obs. 1. p. 44,) relates the case of a young girl, whose genitals were 
 excoriated and violently irritated by a long ride upon an ass, whose rude trot and the 
 hardness of the pack-saddle, were the occasion of the misfortune. Having taken no 
 care of herself, the labia cohered without her having dared to speak of it, and the 
 vulva presented but two small orifices; one through which the menses escaped, and 
 the other opposite to the meatus urinarius. Notwithstanding the almost complete 
 occlusion of the vulva, she married and became pregnant. When her labour came 
 on, the cohering parts were divided with probe-pointed scissors, and the delivery was 
 happily accomplished. 
 
 H In 1814, there came to the Hotel-Dieu at Paris, a woman, twenty-four years of 
 age, well formed, and of a sanguine temperament. She came for advice as to a 
 tumour of the hypogaster, which she supposed to arise from suppression of the 
 menses. Upon a careful examination of the sexual organs, it was found that the 
 vulva was completely obliterated, and the womb greatly distended, forming a globe 
 about the size of the uterus at the sixth month of gestation. Being carefully interro- 
 gated as to the possible causes of her disorder, she confessed that having been sur- 
 prised by some Cossacks in the woods at Fontainebleau, she had been compelled to 
 submit to several of them, and she regarded her malady as really caused by this vio- 
 lence. Notwithstanding the use of venesection, leeches, baths, fomentations, narco 
 tics, &c., her situation became so dangerous that Dupuytren decided to use the bis 
 toury, in order to overcome the adhesions of the organs ; and the consequence was a 
 copious discharge of black putrid blood, exhaling an infectious odour. For fear of 
 impeding the discharge of matters already so long retained, no dressings were em 
 ployed. On the following day a complete relief had succeeded the most violent ago- 
 nies. The abdominal tumour was very much lessened. The discharge was still 
 considerable and bloody ; a suppurative fever came on and lasted a few days, and the 
 discharge, which had become puriform, next became mucous. In order to obviate 
 th§ tendency to cohesion, she was advised to introduce a dilater into the vulva from 
 time to time, and the cure was soon complete. This curious case is related in detail 
 in the Lancette Frangaise , N. 31. 6th annee, 7. 7. 
 
78 
 
 UNION OF THE LABIA. 
 
 napkin; (Isbrand de Diemerbroek, Anat. du Coi'ps Humam, bb. 1. 
 cap. 26 ;) and lastly, by large variolous pustules under suppuration, 
 (Becker, jr., in Pcedioctonia Inculpata, fyc., p. 35; Boyer, Malad. 
 C/iintrg., xx. p. 379 ;) and a variety of other circumstances capable 
 of exciting violent inflammation of the genitals. 
 
 There is yet another cause of atresia (complete or incomplete) of 
 the vulva, but which exists only among the oriental nations. Many 
 authors, and among them Sinibaldus, (Geneanthropia, lib. 4. cap. 12, 
 Rodericus a Castro, lib. 4. cap. 10,) state that in Ethiopia the virginity 
 of the females is made sure of by uniting the sides of the labia as 
 soon as they are born. United by sutures made with silken threads, 
 space is left sufficient only for the natural discharges : when married, 
 the husband makes the section required for the restoration of the 
 natural form. 
 
 Atresia of the vulva is not always the inevitable consequence of 
 the causes we have above signalized ; and where it does take place 
 under such circumstances, it is because the inflammation arising has 
 been neglected or badly managed. 
 
 Whatsoever may have been the occasion of this vulvar symphysis, 
 it is to be cured by re-establishing or completing the external ori- 
 fice of the vagina, by means of a bistoury guided upon a grooved 
 director, and conducted longitudinally upon the middle of the abnor- 
 mal raphe formed by the agglutination of the labia. To prevent 
 the reunion of the surfaces until after the cicatrization is completed, 
 a bit of lint, or what is better, a small compress spread with cerate, 
 should be interposed. When the occlusion is complete, the operation 
 ought to be done as soon as possible after the birth of the infant, for 
 the least delay might produce fatal consequences. But if the cohe- 
 sion has left free course for the urine, and has not been discovered 
 until towards puberty, and is disclosed by the symptoms of accumu- 
 lation of the menses in the vagina and in the womb, we should ope- 
 rate as has already been mentioned ; but it would be most prudent 
 to make only a small opening, so as to allow the blood to escape 
 slowly, in order that the distended parts, recovering by slow degrees, 
 may be less liable to the violent and often fatal inflammation that 
 follows the too sudden evacuation of fluids contained within the 
 visceral cavities. To assist in cleansing the organs, recourse should 
 be had to emollient lotions and baths, to be followed according to 
 circumstances, and the state of the case as to its symptoms, by deter- 
 gent, and in some instances, by antiseptic injections. 
 
 When the discharge of blood has ceased and the parts have reco- 
 vered their normal state, if the method above recommended has been 
 taken, the operation ought to be completed by completely separating 
 the labia, as before directed. 
 
 Whether the operation be performed soon after the birth of the 
 child, or whether the case admits of our waiting for a later period, 
 not only should we make use of a plaster spread with cerate to pre- 
 vent the reunion, but it is advisable to touch the whole surface of 
 one labium with nitrate of silver. These two labia, being no longer 
 in the same condition in consequence of the cauterization of one of 
 
OF COHESION OF THE NYMPHiE. 
 
 79 
 
 them only, it follows that they will be less likely to cohere, and thus 
 the good’effects of the operation will be more easily obtained. 
 
 Union of the labia, even when incomplete, is an obstacle to the 
 union of the sexes, and when, in such cases, conception has taken 
 place, as has often happened, as shown by the annals of medicine, 
 the deformity continues until the attack of labour has rendered an 
 operation inevitable. 
 
 OF COHESION OF THE NYMPHO. 
 
 Congenital cohesion of the nymphse always accompanies that of 
 the labia, but may exist without the latter, and may be the result of 
 a primary or accidental vice. 
 
 We had occasion, in the course of the present year, (February, 
 1837,) to operate upon 'a child two years old, supposed to be labour- 
 ing under stone, from the great difficulty of passing off the urine. 
 Having, by a careful examination, ascertained that the difficulty 
 arose from a congenital cohesion of the nymphse, which seemed to 
 be wholly wanting, or rather to have as their substitute a fleshy mem- 
 brane of a triangular shape and of a bright-red colour, and placed 
 at right angles upon the spot usually occupied by the meatus, and 
 presenting at its base a small orifice directed from below upwards — 
 a small elastic bougie, introduced within this urethral orifice, was 
 promptly arrested by a narrow cul-de-sac about four or five lines in 
 depth. This arrangement explains why the urine could not escape 
 in a direct line, but was compelled to dribble away obliquely back- 
 wards and from above downwards, constantly bathing the labia and 
 th§ fossa navicularis, which had become much inflamed by the almost 
 constant contact of the fluid of the bladder. 
 
 Having introduced behind the nymphae the extremity of a guarded 
 bistoury, which I use in operating for fistula in ano and for relieving 
 the stricture in hernia, 1 destroyed the adhesion, by depressing the 
 handle of the instrument, with a single incision. For the purpose of 
 obviating the consecutive adhesion, I touched one of the surfaces 
 with nitrate of silver ; nevertheless, this precaution did not seem to 
 be an indispensable one, inasmuch as the frequent contact of the 
 urine would, probably, have sufficed to prevent any new agglutina- 
 tion of the parts. 
 
 Professor Duges, in the Trait'e des Mai. de V Uterus , which he pub- 
 lished in conjunction with Madame Boivin, says that a little girl was 
 brought to him to inquire as to the cause of a habitual dysury that she 
 laboured under. The urine escaped by a small orifice near the clito- 
 ris. A probe introduced into it did not pass into the bladder, but, 
 when directed horizontally backwards, entered the vagina near its 
 orifice. There was no appearance of nymphas ; and we ascertained, 
 says M. Duges, that they were coherent, and composed a canal 
 placed at right angles to the orifice of the urethra so as to receive 
 the urine and allow it to escape, partly above near the clitoris and 
 partly below near the vagina. This case differs from the one I have 
 just related only in this, that the urine escaped both above and below, 
 
80 
 
 EXCESSIVE DEVELOPMENT OF THE NYMPHiE, 
 
 while, in my case, it dribbled away only below, that is to say, ob- 
 liquely from above downwards. It should be added that Dr. Buet 
 has published a case very similar to those just mentioned. ( Journ . 
 Comp., t. 39. p. 223.) 
 
 The chirurgical measures adapted to these deformities consist 
 simply in separating the nymphae at the line of coherence, by an 
 incision, guiding the bistoury upon a grooved sound, as M. Duges 
 did, and making use of the precautions we recommend in speaking 
 of the symphysis of the labia pudendi. The guarded bistoury which 
 we used, and which is hardly half a line in diameter, fulfils this indi- 
 cation most perfectly, and renders the operation not only prompt but 
 exempt from all danger, notwithstanding the movements of the child. 
 
 OF EXCESSIVE DEVELOPMENT OF THE NYMPHIE. 
 
 As we have already stated at p. 44, the nymphae are, in common 
 with the clitoris, susceptible of becoming so much elongated that they 
 not only interfere with the act of coition, but become inflamed and 
 excoriated in consequence of their friction in walking, and, in some 
 instances, ulcerate so badly as to require excision for the cure. 
 
 This operation, which, in Egypt,* is a very common one, is also 
 in use in Ethiopia,! in Syria, among the Cops,! t ^ e Arabs and the 
 inhabitants of Malabar, § and it possesses even the force of law|| 
 among most of the oriental nations, whose women, like those of 
 the negro races, are generally subject to elongation of the nymphae. 
 
 Many travellers, however, report that all the women are not sub- 
 jected to the operation in question, and that it is practised, as a gene- 
 ral custom, only in certain countries in Arabia and Persia, near the 
 Persian Gulf and the Gulf of Ormus, (Chardin, Voyages en Perse, tom. 
 iii. p. 207; Wlesling, p. 144;) the Abyssiniatis, although a Christian 
 people, and the women of the kingdom of Juida, who are neither Jews 
 nor Mahometan, still preserve this ancient rite, which is not due to the 
 jealousy of the oriental tribes, but is made use of by them. With the 
 view of preventing a pretended deformity, they operated on all the 
 young girls as soon as they attained a marriageable age, under the 
 persuasion that, by shortening the nymphse and thereby diminishing 
 the frictions, they lessened the provocations to lubricity. The Turks 
 appear to have another end in view in the practice of nymphotomy. 
 According to Sonnini, their object is to remove all the inequalities of 
 the parts for the purpose of facilitating the congress. According to Leo 
 African us, (lib. viii.,) there are, in certain countries in Africa, where 
 enlargement of the nymphse is very common, certain men whose sole 
 business it is to excise whatever is too exuberant in the structure of 
 the external genitals. The same author adds that these operators 
 cry aloud in the streets, “ tV/io is she that ivishes to be cut?” In 
 his Travels in Upper and Lower Egypt, published in 1799, Sonnini 
 
 * Sonnini, Travels in Upper and Lower Egypt, tom. i. 
 
 + Leo African., lib. iii.; Demarchai’s Voyages; tom. iii. chap. vii. p. 153. 
 
 $ Bellon, Observ., p. 4*26. § Voyage de Thevenot, cap. 32. 
 
 y Paul. iEginetta, lib. iv. cap 70; ^Etius Tetrabib IV., Strabo, lib. vii. 
 
EXCESSIVE DEVELOPMENT OF THE NYMPHiE. 
 
 81 
 
 also tells us that the excision of the nymphae and clitoris is still prac- 
 tised in those countries, upon girls of seven or eight years of age; and 
 that the operation, in Upper Egypt, is always performed at the time 
 of the increase of the Nile, by women who go about in the public 
 streets of Cairo crying their trade in the words, “ Here’s ct good circa m- 
 ciser !” A razor and a pinch of ashes comprise the whole apparatus 
 for this excision. 
 
 Although the operation of nymphotomy may have been originally 
 established for the purpose of obviating the unmeasured augmenta- 
 tion of the nymphae, it may possibly have been instituted also for the 
 purpose of maiptaining the cleanliness of the sexual organs; for in 
 the negroes and Coptic women, whose nymphae are very long, there 
 is collected, betwixt the clitoris and nymphae, a quantity of sebaceous 
 matter of a whitish colour that becomes acrid and stimulating, and 
 that moreover exhales in those females a very fetid miasma. 
 
 The Portuguese Jesuits, who, in the sixteenth century, converted the 
 people of Abyssinia to Christianity, were desirous of abolishing this 
 custom as a remains of Mahomedanism, but the girls that remained 
 uncircumcised obtained no husbands, and were looked upon as so 
 unclean that the very vessels in which they ate were broken. The 
 Pope, upon the recommendation of some surgeons who were sent 
 there, authorized the practice of circumcision, which was looked 
 upon as a hygieinic and cleanly precaution for the sex. 
 
 Notwithstanding that exuberant growth of the nymphae is a pretty 
 rare anomaly in European countries, especially in our climate, we 
 nevertheless meet with instances of their projecting beyond the ori- 
 fice of the genitalia several lines, or even several inches. Where 
 the increased size is accidental, it may depend upon inflammatory 
 swelling, upon relaxation of the tissues or hypertrophic action. In 
 such a case, the salient portion becoming irritated and painful from 
 the friction of the clothing, or the motions of the thighs, the exposed 
 surface ulcerates, and the woman is obliged to remain at rest. In most 
 cases the use of baths and of emollient and narcotic fomentations, rest, 
 a horizontal posture, &c., suffice for the dissipation of this accidental 
 enlargement of the nymphae; but cases are met with in which these 
 measures will not answer the purpose, and we are compelled to have 
 recourse to the excision. Mauriceau, in his Observ. cxxxiv., relates 
 the case of a lady who vehemently implored him to perform the ope- 
 ration for her, as well because, being obliged to be often on horseback, 
 the elongation of the nymphae gave her pain from the friction, as 
 because the indecency of the malady was as displeasing to herself 
 as it was to her husband. P. 30, Traill des Mad ad. des Femmes. 
 
 Excessive elongation of the nymphae is not the only circumstance 
 that renders their excision necessary ; for recourse should be had to 
 it in cases where they tyave become fungous, scirrhous, carcinomatous 
 or gangrenous, &c., disorders that may arise in consequence of con- 
 tusion or injury experienced in laborious labour, from venereal taint, 
 or even from inappreciable causes. 
 
 The excision of the nymphae, which has been described by Galen, 
 
 ( de usu Partium ,) JEtius, ( Tetrabib ., lib. v. serm. 4,) Paul. iEgi- 
 6 
 
82 
 
 EXCESSIVE DEVELOPMENT OF THE NYMPHJE. 
 
 netta, (lib. vi.,) Moschion, Suidas, ( Lexic . 81,) Albucasis, (lib. ii. 
 cap. vii.,) Avicenna, (lib. iii. sen. 21. tract, v. cap. 24,) Mathias, 
 Zimmermann, ( De JEthiopum. Circumcis. cap. 9,) Dionis, Levret and 
 many other modem authors, is performed in the following manner: 
 the woman having been placed in the same position as that which 
 has been directed in case of the use of the speculum, the surgeon, 
 after separating the labia, seizes, with a broad forceps or with the 
 thumb and first three fingers of his left hand, the left nympha, and 
 performs the section with a scissors curved upon the flat surface, 
 and held in his right hand. Having completed the first section, he 
 takes the other nympha in like manner with the right hand, and, 
 holding the scissors in the left, performs the excision of the organ. 
 If the sole motive for the operation consists in the mere excessive 
 magnitude of the organ, care ought to be taken not to remove more 
 than the excess ; but where the operation is performed on account 
 of gangrene or carcinoma, the extent of the section should correspond 
 to the necessity for excision, and the instrument should even be car- 
 ried into the sound tissues. The operation being completed, a gum- 
 elastic catheter should be introduced into the urethra and left in the 
 canal. Each wound ought to be dressed with a dossil of dry lint, 
 supported by small, narrow compresses, and by a T bandage, slit 
 opposite to the end of the catheter. 
 
 In case, as in Mauriceau’s patient, copious haemorrhage should fol- 
 low the section, which is very improbable, since the vessels of the 
 nymphae are quite small, the flow would be readily controlled by 
 aluminous lotions, or, if need should be, by the application upon the 
 cut surfaces, of small pieces of agaric cut into a conical shape, or 
 by bunches of lint sprinkled with rosin, and sustained in situ by a 
 bandage and compress. Recourse could also, if required, be had to 
 the use of nitrate of silver or the actual cautery ; but if the vessel 
 should be pretty large, it could be secured by the ligature. 
 
 OF UNNATURAL DEVELOPMENT OF THE CLITORIS, AND OF ITS 
 
 EXCISION. 
 
 As has already been shown at page 45, the clitoris is capable of 
 acquiring dimensions even beyond those of the male penis. It is easy 
 to imagine why an exuberant growth of this organ must interfere 
 with the functions* of the sexual parts, and become the source of a 
 depravation equally disgraceful and disgusting.! For the purpose of 
 obviating the inconvenience and the bad habits! arising from this 
 
 * Paul Zacchias, physician to Pope Innocent X., who, though a diffuse writer, is 
 distinguished for his immense erudition and sound judgment, speaks of a Roman 
 lady who could not cohabit with her husband, because of her clitoris, which was then 
 in a state of erection, and thus was an obstacle to the sexual union. Quest. Med. 
 Leg. Avenione , pars prirna in fo. 1660 . 
 
 | Martial, lib. i., addressed the following to Bassa, 
 
 Essa Videbaris, faleor, Lucretia Nobis ; 
 
 At tu, pro facinus! Bassa, fututor eras, 
 
 Inter se geminas audes committere cunnos, 
 
 Mentitur que virum prodigiosa Venus. 
 
 f Avicenna, under the word Albathara, i. e., clitoris, recommends its excision in 
 women who might abuse the preternatural organ. 
 
DISEASES OF THE CLITORIS. 
 
 83 
 
 anomaly of structure, and the excessive sensibility of the clitoris, 
 the excision of the organ has been recommended, in the same man- 
 ner as it is practised in certain morbid affections of it of a cancerous 
 nature. 
 
 In performing the operation, which is extremely simple, let the 
 woman be placed as for the use of the speculum. Having seized 
 the part with a tenaculum or dissecting forceps, it may be removed 
 at a stroke, either by means of curved scissors or by means of a bis- 
 toury, cutting obliquely and as near as possible to the pubis. The 
 bleeding almost always stops spontaneously ; if it should be too con- 
 siderable, it might be arrested by the ligature, by nitrate of silver, or 
 by the cautery. 
 
 [Cases of the kind just now treated of by M. Colombat must be very 
 rare in this country, and are, probably, so in all Christendom. Having 
 been many years engaged quite extensively in obstetric practice, and in the 
 management of the diseases of women and children, in this great city, I 
 have never seen nor heard of a case of excessive magnitude of this organ; 
 save one — and, as that case was of a most singular character, I shall report 
 it as under the care of Dr. George Norris, one of the surgeons of the Penn- 
 sylvania Hospital, who operated for the case in my presence. 
 
 Mrs. W., aged 36, was affected, fourteen years ago, with a slight swelling 
 at the top of the genital fissure, which gradually increased in size until it 
 attained a very considerable magnitude ; it began after a blow on the part. 
 She was married in 1836, eight years ago. During the eight years in ques- 
 tion, she gave birth to two healthy children, and, so late as 1839, became 
 the mother of a daughter. 
 
 During her lyings-in, she asked the opinion of her accoucheur on the 
 nature of her malady, and was by him referred to a surgeon. In the fall of 
 1843, it was shown to me, and in the month of May, 1844, I saw it, in 
 company with Dr. George Norris, of the Pennsylvania Hospital. 
 
 The drawing of the tumour, which is annexed, gives a very correct idea 
 of its form and situation, and was taken by myself ad vivum, and engraved 
 by Mr. Gilbert. 
 
 It was indolent. It sprung from the upper commissure of the vulva. 
 Its superior part, or dorsum, was composed of a true skin or derm, and 
 was sparsely supplied with pudendal hairs. This portion was of a dusky 
 colour, like that of the exterior pudendum generally. The tumour gravi- 
 tated betwixt the thighs as the patient laid on her back, and was always 
 pendulous in walking. 
 
 Upon lifting up the tumour, whose neck was small and perfectly flexible, 
 the inferior surface was seen of a rose tint, of a moderately pale colour, like 
 that of the lip, and was not dermal but mucous in its structure. The root of 
 the tumour separated the superior part of the labia, portions of which, as 
 well as of the lower part of the mons veneris, had been drawn upwards 
 from the sides and downwards from above, to furnish the material for the 
 development of the new structure. I looked for the nympho, and found 
 
84 
 
 THE CLITORIS. 
 
 Fig. 10. 
 
 that they also had been drawn in, to furnish part of the material, for they 
 were extended up on each side, and rendered very thin, as represented in 
 the cut , whose curved edge is there seen. The observer will please take 
 notice of a small second curved line, which is at last lost in ascending upon 
 the sides of the tumour. That line is the anterior edge of the praeputium cli- 
 toridis, which, in the natural state, is a sort of hood, or semicircular fold of 
 the top of the nymphae, which covers and partially conceals the clitoris, 
 and resembles the male prepuce. But, in this specimen, it is so thin that it 
 is gradually blended with the mass of the swelling : the same appearances are 
 observable on the other side of the tumour. 
 
 The sensibility of the superior part of the mass is the ordinary dermal or 
 tactile sensibility ; whereas, the inferior or ventral surface and part of the 
 sides were endowed in a high degree with the erotic clitoridian sensibility. 
 This was a point which I was desirous to ascertain, and the information on 
 it, given to me by the patient, was clear and candid. 
 
 The tumour, whose form is accurately represented in the drawing, had a 
 dull fluctuation, and the handling of it, and even smart compression of it 
 betwixt the fingers, gave no pain. Dr. Norris proposed, after a careful 
 examination, to puncture it, in order to ascertain the nature of the substance 
 within. He and I concurred in the opinion that the tumour consisted of a 
 morbid alteration of the clitoris, whose praeputium, as before remarked, was 
 seen ascending as a crescentic fold on the sides. It was not skin merely, 
 but half skin and half genito-urinary mucous tissue, containing a fluid of 
 considerable consistence. 
 
OF THE FEMALE URETHRA. 
 
 85 
 
 Dr. Norris plunged a common lancet into the lower end of the tumour, 
 and the instrument gave issue to a thick, blackish fluid, of the consistence 
 of tar or thick molasses, perfectly inodorous, and clearly consisting of blood 
 preserved within the sac from the very commencement of the disease, four- 
 teen years before. She scarcely felt the puncture. The whole of the dark 
 fluid came slowly away, as from a single sac without cells or compartments, 
 leaving the tumour shriveled and looking like a shrunken scrotum, to the 
 great relief of the poor woman, who had been much annoyed by so strange 
 an appendage. The quantity withdrawn was estimated to be twenty-two 
 fluid ounces. No evil consequences followed, and the poor woman was 
 not in the least incommoded by the operation. 
 
 There could not rest a doubt upon the mind as to the seat of the malady — 
 it was a clitoris converted into a cyst. What is wonderful, is that the fluid 
 should have remained so many years locked up within the clitoris, without 
 becoming in the least degree offensive, and undergoing no other change 
 than that which blood undergoes when detained for a long time within a 
 reproductive tissue — as in the case of atresia of the vagina. The liquid is 
 of the same nature as that I have seen, on different occasions, from atretism 
 of the vagina, where the catamenial fluid had been long detained in the 
 womb. 
 
 I beg leave to call the attention of the reader to this most remarkable phy- 
 siological fact; and to say that, so far as my knowledge extends, there is no 
 example of blood detained for months and years in cavities, without under- 
 going decomposition, except when it is detained within the generative 
 tissues. The blood detained in aneurisms is wholly different from the 
 specimens to which I allude. In this case the whole of the genitalia were 
 healthy and in an active state of vitality; with the sole exception of this 
 altered clitoris and nymphae, with their prosputium or hood. ' 
 
 Monday, Sept. 21, 1844. I examined the case to-day; the tumour is form- 
 ing again, and now contains some six or eight ounces of the fluid. I shall 
 refer to this case again, in a note to M. Colombat’s article on hysteria. — M/] 
 
 IMPERFORATION AND STRICTURE OF THE FEMALE URETHRA. 
 
 Although imperforation of the meatus urinarius is generally a con- 
 sequence of the complete union of the labia, it may yet sometimes 
 exist per se, and, in this case, the orifice of the urethra is stopped by 
 a thin and delicate membrane, which, nevertheless, is strong enough 
 to prevent the escape of the urine. 
 
 The existence of such a case ought to be suspected where, the 
 labia not cohering, the napkins of the infant are found not to be 
 wetted with the usual discharge from the bladder, and where, after 
 discharging all the meconium, it still continues to cry and to strain 
 without effect. To these symptoms should be added the gradual 
 enlargement of the hypogastric region, which is tense, painful, resist- 
 ing and rounded, and exhibits a much less perceptible prominence. 
 
 The membrane which prevents the urinary discharge may be con- 
 fined to the orifice of the canal, or may extend to a greater depth 
 
SG OBTURATION OF THE FEMALE URETHRA. . 
 
 within it. In the first-named case, which is the most common and 
 the most easily remedied, the membrane swells outwards with each 
 effort, and even with every cry of the infant; — in the second case, 
 that is, where the imperforation affects a great part of the tube, no 
 membrane can be discerned, and the operation becomes difficult and 
 even very dangerous. 
 
 When the canal is stopped only at the vulvar orifice, all that is 
 necessary for opening a passage for the urine is to puncture the 
 membrane spoken of with the point of a narrow bistoury, and to 
 leave a small catheter in the urethra for a few days. It ought to be 
 added that the latter process is not to be considered indispensable, 
 but seems to us useless, because the contact of the urine and its fre- 
 quent passage would generally suffice to prevent the union of the 
 divided parts. 
 
 By means of an abnormal orifice at the umbilicus, which is more 
 frequently met with in female than in male children, nature some- 
 times obviates imperforation of the urethra. Immediately after birth 
 the bladder, which is still almost wholly above the brim of the pel- 
 vis, approaches the umbilicus, and the incomplete obliteration of the 
 organ facilitates the establishment of this supplemental mode of ex- 
 cretion. 
 
 When this anomaly is met with in a young infant, an incision, as 
 already directed, should be made into the obturator membrane at the 
 mouth of the urethra, after which a catheter should be left for some 
 time in the bladder, in order to restore to the fluid its natural course. 
 The same treatment is applicable at any age. 
 
 Barthelemi Cabrol, an able surgeon at Gaillac, who was appointed 
 by Henry IV., Demonstrator of Anatomy at the School of Montpel- 
 lier, informs us* that a girl, eighteen years of age, had the urethra 
 stopped by a membrane, so that the urine passing, it is probable, 
 along the urachus, escaped at the navel, which projected about four 
 inches and exhaled an intolerable stench. In treating the case, Ca- 
 brol first made an incision through the membrane that had closed 
 the urethra, and then introduced a leaden canula into the bladder in 
 order to give free course to the urine. On the next day, having 
 thrown a strong ligature about the projecting portion of the navel, he 
 cut off the protuberance beyond the ligature. He touched the spot 
 with the actual cautery, and when the eschar fell off he dressed the 
 surface with desiccatives, and obtained a complete cicatrization in 
 twelve days. In such a case the same treatment ought to be adopted, 
 with exception of the cautery, which is unnecessary, and which terri- 
 fies the patient to no purpose. 
 
 Where the orifice exhibits only a narrow opening through which 
 the urine escapes with difficulty, it is a case of stricture of the ure- 
 thral orifice, and not one of imperforation of the canal. In this case 
 the orifice should be fitly enlarged by means of a narrow bistoury 
 and a grooved director. 
 
 [I cannot avoid entering my protest against this doctrine, for it is indu- 
 bitable that in all such cases, when the most delicate probe can be made to 
 
 Observat. Anatom., 23. 
 
FAULTY CONFORMATION OF THE VAGINA. 
 
 87 
 
 pass, the difficulty is easily to be overcome by the daily use of the bougie, 
 beginning with one of a small size, and gradually enlarging it till the orifice 
 has acquired a proper magnitude. It is not necessary to do more than pass 
 the bougie through the stricture, to retain it there about a minute and no 
 longer, when it will be found that a larger one will be admitted on the same 
 terms the next day ; and so on until one sufficiently large can be passed. 
 Its use repeated afterwards from time to time, say once in two, three or four 
 weeks, will perfect the cure. — M.] 
 
 Where the constriction or occlusion of the canal extends through- 
 out a great part, of its tractus, and especially where the urine finds 
 no other outlet, the child must inevitably perish if not opportunely 
 succoured, and even here there is but one means of rescue, and that 
 by a very doubtful operation: I mean the puncture of the bladder 
 by means of a bistoury or a delicate trocar, which should be plunged 
 into the point where the orifice of the urethra ought to be, and thence 
 conducted to the cavity of the bladder. Should the fear of giving an 
 erroneous direction to the instrument or any -other motive lead to a 
 rejection of this operation, then there should be no hesitation as to 
 making a puncture of the bladder through the vagina or rectum, and 
 should the structure of those passages be of such a nature as to 
 oppose these methods, recourse might be had to a puncture above 
 the symphysis pubis. 
 
 It is to be confessed that in these cases the infants are generally 
 lost, even where we have succeeded in re-establishing the course of 
 the urine by any of the methods just pointed out. 
 
 In order to conclude what we had to say upon the subject of pre- 
 ternatural conformation of the vulva and its dependencies, we must 
 add, that although the labia pudendi may possibly be wanting as a 
 congenital defect, they may also be destroyed by gangrene or cor- 
 roding ulcers. In the latter case the lesion is often accompanied by 
 occlusion of the vagina or the meatus urinarius, which will require 
 the treatment we have already pointed out. 
 
 FAULTY CONFORMATION OF THE VAGINA. 
 
 The deformities of the vagina, whether congenital or accidental, 
 that are susceptible of cure by surgical treatment, are, imperforation, 
 obliteration, obturation, congenital narrowness, and stricture or con- 
 traction. 
 
 IMPERFORATION OF THE VAGINA. 
 
 Imperforation of the vagina has been noticed by several of the 
 ancient medical writers. Hippocrates speaks of it in his first book 
 of the Diseases of Women , but points out no treatment for the case. 
 Aristotle, who was preceptor to Alexander the Great, and who lived 
 three centuries before the Christian era, teaches us that some girls 
 have the vagina closed at birth and until the period for men:' lation ; 
 that the blood then gradually secreted gives rise to violent pains that 
 never cease until it has either forced a passage for itself, or until one 
 has been formed for it by artificial means. 
 
8S 
 
 IMPERFORATION OF THE VAGINA. 
 
 Ill some instances no relief has been obtained until death super- 
 vened, in consequence of the violence by which the passage has been 
 produced, or of the impossibility of establishing one. 
 
 Imperforation of the vagina has also been noticed by a great 
 number of other authors, among whom we may mention Celsus,* 
 Soranus of Ephesus, t Moschion,± Roonhuysen,§ Benevenius.|| Ca- 
 brol,1T J. Fabricius ab Acquapendente,** Fabricius Hildanus,tt 
 Schenk, f± Solingen,§§ Meeckren,|||| Mauriceau,1F1[ Ruysch,*** Savi- 
 ard,ttt and many others whose names it would be tedious to cite. 
 
 The imperforation of the' vagina that consists in the occlusion of 
 the anterior orifice of the canal, may be either complete or incom- 
 plete, accidental or congenital ; it may be due either to the hymen or 
 to some other fold of the mucous membrane, or to the presence of 
 cellular or cellulo-fibrous bands crossing in different directions, and 
 found at different distances from the os magnum. 
 
 Complete imperforation is generally not discovered until puberty, 
 or at the commencement qf the mensual office. The young female 
 is at first subject to all the symptoms that precede and accompany 
 menstruation, except that she perceives no discharge of blood. The 
 health that had before been good, suddenly becomes disordered 
 without any evident cause for the change. The abdomen becomes 
 the seat of disorders previously not known to the patient ; the hypo 
 gastrium becomes more and more painful and takes on a gradual 
 and uniform enlargement ; the patient feels pain in the loins, weight 
 within the pelvis, spasms, suffocation, intense cephalalgia; and, in 
 fine, a variety of disorders the seat of which is clearly in the gene- 
 rative organs, and the origin of which is at first always enveloped in 
 obscurity. All these symptoms, which undergo a partial diminution 
 in the course of a few days, augment in violence with each return of 
 them. The abdomen grows gradually larger, and sometimes acquires 
 a size equal to that which it attains in an advanced stage of preg- 
 nancy, most of the symptoms of which are now found to be present, 
 such as swelling of the breasts, nausea, vomiting, disgust, queer 
 appetite, &c. The symptoms in the case so closely resemble those of 
 gestation, that learned physicians have pronounced it to be preg- 
 nancy, though the patient were still a virgin. Samples of this kind 
 are given by J. Wierus,if± B. Cabrol,§§§ Fab. Hildanus,|||||| J. Mu- 
 ratt,1HI1F and some of the modern authors who cite cases of the kind. 
 
 In order to avoid the distressing results of such mistaken diagnosis 
 and remove all doubts on the subject, it is merely necessary to reflect 
 
 * Corn. Celsus de Medjcina, lib. vii. cap. 28. 
 
 t De Utero, et Muliebri Pudendo. Libel, et Aetius, lib. xvi. cap. 95. 
 
 * Gynmciorum de Mulier. affect: et Morb., part i. cap. 3. # 
 
 4 Lib. ii. De Clausura Uteri. || See Abdilis Morb. Causis, cap. 28. 
 
 « Observ. Anat., 23. '* In Operat. Chirurg. de Hymene Imperforato. 
 
 ff Centur. iii., obs. 60. it Lib. iv. De Part Genital. 
 
 §§ In Observ. v. ||!| Observ. Chirurg. 55. 
 
 Observat. sur les Malad. des Femmes. *** Observ. Chirurg. 32. 
 
 Iff Observat. Chirurg. &c. 
 
 De Dcemonum Praesiigiis et Incantationibus, lib. iii. cap. 38. 
 
 §§§ Observ. Medicin., obs. 23. Ilii l Centur. iii., observ. 60. exemp. 3. 
 
 iii Ephem. Curios. Natur. decur. ii., anno. 3. observ. 151. 
 
IMPERFORATION OF THE VAGINA. 
 
 89 
 
 that where the development of the abdomen arises from menses 
 retained in the womb and vagina, in consequence of congenital 
 imperforation or accidental obliteration of the vagina, the develop- 
 ment takes place at intervals, and by periods that correspond to the 
 mensual epochs, that is to say, once a month. 
 
 As each menstruation goes to increase the pre-existing collection, 
 the accumulation of blood becomes enormous, compressing with in- 
 creasing violence not only the parts above that are in the vicinity of 
 the enlarged womb, but also all the contents of the excavation of the 
 pelvis, as the rectum, the bladder, the sacral plexus, the sciatic nerves, 
 &c. It is to this very compression that we have to attribute not only 
 the dysuria and the difficult defecation, but also the engorgement, 
 cramps and swellings of the lower extremities, the weight at the rec- 
 tum and perineum, and, indeed, the uneasy feeling of imperforate 
 females, principally in the pelvic region, felt in walking and standing. 
 Hippocrates* speaks of a young girl who became lame from the 
 accumulation of blood in the vagina, for which there was no means 
 of escape, and which produced compression of the sacral nerves. 
 Morgagni ( De Sec/, et Caus. Marb.) asserts that atresia is capable 
 of producing insanity; for other authors have noticed cases of con- 
 vulsions, hysteria and delirium proceeding from the same cause. In 
 a case of retention of the menses from complete imperforation, De- 
 haent discovered that the Fallopian tubes, from being distended with 
 blood, had given way and occasioned a fatal effusion. 
 
 In some rare cases, the blood effused at each menstruation has. 
 been absorbed so as to disappear during the interval; the abdomen, 
 which had become hard and swollen for several days, has soon 
 returned to its natural size. Patients exhibiting this double anomaly, 
 both physiological and anatomical, may resist the evil for a long 
 time, but with an ever-doubtful health. 
 
 In certain women with imperfect sexual organs, nature affords a 
 substitute for the menstruae, by means of periodical haemorrhages 
 and engorgements, at the anus, the lungs, the breasts, the stomach, 
 the nostrils, the ears, the tegumentary surface, &c. 
 
 A vaginal imperforation is not invariably followed by the conse- 
 quences we have spoken of. These consequences may in some indi- 
 viduals never be made manifest, though the menstruation may 
 wholly fail, and even not find a substitute in any other evacuation 
 of blood. This happens in those cases where, together with imper- 
 forate vagina, there is absence of the womb itself. Such a state of 
 things ought to be inferred in women who have passed the period 
 for the appearance of the catamenia, when the genital apparatus 
 ordinarily enters upon the exercise of its exhalent functions : cases 
 of the kind are to be found in the annals of the science of medicine. 
 
 In general, the diagnosis of vaginal imperforation is quite easy to 
 be made, and an attentive examination of the genitalia suffices to 
 dissipate all doubt upon this rare affection. 
 
 We may ascertain that the obstacle that closes the passage is 
 
 * De Morb. Mulierum. 
 
 f Ratio Medendi, par. 6. 
 
90 
 
 IMPERF ORATION OF THE VAGINA. 
 
 merely the hymen, whenever we discover between the labia a hemi- 
 spherical tumour of a livid or bluish colour, soft and fluctuating, and 
 rendered salient by the weight of the contained blood. In such a 
 case, most authors have recommended that with a view to destroy 
 the obstacle, we should plunge a straight bistoury into the centre of 
 the tumour so as to make a crucial incision, the operation being 
 completed by afterwards removing the flaps or angles by means of 
 curved scissors and a forceps. A tent of lint spread with cerate and 
 introduced betwixt the edges, suffices, in a majority of cases, to pre- 
 vent the reunion of the divided surfaces. 
 
 In cases of occlusion caused by the hymen, Celsus* recommends 
 the incision, which he describes as follows. Si niembrana orx vulvx 
 opposita est....oporlet autem membrnnam duabus lineis, infer se 
 transversis incidere ad similitudinem lit ter x X, magna cura habit a 
 ne urinx iter violetur , deinde undiqne earn membranym excidere. 
 
 Avicennat directed that the membrane should be ruptured with 
 the point of the finger covered with a piece of linen, and Mauriceau 
 advised that it should be torn by means of the finger nail. 
 
 The mode of treating retention of the menses from imperforate 
 hymen by a crucial incision, is often followed by serious conse- 
 quences, for the sudden escape of the fluid renders it impossible for 
 the parietes of the womb, too suddenly emptied, to contract imme- 
 diately, a circumstance that often gives rise to fatal inflammation, 
 and to fever of a bad character. 
 
 In order, as far as possible, to obviate the bad consequences of the 
 
 operation in question, and espe- 
 cially with a view particularly to 
 preserve the hymen, to which is 
 attached a great moral import- 
 ance, we propose the following 
 mode of operation, which is equal- 
 ly simple and easy of perform- 
 ance, and in doing which we need 
 not entertain the least fear of 
 wounding the vagina itself. 
 
 Having placed the woman in 
 the situation required for the use 
 of the speculum, let an assistant 
 separate the labia and nymphse, 
 and then seizing the centre of the 
 tumour with a tenaculum, or what 
 is still better, with broad forceps, 
 the membrane is pulled outwards 
 and a proper portion of it removed 
 by cutting it from below upwards 
 with a scissors curved on the side, 
 or what answers better still, with 
 our scissors emporle piece , ( vid . 
 figure ,) for the extirpation of the 
 
 \ Avicenna, lib. iii., scu. 21. tr. 4. cap. 1. 
 
 * Celsus de Med., lib. vii. cap. 29. 
 
I 
 
 IMPERFOItATION OF THE VAGINA. 91 
 
 frasnum of the tongue.'* The aperture produced in this manner 
 gives a small oval circumference, which nearly resembles the natural 
 orifice of the hymen, admits of a gradual evacuation of the retained 
 blood, and of a regular and slow return of the distended organs to 
 their natural dimensions without too sudden a void. In this way 
 the admission of air in lesser quantity and less suddenly, does not so 
 readily determine the attack of intense and often fatal inflammation 
 that is apt to follow the common mode of operating. 
 
 In some cases it is found that there are two membranes, the one 
 placed above the other. Fred. Ruyscht published a case in which 
 he was obliged to make an incision into each of two membranes. 
 Thomas Willis states that he was called to a woman upon the point 
 of being confined, and who had had severe pains for three days 
 preceding his visit. Upon carefully examining the genital organs, 
 he discovered a membrane that adhered to the circumference of 
 the vulva, and that prevented the delivery of the foetus. Having 
 made an incision into it, and finding that the delivery still did not 
 take place, he again examined the parts, and found that there was 
 another membrane situated at a greater depth within the passage, 
 and which detained the child above it. Having removed this obsta- 
 cle, the labour was soon and happily terminated. 
 
 In some cases a membranous band of greater or less thickness 
 divides the orifice of the vagina into two small lateral apertures ; and 
 it must doubtless be this sort of fleshy column that induced Mor- 
 gagni, Valsalva and other authors to designate the hymen by the 
 descriptive term columna virginiiatis — pillar of virginity. This 
 band, in some specimens, is traversed horizontally by one or more 
 bands producing a cribriform diaphragm, as in cases stated by Fab. 
 HildannSjf Viardel§ and Prof. Flamand.|| 
 
 [Some years since I was invited by Dr. John Ruan to visit a patient with 
 him, who was in a severe labour, in which considerable delay and difficulty 
 were experienced. I found that the vagina was divided into two lateral 
 halves by a septum, which extended from the external orifice or os magnum 
 to near the uterine extremity of the canal, and that the head of the child was 
 pressed into the right one, compressing the other against the left side of the 
 pelvis. It was agreed that I should deliver her with the forceps, which I 
 accordingly did; and she gave birth to a healthy infant without accident or 
 any untoward result. As the malconformation had presented so rare a 
 specimen, I prevailed upon her to allow me to examine the parts after her 
 recovery, which enabled me to discover that the septum had not given way 
 at all during the distension of the right canal. I had no reason to suppose 
 that the septum was repeated in the uterus. — M.] 
 
 * This instrument, Fig. 11, described and figured in our Traite du Begaiement, 
 and in La Revue Medicale, will also be represented in our Dictionnaire Historique et 
 Iconographique de toutes les Operations et les Instruments et Appareils de la Chi- 
 rurgie, Ancienne et Moderne, with 1500 figures, 4 vols. 8vo. Paris, 1836-7. 
 
 f Fred. Ruysfch, Obs. Chir. 22 and 32. 
 
 * Hier. Fab. Hildanus, cent. iii. obs. 60. 
 
 § Viardel, Observ. sur la Prat, des Accouchements, p. 167. 
 
 || Disp. Inaug. du Doct. Villette, annee, 1824. 
 
92 
 
 IMPERFORATION OF THE VAGINA. 
 
 There have been examples of women labouring under imperfora- 
 tion, (and their ignorant physicians have agreed with them,) who 
 have mistaken the meatus urinarius for the orifice of the vagina, 
 supposed to be contracted, and upon dilating it as far as possible, 
 have made it subserve the uses of the latter, thus giving rise to 
 incurable incontinence of urine and other consequences.* 
 
 Dr. Villette states, in his Inaugural Essay , that a lady of Stras- 
 bourg, was under the care of M. Chevalier during her accouchement. 
 Upon performing the Touch he was surprised to find a polished orifice. 
 In the state of uncertainty in which he was placed, he called in Prof. 
 Flamand, who required a close examination of the parts; but what 
 was his surprise to find the urethra sufficiently large to admit the 
 index finger in Touching. At the orifice there was a cribriform 
 lamella, through which the mensual discharge escaped. The mem- 
 brane was excised, and the labour brought to a successful conclusion. 
 
 When the membrane that closes the vagina is very thick, the 
 finger pressed against it meets with more considerable resistance, 
 and it is difficult to discover the fluctuation, which is quite manifest 
 where the membrane is thin. The proper mode of proceeding in 
 such a case consists in making sure, by means of a sound, as to the 
 disposition of the bladder, and in exploring the rectum by the touch. 
 Then after the labia are separated by an assistant, a crucial incision 
 is made with a straight bistoury conducted by the index finger, and 
 wrapped in a bit of linen to within six lines of the point : [a bit of 
 adhesive plaster is a convenient guard for the edge. — M.] When 
 the crucial incisions are completed, the flaps ought to be taken off as 
 has been already mentioned, and the orifice kept open by a dossil of 
 lint, spread with cerate, and to which is attached a piece of thread ; 
 the lint to be renewed daily. The blood that escapes is generally 
 viscous, black and foetid ; it escapes with violence upon making the 
 puncture, and then concludes by escaping drop by drop. 
 
 To assist in cleansing the genital cavities of the patient, and par- 
 ticularly to get off the coagula, which, by remaining, might provoke 
 an attack of inflammation, a free use ought to be made of emollient 
 lotions, and subsequently of detergent and slightly resolvent or even 
 antiseptic injections, according to the circumstances and indications of 
 the particular case. 
 
 Where the vaginal partition is fleshy, Celsust advises us to make 
 a longitudinal incision, and then taking hold of the edge with a for- 
 ceps, to cut a strip from it. He next placed in the wound an oblong 
 tent moistened with vinegar, and over that applied a bit of wool in 
 
 * In the Journal de Medecine, published at Orleans, by M. Latour, 61s, and in the 
 article lmpuismnce of the Did. des Sci. Med., may be found a case related by Mor- 
 gagni. (Lettre 40, n. 12.) A peasant, in the vicinity of Orleans, had misinterpreted a 
 metaphorical expression that had fallen from his confessor, who attributed the ste- 
 rility of his marriage to his not being dans la bonne voie, and was so stupid as to sub- 
 stitute the urethra for the vagina. The beginning was difficult, but by means of pro- 
 gressive dilatation, effected by divers mechanical aids, he attained his object, and 
 remained for some time under his mistake, until the inconvenience of her urine and 
 other symptoms compelled his wife to call in the aid of a physician. 
 
 f Qon* Cels, de Med., lib. vii. cap. 28 . 
 
IMPERFORATION OF THE VAGINA. 
 
 93 
 
 the grease, soaked also with vinegar, the whole being kept in situ by 
 means of a proper bandage. On the third day he removed the dress- 
 ings, and for the rest of the treatment acted as in ordinary wounds. 
 When the cut began to heal, he introduced a leaden canula covered 
 with a substance promotive of cicatrization, and applied externally 
 the same medicament until the cure was perfect. 
 
 For the removal of atresia, resulting from the presence of a thick 
 ipembrane, Hippocrates* and other authors have proposed the use 
 of caustics. Bauhint made use of caustics in a case which termi- 
 nated fatally after the fall of the eschar. A. Paref and his pupil 
 Guillemeau recommended an incision from above downwards: others 
 think it better to make an oblique one, in order to avoid the risk of 
 wounding the urethra. The celebrated Dupuytren, whose practical 
 opinions have such great weight, advised that the incision should be 
 made from above downwards, and especially that the division should 
 be carried to the very lower edge of the membrane, for the purpose 
 of obviating the stasis of the blood and mucus behind it; and par- 
 ticularly to spare her the disagreeable and inconvenient necessity of 
 using vaginal injections. 
 
 Where the obturating membrane is situated very deep in the pass- 
 age, the vagina generally preserves its ordinary dimensions above 
 the obstacle ; but it may, from the prolonged retention of the menses, 
 acquire an unnatural magnitude at its upper part. In order to 
 destroy the membrane in such a case, we must expose it and protect 
 the walls of the vagina by means of a speculum, then make a crucial 
 incision, the cuts being oblique in order to avoid injury to the blad- 
 der or rectum. The four flaps should then be removed as already 
 advised. 
 
 In the case which is not very unfrequently observed, where the 
 membrane, being of a thick and fleshy nature, forms an annular 
 band within the vagina, and has only a very small opening, the 
 menstrual fluid escapes, but only drop by drop. Such cases have 
 been noted by Daniel Sennertus of Breslau, § Chambon,|| A. ParelF 
 and Prof. Flamand.** This sort of dysmenorrhcea always occasions 
 a state of tension of the external genitals, and a feeling of weight 
 about the perineum attended with pretty severe pains in the hypo- 
 gastrium, and an unnatural sensibility of all the organs contained 
 within the cavity of the pelvis. 
 
 The mode of curing this anomaly, which is prejudicial to the con- 
 gress and to conception, consists in enlarging the opening with a 
 probe-point bistoury, making crucial incisions and then removing 
 the flaps, and afterwards keeping up the dilatation with a stout 
 canula or any proper tent. Before resorting to an operation, Ave 
 should clearly ascertain that the occlusion is due only to the pre- 
 sence of a membrane, which may be done by introducing a sound 
 into the little opening which will be found at some point upon the 
 
 * Lib. de Sterilitat. et lib. ii. De Morb. Mul. f Anat., liv. i. chap. 39. 
 
 i Liv. iv. chap. 59. p. 998. § De Morb. Mulierum, lib. iv. part i. 
 
 || Malad. des Filles, liv. i. chap. 2. p. 51. ^ Pare, liv. xxiv. chap. 19. 
 
 ** Lecons Orales ala Faculte de Strasbourg. 
 
94 
 
 CONGENITAL NARROWNESS OF THE VAGINA. 
 
 surface of the obstacle, above or beyond which Ihe end of the sound 
 ought to be movable freely ; but in order that the operation may be 
 safe, even if the occlusion be of the sort in question, the bladder and 
 rectum should both have been emptied before the incisions are made; 
 since the matters, whether solid or liquid, contained in them, might, 
 by rendering them more salient, expose them to injury from the 
 edge of the scalpel. 
 
 OF CONGENITAL NARROWNESS OF THE VAGINA. 
 
 Narrowness of the vagina is a congenital affection, whereas con- 
 striction and obliteration of the passage may depend upon various 
 accidental causes that we shall treat of in a subsequent page. 
 
 Instances have been met with in which the diameter of the vagina 
 did not exceed five or six lines. This original deformity, like those 
 that we have already spoken of, obviates the accomplishment of the 
 purposes for which it was designed by nature. In case that strong 
 and repeated efforts should, during the congress, be made to over- 
 come the obstacle, the consequences would be a considerable inflam- 
 mation and contusions productive of discharges and the symptoms 
 of strangury, leading to suspicions of venereal taint. Under such 
 circumstances, after having removed the inflammation by the use of 
 topical emollients and other antiphlogistic measures, such as venesec- 
 tion, leeches, baths, narcotics and antispasmodics, and diluting and 
 cooling drinks, we should endeavour to dilate the vaginal parietes by 
 the employment of such dilaters as may expand after their applica- 
 tion, such, for example, as sponge tents, bits of gentian root covered 
 with cerate, large bougies and cylindrical caoutchouc pessaries, to be 
 gradually increased in size until the vagina shall have acquired its 
 normal dimensions. 
 
 With the same view, Hippocrates made use of a tin tube. Without 
 following the recommendation thus given by the father of medicine, 
 we are of opinion that use might advantageously be made of a sort 
 of cylindrical dilater, composed of three or four pieces joined by 
 hinges, and made so as to move and separate more or less distantly 
 by means of a screw, adjusted like that in our jointed speculum 
 and which is figured in this work at page 66. 
 
 As the narrowness of the vagina may affect only a portion of the 
 tube, the first thing to be done is to ascertain its situation and extent 
 by using a sound, which should be see-sawed in every direction if 
 possible. If, upon its introduction, it be found confined as to its 
 movements, and particularly if the end of it cannot be made to move 
 freely, we may be sure that the narrowness extends throughout the 
 entire length of the canal; but, on the other hand, if the see-saw 
 motion of the end of the sound is free, we shall have to do with a 
 narrowness extending only a few lines of the length of the vagina. 
 
 Where there is a want of development of the vaginal walls, the 
 internal surfaces have a hard feel and seem to be fibrous and undi- 
 latable. For the purpose of promoting their amplification, we ought, 
 to the use of the dilaters, to add that of injections of oil and muci- 
 
CONGENITAL NARROWNESS OF THE VAGINA. 
 
 95 
 
 lages, of topical baths, of fumigations, and especially the frequent 
 application of suppositories of beurre de cacao introduced within the 
 vagina. 
 
 The means above pointed out act very commonly in an efficacious 
 manner, and are devoid of the dangers that inevitably ensue from 
 the dilatation of the part procured by any other mode of proceeding. 
 Besides, if the success obtained in this way be not always perma- 
 nent, we have it in our power to repeat the treatment if necessary, 
 without any inconvenience and without compromising the lives of 
 our patients. 
 
 [In three cases of congenital narrowness of the vagina that have fallen 
 under my notice, one was that of a lady who was pregnant at the seventh 
 month, and in premature labour when I was called upon to see her. I was 
 greatly surprised, upon making the usual examination, to meet with con- 
 siderable difficulty in the introduction of the index into the passage, and it 
 was not without some time and a very considerable resistance, that 1 at last 
 succeeded in carrying the finger to the os uteri, which was already some- 
 what dilated. The lady, who was young, gave birth, after many hours of 
 severe expulsive action, to a dead foetus of seven months, and she recovered 
 of the effects of her labour, in which she met with no accident. I cannot but 
 believe that she conceived without a perfect congress, which I deem to have 
 been impossible. 
 
 In another case, a lady came from a distant state ; she had been several 
 years married, and many and various efforts had been made to relieve her 
 by the use of bougies, without any success. She spoke of some operation 
 that had been performed with the bistoury, the nature of which I could not 
 comprehend from her description of it. I saw her in comps/ny with Dr. 
 Horner, Professor of Anatomy in the University of Pennsylvania. The 
 vagina received, with some pressure, a full-sized urethra bougie, and it was 
 evident that the narrowness occupied the whole extent of the canal, save a 
 small part of the upper extremity where it embraces the cervix uteri. The 
 treatment consisted in moderate dilatations with the bougie at first, which 
 was followed, in a day or two, by bits of sponge tent. These tents, by 
 their expansion, effected a dilatation sufficiently great to admit of the pass- 
 ing of the index readily to the os uteri. When the passage had by this 
 means been considerably enlarged, the inner surface of the vagina was dex- 
 terously incised by means of a gorget; cutting on both edges, and which 
 was passed into the vagina at first horizontally, so as to nick each side of 
 the vagina, right and left, then obliquely from right to left, and from above 
 downwards, and lastly, from left to right and from above downwards, thus 
 making six incisions with a view to destroy the fibrous and condensed 
 material supposed to be lying outside of the mucous coat. As soon as this 
 was done, an application was made of caustic potash, which was immedi- 
 ately neutralized by injections of vinegar and water. The pain of this ope- 
 ration was very great ; but the dilatation was quite free. The lady soon 
 
96 
 
 CONGENITAL NARROWNESS OF THE VAGINA. 
 
 recovered from the pain of this operation, and returned to her own state, 
 with a metallic dilater to be used from time to time, with a view to maintain 
 the degree of dilatation thus obtained. I have learned that the success was 
 only temporary, and that the narrowness 'has returned, so that she has had 
 no substantial benefit from her sacrifice. 
 
 I have long been well satisfied, that in the dilating of strictures of the 
 urethra, a perfect success is most apt to follow the gentlest mode of opera- 
 tion: I have also familiarly noticed the effects of the pains of labour on the 
 cervix uteri, as well as on the vagina and perineum. Now, in this case, when 
 a contraction of the womb takes place, the presenting part of the child is 
 impelled against the resisting cylinder or cone of the cervix uteri, and often 
 without causing the part to advance at all, at least in appearance ; but the 
 strain and pressure are followed by a disposition in the resisting part to yield, 
 so that at the next pain the part is found to give way very considerably, and 
 this process is repeated both as regards the cervix and the vagina and peri- 
 neum, and it is by acquiring the disposition to yield, that they are enabled 
 to yield without rupture of tissues. A direct application of the force not 
 withdrawn, as by the intervals of labour pains, would inevitably rupture 
 them. I will not pretend to explain the physiological cause of this yielding 
 temper, acquired even by non-muscular structures under pressure, but I 
 have applied the fact to the treatment of manual operations in labour. My 
 hand cannot find room to pass into the vagina in a case of exploration or 
 turning, until, by repeated attempts and pressure, the parts acquire the dis- 
 position to yield, every successive pressure finding the resistance weakened. 
 Ill the treatment of the worst forms of stricture of the urethra, inveterate from 
 fifteen years of duration, it is my custom merely to pass a bougie that can 
 be moved forwards without pain, to leave it in situ for a few moments, and 
 then to use one a little larger the next day, and so on in succession each 
 day, until a full-sized instrument is passed. In doing so I find that the 
 antecedent smaller, has given the disposition to yield to the succeeding 
 larger bougie ; and that the disposition or temper of the tissues so acquired, 
 is not lost until after the lapse of several hours. 
 
 It has already been stated in this work, by M. Colombat, that the female 
 urethra itself is capable of very great dilatation, even equal to the admission 
 of the index into the bladder. The rectum can, by patient trials, be made 
 to yield sufficiently to admit the hand into its cavity. Under such views, it 
 appears to me unnecessary, in any case of narrowness, to resort to other 
 than simple methods of graduated dilatation. I have no belief that the 
 vagina ought to be, from the nature of its physiological office, nor that it is, 
 in point of fact, composed of a fibrous tissue ; but that it is a mucous tissue 
 lying in the midst of a condensed mass of cellular laminae and vessels and 
 nerves. Under these impressions 1 should not deem it proper to use cut- 
 ting instruments in the treatment of congenital narrowness or accidental 
 stricture of the canal. Early in the year 1843, a gentleman from a distance 
 
CONSTRICTED VAGINA. 
 
 97 
 
 came to me with a letter of introduction, and communicated the information 
 that he was two years married, but had been hitherto unable to consummate 
 the marriage on account of some obstruction, for the discovery and removal of 
 which he had been induced to come to this city, bringing his lady with him. 
 I visited her, and found a very healthy and fine young woman, about twenty- 
 four years of age. She had menstruated regularly, and enjoyed in all 
 respects good health. Her menstruations were somewhat painful and 
 tedious. 
 
 Upon separating the labia, I was for some time at a loss to discover any 
 appearance of a vagina. The clitoris and nymphae, as well as the labia, 
 were perfectly developed ; but instead of the os magnum there was, to all 
 appearance, a complete shallow cul-de-sac. It was not until I had repeat- 
 edly pressed the end of a probe against various parts of the extremity of 
 this cul-de-sac, that I found it to make progress, and at length find its way 
 along the course of a vagina, which appeared to be filled by the probe, 
 so strict was the narrowness. I next introduced a small block-tin bougie, 
 and then a middle-sized urethra bougie, which was closely embraced 
 by the vagina. I succeeded, on this first occasion, in carrying a full-sized 
 urethra bougie to the bottom of the vagina. On the following day I used, 
 without difficulty, a larger bougie, and with much force and no little time, 
 introduced the index finger as far as the os uteri. 
 
 I now introduced a half hollow cylinder of German silver to the bottom 
 of the vagina, and then concealing the apex of a similar half cylinder in the 
 groove of the first one, I carried it also to the bottom of the vagina. One was 
 to the left, the other on the right side of the vagina, and when both were 
 adjusted, they equaled in size the index finger, which I had been before 
 able to introduce. Fig. 12 is a repre- 
 sentation of one of them, and Fig. 13 
 resembles it viewed in profile. I next 
 pressed into this speculum or dilater the 
 conical bougie, made of wood, Fig. 14, 
 and very slowly carried the apex forward, 
 until its point was carried home, or to 
 the extremity of the half cylinders. The 
 dilatation gave pain, but I did not think 
 it very severe. At several subsequent 
 operations, I separated the half cylinders 
 while in the vagina by a larger bougie 
 than the one before mentioned, which I 
 considered large enough, and then fur- 
 nishing her with a hollow silver gilt bou- 
 gie, about one inch and a quarter in diameter, which passed without the 
 least difficulty to the bottom of the vagina, I sent her home with directions 
 to pass the bougie once a day. 
 
 7 
 
98 
 
 CONSTRICTION OF THE VAGINA. 
 
 Within a few days, (May 20, 1844,) I had a letter from the gentleman, 
 requesting me to send him another silver gilt bougie rather larger than the 
 last, and stating that he believes that with such an instrument the cure will be 
 complete. Here, then, is a case of congenite narrowness of the entire vagina 
 in a lady two years married, which barely admitted a probe for thp admis- 
 sion of which the orifice was with difficulty discovered, and which, without 
 great pain, or the least evil consequence, was cured by means of a simple 
 apparatus for successive dilatations. I have not any doubt of the permanency 
 of the cure, for I am sure that the congress is possible, and that alone will 
 suffice to maintain the advantage already gained. Should the lady be the 
 subject of a future pregnancy, the cure will be beyond the possibility of 
 relapse. I confess, that seeing the fine health enjoyed by the lady in ques- 
 tion, the regularity with which the catamenial office is performed, and the 
 fitness of the organs, I am in hopes of learning that conception has taken 
 place, and I should entertain no fears of rupture of the vagina, under the dis- 
 tension of a labour with normal presentations of a full-sized foetus. It is, 
 however, a question whether the imperfect dilatation of a congenital nar- 
 rowness of the vagina is to be esteemed a piece of good fortune for the 
 female herself, since there may remain an insufficient means of dilatation for 
 the delivery of a child. A case that fully sets forth the dangers attending 
 delivery in constricted vagina, is related in the Illinois Med. and Surg. 
 Journal for May, 1844. It is stated by Daniel Brainerd, M. D., a highly 
 instructed and able practitioner and teacher at Chicago. Dr. B. was called 
 on the 8th April, 1844, to examine the body of a Mrs. Donnahue, who had 
 died eight hours before in labour. Labour pains began on the 2d April, 
 but the pains went off entirely, so that she was going about on Thursday 
 quite well. Labour began again at 2 A. M. on Friday, and continued that 
 day ; on Saturday the patient became suddenly ill, with cessation of the 
 labour pains, and the signs of rupture of the womb. She died on Monday, 
 the 8th, at 2 A. M. Dr. B. found the womb ruptured transversely in front, 
 just above the vagina, and the child and placenta lying in the peritoneal 
 sack, which prevented the usual results of metro-peritonitis. 
 
 Upon Touching, the vagina was found to be closed above the middle by 
 adhesions which seemed perfectly to have obstructed the passage, and a 
 firm band was found to extend from the left side of it upwards and back- 
 wards, to its termination ; so also after the belly had been opened, drawing 
 the wound upward, “ a rent was perceived at its anterior part, immediately 
 above the attachment of the vagina, extending from side to side. Passing 
 the finger through this into the vagina, it was arrested, as below, by the 
 adhesions, and with a finger on either side, the septum appeared to be half 
 an inch in thickness, and of very firm texture.” “ The closure of the 
 vagina appeared to be perfect, with the exception of a canal through which 
 a quill of small size might be forced, the orifices of which were obscure. 
 
CONGENITE STRICTURE OF THE VAGINA. 
 
 99 
 
 The septum itself was very dense, and composed of the fibrous tissue of 
 cicatrix.” 
 
 It appears further, from Dr. Brainerd’s statement, that the woman was 
 twenty-eight years of age, robust, and had had two children, the first still- 
 born, after a severe labour, the second still-born at the seventh month, after 
 a labour of four hours, having suffered very little. 
 
 It appears to me, from the perusal of the case, that the womb was lace- 
 rated in vain attempts to overcome the resistance of this stricture of the 
 vagina, and as the woman was* seized with symptoms of labour on the 
 2d of April, there was time between that and the 6th, when the organ gave 
 way, to have dilated the vagina by the bougie and the instrument I have 
 described, or even by sponge tent diligently employed. I have preferred 
 to state this important case in brief here, in order to raise the question as to 
 the safety of exposing a female, by an imperfect dilatation of a congenite 
 narrowness of the vagina, to the dangers consequent on conception ; and 
 also to show that in this instance fecundation took place, though the aperture 
 barely admitted a quill of small size. — M.] 
 
 Congenite narrowness of the vagina does not always prevent con- 
 ception, which may be effected, in some instances, without the intro- 
 mission of the penis. The cases already cited at page 76, and others 
 in the records of medicine, are too numerous to leave the least doubt 
 upon this point. “ There may be found,” says Boyer, in the Me- 
 mories de VAcademie des Sciences , 1774, “a case of narrowness 
 of the vagina, which disappeared during pregnancy without any 
 artificial aid. A married woman, sixteen years of age, had so nar- 
 row, a vagina that a common quill could not be passed into it. It 
 was not closed by any membrane. At the menstrual period she felt 
 a pain in the region of the womb, which, without doubt, was due to 
 the difficulty of discharging the menstrual excretion through the 
 vagina, which was narrower near the uterine than the vulvar ex- 
 tremity. Independently of the sufferings she experienced from her 
 menstruations, she was troubled with a young and vigorous husband, 
 who hoped to force a passage, but in vain. At length, after eleven 
 years, she conceived, while not the least change had been effected in 
 the state of the canal. Her surgeon was satisfied that she could not 
 be delivered per vias naturales. Nevertheless, at the fifth month the 
 vagina began to dilate, and continued to do so, and at length acquired 
 the ordinary dimensions of the healthy vagina, and she was happily 
 brought to bed.” The same collection, 174S, contains an analo- 
 gous case. A lady, at Brest, had the vagina so narrow that it would 
 scarcely admit of the introduction of a quill. Notwithstanding, she 
 became pregnant, and in three hours of labour, gave birth to a large 
 healthy child. In this case the dilatation took place only on the 
 night of the labour. 
 
 The Lancette Francaise , Gazette des Hopitaux , for August 14, 
 1832, contains an extract from the Brazilian Medical Review , 
 relating the following case. A mulatto woman was violated by a 
 
100 ACCIDENTAL OBLITERATION, ETC. OP VAGINA. 
 
 Brazilian. Her mistress, who did not notice the enlargement of the 
 girl’s abdomen, and who supposed the servant to be affected with 
 dropsy, administered a variety of medicines supposed to be of a 
 deobstruent character. In the course of a few months the pregnancy 
 was evident, and a surgeon, who was called upon to attend the case, 
 found the vagina so narrow as scarcely to admit the introduction of 
 a writing, quill. She was safely delivered. 
 
 We shall conclude our remarks upon narrowness of the vagina by 
 one additional case. Mad. C.***, twenty-eight years of age, who 
 had been teu years married, but without being able to admit of the 
 consummation of her marriage, having applied to Dr. Caron du Vil- 
 lards, that gentleman ascertained that she had a congenite narrow- 
 ness of the vagina, so great as to permit, with difficulty, the introduc- 
 tion of a common catheter ; and he recommended the dilatation by 
 means of gum elastic bougies, gradually increasing the size of the 
 instruments to be used. After a perceptible increase of size of the 
 canal had been in this way obtained, he substituted for the bougies, 
 a sort of chaplet of sponge tent, the discs of which were cut out by a 
 punch. The discs of sponge tent were strung upon a proper thread, 
 and strongly pressed together so as to compose a single cylinder, 
 capable of being admitted into the vagina as readily as a bougie of 
 similar size. After some weeks’ continuance of the use of this pow- 
 erful dilater, the vagina had become so ample that Madame C.*** 
 became pregnant, and was safely delivered under the care of M. 
 Hatin, adjunct Professor of the Faculty of Paris. M. Caron du Vil- 
 lards informed us of a similar successful treatment, in the case of 
 Madame Taforeau, thirty-four years of age, and who had been mar- 
 ried since her fourteenth year, and who now is Portiere at No. 13 
 Rue de la Seine. The only difference in the two cases is that the 
 latter person has not become pregnant, as Mad. C.*** did, who, it 
 must be remarked, was a younger woman. 
 
 In some cases the vagina is so narrow that the canal seems to be 
 quite lost. 
 
 OF ACCIDENTAL OBLITERATION AND STRICTURE OF THE VAGINA. 
 
 By obliteration of the vagina, we understand either an accidental 
 adhesion of its parietes, whether more or less complete, or a stricture 
 of the canal affecting its whole extent, or only a part of it. 
 
 The causes of vaginal obliteration are always accidental : when it 
 is incomplete and constitutes only a stricture, the diagnosis of the 
 case may very certainly be made either by the introduction of 
 a probe, or by ascertaining that the menses have a proper issue. 
 When the obliteration is complete, the walls of the vagina are more 
 or less adherent over an extent that varies in the different samples ; 
 but so that there exists no communication whatever between the 
 womb and the vulva. 
 
 Adhesion and stricture of the vagina may be situated at the lower 
 end, at the centre, or at the upper extremity of the tube. These two 
 sorts of obliteration that commonly are the results of violent inflam- 
 
ATRESIA OF THE VAGINA. 
 
 101 
 
 mation, or any of the causes that we before pointed out, while on the 
 subject of imperforation, may likewise be occasioned by the thicken- 
 ing and induration of the vaginal tissue, which sometimes follow the 
 imprudent use of astringent injections, employed to remove the traces 
 of libertinism. The spontaneous swelling of the mucous glands, of 
 the rugae and the adipose cells of the vagina, is also to be regarded 
 as among the causes of obliteration of the tube, more or less complete. 
 
 Dr. S6galas, in 1825, communicated to the Acad.de Med. the case 
 of a woman whose vagina having been obliterated in consequence 
 of a laborious labour, caused a complete retention of the menses to 
 take place. At the sitting of March 22, 1834, there was communi- 
 cated to the Academy the case of another woman, whose vagina 
 was obliterated in consequence of the injection into it of half a glass- 
 ful of sulphuric acid, which she did herself, with the wicked inten- 
 tion of bringing on abortion. As the upper two-thirds of the canal 
 were obliterated, the womb gave way by laceration, and the unhappy 
 creature died undelivered. 
 
 [It is surprising to reflect on the rapidity with which occlusion of the 
 vagina may take place after parturition, and that without any perceptible 
 cause or sign being evident, by which it may be known that the process of 
 obliteration is going on. 
 
 About two years ago, a young woman at Salem, New Jersey, gave birth 
 to a healthy child after a moderate labour. She had no illness during the 
 lying-in, and was in all respects as well as women usually are. At the end 
 of the month she rode to the distance of twenty miles from home, to the 
 funeral of a relative, and returned the next day. It was now ascertained 
 that there was no passage beyond the bottom of the vulva, and she was 
 brought to this city that I might take charge of the case. Upon separating 
 the labia very widely, I found a puckered seam at the bottom of the vulva; 
 but I could nowhere make a probe pass into the vagina, so that the atresia 
 was complete. The anterior wall had cohered with the posterior wall of 
 the canal. She came here when her child was about two months old, so 
 that the cohesion was not yet so firm as to indicate the use of the scalpel, 
 for the purpose of effecting its disruption. 
 
 According to my own experience, the cohesion of the labia in young 
 children, may be easily overcome by pressing upon the seam with the bulb 
 of a probe, and I have always readily succeeded by operating in that mode. 
 In the case of this woman I adopted the same plan, and keeping the genital 
 orifice strongly stretched with the thumb and medius, I made horizontal 
 touches with the bulb of a probe at the points of union, and without losing 
 more than two or three drachms of blood, succeeded in breaking up the 
 cohesion of the opposing mucous walls, the villi, which seemed to be mutu- 
 ally implanted in the adverse surfaces, drawing out in the distraction of the 
 labia and the touches of the probe,* precisely as happens in the breaking up 
 of cohesions of the labia. I soon made an aperture, through which I readily 
 passed the index finger to the os uteri. I recommended to her physician 
 
102 
 
 CASE OF ATRESIA OF VAGINA. 
 
 the continued use of cereoles, to be prepared extempore and used daily, 
 until the full amplitude of the organ should be restored. The cohesion 
 occupied more than a quarter inch of the calibre of the vagina. 
 
 In the following case the vagina was lost, and is cited from th ePhilad. 
 Pract. of Mid., by the translator of this work, p. 383, 2d edit. 
 
 “A woman, from a distant part of the country, came to the city last 
 spring, (1837,) to consult Dr. J. Randolph, who was good enough to invite me 
 to see the patient with him. Her story was as follows. More than two 
 years have elapsed since she gave birth to a healthy child, the labour being 
 so exceedingly rapid that the infant was born before the physician could 
 reach the house. The after-birth did not come away for an hour, during 
 which time there was flooding. The woman became very weak. In a few 
 days she was attacked with inflammation of the vagina, accompanied with 
 enormous discharges of matter and great thick pieces of flesh , to use her 
 own account. She was never examined by her physician, who, however, 
 directed washes, injections, &.c. After a long and exhausting hectic, attended 
 with extreme emaciation, her discharges grew less copious, and she gradu- 
 ally, and at the end of some months got well. There was, however, no 
 vagina ; not even a cul-de-sac ; there was only the genital fissure left. Of 
 course no catamenia could appear ; but after several months of good health, 
 she began to complain of pain or misery in the hypogastric and pelvic 
 regions. The pains recurred with intervals of a month, and having at length 
 become intolerable, she found her health declining, and came, as before said, 
 to consult that able and eminent surgeon, Dr. Jacob Randolph. 
 
 “There was a tumour in the hypogastrium that reached half way up to 
 the navel; it was of a firm and resisting feel, not unlike a contracted womb 
 soon after delivery. As there was no vagina, the finger was passed into the 
 rectum, where it came in contact with the same tumour, which seemed 
 to occupy the excavation as it is occupied by the child’s head in labour, 
 filling up the cavity entirely. Upon separating the labia there was nothing 
 but the genital fissure: there was no way for a probe to pass upwards. A 
 sound was passed into the bladder and retained there until a finger was also 
 introduced into the rectum. The only texture that separated the sound 
 and the finger seemed to be, upon careful examination, the walls of the 
 urethra, and the coat of the bowel ; there was no vagina to be felt. Hence 
 Dr. Randolph and I agreed in the opinion that the vagina had been wholly 
 destroyed by the sloughing process which took place shortly after her con- 
 finement. We entertained no doubt as to the nature of the tumour which 
 occupied the pelvis and lower part of the abdomen ; it was the womb her- 
 metically sealed, and retaining within its cavity the accumulated menstrua- 
 tions of nearly two entire years. 
 
 “After much diligent search, we were unable to discover the cervix or os 
 uteri; but we supposed they might possibly be turned upwards towards 
 the top of the os pubis, so as to elude any investigation made through the 
 
CASE OF ATRESIA OF VAGINA. 
 
 103 
 
 rectum alone, the only possible way of making researches in the case. No 
 vestige of a vagina was discoverable by the taxis ; nevertheless, supposing it 
 possible that the whole of the tube might not have been destroyed, and that 
 haply its upper extremity might be reached by the bistoury, Dr. Randolph 
 operated with a view to make an artificial vagina, and to discover the re- 
 mainder, if any, of the original one. 
 
 “ Introducing a strong metallic staff, slightly curved, into the bladder, he 
 took his seat in front of the patient, who laid upon her back on the bed 
 with the knees drawn up and separated. I held the staff firm, while, with 
 the left index in the rectum, to serve as a guide, he dissected by horizontal 
 strokes of the bistoury, the tissue betwixt the rectum and urethra, and carried 
 his incision very nearly up to the substance of the womb itself, without 
 having wounded either the rectum or the urethra: when he had completed 
 his incisions, the finger could be carried up to the bottom of the cul-de-sac 
 he had formed by so skilful and accurate a use of the bistoury. 
 
 “ In consequence of our uncertainty relative to the situation of the os 
 uteri, and from his having successfully removed so considerable a portion of 
 the barrier that opposed the escape of the contents of the uterus, Dr. Ran- 
 dolph suspended his operation at this point with the following views. 
 
 “ It was resolved to keep the passage open by the use of a bougie, made 
 as light as possible and of a sufficient size. The bougie was made of silver, 
 gilt, about four inches in length, and about as large as the thumb, its weight 
 not more than two drachms, being hollow. We hoped that by using this 
 bougie a few months, the progress of the case would be such as to bring the 
 os uteri to the extremity of the instrument, by means of the increasing ex- 
 pansion of the uterine globe, and that the contents of the womb would dis- 
 charge themselves into the artificial vagina, or that they might be so dis- 
 charged by a future incision. The lady returned to her own country, and 
 after an absence of three months, came back to the city, still suffering under 
 the same misery , with increased magnitude of the uterus, but without 
 having had any discharge from the vagina. She had constantly worn the 
 bougie. Upon examination, we found the vagina was now covered with a 
 smooth surface resembling mucous membrane ; the upper end of the bougie, 
 when withdrawn, was covered with a sort of muco-purulent matter, tinged 
 with blood. The sufferings of the patient from the distension of the womb 
 were very great, and it was on that account resolved to puncture the organ 
 in order to draw off its contents. On the 8th July, 1837, Dr. Randolph 
 and Dr. R,. M. Huston, who had been invited by us to witness the operation, 
 met me at the lodgings of the patient. 
 
 “The tumour, felt through the vagina, was hard and resisting, like an 
 enlarged ovarium ; it was softer, and its walls thinner when examined 
 through the rectum. At Dr. Randolph’s request I made use of a curved 
 trocar enclosed within its canula. The trocar was about five inches in 
 length, and about the size of a small writing quill. The patient was laid 
 
104 
 
 CASE OF ATRESIA OF VAGINA. 
 
 upon her back near the edge of the bed. I introduced the forefinger of the 
 left hand into the rectum, and having directed the end of the finger to a point 
 upon the tumour that felt most yielding, carried the point of the trocar along 
 that finger to the place in question, and giving to the point of the instrument 
 a direction as nearly as possible perpendicular to the surface of the tumour, 
 pushed it through the resisting tissues until I found it had freely entered the 
 cavity of the womb; the trocar was now withdrawn, leaving the canula 
 in its place. There immediately issued from the open end of the canula a 
 dark red viscous substance, without odour, of the consistence of meconium, 
 and as adhesive as that substance. The puncture was scarcely felt by the 
 patient. In the course of twenty-four hours, during which the canula was 
 permitted to remain in situ properly secured, about twenty-five ounces of 
 this fluid were discharged; the uterine tumour had disappeared from the 
 hypogastrium, and the mass, as felt through the rectum, was greatly reduced 
 in size, and far more movable. As all the liquid seemed now to be evacu- 
 ated, the canula was withdrawn; no discharge followed its withdrawal. The 
 patient had no symptoms attributable to the puncture ; she rapidly recovered 
 her strength, and left the city with renovated health, and nearly free from 
 the misery that had so long embittered her existence. In the course of 
 about a month after she returned to her home, she had a very copious dis- 
 charge from the vagina, of a fluid similar in consistence to that which came 
 away through the canula, but of a whitish colour, after which her health 
 greatly improved. 
 
 “ On the 14th Dec., 1837, while on her way to this city, for the purpose 
 of taking further advice, she discharged about twenty-five ounces of a sub- 
 stance in all respects similar to that which was first extracted. 
 
 “ In the course of the summer of 1843, 1 again saw this lady. Her health 
 was good ; she has tolerably regular menstruation, which gives pain. The 
 artificial vagina has disappeared, leaving a sinuous opening, very small, 
 which communicates with the cavity of the womb, and by which she men- 
 struates. She could not be prevailed upon to submit to any further treat- 
 ment. I think it highly probable that the sinus could be readily dilated 
 into a full-sized vagina.” — M.] 
 
 Notwithstanding that in some of the cases the adhesions can be 
 easily and without much effort broken up, yet in other circumstances, 
 the purulent matter becomes thickened to such a degree as to form, 
 with the vaginal surfaces, a sort of solid concretion, capable of 
 resisting the greatest violence, especially if the cohesions are of long 
 standing. 
 
 [I cannot avoid remarking the singular use of the word purulent in the 
 above passage. I presume it is to be understood as referring not to pus, as 
 such, but to the coagulating or organizable lymph, which is the bond of 
 union in such cases. — M.] 
 
 Where the inflammation has been very violent, the ruga* of the 
 
TREATMENT OF STRICTURE OF VAGINA. 
 
 105 
 
 vagina become so confounded with each other, that it becomes nearly 
 impossible to dissect them up without perforating one of the sides 
 of the canal, and wounding either the bladder or the rectum; the 
 degree of the inflammation, then, may serve as the index of indica- 
 tion, as to whether an operation should be attempted or rejected, for 
 it is as dangerous as it is difficult, where the obliteration exists for 
 the whole extent of the tube. In such cases, Morgagni proscribes it 
 entirely, and Blasius, as well as Benevoli, each of whom had the 
 temerity to dissect the vaginal parietes after they had been coalesced 
 from inflammation, was obliged to leave the operation unfinished. 
 We shall, however, bring forward a case in which a successful result 
 was obtained by Professor Flamand, and which we take from the 
 account given by Dr. Villette of Paris, in 1821 . A country woman 
 was delivered by a midwife, who ruptured the vagina. The menses 
 did not return after this confinement ; the husband was discontented 
 with his wife, supposing that his embarrassment was owing to her 
 want of condescension. Being at last quite out of patience with her 
 condition, she went to Strasbourg to M. Flamand’s clinic, in order to 
 undergo an operation. There was found a very small opening, that 
 with difficulty admitted the introduction of a grooved director, but 
 what was the surprise of the learned professor to discover that four 
 inches of the vaginal tube had cohered ! In spite of the difficulty of 
 the case he succeeded in removing the deformity, for she had a child 
 a year afterwards. 
 
 Where the obliteration is not complete, we may succeed in arrest- 
 ing its progress, at first by antiphlogistic measures, and by promoting 
 the dilatation of the vaginal parietes by baths, fumigations and emol- 
 lient injections ; and by the use of vaginal suppositories of beurre de 
 cacao , and the use of the dilating measures heretofore pointed out, 
 while speaking of congenital narrowness of the canal. 
 
 Among the fittest means for the fulfilment of this last-named indi- 
 cation, there is one we have made use of with great advantage, and 
 which is recommendable as being both easy of performance and not 
 at all painful. 
 
 It consists in introducing within the vagina a cylindrical sac, very 
 thin and soft, and which is made of the caecal appendage of a calf or 
 a sheep, and which was introduced by an English physician named 
 Condon, for the purpose of guarding the penis against infection in 
 impure coitus. In using this sac, there should be attached to it a 
 gum-elastic sound, so that after the sac has been cautiously intro- 
 duced into the vagina, it may be filled with air, at first in moderate 
 quantity, and then in quantity progressively increased from day to 
 day. The sac should at first be a small one ; the succeeding ones to 
 be larger and larger, and often changed to prevent their putrefaction 
 within the passage. The air may be prevented from escaping by a 
 small cork fixed to the outer end of the gum-elastic sound, or by 
 adjusting upon it a small brass cock, which would conveniently 
 allow the air to escape a little if the sac should happen to be painful 
 from too great an inflation. The use of this method should be con- 
 tinued until the vagina recovers its natural dimensions. 
 
106 
 
 OBTURATION AND ITS TREATMENT. 
 
 In the entire obliteration of the vagina, there remains no other 
 remedy than a dangerous and difficult operation which we shall 
 describe under the head of obturation of that canal. 
 
 OF OBTURATION OF THE VAGINA AND THE MEANS OF CURE. 
 
 In pathology the word obturation refers to the accidental deve- 
 lopment of any substance, filling up more or less completely a 
 natural cavity. 
 
 Obturation of the vagina, which indicates either the presence of a 
 foreign body in the tube, or an intermediate substance confounded 
 with its walls, has excited but little attention among medical men 
 because it has been rarely presented to their observation. 
 
 A vaginal obturation may be complete or incomplete, congenite or 
 accidental. The causes of accidental obturation must be regarded as 
 symptoms of other pathological lesions, and not as organic affections. 
 Such are the polypous, fungous or syphilitic excrescences, membranous 
 bands and fleshy columns developed in the vagina, the swelling and 
 mutual approximation of the carunculae,* encysted and steatomatous 
 tumours, vaginal hernia, and, indeed, all sorts of tumours and vege- 
 tations that may take their rise upon the mucous membrane of the 
 vagina, or which, though foreign to it, may nevertheless project into 
 or against its calibre. 
 
 An obturation may even be produced by prolapsus of the womb, 
 the cervix of which may contract adhesions to the internal edge of 
 the labia externa. A case of the kind is recorded in the Diet, des 
 Sci.-Med ., (article Vagina,) less as a case of obturation than because 
 the os uteri being partially open, so as to admit the finger, any want 
 of attention might lead to the mistaking of the orifice for that of 
 stricture of the vagina. 
 
 When the obturation is congenital, it may, like the accidental case, 
 be complete or incomplete, and occupy a greater or less extent of the 
 vagina. That canal is, therefore, susceptible of becoming primarily 
 obstructed, not only at any given point of its surface, but even 
 throughout its whole extent, which is, in such a case, converted into 
 a solid cylinder, very thick and composed of a cellulo-fibrous mate- 
 rial, quite analogous to the substance of the vaginal parietes. 
 
 Like the vaginal imperforation, the obturation of the tube is, for 
 the most part, undiscovered until the age of puberty, or until symp- 
 toms relative to amenorrhoea lead to its detection. However, the 
 
 * Riolanus, who was appointed Professeur Royal d’Anatomie by Louis XIII., and 
 afterwards became physician to Queen Mary de Medicis, has published (Anat.seuAu- 
 ihrup. cap. 2. p. 35,) the case of a woman in whom the carunculae myrtiformes were 
 so closely approximated, that it was hardly possible to introduce a probe into the 
 opening betwixt them. Notwithstanding this almost complete obturation, the patient 
 was happily delivered of a child, after the excision of the tumour had been per- 
 formed. There is also, in the xxiv. vol. of the Did. des Sci. Med., p. 133, a case in 
 which the shreds of the hymen, after defloration, had united again so as to form a 
 complete diaphragm in the lower part of the vagina. The myrlil'orm caruncles have 
 been sometimes mistaken for syphilitic excrescences; to mention is sufficient to 
 avoid such an error. Our readers should reflect that the fleshy lumps resulting from 
 the destruction of the hymen are generally smooth, loose and of a rose tint. 
 
CASES OF OBTURATION. 
 
 107 
 
 symptoms accompanying obturation are in general less severe than 
 those of the other case, because it has been found to coincide almost 
 always with an imperfect development of the womb itself, which 
 militates in favour of the principle set forth by M. Andral,* that a 
 part is generally not found to be wanting or imperfectly formed, 
 unless those that precede it in the natural state have themselves 
 undergone an arrest of development. 
 
 Although obturation of the vagina, when complete, or even incom- 
 plete, renders the sexual union impossible, the partial introduction of 
 the penis may be effected if the obstacle is found only at the upper 
 end of the canal. A woman so constituted would be exposed to great 
 danger by too violent an effort in coitu. The vagina might be rup- 
 tured, as in the case mentioned by Plazzani in the following words. 
 Ci Juvenis quid am , cum sponsa jnvenciila prima node congressurns , 
 valida veretri intrusione et violent a festinatione non modo uteri 
 cervicem , sed et ipsum intestinum rectum pern/pit ( De Par lib. 
 Generate lib. ii. cap. 14. p. 164.) 
 
 As the records of medicine possess but few authentic cases of vagi- 
 nal obturation, we shall report some cases by Dehaen, Morgagni, 
 Lieutaud, Foder6, Cormick, Professor Stoltz, and mentioned also in 
 a thesis by Dr. Waille de St. Lupicien, as now to be related. 
 
 Dehaent speaks of a girl twenty-four years of age, who, dying in 
 consequence of retention of the menses three days after an unsuccess- 
 ful operation, in which the instrument penetrated the urethra and to 
 the neck of the bladder, was found to have part of the vagina con- 
 verted into a solid fleshy body an inch in diameter, beyond which 
 the passage was filled with a dark-coloured sanies, and was of capa- 
 city sufficient to contain the head of a foetus. 
 
 Morgagni, f while making the autopsy of a female seventy years 
 of age, who died with peripneumony, after having been long sub- 
 ject to an asthmatic disorder, found the vagina completely obstructed 
 except at each extremity, by a sort of solid cjdinder composed of a 
 substance uniformly white and pretty hard, so that it was not possi- 
 ble to discriminate betwixt it and the parts surrounding it and con- 
 tinuous with it. The vagina did not appear to have lost any part of 
 its diameter. The walls of the uterus were thick, the orifice small, 
 the inner surface somewhat moist, and the lower part of the cervix 
 contracted. 
 
 A woman named La Hure,§ of the Faubourg du Temple, at 
 Paris, having never been indisposed, notwithstanding the absence of 
 the catamenia, and having been six years a wife without the con- 
 summation of the marriage, was examined and unsuccessfully operated 
 on, August 6th, 1734, by Dejours, the surgeon, and was subsequently 
 examined by Levret, and afterwards by Saumet, Ferrin, Petit and 
 
 * Anat. Pathol., t. i. p. 109. 
 
 f Ratio. Medend., t. iii. pars. 6. cap. 2; Lieutaud, Histoire Nat. Medicale, t. i. p. 
 326 ; Diet, des Sci. Med., article Imperforation ; Duges Mai. de l’Uterus, t. i. p. 271. 
 
 i Lettre 67 and 10. 
 
 § Causes celebres, t. vil. and 10. 20. cause ; Fodere, Med. Leg., 2d edit. t. i. p. 385 ; 
 Diet, des Sci. Med., article Marriage. 
 
108 
 
 STOLTZ’S CASE. 
 
 Morand. She died at Lyons ten years after this, and upon the 
 autopsy it was discovered that the womb and the vagina constituted 
 merely a compact solid substance, without any cavity. 
 
 Dr. Cormick* was called to examine a woman twenty-three years 
 of age, who, from the age of sixteen, had felt once a month the 
 symptoms arising from retention of the menses ; and was a victim 
 of the most intolerable pains. Upon exploring the genital parts he 
 found a fleshy resisting mass, that appeared to fill up the whole 
 vagina. He was obliged to plunge a trocar to the depth of four 
 inches, before he passed through the obstacle that prevented the 
 escape of the menses. 
 
 To these four cases we shall add a case from the practice of Mr. 
 Stoltz. It appears to us to be the more interesting, as differing, from 
 the others in the total absence of bad symptoms, and as presenting a 
 specimen of perfect obturation, with distinct parietes, and in the faci- 
 lity and the happy success of the operation undertaken for the cure. 
 
 Madame N., of Stotzheim, had reached her twenty-third year 
 without having menstruated. The only menstrual efforts she had 
 experienced consisted in attacks of epistaxis, which, at the age of 
 puberty had recurred, but without any character of periodicity; and 
 from time to time, every week or every fortnight, pains in the hypo- 
 gaster, but not affecting the region of the sacrum at all. Having 
 been married in the year 1827, it was impossible to consummate the 
 union, and it was not until four years had elapsed, that is, in 1831, 
 after she had been four years married, that she submitted to an 
 examination by a midwife, who found the orifice of the vagina 
 closed. 
 
 M. Stoltz, being requested to see the lady, Sept. 25, 1831, for the 
 purpose of performing the operation, found her of middling stature, 
 the countenance perfectly feminine, the mammae pretty well deve- 
 loped, the skin fair and soft, the mons well covered with hair, the 
 external genitalia of a natural appearance, and, learned in a word, 
 that she had all the attributes of the sex, except that the orifice of the 
 vagina was closed by a thick membrane, salient some eight or ten lines 
 like the end of the finger of a glove, and which admitted of being 
 pushed back to an equal distance into the canal of the vagina, like 
 the finger of a glove turned inside out. This projecting part was 
 somewhat wrinkled, of a rose colour, and perfectly indolent. 
 
 At first, M. Stoltz was of opinion that it would only be necessary, 
 by means of scissors, to cut off the principal part of this membrane, 
 in order to open a free passage into the vagina. But he found that 
 the excision only gave access to the interior of a small sac filled with 
 white mucus, of a milky character, and found that the vagina was 
 completely obstructed and filled with a cellulo-fibrous material, which 
 he partly dissected with the scissors, introduced as far as he could 
 properly use them, and then with the index and medius fingers intro- 
 duced into the passage ; after which he broke up the bands or bridles 
 that remained with a Flamant’s guarded bistoury. In order not to 
 
 * Med. and Philos. Commentaries, vol. ii. p. 188; Voigtel Handbuch der Pathol. 
 , Anat., p. 438. 
 
STOLTZ’S CASE 
 
 109 
 
 lose the direction of the vagina, he placed a sound in the urethra, 
 which enabled him. to distinguish both the urethra and the bas-fond 
 of the bladder. 
 
 After having thus torn up the cellular bands that obstructed 
 nearly the entire length of the vagina, with his fingers, partly by 
 separating them in various directions, and partly by using them 
 as blunt crotchets, he at length reached a small hard tubercle, 
 divided by a transverse slit into two parts. This was the vaginal 
 portion of the cervix uteri. He succeeded, with great difficulty, in 
 breaking up the bands that concealed it like a thick spider’s web. By 
 means of the fingers in the vagina and the sound in the bladder, and 
 also by depressing the hypogastric integuments sufficiently to meet 
 the fingers in the vagina, he satisfied himself that the tubercle was 
 nothing more nor less than the womb itself in a rudimental state, and 
 from five to six lines in length from top to bottom. A careless ope- 
 rator, or one not thoroughly acquainted with the anatomy of the 
 parts, might very readily have broken through one of the culs-de-sac 
 of the vagina, while endeavouring to find the womb itself. 
 
 After the completion of the operation, the vagina was found to be 
 sufficiently capacious to admit of the consummation. The constrictor 
 muscle was found to be perfect by its contraction on the index. A 
 stout pledget of lint with a tape fastened to its base, and spread 
 with cerate, was introduced into the vagina, and directions were 
 given to the midwife to change it twice a day. 
 
 The operation was not very painful, the patient made no outcries, 
 and she did not lose more than half an ounce of blood. 
 
 Fifteen days afterwards the midwife informed M. Stoltz that the 
 lady had discovered a slight discharge of a few drops of blood from 
 the vagina, which was at first attributed to an imperfect menstrua- 
 tion ; but as it did not return, it was thought that it might have pro- 
 ceeded from a congress, with some laceration. 
 
 Two years and a half had elapsed when M. Stoltz received the 
 last accounts of the state of his patient. She was in the same condi- 
 tion, had never menstruated, felt from time to time, and at nearly 
 equal intervals, the symptoms of the catamenial action, and had no 
 difficulty in the cohabitation. 
 
 Inasmuch as the symptoms of a case of obturation might be con- 
 founded with those of imperforation or obliteration, and of absence of 
 the vagina, we shall now call to mind some striking traits that may 
 suffice to remove all uncertainty on this point. 
 
 Where the imperforation is incomplete, menstruation may take 
 place ; if it be complete, the finger, if introduced within the vulva, 
 encounters a membrane forming a fluctuating tumour, with an oval 
 projection more or less prominent in front, and in such a case, a 
 simple incision dispels every doubt and dissipates every symptom. 
 Where the occlusion is owing to incomplete obliteration, the dis- 
 charge of the menses takes place, and a style may be passed into the 
 contracted vagina : if the obliteration is complete, and affects the 
 whole breadth of the canal to a greater or less extent of its longi- 
 tude, the diagnosis of the case, which is always accidental , may be 
 
110 
 
 OPINIONS ON OPERATION 
 
 made out by examining by the rectum, and with a sound introduced 
 into the bladder. The obstacle that results from obliteration , instead 
 of being as in obturation a compact, thick cylindrical body, filling up 
 the vagina, consists in a pretty thin membranous septum*, or in cohe- 
 sion of the sides of the canal, — a cohesion that may affect the whole 
 length or only certain points of it. Moreover, in the case of obtura- 
 tion, if the finger be introduced into the vulva, it will be arrested by 
 a very resisting body, whereas in imperforation and obliteration, the 
 obstacle is always movable, membranous and fluctuating. 
 
 Nearly all the authors who have spoken of occlusion of the vagina 
 have furnished few details on the subject ; and have confounded the 
 accidental agglutination of its parietes with obturation of the canal 
 produced by the intermediate body, whose principal characters we 
 have now pointed out. This is probably the reason why they desig- 
 nate these new kinds of occlusion by the same term obliteration, and 
 that they denounce the operation as impracticable and very danger- 
 ous in all instances, wherein the obstacle extends to some depth into 
 the vagina. 
 
 Naboth,* who participated in the generally admitted opinions, and 
 who also confounded the accidental cohesion of the vaginal walls 
 with the congenital obturation in question, said that when there 
 existed an intermediate fleshy body, the operation ought to be re- 
 nounced, for there would be reason to apprehend either a dangerous 
 haemorrhage or very serious inflammation as the consequence of -its 
 performance. Morgagni,! who entertained the same notions, advised 
 his women rather to submit to divorce than suffer an incision to be 
 rashly made. Heisterf also refused to operate for two females who 
 came to consult him ; lastly, Plenck,§ Mahon, || Fodere,1T and nearly 
 all the writers on medical jurisprudence look upon this sort of atresia 
 as cause of absolute impotence and beyond the reach of art. 
 
 Notwithstanding the well or ill founded and generally exaggerated 
 fears of the writers on this subject, we are of opinion that circum- 
 stances may exist to indicate the propriety of an operation ; but 
 that the greatest prudence is required on the occasion ; care being 
 taken not to wound the bladder or rectum. Even if it be true that 
 the results have, in a major part of the instances, been unfortunate, 
 it may with propriety be attributed to the method having been ill 
 chosen, or the case having been contra-indicated, as ordinarily hap- 
 pens when in consequence of a complete obliteration, the walls of 
 the vagina have become agglutinated throughout their entire extent. 
 
 Previously to making any attempt at operation it would be the 
 dictate of prudence, always to wait until compelled, as it were, by 
 the occurrence of symptoms of retained menses, or of other symptoms 
 threatening the very life of the patient ; and which thus afford proof, 
 not only of the existence of a womb, but of its not communicating 
 with any other cavity — which, were it the case, would render the 
 •operation useless. 
 
 * Disput. de Sterilit. Mulierum, p. 23. f Lettre, No. 46. 
 
 i Institut. Chirurg. t. ii, p. 403 and 405. § Element. Med. Chir. Forensis, p. 3. 
 
 U Medicine L6gale, t. i,p. 63. ^ Med. Legale, 2d edit. p. 384. 
 
FOR OBTURATION OF VAGINA. 
 
 Ill 
 
 SURGICAL TREATMENT OF ACCIDENTAL COHESION OF THE VAGINAL 
 
 PARIETES ; AND OF CONGENITAL OBTURATION OF THE VAGINA. 
 
 In a case where the necessity for action is clearly established, the 
 patient should be prepared for it in the same manner as if about to 
 undergo one of the greater operations of surgery; but if upon a 
 retention of the menses, symptoms should arise deemed sufficiently 
 important to menace her safety, no delay should be allowed. In 
 such an instance the only preparation would consist in evacuating 
 the rectum and bladder, with the view of rendering them less liable 
 to be wounded by the bistoury. 
 
 Whether the design be to dissect asunder the vaginal walls acci- 
 dentally coherent, or whether we be about to treat a case of conge- 
 nital obturation produced by an intermediate membrane, the patient 
 should be placed as for the operation of lithotomy ; then having in- 
 troduced the index finger of the left hand into the rectum and a sound 
 into the bladder, for the purpose of exploring the parts anew — and 
 to give a surer direction to the knife, the incision should be made 
 little by little with a straight bistoury, or, with what we should pre- 
 fer, a convex scalpel — and thus the walls of the vagina should be 
 separated, proceeding with all the prudence and care demanded by 
 so serious an operation. — (See Fig. 15.) 
 
 Fig. 15. 
 
 That we may be able throughout the whole course of the operation 
 to retain one finger within the rectum, and at the same time be ac- 
 quainted with the situation of the adjacent parts without being com- 
 pelled to make use of the left hand, we have invented an instrument 
 which is adjusted upon the end of the right index finger, like a 
 thimble, and which is terminated by a Fig. 16. 
 
 small cutting edge, convex in shape, and 
 about three lines in length. (Fig. 16.) 
 
 By using this, we can, with the medius 
 of the right hand, continually inquire as 
 to the resistance of the tissues after each 
 little incision, and guide the cutting edge 
 constantly until it reaches the sanguine collection, that has called 
 for the performance of the operation. After which we should pro- 
 ceed as directed under the head of vaginal imperforalion. 
 
 If we are acting, not to remedy a case of obliteration, but a con- 
 genite obturation, the operation that offers the greatest prospect of 
 success, in this latter case, and that because there is always an inter- 
 mediate substance, and consequently a greater space betwixt the 
 rectum and the urethra, ought to be performed as follows, and with 
 the preliminaries already mentioned. 
 
 In the first place, if there should be found a 'membrane projected 
 
112 
 
 OPERATIONS FOR OBTURATION. 
 
 outwards at the vulva, and placed in front of the obstacle, it should 
 be removed by the scissors or with a straight bistoury, cutting from 
 before backwards ; or, what is still better, by means of two incisions, 
 united below, like the letter V, so as more certainly to avoid the risk 
 of injuring the urethra. 
 
 After having performed this little preliminary operation, whicli 
 will have exposed the real nature of the obstacle, the surgeon will 
 plunge a long narrow bistoury into the middle of the space comprised 
 betwixt the anus and the meatus urinarius, then withdrawing the 
 bistoury, he should introduce the index of the left hand into the 
 wound, in order to dilate the opening thus made, and then continue 
 to push the bistoury forwards, guarding and directing its progress by 
 means of the finger kept near its point. ' 
 
 Should it be preferred, the surgeon may make use of a trocar, 
 which, being introduced gently and carefully, admits of a more rapid 
 operation, which, however, is less certain than the other. For the 
 purpose of guarding against injury to the bladder, a grooved director 
 may be introduced into the wound made by the trocar, and adjusted 
 so as to allow the point of a bistoury moving in the groove, to make 
 two oblique incisions that coincide in the direction of the urethra, 
 like an inverted ^ . 
 
 Whatever may be the method adopted, it is indispensable, for the 
 certainty of the operation, to keep the index of the left hand in 
 the rectum, and to let an assistant take charge of the sound that is 
 in the bladder, directing him, agreeably to Velpeau’s advice,* to 
 press the point of it towards the hypogastrium. Throughout the 
 whole course of the operation, the urethra must be raised up by 
 means of the sound, so as to keep it as much as possible out of the 
 way of the cutting instruments. 
 
 Should the obstructing substance be found to be yielding, the con- 
 duct of M. Stoltz might be imitated, who succeeded in restoring the 
 vagina, and broke up all the bands of cellular matter, by the alter- 
 nate use of his fingers, the scissors, and the guarded bistoury of 
 Flamand. Should a considerable haemorrhage come on, we might 
 follow the example of Dr. Voisin,t in a case of obliteration, and 
 divide the operation into two stages ; and it might be concluded after 
 a short delay, during which the wound should be filled with a piece 
 of sponge tent. After the destruction of the obstacle, union of the 
 parts is to be prevented in the manner pointed out under the head 
 of imperforation of the vagina. 
 
 The accidents accompanying this operation that are most to be 
 feared are haemorrhage and inflammation. The former, when not 
 excessive, prevents the occurrence of the latter, which has never been 
 met with except in cases of imperforation or obliteration. Inasmuch 
 as in both these kinds of occlusion, the assistance of art is not 
 required until after the appearance of important symptoms, the in- 
 flammation may be supposed to depend less upon the operation itself 
 than on the suddemchange effected in the volume of the womb, and 
 
 f Theses de Paris, 1806, p. 116. 
 
 Elern. de Med. Opera!., t. iii. p. 576. 
 
OCCLUSION OF THE CERVIX. 
 
 113 
 
 the tension of the vagina and its appendages. In every case let the 
 patient be subjected to the most rigorous regimen, and to an antiphlo- 
 gistic treatment, conformable to the violence of the fever and in- 
 flammation. 
 
 Whatsoever may be the nature and extent of the obstacle compos- 
 ing the obturation, the attempt to remedy the difficulty ought not to 
 be deferred when the life of the patient is compromised. The opera- 
 tion is, doubtless, the only plank of safety ; but the principles of our 
 art, as well as humanity itself, command us to avail ourselves of it, 
 although liable to be cast upon a shoal, that by means of it we may 
 avoid another and the fulfilment of the ancient adage, so well ex- 
 pressed by Virgil, in the line — 
 
 “Incidit in Scyllam, qui vult vitare, Charybdin.” 
 
 Notwithstanding the proscription of this operation by such authors 
 as Naboth, Morgagni, and Heister, and by many of the modern sur- 
 geons, it is sufficiently justified, even admitting its dangerous nature, 
 by the successes of Messrs. Desgranges, Delpech, Cabaret, Ventusa, 
 Flamand, Willaume, Toulmouche de Rennes, Stoltz, and other names 
 that it is unnecessary to cite in this place. 
 
 OCCLUSION OF THE CERVIX UTERI. 
 
 In some instances while the vagina itself is perfectly free from 
 obstruction, it is the canal of the neck of the womb that is the seat 
 of congenite obturation, or of a complete or incomplete obliteration. 
 
 This deformity, which was first described by Akakia, may depend 
 upon various accidental causes. Thus the sequelae of a labour, the 
 introduction of a foreign body, lacerations from mechanical causes, 
 the amputation of the cervix uteri, ulcers, burns, tumours, polypi, 
 &c., &c. ; these, and all the other causes that we have enumerated in 
 our article on vulvar and vaginal atresia, may serve to explain the 
 formation of occlusion of the cervix, and the retention of the menses 
 consequent thereto. 
 
 Morgagni , while dissecting the sexual organs of a female, found 
 the mouth of the womb closed up by a white thick membrane that 
 shut off all communication betwixt the cavity of the uterus and the 
 vagina. Armand , Simson and Frank ,* Messrs. Cabrol,\ Gau- 
 thier, \ Willaume , § Hervez de Chegoin , || Delpech, *\\ Desgranges ** 
 and some other writers, have likewise noticed either obturation 
 or obliteration, more or less complete, of the vaginal orifice of the 
 womb. 
 
 The consequences of uterine atresia are perhaps still more danger- 
 ous than those of the other kinds of imperforation of which we have 
 already spoken. This arises from the circumstance that in this case 
 we are more easily led into the mistake of regarding it as a state of 
 pregnancy, and as the symptoms have a closer resemblance to those 
 
 * De Retentionibus, t. ii. p. 39. f Ann. Litt. Med. etrang., t. ii. p. 484. 
 
 * Nouveau Journal de Med., t. vii. p. 30. § Seance de l’Acad. de Med., 23 Mai, 1826. 
 
 H Idem 24 Novembre, 1829. ^ Memorial du Prof. Delpech, Mar. 1830. 
 
 ** Idem No. du mois d’Avril, 1830. 
 
 8 
 
114 
 
 OCCLUSION OF THE CERVIX. 
 
 of gestation, it is more difficult to make the diagnosis of retained 
 menses. 
 
 The occlusion may exist in the interior of the cervix, or at its ori- 
 fice ; and there seems to be, according to Boyer, a continuation of 
 the inner membrane of the vagina. Some practitioners, however, 
 among whom may be mentioned Latour, Morland, Flamand and 
 Martin, are of opinion that an obturation can possibly take place 
 during pregnancy. 
 
 An examination by Touching, or the inspection of the parts, ena- 
 bles us pretty clearly to distinguish the faulty conformations of the 
 cervix, whether primitive or accidental, and even to observe the 
 fluctuation occasioned by the accumulation of blood in the viscus. 
 
 Benevoli , surgeon in chief to the Hospital of Florence , who has 
 candidly made known both his success and his errors, was consulted 
 on account of a girl affected with suppression of urine, accompanied 
 with the usual phenomena. Having tried, without success, to intro- 
 duce a sound into the urethra, he discovered that he could not make 
 it reach as far as the bladder, because the distension of the womb 
 had elongated the urethra. An angle in the canal of the urethra had 
 been formed by the distended womb, which had thrust the bladder 
 itself forwards and above the ossa pubis, so that the orifice of the 
 bladder no longer corresponded with that of the urethra. 
 
 Benevoli, as he could not succeed in relieving the bladder on the 
 first day, put off an attempt to pass the catheter until the next day. 
 Instead of introducing the sound into the urethra, he passed it into 
 the vagina without being aware of the mistake he had made. The 
 instrument, which was directed towards the mouth of the womb, not 
 being able to penetrate into the cavity of the organ, Benevoli, sup- 
 posing that it was the sphincter vesicae under powerful contraction, 
 and, that he might be able to overcome it by force, pushed the sound 
 onwards, and it plunged into the womb. Immediately after this, there 
 escaped a very large quantity of a brownish liquid, resembling wine 
 lees, which was at first mistaken for bloody urine. But after the 
 menstrual collection had come away, the urine was rapidly discharged 
 from ’the urethra, a circumstance which showed him that he had in- 
 troduced his sound into the uterus and not into the urethra. The 
 patient, who for three years had found her abdomen increasing in 
 size every month, instantly obtained great relief, with the immediate 
 disappearance of the enormous abdominal swelling caused by the 
 accumulation of menstrual blood in the uterine cavity. Benevoli 
 estimated the quantity discharged after the performance of the opera- 
 tion at thirty-two pounds. 
 
 If, in any case, the symptoms we have described should be sup- 
 posed to depend on a primitive or accidental faulty conformation, the 
 sexual parts ought to be examined with the most scrupulous care, in 
 order to learn whether the absence of the womb does not furnish an 
 insurmountable bar to the object proposed to be attained. 
 
 In order to remedy the occlusion of the neck of the womb, an 
 attempt should be made to pass up an ordinary sound, with a view 
 to overcome the obstacle, if possible. If that cannot be done, then 
 
ATRESIA OF THE FALLOPIAN TUBES. 
 
 115 
 
 the resistance should be overcome by means of a puncture, either 
 with a bistoury, wrapped with linen to within a few lines of its 
 point, [or, what is better, wrapped in a ribbon of adhesive plaster 
 spread on fine linen — M.,] or with a trocar, the canula of which, as 
 advised by Hervez de Chegoin, ought to be left in the wound, as a 
 conductor to a piece of gum elastic catheter, to be followed after- 
 wards by a female catheter. 
 
 Whatsoever may be the instrument, or the method employed in 
 the operation, the inflammatory consequences require the same atten- 
 tions that we have recommended in speaking of the operations for 
 atresia of the vulva and vagina. To prevent or combat these dread- 
 ful consequences, let it be remembered that they demand the most 
 energetic methods ; among which are bleeding, long-continued warm 
 bathing, as of the first rank; the woman should, so to speak, be 
 made to live in the bath until the cure is complete. 
 
 ATRESIA OF THE FALLOPIAN TUBES. 
 
 The Fallopian Tubes are two musculo-vascular conduits, floating 
 loose in the abdomen, and extending from the superior angles of the 
 womb to the margins of the superior strait of the pelvis. As these 
 tubes, which are supposed capable of the state of erection, are hid- 
 den from our researches in the living subject, it is not possible 
 to ascertain the existence of an imperforation of them except in an 
 autopsy. 
 
 Atresia of the tubes, like the other imperforations of the genitalia, 
 is divided into congenite or accidental , and complete or incomplete 
 atresia. 
 
 The causes of congenital atresia are unknown ; in some instances 
 both the tubes may be affected, and the causes may be accidental ; 
 thus, the formation of a membrane that happens to be developed 
 near the point where the tubes communicate with the cavity of the 
 womb, in consequence of an attack of inflammation ; a preceding 
 wound ; an operation — as the Caesarian operation, for example ; a 
 blow on the hypogastrium, suffice to disclose the nature of the acci- 
 dental deformity in question. 
 
 The most common kind of atresia is that that takes place near the 
 insertion into the womb ; it is also, sometimes, observed near the 
 ovaries, to which they are found, in some samples, intimately united. 
 
 Both the total obturation and obliteration being beyond the re- 
 sources of the art, and being not ascertainable until after death, we 
 here close our observations upon the subject, being satisfied with 
 merely mentioning the fact of their existence. 
 
116 
 
 ABSENCE OF THE VAGINA, ETC. 
 
 OF ABSENCE OF THE VAGINA— AND OF CASES IN WHICH THE VAGINA 
 OPENS INTO THE RECTUM OR BLADDER. 
 
 Both Morgagni* and Dupuytrent met with women in whom the 
 vagina was only of one-third its usual diameter and length. Engel % 
 and Boyer§ found the vagina wholly wanting, and the urethra and 
 bladder in immediate contact with the rectum. Individuals affected 
 with these anomalous forms may, at the same time, be wholly un- 
 provided with the uterus, || or, if it does exist, it may be small, ill 
 formed, and unfit for the office of menstruation. Yet, even under 
 such circumstances, the womb has been found quite natural as to its 
 conformation, but it often, in that case, communicates externally by 
 an unusual aperture, and opens by a sort of unnatural vagina into 
 the bladder, IT or into the urethra,** oi; the rectum, tt or even opens 
 on the anterior surface of the abdomen.ff 
 
 These unnatural openings of the vagina, which are of exceedingly 
 rare occurrence, almost always coincide with an obturation of the 
 anterior part of the canal. 
 
 As these deformities do not compromise the existence nor even the 
 health of the subjects of them, they remain unknown until the age of 
 puberty ; that is to say, until the menstrual fluid, escaping per anum, 
 or by the meatus urinarius makes manifest the unnatural disposition 
 of the parts. 
 
 If, in the case of a total absence of the uterus, the mucous mem- 
 brane of the bladder becomes the seat of a sanguine evacuation, 
 vicarious of the menses, it would not be easy to ascertain that the 
 blood is furnished by the bladder and not by the womb itself, whose 
 absence it would be then a difficult matter to pronounce upon. In- 
 asmuch, however, as all these anomalous conditions are beyond the 
 reach of the resources of the art, we shall close our observations upon 
 them at this point. 
 
 [I subjoin an interesting letter, that I have received from Professor Mat- 
 ter, and which needs no comment. 
 
 October 4, 1844. 
 
 “In compliance with your request, I send a brief notice of the case of 
 “ Imperforate Anus,” of which you spoke the other day. About the last 
 of April, 1844, I was requested by Dr. Jewell to visit, in consultation, 
 the female infant (two weeks old) of one of his patients. On examina- 
 tion, the following condition of things was discovered : — The rectum ter- 
 
 * De Sedibus et Causis Morb., epist. 46. 
 
 -j- Repert. Anat. Pathol., t. v. p. 90. 
 
 t De Utero Defic. apud Schlegel, t. i. p. 259. Mem. of Berlin, 1774. Jour, des 
 Savants, 1777. 
 
 § Traite des Mai. Chirurg., t. x. p. 422. 
 
 H Morgag. loc. cit. epist., 11\ 12. Dupuytren, Joe. cit. Boyer, loc. cit. p. 423. t. x. 
 Caillot, Mem. de la Soc. Med. d’Emulation, t. ii. 470. 
 
 1 Boyer, loc. cit. p. 408. 
 
 ** Madame Boivin and M. Duges, Traitb des Mai. de l’Uterus, t. i. p. 273. 
 
 f j- Barbaut Cours d’Accouch., p. 59. Orfila, Med. Legale, t. i. p. 150. 
 
 tt Morgagni, loc. cit. epist. 67. p. 7. Dr. VVaille cites from Huxmann, (Opusc. 
 Phys. Medic, t. iii. p. 3,) the case of a female, 23 years of age, whose meatus urina- 
 
ABSENCE OF THE VAGINA, ETC. 
 
 117 
 
 minated in a cul-de-sac, which extended to within three or four lines of 
 the natural position of the orifice of the gut, which spot was occupied by 
 dense cellular tissue and common integument, and no trace of the anal 
 opening could be distinguished. We were told that the child was in the 
 habit of passing its feces through the vagina, and that each evacuation was 
 attended with violent efforts', while the fecal matter was moulded into small 
 threads. Separating the labia, an opening about the size of a small duck- 
 shot was discovered just within the fourchette, and above it, a well-formed 
 hymen. Through this opening, a probe was readily passed into the rectum, 
 and also through the hymen into the vagina, and both canals appeared per- 
 fectly normal, with the exception, of course, of the defect already ascribed. 
 The indication was obvious, and I at once proposed the following operation: 
 With the view of establishing a proper channel for the feces, and, at the 
 same time, dispose the orifice between the rectum and vagina to contract 
 and thus heal. Passing a small grooved director from the vagina into the 
 rectum, I forced out the tissues forming its lower extremity, and then thrust 
 a trocar down to the director and directly through the spot usually occupied 
 by the natural orifice of the intestine. Withdrawing both instruments, I 
 next, with a probe-pointed bistoury, enlarged the opening made by the 
 trocar, and, as soon as this was accomplished, the child passed an immense 
 quantity of fecal matter, apparently with much relief. A sponge-tent was 
 then introduced into the rectum, and the nurse instructed as to its objects 
 and use. 
 
 “Being on the eve of sailing for Europe, I did not see the child again, 
 but suggested the continued use of the sponge-tent, until the opening made 
 had lost all disposition to contraction ; and, after this, if the orifice in the 
 vagina did not heal of its own accord, in consequence of the natural channel 
 for the feces being established, that it should be touched occasionally with 
 the argent, nitrat. 
 
 “ I did not deem this a case in which the operation of Amussat was advisa- 
 ble, nor was it one that indicated excision of the tissues occupying the 
 position of the anal orifice, nor could any operation upon the fistulous open- 
 ing between the rectum and vagina be with propriety proposed. I preferred 
 the trocar to a sharp-pointed bistoury , for performing the operation, for the 
 simple reason that wounds made with the former instrument are much less 
 prone to heal by the first intention than when the latter is employed ; and 
 
 rius opened upon the middle of the abdomen, a little below the navel, by two distinct 
 orifices, from which the urine was constantly escaping guttatim. A littlfi lower 
 down the orifice of the vagina was seen. Still lower down was seen a transverse 
 orifice, scarcely admitting the introduction of the little finger, which was separated 
 from the vagina by a thick membrane, and communicating with the rectum, whose 
 termination was quite natural as to its situation. This woman, whose menses were 
 perfectly regular, had married a robust sailor, by whom she had a child. The surgeon, 
 Bonnet, who had charge of her in the labour, was unable to deliver her until he had 
 made an incision into the membrane that separated the vagina from the abnormal 
 anus. Both the child and its mother were saved. 
 
118 
 
 ABSENCE OF THE WOMB. 
 
 as it was one object of course to prevent the close of the gut again, an event 
 by no means uncommon, when a simple conical incision is made with a bis- 
 toury, I adopted the plan of operating described. I have not seen the child 
 since my return, but understand from Dr. Jewell that there is some con- 
 traction of the orifice, and that, in all probability, it will be necessary again 
 to divide its margins.” — M.] 
 
 ABSENCE OF THE WOMB AND MEANS BY WHICH IT CAN BE 
 ASCERTAINED. 
 
 The womb may be absent coincidently with absence of the vagina, 
 as in the instances reported by Engel,* Morgagni,! Baudelocque,f 
 Dupuytren,§ Boyer, || and Caillot ;1T the absence of the uterus may 
 also consist with a perfectly natural appearance of the external geni- 
 talia : Colombus,** Lieutaud,tt and other authors have noticed such 
 cases of uterine anomaly. 
 
 For the purpose of ascertaining that the uterus is absent, or that it 
 exists only in a rudimental state, several authors, and among others 
 we may mention Plenck,f± Morgagni, §§ and Fodere,|||| have pointed 
 out the deficiency of the breasts and of the menses, and the obturation 
 of the vagina at its superior extremity; but MetzgerlFIF very properly 
 remarks that these signs, which are very far from being always present 
 in the cases, afford only presumptive evidence, which is not sufficient 
 for the establishment of a positive diagnosis. In fact the normal 
 development of the external genital organs and their appendages may 
 the more readily coincide with the absence of the rudimental state of 
 the womb, inasmuch as it often happens as observed by Engel*** and 
 Dupuytrenttt that the development of the ovaria is quite complete in 
 these cases ; and these organs which are in the female what the testes 
 are in the male, especially constitute the sex of the woman. Besides, 
 Engel, Dupuytren and Professor Stoltz have found the womb absent 
 in women, or in a rudimental condition, when the breasts were per- 
 fectly well formed; we have, ourselves seen a woman, in good health, 
 and the mother of a child, although she had never been regular ; 
 cases of the same nature have fallen under the notice of Zacchias,fff 
 Fodere§§§ and several other medico-legal writers. Indeed, the obtu- 
 ration of the superior extremity of the vagina is not to be regarded 
 
 * De Utero Deficiente apud Schlegel, t. i. p. 239. 
 
 j- Lettre46, n. 11 and 12. 
 
 * Art. des Accouch. 3d edit. t. i. chap. 3. p. 168. 
 
 § Repertoire d’Anat. Pathol, t. v. p. 99. 
 
 || Traite des Malad. Chirurg., t. x. p. 423. 
 
 T[ Mem. de la Soc. Med. d’Emulation, t. ii. p. 470. 
 
 ** Da re Anatomica, lib. xv. p. 495. 
 
 -ff Histoire Anat. Med., t. ii. p. 343. 
 
 Element. Med. Chirurg. Forensis, i. p. 3. 
 
 §§ Morgagni, Lettre 46, No. 13 and 20. 
 
 HU Fodere, Med. Legale, 2d edit. t. i. p. 393. 
 
 HIT Principes de Med. Legale, traduitdel’AUemandparleDocteur J. J.Ballard,p. 278. 
 
 *** De Utero Deficiente, t. i. p. 239. 
 
 Iff Repertoire d’Anat, Pathol., t. v. p. 99. 
 
 *** Qusestiones Med. Leg., lib. iii. tit. i. queest. 2. 
 
 §§§ Med. Legale, t. i.p. 395, 2d edit. 
 
ABSENCE OF THE WOMB. 
 
 119 
 
 as a sign more to be depended on than the others above mentioned, 
 since Haller,* Morgagni, t and NicolonJ have spoken of women pos- 
 sessing the womb itself though deprived of the vagina. 
 
 The best means of making the diagnosis consists in introducing a 
 finger into the rectum and a sound into the bladder, which should be 
 directed so as to turn the convex part of the instrument towards the 
 bowel. By making pressure in this way upon the fundus of the 
 bladder, it would be an easy matter to determine whether any inter- 
 mediate body could be found between the bladder and the intestine ; 
 and if any one should be found, whether it presented the character of 
 the well-formed womb or not. Professor Stoltz recommends, espe- 
 cially in lean women, that to the above mode of exploration, we should 
 conjoin that of palpation above the pubis. This should be done so 
 as to make the fingers pressing down the hypogaster,meet the fingers 
 of the other hand introduced into the vagina. It must be confessed, 
 however, that good modes of exploration are not in every case prac- 
 ticable, and that where they can be used, they may still, in some 
 instances, leave the physician in a state of doubt as to the exact degree 
 of the uterine development. 
 
 £The remark made in a preceding paragraph, by the author, as to the 
 woman who was healthy, and a mother, although she had never been regular, 
 is, I fear, calculated to mislead in an important step. I mean the marriage of 
 persons who have never been the subjects of menstruation. Notwithstanding 
 the case in question, I should esteem it a duty to recommend that marriage 
 should be postponed until after the eruption of the menses; or at least until 
 a competent inquiry should be made as to the fitness of the subject to enter 
 into the marriage contract. The following case is sufficient to confirm this 
 opinion, and I cite it the more willingly as showing not only that coinci- 
 dently with absence of the womb, there may be well-formed mammae and 
 external genitalia, but the most perfect condition of the erotic principle. I 
 cite the case from the Philad. Prac. of Med., second edit., p. 67. Mrs. 
 
 aged twenty-two and a half years, was married to her present husband 
 
 more than two years ago. She is of middling stature, of a fair complexion, 
 and presents all the exterior appearances of a person in perfect health. She 
 is not fat, but has a certain embonpoint, a good figure, and a very feminine 
 and most agreeable expression of countenance. She is, indeed, a handsome 
 woman. She has never menstruated ; nor has she suffered pain or any severe 
 attack of disease; says that, as she did not menstruate at the proper period, 
 medical advice was sought, and followed in the treatment of the case. 
 That treatment proved unsuccessful, and she was married , with the expecta- 
 tion (of her friends) that the marriage would be followed by the eruption of the 
 catamenia. The mammae were, at the period of the marriage, well developed, 
 and the pudendum amply supplied with hair; indeed, all the phenomena of 
 
 * Disp. Anatom, ab Hallero, collect, t. v. p. 327. 
 
 t Morgagni, Lettre 47. p. 256. 
 
 I Theses de la Faculie de Strasbourg, annee 1808. 
 
120 
 
 ABSENCE OF THE WOMB. 
 
 a perfect development of the sexual system were present except the menstrual 
 office. 
 
 The husband found, however, that some unknown cause acted as an 
 impediment to the congress, and after more than two years of concealment, 
 he consulted me upon the subject. * 
 
 An opportunity being allowed to me of making a full investigation in the 
 presence of her mother, I found the external organs perfectly formed ; the 
 mons large ; the labia and nymphae as well as the clitoris perfect, and the os 
 magnum of a natural appearance; but the vagina was a mere cul-de-sac, not 
 more than two inches, and probably less than that, in length. Upon pressing 
 the point of the finger against the bottom of the cul-de-sac, it seemed to have 
 no connection with any part above it. 
 
 I requested the lady to lie upon her back, and introducing an index finger 
 as far as possible into the rectum, I explored with it the excavation of the 
 pelvis, in order to discover any tumour, or any organ that might be contained 
 within the cavity ; but as all the tissues were ductile and very yielding, I began 
 to suspect that there might be no womb at all in the case. Therefore, laying 
 the fingers of the left hand upon the lowest part of the hypogaster, and 
 pressing them firmly towards the finger that was used in exploring the 
 internal parts, I found that they could be brought so near to each other as to 
 make it perfectly clear that there was no womb in the case, or I must have 
 felt it, so near was the approximation of the finger of the right to those of 
 the left hand. Having, by the most careful exploration, in this manner, 
 discovered the unfortunate state of the young lady, I felt obliged, in a consci- 
 entious discharge of duty, to tell her the whole truth, which I did in the best 
 way I could ; and yet, as may be readily supposed, the knowledge of her 
 situation was accompanied with all the appearance of that violent distress 
 and agitation that might naturally flow from such unhappy circumstances. 
 
 The aphrodisiac sense in this lady is very stron g, which might well be 
 the case where the ovaria are fully developed, even though the uterus had 
 never been evolved in her constitution. 
 
 I was deeply impressed myself with the melancholy fate of two estimable 
 persons who would never have placed themselves in so unhappy a condition, 
 if, by a proper exploration before the marriage, the real state of things could 
 have been discovered. The case serves to show how improper it is to permit 
 the rites of marriage to be solemnized for persons who do not possess all. the 
 attributes properly belonging to the sexes. I do not contend that every case 
 of failure to menstruate at the proper time is indicative of the necessity for 
 exploration by the touch : but I think that no case of extraordinary protraction 
 of an emansio mensium, and especially one where any question of courtship 
 or marriage is likely to arise, should be allowed to go on without the acquire- 
 ment by the medical adviser of a true and perfect knowledge of the facts as 
 to the organization of the parts. — M.] 
 
LESIONS OF SITUATION. 
 
 121 
 
 SECOND SECTION. 
 
 CHAPTER VI. 
 
 LESIONS OF SITUATION. 
 
 Of displacements and deviations of the genitourinary organs in the female. 
 
 The womb, in its natural state, being but loosely supported within 
 the pelvis by means of its ligaments, is liable to a variety of displace- 
 ments and deviations which affect its relations with the other portions 
 of the genital apparatus, or with the viscera contained in the cavity 
 of the abdomen. 
 
 Most of the lesions of situation that occur to the female genito- 
 urinary organs have been noticed since the remotest ages, for Hippo- 
 crates ,* Hristotle, t Hretseus, Hspasia, Soranus, Hntilhis and On- 
 basins mention them in their works, some fragments f of which have 
 been communicated to our times by He tilts. 
 
 Hippocrates , who regarded a state of absolute celibacy as one of the 
 principal causes of derangement of the catamenia, and, consequently, 
 of engorgement of the womb, has said (and in that he differs from 
 all modern authors), that women in the conjugal state, and in whom 
 the womb does not continue always void, are less subject than virgins 
 to Uterine disorders: Hv yap ix/xeteat uatv at /xtjtgai artQTiayvfiJftf xat xoiT. t'a 
 [xr] xtvwT!at oi; pvjiditi a Otgetyovtal. Tort' 5 ovv attiov ytvsfat coot's avtaa %v/x[xvsiv 
 
 oia /xrj jiay vsvoixtvrjs t^j ywaixo$ ( Hipp . Op. de Naturci Mitlier.) In this 
 last respect the father of medicine was in error, for the displacement 
 of the sexual organs are much more rare in virgins and sterile women 
 than in those who are married and who have children. 
 
 Where the lesions of situation of the genitals are slight, they 
 scarcely occasion inconvenience to the patient ; but where they are 
 considerable and permanent, they are the more worthy of attention, 
 as likely to result in inconvenience or accidents, that are beyond the 
 reach of medicine. Although too great a degree of mobility of the 
 womb is attended with numerous bad effects, its immobility, if to a 
 considerable degree, becomes also a disturbing cause, as to the sur- 
 rounding parts, and may prevent the womb itself from fulfilling some 
 of its appropriate functions, such as pregnancy and labour, which 
 require considerable changes of its situation. 
 
 Among the lesions of position to be treated of in this section, we 
 place — 
 
 1. Hysteroptosis or prolapsion of the' womb. 
 
 2. Anteversion and retroversion. 
 
 * De Natura Mulierum. f Historia Anomal., lib. vii. cap. 2. 
 
 * Aetius Tetrabib. iv. serm. 4. cap. 76 and 77. 
 
122 
 
 PROLAPSUS UTERI. 
 
 3. Anteflexion and retroflexion. 
 
 4. Obliquity. 
 
 5. Inversion. 
 
 6. Elevation of the womb. 
 
 7. Immobility. 
 
 8. Various hernias of the womb. 
 
 9. Hernias of the ovaries. 
 
 10. Vaginal cystocele. 
 
 11. Vaginal enterocele. 
 
 12. Vulvar enterocele and cystocele. 
 
 13.. Descent of the internal membrane of the vagina, and invagi- 
 nation. 
 
 / 
 
 OF HYSTEROPTOSIS. 
 
 Hysteroptosis * or falling of the womb, is the displacement of the 
 viscus downwards ; and it may be complete or incomplete. 
 
 In the former case the organ escapes entirely from the pelvis, and 
 may be seen completely outside of the vulva ; in the latter case, on 
 the contrary, it projects more or less considerably into the vagina, 
 but does not descend below the inferior strait. 
 
 Prolapsion of the womb may take place not only during preg- 
 nancy and after delivery, but also while the womb is non gravid, for 
 it has been met with even in virgins.t 
 
 The disease in question, which M. Lisfranc correctly regards as 
 being generally produced by engorgement of the womb, has been 
 divided, by most of the writers on the subject, into three degrees or 
 varieties, which we shall proceed to describe. 
 
 In the first degree , which is merely a depression or incipient pro- 
 lapsion, the womb settles down into the middle of the vagina, which 
 it enlarges in order to make a lodgment for itself therein. In this 
 kind of displacement, which is but a slight affection, but that ought 
 to be speedily attended to, the patients complain of dull pain in the 
 loins and of a dragging sensation about the groins ; they also com- 
 plain of a sense of weight at the fundament, and a pressure that 
 becomes more painful by long standing on the feet, or by too long a 
 walk. 
 
 In the operation of Touching, the neck of the womb is soon felt, 
 and the os tincse is found to be resting upon the posterior wall of the 
 vagina, which is thus completely obturated, and two-thirds of its 
 upper portion are inverted like a finger of a glove turned partly in- 
 side out. In its new situation, the womb, as it follows the direction 
 of the axis of the inferior strait, acquires a position totally different 
 from that which it ordinarily assumes. 
 
 The unnatural tumour that projects from the entrance of the 
 
 * From the Greek v't t ( a uterus , *rSnt falling. 
 
 f Displacements of the womb in the virgin state are rarely met with, because of the 
 small size and lightness of the organ, and probably, also, because of the constricted 
 condition of the vagina and surrounding parts. Mauriceau, Saviard, Monro and 
 De Graaf are the only authors who have reported cases of complete prolapsion of the 
 womb in the virgin state. 
 
PROLAPSUS UTERI. 
 
 123 
 
 vagina may be easily raised upwards by the finger, but it falls down 
 again as soon as the support is withdrawn, unless the womb has 
 contracted new 'adhesions with the vaginal parietes. The nature of 
 the tumour is readily distinguished by the presence of the os tineas 
 and the neck of the uterus, whose circumference is surrounded by a 
 sort of cushion composed of the vaginal walls. By placing one 
 hand on the hypogastrium and touching with the index of the other, 
 we are enabled, except when the person is very fat, which is not com- 
 mon in these cases, to perceive the void left in the upper part of the 
 pelvis, by the descent* of the womb ; and in the same way we may 
 discriminate between the prolapsion of the womb, and the elongation 
 of the cervix, which are sometimes very considerable. 
 
 Most of the symptoms of prolapsus in the second stage are pro- 
 duced by the pressure of the womb upon the surrounding parts, espe- 
 cially the bladder and rectum, or by the stretching of the uterine 
 ligaments. This is put beyond question by the fact that all the 
 symptoms are diminished by rest, and particularly by rest in the hori- 
 zontal posture, whereas their violence is redoubled by standing and 
 walking. Where the displacement has been gradually produced, the 
 symptoms attending it are less severe than where it takes place sud- 
 denly ; where it is suddenly produced, it is frequently accompanied 
 with long, protracted faintings, violent floodings, severe pain in the 
 pelvis, vomiting, and sometimes even an intense attack of peritonitis. 
 But, on the contrary, where the displacement takes place slowly, these 
 phenomena are rarely observed, because the organs, having slowly 
 abandoned their natural situation, become, in a measure, accustomed 
 to the unnatural situation they have assumed. 
 
 [Seeing that the womb is attached to the rectum solely by the recto- 
 vaginal septum, and to the bladder by the vesico and urethro-vaginal septum, 
 it is manifest that these two septa furnish the sole means of its vertical sup- 
 port; while it is true that the parts themselves depend upon other attach- 
 ments for their own firmness and ability to sustain the womb. I should 
 think that no one would attribute to the ligamenta lata any other mechanical 
 function in the case than that of acting as a stay, on the right and the left 
 sides, to the womb — a stay by means of which it is kept in place while the 
 woman lies on the right side or on the left side. The ligamenta rotunda, 
 which, coming off from the angles of the womb, pass out through the 
 abdominal canals to be inserted on the sides of the pudendum, must be re- 
 garded also as merely a stay, one for each side, by whose agency it is that 
 the womb is not overset or retroverted every time the bladder becomes filled 
 with urine. These ligamenta rotunda do not sustain the womb vertically at 
 all, but act merely to restrain its tendency to retroflexion and retroversion. 
 
 Such being the anatomical facts in the case, why is it that falling of the 
 womb is so common a malady, and on what does the disposition to that 
 malady essentially depend ? 
 
 It has long since seemed to me, that the writers upon prolapsion have 
 lost sight of one most important element in the pathology of the case, and 
 
124 
 
 PROLAPSUS UTERI. 
 
 that is, the state of the muscles within the pelvis. They ought to have 
 observed and remarked upon this important physiological law, viz : that the 
 diaphragm has an antagonist force in the floor of the pelvis, which is partly 
 muscular, and that where that muscular floor retains, together with the other 
 tissues of the perineum, its full power and energy, there can be no prolapsion 
 of the womb. The repeated distensions and dilatations to which the floor 
 of the pelvis is subjected in labour, cannot but tend to debilitate it and over- 
 come its power of resisting the antagonization of the diaphragm and abdo- 
 minal muscles, and as the parts that sustain the womb depend for their own 
 support on the firmness of the tissues composing the pelvie floor, it is clear 
 that the womb may go down with them and it. But let it be observed that 
 the pelvic floor itself is dependent, not merely upon its textural contractility, 
 but on the muscular power of the levator ani muscles — muscles which 
 relax in labour, and in defecation, by a spontaneous power of relaxation, in 
 order to admit of the descent and protrusion of the pelvic floor in question, 
 and which is restored to its proper level, and drawn upwards, and kept there 
 by the sole power of the levator muscles. Hence it is, I think, clear, both 
 by reasoning and by observing clinically the facts in the case, that the weak- 
 ness and loss of power of the levator muscles have much to do with the 
 pathology of prolapsus uteri. 
 
 It will not, I suppose, have escaped the observation of all persons of ex- 
 perience, that in bad cases of prolapsus, the perineum is thin, feeble in its 
 tension, and that the whole perineum is at a lower level than in those who 
 do not labour under prolapsus. 
 
 It is essential to remark that weakness and prolapsion of the womb are apt 
 to follow bad labours, and to be coincident with the signs of general debility 
 of the muscular apparatus of the whole body. It is not, indeed, met with, 
 except very rarely, in the strong, active, muscular subject, and that even in 
 these subjects, the prolapsion is rather a state of immobility or fixedness of 
 the womb at a low level, than a real prolapsus. 
 
 I fully agree with M. Colombat in his general statement and rationale of the 
 symptoms of our case, but I would call attention to the relations existing 
 betwixt the sacral and hypogastric plexuses of nerves and the renal and 
 solar*plexuses, and indeed as extending to the whole splanchnic system, for 
 an explanation of the extraordinary and complicated sympathies that are 
 awakened in prolapsion of the uterus. M. Colombat has pointed out, as 
 one of the complications of prolapsus, the induction of intense peritonitis. 
 I have never met with such a complication in a long-continued and very 
 extensive range of practice ; but I have met with many cases simulating 
 peritonitis so closely as to render the diagnosis very difficult indeed. I refer 
 to the cases described in the Pliilad. Pract ., at p. 141, and seq. The same 
 kind of observations havo been made by W. Maunsell, in his Dublin Prac- 
 tice of Midwifery , and, so far as I know, by no other authors. I shall 
 reserve for a future page the observations I have to make on the treatment 
 of prolapsus uteri. — M.] 
 
PROLAPSUS UTERI. 
 
 125 
 
 As the phenomena that accompany falling of the womb in the 
 second degree are not always the same, and may vary according as 
 the distension of the uterine ligaments and the pressure of the womb 
 upon the bladder and rectum are greater or less, we shall point out 
 the symptoms most commonly met with. 
 
 The patient cannot, without difficulty, continue either standing or 
 sitting, and finds comfort only in the horizontal position. She feels 
 pain in the groins, the loins and the hypogastric region* with a sense 
 of weight about the fundament, the perineum and vulva; and, 
 lastly, she has a distinct sense of the presence of a large tumour, 
 which, upon the slightest effort, seems as if it would escape at the 
 vulva. Like womdn in labour, she is liable to inappetency, nausea, 
 and even vomiting, which all proceed from the sympathetic connec- 
 tion of the stomach with the womb. To these symptoms must be 
 added those of constipation, of dysuria, and even of ischuria, arising 
 from the pressure of the tumour upon the bladder and rectum, a 
 pressure that is greater and greater as the tumour descends lower and 
 lower into the vagina. The irritation of the womb, produced by 
 this unnatural situation, and probably, also, the obstruction thence 
 arising as to its circulation, often determine an attack of inflamma- 
 tion, accompanied by intense redness, and greater or less swelling 
 of the uterus. 
 
 Incomplete descent of the womb frequently presents to the medical 
 attendant a degree of obscurity that it is quite impossible to dissipate, 
 except by means of the Touchy properly performed, and in the man- 
 ner to be described. In the first place, the woman must be examined 
 in a standing posture, because the prolapsion is then greater than it 
 is in the horizontal position, in which it may even wholly disappear. 
 If the patient is a late riser, the operation should be deferred for 
 several hours, and then it should not be done until after the bowels 
 have been evacuated, as well as the bladder, for the womb is always 
 found to be lower when these parts are distended with their contents. 
 By attending to all these points, and recollecting what we shall 
 further add on the subject, we may very readily ascertain the exist- 
 ence of an incomplete descent, and distinguish between it and the 
 other affections with which it is often confounded. 
 
 Among the disorders that give rise to these mistakes in diagnosis, 
 may be mentioned elongation of the cervix uteri, fungous tumours 
 of the cervix, and particularly polypus of the womb, passing into 
 the vagina through the mouth of the womb. The records of the 
 science show cases in which the surgeon, supposing himself about to 
 extirpate a polypus proceeding from the cavity, or growing from the 
 neck of the womb, has completely extirpated the womb itself, which 
 was affected with prolapsus in the second stage. 
 
 Such a mistake will be avoided by keeping in mind this principle, 
 that tumours composed of the procident uterus are harder and more 
 sensitive than polypus, and, besides, that the os tincse is always to 
 be found at the inferior extremity of the mass, and which cannot be 
 confounded with any accidental opening that might happen to exist 
 upon the surface of a polypus, inasmuch as a probe could not be 
 
126 
 
 PROLAPSUS UTERI. 
 
 made to penetrate so deeply into it as into the uterine cavity. Fur- 
 thermore, the tumour formed by a polypus is always largest at its 
 lower extremity, while that constituted by a prolapsed womb is a 
 cone with the base uppermost, and is consequently smallest below. 
 
 Finally, in order to dispel every remaining doubt from the mind of 
 the practitioner, he should remember that polypus of the womb is 
 irreducible, and that any attempt to reduce it causes insufferable pain. 
 Prolapsus uteri in the second degree is, on the contrary, easily reduci- 
 ble, while its reduction gives great relief to the patient. 
 
 [I beg leave lo caution the inexperienced reader against confiding implicitly 
 in this diagnostic statement. I have met with several samples of polypus 
 uteri, that were occasionally within reach, and on other occasions retired 
 beyond the reach of the index. It is quite reasonable to suppose that a pedi- 
 culated polypus attached to the fundus, should sometimes be forced partially 
 through the os uteri under augmented muscular intolerance of its presence, 
 and afterwards withdrawn into the cavity, on the cessation of the muscular 
 spasm. — M.] 
 
 An incomplete descent of the womb does not prevent conception. 
 We had charge of the case of an itinerant fish-woman, who became 
 pregnant and was safely delivered, notwithstanding she had a pro- 
 lapsus in which the tumour projected an inch beyond the labia. 
 While she was lying down, the womb retreated as much as eighteen 
 or twenty lines within the vagina. Impregnation might possibly 
 take place even in a case of almost complete procidentia, but in such 
 a case the coitus must take place directly within the uterus itself. 
 
 [This is a statement that I look upon as wholly incredible. — M.] 
 
 Choppart cites, on the authority of Marignes, the instance of a 
 female, who had, from the age of fourteen, been troubled with a pro- 
 lapsus that slowly increased. The husband of this girl had no 
 children by her until, after a considerable length of time, he dilated 
 the orifice of the womb, and consummated the act of generation in 
 its very cavity. The pregnancy was in all respects natural, but at 
 the time of her confinement, they were compelled, on account of the 
 rigidity of the os uteri, to make two incisions into it on opposite sides ; 
 after which the child was born dead, and the mother recovered with- 
 out difficulty. 
 
 [Such relations as the above require a stronger confirmation before they 
 should be deemed credible. They are necessarily hypothetical as to the 
 important steps of the doctrine. — M.] 
 
 Several authors, among whom I may mention Haller* (quoting 
 Kalm,) Paul Portalf and Nauche,f have reported instances of prolap- 
 sus uteri occurring during pregnancy; Mauriceau,§ Paul Portal || and 
 
 * Disputat. Chirurg. Select. Haller, t. iii. p. 587. 
 
 f La Prat.des Accouch. Sout. d’un Grand Nombre, d’Observations, Observ. x. 
 
 * Malad. propres aux Femmes, t. i. p. 85. 
 
 § Obs. sur la Grossesse et 1’ Accouch., Obs vi. 
 
 I Loc. citat. Observ. x. 
 
PROLAPSUS UTERI. 
 
 127 
 
 Brodmann* have noticed cases in which incomplete and reducible hys- 
 teroptosis, after having disappeared in the first months of pregnancy, 
 has returned towards the conclusion of it, and even during labour itself. 
 In the cases by Garint and Ducreux,f the prolapsus seems to have 
 taken place without any antecedent falling of the womb, and at the 
 very time of the parturient efforts. In some instances, the womb has 
 remained until the end of the labour, partly within and partly outside 
 of the pelvic cavity. Wagner§ and Choppart|| each relate an instance 
 of this kind. Finally, the prolapsion has, in some examples, been 
 spontaneously reduced at the approach of labour ; as in the cases 
 published by Loder,1T Saviard,** Portaltt and Choppart. 
 
 Whenever an incomplete hysteroptosis becomes complete, then 
 all the symptoms caused by the compression of the bladder and rec- 
 tum immediately diminish and the evacuation of urine, and by stool 
 take place without any difficulty. However, while the symptoms 
 partly disappear, they are succeeded by increased intensity of the 
 symptoms resulting from the stretching and distension of the perito- 
 neal ligaments, and by numerous other symptoms which we shall 
 detail in speaking of complete falling, or procidentia of the womb. 
 
 In this third degree of hysteroptosis, the entire body of the womb 
 has passed out beyond the vulva, and the whole organ, which is seen 
 movable and suspended betwixt the woman’s thighs, has dragged 
 down in its fall not only the vagina that is inverted, but also the uterine 
 appendages, the bladder, and a portion of the rectum.ff The displace- 
 ment of these organs soon forms a cul-de-sac filled with the convolu- 
 tions of the small intestines giving rise to another tumour of greater 
 or less magnitude, which prevents the reduction of the womb itself. 
 
 The distance to which the womb projects forth, is equal, in some 
 samples, to 6, 8, or even 10 inches, §§ and the tumour is either strangu- 
 lated, oval, or globose; but most commonly conoidal, and fills up the 
 whole orifice of the vulva whose labia seem elongated by the presence 
 of the foreign body which keeps them always disparted. 
 
 Whatsoever the form of the procident womb, the cervix uteri is 
 always to be seen with its orifice very much contracted, |||| rounded or 
 semilunar, and generally discharging a mucous substance, and even 
 the mensual fluid, at the catamenial periods. 
 
 * Ephem. decur. ii. an 3 p. 368. + Journal de Med., t. iv. p. 165. 
 
 * Mem. de l’Acad. de Chirurg., t. viii. p. 493. 
 
 § Biblioth. Med., t. xiii. p. 114. 
 
 || Traite des Mai. des Voies Urinaires, t. ii. p. 73. 
 
 1 Jour, fur die Chirurgie, vii. p. 13. 
 
 ** Mem. de l’Acad. de Chirurg., t. iii. et Observ. Chirurgicales. 
 
 ff Journal de Med. xlv. 
 
 The autopsies and cases published by Kerckriug (spicileg. Anat.contin observ. 
 rariorum) — Boehmer, (in Disput. Chir. Haller, t. iii. 557) — Kalm, (ed. pag. 588) — 
 Ruysch (Obs. Anat. viii) — 1. Cloquet , (Theses de Concours, Paris, 1831,) — prove con- 
 clusively that the inverted vagina dragged down by the womb, contains, within the 
 sort of cul-de-sac thus formed, a portion or the whole of the adjoining organs. 
 
 §§ Mauriceau,Saviard, Ruysch and Horn, give cases of complete prolapsus, in which 
 the tumour descended to the middle of the thighs. 
 
 fl|| Boehmer, Disp. Chir. Haller, t. iii. p. 558, says, Orificium uteri ita angustum, ut 
 vix ac ne vix quidem, acu in cavtatem uteri peuetrare potuerimus. 
 
12S 
 
 PROLAPSUS UTERI. 
 
 It sometimes happens that the womb thus displaced, becomes 
 affected with violent pain, and gives rise to copious haemorrhage; the 
 tumour that it constitutes from being always bathed with urine and 
 irritated by the constant friction of the thighs and the dress, becomes 
 inflamed, swollen, excoriated, and often, indeed, wholly or partially 
 gangrenous. It is found, on other occasions, that the unreduced 
 tumour becomes a chronic disease; and the internal membrane of the 
 vagina that lines it, from being exposed to continual friction and to 
 the air, assumes the appearance of the skin ; so that the womb has 
 been actually mistaken for the male organ; and the woman so situ- 
 ated, has been looked upon as an hermaphrodite. Saviard, whose 
 inclinations led him to the collecting of the rarest and most interesting 
 cases in his art, has handed down among his cases as arranged by 
 Devaux, the history of a girl at Toulouse who passed for an her- 
 maphrodite, and who was merely the subject of a complete procidentia 
 uteri.'* The celebrated surgeon of Charles IX., the ingenious Am- 
 brose Pare, relates that a woman, in order to excite pity and procure 
 a more abundant alms, had simulated a procidentia uteri by means of 
 a bladder half filled with air and begrimed with blood which she 
 adjusted by means of a sponge attached to it and introduced within 
 the vagina. 
 
 The reason why prolapsus is so rare among virgins, and is indeed 
 hardly met with, except among women who have borne children, 
 and chiefly in such as have had repeated confinements is, that during 
 pregnancy the ligaments of the womb become considerably stretched, 
 and but slowly recover their natural condition subsequently to the 
 lying-in. By reflecting upon this, and by also recollecting that the 
 womb is much larger and heavier after a labour than it is in the non- 
 gravid state, we may comprehend why displacements of the womb 
 are so frequent, and so easy to be brought about, in the first days that 
 follow the child-birth, especially in women who have been delivered 
 whilst standing up, or who have risen too soon after their lying-in. 
 
 The predisposing causes of prolapsus uteri, are : Congenital ca- 
 paciousness, or brevity of the vagina ; a pelvis of excessive dimen- 
 sions, either actually, or from the want of a proper embonpoint; 
 reiterated pregnancy ; engorgement of the uterus ; scirrhous, fibrous 
 or steatomatous tumours formed upon the womb, or upon the mons 
 veneris, as in the case mentioned by Wagner ;t the abusus coitus, 
 chronic inflammation, and the natural or the accidental relaxation of 
 the peritoneal expansions, by which the womb is attached to the pel- 
 
 * This young fine girl named Marguerite Malaure, had been condemned by the 
 magistrates of Toulouse to wear the male dress; her sex was restored to her by 
 Saviard, who reduced the tumour that had given rise to this strange mistake; after 
 which she was enabled to dress herself in a female dress which she had been forbid- 
 den to wear. It is probable that this complete procidence of the womb was congenital, 
 for she said she /tad never known herself to be different^. Dr. Duval made a mistake 
 of the same sort, but still less excusable, for the woman who gave rise to it had pro- 
 lapsus only in the second degree. 
 
 f Biblioth. Med., t. xiii. p. 114. In Wagner's case, the womb had been depressed by 
 an enormous tumour on the mons veneris, and had yielded to an impulse communi- 
 cated from above downwards, of sufficient power to cause the uterus to yield, but 
 insufficient to sink the tumour along with it into the cavity of the pelvis. 
 
PROLAPSUS UTERI. 
 
 129 
 
 vis, to the rectum and to the bladder. Finally, a chronic and profuse 
 leucorrhosa, a lymphatic temperament, living in a low, damp situation, 
 and especially a sudden or habitual state of emaciation ; these pre- 
 dispose to prolapsus of the womb. 
 
 The occasional causes are not less numerous. Thus, these disor- 
 ders are most common among the inferior classes of the population, 
 in Avhich the women are obliged to be more upon their feet, walk, 
 more, and use violent exercise shortly after their confinement. Falls 
 upon the feet, upon the seat or on the hypogastrium ; pressure on the 
 lower belly by tight dresses or lacing ; violent efforts in raising of 
 burthens, or in carrying them for a long time resting against the 
 abdomen, as is the case with the itinerant saleswomen of Paris ; the 
 jolting of a carriage ; in a word, all motions requiring frequent and 
 powerful contractions of the diaphragm and abdominal muscles ; 
 such as straining at stool or in vomiting, in passing the urine, in 
 coughing, sneezing, singing, dancing, wrestling, leaping, riding on 
 horseback ; any of these may be occasional causes of the affection 
 under discussion. 
 
 Abortion ; violent labour pains, particularly in labours where the 
 woman stands on her feet; traction and imprudent manoeuvres in the 
 extraction of the child, or placenta ; the hurry that women are in to 
 sit up and walk about soon after parturition, and before the uterine 
 ligaments have had time to recover their firmness ; all these causes, 
 indeed, give rise to the various degrees of prolapsus uteri. 
 
 When left to nature alone, a falling of the womb may soon become 
 quite incurable, for its tendency always is to increase, and the chances 
 of success are always more unfavourable as the case is of longer date, 
 the descent greater, and the concomitant circumstances more disad- 
 vantageous. The sequelae of this disorder, even when complete, 
 might, perhaps, never compromise the life of the patient, were it not 
 for the complications that are often the effects as well as the causes 
 of the principal lesion ; complications that always aggravate the prog- 
 nosis, which of itself is bad enough. Thus, a descent and relaxation 
 of the vagina ; a deformity of the pelvis ; a dropsy ; a state of maras- 
 mus ; the presence of a scirrhus upon the cervix uteri, or of polypus 
 in the cavity of the womb, or of a foetus in utero ; a calculus in the 
 bladder, are so many complications changing the indications of treat- 
 ment, always to the disadvantage of the patient, and liable to become 
 fatal, not only by preventing the reduction of the tumour, but also 
 by necessitating certain operations and certain peculiar cares that 
 will soon require our attention. 
 
 In those unfortunate cases that are beyond the resources of medi- 
 cine, and where the physician is compelled to be a sad and impotent 
 spectator merely, there is nothing to be done beyond the suggestion 
 of measures of palliation, and feeble remedies, which, for the most 
 part, give but little relief. 
 
 The treatment of hysteroptosis offers two indications : the first is 
 to replace the organ in its natural position ; and the second is to pre- 
 vent the recurrence of the displacement. 
 
 For the most part, it is an easy matter to restore the womb to its 
 9 
 
130 
 
 PROLAPSUS UTERI. 
 
 natural position, where the prolapsus is in the first or second stage, 
 and unaccompanied with any complication. All that is necessary 
 for this purpose is to make the patient lie upon her back so as to 
 have the pelvis somewhat higher than the head, while the abdominal 
 muscles are allowed to be as much relaxed as possible. The womb 
 will then take its natural position, and the reduction be so much the 
 more readily effected, if, by the introduction of two of the fingers 
 into the vagina, we gently push the womb towards its proper place 
 in the cavity of the pelvis. 
 
 After the reduction, provided no symptoms of inflammation of the 
 organ are left, it is frequently found useful to prescribe, with a view 
 to the radical cure, the use of cold astringent injections, to be repeated 
 twice or thrice a day. They may consist of liquor plumbi acetas, or 
 a solution of one or two drachms of alum in a pint of water or of de- 
 coction of cinchona, or of the roots of the comfrey, bistort, tormentil, 
 pomegranate rind, or any other astringent substance. River bathing 
 in summer, and sulphurous douches and injections may be employed 
 at a later period, as means for consolidating the cure. 
 
 Generally speaking, as the simple depression of the womb or pro- 
 lapsus in the first stage produces but slight inconvenience, it hap- 
 pens that the natural but unreasonable delicacy of the female makes 
 her fearful of confiding her complaint to the medical attendant, pre- 
 ferring to leave in the hands of nature the care of a malady of whose 
 evil tendencies she is ignorant. But as the mischief has a tendency 
 to increase and extend, the malady becomes aggravated, the suffer- 
 ings of the patient increase daily, and a simple depression soon be- 
 comes a positive failing, and finally a complete procidentia. 
 
 There are women who conceal this disgusting and painful in- 
 firmity for years together, and even attain to an advanced age with- 
 out any very serious symptoms. But there are others in whom the 
 womb cannot be reduced, either in consequence of its having formed 
 adhesions, or from its containing within its cavity a foetus of several 
 months, or from other insurmountable obstacles, or such at least as 
 are connected with circumstances that may lead to the sudden death 
 of the patient. We shall shortly point out the course to be taken in 
 those rare and distressing cases in which all attempts at reduction 
 prove to be vain. 
 
 There is always much greater difficulty in effecting the reduction 
 of a complete hysteroptosis than of one in the first or second stage. 
 
 Where the womb has escaped completely from the vulva, it is 
 proper, before proceeding to the reposition, that the patient should 
 empty the bladder and rectum, either spontaneously or by means of 
 the catheter, and the common enema. Provided the uterine tumour, 
 as frequently happens, should be found painful and sore from the 
 action of the air, the urine, or the friction of the clothing, emollient 
 poultices ought to be applied to it, and the swelling should be re- 
 duced by general remedies, such as fomentations, baths, venesection, 
 dieting, diluent drinks, a mild regimen, laxatives, &c. Such mea- 
 sures as these are particularly indicated in chronic cases of falling of 
 the womb. 
 
PROLAPSUS UTERI. 
 
 131 
 
 After the parts have been brought into a condition more favoura- 
 ble for the reposition, the woman should be directed to lie down in a 
 position more inclined even than that recommended in incomplete 
 prolapsus: the surgeon, after having anointed his fingers as well as 
 the tumour itself with cerate or oil, should seize it with his right hand, 
 and, giving a few rotary movements, in a gentle manner, and then 
 elevating and depressing it by turns, should press it backwards into 
 the cavity of the pelvis, following the direction of the axis of the 
 inferior strait, meanwhile using the fingers of the left hand at the 
 labia to facilitate the return of the womb into the body. 
 
 As soon as the upper part of the womb, which is largest, has 
 passed within the vulva, the rest of the tumour, being smaller, rea- 
 dily follows to take its natural position in the body. 
 
 Should the size of the tumour, augmented by being in a state of 
 inflammation, by the thickening of its tissues, or by infiltration, seem, 
 notwithstanding the measures above recommended, to be so great as 
 to make its reduction appear too difficult, we ought to suspend our 
 efforts, and wait, in order to try new measures, to have recourse to 
 a prolonged rest in the horizontal posture, and to all the therapeuti- 
 cal aids calculated to combat the complications of the case. We 
 should not again attempt the reduction until some improvement, 
 some manifest diminution of the sensibility and size of the tumour 
 should invite to the operation. In endeavouring to restore the womb 
 to its natural situation, should we still meet with great difficulties, and 
 have greater reason to dread the induction of an inflammation more 
 dangerous than a permanent procidentia, it would be a duty to 
 renounce all such attempts, and remain content with a treatment 
 merely palliative. 
 
 A medical man ought not, however, lightly to renounce all hopes 
 of reducing a hysteroptosis, no matter how severe nor of what 
 old standing. Saviard succeeded in reducing Margaret Malaure’s, 
 which was congenital. Several other surgeons, as mentioned by 
 Sabatier,* and among them Mauriceau, Saviard, Horn and Leblanc, 
 were successful in the reduction of frighful cases of prolapsus, the 
 size of which had been first reduced by means of prolonged rest, 
 dieting, baths, bleeding, emollients, &c. Dr. Leveille and Dr. Bobe — 
 Moreau, ( Bull . de la Facullt de Med., 1815, No. 4,) — rendered pro- 
 lapsus of long standing reducible by means of pressure with a ban- 
 dage en doloire. However, let us remember the counsel already 
 given, not to insist upon attempts to reposit when too many obstacles 
 are met with. Improvident and ill-advised manoeuvres have brought 
 on fatal disease, such as acute peritonitis and metritis. ( Nouvell 
 Bibliot. Med., deuxieme annee, tom. iv. p. 215.) 
 
 After having made use of the preliminary treatment above recom- 
 mended, if reiterated attempts, vainly made, should render it evi- 
 dently impossible to restore the womb to its place, we must rest 
 
 * Sabatier, in the Mem. de l’Acad. de Chir., t. iii. p. 375, says that “there is no 
 case of procidentia of the womb that cannot be reposited, no matter how large it ma)- 
 be; but this talented practitioner admits that it is not always possible to keep it in 
 place after reposition.” 
 
132 
 
 PROLAPSUS UTERI. 
 
 content with giving due support to the tumour by means of a proper 
 suspensory, which should be anointed with cerate, in order to obviate 
 the evil effects of the friction of the material. 
 
 As a means of more perfectly obviating this inconvenience, we 
 have recommended and have made use of a bandage of oiled silk, 
 doubled, the surface of which, being smooth, produces less friction 
 than even the finest linen ; and the material is desirable, since it may 
 be cleansed several times a day, while its impermeability protects 
 the womb from the painful excoriations which the constant contact 
 of the urine tends to produce. 
 
 Should the procidentia take place at an advanced stage of preg- 
 nancy, the reduction of the womb ought, nevertheless, to be at- 
 tempted, and may be easily effected at an early stage, particularly if 
 the attempt be not long deferred. We have already advised that the 
 bladder and rectum should be emptied before the institution of any 
 attempts to reposit, and it ought not to be forgotten that the intro- 
 duction of the catheter is not always an easy matter, from the dis- 
 tortion of parts produced by the descent. In some of the cases, the 
 female catheter will not answer at all, and we must have recourse 
 to the male catheters, using the instrument with the concavity to- 
 wards the hvpogastrium. 
 
 Where pregnancy is already in an advanced state, the case of long 
 standing, and the reduction difficult, it would be the dictate of pru- 
 dence to abandon ail attempts that might prove hurtful either to 
 the mother or child :* in such cases, it is sufficient to give proper 
 support to the womb by means of such a suspensory as has been 
 mentioned, and make the patient observe the horizontal position, in 
 bed. When the pregnancy has reached its full term, the escape of 
 the foetus may be facilitated by gradually dilating the os uteri; and 
 the placenta should be removed by the introduction of the hand into 
 the womb, so as to take it, and not by pulling at the cord. 
 
 [I cannot avoid remarking upon this passage, that in the vast majority of 
 cases of parturition, the placenta is expelled from the womb by the sponta- 
 neous contraction of the organ, and that no very slight motive should be 
 allowed to operate on us as inducing us to force the womb for the delivery of 
 the placenta. I think the attendant should wait a proper length of time for 
 the spontaneous expulsion, as in a common healthful labour. When that 
 time has elapsed, he may properly carry his hand into the womb in search 
 of the after-birth. — M.] 
 
 After the birth of the child, the reposition may be the more easily 
 effected, as the womb has been suddenly reduced in size, and its 
 strong and reiterated contractions constringe its parietes. 
 
 Should the procidentia take place during the progress of a labour, 
 
 * Mauriceau (Obs.67 and 95) reduced one at the fourth or fifth month; and Giroud 
 likewise succeeded not more than ten days before the labour came on. (M. Duges 
 and Mad. Boivin.) M.Capuron (Mai. des Femmes, p. 301) has shown that the womb 
 may be irreducible after the first months of gestation, and that the uneasiness arising 
 from this irreducibility, may bring on abortion. 
 
THE PESSARY. 
 
 133 
 
 it would be equally dangerous as in the case above treated of, to 
 attempt its reduction ; but we should try to hasten the delivery of 
 the child by dilating the mouth of the womb, and by sustaining the 
 prolapsed organ. The extraction of the placenta ought to be done 
 as before recommended, that is to say, by introducing the hand into 
 the womb, and acting in the direction from the circumference to the 
 centre. When the child is born, the reposition may be effected with 
 little difficulty. 
 
 Before closing our remarks upon prolapsus in pregnant women, 
 we ought to state that it almost always occasions an attack of 
 suppression of urine, that may be relieved by passing up a finger 
 behind the symphysis pubis, and pushing back the womb so as to 
 take off the pressure from the neck of the bladder and the urethra. 
 It will be well to point out this mode of relief to patients so situated; 
 they can make use of it until the time arrives when the womb shall 
 have acquired magnitude sufficient to keep it above the brim, which 
 generally happens about the fourth or fifth month. 
 
 At whatsoever period it may be that the reduction is effected, 
 there always remains an indication that it is essentially necessary 
 to fulfil — that of preventing the escape of the organ, by the use of the 
 tampon and pessaries, of different shapes, dimensions and materials. 
 
 These supporting instruments are not absolutely indispensable 
 where the affection is recent and has suddenly happened, but they 
 are for the most part so, where the woman is of large size and the 
 disorder of an ancient date. 
 
 OF PESSARIES AND THEIR VARIETIES. 
 
 The term pessary* is given to an instrument designed to be placed 
 within the vagina, either to maintain the reduction of a hernia in the 
 part, or to prevent the falling or inversion of the organ itself, or what 
 is most commonly the case, to prevent the prolapsion and deviation of 
 the womb itself. 
 
 The use of pessaries, in the treatment of displacements of the 
 genito-urinary organs, is of the highest antiquity; the Egyptians, the 
 Greeks, the Romans, the Arabians, and all the ancient physicians, 
 without excepting Hippocrates himself, made much greater use of 
 them than the moderns, because they employed them not only as 
 mechanical and chirurgical measures, but as topical medicaments, 
 which they varied according to the supposed nature of the affection 
 they wished to combat ; thus, they prepared pessaries which were 
 emollient, astringent, tonic, emmenagogue, anti-hasmorrhagic, &c., 
 according to the indication to be fulfilled. 
 
 The employment of the pessary as a topical medicament has, for a 
 long time past, fallen almost wholly into neglect, and it is now used 
 solely as a remedy for the displacements and deviations of the genito- 
 urinary organs of the female as before stated. 
 
 The ancients composed their pessaries of various substances, such 
 as wool, the leaves of plants, lint or rolled linen, to which they at- 
 
 From macros, derived from the verb maaw, to soften, to retain, to keep in place. 
 
134 
 
 THE PESSARY. 
 
 tached a string for the purpose of extracting them when necessary. At 
 a later age they made use of gums, resins or wax, which were softened 
 so as to give them the proper shape. The Arabians, among whom we 
 may mention Albncasis ,* in order to support the womb, made use of 
 a small sheep’s bladder filled with air, or with a substance called coto 
 ( impleatur coto) which was left within the vagina until the cure was 
 completed. Professor Osiander, in his Compendium of Midwifery , 
 recommends, in imitation of the Arabians and of Apsyrt.es, the intro- 
 duction into the vagina of a small sac or bag made of fine linen, to 
 be first filled with tan, and then soaked in rough wine. 
 
 Other authors have prescribed the introduction within the vagina 
 of a fine sponge of a cylindrical or oval shape, well smeared with 
 some unguent, and supported by a bandage. Pessaries are also con- 
 structed of more solid materials of various sorts; such as light kinds 
 of wood, as linden or cork ; of hard woods, such as the service tree 
 and the box ; animal substances, as horn, ivory, wax or leather; and 
 lastly, metals, particularly gold, silver, copper, lead and tin. 
 
 As these substances used alone did not fulfil all the desirable pur- 
 poses, they have been combined, in order to improve their qualities. 
 Cork, for example,! possessed the advantage of being light, elastic and 
 firm, but it was too porous, and readily imbibed the mucus and other 
 fluids of the parts in contact with them. This was so much the greater 
 an inconvenience, since the fluid retained in the interstices of the cork 
 rapidly underwent putrefaction, gave rise to a disgusting odour, and 
 to a variety of symptoms more or less to be deprecated. Roussel ( Be 
 Partu Cxsareo ) relates that a woman who was under his care for 
 an inflammation of the bladder and womb, was not relieved of her 
 pains and other morbid symptoms until after the discharge from her 
 vagina of several bits of rotten cork, portions of an old pessary that 
 had been adjusted eighteen years before. Sabatier [Mem. de VAccid. 
 de Chir ., t. iii.) says that M. Grammont communicated to the academy 
 the case of a lady under treatment for putrid fever and inflammation 
 of the bowels produced by a cork pessary that had rotted in the vagina. 
 Delamotte (Mem. de l’ Acad. de Chir., t. ii.) also repeats that in order 
 to relieve the violent pain of a lady under his care, he was compelled 
 to extract a cork pessary that she had worn for three years, and in 
 doing so made use of instruments which required all his strength in 
 making the extraction. He adds that he was ignorant of the cause 
 of the difficulty until he had extractedthe pessary, which was petrified, 
 “so that the pessary resembled a very large urinary calculus.” 
 
 With a view to prevent the imbibition of fluids, the cork pessary 
 was covered with a thick coating of virgin wax, which certainly les- 
 sened the objections to the material and preserved it for a considerable 
 time from change. With the same end in view the linden wood 
 is coated with varnish of different sorts. 
 
 * Albucasis, lib. iii. cap. xix. Quando frangitur vulva mulieris. 
 
 f It was especially in Levret’s time that the cork pessary was put in vogue. That 
 celebrated physician not only bestowed upon them the highest commendation, and 
 preferred them to all other kinds, but he also at great length described the mode of 
 preparing them in a memoir published in the XXXIV vol., p. 428, of the Aucien 
 Journal de Medecine. 
 
THE PESSARY. 
 
 135 
 
 Ivory and the hard woods are too heavy, and injure the parts by 
 their hardness; besides, they are not now made use of except by some 
 of the English practitioners, and for the construction of certain cup 
 pessaries en bilboquet ; Haller published a case, which was that of a 
 lady who wore a globe pessary made of wood, which was employed 
 on account of an incontinence of urine from paralysis of the vesical 
 sphincter. In this case the pessary produced ulceration of the recto- 
 vaginal septum, so that, after the extraction of the instrument, which 
 was got away by means of forceps, her faeces escaped in part through 
 the vagina. ( Collect. Discuss. Med. Chirurg., t. iii. p. 595,) De incon- 
 tinentia urince globulis ligneis curandd. 
 
 Wax and resin have been abandoned as being too brittle, and 
 metals because they are too hard, too heavy, and some of them too 
 costly; besides, they corrode and become oxydized, particularly near 
 the soldering, which may give rise to bad consequences. Morand 
 ( Opuscules de Chirurgie , t. ii.) informs us that having introduced a 
 silver gilt pessary, he was some time afterwards recalled to the lady 
 who was suffering great inconvenience, severe pains in the pelvis 
 and an excessively fostid discharge. She attributed her distress to the 
 pessary, and when Morand removed it, he found it corroded, pierced 
 with several holes, and, moreover, covered with calculous deposit. 
 
 It now remains for us to speak of the pessaries most in use, that is 
 to say, of those that are so erroneously called gum-elastic pessaries, 
 for they are really composed of a coat of linen, silk or cotton, and 
 sometimes of a strong felt covered with several layers of drying lin- 
 seed oil. These are preferable to those before mentioned, although 
 they are not free from the objection of a liability to be decomposed. 
 It may also be objected that they are not very elastic, and that they 
 become readily and frequently covered with a calcareous deposit, 
 which excites violent inflammation of the womb and vagina, ending 
 in ulceration of those parts, with very foetid discharges. 
 
 Dr. Rognetta, in his excellent Memoir on Vaginal Cystocele, pub- 
 lished in the Revue Medicate , 1822, reports the following case at La 
 Charit6, service of Professor Roux. A country-woman entered the 
 hospital to be treated for a disease, as she supposed, of the womb. 
 She was examined by the distinguished surgeon above mentioned, 
 who discovered a foreign body in the vagina. The patient stated 
 that it was a pessary that she had not touched for many years. M. 
 Roux was obliged to make use of strong forceps in the extraction of 
 the instrument, which gave her severe pain. After the completion of 
 the operation, the pessary, which was as hard as a stone, and encrusted 
 with calcareous matter, was found to be of the sort called gum-elastic, 
 and that are most generally made use of notwithstanding their objec- 
 tionable features. When upon the subject of the accidents that may 
 follow the use of the pessary in general, we shall relate another case 
 in some respects still more curious than Mr. Roux’s. 
 
 Finally, we come to the consideration of the real gum elastic pes- 
 sary, pure caoutchouc, in its natural state. This material, by its light- 
 ness, its impermeability, and its elasticity, appears to us to combine, 
 
136 
 
 THE PESSARY. 
 
 in the highest degree, ail the properties that are to be desired in the 
 construction of a good pessary. 
 
 We are indebted to Madame Rondet, sage-femme, of Paris, for the 
 employment of caoutchouc in the construction of pessaries. Those of 
 her manufacture are supported within by a very thin steel spring, 
 surrounded with hair. We have seen some of them, however, that 
 are merely inflated with air, and have no spring or hair within them. 
 
 Our friend and colleague, Dr. Rognetta, the author of some import- 
 ant remarks on different branches of the science, and particularly 
 upon displacements of the genito-urinary organs of the female, has 
 likewise prepared pure caoutchouc pessaries, but simply with gum- 
 elastic bottles, such as are found in the trade. The only preparation 
 that he subjects them to consists in turning in the top like the bottom 
 of a bottle— then he cuts out a piece from the centre of the depression 
 with a punch. It is now a cup with double walls, and the throat of 
 the bottle, which is like the stem of the pessary en "bilboquet, receives 
 a metallic nut for the reception of a screw, to which are attached three 
 braces, designed to keep the instrument in situ by means of a belt, 
 which is itself supported by a pair of suspenders. The pessary is to 
 be removed every night, after which the patient must use cold water 
 injections, and be careful to wash the instrument every morning before 
 she replaces it. M. Hervez de Chegoin, a distinguished practitioner, 
 and member of the Academie de Medecine, has also made use of 
 native caoutchouc in the construction of pessaries, but he cuts the 
 bottles so as to give to the cup different degrees of depth. 
 
 The shape of the pessary varies according to the material of which it 
 is constructed; thus we have pessaries that are round, cylindrical, oval, 
 elytroid, figure of 8, en bon c/on, en bi/boquet, crescent-shaped, ring- 
 shaped, stem pessaries, with springs, cupped pessaries, and several 
 others that we shall in succession review, at the same time pointing 
 out the mode of using them. 
 
 [I take advantage of the close of this section to make a few remarks on 
 the subject of the pessary, and particularly on the pessary as psed in this 
 city ; and, in the first place, I must express my conviction that great abuses 
 are to be met with in the prescription and use of this instrument, while a 
 great many persons are restored to health, and many preserve a tolerable state 
 of healtli by their use, who, but for such aid, would become irremediably 
 diseased, or pass a long life of suffering. Many objections have been cited 
 in the preceding pages by our author to the use, or rather to the abuse of 
 this instrument, and the very natural and perhaps praiseworthy opposition 
 to their employment, arising from considerations of a merely moral nature, 
 ought to be encouraged as a means of preventing their unnecessary use as 
 means of treatment in cases not at all calculated to be benefited by them. 
 It seems to me that, in view of the nature of the support by means of which 
 the womb retains its natural situation in the pelvis, every case of prolapsion 
 or procidentia of the womb ought to be regarded as an affection of the 
 vagina, and that the indication of cure confines itself to the restoration of the 
 vagina and not of the womb as the pathological object. 
 
THE PESSARY. 
 
 137 
 
 The abdominal cavity is terminated above by the cohcave of the dia- 
 phragm, and inferiorly by the floor of the pelvis, consisting of tissues of com- 
 bined muscles, fasciae, cellular tela and skin. In the act of parturition, and in 
 that of defecation, the inferior portion of the abdominal cavity is depressed by 
 the action of the diaphragm and abdominal muscles, which press the mova- 
 ble contents towards the outlet, and depress it. In this act the whole peri- 
 neum descends more or less considerably, and after the completion of the 
 act returns to its natural position, partly by means of its contractility of tex- 
 ture, and partly by the act of the levator-ani muscles — muscles that in almost 
 every instance of this return are put into voluntary activity. 
 
 With the progress of age, and under the debilitating powers of disease, the 
 perineal terminus of the abdominal cavity grows less and less able to resist 
 the antagonization of the diaphragm and abdominal muscles ; so that, in 
 such circumstances, the perineum becomes relaxed, and is found to be 
 nearly horizontal or quite even with the tubera ischii ; whereas, in young 
 and healthy persons it is drawn upwards so as to make a deep sulcus above 
 the level of those tuberosities. 
 
 In all persons possessed of very powerful levators-ani, the extremity of 
 the rectum will be highly retracted within the pelvis, and retained there by 
 the steady and normal tension of those muscles — but in those in whom those 
 levators are thin and weak, the anus is found lower and on a level with the 
 tubera, or even projecting below them. This case may sometimes be 
 detected in young children exhausted with the long tenesmus of summer 
 complaint; in adults, under protracted diarrhoea, dysentery, and other enfee- 
 bling maladies, as well as in women whose constitutions are broken up by 
 frequent parturition. 
 
 Now let it be remembered that the levator ani is a levator vaginae, and, in 
 the same sense, a levator uteri, and that in all persons in whom these mus- 
 cles have become extenuated and weak, there will be a greater or less dispo- 
 sition to, or actual falling of the womb ; and that such a condition is incom- 
 patible with comfortable sensations in the muscles in question. Even the 
 constrictor vaginae muscle is, to a certain degree, a part of the muscular 
 material in question, since the levators and sphincters, both of the anus and 
 vagina, have their fibres more or less blended, and there is a consent in 
 their actions. The levators relax coincidently with the relaxation of the 
 sphincter ani, and their contractile efforts absolutely coincide. 
 
 Seeing now that the uterus depends for its place in the plane of the pelvic 
 cavity, solely upon the place of the vagina, and that the latter is indissolubly 
 connected with the bowel by means of the recto-vaginal septum, it appears 
 clearly that all cases of prolapsion have also a clear connection with a certain 
 morbid condition of the levator muscles. The same thing happens in the 
 case of falling of the palate or uvula, which is clearly a muscular weak- 
 ness, arising from an inflammation, either acute or chronic, of the substance 
 of the palate or uvula. 
 
138 
 
 THE PESSARY. 
 
 \ 
 
 It hence appears, that in cases of prolapsus uteri, I suppose that one 
 great object to be held in view is the restoration to the levators of their lost 
 or diminished contractility. 
 
 Doubtless, cases of prolapsion are most to be feared after long, tedious, or 
 instrumental labours — labours where, from rigidity or bad proportion, the 
 child has remained many hours within the pelvic cavity, jamming the mus- 
 cular and other tissues within against the sides of the ischia, whose bony 
 walls on the one hand contuse these muscles, while the head on the other is 
 equally capable of affecting them with contusion. 
 
 After such a labour, a woman is very apt to get up from her lying-in with 
 weakened levators, with the rectum feebly supported, and the uterus con- 
 sequently lower than it ought to be ; in fact, very few women are to be met 
 with in whom, after giving birth to one or two children, the womb is not 
 found very low in the pelvis. If she early becomes a widow, or at an early 
 age ceases to bear children, the tension of these tissues is at length restored 
 to the womb, and the whole perineum, indeed, rises again, until the approach 
 of age is evinced by the last and permanent fall of the perineum with all 
 the contents of the pelvis. 
 
 Under this view, how necessary does it seem that such patients should 
 avoid all the causes of tenesmus, such as costiveness on the one hand, and 
 drastic or other harsh cathartics on the other, pessaries of a bad construction, 
 of too large a size, strangury, debilitating discharges of leucorrhcea, and, 
 in short, whatever might serve to promote the descent of the perineal texture, 
 the descent of which is incompatible with a due elevation of the organs 
 whose support in situ naturali absolutely depends upon them. 
 
 I beg leave to remark that, in pursuance of a plan of treatment by rest in 
 a horizontal posture very long continued, the muscular force of tfie patient 
 is not unapt to be exhausted, and that it is not unusual for persons subjected 
 to such treatment, to rise from a confinement to the bed of several months, 
 duration, not at all amended in health, and consequently, greatly disappointed, 
 if not injured by the treatment. In such patients, a method calculated to 
 invigorate and enhance the muscular energies would be far more likely to 
 produce a cure which would coincide with a rise or elevation of the perineum. 
 Hence, I have, in many instances, found my patients to recover perfectly, 
 when I have counselled them to take exercise, to be much in the air and light, 
 to live upon a nutritious diet, to take wine and malt liquor, and to disregard, 
 as far as possible, the painful or annoying sensations proceeding from the pro- 
 lapsed state of the womb; assuring them that, probably, in proportion as their 
 general health should improve, so would the local disorders, under which she 
 suffered, gradually lessen and finally disappear. I have seen a lady this day, 
 who, at the age of forty-nine years, informs me that she has scarcely been a 
 day or night without a pessary for fourteen years past, an instrument for 
 which 6he has not the least occasion, and perhaps never has had. 
 
 In making these remarks, I desire to apply them to cases where the use 
 
USE OF THE PESSARY. 
 
 139 
 
 of the pessary is a question of doubt, for, beyond dispute, there are many 
 women who can enjoy neither comfort nor health without the aid of these 
 remedies, which, as our author states, are sanctioned by the common con- 
 sent of the profession for ages past. — M.] 
 
 OF THE PRINCIPAL PESSARIES IN USE, AND THE METHOD OF EM- 
 
 PLOYING THEM. 
 
 Whatsoever may be the nature or form of the pessary selected for 
 the purpose of keeping the womb in place after it has been reduced 
 from its prolapsion, its application should be rendered, generally, 
 subject to the following rules : 
 
 After having emptied the rectum by means of an enema, and 
 directed the patient to evacuate the urine, she should place herself 
 upon the back, with the hips raised upon a cushion, the knees sepa- 
 rated, the legs somewhat flexed, and the feet resting firmly upon the 
 bed. The pessary, anointed with cerate or oil, is then introduced 
 by the surgeon into the vagina, taking care to present it in such a 
 way that its smallest diameter shall be coincident with the smallest 
 diameter of the orifice, and pressing it as much as practicable towards 
 the inferior commissure of the labia, then pushing the instrument 
 carefully from before backwards and upwards, he will carry it up to 
 the height at which he designs that it shall remain, when he gives 
 it the position he may deem requisite, seeing that the os tincse may 
 always correspond to the central opening. 
 
 [In the globe pessary constructed here, and much in use in this country, 
 there is no central opening, and as the instrument is a sphere, it requires no 
 farther care than to place it in the vagina beyond the constrictor muscle. I 
 shall speak of this pessary in another page. — M.] 
 
 In order that the neck of the womb may the more perfectly adapt 
 itself to the concavity of the pessary, the operator, supporting the 
 instrument with the index finger, should allow the patient to rise and 
 sit up for a moment, and even to walk a few steps, and to cough, in 
 order to learn whether the instrument maintains its place, and pro- 
 duces no painful sensation, which, being found to be the case, he 
 should allow her to return to her bed, whence she ought not to rise 
 for a few days. After getting up from her bed, she would do well 
 to pass a few days upon a couch or sofa, and, as far as possible, avoid 
 any sudden movement. 
 
 Round pessaries and pessaries h cuvettes are flattened on the face, 
 and exhibit a central depression of considerable depth, with a central 
 perforation that ought to correspond with the os tincae. The pessary 
 a cuvette differs from the round pessary, properly so called, only in 
 being concavo-convex. These two sorts of pessaries, that for a long 
 time have been made of cork, covered with a coating of wax, or of 
 box-wood, are at the present day generally made with gum-elastic. 
 In introducing them, they are pushed edgewise into the vagina, and 
 afterwards turned so as to make the central orifice correspond to the 
 os uteri. This may be done by introducing the tip of the finger into 
 
140 
 
 USE OP THE PESSARY. 
 
 the opening of the instrument, or, previously to introducing it, a rib- 
 bon may be fastened, by means of a knot, to the smallest end of the 
 pessary, and when the time arrives for turning the instrument, it may 
 be pulled downwards by the ribbon while the piece is supported by 
 one or two fingers, introduced for the purpose, and pressed against 
 the opposite extremity or side. 
 
 This little ribbon should be left in the vagina, for the purpose of 
 more readily extracting the pessary whenever it may be necessary to 
 cleanse it or replace it by another one, or when the parts of genera- 
 tion may require to be cleansed ; should the ribbon, however, be found 
 to irritate or give any trouble, it should be cut off* and taken away. 
 
 The oval pessary, which differs from the round one only in its 
 shape, is objectionable, because it is easily displaced, and because it 
 distends the upper part of the vagina too much, in a transverse di- 
 rection, which, in some cases, is very painful or even insupportable. 
 It is introduced lengthways, being slightly inclined to the left, in 
 order to avoid compressing the urethra. After it has passed quite 
 into the canal, it is turned so as to assume a horizontal position, 
 by means of a loop attached to the end that is first introduced, the 
 loop being pulled downwards by one hand, while the other supports 
 the opposite extremity of the oval pessary. 
 
 Ovoid pessaries are nearly of the size and shape of a small turkey’s 
 egg, and are traversed by a cylindrical hole from end to end. These 
 pessaries, which are employed only by the English and American 
 surgeons, are inconvenient on account of the facility with which they 
 are displaced under the least effort of the patient. Yet the introduc- 
 tion of this sort is very easy. 
 
 [M. Colombat is under some misapprehension in regard to the use of the 
 egg-shaped pessary by the American surgeons. In fact, the egg-shaped 
 instrument is rarely employed, so far as I know. In order to set the matter 
 forth in its proper light, I shall proceed to cite, in this place, some paragraphs 
 from the Philad. Pract. of Midwifery, by the translator, p. 145. “ Pessaries 
 are made of various shapes, and of a great variety of materials. Many are 
 made of a piece of cork, cut into a proper form, and repeatedly dipped in 
 melted wax until covered with a thick coat of that substance. The objec- 
 tion to this kind is, that by the warmth of the organs the wax becomes so 
 much softened that the rough surface of the cork sometimes becomes un- 
 covered, and then irritates the parts with which it is in contact. Others are 
 made of the same material that is used for the construction of elastic cathe- 
 ters and bougies. Others, again, are made of glass, blown by the glass- 
 blower into a convenient size and form. Some are used that consist of 
 silver, and some are of silver washed with gold. Of the metallic pessaries 
 now principally in use, in our American practice, two kinds are prepared; 
 one of which is the flat pessary, or rather the disc-like pessary, which is 
 concavo-convex, with a very thick periphery, and having a small perforation 
 in the centre of its concavity. The other is a globe of silver washed with 
 gold so as to prevent the oxidation of the surface. Both of these pessaries 
 are made of plates of metal so thin that they are sufficiently light; and as 
 
USE OF THE PESSARY. 
 
 141 
 
 the gilded surface admits of a high polish, they are as little likely to irritate 
 the parts they touch as any foreign body that could be constructed. 1 much 
 prefer the metallic to the glass pessary, on account of the greater lightness 
 of the former. It appears to me, that a globular pessary is capable of ful- 
 filling all the indications that could possibly be collected for a mechanical 
 remedy for this affection (prolapsus uteri). I prefer it in general, therefore, 
 to all other forms of the instrument, particularly since it cannot become dis- 
 placed by turning on its axis; a fault frequently found with the flat or discoidal 
 instrument. I am fully confirmed in my appreciation of its superior value. 
 The globe pessary was, I believe, the only instrument used by the late Dr. 
 Physick, in the treatment of prolapsus uteri. He told me that while he 
 was a pupil of Mr. John Hunter, and acting as dresser at Guy’s Hospital, 
 he had under his care the case of a patient who had suffered severely with 
 prolapsus uteri. One day, while paying his visits, he saw a billiard ball 
 that had been rolling about the ward, and the idea struck him that it might 
 serve to support the womb in the case in question. He introduced it, and it 
 succeeded so perfectly in alleviating her distress, that he ever afterwards pre- 
 ferred to employ the globe rather than the disc or any other of the numerous 
 forms of the instrument.” 
 
 I take this occasion to say that both the discoidal and globe pessary are 
 made by Mr. Jos. S. Warner, Merchant street, Philadelphia, »nd that they 
 are sold at the rate of five dollars each, which renders them rather too costly 
 for common use ; yet it is proper to say, that the construction is so perfect 
 that they often remain one, two, or even three years in situ, without under- 
 going oxidation or losing their polish. The plates of hammer-hardened 
 silver of which they are made, are so thin, that the weight of the instrument 
 is very inconsiderable ; many grains of pure gold are put on the surface, 
 which preserves them from oxidation for a long time, as above mentioned. 
 
 For the most part, a globe pessary, of two inches and a quarter in diame- 
 ter, is both small enough and large enough. Occasionally persons are met 
 with, to whom the introduction of one of more than two inches gives con- 
 siderable pain; and others, again, in whom the os magnum is so relaxed and 
 debilitated that two and a half inches are barely large enough for a pessary 
 suited to the case. 
 
 In adjusting this instrument, the general rule laid down by our author 
 ought to be observed. I mean that relative to the evacuation of the bladder and 
 the rectum ; after which the patient should get into bed, lying upon her left 
 side, with her thighs at right angles to the trunk, and the knees flexed, with 
 a pillow between them. If the globe be now dipped in olive oil, and pressed 
 against the os magnum with a gentle force, which should be intermitted or 
 suspended from time to time, in simulation of the dilating processes of a 
 labour or abortion, it will, in general, be found not difficult to adjust the 
 instrument. It is very much to be desired that a good deal of time should 
 be required to place it within the vagina, for if it enters too readily, or with 
 
142 
 
 USE OF THE PESSARY. 
 
 too little force, it will be surely expelled at the first bearing down in defe- 
 cation, or even in evacuating the bladder of urine ; whereas, if it require 
 time and some resolute application of force to adjust it, it will be very little 
 likely to give trouble and vexation by an escape. To every woman who 
 has recently suffered the introduction of such an instrument, the advice 
 ought to be given never to go out without the napkin, lest, in some sudden 
 fit of cough or sneezing or laughter, the ball might be driven from its place, 
 to her mortification and dismay. 
 
 The globe requires no cuvette or depression, because, when adjusted, the 
 anterior face of the cervix uteri lies upon the upper 
 Fig* 17. and posterior segment of the ball, the os tincae 
 
 looking backwards and downwards towards the 
 sacrum, as in the figure, which shows very well 
 that the womb must, under the use of such an in- 
 strument, be very much elevated in the excavation 
 of the pelvis. I may add that every contractile 
 effort of the sphincter vaginae, and more particularly, 
 every contraction of the levator ani muscles must 
 push the globe upwards, carrying the womb upwards 
 along with it. — M.] 
 
 The ring pessary, or pessary en. gimblette , is wide, thick, with 
 rounded edges, and with a central perforation, beveled upon both 
 surfaces, but most upon that which is in contact with the os uteri. 
 These pessaries, which are characterized by several inconveniences, 
 that we shall hereafter refer to, may be introduced edgeways, and 
 agreeably to the rules before laid down, as relative to the round 
 pessary. 
 
 The figure of 8 pessary, invented by Brunninghausen, is notched 
 both on its anterior and posterior edge, for the purpose of avoiding 
 any interference with the rectum or the bladder ; but it is inconve- 
 nient, and much more easily displaced than the ring pessary, which 
 dilates the vagina equably, and forms a sort of circular sulcus, that 
 prevents it from getting out of place. It is introduced in the same 
 manner, and according to the same rules as are applied for the oval 
 pessaries. 
 
 The stern-pessary , or pessary en bilboquet, the employment of 
 which seems chiefly indicated after the reduction of a complete pre- 
 cipitation of the womb, is commonly fabricated of box or ivory, or 
 what is still better, of caoutchouc. At the uterine extremity, these 
 instruments exhibit a concavity, the thick, rounded edge of which 
 resembles that of a pessary en gimblette , and the bottom of which 
 has three larse openings. To the convex surface of the cup is fixed, 
 by means of three branches, a straight stem or rod, which is open at 
 its vulvar end, so as to admit of the ribbons, by means of which it is 
 secured to the girdle or T bandage, which the patient ought always 
 to wear. 
 
 The pessary en bilboquet , invented during the last century, by 
 
USE OF THE PESSARY. 
 
 143 
 
 Suret, a surgeon, has undergone various modifications in the hands 
 of different surgeons, as F. Beaulieu, Saviard, Preuner, Bauhin, 
 Zeller, Desormeaux, Recamier, Villerme, Guillon, Deleau, &c. Beau- 
 lieus’s instrument consists of a silver circle supported by a sort of 
 three-pronged fork. Saviard’s, made of steel, consists of a spring, one 
 extremity of which is surmounted by a small spring, which assumes 
 a curve in the vagina, while the free end is attached to the girdle. 
 Professor Boyer made use of a spring of this sort, which was sur- 
 mounted by a sponge for the purpose of keeping the prolapsed womb 
 in its proper situation ; and he used it particularly in cases in which 
 too much irritation and pain were produced by the ordinary sorts of 
 pessaries. 
 
 In order to render the stem more elastic in its longitudinal direc- 
 tion, M. Recamier conceived the idea of composing it of a spring 
 en boudin , (suspender spring,) probably covered. Professor Duges 
 thought the stem ought to be placed obliquely as to the cup, as the 
 vagina is in regard to the axis of the cervix uteri. 
 
 Bauhin’s pessary was composed of a rather small silver circle, 
 forming a sort, of thick cushion, sustained on a three-branched stem, 
 and pierced with a hole in the centre. Villerme’s, founded on the same 
 principle as that of Saviard, consists in a long arch, the concavity of 
 which embraces the front of the pelvis. The tail of the piece, which 
 is a sort of crotchet, rests upon the hypogastrium, while the head of 
 the instrument, introduced within the vagina, serves to support or 
 suspend the womb in its proper place. Our colleague, Dr. Deleau, 
 to whom the science is indebted for important improvements, has 
 also constructed a pessary which unites the qualities of the pessary 
 en bilboquel and the pessary en gimblette. This ingenious instru- 
 ment is constructed as a spiral spring, the first circle at the top of 
 which is fixed . , while that which is at the base is free, and may be 
 made larger or smaller at will. The whole is coated with caout- 
 chouc. When it is to be used, the circle at the base is more or less 
 reduced, and being introduced into the vagina with the smallest end 
 upwards, it is left there, and accommodates itself to the dimensions 
 of the organ, without any liability to displacement. Dr. Guillon has 
 also modified the stem-pessary by combining the bilboquet and the 
 cork one by means of a hollow stem, which is a screw, by turning 
 which the uterus is elevated at will. 
 
 In adjusting a stem-pessary, the cupule end must be introduced 
 into the vagina gradually, giving to the stem its proper direction. 
 When it has passed far enough, it is to be secured by the T bandage, 
 as already mentioned. 
 
 We shall presently explain the inconveniences connected with the 
 stem-pessary, which, as they rarely remain in the centre of the 
 vagina, are found to see-saw within the passage, which they contuse, 
 and sometimes even perforate with the end of the stem. Dr. Laroche 
 extracted one of this sort, which had fixed itself transversely, so that 
 the stem had penetrated the bladder, while the cupule had pierced 
 the rectum. The cupule had become the nucleus of a stercoral 
 concretion, composed of large crystals that adhered to it, while the 
 
144 
 
 USE OF THE PESSARY. 
 
 stem itself, in the cavity of the bladder, had covered itself with a 
 calculous concretion of uric acid. 
 
 The pessary en bonclon, or conoidal pessary, is commonly made 
 of caoutchouc, and generally in the form of a long, hollow cone, 
 truncated at top, which is cup-shaped, with a central cavity for the 
 reception of the neck of the womb, the other extremity being sup- 
 ported by strings attached to the girdle. These pessaries, which are 
 chiefly used in cases where the vagina remains prolapsed, notwith- 
 standing the reduction of the uterus itself, are inserted with the large 
 end first, which must be compressed in the fingers of the operator, 
 to make it enter the vagina. It is inconvenient, as being too heavy, 
 and as tending, by the sharpness of its edges, to contuse and injure 
 the parts. 
 
 Professor J ules Cloquet is the author of an instrument called the 
 elytroid pessary, of a shape calculated to conform as closely as pos- 
 sible to that of the vagina itself. These instruments are constructed 
 of a web, covered with varnish or caoutchouc. They are hollow, 
 flattened antero-posteriorly so as to present a convex face towards 
 the rectum, and a concave one towards the bladder. At the upper 
 end is a transverse oval depression or cupule. A tubular canal leads 
 from top to bottom of the instrument, for the purpose of a conduit to 
 the mucous and menstrual excretions. The lower end has a rounded 
 angle at each side, which rests within the vagina, above the vulva. 
 These pessaries, which, to a certain extent, mould themselves to the 
 form of the vagina, certainly do support the womb and its append- 
 ages perfectly well ; but, in consequence of their weight, they are 
 found to be fatiguing to the women who use them. They are at- 
 tended with another inconvenience, common, indeed, to all tubular 
 pessaries, which is, that they impede the discharge of the menses ; 
 lor the blood often coagulates within and obstructs the tube. M. 
 Cloquet’s elytroid pessary is closely analogous to that which is 
 figured by Smellie, in the XXXVIII Plate of his Treatise on Mid- 
 wifery. 
 
 In introducing the elytroid pessary, its inventor, M. Cloquet, directs 
 that the cupped end should be presented to the orifice, but directed 
 so that the convex surface of the elytra should look towards the 
 patient’s left thigh. The instrument is now to be slowly pressed 
 upwards, and, when the lower end has passed the vulva, the right 
 index ought to be placed within the hollow of the instrument, and, 
 with the left index, it should be adjusted so that its concavity may 
 be placed in correspondence with the bladder, and its convexity 
 made 1o look towards the rectum. 
 
 Finally, Dr. Brouard has recently invented a pessary with lateral 
 and divergent stems, composed, 
 
 1st. Of an ivory or ebony ring, eighteen to twenty lines in dia- 
 meter. 
 
 2d. Of two branches of silver or other metal, twenty-one lines in 
 width. These branches are attached to the under surface of the 
 ring, and terminate in two ivory buttons. According to its inventor, 
 this pessary, which is easy, both as to its introduction and re- 
 
CHOICE OF THE PESSARY. 
 
 145 
 
 moval, differs from all former ones in size, in its point d’appui and 
 its operation. In fact, the smallness of the ring renders its introduc- 
 tion very easy, and much less painful than that of the other sorts. 
 The point d’appui is not taken in the ratio of the circumference of 
 the ring, but it depends on the divergence of the elastic branches, the 
 buttons of which rest upon the inferior lateral portions of the vagina. 
 
 Should this instrument be found to possess all the advantages 
 claimed for it by the inventor, we have no doubt of its coming into 
 general use ; particularly as a support in cases of procidentia of the 
 womb ; but it never can take precedence of the cylindrical forms of 
 the pessary, in cases connected with the various vaginal hernias. 
 
 OF THE CHOICE OF A PESSARY. 
 
 According to most authors, the round pessary is indicated where 
 the diameter of the vagina is small ; but, under contrary circum- 
 stances, choice is generally made of an oval, or gimblette, or figure 
 of eight pessary. 
 
 The stem or bilboquet pessary is chiefly used where the axes of 
 the superior strait are very large, and the woman emaciated; or 
 where the walls of the vagina, on account of their weakness and 
 flaccidity, could not readily retain the instrument that is placed within 
 them for supporting the womb. 
 
 The pessary ci bondon is reserved for cases in which the vagina is 
 still prolapsed, notwithstanding the uterus itself is reduced. The 
 elytroid pessaries, which, in many cases, supersede the others, are 
 perhaps better suited than any others for the cases of anteversion and 
 retroversion of the womb ; in which we must raise that end highest 
 that is designed to keep the womb in situ, — of the particular devia- 
 tions of which we shall hereafter treat. The cylindrical gum-elastic 
 pessary of Dr. Rognetta fulfils the same indications perfectly well, 
 and is especially excellent as a remedy for vaginal enterocele and 
 cystocele. 
 
 Where the patient has been troubled with a very copious uterine or 
 vaginal catarrh, the use of the pessary ought to be deferred until this 
 particular malady shall have been removed or at least much amended ; 
 for the presence within the vagina of such instruments could only 
 increase the evil. In doing this we should but follow out the prin- 
 ciple laid down by Boyer in his Treatise upon Surgical Diseases , 
 tom. x., where he says that the pessary should never be employed 
 except in cases where the os uteri is neither engorged nor painful, 
 and where we are certain that the symptoms experienced by the 
 patient are dependent upon displacement of the womb, and not upon 
 engorgement or elongation of its neck. 
 
 ACCIDENTS CONNECTED WITH THE PRESENCE OF A PESSARY IN 
 
 THE VAGINA. 
 
 Pessaries of all kinds never fail to excite more or less irritation. 
 The almost inevitable pressure of the instrument upon the parts con- 
 
 10 
 
146 
 
 INCONVENIENCES OF THE PESSARY. 
 
 rained within the pelvic cavity impedes the functions of the organs, 
 more especially those of defecation and urination. It often happens 
 that the uneasiness and the insupportable pains which they produce 
 extend to the loins and the groins, and give rise to engorgement of the 
 inferior extremities. 
 
 Women who make use of the pessary without great attention to 
 means of cleanliness, are often attacked with pernicious symptoms ; 
 for by being left too long in situ, the instrument undergoes decom- 
 position, corrodes, and is coated with calcareous incrustation;* be- 
 coming in this way the cause of permanent irritation, it excites in- 
 flammation and change of texture, ending in the formation of purulent 
 vegetations that exhale the most repulsive odour : the action of the 
 mucous apparatus being increased, acquires an exaggerated vitality 
 that gives rise to vegetations that become so abundant as not only 
 to fill the vagina, but to cover up the whole pessary and com- 
 pletely conceal it from the touch. Desormeaux, the father of the 
 professor whose recent loss we deplore, was obliged to excise a 
 great number of vegetations before he could succeed in extracting 
 a pessary that had perforated both the bladder and the rectum. 
 Professor J. Cloquet, in consultation in the case of a lady under treat- 
 ment for cancer of the vagina, found the canal filled with fungous 
 vegetations: having decided to remove these fungous masses, he 
 discovered a pessary within the vagina and extracted it. The instru- 
 ment which had been forgotten for ten years, was completely covered 
 with fungous matter and coated with a calcareous incrustation. Acad, 
 de Med., 29 June, 1326. 
 
 Whenever the central opening of a pessary, particularly a round 
 one, an oval one, a cupped one, or one with a ring, is too large, the 
 neck of the womb is liable to become slowly engaged within the 
 opening, and at length strangulated, and after a time gives rise to the 
 most serious consequences — such cases have been seen. 
 
 The Annals of Medicine of Ollemburg for Oct., 1826, and the Bib - 
 Uotheque Medicate, t 17, p. 269, mention a young unmarried Dutch 
 girl who, being affected with prolapsus, made use of a ring pessary 
 of ivory, the opening of which being too large, produced a strangula- 
 tion of the womb, exhibiting a tumour external to the organs nearly 
 as large as a child’s head. As the patient was in the utmost pain, 
 
 * On the 25th March, 1832, 1 was requested to see the Baroness de Carl . . . who was 
 then about 75 years of age, and who in common with her whole family supposed herself 
 to be afflicted with cancer of the womb. What seemed in fact to justify this distressing 
 diagnosis was that Madame de Carl . . . was affected with intolerable pain and a most 
 profuse and foetid vaginal discharge. Instead of finding a cancerous tumour, as it 
 had been asserted to be by Dr. B . . . I ascertained that there was a round pessary 
 with a central hole, but which was thickly incrusted with calcareous matter. It had 
 been applied at Vienna, in Austria, after her last confinement, which was at least 30 
 years before. The instrument, which was but little altered, having for a long time 
 given rise to no pain, had been so completely forgotten that she could with diffi- 
 culty believe in its presence until I showed it to her after I had extracted it by intro- 
 ducing a finger into the hole in the centre of the pessary. For the relief of the pain 
 and inflammation I prescribed baths and emollient injections combined w'ith chloride 
 of lime; enemata, of a soothing and narcotic kind, for the bowels, and from that 
 period her health has been good — the prolapsus did not return, notwithstanding that 
 no pessary has been since made use of. 
 
INCONVENIENCES OF THE PESSARY. 
 
 147 
 
 the reduction was attempted, but in vain until after the ivory ring 
 had been divided with a saw. Augustin Roux, Journ. de M£d. et de 
 Chirurg., Jan. 1778, relates that he was obliged to make use of a 
 forceps to extract a pessary of this sort. 
 
 Another very bad effect of pessaries is, that they, especially the 
 bilboquet, are found sometimes to injure the walls of the vagina, and 
 occasion a perforation to take place through the bladder or the rectum, 
 or both at once ; thus giving rise to recto and vesico-vaginal fistulas, 
 the consequences of which are so much the more deplorable as they 
 are frequently beyond the reach of art to cure them. These perfora- 
 tions may take place rapidly where the inflammation is very active ; 
 the pressure mortifies the parts pressed upon, which become gan- 
 grened, and separate in sloughs, through which the instrument passes. 
 
 Sabatier* relates that Camper communicated to the Academy of 
 Surgery a case in which the surface of a bilboquet pessary was found 
 to be quite diminished and the stem bent. The same author adds, 
 that ivory pessaries are not only subject, in process of time, to corrode 
 and become altered, but that they may also become covered with 
 calcareous incrustation. The celebrated author of La Medecine Ope- 
 ratoire , (loc. cit.) also remarks, in speaking of a pessary which he 
 was obliged to cut in two with strong pincers before he could succeed 
 in extracting it, that it was covered with saline incrustation as rough 
 as a rasp, so as even to wound his fingers. Jh. Nollett and Pouteauj; 
 relate cases of the same kind, and express themselves in terms simi- 
 lar to those used by Sabatier. 
 
 Professor Berard found great difficulty in extracting a bilboquet 
 pessary which had lost its stem, and which had perforated both the 
 rectum and the bladder. M. Lisfranc, in a similar case, was obliged 
 to procure an opening into the rectum by dividing the perineum, and 
 the anterior part of the anus. By this means he succeeded in ex- 
 tracting the pessary with pincers ; but the patient fell a victim to an 
 attack of peritonitis.§ [Jour. ZJniv. Hebd. de Med. t. i. p. 263.) 
 
 In the Diet, des Sciences Med., t. vii. p. 47, the following case is 
 found. A country woman had, for many years, worn a pessary en 
 bilboquet, which she did not extract because she never experienced 
 any inconvenience from its presence. In process of time, as she was 
 now suffering violent pains, she endeavoured to extract the instru- 
 ment by pulling at the stem, which became detached, leaving the 
 circle within the vagina. The distress had gradually increased, and 
 she at length found that a portion of her fasces as well as of her urine 
 came away through the vagina. Having got admission to the Hotel 
 Dieu, in hopes of a treatment for her disgusting and painful disorder, 
 she came under the care of Professor Dupuytren, who ascertained, in 
 an examination per vaginam, that the circle of the pessary was ex- 
 posed in the rectum, and that it was also partly in the bladder, which 
 it had perforated, as he ascertained by means of a sound introduced 
 into that organ. All attempts to extract the pessary with the fingers 
 
 * Mem. de l’Acad. de Chir., t. iii. p. 33. f Observat. Chirurg., 33. 
 
 * CEuvres Posthumes, tom. iii. § Revue Med., tom. i. p. 37, 1831. 
 
148 
 
 INCONVENIENCES OF THE PESSARY. 
 
 having been frustrated, Dupuytren was more successful by the use of 
 a strong pincers, with serrge, and which had been constructed for this 
 very purpose. Rest, and the use of a sound in the bladder, where it 
 was maintained for three weeks, cured the woman of both her vesical 
 and rectal fistula. Mauriceau tells us that, “ in 1696 , he extracted 
 from a woman sixtv-seven years of age, a large ivory pessary consist- 
 ing of a ring, which a truss-maker had adjusted for her on account 
 of a falling of the womb. She had worn it for twenty years without 
 having suffered any inconvenience from it; but for the two last years 
 she had been subject to a great defluxion of humours upon this part; 
 a disposition to ulceration had also manifested itself, with a profuse 
 discharge of purulent matter mixed with blood ; and this had con- 
 tinued for six months, so that the patient had become very weak.” 
 
 In speaking on the subject of pessaries without stems, Sabatier, 
 (loc. cit.) says, “ that if the instrument is large enough to rest upon the 
 sacrum, and to resist the impulse that tends to expel it, it produces a 
 retention of urine, a difficulty in passing the faeces, great pain, and 
 tension of the belly. If, on the other hand, the pessary is too small 
 for the vagina, the weight of the womb and superincumbent viscera 
 force it downwards, upon the least effort made by the woman at 
 urine or stool ; or else, in spite of its presence, the patient has a con- 
 stant feeling of weight at the hypogastrium, dragging sensation in the 
 loins, and pains in the thighs, which sometimes make it out of the 
 question for her to walk.” Sponge pessaries, unless removed and 
 washed every day, are also very objectionable, as the fluids from the 
 womb and vagina, with which the sponge cells are filled, undergo 
 decomposition very rapidly. Even the sponges themselves soon 
 become putrid, and the high temperature of the vagina, produced by 
 the inflammation, hastens the progress of these changes. We may 
 expect to have sanious and foetid secretions; whereupon intense fever 
 attacks the patient, and all the symptoms of purulent absorption are 
 disclosed. Dr. Grenier, in his Inaugural Dissertation , relates the 
 following case : During the month of May, 1832 , M. Brodie, of Lon- 
 don, one of the most celebrated of the English surgeons, was called to 
 a lady who had forgotten a small sponge in the vagina. He found her 
 labouring under the incontestable symptoms of typhoid fever, with 
 marked prostration, ftetor of the excretions, &c. In consequence of the 
 nature and the abundance of the vaginal secretions, he suspected, and 
 at last discovered the cause of the malady. He immediately extracted 
 the remains of the sponge, which came away piecemeal; and he then 
 prescribed frequent injections of chlorides, and treated her as if com- 
 bating a typhoid fever. The symptoms were amended upon removing 
 the cause, but the patient recovered very slowly. Were it not, in fine, 
 that we fear being found too prolix upon this point, we could add to 
 the numerous Samples we have already brought forward, a great 
 many cases fitted to set forth the accidents that may supervene upon 
 the employment of the pessary. 
 
 Inasmuch as the use of these instruments is far from being always 
 safe, they ought only to be employed in cases of absolute necessity. 
 
INCONVENIENCES OF THE PESSARY. 
 
 149 
 
 A very good substitute for them is in fact found 
 in the astringent sachets recommended by Osi- 
 ander, or in fine sponges that should be re- 
 moved at night, and carefully washed before 
 they are replaced. I have had a sort of bag 
 made of pure India rubber, filled with air, 
 which, although very supple and light, supports 
 the parts very well, without irritating them. — 
 
 ( Vide fig. 18 .) Besides, as these sachets are 
 shaped somewhat like the male organ,* and as 
 they can be varied as to length and diameter, 
 they adapt themselves to the vagina, and may 
 be retained by means of the T bandage or by 
 the napkin usually worn during the catamenia. 
 
 These priapiform pessaries being easy to adjust or remove, ought only 
 to be made use of in the day time, while the patient is out of bed ; but, 
 in order to prevent the womb from falling, even for a short time, the 
 instrument ought to be adjusted before leaving the bed. If the other 
 kinds of pessaries could be made use of in the same way, the radical 
 cure of a prolapsion in the first or even second stage would often be 
 effected in the course of a few months. 
 
 The irritation and inflammation excited by the application of the 
 pessary ought to be counteracted by rest, by diet, baths, enemata, 
 emollient and opiate injections, and invariably by a temporary sus- 
 pension of the use of the instrument. 
 
 Women accustomed to the use of the pessary, should never lose 
 sight of the fact, that the presence of such an instrument in the vagina 
 requires the most scrupulous attention to cleanliness. They should 
 frequently bathe, and they should have recourse to injections of cool 
 water, or a mixture of wine and water, twice a day. They should 
 also remember that the instruments ought to be removed at least 
 once a fortnight, in order to be replaced or repaired in case of its 
 appearing to be necessary. 
 
 We shall close our observations upon this subject by the remark, 
 that in many cases, especially recent ones, of prolapsus, the displace- 
 ment might be cured by means of astringent injections and fomen- 
 tations with articles of which tannin should constitute the chief 
 ingredient, and which may be rendered still more active by adding 
 alum, or white or green vitriol ; or the patient might try the effect of 
 a small tampon, made of fine linen or sponge, impregnated with the 
 same substances, and introduced two or three times a day into the 
 vagina, and left there about half an hour each time. 
 
 COMPLICATIONS CONTRA-INDICATING THE USE OF THE PESSARY, 
 AND INDICATIONS IN CERTAIN PECULIAR CASES. 
 
 We have said before that certain complications may exist that lead 
 
 * The ancient Greek physicians made use of pessaries like those just mentioned 
 of the form and length of the male organ, which is the reason why they are called 
 wgiciTrts-xwTa, or priapiform pessaries. 
 
 Fig. 18. 
 
150 
 
 PARTICULAR INDICATIONS, ETC. 
 
 us to reject the employment of the pessary, and that chronic vaginitis 
 and metritis require an antiphlogistic treatment, as preliminary to the 
 employment of the instrument. Nevertheless, a superficial excoria- 
 tion or ulceration of the vagina does not always contra-indicate the 
 pessary, as was supposed by Ruysc hand Boyer ; for the reduction 
 of the womb often cures the vaginal inflammation which had been 
 produced by the prolapsion. On the other hand, a cancer situated 
 upon the neck or body of the womb in prolapsion, would forbid the 
 use of the pessary, whether from its increasing the irritation and pain, 
 or whether the reduction of the womb would deprive us of the 
 facilities and warrants of success resulting from different operations, 
 among which I may mention cauterization, excision of the cervix, or 
 the absolute ablation of the cancerous organ. 
 
 Should cancerous ulcerations, situated upon the cervix, from their 
 slightness, not contra-indicate the reduction of the womb, it ought to 
 be supported by a fine sponge, frequently renewed, as the most 
 fitting support in such a case. 
 
 Where a polypus exists coincidently with a prolapsion, the polypus 
 ought to be removed before any attempt at reduction is made, which 
 then becomes an easy task: wherever, also, there happens to be a 
 calculus in the bladder, complicated with falling of the womb, we are 
 advised, both by Ruysch and Dug6s, to remove thb calculus by a 
 direct incision. Lastly, where the prolapsus takes place in the first 
 months of pregnancy, the reduction should be at once effected, and 
 the organ retained in situ by means of a pessary, or the woman 
 should be prevailed upon to lie in bed during the first periods of 
 gestation. Means of support and rest are equally useless subsequent- 
 ly to the fourth month, for at that stage the womb, though in the 
 second stage of procidentia, has acquired a magnitude sufficient to 
 retain it above the superior strait. 
 
 In a case in which the precipitation has taken place and existed 
 throughout the whole of the pregnancy, we must assist nature in the 
 delivery, and follow the example set by Mauriceau, Portal, Ducreux 
 and Wagner, who, after gently dilating the thinned circle of the os 
 uteri, carried in the hand, in order to deliver the child and the secun- 
 dines also, and then reduced the womb, now contracted and dimi- 
 nished in size. Where the lips of the os tincse happen to be affected 
 with an induration, preventing the dilatation of the neck, the orifice 
 may be enlarged by means of two or three incisions, made with a 
 probe-pointed bistoury ; cases of prolapsus in complication with both 
 induration and pregnancy, are very rarely to be met with, for, up to 
 this time, they have been noticed only by Marignes, of Versailles, by 
 Choppart, and our skilful accoucheur, M. Capuron. 
 
 CURE OF PROLAPSUS UTERI. 
 
 The curative treatment of uterine prolapsus is rarely followed by 
 complete success. With a view to the radical cure of the disorder, 
 a great variety of measures, more or less efficacious, have been 
 recommended, and among them protracted rest, and decubitus ; par- 
 
IN THE USE OF THE PESSARY. 
 
 151 
 
 ticularly observing to keep the pelvis elevated higher than the shoul- 
 ders ; the use of pessaries, gradually reducing the size of the instru- 
 ment; aromatic and astringent injections; cold bathing; sachets 
 filled with tan and soaked in rough wine ; and lastly, the tampon, 
 composed of styptic and astringent materials. 
 
 Some authors, particularly M. Delloir, have recommended a sub- 
 sequent pregnancy as an excellent means of obtaining a radical cure 
 of hysteroptosis ; without adopting absolutely the opinions set forth 
 upon this point, we think that the increase of the volume resulting 
 from gestation, could be of no avail, unless the patient should con- 
 sent to maintain a horizontal position during the first five months of 
 the pregnancy; otherwise, we should look upon the state of preg- 
 nancy as an hurtful and even dangerous one. Besides, we must 
 wait until experience and facts shall enable us to speak more confi- 
 dently of the value pf M. Delloir’s recommendation. 
 
 [I look upon it that many women recover from very troublesome prolapsus, 
 by a succeeding pregnancy. I have seen women perfectly restored to health 
 after a pregnancy and lying-in, who had been much distressed by prolapsus 
 for some years before. — >M.] 
 
 In order to effect a radical cure, it has also been proposed to obli- 
 terate the vagina, by making the sides of the canal cohere, but as 
 the mucous membranes cohere very reluctantly, we think there would 
 be great difficulty in bringing about the result proposed. The diffi- 
 culties met with in the cure of recto and of vesico-vaginal fistulas, 
 justify our fears on this point; moreover, an acute, though factitious 
 inflammation of the vagina would not be wholly safe, and might lead 
 to very serious consequences. 
 
 Dr. Marshall Hall has published a case, in which he asserts that 
 he cured an almost complete prolapsus by means of an artificial con- 
 striction of the vagina. He removed a portion of the membrane 
 eighteen lines wide, from the top to the bottom of the vagina, and 
 united the edges by means of the interrupted suture. Prof. Duges 
 expresses a doubt as to the durability of success from this operation, 
 and thinks that, notwithstanding its constriction, the vagina may, 
 after all, be pushed downwards, dilated and prolapsed again by the 
 weight of the womb. We do not indulge in all the fears of the learned 
 Montpellier professor, particularly if care be taken to relieve the 
 engorgement of the womb, which is most generally the cause of its 
 prolapsion. Although this curative method is the most painful, yet 
 it appears to us to be, above all others, the most likely to lead to a 
 radical cure. One thing is certain ; the operation, the first idea of which 
 appears to have originated with M. Girardin, has been successfully 
 performed in France, by M. Berard, and in England, by Mr. Irving. 
 
 [It has been twice performed here, by Dr. William Poyntell Johnston. 
 The success was complete; but, in both instances, the disorder returned in 
 about six months. — M.] 
 
152 
 
 EXTIRPATION OP THE PROLAPSED WOMB, 
 
 EXTIRPATION OF THE PROLAPSED WOMB. 
 
 We shall finish our remarks upon this topic by stating that, on some 
 occasions, the more or less complete extirpation of the womb has 
 been successfully performed, where the prolapsed womb has been 
 found either in a state of gangrene or of cancerous degeneration. 
 This operation, to which, as Astruc* says, we must never resort 
 but in the last extremity, in evidenti mortis periculo, was anciently 
 practised with success, as related by various authors, as Aetius, t 
 Paul of Egina,J Berengarius Carpus, § J. Langius,|| Marcus Gattina- 
 ria,1F Ant. Benevenius,** Christophus a Vega, It Ambrose Par6,JJ 
 and many others too tedious to mention. 
 
 Soranus, who was distinguished among the ancient authors for the 
 fortunate temerity of his operations, recommends that the prolapsed 
 and putrified womb should be extirpated. “ If/’ says he, “the pen- 
 dant portion of the womb becomes ulcerated from the acrimony of 
 the urine and the uncleanness of the parts ; if it putrefies, extirpate 
 it without hesitation ; you are warranted by example to do so ; it has 
 been completely extirpated in some instances with the most perfect 
 success.” (Aetius, Tetrab. iv., Serm. 4. cap. 76; and Peyrille, Hist, de 
 la Chir. t. ii. p 2S2.) 
 
 The gangrenous prolapsed womb has also been removed by a sin- 
 gle ligature applied at the pedicle, or with a double ligature, each 
 comprising one half of the root of the tumour. This method, two 
 successful cases of which are given by F. Rousset,§§ has also been 
 practised by Newnham, Clarke, Marshall, Windsor, Recamier, and 
 by some other distinguished practitioners. Lastly, when the prolapsed 
 womb, in a state of disorganization, leaves no hope from any other 
 method of treatment, resort has been had to a ligature at the root of 
 the tumour, and the excision of all beyond it. This proceeding has 
 been successfully adopted by Carpus, by A. Pare, by Baxter, and by 
 Bernhard. 
 
 METHOD OF OPERATING. 
 
 Although the excision of the womb, which has been long in a 
 state of complete prolapsus, is a very terrible operation, viewed in 
 the light of its immediate or remote consequences, we shall proceed 
 to give a brief description of the different modes of operating em- 
 ployed for the purpose. 
 
 M. R6camier|||| begins with the vagina; then, his first incision 
 being made, he separates the celtular tissue with his fingers, until he 
 comes to the peritoneum : he next divides the upper two-thirds of 
 
 * Maladies des Femmes, liv. ii. t. iii. p. 409. j- Tetrabib., iv.,Serm. iv., cap. 76. 
 
 X Lib. iii. cap. 76, and lib. vi. cap. 6 & 22. § In Isagoge Anatomic:). 
 
 || Epist. Med., epist. 39. 1 Prat. Cap. de Exiiu Matricis. 
 
 ** Observ. Med., obs. ix. de Mirand Morb. Caus., cap. 12. 
 
 jj- Comment, ad Aphorism. IS. lib. viii. t+ LXXIV. cap. xxviii. 
 
 §§ De Partu Csesareo, liber, p. 393. |||| Rev. Med., 1825, t. iv. p. 393. 
 
EXTIRPATION OF THE PROLAPSED WOMB. 
 
 153 
 
 the ligaments, and, by means of Deschamp’s needle, passes a liga- 
 ture round the inferior third, which contains the uterine artery — and 
 finishes the operation by removing the organ. This mode, which 
 was adopted by MM. Recamier and Marjolin, upon a woman with a 
 bad prolapsion, and who also had a fungous cancer of the womb, was 
 followed by imperfect success ; for the patient died two months after 
 the operation. 
 
 Professor Delpech,* whose recent loss is so much to be deplored, 
 made use of this same operation in a female aged sixty-six : he pro- 
 ceeded as follows:— the patient having been placed as for lithotomy, 
 he first carefully divided the whole anterior wall of the vagina, 
 which had been attacked with cancer; then, after having cautiously 
 separated the anterior part of the rectum, which was also affected, 
 he removed the tumour, which was completely isolated; he applied 
 ligatures to the divided arteries, and filled the vacuum left betwixt 
 the remaining vaginal walls with fine sponge, for the purpose of 
 keeping them apart. 
 
 Langenbeck’s method differs from the above, in regard that that 
 able surgeon deems it useful to dissect the whole uterine peritoneum 
 off from without inwards, so that the serous membrane is not 
 wounded by the removal of the womb. This operation was done by 
 M. Langenbeck for a female affected with incomplete prolapsus uteri, 
 and with scirrhous degeneration of the womb, and was crowned with 
 the most perfect success, for the woman’s health was completely 
 restored. The removal of the womb by this method is so long and 
 difficult that we hardly think M. Langenbeck will find any imitators, 
 particularly as we are not convinced of the necessity for dissecting 
 off the whole of the peritoneum, that necessity not having been 
 demonstrated. 
 
 The removal of the womb by the ligature is very painful, and is 
 attended with a risk of there being comprehended within the ligature, 
 either the urethra, as in the case seen by Ruysch, or a loop of the 
 intestine, or even a portion of the urinary bladder. With a view to 
 render the extirpation less painful, and, at the same time, to secure a 
 more prompt separation, Faivre and Windsor both made use of a nee- 
 dle, armed with a double ligature, by which the neck of the tumour 
 was strangulated in two equal halves. If, notwithstanding all the ob- 
 jections we have mentioned, the operator should still desire to proceed 
 by the method of strangulation, we should think it better at once to 
 remove all the substance of the mass beyond the ligature, whether it 
 be a simple or double one, and not wait for a separation produced by 
 the ordinary sloughing process under the ligature. For fear of impli- 
 cating the bladder or an intestinal convolution, the pelvis ought to be 
 shaken before commencing the operation ; anc^ it should be elevated 
 upon a cushion, so as to be higher than the rest of the trunk. How- 
 ever, where the extirpation of the womb affords the only chance of 
 safety to the patient, we think the knife preferable to the ligature, as 
 being less painful and more prompt, and as offering, besides, a greater 
 
 t Memorial des Hopitaux du Midi., t. ii. p. 612 . 
 
154 
 
 ANTEVERSION AND RETROVERSION. 
 
 proportion of successful results than the other methods of ablation 
 that have been used. 
 
 OF ANTEVERSION AND RETROVERSION OF THE WOMB. 
 
 The terms anteversion and retroversion have been applied to those 
 cases in which the longitudinal axis of the uterus has been found 
 placed in a horizontal position. 
 
 As these two uterine displacements exhibit a close analogy to 
 each other, as far as regards their causes, symptoms and treatment, 
 we have thought it best to speak of them under one head, so as to 
 throw more light upon the subject and obtain more precision in 
 detailing the history of the cases by studying them together. 
 
 In anteversion of the womb, the fundus is borne towards the sym- 
 physis pubis, and the os uteri towards the sacrum. In retroversion, 
 the womb likewise becomes horizontal, but the fundus is lodged in 
 the hollow of the sacrum, and the mouth of the womb is carried to 
 the posterior surface of the symphysis of the pubis. 
 
 The writings of Hippocrates contain many passages, proving that 
 the deviations of the position of the womb had caught his attention ; 
 and it is not to be doubted that he was referring to retroversion of 
 the uterus, where he said, Si uteri ad medios lumbos fuerint, dolor 
 imum ventrem, deinde crura detinet ; cumque ventris onus deponit, 
 acutiores suboriuntur, stercusque non nisi vi progreditur, urina gut- 
 tatim fertur, et animo linquitur, &c.* 
 
 In the fragments extracted from the works of Aspasia, ( De reclina - 
 tione'ciscens. et recurs, uteri,) preserved by Aetius,t we find her 
 speaking very distinctly on the subject of retroversion, for which she 
 indicates a rational mode of treatment, which we shall make known 
 presently. 
 
 In his work on the diseases of women, published in 1604, Rod. 
 a Castro, a Portuguese Jew physician, who studied at Salamanca, 
 and afterwards emigrated to Hamburg, where he died, gives us an • 
 imperfect version of the remarks of Hippocrates and Aspasia upon 
 retroversion of the womb. Israel Spach, who was professor at 
 Strasburg, and collected all that had been written previous to his 
 time, on female complaints, likewise speaks of uterine displacements, 
 in his work, published in 1597, under the title of Gynceciorwn , Sive 
 de Mulierum , Jlffcctibus et Morbis. Since the days of these 
 
 authors, Gregoire, a Paris surgeon, was the first to speak particularly 
 of retroversion and anteversion. He taught these displacements in 
 detail, to the pupils of his course on midwifery ; and it was, in 
 fact, to the lectures of this professor, that Walter Wall, the English 
 surgeon, was indebted for his first notions on the displacements of 
 the womb. Upon returning to his own country, he was consulted, 
 in 1754, for a case of retroversion. He recollected the precepts of 
 Gregoire, and requested the celebrated Hunter to assist him with his 
 counsel ; notwithstanding which, the patient sunk on the eighth day. 
 
 * De Natur. Ma). Op., t. ii. p. 542. Ed. Kultn. 
 f Tetrabib., i\\, Serm. iv., pp. 76 and 77. 
 
ANTE VERSION AND RETROVERSION. 
 
 155 
 
 Hunter, considering this affection to be worthy of the regard of 
 the profession, made it the subject of a monograph, which he pub- 
 lished in 1770, in the 4th vol. of the Med. Obs. and Inquiries , and 
 gave it the name of retroversion , which has been ever since gene- 
 rally adopted. Walter Wall and Syme called it hernia uteri. Levret 
 designated it as renversernent transversal ; and Desgranges, as in- 
 cubation. 
 
 Since the publications of Hunter and Syme, a multitude of writers 
 have put forth their observations upon the subject, as Levret,* 
 Wlzezech,t Wall,J Desgranges, § whose memoir was crowned in 
 1783, by the Academy of Surgery ; Fred. Jahn,|| Cockell,1[ Murray,** 
 Baudelocque,tt Merriman,ff G. I. Schweighauser,§§ Schmidt, |||| and 
 Ameline.lFIT There are a great number of observations published 
 in various collections, from Richter,*** Garthshore, Bird and Hoop- 
 er, ttt J. Clarke,tfl Klein, §§§ Schneider,|||||| Kirshner,innr Brun- 
 ninghausen,**** Hervez de Ch6goin,tttt Madame Boivin and M. 
 Duges;±ff ± by M. Bazin de Basseneville ;§§§§ and by other persons 
 whom it is needless to cite. Both anteversion and retroversion may 
 take place in the non-gravid womb, and also during pregnancy; but, 
 in general, the deviations in question, and which are always more 
 considerable in the retroversion, cannot take place later than the 
 fourth month of pregnancy, because, at that period, the longitudinal 
 diameter of the organ exceeds the antero-posterior diameter of the 
 pelvis. 
 
 Anteversion of the womb, though very rare in pregnancy, is of pretty 
 frequent occurrence in the non-gravid female. Retroversion, on the 
 other hand, has most frequently been met with in pregnant women. 
 Frederick Jahn did not admit that retroversion could be complete 
 except in pregnancy ; but Levret and Saxtorph proved by very well 
 ascertained cases that it may occur not only in women who have 
 never had children, but even in the virgin. Dr. Schweighauser, of 
 Strasburg, met with forty-four cases of retroverted womb: thirty-five 
 
 * Remarques sur les Deplacements de la Matrice. Ancien. Jour, de Med., t. xl. 
 
 f De Utero Retroflexo, 1777. t Diss. de Uteri Retrovers., 1782. 
 
 § Journ. de Med., t. lxvi. p. 85. ]| De Utero Retroverso, 1787. 
 
 U Essay on Retroversion of the Uterus, 1785. 
 
 ** Uteri Retroversionum Animadversiones, 1797. 
 
 ft Du Renversernent de la Matrice, 1803. 
 
 ft On Retroversion of the Womb, 1810. §§ Aufsaetze fiber einige, &c., 1817. 
 
 HU Bemerkungen undErfahr.; i. e., Observations and Experiments on Retroversion. 
 Vienna, 1820. 
 
 UU Diss. sur 1’ Anteversion. Paris, 1827. No. 55. 
 
 *** Chirurg. Biblioth., b. v. p. 521 ; b. ix. p. 182. 
 
 -f-ff Med. Obs. and Inquir., t. iv., v. andvii. 
 
 fft Pract. Essay on the Management of Pregnancy and Labour. 
 
 §§§ Chirurg. Bemerkungen, p. 235. ' III II Chirurg. Biblioth.. Richter, 1791. 
 
 Stark’s Archiv. fur die Geburtshulfe, b. iv. st. 3. 637. 
 
 **** Journal de Siebold, b. iii. st. 1. ann., 1819. 
 
 •fj-j-f- Mem. de l’Acad. de Med., t. ii. 319, 1833. 
 
 tttt Traite des Mai. de l’Uterus, 1833. 
 
 §§§§ Mem. sur la Retroversion. Annales franc, and etrangeres, d’Anat. and de 
 Physiol., Mars., 1837. Paris, Levrault. 
 
156 
 
 ANTE VERSION AND RETROVERSION. 
 
 were in women not pregnant, and only five were met with in gravid 
 females. Among the thirty-five mentioned there was one female 
 seventy-two years of age; one ease was noticed following delivery, 
 and one wa£ in a virgin with the hymen perfect. Dr. Bazin de 
 Basseneville, who has given these results from Schweighauser, has 
 likewise published in the Jlnnales Francaises etrcing&res d?Anat. 
 et Physiologie (March 1837) several cases of retroversion, in women 
 without children or virgins. Most of these cases, endowed with all 
 desirable authenticity, are taken from the practice of Messrs. Brun- 
 ninghausen of Wurtzburg, Schmitt of Vienna, Schneider of Balby, 
 and Kirschner of Poeneck ; and, in fine, the Treatise on diseases of 
 the womb by Mad. Boivin and M. Dug6s contains three cases of retro- 
 version in patients not gravid. The displacement therefore is not so 
 rare in non-pregnant women as it has been supposed to be. 
 
 Both anteversion and retroversion may take place either gradually 
 or suddenly. In the first case, the symptoms are slight in the beginning, 
 and daily increase in severity, following, in this respect, the progress 
 of the accident ; but in the second case, the deviation of the womb is 
 accompanied at once with alarming symptoms, particularly if it be a 
 retroversion. The causes that predispose to gradual displacements 
 are a natural mobility of the womb, a certain smallness of the pelvis, 
 a deep curvature of the sacrum, a decided prominence of the sacro- 
 vertebral angle, the gentle and prolonged pressure of the bowels upon 
 the fundus and on one of the surfaces of the womb. The symptoms 
 that supervene have less reference to the extent of the deviation than to 
 the volume of the womb as compared to the antero-posterior diameter 
 of the pelvis. Supposing the womb to be non-gravid, and the cavity of 
 the pelvis of the ordinary dimension, if the displacement takes place 
 gradually, the patient begins to feel an inconvenient sense of pressure 
 within the pelvis ; then the groins, the loins, and thighs, are affected 
 little by little with dragging pains, which become more and more 
 annoying. Soon after this the signs of inflammation of the womb 
 become manifest, and the suffering more acute; the catamenia become 
 disordered, either increasing or diminishing in quantity; a leucorrhoea, 
 which in some instances is bloody, flows during the intervals between 
 the menses ; the digestion is deranged ; the appetite is lost ; the woman 
 grows thin, and her strength diminishes. At length a fever sets in, 
 which, in some cases, is of a high grade and of a continued type; but 
 in others, slight, and characterized only by heat of the skin, and by 
 agitated evenings and nights. If the cessation of the menses takes 
 place naturally, the woman being at the change of life, the uterine 
 deviation may cease to have any influence on the constitution ; and 
 in many, the symptoms gradually lessen, because the womb has 
 diminished in size by losing a portion of its vital properties. 
 
 To the symptoms above mentioned, there is always added a sense 
 of pressure or weight at the bladder and rectum, giving rise to fre- 
 quent desire to urinate and go to the close stool. During the flow 
 of the urine, the jet is soon checked or suddenly arrested, and as the 
 displacement always increases in proportion to the efforts made to 
 expel the urine and faeces, the symptoms are greatly augmented in 
 
ANTEVERSION AND RETROVERSION. 
 
 157 
 
 intensity by those attempts. At length a complete suppression of 
 urine and stool is produced. In cases where the size of the womb is 
 augmented by pregnancy or by engorgement of the organ, the symp- 
 toms are less equivocal, the constipation and suppression of urine 
 becoming complete in a very short time : this is most likely to happen 
 between the third and fourth months of pregnancy. However, from 
 a case published by Smellie;* from that given us by Hunter,! and from 
 Meckel’s case, related by Voigtel,± the term at which a deviation is 
 possible may be stated to be as late as the fifth month. A case is 
 related from Barlett,§ of retroversion at the seventh month. This, 
 and the case related by Merriman,|| who thinks he has met with 
 several samples of this deviation even at the end of pregnancy, were 
 doubtless samples of posterior obliquity of the womb which have been 
 long understood under the title of sur-pubal positions or posterior 
 obliquity of the foetus ;1F or perhaps they were extra-uterine preg- 
 nancies with the foetal sac pushing the womb upwards, out of reach 
 nearly of the index finger. 
 
 Inasmuch as the long diameter of the womb, at the end of the fourth 
 month, equals or even exceeds the antero-posterior diameter of the 
 pelvis, it follows, not only that the displacement cannot happen after 
 that period, but that where it has already existed for some time, the 
 rectum, the neck of the bladder, and the urethra must be compressed; 
 and that the womb, locked up within the excavation, and moulding 
 itself against the resisting surfaces, becomes engorged and inflamed ; 
 thus aggravating the already dangerous symptoms of retroversion. 
 
 Where the retroversion takes place suddenly, it is almost always 
 caused by the violent and sudden contraction of the abdominal mus- 
 cles and diaphragm, such as those that occur in the act of vomiting 
 or in the expulsion of the urine and stool; such as arise from exter- 
 nal violence, as a fall, a blow, strong compression of the hypogaster** 
 or a sudden frighttt causing a violent convulsive movement of the 
 diaphragm. 
 
 It is easy to understand why the displacement of the womb is much 
 more rapid in its progress, and followed by severer consequences, 
 in women that are pregnant. But, inasmuch as the anteversion of 
 the womb is exceeding rare during gestation, we must be content 
 with adding to what has already been said, merely the characteristic 
 signs of retroversion in pregnant females. 
 
 The causes we have mentioned as sufficient to bring about the 
 accident in the non-gravid female, always act with greater force upon 
 such as are pregnant. According to Hunter, Denman, Merriman, 
 
 * Treat, on Mid., vol. ii. p. 150. t Icon. Uteri Ham. Crav. 
 
 * Desormeaux, Diet., 21 vol., article Uterus, p. 130. 
 
 § Bib. Med., lxxvi. p. 125. 
 
 || A Synopsis of Various Kinds of Difficult Parturition, p. 66 and 244. 
 
 t Prat, des Accouch. de Mad. Lachapelle, t. iii. p. 295. 
 
 ** Desgranges of Lyons in his memoir, which was crowned by the Acad, of Sur- 
 gery, relates a case of retroversion caused by the pressure of a kettle full of wet 
 clothes. 
 
 ft In the fourth volume of the Med. Obs. and Inquiries, Hunter gives us the history 
 of a young woman who was attacked suddenly with the symptoms of retroversion in 
 consequence of a great fright. 
 
15S 
 
 ANTE VERSION AND RETROVERSION. 
 
 Callisen, Boer and Sibergundi, the retention of the urine in the blad- 
 der is the most common cause of the displacement in question. This 
 symptom, which, indeed, is, in pregnancy, one of the first that an- 
 nounces the existence of retroversion, may be, at the same time, both 
 a cause and an effect of the accident, and it is difficult to decide 
 whether it be the distension of the bladder that causes the womb to 
 see-saw backwards by raising its os uteri upwards, or whether the 
 gravid organ, sinking by its own weight or any other cause, allows jt 
 to compress the neck of the bladder and urethra, and thus prevent 
 the escape of the urine. 
 
 When retroversion happens in a pregnant woman, the orifice of the 
 urethra is retracted so much behind the pubis that it becomes diffi- 
 cult to find the meatus, and the urethra is so forcibly pressed against 
 the bone that it is for the most part impossible to pass up a catheter, 
 even a flat one. The escape of the urine, which now and then takes 
 place by regorgement, is, in most cases, completely suppressed, so that 
 the distension of the badder may be carried even to the extent of 
 bursting the organ, as in the samples reported by Smellie, Vandoe- 
 veren and Syme. 
 
 The rectum is also so much compressed that the smallest portion 
 of stercora.ceous matter cannot escape through the intestine; and the 
 patient is unable to receive enemata. Coincidently with these symp- 
 toms, there is found a painful tumefaction of the external genitals ; 
 and in performing the touch per vaginam, the womb is found, as we 
 have already shown, higher up than usual ; the anterior wall of the 
 vagina being very tense, while the posterior one is relaxed, and even 
 puckered. The contrary would obtain in case of anteversion. 
 
 The size of the womb continuing to increase with the progress of 
 the pregnancy, the viscus is soon attacked with inflammation : the 
 organ being now locked betwixt the sacrum and pubis, is so power- 
 fully compressed, in some instances, that after death it cannot be 
 extricated without dividing the pubis. (Levret. ) In these dreadful 
 cases, the inflammation exteuds along the peritoneum to the bladder 
 and up to the reins, and death has followed either from these exten- 
 sive inflammations, or from the rupture of the uterus itself, or the 
 giving way of the bladder. Yet the case has been known to have 
 a favourable termination, even where the patient has been aban- 
 doned to the powers of nature alone ; the pain compelling the patient 
 to keep her bed, the womb has reposited itself, all the symptoms disap- 
 pearing, and the pregnancy has gone on to its full term. In some rare 
 instances, abortion has taken place after the spontaneous reposition; 
 but it generally precedes the reposition, and allows it to take place. 
 
 The augmented weight of the womb, and a certain relaxation of 
 its ligaments being the most ordinary causes of its vertical deviations, 
 it would seem surprising that anteversion is not like retroversion, 
 most common in pregnant women. The explanation of the infre- 
 quency of the former and the frequency of the latter or retroverted 
 state, is naturally found in the difference introduced by gestation into 
 the relation of the parts. In fact, the posterior wall of the uterus, 
 which, in the non-gravid state, is more convex than the anterior one, 
 
ANTE VERSION AND RETROVERSION. 
 
 159 
 
 really dilates in pregnancy more rapidly than the anterior face, so that 
 the fundus uteri naturally tends to follow the heaviest portion, which 
 drags it downwards, that is to say, backwards, unless it is stopped by 
 impinging on the face of the sacral curve. This is the reason why one 
 of the principal predisposing causes is ja too deep concavity of the 
 sacrum. Another anatomical arrangement, which also tends to pre- 
 vent the occurrence of anteversion in pregnancy is, that the auterior 
 face of the womb, as it becomes more and more convex, encounters 
 the symphysis pubis, and thus has a point d'ctppui , which tends to 
 repel the organ in a backward direction. It is easy to understand 
 the mechanism of retroversion, and the infrequency of anteversion 
 during gestation, by reflecting that, on the one hand, the greater 
 weight of the posterior wall of the womb draws the organ down 
 towards the sacrum, and that, on the other hand, the retroversion 
 takes place only because the cavity of the sacrum is excessive, allow- 
 ing the womb to be jammed into it, either by a distended urinary 
 bladder, or by the appui of the os uteri against the symphysis of the 
 pubis; the. broad ligaments, becoming shorter and shorter, should 
 tend to hold up the body of the womb in the excavation, but the 
 sacro-vertebral angle hinders its rise, and compels the fundus to 
 incline backwards, and lodge at last in the hollow of the sacrum. 
 
 [I have met with a very considerable number of cases of retroversion of 
 the womb, and though familiarly conversant with medical affairs for more 
 than thirty years, I have not been able to meet with more than one single 
 decided sample of anteversion of the organ. As I do not altogether agree 
 with our author in the views he has presented us under this head, I shall 
 take this opportunity to express, very briefly, my own opinions upon the 
 subject. 
 
 I should judge, from the great number of cases for which I have been 
 consulted — cases coming to me from nearly every State in the Union — that 
 great suffering is by many persons endured, under the idea that the patient 
 has either a prolapsus, or an irritable uterus, or some derangement called 
 disorder of the womb, and which is supposed to be curable by rest, or 
 tonics, or sea-bathing; but which, in fact, can be cured only by the reposi- 
 tion of the dislocated organ. By inspecting the organs in situ naturally on 
 the anatomical subject, it may be clearly seen that the fundus uteri has a 
 very free vibration backwards and forwards ; and that it is only restrained 
 from falling quite down, backwards, by the ligamenta rotunda, which, coming 
 off from the angles of the uterus, and being inserted on the front of the pelvis, 
 cannot permit a retroversion to take place, unless they are morbidly relaxed 
 and extended. A woman who has a very large pelvis, and who allows her 
 bladder to become enormously distended, will be always liable to retrover- 
 sion during such distension, especially upon the occurrence of any sudden 
 effort or succussion of the abdominal muscles — as in a fit of sneezing, cough- 
 ing, or laughter. A jump from a carriage-step, or a chair, or a trip on the 
 pavement, while the womb is pushed backwards by the full bladder, may 
 
160 
 
 ANTEVERSION AND RETROVERSION. 
 
 suddenly and even instantly jam the uterus under the promontory of the 
 sacrum, which, introducing a tenesmic feeling, is followed by bearing down 
 efforts, every repetition of which aggravates the mischief. If the woman 
 be non-gravid, perhaps she will empty the bladder, and the womb, raised 
 upwards again by its anterior chords — its round ligaments — is not suspected 
 to have been retroverted ; but, if she be pregnant at two and a half or three 
 and a half months, and the fundus be once jammed below the promontory, 
 it will probably remain there, even after the bladder shall have been perfectly 
 emptied by the catheter. I have seen it remain so after the most complete 
 evacuation of the urinary bladder, by the catheter. Let the reader think, 
 for a moment, that, when the bladder of urine fills, it fills and distends back- 
 wards, not upwards; but it cannot contain a pint measure of urine without 
 pushing the fundus backwards ; and when the bladder can retreat no further 
 in that direction, if the distension goes on, it rises upwards in the belly, 
 towards the umbilicus, pushing the hvpogaster outwards, whose curve is 
 visibly augmented thereby. 
 
 Let a woman two and a half months gone, get into a stage, or rail car, 
 having neglected to empty the bladder beforehand ; if she sets off on her 
 ride with eight or twelve ounces in the organ, and is prevented for some 
 hours from relieving herself, she will hardly reach her journey’s end with- 
 out having retroversion ; and when she attempts to relieve the bladder, is 
 found to labour under a total suppression of urine, or, at least, a most 
 painful dysury. I have seen such cases. 
 
 A woman who has the habit of permitting large accumulations to take 
 place in the bladder, can hardly fail, in the long run, to relax and overstretch 
 her round ligaments so much as to render them at last useless to her. I am 
 acquainted with more than one lady, whose round ligaments are so loose and 
 useless, that the womb falls over into the hollow of the sacrum, from the 
 slightest effort that she makes. I have had to reposit it many times, and, in 
 doing so, have found the fundus turned quite down to the lower third of the 
 sacrum. I do not think the weight of the superincumbent bowels has, in 
 general, much, if any thing, to do with producing retroversion. I look upon 
 it rather as a case of relaxed round ligaments, and suppose that if there were 
 any surgical means of shortening them, the womb, even one qiost prone to 
 retroversion, would thereby be deprived of the liability to become retro- 
 verted ; unfortunately we possess no such means. There can be little reason 
 to doubt of the contractility of the round ligaments : certainly they seem, in 
 some persons, to be at one time so relaxed as to allow the uterus to fall 
 backwards with the greatest facility, and then they retain it for months in its 
 natural situation ; after which, they again permit the retroversion to take place 
 again and again ; to be succeeded by a period in which they are strong enough 
 to prevent it, perhaps, during the remainder of the woman’s lifetime. 
 
 In retroversion, the os tincae is drawn upwards behind and even above 
 the lop of the symphysis pubis. This state of the os uteri is attributable 
 
ANTE VERSION AND RETROVERSION. 
 
 161 
 
 partly to the fact that the fundus, resting upon the lower portion of the 
 sacrum, compels the other end of the organ to rise into the situation above 
 mentioned; and this especially in such as have a gravid or otherwise 
 enlarged womb. It should be remembered here that the pelvis, measured 
 in an antero-posterior direction from the top of the symphysis to the lower 
 third of the sacrum, is at least four and a half inches in length, but the 
 womb itself is not more than three inches or three and a half inches in 
 length* Hence, when the os uteri is forced up in the situation mentioned, 
 it must be either because the womb is enlarged by pregnancy or by disease, 
 or else because it is strained upwards in that direction by the contraction of 
 its overstretched round ligaments, which are now nearly parallel with the long 
 diameter of the organ. Women, under retroversion, do certainly feel much 
 pain in the groins and pubis from the strain on the ligamenta rotunda. I am 
 very sure that a person in whom these ligaments are still in a healthful and 
 natural stale of tone will be extremely unlikely to have a retroverted womb; 
 and that, where the accident has happened, it will be only necessary to give 
 a slight help towards the reposition to make the ligaments draw the fundus 
 upwards and forwards again, and retain it in situ nalurali when once repo- 
 sited. — M.] 
 
 The mechanism of anteversion of the womb is extremely simple, 
 and so much the more easily understood as the deviation is merely 
 an exaggeration of the natural inclination of the womb. As the 
 fundus uteri always inclines to the front when the bladder is empty, 
 the slight anteversion which follows the evacuation of the bladder pro- 
 duces no inconvenience, and is not in the least degree a morbid state, 
 and is promptly repaired upon the filling of the bladder again. Not 
 so, however, when the weight of the womb is increased, in conse- 
 quence of an engorgement of the fundus or of its anterior wall, for 
 then the ligamenta lata, being constantly stretched, give way by 
 degrees, until at length, whenever the woman stands up, the fundus 
 uteri presses itself against the bladder, whose walls are compressed 
 together behind the symphysis pubis, while the os tincse is pointed 
 backwards, and presses with greater or less force upon the rectum. 
 This displacement is farther increased by the weight of the viscera, 
 which always rest upon the posterior paries of the womb, which now 
 ceases to have a vertical, in order to assume a horizontal position in 
 the pelvis. 
 
 Nevertheless, anteversion may, in some instances, take place inde- 
 pendently of any engorgement of the womb, for the repeated efforts 
 of a painful labour, of vomiting, of constipation, of sexual union 
 with disproportion, and in fine, great fatigue and violent shocks, all 
 such circumstances have been found to act as occasional causes. The 
 morbid adhesions that take place in utero-peritoneal inflammation, 
 may also, by the power of their retraction, cause the womb to incline 
 forwards, and keep it immovably fixed in that position. The symp- 
 toms already described, as following in the train of uterine displace- 
 ments, are not sufficient for the establishment of a clear diagnosis, 
 11 
 
162 
 
 ANTE VERSION AND RETROVERSION. 
 
 since most of them are common to both the cases, i. e., the antever- 
 sion and the retroversion ; and may, indeed, be met with in some 
 cases of mere descent or prolapsion of the womb. It is only by 
 Touching that we can ascertain both the degree and the kind of devia- 
 tion that has taken place. If the patient be placed in a standing posi- 
 tion, we may discover, with the index, a sort of tumour just within the 
 vagina, that seems to fill up the cavity of the pelvis. This tumour 
 is the womb itself, and it is the anterior or posterior surface that we 
 touch, according to the nature of the deviation. In anteversion, we 
 touch the anterior face ; the fundus being diverted towards the sym- 
 physis, and the os tineas to the sacrum. If, on the other hand, the case 
 be one of retroversion, the womb presents its posterior surface to the 
 touch, the fundus resting upon the lower part of the sacrum, while 
 its orifice presses on the pubic symphysis. If we touch per rectum , 
 we encounter a tumour composed of the fundus or os uteri depress- 
 ing the gut. In using the catheter, which it is often difficult to do, 
 we discover against the posterior wall of the bladder the solid and 
 fleshy body, before detected by means of the fingers, and which gives 
 rise to a sensation like that occasioned by the touching of a scirrhus, 
 or of an encysted calculus in the bladder. Levret* confesses that he 
 mistook an anteversion of the womb for a case of encysted calculus 
 of the bladder ; and he did not discover his error until after he had 
 performed an operation for lithotomy, which was followed by the 
 death of his patient, when, by an examination of her body, he found 
 that she really had suffered from anteversion of the womb. 
 
 The position of the os uteri in the pelvis, as being in this or in that 
 situation, points out the nature of the existing displacement, but its 
 being at such or such a height in the excavation does not enable us 
 to judge exactly as to its degree. In fact, we may, in some cases, 
 very readily touch the os tincse with the point of the index, although 
 the retroversion has been carried to the extremest degree, because, as 
 Baudelocque remarks, the cervix uteri is liable to be bent in certain 
 cases like the neck of a retort. 
 
 A fibrous or an encysted tumour, or a pregnancy developed within 
 the substance of the uterine paries, might be confounded with a dis- 
 placement of the womb ; but Touching, whether vaginal, rectal or 
 hypogastric, ought to enable us to decide upon the existence of a dou- 
 ble tumour in the former case or an extraordinary magnitude of the 
 uterus in the latter. However, an inflammatory swelling of the 
 womb might, in some cases, lead us into mistakes. Professor De- 
 sormeauxt informs us that two London physicians had mistaken the 
 one for a morbid tumour, and the other for a simple displacement, a 
 retroverted womb in which the fundus was affected with inflamma- 
 tory swelling that deceived the English practitioners. Dr. Demnanf 
 also says that a tumour, and particularly a serous cyst or an acephalo- 
 cyst, situated betwixt the vagina and rectum, filling up the cavity of the 
 pelvis, depressing the gut the vagina and bladder, may be mistaken for 
 retroversion; but if the tumour coincides with a somewhat advanced 
 stage of pregnancy, it is quite easy to eschew all mistakes on that point, 
 
 * Journ. de Med., t. xl. p. 269. -J- Diet, de Med., t. 21. p. L27. 
 
 \ Introd. to the Pract. of Med. 
 
ANTE VERSION AND RETROVERSION. 
 
 163 
 
 because we readily learn, by means of the hypogastric Touch, that the 
 womb contains the product of a conception : in the non-gravid state 
 the diagnosis would be more difficult; but, as has been observed by 
 Madame Boivinand M. Duges, by touching the orifice of the womb, 
 we are enabled to ascertain, by its direction and mobility, the mutual 
 independence of the organ and the tumour, which, by the way, is not 
 always found upon the median line, and besides, always presents lumps 
 and asperities that are rarely to be found upon the merely deviated 
 womb. Messrs. Bellanger and Lallemand* have related several cases 
 of retroversion that had been mistaken for peritoneal dropsies ; the 
 abdominal distensions and fluctuation having been caused by the 
 accumulation of urine in the bladder, whence it escaped in but 
 very small quantities. By means of the operation of Touching and 
 the use of the catheter, it is easy to dissipate all uncertainty in such a 
 case, and point out the nature and situation of the fluid. 
 
 All other things being equal, the symptoms arising from retrover- 
 sion are more severe than those resulting from an anteversion ; but in 
 either case, the prognosis is so much the more unfavourable as those 
 symptoms are more decided and of longer standing, and as the womb 
 is more or less closely compressed within the pelvic cavity. 
 
 The treatment of anteversion and retroversion offers for its fulfil- 
 ment a variety of indications, consisting not only in the reposition of 
 the organ and the maintenance of it in its natural situation, but also 
 the removal of those obstacles that might render useless every attempt 
 to reposit the womb ; and further, to remedy such accidents as may 
 have arisen from a prolonged displacement, or from antecedent 
 attempts at reduction. 
 
 When the case of deviation is one of long standing and considerable 
 in degree, we should, before proceeding to the reposition, try to remove 
 the inflammatory symptoms by means of general and local blood-let- 
 ting ; by baths and mucilaginous injections. It has often happened that 
 the judicious employment of antiphlogistics has made it possible to 
 effect a reduction, in which all preceding attempts had proved so una- 
 vailing as to lead to the conclusion that reduction was impracticable. As 
 the alvine and urinary discharges are always more or less obstructed, 
 attention should invariably be paid to the re-establishment of a free 
 course to both these evacuations, with a view to remove, as far as pos- 
 sible, every obstacle to the rise of the womb. The use of the catheter 
 and the evacuation of the rectum, or the discharge of the urine by Bau- 
 delocque’s method, which consists in raising up the os uteri, have, in 
 many cases, been sufficent to allow the organ to resume its natural 
 position. Where the retraction of the meatus urinae upwards and 
 backwards, and the flattening of the urethra should happen to render 
 the introduction of the catheter difficult, recourse ought to be had 
 to Segrot’s flat catheter, which may be introduced by turning its con- 
 cavity backwards, and at the same time taking care to push away 
 the os uteri where it compresses the canal of the urethra, which may 
 be done by passing the finger upwards betwixt the symphysis pubis 
 and the womb. 
 
 * Revue Med., t. i. p. 191, arm. 1824. 
 
164 
 
 ANTE VERSION AND RETROVERSION. 
 
 Alarmed at the difficulties experienced in introducing the catheter 
 in certain cases, both Syme and Dussaussoy advise that the bladder 
 should be punctured below the pubis, and Sabatier himself has laid it 
 down as a formal precept for cases where the catheter cannot be 
 applied. After the bladder is emptied by either of the methods now 
 mentioned, rest and suitable posture may suffice to enable the reduc- 
 tion to take place spontaneously, especially if the rectum have been 
 emptied by means of enemata, which, unfortunately, can be done 
 only in a few cases. 
 
 To reduce the womb, the patient should be placed in a proper 
 position; — she ought to lie upon the back in such manner as to allow 
 the muscles of the belly to be as much relaxed as possible; upon 
 which, an attempt ought to be made to restore the organ to its position 
 by drawing upon the os tincae with the finger bent into a hook shape, 
 wheiher it be turned towards the sacrum or above the top of the sym- 
 physis pubis. Should this measure fail of success, let two fingers of 
 the left hand be carried into the rectum in order to push up the fun- 
 dus with them, while with one or two fingers of the other hand 
 passed into the vagina, we try to pull the cervix downwards. In case 
 we cannot reach the os tincae we should endeavour to draw it down 
 with the spoon-shaped instrument of Mad. Boivin, or with the one 
 which we designed for the same purpose, and which we think more 
 convenient. — ( Vide fig. 8, p. 68.) Should all these attempts fail of 
 the desired success, let the woman place herself upon her knees and 
 elbows, because, in this situation, the abdominal viscera press with 
 less force upon the rectum, and by their own displacement, favour 
 the rise of the womb, while the surgeon endeavours to unlock.and 
 disengage it from the cavity of the pelvis. 
 
 Should all these means prove ineffectual, we might follow the plan 
 of Dussaussoy, formerly chirurgien-major of the Hotel Dieu, at Lyons, 
 which was to introduce the whole hand into the rectum* and then 
 push up the body of the womb, which would more readily yield to 
 this attempt, if assisted by a couple of the fingers within the vagina, 
 and acting simultaneously upon the cervix. Should the fingers not 
 find a sufficient hold, the surgeon ought to pass into the bladder a 
 strong catheter, flattened at its vesical extremity, to be made use of as 
 a lever to depress the os uteri, by acting on it from the interior of the 
 bladder, while the fingers, introduced at the same time into the rec- 
 tum, aid in elevating the fundus uteri. This is the plan adopted by 
 Messrs. Bellanger and Lallemand. It has often happened that, in 
 cases where all other means have failed, the womb has been disen- 
 gaged by the see-saw movement effected as above described. It 
 ought to be observed that, for the most part, the first attempt, par- 
 
 * A measure that assists considerably in the dilatation of the rectum, consists in 
 introducing into the bowel, several times before the commencement of the attempt, 
 a suppository of beurre de cacao , either simple or combined with extract of bel- 
 ladonna, in the proportion of one grain of the latter to twenty of the former. The use 
 of this means, which is also very efficacious as a remedy for constipation, produced 
 by constriction of the sphincter, facilitates the introduction of the fingers and the 
 enlargement of the anus, while it lessens the pain arising from the distension of the 
 bowel. 
 
ANTE VERSION AND RETROVERSION. 
 
 165 
 
 ticularly in the case of ante version, succeeds in restoring the womb to 
 its natural position. 
 
 [In certain cases of extreme difficulty encountered in the attempt to reduce 
 the retroverted womb while the patient was lying upon the side or the back, 
 I have readily effected the reposition, upon directing the woman to place her- 
 self upon her knees, with the thighs at right angles to the bed and perfectly 
 vertical, while the top of the thorax, or rather the sternum, should be in contact 
 with the mattress. In such a position, not only is the weight of the viscera 
 taken off, but what is of greater consequence, the power of tenesmic resistance 
 is wholly abolished, while the position favours, in the highest degree, the 
 reposition of the womb. In this posture the woman cannot bear down. I 
 consider such a position as favouring the reduction in a degree far greater than 
 the large bleedings recommended by Dr. Dewees, who bled ad deliquium for 
 the purpose of abolishing the tenesmic power, or the power to bear down, 
 which he considered as one of the chief obstacles to success. In such a posi- 
 tion the surgeon can hardly fail of success, except in cases where reduction 
 is rendered impossible from adhesions contracted in consequence of a long 
 chronic state of retroversion — such cases are to be held as incurable. — M.l 
 
 Where the reposition has been effected and the womb is non-gravid, 
 all that is necessary to prevent a relapse, is to make the woman keep 
 herself in a horizontal posture for several months, to be followed by 
 river or sea-bathing and the use of ascending douches, composed of 
 tonic decoctions, and especially of the sulphurous waters of Bareges. 
 If the disorder were of a very ancient date, and should have reached 
 a certain stage, all these means might be unavailing, and we should 
 be compelled to have recourse to pessaries, especially the pessary en 
 bilboquet , which, receiving the os uteri within the cupel, might lix it 
 in the centre of the pelvic excavation, and compel the fundus to 
 remain in its natural situation. Bilboquet pessaries, when well ad- 
 justed by their stems, by means of a girdle and straps, are least apt 
 to be displaced, and are more sure to prevent a retroversion than 
 any other pessary, which, for the most part, repel the whole organ, 
 and keep it up, but do not so well keep it in its natural attitude. 
 
 Instead of placing a pessary in the vagina, Aspasia (Aetius, loc. 
 ci tat .,) proceeded to the treatment of retroversion in the following 
 manner ( at vero , aversionem versus anam ita curabimus) : She 
 advised the midwife (obstelrix) to introduce a finger into the rectum 
 and push the womb forwards. She next introduced permanently 
 into the rectum a large bougie, (g tandem ,) of the length of four 
 inches, to the end of which a string was attached for the purpose of 
 extracting it readily. She then ordered oily injections for both the 
 rectum and vagina. For the fulfilment of the indication laid down 
 by Aspasia, i. e., to keep the womb reposited, use has been made of 
 sponges, either alone or attached to straight or curved stems, and 
 placed in the gut, or in the vagina, as well as other means mostly 
 inefficacious. Professor Desormeaux, with a view to attain the same 
 end more simply and certainly, proposed the introduction of a ring- 
 
166 
 
 ANTE VERSION AND RETROVERSION. 
 
 pessary of caoutchouc to be placed behind the cervix uteri ; but this 
 plan has been used in vain by several practitioners, and, among 
 others, by M. Nauche. The vagina-shaped pessary, denominated by 
 M. Cloquet the elytroid pessary, or Rognetta’s 
 cylindrical one;— either of them, if provided 
 with a cup-shaped end, cut sloping, like the 
 one represented in our figure, appears to us 
 best calculated to keep the womb in its natural 
 position. If the case be one of anteversion, 
 the salient edge of the cup should be placed 
 betwixt the sacrum and the cervix ; whereas, 
 it ought to be placed betwixt the cervix and 
 the posterior surface of the pubis, if the case 
 be one of retroversion. The absence of the 
 wall and edge of the cup upon one side of the 
 instrument would admit of the uterus being pushed in a direction 
 opposite to that in which the deviation might have taken place, with 
 greater effect than could be produced by a pessary with a cup of the 
 ordinary form, where an unbroken edge would not allow of so com- 
 plete a reposition. 
 
 When anteversion takes place in consequence of inflammation 
 and engorgement of the womb, great care should be taken in regard 
 to the use of the pessary, inasmuch as its presence in the vagina, 
 and immediate contact with the inflamed organ, might increase the 
 irritation, and, consequently, the essential cause of the deviation. 
 Under such circumstances, recourse ought to be had to antiphlogistic 
 remedies — to small revulsive bleedings, to emollients in the form of 
 baths, drinks, injections, cataplasms, and fomentations. These reme- 
 dies persevered in for some weeks, and conjoined with the employ- 
 ment of narcotics, and a dorsal decubitus, upon a bed so arranged as to 
 allow the hips to be raised somewhat higher than the trunk, are 
 means that have often succeeded in obtaining a complete cure. The 
 reposition, by means of a pessary, should, on the other hand, always 
 be preferred where the sensibility of the parts is not too acute. It 
 has often happened that the mechanical irritation produced by the 
 instrument, has caused the total dissipation of a chronic metritis, 
 which had been either the cause or the effect of the displacement. 
 Levret thinks that the employment of the pessary is generally suffi- 
 cient for the cure of an anteversion, but the instrument should be 
 worn from ten to fifteen months ; he adds that the leucorrhoeal dis- 
 charge, which is at first provoked by its presence, soon grows less, 
 and at length disappears altogether, which is a sign of the cure. 
 Desormeaux, who adopted Levret’s views upon this point, was of 
 opinion that the pessary is not required for so long a time, and that 
 the vaginal inflammation resulting from its presence would deter- 
 mine a secretion favourable to the disengorgement of the womb, by 
 acting on the principle of a derivative remedy. One thing is certain, 
 that even if the pessary is incapable of effecting a perfect cure, it at 
 least has the merit of procuring great relief in the displacements under 
 consideration. 
 
 Fig. 19. 
 
ANTE VERSION AND RETROVERSION. 
 
 167 
 
 Where the displacement is a retroversion, prolonged to the third 
 or fourth month of pregnancy, the womb is sometimes found to be 
 so completely locked betwixt the sacrum and pubis, that its reduction 
 is impossible, and the woman becomes exposed to the danger of cer- 
 tain death, if she be not artificially relieved. In this frightful situa- 
 tion, when both the mother and child are devoted to inevitable 
 destruction, there remains a last extreme resource, first proposed by 
 Syme and recommended by blunter.* This last hope of safety, 
 which, after it is resorted to, may admit of the reposition of the womb, 
 consists in plunging a trocar into the viscus, through the vagina, so 
 as to discharge the waters of the ovum, which are of very great 
 volume at that stage, in comparison with the size of the foetus. This 
 operation, in the cases by M. Jourel of Rouen, M. Viricel of Lyons, 
 and more recently by Mr. Baynham, under circumstances that ap- 
 peared to leave no hope of saving the patients, was followed by 
 diminution of the symptoms, brought on abortion, and preserved 
 the lives of the mothers. Having ascertained the necessity for re- 
 sorting to this extreme method, which yet offers considerable chances 
 of safety, it should be undertaken in the following manner : The 
 woman being properly placed, and supported by assistants, the ope- 
 rator should endeavour to ascertain whether the womb is most tense 
 towards the vagina or the rectum ; and then, before he plunges the 
 trocar into the womb, he should use all proper means to reach the 
 cavity of the organ through the os tincse,so as to open the membranes 
 of the ovum, as advised by White, Hamilton, Dewees and Jourel; 
 but attempted by them in vain. To facilitate this perforation, use 
 might be made, as Duges advises, of a male catheter, of a conical 
 shape, and properly curved, so as to enter the os uteri readily : or a 
 gum elastic catheter might be preferred, the flexibility of which 
 would favour its introduction, as it would adapt itself to all the curves 
 and turns that might coexist with the unnatural situation of the 
 parts. When the catheter shall have been penetrated into the cavity 
 of the womb, a flexible style should be passed up through it, and 
 thus easily conducted into the uterine cavity ; and being pushed for- 
 wards, might serve to open the membranes. 
 
 Should the surgeon be unable to effect this purpose, the puncture 
 should be made by a trocar passed through the substance of the 
 vagina and one of the surfaces of the cervix or body of the uterus ; 
 for the operation done in this way is easier and less dangerous than 
 where it is done through the rectum, since, by the latter mode, it is 
 impossible to avoid wounding the peritoneum. Nevertheless, the 
 puncture of the womb from the rectum succeeded in Mr. Baynham’s 
 case, after he had in vain introduced his hand into the bowel, with 
 a view to push the womb upwards. The woman operated on by 
 this able practitioner was in the sixth month of pregnancy, and the 
 retroversion had existed for five weeks. The puncture having 
 lessened the volume of the womb, the reposition was easily effected, 
 and abortion followed soon afterwards. The foetus, which had a 
 wound in the abdomen, was of the ordinary size of the foetus at the 
 
 * Med. Obs. and Inq., v. iv. 
 
168 
 
 ANTE VERSION AND RETROVERSION. 
 
 sixth month. In six weeks the woman was quite recovered. Baron 
 Boyer [Mai. Chirurg., t. x. p. 534), cites another case, treated suc- 
 cessfully by the same method, and mentioned in the Reciteil des The- 
 ses de la Faculle de Paris. 
 
 For making the puncture by the rectum, the common trocar is too 
 short. It is better to use Fleur ant’s trocar, designed for puncturing 
 the bladder from the anus, the curved canula of which is about an 
 inch longer than the common ones, which facilitates the operation 
 very much. But whatsoever be the method adopted, the perforator 
 should be carried pretty deep into the womb. There should be pro- 
 vided a long probe-pointed stilet, for the purpose of clearing the 
 canula, in case of its becoming obstructed so as to prevent the escape 
 of the amniotic fluid. After the operation is completed, we should 
 proceed to reduce the womb to its natural position ; and afterwards, 
 bestow upon the patient all the cares required in cases of forced 
 abortion, which is an almost inevitable result of the puncture of the 
 womb. 
 
 With a view to unlock the womb, when imprisoned in the pelvis 
 by retroversion, and to save the child without exposing the mother’s 
 life to any greater risk, different practitioners, among whom we may 
 name Purcell, Gardien, Baumgarten and Jahn, propose, instead of 
 the puncture, to perform the operation for the section of the symphy- 
 sis ; this procedure, which has never yet been had recourse to, for the 
 cure of uterine displacement, even leaving out of question its danger- 
 ous nature and other inconveniences, does not seem to possess the 
 advantages attributed to it by its friends, for the slight increase in the 
 transverse diameter of the pelvis, procured by the section, gives very 
 little addition to the antero-posterior diameter, which is the one most 
 concerned in the locking of the womb. It is also our opinion, that, as 
 we have it in our power to puncture either the womb or the bladder, 
 we have no right to recur to the hypogastric incision that has been 
 proposed, with a view of getting the hand into the pelvic cavity, for 
 the purpose of raising up the uterus. This mode of proceeding, 
 which is, however, less cruel than the Caesarian operation, seems to 
 us of very doubtful utility, for in the post-mortem examination of a 
 woman who perished from retroversion, Hunter was unable to extri- 
 cate the womb until he had sawed the pelvis asunder. 
 
 Before concluding the observations we had to offer upon the sub- 
 ject of the deviations of the womb, we add that, where, by the use 
 of the measures above pointed out, we have succeeded in repositing 
 the displaced organ, we should advise the woman always to evacuate 
 the bladder at the first indication of desire to do so ; and to take 
 great care to obviate constipation of the bowels, especially by means 
 of a suppository composed of the beurre de cacao. 
 
 The inflammatory sequela? may be counteracted by the use of baths, 
 venesection, and the other antiphlogistics already pointed out. The 
 same kind of measures should be resorted to in case of the occurrence 
 of suppression of urine, dependent upon inflammation from the pres- 
 sure of the neck of the womb upon the neck of the bladder. Where 
 the suppression of urine arises from a state of inertia, produced by 
 
CURVATURE OF THE WOMB. 
 
 169 
 
 the prolonged distension of the cyst, an attempt to restore its tone 
 might be made by means of aromatic and astringent injections, and 
 more especially, by injections of the sulphurous Barege water. The 
 same indication would exist in case of an ischuria or dysury from 
 paralysis of the sphincter-vesicse ; an accident that sometimes follows 
 the compression exerted by the os tincae upon the bladder during a 
 retroversion. 
 
 OF THE ANTEFLEXION AND RETROFLEXION OR CURVATURE OF 
 
 THE UTERUS. 
 
 Although we might as well have classed the anteflexion and retro- 
 flexion of the womb among the cases of lesion of form , as among 
 those of lesion of situation, we have chosen to arrange them among 
 cases of the last-named lesion, in order to make the study of them 
 easier, by approximating them to the cases of anteversion and retro- 
 version, from which they differ very little, either as regards the treat- 
 ment, or in the general symptoms pertaining to them. 
 
 Though the curvature , or flexions of the womb, have hitherto 
 attracted but little attention from either writers or practitioners, it 
 was not because such cases were rarely met with, but because they 
 were most generally confounded with other uterine disorders. 
 
 Notwithstanding that Levret, towards the middle of the last cen- 
 tury, and Baudelocque, a few years later, had noticed that in a cer- 
 tain malposition of the womb, the neck inclined to the same side as 
 the fundus, while the body of the organ is bent like a retort, we are 
 indebted to Denman* for the first accurate account of a case of 
 flexion of the womb, which was published, however, without any 
 circumstantial details. Nevertheless, Denman’s case, and the re- 
 marks made before his time by Levret and Baudelocque, had been 
 almost forgotten, when a new case, communicated by Madame 
 Boivin to Dr. Ameline, and inserted in his Thesis,! fixed the atten- 
 tion of the learned upon the curvatures of the uterus, disorders which, 
 since that date, have been several times ascertained and rationally 
 treated by different medical practitioners, among whom may be men- 
 tioned Desormeaux, Duges and Deneux. 
 
 Where the flexion of the womb is an anteflexion, the neck pre- 
 serves its natural position, but the body of the organ is inclined for- 
 wards, and engaged behind the symphysis of the pubis. In retro- 
 flexion, the viscus is displaced in the inverse direction ; that is, the 
 fundus is turned backwards and engaged in the hollow of the sacrum, 
 notwithstanding the neck, as in the former case, preserves its natural 
 direction. 
 
 The curvatures of the womb do not always exhibit the disposition 
 of parts just mentioned, for some cases are met with where the body 
 and neck are directed to the same point, or these parts are alone found 
 to deviate, while the fundus preserves its natural situation. As this 
 sort of flexion, so much insisted on by Boer, is almost always, when 
 
 * Introduction. 1801. 
 t Dissert. Inaug. Paris, 1827. No. 55. 
 
170 
 
 CURVATURE OF THE WOMB. 
 
 noticed, coincident with the gravid state, we shall merely point it out 
 at present, preferring to go more in extenso into the description of 
 those flexions that are met with in the non-gravid state. 
 
 According to M. Duges, flexions of the womb may be congenital; 
 at least that distinguished practitioner met with it in girls who had 
 not yet attained the age of puberty. Cases of the kind must be very 
 rare. Yet we agree with Duges and Madame Boivin, that the rapid 
 development of the womb that occurs at about the twelfth year of 
 the girl’s age, may sufficiently explain how, in other cases, a more 
 complete development of one wall of the organ may lead to a sort of 
 organic incurvation. The more rapid reduction, and more complete 
 condensation of one of the walls of the womb, after lying-in ; the 
 softening or retraction of one side of the organ, from the healing of 
 an internal ulcer, or the cure of an inflammation; the fibrous dege- 
 nerations ; the adhesion of one of the parietes with the uterine ap- 
 pendages; an obstruction of the canal of the neck, and, according to 
 Denman, a retention of urine, following childbirth, may act as essen- 
 tial causes of flexion of the womb, and particularly of retroflexion. 
 We however believe, with the able Montpellier professor, that the 
 last-named circumstance cannot give rise to a uterine flexion, unless 
 connected with one of the special positions we have mentioned. 
 
 The incurvation that takes place at the point where the upper part 
 of the neck unites with the body of the womb, exhibits a variable 
 curvature, so that the organ which is, in some cases, bent double, as it 
 were, is found in others to exhibit an angle more or less obtuse. The 
 curvature is always somewhat rigid ; and in rare cases, especially 
 soon after delivery, the body of the womb is observed to be movable 
 upon the neck, as pointed out in the case of retroflexion published 
 by Denman. 
 
 The general signs of anteflexion and retroflexion are nearly the 
 same as those of anteversion and retroversion ; for example, the pa- 
 tient complains of pain in the lumbar and hypogastric regions, diffi- 
 culty in the expulsion of urine and stool, and all the consecutive 
 sympathetic affections appropriate to the other forms of uterine de- 
 viations ; such as leucorrhaea, amenorrhcea, dysmenorrhoea, hysteri- 
 cal and spasmodic symptoms ; dragging sensations in the pelvis, the 
 groin, the loins and the thighs ; frequent desire to pass the urine ; and 
 lastly, a feeling of painful pressure upon the bladder and rectum, &c. 
 
 Although it is very difficult clearly to establish the differences be- 
 tween the curvatures of the womb and anteversion and retroversion 
 of the organ, it is yet possible, with an attentive exploration of the 
 parts, to avoid confounding them with each other. 
 
 Previously to making any examination whatever, it is best to cause 
 the bladder and rectum to be freed from their contents. The surgeon 
 should then perform the operation of Touching ; first, while the wo- 
 man is iu a standing posture, and then while she is lying down ; in 
 the same position as if she were placed for the adjustment of the 
 speculum uteri. The right index should be placed within the vagina, 
 while the left hand is applied to the hypogastriuni for the purpose of 
 rendering, by pressure downwards, the body and cervix of the womb 
 
CURVATURE OF THE WOMB. 
 
 171 
 
 more accessible to the point of the index. The surgeon will endea- 
 vour, by gentle pressure, to learn whether the fundus of the organ is 
 in its natural state or not while the neck only is bent ; or whether 
 the latter is in a natural position, the former alone having deviated 
 from it. The latter sort of flexion is much more common than the 
 former, which is less rare than the double flexion of the cervix and 
 fundus in the same direction. 
 
 To enable us to judge methodically of the size of the curve formed 
 by the womb, the viscus ought to be firmly compressed by the left 
 hand applied to the hypogastrium, while, with the index of the right 
 hand, we endeavour carefully to trace the arc described by the flex- 
 ion of the uterus, tracing the left side of it with the right index, and 
 the right side of it with the left index finger, according as we use 
 one or the other hand for the purpose. 
 
 To render the diagnosis as complete as possible, and make sure whe- 
 ther or no there have been formed any adhesions rendering a cure im- 
 possible, we should try to move the womb in different directions, and 
 if any doubt or obscurity* should still remain upon this or any other 
 point, an examination by the rectum should be made ; either in the 
 common mode, or as advised by M. Duges — by introducing the index 
 into the rectum, and the thumb into the vagina, so as to support the 
 womb between the thumb and the finger, and thus form a sort of 
 intelligent calliper well suited to show the curvature, the size and 
 position of the organ. This manoeuvre is generally very easily per- 
 formed for women who are thin, and accustomed lo the coitus; and 
 in lymphatic girls, whose vaginal parietes have become relaxed by 
 chronic leucorrhcea. 
 
 While sterility may, on the one hand, depend upon a uterine cur- 
 vature, so a pregnancy, on the other hand, may bring about a speedy 
 and definitive cure ; for the forced distension of the strangulated point 
 that divides the cervix and the body of the uterus, will sometimes 
 rectify its direction, where care is taken in the early months of ges- 
 tation to keep it in a proper position ; and, especially, by guarding 
 against the accidents that act as the special causes of uterine displace- 
 ments. To prevent a relapse, as soon as the delivery is completed, 
 we should hasten to procure a perfect contraction of the womb, now 
 restored to its natural situation, by means of frictions upon the hy- 
 pogastrium, and by preventing too great an accumulation of urine in 
 the bladder, or of fesces in the rectum. A relapse may also be pre- 
 vented by ordering a dorsal decubitus, in case it be an anteflexion ; 
 and by directing the patient to lie upon her side, or as far over into 
 a prone position as possible, in case we have to contend with the 
 retroflectLve curvature. But whatever be the nature of the curve, the 
 woman should be so situated upon her bed as to have the pelvis 
 higher than the shoulders. 
 
 The treatment of flexions of the womb differs very little from 
 that of the anteversion and retroversion of the viscus ; for the symp- 
 toms arising from them are to be combated by the same general 
 measures. Thus, where there are symptoms of congestion, of ple- 
 thora, or of phlogosis, resort should be had, in the first place, to 
 
172 
 
 INCLINATION, OR OBLIQUITY OF THE WOMB. 
 
 baths, to blood-letting, and to other antiphlogistics, according to the 
 kind of indication ; and then, after effecting the mechanical reduction 
 of the womb, it is to be kept in its proper position, either by M. 
 Dereux’s method, which consists in pressing a sponge betwixt the 
 cervix and vagina, opposite to the curve ; or in adjusting, in the 
 same situation, a ring-pessary of gum-elastic or ivory, which is to be 
 merely introduced ; or, according to Desormeaux’s advice, to be so 
 adjusted that the upper portion of the instrument should sustain the 
 raised fundus, while the opening is large enough to receive the curved 
 extremity of the neck of the womb. We might also do as advised 
 by M. Nauche ; namely, make use of a pessary en bondon , so con- 
 structed that one of its margins may rise highest on the curved side. 
 The application of a cylindrical pessary, modified according to our 
 plan, as a remedy for both anteversion and retroversion, would fulfil 
 this indication still better; but, unfortunately, curvatures of ancient 
 date are very difficult to cure by means of the mechanical remedies 
 within our control. 
 
 The symptoms produced by uterine curvatures might also be ad- 
 vantageously combated, and the powers of the other remedies in- 
 creased by assisting them by the exhibition of stimulants, derivatives 
 and tonics, such as douches of Bareges waters, directed into the 
 vagina and rectum ; frictions, blisters, cauteries, and moxas ap- 
 plied, in the cases of retroflexion, to the groins and pubis; and, in 
 those of anteflexion, to the sacrum and the parts adjacent to the 
 utero-sacral ligaments. 
 
 Let us conclude our remarks upon the uterine curvatures by 
 adding, that Madame Boivin and M. Duges are the only authors 
 who have furnished detailed cases of anteflexion and retroflexion, 
 either in the virgin or in women at various stages of gestation, after 
 childbirth, or as one of the sequelae of abortion. Were it not that 
 we have already been too diffuse on this subject, we should have 
 cited in this place the interesting facts reported in the excellent work 
 of the able practitioners whose names we have just quoted. 
 
 OF INCLINATION, AND OF OBLIQUITY OF THE WOMB. 
 
 Inasmuch as the uterus rarely preserves its vertical position, when 
 in the non-gravid state, it is easy to infer that its lung axis may 
 deviate every moment, where pregnancy is sufficiently far advanced 
 to allow the body of the viscus to lift itself above the plane of the 
 superior strait. Where the inclination is but slight, no inconvenience 
 is experienced from it; but, if the fundus of the womb ceases to be 
 mobile, and remains constantly leaning to either of the sides, such 
 an obliquity constitutes a real malady of the womb, which may lead 
 to very serious consequences. 
 
 The works of the father of medicine contain several passages to 
 prove that his attention had been attracted to the inclinations of the 
 womb. In fact, the lateral inclination, or latero-version, seems to us 
 to be clearly pointed out in the passage of the book : rifpt ywaixfi^or 
 CpVOiO'jj (de nut ura mulier.) where he says, “ If the womb bears over 
 
INCLINATION, OR OBLIQUITY OP THE WOMB. 173 
 
 towards the iliac region , the belly and the sides become painful ; 
 a/id, when we Touch , we find the neck of the womb inclined to- 
 wards one of the iliac regions Aetius* klso speaks of the inclina- 
 tion of the womb ; and, in explaining the doctrines of Aspasia upon 
 this point, he adds that this deviation may furnish obstacles in the 
 way of childbirth: potest et difficult as pariendi contingere, ah 
 cervicis uteri obliquiialem. However, the obliquities of the womb 
 did not begin to fix the attention of practitioners of medicine until 
 Henry Deventer,! a celebrated accoucheur at Groningen, had proved 
 that this affection is among the principal causes of difficult labour, and 
 moreover pointed out the manoeuvre required by cases of the sort. 
 
 Where the womb is found to be inclined forwards, or backwards, 
 it constitutes nothing more or less than the first stage of anteversion 
 or retroversion ; when it is to one side, it is a latero-version , and in 
 such a state, the neck of the womb, which rises higher than its 
 natural level, inclines its orifice towards one of the sides of the 
 vagina, and the patient feels in various degrees the symptoms that 
 proceed from anteversion. 
 
 The inclinations occurring during pregnancy have received from 
 Deventer the appellation of obliquity of the womb. As they can 
 only take place to one side or to the front, they are distinguished 
 into right lateral, left lateral and anterior obliquity; a posterior 
 obliquity, notwithstanding Levret’s opinion on the subject, could not 
 take place in a well-formed woman, since it is prevented by the 
 sacro-vertebral projection. 
 
 Obliquities may be ascertained to exist by the projection, and 
 resistance of the fundus uteri against the abdominal walls. In the 
 anterior obliquity, the upper extremity of the gestative organ is 
 directed forwards, and the os uteri against the sacrum. The inclina- 
 tion is greater in proportion to the number of preceding pregnancies, 
 and it is found to increase with each successive one. 
 
 In some women, the anterior obliquity is found to be so great, that 
 the belly falls down over the external organs of generation, and 
 sometimes so low as to cover the thighs even down to the knees. 
 
 In lateral obliquity the fundus forms a prominence at one side of 
 the abdomen, the os uteri being pointed towards the opposite side. 
 The anterior inclination is the one most frequently met with ; it may 
 depend upon the relaxation of the walls of the abdomen, upon de- 
 formity of the vertebral column, the accumulation of a quantity of 
 fasces in the colon, or any other cause compelling the womb to in- 
 cline itself forwards. 
 
 The right lateral obliquity is also pretty frequent, while a left 
 obliquity is quite rare, for the rectum and the sigma of the colon, that 
 are often distended with faeces, prevent the womb from inclining to 
 that side. Besides the faulty direction of the pelvis, lateral obliquity 
 has been assigned to a variety of causes, such as shortness of one of 
 the ligaments of the womb, a relaxation of one side and constriction 
 
 * Tetrab. iv., Serm. iv. cap. 77. 
 
 f Novum Sumen Obstetricantium, 1701, et ulterius : examen. partuum difficultium, 
 
 1725. 
 
174 
 
 INCLINATION, OR OBLIQUITY OF THE WOMB. 
 
 of the opposite one, in consequence of inflammation or spasm, the 
 habit of sleeping always on one side, particularly the right side ; and, 
 finally, the existence of a considerable tumour in the abdomen or in 
 one of the ovaries. Levret, and most of the accoucheurs, supposed 
 obliquity of the womb to depend upon an attachment of the placenta 
 upon one side of the uterus that was drawn downwards, by means 
 of the weight of the afterbirth. Were this the real cause, the pla- 
 centa would be more frequently found upon the right than upon the 
 left side, and in front more frequently than on the posterior surface, 
 which is not the fact ; though right lateral obliquity takes place in 
 ninety-nine cases in a hundred, while posterior obliquity is looked 
 upon as nearly an impossible state in a healthy conformation of the 
 pelvis and vertebral column. 
 
 [I do not like to let this assertion of our author go forth without protesting 
 against it, as being unfounded in observation. In my own experience, left 
 lateral obliquity is not less frequently met with than that of the right side ; 
 and as to the insertion of the placenta, no man knows the facts as to its 
 place in the general. No man can have such knowledge, since, of the im- 
 mense number of labours that are superintended by medical men, in a vast 
 majority of them the placenta is detached by the time the hips of the child 
 are expelled, or, in other words, by the same contraction that effects the 
 expulsion of the fcetus. Medical men do not know, therefore, where the 
 afterbirth is attached, except in those cases that require the introduction of 
 the hand for its delivery. According to Dr. Churchill, (see Huston’s edit., 
 420,) retention of the placenta has occurred once in 66I3 times, which gives 
 too few opportunities to admit of the attainment of a correct knowledge of 
 its average place of attachment. I take it for granted that practitioners do 
 not go after the placenta , except under a necessity for so doing; and that 
 when the placenta presents itself at, or half through the os uteri, imme- 
 diately after the birth of the child, the attendant is riot competent to say that 
 it was in this or that special place. — M.] 
 
 While the inclinations of the womb that take place in its non-gra- 
 vid state are but little worthy of our regard, those that occur during 
 gestation are of real importance. According to Deventer, they may 
 he classed with the most fruitful causes of difficult parturition. Even 
 admitting that this opinion of Deventer’s is a somewhat exaggerated 
 one, it is easy to conceive why obliquity may not unfrequently occa- 
 sion great difficulty and delay in the termination of a labour, by 
 reflecting that when the mouth of the womb is impelled against one 
 of the sides of the pelvis, the expulsive powers cannot act in the 
 direction of the vagina, and, of course, that the dilatation will not 
 take place, except with difficulty and slowness. Where the pelvis is 
 wide, it often happens that the descending head pushes the body of 
 the womb down before it, so that it comes to present itself at the 
 ostium vaginae, while the os tincae is forcibly driven backwards : on 
 the other hand, where the pelvis is narrow, the womb is not thrust 
 downwards by the head, but the throes that tend to impel the head 
 
INVERSION OF THE WOMB. 
 
 175 
 
 forwards while it is still enclosed in the cervix uteri may give rise 
 to contusions of the part, to violent distensions, and even expose 
 the uterus to the danger of becoming inflamed, or of being lacerated, 
 if the obliquity be not speedily rectified. 
 
 Those inclinations that take place in the non-gravid womb require 
 no special treatment, for the inconvenience resulting from an extreme 
 obliquation are to be readily remedied by means of a suspensory 
 bandage to the abdomen. But for the use of such a precaution the 
 woman would suffer, especially towards the close of pregnancy, from 
 severe pain about the groins and loins, and a sort of numbness upon 
 the side, corresponding with the obliquity. 
 
 As a measure for obviating barrenness, which might arise from a 
 continued obliquity of the womb, the female ought to lie upon the 
 side opposed to the inclination of the cervix, durante coilu ; and the 
 same precaution should be taken in the conduct of the labour. We 
 should endeavour to bring the fundus of the womb towards the 
 centre of the abdominal cavity, by supporting and pressing the 
 uterus, with a hand laid upon the abdomen. Until this can be done, 
 the woman ought to be dissuaded from bearing down. If such 
 measures were to prove insufficient to replace the cervix in the mid- 
 dle of the excavation, success in the attempt is commonly attainable 
 by the use of two of the fingers hooked within the orifice, and kept 
 there until it be pretty well dilated, and the bag of waters formed. 
 By these means, which are equally simple and easy of performance, 
 the patient may be spared many pains, while the favourable position 
 given to the cervix uteri admits of its easier dilatation, and a con- 
 siderable abridgment of the duration of the labour. In the majority 
 of such cases, a venesection will be found to be indicated, particularly 
 if the mancguvre here recommended should not have been put in 
 practice. 
 
 OF INVERSION OF THE WOMB. 
 
 Inversion is a case in which the womb is turned inside out, either 
 completely or partially, like a bag, or a glove-finger, so that its inter- 
 nal surface becomes external, and vice versa. 
 
 Inversio-uteri, which may take place either while the womb is in 
 a state of vacuity or during parturition, exhibits several degrees or 
 stages, from the very slightest depression of the fundus to the com- 
 plete turning of the womb inside out, so that the body of the viscus 
 hangs out betwixt the thighs. Daillez, Levret, and most of the 
 writers on the subject, have admitted but two varieties of this 
 case, which are the incomplete or partial inversion, and the com- 
 plete inversion. The former is when the fundus has fallen down 
 towards the orifice and projects a little into the vagina ; the latter, 
 or the complete inversion, is when the womb is turned entirely inside 
 out, and lies in the canal of the vagina, or escapes quite beyond the 
 orifice of the vulva. 
 
 Leroux, of Dijon, establishes three degrees of inversion. 1. A 
 simple depression which takes place when the top of the womb is 
 
176 
 
 INVERSION OF THE WOMB. 
 
 somewhat indented like the bottom of a glass bottle, as Mauriceau 
 expresses it. 2. The incomplete inversion. 3. The complete inver- 
 sion, already mentioned, and which seems to be intended by Hippo- 
 crates, when he says si pudendo exciderint uteri , dependent vetut 
 scrotum. 
 
 Finally, Sauvages, who, like ourselves, classes the inversion among 
 the lesions of situation, and arranges it as a species of the genus Hys- 
 teroptosis; Professor Delpech;* Dr. Ferrand, in his excellent Thesis ;t 
 Madame Boivin and M. Duges4 admit of principal degrees of this 
 affection, which exhibit distinctive characters, as well in regard to 
 the diagnosis as to the prognosis and treatment. These four degrees 
 may remain stationary, others may be progressive, and increase 
 either gradually or instantly in violence. In the first degree, there 
 is simple depression of the fundus uteri : in the second, the inverted 
 fundus disparts the os uteri a little — in the third, the inverted organ 
 is lodged in the vagina, but the vaginal orifice of the womb has not 
 participated in the inversion, and lastly, in the fourth degree, the 
 rarest of all, the womb, turned inside out, forms a considerable 
 tumour, which may be augmented inside by the presence within it 
 of the ligaments of the womb, and by a portion of the intestines 
 which are ingurgitated in the new cavity formed by the inverted 
 organ. The mechanism of an inversion of the womb is very easy to 
 be understood. The fundus of the organ, which is carried down- 
 wards by whatever cause, is depressed so as to become convex 
 within instead of concave, as in its natural state. This depression 
 increases by insensible degrees, and passes with more or less baste 
 through the different stages of inversion. As the internal face sinks 
 lower and lower, it drags with it the ligamenta lata and ligamenta 
 rotunda, the ovaries, and the tubes, which, as we have before said, 
 take the place that becomes void in the pelvis. Inasmuch as the 
 womb, immediately after labour, is in a condition most favourable 
 to the occurrence of an inversion, that, in fact, is the crisis at which 
 such an event is most likely to happen ; for it never could happen 
 except in consequence of a distension of the walls of the womb, 
 caused either by the presence within it of an ovum, a polypus, or a 
 mole, or the accumulation of a quantity of the serum of the blood 
 within its walls. 
 
 The most common cause of inversion consists in attempts to 
 deliver the placenta immediately after the birth of the child and 
 before the womb has become contracted. 2. Too powerful efforts, 
 of traction upon the cord while the placenta is still attached to the 
 womb, and the pressure of the intestines upon the fundus at the same 
 time. 3. The prolonged efforts at bearing down that some women 
 make after the birth of the child, with a view more speedily to expel 
 the placenta. 4. The spontaneous violent extraction of the placenta, 
 as happens when women are delivered in a standing posture, which 
 often causes the sudden and simultaneous escape of the entire pro- 
 
 * Precis des Malad. Reputees Chir., iii. p. 576. 
 
 t Du Renversement de la Matrice. diss Maury. Paris, 1828. No. 278. 
 
 * Traite Prat, des Mai. de Uterus, t. i. 221, 1833. 
 
INVERSION OF THE WOMB. 
 
 177 
 
 duct of the conception, particularly if the umbilical cord happens to 
 be too short or twisted round the child’s neck or body. Under such 
 circumstances, should the placenta be adherent, and fail to become 
 detached, or should the cord not break, an inversion would be the 
 almost inevitable consequence. 
 
 Inversion of the womb is not always due to the imprudence of 
 the attendant, or to the unfavourable circumstances by which the 
 patient is surrounded during her parturition : there are some cases, 
 certainly rare ones, and which it is not possible to foresee, where in- 
 version occurs, so to speak, spontaneously, and without any external 
 force having been employed to pull upon the internal paries of the 
 womb. 
 
 The women most liable to these spontaneous inversions, as they 
 may be termed, are such as have the womb distended with a great 
 quantity of water up to the last moments of the labour ; such as lie 
 in almost without pain, and with a single bearing down effort ; cases 
 where both the child and the afterbirth are very large ; and lastly, 
 such as have become exhausted by long-protracted sufferings. All 
 the circumstances which may become occasional causes of inertia 
 uteri, and which make the patient liable to flooding after delivery, 
 are also to be regarded as so many predisposing causes of the affec- 
 tion under consideration. To the predisposing causes we may add 
 the antecedent occurrence of an inversion in labour, though promptly 
 relieved ; a chronic state of prolapsion of the vagina and womb, 
 and a certain laxity of these organs attributed to persons of a lym- 
 phatic temperament. It happens, in certain instances of this sort, 
 that the softness and flaccidity of the uterus are so great, that even 
 after a careful delivery, the mere pressure of the superincumbent 
 bowels on the fundus uteri causes it to be inverted without any trac- 
 tion having been made upon the cord. It is easy to conceive the 
 possibility of an inversion, caused by the weight of the bowels press- 
 ing upon the summit of the organ, if we reflect that the impulse may 
 be very sudden and violent, as from the contraction of the diaphragm 
 and abdominal muscles in coughing, sneezing, vomiting or imprudent 
 movements of the patient. 
 
 Notwithstanding inversion of the womb would appear, in a man- 
 ner, to be impossible, except immediately subsequent to the escape 
 of the foetus from its cavity, which is the period when the viscus is 
 most expanded and most flexible; both Ane and Baudelocque* bear 
 witness to its having occurred upon the third day, and Leblanct on 
 the tenth day after delivery. Professor Desormeauxf reports that he 
 was consulted for the case of a woman in whom there was an incom- 
 plete inversion, which was not detected until twenty-one days after 
 the childbirth. 
 
 [I have seen a case in this city in which the occurrence was not verified 
 
 * Diss. inaug. du Dr.Daillez, 1803. 
 f Sabatier, Mem. sur les Deplacements de TUterus. 
 i Diet, de Med., 21 vol. t. xviii., p. 227. 
 
 12 
 
178 
 
 INVERSION OF THE WOMB. 
 
 until thirty days after labour, and another in which eighteen months elapsed 
 before the fact was ascertained. — M.] 
 
 We opine that complete inversion, discovered so late, must have 
 existed, in an incomplete stage, beforehand; and that commonly they 
 must have commenced immediately after delivery. Were this not 
 the case, the womb, doubtless, must have continued distended with 
 coagula, and thus have retained the same volume and flaccidness as 
 belong to it after the sudden expulsion of the ovum. 
 
 Inasmuch as an antecedent dilatation and softness of the uterine 
 parietes are the prime conditions for a possible inversion, it is appa- 
 rent that a lying-in is not the sole predisponent cause of the accident ; 
 in fact, an inversion may take place, not only long subsequent to 
 childbirth, but even in women who have never borne children. For 
 example, inversion has been observed to follow immediately upon 
 the expulsion of a large polypus, or upon tractile efforts made upon 
 such a tumour, where its pedicle has been implanted in the fundus, 
 which has been drawn down by the footstalk, into the vagina. Goul- 
 lard,* Culleriert and Denmanf report cases occurring in this way. 
 
 This affection may also arise from a distension of the womb, caused 
 by a dropsy, or an accumulation of blood in the organ, § whose 
 walls being relaxed, thinned and weakened, yield readily to the im- 
 pulsion of the bowels, and the contractions of the abdominal mus- 
 cles, as soon as the foreign substances have suddenly escaped from 
 its cavity. All these circumstances may, to a certain extent, be com- 
 pared with those existing at the period* of delivery in childbirth ; for 
 the walls of the womb being then nearly in the same condition as 
 in parturition, yield to the slightest impulses, or the least effort. 
 However, Puzos, who, as well as Vigaroux, looked upon excessive 
 obesity as an exciting cause of inversion, read at the Academy a 
 memoir, a mere extract of which only remains at the present day,|| 
 wherein he relates several cases of inversion observed by himself in 
 females who had never borne children, or who had never experi- 
 enced any indisposition during fifteen or twenty years subsequent 
 to their last confinement. Notwithstanding the authority of these 
 two great practitioners, we agree with Gardien and Desormeaux, that 
 it is not to be supposed that, in the cases mentioned by Puzos, the 
 cause of the accident could have been merely the obesity and the 
 weight of the bowels resting on the womb so long non-gravid. 
 Boyerf cites a similar example from a female who had had no child 
 for fifteen years, and whose womb certainly contained no foreign 
 body. As the inversion in this case was not complete, and it being 
 probable that the same was the fact in Puzos’ cases, we must con- 
 clude that the affection was of a very ancient date, and remained 
 undetected for a number of years, because the fundus of the womb 
 
 * Mem. de l’Acad. des Sci., 1732, and Mem. de l’Acad. de Chir., t. iii., p. 377. 
 j- Nauche, Malad. des Femmes., t. i., p. 133. 
 t Plates of a Polypus with an Inversion of the Uterus, 1801. 
 
 § Leblanc d’Orleans; Mem.de l’Acad. de Chirurg., iii., 379. 
 
 || Inserted in le Mercure de France, ann. 1744. 
 
 1 Traite des Mai. Chirurg. 
 
INVERSION OP THE WOMB. 
 
 179 
 
 being but slightly depressed, particularly at the period of the last 
 confinement, the patient’s health was undisturbed up to the time 
 when the inversion, by a gradual progress, had attained to a greater 
 degree of completeness. What tends, moreover, to militate in favour 
 of this hypothesis is, that the records of the science contain nume- 
 rous cases of women who have continued in tolerable health during 
 many years, under inversion of the womb, even when absolutely 
 complete. Thus, Delamotte* says he knew a woman who had had 
 a complete inversion for thirty years ; Levret,t in a woman sixty 
 years of age, found an enormous tumour constituted of the inverted 
 womb and vagina, the ovaries, the tubes, with a portion of the rec- 
 tum, and of the bladder and small intestines. Dr. Daillezf states that 
 Baudelocque met with an inverted womb in the case of a young girl 
 fifteen years old, and he adds, that it could not have been in conse- 
 quence of a clandestine delivery, because the hymen was perfect. 
 This peculiarity seemed to Baudelocque so extraordinary that he 
 looked upon it as the result of a congenital deformity, for he could 
 not be persuaded, and very properly so, that the organ could be the 
 subject of an inversion without any antecedent dilatation. Baron 
 Dubois supposed that the celebrated author might have been led into 
 error by a polypus uteri. As we do not think it possible for Baude- 
 locque to make such a mistake in diagnosis, though such mistakes 
 are not wanting, we conceive it possible that the inversion he met 
 with, in the young girl, might have taken place, in consequence of 
 the distension of the parietes of the womb, produced by a retention 
 of the menses, the accumulation of serum, or the extrication of gases 
 in the organ, and subsequently expelled suddenly. In fine, we may 
 add to the above, the case recently noticed by M. Duges,§ who in- 
 forms us of a lady whom he saw in consultation with the Messrs. 
 Dubois, sen. and jun., who laboured for five years under an inver- 
 sion of the womb, without suffering any inconvenience beyond a 
 sense of dragging weight about the groins and loins, and frequent 
 desire to pass the urine, but which went off as soon as she laid her- 
 self down. 
 
 Previous to closing our remarks upon the causes of inversion, let 
 us add that Dessault, and Herbiniaux proposed that inversion should 
 be temporarily induced in the case of polypus of large size, by draw- 
 ing it downwards, with a view of enabling the operator to adjust a 
 ligature more easily upon the neck of the tumour. According to 
 Desormeaux, this plan was executed successfully, not only by the 
 two distinguished practitioners, but by several other operators. 
 
 The symptoms of the affection in question are different, according 
 to the degree in which it happens to exist, the circumstances which 
 accompanied the accident, and the fact of it having occurred sud- 
 denly or by degrees. 
 
 A mere depression of the fundus of the womb generally lasts but a 
 
 * Observ. 412. 
 
 f Obs. sur les Polypes de la Matrice, p. 140. 
 
 * Precis des Lemons de Baudelocque, sur le Kenversement de la Matrice, 1803. 
 
 § Traite des Mai. de l’Uterus, t. i. p. 245. 
 
130 
 
 INVERSION OF THE WOMB. 
 
 short time ; it is either soon followed by the reposition of the organ, 
 or by its rapid transition to a further degree of inversion. This 
 slight uterine inversion, which constitutes the first stage, may be dis- 
 covered by the painful sense of dragging that the woman complains 
 of, when tractions are made at the cord of a still adhering placenta, 
 or by the cup, like the bottom of a bottle, that may be felt through the 
 abdominal teguments by placing the hand upon the hypogaster ; in 
 such case it is of the highest moment, not only to desist from pulling at 
 the cord, but, moreover, to command the woman to abstain from every 
 attempt to bear down, which would, without promoting the delivery 
 of the afterbirth, inevitably increase the inversion. We ought here 
 to try to detach the placenta, by introducing a hand into the womb, 
 taking care to act from the circumference to the centre of the after- 
 birth, and to restore to the uterus its proper form, by pushing up the 
 fundus, while gentle tractions at the cord, with the other hand, ena- 
 ble us to conclude the delivery. 
 
 The signs and symptoms of inversion in the second, are analogous 
 to those of the first stage, and differ from them only as being more 
 evident, and attended with severer pain. Where the inversion has 
 continued for some time after delivery, the diagnosis becomes rather 
 obscure, because the mouth of the womb surrounds the summit of the 
 tumour, just as it does in the case of polypus; though, in this condition, 
 the summit of the tumour formed by the inverted fundus descends 
 so low as to press open the os uteri, the finger can only touch a con- 
 vex surface whose nature is equivocal, and around which it is impos- 
 sible to penetrate in order to feel and explore it. Nothing, therefore, 
 except the surpubal palpation, and the Touch by the rectum, can re- 
 move the obscurity of the case. In the third stage, the Touch by the 
 rectum and hypogastrium furnishes more positive data than can be 
 got in the second stage of inversion. We can here readily ascertain 
 that the womb has abandoned its natural position, if, as should always 
 be done, we take care beforehand to cause the bladder and rectum 
 to be evacuated, and to place the abdominal muscles in the greatest 
 possible relaxation. The womb is found to be lodged within the 
 vagina, as a distinct tumour, and, as it were, strangulated by the os 
 uteri, which alone, of all parts of the organ, has escaped the act of in- 
 version. Continual haemorrhages, exhausting to the patient, have often 
 led to the suspicion that the tumour composed of the inverted uterus 
 was nothing more than a polypus adhering to the fundus uteri. Such 
 a mistake as this is easily avoided, by observing that the neck or pe- 
 dicle of a polypus is narrower and more elongated than that observed 
 in inversion, in which we have a tumour larger below than above, 
 more or less reducible, and possessing a lively sensibility ; the poly- 
 pus, on the contrary, has very little sensibility to the touch, and is 
 irreducible. It is true that, in either case, the os uteri forms a sort of 
 ring round the root of the tumour, but this ring is less salient in the 
 case of inversion, and does not admit of the passage of the finger or 
 of a sound more than a few lines upwards to its cul-de-sac ; while, 
 should the ring embrace only the neck of a polypus, the sound could 
 be made to pass far upwards without difficulty. Further, when the 
 
INVERSION OP THE WOMB. 
 
 181 
 
 tumour is a polypus, the fundus of the womb may be felt above the 
 top of the pubis, in many cases, especially in emaciated or thin 
 persons— unless, indeed, by the weight of the polypus, the womb 
 should be dragged down into the bottom of the pelvis. In fine, to 
 avoid confounding together an inversion and a prolapsion of the 
 womb, in which there are symptoms common to both of them, such 
 as the dragging weight at the groins and the back, &c., it should 
 be remembered that in prolapsus there is no ring formed by the os 
 uteri like that in inversion ; and that whereas, in the latter case, the 
 tumour is pear-shaped, as it is in the former, the contracted part is 
 above and the largest part below, while the contrary obtains in the 
 case of hysteroptosis. 
 
 It is far easier to recognize inversion of the womb when in the 
 fourth stage. The tumour, which, for the most part, projects beyond 
 the vulva, is generally larger than in the other stages, although still 
 partially reducible, and is covered with dark-looking bloody excre- 
 tion, especially when the inversion is a recent accident. In this con- 
 dition it is found to increase and diminish in size alternately, accord- 
 ingly as it happens to contain portions of the intestinal convolutions 
 or not, since they are occasionally present within the tumour, and then 
 withdrawn from it. When it remains partly within the vagina, the 
 finger introduced into the vagina, betwixt it and the tumour, always 
 encounters a cul-de-sac, situated at an elevation different in different 
 subjects, and preceded by a sort of ring marked in relief at the most 
 constricted part of the tumour ; and, lastly, by touching the hypo- 
 gastrium, we ascertain that the womb has completely abandoned its 
 natural situation. 
 
 Generally speaking, where inversion is about commencing, or in 
 its first or second stage, it is signified by a haemorrhage, if it follows 
 a labour, and by an increased menstruation and leucorrhoeal dis- 
 charge where it takes place under other circumstances. To these 
 symptoms are added violent pain and draggings at the groins and 
 back, with a feeling of weight within the pelvis. The same symp- 
 toms are more strongly marked in the two last stages, to such a de- 
 gree, indeed, that the flooding, which is, particularly in the third stage, 
 the principal symptom, becomes so violent as to prove rapidly fatal. 
 There are lacerating pains felt, accompanied with syncope, that are 
 generally mitigated by pressing the womb upwards into the vagina, 
 though they are sometimes observed to increase during attempts at 
 reduction. Lastly, inflammation and gangrene, which not rarely 
 attack the inverted portion of the womb, are especially to be feared 
 where the organ is pendulous outside of the genital fissure. 
 
 Inversion of the womb is a dangerous accident, that may prove 
 speedily mortal, provided there be the least delay in attending to the 
 reposition of the organ, and the sooner after parturition it occurs, 
 the more dangerous it is to be esteemed. Notwithstanding some 
 women have been known to live very long although affected even 
 with a complete inversion, unreduced, it generally happens that the 
 few who do survive, draw out a miserable existence, and perish at 
 last, being exhausted by profuse leucorrhoea and repeated attacks of 
 
182 
 
 INVERSION OF THE WOMB. 
 
 flooding. The reposition of the inverted organ, which offers the sole 
 chance of cure, and which is generally quite easy of accomplishment, 
 when undertaken immediately after the accident, becomes more and 
 more difficult the longer it is deferred, and often becomes wholly im- 
 possible. However, there are several examples, going to show that 
 the reposition has been successfully performed as late as the fifth day, 
 the eighth day, and even much later. Dr. Daillez reports, in his dis- 
 sertation, that the surgeon Labarre de Benzeville had effected the 
 reduction as late as the eighth month ; and Baudelocque after eight 
 years. Gardien refers to the last-named author, for an instance in 
 the wife of a vine-dresser at Ruel, where the womb was reduced 
 eight days after the labour, by M. Ane. Moreover, the organ, after 
 having been long inverted, has been seen to reduce itself spontane- 
 ously, in consequence of a violent accidental shock ; and, from a let- 
 ter by Laroux, addressed to Louis, which is mentioned in Daillez ’ 
 Thesis , the spontaneous reposition of the womb has been known to 
 take place two months after the occurrence of the accident. 
 
 [I take occasion here to offer some remarks upon spontaneous reposition 
 of the womb after inversion, since I have been very deeply interested in the 
 subject, from having met with two cases of the accident, in which the womb 
 not only recovered spontaneously, but in which the woman became after- 
 wards pregnant. This statement appears so extraordinary, when unsupported 
 by the cases cited by our author in the foregoing passages, that I might justly 
 deem it an imprudence to make a statement of them were it supported by 
 my sole authority. 
 
 I shall begin by remarking that a very complete inversion of the womb 
 is not, if it be early reposited, to be considered as obviating the liability 
 of the patient to a subsequent conception. This I can clearly aver upon 
 the facts in the case, published by me in the Phil. Pract. of Mid., 2d edit., 
 p. 356, where the case, as seen by the late Dr. James, Professor of Mid- 
 wifery in the University of Pennsylvania, by Dr. George Fox, of this city, 
 and by myself, is given at large. In that case the inversion was produced 
 by violent and most painful tractions at the cord by an ignorant midwife, 
 who supposed, after she had drawn the womb entirely forth of the patient’s 
 body, that the huge mass consisted of some unnatural state of the placenta, 
 which, in fact, was adherent to it. The midwife, even after the womb was 
 withdrawn and hanging between the thighs of the woman, made violent 
 efforts to pull it away from her, and only desisted in consequence of her 
 screams, and the apparent approach of death. 
 
 I reposited this womb, not by compressing the organ between my hands, 
 as it is usually directed to be done, but by waiting until the contraction or 
 after-pain had ceased, and then indenting the fundus with a finger, like the 
 bottom of a bottle, and suddenly pushing the cone upwards to the os uteri, 
 and so into the belly again. This patient was as nearly dead from haemor- 
 rhage as any woman 1 have seen recover from flooding. Upon the re-esta- 
 blishment of her health she bore children, and in two instances was delivered 
 
INVERSION OF THE WOMB. 
 
 183 
 
 by my friend and colleague; Professor F. Bache, of Jefferson Medical Col- 
 lege. 
 
 I mention these circumstances in order to show that the extremest degree 
 of inversion — none could be more complete — is not necessarily the cause 
 of lesions to the ovaries, tubes and other organs connected with reproduc- 
 tion, so great as to deprive them ever afterwards of the reproductive power. 
 
 I saw, a few years since, a female in this city, who had been the subject of 
 an inversion of the womb for about two years. This took place at the time of 
 her confinement, when she had a very profuse haemorrhage, so as to be sup- 
 posed to be in danger of a fatal result. Her health gradually improved, but 
 she remained subject to frequent attacks of haemorrhage, by which her 
 strength became again much reduced. At length, a physician, who was called 
 in, detected the existence of inversion of the womb, and invited me to exa- 
 mine the case and verify the diagnosis. I found the womb projecting into 
 the vagina, and I believe it to have been, at the time, completely inverted. It 
 was not much larger than the non*gravid womb, bled readily from pressure 
 at the time, and was not very sensible to touch, as indeed the healthy uterus 
 is not. 
 
 In this case I made the most careful attempt to discriminate between 
 polypus and inversio-uteri, and I remained under the absolute conviction, as 
 did the physician, Dr. Moehring, a highly capable practitioner, that the case 
 was one not of polypus, but of inversion. I gave such a prognosis as I 
 deemed reasonable, but added to it the opinion that she would never again 
 be subject to conception. This female was subsequently examined with 
 care by Professor Hodge, of the University of Pennsylvania, with the same 
 diagnostic result; and later by Dr. Warrington, of this city, well known as 
 a teacher and practitioner of obstetrics. These gentlemen all agree that the 
 case was one of inversion, and the attempts made by myself and by them, 
 to reposit the organ were without the least success. Nevertheless, after some 
 four years posterior to the period of my visit to her, she became pregnant, and 
 miscarried of an embryo of more than three months, under the care of Dr. 
 Warrington, who received the embryo, and who feels as much surprised as 
 I do at the circumstance. I may take the occasion to say that Dr. Hodge 
 and Dr. Warrington have assured me of their convictions of the correctness 
 of their diagnosis in the case, and I may add, that I have not the least doubt 
 of its correctness, for I do not think I could make so gross a mistake where 
 my careful attention had been given to the formation of a correct opinion. 
 Far less can I suppose that the other gentlemen could be equally mistaken. 
 
 May 5th, 1841. — I saw, in company with Dr. Levis, of the city, Mrs. S., 
 aged twenty-seven years. She has two children, the youngest born five 
 weeks ago. Dr. L. informed me that the child was expelled before he 
 reached her dwelling. Upon arriving there, he found her lying upon her 
 back, near the edge of the bed, the feet resting upon chairs, as if she had 
 hardly found time to get upon the bed before the escape of the foetus, which 
 an attendant was then holding up in her hands, in order to keep it out of 
 
184 
 
 INVERSION OF THE WOMB. 
 
 the great pool of blood collected about the hips of the patient. The child’s 
 head, indeed, was quite born before the lady could rise from the pot-de- 
 chambre, on which she had placed herself. Dr. L. removed the placenta 
 from the vagina, having found the womb contracted. 
 
 After the delivery, she flooded a good deal, but, in a fortnight, was much 
 recovered. Subsequently to this period, she was seized with flooding of 
 a severe character, since which she has not been free from bloody dis- 
 charges, which are occasionally quite copious. Two days ago, the doctor 
 examined his patient, and found a tumour projecting from the os uteri, 
 which he suspected to depend upon inversion of the organ. She is now 
 very feeble, is bleeding, and has frequent fits of hysterical delirium. 
 
 Upon Touching per vaginam, and upon inquiry made by means of the 
 speculum, and even by disparting the labia with two fingers of each hand, 
 it was easy to discover a tumour which bore so great a resemblance to an 
 uterine polypus that it was difficult, viewing its size, form, colour and resist- 
 ance, to believe that it was not a polypus which had existed throughout the 
 gestation ; an idea which yet could not be very reasonably indulged, seeing 
 she had gone through a healthful pregnancy to full term ; though I admit its 
 possibility in certain cases. As the parts, as well as her whole frame, were 
 very much relaxed, I introduced half of my right hand into the vagina, be- 
 hind the tumour, so as to enable me to carry two fingers quite far up into 
 the cul-de-sac, behind the cervix uteri, which was not inverted. Having 
 thus possession of the canal, I carried the two fingers forcibly upwards and 
 forwards, so near to the margin of the superior strait, just behind the sym- 
 physis pubis, that the fingers of my left hand, pressed forcibly upon the 
 lower part of the hypogastrium, were but a very small distance from those 
 of the right hand within the vagina. They approached so near to each other 
 that I remained perfectly convinced that no womb was interposed betwixt 
 them, and that the tumour within the vagina consisted of the inverted womb, 
 and nothing else. She remained for some time feeble, and subject to haemor- 
 rhage, which gradually disappeared. She made a journey to one of the 
 Western States, and returned to the city; since which she became pregnant 
 and gave birth to a child. 
 
 Now, in these two cases, I am very confident of my diagnosis; and, since 
 both these women have been the subjects of conception and pregnancy, 
 without artificial reposition of the organ, I rest convinced that the inverted 
 womb, where the accident does not prove suddenly mortal by hemorrhage, 
 nor slowly fatal from exhaustion by inflammation and gangrene, or discharges, 
 may reposit itself in some rare instances. I have made a statement of these 
 cases to Dr. J. Greene Crosse, of Norwich, England, to whom the profession 
 is about to be indebted for a work upon inversion of the womb, which I 
 impatiently expect. I draw from my experience in these cases, and from 
 what is stated by M. Colombat, much consolation for those women who are 
 so unhappy as to be affected with inversion of the womb, irreducible by 
 manual aid. — M.] 
 
INVERSION OF THE WOMB. 
 
 185 
 
 The treatment of inversion, like the other displacements of the 
 organ, presents two chief indications, which are, to restore the womb 
 to its natural situation, and to provide against a recurrence of the 
 accident. 
 
 All practitioners are agreed that the most favourable moment for 
 operating a reduction is that which immediately succeeds the occur- 
 rence. It is always easy to reduce it, when in the tirst stage, and 
 where it has taken place previous to the deliverance of the placenta ; 
 all that is necessary being to carry two fingers into the vagina, so as to 
 push the placenta upwards sufficiently to make the womb recover its 
 natural shape and situation. On the other hand, where inversion, in- 
 complete, takes place after delivery, far from trying to carry the hand 
 up to the depression, within the uterine cavity, we should confine 
 ourselves to an attempt to excite the uterine contractions by irritating 
 the os tincae, and by applying cold cloths to the upper part of the 
 thighs and the external genitalia, or by making use of stimulating 
 frictions at the hypogastrium, and particularly over the ligaments of 
 the womb. Should the placenta be still found adherent to the fundus 
 uteri, and the flooding not prove alarming, we ought, before detach- 
 ing it, to wait until the uterine contractions become established again. 
 However, in case of a complete, or nearly complete inversion, with 
 abundant discharge of blood, especially, I should not hesitate, not- 
 withstanding the opinion of Dr. Ferrand and most other persons to 
 the contrary, to extract the placenta as soon as practicable, by de- 
 taching it with the fingers, acting from the edge to the centre, so as 
 to avoid any traction on the centre of the fundus : this I should do 
 previously to any attempt at reduction, which is far easier when the 
 womb is empty. In this case, it is important to act without delay, 
 because the placenta, which is generally attached to the womb only 
 by some distinct portions of the surface, the rest being detached 
 already, serves, by its presence, rather to keep up than to lessen the 
 flooding, as is generally thought. Where the inversion takes place 
 after the delivery of the placenta, or the escape of any foreign body, 
 we should most expeditiously profit by the occasion of the greatest 
 degree of relaxation to anoint the right hand and carry it into the 
 vagina, while the left is placed upon the hypogastrium, with a view 
 to support the uterus, while we push up the inverted portion with 
 the hand that is inside, and which ought to be kept thus after the 
 reposition, until it be well contracted ; an event that may be pro- 
 moted by frictions above the pubis, with the left hand. The patient 
 should be advised to avoid bearing down, to breathe very gently, to 
 moderate her cries or exclamations, and to observe a horizontal pos- 
 ture, and be as still and calm as possible. After having continued 
 the frictions for some time, the womb should be kept compressed by 
 means of a folded napkin, secured by a binder round the body. 
 
 Pretty much the same method should be followed, in the case of 
 an inversion taking place immediately after the delivery of the foetus 
 and afterbirth. The reduction should be performed by placing the 
 patient upon her bed, with the hips elevated higher than her chest, 
 the legs drawn upwards and flexed; then, with the right hand seizing 
 
186 
 
 INVERSION OF THE WOMB. 
 
 the parts nearest to the pedicle, that is, those that are highest, and 
 which, of course, were the last inverted, they should be pressed 
 upwards, and made to re-enter first ; then, in succession, we should 
 push up the fundus, along the lateral parts, which should be made, 
 little by little, to pass through the os uteri, imitating the manoeuvre 
 made use of in reducing a strangulated hernia. There is also another 
 but less reasonable method which has been recommended, and which 
 consists in depressing, with the hand, the fundus into the globe 
 formed by the inverted organ, and proceeding, in this way, until the 
 rejected cone, which is the base of the tumour, passes through the 
 ring formed by the mouth of the womb. If the parts should happen 
 to be soft and dilatable about the root of the tumour, this mode might 
 prove successful; but in opposite circumstances, and such always 
 exist where the accident is not recent, we should only flatten the fun- 
 dus without overcoming the strangulation formed by the mouth of 
 the organ. Besides, we might practise a mixed method of operating, 
 that is to say, we might make the parts at the root return first, and 
 then, when the fundus alone remains inverted, the whole mass might 
 be pushed upwards with the tips of the fingers. Having the use of 
 the hand alone, there never can be any occasion for the assistance of 
 mechanical instruments, as repel lers, and it will always be found use- 
 less to employ a deal of force, and especially to take a point d’appui 
 against a wall, as was done by an English practitioner.* Having 
 procured the reduction, the hand is to be left within the womb until 
 contraction comes on, after which we should proceed, as before di- 
 rected, in speaking of reduction in incomplete inversion. 
 
 [I cannot think that M. Colombat gives the best counsel as to the method 
 of proceeding for this reduction. It is hardly necessary to remark that the 
 state of inversion does not deprive the womb of its muscularity, and conse- 
 quently of its ability to suffer what are called after-pains. It is also well 
 known that frictions upon the sur-pubal region, and irritations applied to the 
 mouth of the womb, or the internal surface of the organ, are constantly re- 
 sorted to as means of exciting its muscular power. It cannot be, then, that 
 by M. Colombat’s method of grasping the neck of the tumour and shoving 
 it upwards, we could fail to excite or irritate the organ into a violent exer- 
 cise of its muscular force, which could not exist without hardening the 
 tumour and rendering it stiff and inflexible. But if we render it stiff, hard, 
 and inflexible, how shall we expect to return it through its hard and rigidly 
 contracted os uteri ? It is manifest we cannot expect success by so unrea- 
 sonable a method of operating. As the ancients used to say, non cuivis 
 contigit culire Corinthum , so I may say it does not happen to every prac- 
 titioner to have reduced a completely inverted womb ; and the late Prof. 
 Dewees says, at p. 512 of his System of Midwifery , 2d edit., that “ we 
 may justly entertain doubts” of the uterus having been reinstated after com- 
 plete inversion. I have already spoken, at p. 182, of the case which I saw 
 with the late Prof. James and Dr. Geo. Fox, in which the womb was not only 
 
 * Biblioth. Medicale, t. xlvii., p. 271. 
 
INVERSION OP THE WOMB. 
 
 187 
 
 completely inverted, but had been strongly pulled by the midwife. Now in 
 that case, I used the method recommended by Dewees and other authors, of 
 grasping the globe firmly with the hands, in the view of pushing it back 
 bodily into the pelvis — for it was of enormous size, reaching near half way 
 to the knees — but I was unable to meet with the least success, until I had 
 taken off the placenta, which still adhered, though detached in certain parts 
 of the surface and much torn. After I had removed the afterbirth, I found 
 that the organ became alternately soft and rigid, just as happens after de- 
 livery in an ordinary labour ; and I further observed that to handle it was to 
 irritate its contractility and to harden it, which rendered it obdurate against 
 every attempt at reduction. I was compelled, therefore, to do what M. 
 Colombat so pointedly condemns : i. e., to wait until it became relaxed, and 
 then to indent the fundus and to drive that cone through the centre of the 
 globe, and up through the cervix and os uteri, until I had carried my hand 
 so high that the external organs contained my arm not more than four or 
 five inches below the elbow. I feel very confident that if, in any case, 
 I could succeed in indenting a fundus uteri and in bringing the cone up to 
 the os uteri, I could always perfect the operation by gently pressing that 
 cone against the ostium uteri, which, under a persevering maintenance of 
 the pressure, would yield as readily as it does to a labour pain, or to the cone 
 of the hand, when introduced in cases of hourglass contraction or spasm of 
 the cervix under encysted or retained placenta. I dare recommend to the 
 reader, therefore, to disregard the author’s injunction and to adopt the method 
 which I found successful. — M.] 
 
 Should the pressure of the hand on the womb, and the irritation 
 of the os tincse, together with frictions of the hypogaster, fail to 
 cause contractions, and re-establish the tonicity of the organ, rather 
 than make use of spirituous and astringent injections, as recom- 
 mended by some writers, among whom we may mention Gardien, 
 I should prefer to exhibit a few grains of secale cornutum, by which 
 I should expect, not only to excite the contractions, but also to arrest 
 the haemorrhage, which is one of the most serious phenomena in 
 uterine inversion. This method, which has never been attempted 
 in such cases, promises to fulfil the twofold indication, and to be*unat- 
 tended with any inconvenience, when prescribed by a person pro- 
 perly qualified for the emergency. Generally speaking, there is little 
 reason to fear a relapse ; yet the womb has been found to invert 
 itself afresh, even several days after the reposition had been effected. 
 To obviate such an occurrence, the greatest attention should be paid 
 to the state of the organ, and the patient should be advised to keep 
 perfectly quiet, and lie upon the back for several weeks, carefully 
 eschewing all sorts of exertion that might have an injurious effect 
 upon the uterus. 
 
 In the case of an inversion of long standing, and where, from the 
 contact of the air, or strangulation, or fruitless and violent efforts ‘at 
 reduction, the parts are found to be tumefied and inflamed, or where 
 
188 
 
 INVERSION OF THE WOMB. 
 
 the neck of the womb is spasmodically contracted, we might follow 
 the example of Lauverjat, of Hoin, and of Choppart, and divers 
 other practitioners, which is to combat all these affections by means 
 of the antiphlogistic remedies, such as blood-letting, baths, emollient 
 fomentations, opiates, &c. : with a view to lessen the spasm of the 
 cervix uteri, and facilitate its dilatation, it would be well frequently 
 to anoint the tumour, and the circle by which it is strangulated, with 
 a liniment, composed as follows : 
 
 — Beurre de cacao, 
 
 Olive oil, aa ,fss ; 
 
 Extr. belladonnas, gr. viij. 
 
 M. — ft. Liniment. 
 
 When the magnitude of the tumour is increased by the presence 
 within the cavity of intestinal convolutions, they ought to be pushed 
 back into the abdomen, by pressing them carefully from below up- 
 wards, and obliquely from before, backwards. Should the womb be 
 found engorged merely, and not inflamed, the advice of Dessault,* 
 Madame Boivin, and Duges,t should be followed, to try to lessen the 
 volume of the lower portions of the tumour, by means of a steady 
 compression with a small bandage, even when the tumour does not 
 jut forth from the orifice of the vagina This object may be put- 
 sued by means of a linen ball fixed to the cuvette of a stem-pessary, 
 and assisting the effect of this gentle and prolonged compression by 
 making friction over the course of the round ligaments. It might be 
 possible to effect a gradual reduction, even where a prompt reduc- 
 tion was impracticable, or even contra-indicated. 
 
 Having well ascertained the impracticability of reduction, and 
 that a continuance of the attempts could only be productive of in- 
 jury to the patient by aggravating all the symptoms, there are left 
 in the power of the art no means even of palliating the distressing 
 effects of the disease. Thus, for the relief of the floodings, prescrip- 
 tions have been made of all the various astringents; of the permanent 
 tampon ; of sponges, and a variety of means, that always prove of 
 very small efficacy for these unfortunate cases. Under such circum- 
 stances, all that can properly be done is, to endeavour to keep the 
 womb within the walls of the vagina, by means of a pessary, so as 
 to relieve it of the sort of strangulation to which it is subject, when 
 pendulous beyond the ostium vaginae ; and from the mischiev- 
 ous impression of the air upon its surface, as well as those of the 
 frictions, and the contact of the urine. 
 
 Sometimes it happens that the inflammation of the completely in- 
 verted womb is resolved, and the organ remains irreducible without 
 giving the patient any great inconvenience. Millot,f in hopes of 
 relieving the patient of her infirmity, proposes, for the purpose of 
 obtaining the reduction in such cases, that an incision should be 
 made in the cervix so as to take off the constriction, by the use of 
 Frere Gome's lithotome cache. This proceeding, which it seems 
 ought not to be absolutely rejected when all other resources are vain, 
 
 * Diet, de Med., t. xviii. t. 276. f Mai. de 1’Uterus, t. i. p. 238. 
 
 4 Supplement a tous les Trails sur les Accoachements, 1773. 
 
INVERSION OF THE WOMB. 
 
 1S9 
 
 would, we think, be much more efficacious and certain, if, instead of 
 a simple incision, which to do any good, ought to be carried to a 
 dangerous length, the constriction of the cervix should be removed 
 by means of four small incisions, made in an oblique direction from 
 the centre towards the circumference, ‘either with a probe-pointed 
 bistoury, or what is still better, a small lancet, with a concave probe- 
 pointed blade, invented by the author for operating in fistula in ano, 
 and for cutting the stricture in strangulated hernia. Even should 
 these four incisions amount to only half a line each, a greater dilata- 
 tion would be procured by them than from a single incision of four 
 or five lines ; for with such an one, the relaxation could only interest 
 one point of the cervical ring, whereas, by the multiple incisions, 
 the circumference of the os tineas would be enlarged throughout. 
 From these purely geometrical data, we may clearly perceive that the 
 multiple incision, which need not be extensive, would be less liable to 
 induce lacerations upon pushing up the fundus uteri through the os 
 tineas, a single long incision of which would be both hazardous and, 
 at the same time, insufficient for the object proposed.* 
 
 When reduction cannot be obtained, it now and then happens that 
 the disease ends in gangrene. In such event the suppuration should 
 be promoted with the view to produce the separation of the eschars, 
 while we also try to allay the symptoms by tonic drinks and by 
 injections and fomentations with cinchona, camphor, chloride of 
 sodium, &c. But should the symptoms be so severe as to threaten 
 the woman with inevitable death, let the womb be removed either 
 by the ligature or by a direct amputation. 
 
 There are numerous cases to show that this last plank of safety 
 has not been trusted to in vain. Carpue, Osiandert and Wrisbergf 
 have related cases of the completely inverted womb, the extirpation 
 of which has been described. The ligature which has most com- 
 monly been employed has met with success. Rousset§ has published 
 two cases. Faivre,|| Bouchet, sen., of Lyons,! Newnham,** Gran- 
 ville and Gooch, tt Windsor, Johnson, §§ Chevalier, |||| and others 
 have reported facts of the same kind, the authority of which cannot 
 be questioned. 
 
 It is true that to all these instances of success we may oppose a 
 great array of cases in which the extirpation has been followed by 
 the death of the woman. For example, the patient operated on by 
 Deleurye,!! died in the course of a few days ; and, in another case, 
 
 * In our memoir on la Cystotomie sous pubienne quadrilaterale, 1831, we dwelt in 
 much detail on the advantages of multiple incisions to take off* stricture where the 
 object is to obtain a free opening without making extensive wounds. 
 
 f Neue Denkwurdigkeiten, b. i. 312. 4 De Uteri Resectione, &c. Gott., 1787. 
 
 § Traite de l’Operat. Caesar, 354. |j Jour, de Med., Aug., 1786. 
 
 *j[ Collect, de la Soc. Med. de Lyons, t. i. 
 
 ** On the symptoms, &c., with a history of the successful extirpation of the uterus, 
 
 p. 82. 
 
 ff Lond. Med. & Surg. Jour., 1828. ** Med. Chir. Trans., x. 361. 
 
 §§ Dub. Hosp. Rep., iii. 
 
 jlU Traite de Mai. de l’Uterus, by Boivin and Duges, i. 240. 
 
 Precis des Legons de Baudelocque sur les Renversemets de la Matrice, par 
 
 Daillez, 104. 
 
190 
 
 ELEVATION OF THE WOMB. 
 
 the woman died in seventeen days after the application of a ligature 
 upon the root of an inverted womb that was mistaken for a polypus 
 uteri, and in which a post-mortem examination confirmed the diag- 
 nosis that had been given by Goulard before the performance of the 
 operation. Under similar circumstances Baudelocque and Desault 
 were equally unfortunate ; and, in fact, the application of the ligature 
 to the inverted womb, supposed to be merely polypus uteri, was, in 
 two other cases, followed by death — one of these cases being under 
 the care of Dr. Rey, and operated on at Lyons in presence of Marc 
 Antoine Petit, and the other at Paris, where the operation, which was 
 done by a young surgeon, terminated fatally in a few days, though 
 the first symptoms were not so very rapid, and though the organ was 
 really thrown off by gangrene.* M. Dugest states, that in a woman 
 lying under imminent danger of death, Baron Dubois endeavoured to 
 strangulate the uterus by a ligature, which put a stop to the flooding, 
 but the distinguished professor was soon compelled, by the occurrence 
 of alarming symptoms, to remove the thread which he had cast on 
 the neck of the tumour. Be this as it may, the single ligature, as 
 used by the surgeons above mentioned, or even the double one, ad- 
 justed by passing a needle through the middle of the neck, as was 
 done in Baxter’s! case, are the extreme resorts to which we must 
 always turn where no other chance remains of prolonging the life of 
 the patient. 
 
 Previously to closing our remarks upon the treatment of inversion 
 of the womb, we must add that those cases that are produced by the 
 weight of a polypus, or that are voluntarily brought on for the pur- 
 pose of facilitating an operation, almost always reduce themselves 
 spontaneously, as soon as the cause that produced them is with- 
 drawn. 
 
 OF THE ELEVATION OF THE WOMB. 
 
 In some rare cases the uterus becomes so highly elevated above the 
 excavation of the pelvis, that the os tincae becomes almost inaccessi- 
 ble to the Touch , and it is wholly impossible to reach the posterior 
 surface of the womb by the Touch from the rectum. 
 
 The ascension of the womb, which is rare in its non-gravid con- 
 dition, may arise from a variety of causes; such as insufficient length 
 and width of the ligaments; the formation of an abscess within these 
 ligaments ; inflammation, engorgement and dropsy of the tubes and 
 the ovaries; an exfra-uterine pregnancy; the first stage of antever- 
 sion and retroversion; and, lastly, the expansion of the uterine cavity 
 by hydatids or other foreign bodies. 
 
 As the upward displacement of the womb in pregnancy is, in 
 some sort, a normal effect of that condition from the fourth to the 
 eighth month, it does not deserve any special attention, except as it 
 is taken as a sign of several kinds of disorder. As alone consi- 
 dered, it generally causes no sort of inconvenience, there will be no 
 
 * Boyer, t. x. 510. j- Traite des Mai. de l’Uter., loc. cit. 
 
 t Annale de la Litterat. Med. Etrang., t. xv. 578 
 
IMMOBILITY OF THE WOMB. 
 
 191 
 
 reason (o feel uneasy about it, except in view of the causes that may 
 have led to its existence ; and it of course requires no treatment but 
 that applicable to the disorders of which it is a symptom. Besides, 
 where the elevated state of the uterus is a permanent one, as when 
 it results from the faulty state of the broad ligaments, it may act as 
 a cause of barrenness. It might be possible to overcome it by ap- 
 plying by means of a speculum, a small cupping-glass, with exhaust- 
 ing pump, to the cervix uteri, and leaving it in situ a few minutes; 
 the operation to be repeated from time to time, so as not to fatigue 
 the woman too much. And, lastly, to promote the relaxation of the 
 uterine ligaments and modify their recent adhesions and retractions, 
 recourse ought to be had to baths and to frictions with mercurial oint- 
 ment, a drachm each time being rubbed in upon the hypogastric and 
 iliac regions of the abdomen. 
 
 OF ABNORMAL IMMOBILITY OF THE WOMB. 
 
 While too great a degree of mobility of the womb is productive of 
 various displacements, rendering the patient liable to very serious dis- 
 orders, the absolute immobility of the organ, in addition to the ob- 
 struction it causes as to the dilatation of the bladder and rectum, 
 might give rise to other inconveniences still more serious on account 
 of their greater frequency. 
 
 Among the causes of immobility of the womb, may be enume- 
 rated those adhesions that follow attacks of peritonitis, or inflamma- 
 tion of the other organs in the vicinity of the womb and its append- 
 ages, such as the rectum and the bladder. 
 
 Attacks of metritis and metroperitonitis* succeeding laborious par- 
 turition, or difficult menstruation, also give rise to morbid adhesions 
 and to unnatural ligaments, which often attach themselves to the 
 womb as well as the sides of the pelvis, yet remain undetected long 
 after their formation. 
 
 Adhesions producing immobility of the uterus were not properly 
 understood until since the publication of Madame Boivin’st re- 
 searches upon one of the most common causes of abortion. The 
 author of that important work, and also M. Duges,f have remarked 
 
 * Dr. Veindmann, in 1818, published a memoir (Casus Rari) containing a descrip- 
 tion and drawing of an adhesion of the epiploon to the anterior surface of the womb, 
 which was probably the consequence of an attack of puerperal metro-peritonitis. In 
 her subsequent pregnancy she died at the fifth month, with all the symptoms of an 
 internal strangulation. 
 
 [I lost a patient, a married lady, of about thirty-two astat., two years since, with 
 strangulated intestine, which had strangulated itself under an abnormal ligament in 
 the lower part of the pelvis behind the womb. This ligament must have been formed 
 when she was about twelve years of age: at which time she suffered a dangerous 
 and nearly fatal attack of peritonitis. She had all the symptoms of iliac passion, 
 and it was not till after death that the strangulation was ascertained to take place in 
 the pelvis. — M.] 
 
 f Recherches sur les causes les plus, frequentes de I’Abortement. 
 
 * Traite Prat, des Mai. de l’Uterus, t. i. p. 176. 
 
192 
 
 IMMOBILITY OF THE WOMB. 
 
 that scrofulous women, and those who possess a lymphatic tempera- 
 ment ; those who are subject to constipation and irregular action of 
 the digestive apparatus, are also more liable than others to unnatural 
 adhesions, and by consequence, to preternatural immobility of the 
 organ. It would seem, from what M. Duges has observed, that little 
 girls abandoned to habits of masturbation are also liable to this sort of 
 immobility ; for the permanent excitement of their genital organs by 
 sympathetically irritating the peritoneum, and particularly that part 
 of it connected with the womb, must necessarily lay the foundation 
 of adhesions betwixt the womb and the other peritoneal superficies. 
 These opinions, which, however, as M. Duges says, are as yet merely 
 conjectural, require, for their confirmation, the careful observation of 
 many cases. 
 
 By means of the Touch per vaginam , and by learning the past 
 history of the case, it is within our power to foresee that a certain 
 degree of this uterine immobility may render it impossible for the 
 womb to rise upwards properly in the gravid state. By the intro- 
 duction of the finger we discover that the womb is firmly fixed to 
 one side according to the direction it has taken. In some instances 
 it seems to be confined in every direction around it ; in others, only 
 at certain points of its circumference. 
 
 Where the womb rises higher on one side than on the other, it 
 is because one of the round ligaments has become engorged and 
 shortened, so that, at the sixth or seventh month of gestation, it is 
 almost inevitable for the woman to abort, as Madame Boivin has 
 shown by many examples. 
 
 The historical circumstances that may serve to throw light on the 
 diagnosis, are certain maladies, such as inflammations of the womb 
 and the peritoneum, dysentery, abortions, laborious labours, and a 
 variety of physical lesions, such as wounds, lacerations, and abscesses 
 in the uterus and the tissues adjacent to it. 
 
 Although sterility, that is often caused by the adhesion of the Fallo- 
 pian tubes, is to be regarded as a misfortune, conception, in such a con- 
 dition, is a vastly more serious one, since it may give rise to the most 
 important symptoms, by setting on foot a new inflammation, caused 
 by the stretching of the ligaments of the expanding womb, as it con- 
 tinues to rise higher and higher during the pregnancy. This gives 
 the woman violent pain, and dragging in the pelvis, and a feeling of 
 lassitude in the thighs. Abscesses often form in the vagina and rec- 
 tum, and in most cases, the death of the patient, which is inevitable, 
 is preceded by abortion, which may be expected, about the third or 
 fourth month, upon some attack of violent uterine inflammation or 
 profuse haemorrhage. 
 
 While, on the one hand, these preternatural adhesions may tie up 
 the non-gravid uterus, while of its natural dimensions and in its pro- 
 per situation, so on the other, may similar accidental causes operate 
 while the organ is very high up in the abdomen, and distended with 
 the products of conception. In some cases, the omentum, jammed 
 far up in the epigastric region, inflames at a point in contact with 
 the womb, aiid then very readily forms adhesive connections with it. 
 
IMMOBILITY OF THE WOMB. 
 
 193 
 
 This pathological soldoring is in general productive of no inconveni- 
 ence, and is not disclosed by any symptom during the progress of the 
 pregnancy ;* but the case is different where the womb, become freed 
 from the products of conception, returns rapidly towards its non-gra- 
 vid dimensions, descending from the epigastrium down behind the 
 symphysis of the pubis. The omentum, now become too short from 
 its accidentally rolled condition, is powerfully and painfully stretched ; 
 unless, indeed, the adhesions and unnatural bands that bind the womb 
 happen to be weak enough to break and set it free. This perito- 
 neal tension, and the retractive movement of the uterus detained 
 thereby above the superior strait, are recognized by the following 
 symptoms : the colon and stomach are painfully dragged downwards, 
 and their irritation is participated in by the peritoneum, which in- 
 flames from partial ruptures or lacerations taking place at different 
 points of its surface, upon which supervene attacks of vomiting, diar- 
 rhoea, fainting, &c. Lastly, should the adhesions not give way, there 
 is almost always an attack of fatal haemorrhage, brought on in con- 
 sequence of the inability of the womb to contract to its proper size 
 again, thus preventing the great sinuses of the organ from closing, 
 and leaving their orifices so open as to permit a large issue of blood. 
 Samples of this sort are to be found in Madame Lachapelle’st excel- 
 lent work. Fred. Ruysch,f as well as the celebrated Morgagni, § has 
 published cases of the same kind, but of a less distressing result, for 
 they merely gave rise to the painful dragging of the stomach, and 
 some other derangements of the health. 
 
 Unfortunately, the physician, after ascertaining the existence of 
 the adhesions in question, is compelled to remain merely a sad spec- 
 tator of the disorders arising from them. The sole resource we have 
 is to endeavour to prevent the adhesions, and the formation of the 
 bands that fix the uterus in an immovable station. This attempt 
 may be made by the employment of antiphlogistic means, to which 
 should be added the use of mercurial frictions upon the abdomen. 
 Having overcome the inflammation that has produced the attach- 
 ment, there is some probability of effecting the resolution of such 
 adhesions as have not become consolidated, and putting a stop to 
 the pathological action which tends to their production. In their 
 work upon the diseases of the uterus, Madame Boivin and M. Duges 
 have published a case of adhesion of the uterine appendages, accom- 
 panied with symptoms of chronic inflammation, that was cured by 
 means of a mercurial treatment. The mercurial ointment was ex- 
 hibited in friction on the thighs and sides of the abdomen, a drachm 
 at each friction. In the course of one month, all the symptoms dis- 
 appeared, without the occurrence of salivation. After six months 
 
 * It is true,Baudelocque had a case which proved fatal before delivery, in the first 
 stage of labour, where the epiploon was rolled up like a rope and attached to the right 
 lateral anterior part of the womb, so that the stomach and arch of the colon were 
 singularly pulled by it. The fatal termination was preceded by vomiting, diarrhoea 
 and syncope. Traite des Mai. de I’Uterus, par Boivin and Duges. 
 
 f Prat, des Accouch., ou M6m. et Obs., t. ii., p. 376. 
 
 * Obs. Anat. Chir. Centur., p. 59 and 78. § Epistol. Anatom., 46, art. 46. 
 
 13 
 
194 
 
 HYSTEROCELE. 
 
 the woman could scarcely be recognized as the same person, so great 
 was the change in her appearance. The authors prefaced this case 
 with the history of other cases of immobility of the womb in preg- 
 nant women, all of which produced abortion and death between the 
 third and fifth month of pregnancy. 
 
 OF HYSTEROCELE OR HERNIA OF THE WOMB. 
 
 Notwithstanding hernia of the womb is very rare, the annals of 
 medicine contain a sufficient number of cases to prove, beyond cavil, 
 that such an occurrence is possible, not only in the non-gravid, but 
 also in the gravid womb. 
 
 Though in general the womb does not, except in pregnancy, rise 
 above the superior strait, hysterocele has been noticed in several in- 
 stances, of which we shall speak presently, by Choppart,* by Prof. 
 Lallement,t and by Dr. Murat. f 
 
 The principal characters of hysterocele in the non-gravid womb 
 are the following : the tumour is hard, very little reducible, and 
 mostly indolent ; its form is roundish, and its root is thick ; the vagina 
 is stretched, and curved obliquely from below upwards towards one 
 of the groins. The os uteri, which is very high up in the pelvis, is 
 pointed towards the sacrum ; or it wholly disappears, having been 
 lodged within the hernial tumour. The reduction, which ought to 
 be promptly attempted, with the greatest care, cannot be effected, 
 except when the hysterocele is a recent one, of small size, and with- 
 out any adhesions. After the reduction, a relapse should be pre- 
 vented by a large compress of lint, supported by a bandage. 
 
 [A common truss for inguinal hernia would be preferable. — M.] 
 
 While hernia of the non-gravid uterus is liable to be confounded 
 with protrusion of other abdominal viscera, such a mistake cannot 
 be made as to that of the pregnant womb. 
 
 In fact, the volume of the tumour, which daily increases, the dull 
 fluctuation perceptible in it, the motions of the foetus that are dis- 
 tinguishable through the integuments, and the sounds of the foetal 
 heart, ascertained by the stethoscope, yield so many signs, that afford 
 a sure diagnosis, and remove every remaining doubt as to the nature 
 of the hernia. 
 
 There are three kinds of hysterocele, which are : 1. Inguinal, 
 never met with, except in the non-gravid state. 2. Crural , which 
 may occur in that state, but most commonly in the pregnant female ; 
 and 3. Ventral , which may take place where the womb is distended 
 with the products of a conception. 
 
 From a case published by Maret,§ formerly perpetual Secretary to 
 the Academy of Sciences at Dijon, it appears to be possible for an 
 inguinal hysterocele to be congenital. In the instance spoken of by 
 
 * Boyer. Mai. Chirurg., t. viii. p. 381. 
 
 -J- Mem. de la Soc. Med. d’Emulation, 3 ann. 323. 
 
 i Diet, de Med., en. 21 vol., t. ii. p. 162. 
 
 § Consultations Med., Legates: and Mad. Boivin and M. Duges, t. i. p. 39. 
 
HYSTEROCELE. 
 
 195 
 
 this learned observer, the hernia of the womb was upon the right 
 side, which is the most common situation of inguinal hernia uteri ; 
 probably because the womb is naturally somewhat inclined towards 
 that side, and because the round ligament on that side is shorter than 
 its fellow, and thicker. 
 
 The causes of hysterocele in pregnancy may be attributed to 
 weakness, or relaxation of the ligaments of the womb ; to a violent 
 blow and contusion of the belly ;* to the effects of a Caesarian opera- 
 tion in a preceding labour ;t and it should be considered that an 
 abscess in the groinf or hypogaster, a sudden separation of the linea 
 alba,§ an old cicatrix, and certain other lesions, like those we have 
 just named, may give rise to hysterocele upon the occurrence of some 
 violent shock or effort of the patient. 
 
 As these displacements are very rare, we shall confine ourselves 
 to the relation of a few of the cases of each sort that are contained 
 in the records of the science. 
 
 1 
 
 INGUINAL HYSTEROCELE. 
 
 A case of this kind of hysterocele, which most writers look upon 
 as impossible in pregnancy, was met with by Professor Lalle merit, || 
 at the Hospital la Salpetriere, in a woman at the age of seventy-one 
 years. The tumour, which had come through the right inguinal ring, 
 contained the right ovary, the whole of the womb, and a portion of 
 the vagina : the hard life led by this woman had given rise to and 
 caused the gradual increase of the tumour, which, though very pain- 
 ful at first, gradually became indolent. It was pear-shaped, and four 
 or five finger-breadths long. Professor BoyerTT gives the analysis 
 of a case of the same nature, published by Choppart : the woman 
 was fifty years of age ; her worrlb, which almost completely escaped 
 through the inguinal ring, along with the left ovary and tube, was 
 contained, without any adhesions, in a very large hernial sac, and 
 appeared to be much smaller than common. It was of an oblong 
 shape, of a pale red colour, a soft and flaccid consistence. It was 
 constricted near the place of the ring ; and exhibited at the fundus 
 some membranous laminae that seemed to be the result of a former 
 adhesion of the epiploon. 
 
 CRURAL HYSTEROCELE. 
 
 Crural hysterocele may also occur in the non-gravid state of the 
 womb. M. Murat** and Professor Lallementf ±*saw a case of the 
 kind in a woman eighty-two years of age, who died at la Salpetriere 
 
 * Dan. Sennertus, Opera Omnia, de Hernia Uterina, tom. iii. p. 654. 
 t Rousset, Traite de l’Oper. Cesar., loc. cit. 
 t Ruysch, Advers. Anat. Chir. Med. Decas ii. 23. 
 
 § J. L. Petit, CEuvres Posthumes, t. iii. p. 264. 
 
 || Mem. de la Soc. d’Emulation, iii.annee 323. 
 
 T[ Boyer, Maladies Chirurg., t. viii. 381. 
 
 ** Diet, de Med. in 21 vol., v. iii. p. 162. 
 
 •j-f Bulletins de la Faculte de Med. de Paris, t. i. p. 1. 1816. 
 
196 
 
 CRURAL HYSTEROCELE. 
 
 in 1816. She had had the hernial tumour for forty years; it was 
 five inches long and four in width, and occupied the whole bend of 
 the right groin. It. was of a pyramidal shape, the apex above and 
 the base downwards. Upon a careful dissection, it was found that 
 the hernial protrusion had taken place behind the broad ligament, 
 and that the tumour contained the womb, the ovaries, the tubes, and 
 a portion of the vagina. This kind of hernia also takes place in the 
 pregnant womb. Fabricius Hildanus* cites from Doering, t that a 
 woman of Nissa, in Silesia, at the period in her ninth pregnancy, had 
 a tumour in the left groin which grew so as to extend down to her 
 khee. Upon a consultation of physicians being held, it was decided 
 that an incision should be made into the middle of the tumour, to ter- 
 minate the labour deemed by all other means impracticable. A child 
 was extracted, that lived several months ; hut the mother died in the 
 course of three days, after having suffered the most excruciating 
 pain. 
 
 The celebrated Daniel Sennertus,± who died with the plague at 
 Wittemburg, in 1637, states that the wife of a cooper, in the early 
 stage of her pregnancy, being busy helping her husband to bend 
 some hoop-poles, one of them suddenly sprung back and struck her 
 a violent blow on the left groin. Immediately after the accident a 
 tumour appeared upon the part, which increased daily in size, until 
 it became too large to be reduced ; and the patient was under the 
 necessity of supporting it by a suspensory bandage from the shoul- 
 ders. The term of pregnancy being at length come, the Caesarian 
 operation was performed upon the tumour. The promising hopes of 
 success that followed the operation were not, however, sustained, as 
 she died on the twentieth day, though the child lived for nine years. 
 Although it is probable that both this and the case from Hildanus 
 were crural hernia uteri, yet the few details given leave some doubt 
 as to that point ; and it is possible, that in this case the tumour may 
 have been formed through the inguinal ring, or, what is more pro- 
 bable, through a rupture of the muscles of the inguinal region. 
 
 VENTRAL HYSTEROCELE. 
 
 A ventral hysterocele is one that takes place through an accidental 
 separation of the abdominal muscles. No cases of this sort have 
 been met with except during pregnancy ; and it appears to have been 
 often confounded with obliquity of the womb from excessive relaxa- 
 tion of the abdominal parietes, carried to such an extent as even to 
 allow the womb to fall over upon the front part of the thighs. J/L. 
 Petit§ informs us that a woman who had been in labour for three 
 days, suddenly felt a violent pain, accompanied with a feeling of lace- 
 ration, in the belly, followed by extreme weakness, and a complete 
 inertia of the womb. There were two hernias of the belly. One 
 
 * De nova rara et admiranda hernia uterina (Opera. Omnia, p. 893). 
 f De Hernia Uterina atque partus Coesarei Historia. 
 t Opera Omnia de Hernia Uterina, t. iii. p. 654. 
 
 § CEuvres Posthunaes, t. iii. p.264. 
 
VENTRAL HYSTEROCELE. 
 
 197 
 
 extended from the umbilicus t-o the symphysis pubis, and the other 
 from the navel to the xiphoid cartilage. “ The former, that is, 
 the lower one, was so large that the recti muscles were separated 
 from each other to the distance of nine or ten inches. I was told 
 that this tumour had commenced long ago, and had increased with 
 each successive pregnancy and labour ; that for the last six months 
 the growth of the tumour had been more rapid and greater, but had 
 only attained its present enormous size in the course of the last three 
 days.” Petit, having ascertained that the foetus was hydrocephalic, 
 punctured the cranium with a bistoury, and took measures, at the 
 same time, to compress the abdomen with a small pillow, secured 
 by a bandage. The extraction was easily performed, and the woman 
 recovered promptly. Frederick Ruysch* tells us that a woman who 
 became pregnant after having had a suppuration in the groin, found 
 a tumour forming in the part, that grew so large as to reach down to 
 the knee. The time for her confinement having arrived, the midwife 
 succeeded in making the child return into the abdomen, by lifting the 
 tumour up, after which it was soon born by the natural passages. 
 Roussett mentions a case of hernia of the same kind, in a woman 
 who had undergone the Cesarian operation in a preceding preg- 
 nancy. 
 
 We shall cite one more case of ventral hysterocele,that might readily 
 have been mistaken for a case of crural hernia, had it not been sub- 
 jected to a very careful examination. A woman, forty years of age, 
 in her fifth pregnancy, noticed the gradual increase of a tumour 
 that she had had for some years in the groin. It was soon evident 
 that the tumour contained not only the womb, but also a living foetus. 
 Professor Saxtorph, the physician to the patient, trusted the expul- 
 sion of the child to the mere powers of nature, but he had to take 
 away the placenta, by the introduction of his hand, which enabled 
 him to verify the abnormal situation of the womb. The patient reco- 
 vered, notwithstanding that her womb, after resuming its non-gra- 
 vid dimensions, continued to project beyond the abdominal parietes, 
 which showed that the protrusion had taken place through a division 
 in the muscles, and not through a natural opening, as seemed most 
 probable.;]: 
 
 We shall not extend our remarks upon uterine hernia any fur- 
 ther; — merely adding, that the treatment , whether in the gravid or 
 the non-pregnant female, consists in attempting the reduction, and 
 the keeping the tumour reduced, by means of a suitable bandage. 
 Should the reduction be found to be impossible, and particularly 
 where the woman is beyond the child-bearing age, we ought to be 
 satisfied with the application of a containing bandage. Under other 
 circumstances, recourse ought to be had to a gradual compression 
 long continued, as advised by J. L. Petit for adherent enterocele. 
 
 In a case of pregnant hysterocele, where the powers of labour 
 should appear to be sufficient for the delivery, as might be supposed 
 from the regular progress of the labour, the discharge of the waters, 
 
 * Advers. Anat. Chir. Med. Dec. ii., p. 25. f Traite de 1 Oper. Cesar., loc. cit. 
 
 * Bib. Med., t. 67. p. 59. 
 
198 
 
 HERNIA OF THE OVARY. 
 
 and the natural presentation of the foetus in the 
 vagina, we should do nothing more than lift up and 
 support the fundus of the womb, so as to give to the 
 organ, as far as possible, the direction it ought to have 
 in a natural case of parturition. In other and less 
 favourable circumstances, we must have recourse to 
 the Caesarian operation, which, notwithstanding all the 
 dangers accompanying it, succeeded in the woman 
 whose case we have cited from Rousset. In all such 
 cases no decision should be made in favour of a re- 
 sort to extreme measures until after the trial of all the 
 others. Lastly, should there be observed, in a case of 
 hysterocele, signs of a strangulation of the tumour, it 
 should be freed in the common way, by cutting the 
 stricturing edge, or, what is better, by short multiple 
 incisions with a probe-pointed bistoury, or the small 
 sound with a concealed blade, invented by us for 
 operating on fistula ano, and for the multiple incisions 
 of the stricture in all forms of hernia. [See the Figure 
 annexed.) 
 
 HERNIA OF THE OVARY. 7 
 
 Soranus of Ephesus, surnamed the Second , to distinguish him from 
 the other Soranus of the Methodical sect, was the first author to 
 mention hernia of the ovary, in his treatise on diseases of women, 
 a fragment of which was published by Adrian Turnebus, under the 
 title, Be Utero et Muliebri Pudendo libellus , some extracts from 
 which are also given by Oribasius and Aetius. Describing a sort of 
 hernia that he thought very extraordinary, he says, that “ the intes- 
 tines had fallen down into the labia , or, according to his expression, 
 into the scrotum, preceded by the ovaries.”* 
 
 Verdiert met with a similar instance fifteen centuries after Sora- 
 nus ; Hallerf gave a third, and Percival Pott§ a fourth. It was not 
 until since the description given of his case by the celebrated English 
 surgeon, that practitioners have been willing to admit of such a spe- 
 cies of hernia, a species that forms the subject of M. Deneux’s ex- 
 cellent monograph. 
 
 There are six sorts of hernia of the ovary. 1. The inguinal, 
 noticed by Soranus, Verdier, Haller, Pott, Lassus, Babin, Dessault, 
 Lallement, Rougemont, Bessiere, and Billard. 2. The crural, ascer- 
 tained by Messrs. Murat and Deneux. 3. Ischiatic, by Camper and 
 Papen. 4. Umbilical, by Camper. 5. Ventral, by Ruysch, Stein and 
 Lauverjat ; 6th and last, the vaginal or vagino-rectal, by Sir Everard 
 Home, Roux, Barret, Dug&s, Madame Boivin, and other authors. 
 
 * Oribasius. cap. xxxi. and xxxii. lib. xxiv. 
 
 f Mem. de l’Acad. de Chir., t. ii. 
 
 $ Herniar. Adnotat. crit. in opusc. pathoJ. 
 
 § Med. Obs. and Inq.: Works, vol. iii. 
 
 Fig. 20. 
 
HERNIA OF THE OVARY. 
 
 199 
 
 Cases of ovarian hernia are met with on one side alone, or on both 
 sides at the same time. Verdier, Lassus, Deneux, and Billard have 
 proved that though they are most frequently the result of accident, 
 they may also be congenite ; in some cases the ovary alone is the 
 subject of protrusion ; but for the most part, that organ is accompa- 
 nied in its escape by the womb, by portions of intestinal convolutions, 
 and almost invariably by the Fallopian tube. 
 
 Th q predisposing causes of ovaric hernia are ascitic dropsy; sudden 
 emaciation; immoderate use of relaxing drinks, and fat and oily food ; 
 living in damp climates ; the presence of Nuch’s canal, and various 
 displacements of the womb : during infancy, the smallness of the 
 lower basin of the pelvis, the straight elongated form and smooth 
 surface of the ovaries, and, lastly, their situation in front of the psoas 
 muscles, and nearly opposite to the lower opening of the abdominal 
 parietes. 
 
 The occasional causes of ovaric hernia are, in general, those of 
 the other sorts of hernial protrusion; but in adults, they chiefly consist 
 in circular compression acting just above the hips, either by means of a 
 belt, or by a badly constructed corset ; the development of the womb 
 and of the ovary when diseased ; wounds and abscesses of the hypo- 
 gastric and inguinal regions ; in young patients, loud crying continued 
 lor a long time ; the careless application of bandages for the sup- 
 port of the navel during the month ; and, finally, all kinds of exer- 
 tion capable of bringing on the other kinds of hernia of the pelvic 
 viscera. 
 
 There is sometimes a degree of obscurity in the diagnosis of ova- 
 rian hernia, and the signs of its existence may be varied by inflam- 
 mation, adhesion, tumefaction, scirrhus, and dropsy of the organ ; or 
 by its containing hydatids ; or as exhibiting any other diseased con- 
 dition capable of altering the form of the tumour, as well as the 
 configuration and structure of the ovary itself. In spite of all these 
 modifications, brought about in the characteristic signs of ovaric her- 
 nia, it is possible, with a little attention, to discriminate between it 
 and the glandular or lymphatic tumours, the cutaneous abscesses, 
 the epiplocele, the enterocele, and the fatty hernia, with which it 
 has been confounded. Where the displaced ovary preserves its con- 
 sistence, its mobility and its natural structure, especially when it 
 comes through the inguinal ring, which is most commonly the case, 
 the tumour, ordinarily about the size and shape of a pigeon’s egg, 
 is circumscribed, elastic, painful upon pressure — of a glandular feel, 
 inducing no change in the colour of the skin, causing no colic pain, 
 vomiting, or borborygmi, no dragging of the stomach, no constipa- 
 tion; it is not spontaneously reduced, and when the artificial reduction 
 is accomplished, is unattended with gurgitation of air, as in intes- 
 tinal hernia; and lastly, far from obtaining relief from lying upon the 
 side opposite to the tumour, the woman, just as happens from being 
 afoot, has severer pains in the hypogastrium and loins, and a much 
 more distressing sense of dragging. Such are the characteristic signs 
 by which we may recognize the hernias of the ovary, when the 
 protrusion takes place outside of the pelvis, and discriminate be- 
 
200 
 
 HERNIA OF THE OVARY. 
 
 tween them and the cases of entero-epiplocele, with which they 
 might readily be confounded. Lassus has judiciously remarked that 
 there is no sign more available than that derived from the connec- 
 tion of motions communicated to the womb by the hand, through 
 the vagina, or the rectum, with thdse felt at the same time in the 
 tumour, whether by the hand of the patient or that of the medical 
 attendant. 
 
 In young women of a strong habit of body, an ovarian hernia is 
 subject to become strangulated, particularly if the protrusion happen 
 to occur at the inguinal or femoral opening. The occurrence is sig- 
 nified by an increase of the phenomena above pointed out, and, some- 
 times, when the inflammation is of a high grade, by the formation of 
 an abscess, and even by the supervention of an attack of peritonitis. 
 
 It is, therefore, a matter of the utmost exigency to reduce an ova- 
 rian hernia as soon as practicable, and to keep it reduced. The least 
 delay may render the reduction not only more difficult, but even out 
 of the question. The ovary, which has now become compressed, 
 inflames, swells, and contracts adhesive union, rendering it impos- 
 sible to replace it in its natural position. It has, in such case, been 
 found to become scirrhous, which contra-indicates any attempt at 
 reduction, and establishes a necessity for the excision of the organ. 
 
 When an ovarian hernia becomes strangulated, the consequences 
 resulting from it are to be combated by position, by general and local 
 blood-letting, by baths, fomentations, emollient poultices, and injec- 
 tions ; and, finally, by cutting up the stricture, should all other means 
 fail. Having carefully uncovered the ovary by strokes of the bis- 
 toury, layer by layer, and relieved the ring with a probe-pointed 
 bistoury, or by a sound with the concealed blade, which is particu- 
 larly convenient for the multiple incisions, the contents of the her- 
 nial sac should be returned into the abdomen should they prove to 
 be sound, and should the adhesions they may have formed admit of 
 being broken up. Under opposite circumstances, after relieving the 
 stricture, we should rest contented with applying mild dressings until 
 all inflammatory symptoms are gone, and afterwards make use of 
 moderate pressure upon the part by means of a proper bandage. 
 This method is always to be preferred to the excision ; and the ovary, 
 after being carried back into the abdomen, or, at least, within the 
 ring, will, by stopping the canal, be a preventive of enterocele or 
 epiplocele, which are far more dangerous. Should dangerous symp- 
 toms or great inconvenience result from this procedure, we still have 
 within our reach the extreme measure of extirpating the ovary, 
 which in Potts’ case presented neither difficulty nor danger, he hav- 
 ing exscinded the ovaries after tying each of the ovarian ligaments. 
 The patient in Mr. Potts’ case, as well as in M. Lassus’ case, (Pathol. 
 Chirui'g.,) sustained from this sort of female castration, nothing be- 
 yond the loss of certain of the sexual attributes and an absolute bar- 
 renness. In case of a scirrhous ovary, or of one affected with hyda- 
 tids, it would be reasonable to perform the exscinding operation ; in 
 which event, as well as in the operation for cutting up the stricture, 
 the wound ought to be dressed in the same way as any simple 
 wound. 
 
VAGINAL CYSTOCELE. 
 
 201 
 
 VAGINAL CYSTOCELE, OR HERNIA OF THE BLADDER IN THE 
 
 VAGINA. 
 
 The bladder, like most of the organs within the pelvis, is liable to 
 be displaced, and to form various sorts of hernias, which have received 
 the appellation of Cystocele , whether inguinal , crural , perineal , 
 vaginal ’, or vulvar , as they happen to take place at the inguinal ring, 
 the crural arch, at the perineum, the interior of the vagina, or the 
 middle of one of the labia externa. As these two last modes of dis- 
 placement are the only ones peculiar to the sex, we shall consider 
 ourselves as exempt from the necessity of describing the other three 
 kinds. 
 
 To judge from the principal treatises upon general surgical patho- 
 logy, and even from the most approved monographs on hernia, and 
 from all the ancient and modern works specially devoted to the dis- 
 eases of women, the hernia of the bladder called vaginal cystocele, 
 ought to be looked upon as the worst of all displacements. The 
 illustrious Scarpa, in his admirable treatise on hernia, Samuel Cooper, 
 in his excellent Dictionary, Dupuytren, in his Lectures, never spoke of 
 this case. Boyer, in the treatise Des Maladies Chirurgicales, Messrs. 
 Roche and Sanson in their Elements de Pathologie ext erne, and, 
 in fact, most of the highest modern authorities scarcely speak on this 
 point, so that we have but a few facts observed by Mery,* Curade 
 of Avignon, Robert, of Lille, t Divoux,f Christian, of Liverpool, § 
 Sandifort,|| Chaussier,1F Sims,** Astley Cooper, ft Rognetta,lt and 
 Madame Rondet,§§ a midwife at Paris. 
 
 To one perfectly acquainted with the connection of the vagina 
 and bladder, it is easy to understand the mechanism of a vaginal 
 cystocele ; the urinary sac being pushed against the anterior wall of 
 the vagina by a sudden descent of the diaphragm and violent con- 
 tractions of the abdominal muscles, to a certain degree depresses that 
 wall, or, passing through a split in the vaginal fibres, gives rise to a 
 membranous fluctuating tumour, that projects within the vagina, or 
 even appears external to the labia majora. 
 
 The predisponent causes of vaginal cystocele are: too large a 
 pelvis ; numerous repetitions of pregnancy and labour ; a lymphatic 
 temperament; an erect position too long and too frequently continued; 
 an occupation compelling the patient to bear heavy burdens, or to 
 
 * Mem. de l’Acad. des Sci. ann. 1713. Yerdier, Recherches sur la Hernie de la 
 Vesie. Boyer, t. viii. p. 372. 
 
 f Mem. de l’Acad. de Chir., t. ii. Yerdier, [loc. cit.] 
 
 t Disp. de Hernia Vesica Urinaria, 1732. 
 
 § The Edin. Med. Journ., ix. 281. 
 
 || Observat. Anatomica., t. i. cap. 3. p. 58. 
 
 t Leblanc Precis, des Operations de Chir., ii. 368. 
 
 ** Sir Astley Cooper on Abdominal Hernia, p. 57. 
 
 ff On Abdominal Hernia, loc. cit. 
 
 it Considerations sur la Cystocele Vaginale, &c., (Rev. Medicale, June, 1832, p, 
 398.) This memoir of Dr. Rognetta is, beyond contradiction, the best monograph on 
 the subject of Vaginal Cystocele. By his experiments upon the dead subject, he has 
 thrown much light upon the mechanism, symptoms, progress, diagnosis and treat- 
 ment of various displacements of the urinary bladder in the female. 
 
 §§ Mem. sur la Cystocele Vaginale, 1835. 
 
202 
 
 VAGINAL CTSTOCELE. 
 
 make too violent exertion of the muscular power ; a chronic leucor- 
 rhoea ; pregnancy ; retention of urine, and the habit of discharging 
 it too seldom; abusus coitus; hot hip-baths; foot-warmers; tight 
 lacing, especially with a steel or whalebone busk ; and, lastly, a 
 peculiar laxity of the texture of both the vagina and bladder, and a 
 certain conformation by which the bladder is enlarged at the sides, 
 and sunk down behind the symphysis pubis. 
 
 In general, vaginal cystocele is not to be met with except in women 
 who have had children ; yet a case fell under the notice of Sandifort, 
 in a young hysterical girl, who had been tormented by a spasmodic 
 cough, ( Obs . Jbiat., t. i. p. 58,) and one under that of Sir Astley 
 Cooper, in a girl of seventeen, admitted at Guy’s Hospital for a sup- 
 posed falling of the womb.* The disorder has been noticed in the 
 pregnant female by Mery and Curade of Avignon, (loc. cit.,) during 
 labour, by Robert, at Lille, and by Christian, at Liverpool, (loc. cit.;) 
 and lastly, as late as seven days after childbirth, by Chaussier, (Le- 
 blanc, Precis, des Operat. tie Chir ., t. ii. p. 36S.) In this case, the 
 vesical hernia came on in consequence of a violent effort that the 
 patient made in moving a bucket of water. 
 
 Among the determining causes of cystocele, ought to be classed 
 the labour of parturition, violent exertions, strong pressure on the 
 hypogaster. jumping, dancing, coughing, vomiting, trotting on horse- 
 back, the jolting of a carriage without springs, and, in fact, most of 
 the efficient causes of other kinds of hernia. 
 
 It shows itself by a tumour formed by the bladder depressing the 
 anterior walls of the vagina, and presenting itself either within the 
 canal or outside of the orifice of the vulva. The tumour is reddish, 
 [bluish — M.,J rounded, tense, and with a polished surface, when the 
 bladder is full enough to have distended the rugee of the mucous 
 surface of the vagina. On the contrary, it is uneven, wrinkled, and 
 soft, when the bladder contains little or no fluid. In the former case, 
 it fluctuates, and, when pressed from below upwards, it disappears; 
 but the urine escapes from the meatus urinarius, and smells so much 
 the more offensively, as it has been longer detained within the 
 bladder. In fine, violent exercise, long walks, and long standing 
 increase the size of the tumour, which, on the contrary, diminishes 
 under rest and the horizontal posture. 
 
 Vaginal cystocele always produces dysury, and sometimes ischu- 
 ria; it also causes a stinging sensation in the urethra, and, in some 
 instances, a very painful tension and increased size of the abdomen ; 
 symptoms that are mostly attended with agitation — Sleeplessness, 
 dragging of the stomach, and a variety of sympathetic phenomena. 
 
 This species of displacement of the bladder exhibits itself either 
 separately or complicated with cystitis, metritis, and not unfrequently 
 with vaginitis, or various uterine deviations, as anteversion, retro- 
 version, or a more or less complete prolapsion. All such complica- 
 tions of vaginal cystocele should be met by an antiphlogistic treat- 
 
 * [Dr. Matter recently met with a case in a child six months old. The whole 
 bladder, filled with urine, was protruded beyond the genital fissure during a con- 
 vulsion. — M.J 
 
VAGINAL CYSTOCELE. 
 
 203 
 
 ment, employed coincidently with the management of the primary 
 disorder. 
 
 When this vesical hernia occurs in a pregnant woman, it may 
 become so large as to obstruct the passage of the fetus. It would 
 always be easy here to discriminate between the urinary bladder 
 and the bag of amniotic waters by introducing the index into the 
 vagina, so as to make sure that the os tincse is free and situated 
 behind the cystic tumour, which may readily be made to disappear 
 by drawing off its contents with the catheter. This proceeding was 
 successful in the hands of both Baudelocque and Robert, of Lille. 
 
 A vaginal cystocele, developed within a few days after a woman’s 
 confinement, may become sufficiently large to interfere with the es- 
 cape of the lochia until the swelling is reduced. This actually hap- 
 pened in Chaussier’s case, related by Hoin and Leblanc (loc. cit.) 
 
 It has also been found that the projecting part of the bladder, 
 within the vagina, contained urinary calculi that were removed by 
 incising the tumour itself. Francois Tolet* removed five in this 
 way, and Ruyscht in the same manner extracted forty-two of them. 
 
 The treatment of vaginal cystocele presents two chief indications, 
 which are, as for all other cases of hernia, to reduce the tumour, and 
 prevent its future displacement. Where the cystocele is a small one, 
 it may be easily restrained, either by means of a sponge cut into a 
 cylindrical shape and impregnated with some astringent liquid , % or 
 by a gum-elastic pessary, en bondon ; or by Rognetta’s pessary ; or 
 simply by means of a sachet of fine linen, filled with oak bark soaked 
 in red wine, and kept in situ by means of a T bandage. 
 
 When the vesical hernia is a large one, and is compressed by the 
 womb and the adjacent parts, the treatment should be commenced 
 with, what is always useful in such cases, the introduction of the 
 catheter — a male catheter — taking care to turn the concave part of 
 the instrument towards the vagina, so as to correct the faulty position 
 of the urethra, which is ordinarily met with in the case. If, notwith- 
 standing all attempts, it should be found impossible to use the cathe- 
 ter, and particularly if the patient be in labour, and incapable of 
 delivery on account of the obstruction, a trocar ought to be plunged 
 into the centre of the tumour ; and when the urine is discharged, a 
 catheter should be left in the bladder, to prevent the formation of a 
 vesico-vaginal fistula. 
 
 In case the catheter were passed into the bladder, without inducing 
 a flow of the urine, let the tumour be compressed, as in Robert’s 
 case, so as to compel the liquid to flow towards the open end of the 
 instrument. 
 
 The interesting observations made by Mr. Burns, of Glasgow, in 
 the dissection of a case of vaginal cystocele, § would go to show that 
 
 * Traite de la Lithotomie ou de l’Extraction de Ja Pierre de la Vessie. 
 
 f Adversaria Anat. Chir. Med., (Joe. cit.) 
 
 f Dr. d’Huc, in his Manual le Mededn des Femmes , p. 61, recommends the following 
 decoction, which seems to us to he very suitable: B. Khatany, bruised, Jss.; water, 
 lbj. ; boil the mixture, and at the close of the boiling, add Provence roses, 3i; strain 
 the liquor. * 
 
 § Mr. Burns’ anatomical observations are in the Transactions of the Edin. Med. 
 
204 PROLAPSION OF THE URETHRAL MUCOUS MEMBRANE. 
 
 this, like other forms of hernia, is liable to strangulation. The cele- 
 brated English anatomist, as a means of relieving it, proposes to 
 apply the bistoury to the part strangulated. This seems to us to be 
 both dangerous and useless ; for even should a strangulation take place, 
 — and no such instance has been met. with, — it might be overcome 
 either by drawing off the urine with the catheter, or, as we have 
 above advised, by plunging a trocar into the bladder through the 
 vaginal paries, if the application of the catheter is, or should be found 
 to be wholly impracticable. 
 
 We cannot close this chapter without remarking that there is a 
 species of cystocele that might be called urethral, from the fact that 
 the bladder turns out through the canal of the urethra, and presents 
 itself at the meatus urinarius, which it completely fills up and ob- 
 structs. This form of cystocele, very rare it is true, was met with 
 by Dehaen,* and is always coincident with an intestinal hernia, 
 pressing the vagina downwards and carrying along with it the blad- 
 der of urine. 
 
 A perineal cystocele in the female, requires the same treatment as 
 the vaginal cystocele, and exhibits nearly the same diagnostic signs. 
 The perineum is occupied with a large, indolent, slightly elevated 
 swelling, that is soft, disappearing readily on pressure, or upon the 
 evacuation of the bladder ; and increasing in size and firmness when 
 the bladder is full of urine. 
 
 PROLAPSION OF THE MUCOUS MEMBRANE OF THE URETHRA. 
 
 Prolapsus of the internal membrane of the urethra is a very rare 
 disorder, on which it is necessary, nevertheless, to offer a few remarks. 
 This affection, which is owing to a relaxed and thickened state of the 
 mucous coat, is known by a small reddish tumour projecting more 
 or less considerably from the orifice of the urinary meatus, and dis- 
 tinguishable from the urethral fungus, of which we are hereafter to 
 speak, by its regular shape, its reducibility, and especially by the 
 opening discoverable in its centre. In a case of this kind, noticed by 
 Seguin,t the finger could be introduced into the urethra, which was 
 extremely dilatable and relaxed; after having vainly made use of 
 astringents, he passed a female catheter into the urethra, and applied 
 a ligature upon the instrument and protruded membrane, which was 
 followed by her complete recovery in the course of eight days. We 
 have been equally successful, by cauterizing the whole length of 
 the canal with a concentrated solution of nitr. of silver, which was 
 applied upon a bit of sponge fixed in a small cylinder with one of 
 the sides open. The patient in question, who is now twenty years 
 of age, although stout and well made, has the organs of generation 
 in an evidently relaxed state ; the womb is generally an inch from 
 the vulva ; both the labia majora and minora are drooping, soft, and 
 
 Soc., ann. 1824, and in Sir Astley Cooper’s Anatomy and Surgical Treatment of Ab- 
 dominal Hernia, 64. 
 
 * Ratio Medendi, t. i. p. 76. t Biblioth. Med., t. lxviii. p. 86. 
 
VAGINAL ENTEROCELE. 
 
 205 
 
 much more elongated than usual. She was married at sixteen, and 
 has twice been delivered of dead children in consequence of falling 
 on the stairs. She is a washerwoman, which requires her to be con- 
 stantly on foot, which, with her exertions in frequently carrying 
 clothes to a great distance, may, conjointly with a peculiar idiosyn- 
 crasy, be looked on as the predisposing causes of the relaxed and 
 unnatural state of all her genital organs. 
 
 VAGINAL ENTEROCELE. 
 
 Vaginal enterocele consists in a tumour that projects into the va- 
 gina, and that is produced by the displacement of a portion of a 
 bowel. This kind of hernia, rather less rare than the other kinds, is 
 well understood at the present day. Garengeot* is the first author 
 who mentions it; since whom it has been observed by Verdier,t 
 Leblanc4 Hoin,§ Richter, || Dehaen,f and several other practitioners. 
 
 The portions of the vagina that are lined by the peritoneum, that 
 is to say, the anterior and posterior walls, are the only ones that can 
 give way before an intestinal protrusion into the cavity of the tube. 
 The predisposing causes of this sort of displacement are partly the 
 same as those of other hernias — thus, pregnant women, women 
 newly delivered, and such as have many children, are more liable to 
 it than others. Out of fifteen cases of vaginal enterocele, made public 
 by Hoin, # thirteen were in persons who had been confined a few days 
 beforehand ; however, the affection has been noticed in women who 
 had never been confined. 
 
 The occasional causes of this hernia, which, however, may be 
 formed in a slow and gradual manner, are, in general, a fall upon 
 the buttock, an effort to raise a heavy burthen, at stool, and, indeed, 
 almost all the occasional causes of the other modes of displacement. 
 Where a vaginal enterocele has been suddenly produced, the patient 
 feels as if something was descending along the course of the vagina, 
 and a pain, greater or lesser, that spreads throughout the entire ab- 
 domen.. The tumour from this hernia, which is commonly not trou- 
 blesome, unless it becomes very large, is of a soft consistence, and is 
 partially effaced or wholly disappears when the patient lies down. 
 On the contrary, it becomes larger, harder, more tense, and presents a 
 larger base, is of a round or oval shape, and in some instances appears 
 to jut at the vulva, while the patient stands up or makes any muscular 
 effort. In a word, the vaginal enterocele exhibits all the general 
 characters of the other kinds of hernia. By carrying the index to 
 the os tincse, it is found free and in its natural position. This circum- 
 stance, added to the absence of any opening in the tumour, and the 
 other signs enumerated, prevent us from confounding a vaginal en- 
 terocele with any other tumour developed in the vagina. 
 
 * Mem. de l’Acad. de Chir., t. ii. 
 
 f Recherches sur la Hernie. Mem. de l’Acad. de Chir., t. ii. 
 
 * Nouvel Methode d’Oper. les hernies, 1767. 
 
 § Essai sur les Hernies rares et peu connues, 1767. 
 
 H Von der Broken, &c., translated by Rougemont, 1799. 
 
 1 Ratio Medendi, t. i. loc. citat. 
 
206 
 
 VAGINAL ENTEROCELE. 
 
 When the displaced portion of bowel penetrates betwixt the blad- 
 der and the womb, the hernia appears at one of the sides of the 
 anterior surface of the vagina near the os uteri; but it is upon the 
 posterior surface of the canal, when the gut has fallen down between 
 the rectum and the womb. In the latter case, the tumour is often 
 found to extend down to the vulva, or even outside of it, pressing 
 the perineum outwards and compressing the extremity of the rec- 
 tum, so as to render the expulsion of the faeces very painful. 
 
 The thinness and weakness of the walls of the vagina, the great 
 size of the pedicle of the tumour, that is to say, of the communi- 
 cation of the hernial sac with the abdomen, always admit of the 
 return of the intestine and omentum, and, to a certain degree, render 
 it impossible that vaginal enterocele should be liable to strangula- 
 tion. Nevertheless, from the cases of Smellie and Dehaen, it seems 
 that the pressure of the gravid uterus may cause such an accident to 
 happen, which it is difficult to overcome in a case where the tumour 
 is of considerable size. 
 
 As a remedy for this kind of strangulation, in case the reduction 
 should be found impossible, of which no example has been hitherto 
 found, it has been recommended to cut down, upon the most salient 
 point of the tumour, and then dilate the opening by which the bowel 
 ought to be returned, with Leblanc’s instrument for facilitating the 
 reduction of displaced parts. Some surgeons have supposed that an 
 incision ought to be made into the abdomen, so as to permit? the parts 
 to be disengaged by coming at them through such opening : and, 
 lastly, where a vaginal enterocele is found to be omental and pedicel- 
 lated, it has been recommended to tie up the root with a ligature ; 
 but it is very difficult to determine, h priori , which of these three 
 surgical measures is best adapted to ensure success. To decide this 
 question, we must necessarily wait until experience and the candid 
 observation of cases shall suffice to remove all uncertainty on the 
 subject. 
 
 Under these difficult circumstances, the possibility of which, though 
 never yet met with, is admitted, the conduct to be pursued i£ uncer- 
 tain ; but such is not the fact with regard to the great majority of the 
 cases. Indeed, the treatment of vaginal enterocele is very simple 
 and well understood, consisting, as in all other hernias, in reducing 
 and in keeping the tumour reduced. 
 
 For the reduction, we begin by evacuating the rectum with injec- 
 tions; and then, placing the patient on her back, with the head and 
 trunk lower than the pelvis, and the thighs flexed, we introduce two 
 of the right hand Angers, well anointed, into the vagina. The posi- 
 tion of the pelvis should be changed so as to make the womb press 
 as little as possible upon the tumour, which should now be gently 
 compressed so as to cause it to return, little by little, until the whole 
 has passed back into the abdomen. Should the tumour have passed 
 out through the posterior-superior part of the vagina, the patient, 
 instead of lying upon the back, ought to be on her knees upon the 
 mattress, with the head lying upon it. When the hernia is reduced, 
 
VAGINAL ENTEROCELE. 
 
 207 
 
 it .should be kept so by a cylindrical pessary, maintained in situ with 
 a T bandage. 
 
 Previously to closing these remarks, let us add that emollient fumi- 
 gations, directed into the vagina, and also oily injections into the 
 part, before proceeding to the above manoeuvres, will greatly facili- 
 tate the reduction of a vaginal enterocele. 
 
 [I recently attended a woman in labour with vaginal enterocele, an 
 account of which was published in Professor Huston’s Med . Examiner , of 
 Oct. 5, 1844, and which I transfer to these pages, as a case interesting from 
 its rarity. 
 
 Mrs. R., aged about thirty years, the mother of four children, all of whom 
 were born by easy, natural labours, and one of them in a labour of two 
 hours, was seized with the parturient pains at half past eleven o’clock last 
 night. She was at full term, and in good health, save that she had com- 
 plained much of an unusual pain in the right side of the abdomen, and par- 
 ticularly in the right iliac region. 
 
 Her physician, Dr. Bicknell, was called to the charge of the case. Dr. 
 B. discovered a tumour occupying the cavity of the pelvis, which impeded 
 the progress of the labour. The woman’s pains were frequent and violent, 
 and attended with the most excessive tenesmic effort at bearing down. Dr. 
 B. invited me to see the patient; and I arrived at 2 o’clock, P. M., at her 
 house in West Philadelphia. 
 
 The external parts were in a relaxed state. The index finger used in 
 touching, was pressed towards the symphysis pubis by the tumour, which 
 seemed nearly to fill up the pelvic cavity and effectually to debar the head 
 even from engaging in the superior strait, though the labour had continued 
 already fourteen and a half hours, in the case of a woman who, in other 
 labours, was occupied but two hours with the whole process. 
 
 I could just conveniently touch the presenting part of the head, which 
 was in the fourth position of the vertex presentation. The os uteri fully 
 dilated. 
 
 The tumour was compressible. I touched by the rectum, and so disco- 
 vered that the tumour was in the peritoneal cul-de-sac, betwixt the rectum 
 and vagina, but distending that cul-de-sac enormously. The diagnosis could 
 be nothing else, considering the softness of the swelling, than a vaginal ente- 
 rocele, which I immediately proceeded to reduce. 
 
 The woman was placed on her left side ; the knees drawn up. I intro- 
 duced all the fingers of the right hand into the passage, and pressed the ends 
 of them against the lower part of the tumour. By keeping up the pressure 
 a short time, during which I repeatedly exhorted the woman to be passive, 
 and not to bear down at all, I could cause the whole mass of the swelling 
 to rise up towards the back part of the superior strait. As the mass as- 
 cended, it grew smaller, until, on a sudden, the whole tumour slipped beyond 
 the reach of the hand, and was lost. I announced this good fortune to the 
 
20S 
 
 VULVAR ENTEROCELE AND CTSTOCELE. 
 
 patient, and exhorted her not to bear down at all with the approaching pain, 
 lest the gut should again prolapse. The pain that ensued brought the head 
 nearly through the superior strait, and partially rotated the vertex. The 
 second pain rotated the head, and propelled it on to the perineum ; the third 
 brought the vertex considerably beyond the pubic arch, and the fourth 
 expelled a very large and healthy child; after which the placenta came off 
 in a few minutes. 
 
 I look upon this as a very interesting case, not merely on account of the 
 rareness of vaginal enterocele in the pregnant female, but as exhibiting the 
 power of such a tumour to suspend and impede the progress of a labour in 
 all other regards natural and healthy. 
 
 I presume, as so many hours had already elapsed in vain and exhausting 
 efforts bv a strong woman, that there was reason to fear a dangerous stran- 
 gulation or contusion of the displaced bowel ; and that it was fortunate for 
 the patient that the intestine could be returned above the plane of the strait. 
 The rapidity with which the head passed through the whole pelvis and the 
 soft parts, as soon as the obstruction was removed, showed conclusively that 
 the vaginal enterocele was the cause of her distress. As I have never met 
 with such a case before, I thought that the publication of it might prove 
 useful to some of our readers, should one of them happen to meet hereafter 
 with a similar instance of difficulty. — M.] 
 
 VULVAR ENTEROCELE AND CYSTOCELE. 
 
 Enterocele and cystocele of the vulva,* are tumours formed in one 
 of the labia, either by the descent of an intestine, or of the bladder of 
 urine. In this kind of hernia, the displaced parts descend along side 
 of the vagina, without distending its walls, and advance betwixt its 
 lower extremity and the ramus of the ischium into the middle of one 
 of the labia pudendi, where they constitute a round, firm tumour, of 
 greater or less magnitude. This tumour both raises up the skin ex- 
 ternally, and projects inwards into the vulva, and, prolonging itself on 
 either side of the vagina, is found to become harder and more tense 
 when she coughs or bears down, while in a standing position. It is 
 often the seat or radiating point of pain, augmented by violent exer- 
 cise and diverging towards different parts of the abdomen. 
 
 This kind of displacement was first described by Sir Astley Cooper, 
 who denominated it a pudendal hernia, translated by the French into 
 vulvar hernia. Since the publication by the celebrated English sur- 
 geon, Scarpa, t whose recent loss is so universally deplored, met with 
 two instances of it in his practice. One was also noticed by Profes- 
 
 * From a case of vaginal cystocele, dissected by Mr. Burns, of Glasgow, it would 
 seem that one side of the bladder, or even both at once, where they join the vagina, 
 may descend separately along the canal and force a passage even into the substance 
 of the labia, where the hernia appears as a round tumour, which partially disappears 
 upon the emptying of the bladder. The middle portion of the bladder may also pass 
 through the front of the vagina, and appear as a tumour at the ostium vulva), 
 f Archives Generates de Med., t. i. ann. 1823. 
 
INVERSION OF THE VAGINAL MUCOUS MEMBRANE. 
 
 209 
 
 sor J. Cloquet, at the hospital St. Louis ; and another was seen by 
 Dug6s,* in a young girl, who was supposed, by a midwife, to be 
 labouring under prolapsus uteri. 
 
 Examples of vulvar cystocele have been still more rarely met with. 
 M Bompard published the first case ; but up to the present time no 
 one has discussed and ascertained its real nature, save M. Hartmann. 
 
 The treatment of the affection consists in effecting its reduction, 
 and in keeping it reduced. For this end, the woman should lie upon 
 the back, the hips and shoulders being raised by pillows so as to relax 
 the abdominal muscles ; and with the thighs properly flexed and sepa- 
 rated. Having introduced the right index into the vagina, when the 
 hernia is on the right side, and the left one if it is on the opposite side, 
 the operator being seated in front of the patient will gently compress 
 the tumour along one side of the vagina, and embracing, with the 
 fingers of the other hand, the projecting part of the tumour in the 
 labium, he will push it backwards towards the excavation of the pel- 
 vis in a direction parallel with the vagina. The tumour will be known 
 to be reduced by the void that it leaves in the labium, and the cor- 
 responding part of the vagina. 
 
 For the prevention of a new displacement, recourse should now 
 be had to the adjustment of a pessary cn bond-on , or what is still 
 better, a conoidal pessary, the base upwards, to be retained by a T 
 bandage. 
 
 A vulvar hernia is, like other species, liable to strangulation ; but 
 both Sir Astley Cooper and Scarpa, who met with the accident, suc- 
 ceeded in effecting the reduction by the mere taxis. However, as a 
 less fortunate instance might occur, where the cutting up of the stric- 
 ture might be found indispensable, we are of opinion that the following 
 method should be pursued in the management of such a case. After 
 placing the woman as before directed, an incision should be made 
 parallel to the ramus of the ischium ; that is to say, the incision of 
 the stricturing edge should be in a direction backwards, and some- 
 what obliquely outwards — or forwards and somewhat inwards — by 
 so doing we should avoid wounding the vaginal artery, which must 
 be within the sac, and the pudic which is situated outside of it. Let us 
 add, that the chief inconvenience arising from a vulvar hernia consists 
 in a diminution of the size of the vagina, one of the sides of which 
 projects inwards in conformity with the magnitude of the displaced 
 viscera. This, at least, is what was ascertained from the case of the 
 girl mentioned by M. Duges, and which we just now referred to. 
 
 OF INVERSION AND SWELLING OF THE LINING MEMBRANE OF THE 
 
 VAGINA. 
 
 Under this title have been improperly included various displace- 
 ments, such as cystocele and enterocele of the vagina, the inversion 
 accompanying prolapsus uteri, and various other hernias that differ 
 essentially from each other, and possess nothing in common beyond 
 the saiiency of the lining membrane of the vagina into its canal, or 
 
 * Traite des Mai. de l’Uterus par Madame Boivin and M. Duges, t. ii., 599. 
 
 14 
 
210 
 
 INVERSION OF THE VAGINAL MUCOUS MEMBRANE. 
 
 betwixt the labia pudendi. It is important, therefore, to deter- 
 mine precisely what is to be understood by prolapsion, or fall of the 
 vagina, so as to avoid all confusion likely to make the diagnosis more 
 difficult, and add to the obscurity of its description and study. By 
 tall of the vagina, then, nothing more is meant than an affection 
 analogous to fall of the rectum ; that is to say, an inversion of the 
 internal lining membrane, caused by infiltration of the cellular tex- 
 ture that unites the mucous to the subjacent membranes. 
 
 Falling of the vagina is distinguished into complete and incom- 
 plete ; in the former, the tumour projects more or less beyond the 
 vulva, while in the latter case, it merely appears to be prominent 
 within the ostium-vaginae. It has also been divided into universal 
 and partial, accordingly as the tumour is formed by the whole cir- 
 cumference of the vagina, or simply by some portion of the lining 
 membrane, as frequently happens, especially as to that upon the 
 anterior surface of the canal. 
 
 The predisposing causes are a lymphatic temperament, a profuse 
 chronic leucorrhoea, a frequent repetition of the act of parturition, 
 and of abortion ; the abuse of hot baths, and of relaxing drinks ; an 
 habitual bad nutrition, and all the causes of debility and cachexy. 
 
 Among the efficient causes of falling of the vagina, should be 
 enumerated abiisus coitus ; masturbation ; the friction and compres- 
 sion of the walls of the vagina by the head of the child in labour, or by 
 the accoucheur’s hand or his instruments during an obstetric operation. 
 It may also be brought on by the causes common to all the species of 
 hernia, such as external violence, efforts at lifting heavy weights, or 
 in the expulsion of the faeces ; and, in fine, the shock of a fall, of leap- 
 ing, of laughing, sneezing, coughing, and particularly of vomiting. 
 It has been produced by the blow of a cow’s horn, which struck 
 upon the vagina. Professor Dcsormeaux, who relates the case, says 
 that mostly in women, about the change of life, a partial falling of 
 the vagina is caused by chronic inflammation, whose origin is to be 
 sought in some herpetic taint, but that it is sometimes impossible to 
 discover the real cause. 
 
 The symptoms of falling of the vagina vary in proportion to the 
 extent of the displacement, and the degree of the inflammation. In 
 a partial but simple prolapsus, the tumour is rounded, or it is double, 
 or it forms a circular cushion, accordingly as the descent implicates 
 both the anterior and posterior walis, or extends to the whole surface 
 of the tube. When the woman is on foot, or seated, she has a feeling 
 of weight and uneasiness about the ostium vaginae and at the fun- 
 dament ; dragging sensations in the lumbar region, and various in- 
 convenient feelings, that partially vanish after lying down a few 
 moments. Where the falling is complete, to the symptoms now 
 mentioned are added a discharge of puriform mucus, and obstinate 
 constipation, with a sort of urinary tenesmus, and even positive stran- 
 gury. The action of the urine on the surface of the tumour pro- 
 truded beyond the vulva, and the friction of the part produced by 
 exercise in walking, often cause a severer degree of inflammation, 
 painful excoriations, a sense of tension extending towards the region 
 
INVERSION OF THE VAGINAL MUCOUS MEMBRANE. 211 
 
 of the kidneys, or even gangrene, from the great swelling and stran- 
 gulation of the tumour at the point where it issues from the vulva. 
 Heister relates a case that shows that gangrene may follow upon 
 fruitless manoeu vres made for the purpose of reducing a vaginal pro- 
 lapsus ; and Loder, in his journal, quotes a case from Stoeller, going 
 to show that calculous concretions may he deposited from the urine 
 in the infiltrated mucous tissue of the prolapsed vaginal membrane. 
 
 This disorder not only proves very troublesome and obstructive 
 during labour, but may even become dangerous. Piesch* states that 
 in such a case the tumour projected five inches ; and the position of 
 the child having rendered it necessary to turn, the consequence was 
 a laceration, from which, however, the woman soon recovered. 
 Lodert informs us that, in another case, the vagina fell every time 
 the woman was confined, and made a tumour as large as a man’s 
 head. The accoucheur always succeeded in extracting the child 
 with the forceps, taking care to support the prolapsed parts. Where 
 this is found to be impossible, Richterf advises that an incision be 
 made upon the lateral part of the procident tumour, and adds that 
 such an operation is to be less dreaded, inasmuch as the vagina has, 
 in similar circumstances, been ruptured without any serious conse- 
 quences. 
 
 [I had a case where the vagina prolapsed at least five inches, and was as 
 large as my arm. When labour came on, it was drawn within the vulva, 
 and the child was soon safely born. — M.] 
 
 Where the inversion is complete, the shape and volume of the 
 tumour vary in some instances so greatly as to render the diagnosis 
 extremely difficult. Bartholin, § Hagendorn|| and SchacherIF report 
 Some curious instances in point ; and the last-named author quotes 
 Widman for a case of prolapsion of the vagina, which, from its pyri- 
 form shape, was mistaken for a prolapsus uteri, until it was disco- 
 vered, upon dissection, that the tumour was formed by the internal 
 lining membrane of the vagina. To avoid making such mistakes, it 
 is only necessary to reflect, that in complete inversion, the tumour, of 
 a reddish colour, of an oval or cylindrical shape, and soft consistence, 
 has circular rugse or wrinkles, and is thicker at its lower part than 
 anywhere else. It should also be remembered, that in the centre of 
 the projecting mass is a hole large enough to admit the finger, which, 
 upon passing upwards sufficiently far, encounters the os uteri. 
 
 The pi'ognosis of the disorder in question is generally not bad, 
 though it is rare to obtain a perfect cure, where the prolapsion is 
 complete, and particularly where the whole circumference of the 
 vaginal membrane composes the tumour. Yet such a fortunate result 
 has been known to succeed to an inflammation brought on by the 
 presence of a pessary in the vagina. Moraud has reported such an 
 
 * Journal de Med., t. iii. f Journal, t. i. 490. 
 
 \ Biblioth. und Aufang. der Wundaetzn, b. vii. cap. iv. 
 
 § Casus Pudendi Mulieb. monstrose conform., centur. v. hist. 9. 
 
 | Procidentia Uteri instante partii, cent. iii. obs. 3. 
 
 t Prog, de Prolapsu Vaginse Uteri. 
 
212 
 
 INVERSION OF THE VAGINAL MUCOUS MEMBRANE. 
 
 instance in the memoirs of the Academy of Surgery , and Schacher 
 (De Prolapsu Vug. Uter.) makes mention of a woman who, for the 
 cure of an inverted vagina, introduced within it a small porcelain 
 cup, which remained a year in the part, and was extracted with 
 severe distress, and then not until it was broken to pieces, so violent 
 was the inflammation which it excited; but this occurrence, at first 
 deemed so prejudicial to the woman, effected a perfect cure, which 
 had by no means been looked for. 
 
 The treatment in simple, incomplete prolapsus, consists in the 
 use of antiphlogistics, especially as local applications, and continued 
 until the inflammatory symptoms are overcome. Should there be 
 some special cause of the inflammation, and dependent on a state of 
 the constitution, recourse should be had to an appropriate treatment; 
 and, indeed, such is the only state in which general remedies are of 
 any use. Whether the treatment may have begun with the reduction 
 of the tumour, or whether it may have been deemed preferable to 
 wait— a better plan — until the local phlogosis and swelling have dis- 
 appeared, we should, in this stage, merely make use of tonic and 
 astringent lotions and injections. A decoction prepared conformably 
 to the following formula, perfectly fulfils the indication : 
 
 Take of yellow-bark, in powder, and of oak-bark, bruised, of each three drachms ; 
 boil them in half a bottle of claret ; add of sulphate of alumina two drachms, and filter 
 the liquor. 
 
 This mixture should be used at first, diluted with an equal quantity 
 of water; then a third, and afterwards a fourth part of water, and, 
 at length, without any dilution. To add to the efficacy of the 
 remedy, recourse might be had to exutories, and particularly to the 
 formation of small issues; or to some moxas to the sacrum, as practised 
 by Baron Larrey. Except where the relaxation is excessive, under 
 a well-managed treatment of this kind, the use of the pessary, to 
 support the membrane, would be rarely found necessary. 
 
 In a complete falling of the whole circumference of the vaginal mem- 
 brane, the reduction should be effected as soon as possible, always 
 taking care, by proper measures, to combat the inflammation and 
 swelling, before we attempt to replace the parts in their natural 
 position. Any prospective relaxation and displacement of the mem- 
 brane should be counteracted, not only by the employment of tonic 
 and astringent lotions, such as we have above mentioned, in speak- 
 ing of partial and incomplete falling of the vagina, but also by the 
 introduction of sponges, impregnated with the same liquid, or by 
 small sachets filled with the ingredients of the lotions in question. 
 A pessary also may be adjusted, properly adapted to the form of the 
 vagina, and left in situ until some slight inflammation has been 
 excited, as in Schachers case, before cited, and which might serve to 
 procure a radical cure. Should the prolapsed membrane exhibit 
 large gangrenous eschars, the scarifications recommended by Ilcis- 
 ter* could be productive only of benefit. In such a case, and, 
 indeed, in all cases, the system ought to be invigorated by the use of 
 cold acidulous chalybeate waters, as those of Passy, Spa, Forges, &c. 
 
 • Inst. Chir. <le Vulvae Procidentia, t. ii. cap. cxlviii. p- 1032. 
 
INVERSION OF THE VAGINAL MUCOUS MEMBRANE. 
 
 213 
 
 Where the disorder is of long standing, the tumour sometimes be- 
 comes irreducible, or, at least, its reduction is very difficult, for the 
 prolapsed membrane groves hard, and becomes the seat of excoria- 
 tions and even of ulcerations. Under such unfavourable circum- 
 stances, we ought, as far as possible, to endeavour to lessen the pain 
 and distress by advising her to support the displaced parts with a com- 
 press, spread with opiated cerate, kept in place by a suspensory and 
 a T bandage. 
 
 The celebrated accoucheur Levret,* and also M. Hoin,t of Orleans, 
 inform us that by rest and the dorsal decubitus, they succeeded so far 
 in reducing a tumour that projected to the distance of seven inches, 
 that after a month, under the treatment, the remainder of the tumour 
 was reduced. Richterf advises the reduction of the vaginal prolapsus, 
 where the case is a difficult one, by the method followed by some 
 authors, in treating large omental hernias. This consists in making 
 the woman lie on her back, with the thighs drawn somewhat up- 
 wards, and then keeping up a gentle compression of the tumour, 
 while a long course of diet is prescribed, with the administration of 
 mercurial purgatives. 
 
 M. Dieffenbach, instead of resting content with merely reducing 
 the tumour and keeping it reduced by means of a pessary, supposed 
 that Dupuytren’s plan for treating prolapsus of the rectum might be 
 adopted. 
 
 That distinguished Berlin surgeon, after reducing the tumour, 
 exscinds, by means of a forceps and scissors, all the loose folds of the 
 inner surface of the labia pudendi. The operation, which is easily 
 performed, should be so conducted that the folds, as they are re- 
 moved, should constitute so many radii converging to the centre of 
 the vagina, so as to allow the upper end of each one to terminate 
 about one inch within the orifice of the canal. The after treatment 
 consists in merely cleansing the parts once a day, or if it be deemed 
 desirable to make them suppurate, in introducing a fascicle of lint, the 
 base of which, being divided into rays, would furnish a small fasci- 
 culus to each one of the little incisions. The end proposed in this 
 operation, is to contract the ostium vaginae, which thus acquires the 
 desirable resisting power. To arrive at the same result, Messrs. 
 Marshall and Hemirig have successfully adopted a mode that con- 
 sists in exscinding a large elliptical lamina of the mucous membrane, 
 and immediately uniting the wound by suture. This mode, both 
 difficult and painful, appears to us less suitable than Dieflenbach’s. . 
 
 Should the patient absolutely ask to be relieved of her disgusting 
 deformity, where the reduction is impossible from the transformation 
 and degeneration of the tumour, there is no other method of proceed- 
 ing than the amputation of the extensive mass of membrane, which, 
 according to Stalpaart Van der Wiel,§ J. A. Meckren,|| and other 
 writers, has been successfully done in similar cases. In deciding upon 
 
 * Mem. de l’Acad. de Chir., t. ii. 
 t Essai sur les Hernies rares et peu connues. 
 t Biblioth. und Aufang. der Wundaetzn, b. vii. cap. iv. 
 
 § Observ. Rariores Medecin., t. ii. 1 Observ. Chir., obs. 45. 
 
214 
 
 INVAGINATION OF T^IE VAGINA. 
 
 this extreme measure, as in M. Berard, jun.’s, instance,* it would be 
 requisite, previous to any operation, not only to make sure of the 
 state of the bladder and rectum, but also to endeavour to learn that 
 the vagina alone is prolapsed, and that the womb is not compre- 
 hended in the mass. And lastly, Boyer’s advice should be followed, 
 not lightly to resolve upon this operation, which is far from being 
 free from danger. 
 
 We may not close this article without remarking, that a falling of 
 the lining membrane of the vagina must not be confounded with in- 
 vagination of that canal; a case whose character is displayed in the 
 following chapter. 
 
 INVAGINATION OF THE VAGINA. 
 
 Invagination of the vagina consists in a displacement of the upper 
 parietes of the tube, which, being gradually carried downwards by 
 the womb, in a prolapsed state, become intussuscepted in a part of 
 the vagina nearer to the vulva. There are different stages of this 
 prolapsus that it is well to explain. In the first stage we find, at the 
 orifice of the vulva, a sort of cushion, in irregular folds, more or less 
 protruding, in the centre of which, upon Touching, we find the os 
 tincoe, which is always, in this stage, lower than natural. The softish 
 red circle, formed by the invagination of the superior portion of the 
 vagina, is found to be less projecting and voluminous after some 
 time resting in a horizontal posture, but it increases and becomes far 
 more apparent in a vertical posture, giving rise not only to a distress- 
 ing weight about the groins and hypogastrium, but also to a painful 
 tenesmus and dysury, proceeding from the change in the direction of 
 the urethra. 
 
 In the second and third stage, the tumour, now more elongated 
 and cylindrical, exhibits, as it does in the first, an irregular opening 
 at its lower end, the orifice of a narrow passage, at the bottom of 
 which is the os uteri. 
 
 In some cases of invagination of the vagina, the neck of the womb 
 is found to be considerably elongated, but it is a difficult matter to 
 decide which of these lesions is the cause of the other. In fact, if we 
 may, on the one hand, suppose the elongation and hypertrophy of 
 the cervix to be the cause of the uterine prolapsus and consequent 
 invagination, we may, on the other, aver that the cervix has be- 
 come elongated since the occurrence of the prolapsus, by extending 
 gradually in a direction wherein it met with no resistance ; the body 
 of the organ being meanwhile retained at a certain elevation by its 
 natural ligaments and attachments. 
 
 The vaginal invagination is generally looked upon by modern 
 authors as a lesion secondary to, and symptomatic of, the prolapsus 
 of the womb, which is its determining cause. 
 
 Where the complaint is of long standing, and especially if the 
 woman has, for a long time, had no assistance, the cushion becomes 
 
 * Velpeau, Elements de Medecine Operatoire, t. iii. p. 590. 
 
CONTUSION OF THE LABIA. 
 
 215 
 
 engorged, the tumour is elongated and acquires a harder consistence, 
 but still has an opening below, through which the menses are dis- 
 charged as if through the os tincae at each menstrual period. In 
 fine, the projection formed by the invagination resembles, in shape 
 and colour, the cervix of the womb when completely prolapsed, so 
 much so, indeed, as to have deceived several practitioners, among 
 whom I may mention the names of Bartholin, Widman, and Job a 
 Meckreen. It is unnecessary to observe, that with the least attention, 
 it is easy to avoid falling into such mistakes. 
 
 Invagination of the vagina differs from the tumefaction and fall 
 of the lining membrane, in this, that it can only commence at the 
 superior extremity of the canal and near to the collum uteri, 
 while the inversion of the mucous membrane may occur at any 
 part of its length. In invagination the finger is carried up to thd 
 womb, and ascertains that the bottom of the vagina, being doubled on 
 itself, or folded, still accompanies the womb, which is always dis- 
 placed ; in the other case, or prolapsus of the internal coat, the index, 
 when introduced betwixt the cushion and the circumference of the 
 opening, is arrested by the fold composed of the relaxed mucous 
 membrane as it descends, in order to escape through the os exter- 
 num. Finally, invagination always accompanies prolapsus uteri, 
 whereas, inversion of the membrane is generally independent of any 
 uterine displacement. 
 
 The tumour arising from the lesion under consideration is liable 
 to become inflamed, to ulceration, and the consequences that may 
 flow from such affections. The means of preventing or remedying 
 these evil consequences, are, as soon as possible, to replace the pro- 
 lapsed parts, and keep them reduced by a pessary ; and the other 
 resources we have already pointed out in our remarks upon falling 
 of the womb. By curing the disorder just mentioned, we put an 
 end to that of the vagina, which is the consequence of it. 
 
 SECTION THIRD. 
 
 CHAPTER VII. 
 
 PHYSICAL LESIONS. 
 
 To facilitate the study of the physical lesions of the external and 
 internal genital organs of the female, we divide them into three 
 classes, which are : 
 
 1. Contusions, wounds and lacerations of the vulva, perineum, 
 vagina and uterus ; ruptures of these organs ; and finally contusions 
 and wounds of the mammae ; 
 
 2. Vesico-vaginal, utero-vaginal and recto-vaginal fistulas; 
 
 3. The accidental introduction of foreign bodies into the genital 
 cavities. 
 
216 
 
 CONTUSION OF THE LABIA. 
 
 CONTUSION OF THE LABIA MAJORA. 
 
 From their situation at the inferior extremity of the trunk, the 
 external sexual parts which protect and circumscribe the vulva, to wit, 
 the mons veneris, the labia majora and the perineum, are exposed 
 to contusions, to wounds and to lacerations which may result either 
 from a fall, from a wound, or a blow ; from the first attempts at sexual 
 intercourse; or from the "effects of criminal copulation. The disor- 
 ders depending upon the latter cause are the more severe in propor- 
 tion to the resistance the female has made; the disproportion between 
 the genital organs of the two sexes ; whether the violence have been 
 exerted upon a virgin girl ; and especially whether she be still far 
 from her full development. *** 
 
 The loose texture of the cellular tissue of the labia majora causes 
 these two folds frequently to become the seat of ecchymoses and 
 sanguine infiltrations, developed under the influence of the causes 
 which we have just enumerated, and most frequently after a more 
 or less laborious labour. Assisted by the depending position of the 
 vulva, the tumefaction soon becomes considerable, and the parts 
 assume a livid, a deep violet, or almost black colour; yet it seldom 
 happens that the contusion is severe enough to determine gangrene ; 
 it frequently does not even form an abscess, and then we find the 
 extravasated blood become rapidly absorbed, and the swollen organs 
 soon regain their natural colour and volume. 
 
 When the contusion is slight, and produces only a simple ecchy- 
 mosis, we should restrict ourselves to the employment of some re- 
 solvent topical application, such as compresses wet with Goulard’s 
 extract, or even with cold water alone, to which we might add for 
 every glassful of the fluid a spoonful of vinegar or Cologne water. 
 In order to retain these resolvent applications, and especially to aid 
 their absorption, we may have recourse to steady pressure made by 
 means of a bandage fitted to the parts. 
 
 If the contusion have been violent, and especially if there results 
 from it a considerable effusion of blood, we should order an appli- 
 cation of leeches around, but not on the ecchymosed spots ; and 
 afterwards follow the same plan as we indicated above. Where 
 compression has not been used in the beginning, or where it cannot 
 be borne on account of the pain it produces, we have a good substi- 
 tute in the use of resolvent and emollient cataplasms, made of rice 
 Hour boiled in decoction of marshmallow, or of flax-seed meal and 
 infusion of roses, with the addition of a little red wine or a teaspoon- 
 ful of lead water. The first of these cataplasms, which should be 
 enclosed in gauze, is commonly preferred by the patient, because it 
 does not soil their linen, and the parts upon which it is applied. 
 
 The employment of all these remedies should be suspended, if the 
 tumour, having rapidly acquired greater size, were to become the 
 seat of inflammatory symptoms announced by more acute pain, by 
 uniform redness, by heat and tension of the skin. Recourse should 
 
RUPTURE OF THE PERINEUM. 
 
 217 
 
 then be had to emollient and maturative applications, in order to 
 favour the suppuration about to be established, and which is mani- 
 fested particularly by rigors and by increased pain. When fluc- 
 tuation has become evident, the tumour should be freely opened 
 in order to give ready issue to the blood and pus. The after 
 treatment should be like that employed after the opening of other 
 abscesses ; that is to say, the use of emollient cataplasms, and when 
 the signs of inflammation have nearly disappeared, the use of mild 
 discutients, in order to hasten the disengorgement of the part and the 
 cicatrization of the wound. 
 
 OF RUPTURE OF THE PERINEUM AND THE MEANS OF REMEDYING IT. 
 
 Though the wounds and lacerations which may result from the 
 action of cutting or puncturing instruments upon the labia majora, 
 require for their treatment only the means employed for wounds in 
 other parts of the body, there is one kind of solution of continuity to 
 which these two pudendal folds are much more frequently exposed, 
 and which, for this reason, requires us to treat of it more in full. The 
 lesion to which we refer is the laceration of the posterior commissure 
 of the labia majora, which takes place sometimes in the most natural 
 labours, but much more frequently when the woman is delivered 
 without assistance, or after imprudent operations,* or awkward at- 
 tempts at traction .with the forceps. 
 
 When the laceration is confined to the fourchette or posterior com- 
 missure of the vulva, the accident never produces any serious con- 
 sequences, because, by means of rest, and by bringing the thighs 
 properly together, the reunion and cicatrization of the parts soon 
 occur spontaneously; sometimes, indeed, the same thing happens 
 from the efforts of nature alone, even when the laceration has ex- 
 tended far upon the perineum. 
 
 Unfortunately, the same result does not follow when the sphincter 
 of the anus and the rectum are comprised in the solution of conti- 
 nuity. The edges of so extensive a division being always irregular, 
 dentated and puckered, as it were, unite with difficulty by the first 
 intention: besides, the constant flow of the lochia acts to prevent it; 
 whence it happens that the surfaces of each lip of the wound, after 
 having suppurated for a long time, end by cicatrizing separately, and 
 the opening of the vulva is thus enlarged in proportion to the extent 
 of the laceration. The solid and liquid matters now escape involun- 
 tarily, and the absence of the support which the perineum lends to the 
 neighbouring parts, becomes a cause of procidentia of the vagina, or 
 of prolapsus of the womb ; finally, this disgusting infirmity not only 
 renders the woman insupportable to herself, but often gives rise to 
 conjugal difficulties which may have the most unhappy conse- 
 quences. 
 
 * Dr. Boudet (Theses de la Faculte de Med. de Paris) reports cases of rupture, or 
 rather of division of the perineum, by means of a sixpence. This method, as absurd 
 as barbarous, was employed by an ignorant midwife, for the purpose of augmenting 
 the diameter of the vulva, and thus facilitating the escape of the child. 
 
218 
 
 RUPTURE OF THE PERINEUM. 
 
 To prevent, as far as possible, the terrible accidents which we 
 have just enumerated, it is necessary to support the perineum with 
 the hand at the moment that the head of the child distends the vulva, 
 in such a way as to force the head to rise towards the pubis, but not 
 to prevent its descent. It is equally important, as soon as the parie- 
 tal protuberances have passed beyond the tuberosities of the ischia, 
 to tell the woman to moderate her expulsive efforts, particularly if 
 the labour be rapid, and no^ to bear down more and more, as is re- 
 commended so mal-a-propos by the old women, by the midwives, and 
 by most obstetricians. It is at this stage of the labour that the parts, 
 in some sort surprised , give way because the head, too violently 
 propelled, does not permit them to yield so rapidly and to mould 
 themselves upon it. The chances, therefore, of preserving the peri- 
 neal septum in its integrity, will be the greater, in proportion as the 
 vulva has been traversed more slowly. If it be not in the power of 
 the obstetrician wholly to prevent this kind of laceration, he can 
 always prevent its extending too far, which is extremely important. 
 
 [The direction to support the perineum above given is insufficient; it 
 should have been more explicit, as I am convinced that the instruction ill 
 the medical schools does not fully inform the young practitioner of the mo- 
 tive for the rule. The direction ought to be, to press the perineum in such 
 a way as to make the head turn upwards in front of the symphysis in pro- 
 portion as it emerges more and more from the pelvis. It should be to cause 
 the head, by supporting it, to move in coincidence with Professor Cams’ 
 circle. Now, Cams’ circle, is a circle whose radius equals the semi-dia- 
 meter of the pelvis, measured from front to rear. To draw this circle, take 
 a pelvis and saw it through at the pubis and sacrum so as to divide them 
 vertically. Set one leg of a compass on the posterior margin of the cut sur- 
 face of the symphysis, open the other leg to half the diameter of the excava- 
 tion, and with that leg describe a circle in the pelvis. This is Cams’ circle, 
 and it indicates the curved axis of the pelvis. It is along this axis that the 
 centre of the head moves as it is born; and to hold the perineum, means, 
 to make it move until it is born, in coincidence with that line. When this 
 is properly done, lacerations of the perineum rarely occur. — M.] 
 
 Cases have been seen of women delivered without aid, in whom 
 the child has passed through an opening in the perineum, without 
 lesion of the fourchette or anus. Professor Moreau, who has treated 
 of this subject before the Academy of Medicine, affirms that the 
 annals of science contain more than thirty facts of this kind well 
 established, and observed some in France, others in foreign coun- 
 tries.* M. Deneuxt has likewise reported the case of a woman in 
 whom the placenta was extracted through the perineum, the vulva 
 scarcely permitting the introduction of the finger ; in another female, 
 after a rupture of this kind, there existed a prolapsus of the uterus 
 
 * Seance de l’Acad^mie de Medecine du 16 Octobre, 1832. 
 
 •j- Seance de l’Acad^mie de Medecine, meme jour, et merne annee. 
 
RUPTURE OF THE PERINEUM. 
 
 219 
 
 through the perineal opening: finally, in the early part of October, 
 1832, we saw at the Hotel-Dieu, at Paris, Salle St. Jean, No. 1, a 
 woman who had been spontaneously delivered, in whomthe escape 
 of the infant, at term had taken place through a laceration of the peri- 
 neum, without lesion of the posterior commissure of the labia majora 
 or of the anus. The labour had lasted only four hours; the symphy- 
 sis and the pubic arch were properly formed. 
 
 It has sometimes happened even when a central perforation of the 
 perineum has been produced, that the foetus has nevertheless passed 
 out through the vulva, the edges of which have remained perfect. 
 Madame Lachapelle, who has seen and reported several such cases, 
 assures us that if the women had not been uncovered, and the 
 sexual organs exposed to view, she might have supposed that the 
 child had passed through the perineal rupture ; and she thinks it 
 probable that the same thing has occurred in the greater part of the 
 cases reported by authors. Yet, notwithstanding the opinion of 
 Madame Lachapelle, we cannot doubt that the foetus has sometimes 
 been expelled through the central laceration of the perineum. Profes- 
 sor Delpech saw this rupture take place at the left and posterior side of 
 the vagina, and extend along the base of the external labium of the 
 same side, which was in this way detached from the pubic arch ; 
 the vulva being forced to the right, the delivery took place through 
 the accidental perforation. 
 
 [My colleague, Professor Miilter, informed me that he saw a case about 
 three years since, in which the child’s head had passed through a lacerated 
 perineum, and the head being delivered, the attendant could not bring down 
 the shoulder. The professor being called in on account of the difficulty, 
 divided the anterior band or edge of the perineum, whereupon the foetus was 
 immediately born. — M.] 
 
 Sometimes the laceration extends towards one of the thighs, and 
 exhibits the form of a capital L ; in other cases it extends towards 
 both thighs at the same time, and assumes the form of the letter T. 
 Solutions of continuity of this kind usually suppurate, and terminate 
 most generally by spontaneous reunion, forming a solid cicatrix. 
 Such has been the result in the cases of this kind, observed and 
 reported by Denman, Baudelocque, Desormeaux, Delpech, Dupuy- 
 tren, Madame Lachapelle, and some other practitioners. 
 
 The custom, which is so common, of placing a great many pillows 
 under the head and shoulders of women, during the progress of 
 labour, is one of the causes which contribute to the laceration of the 
 perineum. It happens in this way that the trunk, assuming a nearly 
 vertical position, the weight of the child, and particularly its head, 
 compresses the perineal septum very strongly, and the expulsive 
 efforts of the womb are sometimes sufficiently powerful to force the 
 perineum to yield by bursting it, and in this way overcoming the 
 arrest which existed in consequence of the vicious position of the 
 female. 
 
220 
 
 RUPTURE OF THE PERINEUM. 
 
 This unfortunate accident, which occurs with great facility in 
 women in whom the orifice of the vagina is placed very much in 
 front, and almost on a level with the bones of the pubis, might gene- 
 rally be avoided by keeping the trunk and head of the female in an 
 almost horizontal position, and by sustaining the perineum during 
 the whole of the labour in such a way as to lift the child’s head up- 
 ward in the direction of the symphysis pubis. 
 
 When it has proved impossible to prevent the laceration of the 
 perineum, we should seek to obtain the reunion of the edges of the 
 wound by causing the patient to lie upon her side, and by recom- 
 mending her to keep her thighs approximated and always in the same 
 position. Though this means be often without avail, we should never 
 fail to put it in practice, because it has sometimes been followed by 
 the reunion of the whole, or at least of a portion of the laceration ; an 
 instance of which M. Sedillot, jr., has reported.* When these pre- 
 cautions and first attempts at reunion fail, and, especially, when the 
 cicatrization of the lips of the wound is complete, there remains a 
 resource, which is sometimes successful, consisting in the reunion 
 by several points of suture. This operation, already performed with 
 success, by Forestus,t Delamotte,f Trainel and Noel,§ Saucerotte,|| 
 Asdrubali,! Dupuytren,** Montain,tt Emile Barthelemi,ff Dieffen- 
 bach,§§ and lately, by M. Vidal de Cassis, |||| has been fully introduced 
 into surgical practice, through the brilliant results obtained by Pro- 
 fessor Roux, which we are now about to report very succinctly. 
 
 The first patient of whom we shall speak, is the wife of a distin- 
 guished physician in a small provincial town, who had already been 
 operated upon, without success, for a laceration of the perineum 
 communicating with the anus, the result of a labour terminated by 
 the forceps. The first operation was performed in the month of 
 January, 1832, with the twisted suture; but the union, which had at 
 first seemed complete, was only apparent; for the perineal division 
 soon recurred as before. 
 
 This failure discouraged neither the patient nor her husband, and 
 a new attempt was resolved upon, with still greater care, and with a 
 modification of the mode of operating. M. Roux, to whose care the 
 lady had been confided, having reflected upon the causes of the fail- 
 ure of the first operation, thought that the greatest obstacle to reunion 
 was the impossibility of bringing the deep-seated parts into exact 
 contact with the twisted suture, and that under such circumstances 
 
 * Recueil perioddque de la Societe roy. de Medecine de Paris, tom. vii. 
 
 fDe Morbis Mulierum, page 759. 
 
 tTraite Compl. de Chirurg. cont. observat. 405. 
 
 § Recueil period, de la Societe roy. de Med. t. vii. p. 187. 
 
 || Idem. tom. iv. p. 117; Melange de Chirurg., t. ii. 
 
 ^ Tom. ii. p. 248. 
 
 ** Le 9 ons Orales et Lancette Fran^aise t. vi. n. 102. p. 418. 
 
 ff Revue Medicale, annee 1821, tom. v. p. 204. 
 
 4$ Lancette Franeaise, t. vi. n. 104. p 427. 
 
 §§ Journal Complcmentaire, t. 38. p. 193. 
 
 1 11 Doctor Vidal de Cassis has practised, with success, in two cases, the suture of 
 the perineum, by means of straight needles with handles, and by a simple and inge- 
 nious process, which we shall describe when speaking of vaginal fistulas. 
 
RUPTURE OF THE PERINEUM. 
 
 221 
 
 the quilled suture was preferable, because its action extended to a 
 greater depth. In fact, curved needles take up more tissue ; the liga- 
 tures penetrate deeper, and the pressure of the cylinders exposes less 
 to danger of laceration, and is more equable ; he had to fear, therefore, 
 neither strangulation nor constriction of the edges of the wound; con- 
 sequently, the chances of success were much greater. In the second 
 operation, in which the edges of the laceration were freshened as be- 
 fore, two or three arterioles bled and were tied; four points of suture 
 were placed so as to involve the parietes of the vagina, but to a vury 
 slight depth, in order to avoid eversion of the labia, which would 
 have placed in contact two mucous membranes, which unite with 
 the greatest difficulty ; a gum-elastic bougie formed the cylinder, 
 and the ligatures were strongly tied ; the coaptation was now perfect 
 upon the interior, but not on the exterior, where the edges of the 
 wound formed a projection ; the coaptation was made complete by 
 means of five ligatures placed in the intervals ; the ligatures were 
 not cut, nor the needles removed, until six days had elapsed ; abso- 
 lute diet was prescribed, and the most assiduous attentions paid. 
 
 It was not until the twenty-second day that the patient went to 
 stool, and passed faeces so consistent that it was necessary to aid the 
 defecation by means of the fingers introduced into the vagina ; but 
 by this time, the cicatrix was sufficiently strong to resist the strain. 
 
 A puriform discharge appeared from both the vagina and the anus, 
 but there was neither haemorrhage nor pain. 
 
 There now remained only a small opening at the anus, which 
 suppurated: a tent was introduced into the rectum; the consolida- 
 tion was soon perfect; the raphe became linear and solid, but there 
 remained a small recto-vaginal fistula, which, with difficulty, admit- 
 ted the introduction of the extremity of the little finger. This fistula 
 gave issue to some gas, without allowing of the escape of any sterco- 
 raceous matter. M. Roux heard, some time after, through a letter 
 from the husband, that the journey, undertaken on the fifth day after 
 first leaving the bed, had not occasioned any accident, and that the 
 fistulous point which existed between the rectum and vagina had 
 ceased to suppurate two months before, and was cicatrized. The 
 patient recovered perfectly; her perineum presents the ordinary thick- 
 ness and firmness, and the most practised eye could detect no trace 
 of the operation. As soon as the suppuration had ceased, the sexual 
 congress took place, at first with great care, and finally without any 
 kind of precaution. This lady has regained her natural complexion 
 and spirits. 
 
 This perineal suture (the first performed by M. Roux,) was the 
 subject of a paper read before the Academy of Medicine, on the 30th 
 October, 1832. The case is published in the number of the Lancette 
 Frangciise for the first of November of the same year. 
 
 The second case is taken from the clinic of La Charite. The wo- 
 man who was the subject of it was Pauline Evrard, aged 22 years, a 
 housemaid, and entered the hospital March 15, 1833, in No. 24 of the 
 Salle Ste-Catherine. 
 
 This person, enjoying good health, having become pregnant in 
 
222 
 
 RUPTURE OF THE PERINEUM. 
 
 1831, entered the Maternite a month before her delivery, where she 
 had so laborious a labour that it was followed by the laceration of 
 the perineum. Notwithstanding this infirmity, she again became 
 pregnant ; and her labour, though still difficult, was much Jess so 
 than on the first occasion. Some time after this last lying-in, Pau- 
 line was admitted into La Charite, where, during the first eight days 
 after her entrance, she was put upon very strict diet and the use of 
 diluents. On the 22d of March a purgative was administered; 
 finally, on Saturday the 23d of March, M. Roux proceeded to the 
 operation, which was conducted in the following manner: 
 
 From the two surfaces of the wound a thin segment of tissue was 
 removed, so that by approximating the two edges of the division, 
 reunion might readily take place. Three sutures were introduced, 
 one near the anus, another near the vulva, and the third between the 
 two first. These three points each comprised a portion of the vagina, 
 for the purpose of avoiding, at the same time, any gaping of the 
 wound exteriorly, and any effusions of purulent matter upon the inte- 
 rior. To form the loops on one side, the ligatures were cut and tied, 
 and between the two ends thus knotted, a piece of gum-elastic was 
 placed and drawn tight by the other ends. Between these last, a 
 second piece of gum-elastic was placed and tied with a knot. Two 
 days after the operation, the patient had retention of urine, which 
 required the introduction of a catheter into the bladder, which was 
 left there ; this allowed the urine to flow off as fast as it was brought 
 to the bladder ; but two days elapsed before it was deemed proper 
 to solicit an alvine evacuation by the administration of a mild purga- 
 tive dose of calomel, ten grains. The matters discharged passed alto- 
 gether by the rectum, and not at all by the vagina, ahhough, during 
 a fortnight, the patient could perceive that in voiding gas, a portion 
 escaped through the vagina. Pledgets spread with cerate, and intro- 
 duced between the lips of the wound, in a short time entirely obli- 
 terated the communication which existed between the rectum and 
 the canal of the vagina, and the foecal matter, as well as the gas, 
 escaped only through the anus. The patient recovered perfectly, the 
 only thing remaining being a slight contraction of the orifice of the 
 vagina. 
 
 If the suture of the perineum, which was performed with success 
 by Dupuytren, twenty-five years since, (see our note, p. 77,) has 
 frequently been employed without advantage, it is because, in the 
 greater number of cases, the operation has been performed too soon. 
 As it is very uncommon for the lips of the wound to be in a condi- 
 tion favourable to immediate reunion, it is much better to postpone 
 the operation. We are so convinced of the advantage of waiting, that 
 we fear not to say that success would be almost certain, if the ope- 
 ration could be deferred until suppuration had produced disengorge- 
 inent and contraction of the edges of the laceration, and especially 
 until the lochia were completely suppressed, or, at least, very much 
 diminished. In fact, it is the escape of this fluid which more than 
 any thing else hinders the reunion of the wound, and consequently 
 the success of the operation, and it was assuredly this which pre- 
 
RUPTURE OF THE PERINEUM. 
 
 223 
 
 vented the success of the operation for perineal suture, performed 
 in 1 S32, by Dr. Guersent, jiui. 
 
 The operation for reunion of a laceration of the perineum consists, 
 then, simply in first freshening the cicatrized surfaces with a bistoury 
 or with curved scissors, as was done successfully, ten years since, by 
 Doctor Emile Barthelemi ;* and then bringing the parts together 
 with great accuracy by means of points of suture. The first should 
 be placed towards the anus, the second near the vulva, and the 
 others between these two. We may add, that in general, three su- 
 tures are sufficient, and that the time chosen for the operation should 
 be as distant as possible from the menstruation ; and that, following 
 the example of M. Roux, the precaution should be observed of pre- 
 paring the female for the operation, by restricting her for eight days 
 before, to a strict diet and the use of diluents. It is also very im- 
 portant after the operation, to keep the bowels soluble and to main- 
 tain even a slight diarrhoea ; for the effects caused by the expulsion 
 of hardened faecal matter have often led to failure of the operation, 
 by causing laceration of the points of suture and of the incipient 
 union. 
 
 From the operation not being performed for a long time after the 
 occurrence of the accident, should the skin be too rigid to allow of 
 the approximation of the parts, we ought, in M. Dieftenbach ? s man- 
 ner, to make a deep incision to the right and left, so as to permit 
 the surfaces to be brought into contact without stretching, though this 
 may have seemed before quite, impossible. Finally, if there be no 
 chance whatever, by means of a surgical operation, we should seek 
 to afford some relief to the patient by means of a plug placed in the 
 vagina, or by some apparatus devised according to the circumstances 
 of the case, and maintained by an appropriate bandage. 
 
 [The lacerations of the perineum are sometimes, when uncured, disastrous 
 for the future peace and happiness of the sufferer: yet it is not so with 
 every one, as I can testify from my knowledge of a case which I shall 
 relate. 
 
 Many years ago, a lady here was delivered of her first child, with forceps, 
 under the care of a distinguished practitioner, and suffered a frightful lacera- 
 tion of the perineum, from the effects of which she recovered her health 
 after long and severe sufferings. She subsequently gave birth to two chil- 
 dren, under the management of the same gentleman ; after which I attended 
 her in all her subsequent confinements, amounting to four. 
 
 Knowing nothing of the peculiar nature of her situation, as she was in active 
 labour, I Touched the child soon after arriving, and discovered nothing extra- 
 ordinary. Sometime later, as the waters had gone off, I Touched again, and 
 was shocked to find that there were faeces in the vagina, which, at first, I 
 felt disposed to assign to a recto-vaginal rupture, which might have occurred, 
 as I supposed, during some one of the violent throes that she was experi- 
 
 * La Lancette Fran^aise, t. vi. n. 102, p. 4! 8. 
 
224 
 
 RUPTURE OF THE VAGINA. 
 
 encing. The child was born, however ; and, after the delivery of the placenta, 
 I carefully examined the vagina. I*now learned that what I had supposed to 
 be a regularly formed vulva and vagina consisted of an opening extending 
 from the posterior half of the anus to the anterior commissure of the vulva, 
 or, what might very properly be called a cloaca; for the anterior perineum 
 had wholly disappeared, and, along with it, all the anterior semicircumference 
 of the lower part of the rectum, whose anterior margin I felt up within the 
 cloaca, and lying near the sacrum. Under such circumstances, of loss of 
 substance and structure, had she now borne three children, and has had 
 three others since that time. I am assured by her that, except when she 
 labours under some diarrhoea or looseness of the bowels, she has not the 
 least trouble on account of this new stale of the parts ; discharging her faeces 
 at regular and stated times, and with the same facility as a person in health 
 might enjoy. Moreover, her health is good. 
 
 I take pleasure in stating this case, since it may enable ns to offer some 
 hope and encouragement to others who may chance to be affected in a simi- 
 lar manner. — M.] 
 
 OF LACERATIONS AND OF RUPTURE OF THE VAGINA. 
 
 The vagina, as we shall see presently, is exposed not only to rup- 
 ture during labour, but the walls of the canal are, moreover, subject 
 to lacerations or perforations produced by wounding bodies or by 
 external violence. Plazoni* cites the case of a young woman whose 
 recto-vaginal septum was perforated by the violent efforts of a first 
 copulation. Diemerbroeckt also mentions two young Dutch women 
 who not only experienced the same accident, but who actually per- 
 ished of haemorrhage the first night of their marriage. Lacerations, 
 not less considerable, have often been produced without haemor- 
 rhage, by wounding bodies still more capable of determining dan- 
 gerous consequences. We attended a young girl, aged seventeen 
 years, who, while balancing herself with one of her friends on the 
 trunk of a tree, had both the vagina and the has fond of the -blad- 
 der perforated by a sharp splinter of wood upon which she suddenly 
 fell. The laceration, which was triangular, and was more than 
 six lines of diameter, produced scarcely any flow of blood. We 
 passed a catheter into the bladder, and left it there to give issue to 
 the urine and prevent it from impeding the cicatrization of the 
 wound. The inflammatory symptoms we afterwards combated by 
 means of prolonged baths, by bleeding, by the application of leeches 
 to the hypogastrium, rigorous diet, etc. Five weeks after the acci- 
 dent, the cure was complete. The Lancetle Frangaise published, 
 not long since, the case of a young girl, in the environs of Bordeaux, 
 who, while playing on a hay-rick, had the recto-vaginal septum 
 perforated by the point of a pitchfork. Although the injury result- 
 ing from this accident was very great, there was scarcely any hsemor- 
 
 * De Part. Generat. Inservientibus, lib. ii. cap. xiv. p. 164. 
 
 f Anat. Corporis Humani, lib. x. cap. 36. 
 
RUPTURE OF THE VAGINA. 
 
 225 
 
 any haemorrhage, and the patient, under a rational treatment, soon 
 recovered. Finally, we are about to give another example still 
 more remarkable, which is very analogous to the one just mentioned, 
 and is to be found in the fifty-sixth volume of the Dictionnaire des 
 Sciences Medicates , p. 461. A girl, twenty years old, sliding down 
 a haycock, fell upon a sharp stick of wood, that was armed with a 
 lateral hook, the handle placed against the ground. The stick was 
 an inch in diameter, the point obtuse, the hook sharp and crooked: 
 there was an interval of five inches and a half between its point and 
 that of the stick, and a distance of eighteen lines between the point 
 and the stick itself, without counting the thickness of the latter. All 
 this part of the instrument penetrated within the vulva; and when 
 the first attempts at extraction were made, the hook, which had 
 penetrated the abdomen through the posterior wall of the vagina, 
 became fixed between that canal and the rectum. After frequent 
 attempts made by another physician, Dr. Rey succeeded in extracting 
 the foreign body without incision and without much violence. He 
 commenced by disengaging the point of the hook by turning it 
 towards the pubis, while, at the same time, he strongly depressed 
 the wound in the vagina. The extraction was then instantly accom- 
 plished. A consecutive peritonitis was quelled, and the cicatriza- 
 tion was completed in seven weeks. 
 
 Though such lacerations and accidents as the above are not always 
 mortal, nor even followed by haemorrhage, it sometimes happens that 
 solutions of continuity of the vagina, of little depth, and even simple 
 excoriations or slight cuts of the lining membrane of this canal, have 
 produced dangerous losses of blood, and even death itself. Accidents 
 of this kind occur particularly when the vaginal mucous membrane 
 has become the seat of a varicose disorder, which renders it less 
 resisting, and augments, at the same time, the danger of the wounds. 
 These varices of the vagina, which often burst during labour, some- 
 times give rise to effusions of blood, which, involving the pelvic 
 cellular tissue, and especially the lips of the vulva, occasion the most 
 frightful accidents, and those dangerous and often fatal thrombuses of 
 the vulva to which Professor Boer,* Madame Lachapelle,t and espe- 
 cially M. Deneux,f have directed the attention of the profession. 
 
 The indication presented by thrombus of the vulva, is the follow- 
 ing : to give issue to the accumulated blood by means of an incision 
 made from without ; and to procure the approximation of the edges 
 of the cavity by plugging up the vagina, in such a way, however, as 
 to leave a free passage to the uterine fluids, by means of a large 
 canula. 
 
 Lacerations of the vagina, effected during labour, may take place 
 either in the superior portion of the canal, that is to say, towards 
 the point where it unites with the neck of the uterus, or in its 
 middle and inferior portion. This kind of rupture is always the 
 effect of extreme distension, produced by the head of the child, or 
 
 * Mat. Med. Obs., lib. vii. p. 24. 
 
 f Pratiq. des Accouch. ou Mem. et observ. choisies, etc., t. iii. pp. 130. 197. 199. 
 
 t Memoire sur les Tumeurs Sanguines de la Vulve et du Vagin., 1830. 
 
 15 
 
226 
 
 RUPTURE OF THE VAGINA. 
 
 the result of the direct action of the hand or of obstetrical instru- 
 ments. Laceration of the upper extremity of the vagina, which is 
 the most frequent of all, has often been mistaken for rupture of the 
 uterus itself. It is true, ihat laceration of one of these organs some- 
 times extends to the other, whichever be the one in which it com- 
 menced. When the rupture of the vagina has occurred above, the 
 canal seems simply to have broken its connection with the cervix 
 uteri; for division of the superior portion assumes almost always 
 a transverse direction, which is not the case when the laceration takes 
 place upon any other point. 
 
 A rupture of the middle portion of the vagina often extends to the 
 perineum, and is merely a continuation of the laceration of this infe- 
 rior paries of the pelvis. It is useless for us to dilate at this point 
 upon the symptoms of these lacerations, as they bear the strongest 
 analogy to those of the uterus, of which we shall soon treat; it is 
 sufficient to say, that the prognosis is usually more favourable than 
 for laceration of the womb, and that the patients have soon been re- 
 stored, even in cases where the intestines had passed into the vagina, 
 and in others, when the child had escaped into the cavity of the 
 abdomen. The extraction of the foetus and placenta, which is the 
 most important indication, is always effected without much difficulty 
 through the accidental perforation of the vagina, the edges of which 
 do not contract like those of the uterus ; so that an attentive and 
 dexterous practitioner may often accomplish a perfect delivery 
 without employing violence, and thus remove the principal obstacles 
 to cicatrization. We should not omit to state that what especially 
 distinguishes rupture of the vagina from that of the uterus, is that 
 vaginal lacerations preserve the same extent and breadth after the 
 termination of the labour, while uterine lacerations lose in diame- 
 ter in proportion as the gestative organs become contracted. In 
 some very rare cases a double rupture of the vagina takes place, 
 that is to say, the laceration extends into the walls both of the bladder 
 and of the rectum. Professor Chaussier exhibited to the Society of 
 Medicine of Paris, a specimen, which presented a double rupture 
 occupying both the anterior and posterior walls of the vagina. This 
 specimen was taken from a female who had been the victim of ill- 
 directed manipulations during her labour. 
 
 If laceration of the vagina be less dangerous than that of the 
 uterus, it is because of the greater facility of extracting the child, 
 and because of the small quantity of blood which escapes after the 
 accident.* 
 
 * Veslingius, however, remarks that he has twice seen rupture of the vagina fol- 
 lowed by mortal haemorrhage. Bis enim notavi, cum uteri vagina secundum latus 
 dextrum esset disrupta , quamvis foetus extinctus intcgre cum secundinis educeretur, sub- 
 sequente ex laceratis hypogastricis vasis cnormi sanguinis projluvio, matrem paulo post 
 pariterfalo cccisse. It is probable that in these two cases, and in most others of the 
 same kind, the vaginal mucous membrane was the seat of a varicose condition, 
 which had facilitated the rupture and determined the haemorrhage. 
 
CONTUSION AND WOUNDS OF THE UTERUS. 
 
 227 
 
 OF CONTUSIONS AND WOUNDS OF THE UTERUS. 
 
 When empty, the uterus being movable and concealed in the pel- 
 vic cavity, is very rarely injured by external violence or wounding 
 bodies. 
 
 While operations performed upon the neck of this organ, and lace- 
 rations produced by the ignorance of obstetricians, and by the head 
 of the foetus, prove that wounds of this part are not usually dan- 
 gerous, it is not so in regard to those seated in the body of the womb. 
 Nevertheless, wounds of the body of this viscus are not always 
 necessarily mortal ; for instances of recovery are on record, not only 
 after the Caesarian operation, but even after the rupture of the organ, 
 or after wounds which seemed really to leave no hope. Reichard,* 
 in his excellent dissertation, reports the case of a woman pregnant 
 and at term, who received several wounds from a gvn loaded with 
 small balls, one of which struck her in the left side of the hypogas- 
 trium. This wound, in particular, gave rise to an abundant haemor- 
 rhage, which was soon followed by syncope, but labour having come 
 on, and delivery taken place spontaneously, it was discovered that 
 the child had been struck under the right clavicle, and that there was 
 a wound in which was found one of the balls and a portion of the 
 mother’s clothing. Notwithstanding this, both of them recovered, 
 but the wound of the mother remaining fistulous, was, for a long 
 time, the seat of a purulent discharge, and what is more extraor- 
 dinary, gave issue to the menstrual fluid ; this wound, which did not 
 close until three years after, would have done so much sooner had 
 it not been dilated by a canula, which it was thought proper con- 
 stantly to retain in it. The same author cites other examples of 
 wounds of the uterus, from Langius and Hoffman, which were fol- 
 lowed by very rapid recovery. In one of the cases the wound was 
 made by - a knife, which had opened the cranium of the child ; in 
 another, it was produced by a blow from a pointed stick, which 
 had injured the thorax of the infant ; finally, in a third case, which 
 we regard as impossible or as incorrectly reported, there is mention of 
 a woman whose ute/ine and abdominal parietes were so extensively 
 lacerated by a bulks horn, that the foetus enclosed in its membranes 
 escaped through the wound and fell upon the ground. The child 
 having been replaced in the womb, and the parietes of the abdo- 
 men closed by means of a suture, the women recovered perfectly, 
 and gave birth, at the usual period, to a healthy girl. M. Deneux,t 
 and Dessaitlt,f report from Sue, Schmucker, and other authors, au- 
 thentic facts nearly similar and followed by entire recovery, but in 
 these cases, the child had escaped, or had been instantly extracted 
 through the open wound of the abdomen and uterus. Roussel§ like- 
 wise cites the instance of a female who recovered perfectly of a wound 
 produced by a musket ball, which, traversing the abdomen and 
 
 * Dissert, exhib. uterum gravide una cum foetu vulneratum. 
 
 f Essai sur la Rupt. de la Matrice, etc., p. 24. 
 
 4 Journal de Chirurgie, t. ii. 
 
 § Traite nouv. de l’Hysteromotokie ou enfant, Cesar., p. 120. 
 
228 
 
 CONTUSIONS AND WOUNDS OF THE UTERUS. 
 
 parietes of the womb, had destroyed the child In the History of the 
 Academy of Sciences, (for the year 1709, p. 22,) mention is made 
 of a washerwoman who, at the sixth month of gestation, was 
 wounded in the uterus by a pointed stake of a palisade. After the 
 occurrence of the accident, a good deal of blood and then pus 
 escaped by the vagina ; several abscesses formed afterwards : finally, 
 after opening a considerable tumour, whence escaped the remains 
 of the foetus, perfect recovery took place shortly afterwards. Do we 
 not know, moreover, that the operation of tapping was performed 
 successfully in a woman aged fifty-three years, whose uterus was 
 distended by an enormous quantity of serous fluid,* and that, in an- 
 other case, the womb of a pregnant and dropsical female was acci- 
 dentally pierced by a trocar ? Doctor Simmonst states that the acci- 
 dent was recognized by a discharge of blood and the acute pain 
 which followed the puncture, and adds that, notwithstanding this 
 wound of the uterus, the gestation went on regularly to term. 
 
 Although the facts that we have just mentioned seem to show that 
 the prognosis of wounds of the uterus is not so grave as one might 
 at first suppose, there is a much greater number of cases on record 
 where death has been the immediate consequence of wounds, even 
 slight ones, of the parietes of this organ. In order not to dilate too 
 much on this subject, we shall content ourselves by quoting some of 
 these examples. Brendeliusf records the case of a young girl, who, 
 wishing to procure abortion, had several times plunged a sharp instru- 
 ment through the walls of the neck of the uterus, which perforated 
 the membranes and destroyed the child. This criminal act was fol- 
 lowed by a considerable haemorrhage, then by delirium, convulsions 
 and^death. Devaux§ states, that he was called, on the 8th March, 
 1695, to Jane Berthot, pregnant at eight months, who had just been 
 wounded by a sword in the hypogastrium, at the distance of three 
 finger-breadths from the umbilicus ; this woman was dead before any 
 dressing could be applied : the autopsy showed that the sword, 
 after having passed through the uterus near its fundus, had taken 
 effect in the thorax of the child, and occasioned a large effusion 
 of blood, which explained the sudden death of ^he mother and child. 
 Planchon|| also speaks of a woman pregnant at seven months, whose 
 abdominal parietes were pierced by a large nail three inches from 
 the umbilicus ; this wound, which at first occasioned little pain, was 
 followed by an abundant discharge of blood, mixed with water ; 
 the abdomen soon collapsed and the uterus contracted •, on the fol- 
 lowing day convulsions came on ; there was frequent singultus, 
 bilious vomiting, and death, which occurred sixty hours after the 
 accident. Upon the examination of the body, it was found that the 
 foetus had been slightly wounded in the right shoulder, and that the 
 
 * Wirer Annales de Lit. M£d. etrangere, p. 190. 
 
 f Idem. tom. ii. p. 460. 
 
 i Ephemerides Natur. cur observat. 147, centur. iii. et iv. 
 
 § L’Art de faire des Rapports en Chirurg., p. 176 et 177. 
 
 U Traite de l’Operat. CLsar. (loc. cir.) 
 
CONTUSIONS AND WOUNDS OP THE UTERUS. 
 
 229 
 
 puncture in the uterus was very small, and situated two inches 
 lower down than that in the abdominal parietes. 
 
 Wounds of the uterus, during pregnancy, are therefore in general 
 very dangerous, not only because of the augmented sensibility and 
 great dilatation of the vessels of that organ, but also because they 
 most commonly bring on abortion, give rise to haemorrhage, and 
 especially to sanguine extravasations, which it is as difficult to guard 
 against as to arrest. 
 
 Wounds of the gestative organ are detected by the situation of the 
 external wound, by the direction of the wounding body, by the 
 pain felt in the hypogastric region, in the groins, loins, thighs; by the 
 uterine haemorrhage, the distension of the abdomen produced by the 
 effusion of blood, and the other symptoms common in wounds of the 
 abdominal viscera. In cases of this kind, recourse should be had, 
 without delay, to the most powerful antiphlogistics, such as repeated 
 general bleedings, the application of leeches, of emollient fomenta- 
 tions, the use of demulcent, narcotic and camphorated enemata, of 
 small bulk, so as to be retained ; finally, mucilaginous, astringent and 
 antispasmodic drinks, and a number of other remedies, which should 
 he modified according to the case and the symptoms. 
 
 Traumatic uterine haemorrhage presents but little danger in the 
 non-gravid state ; it is arrested without much difficulty, by repose 
 and the use of cold and astringent drinks. Should the flow of blood 
 be obstinate, and especially if the patient be already prostrated, we 
 should have recourse to a much more active medication ; for exam- 
 ple, we might prescribe a cold solution of sulphate of alumina, to be 
 used as a drink, as an injection into the vagina, and as a topical appli- 
 cation to the- exterior orifice of the wound, by means of linen wet 
 with it. We might, with advantage, substitute for the internal use 
 of the alum a solution of extract of rhatany, (two drachms to the 
 pint of water,) sweetened with syrup of comfrey root.* This astring- 
 ent substance seems to exert a special influence upon the uterus, and 
 to be more efficacious than any other remedy of the same kind in 
 arresting haemorrhage from the organ. It would be equally well to 
 prescribe the extract of rhatany in enemata, and with addition of 
 two grains of camphor, or assafostida, and ten drops of tincture of 
 castor, if the haemorrhage were accompanied by hiccough and other 
 nervous symptoms. Traumatic uterine haemorrhages are generally 
 difficult to arrest during pregnancy ; unfortunately, all the remedies 
 we can propose often fail, and the bleeding ceases most frequently 
 only after delivery, of which, therefore, we must try to hasten the 
 termination. 
 
 CONTUSIONS AND WOUNDS OF THE MAMM2E. 
 
 Though the mammae are very much exposed by their situation to 
 
 * The following mixture, taken in tablespoonful doses every quarter of an hour, has 
 been followed by good results, whenever we have used it, in cases of uterine haemor- 
 rhage, which other means had failed to arrest. 
 
 R. — Infusion of orange leaves, 3 viij ; extract of rhatany, 3 ij ; syrup of comfrey root, 
 ^i. ; syrup of poppy-heads, 3 i. ; sulphuric ether, Ti|x. 
 
230 
 
 CONTUSIONS AND WOUNDS OF THE MAMMAS. 
 
 the contact of external bodies, and consequently to various contusions, 
 it is uncommon for them to be wounded by pricking or cutting in- 
 struments, unless in some surgical operation. 
 
 Contusions of the breasts, however slight, are always painful ; 
 yet they are rarely followed by ecchymosis ; and though they occa- 
 sion only mild symptoms at first, often produce, after several days, 
 swellings, induration and engorgements, which deserve the more to 
 fix the attention of physicians, because they are the most frequent 
 cause of cancer of the mammae. 
 
 When contusions or wounds of the mammae have occurred during 
 the menstrual flow, it often happens that that discharge is modified, 
 that is to say, suppressed, diminished, or increased. During gestation 
 and lactation, these contusions of the mammae produce more serious 
 consequences. In the former case, the breasts being more highly 
 endowed with sensibility, become the seat of more considerable in- 
 flammation and engorgement ; in the latter, there is conjoined to these 
 symptoms, diminution of the secretion of milk, and often complete 
 suppression of the secretion. 
 
 The consequences of blows received upon the mammae are more 
 or less grave, in proportion as the pain they produce is superficial 
 or deep seated. When the pain is superficial, the subcutaneous cellu- 
 lar tissue is generally alone affected ; in the contrary case, the mam- 
 mary gland is the seat of the pain, and the prognosis becomes still 
 more unfavourable if the patient have arrived at her critical period. 
 
 Contusions of the breasts then merit the greater attention, because 
 of the unfortunate consequences which sometimes result from them : 
 we should therefore resort to the employment of antiphlogistics, 
 such as general bleedings, the application of leeches around the part 
 contused, discutients, if there be ecchymosis, cataplasms of flax-seed 
 meal sprinkled with laudanum; and, indeed, we should persevere 
 with all these remedies until the pain and all traces of inflammation 
 have disappeared. 
 
 Wounds of the breasts, produced by puncturing instruments, such 
 as a nail, a needle, etc., require, in the same way, the employment of 
 general and local bleedings, and of discutient, emollient, and narcotic 
 applications, according to the nature of the wound and the symptoms. 
 During pregnancy we should prefer bleeding from the arm to the 
 local use of leeches, unless important circumstances contra-indicate 
 it. If the woman be suckling we ought to dispense with the use of 
 sanguine evacuations, excepting in cases where the breasts are much 
 engorged or when there is suppression of the milk. 
 
 When the contusion or wound of the mammae has produced a dis- 
 tinct diminution or suppression of the menstruse, we should endea- 
 vour to recall this discharge, or substitute for it an application of 
 leeches to the vulva, or to the superior and inferior portion of the 
 thighs. 
 
 OF RUPTURE OF THE UTERUS. 
 
 Rupture of the uterus is a solution of continuity of the parietes 
 
RUPTURE OF THE UTERUS. 
 
 231 
 
 of this organ occurring spontaneously during pregnancy, and most 
 generally during labour, or caused by wounds or violence exerted 
 upon the hypogastric region. In some cases the external agents 
 open the abdominal parietes, and act directly upon the gestative 
 organ. Rupture of the womb has several times been seen to be the 
 result of a wound of this viscus by the horn of a furious bull ;* 
 the same accident has followed a wound produced by the fragment 
 of a glass chamber-pot, upon which the woman was seated ; it has 
 followed a gun-shot wound, a blow with a sabre or a bayonet, 
 and has been caused by the iron ferule on the end of a gig shaft,! 
 and finally by other wounding bodies which it is useless to indicate. 
 Accidental rupture of the uterus takes place also in cases where the 
 parietes of the abdomen have remained uninjured, in consequence 
 of strong pressure, distending the uterine fibres to a greater degree 
 than comports with the ductility and extensibility of which they 
 are susceptible. 
 
 The records of science contain the case of a female whose uterus 
 was ruptured in consequence of violent compression of the abdo- 
 men, between a carriage and a wall;! in another person, the same 
 accident took place from her being kicked by an unruly horse, and 
 thrown on a sharp stone which struck against the umbilical region :§ 
 finally, in a third, the rupture was the unfortunate result of a severe 
 fall upon the abdomen. In the greater part of the cases which we 
 have just reported, the child passed wholly or partially into the 
 cavity of the peritoneum ; but the rupture did not occur immediately 
 after the accidents which were the cause of it. The too great ex- 
 tension of the fibres of the uterus, and their weakness, determined 
 by contusions or wounds, although not involving, in all cases, the 
 whole thickness of the parietes of the organ, probably facilitated 
 the subsequent complete laceration, either by the power of a uterine 
 contraction, or some other effort, or by the giving way of the eschar 
 of the contused parts, which had mortified. There is yet another 
 rather frequent cause of rupture of the uterus, the forcible introduc- 
 tion of the hand into the cavity of the organ, and, still more, of for- 
 ceps and certain instruments, which act as puncturing or cutting 
 instruments, producing real wounds, or causing pressure or tractions 
 which lacerate the fibres of the organ. We ought, however, to 
 confess that, in a great number of cases, it is very difficult, and even 
 impossible, to ascertain whether the rupture has taken place sponta- 
 neously, or whether it has been produced by the imprudent mani- 
 pulations of the accoucheur, or by some extrinsic influence. The 
 following case, reported by Professor Desormeaux, on the authority 
 of Dr. Moulin, shows the obscurity which prevails on this pdint: — 
 In a woman who was suffering the most violent parturient pains, 
 the uterus presented a very marked anterior obliquity. The mid- 
 wife, who had vainly endeavoured to restore the organ to its natural 
 
 * Sue, Essai histor. sur l’art des accouch., t. i. p. 209. Deneux, from Lechaptois : 
 Essai sur les Rupt.de la Matr., p. 35. 
 
 | Planchon. Traite de I’Operat. Cesar., p. 77. 
 
 $ Ancien. Journal de Medecine, t. liv. p.534 et 672. 
 
 § Mauritaneus Cordseus. Hist, de l’Acad. des Sciences, 1709. 
 
332 
 
 RUPTURE OF THE UTERUS. 
 
 direction, wishing to renew her attempts, took advantage of a pow- 
 erful uterine contraction, to introduce a finger into the vagina; but 
 scarcely had this introduction commenced, when the woman cried 
 out that they were tearing her insides. Symptoms ensued, which 
 made it necessary to transfer the patient to the Hotel-Dieu, where a 
 rupture of the inferior portion of the uterus was discovered, which 
 was soon followed by death. 
 
 The predisposing causes of the affection which now occupies our 
 attention are, excessive irritability of the uterus; weakness or too great 
 rigidity of its tissue ; a scirrhous condition of the cervix ; occlusion of 
 its orifice ; contracted pelvis ; osseous or fibrous tumours in that cavi- 
 ty ; obliteration of the vagina, and incomplete atresia of the vulva ; 
 scirrhous tumours of the ovary ; faulty position of the foetus, and all 
 the causes that act as obstacles to delivery and render the expulsive 
 efforts vain: finally, there have been reckoned amongst the pre- 
 disposing causes of rupture of the uterus, undue distension and thin- 
 ning of that portion of the viscus which' corresponds to the insertion 
 of the Fallopian tubes, unequal thickness of the parietes of the same 
 organ, and, lastly, weakness of its tissue, whether resulting from an 
 ancient cicatrix, from a wound, from an antecedent suppuration, from 
 the presence of a fibrous tumour,* or from any cause whatever. 
 According to Denman, pressure and attrition between the child’s 
 head and projecting points 'of bone in badly-formed pelves, may 
 wear away, mechanically, the walls of the uterus. When any of the 
 predisposing causes we have just indicated exist, rupture may be 
 produced by the sudden contractions and more or less violent efforts 
 which result from coughing, sneezing, vomiting, or from lifting a 
 heavy burden. The same accident may occur from violent anger, 
 or sudden fright. M. Duparque has published several cases, which 
 leave no doubt on this point. 
 
 The determining causes of spontaneous rupture of the uterus are 
 very difficult to ascertain. Some authors, as Delamotte, Levret, 
 Deventer, Crants, and M. Egge,t regard the violent and convulsive 
 movements of the foetus as their only cause. According to Roe- 
 derer, this cause cannot be admitted ; and in this we agree with him, 
 because, before the rupture, the child is too strongly compressed by 
 the uterine contractions to be enabled to excite movements capa- 
 ble of rupturing the parietes of the womb; besides, the rupture 
 has often taken place even where the child had been dead for seve- 
 
 * Madame Lachapelle, Madame Boivin, obs. iii.; the Lancette Frar^aise, t. viii. n. 
 126, p. 389, quotes from an English journal, (the Edinburgh Med. & Kurg. for July, 
 1833,) a case of rupture of the uterus, observed by Dr. John Dunn, which took place 
 during labour, on the 15th April, 1829. The laceration had occurred along the margin 
 of a large fibrous mass. The foetus was extracted immediately through the natural 
 passages; and the patient, aged thirty-seven years, recovered so entirely, after the 
 spontaneous opening of an internal abscess, which discharged a large amount of 
 purulent matter by the anus, that, fifteen months after her cure, she was delivered, 
 without accident, of a dead child, and, on the 27th October, she was again safely 
 brought to bed of another child, which was still living on the 9th of February, 1835; 
 that is to say, it was aged nearly two years when this interesting case was made 
 public. 
 
 f Med. & Physic. Journal, November, 1828. 
 
RUPTURE OF THE UTERUS. 
 
 233 
 
 ral days ; and, as Planchon remarks, no part of the foetus had become 
 engaged in the fissure, which would certainly have been the case, 
 had the solution of continuity been produced by the movements of 
 the infant. It seems more natural to us to suppose, that spontaneous 
 rupture is generallycaused by a violent contraction of the uterus, 
 which is, at the same time, under the influence of one of the pre- 
 disposing causes above cited. Effectively, it has almost always 
 been observed, that it is during an energetic and convulsive con- 
 traction of the uterus and of the inferior extremities, that uterine 
 lacerations have taken place. 
 
 Baudelocque regards, as a very frequent and very powerful cause 
 of this accident, the sudden and forced movements of the trunk dur- 
 ing the uterine contractions. In our opinion, this cause, if it does not 
 produce, may at least promote spontaneous rupture; and we are the 
 more inclined to admit it, because it acts at the same time with the 
 exciting causes which we have mentioned. 
 
 Although ruptures of the uterus have generally taken place after 
 the membranes have given way, and particularly when the uterine 
 contractions had reached their greatest degree of violence, it has 
 sometimes happened that they have occurred at the beginning of 
 labour, and even during gestation. M. Collineau* saw a case of 
 rupture of the womb, which occurred in the second month of preg- 
 nancy, in consequence of vomiting. Dr. Puzint has cited an example, 
 which was brought on in the third month, by an attempt to carry a 
 heavy burden. M. Moulin £ has published another, which took place 
 at the same period. Finally, M. Campbell § and M. Duparque|| speak 
 of rupture of the uterus at the fourth month ; M. Thomas Hott,1T at 
 the sixth, and M. Bochard** at the seventh. 
 
 In order to explain the above cases, we are obliged to admit that 
 the ruptures were determined by the organic causes mentioned 
 above, or else we must suppose them to have occurred during semi - 
 extra-uterine pregnancies — that is to say, those which are seated in 
 an abnormal cavity formed in the substance of the walls of the uterus. 
 
 Authors have mentioned, as precursory signs of rupture, tension of 
 the abdomen, elevation of some part of the uterus into a point, vio- 
 lent movements of the child, a fixed and acute pain in the same spot ; 
 again, strong pains without any effect, and finally, some other phe- 
 nomena which are far from being always present, or which exist 
 without the occurrence of rupture : nevertheless, the accident is to 
 be apprehended when there are great obstacles to delivery, and 
 especially where the uterine contractions are violent, prolonged, and 
 accompanied by very severe pains. 
 
 The symptoms showing that rupture has taken place, are the fol- 
 lowing: the female, after an energetic and convulsive contraction, 
 
 * Journal General, de Med., 1808. -^Dissertation Inaugurate, 1803. 
 
 * Archives Generates de Medecine, t. ix. p. 132. 
 
 § The Lancet, vol. i. p. 31. 
 
 fi Hist. Compl. des Rupt. et de la Chirurg. de l’Uterus, p. 42. 
 
 K London Medical Repository, May, 1817. 
 
 ** Journal de Med., t. v. p. 42. 
 
234 
 
 RUPTURE OF THE UTERUS. 
 
 suddenly feels a much more intense pain, accompanied by an inward 
 sensation of laceration, and by a peculiar noise, or rather a sort of 
 tearing sound, that has sometimes been heard by the attendants. The 
 place where the rupture has occurred, then becomes the seat of an 
 excessively acute pain, like that from a violent cramp. The patient 
 litters a piercing cry, her face becomes pale, her pulse grows feeble, 
 she faints or becomes calmer, general coldness ensues, and sometimes 
 a gentle warmth extends over the whole of the abdomen, which sud- 
 denly changes its form; the movements of the foetus disappear little 
 by little, but the labour, which up to this moment had been too active, 
 is instantly suspended ; finally, in the greater number of cases, death 
 follows a more or less considerable effusion of blood into the abdo- 
 men and from the vulva. 
 
 Although any portion of the uterine parietes may be the seat 
 of laceration, there are, nevertheless, certain parts which are more 
 liable to it than others ; for example, the cervix, the sides and the 
 fundus. If the anterior and posterior walls are less subject to it, it 
 is probably because they have a point of support, one upon the 
 anterior paries of the abdomen, and the other upon the vertebral 
 column. 
 
 The foetus and its appendages do not always escape from the 
 cavity of the uterus, after the organ has been ruptured sponta- 
 neously, or from a wound, though it be true that the contrary gene- 
 rally happens ; yet in some cases the body of the child, or only a part 
 of it, passes through the rent, while the rest remains in the uterus, 
 even though the placenta may have escaped.* When death does not 
 promptly follow, the laceration of the body or fundus of the gestative 
 organ soon diminishes in size, from the contractions of the muscular 
 fibres, and if a portion of the foetus or placenta, or even a loop of 
 intestine, should have become engaged in it, they are constricted, and 
 strangulated as it were.t Lacerations of the neck, on the contrary, 
 sometimes remain open for a long time, and allow of the escape of a 
 considerable portion of intestines and epiploon ; finally, we deem it 
 
 * Doctor Goldson, in a pamphlet published in London in 1787, has sought to show 
 that the cases of rupture of the uterus, reported by Van Derwiel, Douglass, Bonnet, 
 Pouteau, Manning and some others, were really only lacerations of the vagina which 
 had occurred near its insertion into the cervix. Dr. Goldson in this way explains the 
 facility which these observers met with in the extraction of the foetus, which had 
 completely passed into the abdominal cavity. It is true that the child rarely escapes 
 quite through a rupture of the womb, unless there be at the same time rupture 
 of the vagina, because even when the laceration is large enough, it immediately di- 
 minishes, in consequence of the reduction produced by the contractions of the organ, 
 and permits only of the escape of a portion of the foetus ; for example, the head alone, 
 (Radford), or accompanied by an arm, (Behling), or, finally, the two superior ex- 
 tremities and the trunk, the feet remaining in the cavity of the uterus, as was ob- 
 served by Philippe Peu (Prat, des Accouch., p. 79). Sometimes the placenta has 
 been driven into the abdomen, while the child has escaped only in part; at other 
 times it is expelled alone through the natural passages, while the fmlus is in the ab- 
 dominal cavity, where it is found by tracing the cord; finally, the membranes may 
 be retained in the womb, w’hatever be the position and place occupied by the child. 
 
 + Rungius, Institut. Chirurg. pars secunda, p. 728. Tousaint Beauregard, Ancien 
 Journ. de Med-, t. lxxix, p. 68. Deneux, from Percy, (loc. cit, p. 53.), 
 
RUPTURE OF THE UTERUS. 
 
 235 
 
 proper to add that the amniotic fluid alone sometimes escapes into 
 the peritoneal cavity, but this effusion is commonly of little conse- 
 quence, and never gives rise to results so fatal as those produced by 
 the effusion of blood. 
 
 We repeat again, that rupture of the womb is a very dangerous, 
 and almost always fatal accident.; if the woman does not perish im- 
 mediately from external or internal haemorrhage, she soon succumbs 
 under the influence of inflammation, caused by sanguine effusion 
 and the presence of the foetus and placenta in the cavity of the peri- 
 toneum. Nevertheless, death does not always follow rupture of 
 the uterus, in which case the parietes of the cyst become anew 
 the seat of acute inflammation, and of purulent secretion, which 
 opens a passage either upon the exterior surface of the abdomen, 
 into the cavity of the vagina or vulva, or into the rectum, the colon 
 and other intestines, as was observed by Doctor John Dunn,* or into 
 the bladder, as in a case seen by M. Morlane, and another, still 
 more recent, communicated, by M. Lecieux, to the Societe Medicate 
 d'hnulation of Paris,! or, finally, into the stomach even, as Marcel- 
 lus Donatus,f George Salmuti,§ and Bernard Montana, || seem to have 
 seen examples of, and certain of which have also been reported by 
 Thomas Bartholin, If Professor of Anatomy at Copenhagen. Accord- 
 ing to the authors we have just quoted, the remains of the foetus, 
 partly in a state of putrescence, were swept off by the purulent 
 fluids, and expelled from the body; in some cases through the anus, 
 through the vulva, or by a spontaneous opening in the abdominal 
 parietes, and in other cases, by means of vomiting ; finally, in the 
 case by Doctor Lecieux, the bones of the fetus passed into the blad- 
 der, and there became the nuclei of several urinary calculi. While 
 some women have perished, because nature has been unable, in their 
 cases, to produce such salutary movements, others have died, be- 
 cause, after a primary evacuation of the debris of the fetus, one of 
 the bones of the latter has presented across, or being too voluminous, 
 has blocked up the passage by which the complete expulsion might 
 have been effected. 
 
 Of all the means of diagnosis, the introduction of the hand into the 
 vagina and uterine cavity, is that which is in all cases the most faith- 
 ful, and leaves the least obscurity upon the different ruptures of 
 the womb. Indeed, if able to distinguish the fetus with some cer- 
 tainty by means of abdominal palpation, and near it a hard and 
 rounded tumour formed by the more or less contracted womb, we 
 shall discover, by carrying the hand into the vagina and through the 
 orifice of the uterus, not only the rupture itself and the place where it 
 exists, but also the circumstances which accompany it. If the lacera- 
 tion has taken place in the neck, the chances are less unfavourable, 
 because we can generally extract the foetus through the wound and 
 
 * The Edinburgh Med. and Surg. Journal, July, 1833. 
 
 | Bulletin de la Societe Med. d’emul., 1822. 
 
 \ De Historia mfdica mirabili, 1586. 
 
 §Observationuni medicarum centur. posthum., 1658. 
 
 II Libro del anat. del hombre, 1550. 
 
 t De insolitis partus viis, 1664. 
 
236 
 
 RUPTURE OP THE UTERUS. 
 
 vagina, without being obliged to perform the operation of gastro- 
 tomy. In all cases, the prognosis is very grave, but, as we have 
 already said, the records of science possess a considerable number of 
 facts, which prove that women have recovered from rupture of the 
 body of the womb, especially when succoured in time by skilful 
 hands. 
 
 The most pressing indication to be fulfilled after a rupture of the 
 womb, is, first, to effect as soon as possible the extraction of the foetus 
 and placenta, the presence of which constitutes the most unfavoura- 
 ble complication, and then to combat the secondary symptoms ac- 
 cording to circumstances. If the child have not passed entirely into 
 the abdominal cavity, we should always endeavour to terminate the 
 labour by the natural passages; but in the contrary case, recourse 
 must be had as soon as possible to gastrotomy, because this extreme 
 means offers some chance of safety to the mother, and especially 
 to the child, which would indubitably perish unless we should act 
 with great promptitude. 
 
 The operation of gastrotomy is performed in the following man- 
 ner : having placed the female on a firm bed, with a cushion under 
 the hips, in order to increase the prominence of the abdomen, the 
 operator, placed upon the left of the patient, makes in the abdominal 
 parietes and towards the region occupied by the child, a longitu- 
 dinal or oblique incision, which he should always be careful to 
 limit to an extent of from five to six inches. This first abdominal 
 incision, the place and direction of which must be determined by the 
 position of the foetus, should include only the skin and subcutaneous 
 cellular tissue ; then, carrying the bistoury carefully into the inferior 
 angle of the wound, an opening sufficient to permit the introduction 
 of the fore-finger of the left hand should be made ; next, substitut- 
 ing for the first instrument a probe-pointed bistoury, the surgeon 
 carries this last into the abbomen by gliding it along the finger re- 
 tained in the wound, and cuts the muscles and aponeuroses in the 
 same direction, and to the same extent, as the first incision that was 
 made externally. If large vessels should be opened during the 
 operation, they must be tied, or, still better, twisted; in the con- 
 trary case, a hand should be introduced into the abdomen without 
 delay, to extract the foetus and placenta; yet, if the latter have 
 remained in the cavity of the uterus, it would be better, perhaps, 
 after having tied the cord, to trust its expulsion to the efforts of 
 nature. 
 
 The dressing of the wound is very simple ; it consists in the ap- 
 plication of adhesive strips, and some pledgets of charpie, covered 
 with compresses, and maintained in situ by means of a moderately 
 tight bandage around the body. In order to facilitate as much as 
 possible the approximation of the edges of the wound, the patient 
 must be placed in a suitable position; she should be advised to 
 have the child applied to the breast, in order to diminish the flow of 
 the lochia, and especially to produce a revulsive mammary irritation, 
 which could not but be favourable to the cure. She should be re- 
 stricted to a close diet, and the inflammatory and nervous symptoms 
 
RUPTURE OF THE UTERUS. 
 
 237 
 
 must be combated by the most powerful antiphlogistics and anti- 
 spasmodics, which ought to be varied according to circumstances. 
 In all cases, it could not but be advantageous to prescribe emol- 
 lient and anodyne vaginal injections, to which might be added the 
 use of fomentations and enemata of the same kind. 
 
 When we have the good fortune to see the wound cicatrize, we 
 should advise the female always to wear a well-made belly-band, 
 in order to sustain the abdominal viscera, and in this way prevent 
 their displacement. These means have sometimes succeeded; M. 
 Nauche* states that after an operation for gastrotomy, performed 
 by Thibaud Dubois, some hours subsequent to a rupture of the womb, 
 the woman, whose child was dead, suffered no other symptoms than 
 those which result from an ordinary labour. Sabatiert also states 
 that Lambron, a surgeon of Orleans, succeeded in two similar 
 cases, in the same female. Gastrotomy was performed on the 
 first occasion twenty-four hours after the rupture, from which it 
 necessarily resulted that the child was extracted dead ; an abscess 
 followed in the neighbourhood of the wound ; yet notwithstanding 
 this complication, the patient recovered, and became pregnant again 
 the following year. The uterus being ruptured anew, Lambron 
 performed gastrotomy a second time a few moments after the acci- 
 dent ; the child evinced some signs of life, but soon died ; the mother 
 being once more perfectly restored, became pregnant again, and was 
 delivered, without accident, of a child, which survived. This opera- 
 tion, which does not always terminate so happily, and yet to which 
 we should not hesitate to recur, since it offers almost the only chance 
 for safety in a great number of cases, has likewise been successfully 
 performed by several other practitioners, amongst whom we deem 
 it sufficient to cite MM. Fritzel,f Powel,§ Sommer, || MackenzielT and 
 Neville.** 
 
 We shall terminate what we have to say upon this subject by add- 
 ing, that as rupture of the uterus is an accident of the most serious 
 character, it is exceedingly important to attend to all the means proper 
 for preventing it, that is to say, to remove, as soon as possible, all 
 obstacles that might render the uterine contractions unavailing. 
 Thus, in some cases we shall succeed in preventing the laceration by 
 performing the operation of turning, or by restoring the gestative 
 organ to its normal direction ; in others, we shall attain the same 
 result by incising the cervix, when it is the seat of a callosity, or 
 by resorting to symphyseotomy when contraction of the pelvis op- 
 poses the escape of the child ; and finally, by employing every means 
 proper for facilitating delivery, such as baths, emollient injections 
 and fumigations, and especially general bleedings at the arm. 
 
 Unfortunately, lacerations of the uterus cannot, generally, be either 
 foreseen or prevented; either because they take place suddenly and 
 
 * Maladies de Femmes, tom. i. p. 267. 
 
 -j- Medecine Operatoire, tom. i. p. 340. 
 
 * Trans, of Iceland, t. i. 
 
 9 Med. Reposit., new ser., t. iv. 
 
 ** Med. Soc. of London, Feb. 1824. 
 
 § Trans, of London, t. xii. 
 
 If London Med. Gazette, Oct. 1830. 
 
238 
 
 RUPTURE OF THE UTERUS. 
 
 without precursory symptoms, or else because women are attended 
 by persons incapable of judging of their condition and acting ac- 
 cordingly. 
 
 The Fallopian tubes and ovaries, also, like the vagina and uterus, 
 are liable to laceration when they become the seat of extra-uterine 
 conception. Baillie* reports a case of rupture of the Fallopian tube, 
 which occurred from the progressive development of a foetus con- 
 tained within it, and gave rise to fatal haemorrhage ; moreover, these 
 kinds of laceration, which are very rare, require the same treatment 
 as that which has been indicated for ruptures of the vagina and of 
 the uterus. See a case in Philad. Prac. Mid., p. 106. 
 
 OF VAGINAL FISTULAS. 
 
 The vagina may communicate by means of one or more acci- 
 dental openings, with the bladder or urethra by its anterior paries, 
 and with the rectum by its posterior paries, or at the same time in 
 front and behind, with each of these cavities. These kinds of per- 
 forations constitute what are called vaginal fistulas , which are dis- 
 tinguished into vesico-vaginal and reclo-vagin al fistulas ; and into 
 double or multiple vaginal fistulas, according to the situation and 
 number of the perforations in the vul vo-uterine canal. 
 
 OF VESICO-VAGINAL AND RECTO-VAGINAL FISTULAS. 
 
 Vesico-vaginal fistula, that is to say, the anormal aperture which 
 allows the urine to enter the vagina and to flow off' constantly 
 through it, against the will of the person affected, is a physical 
 lesion which, though rare, is met with often enough to deserve all 
 the attention of men of art. This disease, or rather this disgust- 
 ing infirmity, is one of the most unfortunate and painful accidents 
 to which women are liable. In fact, the inconveniences which 
 result from it reduce them sometimes to such despair, that they 
 always accept without hesitation the most painful operations, and all 
 other means proposed to them. Though never mortal in itself, the 
 affection is, nevertheless, a very serious one, not only from its reduc- 
 ing the patient to the most deplorable condition, but particularly be- 
 cause of the great difficulty almost always met with in obtaining a 
 radical cure. 
 
 The causes which give rise to vagino-vesical fistula are, most 
 generally, the prolonged detention of the foetal head in the excava- 
 tion of the pelvis during laborious labours, and compression of the 
 superior portion of the vagina against the symphysis pubis, from 
 which result gangrenous eschars, whose fall almost always pro- 
 duces vaginal perforations. To the causes just mentioned, must be 
 added violent manipulations, and the employment of the lever or 
 forceps, directed by awkward hands, the prolonged retention of 
 a calculus or other foreign body in the bladder, of which Fabricius 
 
 * Anatomie Pathologique, chap, xxiii. sect. 5. 
 
RUPTURE OF THE UTERUS. 
 
 239 
 
 Hildanus cites an example ;* that, of a pessary in the vagina, t vagi- 
 nal cystotomy, and finally, vesico-vaginal fistulas have also been 
 known to occur from venereal ulcerations, or from a cancerous ulcer 
 situated upon the neck of the womb, and still more upon the vagino- 
 vesical septum. 
 
 The signs of this affection, which may likewise be congenital^ 
 present but few differences in the women attacked by it. When it 
 follows a laborious labour, retention of urine is almost always pre- 
 sent, which is relieved at first by the introduction of a catheter into 
 the bladder, but is gradually converted into complete incontinence 
 after the fall of sloughs of greater or less size, which usually takes 
 place from the seventh to the twelfth day. 
 
 Vesico-vaginal fistula may occur in the canal of the urethra, and 
 at the neck, or bas-fond of the bladder. Those of the first kind, 
 to wit, the urethral, are the least unfavourable, because the urine 
 does not flow except during the voluntary expulsion of this fluid, 
 which escapes partly by the meatus urinarius, and partly by the 
 accidental perforation. The anormal discharge of the vesical fluid, 
 whose quantity varies according to the dimensions of the fistula, 
 by bathing the wall of the vagina and the internal surface of the 
 labia majora almost constantly, soon causes an active irritation in 
 those parts, and develops in them either an habitual erysipelatous 
 condition, or an eruption of large pimples, or else grayish ulcerations 
 and smarting, and very painful pruritus, which it is more difficult to 
 prevent than to cure. 
 
 When the perforation is situated at the neck of the bladder, all the 
 symptoms we have just mentioned become still more serious, for 
 the patients are unable to retain their urine, except in a few cases 
 when seated or standing, because the womb in these positions gra- 
 vitates, and closes the fistulous aperture, the lips of which it 
 maintains in contact by approximating the superior edge to the infe- 
 rior. In order for this result to be obtained, it is necessary, on the 
 one hand, that the perforation shall be slight, and on the other, that 
 the female shall avoid the expiratory efforts which occur in sneez- 
 ing, laughing, spitting, coughing and blowing the nose, a thing 
 difficult, if not, indeed, impossible. In reality, every time that the 
 diaphragm forces the abdominal viscera downwards by a sudden 
 contraction, the bladder, which is compressed at the same moment, 
 likewise contracts, and a change in the direction of the fistula is 
 produced, which then allows the urine to escape, in spite of the pre- 
 cautions taken by the woman. 
 
 When the perforation is seated at the bas-fond of the bladder, the 
 flow of urine is continual, no matter what be the position that the 
 patient assumes. In this case, the most unfortunate of all, their beds, 
 their garments, the cavity of the vagina, and the internal surface 
 of the labia majora, are constantly bathed with urine, and there 
 
 * Opera omnia, centuh i. observ. 68. 
 
 f Journ, compkm. des Sciences Med., tom. xxxvii., and various cases that we 
 cited while treating of pessaries, in the early part of this work. 
 
 Die. des Sciences Med., t. lvi. p. 303. 
 
240 
 
 RUPTURE OP THE UTERUS. 
 
 is no precaution, no means of cleanliness which can guarantee them 
 from being constantly wet, and especially from the urinous and 
 disgusting odour which they exhale. There are some even who 
 are compelled to pass their lives in chairs with holes, in which are 
 placed vessels intended to receive the urine as it escapes from the 
 vagina. 
 
 Notwithstanding the sad picture we have just traced of vesico- 
 vaginal fistulas, they did not attract the attention of surgeons until 
 the commencement of the present century, and we find no good his- 
 tory of them except in the most recent works. Nevertheless, these 
 kinds of perforation have existed at all periods, and must have been 
 more frequent formerly than at present, because prior to the disco- 
 very of the forceps, in the last century, difficult labours were termi- 
 nated only by the efforts of nature alone, or by means of dangerous 
 operations. It is clear that, in such cases, the prolonged pressure 
 of the head against the vagino-vesical septum and symphysis pubis, 
 must often have produced gangrene, which is the most common and 
 almost the exclusive cause of the affection which now occupies our 
 thoughts. 
 
 The diagnosis of vesico-vaginal fistula rarely presents any dif- 
 ficulty, and, in general, with the aid of the touch and the direct ex- 
 ploration by means of the speculum vaginae, we may almost always 
 discover not only their existence, but also their form, their situation 
 and extent. There are, nevertheless, some circumstances which we 
 think ought to be mentioned, as they may cause some obscurity in the 
 diagnosis. 
 
 When incontinence of urine manifests itself only a few days after 
 delivery, we might confound this involuntary discharge with that 
 of the lochia, and attribute the diminished escape of cystic fluid to 
 an inflammatory, or some other pathological condition of the renal 
 glands. It is sufficient merely to mention this possible cause of error, 
 in order to avoid falling into it. It is also well to know, that when 
 the vesico-vaginal fistula, which occurs after a laborious delivery, 
 is the result of a laceration or division, the incontinence of urine 
 supervenes immediately after parturition ; on the contrary, where 
 the perforation follows the formation of a slough, it is only after 
 the falling of the latter, which takes place generally from the 
 seventh to the twelfth day, that the incontinence of urine becomes 
 manifest. We should, nevertheless, remark, that the involuntary 
 expulsion of urine following a difficult labour, is not always the 
 result of a communication established between the vagina and 
 bladder, since it may depend also upon violent contusion of the 
 neck of the bladder, without formation of a slough. Although, 
 in this last case, the incontinence is usually of short duration, it 
 may sometimes persist as though a fistula existed, and give rise to 
 difficulties in the diagnosis, which are, however, readily removed 
 by exploration of the parts. Finally, in order to terminate what 
 we had to say upon the circumstances which may complicate the 
 diagnosis of vesico-vaginal fistulas, we shall add that the presence of 
 a deep slough on the neck of the bladder does not commonly pro- 
 
VESICOVAGINAL FISTULAS. 
 
 241 
 
 duce incontinence, until after having first determined complete reten- 
 tion of urine. 
 
 If, after a laborious labour, we should have some reason to believe 
 in the existence of a fistula, it would become necessary to remove 
 all uncertainty upon the point at once, because, in these cases, the 
 least delay may give rise to the most deplorable consequences. In fact, 
 if we wait until the edges of the perforation have become cicatrized 
 separately, there remains no chance of cure except from a painful 
 and often unsuccessful operation. When, on the contrary, the pre- 
 sence of the accident has been recognized in good time, we may 
 hope for complete reunion by the efforts of nature alone, examples 
 of which have been cited by Fabricius Hildanus,* Paletta,! Philippe 
 Peu,f Ryan,§ Duparcque,|| Blundell, Capuron, and other authors; or 
 we may at least hope for some diminution of the extent of the fis- 
 tula, the radical cure of which to be afterwards readily obtained by 
 means of cauterization. 
 
 The moment we have any motive for fear, it is of the highest 
 importance to assure ourselves as soon as possible whether a vaginal 
 perforation exists, for immediately after delivery, the vagina and 
 uterine ligaments are relaxed, the uterus heavy, and the edges of the 
 wound bleeding or in a state of suppuration. As all these circum- 
 stances are very favourable to the approximation and agglutination 
 of the lips of vesico-vaginal fistulas, the chances of cure would be- 
 come more numerous and sure, in proportion as art should assist the 
 efforts of nature, either by the use of a sound, introduced and main- 
 tained in the bladder ; by means of favourable position, and com- 
 pression of the abdomen ; or by other means, to be varied according 
 to circumstances, and the effects of which would be less powerful at 
 a later period. 
 
 It remains for us to say, that vesico-vaginal fistula, caused by 
 laborious labour, is almost always either transverse or oblique ; those 
 produced by other causes are more frequently longitudinal ; aban- 
 doned to themselves, they commonly incline to last for indefinite 
 periods of time, although, in a certain number of cases, they do con- 
 tract spontaneously, and, as we have already stated, even close, by 
 the inherent power of the organism, and under the influence of con- 
 ditions which it is difficult to appreciate. 
 
 In order to acquire as exact an idea as possible of the form and 
 dimensions of vaginal perforations, M. Lallemand, Professor at the 
 Faculty of Montpellier, has devised an ingenious method of diag- 
 nosis, which consists in the introduction into the vagina of a piece 
 of wax properly prepared, by means of a large porte empreinte IT 
 supported by the index and middle finger of the left hand. The wax, 
 
 * Centur. i., obser. 68 el centur. iii. obser. 69. 
 
 t Chirurgie, deuxieme partie, p. 21. 
 
 * Prat, des Accouchements, p. 384. 
 
 § Manual of Midwifery. 
 
 H Hist. Compl. des dechir. et des ruptures de Tut., p. 328. 
 
 U An instrument for holding the wax intended to receive the impression. — Trans . 
 
 16 
 
242 
 
 VESICO-VAGINAL FISTULAS. 
 
 by remaining a few moments in the vagina, becomes softened; when 
 it is perceived to have become sufficiently so to answer the end pro- 
 posed, it is raised up and applied as closely as possible to the fistula, 
 the impression of which it receives with the varied forms of its 
 orifice and edges, as well as the appearance of all the surrounding 
 parts, which is faithfully reproduced. In order to ascertain the exact 
 depth of the seat of the lesion, all that is necessary is, while remov- 
 ing the wax, to apply the thumb upon th e porte empreinte, on a 
 line with the orifice of the vulva. This excellent means of diag- 
 nosis, to which it is always well to have recourse, furnishes the 
 befiting complement of that preliminary knowledge which is indis- 
 pensable to the surgeon, in order for him to operate with certainty. 
 
 The degree of curability or incurability of vesico-vaginal fistula, 
 depends not only upon its situation and form, but also upon the 
 nature of the causes which have produced it, upon its position in 
 relation to the mouths of the ureters, and finally upon the absence or 
 existence of a division of these canals at the points where they open 
 into the bladder; the prognosis is likewise more unfavourable, if the 
 urethra, the neck of the bladder, or the vesico-vaginal septum be 
 partially or entirely destroyed, and also where there exists a pro- 
 trusion of the vesical mucous membrane between the edges of the 
 perforation. 
 
 Though it be contrary to the general opinion, we regard those 
 fistulas, that are situated behind the vesical opening of the ureters, 
 as being more favourable than those situated more in advance of 
 these canals, because, in the former case, if we keep the patient in a 
 more or less vertical position, and retain in the bladder a catheter 
 which passes but little beyond the neck of the organ, all the urine 
 may escape through the instrument without bathing the fistula ; on 
 the contrary, where the perforation is in front of the ureters, and 
 especially when near the neck, a portion of the urine constantly 
 flows over the perforated point, which constitutes one of the greatest 
 obstacles to spontaneous cure, as well as to the agglutination of the 
 edges when approximated by an operation. 
 
 Vesico-vaginal fistulas, which have been caused by the pressure 
 of a pessary in the vagina, seem, in general, to be less grave than 
 those arising from other causes; for from the cases which we related 
 while speaking of the accidents produced by these instruments, it 
 has been seen that they often close spontaneously, from the moment 
 that the pessary is withdrawn. We may say, moreover, that in 
 addition to the circumstances already mentioned, the chances of cure 
 are in proportion to the diameter of the opening in the bladder ; the 
 greater the loss of substance, the more have we to fear that art, how- 
 ever ingenious it may be, can oppose but feeble arms to the disease. 
 
 The curative treatment of vesico and urethro-vaginal fistula, 
 should always be preceded by the treatment of the internal causes 
 which may have produced it, and by the removal of any complica- 
 tions that might aggravate it. Thus, were the vaginal perforation 
 the result of a syphilitic ulceration, it becomes necessary first to 
 
VESICO-VAGINAL FISTULAS. 
 
 243 
 
 employ a general and local treatment proper for affections of this 
 kind. Where the fistulous opening is caused by the presence of one 
 or more calculi, or any other foreign body irj the bladder, which may 
 be ascertained by the catheter, or by the Touch through the vagino- 
 vesical septum, we ought to perform lithotomy by the vagina, or 
 destroy the urinary concretions by lithotrity, or by any other method 
 that might seem more advantageous. If a contraction of the ure- 
 thra exists, it should be treated by appropriate remedies, and if the 
 fistula coincide with large and projecting callosities, with deep exco- 
 riations or urinary abscesses of the labia majora or nymphae, it should 
 be subjected to preliminary treatment, consisting especially in the use 
 of emollient fomentations and lotions, whose action would be aug- 
 mented by methodical dressings ; in fine, we should never think of 
 obtaining reunion and agglutination of the edges of the fistula, until 
 after having restored it to a simple condition, and removed all the 
 complications capable of preventing the success of the attempts that 
 we may make. 
 
 Amongst the methods which have been employed or proposed for 
 the treatment of fistulas, are, in following the chronological order, 1, 
 the palliative method; 2, the use of the tampon; 3, cauterization; 4, 
 the suture; 5, approximation of the edges of the perforation by means 
 of particular instruments, such as sounds and hooked forceps, etc. 
 
 OF THE PALLIATIVE METHOD. 
 
 The palliative ought, necessarily, to be the oldest of the methods 
 that have been employed, as far as possible, to relieve vesico-vaginal 
 fistula; for, until the close of the last century, the cure of this kind of 
 perforation was regarded as beyond the resources of surgery, and 
 especially as unsusceptible of cure by any operation. 
 
 This method should be made use of only when the fistula is known 
 to be incurable ; that, is to say, when it depends upon the presence 
 of an advanced state of cancer of the uterus or vagina, and even 
 when it has been produced by any other cause, provided different 
 attempts at a cure had proved unsuccessful. 
 
 The means to be employed in these unfortunate cases consist of 
 such attentions to cleanliness as may protect the vaginal cavity, the 
 labia majora, the perineum and the thighs, against the acrimony of the 
 urine, and, in the use of different contrivances destined to receive the 
 fluid, so that it may incommode the patient as little as possible. 
 
 The first indication is met by the frequent use of baths, of lotions, 
 and emollient and narcotic injections; and we may partially relieve 
 the inconvenience of the constant flow of urine, by means of an 
 instrument which has been indicated only by J. L. Petit, under the 
 name of urinal or Irou d’enfer ; but the real inventor of which is 
 Feburier. This instrument, which may be found at all the bandage- 
 makers, is a sort of bag or sac of India-rubber, which may be kept 
 in front of the vulva, and introduced in part into the vagina, so as 
 to receive the urine, without preventing the woman from walking 
 and attending to her business. To answer the same end, M. Barnes, 
 
244 
 
 VESICO-VAGINAL FISTULAS. 
 
 of London, makes use of a gum-elastic bottle, which is placed 
 partly in the vagina, and has a sponge upon its anterior face, 
 in which an opening is fixed, that should be carefully directed 
 towards the fistula in such a way that the urine may be absorbed. 
 The urinal ought to be removed several times a day, in order to 
 squeeze the urine out of it. In addition to several other contrivances 
 of the same kind, proposed chiefly by manufacturers of bandages 
 and gum-elastic instruments, we may resort to the employment of 
 fine sponges, and plugs of linen introduced into the vagina, and 
 renewed, more or less frequently, in the course of the day. Finally, 
 in order to compel the urine to escape by the urethra, or by a sound 
 or syphon placed in it, M. Chailly has proposed the semi-flexed posi- 
 tion on the abdomen; unfortunately, such result is far from being 
 obtainable, and the experiments made by MM. Schreger and Sanson 
 have proved that women placed in the position indicated by M. 
 Chailly, have been able to maintain it only a short time, because it is 
 too awkward and painful, and threatens speedily to produce sloughs 
 on the knees, elbows and iliac spines. 
 
 TEMPORARY PALLIATIVE METHOD. 
 
 In some cases, the palliative method ought to be temporarily 
 employed ; for example, it should be resorted to in cases of trans- 
 verse and oblique fistula the edges of which remain separate, in 
 spite of abdominal compression, the various positions given to the 
 patient, and the formation of fibrous tissue on the lips of the perfora- 
 tion ; we should, therefore, before commencing a curative treatment, 
 insist, for a longer or shorter period of time, on warm baths and injec- 
 tions, emollient fumigations directed towards the sexual parts, and, 
 in fine, have recourse to the employment of all the means capable of 
 facilitating the descent of the uterus, and especially the relaxation of 
 that part of the vagina situated above the fistulous orifice. 
 
 During the time not yet very remote, when it was supposed that 
 the cure of vesico-vaginal fistula was always beyond the resources of 
 art, and especially that it was useless to attempt the radical cure by 
 means of a surgical operation, the palliative method, which was gene- 
 rally employed with the sole view of diminishing the inconveniences 
 of a disgusting infirmity, was sometimes found to be successful in the 
 cure of the patient. Fabricius Hildanus,* who died at Berne, in 
 1634, relates a complete cure obtained in this way in a lady affected 
 with a vagino-vesical fistula, following a laborious labour. Accord- 
 ing to this celebrated author, the cure was obtained by a treatment of 
 eight months’ duration, which consisted simply in the use of some pur- 
 gative doses, and of frictions upon the loins, but especially in the fre- 
 quent employment of injections, composed of a decoction of barley, of 
 quince-seeds, and the seeds of the fenugreek (trigonella fcenurn grae- 
 cum), to which he added oil of sweet almonds and honey of roses. 
 We subjoin, moreover, the most important passage from this curious 
 
 * Opera Omnia, centur. iii. observat. 69. 
 
OP TAMPONNEMENT, ETC., IN FISTULA. 
 
 245 
 
 case : “ Ilia autem continud usa medicamentis (ut dixi) conglutinan- 
 tibus, et per intervalla etiam pargantibus, intra menses octo, non 
 sine admiratione omnium eorum quibus res cognita plane curata fuit, 
 adeo ut nunc Dei optimi maxima gratia ne guttula quidem urinae invo- 
 luntariae affluat, sed & vesica colligatur, retineatur et excernatur non 
 aliter ac si antea nunquam male affecta fuisset.” 
 
 OF TAMPONNEMENT, AND OF DESSAULT’S METHOD. 
 
 Recourse has been had to a large, cylindrical tampon of linen, intro- 
 duced and maintained within the vagina, for the purpose of closing 
 the fistula, and to press its anterior against its posterior lip, so as to 
 effect their cicatrization, by keeping the opposite edges in as close 
 contact as possible. This method, which was first employed by 
 Fabricius Hildanus,* Hilscher,t Paletta,f and also by Dessault, who 
 added the sound already proposed by Schulzius,§ and made use of by 
 Boudon,|| and J. Paletta,!" seems in some cases to have succeeded, espe- 
 cially in the treatment of urethral fistula, and also those of the bladder, 
 when they were recent, of slight extent, and presented a transverse 
 opening. In more severe cases, the use of the vaginal plug is al- 
 most always useless, and fails, in spite of ail the patience of the 
 sick, and all the dexterity of the physician. 
 
 This method, which, besides the inconvenience of its rarely attain- 
 ing the success we seek, has the further one of requiring a protracted 
 application of from six to ten months, is described by Dessault in the 
 following manner: 
 
 That great surgeon, in his treatise on urinary diseases, recommends 
 the introduction into the bladder of a sound, of large calibre, with 
 very large eyelets, to be retained by means of an apparatus like a 
 truss; the circle of which, being long enough to embrace the upper 
 part of the pelvis, supports, at its middle point, an oval plate, which 
 should be placed on the pubis. In the middle of this plate is a groove, 
 in winch slides a silver rod, curved in such a way that one of its ex- 
 tremities, pierced with a hole, falls over the vulva, upon a line with 
 the meatus urinarius. The rod of silver is fixed upon the plate 
 by means of a screw. When all is arranged in the mode that we 
 have just described, the end of the sound is passed through the open- 
 ing in the rod traversing the groove. 
 
 This kind of truss, invented by Dessault, was preferable to the 
 double T bandage in use ; to which ribbons were fastened, carried 
 over the outer end of the sound, and afterwards attached to the hair 
 of the vulva. 
 
 The lips of the vagino-vesical perforation were then brought as 
 close together as possible, by means of a linen plug, introduced into 
 
 * Opera Omnia, centur. i. observ. 68. f Chirurg., de Haller, tom. iii. § 599. 
 
 * Chirurg. deuxieme partie, (loco citat.) 
 
 § Deuxieme Supplement aux oeuvres de Frederic Hoffman. 
 
 11 Traite des Accouch., conten. des observ. import, par Nicolas Puzos, p. 138. 
 
 H Chirurg , (loco citat.) 
 
246 
 
 CAUTERIZATION OF VAGINAL FISTULAS. 
 
 the vagina, and pushed from without inwards, in order that the 
 fistulous opening might in this way be entirely closed, and, at the 
 same time, be converted into a transverse slit. 
 
 This method, the only one of which Professor Boyer treats, and 
 which, as we have proved, ought not to be attributed to Dessault, 
 except as regards the truss, was employed several times, with success, 
 by that great surgeon, who, however, reports but a single case, that of 
 a female, which appears to have been cured. As it required months, 
 and even years, of the permanent use of the plug and sound, to obtain 
 any results, we think that the cures which have been thought to 
 result from the employment of such means, might have occurred, in 
 most of the cases, spontaneously, or at least with the aid of a sound 
 retained in the bladder. 
 
 Though we must reject, in general, the method indicated by Des- 
 sault, we believe that in cases of perfectly transverse fistula, it might 
 often be used with advantage, provided some modifications that we 
 are about to mention were made in it. 
 
 In the first place, before introducing a tampon into the vagina, 
 it would be necessary, in order to place the wound in the best possi- 
 ble condition, to cauterize the cicatrized edges separately, taking care 
 to act principally upon the angles where the agglutination always 
 commences. 
 
 In case the edges of the fistula should be very much separated, 
 that is to say, if it were a very large one, and almost circular in 
 shape, instead of resorting to cauterization, we ought, in order to 
 give to the oval perforation as much as possible the form of a button- 
 hole, which is the most favourable to reunion, — we ought, we say, 
 in the first place, to enlarge it a little, in the direction of its greatest 
 diameter, by means of a small incision, half a line, or a line, on either 
 side, and then freshen the lips of the opening, as we shall show in 
 speaking of other methods of operation. 
 
 The plug, introduced into the vagina, should be a sort of pessary, 
 made of gum-elastic, of a conoidal form, with its base upwards, whose 
 circumference should not be prolonged beyond some five or six lines, 
 so as to press backwards the anterior edge of the fistula, by means 
 of the transverse tension which would be produced in the direction 
 of the greatest diameter of the aperture : finally, the forward pres- 
 sure, or rather the approximation of the posterior lip, would be faci- 
 litated by the weight of the womb, rendered slightly prolapsed by 
 means of a reclining position directed for the patient, and, with the 
 aid of a bandage around the trunk, designed to fix both the sound 
 and the pessary. 
 
 OF CAUTERIZATION. 
 
 Cauterization, though seeming at first view to tend merely to in- 
 crease the loss of substance and the extent of the perforation, was 
 used with success by Monteggia,* and, in like manner, by Dupuy- 
 
 Maladies Chirurgicales, t. v. p. 339. 
 
CAUTERIZATION OF VAGINAL FISTULAS. 
 
 247 
 
 tren ; it constitutes, nevertheless, one of the best means which the art 
 can oppose to vesico-vaginal fistula. This method, the happy results 
 of which are especially observable where the perforation is of small 
 extent, is worthy qf all attention from practitioners ; but, in order that 
 it may be crowned with success, we must know how to apply it pro- 
 perly, and according to certain rules which we shall soon describe. 
 
 Cauterization should be practised only with the actual cautery, or 
 with the nitrate of silver ; and we should always reject as useless, 
 and even injurious, both the acid nitrate of mercury, and the concen- 
 trated acids which were first employed by Professor Dupuytren. The 
 nitrate of silver is generally preferable ; and we should resort to the 
 incandescent wire, which acts more rapidly and with greater energy, 
 only where the edges of the fistula are hard, callous and difficult to 
 irritate. 
 
 Whether we use one or the other of these two modes of cauteri- 
 zation, the patient must be placed in the position which we have 
 advised for the application of the speculum, that is, on the back, with 
 a folded sheet under the hips, the head supported by pillows, the 
 thighs flexed upon the abdomen, the legs upon the thighs, which 
 should be separated and firmly held by assistants. Nevertheless, to 
 prevent the urine from extinguishing the cautery too soon, when the 
 wire is used, it would, perhaps, be convenient to place the female in 
 the opposite position, that is to say, on the hands and knees. Should 
 we adopt this last method of cauterization, it becomes necessary, in 
 order to protect the surrounding tissues, and leave only the fistula 
 uncovered, to introduce into the vagina a common cylindrical spe- 
 culum, but having, in the whole or a part of its 
 length, a fenestra placed so as to correspond to 
 the vaginal perforation. When all has been thus 
 arranged, we must apply to the circumference of 
 the fistula a large stilet, heated to a white heat, or a 
 small cautery, in the shape of a bean, which we 
 must be careful to retain in contact only a few 
 moments, in order to irritate merely the edges of 
 the wound, and not to erode and destroy them by 
 prolonging the application of the heat too long. 
 
 Professor Delpech, who, like Dr. Bellini, of Rovigo, 
 has successfully employed the actual cautery, 
 thinks that it should be applied less to the vesical 
 portion than to the vaginal circumference of the 
 fistula, so as to prevent, as far as possible, loss of 
 substance, while producing the irritation necessary 
 to effect the contraction of the lips of the wound 
 and its cicatrization. 
 
 To perform the operation of cauterization with nitrate of silver, the 
 patient should be placed as we have above directed, and the specu- 
 lum should likewise be applied according to the rules which we have 
 just laid down. After having fixed a piece of solid lunar caustic in 
 a port-crayon, by means of a thread, in such a way that it may form 
 a right angle with the blades of the instrument, the surgeon should 
 
248 
 
 CAUTERIZATION OF VAGINAL FISTULAS. 
 
 carry the caustic into the vagin o-vesical aperture, and rub it during a 
 proper period, on the edges and angles of the wound, which latter he 
 should in particular cauterize completely ; for it is there, as we have 
 already said, that the agglutination always commences. In order 
 
 to prevent the hand from 
 masking the parts, and to 
 render the operation very 
 easy, whatever be the form, 
 extent and situation of the 
 fistula, we have caused a 
 caustic-holder to be made, 
 whose handle is bent at 
 nearly a right angle, while 
 its anterior extremity is 
 movable, so that it may 
 act in all directions. This 
 instrument, which resem- 
 bles the letter Z,and which 
 we have called a vagino- 
 causte , is merely a modi- 
 fication of the caustic-hold- 
 er, which we daily use for 
 the cauterization of the 
 tonsils and the walls of the pharynx. ( See Jig. 22.) 
 
 In whatever mode the cauterization may have been performed, it 
 is useful to resort at once to emollient injections, and to place the 
 patient in a warm bath, in order to diminish the pain which follows 
 the operation, and prevent too intense an inflammation, which might 
 supervene. 
 
 In general, a single cauterization with the nitrate of silver is not 
 sufficient to freshen the edges of the fistula, especially when it is hard 
 and callous ; in this case, it. becomes necessary to repeat the operation, 
 allowing four or five days of interval between each cauterization, to 
 permit the slough to fall ; finally, when the edges are fully renewed, 
 a catheter should be introduced and retained in the bladder, so that 
 the urine, escaping freely into a vessel placed in front of the vulva, 
 may not prevent the approximation of the parts. As long as the 
 occlusion of the aperture remains imperfect, we should persevere in 
 these measures, especially if we perceive that the diameter of the 
 fistula gradually diminishes. 
 
 We shall conclude by saying that cauterization favours the cica- 
 trization of vesico-vaginal fistulas by three simultaneous modes of 
 action ; 1, by freshening the edges of the orifice, and thus placing them 
 in a condition favourable to their cohesion ; 2, by inducing tumefac- 
 tion of the edges, and producing a new tissue (modular tissue), 
 whose contraction contributes powerfully to the approximation of 
 the parts ; 3, by modifying the nature and vitality of the vagino- 
 vesical mucous membranes, and destroying the epithelium, which, 
 in its natural state, is the principal obstacle to their cohesion when 
 put in contact ; finally, we shall add that cauterization is commonly 
 
 Fig. 22. 
 
THE SUTURE IN VAGINAL FISTULAS. 
 
 249 
 
 followed by success, only in small fistulas and in urethro-vaginai 
 fistula; as it almost always fails in those extensive perforations 
 that we most desire to cure, it should be rejected in severe cases, 
 while, in order to terminate the cure of fistulas that we have suc- 
 ceeded in diminishing, recourse is always to be had to one of the 
 methods yet to be described. 
 
 OF THE SUTURE. 
 
 The use of the suture, in the cure of vaginal fistula, dates *only 
 from the early part of this century. J. L. Petit* thought it so in- 
 effectual, that he violently contended against the advice of a physi- 
 cian called in consultation with several others, on a lady affected 
 with vesico-vaginal fistula. This celebrated surgeon, who died in 
 1750, says, in his posthumous works published by Lesue, his former 
 pupil, that the consulting physician who proposed the suture, and 
 who, moreover, stood alone in his opinion, adopted the common 
 opinion, because he made him feel “ not only the difficulty of per- 
 forming the operation in a part so deep-seated and obscure ; but, 
 also, the necessity of freshening the edges of the whole circum- 
 ference of the perforation, and the impossibility of doing it com- 
 pletely/’ 
 
 According to M. Chelius, to whom Professor Velpeaut refers, the 
 suture was proposed by Roonhuysen, an accoucheur and surgeon at 
 Amsterdam, who flourished about the middle of the seventeenth 
 century, and was celebrated as the inventor of the lever, which was 
 for a long time a secret as to the public. The method of Roonhuy- 
 sen, which appears to have been pointed out to him by his nephew, 
 consisted in freshening the edges of the fistulous orifice, re-uniting 
 them by means of needles made of pieces of swan-quill maintained 
 by the twisted suture, and, lastly, in filling the vaginal cavity with 
 sponge. It would seem that this method afterwards succeeded in 
 the hands of Fatio and Walter ; but the proofs we have of their suc- 
 cess are not sufficiently conclusive and authentic to remove all doubt 
 in regard to it. 
 
 M. Lewzinski proposed the suture, in a thesis defended before 
 the Faculty of Medicine of Paris in 1802. The instrument that he 
 recommends for the operation, is simply a flat catheter, slightly 
 curved, and pierced with two holes at its vesical extremity, so as to 
 give passage to a needle also curved. After the catheter has been 
 introduced into the bladder, “the needle is pushed along the vagina 
 through the posterior lip of the fistula, by means of a watch-spring, 
 contained in the hollow of the instrument. The needle, which has 
 thus traversed the vesico-vaginal septum, is immediately withdrawn 
 through the vulva, bringing along with it a thread, of which a suture 
 point is made, after having perforated the opposite lip of the wound ; 
 finally, when a number of threads sufficient to keep the edges of the 
 
 * Traite des Maladies Chirurg. et des Operat. etc., tom. iii. p. 87. 
 \ Medecine Operatoire, tom. iii. p. 648. 
 
250 
 
 THE SUTURE IN VAGINAL FISTULAS. 
 
 division in contact have been in this manner adjusted, they are knot- 
 ted and secured by means of a serre-noeud. 
 
 M. Nsegele, professor at Heidelberg, used the suture successfully 
 in 1812. For its application he proposes several methods, which 
 we shall describe, after explaining the mode he takes to freshen 
 the edges of the wound, and which he executes in the following 
 manner : After introducing a catheter into the bladder, which ought 
 to be held there firmly, he carries a pair of sharp-pointed scis- 
 sors into the vagina, by conducting them along the fore-finger, and 
 with them dissects the tissues so as to revive the edges of the fistula 
 which are supported by the catheter. If this cannot be completed 
 with the scissors, he terminates it by means of a bistoury with a con- 
 cealed blade, which is projected as soon as it comes in contact with 
 the parts on which it should act. When the edges of the fistula 
 have been sufficiently renewed, Professor Naeg&le proceeds to the 
 ligature, first, by means of a needle, like Deschamp’s needle, for the 
 ligature of the popliteal artery. This needle, mounted upon a ring 
 in which the fore-finger of the right hand engages, is carried on the 
 left index, which covers its point, until it reaches that part of the 
 edge of the fistula which we wish to puncture. Then the finger, 
 which now ceases to cover the point of the needle, supports the lip of 
 the wound during the puncture, which takes place first from the 
 vagina towards the bladder, and then from the bladder towards the 
 vagina for the opposite side. 
 
 As soon as the point of the needle appears, after traversing the 
 vesico-vaginal septum, the ligature, which is carried by an eye in the 
 needle, is disengaged, and the needle itself withdrawn by a retro- 
 grade movement, in order to arm it with a new thread, so as to 
 apply as many sutures as may be deemed necessary. Finally, the 
 operation is terminated by uniting the ends of all the ligatures, which 
 are twisted and their ends secured by nfeans of adhesive strips, after 
 which, with the view of supporting the anterior wall of the vagina, a 
 quantity of charpie is introduced into the cavity. 
 
 M. Nsegele proposes another method which consists in piercing 
 the edges of the fistula with curved needles, each held in a pair of 
 forceps; when the needles have perforated the vaginal septum, they 
 are left in situ, and after having withdrawn the forceps, are sur- 
 rounded by a waxed thread which approximates the edges of the 
 wound, in the manner of the twisted suture. 
 
 Finally, M. Nsegele has described a third method, which differs 
 so little from that of M. Lewzinski, that we deem it sufficient to state 
 that it is also executed by means of a curved catheter containing a 
 spring terminated by a spear-point, the eye of which carries a waxed 
 thread. The mechanism and application of the instrument are in 
 other respects the same as in the proceeding of M. Lewzinski. 
 
 M. Ehrmann, of Strasbourg, and also M. Deyber, have succeeded 
 in curing vagino-vesicai fistula, by means of the suture, applied 
 with a curved needle, that was carried into the vagina upon a port- 
 needle, ( porte-aiguille ,) similar to that which Professor Roux makes 
 use of for staphyloraphy. The ligatures were crossed in such a 
 
THE SUTURE IN VAGINAL FISTULAS. 
 
 251 
 
 way that the end of the first escaped by the right side, and the 
 other at the opposite side. The second ligature was placed in the 
 opposite direction, and then all the ends knotted on each side. 
 
 M. Schreger, who had brilliant success with the suture of Pelle- 
 tier, has practised it by means of a curved needle and forceps of a 
 peculiar kind ; when the ligatures had been put in situ, he passed 
 their extremities through a number of beads and then made a knot 
 on the last one. 
 
 M. Chranam has also used the suture with success, employing 
 the same method nearly as MM. Ehrmann and Deyber : at the end 
 of five days, the ligatures fell off’ without the knots having been un- 
 tied, and the cure was perfect. 
 
 Again, on the 28 th August, 1828 , M. Malagodi of Bologna, was 
 as fortunate as the gentleman we have just cited, in the application 
 of the suture for uniting the edges of a vesico-vaginal fistula : this 
 dexterous surgeon describes the operation himself in the following 
 words : 
 
 “ I introduced the index of the right hand, covered by a leather 
 finger-stall, into the fistulous opening ; I flexed the two last phalanges 
 into the shape of a hook, and, dragging the left callous edge of the 
 opening downwards, drew it as near to the orifice of the vagina as 
 possible : I then took a straight bistoury in my other hand, and cutting 
 upon my finger, made a semi-lunar incision in the edge which I had 
 caused to project. I repeated the same operation on the opposite side, 
 changing, of course, the hand ; that is to say, introducing the left, 
 and operating with the right hand. By freshening in this way the 
 edges of the wound, I had not yet attained the end which I sought 
 to establish, namely, union by the first intention. Three pieces of 
 ligature, having at each of their extremities a very small curved 
 needle, and a rod upon which the needles could be fixed and left at 
 will, were the instruments with which I had provided myself to 
 eflect this reunion. I introduced the right index finger into the fresh- 
 ened opening, so that the back of the hand was towards the body of 
 the patient, the thumb below and the little finger above, and then 
 drew into sight the left lip of the vagino-vesical orifice. Pushing 
 with the left hand, a needle fixed in its handle, I now engaged it 
 near the posterior angle of the wound, making it penetrate, with 
 the aid of the fingers, from behind forwards. After this first needle, 
 I passed a second in the same way, then a third, at equal distances; 
 so that having repeated the operation on the opposite side, I tied the 
 ligatures, two and two, and could then bring the edges of the wound, 
 throughout their whole length, which I had before made to corre- 
 spond by the two semilunar incisions, into immediate contact. 
 
 “ I placed the patient in bed, and cautioned her to lie upon her 
 back. I introduced a catheter into the bladder, through the urethra, 
 which was to remain there, to conduct the urine discharged by the 
 ureters, into a vessel placed below. This precaution seemed to me 
 indispensable, lest the retention of the urine might interfere to pre- 
 vent the immediate reunion which I sought to obtain. 
 
 “ During the second day, the urine passed through the catheter, and 
 
252 
 
 THE SUTURE IN VAGINAL FISTULAS. 
 
 not a drop by the wound. It was not so on the following day, when 
 I found the charpie which I had introduced into the vagina bathed 
 with urine ; on the fourth day I placed the patient in the position for 
 the operation. I saw that the two posterior points of suture had 
 maintained themselves; I removed them, and the reunion was found 
 to be quite perfect where the edges had remained in contact. The 
 anterior suture point, on the contrary, had lacerated the left lip of the 
 wound ; from which it happened that about one-third of the primary 
 opening had not cicatrized. . I did not despair, nevertheless, of ob- 
 taining a complete cure, even though cauterization with the nitrate 
 of silver had produced no advantage when the fistulous opening 
 allowed of the passage of the finger : I hoped that the same remedy 
 might be more efficacious now, when the opening had been reduced 
 to the diameter of an ordinary catheter. I had recourse, therefore, to 
 cauterization, and at the end of about three weeks, obtained a sen- 
 sible amelioration. The catheter was constantly kept in the bladder. 
 I continued the use of the caustic during some weeks, and the patient 
 was entirely cured towards the beginning of January.” 
 
 Though the suture be of very difficult application, and even while 
 its employment has not been crowned with success in the hands of 
 such skilful practitioners as MM. Roux, Dieffenbach, Duges, Ro- 
 bouham and some others, we yet believe that it is the best means we 
 can make use of in cases of transverse and oblique fistulas, the edges 
 of which cannot be properly approximated, and the cure obtained 
 either by cauterization, or by the methods of which we have yet to 
 speak of. 
 
 METHOD OF THE AUTHOR. 
 
 With a view to render the application of the suture incomparably 
 more easy, we have invented various instruments and methods, which 
 differ according to the direction of the vagino-vesical perforation. 
 
 When the diameter of the opening is large, and presents itself in a 
 longitudinal direction, that is to say, antero-posteriorly, we resort to 
 the continuous suture, (whip suture — furrier’s suture,) which is em- 
 ployed advantageously for the union of wounds of the intestines and 
 stomach, and proceed to its application in the following manner : 
 
 Having placed the woman in the position described in speaking of 
 cauterization, and exposed the fistula by means of a spend urn , with a 
 longitudinal fenestra, ( vid. Jigs . 25, 26, 27,) we seize one of the edges 
 with a pair of forceps, made movable, and so arranged that they can 
 act in every direction, whatever be the direction of the wound .— (See 
 
 Jig. 23.) The 
 edge, held in 
 the forceps, is 
 then remov- 
 ed by means 
 of a small 
 probe - point- 
 
 Fig. 23. 
 
 ed, double-edged blade, nine or ten lines in length; this blade, mounted 
 
thf suture in vaginal fistulas. 
 
 253 
 
 vertically and at right angles, upon an iron rod, four or five inches 
 long, and terminated by a handle, curved like that of the speculum, 
 may be turned so as to cut from before backwards, from right to left, 
 or obliquely, according to circumstances .— {See Jig. 24.) 
 
 Fig. 24. 
 
 We have also invented, for the purpose of freshening the edges 
 of the fistula, a pair of long forceps, whose blades, one cutting, 
 
254 
 
 THE SUTURE IN VAGINAL FISTULAS. 
 
 Fig. 28. and the other terminating by a small leaden 
 ... . . plate, intended to sustain the tissues during their 
 suture, are movable, like those of the other for- 
 ceps, and so arranged as to act in all directions. 
 — [See Jig. 28.) Moreover, whichever of these 
 instruments we may choose, we should take care 
 to enlarge the angles of the fistula half a line, or a 
 line, at most, with the small double-edged blade, so 
 that the renewal maybe quite perfect at these points 
 where the cicatrization always commences, and 
 also to give to the perforation as nearly as possible 
 the form of a button-hole, which is very favourable 
 to the reunion and agglutination of the parts. 
 
 After finishing this first step in the operation, 
 which is properly regarded as the most difficult, 
 and that upon which success in great measure 
 depends, we approximate the raw edges, by means 
 of a spiral needle like a cork-screw. This needle, 
 fixed upon an ivory handle, has, at its sharp extre- 
 mity, a small spear-head, three or four lines long ; 
 and at the opposite end, that is to say, at its point 
 of union with the real instrument, an eye armed 
 with a ligature, which is lodged in a groove, 
 formed in the external edge of each circumvolu- 
 tion, and there secured by a small screw, with a 
 projecting head . — ( See Jig. 29.) 
 
 Fi g 29 . We introduce the perfo- 
 
 rating instrument, thus 
 armed with its ligature, 
 into the cavity of the 
 speculum, to a point cor 
 
 responding with the inferior angle of the fistula, then, commencing 
 upon its vesical aspect, we perforate the left lip two lines from its 
 edge, and causing the handle of the needle to execute a movement of 
 demi-rotation with the fore-finger and thumb, and afterwards a slight 
 see-saw movement from above downwards, and from left to right, 
 pierce the opposite edge, which is traversed, therefore, in a con- 
 trary direction, that is to say, from the 
 vagina to the bladder. — [See Jig. 30.) 
 We continue the same process until 
 the lips of the perforation are com- 
 pletely approximated throughout their 
 whole extent ; then, with the blades of 
 the forceps, which have served to fix 
 the edges of the fistula during the operation, 
 we seize the spear-head, to render it immo- 
 vable, while we impart a slight rotary move- 
 ment to the rest of the needle from the oppo- 
 site side. To prevent the ligature from being 
 loosened, its two ends, brought out at the 
 
 we 
 
 Fig. 31. 
 
THE SUTURE IN VAGINAL FISTULAS. 
 
 255 
 
 vulva, are twisted together throughout their length, and then fastened 
 close to the suture by means of a small portion of sealing wax, 
 heated until softened . — (See jig. 3i.) When we suppose the union 
 to be perfect, we cut the threads, above the point where they are 
 fastened by the wax, and carefully withdraw them. 
 
 This method has the advantage of being more easily applied than 
 any of the others, and also of perfectly uniting the lips of longitudi- 
 nal fistulas, by means of the whip-suture, which is more regular and 
 equal even than when made in cloth, with a common needle. We 
 must, moreover, recall to the reader’s attention, that it was to the use 
 of the whip-suture that M. Schreger is indebted for the success we 
 have above related. 
 
 As our spiral needle is applicable only in cases of longitudinal 
 fistula, we have invented other needles for the treatment of trans- 
 verse and more or less oblique vagino-vesical perforations by suture. 
 
 The needles, two in number, are arranged as follows : a shank, 
 mounted upon a handle, bent at an obtuse angle, forms a kind of for- 
 ceps from its upper and third portion, and is then divided into two 
 blades, which are afterwards curved vertically at a right angle, and 
 which again, at the distance of eight or nine lines, are once more curved 
 for about a line, in order to sei^e by their approximation by means of 
 a sliding-ring, a little spear-point, of about three lines in length, the end 
 of which descends again parallel to the ascending shank . — ( See Jig. 32.) 
 
 Fig. 32. 
 
 This perforating extremity of the instrument has, at its other end, 
 an eye, into which a ligature is passed and lodged in a groove cut 
 in the length of the shank, and secured by means of a small screw- 
 head, placed near the handle . — ( See Jig. 33.) The only difference 
 between the two needles is that the spear- 
 F, §- 33 - point of the one which serves to pass the 
 
 ^ ligature through the posterior edge of the fis- 
 tula, descends again in front of the vertical 
 shank, while that which is designed to place 
 the ligature in the lip nearest the vulva is terminated by a little 
 spear-point, which is behind the same shank . — (See Jig. 34.) 
 
 After the edges of the fistula have been freshened, by means of 
 the instruments, and in the mode described above, we carry into the 
 cavity of the speculum and up to the fistula, the needle whose perfo- 
 rating extremity is beyond the vertical shank, (Jig. 33,) and after 
 introducing it into the bladder through the fistulous orifice, lower the 
 
256 
 
 THE SUTURE IN VAGINAL FISTULAS. 
 
 whole instrument until slight resistance is 
 felt from the perforation of the posterior lip, 
 which ought to be made about two or three 
 lines from its edge, not by strongly pressing 
 upon it, as this would endanger laceration, 
 but by gentle lateral movements. Then, 
 removing the slide which held the blades 
 together, and disengaging the ligature still 
 fixed to the instrument, we remove the lat- 
 ter from the speculum, and by means of the 
 forceps with movable blades, which served 
 to sustain the parts during their renewal and 
 perforation, seize the spear-point which pro- 
 jects into the vagina, and bring it towards 
 the vulva, in order to separate from it the ligature, one of whose 
 ends is withdrawn from the wound. 
 
 Having applied as many points of suture as necessary in the pos- 
 terior edge of the fistula, we place the same number with the other 
 needle, in the anterior lip, taking care that each suture be made with 
 the same thread ; that is to say, that the largest end of each thread, 
 placed in the posterior lip, shall serve for the opposite and corre- 
 sponding point of the anterior lip, and so as to the others. Finally, 
 when all the sutures have been inserted in both edges of the fistula, 
 we readily recognize the ends which correspond, and which should 
 be tied together, by means of the precaution we always take to place 
 a white thread for the first ligature, a red, or some other striking 
 colour, for the second, a black for the third, etc. This precaution, 
 which may seem puerile, or, at least, useless, to some persons, lessens 
 very considerably the time taken up in ascertaining the ends of the 
 several ligatures. This done, we tie the threads of the same colour 
 in a double knot, possible ; or, should this be too difficult, by a single 
 knot, which is prevented from being loosened by twisting the two 
 ends of the threads nearly up to the suture, and securing them 
 both with a little common wax, or sealing wax softened by heat. If 
 nothing interferes with the progress of the agglutination, it may be 
 completed on the fourth or fifth day ; but unless something occurs to 
 make it necessary, it is better not to examine the parts with the 
 speculum earlier than the eighth day, and even then it must be done 
 with the utmost care, and with a small speculum having a large open- 
 ing in the direction of its long diameter. In order still more to avoid 
 every kind of stretching, we should endeavour to explore the wound 
 with the rectum-speculum, or by merely separating the vaginal pari- 
 etes with the fingers. Should we be in too much haste to ascertain 
 the condition of the parts, the success of the operation might be com- 
 promised, as indeed has sometimes happened, particularly after the 
 use of the cautery; on the eighth day, the ligatures at the angles of 
 the wound may be removed, and two or three days later, the others. 
 Generally, three ligatures suffice for the largest fistulas; very rarely 
 more than four are applied ; long scissors, with very narrow blades, 
 and blunt points, serve to cut the threads, and to secure them, they 
 
 Fig. 34. 
 
VAGINAL FISTULAS. 
 
 257 
 
 are to be seized with a pair of forceps, which may usually be done 
 with great facility. 
 
 The method we have just described for the relief of transverse and 
 oblique fistulas, in which cauterization would have failed, is equally 
 applicable to longitudinal fistulas, provided, to unite their edges, we 
 employ the interrupted, in preference to the whip suture by means 
 of our spiral needle. 
 
 We think we may affirm that the instruments and modifications 
 proposed by us have the advantage of rendering the renewal and 
 reunion of the edges of all vagino-vesical fistulas, easier, quicker, and 
 always practicable? be their form, extent and situation what it may. 
 Indeed ; 
 
 1. The renewal of the edges of transverse and oblique fistulas, 
 which is the most tedious and difficult part of the operation, is easily 
 and rapidly accomplished, either by means of our double-edged knife 
 with vertical blade, which takes any desirable direction, or with our 
 cutting forceps, whose movable blades are so arranged as to cut 
 either from behind forwards, from before backwards, from right to 
 left, or obliquely. 
 
 2. The union of the edges is effected with equal facility, in longi- 
 tudinal fistula, by our spiral needle, and with our two needles with 
 curved shanks and handles, terminated by a small spear-point, which 
 may be placed in the edges of any vaginal fistula, whatever be its 
 direction. 
 
 3. Our forceps, designed to sustain the edges of the wound during 
 their removal by the cutting instrument, and perforation by the nee- 
 dles, are applicable in every direction, and are especially adapted for 
 seizing the anterior lip of transverse and oblique fistulas, which it is 
 impossible to do with any other forceps. We may add, that our 
 bent and movable cautery and our caustic holder, of the same shape, 
 render the cauterization by which we should always commence the 
 treatment of vaginal fistulas communicating with the bladder or 
 rectum, both easier and more commodious. 
 
 OF THE APPROXIMATION OF THE EDGES OF VAGINO-VESICAL FIS- 
 
 TULAS BY MEANS OF PECULIAR INSTRUMENTS, WITHOUT THE 
 
 USE OF THE SUTURE. 
 
 In 1826, Professor Lallemand, wishing to combine immediate 
 union of the wound with previous cauterization of its edges, resorted 
 to the following method : 
 
 In the first place, he cauterized with lunar caustic fixed in a 
 ring carried upon the index finger until the lips of the fistula were 
 moderately inflamed; he then introduced into the bladder through the 
 urethra, a silver catheter, called a hooked catheter, ( sonde airigne ,) 
 the object of which is to procure a constant flow of urine, and which 
 contains in its cavity curved hooks moved by a screw also placed in 
 the interior of the instrument, in such a way as to project through the 
 eyes of the instrument at will, and to become attached to the poste- 
 rior lip of the fistula about six lines beyond its edge. A finger car- 
 17 
 
258 
 
 VAGINAL FISTULAS. 
 
 ried into the vagina, sustains the anterior paries of that canal, pre- 
 vents its yielding, and facilitates the insertion of the hooks. When 
 these have firmly seized the vesico-vaginal septum, a silver plate, 
 which has been until then retained in the anterior extremity of the 
 instrument, is pushed towards the beak of the catheter by a spring 
 with a button-end, and left to itself. A thick layer of eharpie, 
 placed in front of the urinary meatus, receives the pressure of the 
 plate which forces the canal of the urethra and the anterior edge of 
 the fistula backwards, whilst the posterior lip is drawn forwards 
 by the hooks of which we have spoken. The learned and ingenious 
 author of this method and apparatus has published a case of chronic 
 vesico-vaginal fistula cured by its application ; nut it would seem 
 from Professor Velpeau* that the success was not permanent, and 
 that in that patient, as well as several others treated in the same way, 
 the infirmity returned just as before the operation. We cannot 
 moreover determine any thing from the satisfactory results which 
 were at first obtained ; for as the operation had been commenced and 
 terminated by cauterization, it might very well be that the first suc- 
 cesses were owing to this means which already numbers a good many 
 examples of complete cure. We add, moreover, that other attempts, 
 made with the apparatus of M. Lallemand, as well as that we wit- 
 nessed in 1829, at the hospital of Beaujon, did not yield the good 
 results at first looked for. 
 
 The illustrious Dupuytren successfully used an instrument, con- 
 sisting of a large female catheter, which has upon its sides two leaves, 
 opening like wings or shutting up closely, according as we withdraw or 
 push forwards a central movable stilet, intended to move them. After 
 the closed instrument has been passed into the bladder, we open and 
 fix the movable leaves by means of the central stilet, and then draw 
 it towards us as though we designed to remove it while arranged in 
 this manner. The leaves remaining separated, prevent the catheter 
 from engaging in the urethra, but they drag forwards the posterior 
 lip of the fistula, at the same time that the urethra and anterior lip 
 are forced backwards by means of a tampon of eharpie or linen, 
 placed between the urinary meatus and the external portion of the 
 instrument. This process, which possesses the advantage of perforat- 
 ing neither the vagina nor the bladder, seems to us to be incapable of 
 effecting the complete approximation of the edges, and it is probable 
 that the successes which have followed its employment are due to the 
 cauterization, to which it may become,. however, an useful accessory. 
 
 M. Laugier invented a hooked forceps, intended to approximate 
 the edges of fistulas, which, unlike M. Lallemand’s, acts from the 
 vagina towards the bladder, by changing the direction of its hooks, 
 according as the perforation is transverse or longitudinal. In the 
 former case, the hook-forceps presents two parallel blades which 
 glide upon each other, or separate at will, and are terminated at 
 their holding extremities by a double hook intended to be fastened 
 in the anterior and posterior edges of the fistula. After the parts are 
 seized, a simple contrivance brings the hooks together so as to ap- 
 
 Medecine Operatoire, t. iii. p. 654. 
 
VAGINAL FISTULAS. 
 
 259 
 
 proximate the edges. In longitudinal fistulas, it is necessary that the 
 hooks on each claw should be parallel to the axis of the body, and 
 the extremity that supports them, bent upon the edge : lastly, the 
 forceps should have the blades more or less curved, where the fis- 
 tula is oblique. When the coaptation is effected, the whole is main- 
 tained in place by means of charpie, placed in the anterior part of 
 the vagina. The method of M. Laugier, which we have been told 
 was lately employed unsuccessfully by himself, has inconveniences 
 like the others, which have been pointed out by M. Velpeau, 
 and which we refrain from mentioning here, lest we should extend 
 our remarks too far. It is for the same reason, that we avoid de- 
 scribing the method and instruments proposed by Doctor Dufresne 
 Chassagne, in a thesis defended by him before the faculty of medi- 
 cine of Paris, on the 30th January, 1834, and which may be con- 
 sulted with advantage. 
 
 It now remains for us to speak of the instruments invented by M. 
 Recamier, which were exhibited to us by that celebrated and dexte- 
 rous practitioner. One of them, intended for reviving the edges of 
 the fistula, has two stenjs which slide upon each other. The larger 
 of these stems, hollow in its whole length, is terminated at its vesi- 
 cal extremity by a small square plate, and is bent above at a 
 right angle, so as to rest against one of the lips of the vagino- 
 vesical perforation, and revive it by an incision made with a small 
 cutting blade placed at the end of the solid stem, sliding in the 
 first. Another instrument, differing slightly from this, is employed 
 for the renewal of the other edge. When this first step of the ope- 
 ration is finished, a kind of small steel forceps, terminated by several 
 claws of silver, is intended to unite the edges of the fistula, by the 
 approximation of the two blades of the instrument. Though these 
 different methods proposed by M. Recamier are very ingenious, we 
 think that, having been made for a particular case of longitudinal 
 fivStula, they would require several modifications to become appli- 
 cable in cases of oblique and transverse perforations. 
 
 We shall conclude our remarks on the treatment of 
 vagino-vesical fistula by saying, that the hooks which Fig. 35. 
 are applied with difficulty in longitudinal fistulas, might 
 be substituted by a spiral needle like that we have 
 already spoken of, with this difference, however, that 
 it should have no groove, and must be made according 
 to the size of the perforation, so that when once applied, 
 it may remain untouched and preserve the edges of the 
 wound united much better than any of the catheters or 
 hook-forceps. The spear-point which terminates the 
 •needle, should be removed when it is fixed in the va- 
 gino-vesical septum ; and when the operator supposes 
 the consolidation to be complete, he readjusts the handle 
 which had also been withdrawn and had served to fix 
 the instrument ; he then disengages the needle properly 
 so called, by unscrewing it, and by following a direction 
 the reverse of that which he had used for its appli- 
 cation to the edges of the fistula. 
 
260 
 
 VAGINAL FISTULAS. 
 
 Whatever be the method used in the treatment of these cases, 
 a catheter must be kept in the bladder, and abdominal compression, 
 suitable position, and, in fine, whatever can serve to favour the 
 coaptation of the parts, and the escape of the urine through the 
 canal of the urethra, must also be attended to. 
 
 We have still to refer to a method which M. J. Jobert de Lam- 
 balle appears to have used successfully, videl. the closure of a shal- 
 low fistula in the vagina by means of a flap taken from the inner 
 surface of one of the labia externa by careful dissection, then car- 
 ried from before backwards and maintained upon the anormal per- 
 foration, with suture points. 
 
 Seeing that almost all the surgical means for the 
 Fig. 36. treatment of vagino-vesical fistula failed, one of the most 
 distinguished of our young practitioners, M. Vidal de 
 Cassis, conceived the idea of obliterating the vagina, so 
 as to make it an appendage to the bladder, and a sort 
 of bas-fond for this organ. This method, which was 
 employed by its author, on the 5th July, 1834, at the 
 venereal hospital, upon a female whose vagino-vesical 
 septum was largely perforated, with great loss of sub- 
 stance, is executed by means of two strong straight 
 
 ! |j needles mounted upon small ebony handles, whose per- 
 il forating end arranged in the form of a spear-point, has an 
 1 eye in the centre large enough to receive a double liga- 
 II ture. After having freshened the whole circumference of 
 11 the vaginal orifice, one of the needles is inserted a little 
 
 |j within the right nympha three lines from the bleeding 
 
 ® surface, and as soon as the spear-point projects into the 
 vagina, the loop of the double ligature is seized with a 
 pair of dissecting forceps which should be held by an aid, while the 
 needle is withdrawn by the same route that it was introduced. 
 Then the other needle is inserted in the same way as the first, but 
 upon the opposite side, and a little within the left nympha, after which 
 the ligature, having been seized as the first was, the instrument is 
 withdrawn, deprived of its ligature as upon the right side. 
 
 After the needles have been removed, the two loops of thread re- 
 main at the orifice of the vagina; the left loop should, be passed 
 through the right, so that by drawing down the two threads forming 
 the latter, we shall bring along with them the threads which form 
 the other one. It follows from this that the double ligattire of the 
 right feide is drawn completely away, whilst the double thread of the 
 left side follows the route which the two needles pursued, in order 
 that it alone may effect the reunion of the two edges of the wound. 
 If we wish to employ the quill suture, it is only necessary to sepa- 
 rate the two threads and interpose between them a piece of catheter 
 or the end of a quill ; if the simple suture should be preferred, we 
 have merely to cross the threads and tie them. 
 
 The vaginal obliteration attempted by M. Vidal, in the mode just 
 described, was not followed by entire success. The union of the 
 
RECTO-VAGINAL FISTULAS. 
 
 261 
 
 parts became quite established, cicatrization was rapidly advancing, 
 the urine escaped wholly by the catheter introduced into the bladder, 
 and every thing promised success, when the resident physician at- 
 tached to M. Vidal’s wards, broke open the nearly complete cica- 
 trix, because the patient complained of pain above the vaginal 
 obturation. It is unfortunate that this attempt, as novel as it was 
 ingenious, was not followed by the result which every thing at first 
 gave reason to hope for. 
 
 We fear that the closure of the vagina, proposed by M. Vidal, 
 though its object be to remedy a disgusting infirmity, which is gene- 
 rally beyond the resources of our art, can rarely be employed, because, 
 even supposing that no objection could be made to it on account of 
 the injurious action which the urine would probably exert on the 
 walls of the vagina, it would still have the inconvenience of pre- 
 venting the flow of the menses which could take place only through 
 the urinary meatus, and besides, it would be a positive obstacle to a 
 sexual intercourse. If the method were essayed only upon women 
 of advanced age, most of these objections would no longer hold, 
 and the chances of success would be much greater. However, the 
 suture applied in the mode just described is extremely simple and 
 easy ; we regard it as highly advantageous for the reunion of very 
 thick tissues presenting broad surfaces, as happens in suture of 
 the perineum, which has been successfully performed twice by M. 
 Vidal. 
 
 OF RECTO-VAGINAL FISTULAS. 
 
 By recto-vaginal fistulas, are meant perforations that open a com- 
 munication through the posterior wall of the vagina, and the anterior 
 wall of the rectum. 
 
 These fistulas, which are generally longitudinal, are mostly the 
 result of lacerations produced during labour, either by the head of 
 the child or by the blades of the forceps. They may also be caused 
 by cancerous or syphilitic ulcerations of the recto-vaginal septum ; 
 by the presence of a lipoma or any other tumour which has become 
 inflamed and produced an abscess communicating with the rectum ; 
 finally, they may be produced by angular bodies introduced acci- 
 dentally into the rectum or vagina, and especially by the action of 
 pessaries on the posterior wall of that canal. 
 
 Several authentic cases go to prove that communications be- 
 tween the vagina and the rectum may be congenital; Barbaut* 
 and Professor Orfila,t cite examples of the kind. The celebrated 
 Dupuytrenf refers to a case observed by M. Lepine, who saw a 
 little girl six days old, in whom the vagina gave issue to portions 
 of meconium ; the child exhibited all the symptoms produced by 
 retention of foecal matter, and the recto-vaginal fistula had begun to 
 be formed but a short time before, as there was no sulcus between 
 the thighs. 
 
 * Cours d’accouchement, p. 59. t Medecine legale, tom. i. p. 150. 
 
 % Dicdonnaire de Medecine et de Chirurg. prat. t. iii. p. 121. 
 
262 
 
 RE CTO- VAGINAL FISTULAS. 
 
 A surgeon attempted to discover the anus, and made an incision 
 through the integument of the perineum, between the point of the 
 coccyx and the posterior commissure of the vulva. This incision dis- 
 closed a fluctuating tumour, formed of intestine, which was seen be- 
 tween the edges of the wound. An opening made in the lower part 
 of the tumour gave issue to a large quantity of gas and meconium ; 
 the recto -vaginal fistula closed entirely, and the child perished three 
 years after of a disease which had no connection with its congenital 
 defect. 
 
 Dr. Ricord,* surgeon to the venereal hospital, reports the case of 
 a woman twenty-two years of age, large, strong, and in good 
 health, who is without an anus, and in whom the stercoraceous mat- 
 ter is voluntarily expelled through a recto-vaginal opening or rather 
 passage. 
 
 It is probable, says M. Guerbois,t who also mentions these cases, 
 that in this woman the recto-vaginal opening is provided with sphinc- 
 ters to prevent the involuntary escape of the stercoraceous matter, 
 which would prove that nature, even in her deviations, always tends 
 to diminish the sufferings and accidents to which the human spe- 
 cies is exposed. 
 
 Perforations of the recto-vaginal septum, with loss of substance, 
 give issue to the fluid portions of the faecal matter, and intestinal gases, 
 which latter escaping involuntarily through the fistula, pass out by 
 the vulva, whilst the solid portions are expelled in part through the 
 vagina, and in part through the anus, but only during defecation. 
 
 Recto-vaginal tend more to spontaneous cure than vesico-vaginal 
 fistulas, and for this reason it is that they have attracted the atten- 
 tion of the profession even less than the latter. When recent, they 
 not unfrequently close of themselves, especially when aided by ab- 
 solute rest, by position upon the side, emollient lotions, mucilagi- 
 nous and anodyne enemata, severe regimen, and attention to clean- 
 liness. F. Ruysch,± who died in 1731, has recorded a case of 
 spontaneous cure of a large recto-vaginal fistula. Sedillot and M. 
 Philippe de Mortagne§ have published some nearly similar cases ; 
 Professor Velpeau also mentions a young woman in his wards, at La 
 Pitie, who in a single fortnight was cured by injections of red wine, 
 of a recto-vaginal fistula which had lasted eight months ; finally, 
 M. Deschamps,|| at that time resident physician at the hospital Co- 
 chin , cites an example of this kind met with in a female sixty- 
 eight years of age, who died at the hospital La Salpetriere, in 1833. 
 Unfortunately, as M. Velpeau says, the organism does not always 
 respond to the wishes of the physician, and perforations of the 
 vesico-vaginal septum persist in spite of the best-directed medical 
 treatment : we are then compelled to resort to the employment 
 of the means already proposed for vesico-vaginal fistula ; for exam- 
 
 * Journal hebdom. de M6d. t. xiii 
 
 | These de concours pour une chaire de clinique Chirurg., p. 20, 1834. 
 
 i 59th case. 
 
 § Velpeau Medecine operatoire, tom. iii. p. 663. 
 
 11 Guerbois, These de concours, Juillet, 1834, p. 20. 
 
RECTO-VAGINAL FISTULAS. 
 
 26 3 
 
 pie, to cauterization, to the suture, or the approximation of the edges 
 by means of various instruments. 
 
 When the fistula is small, cauterization, with the nitrate of silver, 
 in the manner we described while treating of vesico-vaginal fis- 
 tulas, ought generally to be made use of first ; if large, on the con- 
 trary, this method, which would offer scarcely any chance of suc- 
 cess, especially if employed alone, should be rejected j and it then 
 becomes necessary to resort to the employment of the suture, chiefly 
 the whip suture, made with the spiral needle described while speak- 
 ing of antero-posterior fistulas of the vagino-vesical septum. Before 
 attempting the operation the patient should be prepared for it several 
 days beforehand, by the use of gentle laxatives, and particularly by 
 frequent suppositories of beurre de cacao, in order to keep the 
 bowels soluble and diminish the contraction of the sphincter ani, 
 which often necessitates efforts for the expulsion of the faecal matter 
 capable of tearing the suture. 
 
 In a case of very narrow, recto-vaginal fistula, the elder Cullerier, on 
 one occasion, successfully employed compression by means of a couple 
 of plates, one of which was introduced into the anus, and the other 
 into the vulva; we ought to mention that this method has been used 
 several times by the younger Cullerier, and that that able practitioner 
 was obliged to renounce it, on account of the numerous accidents 
 which it occasioned. Finally, \ve must speak of a method which 
 consists in treating fistulas that open into the vagina very near the 
 vulva by incision, as though they were cases of fistula-in-ano. This 
 method, recommended by M. Velpeau, has been several times used 
 with success by that practitioner, and once by us in the month of 
 May, 1835, in the case of a female twenty-nine years of age, a wine- 
 dealer in the rue du Cherche Midi. 
 
 We shall conclude with the remark, that double fistula, which is most 
 frequently caused by the presence of a pessary in the vagina, seldom 
 requires any thing more than attention to cleanliness. We ought rarely 
 to resort to operations in such cases, which should be performed, 
 moreover, if at all, one after the other ; that is to say, we should not 
 seek to close the recto-vaginal fistula, until that of the vesico-vaginal 
 septum is entirely cured. We may add, that in cases where there is 
 some reason to suppose the affection to depend upon venereal dis- 
 ease, we should make use of a specific treatment, both general and 
 local, as we should likewise confine ourselves to a palliative treat- 
 ment where the perforation has been produced by cancer of the neck 
 of the womb. 
 
 [A most ingenious and' successful treatment of recto-vaginal fistula is that 
 invented and practised by that able and well-known surgeon, Dr. J. Rhea 
 Barton, of this city, who gave an account of it in the American Journal of 
 the Medical Sciences, under date, Philadelphia , June , 1840. This most 
 interesting case is republished here from the original, in Hays’ Journal, (loc. 
 cit.) and is republished, both on account of the intrinsic interest of the case, 
 and for the purpose of extending still further the correction of an act of edi- 
 
264 
 
 RECTO-VAGINAL FISTULAS. 
 
 torial injustice in relation to it. The case may be found in Dr. Hays’ Jour- 
 nal, for August, 1840, at p. 305. It is the second article of that number, 
 and is headed 
 
 A RECTO-VAGINAL FISTULA, CURED BY J. RHEA BARTON, M. D. 
 
 Miss R — , of Virginia, an unmarried lady, aged twenty-two, most respect- 
 ably connected in Philadelphia, shortly after her return from a visit to this 
 city, in June, 1835, experienced all the symptoms of an acute abscess in 
 the region of the rectum and vagina. It formed, and broke on one side, 
 and was lanced on the other. After a copious discharge of its contents, one 
 of the openings healed, whilst the other became fistulous, and remained so 
 most obstinately for the period of about four years ; resisting both general 
 and local treatment, including injections, tents, setons, caustic, incisions and 
 excisions. She came to Philadelphia for further treatment, and in March, 
 1839, was placed under my care. 
 
 “ The fistula was found commencing about three-fourths of an inch 
 within the labium of the right side, thence passing by a very irregular 
 course, up the pelvis, and inclining towards the rectum, into which cavity it 
 finally opened, about three and a half or four inches from its inferior aperture 
 in the vagina. Through this sinus there issued fluids insufficient quantity to 
 keep the genitals continually moist. Flatus, also, at times, found its way 
 through this channel. 
 
 “ The discovery of the real nature, and the extent of this sinus, passing 
 as it did from one to another important cavity, and establishing a communi- 
 cation between them, presented an embarrassing view of the case, as to the 
 mode of cure. It was now clear that the case must be treated with refer- 
 ence to its connection with the rectum, and upon the same principles that 
 govern us in the cure of fistula-in-ano ; for, in fact, it was virtually such a 
 case modified by the unfortunate implication of the vagina. 
 
 “ It was nevertheless apparent that this sinus could not be included in a 
 seton and ulcerated through, nor be laid open, as is usually done in the 
 common fistula-in-ano, without destroying the perineum, and laying these 
 two great cavities into one ! thereby causing a more unhappy state of the 
 parts than had previously existed. The duty, therefore, of the surgeon was 
 very clear, either to consign the patient to a continuation of her loathsome 
 complaint, or to adapt an operation to her peculiar case. The latter was 
 successfully done, as follows. 
 
 “ A fine tent was inserted, for a few days, to dilate the sinus, and to render 
 its course less tortuous. A seton was then introduced, with an eyed probe, 
 into the sinus per vaginam, and passed through its whole extent until it had 
 penetrated the rectum, by the orifice into that cavity. It was then brought 
 down and out per anum. The two ends were then loosely tied together, 
 merely for security against its slipping out. After a few days the loop was 
 opened, and the end of the seton passing out of the vagina was put through 
 
RECTO-VAGINAL FISTULAS, 
 
 265 
 
 the eye of a probe, which was previously crooked at the other end. This 
 probe was then inserted into the orifice of the vagina ; thence about an inch 
 and a half up the sinus ; then its point was directed toward the perineum, just 
 exterior to the sphincter ani muscle. Here a small but somewhat deep inci- 
 sion was made, and the probe pushed through it, bringing along with it the 
 end of the seton which had been doubled upon itself. Theseton now, instead 
 of passing out of the vagina, as at first, after coming down from the bowel 
 through only part of the sinus, descended through the new channel I had 
 made for it. The ends lying almost side by side, were now tied together, 
 thus forming a loop, in which were included the parts between the outer 
 surface of the sphincter ani muscle and the rectum. This seton or ligature 
 was subsequently drawn or twisted tighter and tighter from time to time, in 
 order to cause its ulceration through the included parts, as we do in com- 
 mon fistula-in-ano, when operating by the ligature or wire. So soon as by 
 these means, the new and direct channel was formed, and had attained a 
 larger size than that penetrating the vagina, the discharges from the rectum 
 deserted that portion of the route which led into the vagina, and took the 
 course of the seton. This was exactly the end I designed to accomplish by 
 my operation ; believing that, if I could establish a freer and more direct 
 passage for the escape of the fluids of the rectum than that per vaginam , the 
 sinus opening into this cavity would heal sua sponte , and become perma- 
 nently obliterated. My opinions were confirmed, for long before the seton 
 had made its way out by ulceration, the vaginal portion of the sinus had 
 healed, and the integrity of this organ had been restored. I had now only 
 to pursue the treatment of this case as I should have done, had it been a 
 simple case of fistula-in-ano — namely, by continuing to tighten the ligature 
 every day or two, until it finally came so near away, that a slight clip by the 
 scissors divided the insignificant intervening portion yet retaining it when it 
 was released. These parts healed up in a few days. 
 
 “ I had now the satisfaction of finding that my treatment of the patient 
 was completely successful. She was entirely cured, and without disfigure- 
 ment of a recto-vaginal fistula, existing at an interesting period of her life, 
 and under circumstances and embarrassments rarely to be met with in the 
 same case. 
 
 “It is now nearly one year since my patient was discharged cured, and 
 recent accounts from her announce her to be in perfect health. 
 
 “ Philadelphia , June, 1840.” 
 
 The lady was in Philadelphia within a short time past, (August, 1844,) 
 and continues to be perfectly free from her complaint, now full four years 
 since the operation. 
 
 Nothing could be more ingenious in the devising, nor successful in the 
 application, than this new triumph of the skill of the surgeon, and it is just 
 that, whatever praise ought to be meted out to those who make great im- 
 provements in important affairs, should be duly paid. There is reason to 
 
266 
 
 RECTO-VAGINAL FISTULAS. 
 
 believe that full justice is not done to Dr. Barton for this operation, in con- 
 sequence of some mistake of the Gazette Medicate of Paris, in the number 
 for Saturday, May 1, 1841. In that number, p. 283, is stated, an Obser- 
 vation de Fistule recto-perineale ; (Yaginale) eommuniquee par M. le Docteur 
 Valentine Mott. 
 
 M. Guerin, the editor of the Gazette , gives a translation of Dr. Barton’s 
 account of his beautiful process, as that of Miss R — , of Virginia, aged 
 twenty-two, &c., but he adds, that shortly after a journey from Philadelphia 
 to New York, she experienced the symptoms of an abscess, &c. &c., after 
 which the case is given in full, as we have just copied it. The unfortunate 
 mistake consists in adding the word New York to the translation. No such 
 word was to be found in Dr. Barton’s statement, and they do him the addi- 
 tional injustice of wholly leaving out his name at the head of the article, and 
 indeed no allusion is made to him throughout the entire French publication 
 of his paper, nor the least regard paid to his date, of “ Philadelphia, June, 
 1840,” at the foot of his statement. By the appearance of Dr. Mott’s name 
 as the communicator, and the introduction of the word New York in the 
 translation, the learned world suppose Dr. Mott to be the operator and 
 inventor of the operation, and he was accordingly complimented for it by 
 the Provincial Medical Journal, the London Medical Gazette, and others, as 
 its author. This was the result of some want of care or precision in the 
 translation of the paper of Dr. Barton, who gave it to Dr. Mott, whilst in 
 Paris, in 1841, that sur'geon being desirous to cause its publication in 
 ^ Paris Journal. Dr. Mott’s note to Dr. Guerin, accompanying Dr. Barton’s 
 paper, and complimenting him (Dr. B.) for his operation, shows that the 
 mistake was not chargeable to Dr. M., but it is presumable that Dr. Guerin’s 
 Journal, having given accidentally the meed to the New York surgeon, our 
 townsman must submit to a temporory stasis in some parts of Europe at 
 least, of the reputation which his other great operations have acquired for 
 him, and which would have been as greatly increased as this success de- 
 served that it should be, had it not been for this unfortunate mistake. The 
 readers of M. Colombat’s article on recto-vaginal fistula at least will learn 
 the value and the author of the operation. — M.] 
 
 OF FOREIGN BODIES ACCIDENTALLY INTRODUCED INTO THE VAGINA, 
 THE UTERUS AND THE CANAL OF THE URETHRA. 
 
 Of all the cavities lined by mucous membrane, the vagina is the 
 one in which we most frequently meet with foreign bodies, which 
 have been introduced either with a therapeutical view, with criminal 
 intentions, or to satisfy a childish curiosity. 
 
 Notwithstanding its size and direction, the vulvo-uterine canal 
 readily retains bodies which have passed its orifice, because of the 
 great number of its transverse folds which are found, especially at the 
 inferior portion of its cavity. 
 
 The presence of a foreign body in the vagina, gives rise to inilam- 
 
FOREIGN BODIES IN THE VAGINA. 
 
 26 7 
 
 mation more or less violent according to its nature, and at the same 
 time occasions a number of symptoms, such as severe pain, ulcer- 
 ation, ichorous and very fetid discharges, perforations, dysuria, hectic 
 fever, and various other disorders, which we enumerated while treat- 
 ing of pessaries, and which we shall not here recapitulate. — (See p. 
 249 et seq.) 
 
 In addition to pessaries forgotten in the vaginal cavity, examples 
 of other bodies are cited, whose detention, even for a short time, 
 have produced very serious disorders. 
 
 The celebrated Dupuytren* was called to a woman who, with 
 intentions she cared not to confess, had introduced into her vagina a 
 small Delft pomatum-pot; as the introduction of the little vase, 
 which was of conoidal form, had been made by the base, and as 
 its presence in the vagina had occasioned swelling and tumefaction 
 of the mucous membrane situated below it, it was difficult to as- 
 certain the nature of the foreign body, and its extraction could 
 only be accomplished after it had been broken by means of strong 
 pincers. The same professor also states, in his Legons Orales , that 
 he once had occasion to extract from the vagina a great number 
 of needles which had fallen within that cavity from a large needle- 
 case, that had opened after its introduction. Although the records of 
 science contain other observations of the same kind, we shall rest 
 content with quoting one which is very recent, and which is reported 
 in a thesis by Dr Grenier, t 
 
 In the year 1832, an unfortunate idiot female, living in the hospital 
 de la Vieillesse , in the women’s department, passed into her vagina 
 a needle-case, which opened and allowed the needles that it contained 
 to escape. When M. Grenier saw the patient, she was suffering the 
 most violent pain, her face expressed the greatest anxiety ; the skin 
 was burning hot, and she experienced constant desire to urinate, with 
 impossibility of satisfying it. After the needles had been removed, 
 she was placed in a warm bath for some time, an anodyne potion 
 was administered, and the symptoms soon disappeared. 
 
 The operative methods to be employed for the extraction of foreign 
 bodies in the vagina, should vary according to their nature and 
 situation. The surgeon should always begin by exploring the va- 
 gina, after having placed the patient on a bed, in the position indi- 
 cated for the application of the speculum. When the nature, form 
 and situation of the foreign body or bodies have been exactly ascer- 
 tained, the operator must disengage and take them away, either with 
 his fingers, with pincers, a scoop, a blunt hook, and sometimes even 
 with a terebra. The speculum, with movable blades, may, in some 
 cases, be useful to dilate the external orifice of the vagina, and in 
 this way, assist the escape of pricking or irregular bodies, by pro- 
 tecting the tumefied and irritated parts through which they must 
 pass in order to escape. If the foreign body cannot be extracted 
 entire, as often happens in the case of pessaries forgotten in the 
 vagina, it becomes necessary to break or divide it while in that 
 cavity, by means of strong pincers or long cutting forceps. 
 
 * Lecons Orales, 1827. f Dissert, sur les corps Strangers, Paris, 1834. 
 
268 
 
 FOREIGN BODIES IN THE WOMB. 
 
 After these operations, which are often very difficult, and always 
 painful, it is proper to prescribe demulcent and narcotic injections, 
 conjointly with some sedative potion at first, and then with a view 
 to prevent and combat inflammatory symptoms, we must resort to 
 strict diet, to emollient enemata and fomentations, and, finally, to the 
 application of leeches to the hypogastric region, and even to general 
 bleeding, if the violence of the inflammation should require it. 
 
 It is very rare for foreign bodies to be introduced into the uterus 
 through its vaginal orifice or its parietes, except during pregnancy, 
 because in the state of vacuity, it is so small, and has so small a 
 cavity, that it is almost impossible for this kind of lesion to take place. 
 M. Crouzit, of Rochechouart, has published a very interesting case 
 of a female who, with criminal intentions, had introduced a seton- 
 needle through her vagina and os tineas, which escaped, and was 
 lost in the uterine cavity, whence it did not pass out until after the 
 lapse of seventy-nine days, and then through one of the groins. 
 The same practitioner adds that the presence of the needle in the 
 womb, and the perforations which took place during its escape ex- 
 ternally, gave rise to serious disorders and to a metro-peritonitis, 
 which brought the patient to the very gates of death. 
 
 The accidental introduction of foreign bodies into the canal of the 
 female urethra is extremely rare. Nevertheless, the annals of the 
 science possess some examples of the kind, since hair-pins and 
 other analogous bodies introduced to satisfy a childish curiosity, or 
 during an attack of erotomania, have been removed, either through 
 the urinary meatus, or by means of an incision made into the blad- 
 der, for, when caught in this organ, they could not be removed 
 through the canal by which they had been introduced. 
 
 To extract foreign bodies and even calculi engaged in the meatus 
 urinarius, the woman should be placed as we have described above; 
 then having prepared the canal of the urethra with some oily injec- 
 tion, we may employ the ring forceps, or, still better, what is called 
 Hunter’s forceps. When the operation is terminated, we should 
 prescribe protracted warm bathing, narcotics and antispasmodics 
 internally, and, finally, local capillary blood-letting. 
 
 FOURTH SECTION. 
 
 CHAPTER VIII. 
 
 VITAL AND ORGANIC LESIONS. 
 
 We include amongst the vital and organic lesions all superficial 
 and deep-seated inflammations, degenerations, excrescences, transfor- 
 mations, and, in fine, all morbid productions of the vulva, vagina, 
 uterus, Fallopian tubes, ovaries and mammae. 
 
PRURIGO OF THE VULVA. 
 
 269 
 
 SUPERFICIAL INFLAMMATION OF THE VULVA. 
 
 The external parts of generation in the female are liable to dif- 
 ferent superficial inflammations, which vary in degree, according to 
 the causes which have produced and which maintain them. In 
 female infants at the breast, the contact of the urine and foecal mat- 
 ters, often gives rise to erythema and painful excoriations of the mu- 
 cous and cutaneous surfaces of the Jabia majora, which may, in 
 some cases, if neglected, become the origin of severe, gangrenous, 
 and fatal erysipelas. Such unfortunate results may easily be avoided, 
 by due attention to cleanliness, and we may cure the superficial in- 
 flammations of the vulva by the use of baths and emollient fomenta- 
 tions, and by the application of pledgets of linen covered with cerate, 
 or imbibed with oil beaten in pure water or lime water. The 
 powder of lycopodium and of starch, or of worm-eaten wood is 
 likewise useful when the parts are too much relaxed, or are the seat 
 of a sero-mucous discharge. 
 
 The neglect of cleanliness may also produce troublesome conse- 
 quences in girls of more advanced age; for their external genital 
 parts are often the seat of a very acute inflammation, caused by 
 sebaceous white and concrete matters, which have been allowed to 
 collect and become rancid around the clitoris nymphse and in the 
 folds of the vulva, where they are secreted. From these kinds of 
 irritation, smarting pains, and often intolerable itching, arise, which 
 excite to repeated handling, and even to an irresistible propensity 
 to masturbation. This unfortunate habit also arises from the pru- 
 ritus aroused by vermicular ascarides which have passed from the 
 rectum into the folds of the vulvo-vaginal mucous membrane. To 
 remove this cause of irritation, it is sufficient to keep the parts clean, 
 and to make use of vermifuge lotions and injections. 
 
 The superficial inflammations of the vulva, caused by erotic ex- 
 cesses of coitus or by solitary vice, are usually soon cured by repose 
 of the parts, by demulcent and acidulated drinks, by the application 
 of leeches to the external surface of the labia majora, and especially 
 by the use of emollient and gelatinous baths. Those which are due to 
 an exanthema, as variola, or measles, etc., disappear with the general 
 disease, to which, therefore, we should chiefly direct our attention. 
 
 Finally, erysipelas of the vulva, which, like erysipelas of other 
 portions of the body, may be accidental, spontaneous, fixed, irregular 
 or wandering, requires nothing in particular, except to prevent adhe- 
 sion of the inflamed parts, by the frequent use of emollient injections 
 into the vagina, and the introduction into the canal of a large plug of 
 charpie or a tampon of soft linen, soaked in some mucilaginous de- 
 coction. 
 
 OF PRURIGO OF THE VULVA. 
 
 This affection, characterized by violent, intolerable itching and ex 
 cessive smarting of the vulva, may be seated in the labia majora 
 
270 
 
 PRURIGO OF THE VULVA. 
 
 alone, or may extend to the mucous membrane of the orifice of the 
 vagina, and even to the mons veneris. It has frequently been mis- 
 taken for a true herpetic eruption, some of whose characters it pre- 
 sents, jmst as in some cases the itching, which has been attributed to 
 it, was in fact due to the presence of parasitic animals (pediculi-pubis). 
 
 . The circumstances under whose influence prurigo of the vulva 
 most frequently occurs, are the change of life, pregnancy, and the 
 approach and derangements of menstruation, especially in women 
 subject to acrid discharges, and who are inattentive to the calls of 
 cleanliness. 
 
 The chief symptom of this malady is a pruritus, which augments 
 in proportion as the patient yields to it. The itching is most intense 
 when the patient is in bed, and after eating and exercise, especially 
 in situations where the temperature is high. The disorder usually 
 has intermissions of some hours, and even days. Upon examining 
 the parts, we discover little pimples, scarcely distinguishable and 
 slightly raised into points. When inflamed but slightly, they con- 
 tain no matter; but when torn by the nails, they secrete a little drop 
 of sanguineous serosity, which by its desiccation forms a brown crust 
 of the size of a millet seed. 
 
 When the disease is slight, which is commonly the case, it readily 
 yields to the employment of some of the topical remedies that we 
 shall mention; in the contrary case, especially when the affection is 
 of long standing, the epidermis becomes hard and exfoliates, the 
 patient, tormented without cessation, soon emaciates, and often falls 
 into a state of melancholy and despair. 
 
 If the prurigo have commenced during pregnancy, or during the 
 flow of the menstruae, it is necessary merely to moderate the itch- 
 ing by means of emollient and narcotic lotions; we have em- 
 ployed in these cases, and always with advantage, lotions of warm 
 water, with addition of a tablespoonful of Cologne water to each 
 teacupful of the former fluid. It is proper to remark, however, that 
 the itching does not cease entirely in the first case until after the wo- 
 men are confined, and in the second until after the close of the men- 
 strual evacuation. When the disease coincides with amenorrhoea or 
 with inflammation of the womb, it commonly disappears after the 
 re-establishment of the suppressed flux and the cessation of the phleg- 
 masia, which alone ought to engage the attention of the physician. 
 
 In all other cases, we should add to the means just enumerated 
 the use of simple and sulphurous baths; and, should the inflamma- 
 tion be acute, the application of leeches. In his work upon diseases 
 of the skin, Dr. Wilson recommends lotions of twelve grains of cor- 
 rosive sublimate in eight ounces of lime water, to be frequently re- 
 newed; M. Trousseau has, also, prescribed advantageously lotions 
 of a solution of three drachms of subcarbonate of potash to four 
 ounces of distilled water, of which a teaspoonful must be put into a 
 basin containing about two pounds of warm water; the proportion 
 of the solution was gradually augmented, each day, until slight 
 sweating was produced. The same practitioner also prescribes 
 lotions with a mixture of two drachms of corrosive sublimate, dis- 
 
PRURIGO OF THE VULVA. 
 
 271 
 
 solved in a sufficient quantity of alcohol, and ten ounces of distilled 
 water. This solution he, at first, employed in the proportion of a 
 teaspoonful to a pound of warm water, and successively of three or 
 four tablespoonfuls, to he applied by washing two or three times a 
 day. While these lotions, which were continued some days after 
 the cessation of all the symptoms, were employed, M. Trousseau 
 prescribed the use of diluent drinks and of some laxative, and for- 
 bade wine, cordials and acrid stimulant and spiced food. 
 
 In cases of idiopathic prurigo, we have employed, with advantage, 
 cold lotions made with a very weak solution of sulphate of zinc, iron 
 or alum; Goulard’s lotion, oxycrate, laudanum mixed with water, 
 have also sometimes succeeded in our hands; Dr. Ruan,* (of Phila- 
 delphia,) in cases of very obstinate prurigo, has obtained cures by 
 the internal use of balsam of copaiba, of carbonate of soda, and by 
 the external application oft bread and milk poultices, with additions 
 of laudanum ; finally, by the use of lotions made with a solution of 
 powdered sub-borate of soda, or of carbonate of zinc. If active 
 inflammation should supervene after the employment of these reme- 
 dies, as we have known to happen, it should be combated by general 
 and local emollient and narcotic baths, or by baths of gelatine or of 
 bran. Finally, in very obstinate cases, slight cauterizations with the 
 nitrate of silver, or even with the actual cautery, have been employed 
 with success, and triumphed over a disease which had resisted all 
 other means. We should never, however, forget that the too sudden 
 suppression of the prurigo may be followed by serious disorders, 
 which it is possible to prevent by means of a large blister applied to 
 one of the arms, or, still better, to one of the thighs. 
 
 [I have not any thing special to add to M. Colombat’s article, except an 
 account of the successful use of Dr. Ruan’s remedy with some modification. 
 The late Prof. Dewees, of this city, so long and so well known as a prac- 
 titioner at the head of his profession in this country, used to speak of cases 
 of this kind, in which the inner surface of the genital parts was covered 
 with aphthae, very like the aphthae faucium ; and it was in these cases that 
 he strongly recommended the borate of soda, agreeably to the experience of 
 my venerable fellow-citizen, Dr. John Ruan, also a person of great clinical 
 experience. 
 
 I confess that I have not perceived, upon examination, nor have I been 
 informed by the patient, of the aphthous condition of the mucous surface, 
 but I have found it excessively red and dry, and the subject of the most 
 insupportable pruritus, — which has continued to torture the sufferer for 
 months, and until the gestation has concluded, notwithstanding all the 
 efforts that could be directed against it. But I am free to say, having been 
 a great many times consulted for the relief of pruritus vulvae, and most fre- 
 quently in pregnant women, I have rarely had occasion to order any thing 
 more than the following formula, viz: 
 
 * Revue Medic., tom. i. p. 305, 1829. From the North Amer. Med. and Surg. 
 Journ., 1828. 
 
212 
 
 OF PHLEGMON OF THE LABIA MAJORA. 
 
 R. — Sodae borat. 3ss. 
 
 Morph iae sulphat. gr. vj. 
 
 Aq. rosae destillat. 3 viij. 
 
 M. — F. to sec. art. misturae. 
 
 I direct the person to apply it thrice a day to the affected parts, by means 
 of a bit of sponge or a piece of linen, taking the precaution first to wash 
 the surfaces with tepid water and soap, and to dry them before applying the 
 lotion. I can confidently recommend the prescription as suitable in most of 
 the cases of this most annoying malady. — M.] 
 
 OF PHLEGMON AND DEEP-SEATED INFLAMMATION OF THE LABIA 
 
 MAJORA. 
 
 Phlegmon of the labia majora is far from being rare ; for independ- 
 ently of that developed after contusions occurring during labour or 
 the sexual congress, and shocks of other kinds, there are some which 
 commence without our being able to discover the cause. Females 
 recently married are much more subject to them than those more 
 advanced in years ; in some, this kind of phlegmon is reproduced at 
 each appearance of the menstrual discharge ; they present nothing 
 peculiar, except that they almost always terminate by suppuration ; 
 their treatment consists in the employment of emollient and matu- 
 rative poultices, low diet, local bleedings, &c. ; when suppuration 
 takes place, the abscess must be opened by a longitudinal incision 
 on the internal surface of- the labium externum. In the periodical 
 phlegmon, however, a simple incision is not sufficient, because, in 
 cases of this kind, the walls of the abscess are smooth like those of a 
 cyst; they unite with difficulty, and on this account should be irri- 
 tated by means of injections capable of producing granulations upon 
 their surface. These injections, which it is necessary to use two or 
 three times a day, may be made simply with equal parts of wine 
 and water, or with a mixture of an ounce of rose-water and a 
 drachm of aqua ammonias. 
 
 Abscesses of the vulva, which, from feelings of shame, have been 
 left without treatment, terminate in tortuous sinuses communicating 
 with the rectum, and thus occasion fistula of the labium externum 
 by giving passage to stercoraceous matter; these should be largely 
 opened with a narrow bistoury. 
 
 Dr. Vidal de Cassis* has lately described certain small abscesses, 
 which occur around the vulva during blennorrhagia, and which are 
 very common amongst prostitutes. In the opinion of this practi- 
 tioner, these abscesses, though but little known, merit serious atten- 
 tion; for they are almost always followed by fistula and sometimes 
 even by very serious nervous symptoms. As this is not the proper 
 place to detail their history, we shall rest content with saying that 
 they appear during the progress and even towards the termination of 
 the blennorrhagia, that they are generally seated in the substance of 
 the labia, of the vulva and especially at the point where the nymphae 
 
 * Traite de Pathologie Chirurgicale, t. i. p. 246, 1838. 
 
GANGRENOUS INFLAMMATION OF THE LABIA MAJORA. 273 
 
 terminate in the labia majora. The purulent collection being com- 
 monly inconsiderable, these abscesses, though painful, remain, for 
 some time, undetected, and their existence is often declared only 
 because the pus, nearer to the mucous membrane than to the skin, 
 comes at last to bathe the edges of the vulva, after having opened a 
 passage for itself. 
 
 [It appears to me that the author ought to have guarded the young and 
 inexperienced practitioner against the danger of making a mistake in the 
 diagnosis of these affections. At least should he have referred him back to 
 page 206, for the diagnosis of vulvar enterocele. Nothing could be more 
 dreadful than to plunge a lancet into the intestine, confined within the 
 labium of a patient, under the mistaken design of discharging a supposed 
 abscess. — M.] 
 
 GANGRENOUS INFLAMMATION OF THE LABIA MAJORA. 
 
 The external genital organs of the female, like the vagina, some- 
 times become the seat of gangrenous sloughs, produced by the 
 violent pressure of the foetal head during labour. In other cases 
 gangrenous affections of the external genital parts prevail epidemi- 
 cally in hospitals for lying-in-women, and are then one of the symp- 
 toms of a typhoid fever, or of a metritis, which is almost always 
 fatal. 
 
 The treatment of symptomatic gangrenous affections consists in 
 uniting the utmost cleanliness together with emollient ablutions to 
 the treatment of the principal disease; then in the use of tonic 
 lotions made with honeyed wine of cinchona, or lotions with Labar- 
 raque’s disinfecting solution. 
 
 There is a kind of primitive gangrene, happily very rare, which 
 has been designated by the term, carbuncle of the genital organs . 
 The disease, which is extremely dangerous, commences sometimes 
 with phagedsenic ulceration, or by oedematous, but more frequently 
 by phlegmonous engorgement When it begins in the latter form, 
 the pain at first is very acute and the heat intense ; the swelling 
 shows itself particularly about the mans veneris; the integuments 
 are of a dusky-red colour, and present a smooth and shining aspect. 
 A progressive diminution of sensibility, and the appearance of a 
 violet spot, depressed in its centre, and becoming more and more 
 deeply-coloured, announce the approaching attack of gangrene, 
 which speedily iuvades the neighbouring parts and spreads to an 
 extent that varies with the duration of the disease : the prognosis 
 of this affection is always very grave; for it almost always termi- 
 nates fatally. The treatment consists of local depletion, topical ap- 
 plications of refrigerant detergents, and emollient applications ac- 
 cording to circumstances ; if the disease begin with oedematous 
 engorgement, blisters and the actual cautery might stay its progress. 
 It would be proper, also, to resort to vinous, alcoholic, camphorated 
 and chlorinated lotions, or those made with decoction of cinchona; 
 internally, the mineral acids, anti-scorbutics and the preparations of 
 18 
 
274 
 
 ACUTE INFLAMMATION OF THE VAGINA. 
 
 cinchona should likewise be employed, especially if the march of 
 the disease should seem sensibly arrested by the remedies first put in 
 practice. 
 
 ACUTE INFLAMMATION OF THE VAGINA. 
 
 Although acute inflammation of the vagina generally coincides 
 with that of the womb, which is soon to occupy us, it may, never- 
 theless, exist separately, or at least extend only to the mucous mem- 
 brane of the vulva, which at the same time becomes the seat of a 
 more or less abundant exudation. 
 
 Acute vaginitis may be produced by erotic excesses, resulting from 
 repeated coitus, or from solitary vice; by irritating injections; by the 
 detention of hard and voluminous foreign bodies in the vagina ; by 
 violation, especially if committed upon a person of tender age; by 
 obstetrical operations; by venereal infection; and, finally, by any 
 agent capable of producing an irritating action in the vulvo-vaginal 
 mucous membrane. 
 
 Whatever be the cause of this affeetion, it begins with slight pru- 
 ritus and sensation of weight in the genital parts ; the patient feels 
 a kind of constriction at the vagina, or dragging in the groins, with 
 vague pains in the hypogastric region, in the hips and loins; the pru- 
 ritus, at first slight, soon changes into a painful and burning sensation, 
 especially during the discharge of urine. Tumefaction occurs along 
 the whole length of the vagina, which is sometimes so considerable 
 as to make it difficult to introduce the finger. On the third or fourth 
 day, a limpid and not very abundant mucous discharge is established. 
 The desire to urinate becomes more frequent, and the pain which 
 accompanies it more acute : little by little the discharge increases 
 and varies in colour, white, yellow or greenish, and sometimes the 
 local inflammation becomes so intense that even fever arises, and 
 the vaginal secretions excoriate the greater and lesser labia. When 
 the inflammation has extended as far as the os tincae, the patient 
 feels a sensation as of a large tumour causing weight at the bottom 
 of the vagina, especially when she tries to walk. In performing 
 the Touch, which is generally very painful, we find the neck of the 
 uterus swollen, sensitive and burning; if we resort to exploration by 
 means of the speculum, the circumference of the mouth of the womb 
 is seen to be red, tumefied and often excoriated. 
 
 Ordinarily the symptoms begin to decrease towards the tenth or 
 twelfth day, the discharge gradually loses its colour, and, finally, the 
 inflammation terminates by resolution and soon disappears, unless 
 it pass into the chronic form. It happens, nevertheless, that in some 
 cases acute vaginitis terminates in suppuration, giving rise to indo- 
 lent abscesses which might be mistaken for vaginal enterocele, and 
 this the more probably because the tumours which result from them 
 are soft and insensible, and the pus they contain disappears under 
 the pressure of the fingers, as the loop of intestine does when we 
 effect its reduction. When the vaginal inflammation is the result of 
 a mechanical lesion, it frequently terminates in gangrene, which, 
 
ACUTE INFLAMMATION OF THE VAGINA. 
 
 275 
 
 after the fall of the sloughs, occasions a loss of substance, producing 
 recto and vesico-vaginal fistula. 
 
 The treatment of acute vaginitis, not dependent upon syphilis, 
 consists in the use of baths, of emollient and narcotic lotions and 
 injections, and of general or local depletion, according to the violence 
 of the symptoms ; to these should be added diluent drinks, sedative 
 and demulcent enemata, rest, strict diet, or at least mild and light food, 
 and the treatment is concluded with astringent lotions and injections. 
 Should the disease terminate by suppuration, it is necessary to open 
 the abscess as soon as it is detected ; and in case gangrenous sloughs 
 form, we must resort to tonic and chlorinated lotions. 
 
 Although we do not intend in this work to treat of diseases belong- 
 ing properly to general pathology, such for example as the venereal 
 disease, we shall, nevertheless, make some remarks upon contagious 
 vaginitis or blennorrhagia of the female. 
 
 The contagious character is not inherent in that form of vaginitis 
 only which results from an impure coitus; for, it has long since 
 been proved, that when once established under the influence of any 
 cause whatsoever, it may, during the venereal act, communicate an 
 urethral blennorrhagia to a male. 
 
 This contagious property of vaginitis is not a constant one ; it may 
 be developed under some circumstances, and cease to be manifested 
 under others. It has been known, after having been for a long time 
 innocent, to become contagious after the woman has committed 
 excesses in eating, after frequently-repeated sexual intercourse, or 
 even after violent exercise. What is most worthy of remark is, that 
 the affection contracted from a female labouring under vaginitis is 
 not invariably a blennorrhagia, but consists often of ulcerations or 
 of vegetations, etc. It is proper to say, however, that the power of 
 giving rise to these different symptoms is not common to all forms 
 of vaginitis, but that it seems to belong especially to that which is of 
 syphilitic origin. 
 
 It is much to be desired that some external signs could be discovered 
 by which we might, from the very first, distinguish whether a case 
 of vaginitis is or is not contagious ; unfortunately, the symptoms just 
 described have nothing decisive in them, and are often, indeed, quite 
 uncertain.* Although, in general, we may affirm a vaginal discharge 
 to be contagious when the redness is acute, the pain intense, and the 
 swelling considerable ; when the urethra, conjointly with the vagina 
 is very much inflamed; in a word, when the inflammation is violent'; 
 we cannot assert that blennorrhagia may not be communicated 
 by contagion even when it is slight in appearance, and fails to pre- 
 sent the symptoms we have enumerated. 
 
 We shall conclude with the statement, that when fully convinced 
 that vaginitis is the result of syphilitic infection, we should com- 
 bine with the antiphlogistic treatment the use of mercurials and 
 
 * The chemical and microscopic researches of Dr. Donne have, in great measure, 
 enlightened this difficult point of diagnosis. We do not mention them here, because 
 we shall describe them in treating of the characters which distinguish syphilitic vagi- 
 nitis and leucorrhcea properly so called. 
 
276 
 
 ACUTE INFLAMMATION OF THE WOMB. 
 
 various other means we shall mention in speaking of chronic catarrh 
 of the vagina and uterus. Lastly, if the disease be connected with 
 a scrofulous, herpetic, rheumatic or verminous disorder, etc., the 
 treatment ought in the same way to be directed to the principal 
 disease, without however omitting the local remedies, especially 
 resolvent, astringent, tonic, opiate, mercurial and balsamic injections, 
 etc. We might also resort to cauterization with the solid nitrate of 
 silver, which our fellow-practitioner and friend, M. Ricord, has em- 
 ployed with the greatest success in the treatment of acute and chronic 
 vaginitis, and which we have likewise employed for six years past, 
 in order to modify and cure several different affections of the vocal 
 organs. When speaking of the treatment of leucorrhoea or vagino- 
 uterine catarrh, we shall describe the method followed by M. Ricord, 
 who calls the nitrate of silver the antiphlogistic caustic. 
 
 [In the treatment of vaginitis, it would be proper to keep always in view 
 the liability of the canal to become greatly injured by stricture of greater or 
 less breadth, and even by the occurrence of the adhesive inflammation, end- 
 ing in complete cohesion of large portions of the opposing surfaces of the 
 tube. I beg leave to refer the reader to page 101, for the history I have 
 therein related of such a case, with the mode adopted in effecting the 
 cure. The misfortune is, that the modesty of the patient causes her almost 
 invariably to conceal from the medical attendant, any secret distress, or any 
 disorder that might expose her sensibility to some shock by its disclosure, 
 and hence he is apt not to discover the existence of disease until it has had 
 time to produce its permanent evil effects. 
 
 Knowing this disposition of the female, he should feel bound to make 
 such occasional inquiries as might keep him fully informed of any threat- 
 ened danger to the object of his care. Complaints being made to him, and 
 neglected, or put off by some slight direction or prescription, become serious 
 charges against his conscience, should they be followed by evil consequences 
 that might, by proper attention, have been obviated. — M.] 
 
 INFLAMMATION OF THE PARENCHYMA AND LINING MEMBRANE OF 
 
 THE UTERUS. 
 
 Notwithstanding the great improvements in pathological anatomy, 
 yve still remain imperfectly acquainted with the alteration of the 
 parenchyma produced by acute inflammation of the womb : it is 
 easy to understand why there still remains some deficiency in the 
 history of this disease, when we reflect that opportunities for observ- 
 ing it, and especially for making the autopsy of persons who perish 
 from it, seldom occur. 
 
 The authors who, from Hippocrates down to the middle of the 
 last century, have treated of acute metritis, do not always agree upon 
 its true seat, and have generally published only imperfect cases. 
 Some have confounded the disease with uterine catarrh, others with 
 puerperal peritonitis, and it is only since the labours of Cigna, per- 
 
ACUTE INFLAMMATION OF THE WOMB. 
 
 277 
 
 petual secretary of the Academy of Sciences of Turin* have been 
 made known, that physicians universally understand by acute metri- 
 tis, inflammation of the proper tissue of the uterus. 
 
 Where the inflammation is superficial, that is to say, where it is 
 seated chiefly in the lining membrane of the organ, it constitutes the 
 catarrhal metritis which received, in 1822 , from Doctor Blatin,t 
 the name of uterine catarrh, which is now generally adopted. But, as 
 these two kinds of inflammation rarely exist separately, and as their 
 causes, symptoms and treatment offer but slight and unimportant dif- 
 ferences, we shall describe them under the common denomination of 
 metritis, while recording the symptoms that serve to distinguish 
 whether the inflammation predominates in the mucous membrane of 
 the womb, in the parenchyma of the organ, or whether it occupies 
 either of these parts exclusively. 
 
 This affection is very rare before the age of puberty, because, up 
 to that epoch, the womb remains in a kind of atrophy and inactivity, 
 which render it passive as it were, in the midst of the living economy. 
 Nevertheless, acute metritis is sometimes observed in little girls of 
 early age. Doctor Dance , X amongst others, has published a case 
 which seems to have been the sequela of a chronic peritonitis. 
 
 Acute inflammation of the uterus is also rare in women who have 
 passed the critical age ; it particularly attacks marriageable girls 
 during menstruation, persons who indulge to excess in the pleasures 
 of venery, in masturbation, and still more those in the lying-in state, 
 or who have been recently delivered. Sometimes it has been observed 
 to come on during pregnancy, and cause abortion ; it may extend to 
 the whole uterus, or occupy the body and fundus of the organ alone. 
 
 The causes that may give rise to acute metritis are very nume- 
 rous ; some of them are common to all the phlegmasise, while others 
 having a more direct action upon the uterus are divided into predis- 
 posing and efficient causes. Amongst the former are youth, an erotic 
 and sanguine temperament, acute sensibility and a first labour. 
 
 Amongst the efficient causes of this disease, should be classed pre- 
 mature suppression of the menstruse ; too frequently repeated coitus, 
 and absolute and relative disproportion of the organs; solitary enjoy- 
 ment; celibacy; widowhood and unsatisfied desires ; irritating injec- 
 tions ; suppression of hemorrhoidal discharges; leucorrhosa; the use 
 of violent emmenagogues employed in forcing the menses or in pro- 
 voking abortion ; sudden cooling of the extremities ; cold bathing of 
 the vulva and vagina ; cold baths and iced drinks, especially during 
 menstruation ; fatiguing walks; violent exercise on horseback or in 
 carriages, without springs ; dancing ; loss of sleep ; wounds ; falls 
 and blows on the hypogastric region ; the application of a pessary; 
 heating and stimulating food ; highly-seasoned meats ; spirituous 
 drinks; wine ; coffee; tonic, stimulating and aromatic remedies admi- 
 nistered at improper times ; moral disturbances, which may suspend 
 the flow of the menstruee and of the lochia, etc. 
 
 * Uteri inflammatio, etc., dissert., Turin, 1756. 
 
 f Du catarrhe uterin ou des flueurs blanches. Paris, an. x. 
 
 $ Archives gener. de Medecine, Octobre, 1829. 
 
278 ACUTE INFLAMMATION OF THE WOMB. 
 
 The causes that act particularly during pregnancy, are premature 
 labour, immoderate coitus, and the introduction of a foreign body 
 into the womb with the intention of producing abortion, and falls or 
 blows on the thighs or abdominal region. 
 
 Metritis may also be caused during labour by its long duration, by 
 manipulations with the hands, and especially with the forceps, for the 
 purpose of effecting the version of the child or the detachment of the 
 placenta; by lacerations of the uterus; by too often repeated examina- 
 tions and too frequent frictions on the abdomen to excite the uterine 
 contractions. The same disease may be determined immediately after 
 delivery by the retention of the placenta, or some of its connections, 
 or even by a coagulum; by the injection of an astringent liquid, or of 
 iced water into the vagina and uterus, with the view of arresting 
 haemorrhage ; by the employment of stimulating drinks, and espe- 
 cially of roasts cooked with wine, cinnamon and nutmeg, which the 
 nurses have the habit of giving to women recently delivered, in 
 order to re-establish their strength ; finally, metritis may be occa- 
 sioned by sudden suppression of the lochia or milk, produced by 
 rapid cooling of the body or by a vivid emotion, as fright, joy, anger, 
 bad news, etc. The venereal virus, and especially cohabitation with 
 a person affected with gonorrhoea, are likewise causes which, in all 
 possible conditions of society, may sometimes occasion the develop- 
 ment of acute inflammation of the uterus. 
 
 The symptoms of the disease, which may be either idiopathic, 
 symptomatic or metastatic, and which is often determined by conti- 
 nuity of inflamed organs, are divided into local and general, which 
 vary according as the inflammation occupies the internal mem- 
 brane, the neck, the fundus, the whole or a part of the body of the 
 organ. 
 
 It is probable that the inflammation is seated chiefly in the mucous 
 membrane of the cervix, when the secretion of mucus is found to be 
 abundant, and the pain slight ; especially if pressure does not increase 
 it ; and finally, where the cause under whose influence it has arisen, 
 has acted principally upon the lining membrane of the gestative organ. 
 We may be almost certain, on the contrary, that the inflammation 
 occupies particularly the substance of the uterus, when there is no 
 discharge ; when the pain is very acute and pulsative, the swelling 
 very marked, and, in fine, where the pain has manifested itself after 
 a blow, a puncture, or a fall upon the hypogastric region. 
 
 When the inflammation occupies only the fundus of the organ, the 
 pain is seated towards the hypogastric region and extends, to the 
 umbilicus ; if the metritis be puerperal, the pain is increased by pres- 
 sure, and the tumour is very sensitive especially at its upper part. If 
 the anterior paries be affected, the painful point is at the pubic region, 
 and the emission of urine is difficult and sometimes impossible ; if 
 the posterior wall be diseased, the expulsion of the faecal matter is 
 extremely painful, and the distress in the loins and back intolerable; 
 the female feels a sensation of weight which obliges her continually 
 to make expulsive efforts, like those of labour or of defecation. 
 
 When the inflammation chiefly occupies the lateral portions of the 
 
ACUTE INFLAMMATION OF THE WOMB. 
 
 279 
 
 gestative organ, the ligaments participate in the inflammatory state, 
 the groins and thighs are painful, the legs and feet are benumbed, the 
 woman lies upon her back with the inferior extremities drawn up, 
 for any other position is insupportable. 
 
 In cases where the neck of the uterus alone is affected, the patient 
 feels an acute pain at the bottom of the vagina; if the phlegmasia 
 has succeeded to a laborious labour, there occurs from the vulva a dis- 
 charge of blood and of sanguineous mucus which is prolonged beyond 
 the usual period, and in performing the Touch, we find the os tincse 
 hard, swollen and always more or less torn. When on the other hand 
 it has followed the first sexual connection, the neck only is swollen, 
 burning, very sensitive, and seems almost always to be nearer to the 
 vulva. In general, all these partial inflammations terminate happily. 
 
 It is not so where an acute inflammation occupies the whole of the 
 womb; the symptoms which then arise are al ways extremely serious, 
 because, in the greater portion of the cases, the evil extends not only 
 to the uterine serous membrane, but also to the rest of the peritoneum. 
 
 Metritis generally declares itself immediately or shortly after deli- 
 very ; it begins with rigors of longer or shorter duration, great lan- 
 guor, general anxiety, and a dull, gravative and sometimes very 
 acute pain, which, commencing in the hypogastrium, extends rapidly 
 over the whole abdomen. 
 
 This pain is continuous ; it is much increased even by slight pres- 
 sure upon the lower part of the abdomen, as well as by the move- 
 ments of the diaphragm which take place during coughing, the act 
 of spitting, deep inspiration, and singultus, etc. The patient com- 
 plains of a sense of weight about the rectum ; she cannot visit the 
 close stool; the emission of urine is difficult, painful, and often impos- 
 sible ; the hypogastrium enlarges, becomes more and more sensitive, 
 and the hand applied upon that region finds the body of the uterus 
 harder and more distended than in the normal condition. By the Touch , 
 we ascertain that the neck of the uterus is soft, swollen, extremely 
 painful and always warmer than the vagina, which, as well as the labia 
 externa, is often tumefied and inflamed. If the metritis have occurred 
 immediately after parturition, the breasts decrease, milk is not secreted, 
 the lochial discharge is arrested, and the same takes place in regard 
 to the menstruse, when the disease coincides with the period of that 
 evacuation. Sometimes there is a more or less abundant discharge 
 of sanious and reddish fluid, and in certain cases the patients discharge 
 both fluid blood and clots. These various discharges, which are, at 
 times, intermittent, are preceded by acute pain, caused by the efforts 
 of the womb to expel the materials collected in the cavity. 
 
 As the viscus has very intimate sympathies with all the other 
 organs of the economy, it reacts when acutely inflamed upon, those 
 organs, and to a greater or less extent disturbs their functions. In- 
 deed, certain general symptoms, which vary according to the intens- 
 ity of the inflammation, are added to the local symptoms which we 
 have above described. 
 
 In most cases, acute metritis is preceded by rigor, accompanied 
 with uneasiness and anxiety, to which succeed general heat of the 
 
280 
 
 ACUTE INFLAMMATION OF THE WOMB. 
 
 skin, fugitive pains, and a sense of weight about the uterus. It often 
 happens that the disease makes its appearance suddenly, and then 
 we observe the local symptoms which are peculiar to it immediately 
 after the attack. When the disease becomes completely established, 
 the general and local symptoms accompanying it are great change 
 in the expression of the features, constant restlessness, extreme feeble- 
 ness, frequency of the pulse, heat, dryness of the tongue, and intense 
 cephalalgia ; the face, which bears the impress of suffering, is pale and 
 pinched ; the eyes are sunken and surrounded by a bluish ring ; the 
 tongue is cracked and dry, white or yellowi^i in the middle, and red 
 at the point and edges ; the thirst is great, and the anexoria intense ; 
 the patient constantly complains of constriction in the throat; she 
 has incessant nausea, often amounting to vomiting; sometimes a fetid 
 diarrhoea or obstinate constipation comes on ; the discharge of urine 
 is difficult and painful ; it is red, loaded and irritating ; the respiration 
 is suspirious and laboured, partial viscid sweat covers the forehead ; 
 the sight becomes dim ; the breasts, which are also painful, become 
 flaccid and shriveled; but this phenomenon, which is not constant, is 
 very apt to be wanting when a discharge from the vagina has been 
 established. Generally speaking, the patient, who is in a state of 
 continued wakefulness and wandering, can lie only on the back, with 
 the legs flexed on the thighs, and the latter on the pelvis. In tine, 
 when to these symptoms are added tympanitis, singultus, delirium, 
 smallness of the pulse, picking at the bed-clothes, subsultustendinum, 
 coldness of the extremities, excessive prostration, and especially a dis- 
 charge of blackish, extremely fetid matter from the vagina, death is 
 not far from the victim. This affection, which rarely destroys the 
 patient before the end of the first week, but which is sometimes pro- 
 longed for a fortnight or a whole month, may, in certain cases, reach 
 such a degree of intensity, that the disorder it then determines in the 
 genital functions leads to a fatal result as early as the third and even 
 the second day. We should observe, however, that a termination 
 so rapid and fatal does not usually occur except where the disease 
 has come on after parturition, because, in this case, the inflammation 
 extends to the peritoneum. * Moreover, the pus that is formed on the 
 lining membrane, in the parenchyma, and especially in the sinuses 
 of the womb, is often absorbed by the veins of the organ, and thus 
 mingled with the blood of the general circulation, goes to expend 
 its deleterious activity on the whole economy. It is this purulent 
 absorption particularly that so often renders puerperal peritonitis 
 fatal. 
 
 It often happens, where the inflammation has extended to the peri- 
 toneal coat, or into the substance of the ligaments of the womb, that 
 suppuration takes place and abscesses are formed that open either 
 into the cavity of the peritoneum, into the rectum, the bladder, or the 
 vagina. Sometimes, also, the pus forms a passage to the exterior 
 surface ; for example, through the umbilical region, * at the groin, t 
 
 * Smellie, Midwifery, vol. iii. p. 444. Lamotte, Traite d’Accouch., observ. 420. 
 Pinel .Nosograph. philos., t. ii. p. 286. Van Swieten, comment, on the aphor. of 
 Boerhaave, t. iv. 
 
 f Lamotte, Trail© d’Accouch. (loco citat.) 
 
ACUTE INFLAMMATION OF THE WOMB. 
 
 281 
 
 in the loins, or on the thigh, * and, in effecting its escape, follows some- 
 times a direct route, and at others burrows through the cellular tissue, 
 in a tortuous course. It is proper to remark, however, that, as these 
 cases have been observed only in women who survived, some doubt 
 may perhaps exist as to the point of departure and the course of the 
 suppuration. Moreover, as the dense and compact structure of the 
 womb yields but slightly to the formation of pus, it is probable that 
 the greater part of the purulent collections which appear externally, 
 after metritis, are developed in the peritoneal tissue, or in the neigh- 
 bouring inflamed organs, and not in the uterine parenchyma. 
 
 Generally speaking, the formation of pus is to be apprehended, 
 when the symptoms of metritis last, with undiminished violence, 
 beyond the second week ; and we may be assured of its occurrence 
 where the pain augments and becomes pungent or pulsating at the 
 same time that fever comes on with transient rigors and horripila- 
 tion. Henceforward, too, the uterine and alvine evacuations are sup- 
 pressed; night sweats, which afford no relief, come on ; the patient is 
 attacked with extreme restlessness, with more violent headache ; and 
 it is the diminution of these symptoms which indicates that suppu- 
 ration is completed. 
 
 When acute metritis terminates by induration, the pain and fever 
 diminish gradually, but the womb loses nothing of its size, density or 
 weight. 
 
 The termination of metritis in gangrene, observed by several cele- 
 brated physicians, as by Morgagni, Lieutaud and Smellie, is preceded 
 from the third to the seventh day, by vomiting, hiccough, comatose 
 delirium, and constantly increasing meteorism; the alvine evacuations 
 become involuntary, black, frequent, and of a cadaverous odour. A 
 discharge of fetid matters takes place from the vagina; the pain and 
 heat cease completely ; the pulse is frequent, very small, and inter- 
 mittent; finally, convulsions, syncope, and coldness of the extremi- 
 ties close the mournful scene. 
 
 In cases of very acute metrilis, speedily terminated by death, we 
 find portions of the uterus softened and converted into a kind of 
 liquid and sanious putrescence, which seems to have macerated the 
 parenchyma of the organ. At other times the viscus is more or less 
 gangrenous, and its cavity contains viscid and blackish matters, which 
 exhale a putrid odour. We should, however, observe, that the two 
 last symptoms do not always announce gangrene of the womb, espe- 
 cially when the metritis has occurred soon after labour. Indeed, the 
 black colour and gangrenous odour of the substances found within 
 the uterus after death, or which flow from the vagina during life, are 
 often due to the putrefaction of the placenta, or of large clots of blood, 
 which have been retained in the cavity of the womb. Where the 
 disease has not been so rapidly fatal, the mucous membrane of the 
 womb is generally very much thickened and of a deep red colour ; 
 the tissue of the organ is softened and engorged ; its cavity contains 
 a bloody, mixed with a sero-mucous fluid, which gives it a sanious 
 appearance, and which escapes, by pressure, from the uterine paren- 
 
 * Mauriceau, Traite des Maladies des Femmes, t. ii. observ. 254, p. 211. 
 
282 
 
 ACUTE INFLAMMATION OF THE WOMB. 
 
 chyma, as from a sponge. These changes frequently do not extend 
 over the whole of the viscus ; sometimes they are seated only in the 
 neck, and at other times in the fundus and on the interior and poste- 
 rior paries. The tissue of the healthy portions, ordinarily pale, 
 always appears thinner and denser than that of the inflamed portions. 
 Finally, it happens not unfrequently that the Fallopian tubes, the 
 ovaries and the parts in the neighbourhood of the womb, participate 
 in the disorders of which it is the point of departure and the princi- 
 pal seat. 
 
 Where metritis terminates in resolution, which is most apt to oc- 
 cur where the inflammation is of small extent and where the disease 
 is unconnected with delivery, the symptoms gradually become less 
 acute, the uterus becomes disengorged, and its disengorgement is 
 assisted and made evident by a sanguine or sero-mucous discharge 
 from the vagina. It is then of the utmost importance to watch the 
 patient, and continue for some time, and according to circumstances, 
 therapeutic and hygienic measures, to prevent, as far as possible, the 
 uterine inflammation from passing into the chronic state. Frequently 
 women, relieved of the greater part of their sufferings, and supposing 
 themselves out of danger, abandon their disease to the efforts of 
 nature alone, and, in their foolish security, often partaken by their 
 physician, soon pass from a cure almost complete, to a permanent 
 pathological condition, constituting the chronic metritis, of which we 
 shall soon have to speak. 
 
 The fortunate termination of puerperal metritis is also preceded 
 a diminution of the symptoms, but particularly by the re-appear- 
 ance of the lochia, the swelling of the mammae, and the establish- 
 ment of the milk secretion. When metritis attacks during preg- 
 nancy, it almost inevitably brings on premature labour, the death of 
 the foetus, and very often that of the mother also. 
 
 The diagnosis of acute inflammation of the uterus is often rather - 
 obscure, because the disorder presents symptoms having some 
 analogy to those of peritonitis, hysteria, uterine catarrh and acute 
 cystitis. When the inflammation is confined to the neck of the 
 womb, the symptoms, usually mild, might be regarded as the una- 
 voidable consequences of a laborious labour, or as the effects of a slight 
 irritation established upon the os tincae. If, on the contrary, the dis- 
 ease extends to the body of the womb, the peritonitis, which very 
 frequently accompanies it, alone attracts the attention of the physi- 
 cian, and thus prevents him from attending to the metritis, whose 
 existence he cannot suspect. When the inflammation occupies the 
 uterus and peritoneum at the same time, the symptoms of metritis 
 always exist. Though they may be veiled by those of the peritonitis, 
 it will, nevertheless, be possible, with a little care, to discern them. 
 
 In fact, the sensibility of the neck to the touch, its softness, its enlarge- 
 ment, the pain produced by the slightest movement communicated 
 to the body of the uterus, and the spasm propagated towards the rec- 
 tum and bladder, are so many phenomena which are absent in peri- 
 tonitis, and which reveal the existence of an acute phlegmasia ot the 
 gestative organ. Moreover, in peritonitis, the pain, which is more 
 
ACUTE INFLAMMATION OF THE WOMB. 
 
 283 
 
 general and more lacerating, often occupies the whole abdomen, and 
 the slightest touch exasperates it to such a degree, that not only is 
 the patient unable to move in bed, but it is sometimes impossible for 
 her to bear the contact of the lightest poultices, or even that of the 
 bed-clothes or of a single sheet. In metritis, the tension of the abdo- 
 men is less general, and the pain, which seems circumscribed and 
 seated only at the point corresponding to the uterus, is never ac- 
 companied by expulsive efforts, which are proper to acute inflamma- 
 tion of the uterine parenchyma. 
 
 Acute metritis may be easily distinguished from hysteria, by recol- 
 lecting that in this last disease pressure upon the abdomen does not 
 cause pain, that the abdomen, far from being tumid, is often retracted, 
 and that the pulse is corded, but not frequent; finally, that the pa- 
 tient, whose pains are irregular and whose tongue is in a natural 
 condition, always feels a sensation of strangulation and suffocation, 
 produced by the globus hystericus which seems to arise in the -hypo- 
 gastric region, and traverse the abdomen and thorax to be arrested 
 in the throat. In addition to the symptoms we have just enumerated, 
 we should not forget that hysteria is a nervous and apyretic affection, 
 manifested by attacks of general convulsion, with suspension, more 
 or less complete, of the intellectual faculties; moreover, the Touch, 
 which affords us the least equivocal signs for recognizing metritis, 
 teaches us also that in hysteria the womb is generally in a healthy 
 state. 
 
 In uterine catarrh, the internal membrane of the uterus is alone 
 affected; the inflammatory phenomena and the fever are moderate, 
 the pain less severe, the sensibility of the Uterus less exalted, and 
 the discharge which takes place by the vulva, and which determines 
 a sensation of tingling in urinating, is not sanious and reddish, like 
 that which occurs during acute metritis; moreover, the facts ascer- 
 tained in regard to the invasion of the disease and the causes which 
 produce it, are always sufficient to establish the diagnosis. 
 
 Acute inflammation of the uterus may easily be distinguished from 
 that of the bladder, if we reflect that in the latter disease, the desire 
 to urinate is much more frequent and more painful than in metritis, 
 and that it is necessary to make violent efforts in order to pass a few 
 drops of urine. Most commonly, this fluid is thick, and mixed with 
 mucus, which is deposited at the bottom of the vessel in the form 
 of a tenacious, gluey and grayish substance. Cystitis is sometimes 
 accompanied by other more serious symptoms ; the bladder distended 
 with urine, projects above the pubis ; the whole abdomen increases 
 in size and becomes very sensitive ; the body exhales a distinct 
 urinous odour ; finally, there is at the same time a sort of vesical 
 tenesmus with painful pruritus in the urinary meatus and constant 
 factitious desire to go to stool. Therefore, as these symptoms are 
 absent in acute metritis, it becomes impossible to confound the dis- 
 ease with inflammation of the bladder. 
 
 The prognosis of acute metritis, which is generally very grave, 
 depends upon the extent and degree of intensity of the inflamma- 
 tion, its co-existence with peritonitis, or with any other complication, 
 
2S4 
 
 TREATMENT OP ACUTE METRITIS. 
 
 on the more or less advanced period of the disease, or the effects of 
 the first therapeutical means employed ; finally, on the age, and the 
 constitution, as well as the hygienic condition of the patient; upon 
 her docility in following the advice of the physician ; the season, the 
 prevailing temperature, the epidemic influences and the circum- 
 stances under which the invasion of the disease has taken place. 
 Other things’ being equal, acute inflammation of the womb is most 
 dangerous during gestation, especially when developed under the 
 influence of certain epidemic constitutions. It is a disease to be 
 dreaded, not only because it often produces death, but likewise be- 
 cause, in cases where women attacked with it fail to perish, it be- 
 comes the germ of other diseases, and especially of chronic metritis, 
 which, in its turn, may produce ulceration, degeneration and cancer 
 of the uterus. 
 
 TREATMENT OF ACUTE METRITIS. 
 
 The treatment of acute metritis demands certain hygienic precau- 
 tions, which cannot but augment the efficaciousness of the therapeu- 
 tical agents that we are about to treat of. 
 
 The woman should be kept in the most absolute repose. Her 
 chamber, which ought to be darkened and free from all kinds of 
 emanations, should be kept at a moderate temperature, and iso- 
 lated, as much as possible, from whatever might disturb the moral 
 and physical quietude. The air should be frequently renewed, 
 with the precaution that no current be directed upon the patient. 
 Mattrasses of wool and feather-beds ought to give place to hair- 
 mattrasses, and if the weight of the coverings be inconvenient or 
 painful, we may prevent their contact with the abdominal parietes, 
 by means of hoops. To diminish the pain by keeping the abdomi- 
 nal muscles as much relaxed as possible, the patient should lie upon 
 her back, the head raised and flexed by means of pillows, the legs 
 separated and the thighs flexed with the aid of cushions. Finally, 
 we should remove all the causes capable of producing a vivid moral 
 or physical impression upon the patient, and especially we should 
 remove all persons that might vex or injure her by reporting bad 
 news. 
 
 Acute metritis, like all other inflammations, must be combated 
 by the most vigorous antiphlogistics ; in general it is necessary, from 
 the beginning, to have recourse to general and local bleedings not- 
 withstanding the smallness of the pulse, for, in proportion as the 
 blood flows, the pulsations rise and become more developed. Though 
 all the ancient and modern authors agree upon the necessity of san- 
 guine evacuations, they are not of the same opinion as to the choice 
 of bleeding from the arm or from the foot. Amongst the ancients, 
 Galen, Oribasius, iEtius, etc., and amongst the moderns, Mauriceau, 
 Dionis, and Astruc, as well as almost all the practitioners of our 
 own day, give the preference to bleeding from the arm, while Mercu- 
 rialis, Hoffman and some others, advise bleeding from the foot, 
 which is also recommended by Pasta, always preceded, however, by 
 
TREATMENT OF ACUTE METRITIS. 
 
 285 
 
 that from the arm. If the disease have not been caused by suppres- 
 sion of the menstrual flow, bleeding from the arm is alone indicated; 
 in the contrary case, we might advantageously open the veins of the 
 inferior extremities, and then resort to applications of leeches to the 
 vulva, and to the superior and internal surfaces of the thighs: as a 
 general rule, bleeding in the brachial veins should be preferred, either 
 because it is of easier performance, because we can take more blood 
 in less time, and from its being more certain; or else because we can 
 better appreciate the quantity of blood obtained, and from its being 
 less incommodious to the patient, whom it is unnecessary to uncover 
 and whom we are not forced to move, which always increases her 
 sufferings. 
 
 After general bleeding, which we should not fear to repeat, though 
 the pulse is often small and frequent, it is proper to resort to capil- 
 lary and local bleeding, by means of leeches applied to the vulva, 
 to the inguinal and hypogastric regions, to the anus, and even over 
 the whole abdomen, if the metritis were complicated with peritonitis, 
 which often happens. Scarified cups upon the mammae, the loins, or 
 the hypogastrium and to the thighs, are likewise indicated. 
 
 At the same time the hypogastrium should be covered with emol- 
 lient applications, and particularly with fomentations made with 
 flannel dipped in a decoction of flax-seed and poppy-heads. Demul- 
 cent and narcotic injections into the vagina should also be prescribed, 
 as well as small enemata of the same nature, absolute repose, rigor- 
 ous diet, gummy and cooling drinks, and in due time veal broth, 
 whey, almond emulsion, and sometimes slightly laxative or diu- 
 retic tisans. The pulp of tamarinds, and dog-grass with nitre, fulfil 
 very well the two last indications. If the pain be extremely severe, 
 we should order a sedative potion, and insist upon injections of the 
 same nature ; flying sinapisms and blisters placed upon different 
 points of the surface of the body, are, after the use of depletion, usually 
 advantageous, because they recall the blood and vital forces from 
 the centre to the extremities. The drawing of the breasts, in recently 
 delivered women, or the application of cups to these organs, irritate 
 and excite in a very efficacious manner the derivative movement 
 which we are seeking to provoke. Although it seems as though we 
 might obtain good results also from general baths, we think that 
 they ought to be rejected in the greater number of cases, because, 
 independently of the frighful suffering which the patient undergoes 
 in the removal to the bath, there often arise dangerous conse- 
 quences from the action of the air on the skin, or perhaps from the 
 difficult adjustment of a suitable temperature. As a substitute for 
 the bath, and to avoid perspiration, Chaussier recommended the 
 introduction of the vapour of water into the bed, by means of a 
 tin tube. The coverings should first be raised up by means of 
 a hoop. If, after the active and well-directed application of all these 
 means, the womb still remains tumefied and engorged, although the 
 general phenomena and acute local symptoms have in part disap- 
 peared, we can assist and almost always obtain a resolution of the 
 disease, by means of frictions with tartar-emetic ointment first to 
 
286 
 
 TREATMENT OF ACUTE METRITIS. 
 
 the internal part of the thighs, then to the sides of the trunk, and 
 finally upon the abdominal parietes. This method, which was recom- 
 mended and employed with much success by M. Duparcque, has 
 been used by us for a long time, not only in the same circumstances 
 as by the excellent practitioner of whom we have just spoken, but 
 also in the treatment of different affections of the vocal organs.* 
 
 The diseases which sometimes complicate acute metritis, ought to 
 lead to great modifications in the treatment. Thus, in the case of 
 complication of a bilious or gastric kind, we should be more careful 
 in our employment of bleeding, and it will be useful to administer 
 emetics of ipecacuanha, followed by some mild laxative, especially 
 when the disease is attended with obstinate constipation. If typhoid 
 and adynamic symptoms occur in the course of the metritis, it would 
 be necessary, after having used with circumspection, and to a mode- 
 rate extent, some sanguine evacuation, to resort to the use of topical 
 remedies, and then to derivatives, especially blisters ; finally, in case 
 nervous and ataxic symptoms make their appearance, we Should 
 prescribe antispasmodics and narcotics. 
 
 When metritis terminates by suppuration, it is necessary to open 
 in good time the abscesses accessible to light and touch, in order to 
 avoid the purulent collections which might form in the abdomen ; 
 if the pus had opened into the uterine cavity, the vagina, the rectum 
 or the bladder, we should throw injections into these cavities, at first 
 emollient, and then gently detergent. In case the metritis should 
 terminate by gangrene, it would be necessary to suspend the anti- 
 phlogistics, and have recourse to antiseptics and tonics, which should 
 be simultaneously administered in drink, in fomentations, in injections 
 and in enemata. 
 
 [I regret that M. Colombat should have separated the discussions on the 
 subject of acute metritis, from those that will be found in a subsequent one 
 on puerperal fever, since it is desirable, in order to enjoy a good coup-d’oeil 
 of the whole subject, to have them as nearly approximated as possible, thus 
 preserving a sort of natural order in the arrangement of these so frequently 
 coincident, if not identical affections. As I propose to make some remarks 
 on the subject of puerperal fever, when that topic shall have been reached 
 in the course of this publication, I shall, for the sake of avoiding iterations, 
 postpone any remarks that I may have for that occasion, and I accordingly 
 refer the reader to that portion of this work, merely stating that the valuable 
 labours of Robert Lee, of London, in his treatise on the subject, may he 
 found in a volume published in 1842, here, in Bell’s Library, where it is 
 accompanied by the previous tracts of Gordon, Hey of Leeds, and John 
 Armstrong, on the same topic. 
 
 There is an affection of women, of no small importance, and not (infre- 
 quently met with in practice, which has wholly escaped the attention of 
 M. Colombat. The disease to which l allude is rheumatism of the womb, 
 
 * Our opinions upon this point were expressed in our treatise upon the diseases of 
 the organs of voice, published some years since. 
 
RHEUMATISM OF THE WOMB. 
 
 28 7 
 
 concerning which not much has been as yet published. Neither Moreau nor 
 Chailly, among the latest of the French system writers on Midwifery, having 
 Said any thing about it, except a very meagre allusion to the disorder by 
 Chailly, at p. 717. The elegant and valuable treatise on Midwifery, by M. 
 Cazeaux, which came out in 1840, has a tolerably full account of it, in 
 Chap. 6th, at p. 646, of the Traite Theorisque et Pratique de VArt des 
 Accouchements , 8vo. Paris, 1840, p. 836, with plates. As Mons. Ca- 
 zeaux’s article is a very sensible and discreet one, and presents a description 
 of the malady in accordance with my own experience at the bed-side, I shall 
 think that the value of this publication will be enhanced by transferring to 
 these pages, the whole of his article on rheumatism of the womb. 
 
 “ Rheumatism of the womb,” says M. C., “after having long attracted the 
 attention of the German practitioners, was but little known in France, when 
 M. Dezeimeris, in his journal, (V Experience,) made public a series of facts 
 already known and published by certain German authors. About the same 
 time, M. Stolz, who had become acquainted with the labours of our neigh- 
 bours on this subject, studied the affection at the Clinical Hospital at 
 Strasburg, and communicated the results of his researches to his pupils. 
 One of these gentlemen, Dr. Salathe, has very recently defended a thesis on 
 this topic. To his work, and to the bibliographical researches of M. Dezei- 
 meris I am indebted for what I am about to say upon this disorder, which 
 is hitherto unknown to our French nosologists. 
 
 “ According to Radamel, rheumatism may attack the non-gravid womb ; 
 but our business here is to study it only as occurring in pregnant women. 
 It may attack at any stage of gestation, and we shall, therefore, after some 
 general considerations on the subject, point out the influence it may exert in 
 pregnancy, in labour, and in the lying-in. 
 
 “ Causes . — All such circumstances as are favourable to the development 
 of rheumatic affections, may likewise lead to an attack of rheumatism of the 
 womb. Thus exposure, whether momentary or prolonged, to dampness 
 and cold, insufficient clothing, sudden transposition from an elevated to a 
 very low temperature, and all other causes, constitutional and atmospheric, 
 regarded by medical authors as occasional or predisposing causes of rheu- 
 matism, may also produce that of the uterus. But, besides these general 
 causes, there is one peculiar to the malady under consideration. I allude to 
 the facility with which this organ, under the thinned integuments of the 
 abdomen, feels the impression of cold in the latter months of pregnancy; 
 the abdomen being guarded, when it encloses the uterus by extremely light 
 garments, which are closely in contact with it, and the antero-sacral region 
 being often badly protected by jackets of insufficient length. 
 
 “ Symptoms . — Rheumatism of the womb often attacks persons consti- 
 tutionally predisposed to nephritis. It may coexist with a general affection 
 of the same nature; but, in a majority of cases, the uterus alone, and the 
 adjacent structures, are the seats of the disorder. It has, besides, been fre- 
 
288 
 
 RHEUMATISM OF THE WOMB. 
 
 quently found to be a consequence of the sudden cessation of rheumatic 
 pain, originally situated in some other part, and suddenly transposed to the 
 womb. Whatever may be the mode of its onset, the disorder is easily 
 recognized by very decided characteristic features. Its principal symptom 
 is pain, where not the least violence has been offered to the organ, the womb 
 becomes the seat of a general or partial pain, the intensity of which varies 
 from the very slightest sense of weight up to the most insupportable agony. 
 It may affect the uterus wholly, or only attack some particular part of it, as 
 the orifice, the fundus, or the cervix. Where the rheumatism is fixed in the 
 fundus only, the pain is felt in the region above the umbilicus. It is in- 
 creased by pressure, by the contraction of the abdominal muscles, and some- 
 times by the mere weight of the clothes ; the patient, often, is unable to 
 move ; if the disorder is seated lower down, there are shooting pains that 
 run from the loins towards the pelvis, the thighs, the external genitals, and 
 the sacral region, along the ligaments of the uterus. Lastly, when the 
 cervix is the affected part, it may be known by the vaginal touch which 
 gives rise to excessive suffering. But of all the causes that serve to exas- 
 perate the pain, none is so distressing as the incessant motions of the child. 
 
 “ Like other rheumatic pains, those of the womb are movable, and are 
 observed occasionally to pass suddenly from one portion of the organ to 
 another. They often suddenly cease, and proceed to attack some other 
 organ. This is most apt to happen, where the uterine rheumatism has 
 been preceded by a fixed pain of some other part of the body, and where 
 remedies are in use calculated to recall the pain to its original seat. 
 
 “ These pains are characterized by frequent exacerbations that are 
 variable as to their duration and intensity ; according to the stage of 
 the malady, they are succeeded by remissions, during which the patient 
 scarcely complains of a vague sense of weight. 
 
 “ The pains of uterine rheumatism are generally attended with a degree 
 of recto-vesical tenesmus, which is violent in proportion to the severity of 
 the pains and the approximation of the seat of the rheumatism to the 
 lower segment of the organ. In such cases, the patient is tormented by 
 perpetual desire to urinate. The discharge of the urine is accompanied 
 with smarting pain, sometimes with severe pains, and in some instances 
 the discharge cannot be effected at all ; the efforts to discharge the contents 
 of the rectum are, in some cases, equally fruitless. Most of the German 
 authors attribute this double recto-vaginal tenesmus to the rheumatic dis- 
 ease, which is not always confined strictly to the uterus alone, but may 
 likewise invade the circumjacent organs. M. Stolz seems disposed to 
 think that it arises from the close sympathetic relations of parts so 
 nearly approximated to each other. Should these new pains be owing to 
 a vesical or rectal rheumatism, those of the womb would disappear, or at 
 least be diminished in degree, according to the views of M. Salathe in his 
 Thesis. 
 
RHEUMATISM OF THE WOMB. 
 
 289 
 
 “ It is to be supposed that there is a degree of heat and swelling of the 
 affected parts; but it is easy to perceive the difficulty of absolutely deter- 
 mining this point, one which we are compelled to admit from analogy. 
 
 “Pains of such violence, situated in an organ so important, must of 
 necessity produce a pretty severe general reaction. The disorder, like most 
 of the inflammatory diseases, generally commences with a slight rigor, 
 which lasts fifteen or twenty minutes. The succeeding fever diminishes, 
 or may even wholly cease during the interval between the attacks, yet 
 while they last it is commonly quite severe; the pulse is hard and fre- 
 quent, the face flushed and excited, the tongue red and dry, the thirst 
 urgent; the skin is hot, and the patient is often found to be extremely 
 agitated and restless. Towards the close of the paroxysm, there fre- 
 quently supervenes a copious sweat, which seems to be the harbinger of a 
 decided improvement. After this, these general symptoms are appeased, 
 together with the uterine pains, only to reappear with them, after the lapse 
 of a few hours, or even of several days. 
 
 “ 1st. Influence of Rheumatism on the progress of Pregnancy . — Where 
 the attacks may have persisted for a length of time, or where they have 
 been very violent, they are followed by uterine contractions, and may, in 
 this way, bring on premature delivery. In such a case the patient suffers 
 from severe tensive pain. This feeling of tension is not equable, for it rises 
 to a great height, and then subsides — to begin again and pursue the same 
 course at different intervals. At first the womb becomes partially, and 
 afterwards universally hardened during the pain. The cervix becomes 
 rigid and partially dilated, but its dilatation is at first slow and difficult, and 
 its subsequent progress does not correspond with the pace of the pains. 
 The abortion, with which she is now menaced, is more likely to take place 
 in the febrile than in the apyretic form of rheumatism. Indeed, abortion 
 is not so common an occurrence in the case as might be presumed. In 
 some instances the os uteri has been observed to dilate to the extent of two 
 or three centimeters in diameter, the bag of waters has been formed, and 
 afterwards withdrawn little by little, the orifice closing again, and all symp- 
 toms of labour wholly to disappear. As long as the diameter of the os 
 uteri does not reach the extent of five centimeters, we may reasonably 
 hope to put off the labour. These uterine rheumatic pains may simulate 
 labour pains, and. lead to the belief that they are really labour pains, 
 while in fact they are not at all so. The characteristic signs of the rheu- 
 matic pains, given in the following paragraph, should serve to prevent 
 such a mistake. It is surely to mistakes of this kind, that we ought to 
 refer those cases of supposed protracted pregnancy, and those instances of 
 real labour, begun, and suspended again for weeks and even for months 
 together.” 
 
 On the 29th January, 1842, Mrs. 0., aged twenty-eight, in her first preg- 
 nancy eight and a half months, was suffering with the symptoms of severe 
 
 19 
 
290 
 
 RHEUMATISM OF THE WOMB. 
 
 rheumatism of the womb, which had afflicted her since about the 12th of 
 the month. On the 15th of the month, fearing that labour was begun, I 
 examined and found the os uteri dilated fully a quarter of an inch, and the 
 cylindrical tubule of the cervix wholly gone; but on the 29th of the month, 
 or fourteen days later, during all which time she suffered more or less, the 
 os uteri was not only closed up, but the cylindrical tubule of the cervix was 
 reproduced, and continued so until her child was born on the 1 6th day of 
 February. 
 
 About three years since, a lady, a missionary, landed here from a voyage 
 from Madras, of one hundred and twenty days. She walked a good deal 
 on the day of her debarkation, and was seized with the signs of labour the 
 same evening, being not quite eight months gone with child. The pains 
 were strong; I found the os uteri an inch and a half in diameter, with the 
 membranes tensely drawn across the opening. The labour was suspended 
 in the night, but returned again the next afternoon ; and during twenty-four 
 days that she continued to be annoyed, more or less, with signs of labour, 
 the os uteri never closed, and, at the end of that time, she gave birth to a 
 small, but healthy male child. I have had many occasions to see persons 
 threatened with labour, and even precipitated into it, by rheumatism of the 
 womb. 
 
 M. Cazeaux says nothing of the diagnosis, which I regard as one among 
 the most difficult that can be presented to the mind of a physician. To 
 make the diagnosis between pleurisy and pleurodyne, is often a very diffi- 
 cult task, and one of considerable moment, too ; but, to make out satisfac- 
 torily all the points of difference betwixt rheumatism of the womb and the 
 acute inflammations of the organ, especially in the lying in, is still more mo- 
 mentous. Rheumatism is, so far as my experience of it enables me to speak, 
 most apt to attack very nervous and susceptible women who have become 
 weakened and reduced in strength, from whatever cause. In such subjects, 
 it is highly desirable to get through the case without much resort to the 
 stronger antiphlogistic measures; but, if we mistake an intense metro-peri- 
 tonitis for a case of rheumatism of the uterus, we shall abstain from any 
 vigorous and eradicative employment of the lancet, pnder the vain hope of 
 curing our patient by milder and less costly processes than the exhausting 
 venesections which are so indispensable in the true inflammation. 
 
 I have had such great difficulty in settling, to the satisfaction of my own 
 judgment, the diagnostic differences betwixt the two maladies, in several 
 violent cases that have fallen under my notice, within a few years, that 
 I should be thankful for the indication of a clear method of coming to the 
 decision. In both maladies is the fever often violent; in rheuraatismus 
 uteri there is rheumatic neuralgia of other parts, and a preceding history, 
 that may enlighten the practitioner to his decision. In the two diseases 
 there is equal sensibility of the abdomen ; meteorismus may accompany 
 both. The heat of skin, and frequency and volume of the pulse, are alike 
 
RHEUMATISM OF THE WOMB. 
 
 291 
 
 in each — the decubitus similar; but the tongue is clean, so far as I have 
 noticed it in the rheumatic case. Distracted with the uncertainty and doubt 
 in which the case is involved, I have commonly been able to satisfy my 
 mind by a direct appeal to the organ itself, in the operation of Touching. 
 In both maladies, the Touch is at first painful ; in metritis and metro-perito- 
 nitis, it is so under all circumstances ; but, in rheumatismus uteri* though 
 the first touch of the womb is painful and quick , yet when the organ is 
 gently and slowly raised upwards with the index and medius, the pain 
 either ceases wholly or is much mitigated, by taking off, in this way, the 
 tenesmus uteri ; not so in the inflammation, where every touch is more pain- 
 ful the more it is prolonged. I may be permitted to add, that I have heard 
 of several cases of death from puerperal fever, where, upon an autopsy, not 
 the least vestige of inflammation was discovered, either in the peritoneum, 
 the uterine veins, the substance of the uterus, or any of its appendages. Is 
 it uncharitable to suppose that such patients died, not with the malady for 
 which they were treated, but with another disorder, to wit, rheumatismus 
 uteri, which demanded quite a different mode of cure?* but I fear to extend 
 this note too far, and therefore M. Cazeaux proceeds as follows : M. 
 
 “2 d. Influence of Rheumatism upon Labour . — An attack of uterine 
 rheumatism generally retards the progress of a labour, and sometimes 
 even renders the spontaneous expulsion of the foetus wholly impos- 
 sible. In addition to the general phenomena I have described, there are 
 here some special ones to be met with. 1st. It is well known that a normal 
 contraction does not begin to be painful until it has accomplished the greater 
 part of its task, and is in the act of dilating and distending the os uteri ; in 
 other words, the true pains of labour do not begin until the instant at which 
 the energy of the corpus uteri begins to overcome the resistance of the cervix. 
 In rheumatism of the womb, on the other hand, the uterine contraction 
 begins to be painful from the start, and before the least power is exerted on 
 the neck; so that the cause of the pain is not in the violent distension of 
 the orifice, but in the contraction itself, in other morbid circumstances, and 
 in other relations of the nerves and contractile fibres of the womb. 2d. In 
 a natural labour, the contractions commence at the fundus uteri, and are 
 directed towards the lower segment. In rheumatism, instead of commencing 
 at the fundus, they commence at the painful point, and run towards the neck 
 in an irregular manner. Again, the pains exist before the contractions of 
 the womb ; and, under their influence, when they are established, acquire a 
 high degree of intensity. Their violence sometimes arrests the contractions 
 
 * M. Cazeaux himself, near the end of this article, says that it is often liable to be 
 mistaken for a pure inflammation, and then treated by remedies more likely to be 
 injurious than beneficial. If it be true that the danger to life from rheumatismus 
 uteri be but small, as Mr. C. supposes, it is at least dangerous when improperly 
 treated under a false apprehension of its dangerously inflammatory and destructive 
 character. 
 
292 
 
 RHEUMATISM OF THE WOMB. 
 
 before they have run through their ordinary cycle. They are, in such a 
 case, brisk, short, and grow less and less frequent. 3d. Towards the close 
 of the labour, when the action of the womb requires to be sustained by the 
 voluntary contraction of the abdominal muscles, the woman, for fear of in- 
 creasing her sufferings, refrains from contracting her abdominal muscles, 
 which causes the labour to be excessively slow. The patient is in a state of 
 extreme anxiety ; the frequent pulse, the hot skin, the thirst, the urinary 
 tenesmus, are much augmented. When the sufferings are too much pro- 
 tracted, she at last falls into a collapse, (which is often a fortunate event for 
 her;) during which the pain is suspended. Under these circumstances, a 
 profuse sweat has been observed, which has had the happiest effect on the 
 rest of the labour. But, in other instances, the womb grows more and more 
 painful ; it is rather in a state of permanent contraction, or fibrillar vibration, 
 than of real contraction; the pulse becomes accelerated, and now the woman 
 is under the influence of a metritis which renders the labour extremely 
 painful. 
 
 “3d. Influence of Rheumatism of the Womb on the puerperal func- 
 tions. — One may conceive, d priori , that uterine rheumatism, by causing 
 irregular or partial contractions of the organ immediately subsequent to the 
 birth of the child, might be the occasion of much difficulty in the delivery of 
 the placenta ; hut this is not the place to discuss that point. 
 
 “ In health, after the delivery, the womb contracts, and thus prevents 
 haemorrhage. But in rheumatism this return of the organ is very incom- 
 plete ; it remains above the pubis and is large. The after-pains are now 
 very painful, and continue for a long time. The uterine vessels are less 
 compressed, whence may arise very copious floodings. On the other hand, 
 the state of suffering in which the organ is placed diminishes the lochial 
 discharge, and the secretion of milk. The persistence of abdominal pain, 
 added to the symptoms of a general reaction, might lead to the diagnosis of 
 a peritoneal inflammation, though none such should really exist. 
 
 “ Prognosis . — Rheumatism of the womb is not a disease capable of caus- 
 ing the loss of the mother’s life; but from the pain it. occasions, and the 
 mistakes to which it leads, it nevertheless merits all the attention of the 
 physician. In pregnancy, it may cause abortion ; and though it does not 
 generally exhibit itself until the sixth month, it is always unfortunate for the 
 child to be born before full term. We have already remarked upon the 
 unfavourable effect produced by the disorder on the course and character of 
 labour-pains. On many occasions it has led to the necessity of artificial de- 
 livery. It may likewise render the delivery of the after-birth difficult, and 
 derange the course of the phenomena that ought naturally to follow after 
 the birth of the child. At this period it is often confounded with phenomena 
 that are purely inflammatory, and is then treated by measures that are hurt- 
 ful rather than beneficial. 
 
 “The disorder is for the most part less favourable when attacking at an 
 
CHRONIC METRITIS. 
 
 293 
 
 early than at a late period of gestation ; because it has a more unfavourable 
 influence on the progress of the gestation as yet incompletely established 
 and settled ; and also because it lias a tendency to be reproduced again and 
 again before the completion of the term, and on account of its disposition 
 to return during the labour, which it is apt to render laborious. 
 
 “ Treatment. — 1st. During pregnancy, blood-letting, intestinal revulsives 
 (ipecac., castor oil) baths, opiated lotions for the abdomen — anodyne potions, 
 sudorific drinks. Such are the measures which have been most constantly 
 successful. In cases where the affection of the uterus had followed the 
 sudden disappearance of a rheumatic pain of some other part, revulsives 
 should be applied to the part first affected. 2d. During labour, the same 
 means are applicable ; should they fail, and the os uteri as to its dilatation 
 admit of it, let the delivery be effected by means of turning or the forceps. 
 3d. After delivery, sudorific drinks, anointing the abdomen with opiated 
 ointments, baths, leeches to the vulva, and when the lochial discharge has 
 failed, ipecac, and opium combined.” 
 
 ✓ 
 
 OF CHRONIC METRITIS OR SUBACUTE INFLAMMATION OF THE 
 PROPER TISSUE OF THE UTERUS. 
 
 Of all the diseases to which women are exposed, there is none 
 more common, or more apt to be misunderstood than chronic inflam- 
 mation of the womb. This affection, not in itself very dangerous, 
 is nevertheless often followed by the most unfortunate results, because 
 persons who are attacked with it, guided by a sense of natural, but 
 unreasoning modesty, put off consulting the physician until their 
 sufferings and inconveniences become altogether insupportable, and 
 sometimes even until the march of their disease has placed it beyond 
 the resources of art. 
 
 This affection, like acute inflammation of the uterus, may occupy 
 the whole of the organ or be confined to the neck, and in the same 
 way may succeed to acute metritis, or declare itself primarily in the 
 chronic state. These observations upon the seat and etiology of 
 uterine inflammations, had already been made by the ancients ; for, 
 in speaking of the disease which now engages us, JEtius* expresses 
 himself in the following manner: « Uterus interdum millo prius 
 indicant e signo repent e induratur ” and Paul of Egina, who 
 copied a part of the works of Alexander Traliianus, and who was 
 of great authority amongst the Arabian physicians, says also : 
 “ In scyrrhum\ induratur uterus aliquando derepente mulla 
 praegressd enusd 
 
 When chronic inflammation of the womb follows acute metritis, 
 it recognizes the same causes ; when, on the contrary, it is primitive, 
 it results from special causes, which we shall divide into predisposing 
 
 * Contracts ex veter. Tetrab., lib. xvi.cap. 86. 
 
 f De Medic., lib. xxiii. cap. 64. Paul of Egina, (loc. cit.) arid H3tius, (loc. cit.) de- 
 signate chronic inflammation of the body of the womb by the word Scyrrhus, and 
 that of the neck of this organ, by the term Selcroma. 
 
294 
 
 CHRONIC METRITIS. 
 
 and exciting. Among the former, we should include depressing 
 moral affections, a lymphatic temperament, scrofulous childhood, 
 herpetic or syphilitic diathesis, cancerous hereditation, bad alimenta- 
 tion, dwelling in a low, humid or imperfectly ventilated place, the 
 custom of wearing tight corsets, and of reading works which pro- 
 duce turgescence of the uterus. Chronic metritis is most common 
 from the twentieth to the fortieth year ; it occurs more particularly 
 in women who have borne several children, who have had easy 
 abortions or premature confinements ; in young women without chil- 
 dren, and in girls at puberty, whose menstruation is painful and 
 irregular, and finally in women approaching the critital age. 
 
 When this disease is primary, it may, like acute metritis, be deter- 
 mined by excessive coitus, by masturbation, by the presence of a 
 pessary in the vagina, by herpetic or rheumatic metastasis ; by the 
 cooling of the extremities during or after violent exercise; by the 
 application of a cold body to the thighs to suppress uterine hemor- 
 rhage ; by cosmetic lotions during or after the flow of the menses ; 
 by sitting on a cool and damp place, as a stone-seat, or the grass ; the 
 immoderate use of ices or sherbets at balls ; violent emmenagogues, 
 prolonged celibacy, and absolute continence ; the real or relative dis- 
 proportion of the sexual organs ; the presence of one or more polypi 
 and attempts at their ligature or extraction ; the forced dilatation of 
 the mouth of the uterus ; the use of foot-stoves and exposure of the 
 genital parts to great heat ; the use of tea or of alcoholic drinks ; and 
 finally, this affection may come on sometimes without appreciable 
 cause that can be explained. Chronic metritis is generally difficult 
 to recognize at the commencement, and we may at most, perhaps, 
 suspect its existence, because of the changes which occur in the 
 temper of the woman, who becomes sad, melancholy, impatient and 
 irascible. But these symptoms are commonly useless to the physi- 
 cian, who is seldom consulted previous to a period at which the dis- 
 ease is made evident by symptoms sufficiently distinct to remove 
 all uncertainty. 
 
 In order to place the diagnosis and treatment of subacute and 
 chronic metritis in greater order or clearness, we shall mention the 
 principal forms under which it presents itself to observation, to wit : 
 1. Subacute and simple inflammation without engorgement; 2. 
 Chronic inflammation with engorgement ; 3. Subacute and chronic 
 catarrhal inflammation ; 4. Inflammation with ulceration ; 5. In- 
 flammation with granulations. 
 
 CHRONIC METRITIS WITHOUT ENGORGEMENT. 
 
 This form of chronic metritis has been described by M. Lisfranc, and 
 called by that able practitioner, sub-inflammation without engorge- 
 ment ; it is characterized by acute pain increased by long standing, 
 by exercise on foot and in a carriage, and especially by coitus. 
 Women attacked by it feel a sensation of great heat and smarting in 
 the pelvis, accompanied with weight in the lumbar and iliac regions, 
 
CHRONIC METRITIS. 
 
 295 
 
 and a kind of turgescence and burning heat in the uterus. The 
 sensibility of the organ is so much augmented, that the effort to 
 expel the faecal matter gives pain. 
 
 Notwithstanding these symptoms of irritation, in whatever mode 
 the Touch is performed, we find nothing anormai in the volume, con- 
 sistence or situation of the neck and body of the gestative organ, un- 
 less it be that the orifice of the uterus presents a rather greater degree 
 of dilatation than is customary. The introduction of the finger and 
 still more of the speculum into the vagina is extremely painful ; 
 this latter mode of exploration enables us to ascertain that the os 
 tincae is free from engorgement, and presents nothing anormai. 
 
 This sort of chronic metritis, without appreciable change in the 
 uterus, sometimes comes on without any evident cause, and pro- 
 duces pains which are remittent or more frequently intermittent. It 
 is chiefly on this account that most practitioners, regarding the affec- 
 tion as purely nervous, are satisfied to prescribe palliative means, or 
 they abandon the disease 'to itself, whence it happens that it makes 
 rapid progress, and the pains constantly go on augmenting. 
 
 It is therefore of the greatest importance to recur from the first to 
 antiphlogistics, and especially to general bleeding, to baths, to emol- 
 lient and narcotic enemata, to demulcent drinks, etc. If the pain 
 continues to attack in paroxysms, we might resort to the use of sul- 
 phate of quinia, combined with the watery extract of opium. 
 
 CHRONIC METRITIS WITH ENGORGEMENT. 
 
 It is under this form that chronic metritis most frequently presents 
 itself to our observation. 
 
 The engorgements of which the neck or body of the womb may 
 be the seat, ought to be divided into two classes, presenting several 
 varieties. 
 
 In the first class, comprising all the engorgements without indura- 
 tion, are found, simple hypertrophy, oedematous engorgement, and 
 sanguine engorgement, with or without haemorrhage ; in the second 
 class, which comprises *engorgement with induration, we range 
 hypertrophy with induration or simple white engorgement, scirrhous 
 engorgement, and tubercular induration. 
 
 Before describing the sensible signs which distinguish all these 
 varieties of engorgement, we shall enumerate the symptoms which 
 are common to the greater part of them, and which depend in part 
 on the augmentation in weight and volume of the uterine organ, as 
 well as partly upon the disturbance of the neighbouring parts. 
 
 Commonly, when the organ is the seat of any engorgement or 
 hypertrophy whatever, it almost always prolapses, either preserving 
 its natural direction, or taking one more or less considerably inclined. 
 The pressure, which in this case is exerted upon the rectum and 
 bladder, often gives rise to obstinate constipation, to pains more 
 or less acute in the expulsion of the faecal matter and urine, and 
 almost always to a sensation of weight, and painful troublesome 
 
296 
 
 CHR0XIC METRITIS. 
 
 dragging about the sacrum, in the groins and loins, and even along 
 the whole extent of one of the sciatic nerves. 
 
 We must add to these symptoms a feeling of heat, a deep-seated 
 obscure pain in the hypogaster, which increases at intervals while 
 standing, or walking, and especially during coitus, from the pressure 
 of the penis on the os tincae. This increase of pain is associated 
 With a sense of pruritus and rawness in the pelvic cavity, and 
 most commonly with a transient or continued fever, in either case 
 slight, and perceived particularly during the period of menstruation ; 
 finally, the phenomena common to all the chronic inflammations of 
 the womb, under whatever form observed, are the following: the 
 women suffer remarkable modifications of their menstruation ; if 
 their menses appear at the ordinary epoch, they generally last a 
 shorter time, and the blood is pale and almost serous ; when, on the 
 contrary, they fail for several months, a haemorrhage almost always 
 occurs, which lasts ten, fifteen and even twenty days, and which 
 produces discoloration of the face, feebleness and emaciation. Be- 
 tween each menstrual epoch, there takes place from the vulva a sero- 
 mucous or sanguineous, or even a fetid discharge, which has been 
 described as the principal character of confirmed cancer, and the 
 colour of which, its consistence and quantity, are extremely varia- 
 ble. Hysterical phenomena almost always appear, especially in 
 young women ; some suffer from mammary pains, and other ner- 
 vous symptoms, such as palpitation, cramp and formication in the 
 legs, oppression, and general restlessness ; the stomach, which is con- 
 nected with the uterus by the strongest sympathy, almost always 
 partakes of the pathological condition of the organ ; the patients lose 
 their appetite ; their digestion is laborious and accompanied with 
 nausea, eructation, and vomiting, which is peculiar, inasmuch as it 
 generally relieves the female, so that when the stomach has rejected 
 the first aliment that it contained, what is afterwards taken may 
 frequently be retained. 
 
 When the disease is left to itself, the vaginal discharges become 
 more abundant from day to day, the health steadily deteriorates, 
 the debility increases, a slow fever sets in, finally the whole economy 
 seems to participate in the morbid condition of the uterus, whose 
 chronic inflammation is often the prelude to a fatal disorder ; in some 
 cases, on the contrary, the woman seems to enjoy a moderate degree 
 of health for a long time, and to preserve her embonpoint, colour 
 and strength pretty well, notwithstanding the progress of the dis- 
 ease. 
 
 The major part of the symptoms we have just enumerated, and 
 which can be learned only from the report of the patient, always 
 indicate that the uterus is in a pathological condition ; but taken 
 separately, they are of little value in making a positive diagnosis, 
 since they give as good reason to suspect the existence of a com- 
 mencing degeneration, of a polypous tumour, a prolapsus, or any 
 other lesion of situation, as to clearly show that the gestative organ 
 is the seat of a chronic phlegmasia, or of a simple or ulcerated en- 
 gorgement. 
 
ENGORGEMENT OF THE WOMB WITHOUT INDURATION. 2 97 
 
 To remove all uncertainty upon this point, it becomes necessary to 
 resort to the touch and to the application of the speculum, which are 
 the more valuable as means of making a good diagnosis, inasmuch 
 as they alone yield us certain signs for recognizing and perfectly 
 distinguishing all the chronic affections of the uterus. 
 
 ENGORGEMENT OF THE UTERUS WITHOUT INDURATION. 
 
 Uterine engorgement without induration, is nothing else than the 
 disorder called by M. Lisfranc, morbid hypertrophy , the chief cha- 
 racter of which is an augmentation in size of the uterus without 
 alteration of tissue. 
 
 The engorgement without induration, may occupy the whole of 
 the uterus, or simply its neck, but commonly this latter part is alone 
 affected, and it is well to remark that when the morbid hypertrophy 
 attacks a part of the gestative organ, it occupies it entirely, and not 
 by isolated points, as happens in scirrhous engorgement. 
 
 Chronic metritis without induration, is recognized not only by the 
 symptoms which we have already enumerated, but also by other 
 more certain signs afforded by the Touch and by the speculum. 
 
 On carrying the index-finger into the vagina, we find that the walls 
 of this canal, as well as the neck of the uterus, are the seat of anor- 
 mal heat and much greater sensibility than in scirrhous hypertrophy. 
 The os tineas and the body of the womb present nearly the consist- 
 ence proper to them in a pregnancy of a month or six weeks. Were 
 we desirous, says the celebrated surgeon of La Pitie, to give a com- 
 parative idea of the sensation felt by the finger, we should call to 
 recollection that which is produced by a lipoma not yet degenerated, 
 or the mamma of a young girl who has perished by a sudden death, 
 or, finally, that of a body slightly compressible or resisting, elastic or 
 somewhat spongy; in performing the Touch per rectum, we feel the 
 body of the uterus yield under pressure, as though we pressed upon 
 a cushion full of wool or cotton which had been compressed. 
 
 The orifice of the neck is generally found more dilated than in its 
 normal state, and the end of the index-finger may frequently be car- 
 ried into it, but in this case we do not feel the sensation of craque- 
 ment, which exists in engorgement with induration. If we explore 
 the parts by means of the speculum, the neck, partly effaced and 
 tumefied, as in pregnancy, is of a more or less deep red colour, and 
 sometimes even of a brown or vinous red, but the colour is uniform 
 throughout its whole extent ; nevertheless, in certain cases, small 
 isolated spots may be remarked here and there, which give a dotted 
 aspect to the surface of the os tincse. 
 
 It is of the utmost importance not to confound simple engorgement 
 of the uterus with another much more serious affection which differs 
 essentially from it, and which is nothing else than softening of the 
 uterine parenchyma. Where this pathological condition is present, 
 the tissue of the gestative organ recedes under the pressure of the 
 finger like the skin of a rotten apple; instead of meeting an elastic 
 spongy tissue, one giving the sensation of the mamma of a young 
 
298 
 
 ENGORGEMENT OF THE WOMB WITHOUT INDURATION. 
 
 girl, or of a lipomatous tumour, we find a pultaceous aetheromatous 
 tissue, whose envelopes seem to contain matters having the consist- 
 ence of a brownish bouillie or semi-fluid honey; this morbid condi- 
 tion, which is often accompanied by superficial ulceration, constitutes 
 what most authors have called occult cancer. 
 
 As this last pathological lesion offers no chance of safety except 
 by the removal of the degenerated portions, it becomes very import- 
 ant not to confound it with simple morbid engorgement, which is 
 very curable, and never requires any operation. To the differential 
 signs which we have just mentioned, we might add that, hypertrophy 
 without induration is ordinarily of recent date, and that it occupies 
 the neck, and frequently the whole of the womb, while scirrhus and 
 cancer date from a more distant period, and remain a longer time 
 limited to a small portion of the uterine organ. 
 
 The treatment of this kind of chronic metritis offers two different 
 indications, according as the engorgement exists with or without 
 pain ; in the first place, we should have recourse to antiphlogistics, 
 to emollient and soothing drinks, to injections nearly cold, and to 
 sedative enemata of the same temperature ; to small bleedings from 
 the arm, which ought to be rather revulsive than depletory, and 
 which should be used, as far as possible, six or eight days after the 
 flow of the menstruae, with the view of dissipating the weight, the 
 pain, and the remains of the congestion commonly present after each 
 menstrual evacuation. 
 
 If the woman, however, were strong, and of a sanguine and ple- 
 thoric temperament, the treatment should be opened by a depletory 
 bleeding of eight or twelve ounces. In every case we should pre- 
 scribe absolute rest, complete abstinence from the conjugal approach, 
 and the patient should be submitted to a regimen, which might be 
 somewhat modified according to her habits and temperament, but in 
 general it should consist of vegetables, white meats, fish, preparations 
 of milk, cooked fruits, etc. 
 
 If the engorgement were accompanied by but little pain, and if 
 there remained merely a sensation of weight in the pelvic cavity, 
 we should, in like manner, have recourse to the remedy already men- 
 tioned ; but in this case it would be well, (in order to hasten the reso- 
 lution,) to allow of a little exercise, and to recur to revulsives, such as 
 dry or scarified cups, douches about the pelvis, small moxas, whether 
 after the method of .Baron Larrey, or by means of an iron hammer 
 dipped in boiling water, as recommended by M. Mayor of Lau- 
 sanne. For ordinary drink, we might prescribe bitter infusions, and 
 allow a moderate coitus, which, by procuring slight excitation, might 
 contribute to dissipate the remains of the disease ; in case the woman 
 should continue, notwithstanding the methodical employment of 
 these measures, to experience some uneasiness and pain in the pelvis, 
 we should assure ourselves of the state of the parts with the aid of 
 the speculum, and should excoriations be discovered upon the os 
 tincae, we might cause their disappearance by cauterization with the 
 acid nitrate of mercury. 
 
 Though this treatment be simple, it ought, in order to succeed, to be 
 
(EDEMA OF THE OS UTERI. 
 
 299 
 
 followed scrupulously and with perseverance, for the cure, which 
 commonly requires from one to three months, may, in some cases, be 
 prolonged much beyond this. The patient and physician should then 
 arm themselves with patience, and not judge of the progress of the cure 
 by the march of the pains, for, as M. Lisfranc has remarked, these 
 sometimes augment in proportion as the engorgement diminishes. 
 
 OF (EDEMA OF THE NECK OF THE UTERUS. 
 
 This increase in size of the neck of the uterus, which has been 
 described by M. Duparcque,* is an extremely rare disorder, which 
 seems principally to attack women of the lymphatic temperament, 
 subject to catarrhal affections, and especially to old and profuse leu- 
 corrhoea. 
 
 The determining causes of oedema of the neck of the womb are 
 unknown, yet it would appear that it may be the result of the sudden 
 suppression of an abundant and serious uterine catarrh, especially in 
 persons convalescing and still labouring under general atony ; accord- 
 ing to M. Duparcque, (loco citato) this affection may also be the 
 result of violence applied to the neck of the uterus during labour ; 
 but in such case, the oedematous engorgement, which persists or aug- 
 ments up to the appearance of milk-fever, diminishes or disappears 
 ordinarily before six weeks or two months. 
 
 In performing the vaginal examination, the neck of the womb, 
 which is commonly depressed, is found to be the seat of a tumour in 
 form of a circular swelling, presenting at its centre an infundibular 
 depression which terminates in a narrow orifice. Carried up to a 
 level with the insertion of the vagina, or introduced into the vagina, 
 the finger readily ascertains that the tumour is strangulated above, 
 and lost in the body of the uterus, whose size is not increased. The 
 kind of engorgement which is felt is indolent, almost insensible to 
 the touch, and much lighter and more elastic than the others ; more- 
 over, it will always be easy to distinguish and establish a certain 
 diagnosis by means of the speculum, which will allow us to perceive 
 a transparent whitish tumour, retaining the impression of the finger, 
 and forming a ring-like projection, which seems to be strangulated at 
 its point of junction with the uterus. 
 
 It appears that the local treatment of this oedematous affection, 
 which has been little observed, ought to consist in the employment of 
 punctures made in the circumference of the os tines and in astringent 
 injections. The general treatment should vary according to the cir- 
 cumstances and causes which have produced and keep up the 
 disease. However, in the greater part of the cases, we should pre- 
 scribe the use of diuretics, and aromatic sudorifics conjointly with 
 stimulating and dry fumigations, made with gum benzoin or juniper 
 berries. We think that it would also be advantageous to recur, 
 under some circumstances, to the employment of tonics, and princi- 
 pally the martial preparations. 
 
 * Traits des Alterations organiques de la Matrice, p. 92. 
 
300 
 
 HYPERiEMIA OF THE WOMB. 
 
 SANGUINE ENGORGEMENT OF THE UTERUS WITH AND WITHOUT 
 
 HAEMORRHAGE. 
 
 The congestive engorgements which, as well as the preceding, 
 have been described by M. Duparcque, present two varieties, whose 
 characters we are about to lay down, from the able practitioner 
 whom we have just cited. 
 
 The first kind, or engorgement from simple congestion, besides its 
 development at the menstrual epochs and after labour, may be pro- 
 duced by all the general causes of metritis, and the special excitants 
 capable of provoking and maintaining a too considerable sanguine 
 afflux towards the gestative organ ; simple sanguine engorgement, 
 which is variable in its size, may be carried to such a degree, that 
 the womb sometimes acquires, in a little while, a volume equal to 
 that which it presents at the fourth or fifth months of pregnancy. 
 This state of congestion of the uterine parenchyma, which somewhat 
 increases the natural consistence of the parts, and which determines 
 no other pain than that which results from the contractions of the 
 organ, ought not to be confounded, with the engorgement produced by 
 acute inflammation of the womb. The latter affection may be distin- 
 guished from it by different symptoms which we will describe pre- 
 sently, and especially by great sensibility ; by the less considerable 
 development of the organ, and by all the general and local phe- 
 nomena indicative of inflammatory action. 
 
 According to M. Duparcque, whom we quote literally, the symp- 
 toms of sanguine engorgement of the uterus, are nearly the same 
 as those of metritis, but in a less degree ; sensation of enlargement, 
 tension and weight in the pelvis; lumbar, sacral and inguinal 
 pains ; uterine pains, in paroxysms more or less frequently re- 
 peated and prolonged, during which, it seems as though the uterus 
 contracted violently to expel the blood with which it is engorged ; 
 peculiar pains, known by the name of uterine colic or cramp ; ute- 
 rine tenesmus ; and lastly tormina. These pains are sometimes so 
 violent, that the patients are forced to bow themselves strongly 
 while they last. Nevertheless, pressure, as well as the touch, show 
 the insensibility of the engorged parts, at least in the intervals of 
 the tormina, which is the reverse of engorgement with inflammation, 
 a case accompanied by most violent pains and constant soreness. 
 
 The general symptoms, sometimes absent, at other times very 
 marked, bear upon the nervous and circulatory system ; whence 
 various forms of neurosis, and also fever, a general condition rare 
 at this time, or which lasts but a short time. 
 
 M. Duparcque has reported several cases which prove that en- 
 gorgement from congestion passes into the condition of subacute 
 inflammation, and thence into the most profound organic transfor- 
 mations. He adds that this affection often serves as a prodrome to 
 acute and chronic metritis, as well as to the haemorrhagic engorge- 
 ments of which we are about to speak. When the congestion exists, 
 the slightest causes may develop inflammation or excite sanguine 
 losses. Besides, simple and recent sanguine engorgement leaves few 
 
HYPER2EMIA OP THE WOMB. 
 
 301 
 
 or no traces at the autopsy, because, at death, the engorging fluids 
 retrograde and abandon the vascular system of the gestative organ. 
 
 The treatment of this affection ought to consist, first, in the dimi- 
 nution of the fluxionary movement, by removing the causes which 
 have determined or which maintain it, and in recalling it towards the 
 other organs by means of derivative bleedings, of cups, and of irri- 
 tants applied more or less freely to the congested organ. If, after 
 the employment of derivatives, the engorgement should not be dissi- 
 pated, we must encourage the establishment of the local haemorrhagic 
 flux, which is the most natural mode of termination of the uterine 
 congestion. Then, we must resort to local baths, to relaxing drinks, 
 to emollient applications, to antispasmodics, and to sedatives, to com- 
 bat, at the same time, the rigidity of the womb, which, as well as the 
 nervous and anormal condition of this organ, may be the cause of the 
 retention of the sanguine flux. Finally, we might supply the place 
 of this discharge by means of an application of leeches to the os 
 tincge ; and if the congestive engorgement be kept up by an atonic 
 state of the organ, it should be treated by astringents or by ergot, to 
 the amount of a drachm, taken in doses consisting of several grains, 
 and repeated every two hours. If the sanguine congestion should 
 resist means, based upon the principles which we have just ex- 
 plained, it is probable that we have to do with some other altera- 
 tion, which we should seek to recognize and oppose by therapeutical 
 agents, to vary according to the nature of the disease. 
 
 CONGESTIVE ENGORGEMENT, WITH HEMORRHAGE. 
 
 This species of engorgement, which may occupy the whole or 
 only the neck of the uterus, develops itself in the same manner as 
 the preceding ; it is likewise produced by the same causes, that is to 
 say, by a fluxionary movement, which, in this case, is excessive, and, • 
 in particular, more prolonged; and which, moreover, is always accom- 
 panied by an abundant and continual haemorrhage. This sanguine 
 discharge from the vulva, the colour, quantity and consistence of 
 which are variable, is the most constant symptom of the engorge- 
 ment which occupies our attention. 
 
 If we explore the parts by means both of the Touch and specu- 
 lum, we find the neck tumefied, softened and of a more or less deep 
 red colour; the mouth of the uterus, which is enlarged in proportion to 
 the engorgement, as well as the whole surface of the tumour, is the 
 seat of a sanguine exudation which, though often considerable and 
 permanent, does not at all diminish the congestion. The os tincae, 
 covered with clotted blood, appears smooth to view, but somewhat 
 uneven to the touch ; by gentle pressure, we perceive a slight sen- 
 sation of crepitation, and cause an oozing of black blood, which 
 escapes as from a sponge. 
 
 The general phenomena, which are the consequence of the con- 
 tinual losses of blood, vary according to their duration and amount. 
 The skin becomes tense and pale, the strength gradually diminishes, 
 
302 
 
 CONGESTIVE ENGORGEMENT WITH HEMORRHAGE. 
 
 and the patient, who feels a sensation of dragging and weakness in 
 the praecordial and hypogastric regions, soon loses her appetite, or 
 it sometimes becomes insatiable. 
 
 When the disease has reached its last, stage, the skin assumes a 
 yellowish, straw tint, as in ordinary cancerous affections ; the eyes 
 seem dull, and if some women are observed to retain a certain 
 degree of embonpoint, it is because the surface of their bodies has 
 become the seat of a general bloating which conceals the wasting 
 of their muscles. On examination per vaginam, the neck of the 
 uterus is found to be macerated, and transformed into a sort of ulcer, 
 presenting a layer, which is softened and putrid, surrounded by a 
 hard, and, as it were, scirrhous tissue. Haemorrhagic engorgement, 
 which has reached this stage, is extremely serious, and there is no 
 hope of seeing tissues so profoundly changed, return to their normal 
 condition. When the disorder is recent, or seems to be the continua- 
 tion or augmentation of the haemorrhagic congestion of the menstrual 
 epochs or of labour, the prognosis is less unfavourable, and we may 
 even hope to obtain a perfect cure by resorting to a rational plan of 
 treatment, one modified according to circumstances. In general, the 
 danger of the disease is in proportion to the violence and duration of 
 the uterine haemorrhages. 
 
 The treatment of engorgement from congestion with sanguine 
 discharge, in the early stage, that is to say, without softening of the 
 tissues, is nearly the same as that of engorgement from simple con- 
 gestion: thus, it should, like that, be at first confined to derivative 
 bleedings, to dry and scarified cups, to sinapisms, etc. If, as often 
 happens, these remedies should not arrest the fluxionary movement, 
 and consequently the uterine discharges, the employment of bleeding 
 should be abandoned, in order to recur to an astringent and styptic 
 medication, which, though injurious in the commencement, suits very 
 well where the haemorrhagic engorgement is maintained by an atonic 
 and relaxed condition of the diseased tissues, which is mostly the 
 case where the disease, existing for a long period, has occasioned a 
 general debility. In this condition, we may obtain the happiest 
 results, from the internal use of extract of rhatany, of decoctions of 
 oak- bark, solutions of alum, the mineral acids, ferruginous prepara- 
 tions and natural or artificial ferruginous mineral waters ; amongst 
 others, those of Spa, of Forges, of Passy, etc.; finally, ergot seems, 
 in some cases, to offer advantages which have been ascertained by 
 several practitioners, particularly by Dr. Duparcque. When the dis- 
 ease has reached such an extent that the parts have become softened 
 and disorganized, the medical treatment should be limited to the use 
 of palliatives. We can hope to effect a cure only by the destruction 
 of the diseased part, by means of a cutting instrument or by cauteri- 
 zation ; but, unfortunately, it is difficult, and even impossible, to ascer- 
 tain the limits of the alteration, and consequently to know whether it 
 be entirely accessible to surgical operations. We shall conclude by 
 saying that engorgement from congestion, with haemorrhage, presents 
 so great an analogy to fungous haematodes, that it is probable that a 
 large number of the cases of fungous cancer of the womb, reported 
 
PRIMARY ENGORGEMENT WITH INDURATION. 
 
 30 3 
 
 by authors, were nothing more than haemorrhagic engorgement, 
 in the last stage. What especially distinguishes the latter lesion 
 from the cases of fungus is, that the haemorrhages accompanying it 
 are more obstinate, more abundant and more constant, and that the 
 tumour does not present a narrowed base and indurated pedicle, 
 as usually happens in fungous cancers of the uterus. This distinc- 
 tion is of the greatest importance for the surgical treatment ; in the 
 fungus we may hope to attain the limits of the disease, while, in 
 haemorrhagic engorgement, it often happens that the alteration of 
 tissue extends as far as the body of the organ, which contra-indicates 
 any surgical operation, which is, nevertheless, the only means to be 
 employed with any hope of success. 
 
 After death, we find the cervix uteri swollen, and transformed 
 into a soft, friable tissue, of a blackish colour The parenchyma of 
 the uterus is also more or less disorganized, and reduced into a mass 
 of libro-cellular and vascular filaments, tearing readily, and lost in 
 the midst of black and coagulated blood with which it has been 
 infiltrated ; M. Duparcque compares this alteration to the tissue of 
 an engorged and semi-putrified spleen. The external surface of the 
 organ commonly presents a layer of healthy tissue of greater or less 
 thickness, whilst the parenchyma is found the more disorganized, 
 the nearer to the cavity of the uterus we examine it. 
 
 OF PRIMARY ENGORGEMENT WITH INDURATION. 
 
 This kind of engorgement with induration offers more than one 
 point of similarity with simple engorgement without induration. It 
 is produced by the same causes, announced by the same symptoms, 
 and gives rise to the same general disorders ; but the hardening of 
 the tissue of the womb, which the touch reveals to us, is so charac- 
 teristic a sign of engorgement with induration, that it is impossible 
 to mistake it for the morbid hypertrophy without induration, of 
 which we have spoken before. 
 
 Simple white engorgement with induration ordinarily dates from 
 a period not long foregone and the greater part of the patients say 
 that their sufferings have begun after a sudden suppression of their 
 menstruas, after a recent abortion, or a labour which, like the other 
 two accidents, has taken place within two or three months. The 
 recent origin of the induration renders the cure commonly prompt 
 and easy, but it is important to distinguish this species of engorge- 
 ment from scirrhous engorgement. 
 
 In both cases, the pain may be null or equally lancinating, and in 
 performing the Touch, we discover that the womb is a weight 
 and volume more considerable than in its normal condition. In 
 engorgement with simple induration, the tissue is rather less hard, 
 and presents an even surface of a rose colour; while the scirrhous 
 engorgement exhibits bosses and irregularities, and besides the mu- 
 cous membrane of the cervix uteri, which appears of a dull white 
 colour, is much more sensible to the touch. Finally, the treatment 
 being the same in all points, hypertrophy with simple induration, 
 
304 
 
 SCIRRHOUS ENGORGEMENT. 
 
 generally requires a treatment of only one or two months ; it requires, 
 on the contrary, a much longer time to obtain the resolution of a scir- 
 rhous engorgement, which becomes extremely difficult, and even im- 
 possible where the disease is ancient. M. Duparcque says very justly 
 that it is not easy to seize upon the transition of hard engorgements 
 from the curable to the incurable state ; it is in fact only upon 
 eventual circumstances that we can, in this respect, establish a diag- 
 nosis. According to this author, the cure is possible so long as the 
 induration continues to be formed of a fibro-albuminous substance, 
 disposed in the meshes of the cellular tissue of the diseased organ ; 
 but the resolution cannot take place, when the same substance 
 passes into the cartilaginous condition, and still more into a state of 
 ossification. Moreover, the diagnosis is less important than one 
 might suppose, because the treatment is the same in either case, only 
 the chances of cure are very different. The curative means of the 
 hard primary engorgements are equally indicated in the scirrhous 
 engorgements; but then they are merely palliatives, which some- 
 times arrest the progress of the disease and render the pain much 
 more bearable. 
 
 The treatment of simple engorgement with induration differs but 
 little from that of simple engorgement without induration ; that is to 
 say, we must first resort to antiphlogistics, then to resolvents and 
 discutients, administered either internally, or externally in the form 
 of frictions. Sulphurous baths, and ascending douches about the 
 neck and the pelvis are likewise prescribed with advantage. Finally, 
 if the disease prove refractory, we may add to these means the 
 powerful revellents, such as moxas, setons, the cautery, etc. Gene- 
 rally speaking, the disease readily yields to the remedies directed 
 against it. Sometimes the cure is effected by the efforts of nature 
 alone, but commonly, when the disease is left to itself, it degene- 
 rates into scirrhus, and is soon beyond the resources of our art. 
 
 OF SCIRRHOUS ENGORGEMENT. 
 
 Scirrhous engorgement is produced by the same causes, and pre- 
 sents the same symptoms as simple engorgement with or without 
 induration: although the lancinating pain which it determines is 
 commonly more acute, and more frequent, we should not, as most 
 authors pretend, regard it as having an essential character, since it 
 may exist in engorgement without scirrhous degeneration. 
 
 The symptoms that particularly distinguish scirrhus of the neck 
 of the womb are, as we have already said, the slowness with which 
 the tumour is developed, the hardness, comparable to that of a petri- 
 faction, and the irregularities and protuberances which the finger 
 meets with when we examine per vaginam; finally, the dull white 
 colour or ivory yellow which the cervix uteri presents when the parts 
 are examined with the speculum. 
 
 The treatment does not differ from that of engorgement with sim- 
 ple induration ; it should never be lost sight of that from the treatment 
 being generally very protracted, it becomes necessary, for that reason, 
 
SCIRRHOUS ENGORGEMENT. 
 
 305 
 
 to husband the strength of the patient, and not to recur to sanguine 
 evacuations except with much Care and prudence ; besides, we must 
 moderate the activity of the circulation by the use of cooling drinks, 
 baths, repose, rigorous diet, the internal use of nitre, and of digitalis ; 
 and with the view of modifying the organic elements of the blood 
 which seem more especially to concur in the formation of scirrhous 
 engorgements, we should insist more upon pills of soap, the saline 
 laxatives, exutories, diaphoretics, etc. Finally, in order as far as pos- 
 sible to direct the sanguine affhixion towards parts more or less dis- 
 tant, we should frequently repeat dry cupping, stimulating frictions of 
 the skin, flying sinapisms, sulphurous baths, douches, etc. In speak- 
 ing of the general treatment of engorgements of the uterus, we shall 
 treat of the mode of employing the different remedies in question, 
 and the different modifications which their application demands, ac- 
 cording to circumstances. 
 
 Though most authors have regarded the hard engorgements as 
 nearly incurable, we believe, with MM. Lisfranc, Recamier, Du- 
 parcque and other distinguished practitioners of our period, that 
 scirrhous tumours of the womb may, as often happens for those of 
 the breasts, yield to a persevering and well-directed treatment. The 
 three practitioners whom we have cited have published numerous 
 cases which confirm this opinion; besides, if Hippocrates, Galen, 
 Fearon, Hufeland, Ledran, Vacher, Pouteau, Marc Antoine Petit, 
 of Lyons, MM. Recamier and Lisfranc, and some others, have suc- 
 ceeded in dissipating indurated tumours of the mammae, wherefore 
 refuse to admit a similar result for hard and chronic engorgements 
 of the uterus ? What proves, moreover, the practicability of the reso- 
 lution of scirrhous tumours, is that it has been found to result from 
 the efforts of nature alone ? M. Pauly reports that two women, con- 
 demned by M. Lisfranc as having an engorgement of the womb, 
 recovered perfectly without being submitted to any treatment. {Ma- 
 ladies de V Uterus, p. 315.) 
 
 We shall conclude by saying that ail hard engorgements, simple, 
 or presumed of scirrhous nature, which have been developed after 
 some disorder of the menstruation or after labour, are generally 
 susceptible of resolution. Those that commence or augment at the 
 critical age commonly resist all the means opposed to them; but 
 with the aid of a well-directed treatment, they often remain station- 
 ary. Finally, the hard engagements, whose prognosis is most un- 
 favourable, are those which are covered with soft protuberances, and 
 which occasion lancinating and deep-seated pains; in such a case, 
 we may be certain of their early and inevitable transformation into 
 ulcerated cancer. 
 
 TUBERCULAR INDURATION. 
 
 Tubercular induration of the uterus is more frequent than is gene- 
 rally supposed. It mostly attacks women of lymphatic temperament 
 and of feeble and delicate constitution. The nature of this affection, 
 and the immediate cause which produces it are unknown ; we, how- 
 20 
 
306 
 
 SCIRRHOUS ENGORGEMENT. 
 
 ever, range ourselves on the side of those physicians who regard it 
 as the effect of a chronic inflammation, which may develop itself 
 only in persons who are predisposed. The circumstances which it 
 is reasonable to allow as having the power of facilitating the pro- 
 duction of the tubercular induration which now engages us, are the 
 internal use of mercury, want of exercise, living in dark rooms, 
 sedentary occupation, a poor diet, and several other causes, which 
 have no activity without a certain predisposition that we are unable 
 to appreciate. 
 
 The signs which enable us to recognize tubercular induration of 
 the neck of the womb are furnished us by the vaginal Touch, and by 
 exploration with the speculum. By carrying the finger to the os 
 tincae and making slight pressure, we find that its tissue is the seat 
 of hard points which form a more or less considerable projection, 
 and which are separated from each other by depressions having the 
 normal consistence of the neck of the womb in its healthy state. It 
 happens sometimes, however, that the depressed tissue which sepa- 
 rates each induration is found to be hypertrophied by the tubercular 
 matter. In some cases the salient points converted gradually and 
 by separate portions into a puriform fluid, soon open and give rise to 
 little scrofulous ulcerations, which we shall speak of at another 
 time. While the tubercles, although softened, are not open, they 
 give to the exploring finger the sensation of a partial degeneration, 
 and in this case the diagnosis cannot be made in a very positive man- 
 ner, because we then rely in some sort only upon the constitution 
 of the female. The exploration with the speculum almost always 
 allows of our discovering the nature of the lesion, when the tuber- 
 cular engorgement is open, because, by pressing the extremity of the 
 instrument gently upon the cervix uteri, we see starting from the 
 centre of the opening a drop of puriform matter of a tubercular nature. 
 
 The progress of this disease is generally slow; it commonly threat- 
 ens but little danger in itself, since, by the efforts of nature alone, tuber- 
 cular cavities have been seen to cicatrize temporarily or definitively ; 
 however, this fortunate termination ordinarily takes place but slowly, 
 because new tubercular cavities often form in proportion as the old 
 ones advance towards cicatrization. Moreover, the malady demands 
 the local and general treatment proper to scrofulous ulcerations; that 
 is to say, in cases where it is recent, we must have recourse to anti- 
 phlogistics, employed with care, because of the feeble constitution of 
 the patient ; we should then prescribe, especially if the disease be 
 chronic, the bitter infusions of hops or of gentian, the ferruginous 
 preparations, the tincture of iodine in doses of ten to thirty drops 
 daily, the use of sulphurous waters, particularly those of Bonnes and 
 Barege, natural or artificial, mercurial frictions upon the internal sur- 
 face of the thighs and on the hypogastric region ; lastly, resolvents, 
 tonics, and all the therapeutic, hygieinic and dietetic means which 
 apply to tubercular affections. 
 
LEUCORRHCEA OR WHITES. 
 
 307 
 
 OF LEUCORRHCEA, OR THE WHITES. 
 
 Of all the names given to this disease, that of vterine catarrh 
 seems at first the most correct, because it is agreed that we shall 
 comprise, under the general term catarrh , all inflammations of the 
 mucous membranes, and because leucorrhcea is commonly regarded 
 as being the result of an inflammation of the internal membrane of 
 the uterus. Yet if, on the one hand, we reflect that the denomina- 
 tion of uterine catarrh does not separate the idea of leucorrhcea, pro- 
 perly so called, from that of syphilitic blennorrhagia, which it is always 
 necessary to distinguish, and especially in practice ; and, on the other 
 hand, we recollect that the leucorrhoeal discharge, far from being 
 always the result of inflammation of the uterine mucous membrane, 
 is more frequently determined by relaxation and atony of the utero- 
 vaginal mucous membrane, it will be conceded that the term uterine 
 catarrh is not beyond the reach of a just criticism. For example, 
 it is allowable to regard as the result of an inflammation of the in- 
 ternal membrane of the womb, that leucorrhcea which succeeds to 
 warm baths, to a debilitating regimen, and especially that which, 
 after some vivid emotion, appears suddenly, flows without pruritus, 
 without pain, and is unaccompanied, except with certain nervous 
 symptoms, such as yawning, slight uneasiness in the stomach, and 
 general malaise ceasing with the moral cause which gave them birth. 
 Does not this transient state bear with it the marks rather of a debi- 
 lity or of a spasmodic affection than those of a true inflammation ? 
 Can we more properly ascribe to a periodical inflammatory state, the 
 sero-mucous flux which prepares, completes, or even substitutes itself 
 for the flow of the menstruae ? 
 
 Although the word leucorrhcea does not in itself possess perfect 
 exactitude, and though it expresses only the constant symptom of a 
 utero-vaginal affection, characterized by a discharge more or less 
 white, we have thought it would be preferable to the word uterine 
 catarrh, whether, because, like the last, it does not make us infer any 
 thing as to the causes, nature and seat of the disease, or because it is, 
 moreover, consecrated by general use. 
 
 Leucorrhoea, which derives its name from two Greek words, 
 white, p fW , I flow, has been observed from the highest antiquity, 
 and has received almost as many denominations as there are authors 
 who have written upon it. Hippocrates, Aretasus, Galen, and Avi- 
 cenna treat of it with much detail, but, like most of their successors, 
 being supported only by the anatomical and physiological knowledge 
 of their day, they have emitted opinions more or less incorrect upon 
 the nature and seat of the disease. If Avicenna and F. Hoffman 
 have wandered least from the truth in assigning the vessels secreting 
 the menstruae as the point of departure of leucorrhcea, Degraaf, Heur- 
 nius, Severin Pinault, and especially Chareton, Morgagni and Bon- 
 net approach much more nearly to it, in considering this discharge 
 as a pathological secretion of the mucous glands, whose existence 
 and orifices they had discovered upon the interior of the genital 
 parts. But it was reserved for the labours of modern physicians, 
 
308 
 
 LET7CORRHCEA OR WHITES. 
 
 especially those of Pinel and Bichat to describe in a positive manner 
 the diseases, organization and functions of the mucous membranes. 
 
 Without regarding inflammation as the sole cause of leucorrhoea, 
 we assert, that whatever be the origin of the affection, it has, as a 
 principal and constant character, an anormal secretion of mucous 
 fluid, more or less white, escaping from the vulva in uncertain 
 quantity, and of variable shades and consistence. 
 
 Wishing to isolate this disease, as it ought to be, as to its study and 
 treatment, we shall comprehend, under the name leucorrhoea, only 
 the essential and sero-mucous supersecretion, which results either 
 from simple subacute or chronic inflammation of the utero-vaginal 
 lining membrane, or from a state of general or local atony. We 
 shall not treat in this chapter, therefore, of those symptomatic puru- 
 lent discharges which depend on blennorrhagia and other syphilitic 
 affections, of acute uterine catarrh, properly so called, which has a 
 rapid course, or finally, of those produced by the presence of a pes- 
 sary or other foreign bodies, by various alterations of the uterus and 
 vagina, as by scirrhous polypous-fibrous or cancerous tumours, by 
 ulcerations of the os tineas, dropsy and suppuration of the ovaries 
 and Fallopian tubes, and various other lesions which it is useless to 
 recapitulate. 
 
 Though it is generally agreed at present, that leucorrhoea has its 
 immediate source in the follicles, and upon the whole surface of 
 the lining membrane of the uterus and vagina, various circumstances 
 would make it appear probable that the leucorrhoeal discharge may 
 also be in part formed by a serous exhalation from the vessels that 
 secrete the menstrual blood. In fact, has it not been remarked, 
 that a serous fluid, regarded as slight fluor albus, ordinarily precedes 
 the eruption of the menstruse, and that when this latter evacuation 
 is irregular, it alternates with a leucorrhoea that augments in pro- 
 portion as the sanguine discharge is less abundant, and vice-versa. 
 Do we not also see suppression of the menses often replaced by a 
 salutary leucorrhoea, and do we not know, as Freind has observed, 
 that women, who, in this condition, have abundant fluor albus, suffer 
 less injurious results from their suppression, and that' the same phe- 
 nomenon often presents itself in them at the final cessation of the 
 menstruae. Though the intimate connections of these two evacuations 
 can be rendered still more evident by the remark, that the appearance 
 of the menstrual discharge commonly suspends leucorrhoea, it may 
 be proved, on the other hand, that fluor albus, coming on during 
 pregnancy, is furnished solely by the mucous crypts of the vagina, 
 which, moreover, would tend to prove that leucorrhoea may have its 
 origin in any of the sources that we have just mentioned, or in either 
 one of them at one time. Unfortunately, positive facts are wanting, 
 and without them there remain only conjectures and uncertainty. 
 
 In populous cities, as in a most favourable soil, leucorrhoea is deve- 
 loped under the influence of so great a number of causes, that there 
 are few women, especially at Paris, who are completely exempt 
 from it. Although this affection makes its appearance, particularly 
 from the first approach of menstruation up to the period of its ces- 
 
LEUCORRHCEA OR WHITES. 
 
 309 
 
 sation, there is no age free from it. G. P. Neuter, Johannes Doleeus, 
 Roderic a Castro, Fernel, Morgagni, met with little girls of six or 
 eight years of age who were attacked with it ; we, ourselves, have 
 had occasion to observe several examples of it ; among others one in 
 a new-born infant. 
 
 Utero-vaginal catarrh, which M. Alibert regards justly as that to 
 which the female is most frequently subjected by her peculiar organic 
 constitution, may likewise be allied to any of the temperaments; but 
 a lymphatic temperament, general debility, a cachectic state, and a 
 certain inflammatory susceptibility of the mucous membranes, pecu- 
 liar to certain subjects, are circumstances which predispose to this 
 affection. 
 
 Thus it is met with more particularly in females who are large, 
 fair, nervous, hysterical, slight, delicate, and in those with red hair, 
 and who have the skin covered with stains. Though women with a 
 brown skin, and black hair, are not exempt from it, it belongs rather 
 to those who are in the opposite circumstances. 
 
 A temperature habitually cold and humid, and a prolonged resi- 
 dence in low marshy regions, also, in an especial manner encourage 
 the production of leucorrhoea ; it is chiefly to the union of these two 
 conditions, that Sylvius attributed the frequency of the disease 
 amongst the women of Holland, which, for the same reason, is com- 
 mon in a part of Belgium, in Lower Normandy, and in certain parts 
 of England. 
 
 The mode of life to which the social condition condemns women 
 inhabiting large cities, delivers them over, so to speak, defenceless, 
 against the numerous causes of the chronic inflammations of the 
 utero-vaginal mucous membrane. 
 
 Thus, in populous cities, idleness, effeminacy, a sedentary life, the 
 constant contact of the two sexes, and the frequenting of places 
 where every thing inspires pleasure ; prolonged watching, dancing, 
 frivolous occupations and the study of the arts that give new acti- 
 vity to the imagination ; erotic reading, the pernicious establishment 
 of an early and artificial puberty ; the premature shock of the 
 genital organs ; solitary pleasures ; the concentration of the senti- 
 ments and thoughts on objects which keep the genital organs in a 
 sort of permanent turgescence and excitation : finally, a number of 
 vicious habits and excesses of all kinds, which, by introducing modi- 
 fications more or less profound into the general constitution, react 
 more particularly upon the sensibility of the womb, which, in the 
 female, is not only the organ most apt to lend itself to fluxionary 
 movements, but likewise the centre towards which all the morbific 
 actions seem principally to tend. 
 
 The use of foot-stoves, and of coffee and of tea, may also contribute 
 a good dSal to the production of leucorrhoea; the same is true of 
 the too frequent use of salt meat and fish, shell-fish, farinaceous sub- 
 stances, whether indigestible or too succulent, beer, spiced dishes, 
 ablutions too often repeated, the abuse of warm baths, of purgatives, 
 of emmenagogues, and of preparations of milk. Nota mild sunt 
 exempla , says Stahl, puellas mterdum satis dill a jluxu albo curato 
 
310 
 
 LEUCORRHCEA OR WHITES. 
 
 ■mansisse immunes ; ut primum vero lac sump sere, continuo reci- 
 divun fuisse passas. 
 
 It is necessary also to range among the causes of leucorrhoea, the 
 sudden cessation of excretions, whether natural or artificial, amongst 
 others those of general or partial perspiration of the feet, of the hands, 
 and of the arm-pits ; there are some women in whom it is sufficient to 
 have the arms uncovered, to wet their feet, or to sit down upon a 
 cold or damp body, in order to be seized, immediately, almost, with 
 fluor albus. The suppression of an exutory, such as a cautery, a 
 blister or a seton ; that of an habitual vomiting, of a diarrhoea, of a 
 hsemorrhoidal discharge, of the suppuration of an old ulcer; the 
 retrocession of cutaneous eruptions, of an herpetic, psoric, arthritic 
 affection, etc. ; lastly, derangements of menstruation, failure of lacta- 
 tion, debility of the gastric system, the sudden disappearance of a 
 coryza, of a pulmonary catarrh, or of any other disease of the mucous 
 membrane ; these are all likewise so many causes that may determine 
 an attack of leucorrhoea. 
 
 The close sympathy between the brain and the organs of genera- 
 tion, accounts, to a certain degree, for the development or augment- 
 ation of the affection which engages our thoughts, in consequence of 
 a moral disorder. However it may be, we often see it suddenly arise, 
 or become increased, when it already exists, under the influence of 
 some vivid emotion, some tormenting chagrin, some profound dis- 
 appointment, anger, or sudden fright, etc. A lady, seeing an only 
 daughter on the point of being torn from her by a cerebral fever, 
 was suddenly inundated with a leucorrhoeal discharge. A young 
 girl, twenty-three years old, who was at No. 12 of the Rue Transo- 
 nain, during the night of the 13th to the 14th of April, 1834, having 
 seen her lover killed by some soldiers, and owing her own safety to 
 chance merely, was immediately attacked with abundant fluor albus. 
 
 Finally, we shall conclude what we have to say upon the causes of 
 the disorder, by adding that it has been known to prevail epidemi- 
 cally, under the influence of inappreciable and fugitive principles of 
 the atmospheric constitution, often noticed under entirely opposite 
 conditions. 
 
 Morgagni, Raulin and Broussonnet have had occasion to observe 
 epidemics of this nature. The last of which Raulin was witness, 
 occurred at Paris, in 1765, during a burning heat of the weather, 
 and excessive drought. Epidemic leucorrhoea has also been observed 
 during cold and damp weather. Moreover, the latter cause of the 
 disease is one of the most frequent. Weikard, the translator of 
 Brown, states that, in a convent at St. Petersburg, all the pupils were 
 affected with fluor albus, because they had been reared in exposure 
 to rigorous cold, under the pretext of giving them a more robust 
 constitution. 
 
 As acute inflammation of the utero-vaginal mucous membrane 
 really exists only in recent blennorrhagic discharges, or in those 
 which depend upon a local cause ; for example, the presence of a 
 pessary, or of some other foreign body in the genital cavities; upon 
 the constant abuse of venery; upon criminal copulation; relative or 
 
LEUCORRHCEA OR WHITES. 
 
 311 
 
 absolute disproportion of the organs; masturbation, irritating in- 
 jections, etc. : we have thought it right not to speak, in this place, of 
 acute uterine catarrh, depending on the causes which we have just 
 mentioned, in order not to present to the consideration of the reader, 
 the essential leucorrhcea, properly so called, except in its subacute 
 and chronic forms, which are the true types of the disease. This 
 division, which, moreover, has no inconvenience in practice, has the 
 advantage of facilitating the study of the disease, and especially of 
 distinguishing it from the symptomatic discharges and acute inflam- 
 mations of the utero-vaginal mucous membrane, with which it is 
 always confounded. 
 
 The subacute leucorrhcea which opens with truly inflammatory 
 symptoms, and sometimes even with a febrile movement, begins with 
 slight pruritus, which is at first confined to the vulva, but soon extends 
 itself to the vagina and uterus. The patient feels dull pain in the 
 hypogaster, sensation of heat v and weight in th'e centre of the pelvic 
 cavity, draggings in the loins, groins and thighs. She is tormented 
 by frequent desire to urinate, and sometimes by venereal desires. 
 The voiding of the urine is often accompanied with some difficulty, 
 and a feeling of uneasy and painful heat. Finally, there is not un- 
 frequently conjoined with these different phenomena a sensation of 
 hysteric strangulation and spasmodic oppression at the upper part of 
 the thorax. 
 
 The discharge, which is at first small in quantity, clear, serous or 
 sanguineous, especially if it follows uterine haemorrhage, soon aug- 
 ments, becomes thicker, and presents a colour which is variable, and 
 which may be white, lactescent, yellow or greenish. The secretion 
 is sometimes so abundant that the female is compelled to guard 
 herself, as during the menstrual evacuation; the spots on her linen 
 are yellow or greenish, and give it a starched stiffness. Exploration, 
 by means of the touch or speculum, reveals to us that all the genital 
 parts are redder, more inflamed and more sensitive ; that the neck 
 of the womb is more dilated than in its normal state ; finally, that the 
 mucous membrane of the os tincae and vagina is swollen, doughy and 
 sometimes even excoriated or slightly ulcerated. 
 
 In cases of recrudescent leucorrhoea, that is to say, those which 
 diminish, augment, or disappear alternately, it is often difficult to 
 distinguish certainly what form we have to deal with ; and it is only 
 by groping, that we are able, in certain equivocal cases, to recognize 
 the true character of the affection, and direct the treatment which 
 suits it. We should, however, regard as subacute or active, the leu- 
 corrhma that alternates with the menstruae, at least during the day 
 preceding or immediately following their evacuation; that which 
 comes on after a universal febrile movement in young and sanguine 
 women ; finally, that which is determined by the constant abuse of 
 coitus, by extreme fatigue, or other causes of general excitation ; 
 such, for example, as long watching, the immoderate use of sea- 
 soned, salted and stimulating dishes, and alcoholic liquors, etc. 
 
 The passive chronic leucorrhoea , although succeeding often to the 
 subacute form, may not only exist without presenting any inflam- 
 matory character, but may even depend primarily upon a state of 
 
312 
 
 LEUCORRHCEA OR WHITES. 
 
 general relaxation or local debility. The chronic lencorrhoeal dis- 
 charge resulting from this form is met with chiefly in lymphatic 
 women and those of a loose fibre ; and it is for this reason that the 
 infirmity is much more common in cold and humid regions. It is 
 equally frequent in women whose genital organs are relaxed by 
 numerous labours or excessive venery. It co-exists ordinarily with 
 chlorosis, amenorrhoea, and may be the cause, the effect, or index of 
 a state of general atony and relaxation. 
 
 Women afflicted with chronic leucorrhoea, depending on debility 
 of the genital organs or of the general constitution, although possess- 
 ing a vermilion tint and seeming to enjoy good health, generally have 
 a peculiar facies , which may help to enlighten the physician and lead 
 to the recognition of the disease ; the face and lips are pale, the eyes 
 surrounded by a dark areola, the eyelids are often swollen, and, 
 finally, an expression of languor in all the features gives to their 
 whole appearance an air of dejection. Quando autem de matrice 
 humor es multi sunt , oculi dolent , caput calidum hahent vel lan - 
 guidum et vertiginem pa Hunt ur, says Hippocrates. 
 
 Essential chronic leucorrhcea is never accompanied by signs of 
 irritation of the genital organs ; the period of its invasion is almost 
 always unknown, no matter what the cause which may have pro- 
 duced it; its progress is very irregular, and its duration unlimited. 
 As happens in the acute form, the colour, consistence and quantity 
 of the discharge vary in different cases ; its amount is often very 
 slight, and it is then a mere inconvenience, which attention to clean- 
 liness prevents from becoming too disagreeable; at other times it 
 escapes from the vulva in sufficient, quantity to keep the external 
 genital organs and the upper part of the thighs constantly wet, and 
 to produce slight excoriations and superficial inflammations of these 
 parts, which are easily prevented or dispelled by lotions and topical 
 bathing. 
 
 It happens, not unfrequently, that the affection is complicated with 
 relaxation of the vagina and falling or vicious inclination of the 
 uterus ; but these lesions of situation, which augment the inconve- 
 niences of leucorrhoea, and which are betrayed by sensations of 
 weight about the rectum and bladder, are rather the effects than the 
 causes of fluor albus properly so called. 
 
 When small in quantity, the discharge is commonly mucous, and 
 hardly stains the linen ; it has scarcely any odour, and the colour is 
 whitish like that of thick whey. If, on the contrary, the leucorrhoga 
 be abundant, the mucous discharge is usually lactescent, and from its 
 colour and consistence sometimes bears sufficient resemblance to 
 milk to have attracted credence to the so-called milk diseases and 
 to give plausibility to the false theories of the humoralists. Under 
 these circumstances the discharge, when dried, stiffens the linen and 
 leaves a grayish spot, deepest at its edges, very similar to that 
 produced by the nasal mucus. Sometimes the secretion is more con- 
 sistent, fiocculent and even caseiform ; when abundant, and espe- 
 cially when of long standing, whatever be its colour and consistence, 
 it always occasions certain lesions of the functions, and a great num- 
 ber of sympathetic phenomena. The women complain of weight in 
 
LEUCORRHCEA or whites. 
 
 313 
 
 the lumbar and hypogastric regions, of vague sensations of lassitude, 
 of pains in the epigastrium and of cholic. They suffer from depraved 
 appetite, from acidity, nauseous eructation, headache, frequent yawn- 
 ing and hiccough; the skin is cool, and sensitive, to the least atmo- 
 spheric Variation; they perspire but little; they complain of unusual 
 heat in the head, of vertigo, syncope, palpitation of the heart, exces- 
 sive coldness of the feet, occasional pains under the left breast ; the 
 face becomes pale, the eyes hollow, and they weep without cause ; 
 they become careless, impatient, and feel a sort of languor and 
 dejection, a sensation of strangling or choking, and an involuntary 
 sadness ; they are apathetic, melancholy, hypochondriacal ; in fine, 
 they never exhibit the happy physiognomy characteristic of the sex, 
 and are often tormented by erotic desires, which drive them into 
 vicious habits, and at the same time augment their languor and ex- 
 haustion. When menstruation becomes re-established in cases of 
 amenorrhpea and chlorosis, the leucorrhceal discharge diminishes, or 
 ceases entirely ; with it disappear all the nervous symptoms ; the 
 paleness soon passes away, gaiety returns, and the functions of the 
 stomach, as well as the general health, return to their natural con- 
 dition. 
 
 When the discharge is constant, profuse and of long standing, ex- 
 haustion and degradation of the constitution are soon found to be the 
 unfortunate and necessary results of this dux, which never ceases, 
 and which seems to attract to itself the sources of all the other excre- 
 tions, and thus to cause a drain upon the whole economy. The skin 
 now becomes more and more discoloured, the emaciation increases, 
 the flesh becomes loose, the breasts are soft, the pulse small and fre- 
 quent, and the breath fetid ; the eyelids become bloated, the legs are 
 always cold, and the whole body sometimes becomes oedematous. 
 The patient complains of almost continual cholic, and of pains along 
 the vertebral column, in the loins, hips and hypogastric region. She 
 is tormented with constant thirst ; the appetite is lost ; she suffers 
 from habitual pain in the stomach and from obstinate constipa 
 tion ; she is subject to nausea, eructations and acid vomiting ; the 
 urine is turbid, flocculent and in small quantity. When leucorrhoea 
 reaches this degree of severity, the patient acquires a disgust and 
 indifference for every thing ; her faculties become enfeebled ; she is 
 unfitted for reproduction as much by her indifference as by the dis- 
 gust which she inspires : finally, moral debility and settled despair, 
 together with hectic fever, exhaust the few remains of strength, after 
 having destroyed all that lends a charm to life. 
 
 Amongst the discharges which might be confounded with essential 
 leucorrhoea, are naturally found those which depend upon a syphilitic 
 taint, and those which are symptomatic of some other more or less 
 serious affection of the uterus or vagina; Walter Charleton, Van 
 Swieten, De Graff' and some others supposed leucorrhoea to be seated 
 in the vagina and uterus, whilst blennorrhagic discharges have their 
 point of departure at the entrance of the vagina, and especially in 
 the neighbourhood of the urinary meatus and in the lacunae situated 
 between the nymphae. Astruc, Baillou, Pitcairn and Raymond, 
 
314 
 
 LEUCORRHCEA OR WHITES. 
 
 without regarding the examination of the parts as an infallible mode, 
 think with propriety that it may be useful in making out the diagnosis. 
 Benjamin Bell placed the seat of syphilitic discharges in the canal of 
 the urethra, and, like M. Ricord, advises pressure upon this canal from 
 behind forwards with the extremity of the finger; “we shall express 
 in this way,” says this author, “the matter of the syphilitic infection.” 
 But numerous and well-observed cases prove that the inductions 
 drawn from the presumed difference of seat deserve but slight con- 
 fidence ; the same is true as to the persistence of the blennorrhagic 
 discharge during the flow of the menstruse, and the suspension, on 
 the other hand, of the leucorrhoeal flux upon the appearance of men- 
 struation. In fact, the signs indicated by Jean Fernel.* physician to 
 King Henry II, by Jean Liebault,t Louis Mercatus,f Roderic & Cas- 
 tro^ Lazare Pe,|| Primrose, IF Mauriceau,** Charleton,tt Pierre Fre- 
 sart,f J and which were regarded by Baglivi §§ as infallible, are just 
 as illusory as those already mentioned ; for, with Baillou, Astruc and 
 several other physicians, we have seen both these sorts of discharge 
 occurring at the same time. 
 
 The pain which precedes a blennorrhagic discharge, and which, 
 according to Pinel,is never present in leucorrhoea, the sensation of heat 
 and smarting felt while urinating, which has been indicated by seve- 
 ral authors, and especially by Charleton, (loc. cit.,) as a characteristic 
 mark of syphilitic discharges, the co-existence of arthritis with vagi- 
 nitis, described by M. Ricord, and finally the pale red tint and whitish 
 and coppery spots, which M. Richerand regards as the marks of blen- 
 norrhagia properly so called, are not really pathognomonic signs 
 upon which a positive opinion as to the nature of the disease can be 
 safely made out. 
 
 The consistence, the different alterations, and the various tints of the 
 utero-vaginal secretions are quite as deceitful; for, as M. Lagneau has 
 said, “ the green or yellow colour of the discharge, its greater or less 
 quantity, its ever-variable duration, the differences in the intensity of 
 the inflammation, are not data sufficient to allow a prudent physician 
 to pronounce positively, for syphilitic blennorrhagia is often indolent, 
 lasts but a short time, and furnishes little matter, the colour of which 
 is almost always of a milky white ; whilst we daily meet with dis- 
 charges we are compelled to regard as non-virulent, presenting these 
 different phenomena in the most marked manner.” 
 
 The contagious property of the discharge, and its transmission by 
 coitus, are not better calculated for solving the problem ; for daily 
 experience shows that it is possible to cohabit with a woman 
 
 * La Pathologie de J. Fernel, lib. vi. cap. 16. 
 t De la sante, fecondite et maladies des femmes, liv. v. 
 t De affect, mulierum, lib. i. cap. 15. 
 
 § De morbis mulierum, lib. i. cap. 4. 
 
 II Maladies des femmes, liv. ii. ch. 36. 
 
 *[ De morbis mulierum et symptom, lib. v. 
 
 ** Maladies des femmes, anat. des part. enit. chap. 6. 
 ff De Calam. et uteri rheumatismo, cap. 8. 
 
 Emmenolog. cap. x. 
 
 §§ De praxi medica, lib. ii. cap. 8. 
 
i 
 
 LEUCORRHCEA OR WHITES. 
 
 315 
 
 having syphilitic blennorrhagia without contracting the same disease, 
 whilst leucorrhoea may become so irritating as to communicate an 
 acute blennorrhagia. The age, the moral character of the patient, 
 and the antecedents may likewise lead to error. Mauriceau states 
 that three little girls, the eldest of whom was only nine years old, 
 were brought to him, supposed to have lluor albus. He having 
 interrogated them, soon convinced himself by their answers, not- 
 withstanding the absence of all violence upon the genital parts, that 
 they had been infected by some wicked domestics. 
 
 From what we have now said, it is easy to see that the signs 
 proper to distinguish a true leucorrhoeal discharge from one depend- 
 ent upon syphilitic blennorrhagia, have always presented the great- 
 est uncertainty even to the most experienced practitioners. Cullerier, 
 whose opinions upon this matter are of the hightest value, leaves 
 the question undecided. M. Ricord, who, by his excellent judgment 
 and varied observation, is better fitted to decide upon this subject 
 than any one else, does not conceal his embarrassment ; for, he says, 
 in one of his memoirs, “ that without the actual existence of conse- 
 cutive symptoms, which, moreover, must be fully ascertained, we 
 remain in the greatest uncertainty as to the diagnosis, being able in 
 reality merely to recognize the physical alteration of the parts and 
 their secretions, without having the power of learning the intimate 
 nature or essence df the disease, if we may so express it, and finding 
 ourselves reduced to the detection of the existence of an urethritis, 
 vaginitis, or uterine catarrh, while beyond this all is probability, and 
 very often error.” Sauvages, in his Methodical Nosology , (class 10,) 
 also concluded that Medicine supplies no certain signs by which to 
 distinguish gonorrhoeal discharges from the leucorrhoeal secretion, 
 properly so called: nec dantur limites qui genus gonorrhese in 
 mulieribns h leucorrhed discernant. 
 
 The uncertainty which, for so long a period, has prevailed as to the 
 diagnosis of the discharge from the genital organs of the female, has 
 just been removed in great part by the researches, as novel as they 
 are ingenious, to which Dr. Donne, ex-chief of the Clinic of the Faculty 
 of Medicine of Paris, has been recently devoting himself. As it is of 
 the greatest importance for the therapeutical, and often for the moral 
 interests of the patient, dearer still than those of health, to remove 
 all uncertainty as to the nature of utero-vaginal secretions, we shall 
 proceed to point out in few words the differential signs, mentioned in 
 the excellent memoir,'* published by the young physician we have 
 just cited. 
 
 In venereal blennorrhagia the discharge is always purulent, that 
 is to say, a certain quantity of pus is mixed with the proper mucus 
 of the vagina. In this condition the secreted matter contains a mul- 
 titude of animalcules, edited by M. Donne, vaginal trico-monas , 
 which are discovered by placing a drop of the muco-purulent fluid 
 between two fine glasses, and examining them with a microscope, 
 
 * Recherches microscopiques sur la nature du mucus et la matiere des divers 
 ecoulements des organes genitaux-urinaires chez 1’homme et chez la femme- Paris, 
 1837 . 
 
316 
 
 X.EUCORRHCEA or whites. 
 
 magnifying from two hundred and fifty to three hundred times. 
 These infusory animals, whose bodies are transparent, and of round 
 or oval form, with a diameter of to -£$ of a millimeter, are most 
 commonly united in groups of from two to six individuals. When 
 examined with the light of a lamp, they may sometimes be seen 
 to move, more especially to agitate in every direction a long filiform 
 and very delicate appendage, which serves to distinguish them from 
 the spherical and inanimate globules of true phlegmonous pus, in 
 which they are never observed to exist. 
 
 The discharge of true leucorrhoea is thick, creamy, and does not 
 stick to the fingers ; it reddens litmus paper, and seems' to be com- 
 posed of little oval bodies, having the appearance of pellicles or 
 scales from the mucous membrane ; finally, it never contains the 
 infusory animalcules found only in syphilitic discharges, and besides, 
 ammonia gives it a slimy and ropy consistence when it is mixed with 
 pus, which does not occur in the contrary case. If the muco-puru- 
 lent discharge be occasioned either by the presence of a foreign body 
 in the genital cavities, by an irritating injection, or any other local 
 cause of inflammation, independent of the venereal virus, the trico- 
 monas is never developed, although the secreted matter then resem- 
 bles that of the syphilitic blennorrhagia, that is to say, when treated 
 with ammonia, it assumes a viscid, tenacious and ropy appearance. 
 
 To distinguish vaginal from uterine mucus, it is sufficient to know 
 that the former is not only thick, creamy and never ropy, but also 
 that it is acid, and that it reddens litmus paper, while mucus secreted 
 by the womb is always alkaline, returns the blue colour of litmus 
 paper, turns the syrup of violets green, and finally, has such a slimy, 
 ropy and tenacious consistence, that it is with great difficulty it can 
 be detached from the margin of the os uteri. Such, in a few words, 
 are the means of diagnosis, pointed out by M. Donne, whose memoir 
 we recommend. In it will be found related, with as much detail 
 as clearness, the results of the interesting researches he has made 
 upon this subject. 
 
 If the discharge proceed from a cancer, an abscess, a polypous 
 tumour, or any other organic lesion of the womb or vagina, we 
 might easily make the diagnosis by a consideration of the symptoms 
 proper to these affections, and especially by the exploration of the 
 parts by the Touch and the speculum. 
 
 The prognosis of leucorrhoea depends upon the cause, the duration 
 of the discharge, its quantity, the complications, the strength of the 
 female, her age, temperament, and finally, the hygienic condition in 
 which she may be placed. Where the cause is a permanent one, 
 such, for example, as the presence of a pessary in the vagina, the 
 use of foot-stoves, of coffee, of unhealthy aliment, a moral affection, 
 &c., the removal of the cause is soon followed by a cure, unless the 
 disease persist from the habit of fluxionary movement, which then 
 renders the case more uncertain and more difficult. Leucorrhcca, 
 coming on in the subacute form, is also easier to cure ; in general, 
 the older the discharge, the less are the chances of cure ; in women 
 
LEUCORRHCEA OR WHITES. 
 
 317 
 
 of advanced age, it is almost always incurable, which fact justifies 
 the unfavourable prognosis made by Hippocrates, when he said : 
 (De Morb. Mu tier.) hie Jluor senioribus prope incur abilis est , et 
 eas usque ad mortem comitatur. If the leucorrhoeal flux be abun- 
 dant and accompanied by numerous sympathetic phenomena, if it 
 date from several years back, if it seem to be hereditary and consti- 
 tutional, or finally, if it be complicated with cachexia, with scrofula, 
 or with herpetic affections, the progress of the disease is difficult to 
 arrest, and it often proves rebellious under all the means opposed 
 to it. 
 
 After death we generally find the vagino-uterine mucous mem- 
 brane softened and swollen ; the os tincae is dilated, reddish, soft and 
 hypertrophied ; the mucous membrane covering the vagina and vulva 
 presents a slaty or bluish tint; when compressed there oozes from 
 all parts a fluid analogous to that which was secreted during life. 
 The surface of the uterine cavity is overspread with little vesicles 
 filled with a sero-mueous fluid ; the membrane which lines it, com- 
 monly soft, loose and infiltrated, is sometimes marked by dilated 
 vessels, and exhibits ulcerations, erosions, or, more rarely, it has the 
 aspect of a cartilage, and is covered in several places with gan- 
 grenous spots. 
 
 Before entering upon the treatment of leucorrhoea, let us add a few 
 words as to its more or less sudden suppression, and the accidents 
 resulting therefrom. 
 
 The suppression of a leucorrhoeal discharge may take place sud- 
 denly, as an effect of different physical causes, as the use of astring- 
 ents taken internally or applied locally to the genital organs; of an 
 emetic, of purgatives, of cold baths, the application of ice, the in- 
 vasion of another disease ; finally, the intemperate use of a number 
 of panaceas, whose grotesque titles with impunity disgrace the 
 columns of our journals and the walls of all our houses. 
 
 The dangers of a suppression of a vagino-uterine discharge are 
 the more serious as the secretion is more abundant, and especially 
 of longer standing. Although we should have to prepare an almost 
 complete nosographical table in order to enumerate all the disorders 
 which, according to most authors, might follow suppression of the 
 leucorrhoeal discharge, we believe that these disorders are much 
 exaggerated, and that it is wrong to persuade women that their 
 disgusting infirmity is a salutary emunctory, the very guarantee of 
 their health. Let it not be supposed, however, that we believe it 
 possible to suppress an ancient and abundant secretion suddenly with- 
 out inconvenience, for we are as far removed from the audacity oi 
 empiricism, as from the timidity of ignorance. Our intention is merely 
 to reduce to their just value the exaggerated fears of practitioners, 
 and to prove to them that while we believe the cure of leucorrhoea 
 ought to be undertaken, we are perfectly convinced that a true cure 
 cannot be obtained except by acting in a gradual manner, and by 
 insensibly restoring the economy to its normal state. It is, in our 
 opinion, the more necessary not to abandon this disease to itself, be- 
 cause it not only compromises the reproduction of the species, but may 
 
318 
 
 LEUCORRHCEA OR WHITES. 
 
 also lead to unfortunate moral consequences, and often does become 
 the source of very serious alterations. 
 
 Besides, if, while acting prudently and rationally, accidents should 
 happen to occur, we could always treat them and arrest their pro- 
 gress as soon as they appear. 
 
 The treatment of leucorrhoea ought necessarily to differ, as occur- 
 ring in the subacute or active form, and in the chronic or passive form. 
 
 In the subacute form we ought, especially if the disease be recent, 
 and the female young and plethoric, to resort to general bleeding, 
 which acts, either as a derivative or by lessening the fluxionary 
 movement which tends to localize itself upon the genital mucous 
 membrane ; it is necessary, however, to employ sanguine evacua- 
 tions with prudence and care, or instead of diminishing the general 
 susceptibility, we might often produce debility, and run the risk of 
 forcing a subacute leucorrhoea near its term of resolution, to assume 
 a chronic and passive type. 
 
 Among the means which serve to increase the effect of small gene- 
 ral bleedings, and which, in most cases, are sufficient of themselves 
 to moderate or entirely remove the inflammation, we include a more 
 or less strict abstinence; diluent, mucilaginous, and acidulated drinks; 
 emulsions, and especially decoctions of hemp-seed with nitre ; emol- 
 lient and opiate injections; enemata and poultices of the same nature; 
 and continuous irrigations made by means of a large curved canula 
 introduced into the vagina. To avoid the irritating effect of a jet of 
 the medicated fluid, we employ a tin or gum-elastic canula, the end 
 of which, being pierced with a great number of holes, contains a 
 small sponge with a ribbon attached to it, by which to withdraw and 
 renew it as often as may be necessary. 
 
 If the local inflammatory symptoms refuse to yield to the measures 
 now indicated, we may have recourse to applications of leeches 
 about the margin of the anus, especially if there be hemorrhoids, or 
 to the vulva in cases of amenorrhoea; finally, should the disease 
 prove very obstinate, we must establish a revulsive movement 
 towards the intestinal mucous membrane by the use of purgatives, 
 such for example as rhubarb, which is at the same time purgative, 
 tonic and astringent. Goliken and Riverius obtained great advan- 
 tages from the use of it; and Hippocrates, Forestus, Sydenham, 
 Ettmuller, and many other physicians, had a like success from the 
 employment of drastic purgatives. It was to the application of this 
 derivative method that Galen * owed the brilliant success which 
 
 * De Praecognit ad Posthum., cap. 8. The father of medicine, who was acquainted 
 with the ‘sympathetic relation connecting the stomach and womb, likewise prescribed 
 emetics in the treatment of fluor albus, provided the patients were still young and re- 
 tained sufficient strength. Ettmuller, Fonseca, Hoffman, and some other physicians, 
 have also recommended them; Doctor Rast, of Lyons, treated all cases of leucor- 
 rhoea by the use of ipecacuanha, administered in minute doses, and Barthez frequently 
 pursued this method with like confidence. Though we deem it improper to resort to 
 such energetic remedies without much reserve, we are of opinion that the physicians 
 of the present period err in rejecting them altogether; and we believe, judging from 
 our own observation and from a large number of cases collected by various authors, 
 that gentle emetics, managed with skill, and repeated at suitable intervals, are really 
 useful in cases that prove rebellious to antiphlogistic remedies. 
 
LEUCORRHCEA OR WHITES. 
 
 319 
 
 spread his renown even to the palace of Marcus Aurelius. This 
 celebrated physician of ancient times, by the use of purgatives, diu- 
 retics, and frictions over the whole surface of the body, very speedily 
 cured the wife of Boethus, suffering from a profuse leucorrhoea, which 
 the skill of the first physicians of Rome had failed to relieve. 
 
 The utility of derivatives to the surface is perhaps more clearly 
 established than that of derivatives to the intestinal mucous mem- 
 brane, and it is, no doubt, for this reason that modern practitioners 
 more frequently resort to the former method than to the latter. 
 Diaphoretics, which are indicated by several of the causes of the dis- 
 ease, should be employed conjointly with stimulating and aromatic 
 frictions, and the use of warm clothing and flannel to the skin. 
 Should we find it necessary to determine a cutaneous irritation, as 
 derivative from the utero-vaginal inflammation, and powerful enough 
 to recall to the exterior surface any eruption to whose suppression 
 might be attributed the existence and obstinacy of the discharge, we 
 might resort to mustard poultices, to moxas applied upon the pelvis, 
 and to flying or permanent blisters. Permanent exutories answer the 
 double end in this case of causing revulsion from the genital mucous 
 membrane, and of being at the same time supplementary to the 
 leucorrhceal discharge. In fine, the treatment of subacute leucor- 
 rhoea presents two well marked periods; the first comprises the 
 employment of antiphlogistics so long as there are inflammatory 
 symptoms, and the second the use of derivatives conjointly with 
 revellents. During this second period we ought not only to allow a 
 more nutritious food, but we should even prescribe some light tonics, 
 such as bark, gentian, extract of centaurea benedicta, and rhubarb in 
 small doses, infusions of common European centaury, of sage, balm, 
 etc. We should likewise try slightly astringent injections, such as a 
 mixture of water and red wine, sweetened aluminous water, acetate 
 of lead, sulphate of zinc, etc., gradually rendered more and more active. 
 It would be well to recur also to balsamic substances, for instance, tolu, 
 cubebs, turpentine, and infusion of the cones of the European silver fir. 
 The balsam of copaiba has always answered best in our hands, whe- 
 ther because we administer it in the form of sugar-plums* and of 
 pills, or because we employ it in small enemata or in the form of 
 suppositories prepared in the manner we shall presently describe. By 
 the methodical use of these remedies, the disease is almost always 
 soon overcome, and a radical cure obtained. But in order to attain 
 this fortunate result, we must always favour the action of the thera- 
 peutical agents by the absolute repose of the genital organs, by 
 attention to hygieine, and especially by the indispensable precaution 
 of avoiding all kinds of excess or changes of regimen, which would 
 not only prove a continual source of irritation, but would also renew 
 the inflammation, where we had succeeded in quelling it. 
 
 * We addressed, six years since, to the Academy of Medicine, two memoirs on the 
 copaiba and its preparation in the form of dragees (sugar-plums) without disagreeable 
 odour or taste. Administered according to our formula, this remedy does not disgust 
 the patient, causes no cholic, and acts in a more efficacious manner than in any other 
 form. 
 
320 
 
 LEUCORRHCEA OR WHITES. 
 
 An entirely different method of treatment should be adopted where 
 the leucorrhcca is of the passive form, whether it has succeeded to 
 some preceding type, or whether it be primitive, as for instance, 
 when coincident with chronic amenorrhoea, with chlorosis or with 
 relaxation of the sexual organs, due to a lymphatic constitution, to 
 numerous pregnancies, or excessive coitus and masturbation, espe- 
 cially when these occur in women advancing in years. 
 
 As the genital cavities are but slightly sensitive in passive chronic 
 leucorrhoea, we should always assure ourselves by the Touch and 
 the speculum, whether the discharge is really idiopathic, or whether 
 it is symptomatic of some alteration of tissue, or some lesion of the 
 vagina or neck of the womb. Should ulcerations or erosions exist, 
 they must be cauterized with the acid nitrate of mercury, observing 
 the rules and precautions presently to be mentioned. W e must act 
 in the same manner if small vegetations be found, but if large, they 
 must be excised by some of the methods to be described hereafter. 
 When the mucous membrane is found infiltrated or indurated, resort 
 must be had to revellent frictions with ointment of hydriodate of pot- 
 ash, or mercurial ointment on the hypogastric region or on the inside 
 of the thighs ; and if the patient can bear it, a large plug of charpie, 
 covered with a layer of mercurial ointment, may be introduced into 
 the vagina. 
 
 When leucorrhoea becomes chronic and passive, it is not a mere 
 local alteration that we have to treat, but the whole economy which 
 is to be modified and restored to its normal condition. The object 
 we must then seek is to dry up a morbid discharge, which is, at 
 one and the same time, the cause and effect of the general and local 
 debility, by reconstituting, so to speak, and giving tone to the various 
 functions which are in a more or less perverted condition. 
 
 For this purpose experience has shown the efficacy of gentian, of 
 rhubarb in small doses, and particularly of cinchona, which acts as 
 a tonic, and perhaps also by interrupting the habit of the discharge. 
 We have also tested the happy effects of the infusions of absinthium 
 recommended by Professor Alibert; of the extract of centaurea bene- 
 dicta, which forms the basis of the anti-leueorrhoeal pills, upon which 
 Stahl pronounces so pompous an eulogium ; of steel filings mixed 
 with myrrh, from which Halle obtained great advantages; of the 
 ferruginous acidulated mineral waters, of Forges, Spa, Vichy, Pou- 
 gue and Passy ; and of different martial preparations, amongst others 
 the sub-carbonate and hydriodate of iron, but chiefly the black 
 oxide of that metal, in doses of from three to six grains daily. Of 
 the preparations administered internally, no one has been more con- 
 stantly successful in our hands than the anti-leucorrhoeal troches of 
 copaiba, which formed the subject of a memoir, presented by us to 
 the Royal Academy of Medicine, in 1832. The dose of our balsa- 
 mic troches is eighteen per diem, six early in the morning, four in the 
 course of the day, and eight in the evening upon going to bed. 
 The number may be increased to thirty, and even forty, taken at 
 three different times ; but all the inflammatory symptoms must first 
 have disappeared, and it is for this reason patients should never employ 
 
LEUCORRHCE A OR WHITES. 
 
 321 
 
 them, without the preliminary advice of an enlightened physician, 
 who can decide as togthe propriety of using them. 
 
 The copaiba may also be administered by the rectum, in the mode 
 proposed by Professor Velpeau,* who prescribes it in small ene- 
 mata, prepared with six ounces of mucilage of marsh-mallow or flax- 
 seed, and from four to six drachms of copaiba mixed with the yolk 
 of an egg, with the addition of a grain of gummy extract of opium. 
 These balsamic enemata ought to be retained. The quantity of 
 copaiba may be gradually increased to an ounce, and even an ounce 
 and a half, according to the degree of sensibility, which is different 
 in different individuals. It may likewise be used, as we have em- 
 ployed it for a long time, in the form of suppositories, which we pre- 
 scribe according to the following formula : 
 
 Balsam of copaiba, 
 
 Beuerre de cacao, 
 
 Solid resin of copaiba, 
 
 Gummy extract of opium, gr. ss. 
 
 To be made into a suppository. 
 
 The anti-blennorrhagic and anti-leucorrhoeal suppositories should 
 be used twice daily, in the morning, and at bed-time.t 
 
 To these means should be added the use of tonic and slightly as- 
 tringent injections, consisting either of a mixture of water and sweet- 
 ened wine, of decoction of bistort root, pomegranate bark, or a very 
 weak solution of sugar of lead or sulphate of zinc ; these last injec- 
 tions should be used with care, in order to avoid too sudden suppres- 
 sion, and with the precautions that we mentioned while speaking of 
 subacute leucorrhma, after the example of Dr. Fleetwood Churchill, 
 of Dublin, we might also make use of vaginal injections consisting 
 of a solution of nitrate of silver, in the proportion of a grain to an 
 ounce of distilled water ; while, however, augmenting progressively 
 the quantity of the salt, we think it would be dangerous to carry it 
 so high as the Irish physician recommends.^ 
 
 * Researches and observations upon the employment of copaiba, etc.: administered 
 per anum in blennorrhagia. (Archives Gen. de Med., tom. xiii. p. 33, 1827.) 
 
 f Doctor Donne has also used the copaiba in the form of suppositories; though his 
 formula differs but little from our own, we feel convinced that our worthy fellow 
 practitioner was acquainted with our two memoirs on copaiba. 
 
 t Dr. Ricord employs the solid nitrate of silver, which he fixes in the slender 
 blades of a pair of elastic forceps, so arranged as to grasp the caustic uniformly, as 
 it dissolves, without allowing of its direct action upon the vaginal or uterine mucous 
 membranes, through the lateral openings of the instrument. Six or eight hours after 
 the cauterization, the patient should use injections of cold water, to be continued 
 until the time for a new application of the nitrate of silver arrives, if this should be 
 deemed necessary. When an examination of the diseased surfaces, and of the state 
 of the secretion, shows that a sufficient change has been brought about, a tampon of 
 dry charpie is introduced into the vagina, in order to separate the walls of that canal, 
 which are then promptly restored to their normal state. We ought to add, that M. 
 Ricord exposes the organs of generation by means of a speculum, and that he caute- 
 rizes first the uterine mucous membrane, then returning to the neck, he carries the 
 caustic rapidly from the summit to the base, circularly, as well as over the whole 
 vaginal mucous membrane, by bringing the instrument rapidly towards himself, as 
 far as the vulva. Finally, in order to procure an immediate application, he is care- 
 ful first to wash the surfaces with suitable injections. When the mouth of the uterus 
 
 21 
 
322 
 
 LEUCORRHCEA OR WHITES. 
 
 In order to keep up a continuous action, Doctor Ricord uses tam- 
 pons of soft charpie or fine sponge, impregnate^ with aromatic wine, 
 with an astringent decoction, or with Goulard’s lotion, carefully in- 
 troduced to the bottom of the vagina, either with the index finger, or 
 by means of the speculum ; he then administers another injection in 
 order to moisten the vaginal plug throughout, which are allowed to 
 remain, and which should merely fill up without distending the vulvo- 
 uterine canal. 
 
 In the employment of this tonic and astringent medication, it is 
 necessary to be careful not to exceed a proper degree of stimulation, 
 and to be always prepared to arrest its effects by means of sedatives, 
 baths, and the antiphlogistic remedies. 
 
 As it would be useless in this place to cite all the substances which 
 have been advantageously employed in the treatment of leucorrhoea, 
 we shall rest content with mentioning those that have enjoyed or 
 still possess most credit; for example, myrrh, incense, mastich, the 
 balsams of copaiba and tolu, powdered cubebs, the cones of the 
 northern fir, turpentine, ergot, recently employed by MM. Bazoni, 
 Negri, Hatin, Dufrenois and Bocquet; finally the distilled cherry- 
 laurel water, used both internally and by injection, by Doctor Caron 
 du Villars; the cicuta, recommended by Storck and Quarin ; and 
 opium, which several practitioners have found serviceable, amongst 
 whom M. Alibert, especially when nervous symptoms and hysterical 
 spasms were present. 
 
 In spite of the careful employment of the curative means just enu- 
 merated, leucorrhoea often resists the efforts of the physician, unless 
 he be seconded by the patient and by proper attention to hygieine. 
 The regimen should be directed on the same principles as the medi- 
 cines, that is to say, it should be fortifying without being irritating ; 
 the clothing must be warm, and flannel next to the skin ought to be 
 recommended ; we should advise a residence in the country in a pure 
 and healthy air, especially in the summer season, which means have 
 been known to dispel a chronic leucorrhosa very speedily, which, how- 
 ever has again appeared at the approach of winter or on returning 
 to the city. The patient should use all her endeavours to overcome 
 certain inclinations and illicit habits, which are frequently the chief 
 and unknown cause of her sad and disgusting malady. She should 
 compel herself to take muscular exercise without carrying it to fa- 
 tigue, which will dispose her to take food at first light and of easy 
 digestion, and then more abundant and more substantial. 
 
 We shall conclude by saying that the approach of the first men- 
 struation, the pregnant state, and the critical age, are so many causes 
 which should not be rashly interfered with. Prudence demands that 
 
 is not large enough to allow of the introduction of the nitrate of silver, M. Ricord has 
 recourse to caustic injections made with the double-acting syringe, described in the 
 memoir on blennorrhagia, presented by him to the Academy of Medicine. This 
 method has been employed a great number of times for discharges which had resisted 
 general medication and local agents; for cauterizing ihe vaginal mucous membrane, 
 the proper method is to use a small sponge impregnated with a concentrated solution 
 of nitrate of silver, and fixed on the extremity of a little shank of wood, or on our 
 caustic-holder. 
 
LEUCORRHCEA OR WHITES. 
 
 323 
 
 we should wait until their influence is no longer felt, and that we 
 should also respect the critical discharges, for fear of recalling the 
 disease, of which they are the substitutes. It is not proper to cure 
 leucorrhma except where it persists after the primary affection, and 
 besides, we should always take the precaution to prevent, as far as 
 possible, a recession, by means of an issue, and by the use of saline 
 purgatives. 
 
 Such is a sketch of the numerous resources of medicine in leu- 
 corrhoeal discharges, the treatment of which would doubtless be 
 more successful if a bolder and more energetic therapeia, always 
 based, however, on reason and the nature of the disease, were re- 
 sorted to. 
 
 % 
 
 OF REDNESS, SIMPLE ULCERATIONS, AND ERUPTIONS UPON THE OS 
 
 TINCJ3. 
 
 Chronic metritis, accompanied with profuse discharge, is almost 
 always followed by softening of the uterine mucous membrane, and 
 sometimes by the development upon the os tincse of red spots, exco- 
 riations, granulations, vegetations and different degenerations, which 
 we shall proceed to pass in review. 
 
 The permanent contact of fluid secreted by the uterus determines 
 a redness of the posterior lip chiefly, which is of no importance in 
 itself, but which may become the germ of more dangerous altera- 
 tions. These reddish spots, which sometimes extend to the vaginal 
 mucous membrane, are disposed in groups resembling the vivid red- 
 ness of herpetic inflammation, observed most frequently upon the 
 face. In some women, they consist of small distinct points like 
 flea-bites, and give to the mucous membrane, as M. Lisfranc ob- 
 serves, the appearance of the skin of a salmon trout. In other cases, 
 the cervix uteri is the seat of a superficial ulceration which at first 
 destroys only the mucous layer of the cervix to a greater or less ex- 
 tent; M. Dupuytren said, in his Lecons Or ales y that this affection 
 might easily be misunderstood if we contented ourselves with an ex- 
 ploration made with the finger, and that unless the disease were 
 brought into view by means of the speculum, we might suppose the 
 presence of a deep cancer of the organ. When the os tincae and cervix 
 are engaged in the superior portion of the instrument, we perceive a 
 superficial ulceration on one of the lips, or upon the external face 
 of the cervix a reddish ulceration, which looks as though it had been 
 made with a punch, confined to the mucous membrane, and which 
 we know not what better to compare to than to ozaena of the nasal 
 fossae; an ulceration, nevertheless, which finally produces the death 
 of the patient, unless relief is afforded. 
 
 When the nature of the affection is clearly ascertained, a cure is 
 easily obtained by local bleeding at first, particularly if the female is 
 young and the cervix very painful; then by baths, emollient injections, 
 and cauterization with the acid nitrate of mercury, practised in the 
 manner we shall explain after a time. It is proper to state, how- 
 ever, that this operation must be repeated until the cicatrization is 
 
324 REDNESS, ULCERATIONS, ERUPTIONS ON OS TINC.E. 
 
 complete. Doctor Jobert, in a memoir on cauterization,* states that 
 he has seen Professor Marjolin repeat it as often as twenty different 
 times. In such cases we have never found it necessary to repeat the 
 operation more than five times, and most commonly two cauteriza- 
 tions have been sufficient. 
 
 There is another superficial lesion of the os tincae, which has been 
 carefully observed and described by Madame Boivin and M. Duges. 
 This affection, easily misunderstood if examined by the touch alone, 
 is accompanied by a whitish discharge from the vulva, and some- 
 times by pruritus of the sexual organs, which may go to the extent 
 almost of producing nymphomania. This pathological condition, de- 
 signated by the term gran ulation of the os tincse , is characterized by 
 the presence of more or less numerous elevations on the circumference 
 of the uterine orifice. These elevations, which the speculum alone 
 enables us to observe accurately, are of variable form and dimen- 
 sions : they are commonly numerous, of the size of a millet seed, 
 of whitish colour, of soft consistence, of a vesicular appearance, and 
 always without pedicles ; at other times they are pediculated, as it 
 were, few in number, red, and offer some resemblance to certain 
 venereal vegetations ; finally, there are some which present them- 
 selves in the form of small hard seeds, occupying only the extreme 
 superficies of the organ, and others, which are pretty large, but so 
 flat, as to be scarcely perceptible to the touch. 
 
 Though these forms of miliary and phlyctenoid eruptions may ter- 
 minate without leaving any solution of continuity, their rupture often 
 occasions small superficial ulcerations, which, by running together, 
 sometimes end by forming a single ulcer. 
 
 Granulations of the mucous membrane of the os tincae, as well as 
 redness and superficial ulcerations of that organ, generally begin 
 with the more or less acute symptoms of simple chronic metritis ; such 
 as sensation of heat and smarting at the bottom of the vagina, 
 abundant discharge, acute pain during coitus, and sometimes during 
 defecation, weight at the fundament, dragging in the groins and 
 loins, flushings of heat on the face, attacks of hysteria, etc. The 
 application of the speculum not only enables us to discover the local 
 lesions we have enumerated, but also a soft swelling, and a state of 
 inflammatory congestion, marked by a deep red tint, by a sort of 
 ecchymosis, and finally, by extreme sensibility of the parts, and 
 oozing of blood provoked by the contact of the exploring instru- 
 ment, by the operation of the touch, and by the genital act. 
 
 The treatment of granular inflammation of the cervix requires, like 
 the preceding affections, antiphlogistics, small revulsive bleedings, 
 narcotics, derivatives, absolute repose of the parts, and finally, cau- 
 terization with the acid -proto-nitrate of mercury. Should the affec- 
 tion, however, occupy the whole surface of the os tincae, it would be 
 proper to cauterize only a portion, lest, from determining too great 
 an excitation, serious accidents might occur; in six or eight days 
 the same operation should be repeated, applying the caustic only 
 to the points which had been avoided on the first occasion. 
 
 * Journal Hebdomad, de Medecine, tom. vi. p. 137. 
 
CHANCRE, SCROFULOUS ULCER, ETC., OF OS TINCJE. 325 
 
 If the disease depended on syphilitic or scrofulous taint, etc., it 
 should be treated by the general and local means which experience 
 has shown most useful in combating these different diseases. 
 
 OF CHANCRES, AND SCROFULOUS ULCERS, ETC., UPON THE OS 
 
 TINGLE. 
 
 It has been found, in a large number of cases, that the cervix uteri 
 may be the seat of ulcers, developed primarily or consecutively, 
 under the influence of a special predisposition, such, for instanse, as 
 the venereal virus, or some scrofulous or herpetic affection, etc., 
 whose principal characters we are about to lay down in a few 
 words. 
 
 The chancrous ulcer of the os tincm depending on a syphilitic 
 cause, is rounded, its bottom is of a grayish colour, and its edges 
 abrupt; in a word, it resembles those of the same nature developed 
 on the glans penis. The patients feel burning and aching pains, and 
 know not what position to assume to diminish them. There flows from 
 the orifice of the vulva a sero-mucous fluid, commonly greenish, and 
 so irritating that it produces an inconvenient and often painful pruri- 
 tus, and even erythema of the parts with which it remains in con- 
 tact. Moreover, the syphilitic chancrous ulceration is very often 
 characterized by other primary or consecutive symptoms of venereal 
 infection, such as blennorrhagia, pustules, vegetations, and chancres 
 at the vulva, etc. Although the majority of practitioners assert the 
 contrary, it is less rare than is generally supposed, and requires a 
 local and general anti-syphilitic treatment, which should always be 
 preceded by the use of baths, injections, and demulcent and sedative 
 lotions and applications. 
 
 According to MM. Cullerier, Colineau and Jacquemin, ulcerations 
 of this kind are not very apt to degenerate into cancer ; what would 
 seem to militate in favour of the opinion of these distinguished practi- 
 tioners is that daily observation proves that prostitutes, though very 
 liable to syphilitic ulcerations of the cervix uteri, do not furnish more 
 frequent examples of cancer of the womb than women met with in 
 ordinary practice. 
 
 There are certain simple chancrous ulcers consecutive of chronic 
 metritis, which, though presenting nearly the appearance as those of 
 a syphilitic nature, not only do not yield to a methodical mercurial 
 treatment, but under its influence, even acquire increased severity. 
 We should, in this case, at first insist chiefly upon the employment 
 of antiphlogistics and narcotics, recurring afterwards to chlorureted 
 injections, to astringents, and the local application of pledgets of 
 charpie impregnated with the same solutions; should the disease resist 
 these remedies administered successively or simultaneously, cauter- 
 ization, with acid nitrate of mercury would become a resource that 
 would conclude the treatment. We add that non-specific chan- 
 crous ulcers are generally more serious than those of syphilitic na- 
 ture, and that when developed at the critical age, they have greater 
 
326 CHANCRE, SCROFULOUS ULCER, ETC., OF OS TINC.3E. 
 
 tendency to be transformed into cancer than tho§e observed in younger 
 women. 
 
 Scrofulous ulcers are commonly the result of the softening of the 
 tubercles of the cervix uteri, whose characters anterior to their period 
 of softening and suppuration we have pointed out. Ulcerations of this 
 nature are always preceded by the escape of a caseous matter ana- 
 logous to that which is furnished by suppurating cervical ganglions; 
 the discharge of this matter takes place through a small fistulous 
 opening, which enlarges little by little, and soon exposes to view 
 certain fringed, uneven and abrupt edges, circumscribing a base of 
 a grayish red colour, which secretes a sero-caseous curdled liquid, 
 and exhales a disagreeable odour, not, however, like that of cancer. 
 Engorgement of the cervix and even of the body of the uterus often 
 exists, and these parts may likewise be the seat of protuberances, 
 easily mistaken for the result of carcinomatous degeneration, be- 
 cause, excepting the lancinating pains, the symptoms are nearly the 
 same. To avoid all error on this point, it is merely necessary to 
 recollect that tubercles, prior to suppuration, always present a fluc- 
 tuation, whilst scirrhous indurations and protuberances are always 
 very hard ; at a later period, the mistake becomes altogether impos- 
 sible, after the tubercles have opened and given issue to the casei- 
 form matter ; moreover, the facility with which the ulcer deterges 
 itself, and especially the rapidity of its cicatrization, will suffice to 
 remove every doubt that may remain in the mind of the observer. 
 
 It is not commonly until after the tubercles have been converted 
 into ulcers, that we suspect their existence ; for, before this period, 
 their presence does not appear sensibly to modify the menstrual 
 evacuations, nor determine, consequently, any disorder in the general 
 functions of the organism. It sometimes, however, happens that 
 tubercular abscesses pursue a course resembling that of phlegmo- 
 nous suppuration, and that the pain resulting from them attracts the 
 attention of the physician ; the finger, in this case, carried into the 
 vagina, perceives the fluctuation of the tubercles, which, being ex- 
 posed to view by the speculum, may be opened by a bistoury plunged 
 into their most projecting point. Should any doubt remain as to the 
 scrofulous nature of the ulcer, the constitution of the female, her 
 mode of life, and especially the presence of old cicatrices and engorged 
 glands in the neck, would greatly assist in making the diagnosis more 
 clear. 
 
 The treatment of scrofulous ulcers should at first be directed to- 
 wards removing the inflammation, if any exists; watching the anti- 
 phlogistics, however, especially bleeding, because of the constitu- 
 tion of the patient. Recourse should then be had to astringent in- 
 jections and to cauterization, the efficacy of which may be increased 
 by the internal use of bitters, and some of the preparations of iodine, 
 conjointly with all the hygieinic and dietetic means calculated to 
 modify the constitution. 
 
 Before passing on to the subject of cancerous ulcers, we will add 
 that there are sometimes found, upon the internal surface of the lips 
 
CARCINOMATOUS ULCERS. 
 
 327 
 
 of the cervix uteri, phlyctamas similar to those so often observed 
 upon the surface of the buccal mucous membrane, which, by opening, 
 give rise to small ulcers. 
 
 OF CARCINOMATOUS ULCERS. 
 
 Carcinomatous ulcers differ from ulcerated cancer in the respect 
 that, like noli me tangere of the skin, they are commonly primary, 
 or at least succeed to simple or specific ulcerations that are neglected 
 or badly treated, and which we have already treated of ; whilst, in 
 cancer properly so called, the ulceration is always preceded by scir- 
 rhous engorgement of the subjacent parts. 
 
 When the disease has commenced as a carcinomatous ulceration, 
 the base of which consecutively becomes hard, blood flows upon the 
 slightest contact, the pains are superficial and slight, the patient some- 
 times feels a sensation of gnawing, which she cannot define, but 
 which, being ordinarily rather agreeable than unpleasant, excites to 
 coitus, which generally occasions acute lancinating pain. The ulcer, 
 the existence of which may be ascertained very early in the dis- 
 ease, is neither accompanied by much swelling nor by deep indu- 
 ration ; its surface presents a grayish and seemingly inorganic layer, 
 which is continually detached and renewed. The fluid it secretes is 
 very viscid and readily concretes while the disease is stationary ; but 
 as soon as it begins to progress and extend to the neighbouring parts, 
 the i ichorous serosity loses in viscidity what it gains in quantity and 
 foetoir; the base of the ulceration hardens more and more, and, soon 
 assuming -ah the characters of cancer, properly so called, produces 
 the same exhaustion of the organism, and leads as certainly to the 
 death of the patient. 
 
 Primary carcinomatous ulcers, though they produce disorders ana- 
 logous to those of ulcerated scirrhus, and require the same treatment, 
 are much less apt to relapse when we once succeed in removing them. 
 In fact, the induration, which forms the base of carcinomatous ulcers, 
 is accidental and consecutive, and even seems to depend on the exist- 
 ence of the ulceration. The indurated layer on which they repose is 
 sometimes so thin that it is difficult to distinguish it by dissection, 
 while the base in consecutive ulcerated cancer is always primary 
 and of considerable depth, which explains very clearly the much 
 greater frequency of relapses after medical treatment or an operation. 
 
 There is no doubt, in our mind, that the pretended cancers whose 
 cures, by means of injections and topical remedies of different 
 kinds, have been proclaimed to the public, are nothing more than 
 primary carcinomatous ulcers, and not true ulcerated scirrhous tu- 
 mours, having all the characters of cancer, properly so called. 
 Though we believe it possible to obtain the resolution of a consecu- 
 tive induration of small extent, by the modification, and especially by 
 the destruction of the primary ulceration which has provoked its 
 development, we regard as impossible the prompt and lasting dis- 
 persion of an ulcerated scirrhus, whatever be the therapeutical 
 agents employed for its cure. 
 
328 
 
 CANCER OF THE WOMB. 
 
 It is, therefore, of the utmost importance to distinguish a carcino- 
 matous ulcer from ulcerated cancer ; these two pathological condi- 
 tions are the more easily confounded, as they both present an ulcera- 
 tion with hardened base ; the former, which is usually the largest and 
 of the least depth, reposes on an indurated base, small in proportion 
 to its extent, and which is always thinner than that of ulcerated 
 cancer. To make a correct diagnosis, it is necessary, therefore, to 
 recollect, not only the differential signs we have already established, 
 but to take into account, likewise, the origin, progress, depth and 
 thickness of the induration on which this kind of solution of conti- 
 nuity rests. We dwell no longer at present on this important point, 
 because we shall have to revert to it when treating of the diagnosis of 
 ulcerated cancer. 
 
 Carcinomatous ulcers require the therapeutical remedies that we 
 proposed for engorgements and simple ulcerations ; that is to say, 
 antiphlogistics, emollient and narcotic injections, revulsive bleedings, 
 derivatives, etc. If, notwithstanding the careful employment of these 
 means, the symptoms should be aggravated and threaten to destroy 
 all hope of cure, we must resort either to cauterization, especially if 
 the cervix is not much swollen, and if the ulceration is superficial, or, 
 lastly, to the excision of the diseased part by means of a cutting in- 
 strument, which, under these circumstances, can always cut beyond 
 the limits of the disease. It is in this condition, more than any other, 
 that the operation is called for, and promises the best chance of suc- 
 cess, because the ulceration, which has been developed from without 
 inwards, reposes upon a secondary induration of no great depth. 
 
 OF CANCER OF THE UTERUS. 
 
 As our intention is less to concern ourselves with what relates to 
 pathological anatomy than to trace a succinct history of each lesion 
 in a practical point of view especially, it will be readily understood 
 why we here refrain from adverting to the more or less ingenious, 
 or more or less absurd opinions which both ancient and modern 
 authors have set forth upon the nature, seat, mode of development 
 and varieties of the different cancerous affections. As medical 
 science remains in a state of doubt and uncertainty on this subject, 
 we shall retain the metaphysical and eminently vicious expression 
 cancer, to indicate in a generic manner various organic alterations, 
 whose inherent nature is unknown to us, but which, though of varied 
 form and appearance, constitute one and the same lesion, and have 
 as common characters, the property of changing and disorganizing 
 the texture of the uterus, the tendency to spread superficially and in 
 depth, and finally, are usually beyond the resources of medicine pro- 
 perly so called. 
 
 The cancerous affections of the womb, as just defined, present dif- 
 ferent modifications, or forms, which may be classed in the following 
 manner : 
 
 1. Scirrho-cuncer , characterized by hard engorgement, and al- 
 teration of the shape of the organ, which presents protuberances, 
 
CANCER OF THE WOMB. 
 
 329 
 
 some of them indurated, and others more or less softened, and subse- 
 quently ulcerated. This condition is accompanied by lancinating 
 pains, by frequent haemorrhages, especially if the disease occupy 
 only a part of the womb, and finally, by a leucorrhoeal discharge, 
 which is either small in quantity or very abundant. This altera- 
 tion of tissue, which may vary from the lardaceous and solaniform 
 to the cartilaginous, or, in certain cases, the osseous condition, 
 produces all the sympathetic and nervous symptoms and pheno- 
 mena which depend upon the circulation, the size, and change of 
 situation of the organ, as is the case in simple engorgements. 
 
 What particularly distinguishes the cartilaginous or osseous altera- 
 tion, is the circumstance of the organ being less changed in shape 
 than in the scirrhous or tuberous cancer, and that we do not have, 
 as in the latter form, acute pains, or purulent and sanguine dis- 
 charges from the vulva. It is likewise less dangerous, and some- 
 times occasions so little disturbance to the economy, that women 
 long affected with it have been known to live to a very advanced 
 age. Let us add that the cartilaginous or osseous degeneration of 
 the uterus is always beyond the resources of art. 
 
 2. Ulcerated cancer , which is the last stage of scirrhus, is recog- 
 nized by a solution of continuity, with hard inverted edges, and une- 
 ven surface of a . grayish colour. The discharge, which may be 
 simply serous, generally consists of a sanious acid, horribly fetid, 
 sometimes watery and slightly sanguineous matter, which escapes 
 in such abundance, that it soon impregnates the frequently renewed 
 cloths with which the female protects herself. The ulcerated sur- 
 faces are sometimes covered with excrescences and vegetations, 
 which may remain for a long time in the scirrhous state, but which 
 commonly increase with great rapidity, and form soft, fungous tu- 
 mours, bleeding at the slightest touch. 
 
 This form of cancer, which is the most formidable of all, and 
 whose progress is the most rapid, is accompanied by haemorrhages 
 profuse in proportion to the extent of the disease and the amount of 
 corrosion of the vessels. 
 
 3. Fungous cancer is that form which appears in the shape of 
 a mushroom-like tumour whose pedicle of greater or less size is 
 attached to the circumference of the os tineas. The consistence of 
 the tumour is soft and spongy, its surface is granular, uneven, and 
 formed of a multitude of projecting globules, connected like the gran- 
 ules of a raspberry or cauliflower ; its colour, which is violet, livid 
 or reddish brown, approximates to that of the placenta ; the least 
 pressure upon it determines a considerable discharge of black blood, 
 an almost constant exudation of which, moreover, is mingled with 
 that of a reddish, ichorous serosity of most disgusting fetor. In this con- 
 dition it is easy with the finger to detach portions of soft, brown and 
 very friable vegetations; one circumstance we may note here is, that 
 women generally complain to the last physician they consult, of the 
 brutality of the first who attended them, and who, according to their 
 statement, made the examination with so little care, as to cause 
 abundant bleeding. 
 
330 
 
 CANCER OP THE WOMB. 
 
 The fungous cancer, called by M. Duparcque mural cancer, pre- 
 sents itself sometimes in the form of a non-pediculated fungus, having 
 on its surface a number of smooth globules, equal, of soft consistence, 
 vesiculous appearance, and accumulated in masses around the os 
 tincse. These globular granules, which resemble gooseberries, ( ribes 
 uva crisp a,) secrete a serous liquid, which is so abundant at times, 
 as to pass through the mattrasses during the night, and compel the 
 patient to change her cloths twenty or thirty times a day. More- 
 over, the fluid secreted by this grape-like fungus is almost colour- 
 less and inodorous. M. Duges has published several cases of this 
 second variety of uterine fungus ; an example of which we ourselves 
 saw in 1833, in the wife of a water-carrier, whom we advised to 
 enter the hospital of La Pilie , in M. Lisfranc’s wards, where she 
 probably died. These two varieties of fungous cancer, and espe- 
 cially the latter, are not only the least painful, but are those also 
 which offer the best chance of cure. 
 
 The luematode cancer (bloody cancer of M. Duparcque), hae- 
 matoma of Hooper, and spongoid inflammation of Burns, although 
 possessing very marked differential signs, had not been clearly sepa- 
 rated from the other forms of cancer, before the works of MM. 
 Hooper, 7 * Duparcque,! and Dugesf appeared. As M. Duparcque is 
 the first French author who has well described this variety of can- 
 cerous alteration, we shall quote its principal characters from that 
 excellent practitioner : “ We recognize this form of cancer by the 
 enlargement of the uterus without deformity, and especially of its 
 neck, where it is most commonly seated ; by the remarkable soft- 
 ness of its tissue, by the sensation of crepitation felt in touching it ; by 
 the constant discharge of black and grumous blood, mixed with clots, 
 and by the oozing of an analogous fluid, coming from the whole 
 surface of the tumour, as though it were squeezed like a sponge. 
 At a very advanced period of the disease, there are mixed with 
 the blood certain putrid filaments, and fetid matters resulting from 
 the detritus and decomposition of the altered tissue, a decomposition 
 which generally extends from the centre to the circumference, like 
 ramollissement, or, in other words, which commences towards the 
 mouth, and extends from thence both to the neck and body of the 
 womb. This produces a seemingly ulcerous excavation, and the 
 disease then assumes the form of ulcerated cancer.” We add that 
 the tumour is of a brownish-red colour, and its surface, which ap- 
 pears smooth to the eye, is always covered with lamina of clotted 
 blood, and feels slightly uneven when touched. It is probable, 
 says M. Duparcque, that the very marked sensation of crepitation 
 which is felt, depends upon the displacement of the serni-coagulated 
 blood, which infiltrates the diseased tissue. 
 
 What particularly serves to distinguish the bloody from fun- 
 gous cancer is, that the latter is supported by a pedicle fixed upon 
 the neck of the uterus, and never passing beyond it, while the tumour 
 
 * The Morbid Anatomy of the Human Uterus, 1832. 
 
 f Traite des alterations organ, de la matrice, p. 395. 
 
 4 Traite des maladies de l’uterus, tom. ii. p. 180. 
 
CANCER OF the womb. 
 
 331 
 
 of sanguine cancer is without any pedicle, spreads to the body of 
 the viscus even, and has a strong tendency to extend in depth. This 
 distinction, which is of little importance in the medical part of the 
 treatment, is of very great importance for the surgical treatment. 
 Effectively we may hope much from the excision of a fungous can- 
 cer, when seated upon an organ whose tissues, perhaps, are healthy, 
 while the same operation could only hasten the death of the patient, 
 or even immediately determine its occurrence, were it performed 
 with a view of destroying a sanguine cancer, which extends more or 
 less to the body of the womb. The only operation that ought to be 
 attempted in such a case as this is cauterization, by means of the 
 actual cautery, as we have seen it done by the celebrated Baron 
 Larrey. 
 
 5. The Encephaloid or Medullary Cancer is characterized by a 
 tumour of variable size, whose external surface is divided into more or 
 less projecting lobes, containing a cerebriform substance of dull white 
 colour, and of moderate consistence at first, but afterwards becoming 
 pulpy and liquid, like thick pap. This substance may exist in small 
 encysted masses, or in small lobes which are not encysted, but sepa- 
 rated by fissures, less deep and regular than those of the encysted 
 encephaloid masses ; finally, the cerebriform matter may be contained 
 in masses not circumscribed, but it is infiltrated, as it were, in the tis- 
 sue of the organ. This form of cancer, which often exists in different 
 parts of the economy at the same time, and which sometimes follows 
 tubercular degeneration, is accompanied by a puriform, ichorous, and 
 very fetid discharge, bringing along with it softened fragments of the 
 uterine tissue, whose separation gives rise to profuse haemorrhages. 
 
 The various pathological degenerations, just described by us, as 
 so many forms which uterine cancer may assume, are sometimes 
 found united, wholly or partially, in the same uterus, and constitute 
 in that case, the mixed cancer , met with particularly at an advanced 
 period of this frightful disease. 
 
 We have not desired to make different species of the varieties and 
 forms which we have just described, as starting from the same point, 
 but merely to present the same disease under all its different aspects 
 and modifications, without destroying that pathological unity which 
 it ought to retain in theory and practice. 
 
 The causes of cancer are numerous and varied ; they have a more 
 or less direct action upon the production of the disease ; some of them 
 are general or predisposing, others determining or local. 
 
 Amongst the predisposing causes are hereditary predisposition, age, 
 constitution, and mode and habits of life. 
 
 Though in the present state of the science it seems difficult to ad- 
 mit of a cancerous virus transmissible by generation, it is yekincon- 
 testable that cancer in many cases appears to be hereditary, that is to 
 say, persons born of parents dying of a cancerous affection are very 
 much disposed to contract the same disease. We could cite many 
 authentic facts in support of this opinion, particularly in relation to 
 cancer of the uterus, which is more disposed than any other organ 
 to carcinomatous degenerations, probably from the nature of its func- 
 
332 
 
 CANCER OF THE WOMB. 
 
 tions, from its close and compact structure, and especially the great 
 abundance of fibro-cellular* tissue with which it is supplied, particu- 
 larly about the cervix. 
 
 Cancer may develop itself at any period of life, but it is very rare 
 for that of the uterus to make its appearance earlier than at twenty - 
 five years : nevertheless, we have observed, and writers have reported 
 several examples of uterine cancer even before twenty years of age. 
 From the statistical researches we have been enabled to make in 
 hospitals, from our own particular practice, and especially from the 
 works published upon this subject, we have found, by following 
 the order of frequency, that this frightful malady appears most 
 commonly at the age of from forty to forty-five years, then from 
 thirty to forty, from forty-five to fifty, from twenty-five to thirty, 
 from fifteen to twenty, from fifty to sixty, and finally, from sixty to 
 seventy. It may be seen from this table that cancerous affections of 
 the uterus are the more frequent in proportion as that organ is in a 
 greater state of activity, and where it begins to pass into the physio- 
 logical inertia of the critical age. 
 
 Badly regulated women ; those who have some anomaly of the 
 menstrual function; those who are nervous, irritable, sensitive, or sub- 
 ject to the more vivid emotions; those of an erotic temperament, and 
 who, constantly tormented by venereal desires, give themselves up 
 with excess to masturbation or venery ; those who pass their lives 
 in crowded parties, and the tumult of fashionable society ; those in 
 whom an habitual leucorrhcea, cutaneous eruptions, neuralgic or 
 rheumatismal pains have suddenly ceased; finally, women who inha- 
 bit large cities, and particularly those who have borne many children, 
 or had numerous abortions, or frequent attacks of metrorrhagia, are 
 more subject than others to cancerous affections of the womb. We 
 should also range amongst the predisposing causes to these lesions, 
 celibacy, sterility, violent grief, frequent paroxysms of anger, and all 
 the strong passions ; we must confess, however ; that circumstances 
 diametrically opposed do not prevent the development of the disease, 
 which may show itself under the influence of causes inappreciable, 
 but inherent in the constitution of some persons. 
 
 The occasional causes of uterine cancer are all those whose action 
 may give rise to metritis. Such are criminal attempts to produce abor- 
 tion; the presence of a foreign body in the vagina; disproportion be- 
 tween the genital organs of married people, and the contusions which 
 may result from this cause ; venereal enjoyments before puberty, at 
 the epoch of the physiological revolution, and after the critical age: 
 the presence of cellulo-vascular polypi upon the os tincae or in the 
 interior of the cervix uteri ; and finally, all causes capable of produc- 
 ing inflammatory and congestive engorgements, which it is useless to 
 recapitulate. 
 
 ■* Professor Cruveilhier has proved, by a vast number of interesting: observations 
 and researches, printed in the Bibliotheque Medicate, that the fibro-cellular tissue is 
 the organic element chiefly affected in cancer, and that this degeneration seems to 
 have a peculiar predilection for those organs into whose composilion a large quan- 
 tity of this tissue enters. Such are particularly the uterus, the mammae, the testicles, 
 and all the glands, etc. 
 
CANCER OF THE WOMB. 
 
 333 
 
 Whatever may be the origin and causes of cancerous degeneration 
 of the womb, the first symptoms of the disease generally escape the 
 attention of the physician, who is very rarely consulted until exten- 
 sive disorder already exists Moreover, the derangements which 
 women experience at the beginning are so slight, that they them- 
 selves pay no attention to them, and it may happen also that the 
 disease shall attain a very advanced stage without any precursory 
 symptom to cause its presence to be suspected. There are, in fact, 
 young, fresh and brilliant women, appearing to have all the attributes 
 of perfect health, in whom cancer has taken deep root, and in whom 
 the uterus is reduced to the state of a putrid slough presenting a mere 
 fetid cloaca. We have seen cases of this kind, and several modern 
 authors, among others MM. Lisfranc, Recamier, Pauly, Tealier, etc., 
 have published examples of them. 
 
 In general, the first symptoms that make their appearance, are 
 derangements of the menstruation; augmentation; diminution or tran- 
 sient suppression of the menstruse; their frequent and irregular return; 
 a leucorrhoeal discharge mixed with sanguineous stria?, and having a 
 redder tint after coitus ; sensation of pressure on the anus, and weight 
 in the hypogastrium, dragging in the loins and lumbar regions, a 
 sort of vesical tenesmus and painful sensation during the expulsion 
 of the urine and during defecation. Some women experience a sort 
 of voluptuous pruritus in the genital parts, especially at the vulva, 
 which inclines them to coitus and illicit manoeuvres ; the conjugal 
 act generally, but not always, causes more or less acute pain ; to 
 these symptoms are added acute and transient pains in different parts 
 of the body, especially in the breasts, which become firmer and 
 larger ; the patients experience alterations of tension and retraction 
 of the abdominal walls ; attacks of hysteria ; unusual melancholy ; 
 extreme disgust for food ; strange longing, and finally, a general un- 
 easiness which cannot be accounted for, until all doubts are removed 
 as to the existence of the disease. 
 
 When such phenomena as these make their appearance, and espe- 
 cially when they last beyond the period of transient irritations, it is 
 of the greatest importance to examine the sexual organs to convince 
 ourselves as to the nature of the evil ; the least delay would expose 
 the patient to irremediable danger, and might compromise the honour 
 of our art and the reputation of the physician. 
 
 In the first stage of the disease, the os tincse is found, upon exa- 
 mination, hard, tumefied, warm, painful and sometimes softened, 
 and uneven at different points ; the posterior lip is always more 
 projecting and more voluminous than the anterior ; the mouth of the 
 uterus is partially open and irregular ; the finger, especially its ex- 
 tremity, when withdrawn from the vagina, is commonly covered 
 with bloody mucus, like that provoked by copulation. It is often 
 difficult to distinguish commencing cancer from subacute metritis 
 with simple induration ; when of scirrhous nature, however, the 
 neck of the uterus is less regular in its form, generally softer, less sen- 
 sible and larger than usual. The engorgement is then more cir- 
 
334 
 
 CANCER OP THE WOMB. 
 
 cumscribed, and rarely extends to the body of the organ, as in simple 
 engorgements. 
 
 Instead of following a progressive course, it sometimes happens 
 that cancer in the first stage remains stationary, until some inap- 
 preciable cause, by communicating to it a new impulse, hastens its 
 progress. The first doubts as to the diagnosis soon cease altogether. 
 The disease makes rapid progress, and new symptoms make their 
 appearance. The pain becomes pungent, the losses of blood more 
 frequent, and the vaginal discharges more abundant. The Touch 
 at this second period, in connection with the exploration by the 
 speculum, shows the uterus to have acquired the weight and dimen- 
 sions which it possesses at the second month of pregnancy. The 
 orifice of the neck resembles a hard, knobbed and uneven ring, 
 more or less red, and covered with a sanguineous mucous fluid, or 
 is even bathed in pure blood. If the entire organ be implicated, the 
 rectal and hypogastric examination commonly enables us to distin- 
 guish the extent of the tumour and the rounded inequalities which 
 project more and more from its surface. When the degeneration is 
 encephaloid, we see the cancerous diathesis promptly manifested by 
 softening and ulceration of the tumour, and by the rapid growth of 
 the disease in extent and depth. The pains which are then almost 
 constant are often dull and gnawing, but always accompanied by 
 acute shootings, which the patients compare to a flash of fire, or to 
 the pricking of a needle or a penknife. Generally, they concentrate 
 upon the uterus whence they extend to the ligaments of the organ. 
 The body of the uterus, which becomes more and more hyperiro- 
 phied in consequence of the extension of the disease, causes com- 
 pression of the vessels and nerves of the pelvis, and then becomes 
 one of the chief causes of the deep-seated lancinating pains which 
 are felt in the hips, thighs and loins, in the direction of the sciatic 
 nerve and its branches. Sometimes the pains seem no longer to 
 arise in the pelvis, but extending in various directions, they become 
 so acute in the different articulations of the inferior extremities, as to 
 simulate rheumatism more or less accurately. The functions of the 
 neighbouring organs become impaired ; the constipation is obstinate, 
 the desire to urinate continual, and finally the uterine haemorrhages 
 augment in frequency and often become permanent, when the scir- 
 rhous tumour has ulcerated, or when fungosities, vegetations, and 
 especially true fungous haematodes have been developed on the cervix. 
 
 In the third stage, the primary cancerous ulceration, or that pre- 
 ceded by scirrhous engorgement, is bounded by edges which are 
 indurated, torn, bleeding, and unequally inverted on the exterior 
 circumference of the cervix uteri. The bottom of this orifice is soon 
 found changed into a kind of putrid slough, which the finger rea- 
 dily penetrates, and whence flows a characteristic ichorous and san- 
 guineous matter, that corrodes the thighs, is of disgusting odour, 
 and so horribly fetid as to persist a long time after the touch, in spite 
 of repeated washings with soap or chlorinated water. From the bot- 
 tom and whole surface of the ulceration, bleeding granulations and 
 ftjngous vegetations, of which we have already spoken, often arise. 
 
CANCER OF THE WOMB. 
 
 335 
 
 As the disease now makes rapid progress, the walls of the cervix 
 may soon be eaten away, and reduced to the state of a slough ; the 
 disorganization often extends to the body of the organ, which is some- 
 times perforated, so as to establish a communication with the perito- 
 neal cavity ; it may, also, in some cases, be propagated to the neigh- 
 bouring organs, the bladder, for instance, the rectum, the vagina ; 
 and even the exterior parts of generation have been known to be 
 included in this focus of destruction, and to form a hideous cloaca 
 where the urine and the faecal matter mingle with the cancerous 
 rpatter; sometimes portions of softened flesh, and clots of black and 
 putrified blood detach themselves from the cancerous fungosities, 
 whence also flow ichorous, sanguineous and blackish matters, or 
 matter resembling wine lees. Then come on haemorrhages whose 
 abundance so rapidly exhausts the forces, and often cause the 
 death of the patient some months before the period when it would 
 have taken place, without this accident. When the suffering is 
 slight, women retain a certain degree of embonpoint and freshness, 
 but generally the pains are so agonizing as to render life insupport- 
 able, and their exaggeration may cause death in a few days, as MM. 
 Bayle, and Cayol,* Tealier,t and other authors have stated, with 
 cases in point. 
 
 Beside these local symptoms, we must mention the phenomena of 
 cachexia or general alteration of the organism which constitute the 
 most unfortunate effect and last stage of the cancerous diathesis. 
 
 When women reach this frightful period of the disease, they pre- 
 sent the most heart-rending picture of human misery ; in fact, the 
 functions of assimilation are exhausted ; appetite is gone, digestion 
 is deranged in a thousand ways; emaciation, more or less rapid, 
 sometimes passes into marasmus ; the osseous system participating in 
 the disease, becomes friable, fragile and breaks of itself, as it were. 
 The skin, which is dry, swollen, wrinkled, and adherent to the bones, 
 assumes the dull white colour of wax, or the yellow straw colour 
 which characterizes cancerous affections; the attitude has a peculiar 
 character in this pathological condition ; the sad and drooping 
 expression bears the impress of suffering and depression ; the eyes 
 sunken in their orbits, the livid and singularly contracted lips, the 
 fuliginous teeth, the drawn, hippocratic face, furrowed with deep 
 wrinkles, give to the patient the aspect of a corpse : finally, colliqua- 
 tive diarrhoea, symptomatic of intestinal ulcerations, vomiting, oedema 
 of the inferior extremities, dropsy, hectic fever, insomnia, intolerable 
 sufferings, profuse haemorrhages, despair and death come to com- 
 plete this sad and afflicting scene. 
 
 The progress of cancer varies according to its kind and the epoch 
 at which has been developed the organic modification which predis- 
 poses to scirrhous and encephaloid degeneration, fundamental altera- 
 tions for the greater number of cancerous affections. If the disease 
 begin with the scirrhous state, it may remain indolent and stationary 
 for a long time, and softening of the tumours may occur, with great 
 slowness, so that sometimes females are not prevented from reaching 
 
 * Dictionnaire des Sciences Med., art. Cancer. 
 -j- Du cancer de la Matrice, p. Ill, 1836. 
 
336 
 
 CANCER OF THE WOMB. 
 
 very advanced old age. Rapid ulceration of cancer produces the 
 most serious disorders in a short time, and a few months may suffice 
 to bring it to its last stage ; nevertheless, this unhappy termination 
 has been known not to occur until after several years ; it is probable 
 that the difference depends on the multiplicity and intensity of the 
 predisposing causes, as, for example, the temperament of the patients, 
 their sensibility, and particularly the kind of treatment. Death often 
 occurs, either after a terrific haemorrhage or after sanguine losses in 
 small quantity but too frequently repeated, after peritonitis, violent 
 convulsions, pneumonia, or other affections, which are frequent com- 
 plications of uterine cancer. We -should add, that the disease gene- 
 rally makes more rapid progress in proportion as the female is 
 younger, and that though in some cases ulceration seems to stay its 
 progress, and afford some consolation to the patient and hope to the 
 physician ; this happy change, which is always ephemeral, does 
 not long justify the advantages which had been thought to be de- 
 rived from the therapeutical means put in practice. The patient, who 
 had been relieved at first by a palliative treatment, is soon discou- 
 raged ; she changes her physician, essays the strongest remedies, and 
 in her despair applies to old women, to charlatans, to magnetizers, to 
 homoeopaths, who in turn promise her a speedy and radical cure, 
 but who only hasten on the fatal event. 
 
 While the diagnosis of cancer of the womb is not generally ob- 
 scure in the latter periods of the disease, all authors agree in the 
 opinion, that it is quite otherwise in the beginning. Effectively, in 
 chronic metritis with simple induration, the cervix uteri, as in scir- 
 rhous engorgement, is larger and harder than in the normal state ; 
 the surface of the tumour may be at first smooth and polished in both 
 cases, and finally the pain may be wanting, it may be slight, or even 
 lancinating, in cases of simple induration as in those of scirrhous in- 
 duration, or commencing cancer. M. Lisfratic, whose experience is 
 very great, and whose opinions are of so much importance in this 
 matter, published in the Gazette Medicate, the following differential 
 signs. 
 
 1. Simple engorgement is softer, and its surface is more *even to 
 the touch than scirrhus, which presents prominences and inequali- 
 ties. 
 
 2. In scirrhus, the mucous membrane of the neck is of a dull 
 white colour, which, according to this celebrated practitioner, is not 
 the case in simple engorgement. 
 
 3. Scirrhus is developed more slowly ; for example, when an en- 
 gorgement dates from one or two months only, and especially when 
 it follows abortion, ordinary labour, or sudden suppression of the men- 
 struge, we infer, says M. Lisfranc, that it is not of a scirrhous nature. 
 
 4. Finally, simple engorgement requires a treatment of a month 
 or six weeks, whilst scirrhus is much longer in recovering. We 
 will add to the characters of scirrhus mentioned by the able surgeon 
 of La Piti&, that engorgement is generally less sensible, less active, 
 and more circumscribed than simple induration ; we shall also add, 
 that its formation is not accompanied by such marked symptoms, nor 
 
CANCER OF THE WOMB. 
 
 337 
 
 does it produce at the outset such troublesome symptoms or such 
 well-marked general phenomena. Finally, let us say that, under the 
 influence of bleeding, strict diet, repose, antiphlogistics and resolvents, 
 simple engorgement of the uterus usually diminishes with great 
 rapidity, which never occurs in scirrhous degeneration, even at the 
 beginning. 
 
 When induration of the cervix does not present the characteristic 
 signs of scirrhus in a marked degree, we should infer the absence 
 of this alteration, and act as though we had positively ascertained a 
 simple hard engorgement, that is to say, we should resort with me- 
 thod and perseverance to the various therapeutical means of which 
 we spoke under the head of chronic metritis and induration. 
 
 We shall be able to distinguish scirrhus from polypus of the uterus 
 if we reflect that the latter tumours are altogether insensible, that 
 they are isolated from the os uteri and present a smooth surface, a 
 peculiar elasticity, and an oval, regular and pediculated shape, while 
 scirrhous indurations are adherent, uneven, irregular, more or less 
 sensible, hard to the touch, and of almost stony consistence. Fibrous 
 tumours, developed in the thickness of the walls of the cervix uteri, 
 are also recognized by their firmness, insensibility, and considerable 
 size ; and by their rounded and not lobular form. It should never 
 be forgotten, moreover, that the cervix uteri is susceptible of consi- 
 derable elongation, which we have spoken of before ; that the os 
 tincse, which varies considerably as to size in the normal state, is in 
 some women hypertrophied without being diseased at all; and, 
 lastly, that labour often causes protuberances and fissures of its tissue 
 which are easily distinguished from cancerous tumours. 
 
 As we gave, under the head of carcinomatous ulcers, their differen- 
 tial diagnosis, we deem it unnecessary to revert to this subject, and 
 we shall also pass by in silence, the characteristic symptoms of dif- 
 ferent lesions, among others the cellulo-vascular polypus, which we 
 described in another part of the work, and pointed out as having 
 some symptoms analogous to those of cancer of the cervix uteri. 
 
 The prognosis of uterine cancer is always unfavourable; for it is 
 the peci\Jiar property of this disease to disorganize and destroy, more 
 or less rapidly, not only the part in which it is seated, but likewise, 
 step by step, those which lie near it. Nevertheless, when the os 
 tincce alone is implicated, especially if the cancer be the result of a 
 degenerated primary ulcer, the prognosis is less unfavourable, and 
 the disease offers some chance of cure ; we ought, on the contrary, 
 no matter what be its origin, form and mode, of development, to 
 regard it as almost certainly fatal, when it passes beyond the cervix 
 uteri and extends to the body of the organ. It is, therefore, of the 
 utmost importance to attack cancer at its very commencement, and 
 never to lose sight of the excellent advice given by Doctor Miller,* 
 when he said : “ any prolonged derangement of the genital organs of 
 the female or of their functions ; any inconvenience which exists ; 
 any suffering, even slight, which is repeated, should arouse the atten- 
 
 * Memoirs de l’Acad. de Med., tom. ii., p. 333. 1832. 
 
 22 
 
338 
 
 TREATMENT OF CANCER OF THE WOMB. 
 
 tion of the physician and demand examination ; unfortunately, women 
 rarely demand the assistance of medicine, at the first appearance of 
 the symptoms, or rather they refuse to submit themselves to any kind 
 of exploration ! they trust to nature the care of their cure ; but, vain 
 hope ! they are ever deceived in. their expectations. 
 
 TREATMENT OF CANCER OF THE WOMB. 
 
 All the efforts of the physician should have as their object not 
 merely to arrest the first steps of the disease and crush it at its origin, 
 but also to prevent its return by the most attentive care, and by 
 removing all causes which tend to reproduce or keep it up. There 
 is no doubt that the primary source of cancer of the womb is chro- 
 nic inflammation of that organ. To cure this affection, and thus 
 dispel the irritation which maintains the engorgement, is most com- 
 monly to prevent uterine cancer, and consequently save the women 
 from the most frightful of diseases. As we have already dilated at 
 length upon the treatment of chronic metritis, and the different 
 engorgements which it may occasion, we deem it unnecessary to 
 revert to this subject here. 
 
 The basis for the treatment of a commencing cancer, is just the 
 same as that for primary engorgements of the uterus, or for the 
 ulcerations which may be their cause or effect. Thus, to diminish 
 the pain and arrest the progress of the disease, we should have re- 
 course to revulsive bleedings, to exutories, and to a soothing regi- 
 men ; we should prescribe a milk diet, white meats, repose, baths, 
 emollient narcotic and astringent injections, enemata and poultices of 
 the same nature, and the other different therapeutical agents which 
 we have already mentioned. 
 
 The diet. We should commence by depriving the patient of one- 
 fourth of her ordinary aliment, then of a third, and finally of the half, 
 if her constitution permits ; for there are some women who support 
 rigid diet with the greatest difficulty. The dishes that ought to be 
 allowed are white meats, fish, herbaceous and vegetable substances, 
 feculent substances prepared with much dilution, preparations of 
 milk, and cooked fruits or very ripe un-cooked fruits. Spirituous and 
 aromatic drinks must be positively forbidden; water, slightly reddened 
 with wine, may be allowed during the repasts, but at other times the 
 use of emollient drinks must be continued. We add that the diminu- 
 tion of the aliment or the cura famts is one of the most important 
 elements in the treatment of cancer. 
 
 Bleeding should be employed when the female is young and 
 plethoric, when the pulse is full, and especially when there exists a 
 fluxionary movement towards the uterus. Bleeding from the arm 
 acts not only by diminishing the mass of the blood, but also by 
 creating a revulsion, which carries the blood towards the supra-dia- 
 phragmatic regions. It should amount, generally, to half a palette,* 
 a palette and a half, or two palettes at most, according to the strength 
 
 * A palette contains four ounces. — Tram. 
 
TREATMENT OF CANCER OF THE WOMB. 
 
 339 
 
 and constitution of the patient. It ought never to be employed 
 except about eight days before or after the epoch of the menstruae, 
 and should be repeated less frequently when the disease is already 
 of long standing. The methodical use of general bleeding, the ad- 
 vantages of which in . the treatment of cancerous affections and in- 
 flammations of the uterus are incontestable, dates from the era of 
 Hippocrates: this principle, which has become a fundamental one in 
 medical science, and which was followed also by Galen, Pare, Val- 
 salva, Morgagni, Heister, Ledron, Fearon, and Hufeland, is justly 
 recommended by all modem authors, and particularly by M. Lisfranc. 
 
 After the revulsive or depletory general bleedings, conjointly with 
 other antiphlogistic remedies, have dissipated the inflammatory symp- 
 toms and the local pain, several practitioners, among others M. Du- 
 parcque, Miller and Teallier, recommend applications of leeches to 
 the os tincse, which is exposed by means of the speculum of M. Re- 
 camier. The latter plan, which we have seen employed with advan- 
 tage on several occasions in simple engorgement with or without 
 induration of the neck, should be applied in the following manner: 
 when the womb is in a state of procidentia, it is sufficient to separate 
 the labia majora in order to expose the os tincse : if the uterus, on 
 the contrary, is situated more deeply, the cylindrical speculum must 
 be used ; from six to fifteen leeches must be introduced through it 
 up to the cervix, and retained upon it either with a plug of linen, or 
 with a sort of hollow central piece six or eight lines in depth. With 
 this instrument, which is lined with a piece of transparent gauze, and 
 fastened at the bottom by a shank with a handle bent at an obtuse 
 angle, we can readily keep the leeches in their places, while they are 
 prevented from moving about and attaching themselves elsewhere 
 than on the neck, from being unable to create a vacuum on the tissue 
 of the gauze, which makes it impossible for them to fasten them- 
 selves upon it, as they often do in the parietes of the speculum. To 
 render their application still more convenient, we should be careful 
 to remove with a small sponge or fine pencil of charpie, the mucus 
 upon the surface of the neck, and then wash them away by means 
 of repeated injections. Ten or fifteen minutes suffice to fill the 
 leeches, which are then to be removed, as they fall off, by forceps. 
 The discharge of blood ought to be encouraged by warm injections, 
 which at the same time remove the clots of blood. If the haemor- 
 rhage prove too abundant, it may be arrested by plugging the 
 vagina. 
 
 Without entirely rejecting the application of leeches to the cervix 
 uteri, we believe with M. Lisfranc, that it often has the inconveni- 
 ence of increasing the congestion of the organ, and we think it should 
 never be resorted to after induration of the neck has assumed the 
 scirrhous character, because, in this condition, as we have several 
 times seen happen, each puncture may be converted into so many 
 cancerous ulcerations. We also regard as almost always hurtful in 
 the treatment of cancer, leeches applied to the anus, the vulva, groins, 
 and around the pelvis; for, excepting in some particular cases, they 
 augment the congestion of the uterus, and all the disorders dependent 
 
340 
 
 TREATMENT OF CANCER OF THE WOMB. 
 
 upon if. Simple and emollient general baths, heated as moderately 
 as possible, yet prepared in such a way that the patient shall not feel 
 chilled, are an excellent means for diminishing the nervous erythism 
 and pain which accompany affections of the uterus ; the duration of 
 the bath should be at least one hour, and at. most six hours, and they 
 may be renewed every day, or every two days, according to the 
 strength, habits and constitution of the patient. The heat of the water 
 should be maintained at an equal temperature ; we must be careful 
 not to prescribe this excellent therapeutical means for women in 
 whom it produces oppression, uneasiness, or different nervous symp- 
 toms. 
 
 Hip-baths ought to be forbidden, as they always determine uterine 
 congestion, and, as a consequence, more or less acute pains. 
 
 The injections must be emollient sometimes, at others narcotic or 
 discutient, according to the indications ; they should be at a tempe- 
 rature of fifteen or twenty degrees of Reaumur, and are used not 
 only with the view of cleansing the cancerous ulcers, but also of con- 
 tributing to the resolution of the scirrhous indurations of the neck of 
 the uterus. As they sometimes act like true douches, it is necessary 
 to moderate their discutient and often too exciting action, by throw- 
 ing the liquid with more or less force, according to the effect we seek 
 and the results we may already have obtained from their employ- 
 ment. These injections, which are especially useful in chronic and 
 indolent indurations, ought to be made with a syringe, having a 
 curved gum-elastic canula, previously oiled. 
 
 Irrigations or prolonged injections, as well as douches, are still 
 more powerful means for effecting the resolution of hard and indo- 
 lent engorgements. They are simple or medicated, according to the 
 nature of the liquid, the temperature of which ought to be nearly cold. 
 The former are composed of infusions of aromatic plants, or of saline 
 or sulphurous solutions, according to the indications. We prepared in 
 the year 1828 , a very simple apparatus for administering continuous 
 irrigations or douches. The apparatus consists of a kind of trestle 
 with three legs, three meters high, in the middle of which is sus- 
 pended a wooden pail communicating with a flexible tube terminated 
 by a gum-elastic tube introduced into the vulva. The force of the 
 jet is in proportion to the elevation of the vase and the quantity 
 of fluid allowed to escape. When we desire to use irrigations and 
 not the douche, the force of impulsion of the water is lessened by 
 means of a small sponge placed at the extremity of the canula in- 
 troduced into the vulva. The liquid with which the sponge is im- 
 pregnated then flows drop by drop into the vagina, whence it escapes 
 to fall into a tin basin, placed under the hips of the patient, at the 
 centre of an opening formed in the mattrass. A second flexible tube 
 is adapted to the hollow handle of the basin which is in the bed, 
 and conveys the fluid as it is received into another vessel placed 
 on the floor. We can in this way, and without wetting the woman, 
 administer irrigations for as long a time as we desire ; when we 
 think proper to arrest the flow of the liquid, the apparatus is with- 
 drawn, and the opening in the mattrass filled up by the separated 
 
TREATMENT OF CANCER OF THE WOMB. 
 
 341 
 
 portion of this last, which fits perfectly. In cases of vaginal fistula, 
 with incontinence of urine, a mattrass and basin disposed as we have 
 just described, present advantages which it is useless to dwell upon. 
 M. Charriere, a distinguished manufacturer of surgical instruments, 
 has invented a sort of pump-syringe, which shows great ingenuity, 
 and may serve to administer douches and irrigations; but it obliges 
 the patient or some other person to work the piston during the time 
 that the fluid is running. 
 
 Compression , which that able practitioner, M. Recamier, has pro- 
 posed as a method of treatment for cancerous tumours, is a means 
 which, although very useful in a number of other cases, particularly 
 in indurated tumours of the breast, does not seem to offer the same 
 advantages in scirrhous indurations of the uterus, either because of 
 the situation of the organ, which renders its employment difficult, or 
 because of the inflammation and pain which it almost always causes 
 in the vagina, bladder and uterus. It is always necessary, therefore, 
 to refrain from its use unless the tumour is entirely indolent, and if it 
 be the seat of the least irritation. The mode in which it is used is 
 simply to employ a cup and ball pessary, in which the cervix uteri 
 lodges itself, and is compressed by the weight of the organ, and that 
 of the abdominal viscera. 
 
 Absolute repose and a dorsal decubitus are the more useful, be- 
 cause, without them, all other means are nearly powerless. We 
 should request the patient, therefore, to confine herself to bed, which 
 ought to be hard and made of hair mattrasses. But, as rest in bed 
 has the inconvenience of producing congestions of the pelvis, and 
 even excitement of the genital organs, it is necessary, agreeably 
 to the advice of M. Lisfranc, to recommend, during the day, either a 
 pallet or a mattrass, thrown upon the floor or on a table. 
 
 Narcotics are likewise administered for the purpose of diminishing 
 the pain and stimulus which give rise to the uterine congestion. They 
 are prescribed in the form of injections made of decoctions of poppy- 
 heads, of morel, of hyoscyamus, of cicuta, of potato-tops, etc., in 
 small enemata, with addition of from eight to fifteen drops of lauda- 
 num ; and internally, in the form of pills or antispasmodic draughts. 
 We may add to these remedies, the internal use of resolvents, such as 
 tincture of iodine, from which M. Hahnemann says he derived great 
 benefit in a case of cancer of the uterus, which had reached a high 
 degree of intensity ; lime-water, administered by M. Kempel,* in the 
 dose of from one to three ounces, in a cup of milk ; ergot, which has 
 an altogether special action upon the uterus,! the extract of cicuta, J 
 
 * Revue Medicale ; aout 1825. 
 
 f Ergot advantageously employed, in the pillular form, in the dose of from two to 
 ten grains daily, in cases of haemorrhagic engorgement, has likewise been used with 
 great success, in cases of engorgement of the os tincae with ulcerations, first by Doc- 
 tor Pauly, then by M. Malgaigne, Vigny, and by ourself, who, like those practition- 
 ers, have prescribed it several times in combination with gummy extract of opium, in 
 very small doses, the sixth or quarter of a grain in each pill. M. Lesuerre, pharmaceut- 
 ist, at No. 71 Rue de la Harpe, prepares, under the direction of Doctor Pauly, a syrup 
 of this substance, one tablespoonful of which contains two grains and a half of ergot, 
 and one-twelfth of a grain of extract of opium. The ordinary dose of syrup is two 
 spoonfuls per diem. 
 
 f The extract of cicuta, whose marvellous effects have been recounted by Storck, 
 
342 
 
 TREATMENT OF CANCER OF THE WOMB. 
 
 and the cherry-laurel water, employed by MM. Osiander and Carron 
 du Villards. Finally, it might be useful to employ, at the same time, 
 revellents, as sulphurous douches, like the stream from a watering- 
 pot, and derivatives', such as cauteries, moxas and blisters applied to 
 the sacrum, groins, loins and internal surface of the thighs. External 
 resolvents are likewise recommended, amongst others, frictions to the 
 regions just indicated, and especially to the hypogaster, with mercu- 
 rial ointment, or with the ointment of hydriodate of potash, which 
 have also been used with advantage in cancerous ulcers, by Doctor 
 IJlmann, of Marburg;* and finally, frictions beneath the tongue and 
 to the internal surface of the labia majora, with the oxide of gold, 
 from which M. Chretient asserts that he has obtained wonderful effects. 
 
 If all these means combined, fail to arrest the disease, or prevent 
 the softening and ulceration of the cancer, or the extension of a pri- 
 mitive carcinoma, the disease is incurable by medicine, properly so 
 called, alone, and henceforth the mission of the physician consists less 
 in attempting to cure the disease than in trying to arrest its progress, 
 to alleviate suffering and prolong life. The only means which re- 
 main must be drawn from surgery, and consist of cauterization, and 
 of the partial or total ablation of the organ. 
 
 To fulfil his duty properly the physician should employ, not only 
 all the resources which may be at his disposal, but he should endea- 
 vour also to console and encourage his patient, to raise her hopes, 
 and decide her as soon as possible to submit to the operations which 
 he may deem necessary, and which offer some chance of success. 
 
 The medical treatment will now be merely palliative and sympto- 
 matic. We should resort, at this period, to narcotic injections, made 
 with decoctions of morel or hyoscyamus, in union with some emol- 
 lient liquid. We may resort, also, to injections of cherry laurel, to 
 continuous irrigations simply emollient, or mixed with the decoctions 
 of the plants we have just mentioned, to prolonged baths, to ene- 
 mata, and to vaginal poultices made of the pulp of the pumpkin, or 
 of grated or boiled carrots, and rendered narcotic by concentrated 
 decoctions of poppy-heads, of belladonna leaves, of morel, of cicuta, 
 etc.f Fomentations of the same nature, frictions to the hypogas- 
 trium with Rousseau’s laudanum, or with the oil of hyoscyamus, 
 may likewise be employed. 
 
 and the efficacy of which, in the treatment of cancer, M. Recaraier speaks of having 
 often witnessed, has always appeared to us to have but little effect, and to produce ,no 
 advantageous result. We have found, on the contrary, that cicuta commonly de- 
 ranges the digestive functions, and determines more or less severe headaches. MM. 
 Marjolin, Duges, Pauly, and some other physicians have remarked the same thing. 
 This may possibly depend on the faulty mode in which the extract of cicuta is pre- 
 pared by most pharmaceutists. 
 
 * Gazette de Sanle, Sept. 5th, 1823, and May 25th, 1824. Doctor Ulmann has like- 
 wise employed the hydriodate of potash by injection. 
 
 j- De la methode Jatraleptique, p. 318. 
 
 t To employ the vaginal poultices, and prevent their solid materials from escaping 
 and collecting in the vagina, we observe the precaution of retaining them in that 
 cavity by means of a small gauze bag, the tissue of which is sufficiently close. In 
 this way they are introduced and withdrawn with the greatest facility. The bag is 
 first introduced into the vagina with the nozzle of the syringe, which serves to inject 
 the liquid poultice. 
 
TREATMENT OF CANCER OF THE WOMB. 
 
 343 
 
 The insomnia should be treated by the internal use of gummy 
 extract of opium, in doses of half a grain, gradually increased to 
 four grains. The small enemata of water or milk, as advised by 
 Morgagni,* with addition of a grain of gummy extract of opium, 
 or several drops of laudanum, generally procure great relief. Blis- 
 ters sprinkled with one or two grains of muriate of morphia, and 
 applied to the lumbar region and internal part of the thighs, are 
 commonly very useful, and have not the disadvantage of constipa- 
 ting the patient. The same is true as to the suppositories of beurre de 
 cacao , which we prescribe every evening, and direct to be made of 
 a drachm of cocoa and a quarter of a grain or a grain of acetate of 
 morphia. We might likewise, in order to calm the pain, add to each 
 injection five or six drops of phosphoric acid ; we should mention, 
 however, that the plan recommended by M. Alibert,! has failed in 
 our hands. 
 
 The infectious odour exhaled from carcinomatous ulcers, which 
 fatigues the patients as much as the persons who attend them, may 
 be partly neutralized by means of chloruretted injections and lotions, 
 and also by soot-water and the solution of creosote injected into the 
 vagina. These different means have not the advantage merely of 
 destroying the disgusting odour of the discharge, but of calming the 
 violence of the pain, of diminishing the quantity of the secretions, 
 and even of staying the progress of the disease. 
 
 To moderate the profuse serous discharges and haemorrhages 
 which rapidly weaken the patient, we should resort to the internal 
 employment of some astringents, such, for example, as the water of 
 Robel, (a mixture of sulphuric acid one part, and alcohol three parts,) 
 in the dose of half a drachm or a drachm in a draught ; to extract 
 and tisan of rhatany, and to lemonade made with citric acid and 
 with syrup of quinces or comfrey. We may also employ, in some 
 cases, but with more care, cold astringent injections, made with de- 
 coctions of oak bark, of bistort, of Goulard’s lotion, or with very 
 weak solutions of sulphate of alum or of zinc, etc. We ought to 
 mention that, though the astringent injections often arrest the bleed- 
 ings, they have the serious inconvenience of irritating the ulcerations 
 and hastening their progress. 
 
 The plugging of the vagina is a means which, in this case, may be 
 very useful, but it always causes acute pain, unless, as M. Lisfranc 
 recommends, we observe the precaution of plugging the inferior 
 portion only; finally, small revulsive bleedings and applications of 
 cups and leeches under the breasts are remedies which it is well not 
 to reject. 
 
 The constipation determined by the internal use of narcotics, may 
 be opposed by mild laxatives, especially by decoctions of tamarinds 
 and prunes, by enemata of honey, with addition of a tablespoonful of 
 olive oil, and finally, by suppositories of beurre de cacao, used morn- 
 ing and evening. If vomiting supervene, we should prescribe Selt- 
 zer water, Riverius’s draught, and sub-nitrate of bismuth, etc. ; 
 finally, we must relieve retention of urine by means of catheterism. 
 
 + De Sedib. et caus. morb., epist. 47, art. 25, 1660. 
 
 4 Elements de Th6rapeutique. 
 
344 
 
 SURGICAL TREATMENT OF CANCER OF THE WOMB. 
 
 Such are nearly all the means which, in these disastrous cases, pre- 
 sent themselves to the physician for relieving the sufferings and pro- 
 longing the lives of his patients. 
 
 SURGICAL TREATMENT OF CANCER. 
 
 When the cancerous affection is well marked, when there remains 
 some doubt even as to its true nature, if the disease has advanced in 
 spite of the methodical employment of the therapeutical resources 
 we have described, we ought to resort, as early as possible, to the 
 means offered us by surgery, that is to say, to cauterization or to the 
 excision of the affected part. 
 
 The cauterization of simple or cancerous ulcerations of the cervix 
 uteri, was first brought into repute in France, by M. Recamier, and 
 after him, by Dupuytren, M. Lisfranc, and several other practitioners. 
 This energetic and often efficacious means is useful, not only in chang- 
 ing the mode of vitality and the sensibility of simple ulcers which 
 resist ordinary treatment, but also in destroying fungous vegetations 
 and cancerous or carcinomatous ulcerations, having but little depth 
 or surface. As a general rule, we should defer its employment as 
 long as there exists acute inflammation, or considerable tumefaction 
 of the cervix. It is necessary to reject it altogether, even when we 
 are uncertain of reaching the limits of the disease. It is equally 
 contra-indicated, during the four or five days which precede the 
 menstrua?, during their presence, and for three or four days after 
 their cessation. 
 
 Though Baron Larrey seems to have employed the iron heated to 
 redness* with advantage, the powerful caustics are generally pre- 
 ferred, such as solid nitrate of silver, caustic potash, arsenical paste, 
 chloride of antimony, the sulphuric and nitric acids, concentrated 
 nitro-muriatic acid holding in solution sixteen grains of chloride of 
 gold or platinum to the ounce, t the chloride of zinc,f creosote, § which 
 
 * M. Larrey applies the actual cautery by exposing the parts by means of an ivory 
 speculum, because the metallic speculums being good conductors of caloric, are 
 rapidly warmed by the hot iron and produce too much heat in the walls of the vagina; 
 a speculum of wood, of bone or of glass, would answer as well as that of M. Larrey, 
 and has the advantage of being cheaper. 
 
 f This caustic, which was proposed by M. Recamier, and which we have seen em- 
 ployed by that able and ingenious practitioner, has not fulfilled the anticipations 
 which it gave rise to at first. 
 
 i Doctor Cancoin has extolled the chloride of zinc, as possessing the advantage of 
 giving less pain and producing a dry slough. This practitioner, with two, three, or 
 four parts of flour, forms a soft paste, the thickness of which ought to be in propor- 
 tion to the depth of the part to be destroyed. For superficial cauterization, M. Can- 
 coin uses a mixture composed of eight parts of nitric acid to one of chloride of zinc. 
 
 § We communicated to the Academy of Sciences in 1834, a case of cure of sanious 
 ulceration of the neck of the womb, which had resisted every other means, even the 
 cauterization with the acid nitrate of mercury, but which soon cicatrized after several 
 cauterizations with a mixture of ninety parts of distilled water to one of creosote. 
 This case has since been reported in an excellent memoir, by Doctor Miguet, 
 published at Taris, in 1834, the title of which is: Recherr.hes Chimigues et Mtdicales 
 sur la Creosote , in 8v., observ. iii. p. 70. Notwithstanding this favourable result, we 
 have been forced to limit the employment of the new substance which was discovered 
 by Reichenback, because its application is often very painful. Our brother practi- 
 
SURGICAL TREATMENT OF CANCER OF THE WOMB. 
 
 345 
 
 cleanses the ulcers and hastens cicatrization; and finally, the acid 
 nitrate of mercury, which is most frequently employed, because it is 
 more active and easier of application than any of the caustics. 
 
 For cauterization, the patient must be placed across the bed, as for 
 the application of the speculum. This instrument should be intro- 
 duced and placed in such a way that its mouth may embrace the 
 cervix uteri, and protect the walls of the vagina from the contact and 
 spreading of the caustic. When the os tincse is fully exposed, we 
 remove the mucus from its surface with a piece of linen, a sponge 
 or a pledget of charpie, fixed upon a little stick of wood, in a pair 
 of dressing-forceps, in our caustic-holder, or in a forceps attached 
 to the handle of our small lever for redressing the cervix. We 
 then finish the cleansing of the parts with one or two injections 
 of cold water, the jet of which should be directed upon the sides of 
 the speculum, and not into the cervix ; then, having dipped a little 
 pencil of charpie, or the sponge of our caustic-holder, into the acid 
 proto-nitrate of mercury, prepared with two drachms of this salt to 
 an ounce of nitric acid, we touch the ulcerated surfaces the more 
 lightly in proportion as they are more superficial, and as we approach 
 nearer to the edges of the diseased parts. 
 
 The caustic should be left at least a minute in contact with 
 ulcerations of a cancerous nature, and, in this case, it is useful to re- 
 peat the cauterization several times in succession. For this purpose, 
 we should observe the precaution to wet the pencil each time, and 
 pass it lightly against the edge of the vessel which holds the acid, in 
 order that it may be charged only with the quantity strictly neces- 
 sary for acting upon the ulcerated surfaces. We prevent, by this 
 means, the action of the caustic upon the neighbouring parts from 
 producing inflammation and adhesion of the walls of the vagina, and 
 the various accidents described by MM. Marjolin, Lisfranc, Duges, 
 Pauly, Loir, and other practitioners. 
 
 When the operation is terminated, we should immediately make 
 use of an injection of cold water, or of some emollient or narcotic 
 decoction, which ought to be left during several minutes at the bot- 
 tom of the speculum, so as to bathe the os tincae and diminish the 
 pain, which, however, is not generally severe. If the first cauteriza- 
 tion be not sufficient, it must be repeated after the fall of the slough, 
 which takes place on the fifth or sixth day, and the same means 
 should be renewed until we have completely destroyed the altered 
 portions, which is known to be the case when the ulcerated surface 
 presents granulations like those developed in simple wounds. In 
 general, cauterization should not be used except for ulcerations of 
 slight depth and extent of surface, or in order to destroy fungus 
 resting on healthy tissues : in this last case, we ought, before ap- 
 plying the caustic, to excise the vegetations with the curved scis- 
 sors which we invented for this purpose, and satisfy ourselves before 
 
 tioner, Doctor Teallier who, since the publication of our case has likewise made 
 use of the creosote, seems to have renounced it for the same reason. That able prac- 
 titioner employed this extremely active remedy in the proportion of ten drops to a 
 tablespoonful of water . — ( Du Cancer de la Matrice , p. 244, 1836.) 
 
346 
 
 SURGICAL TREATMENT OF CANCER OF THE WOMB. 
 
 operating, that the surrounding tissues are not the seat of an acute 
 inflammation. If such were the case, we should first employ baths, 
 enemata, emollient injections and poultices, and we should treat the 
 consecutive inflammation by the same means, and by general and 
 local bleedings. 
 
 We shall conclude what we had to say upon cauterization, by 
 adding that, though it is often efficacious in cases of superficial ulcera- 
 tion, it is always useless, and even injurious, in extensive ulcerations 
 and deep scirrhous degenerations. The resection of the diseased 
 parts is then the only resource which offers any chance of success. 
 
 AMPUTATION OF THE NECK OF THE UTERUS. 
 
 The resection of the neck of the uterus above its connection with 
 the vagina, though a triumph of modem surgery, had already been 
 recommended by the ancients. Ambrose Pare* advises the section 
 of the thym of the neck of the womb, which is ‘‘hard, rough or 
 uneven, of a livid colour, fungous, with a pricking pain, like points 
 of needles.” In speaking of malignant thym , he says, “ that it be- 
 comes angry at being touched, and throws out a large quantity of 
 blood when cut or irritated, especially after commerce with men, or 
 when the woman has walked or taken violent exercise.” He adds, 
 “ that we may apply the speculum matricis, in order to see more 
 easily . . . .” Lapeyronie, being consulted for a sarcoma attached 
 to the margin of the uterus, which was callous at that point, thinking 
 that the tumour might be extirpated with the callosity from which it 
 grew, cut into the healthy part, and the patient recovered perfectly. 
 N. Tulpius, who died in 1674, assertst that scirrhous tumours of the 
 uterus, which had already acquired the malignity of cancer, have been 
 successfully extirpated. Judging, however, from the drawing he gives 
 of one, which was removed from a woman named Gertruda Turina, it 
 would seem that these tumours were in fact mere polypi. According 
 to Baudelocque, the resection of the cervix uteri was proposed by 
 Lauvariol, in 1780; it was also advised by Wrisberg,f in 17S7; by 
 Monteggia, in 1788, in a work§ translated into German by Dr. Schless- 
 ing, and commented upon by Dr. Kravel, in a dissertation published 
 at Jena in 1786, where he renews the proposition of the celebrated 
 surgeon of Milan; and finally, in 1801, Professor Osiander pub- 
 lished the first well-authenticated case of resection of cancerous os 
 tincae. Having published, seven years later, in the Bulletin of the 
 Royal Society of Gottingen, a memoir in which he described the 
 results of several operations of the same kind, his successful attempts 
 produced so great a sensation in Germany, that the Josephine Aca- 
 demy of Vienna proposed a reward of two hundred florins for the 
 best essay upon this subject. 
 
 This new and bold operation made a great noise in France, and 
 
 * CEuvres d’Ambroise Pare, lib. xxiv. p. 1012. 
 f Observat. Medend., lib. iii. cap. 34. avec fig. 1641. 
 t De Uteri Resectione, etc. Goetingue, 1787. 
 
 (j Annotazionni pratiche sopra gli mali. ven., p. 179. 
 
AMPUTATION OF THE NECK OF THE WOMB. 
 
 347 
 
 was adopted and several times performed by Dupuytren and Pro- 
 fessor Recamier, to whom the science is indebted for the cylindrical 
 speculum. But the hopes which the first results gave rise to, not 
 being realized, it was in some sort abandoned by the surgeons who 
 had been its first partisans, when, in 1826 , the numerous cases pub- 
 lished by M. Lisfranc, forced the most incredulous to recognize the 
 little immediate danger usually incurred, and to acknowledge that 
 when practised in good time, and in the proper mode, it forms the 
 only resource which affords any chance of success in cases rebellious 
 to all other means. 
 
 Several methods have been proposed or employed for performing 
 the resection of the cervix uteri, either by bringing the organ down 
 to a level with the vulva, or by operating without displacing it. 
 
 M. Osiander, having carried two curved needles, armed with liga- 
 tures, up to the cervix uteri, and pierced it in two opposite points of 
 its circumference, drew the organ as near as possible to the vulva by 
 making gentle traction ; he then divided the diseased parts with Pott’s 
 bistoury, and afterwards plugged the vagina with masses of charpie 
 on a small sponge, covered with a mixture of powdered alum, gum- 
 arabic and resin. 
 
 Professor Dupuytren, and in his manner, most surgeons, have sub- 
 stituted for the ligatures of Osiander a very long Muzeux forceps,* 
 with slightly curved hooks, to seize or loosen at will the cervix uteri ; 
 we shall detail in a few words the method of M. Dupuytren, as it is 
 described in the Medecine Op&ratoire of Sabatier. “ The surgeon 
 introduces the speculum, properly oiled, into the vagina, and gives it 
 to an assistant to hold. This done, he seizes and draws gently to- 
 wards him, with a Muzeux forceps, held in the left hand, all the por- 
 tion of the cervix uteri affected with carcinomatous degeneration, and 
 removes, with a double-edged knife, curved laterally, or what is better, 
 with very long and strong scissors, also curved laterally, and exceed- 
 ingly sharp, which should be held in the right hand, and carried 
 alternately above, below, and on the sides, turning the concavity in- 
 wards N and causing them to act as much as possible on the parts 
 situated beyond the limits of the disease.” 
 
 The method of M. Lisfranc, which is the one most generally followed, 
 also consists in drawing down the womb to a level with the vulva ; 
 the apparatus and instruments necessary for the operation, are a bi- 
 valve speculum, two of Muzeux’s forceps, two probe-pointed bis- 
 touries, one straight and another with the blade curved on the edge, 
 strong scissors, curved on the flat, a pair of forceps for torsion, liga- 
 tures, compresses, charpie, and finally, a T bandage. 
 
 In order that nothing may be omitted, and the better to describe 
 the method in all its details, we shall give it here, as we described 
 it in our memoir on amputation of the neck of the uterus, from the 
 
 * So called after the surgeon who invented them. They resemble, in general 
 arrangement, the ordinary dressing-forceps of the pocket-case, but differ in having 
 the blades to terminate in small hooks, which lock when the instrument is shut, and 
 in being more or less curved. — Trans. 
 
348 
 
 AMPUTATION OF THE NECK OF THE WOMB. 
 
 thesis of Doctor Avenel, of Rouen, formerly pupil and prosector of 
 the course on operative medicine given by M. Lisfranc. 
 
 The woman being placed in bed, as directed for our method, M. 
 Lisfranc employs a speculum, composed of two half cylinders of tin, 
 to the extremities of which are soldered two pieces of iron, which 
 articulate with each other. From this arrangement it follows that 
 by pressing on the .free extremities of these pieces of iron, the two 
 cylinders separate from each other ; their separation allows the very 
 large neck to be received between them more easily, and gives room 
 for the passage of the instruments necessary for the operation. Be- 
 sides, by stretching the vagina through its whole extent, it prevents 
 that canal from covering the neck more or less, by forming a fold at 
 its bottom; The forceps of Muzeiix, employed by M. Lisfranc, are 
 longer and stronger than those generally used ; their hooks, which 
 are less curved, hold the organ very well, without our being obliged 
 tO f separate them to a great extent; their length, moreover, helps 
 to keep the hand of the assistant who holds them, out of the way. 
 The operator, having ascertained the position of the cervix, in order 
 that he may find it as soon as possible, and with the greater ease, 
 introduces the speculum. 
 
 The os tincoe is cleansed, if necessary, in order to be sure of its 
 presence, and of its not being covered by any fold of the vagina. 
 The forceps, closed, are carried directly beneath the organ ; as soon 
 as the blades are sufficiently open, and engaged between the cervix 
 and sides of the speculum, to seize, if possible, two points directly 
 opposed to each other, the operator presses lightly upon them in pro- 
 portion as he buries them in the tissue of the womb. 
 
 This manoeuvre is indispensable in order to follow the upward 
 movement of the organ, one which exposes us to the liability of 
 seizing it too low down. The speculum is then readily withdrawn 
 alone, as the forceps can pass through the interval, separating the 
 semi-cylinders. The first thing to be done is to make gentle, slow, 
 and gradual traction upon the uterus by the’ aid of which we en- 
 deavour to bring it down to the inferior part of the vagina, first in 
 the direction of the axis of the superior, and then in that of the infe- 
 rior strait ; but in order that the uterus may be more completely 
 taken hold of, and the entire circumference of the inferior portion of 
 its neck likewise project externally, the surgeon applies the blades of 
 a second pair of forceps to the extremities of the transverse or an- 
 tero-posterior diameters of the organ, according to the direction to 
 which the first has been applied. 
 
 In this way, whatever tendency the uterus may have to resume its 
 position in the abdominal cavity during the section, the tissues main- 
 tained in situ may be divided, either at the same or at different 
 heights, according to the pathological condition. The index finger 
 being now carried up to the point of insertion of the vagina, easily 
 recognized by the presence of a kind of ring above which pressure 
 causes an empty space to be felt, the surgeon confides the forceps to 
 an intelligent assistant, who, by uniform traction, maintains the cervix, 
 which is susceptible of a greater or less prolapsus, in different subjects, 
 
AMPUTATION OF THE NECK OF THE WOMB. 
 
 349 
 
 in a proper position. The assistant should stand in front of the pa- 
 tient, while the operator must be placed like him between her thighs, 
 and to the left, holding a curved bistoury cutting upon its concavity, 
 the half of which corresponding to the articulation of the blade with 
 the handle, must be covered with linen within about an inch and a 
 half, more or less, of its blunt extremity, according to the size of the 
 cervix. The operator directs the assistant to raise the forceps, so as 
 to give to the inferior portion of the womb a see-saw movement, which 
 causes the posterior part of the neck to project to a greater extent ; 
 in this way fhe limits of the disease will be better seen, and he can 
 cut higher up. The surgeon now glides the left index finger semi- 
 flexed behind the os tincae, and measures with this finger, the palmar 
 face of which is directed downwards, the height at which the sec- 
 tion ought to be made ; the bistoury is placed immediately beneath 
 it, and as the instrument advances, he directs and gives to it a point 
 d’appui, whilst the assistant gradually lowers the forceps, in order 
 to make the other portions of the cervix uteri project in their turn, 
 in proportion as the surgeon cuts at different heights. It ought to be 
 well understood, as the disease may extend higher on one side than 
 on the other, and so that the disease may be completely removed, 
 that the assistant must be directed to give suitable inclinations to the 
 inferior extremity of the uterus by means of the forceps, and espe- 
 cially not to exert too strong a traction as the division terminates, 
 lest the tissues be torn. The bistoury, moreover, ought to advance 
 by sawing movements, and with gentle strokes, so as to prevent in- 
 juries to the labia majora, irregularity of the wound and dangerous 
 slips. This part of the operation is rather difficult, because of the 
 resistance which the tissue of the cervix uteri in its natural state 
 presents. 
 
 In some cases the cervix is too large to be received into the spe- 
 culum : we are then obliged to remove the instrument, and conduct 
 the hooks up to the os tincae upon the finger. 
 
 MODIFICATIONS OF THE OPERATION BY THE AUTHOR. 
 
 In order to avoid the employment, at the same moment, of two 
 of Muzeux’s forceps, which we are compelled to confide to assist- 
 ants, whose hands embarrass the manipulations, and especially in 
 order to seize, in every direction, readily and firmly the neck of the 
 
 Fig. 37. 
 
 uterus, the part to be drawn down, we invented, in 1828 , a hook with 
 eight claws, which approach or sepaiate by means of a central 
 
350 
 
 AMPUTATION OF THE NECK OF THE WOMB. 
 
 shank fixed upon a slider, arranged in the form of a cross. With this 
 instrument called by us the utero-ceps , from the 
 Fig. 38. Latin words uterus womb and eapere , to take, a 
 surgeon may operate alone ; he may, for this reason, 
 execute all the traction more uniformly, and finally 
 direct more methodically the movements of elevation, 
 descent and later&lity, which the section of the dis- 
 eased parts requires. 
 
 The handle of our quadruple hook, which is made 
 movable by means of a hinge, ought to be directed 
 towards the anus, so that the hands of the operator 
 may not cover the entrance of the vulva and the in- 
 terior of the speculum, as happens when the forceps 
 of Muzeux is employed. To perform the amputation of the neck of 
 the uterus with the utero-ceps , it is introduced into our speculum 
 or any other multivalve speculum, then, after having fixed the claws 
 firmly into the circumference of the neck, the handle is bent in the 
 direction of the shanks of the hook, and the dilating instrument with- 
 drawn as done by M. Lisfranc. 
 
 After the removal of the speculum, we give to the handle of the 
 utero-ceps the direction which it had had at first, that is to say, it is 
 brought back again towards the perineum, in order to accomplish 
 the descent of the uterus slowly and carefully, and according to the 
 principles we pointed out above. 
 
 The operator, in using our forceps, not only seizes the cervix with 
 a single instrument, but he has also much less occasion to fear lace- 
 ration, which often results either from tractions made unequally, and 
 in one direction rather than in another, or from the fatigue or awk- 
 wardness of the assistants, who, from being unable to keep the blades 
 of Muzeux’s forceps shut for a sufficient length of time, loosen them 
 so much as to allow them to slip from the cervix, an accident of 
 which we could, cite several examples. We have even seen a 
 professor of the Ecole obliged to abandon the operation after this un- 
 fortunate accident, which unhappy attempt was followed by intense 
 nervous symptoms, and a metro-peritonitis, which caused the death 
 of the patient. 
 
 If, having adjusted the hook, it should be found impossible, as 
 often happens, to bring down the uterus to a level with the vulva, we 
 must not for that reason abandon the operation ; it would become 
 necessary, in such a case, to replace the speculum without removing 
 the utero-ceps, and then make the section of the neck, either with 
 our knives, with the ends formed like a hook, or with extremely 
 curved scissors, drawings of which we have given in this volume, 
 [vide cut). We might, likewise, make use of these two last instru- 
 ments to make the section of the neck, even after having seized it 
 with the forceps of Muzeux. 
 
 We shall conclude by saying, that in operating with the modifica- 
 tions and instruments we have now described, we have no occasion 
 for educated assistants who have frequently witnessed the operation, 
 and who can be found only in the large hospitals of Paris. 
 
AMPUTATION OF THE NECK OF THE WOMB. 
 
 351 
 
 OF HYSTEROTOMY PERFORMED WITHOUT DISPLACING THE UTERUS. 
 
 The numerous amputations of the neck of the uterus, performed 
 by the preceding methods, have proved that the tractions exerted 
 upon the organ and its appendages, rendered the 
 operation generally very tedious, and always dif- Fig 39. 
 
 ficult and painful, while the section of the neck 
 scarcely caused the patients to suffer any conside- 
 rable pain, and was, in some cases, almost unno- 
 ticed by them. 
 
 These motives, the difficulty, and even impos- 
 sibility, experienced of bringing the uterus down, 
 in cases of soft, fungous and fringed cancer, etc. ; 
 the decided prolapsus which sometimes results 
 from the operation, and which retards or presents 
 the cicatrization of the wound by reiterated fric- 
 tions ; the nervous disorders, and all the unfa- 
 vourable symptoms which depend on the trac- 
 tions, displacements, violent and sudden exten- 
 sion of the tissues, membranes, ligaments, nerves 
 and vessels* not only of an organ already dis- 
 eased and inflamed, but also of several other or- 
 gans, whose anatomical relations are, like those 
 of the womb, more or less changed ; the danger 
 of perforating the vagina, as has happened, 
 while operating in this cavity with several instru- 
 ments which we shall make known; and finally 
 the hope of being able to offer a surgical re- 
 source for a disease, whose nature and progress 
 have made all other operative methods seem in- 
 applicable, have suggested to us the idea of a 
 method of hysterotomy which, acting without 
 the exertion of traction, seizes and cuts at the 
 bottom of the vagina previously dilated by means 
 of the speculum, the cervix uteri at the proper 
 height. 
 
 Our hystero/omisi, which name is derived from 
 the Greek words vstspa, womb, and tstivhr, to 
 cut, is a somewhat complicated instrument, and is 
 composed of the following parts : 
 
 A steel tube, AA, three lines in diameter, and 
 six inches in length, terminated at one of its ex- 
 tremities by a double-hooked forceps BB, .the 
 blades of which are approximated in such a way 
 as firmly to seize the neck, by means of a shank 
 CC, designed to push forward the movable slider 
 D, which should shut or separate the grooved 
 blades of the hooked forceps BB. The shank CC, 
 which traverses the whole tube A A, traverses like- 
 wise the ivory handle E, which is terminated by a button F, by 
 
35 2 
 
 colombat’s operation. 
 
 which the shank CC, to which it is fixed, is moved. At the middle 
 of the instrument is a copper cylinder G, terminated inferiorly by a 
 kind of pulley H, upon which are the spring I, and* the hook L, 
 which keeps the lever M elevated, and which rests upon the enlarge- 
 ment N of the cylinder G, serving as a guide to the blade 0, intended 
 to amputate the cervix uteri. This lever M, which is raised by 
 pressing its extremity P, remains fixed to the hook L. It is mounted 
 in this way, and as we now describe it, the hysterotome ought to be 
 introduced into our speculum. 
 
 DESCRIPTION OF THE OPERATION. 
 
 The ..patient should be placed on her back at the edge of the bed ; 
 two assistants should keep the legs strongly separated, and fix the 
 pelvis in such a way that it cannot move. The legs should be flexed 
 upon the thighs and these on the pelvis. The hips must be so ar- 
 ranged as to be slightly elevated, and they should project a little over 
 the edge of the bed. 
 
 Every thing being thus arranged, the operator proceeds to the in- 
 troduction of the speculum uteri , and then after confiding the handle 
 to an assistant, and being well assured that the os tineas i^ embraced 
 in the instrument, he introduces the hysterotome , and pushes with 
 the right hand the shank CC, which causes the blades and claws of 
 the hooked forceps BB, to approximate and seize the cervix at a 
 greater or less depth, according to the extent of the disease. Conti- 
 nuing to push forward the shank CC, the guide cylinder, by means 
 of the lever M, carries the blade 0 in front of the claws of the for- 
 ceps ; when we press upon the two stops, P and Q, the blade, which 
 is attached to the lever, falls suddenly on the part we design to cut 
 off, thereby imparting a movement of rotation to the cylinder G; the 
 lever M turns around the neck, which is amputated circularly by the 
 blade 0. 
 
 Before loosening the stops P and Q, it is necessary to be careful to - 
 draw slightly upon the uterus, in order that the tissue, being made 
 tense, may cut more readily. The instrument, at the extremity of 
 which is fixed the portion of the cervix cut off', is then withdrawn, and 
 after having removed the speculum, the patient is placed in bed. 
 
 We are far from pretending that our method of operating ought to 
 be employed in all cases; we think, on the contrary, that it should be 
 used only in certain circumstances ; amongst others, when the woman 
 is extremely nervous; when the womb is very high up and not very 
 movable ; when the neck of the organ is soft, friable and lacerated; 
 and lastly, in cases where the other methods had been vainly attempt- 
 ed, and when they would seem to be of difficult, tedious, dangerous, 
 or altogether impossible application. 
 
 When the womb presents the opposite conditions, that is to say, 
 when it is naturally low down, movable, and sufficiently consistent 
 to support the efforts made with the hooked forceps, we think that 
 hysterotomy should be performed, by drawing down the uterus with 
 two hooked forceps, or, as we have proposed, with our own hooked 
 
colombat’s operation. 
 
 353 
 
 forceps of four blades, which has the advantage of holding the cervix 
 in every direction and very firmly, and does not require the assist- 
 ance of other hands to bring down the womb, or the aid of an intel- 
 ligent surgeon, who has already seen the operation frequently per- 
 formed, and who can be procured only in some of the great hospitals 
 of Paris. 
 
 In order not to extend our remarks too far, we shall give merely 
 the most important details of the different operations, the three first 
 of which are particularly interesting, on account of the very consider- 
 able size of the tumours, and the impossibility of removing them by 
 the ordinary methods. The two others possess no interest, except 
 that they were but slightly painful, very easily performed, without 
 accident, and almost without consecutive haemorrhage. 
 
 Madame Ch , aged thirty years, was of a sanguine-bilious tem- 
 
 perament, with brown hair, of large frame and good constitution; the 
 mother of three children ; affected twice with syphilis, communicated 
 by her husband; after some domestic chagrin, and the loss of a 
 moderate fortune, she found herself attacked with lancinating pains 
 in the groins, loins, thighs, and uterus. Though well regulated 
 before the appearance of all these symptoms, she had experienced, 
 for some time past, certain irregularities of menstruation, and had 
 uterine haemorrhages, so frequent as to be almost continual : a white 
 discharge, mixed with blood, and of a fetid odour, always accom- 
 panied the sanguine effusions, which had so much reduced her 
 strength, that it was almost impossible for her to walk, or attend 
 
 to her ordinary occupations. Madame Ch , finding that none 
 
 of these symptoms diminished, consulted her family physician, M. 
 Bertrand, who, having made an examination, suspected cancer of 
 the cervix uteri, and was assured of it by means of a speculum, 
 applied by Dr. Berthelot, who had been called in consultation. 
 The cervix was very large, softened, and covered with numerous 
 ulcerations and vegetations; it was fringed upon the edges, and 
 presented all the characters- of an enormous cancerous fungus. The 
 operation by our method being regarded as the only means of safety 
 which remained to the patient, and the only surgical means appli- 
 cable in the case, MM. Bertrand and Berthelot informed me of 
 their determination, and we proceeded to the operation on the 
 fifteenth of November, 1828 . A few moments were sufficient to 
 terminate it, notwithstanding the difficulties we had to surmount in 
 fixing the hooked forceps of the hysterotomist into the cervix uteri, 
 which was two inches and a half in diameter, softened, and bathed 
 in blood. Our speculum with six blades was employed, and its in- 
 troduction into the vagina was not at all painful. The patient told 
 us that she had suffered less during the operation than when, in order 
 to explore her disease, the speculum with two blades had been ap- 
 plied, A rather abundant haemorrhage occurred during the opera- 
 tion, but ceased as soon as Madame Ch was placed in bed. None 
 
 of the accidents which generally take place occurred. There was no 
 syncope; no nervous symptoms, subsultus tendinum, or delirium. 
 Two attacks of vomiting followed ; we had taken care, in order to 
 23 
 
354 
 
 colombat’s operation. 
 
 prevent fatiguing efforts, to moderate them by causing the patient 
 to drink some sweetened water. Not a symptom of fever, of metritis, 
 or of peritonitis made its appearance ; a single bleeding was per- 
 formed the day after the operation, on account of a slight increase 
 of the pulse ; moreover, the patient lost so little blood afterwards 
 that the sheets were scarcely soiled. Eight days after the opera- 
 tion, another application of the speculum enabled us to observe a 
 commencement of cicatrization, and a wound of the finest appear- 
 ance. General and local baths, emollient injections, and then injec- 
 tions of chloride of lime were prescribed. Strict diet was observed 
 from the first, and the ordinary drink was a ptisan, made of pearl bar- 
 ley and gum, sweetened with lemon-syrup. Twenty-five days after 
 the operation, the patient was entirely cured, and the cicatrization 
 complete. A lead-coloured and jaundiced tint, and a sad and anxious 
 expression were soon replaced by a serene and well-coloured counte- 
 nance. Finally, Madame Ch , before a month had elapsed, could 
 
 attend to her occupations, which she had been, for a long time, obliged 
 to abandon. In order that no doubt might remain upon the nature 
 of the alteration of the cervix, I showed it to MM. Dupuytren, Reca- 
 mier and Blandin, as well as to a great number of other surgeons, who 
 were of opinion that the portion excised was of carcinomatous nature. 
 
 Unfortunately the favourable result of the operation did not pro- 
 long the life of Madame Ch . As she had evidently a cancerous 
 
 diathesis, the disease showed itself again ; not in the uterus, but below 
 the urinary meatus, as a scirrhous tumour, which, preventing the 
 expulsion of the uriue, was removed by Doctor Berthelot ; the car- 
 cinomatous affection afterwards appeared in the vagina, and extended 
 step by step to the gestative organ, where it had commenced ; this 
 patient, however, enjoyed pretty good health for eight or nine months 
 after the operation, and it was not until fourteen months after, that 
 she perished from the return of the disease. At all events, there is 
 no doubt that the operation prolonged her life at least a year. 
 
 On the fifteenth of February, 1829 , we were called to Longjumeau, 
 ( Seine et Oise,) by Doctor Guenee, to see a woman, thirty-six years 
 of age, who was affected with fungous cancer, of very considera- 
 ble size, seated in the cervix uteri, and extending nearly to the inser- 
 tion of the vagina. The tumour, extremely friable, soft and disor- 
 ganized, was the seat of a fetid discharge, and of almost constant 
 haemorrhage. In spite of the extent of the disease, and the difficul- 
 ties we should have to encounter, we proceeded to the operation, 
 assisted by M. Guenee, physician to the patient, and by M. Ducreux. 
 Though we had a good deal of difficulty, from the size of the tu- 
 mour, and the sanguine discharge which took place in adjusting the 
 hooked forceps of our hysterotomist, the diseased portions were soon 
 removed; the haemorrhage, which had lasted for several months, 
 ceased as soon as the patient was replaced in bed, and not a nervous 
 or inflammatory symptom followed. The pulse, which was frequent 
 before the operation, far from being accelerated, diminished in rapi- 
 dity, and the patient soon recovered her strength, appetite and ability 
 to sleep, of which she had been long deprived by the frightful pain 
 she had been subject to. This case was inserted in the Lancettc 
 
colombat’s operation. 
 
 355 
 
 Frangaise , vol. i., No. 49; the tumour was seen by MM. Breschet, 
 Velpeau, Fabre, and several other distinguished physicians. 
 
 We also performed the amputation of the neck of the womb in 
 another case nearly similar to the preceding. The tumour, in this 
 case also, was a very friable fungous cancer, presenting, however, 
 a rather narrow pedicle springing from tissues which seemed 
 healthy, or, at least, not deeply indurated. The operation was per- 
 formed on the 2d of June, 1830, in the presence of MM. Caignoux, 
 Bonfils and Lachaise. No consecutive haemorrhage appeared ; the 
 nervous symptoms were confined to two attacks of vomiting; the 
 fever was very moderate, and the patient, who was twenty-eight 
 years old, and whose disease dated more than fifteen months back, 
 soon recovered perfectly ; the cicatrization of the wound was com- 
 plete in six weeks: finally, up to the 2d of April, 1832, the epoch 
 
 at which Madame C died from an attack of cholera, she had 
 
 suffered only from an habitual feeling of weight in the pelvis and 
 some rather acute pains before the appearance of the menstruae. 
 The excised portion was shown to MM. Breschet, Cruveilhier, 
 Blandin, Recamier, Dupuytren and several other practitioners, who 
 all regarded it as a cancerous degeneration of the cervix uteri. 
 
 The excision of the os tincae was also performed by us with entire 
 success on a woman twenty -six years of age, who had consulted MM. 
 Dubois, Marjolin, Boyer, Lagneau, and her relative, Doctor Sulp . . . 
 The cervix uteri, without being very voluminous, was, nevertheless, 
 hypertrophied, and exhibited an ulceration with a hard base, of a 
 grayish colour, giving rise to a fetid ichorous discharge in such quan- 
 tity that a few moments sufficed to soil several napkins. As the dis- 
 ease continued to advance and had resisted every means, including 
 a mercurial anti-syphilitic treatment and the rob de Laffecteur, we 
 proposed the resection of the neck, which was performed very easily 
 and almost without pain, on the 13th of January, 1831, in the pre- 
 sence of MM. Deganose, and Doctor Sulp , a cousin of the 
 
 patient. The haemorrhage was rather more abundant than in the 
 preceding cases, but there were no consecutive nervous symptoms. 
 The cicatrization was complete in less than two months. This lady, 
 who has become a widow within two years, continues to enjoy per- 
 fect health. The os tineas which was cut off was presented to the 
 Anatomical Society of Paris. 
 
 Lastly, we performed the operation of hysterotomy, by our method, 
 upon the wife of a cab-driver; but the operation, which was easy and 
 without unfavourable consecutive symptoms, did not prevent the 
 patient from dying of a relapse, ten months after the excision of the 
 affected parts. We ought to state, however, that the cancerous dis- 
 order seemed to be hereditary in the case, for her mother died from 
 the sequelae of a cancer of the breast which had been extirpated at 
 the Hotel- Dieu, by M. Dupuytren. " 
 
 For operating at the bottom of the vagina, M. Jules Hatin has 
 proposed, and in one case put in practice a method of which we shall 
 say a few words. 
 
 The operation is divided into two periods ; in the first is applied 
 
356 
 
 JULES HATIN’s OPERATION. 
 
 the speculum with three blades, which can be opened at once by a 
 screw, and which allows an instrument for holding the cervix and 
 corpus uteri to be introduced into the uterus. This instrument is 
 composed of three shanks, which separate from each other when 
 opened in the uterus, in such a way as to fix that organ and make it 
 tense. The uterotomist is then introduced, which is composed of two 
 separate portions united by means of an articulation similar to that of 
 the forceps , in the middle of which is an opening to allowsof the 
 passage of the shank, whose extremity is within the cavity of the 
 womb. These two portions, which are adjusted one after the other, 
 and united within the speculum , carry, at their uterine extremity, 
 two crescentic blades, the approximation of which effects the section 
 of the cervix. 
 
 We have but little to say upon the method of Doctor Canella, 
 which, in our opinion, has but a single inconvenience, that of being 
 inapplicable to any case. The instrument described by this physi- 
 cian in the Revue Mklicale , more than two years after the publica- 
 tion of our memoir upon the amputation of the neck of the uterus, 
 inserted in the number for May, 1828, of the same journal, is com- 
 posed of a cylindrical speculum, into which is introduced a second 
 speculum armed with a blade, designed to cut the cervix, by making 
 the tube which supports it revolve on its axis. A pair of Muzeux’s 
 forceps should be used to hold the organ during the operation. 
 
 ADVANTAGES OF THE AUTHOR’S METHOD. 
 
 1. By making the incision of the os tincae at the bottom of the 
 speculum, we avoid not only the very acute pain caused by the trac- 
 tions which it is necessary to make in order to bring the uterus to 
 the level of the vulva, but also most of the secondary nervous symp- 
 toms which, according to our observation, seem to depend less upon 
 the section of the organ than upon its displacement and the sudden 
 distension of its ligaments. The secondary haemorrhage, likewise, 
 has always been slight after the application of our method, and has 
 always ceased spontaneously, which, we may remark, is more diffi- 
 cult of explanation than the absence of the secondary nervous phe- 
 nomena. 
 
 2. There is less cause to fear metritis and peritonitis, which often 
 result from the violent manipulations, the lacerations and the trac- 
 tions of the organ, or from the introduction within its cavity of an 
 instrument designed to hold or draw it down, as performed by MM. 
 Hatin, Guillon and others. 
 
 3. It is not necessary to renounce the operation, as has often been 
 done, when the neck is softened, lacerated, and voluminous, or when, 
 in other circumstances, the uterus cannot be brought down, even by 
 the most methodical tractions. 
 
 4. The walls of the vagina, the labia majora, and all the neigh- 
 bouring parts protected by the speculum, are not exposed to the 
 danger of being wounded, and perforated by the cutting instrument, 
 or by Muzeux’s forceps. 
 
COLOMBAt’s OPERATION — ITS ADVANTAGES. 
 
 357 
 
 5. Prolapsion of the womb, a consequence of tractions exercised 
 upon the organ, not occurring, cicatrization is always more rapid, 
 from not being retarded, and rendered impossible, even, by the re- 
 peated frictions which the inferior portion of the viscus, in an unusual 
 state of descent, undergoes. 
 
 6. The operation, which does not require intelligent assistants, is 
 more rapid, easier, and always less painful than by any of the other 
 methods. At a single blow, especially if the neck be not very large, 
 we remove the diseased portions which have been carefully explored 
 by means of the touch, the speculum and our concave mirror, with- 
 out fear of the accident which happened to the professor at the Ecole: 
 in this case, when the cervix had been half cut, the uterus, which had 
 been drawn to the exterior with a great deal of trouble, returned into 
 the vagina, when it was impossible to seize it again in order to finish 
 the operation, the effects of which were so unfortunate that the patient 
 died in a few days. 
 
 Should the objection that we are unable to make other than hori- 
 zontal sections be brought against us, we reply, that inasmuch as hys- 
 terotomy affords some chance of success only where the cancerous 
 ulceration does not extend beyond the os tineas, our method is always 
 applicable in the cases which are much the most common : besides, 
 if the disease should extend to one of the sides of the neck, we think 
 it would be better to cut transversely, on a level with the diseased 
 point, in order to be certain of destroying all the cancerous germs, 
 and to obtain more rapid cicatrization, the wound being of less extent 
 than when the section is made diagonally. Moreover, we repeat., 
 should our method not be applicable in all cases, and though it may 
 often be necessary to prefer that of M. Lisfranc, it is, as we have 
 proved, an useful addition to surgery, and a resource to which prac- 
 titioners might have recourse, especially when other methods seem 
 to be contra-indicated, less by the extent of the disease than by 
 certain dispositions of the parts which render hysterotomy, by draw- 
 ing down the organ, of difficult and often impossible application. 
 
 Amongst the consecutive phenomena of the operation, we should 
 include different nervous symptoms, which alarm persons who have 
 never witnessed them. They are generally of short duration, and 
 rarely last more than two or three hours, especially when some anti- 
 spasmodic is administered to the patient. 
 
 The blood, which often flows very rapidly, forms a clot which fills 
 the vagina and occasions tenesmus, frequent stools and ineffectual 
 desires to urinate. Sometimes frequent vomiting comes on, or eruc- 
 tations, singultus and nausea, which occasion great suffering. The 
 contraction of the abdominal muscles, and the shocks which they 
 occasion, expel from the vagina the clot which had arrested the 
 ^haemorrhage. The blood, which flows afresh, relieves all these symp- 
 toms ; but it often happens, when the discharge continues, that the 
 face becomes pale and the pulse feeble, and vertigo, trembling, tinni- 
 tus aurium, subsultus tendinum, and other nervous affections make 
 their appearance : finally, syncope often follows, which causes all the 
 phenomena to cease, and which ought the less to disquiet us, as it is 
 
358 
 
 AMPUTATION OF THE NECK OF THE WOMB. 
 
 a means which nature employs to arrest obstinate haemorrhage. We 
 should restore the patient, tranquillize her, but avoid the use of the 
 tampon, unless the woman is threatened with death, from the long 
 continuance of the bleeding after the syncope. 
 
 It is very unusual for it to become necessary to use the tampon ; 
 but, when obliged to do so, it should be left only a short time in the 
 vagina, because, by the pressure which it exerts, it may give rise to 
 inflammation, and arrest a sanguine evacuation capable of preventing 
 or diminishing it, if it already exist. 
 
 As these accidents occur several hours after the operation, it would 
 be very imprudent to quit the patient or leave her alone for a single 
 instant. 
 
 AFTER-TREATMENT. 
 
 Sometimes the phenomena just described do not follow the opera- 
 tion. When the blood does not flow in sufficient quantity, we have 
 to fear a violent attack of fever. It then becomes necessary to 
 examine the state of the patient, to carry the finger into the vagina, 
 in order to remove the clot which had arrested the hgemorrhage, and 
 to employ, according to the advice of M. Lisfranc, warm, emol- 
 lient injections. Small bleedings from the arm should be practised, 
 at longer or shorter intervals, as the state of the pulse permits and 
 the other symptoms require. These small bleedings, which are also 
 used to arrest the haemorrhage, diminish the violence of the fever 
 very much, and check the inflammation which is developed around 
 the wound of the uterus. 
 
 If we perceive symptoms of gastro-enteritis, and if the patient suffer 
 from pain at the epigastrium, it becomes necessary to apply leeches 
 to that part, to order enemata and fomentations of flax-seed mucilage, 
 and to apply emollient poultices, unless the abdomen be too painful. 
 
 After some days, and when all the symptoms have disappeared, 
 the vagina ought to be well washed out with injections of marsh-mal- 
 lows ; then, when the irritation has entirely passed away, and the 
 wound seems to be cicatrizing, we should again employ injections, 
 at first of pure water, and then of chloride of lime in solution, gradu- 
 ally increasing its strength. This kind of injection powerfully assists 
 the cicatrization, which is often retarded by the white discharges, 
 to which almost all women affected with diseases of the womb are 
 subject. 
 
 These discharges sometimes continue after the operation, and give 
 rise to bleeding granulations, which it is necessary to cauterize with 
 the acid nitrate of mercury. Cauterization, performed in this way, 
 not only destroys the fungous granulations, but also checks the 
 healthy granulations, whose exuberance prevents the cicatrization. 
 
 For several days after the operation, the patient should be kept on 
 a rigorous diet. It will be proper to recur, from time to time, to 
 revulsive bleedings, and to order baths, emollient injections and 
 enemata. When the cure is complete, vve should prescribe a mild 
 regimen, more particularly a vegetable one : coitus should be used 
 
AMPUTATION OP THE NECK OF THE WOMB. 
 
 359 
 
 with the greatest moderation, and abstained from altogether, in case 
 it should cause acute pain. 
 
 We shall conclude by saying that amputation of the neck of the 
 uterus is an operation that ought to be resorted to with the great- 
 est reserve, and only as the last resource, in cases where the thera- 
 peutical means we have mentioned have failed to arrest the progress 
 of the disease, which thus renders the death of the patient inevitable. 
 Yet we must not wait until the cancerous affection has implicated the 
 whole cervix ; for, independently of the greater danger which would 
 result from the operation in such case, relapse would be almost ine- 
 vitable, should the disease, having spread beyond the os tincse, require 
 the removal of the whole or a great portion of the neck, and especially 
 if we have to scoop out its cavity, as most practitioners recommend. 
 It is this reason that renders the horizontal sections most commonly 
 suitable, and makes our method applicable and sufficient in a large 
 proportion of the cases. Besides, if portions of a suspicious character 
 remain, it would always be easy to remove them by means of our 
 hooked forceps and one of our sickle blades, as in the case of the 
 woman upon whom we operated at Longjumeau. 
 
 The operation offers a better chance of success when the affection 
 is a primitive ulceration, resting upon a very thin indurated layer, 
 and consecutive to a carcinomatous degeneration. The fungous 
 cancer , whose pedicle, whether large or small, is fixed by shallow 
 roots in the os tincse, is one of the forms of cancer least disposed to 
 relapse, after the excision of the parts. In all cases, the operation 
 should be deferred, so long as the disease seems to remain stationary, 
 and there is a hope of arresting its progress by any other means. 
 Finally, hysterotomy should be absolutely rejected, when the lesion 
 is not confined to the cervix, or when it affects other organs at the 
 same time : it is well also to take into consideration the hereditary 
 predisposition, the course and duration of the disease, and the age 
 and constitution of the patient. Ulcerated scirrhus, encephaloid, and 
 hematode cancer, are much more liable to relapse, especially if there 
 be any hereditary predisposition. We ought to state that this last 
 circumstance renders the reproduction of the disease almost inevita- 
 ble, and generally contra-indicates the operation. 
 
 We shall conclude by remarking, that even though amputation of 
 the cervix uteri should not succeed more than once in six, and even 
 once in twenty cases, it would nevertheless be a valuable acquisition 
 to modern surgery, since it may save the lives of women devoted to 
 certain death, or, at least, often postpone the fatal event. We may 
 add that the operation, which is much less painful and less dangerous 
 than cystotomy, has not prevented seyeral women who have under- 
 gone it from becoming pregnant and being happily delivered.* If 
 
 ♦ Madame Carpentier, operated upon by M. Lisfranc, has had four children, of 
 ■which two were twins; what is remarkable, is, that before the operation she had 
 never conceived, although she had been married for several years. In this case, and 
 in some others that we might cite, it is probable that the section had not gone much 
 beyond the os tincce. 
 
360 
 
 EXTIRPATION OF THE CANCEROUS UTERUS. 
 
 in some cases, on the contrary, obliteration of the inferior orifice of 
 the womb may result, and, consequently, an obstacle to conception, 
 and to the flow of the men strum ; but it is easy to prevent this 
 accident by the introduction of a small gum-elastic bougie into the 
 mouth of the os tincse, when we examine the state of the womb and 
 the progress of the cicatrization by means of the speculum. In order 
 to perform the section of the cervix without fear of haemorrhage, 
 M. Mayor, of Lausanne, has proposed* the ligature applied in such 
 a way as to separate the diseased portions by a strangulation capable 
 of destroying their vitality and the phenomena depending upon it. 
 It is useless to say that this method presents too many inconve- 
 niences and too many difficulties in its execution to have met with 
 many partisans; besides, the haemorrhage, which M. Mayor seems 
 especially anxious to avoid, prevents, or diminishes when it is mode- 
 rate, the inflammation of the uterus ; in case it should be too abundant, 
 we might make ourselves master of it, either by means of plugging, 
 or by cauterizing the open vessels which furnish the blood, with a 
 blunt stilet heated to a white heat, and carried up to the wound with 
 the aid of the speculum. 
 
 We shall speak, also, merely to make mention of it, of the cutting 
 spoon of Dupuytren , which is inconvenient, and only makes sections, 
 which are always oblique, unequal and ragged ; the scissors, curved 
 in a semi-lunar form; and attached at a right angle to their handle, 
 proposed by M. Arronsohn, of Strasbourg, have the inconvenience 
 of cutting while pressing, and especially of requiring too great a sepa- 
 ration to allow of their being introduced to the bottom of the specu- 
 lum and embracing the cervix uteri, which is always found to be 
 enlarged and engorged when it is the seat of a cancerous affection. 
 
 EXTIRPATION OF THE CANCEROUS UTERUS. 
 
 Where the cancerous degeneration has extended its ravages to the 
 body of the womb, it has been recently proposed to perform an ope- 
 ration for its complete extirpation. This frightful and daring opera- 
 tion is performed in several different ways ; when the womb, wholly 
 changed in structure, is found precipitated without or beyond the ge- 
 nital fissure, three different modes of operating may be discussed, viz : 
 1st, the extirpation, by means of a ligature passed round the root of 
 the tumour formed by the inverted vagina. 2d, by a ligature ap- 
 plied in the same manner, but followed by the excision of the tu- 
 mour, beyond the constricted point. 3d, the simple excision of the 
 part with cutting instruments, and without the employment of the 
 ligature. As, im speaking of the chirurgical treatment of prolapsus 
 uteri, we have already discussed these different methods of effecting 
 the extirpation, it seems unnecessary to recur, at great length, to the 
 subject in this place ; and we shall be satisfied, therefore, with add- 
 ing, that the last-named mode of proceeding labours under the dis- 
 advantage of giving rise to dangerous haemorrhage, and of admitting 
 
 •Seance de l’Acad^mie des Sciences da 19 Fevrier, 1827. 
 
EXTIRPATION OF THE CANCEROUS WOMB. 
 
 361 
 
 the atmospheric air suddenly within the peritoneal sac, an event that 
 is almost invariably followed with most acute inflammation of that 
 serous membrane. While the first-named operation is devoid of the 
 danger of haemorrhage, it nevertheless labours under an objection, that 
 of producing severe and protracted pain, and the more so, as the stran- 
 gulated womb does not become detached for several days ; during 
 which, the patient, affected by the putrid odour of the part, is liable 
 to the most alarming nervous disorders, and to the most serious in- 
 flammatory attacks. Both of these methods ought, therefore, to be 
 rejected, in favor of the second-named one, viz : the application of 
 the ligature, and the excision of the parts beyond it. This operation 
 is as simple as possible; it moreover avoids the haemorrhage, the lay- 
 ing x open of the peritoneal sac, the swelling and putrid calluvies of the 
 womb, and lastly, most of the severe accidents following in the train 
 of the other operations. 
 
 Whether the womb be found already prolapsed beyond the vulva, 
 or whether it be drawn down by the operator himself, we ought al- 
 ways; previous to applying the ligature to the neck of the tumour, 
 clearly to ascertain whether the bladder, or a part of the bowel, has 
 fallen down into the cavity of the inverted vagina ; and care, more- 
 over, should be taken not to wound those organs: this is done by 
 raising the woman’s hips a little higher on the bed than the rest of her 
 body, and by getting the parts well out of the way, by tapping the 
 hypogastrium and other parts somewhat smartly with the hand. The 
 surgeon, with a needle armed with a double silk ligature, of suffi- 
 cient strength, now transfixes the walls of the vagina, in a direction 
 from front to rear, and removing the needle, separates the ligatures, 
 one of which should be tied firmly on the right, and the other on the 
 left side. In this way, the strangulation is more immediate, and the 
 ligature less liable to slip after the excision of the womb ; which, as 
 before mentioned, should be made beyond or below the ligature. 
 
 To draw down the non*prolapsed womb, with a view to its ablation, 
 it is convenient to make use either of our quadruple hook forceps, 
 (vide cut,) or of a sort of hollow sound, to be passed into the cavity of 
 the womb, the walls of which are seized by four small hooks that 
 are thrown out by means of a screw, at the lower end or handle 
 of the instrument. This sound, which is moved by the same mecha- 
 nism as that of our tire-tele , invented by us in 1828, for experiment- 
 ing, upon the dead subject, along with M. Lisfranc, who was then 
 about to operate for the total extirpation of the uterus, should be used 
 only in case the cervix should not allow of a sufficient hold to the 
 hook-forceps, and where the interior of the uterus, as yet not softened 
 and diseased, could admit of a firm and solid attachment. M. 
 Guidon’s instrument, and Professor 'R6camier’s, which are analo- 
 gous to ours, might also be made use of ; but they cannot be so 
 firmly fixed, nor have they a graduated scale to indicate the precise 
 degree of separation of the branches ; nor can they be introduced, 
 or withdrawn so readily, from the greater size and excessive sali- 
 ency of their bent extremities. 
 
 Extirpation of the ivomb in situ . — Where the rigidity of theliga- 
 
362 
 
 EXTIRPATION OF THE CANCEROUS WOMB. 
 
 merits prevents the drawing forth of the womb, which makes the 
 operation much more difficult, longer, and more hazardous, its total 
 ablation may nevertheless be effected in two different ways. The 
 first, which is called the hypogastric or surpubal operation , was 
 first proposed, and methodically described in 1814, by M. Gutberlat; 
 this method, which is one of the most daring attempts of modern 
 surgery, and which we absolutely protest against, under all circum- 
 stances, consists, in the first place, in embracing the cervix uteri in a 
 sort of ring, mounted upon a rod and handle, so as to fix the womb 
 firmly in one position ; then in opening the abdomen along the linea 
 alba sufficiently to admit the hand, with which the womb is to be 
 held firmly, while, with a scissors in the right hand, he cuts away 
 the ligamenta lata and rotunda, and the superior extremity of the 
 vagina. 
 
 This operation, the most dangerous of all, yet the easiest of exe- 
 cution, has been performed on the living subject, by Langenbeck, of 
 Gottingen, and also by Professor Delpech. Without pointing out the 
 modifications of the method introduced by these two distinguished 
 surgeons, we shall confine ourselves to the simple remark, that both 
 the women perished; one in thirty-two hours, and the other three 
 days after the operation. 
 
 So few are the chances of success presented by this horrible opera- 
 tion, that not only should it never be attempted, but even the works 
 on operative surgery should notice it, only for the purpose of utterly 
 proscribing it. 
 
 The ablation of the womb, in situ, by the sub-pubal operation, 
 was performed for the first time, in 1822, by M. Sauter, of Constance, 
 physician to the Grand Duke of Baden. Previously to commencing 
 the operation, he emptied the bladder and rectum, and then placing 
 the woman as recommended for the excision of the cervix uteri, and 
 directing an assistant to press the womb downwards, and at the 
 same time support the bowels, after driving them upwards with the 
 edge of the hand applied above the symphysis, the palm looking 
 towards the pubis, “the operator introduced the left index and 
 medius into the vagina, as far as the cul-de-sac ; he next passed up 
 a convex bistoury between the fingers, and cut the vagina in a circu- 
 lar line upon the cervix, to the depth of two or three lines ; he next 
 introduced between the same fingers, a pair of scissors curved on the 
 edge, with which he separated the womb from the bladder up to the 
 peritoneum, bearing hardest on, or cutting nearest to the uterus. 
 With this view, he made use of his fingers to pull down and bring 
 within reach of the scissors, the lowest portions of the cellular tissue, 
 so as to cut them with great care. This is an easier and safer mode 
 than to use the concave bistoury. This division, carried as far as the 
 peritoneum inclusive, ought to be concluded at the posterior surface of 
 the womb, by means of scissors curved on the flat, the concavity look- 
 ing towards the womb, and by detaching it completely from the rec- 
 tum, so as to permit the fingers to slide up along side of the womb and 
 penetrate within the abdomen. Having gone thus far, the operator 
 introduces the whole of the left hand, the palm looking backwards, 
 
EXTIRPATION OF THE CANCEROUS WOMB. 363 
 
 • 
 
 and embracing the uterus; with the index and medius he next draws 
 down the highest of the lateral attachments, and divides it with the 
 concave bistoury, which should be gently and carefully passed up 
 between the fingers. The same division is effected for the other side, 
 operating upon them alternately, so as to be enabled to make the 
 section with safety on both sides, while the womb retains its position. 
 It is hardly necessary to say that every successive section ought to 
 fail upon its antecedent, so as not to prolong the operation uselessly. 
 
 “ During all this time the assistant should keep his hand as above 
 directed ; when the extirpation is completed, the surgeon will find 
 it necessary to attend to the bleeding. It may be that not much 
 haemorrhage will attend the operation, as was the case with my 
 patient, and as ought to happen, if we keep close to the womb, 
 whose blood-vessels are of small size, as I have learned by much re- 
 search. Under such circumstances, the bleeding demands no particular 
 care, but if it should appear to be considerable, or give rise to appre- 
 hensions, a large bundle ofcharpie should be immediately introduced 
 into the pelvis, and pressed against the bowels, after which, the whole 
 circuit of the vagina should be covered with large pieces of prepared 
 agaric, filling up the void space with charpie; this simple method 
 seems to me preferable to the use of styptics. 
 
 “After this dressing, let the patient be put to bed, and kept in a 
 horizontal posture. Not until this is done should the assistant cease 
 to restrain the downward tendency of the bowels with the pressure 
 of his hand. 
 
 “Should no symptoms supervene foreign to the natural conse- 
 quences of the operation, the case requires only the simple precau- 
 tions of prudence. Every thing must be avoided that might tend to 
 force the bowels down into the excavation of the pelvis; and all that 
 is necessary in this respect is, that the patient make no change in her 
 position for several days. Injections into the vagina, if any are 
 deemed requisite, ought to be made with gentleness, that they may 
 not penetrate into the abdomen. The same kind of care must be 
 taken in adjusting the charpie. In common cases these precautions 
 are sufficient, the rest must be left to nature, whose office must not 
 be interfered with .’ 5 — ( Memoire de Sauter , traduit par le Dr. Pes- 
 chier , of Geneva , and inserted in the Melanges de Chirurgie etran- 
 gere, 1824.) 
 
 The woman thus operated on by Sauter, January 28th, 1824, died 
 four months afterwards. M. Hoelscher, who operated in the same 
 manner, lost his patient in twenty-four hours. He was obliged to 
 cut into the side of the vagina, in order to introduce his hand and 
 facilitate the manoeuvres ; and, in order to guide his cutting instru- 
 ments during the act of separating the vaginal insertion into the 
 anterior face of the cervix, he passed a sound into the bladder. Both 
 of the patients operated on by M. Siebold, one the 19th April, 1S24, 
 the other, July 25, 1825, died, one in sixty-five and the other in 
 twenty-four hours. Those of M. Langenbeck, operated on January 
 11th and August 5th, 1825, also perished in thirty-two and fifty 
 hours, respectively. This well-known surgeon made an incision into 
 the perineum from before backwards ; then, after dividing the vagina 
 
364 
 
 EXTIRPATION OF THE CANCEROUS WOMB. 
 
 posteriorly, upon the sides, and in front, he seized the womb by its 
 fundus, and removed it entirely, by a careful dissection. 
 
 The four women who were operated on by Dr. Blundell, likewise 
 perished. The first one, who was supposed to be cured, died in a 
 year, from a relapse of the cancer ; the second, in thirty-nine hours; 
 the third, in nine hours; while the fourth lived only a few minutes. 
 Dr. Blundell began the operation by detaching the vagina behind ; 
 and after penetrating the cavity of the peritoneum, between the 
 womb and rectum, seized the i'undus uteri, which he retroverted 
 towards the coccyx; then, dividing the broad ligaments, he finished 
 the ablation by separating the organ from the bladder,’ in such a way 
 as to wound neither the uterus nor the neck of the bladder. The 
 patient on whom M Bauner operated, on the 2d September, 1828, 
 died on the fourth day. After having detached the womb behind 
 and in front, and cut away the broad ligament upon one side, he 
 turned the organ upon its opposite side, and then closed the operation 
 by separating the remaining ligaments, which, up to that period, he 
 had left untouched. 
 
 M. Lizars, of Edinburgh, who adopted Langenbeck’s operation, in 
 October, 1828, also lost his patient, who died in twenty-four hours. He 
 made an incision into the perineum, but prolonged it into the rectum; 
 then, having turned the womb over, he detached it from the vagina, 
 before and behind. Finally, M. Langenbeck, who operated for the 
 third time in 1829, by the sub-pubal or vaginal method, modified, as 
 has already been explained, was not more fortunate than he had 
 been upon the two first occasions; for his patient survived only four- 
 teen days. 
 
 M. Recamier, who is as skilful as a surgeon as he is ingenious and 
 learned as a physician, performed the first operation in France, for 
 the extirpation of the womb, July 29, 1S29 ; but he had the misfor- 
 tune to lose his patient, after the lapse of a year. M. Recamier’s 
 method is the same as Sauter’s, which, by means of some important 
 modifications, has been rendered more methodical, easy and safe. 
 Where the descent of the womb has been found to be practicable by 
 means of the hook forceps, or any other of the instruments already 
 described, the vagina and its peritoneum are laid open, both behind 
 and in front of the cervix, in such manner as to avoid the ureters 
 and the fundus of the bladder. These incisions should be made with 
 a guarded bistoury, and a probe-pointed one, carried upwards along 
 the fingers to its extremity ; the end of the left index finger is next 
 passed into the opening, and serves as a conductor to the probe- 
 pointed bistoury, with which the first opening is extended right and 
 left, to near the ligamenta lata, always keeping close to the surface 
 of the womb. The same mode is followed as to the posterior surface 
 of the uterus, which now remains attached only by its sides. At this 
 stage, a ligature is passed around each of the broad ligaments and 
 secured by means of a serre noeud. Finally, the operation is brought 
 to a close, as in prolapsus, by leaving on each side only a sufficient 
 portion of tissue to hold the ligatures. 
 
 In cases where the womb admits of no hold being taken of it, and 
 
EXTIRPATION OF THE CANCEROUS WOMB. 
 
 365 
 
 (he rigidity of its ligaments renders it impracticable to draw it down, 
 M. Recamier opens the vagina behind, after the manner of Sauter ; 
 but, for this purpose, he makes use of a pharygotomist, and then, car- 
 rying Frere Come’s lithotomist into the anterior opening, and guiding 
 it by the left index finger, extends the incision along each side of the 
 womb, as far as the broad ligaments ; and lastly, having repeated 
 the same manoeuvre on the posterior surface, casts a ligature round 
 each of the ligaments, which are then cut off, near the uterus. The 
 viscus, now completely severed from all its natural attachments, may 
 he seized with a hook forceps, and easily extracted from the cavity 
 of the pelvis. It is proper to state that M. Recamier does not in- 
 clude in his ligature more than the lower third of the broad liga- 
 ment, for there are situated the principal blood-vessels of the womb. 
 In the experiments made by us upon the dead subject in the Hospital 
 de la Pitie, we made use of a sort of probe-pointed lithotomist, which 
 to us appeared preferable to Frere Come’s, because its blade, which 
 cut only in the concavity, was less likely to wound the adjacent parts. 
 For the adjusting of the ligature, we employed our needle -forceps, as 
 being more convenient and easy of application ; by which the needle 
 was passed through the inferior third of the broad ligament, pre- 
 viously to commencing the division of it. Lastly, the manoeuvres 
 were rendered more simple and easy, by means of a small perineal 
 incision, which greatly enlarged the vulva, and, by introducing a 
 small sound into the bladder, for the purpose of protecting that organ, 
 as well as guiding the action of the cutting instrument. 
 
 As haemorrhage would be rendered impossible by the ligatures, 
 and as the bowels would be kept above the pelvic excavation, by 
 confining the patient to a horizontal posture, the tampon, in any 
 shape, is not only useless, but pernicious; and all that is necessary is, 
 to cover the vulva with emollient stupes, and take care not to allow 
 the urine to flow into the vaginal cavity. The patient should be 
 kept in a state of profound repose, and the only remedies should 
 consist of antispasmodic draughts, cataplasms and fomentations, in- 
 jections, cooling drinks, and, lastly, blood-letting, either general or 
 local, proportioned to the strength of the patient and the nature of 
 the symptoms. 
 
 We shall not describe the processes of Messrs. Tarral and Gendrin, 
 because they have been practised only on the dead subject ; and we 
 shall say but a few words on M. Dubled’s, which is an improvement 
 on the partial excision of the body of the uterus, as performed in 
 1828, by M. Bellini, as follows : 
 
 Having drawn the organ as far down as possible, the operator, 
 with a bistoury, separates the vagina from the cervix, both in front 
 and behind ; then, in the same way as M. Recamier, he secures the 
 lower third of the ligamentum latum, with a ligature, and cuts it off 
 close to the womb. As the viscus now holds only by its fundus 
 adherent to the peritoneum, it becomes an easy matter to depress it 
 still more, and remove all the diseased portions, leaving the sound 
 parts behind. M. Dubted’s patient, operated on June 20th, 1830, 
 survived only twenty-two hours, although the whole of the womb 
 
f 
 
 366 PHYSOMETRA. 
 
 was not removed. In fine, two patients operated on by M. Roux, 
 one by M. Delpech, and a second case by M. Recamier, perished 
 alike, a few hours after the operation. 
 
 This statistical and funereal record of extirpations of the uterus, 
 is fitter than any course of reasoning, to deter the practitioner from 
 so redoubtable an attempt. It ought, therefore, to be rejected from 
 the practice of surgery, the chief aim of which is to save life ; except, 
 perhaps, in cases where the womb, already partially expelled from 
 the pelvis, and, in some sort, detached from the rest of the organism, 
 may, in a sense, be said to have lost its right to inhabit the cavity of 
 the pelvis. 
 
 PHYSOMETRA, OR TYMPANITIS OF THE WOMB. 
 
 The term physometra, from the Greek words $voa, gas, and /ujtpa, 
 womb, is applied to an affection in which the uterus becomes dis- 
 tended with air or gas, either extricated within or accidentally intro- 
 duced into its cavity. 
 
 The presence of aeriform fluids within the womb may be easily 
 explained. In some cases, it is atmospheric air that has got into the 
 viscus through the os uteri, which may have become partially dilated 
 by a pessary, by masturbation , by coitus, by a diseased conception, 
 by the discharge of the catamenia or some unnatural flux, a transi- 
 tory inertia or weakness of the fibres, a passive haemorrhage, partu- 
 rition, &c. Let it be supposed that, in this condition, a sudden spasm, 
 a coagulum, a collection of mucus, a falling of the womb, some dis- 
 placement, or any other cause, happens to close the orifice, then it is 
 easy to conceive that the gaseous fluid may become rarefied, may 
 distend the walls of the organ that contains it, and escape from its 
 imprisonment, upon some sudden motion or effort made by the 
 patient, or some slight pressure on the hypogastric region. 
 
 In other instances, the gas is extricated within the parietes from 
 some chemical action, or the decomposition of coagula of blood, or 
 of portions of the placenta left after delivery ; or of a putrid foetus, 
 retained within the uterus. Whenever it happens, under such cir- 
 cumstances, that the torpor and atony of the womb prevent it from 
 contracting and expelling the aeriform fluids within it ; when the os 
 uteri becomes spasmodically contracted, or is obstructed by a mem- 
 brane, by a scirrhous tumour, or a polypus, or any other of the 
 causes heretofore enumerated, symptoms of physometra become 
 manifest ; and they are variously designated by the terms uterine 
 tympany , uterine pneumatosis , flatulent pregnancy and wind- 
 mole. 
 
 Little is known of the nature and constitution of the gases deve- 
 loped within the womb. If we imagine the gas to be generally a 
 sulphuretted hydrogen, we judge so, not from a chemical analysis, 
 but from its odour ; and especially, from the colour it communicates 
 to the flame of a candle. Leduc, the surgeon, was witness to a very 
 remarkable circumstance in this relation : he had scarcely withdrawn, 
 with his crotchet, the putrid body of a foetus, when there escaped, 
 
PHYSOMETRA. 
 
 367 
 
 with impetuous force, a quantity of gas, smelling of sulphur, and 
 which burned with a violet-coloured flame. Baudelocque mentions 
 a case in which a very fetid gas escaped as he was introducing the 
 first blade of his forceps. M. Deveux states that having removed a 
 clot that filled the mouth of the womb, an offensive gas escaped, 
 with explosion, from the vulva; and another instance of a like kind, 
 upon removing a portion of the membranes that occupied the os 
 uteri. A fact of a very remarkable character, in pathological anatomy, 
 was observed by Baudelocque, as he was about to proceed to the 
 autopsy of a female who died in labour, — a loud explosion of gas from 
 the vulva took place, and, at the same time, the foetus was expelled 
 with violence. Torally also reports a very curious case, in which the 
 womb itself was inverted and pushed out of the body ; which must 
 have been caused by the very considerable extrication of gas in the 
 bowels. 
 
 Although the formation of gases in the uterine cavity is mostly 
 produced by the decomposition of the foetus, placenta, or various collec- 
 tions of blood, or other fluids amassed within it, it cannot be denied, 
 that in some of the instances, the aeriform gases are the products of 
 an inappreciable morbid exhalation. This essential kind of physo- 
 metra has been described and observed by several writers, among 
 whom are Franck,* Mauriceaut and Delamotte. The Revue Mbdi- 
 cale , 1830 , t. iv. p. 484 , quotes a case from a Bolognese work.f A 
 woman, forty years of age, who had never borne any children, ima- 
 gined herself pregnant, because her menses, always regular previ- 
 ously, had become suddenly suppressed, while the abdomen enlarged, 
 so that the womb had reached the fifth month of development, 
 mounting upwards as high as the navel. The os uteri was perfectly 
 closed, and the uterus could be completely circumscribed by means 
 of moderate pressure with the hands. Such was her condition, when 
 all the hopes of the pregnancy vanished; one day, upon stooping 
 down, a great quantity of flatus suddenly escaped from the womb ; 
 the belly was reduced, and after some days recovered its natural size. 
 We are acquainted with a lady, twenty-eight years of age, who had 
 been declared by several physicians pregnant, and who met with a 
 similar disappointment while making a movement to get upon her 
 bed. 
 
 The distension of the womb by gases, although a rare disorder, 
 was also observed by many ancient authors, among whom we may 
 cite Valescus de Taranta,§ J. M. de Gradibus,|| Thaddeus Dunus,1T 
 Rembertus Dodonseus,** Ph. Hcechstetter,tf Mauritius de Cordibus,f f 
 
 * Epit. de curand. morb. de retent., t. i. 
 
 f Traite des mal. des femmes grosses, t. i. p. 74. 
 
 $ Opusc. della Societd, Med. Chirurg. di Bologna, t. iv. 
 
 § Philonium. et Chirurg. de Med., lib. vi. cap. 15. 
 
 || Practica, seu Commentar. in Nonum Rhasis cap. de mola. 
 
 1 Mulier. morb.remed. miscell. cap. 8. 
 
 ** Medicinalium observationum, exempia rara, obs. 49. 
 
 -j-j- Rariorum observat., decade v. obs. 4. 
 
 $$ Hipocratis de. mulier. morb. interp. et explic. in lib. i. comment, 3. 
 
368 
 
 PHYSOMETRA. 
 
 Ambrose Pare,* Ph. Salmuth,t Reinier Solenander,± Astruc,§ and 
 others. 
 
 . From cases noticed by all the authors, uterine pneumatosis has 
 been more frequently met with in women who have had children 
 than in virgins. It has been thought that the age from forty to fifty 
 years is the one in which it mostly occurs, and that persons of a ner- 
 vous temperament are most subject to it. Sauvage tells us of a hys- 
 terical woman whose physometra always disappeared shortly after 
 the occurrence of her catamenia. 
 
 Authors have distinguished t wo kinds of physometra, — the dry and 
 the humid. In the former, which is generally transitory, the womb 
 contains nothing but gas, and does not, in general, surpass in size 
 the volume of the gravid uterus of the third month. The latter or 
 humid physometra, is so called because the womb contains, not gas 
 only, but also a variable quantity of fluid, which may be serous, clear, 
 turbid, muddy and fetid ; this species, which was observed by Bene- 
 dicti,|| De Vega,Tl Laurent Jourbert,** Portal, Franck, &c., and which 
 acquires a more considerable magnitude, since it is often mistaken 
 for pregnancy, is distinguished from the former by the weight, mass 
 and fluctuation of the tumour. Franck says that the gas occupies 
 the upper part of the tumour, and that by making the woman change 
 her position, the womb changes its form, and gives out a gurgling 
 sound. 
 
 The same author remarks, that by taking the womb betwixt both 
 hands, the sensation of a bladder filled with air is felt, and which is 
 much more sonorous above than below. We may also ally with the 
 physometric disorder, two other varieties that were noted by Franck. 
 He says, ( loc . citat.,) that a physician in Lorraine published a case 
 in which a bladder full of air, (or a wind-mole) suddenly escaped from 
 the womb and fell upon the floor, bounding like a ball. He also tells 
 of a Dutch woman who, after being long subject to floodings, dis- 
 charged a fleshy mass, containing a number of vesicles, some of 
 which were full of a yellowish serum, and others with a gaseous 
 fluid. 
 
 [I have been closely attentive to the complaints of patients under my care 
 as to physometra, and I rest under the conviction, that the cases of the dis- 
 order that have fallen under my notice during the last thirty years, are not 
 strictly entitled to the appellation of physometra. It is true that I have been 
 conscious of the discharge of gas from the uterus , yet never but on one 
 occasion, and that was during an embryotomy operation for a woman with 
 distorted pelvis, who was twice afterwards subjected to the Caesarian opera- 
 tion, in this city. In that case, the placenta was absolutely, when I removed 
 it, putrid, black, and emphysematous from the extrication of the putrid gas 
 
 * CEuvres, livre xxiv. chapitre xc. 
 
 f Observat. medic, centuriae, centur. ii. obs. 57. 
 
 * Concilior. medicinal sectioned quinque. 
 
 § Traite des maladies des femmes, t. iii. p. 377. 
 
 II De Curandis morbis. lib. xxv. oper. omn. 1539. 
 
 ^ De Morbis. medend. libri tres, sect. 10, cap. 32, 1576. 
 
 ** Operum. Latin, cap. 13, de urinis. 
 
PHYSOMETRA. 
 
 369 
 
 in its texture. I was, I say, conscious of the discharge of gases from this 
 uterus, but they were the gaseous products of a putrefying after-birth — not a 
 disease of the womb, nor at all fit to be called a uterine disorder, but a mere 
 accidental extrication of putrid gases from a foetus and placenta in putrefac- 
 tion; this is the only case. As I have been a great many years very busily 
 occupied in obstetric practice and in the treatment of female complaints, I 
 should be supposed to have had good opportunities of becoming acquainted 
 with the disease called physometra did the case really exist, except as an 
 accident upon the mechanical obturation of the os uteri or vagina. 
 
 I do not perceive how a person of such good judgment as M. Colombat, 
 can admit that a gaseous fluid could, under any other circumstances, be capa- 
 ble of filling the uterus. A gaseous fluid would escape from the os uteri 
 under the contractility of texture of the uterine fibre alone; and, a fortiori , 
 under that of the womb and abdominal muscles together — particularly since 
 every inspiration of the breath finds its antagonist force at the floor of the 
 pelvis. The pressure of such antagonism would always expel the gas from 
 the uterus. Its stay in the womb would be impossible. 
 
 It is true, however, that I am accustomed not unfrequently, after labours, 
 to hear loud explosions of air from the vagina ; but I do not regard them as 
 the results of a true physometra, as I suppose they consist of portions of 
 air, ingurgitated into the loose and flaccid walls of the vagina, upon the 
 cessation of the expulsive effort of the womb immediately after the escape 
 of the foetus. The womb, in this stale, is jammed down to the bottom of 
 the pelvis almost, as the child goes forth from its cavity — and as soon as 
 the tenesmic effort is suspended, it rises again to its place, and acts in the 
 manner of a piston, drawing after it into the vagina a portion of air, which 
 is again expelled when the woman renews her effort at bearing down for 
 the delivery of the placenta. This is the mode in which I account for the 
 noise so frequently heard upon the woman’s making a bearing-down effort. 
 I delivered a patient of a child at seven o’clock this morning, Nov. 14, 1844. 
 It was a case with adherent placenta. The patient bore down with great 
 force until the whole of the child was expelled, and of course the globe of 
 the womb, containing the undetached placenta, was pushed very low down, 
 in order to chase the foetus quite out of the body. As soon as the effort 
 ceased, I heard a great sound as of the ingurgitation of air which rushed into 
 the loose vagina and the expanding womb. In a short time afterwards I 
 compressed the lower belly with my hand, to promote the expulsion of the 
 placenta — and upon doing so, I forced the ingurgitated air to rush out again, 
 ♦with amphoric sound nearly as great as that made by its ingurgitation. But 
 is this accident at all worthy to be called physometra, a dynamic state, and fit 
 to establish a belief in the power of the inner walls of the womb to excrete 
 gaseous fluids? The same thing is true of the supposed physometra of the 
 non-gravid female, or of the woman two or three months gone with child. If 
 she happen to have a loose and flaccid vagina, with a heavy womb, that organ 
 24 
 
370 
 
 PHYSOMETRA. 
 
 descends more or less, from her being long on foot — and then, when she lies 
 down, it again ascends to its place, drawing imperceptibly after it, enough air 
 to occupy the vagina. If now she should cough or sneeze, or make pressure 
 on the hypogaster, or suddenly get up from the couch, the air is as suddenly 
 expelled, with more or less sound. Such is the explanation of this occur- 
 rence I have been accustomed to give to the patient, who is generally found 
 to be much distressed with so unusual and disagreeable a phenomenon, and I 
 have always explained it by the same rationale to my classes, in the public 
 lectures at the Medical College. I cannot but add, that I have never known 
 it to take place except in women somewhat low in health, and of weak and 
 relaxed fibre, excepting always the instances following labour, where the 
 state of the woman’s general health is indifferent in the calculation; the 
 strongest and the weakest subjects seeming alike liable to the occurrence. 
 Franck’s citation of the Lorraner who saw a ball full of air bounding on 
 the floor, must be deemed, I fear, as in the apocrypha of physic; and old 
 De Vega, Joubert Valescus de Tarenta, Mathaeus deGradibus, and even faith- 
 ful old Pare, are not of sufficient authority to settle this point in the affirma- 
 tive. What satisfies me is, that the canal of the cervix uteri is always free 
 to admit a full-sized bougie — and to emit the menstrual secretion pleno rivo. 
 Who shall convince me that it shall become air tight? Not even M. Bau- 
 delocque himself, who is the magna parens of scientific midwifery. 
 
 The Bulletin of Med . Sciences , by Dr. Bell, for Sept. 1844, p. 309, con- 
 tains an article on Physometra, of which the following are extracts. The 
 article is from the British and Foreign Review. “M. M. Stoltz and Nae- 
 gele, two of the most celebrated practitioners in the diseases of females 
 of the present day, at the Medical Congress, held at Strasbourg, in 1842, 
 expressed their belief that tympanitis of the uterus was impossible ; and 
 that the alleged cases of its occurrence were apocryphal.” The article 
 contains remarks on several cases seen by M. Lisfranc, and proceeds to 
 say that “ M. Lisfranc does not appear to have seen any case in which 
 tympanitis was purely dynamic , that is, independent of the presence of 
 any extraneous substance in the womb.” Dr. Waller, ( Lectures on the 
 Functions and Diseases of the Womb , p. 75,) seems to admit of the disorder, 
 as he says, “ The constitution of those who suffer from this disease is very 
 generally weak and delicate, a collection of air in the cavity of the womb 
 not being the only symptom under which she is suffering, but one in com- 
 mon with many others. The air appears to be secreted by the menstruating 
 membrane of the uterus ; for if pregnancy occurs, the disease is for a time, 
 if not permanently, cured.” To think of the womb “ secreting ” air ! — M.] 
 
 The symptoms of physometra consist in a feeling of uneasiness and 
 tension in the hypogastric region ; the woman complains of a pain, 
 beginning in the womb, and running off towards the groins, loins, 
 thighs, and, in some instances, even to the diaphragm. In most cases 
 the menses are suppressed, yet there are some women who continue 
 
PHYSOMETRA. 
 
 371 
 
 to have them regularly. The abdomen, which enlarges, presents a 
 uniform, circumscribed tumour, tense, and resounding upon percus- 
 sion like a drum. The womb, which gradually rises above the pubis, 
 tends towards the umbilicus, and may even reach above it, does not 
 increase in weight, though having acquired, as in many instances, 
 considerable magnitude. This evolution is sometimes accompanied 
 with thirst, anorexia, rigors, and slight fever, increasing generally 
 towards evening : the excretions of stool and urine are more or less 
 disordered; the patient has some respiratory uneasiness; becomes 
 inactive, dislikes to move, and it is, indeed, not uncommon for the 
 uterine distension to excite sympathetic action of the breasts, which 
 swell, and even secrete a sort of milky fluid. 
 
 In this state of things, the expulsion of a portion of gas from the 
 vulva gives relief; and, generally speaking, an abundant discharge 
 of it, which is commonly accompanied with noise, dissipates all the 
 symptoms of the malady. This sort of uterine eructation may 
 happen at very various periods : it is rare, however, for the gas to be 
 retained within the womb beyond five or six months. Under such 
 circumstances, the menses not returning, the woman is apt to suppose 
 herself pregnant, and the more so, as the feelings she experiences 
 resemble those occurring in pregnancy. 
 
 A case of physometra could hardly be mistaken for pregnancy, 
 except during the three or four first months: in fact, from that period, 
 the little alteration that takes place in the cervix uteri ; the absence 
 of the ballottement (tilting;) the lightness of the tumour; the daily 
 differences perceived in the form and size of the tumour ; the reso- 
 nance on percussion; the negative stethoscopic signs; the rapid in- 
 crease of the abdomen ; the absence of the motions of a child in 
 utero, &c., should leave no doubt in the mind as to the nature of 
 the affection. An error would be absolutely unpardonable, should 
 the woman be of an age, or in a situation, to render it improper for 
 her to conceive. 
 
 [I have seen some cases of supposed pregnancy, in which medical gentle- 
 men, of sufficient information, had allowed themselves to be deceived, and 
 permitted the patient to go to the end of the supposed term before the error 
 was ascertained. Yet, in all these cases, and they have been many, I never 
 allowed myself to suppose, even for a moment, that the womb was the seat 
 of the flatulent development; and I entreat the younger reader to distrust 
 M. Colombat’s remarks as to the results of the sur-pubal percussion, above 
 stated; because, though he may find, in such case, the sonorous percussion, 
 I conceive he will have no ground to infer that the resonance is uterine, and 
 not intestinal. I must also take so great a liberty with the author, as to 
 re-assert my disbelief (vide p. 368) in the existence of the malady he has 
 so fully described ; I look upon it as a pathological impossibility ; I repeat 
 that the supposed gases could not be retained in the womb, except under an 
 absolute imperforation of the vagina or cervix ; and, in such event, there 
 could be no such gases extricated or expelled. I confidently believe that 
 where the womb, under physometra, has been thought to extend up to the 
 
372 
 
 PHYSOMETRA. 
 
 navel, there has been a mistake of diagnosis, or a voluntary deception on the 
 part of the patient. Such mistake, or such deception, is easy to be made, 
 since the bladder, when filled with urine, could easily be mistaken for the 
 uterus itself, and yet yield a sonorous percussion from the transmitted reso- 
 nance of the intestines behind and below it. 
 
 Finally, I regard the cases of physometra as likely, all of them, to prove, 
 upon a careful diagnosis, to be cases of chronic tympany ; an affection so 
 common in nervous and hysterical women, as to be frequently met with in 
 practice. Having offered these remarks, I continue the translation of M. 
 Colombat’s article, of which, let the reader judge, as follows. — M.] 
 
 The diseases with which physometra may be confounded, are 
 to be divided into three classes. The first comprises the affections 
 that consist in increase of size of the womb itself, as pregnancy ; 
 dropsy of the womb ; accumulation of blood, or a collection of hy- 
 datids within the organ ; a polypus or mole ; concretions, whether 
 calculous, lymphatic or sanguine ; hysteria, &c. In the second class 
 are comprised the morbid changes that supervene in the uterine ap- 
 pendages ; such as scirrhus and dropsy of the ovary ; ovarian and 
 tubal pregnancy ; and, lastly, in the third class are arranged divers 
 abdominal disorders, such as ascites, intestinal and peritoneal tym- 
 pany, purulent collections and tumours of the omentum, of the mesen- 
 tery, or of the abdominal parietes. Though the number of these 
 affections is very considerable, all ridiculous as well as serious mis- 
 takes will be avoided by attending to the origin and progress of the 
 disease, and by prevailing on the patient to submit to the slightest 
 examination. Besides, le pet vaginal would furnish a very conclu- 
 sive sign, could its existence -be ascertained. 
 
 It must likewise be remembered that a physometra may not only 
 co-exist with a hydrometra, but that these disorders may alternate 
 with each other, particularly as they appear to arise from the same 
 causes, acting in different degrees. In the case of hydrometra, the 
 development of the abdomen proceeds gradually, while, in physo- 
 metra, it is commonly sudden. In the latter, the tumour, which is 
 more elastic, recovers its size quicker, and gives rise, upon pressure* 
 to the sensation of a bladder filled with air and squeezed with the 
 hands. 
 
 For the most part, the prognosis in physometra is not very grave ; 
 if there be any danger in the case, which is often very protracted, 
 that danger arises less from the malady itself than from the patholo- 
 gical lesions and alterations that give birth to it, and of which it is 
 but a secondary symptom : even where it is essential, it constitutes 
 rather an inconvenience than a real disease. 
 
 The treatment of physometra consists in fulfilling the two chief 
 indications of giving issue to the aeriform fluids, and preventing 
 their development or their introduction. As pneumatosis of the organ 
 may depend upon the numerous causes we have mentioned, we ought 
 first to try to ascertain what they are. Should the formation of the 
 gases and the obstruction of the os uteri depend upon a fastus, a pla- 
 
PHYSOMETRA. 
 
 373 
 
 eenta, a portion of membrane, or a fibrinous clot in a state of putre- 
 faction, and retained within the womb, we should follow M. Deneux’s 
 example, and remove the obstruction with the point of the finger, 
 and then prescribe injections of emollients and chlorides. Should the 
 physometra be complicated with a polypus too large to be extracted 
 without aid, we might adopt Dupuytren’s method, of slitting the 
 cervix uteri, either from without inwards, or vice versa ; yet we are 
 of opinion that, in order to obtain a sufficient enlargement, without 
 carrying the incision too far, it would be preferable to make several 
 small incisions into the circumference of the os uteri. In case the 
 tympany, whether essential or introduced into the womb from with- 
 out, be deemed to depend upon spasmodic constriction of the neck, 
 or on inertia of the uterine fibres, we should, in the former state, 
 order emollient uterine injections, baths, and fumigations; opiate 
 draughts, and anodyne injections into the rectum ; after which, by 
 the use of the speculum, portions of belladonna ointment might be 
 carried up to the cervix uteri, or introduced into the vagina as far 
 as the os tinea?, which should be titillated, while, with the other 
 hand on the hypogastrium, pressure is made on the womb, so as 
 to press out the gas In the latter case, which is when the tym- 
 pany depends upon inertia of the womb, directions ought to be given 
 for the employment of tonic drinks, of stimulating frictions for the 
 abdomen, and of small doses of ergot, to excite the uterus to con- 
 traction. Where the woman seems weak, which is common, her 
 strength should be sustained, not as to the womb only, but as to 
 the general system, by chalybeate medicines and ferruginous waters, 
 decoctions of cinchona, pills of quinine, gentian, and other tonic arti- 
 cles; by stimulating frictions and vinous fomentations; by placing 
 hot flannel on the hypogastric region, which is of much use in the 
 treatment. We might also condense the gas in the womb, and at 
 the same time increase the irritability of the viscus by covering the 
 region of the uterus with a bladder, filled either with ice or with 
 cold water. 
 
 For a strong patient, young and plethoric, blood-letting, general or 
 local, may be beneficial. After trying all other remedies in vain, and 
 clearly ascertaining the non-existence of pregnancy, and especially 
 should any bad consequences happen to follow the collection of gas 
 in the organ, it might be withdrawn by gently introducing a flexi- 
 ble catheter into the cavity through the canal of the cervix. It would 
 be well to attach to the outer extremity of the catheter an empty 
 bladder, in order to collect the gases expelled, for the purpose of sub- 
 jecting them to a chemical analysis. After their evacuation, attempts 
 should be made to prevent a relapse, by the use of baths, lotions, 
 douches and tonic injections, or the injection of anodynes, opiates, 
 emollients, detergents and chlorides, according to the indications and 
 circumstances of the case. With a view to determine the expulsion 
 of gases from the womb, it has also been recommended to use pur- 
 gative medicines, leaping, dancing, and different kinds of violent 
 exercise. Such methods ought to be rejected, as well as all sorts of 
 carminatives, which are rather injurious than useful. 
 
374 
 
 HYDROMETRA. 
 
 We shall conclude by observing, that there is another kind of 
 pneumatosis of the female sexual organs, called by writers CEdoco- 
 phy * garrulitas vulvas and pet de la vulve. CEdocophy, which is 
 rather an inconvenience than a disease, is the expulsion, more or 
 less noisy, of gases contained in the vagina. These aeriform fluids 
 may get into the passage through a recto-vaginal fistula, or directly 
 through the vulva, during the separation of the labia pudendi. Ac- 
 cording to Franck, this troublesome complaint is more frequent than is 
 generally supposed ; and the reason why physicians rarely hear of 
 it, is that women, from a feeling of modesty, dislike to make their in- 
 firmity known ; it is apt to occur in coitus in 'such patients. Lame 
 women, who limp in their walk, appear to be most subject to it, 
 probably from the alternate dilatation and closing of the passage 
 while moving on foot. 
 
 [I shall finish this article by quoting a passage from Madame Boivin 
 and M. Duges, Pract. Treat, on Disease of the Uterus , p. 134. It is in the 
 following words. “ We have never known the existence of an aeriform 
 body in the uterus, except in obstetric cases, as in retention of the mem- 
 branes, or of portions of the dead foetus, or of putrefied coagula, causing 
 gaseous exhalations found in the uterus after death, or escaping per vagi- 
 nam during life.” It is true, that they add, at p. 136 : “ The symptoms of 
 physometra are too characteristic to admit of any doubt, after careful exa- 
 mination,” &c. I merely wish to remark, that the immense public and pri- 
 vate practice of the authors, ought to have made them acquainted with phy- 
 sometra, were it really a disease. — M.] 
 
 OF HYDROMETRA, OR DROPSY OF THE WOMB. 
 
 Hydrometra is a very rare disorder, and consequently but little 
 known ; it is nothing more than a collection of serous or sero-mucous 
 fluid in the cavity of the uterus. 
 
 The causes of the disorder are a feeble constitution debilitated by 
 floodings, by profuse and protracted leucorrhoea, by miscarriages, 
 by frequent hysterical attacks, a fall or blow on the hypogastrium, 
 an acute or chronic metritis, or any cause capable of keeping the 
 womb in a state of debility or protracted irritation. We ought to 
 add, that although such causes may give rise to a considerable secre- 
 tion of fluid into the cavity of the uterus, an attack of hydrometra 
 cannot occur unless the os tincae be closed, either by the cohesion or 
 swelling of the labia of the os uteri, or from fungoid tumours, a 
 polypus, or, in a word, anyone of the obstructions we enumerated 
 in our article on physometra. Although cases of hydrometra are 
 very rarely met with, they would be still more uncommon, should we 
 comprise under that denomination only the real instances of a pro- 
 duction and retention of serous fluids within the cavity of the womb. 
 But the disorder, which is not met with in virgins, is symptomatic, 
 and is found to follow various alterations and inflammations, whether 
 
 a ihia, the sexuat organs, and xc<t>ev, crepitum edo. 
 
HYDROMETRA. 
 
 375 
 
 acute or chronic of the uterus. In such cases, the fluid, instead of 
 being bland and limpid, is found to be thick, foetid, bloody, opaque, 
 and somewhat similar in appearance to coffee grounds and to lotura 
 carnium. Schenck, of Nuremburg, in his valuable collection of 
 cases, (lib. iv., case 220,) published A. D., 1600, takes notice of this 
 sort of symptomatic hydrometra, and of the brown, muddy, foetid 
 liquor contained in the organ. 
 
 Under the title, therefore, of hydrometra, has been comprehended 
 any collection in the womb, consisting of fluid, whether serous, albu- 
 minous, sero-mucous, or purulent, whose quantity, colour and con- 
 sistence vary according to the causes producing them. Sometimes 
 the cavity contains scarcely a pound or two of fluid, and at other 
 times it is found to be distended, so as to give rise to a belief that 
 the patient is pregnant, or labouring under ascites. Blankard* re- 
 lates the case of a woman, whose uterus contained eighty-five 
 pounds of ichorous and oily matter. Vesalius, (opera omnia,) says, 
 he examined the body of a woman whose uterus contained sixty 
 measures of water, of three pounds each. Theophilus Bonnett 
 quotes several cases not less curious, and John Schenck, ± who died 
 in 1588, asserts that he found a womb large enough to contain a child 
 ten years of age. 
 
 Symptoms . — The size of the abdomen increases with more or less 
 rapidity, and the swelling, which commences in the middle of the 
 hypogastrium, gradually extends from below upwards. During the 
 first months the woman supposes herself pregnant ; the breasts either 
 lessen or increase in size; the countenance, which is bloated and pale, 
 bears the impress of languor ; she has a feeling of weight in the 
 pelvis, pains in the loins, dragging sensations in the groins, and some- 
 times a slight degree of fever. By the touch, we discover a rounded 
 and firm tumour in the hypogastrium, which appears to come up 
 from the pelvis, to a certain height, greater or less. The position of 
 this tumour is very little changed by the changes of her position, and 
 we find a deep-seated, obscure, circumscribed fluctuation in it; but 
 the least equivocal sign is that ascertained by Touching : in fact, by 
 introducing a finger into the vagina as far as the cervix uteri, and then 
 pressing the tumour with the other hand, we readily feel the shock 
 of a fluid, and a very distinct fluctuation. This is not a symptom 
 of ascites nor of dropsy of the ovaria, or tubes; for in those affec- 
 tions, the cavity of the uterus is not distended with fluid, but the 
 organ is itself jammed down towards the bottom of the pelvis with- 
 out any increase of size. 
 
 The diagnostic characters of hydrometra may be supposed some- 
 what more obscure from the rarity of the opportunities for studying 
 them ; and as it may be confounded with pregnancy, particularly in 
 the early months, it is of the utmost importance not to mistake the 
 symptoms of one for the other condition. Such errors, which might 
 have the most serious consequences, may be avoided by calling to 
 
 * Anat., &c.; sive. de cad. morbis de nat. anatom, inspectio, 1688. 
 
 f Sepulchretum, seu anat. pract., lib. iii. sect. xxi. case 55, 16S8. 
 
 * Obs. med. rarum. nov. admir. et monstr. volumen lib. iv., obs. 6. 
 
376 
 
 HYDROMETRA. 
 
 mind the fact that in dropsy of the womb there is absence of bal- 
 lottement which is ascertained by Touching, and that the abdominal 
 palpation and auscultation by the stethoscope, reveal neither foetal 
 movements nor beatings of its heart. Finally, the absence of reso- 
 nance in the tumour, and its fluctuation will not admit of its being 
 mistaken for a case of pneumatosis of the womb. It is equally im- 
 portant not to confound the disease in question with a collection of 
 blood in the organ. The symptoms we have given of the latter, 
 at page 89, would soon remove all uncertainty upon this point. 
 
 The prognosis of hydrometra varies with the causes of the malady: 
 in general, it is not so unfavourable, when a portion of the fluid is 
 allowed from time to time to escape, as happens in some instances. 
 Fernel, who was physician to Henry II., mentions a case of dropsy 
 of the womb, which disappeared once a month, and was renewed 
 after each mensual evacuation.* Generally speaking, the disorder is 
 not very dangerous, and whenever it does give rise to any apprehen- 
 sions, they are derived from the circumstances which have occa- 
 sioned it, and from the frequent repetition of relapses. In some 
 cases it ceases towards the term of gestation, or the evacuation takes 
 place about the third or fourth months, and in such cases it often 
 happens, according to Mauriceau and Nauche, that the disease re- 
 turns no more. 
 
 When the liquid is limpid and inodorous, we find, on examination 
 after death, the lining membrane of the womb nearly in a natural 
 condition. Where the collection is thick, purulent, ichorous and 
 foetid, the mucous membrane of the womb exhibits traces of chronic 
 inflammation and ulceration of different kinds. 
 
 Hydrometra is more frequently met with in pregnant than in non- 
 gravid women. Here the symptoms of the uterine dropsy are con- 
 founded with those of gestation. The abdomen is larger than in a 
 simple pregnancy ; the dyspnoea is also greater and more distressing; 
 the lower extremities are oedematous, and the infiltration often ex- 
 tends over the whole body. The motions of the child are commonly 
 obscure, the cervix is higher up in the pelvis from the greater deve- 
 lopment of the womb, and the child, following the impulsion of the 
 mother’s movements, is tilted in every direction in the midst of the 
 waters. 
 
 As few occasions have offered of examining the body after death 
 with hydrometra during gestation, authors are far from agreeing as 
 to the seat of the morbid fluid in pregnant persons. Mauriceau, 
 Puzos, and Mess. Itard and Nauche, together with some other wri- 
 ters, have placed it between the chorion and the internal surface of 
 the womb ; M. Nsegele, and some other persons, supposed the collec- 
 tion to be formed betwixt the laminae of the caduca ; others, again, 
 like M. Duges, imagine that the fluid of hydrometra (in pregnancy) 
 
 * Marcellus Donatus, (Medic, histor. mirabil. lib. iv., cap. 25,) and D. Monro, 
 Essay on Dropsy, p. 164, say that they have observed the menstruation to be regular 
 in women labouring under hydrometra ; this phenomenon, of which Donatus himself 
 gives an explanation, could be derived only from a sanguine exhalation from the va- 
 gina and os tincse, as takes place in certain cases of gestation. 
 
 
HYDROMETRA. 
 
 377 
 
 is contained in the sac of the allantois, betwixt the chorion and am- 
 nios. As all these opinions are founded only upon theory and inge- 
 nious explanations, all of them debatable, we conclude that the 
 question is still open, and likely to continue so for a long time. 
 
 The treatment of hydrometra consists, at first, in combating the 
 organic disease of the womb, of which it may be only a secondary 
 symptom. Where the affection is essential, the womb appearing to 
 be sound, and clearly not gravid, we may, for the purpose of giving 
 a shock, in accordance with the advice of Monro and Astruc, and most 
 other authors, have recourse .to the drastics, to emetics, to sternuta- 
 tories, or to irritating injections, and to vaginal injections of the same 
 kind, with a view to excite the uterine contractions. It should be 
 observed, however, that- before resorting to the measures above indi- 
 cated, it would be well to soften or relax the cervix uteri as much as 
 possible, by means of baths and emollient and narcotic injections 
 and fumigations. Some broken doses of secale cornutum, exhibited 
 conjointly with an application of belladonna ointment to the os tincae, 
 might probably be prescribed with advantage where the cervix is 
 soft, and the obstacle to the discharge of her waters does not consist 
 of a polypus, or a scirrhous tumour, but is due solely to the inertia 
 or the spasmodic constriction of the neck of the womb. 
 
 In some cases, a finger, a blunt stilet, or, still better, a straight silver 
 or gum-elastic bougie introduced into the os uteri, has been em- 
 ployed to open the orifice and procure the discharge of the fluid. In 
 case - the obstacle should consist of a polypus that could not be 
 pushed out of the way with the point of a finger, we should try to 
 penetrate to the cavity of the womb with a flat catheter, passing along 
 the side of the polypus, the subsequent removal of which might lead 
 to a radical cure. 
 
 Should these measures, as sometimes happens, prove to be inef- 
 ficacious, a trocar might be made use of to puncture the womb. 
 Francis Wirer* performed the operation successfully, by passing the 
 trocar an inch and a half above the pubis, and at the same distance 
 from the linea alba. Fifty-three pounds of a thick, blackish, bloody 
 liquid escaped through the canula ; steady pressure was afterwards 
 kept up with Monro’s bandage and several napkins ; the patient, who 
 was fifty years of age, was completely cured ; for ten months after 
 the operation, there was no return. The sub-pubal puncture was 
 also performed with advantage by Noel Desmarais, in a case of 
 hydrometra coincident with pregnancy. In that case, as in simple 
 dropsy of the womb, we should prefer the puncture through the 
 orifice of the uterus, as recommended by Huermann,t Zancf and 
 others. However, as hydrometra might possibly be confounded 
 with true pregnancy, and as the operation might be followed by 
 fatal consequences, as in the case reported by Cruveilhier,§ too 
 much reserve could not be employed in the use of a measure never 
 
 * Loder’s Journal, th. iv. st. 2. p. 300 ; and annal. litt. med., &c., t. ii. p. 290. 
 
 f Abhandl. von den Vornehemsten chir. op., th. i. nap. 5, s. 186, p. 410. 
 
 i Darstell, blut. heilk. operat., th. iii. abhand. i. 289. 
 
 § Anat. patholog., t. i. 281. 
 
378 
 
 HYDATIDS OF THE WOMB. 
 
 to be attempted except as a last resource.* We conclude by remark- 
 ing, that whatsoever be the mode by which the liquid may have 
 been discharged, we should provide against a relapse by the prescrip- 
 tion of mild detergent injections, by keeping the cervix open for 
 some time with a small gum-elastic bougie, and by combating the 
 general as well as the local symptoms which may have been deemed 
 the causes of the secretion. ♦ 
 
 OF HYDATIDS OF THE WOMB. 
 
 Notwithstanding the existence of abdominal hydatids was known 
 to the highest antiquity, for they are mentioned by Aretseus/f Aetiusf 
 was the first among the ancients to speak of those of the womb. 
 These morbid productions, classed among the acephalocysts, compose 
 a .peculiar class of vesicular worms, which, though well described as 
 far back as 1805, by Laennec, is not yet admitted by the German 
 and Italian helminthologists. 
 
 Two species of hydatid acephalocysts have been admitted : 1. 
 Acephalocysts in bunches, or pediculated hydatids; 2. Free acepha- 
 locysts; of which there are two varieties: 1. Hydatids with claws, 
 and, 2d, single hydatids, which are not provided with claw or pedicle. 
 
 The pediculated hydatids, or acephalocysts in bunches, which are 
 found only in the womb, and which are at present regarded as trans- 
 formed products of conception, or as cysts in a peculiar state, are 
 produced not only in certain abortive pregnancies, but occasionally 
 also in true pregnancy. 
 
 The pediculated hydatid is a vesicle of a white or amber colour, 
 and consists of a membranous cyst, filled with a transparent limpid 
 fluid, that is sometimes reddish and of a gelatinous consistence. They 
 float in a serous liquor, and adhere together each by a very delicate 
 pedicle, which is attached to a large pedicle after the manner of a 
 bunch of grapes. They contract adhesions either to the membranous 
 bag that encloses them, or to the walls of the uterus, to the umbilical 
 cord, to the placenta, or to a fleshy mole which they are sometimes 
 observed to accompany. 
 
 Hydatids with claws are of a lenticular shape ; they are few, 
 and not so large as the preceding ; they develop themselves in the 
 vagina, and within the rugse of the orifice of the womb; but they 
 are always found there in considerable numbers. Generally speak- 
 ing, they are covered with an extremely thin membrane, and adhere 
 by their claw to the point upon which they commenced their exist- 
 ence. 
 
 The non-pediculated acephalocyst, without the claw, has been 
 more particularly observed in the ovaries, and in the Fallopian tubes 
 
 * In order to avoid the puncture, Sanctorius invented a sort of small-jointed speculum, 
 designed to open the mouth of the womb, evacuate the water, and admit of injections 
 into the cavity. (Comment in prim. fen. canon Avicennae, p. 608.) 
 
 f Aretaeus de causis et signis diuturn. morb., lib. iv. cap. i. 
 
 i Med. contractae tetrabib. iv. serm. iv. cap. 79. 
 
HYDATIDS OF THE WOMB. 
 
 379 
 
 when dropsical. Their form is that of an egg-shaped sac, of a whit- 
 ish mother-of-pearl colour, of soft and fluctuating consistence. They 
 are always free, sometimes single and isolated, but generally nume- 
 rous, and contained within a common cyst filled with fluid, in which 
 they float without adhering to each other. The cyst that serves as 
 their envelope, and which is chronically inflamed, is liable to become 
 much thickened, gives out when compressed a sort of crepitating 
 sound, that may be compared to the sound produced by squeezing 
 a snow-ball in the hands.. 
 
 The specific gravity of the free hydatid is scarcely greater than that 
 of water; their walls are thin and without any demonstrable ves- 
 sels; they are mostly diaphanous, but sometimes are grayish, opaque 
 or amber-coloured ; the texture is homogeneous and without fibres; 
 though pretty extensible, it resembles half-cooked white of eggs, and 
 separates into several layers, particularly in the larger hydatids. 
 
 Whilst we admit that the free acephalocyst of the non-gravid womb 
 may be possessed of vitality, we think, on the other hand, that the 
 hydatid vesicles, resulting from morbid transformation of the pla- 
 centa are not endowed with an individual independent life, but like 
 the serous cysts receive their life through the pedicle that sustains 
 them. A circumstance that militates in favour of this opinion is 
 that when removed from the situation in which they were originally 
 developed, they become wilted or shriveled, and perish, like other 
 serous cysts, as soon as the stalk that unites them with the surround- 
 ing parts, is destroyed. Instead of moving in water, and even in 
 the paim of the hand, as stated by Percy,* the placental vesicles 
 exhibit merely a sort of tremor and undulation produced by a fluid 
 contained within an extremely delicate elastic membrane. 
 
 The fluid contained in the bunch-like hydatids, is perfectly limpid ; 
 its density is less than that of distilled water ; it turns syrup of vio- 
 lets green, is not coagulable by heat nor alcohol, which proves that 
 it is not albuminous, and is similar in character to the fluid of the free 
 acephalocysts. 
 
 The causes of hydatids of the womb , and other female genital 
 organs, are but little understood ; it is supposed, however, that a 
 lymphatic temperament, a chronic leucorrhcea, a suppression of the 
 menses, and whatever may excite or keep up an irritation of the 
 sexual organs, may contribute to the production of the disorder. 
 
 The symptoms and diagnosis of hyatids are very obscure. In 
 the commencement of the disorder, it is generally confounded with 
 pregnancy or with hydrometra, nearly all the external characters 
 of which it exhibits, except that the distension of the abdomen does 
 not proceed rapidly, nor to so great a degree. The mere presence of 
 hydatids within the uterus produces, per se, very trifling conse- 
 quences ; but as the vesicles increase in number and magnitude, the 
 hypogastric region becomes flatulent, soft and swollen. Upon Touch- 
 ing, the womb is found to be much larger than in the natural state, 
 but its orifice continues to be somewhat open, and scarcely altered 
 
 * Jour, de Med., par Corvisart, Leroux, and Boyer, Sept. 1811. 
 
380 
 
 HYDATIDS OF THE WOMB. 
 
 either as to its shape, or position in the pelvis. Palpation of the 
 hypogastrium reveals a globose, compressible and indolent tumour, 
 which has an obscure fluctuation when compressed from above in a 
 downward direction. In most cases, the tumour yields almost all the 
 symptoms of pregnancy ; the menses are suspended, or are super- 
 seded by signs of flooding, more or less, which recur at irregular 
 periods ; sometimes the breasts swell, a weight in the pelvis is felt, 
 with very severe pains in the uterus, and in the inguinal, hypogastric 
 and lumbar regions. Sooner or later the woman, after having been 
 a prey to sufferings and losses of blood, and with pains as violent as 
 those of child-birth, suddenly discharges a quantity of vesicular 
 hydatids, which come away altogether or at several different times, 
 and accompanied or not with a foetus. The product of such a la- 
 bour is what is called an hydatid mole or a hydatid dropsy, or vesi- 
 cular dropsy. Hydrometra hydatica , vel vesicularis. 
 
 The species of pregnancy resulting from the presence of pedicu- 
 lated hydatids in the womb, does not, in general, proceed beyond the 
 sixth or the seventh month, yet the expulsion of the vesicles has 
 been known to take place so late as the fourteenth month. To assist 
 the escape of them, it has been necessary to use injections of a mix- 
 ture of vinegar and salt in water, and in some instances to carry the 
 hand into the womb for the purpose of rupturing the sac which con- 
 tains them. After such a labour, the patient commonly experiences 
 all the symptoms that, usually follow a regular accouchement, such as 
 discharge of lochia, milk fever, swelled breasts, metro-peritonitis, &c. 
 
 When the discharge of the hydatic bunches does not take place 
 soon enough, the woman, who emaciates rapidly, is liable to syncope 
 and frequent floodings ; and in addition to these symptoms, there are 
 sometimes conjoined oedematous swelling of the limbs, a bloated 
 state of the face, hectic, marasmus and death. 
 
 Notwithstanding the vesicular hydatid, with or without an ac- 
 companying embryo, is never met with except in the condition of 
 maternity, the real acephalocyst of the uterus may be found in the 
 virgin state, and hydatids, properly so called, may originate in the 
 womb, as well as in any other part of the body. The celebrated 
 Percy relates a case that removes all doubt on this point, and in 
 which it appears that he succeeded, by undeniable proofs, in pre- 
 serving the reputation of a canoness of twenty-six years of age, who 
 had been subjected to the most unjust suspicions. 
 
 The expulsion of the acephalocyst is the only pathognomonic sign 
 of uterine hydatids. After the womb has contracted, the patient is 
 to be treated in the same manner as after a natural delivery ; and 
 when all signs of irritation are gone, she should have bitters, tonics, 
 chalybeates, frictions, and aromatic fumigations to the genitalia, for 
 the purpose of restoring the strength of the constitution, and pre- 
 venting the formation anew of the hydatid vesicles. 
 
 Hydatids, that have neither pedicle nor unguicle, and that are only 
 met with in certain cases of uterine or ovarian dropsy, require no 
 treatment beyond that addressed to the primary affection. The signs 
 of them are also similar, for their presence is not discovered until 
 
CALCULUS OF THE WOMB. 
 
 381 
 
 they are found escaping with the fluid, or obstructing its escape 
 when a puncture has been made, for the purpose of drawing it oft*. 
 The unguicular hydatid, which is the most rarely met with, and which 
 forms in the vagina and upon the neck of the womb, gives rise to few 
 symptoms ; when discovered by means of the speculum, all that is 
 necessary is to detach them, and prevent their reformation by atten- 
 tion to cleanliness, and particularly by using vaginal injections of 
 sulphur water, or weak decoctions of the oak or pomegranate bark. 
 
 As the mode in which the hydatid is developed and reproduced is 
 as yet wholly unknown, we feel it unnecessary to bring forward in 
 this place the opinions of Ruysch, Albinus, Morgagni, Boerhaave,Val- 
 lisnieri, Morand, Pallas, Reuss, Baer, Percy, Bremser, Desormeaux, 
 Bichat, Laennec, Soemmering, Cloquet, Breschet, Cruveilhier, Andral, 
 Velpeau, Raspail, and many other writers, whom it is not requisite 
 to enumerate. 
 
 OF CALCULI OF THE WOMB AND OTHER GENITAL PARTS. 
 
 There are numerous cases that show clearly that calculous concre- 
 tions may be formed within the cavity of the womb. Hippocrates 
 speaks of the servant of Dyseris, of Larissa, who, at sixty years of 
 age, was seized with pains as strong as the pains of labour, and dis- 
 charged a stone as large as a peson. iEtius also makes mention of 
 uterine calculi, and recommends that they should be extracted by 
 an incision of the cervix. 
 
 Most of the cases reported by writers of the last few centuries, 
 have been collected by Louis, in a memoir inscribed among the 
 Mem. de VAcad. de Chirurgie. They contain an account of a girl 
 sixty years of age, who introduced into the uterus, [vagina M] a 
 stone the size of a hen’s egg, without being much incommoded by it. 
 It weighed nine drachms and a half. Another woman had a calcu- 
 lus which weighed but four ounces, and which, according to Louis, 
 might have weighed a pound, had the material not been so porous. 
 The symptoms felt by these women were difficulty in walking, and 
 itching of the vulva and internal surface of the thighs, while, in 
 some of the cases, the symptoms were still more slight from the 
 smallness of the calculi ; in others, the patients fell victims to the 
 exhaustion arising from profuse suppuration, from ulceration, and a 
 local degeneration, produced by the presence of calculus in the womb. 
 
 In these unfortunate cases, not only were calculous concretions found 
 after death, within the cavity of the uterus, but the body of the viscus 
 was ascertained to have been converted into a substance resembling 
 dried tallow. The same author says, that in one of the women the 
 parietes of the womb were ossified, and, as it were, moulded round 
 the calculus. He also adds, citing several instances, that in the more 
 fortunate cases, the lithic concretions have been expelled by the spon- 
 taneous powers of the womb. 
 
 The cases collected by Louis, and those published by Regnier de 
 Graff*, Swammerdam, Waither, Van Swieten, Morand, &c., leave no 
 
382 
 
 CALCULUS OF THE WOMB. 
 
 doubt upon the subject of uterine calculi. One of the most curious 
 cases is that by Bartholin, who mentions a rough black calculus 
 weighing four pounds, taken from the womb of a peasant woman. 
 Bromfield also speaks of concretions, as large as a child’s head, formed 
 in the cavity. Finally, another case, quite as remarkable, is the one 
 reported by Ruysch, (Ioc. citat.,) who informs us that he removed 
 from the womb forty-two calculi of different sizes. Were it not for 
 fear of trespassing on the limits assigned for this work, we might 
 quote many curious examples from Marcellus Donatus,* J. Schenck,t 
 Theoph. Bonnet, ± Steph. Blancard,§ Michael Morus, || J. Lieutaud,H 
 Joubert,** M. Nauche,tt and some from more modern writers. 
 
 The causes , under the operation of which uterine calculi are 
 formed, are still imperfectly known. The celebrated Louis, whose 
 opinions upon the subject are adopted by most of the modern patho- 
 logists, thought that they proceeded from the aggregation of the more 
 solidifiable portions of the morbid secretions of the organ in the same 
 manner as urinary and biliary calculi are formed in the bladder or 
 the biliary cyst. 
 
 Professor Roux, in his Melanges de Chirurgie, emits the more 
 probable opinion that the calculi met with in the womb are pro- 
 duced from the ossification of fibrous tumours developed with the 
 organ, or in the substance of its walls. Pecquetlf reports two in- 
 stances that favour this view of the question, and adds, adeo ut pro 
 scirrhis lapidescentibus haberi debeant jrrsedicta corpora. Accord- 
 ing to M. Roux, fibrous tumours, while undergoing alteration, be- 
 come gradually ossified, or at least, are invested with a covering, more 
 or less thick, composed of the saline residuum of the uterine mucus. 
 What militates in favour of this opinion of the distinguished surgeon 
 of the Hotel-Dieu, is that a chemical analysis of one of these calculi, 
 proved it to be composed of a considerable quantity of animal mat- 
 ter in combination with salts of potassa, soda and lime.§§ In another 
 calculus, of the same kind, M. Amusat found phosphate of lime and 
 gelatin. 
 
 Concretions of the womb may also arise from small concretes, or 
 fragments of an embryo that may have passed down through the 
 Fallopian tubes, in a case of extra-uterine pregnancy. They may 
 likewise owe their existence to the ossification or incrustation of a 
 hardened mole, or of hydatids, or an embryo, or foetus that had per- 
 ished at an early stage of pregnancy ; or, in fine, to foreign bodies 
 brought into the womb, which have, in some examples, constituted 
 the nuclei of concretions. Brugnatelli, who gives the chemical ana- 
 
 * De histor. medic, mirabili. lib. iv. cap. 30, 1586. 
 
 j- Observat. med. rar. nov. admirand. monstr. lib. iv., 1600. 
 
 * Sepulchret. seu anatom, practica. lib. iii. sec. 24. obs. 18, 1679. 
 
 § Anat. prac. ration : sive varior. cadav. morb. &c.,obs. 74, 1688. 
 
 H Acta eruditor. Lipsien. August, anno 1712. 
 
 * Histor. anatomic, med. sistens numer. cadaver, human, t. i. p. 340, 1767. 
 
 ** Mem. de l’Acad. de Chirurg., t. ii. p. 140. 
 
 ff Maladies des femmes, t. i. p. 214. 
 
 t± Exper. Nov. Anatom. 1651. M. Nauche also relates a case met with at la Sal- 
 petriere in 1799. 
 
 §§ Revue Medicale, tom. ii. p. 301, ann. 1824. 
 
CALCULUS OF THE WOMB. 
 
 383 
 
 lysis of several of these calculi, says that one of them, weighing 
 about two ounces, and of a peculiar odour, was an amorphous mass 
 with an irregular surface, and of a whitish colour. Being insoluble 
 in water, it was broken by a blow with a hammer, and no little sur- 
 prise was felt to find within it part of the tibia of a chicken. Probably 
 the whole bone had been introduced under an attack of erotomania, 
 and had served as the means of a shameful and disgusting manoeuvre.* 
 The symptoms of calculus in the womb are either null, or, in some 
 of the cases, very obscure — however, the patient generally suffers 
 from dull or pungent pain in the hypogaster, and a feeling of weight 
 in the back and groins. To these symptoms are added an intolerable 
 pruritus of the vulva, and mucous, purulent and sanguineous dis- 
 charges from the vagina. The pains increase, or return at intervals, 
 and sometimes become so acute that they end in the spontaneous 
 expulsion of the calculous matter. The presence of these foreign 
 bodies interferes with the urinary and alvine excretions: and when 
 they are situated near the neck, and especially when the os tincse 
 
 * In No. 3., Jan. 6, 1838, of la Lancette Fran5aise, we read a very curious case 
 which we quote as related in that excellent journal, from an English periodical. 
 
 “ A woman, habitually subject to suppression of urine, was seized, on the tenth 
 of June, with total suppression of urine. A physician being called in, she was 
 relieved by the catheter. The suppression continued for two months, so that the 
 patient could not empty her bladder, save by the catheter, which the physician intro- 
 duced twice each day. At the end of this period, being unable to defray the expense, 
 she introduced the catheter herself, making use, for the purpose, of the stem of a 
 tobacco pipe. She was successful for some time, but at length the tobacco pipe 
 broke in the urethra, and her attempts to extract it, forced it into the bladder, where 
 it was lost. 
 
 “The accident happened on the fifteenth September. The woman now procured 
 a metallic catheter, and continued the use of it, having forgotten, as it were, the 
 foreign body in the bladder, until the twenty-seventh April. At that time she was 
 seized with pains, like labour pains. M. H. Martin, who was called in, examined 
 the parts, and found the pipe-stem in the cavity of the womb. One end of it was 
 projecting from the os uteri, and was so strongly grasped by the organ, that he was, 
 for its extraction, obliged to make use of a pair of pincers, and use considerable 
 force for the purpose. The extraction was quite a difficult task, for the pipe-stem 
 broke several times while he was doing it. 
 
 “ Three years afterwards the woman died with phthisis, and her genito-urinary 
 organs presented the following appearance upon dissection: 
 
 “The bladder was thickened, and contained no foreign body. At its left side not 
 far from the orifice, was a patch, the size of a sixpence, much softer than the rest of 
 the mucous surface, and which tore upon the lightest touch of the fingers. ‘I con- 
 cluded,’ says the author, ‘ that it was here the foreign body passed from the bladder 
 into the vagina, and thence into the os tincse. It seemed to me, indeed, impossible 
 that it should have passed directly from the bladder into the womb, for no cicatrix, 
 nor way of communication was discovered betwixt these two organs.’ 
 
 “ The broken pipe-stem was three inches in length, and much incrusted with cal- 
 careous matter .” — East London Lying-in Institute. 
 
 This case is very curious, from the rarity of the circumstances accompanying it. 
 It is true, that cases are known of inorganic bodies found within the womb, such as 
 calculi, that have given rise to strange symptoms, ( Sabatier , Mem. de P Acad, de Chi- 
 rurg .) ; cases also are known of urinary calculi that had passed into the vagina, but 
 none of them can be compared with this one. 
 
 We cannot refrain, however, from remarking, that it is doubtful whelher the pass- 
 age of the pipe-stem took place by the route indicated by the English surgeon. We 
 should rather be inclined to think, that the woman, making a mistake in using the 
 catheter, passed it into the womb, and not into the bladder. The softened patch in 
 the bladder, was perhaps the cause of the suppression of urine in her case. 
 
384 
 
 CALCULUS OF THE WOMB. 
 
 is partially dilated, they can be touched, either with the finger, or with 
 a sound or catheter. 
 
 The signs above pointed out are far from being always present, 
 for the calculus may give rise to no symptom at all, and be disco- 
 vered only after death. They are in general found only in persons 
 at a somewhat advanced age, yet they have also been met with in 
 young persons; in girls of twenty-nine years, of fifteen years, and 
 even in a little girl eight years old, who fell a victim to suppression 
 of urine. At the post-mortem examination, the bladder was quite 
 sound, but a calculus of a white colour, and of the size of a large 
 pigeon’s egg, was found within the uterus. Rammazini* informs us 
 that he also saw a spongy calculus extracted from the uterus of a 
 little girl. 
 
 The treatment of uterine calculus varies according to circum- 
 stances, as to their form, size and situation in the womb. As long 
 as the calculus does not interfere with the general health, and its 
 existence is only betrayed by the discharge of some fragments, we 
 should confine ourselves to the administration of such measures as 
 are calculated to favour its entire expulsion, such as baths and emol- 
 lient and narcotic injections. 
 
 In case of any serious symptoms arising, and with the cervix uteri 
 large and readily dilatable, the immediate extraction of the calculus 
 should be attempted with a pair of long, narrow pincers; or use 
 might be made of what is called Hunter’s forceps, or what is still 
 better, the three-pronged forceps of the lithontriptic set. Should the 
 os uteri not admit of the introduction of instruments, it should be 
 enlarged by several incisions, according to the plan practised by 
 Aetius more than 1300 years ago, after which the operation might 
 be very easily concluded. If a calculus should be found to adhere, 
 it should, if possible, be detached, by carefully moving it in different 
 directions. In fine, where the stone is moulded by the shape of the 
 cavity of the womb, and especially where its surface is rough and 
 uneven, all attempts at exti'action would prove not only nugatory, 
 but would lead to fatal lacerations. Under such circumstances, re- 
 garded by all practitioners as beyond the reach of art, we imagine that 
 recourse might be advantageously had to lithotripsy in order to reduce 
 the calculus to powder, which might be done with less danger than 
 if the stone were in the urinary bladder. We shall conclude by ob- 
 serving that no attempt to perforin such operations as have been 
 described should ever be made except under an absolute and certain 
 knowledge of the existence of a calculus in the uterine cavity. All 
 doubt on the subject may be dissipated by the use of a sound, which, 
 by the shock and friction of its point, enables us to appreciate the 
 consistence and hardness of the concretion, and even to break off 
 fragments of it. Such bits of calculus, when brought away, would 
 furnish clear evidence of the case, could we make sure that they did 
 not come from the urethra or had not been formed in the vagina by 
 some vesical fistula. 
 
 Ephemerides Natur. Curios., sec. i. 75. Num. 4, 5. Obs. 65. 
 
POLYPUS OF THE WOMB. 
 
 385 
 
 Small concretions formed in the substance of the womb require 
 no treatment ; and they give rise, moreover, to no symptoms, and 
 cannot be ascertained during the life of the patient by any appreci- 
 able sign. Those that are formed in the vagina, look like red gravel, 
 and are composed of uric acid ; or, they may be of larger size and 
 of a chalky appearance, and a whitish colour, in which case they 
 will be found to consist of a phosphate of lime and an ammoniaco- 
 magnesian base. Vaginal calculi of this kind may sometimes be 
 found of great magnitude. Koeler* met with live such, weighing 
 about seven ounces, in the vagina of a woman labouring under prolap- 
 sus uteri. These concretions are chiefly met with in cases of displace- 
 ment of the organ, and have been well described by Graaf, Lank- 
 risch, and Bouvet. Foreign bodies, allowed to remain and become 
 altered in the womb, are frequent causes of calculus. Their nucleus 
 is commonly portions of sponge, or of cork or wax pessaries. Hoff- 
 man, Walter and M. Breschet, and other authors, cite examples of 
 this kind. 
 
 These vaginal concretions, which in themselves considered are not 
 very dangerous, but often exceedingly, inconvenient, may be pro- 
 duced either by a morbid secretion of the procident womb or by 
 infiltration of urine. They form like the calculous incrustations on 
 pessaries left for a long time in the vagina. They are readily disco- 
 vered by the finger, or by means of a sound passed into the vagina. 
 As soon as they are discovered, they should be removed with proper 
 pincers or forceps, after which the patient should be directed to use 
 vaginal injections, and frequent baths, to prevent their formation 
 again. Lastly, calculous concretions, which certain authors, among 
 whom may be named Stoeller and Soemmering, say they have found 
 in the surface of the labia and nymphae, may be easily recognized 
 by the simple inspection of the parts, and it would always be easy 
 to remove them at once. 
 
 OF POLYPUS OF THE WOMB AND VAGINA. 
 
 It is difficult accurately to define a polypus of the womb, for several 
 dissimilar tumours, having nothing in common except their situation, 
 have been comprised under the appellation. In general, by the term 
 polypus of the womb, is now designated any tumour, any excre- 
 scence or preternatural tumour, rising by a base or pedicle, whether 
 small or large, from the mucous membrane of the neck or body of 
 the organ. 
 
 Polypus uteri, though not well described before the eighteenth 
 century, was nevertheless known to the highest antiquity ; and 
 while Hippocrates, Celsus and Galen make no mention of it, Philo- 
 tenus,t who lived antecedent to the two latter authors, indicates with 
 sufficient clearness the progress of the uterine polypus. If we may 
 judge from the few words he has uttered ou the subject of the treat- 
 
 * Diet, de Med., t. iv. art. calcul. 
 
 t Harmonia Gynaeciorum, p. 138, 1566, and Peyrilhe, p. 115, 1780. 
 
 25 
 
386 
 
 POLYPUS OF THE WOMB. 
 
 ment, we may infer that the method he employed was to tear them 
 away, and to excise them with instruments. Moschion, in his 
 Treatise, ( de mul. affectibus ,) which was published by Spachius, 
 in 1566, was the first to give the name pulps or polypus to the 
 pediculated fibrous tumours of the uterus ; but his words show that 
 his notions on their nature were not any dearer than those enter- 
 tained by his predecessors. We must come down to the time of 
 Guillemeau, who was the pupil of Ambrose Pare, to find a pretty 
 clear description of the polypus ; but to Levret* belongs the honour 
 of having, by the study of different cases, dissipated the obscurity 
 that covered the anatomy, the diagnosis, and treatment of polypous 
 tumours This subject, which had, in the last century, been more or 
 less illustrated by Lamzweerdet, Schacher,f Kaltschmitt,§ and Her- 
 biniaux,|| requires scarcely any further development, since the la- 
 bours of Dessault,^ of Bichat,** of Denman, tt of Boyle,±± of Mess. 
 Roux,§§ Grainger, mi Mayer, Breschet,*** Hervez de Chegoin,ttt 
 Simson,tf± Dupuytren,§§§ Malgaigne,|||||| Gerdy,1HfH Duges,**** 
 Blandin,tttt and others too tedious to mention. 
 
 We shall say but little as to the pathological anatomy of the 
 polypous and fibrous bodies of the uterus, because we have nothing 
 new to offer upon the subject, and also, because, to set forth all the 
 various opinions of authors concerning them, would extend the 
 notice too far. 
 
 Levret distinguished two species of polypus, and since his day, 
 most of the writers on the subject have increased the division, and 
 embraced within it the white vesicular polypus, the red vesicular 
 polypus, the fibrous polypus, and also the sarcomatous polypus, 
 which is of a deep red colour, an irregular shape and a some- 
 what botryoidal tuberculated surface. At the commencement of 
 their growth, they are indolent, but they soon become the seats of 
 lancinating pain, rapidly assume a cancerous character, and excrete 
 from the surface a bloody discharge, which is often found to be con- 
 
 * Obs. sur la cure radicale de plusieurs polypes de la matrice, 1740. 
 
 f Hist naturalis mal. uteri., Lugd., in 12mo., 1686. 
 
 4 Programma de polypis, &c., Leips., 1721. 
 
 § De mola scirrhosa in utero extirp., Jena, 1734. 
 
 H Traite des acc. labor, et sur les polypes de la matrice, t. ii., 1782. 
 
 ^ CEuvres chirurg., t. ii. 
 
 ** Mem. de la soc. med. d’emulation.t. ii. 
 
 •ff Plates of a polypus, &c., of the uterus, 1801. 
 
 44 Diet, des Sci. Med. 
 
 §§ Memoires sur les polypes. Melanges de chir. 
 
 || || Med. and Surgical remarks, &c., method of removing polypi from the ute- 
 rus, 1815. 
 
 m De polypis uteri. Berolini, 1821. 
 
 *** Diet, de Med., in 21 vols., vol. i., 17. 
 
 Iff Journal General de Medicine, Oct. 1817. Remarques sur la disp. anat. des 
 polypes de la matrice. 
 
 444 De polypis uteri. Berolini, 1828. 
 
 §§§ Clinique chir. Le 5 ons orales, t. iii. 
 
 Him Des polypes uterins. These d’aggregation en chir., in 4o. 1832, and in 8vo.l833. 
 
 Des polypes et de leur traitement, 1833. 
 
 **** Mal. de l’uterus, t. i., 1833. 
 
 -j-f-j-j- Diet, de Med., et ehir. pratiques, t. xiii., 1835. 
 
POLYPUS OF THE WOMB. 
 
 387 
 
 stant. M. Malgaigne ( loc . citat.) makes five divisions : 1, the vesicu- 
 lar; 2, the cellulo-vascular ; 3, the polypus from hypertrophy; 4, the 
 moliform, and 5, the fibrous polypus. Inasmuch as we look upon 
 some of these varieties of polypus as being merely the fungous vege- 
 tations of the haematode cancer of the womb, or the carcinomatous 
 degeneratibn of a fibrous polypus, we shall confine our observations 
 to the two kinds most commonly met with, videl. : the cellulo-vascu- 
 lar or soft polypus, and the fibrous or hard polypus, which are sub- 
 divided into pediculated, and sessile or non-pediculated. 
 
 The cellulo-vascular polypus is commonly found upon the os 
 tincse, and within the canal of the cervix uteri. In general, it is not 
 large, is readily compressible, indolent, light, of soft consistence ; its 
 colour is white, or more or less deep rose or red-tinted, according to the 
 number of its blood-vessels. These polypi may be simple or multi- 
 ple, immovable, with a broad base, though for the most part they are 
 attached by means of a pedicle, of various lengths in different spe- 
 cimens. These polypi, which are rare and not very dangerous, 
 incommode the patient only by causing a very abundant sero-mucous 
 discharge. 
 
 Where the cellulo-vascular polypus attached to the os tincm is of 
 small size, it is often a difficult matter to detect it by the touch, for it 
 flees before the contact of the finger, which flattens or glues it to the 
 side of the womb. The best way here is to move the finger in a 
 transverse direction across both the inner and outer surface of the 
 uterus, by doing which we shall discover one or more tumours, soft, 
 almost undulating, and somewhat salient, that maybe moved in any 
 direction. 
 
 In the Bulletin des Sciences Medicates for October, 1827, Profes- 
 sor Dopuytren points out the following characters : 
 
 “ The cellular and vascular polypi presenting symptoms analogous 
 to those of cancer of the cervix uteri, escape, by their minuteness, 
 the most careful search. They force both physician and patient to 
 despair. The discharges, whether white or red, are commonly 
 attended with a sense of fatigue in the loins, dragging feelings in the 
 groins and pressure at the fundament; there is both physical and 
 moral exhaustion, which is promptly induced by the loss of blood, 
 and the continued pain. This bleeding, and still more the white dis- 
 charge, are easily brought on by the slightest touch, by coitus, by the 
 approach of the menses, and they are easily detected, either by the 
 touch or by the use of the speculum. Let the finger be conducted 
 to the os tincae, and within its circuit we shall find one, two or more 
 small, elongated pediculated bodies, implanted in the lower part of 
 the canal of the cervix ; they vary in size from that of a pea to that 
 of a lddney-bean; they bleed at the lightest touch; and if, instead of 
 trusting to the touch alone, we examine them with the speculum, we 
 find the neck and the mouth of the womb red, dilated, and filled 
 with little reddish bodies elongated, pediculated and implanted upon 
 the neck. There is no disease with which this malady has not been 
 confounded.” 
 
 The treatment of polypous tumours of this sort consists in eradi- 
 
3SS 
 
 POLYPUS OF THE WOMB. 
 
 eating them by a mixed process of avulsion and torsion. For this end 
 the parts should be exposed by means of our jointed speculum, which 
 enables us to dilate the vagina in every dimension, and that chiefly 
 at the part on which we have to operate ; and then after cleans- 
 ing the polypous tumour with a plumaseau of charpie, held in a 
 long forceps, or on the handle of our port-caustic, it should be seized 
 with a proper pair of forceps so as to twist it off and remove it, taking 
 care to carry the open gripe of the instrument to the very root of the 
 pedicle, so as to be sure of effecting a complete eradication of it. We 
 may be sure of having effected this object, if we find with the finger 
 a pit or depression at the spot whence the pedicle sprung. The 
 hypertrophy and the oedema of the neck of the womb which fre- 
 quently accompany the cellulo-vascular polypus, may be subse- 
 quently treated by the measures pointed out in our remarks upon 
 those affections, while the simple ulcers caused by the avulsion of the 
 pedicles, should be managed by the use of antiphlogistics, rest, and 
 cauterization. 
 
 The pediculated fibrous polypus is ordinarily of a rounded form, 
 as long as it continues to inhabit the cavity of the womb, but as soon 
 as it escapes from that organ, it becomes pear-shaped, with the large 
 end downwards. The tumour, which is at first small, increases m 
 some instances rapidly, and in others remains stationary, after ac- 
 quiring certain dimensions. According to Boyer, some of them then 
 diminish in size and almost wholly disappear, by the powers of 
 nature merely. These tumours are connected with the womb, by a 
 pedicle, which differs in different specimens as to its point of attach- 
 ment, its size and its organization. 
 
 Indeed, the pedicle which adheres to the inner surface or cavity of 
 the womb, or the canal of the cerevix, or to one of the lips of the os 
 tincae, may be thin, slender, long, and weak, or hard, thick, short and 
 strong. 
 
 The interior texture of the fibrous polypus uteri, is very similar to 
 that of the organ itself, that is to say, it is dense, firm, strong, and exhi- 
 bits the same inextricable decussation of fibres. Vessels are found in 
 it which are not always very apparent, though their existence is indu- 
 bitable, from the red colour, and more especially from the growth 
 of the tumour. When cut into, it creaks under the knife, and the 
 sensation it gives rise to is like that produced by cutting the sub- 
 stance of the uterus. Along with the reddish tint we have mentioned, 
 is conjoined a slightly yellowish colour, which is the paler, as the 
 density is greater. Though the existence of nerves in these bodies 
 cannot be demonstrated, their presence is proved by the pain result- 
 ing from the constriction of their pedicles. 
 
 [I cannot agree with Mr. C. in this view. Such a tumour is insensible 
 to pressure, though the stricture of it may disturb or distract the sensitive 
 parts upon which it sits. A surer proof of its possessing nerve power is the 
 fact of its having power to grow. The tumour is organized — not crystal- 
 lized, as by simple aggregation of its molecules, but by regular nutrition — 
 
POLYPUS OP THE WOMB. 
 
 389 
 
 which cannot be hypothecated of any non-nervous structure. The simple 
 fact that it has blood-vessels shows that nerve filaments must accompany 
 those vessels — both the vessels and the tumour would perish without nerves. 
 As to the pale yellowish red colour of this fibrous polypus, I beg leave to say 
 that I saw one discharged by violent labour pains from the uterus of a negro 
 woman, at Augusta, in the State of Georgia, in 1812. It was as large as 
 the head of a full-grown foetus, and had been attached to the fundus uteri by 
 a pedicle as large as the little finger. The uterine contractions, after dilating 
 the os uteri and expelling the mass into the vagina, with prodigious pain, 
 forced the tumour through the vulva, when the pedicle parted, and the 
 woman was freed from a long trouble. The surface of that tumour was of 
 a blackish soot-colour, and very rough — it was hard and elastic — and upon 
 laying it open with a scalpel, was found to consist of spherical and oval cells 
 or loculi, some an inch in diameter with an infinity of smaller ones; the 
 cells were filled with a viscous fluid resembling bloody synovia. I removed 
 one in 1843, which was of a whitish colour, faintly tinged with brown. It 
 had occasioned enormous floodings and the most distressing anemia trauma- 
 tica, for six or eight years — in that case there were no cells in the substance 
 of the tumour. — M.] 
 
 Fibrous polypi, developed in the sub-mucous tissue of the uterus, 
 are covered with the mucous membrane of that organ which extends 
 with the growth of the tumour, and composes, in conjunction with 
 the blood-vessels, and some fibro-cellular tela, which it invests, the 
 pedicle or stalk by which the morbid production is attached. This 
 pedicle grows smaller, in some instances, to such a degree as to break 
 olf, and permit in that way a spontaneous cure, as in instances cited 
 by Mauriceau, Ruysch, Hoffman, Levret, Dupuytren, and Hervez 
 de Ch6goin. It occasionally happens, on the other hand, that the 
 pedicle is hard, solid, and does not stretch at all, or it even accpiires 
 greater and greater thickness as the tumour enlarges. Polypi have 
 been met with, whose pedicle had grown sufficiently to measure 
 above four inches in circumference. 
 
 Though the shape of the pediculated fibrous tumour is commonly 
 ovoidal or pyriform, they are sometimes botryoidal, flattened, angu- 
 lar, cylindroidal, strangulated, irregular, and divided into lobes. 
 They vary in size from that of a lentil (Bayle) to that of a man’s 
 head. M. Marjolin mentioned in his lectures, that he had seen a 
 polypus uteri as large as the head of an adult. The tumour, which 
 had inverted the womb upon descending into the vagina, compressed 
 the bladder and the rectum violently. After fruitless endeavours to 
 extract it with the forceps, it was proposed to make a section of the 
 symphysis, which merely rendered the tumour more salient ; and it 
 was not extracted until after the woman’s death, when it was re- 
 moved through the hypogastrium. The old Journal de Medecine , 
 tom. 63, speaks of a polypus weighing ten pounds and a half, and 
 eighteen inches in circumference at the base, and thirteen inches long. 
 This polypus, whose proper tissue consisted of fleshy fibres running 
 in various directions, was inserted upon the os tincae. In fine, M. 
 
390 
 
 POLYPUS OF THE WOMB. 
 
 Gaultier de Claubry, sen., has published an account of a polypus 
 weighing thirty-nine pounds, and thirty-five inches in its vertical cir- 
 cumference by twenty-nine inches in horizontal circumference. These 
 large polypous masses distend the uterus almost as much as a foetus at 
 term, and produce modifications, analogous to those of pregnancy, 
 not in the womb only, but in the breasts, and, indeed, throughout the 
 entire constitution of the female. 
 
 [M. de Claubry’s polypus, of thirty-nine pounds weight, could not pos- 
 sibly have been contained within the womb, or the womb and vagina toge- 
 ther. The comparison with the foetus at term is useless; the heaviest foetus 
 I have seen weighed thirteen and a half pounds. Twins, born under my 
 care, weighed eight and a half pounds respectively, aud triplets, carefully 
 weighed, furnished a sum of twenty-one pounds weight. But these are 
 far short of thirty-nine pounds. Here we must suppose M. de C.’s case to 
 have been extra-uterine in its location. — M.^] 
 
 Certain kinds of polypi, instead of forming a compact fibrous 
 mass, exhibit cavities in the interior, giving rise to so great a resem- 
 blance to the womb itself, that many limes a surgeon, who had 
 extirpated a polypus, has supposed himself to have effected the com- 
 plete ablation of the womb. Boudon, Maune, and Collin, not only 
 fell into this mistake, but what is still more extraordinary, affirmed 
 that their patients again became pregnant after the operations. Such 
 a mistake may be readiiy conceived of, when it is a fact, that in the 
 year 1823, and in the hospital St. Louis, two practitioners, so distin- 
 guished as Mess. Richerand and J. Cloquet, having extirpated a hol- 
 low polypus, supposed they had removed the entire uterus, which, 
 however, was found in its proper place upon the death of the woman, 
 which took place subsequently. There is yet another kind of hol- 
 low polypus, that must not be confounded with those' we have men- 
 tioned ; we speak of polypi, whose interior cavity contains cerebri- 
 form matter, fungous substance, effused blood, or any of the products 
 of the cancerous degeneration. 
 
 The polypi that are most liable to undergo this pathological trans- 
 formation, are those in which there is a predominance of cellular 
 tissue. Those, on the other hand, in which the fibrous exceeds the 
 cellular element, only degenerate into an osseous state, or, at least, if 
 they do become scirrhous or cancerous, the transformation proceeds 
 from the circumference towards the centre, because, in that case, it 
 does not depend upon the reaction of the different elements upon 
 each other, but upon an inflammation of the womb, and especially 
 of the internal membrane of it. Inasmuch as it appears, from a 
 remark made by Dupuytren, [Med. Opera/, de Sabatier , t. iv., 337,) 
 that the external layers of polypi are the parts that first pass into the 
 cancerous condition, and that the body, or at least the pedicle of the 
 tumour, is almost always found in a sound state ; we may attack 
 them, with some hopes of success, even where they seem to be already 
 somewhat advanced into a condition of cancerous degeneration. 
 
 Professor Cruveilhier speaks of another kind of hollow polypus, of 
 which he has met with several specimens. They result from a true 
 
POLYPUS OF THE WOMB. 
 
 391 
 
 hypertrophy of the proper tissue of the uterus, and contain certain 
 cavities similar to the ^uterine sinuses, and which are commonly 
 found full of black grumous blood. 
 
 Inasmuch as the pathologists are not agreed as to the various sorts 
 of pediculated polypi, we shall dispense with any remarks upon the 
 subject, particularly as no good could arise from them in a practical 
 point of view. 
 
 The non-pediculated fibrous polypus, or fibrous tumour of the 
 uterus, is a tumour of the same internal texture as the pediculated 
 kind, but differs in respect that it grows without any pedicle, and 
 springs either from beneath the peritoneal coat or in the substance of 
 the uterine texture. The latter, though enclosed within the substance 
 of the womb, are not connected with it by any continuity of tissue, 
 but, being produced de novo, they are circumscribed and enveloped 
 in a layer of cellular tela, compact enough to make them appear as 
 if enclosed and shut up in a cyst. Those that project upon the peri- 
 toneal surface, are sustained there by a large base or by a stout 
 pedicle, consisting of peritoneum and some laminee of cellular texture. 
 
 These polypous productions, generally designated by the term 
 fibrous tumour, may be either simple or multiple. M. Roux has 
 seen as many as ten or twelve protruding from the surface ; we, on 
 one occasion, found eleven in the uterine parietes of an aged subject; 
 and, lastly, M. Cruveilhier met with three, with broad bases in the 
 uterine cavity of a subject thirty years old, who died with phthisis. 
 
 The shape of the fibrous tumour is almost always round ; the 
 surface, like that of the pediculated polypus, is, in some instances, 
 smooth; in some, uneven ; in others, full of anfractuosities, and, as 
 it were, divided into several lobes. The size varies from that of a 
 lentil or small nut to that of an adult head. In fine, the colour, con- 
 sistence and origin being the same as in the pediculated fibrous poly- 
 pus, we shall here close our remarks upon those points, particularly 
 as we shall have to recur to it when we come to consider the diag- 
 nostics and treatment of fibrous tumours in general. 
 
 The causes of polypi are for the most part difficult to ascertain. 
 Among the predisposing causes have been mentioned a lymphatic 
 temperament, the herpetic, syphilitic or scrofulous taint ; a chronic 
 leucorrhosa, celibacy, barrenness, abortion, and sedentary employ- 
 ments, such as those of the cook, the ironer, the seamstress, &c. The 
 period of life, when advanced, appears also to have some influence 
 upon the development of polypous tumours; indeed, the age from 
 thirty to forty, and that from forty to fifty years, are the terms in 
 which uterine polypi are most frequently met with. Out of fifty-one 
 cases collected by authors, M. Maigaigne found between 26 and 30 
 years, 4 cases; from 30 to 40 years of age, 20; from 40 to 50, 16 
 cases ; from 50 to 60, 4 ; from 60 to 70, 3 ; and from 70 to 79, 4 cases ; 
 in all, 51 cases. From this statistical report, it appears that polypous 
 excrescences are rare in very aged persons, in young women, and 
 especially in girls under twenty-five years of age ; yet Dessault ex- 
 tirpated a polypus in a girl of fifteen years old, and Dr. Simpson 
 foe. cit., p. 22) informs us that Siebold has observed three polypi in 
 the case of a girl with the hymen perfect. 
 
392 
 
 POLYPUS OF THE WOMB. 
 
 The fibrous tumours, properly so called, that are developed under 
 the same influences as those that produce <he pediculated sort, are 
 far more frequent than the latter. Bayle estimates at one-fifth, the 
 number of women beyond thirty-five years of age, in whom he met 
 with samples of one or more fibrous tumours. Portal found a still 
 larger proportion, since, in twenty wombs that he examined in 1770, 
 there were thirteen exhibiting the fibrous excrescence : lastly, accord- 
 ing to Dupuytren, there are almost no specimens of the womb, in 
 aged women, that are unaffected with tumours of the kind in 
 question. 
 
 It is equally difficult to say what are the determining causes of 
 polypus uteri. Nevertheless, it may, as a general rule, be correct to 
 say that the primary and essential cause consists in a certain mode 
 of irritation, whose persistence, at a given point of the womb most 
 affected, determines at that point a new mode of nutrition and 
 vitality , the precise nature of which it will be forever impossible 
 to explain, but which may, to a certain extent, be compared with the 
 ligneous excrescence arising from punctures made by the Cynips 
 Gat lx, or the oak twigs that produce the nut-gall. 
 
 Many circumstances may dispose to the local irritation that gives 
 rise to and favours the development o*f the polypus ; such as punc- 
 tures, fissures, excoriations, abusus coitus, all sorts of vaginal dis- 
 charges, laborious labours, inconsiderate manipulations for the expe- 
 diting of delivery, astringent injections, and, indeed, all sorts of agents 
 capable of establishing an habitual or frequently renewed irritation 
 of the genital organs. Let us add, that different authors inform us 
 of the very frequent occurrence of polypus uteri among certain ori- 
 ental nations, whose women make use of irritating pessaries for the 
 purpose of exciting their lubricity. • 
 
 The primary symptoms, or rational signs that should lead to a 
 suspicion that a fibrous polypus exists in the uterus, are about the 
 same at first, whether the tumour is situated near the peritoneal sur- 
 face, or whether it projects into the cavity of the organ. The ordi- 
 nary indices of the disorder consist of a set of sympathetic phenomena, 
 such as vomiting, disgust, paleness and leuco-phlegmasia; the menstru- 
 ation becomes more frequent, profuse and protracted ; if the tumour 
 occupies the body of the womb, the haemorrhages which, under such 
 circumstances, are still more irregular as to their recurrence, become, 
 in certain instances, so profuse as soon to exhaust the woman, who 
 at length dies of debility. These serious symptoms are ordinarily 
 attended with a leucorrhoeal discharge, which is at times fetid and 
 bloody, and which mostly precedes the formation of the polypus; but 
 which, nevertheless, does, in some of the instances, fail to manifest 
 itself until after the tumonr has long been formed. It is proper also 
 to observe that where the tumour is situated upon the cervix, the 
 vagino-uterine discharge exists simply, that is to say, without any 
 haemorrhagic discharges ; in fine, we have to add that the patient, at 
 the same time, suffers from dragging sensations in the groins and back; 
 a sense of weight in the hypogastrium, and distension in the inte- 
 rior of the pelvis, and at a more advanced stage, a sort of uneasiness 
 
POLYPUS OF THE WOMB. 
 
 393 
 
 and compression about the bladder and rectum, that interferes with 
 the evacuations of stool and urine ; but these last symptoms do not 
 appear until the magnitude of the tumour has become considerable. 
 
 The sensible signs of polypus uteri are not to be discovered in 
 every stage of the malady; and further, they differ according to the 
 situation and size of the tumour. Although the menstrual derange- 
 ment, the nausea, the swelling and pain of the mammae, the change 
 in the physiognomical expression, the bloated appearance of the eye- 
 lids, and most of the symptoms we have pointed out, may, in the 
 commencement of the disorder, sufficiently show to the medical 
 attendant that there is disease about the uterus, it is often quite diffi- 
 cult to say precisely, what is the nature of the affection, while the 
 polypus continues to be shut up within the cavity of the organ. 
 
 The rational and sensible signs , as well as the progress of poly- 
 pus uteri, differ according as the tumour happens to be situated upon 
 the os tincae, within the cavity of the neck, or in the cavity of the 
 womb proper. 
 
 A polypus implanted upon one of the lips of the cervix, generally 
 presents no symptom beyond a leucorrhoea, more or less profuse ; 
 and on this account it is often unsuspected until it becomes large 
 enough to descend near to the vulva, and impede the expulsion of 
 the urine. By the examination per vaginam, we are enabled to 
 ascertain the presence of a tumour of different size and consistence in 
 different specimens, of ovoidal shape, and adhering by its contracted 
 or pediculated portion to the cervix. The diagnosis is completed by 
 bringing the tumour into view by means of the speculum. 
 
 These polypi become, in some instances, so large that they not 
 only dilate the vulva, but even descend betwixt the thighs, dragging 
 the womb along with them, but without inverting it. The polypi 
 that are inserted within the canal of the cervix, are more difficult of 
 ascertainment. By introducing a finger into the vagina, we feel a 
 tumour circumscribed by a thick circle, which is the os uteri distended 
 by the polypus. Upon discovering that the tumour is implanted 
 higher up than the os uteri, we should endeavour to learn whether it 
 is fixed upon the canal of the cervix, or upon the paries of the ute- 
 rine cavity, properly so called. This may be done, either by carry- 
 ing forward the point of the finger to the root of the tumour, if pos- 
 sible, or by using a female catheter, with which we may explore the 
 whole surface of the cervix ; but which will be arrested by the neck 
 of the tumour, should it spring from the wall of the cervix. As the 
 polypi that are so situated are liable to be more or less violently com- 
 pressed, they are more frequently than the other kinds attended with 
 hasmorrhage, and as they increase in size, they descend along the 
 vagina, and soon present themselves at the vulva. 
 
 Polypous tumours adhering to the fundus uteri should be differently 
 regarded, accordingly as they happen to be still within the cavity of 
 the womb, in the canal of the cervix or in the vagina itself. 
 
 When they are still within the cavity there are no distinctly marked 
 sensible signs of them ; the woman complains merely of a sense of 
 weight in the pelvis, and a little difficulty in the urinary and alvine 
 
394 
 
 POLYPUS OF THE WOMB. 
 
 discharges. Should we discover by the sur-pubal palpation and the 
 examination per vaginam that there is a tumour, we should remem- 
 ber, that such an enlargement might arise from a collection of blood, 
 a calculus, ora bunch of hydatids; from a fibrous tumour growing in 
 the substance of the uterine paries, or even from a hypertrophy of 
 the womb itself ; in such case the most prudent course is to wait, 
 and in the mean time prescribe for symptoms. 
 
 In this early stage, the health of the patient is but little disturbed, 
 yet they mostly complain of pain in the groins, back and thighs; are 
 subject to leucorrhceal discharges; and their menses, which are irre- 
 gular, and more prolonged, also return with shorter intervals. 
 
 In the second stage of the development and progress of the poly- 
 pus, the tumour, when attached to the fundus uteri, after slowly 
 dilating the cervix, engages in the canal like a wedge, as Levret 
 remarks, and soon makes its appearance at the os tincse. The orifice, 
 which is now gaping, admits of the introduction of the finger, which 
 is stopped by a convex, resisting, smooth, nearly insensible tumour, 
 the whole substance of which may be moved slightly upwards by 
 gradual pressure on the part below. This tumour is separated from 
 the circle of the os uteri, which it fills up, by a circular sulcus and by 
 the projecting lips of the os uteri, all round tire outside of which the 
 surgeon can feel nothing except the cul-de-sac formed by the inver- 
 sion of the vagina. When the polypus has attained a certain size 
 Within the uterine cavity, there is often considerable difficulty in its 
 escape through the orifice ; and in some instances, it may even be 
 impossible for it to do so, owing to the exceeding rigidity of the os 
 uteri. The womb, in such a case, must expand, pari passu , with the 
 expanding volume of the tumour; the hypogastrium also augments 
 in size, the breasts enlarge from sympathy, and the pains experienced 
 by the patient, and which become more and more severe, are accom- 
 panied by almost continual losses of blood, so that the patient cannot 
 move, while her general feebleness is constantly increasing. The 
 pulse is small, weak and frequent ; she is attacked with repeated 
 faintings, her face and eyes become bloated ; dropsy, which is at first 
 partial, and then general, comes on, and death is the invariable result 
 of this scene of sufferings, if the physician does not hasten to apply 
 the proper remedies. 
 
 Where the polypus has fallen into the vagina, whether by slow 
 and gentle progress, or in a sudden/manner, after some fall or shock 
 of any kind, or bearing-down effort, like the tenesmic effort of labour, 
 the tumour is generally regarded as in its third stage. The pains are 
 now suddenly lessened, because the womb is not now so violently 
 compressed, nor does it continue to contract as before. But a copious 
 flooding generally comes on, produced, as Levret and Sabatier sup- 
 pose, by the compression of the superficial veins of the tumour by 
 the constricting cervix uteri. This compression, which prevents the 
 return of blood from the tumour, fills the veins to bursting. 
 
 By Touching, when the polypus has descended quite into the 
 vagina, we discover a firm tumour, of a pear shape, the larger end 
 downwards, while the neck enters into the womb. The symptoms 
 
POLYPUS OP THE WOMB. 
 
 395 
 
 and sufferings, which had become less severe, soon acquire increased 
 energy ; for the polypus, by increasing in size, comes to press upon 
 the rectum and bladder, more and more severely every day, until 
 the alvine and urinary discharges, which had both been only incom- 
 moded before, now come to be absolutely impossible. The fundus 
 of the womb is almost always drawn down, and we have both a 
 case of incomplete inversion and prolapsus uteri combined. The 
 dragging pains in the inguinal and lumbar regions are felt with 
 greater force; the patient cannot stand upon her feet; and, now 
 the tumour, precipitated by its own weight, or by the contractions of 
 the parts, shows itself at the labia pudendi, and, being continually 
 soiled by the urine and the utero-vaginal secretions, rapidly passes 
 into a state of disease still more to be deprecated. 
 
 When, in consequence of the large size of the polypus, or the 
 rigidity of the uterine ligaments, the tumour has been prevented 
 from descending low enough to come out of the vagina,* the mucous 
 membrane of that canal becomes irritated with the contact, and even 
 inflames, its surface becomes swollen, uneven, tubercular, and bathed 
 in putrid sanies of an extremely fetid odour. To the paleness arising 
 from repeated floodings, and the general anaemia of the whole sys- 
 tem, are now added the straw-yellow tint of the skin, which charac- 
 terizes the cancerous degeneration which almost invariably attacks a 
 polypus thus retained and left to the powers of unassisted nature. 
 
 It is a rare thing for a polypus uteri to escape spontaneously 
 through the vulva, either because they remain stationary, after grow- 
 ing to a certain size in the vagina, or because they are extirpated by 
 the surgeon before they become large enough to pass out; or, finally, 
 because the patients commonly die with the floodings or sero-puru- 
 lent discharges; but we may see that, on different occasions, a large 
 polypous tumour has been seen depending betwixt the thighs, and 
 pretty closely resembling a complete prolapsus, or more especially 
 an inversion of the womb. 
 
 The existence of a polypous tumour in the womb is not necessarily 
 an obstacle to conception, gestation, or even accouchement at term. 
 Levrett relates three cases, that remove all doubt upon this point. 
 One of them fell under his own observation, and the other two are 
 cited from Boudon and Thoumain. In the two first cases, the preg- 
 nancy was quite natural, and what is most remarkable is, that during 
 its entire continuance, the polypus disappeared, and did not reappear 
 until after her delivery. In Thoumain’s case, the tumour caused the 
 woman to miscarry, which is the most general result. Dr. Huguier 
 aggrege et prosecteur of the Faculty, and one of the most distin- 
 guished young physicians of Paris, informed us that a girl, eighteen 
 years of age, who, notwithstanding she had a polypus attached to 
 the os tineas, which projected into the vagina, was married and 
 became pregnant. As the tumour incommoded her considerably, and 
 
 * Baudelocque saw a case of polypus uteri retained in the vagina, and of so large a 
 size as to fill the entire cavity of the pelvis, and push up the womb- as high as the 
 umbilicus. (Recueil. Period, de la Soc. Med., t. iv. p. 137.) 
 
 f Mem. de l’Acad. de Chir., t. iii. 
 
396 
 
 POLYPUS OF THE WOMB. 
 
 excited her fears as to her confinement, she decided upon allowing it 
 to be removed, which she had always refused to do before. The 
 section of the pedicle, which was done with a bistoury, was followed 
 by a very slight haemorrhage, but the woman miscarried the day 
 after the operation. The physician who attended this woman, who 
 lives near Paris, told M. Huguier that she is now (January, 1838,) 
 perfectly well. 
 
 [The American Journal of the Medical Sciences for October, 1843, at p. 
 519, contains the history of a case as follows : “The spontaneous expulsion 
 of a large polypus, two days after the delivery of a fine healthy male child; 
 by John Davis, M. D., of Smithville, Abbeville District, South Carolina. 
 
 “May 22d, 1843, I was summoned to Mrs. C , set. thirty-two. 
 
 When I arrived, I found her to have been in labour twelve hours, with her 
 fifth child. The presentation was natural, and the soft parts well dilated; 
 the pains were, and I was informed had been, pretty strong for three hours 
 previous to my arrival, yet they were irregular, intermitting and of little 
 effect. She was greatly exhausted by the continuance of her sufferings and 
 the violence of her exertions.” The relator proceeds to say that the patient 
 after flooding and great debility, “ was delivered of a large healthy male 
 child. The after-birth seemed to be slightly adherent, but was soon deli- 
 vered, with little difficulty and without much haemorrhage. In short, all 
 things seemed to do well, excepting the uncommonly severe after-pains, which 
 led me to place my hand over the abdomen, when I was a little surprised to 
 find it but slightly diminished in size, especially immediately over the region 
 of the womb. This led to a still further examination, per vaginam, and, to 
 my utter astonishment, 1 discovered a large resisisting tumour firmly im- 
 pacted in the uterus. Satisfying myself as to its character, I did not examine 
 as to its location, as the soft parts were very tender to the touch, and as the 
 patient was very much enfeebled ; nor was it necessary, as that was not the 
 proper time to search for a pedicle or neck, or, if its location were ascer- 
 tained, to apply the ligature.” The Doctor, having given such directions as 
 seemed proper, left his patient doing well, but was recalled hastily, “late in 
 the afternoon of the day following;” but before he arrived, “she was sponta- 
 neously delivered of a polypus, weighing eleven ounces, without the slightest 
 haemorrhage. 
 
 “The polypus is now in my possession ; its pedicle or stem is about an 
 inch long, and about two in circumference ; it is similar to a fungous'excre- 
 scence, and is covered by a thick membrane ; it is full of large veins and 
 arteries, some of the former being varicose.” 
 
 The relator says, “this is the 19th of June, and the lady has recovered 
 entirely.” 
 
 I presume there can be no doubt as to the authenticity of this case, and I look 
 upon it as a most interesting one, seeing that it exhibits an amazing example 
 of the power of the reproductive organ to tolerate what might, a priori, be 
 
POLYPUS OF THE WOMB. 
 
 397 
 
 regarded as an intolerable burthen, the weight, to wit, of the tumour, together 
 with the ovum and its contents. It is highly probable that the development 
 of the tumour must have proceeded at a great rate during the latter months 
 of the gestation. — M.] 
 
 The symptoms of the non-pediculated fibrous tumour, or fibrous 
 body of the womb, are not so marked as those of the polypus, 
 because they produce less disorder in the menstrual atid other func- 
 tions of the organ. The sub-peritoneal fibrous tumour, especially 
 a small one, yields no sign of its existence ; it only becomes evident 
 when it has attained to a certain magnitude. By resorting to th£ 
 sur-pubal palpation, we may perceive an indolent tumour, of a cer- 
 tain size, of a roundish shape, and which projects either in the mid- 
 dle, or to one side of the belly. The patient, has an uneasy sensation 
 in the abdomen, which is aggravated by any sudden movement. 
 But we ought to state that these signs are insufficient to distinguish, 
 ll priori, the sub-peritoneal fibrous tumour from the other kinds of 
 tumours that may happen to exist in the pelvis, such as a scirrhus, 
 or an encysted dropsy of the ovary. However, a mistake in the 
 diagnosis can by no means prove prejudicial to the patient; for in 
 these cases, all that the medical attendant has to do, is to remain a 
 mere spectator of the events of the case, confining himself to the 
 administration of a palliative treatment. 
 
 Fibrous tumours in the parietes of the corpus uteri, especially 
 small ones, may also exist without exhibiting any signs of their pre- 
 sence ; yet in most cases, we are enabled to determine the question 
 as to their existence, with considerable precision. In fact, by ex- 
 ploring the lower part of the abdomen, a tumour may be felt, which 
 grows daily in size so as to rise in some cases above the umbilicus. 
 By fixing this tumour firmly with the left hand pressed upon the 
 hypogastrium, and carrying the index finger into the vagina, so as 
 to enable us to push the tumour suddenly upwards, the impulse is 
 communicated to the other hand ; if, on the contrary, the tumour 
 being pushed by the left hand from left to right, we perceive a cor- 
 responding movement, but from right to left, it indicates that the 
 tumour is continuous with and part of the womb itself. 
 
 A non-pediculated fibrous body situated upon the vaginal surface of 
 the neck is much more easily recognized, for it may be detected by 
 means of the speculum, as well as by the Touch. However, it should 
 be observed that considerable obscurity may attend the diagnosis 
 whenever the tumour, instead of occupying the surface, is deep-seated. 
 In such a case it happens that the woman merely complains of an 
 uneasy sensation, as if produced by a foreign body in the vagina; 
 but this foreign body, which may become of considerable size, really 
 consists of the cervix itself enlarged at some particular point, or in 
 several places at once : let it be also remarked, that women who are 
 still regular, and who are affected with fibrous tumour of the sub- 
 stance of the womb, are generally subject to sanguineous and leucor- 
 rhoeal discharges, more or less profuse in different instances, and that 
 they are commonly remarkable for the paleness of their complexion, 
 
398 
 
 POLYPUS OP THE WOMB. 
 
 and a peculiar bloat, accompanied with languor ; some of them re- 
 cover their healthy and fresh colour, and look as they did before the 
 attack, and indeed feel nothing more than the uneasy sensations due 
 to the presence of the tumour. 
 
 The differential diagnosis of various conditions of fibrous polypus 
 of the womb have been already pointed out. We shall now proceed 
 to speak of the affections that may be confounded with them, and 
 which have heretofore led to the most serious mistakes. 
 
 A fibrous tumour, contained within the womb, may lead to the 
 supposition of pregnancy, the more readily, as it frequently happens 
 that the enlargement of the abdomen, and the tumefaction of the 
 breasts, are conjoined with numerous sympathetic phenomena that 
 attend the state of gestation. This mistake may be avoided by recol- 
 lecting that the enlargement of the -abdomen proceeds much more 
 rapidly in pregnancy ; that in the case of polypus uteri, there is no 
 ballot tement ; that the use of the stethoscope discloses neither the 
 pulsations of the foetal heart nor those of the placenta ; and lastly, 
 that the health of the patient undergoes changes that belong not to 
 the gravid female in true pregnancy. 
 
 An incomplete prolapsion of the womb may be readily distin- 
 guished, inasmuch as the tumour formed by the womb has its apex 
 or smallest end downwards, while the contrary obtains in the poly- 
 pus; besides, at the lower end of the tumour, we find the os uteri, 
 which admits of the introduction into it of the finger, or a bougie, or 
 a stilet. 
 
 A polypus that has descended betwixt the labia pudendi has like- 
 wise been confounded with the complete descent of the womb. To 
 avoid such a mistake, it is only necessary to be aware, that in this as 
 in the preceding case, the tumour composed of the womb is smaller 
 below than above ; that it is painful, reducible, and has a transverse 
 slit which is the orificium uteri. 
 
 Polypi have also been confounded with complete and incomplete 
 inversion of the womb. In incomplete inversion the neck is found 
 to be partially dilated, and we may feel within it a rounded sphe- 
 roidal tumour. Though this be true of the polypus beginning to 
 pass through the os tineas, the tumour exhibits a different character 
 in the two cases; for, when the womb is incompletely inverted, we 
 may reduce, or rather we may make the tumour wholly disappear 
 by pushing it upwards. If it be a polypus, then, instead of disap- 
 pearing under pressure of the fingers, the tumour continues to retain 
 the same volume and preserve the same convexity. It is proper 
 also to distinguish betwixt the surface of the uterus, and that of a 
 polypus. The superficies of a polypus, which is insensible, is al- 
 ways firm, and sometimes smooth, sometimes uneven and lumpy. 
 On the other hand, the superficies of the inverted womb is velvety, 
 soft, and very sensitive. Herbiniaux says, that the inversion of the 
 womb is not attended with floodings nor purulent discharges, 
 whereas they always are present in the case of polypus. We have 
 moreover, to add, that in inversion of the womb, the finger will not 
 pass more than a few lines upwards betwixt the tumour and the 
 
POLYPUS OF THE WOMB. 
 
 399 
 
 neck ; and that the hypogastric palpation shows the cavity of the 
 pelvis to be almost empty, but where there is polypus, the womb 
 may be readily felt. Finally, Malgaigne has proposed an ingenious 
 mode of completing the diagnosis, which consists in introducing a 
 male catheter into the bladder, so that the point, when directed back- 
 wards and downwards, until it rests on the fundus of the inverted 
 organ, communicates the sense of touch to the index, finger intro- 
 duced into the vagina, and pressed upon the opposite surface of the 
 organ. 
 
 A complete inversion of the womb may so much the more easily 
 be mistaken for a polypus, inasmuch as the tumour being swollen 
 inferiorly presents all the appearances, and the shape of the polypus. 
 Yet, an attentive examination will always obviate the risk of mak- 
 ing such a mistake. It is only requisite to know, that the pedicle of 
 the polypus is long, slender and solid, while the contracted portion 
 of the inverted womb is short and of a soft consistence. Besides, it 
 ought not to be forgotten, that in inversion, the tumour, which is red, 
 or of a reddish brown colour, is painful to the touch, easily reducible, 
 and always leaves, after its descent, a void above the pubis : a poly- 
 pus, which, as we have already stated, is hard, insensible, and of a 
 whitish-yellow colour, cannot return into the vagina without exciting 
 severe pain, nor without the greatest difficulty. Where the inversion 
 has been caused by the presence of a polypus, there will be found two 
 tumours, one above and the other below ; above the lower tumour 
 we may feel the pedicle of the polypus, which is attached to the 
 fundus inverted; in fine, a vaginal hernia, a cancer uteri, may also 
 simulate a polypus, but the softness, the shape, and the reducibility 
 of the tumour in the former case, its irregularity, its being ulcerated, 
 and the lancinating pains that attend it, in the latter, ought to suffice 
 to dispel all doubts on the subject. 
 
 The prognosis of fibrous tumours of the womb, although in general 
 serious, differs according to their situation, and the symptoms to 
 which they give rise. Those that form beneath the peritoneum, or 
 within the parietes of the womb, though beyond the power of the 
 physician’s art, are not necessarily mortal ; for women have been seen 
 to reach an advanced age, with very tolerable health, though affected 
 in this way for years. 
 
 The polypi that remain within the uterine cavity, are generally 
 more serious than those that escape from the orifice, and become, in 
 that way, accessible to the hand of the surgeon. Notwithstanding 
 it is true, that the removal of a polypus has in some instances caused 
 the death of the patient, it has most generally been followed by her 
 cure. We add that the gravity of the prognosis is augmented by 
 the simultaneous presence of several distinct polypous tumours, and 
 that those that grow from the canal of the cervix and from the os 
 tincae, are never so dangerous as the other species. The rare cases 
 in which a cure has followed the spontaneous disruption of the neck 
 of the tumour, or its passing into gangrene, offered the happiest ter- 
 mination of the disease. Lastly, ‘the size of the pedicle, the volume 
 of the polypus, the age of the tumour, its degeneration into cancer, 
 
400 
 
 POLYPUS OF THE WOMB. 
 
 and especially, the general state or condition of the patient, modify 
 the prognosis, so as to render it more or less unfavourable^ 
 
 The treatment of fibrous polypus of the womb is either palliative 
 or curative ; tumours situated within the cavity of the organ, in its 
 proper texture, or on the peritoneal surface, require nothing beyond 
 palliative measures ; for example, hemorrhage must be checked by 
 means of rest, by a horizontal posture and the use of astringent in- 
 jections. The patient should be supported by an analeptic regimen, 
 and by tonics, particularly the bark, bitters and antiscorbutics. Un- 
 married patients should decline the marriage tie ; and those who are 
 already married should, by all means, avoid becoming pregnant ; for 
 the life and that of the child of such a person would be exposed to 
 the greatest danger. 
 
 Before we proceed to speak of the surgical treatment of the poly- 
 pus, it is proper to mention, that where such a tumour, although still 
 retained within the uterine cavity, has begun to show itself at the 
 orifice and given rise to expulsive and dilating pains, its escape might 
 be advantageously assisted by means of the secale cornutum ; as has 
 been successfully attempted in a case, for which see The Lancet, 
 vol. i., Lond. 1828. 
 
 The surgical measures that have been proposed for the removal 
 of polypus uteri, when accessible to the operation, consist in the 
 cauterization, avulsion, crushing, torsion, ligature or excision of the 
 tumour. 
 
 The application of the actual cautery, as advised by Hippocrates,* 
 for the destruction of nasal polypus, as well as the cuth&'ctique sub- 
 stances made use of with the same view by Celsus,f and, according 
 to the report of Galen, by Philoxenus, Antipater, Ant. Musa,± and 
 also by Scribonius Largus,§ Aetius,|| Alexander Trallianus,1f and 
 other physicians of a remote antiquity, was never resorted to in the 
 treatment of the cases of uterine polypus mentioned by those prac- 
 titioners. As this operation appears to us equally dangerous and 
 inefficacious, particularly for the purpose of destroying the fibrous 
 polypus, we shall make no further mention of it. 
 
 We shall also say but little as to the practice of torsion, or that of 
 avulsion of the polypus, inasmuch as we have already treated of 
 them at page 387, and also for the reason, that these methods, 
 •whether made use of separately or together, are unsuitable for the 
 treatment of the fibrous polypus, being adapted only for the vesicular or 
 cellulo-vascular kind, which are of small size, of a soft consistence, 
 and have a slender and very friable pedicle. Let us merely add, 
 that this mode, successfully used by Boudon,** Mess. Recamier, Lis- 
 
 * Hippocrates de morb., lib. iii. p. 471., de effect., p. 517. 
 
 f Lib. vi. cap. viii. t. ii. p. 61. 
 
 $ Galen de compos, med. sac. loca., lib. iii. 
 
 § De composit. med. cap. 9. col. 201. collect. Stephan. 
 
 ]j Tetrabib. ii. serm. 2. cap. 92. 
 
 ^ Lib. iii. cap. 8. p. 206. Translation by J. Gaultherius, of Andernach. (24!) 1544. 
 
 ** Levret (loc. cit.) relates that Boudon, after having in vain attempted to put the 
 ligature on a polypus as large as a cricket-ball, which was implanted in the fundus 
 uteri, twisted it off with his fingers, and thus effectually extirpated it. Lapeyronie 
 
POLYPUS OF TIIE WOMB. 
 
 401 
 
 franc, and other practitioners of the present day, was not recom- 
 mended by Dionis or Heister, except in nasal polypus, and not for the 
 fibrous polypus uteri, an opinion that meets the approbation of 
 nearly all the modern writers. 
 
 The crushing process was brought into use by M. Recamier, who, 
 finding it impossible to apply a ligature, or to excise a polypus with 
 the treatment of which he was charged, broke it to pieces with hook 
 forceps, and with his fingers. In another case he divided the tumour 
 into two parts by pressing the index finger against it, and then re- 
 duced it to a pulpy consistence with his hand, so that he extracted it 
 in less than two minutes. In another instance, this distinguished 
 practitioner, in consultation with Professor Dupuytren, made use of 
 the combined methods of crushing and avulsion, proceeding as in the 
 management of a case of nasal polypus. The latter appears to me 
 preferable to the two before-mentioned procedures, and should be 
 resorted to in certain cases, where we can neither succeed in adjust- 
 ing the ligature, nor in amputating the root of the tumour. 
 
 The ligature of polypus uteri, and also the operation by excision, 
 were recommended by JPhilotenus, (loc. citat.,) who, according to the 
 historical researches we have made on this point, is the only ancient 
 author by whom it has been mentioned. Where the works of Hip- 
 pocrates, and those of the Arabians, allude to the subject of polypus, 
 it is always to nasal polypus that they refer ; the ligature, employed 
 solely in this case, was improved many centuries afterwards by 
 Salvid Fallopias, but it is to Levret that really belongs the merit of 
 having employed it in the cure of polypous tumours of the womb, 
 and of having invented some very ingenious instruments in 1742, 
 for the purpose of adjusting the ligature upon the tumour. Dr. Her- 
 biniaux, a physician at Brussels, was not satisfied with Levret’s 
 direction as to the application of the ligature to the polypus after its 
 descent into the vagina only, but positively directs it to be applied 
 even to the tumour, while still contained within the cavity of the 
 womb. Several other surgeons, among whom we may mention the 
 names of Theden, Lecat, David of Rouen, Brasdor, Dessault, Nys- 
 ten, Clarke, Laugier, Loefier, Cullerier, Bouchetof Lyons, Mayor, of 
 Lausanne, Paul Dubois, and many others quoted by Meisner in his 
 Treatise, have also invented instruments for tying the polypus uteri. 
 As those of Dessault are generally employed by practitioners at the 
 present time, and as they are moreover suitable in all the varieties 
 of the case, we shall confine ourselves to a description of that dis- 
 tinguished surgeon’s method. 
 
 Dessault’s instruments are three in number ; 1, a port-knot forceps, 
 which consists of a bifurcated steel rod, whose branches terminate 
 each in a half ring, which, when brought together, are converted 
 into a complete ring. This rod slides within a silver canula, so that 
 the two branches of the steel rod may be brought together, or sepa- 
 
 also menlions a case of polypus torn off in the same manner By a midwife. The 
 patient, who was sixty years of age, recovered very well; although the avulsion was 
 performed with the design of reducing a prolapsed womb, for which the tumour was 
 mistaken. 
 
 26 
 
402 
 
 POLYPUS OF THE WOMB. 
 
 rated by moving the rod forwards or backwards in the canula. The 
 canula, which is two inches shorter than the rod, is itself five or six 
 inches in length, and has a notch at the lower end. 2d, a port-knot 
 canula , about seven inches in length, slightly curved for the purpose 
 of adapting it to the convexity of the polypus, and having two rings 
 at one end, while the other terminates in a blade. 3d, a knot-tyer , 
 which consists in a steel or silver rod of a given length, with a ring 
 at one end, fixed at right angles to the rod, while at the other end, 
 which is flat, there is a longitudinal slit for receiving the ligature. 
 For use, these instruments are to be arranged as follows : in the first 
 place, the canula of the port-knot forceps is to be pushed forward 
 until the semicircles unite into a complete ring ; through this is to 
 be passed one end of a strong waxed ligature two feet long; the end 
 of the ligature is then fixed in the notch at the end of the steel rod ; 
 the other end of the ligature is carried through the port-knot canula, 
 and secured to one of the rings. Before proceeding to operate, a 
 jointed speculum uteri ought to be provided, as well as some small 
 fine sponges, several napkins, some sweet oil, and several ligatures ; 
 all things being thus prepared and arranged as above mentioned, we 
 proceed to the operation in the following manner. 
 
 The patient having been placed on the bed, in the same manner 
 as for the application of the speculum, and after having again ascer- 
 tained, both by touching and by inspection, the position of the poly- 
 pus, the thighs as well as the labia are to be separated by assistants, 
 while the port-knot forceps and canula are both introduced by the 
 surgeon, who holds them close to and parallel with each other, pass- 
 ing them upwards between the parietes of the vagina and the tumour, 
 and, if necessary, betwixt the tumour and the womb. Having reached 
 the highest point of the pedicle, he detaches the end of the ligature 
 which was secured in the ring of the canula, which he takes hold of 
 with the right hand, while with the left hand he keeps the port-knot 
 forceps steady in its place. He next carefully encircles by the uterine 
 extremity of the canula, the entire circumference of the pedicle, so as 
 to enclose it, by bringing the canula round close to and parallel with 
 the forceps, which had been kept unmoved in its place. Changing 
 hands as to the two port-knots, the canula is now moved by the left 
 hand outside of the forceps, whence it follows, that the two ends of 
 the ligature are crossed in such a way that the one in the canula 
 being retained by the other, the canula may be withdrawn with- 
 out any fear of deranging the other loop of the ligature. Lastly, 
 having next untied the end that was attached to the forceps, it is 
 united with the other so as to pass them both together through the 
 opening of the knot-tyer, which is pushed in as far as the pedicle, 
 while the surgeon tightens the two ends so as to make the loop 
 gradually close upon the polypus ; when it is deemed that the con- 
 striction is sufficiently great, the two ends of the ligature are to be 
 secured at the slit in the knot-tyer, to prevent them from relaxing the 
 hold This being done, the operation is concluded by securing the 
 knot-tyer to one of the patient’s thighs with a bandage. 
 
 For the purpose of more readily adjusting the ligature to the 
 tumour, and particularly with a view to simplify the process by 
 
POLYPUS OF THE WOMB. 
 
 403 
 
 making use of a single instrument, the au- Fig. 40. 
 
 thor invented a port-knot forceps, which 
 he has denominated the polypodeon,* and 
 which consists of two blades eight inches 
 in length, and mounted like those of the 
 common dissecting forceps, but provided 
 with a very broad extremity, shaped like 
 a spoon, and with a slide to approximate 
 the ends by moving a rod lodged be- 
 twixt them. This rod also serves to 
 carry forward a port-knot — (port-loop) 
 between the blades, and beyond the 
 uterine extremity of the instrument, arm- 
 ed with a simple loop of the ligature, 
 arranged as in the fig. 40, annexed. The 
 ends of the ligature are passed^ from 
 within outwards through the holes and 
 in front of the little pullies at the end of 
 the stems of the port-loop. Every thing 
 being arranged as above, (see the figure,) 
 the end of the forceps is to be carried up 
 along the sides of the polypus, and, by 
 pushing forward the central rod by the 
 ring, the tumour will be grasped at the 
 same time that the port-loop will be car- 
 ried up to its pedicle, that is to say, to 
 the point to which it is designed to affix 
 it. Should the tumour be found too 
 large, the carrying forwards of the loop 
 would be much facilitated, by pulling 
 separately and alternately upon the ends 
 of the ligature, until it reaches, upon the 
 pedicle, the point on which it is desirable 
 to affix it. When this is done, which is 
 generally an easy task, both ends of the 
 ligature are to be pulled so as moderately 
 to compress the pedicle : in the next 
 place, the central rod, which moves the port-knot, is to be retracted, 
 which will withdraw both the port-knot and the branches of the for- 
 ceps, so that the whole instrument being now completely opened 
 again, is removed from the vagina, leaving the pedicle secured in 
 the loop. 
 
 For the purpose of completing the strangulation of the pedicle, we 
 make use of an instrument, consisting of a number of small tubes, 
 each about eight or ten lines in length. To make use of this jointed 
 constrictor, {vide jig. 41,) we twist the two ends of the ligature 
 into a single cord, and then, having passed the cord through as 
 many of the tubes as may be necessary, we secure it to a small 
 
 * From the Greek ttoXi/ttouc, polypus and tew from the verb tet» I tie. 
 
404 
 
 POLYPUS OF THE WOMB. 
 
 tourniquet, which enables us to 
 tighten the noose at pleasure. A 
 long large-eyed needle, or a bodkin 
 may be used to pass the cord more 
 expeditiously through the tubes, or 
 a piece of wire, bent into a hook at 
 one end, may serve to thread the 
 tubes with. 
 
 This instrument, which we con- 
 structed ten years ago, and which 
 we supposed to have been original, 
 is very analogous to one that a rich 
 citizen of Cologne, M. Roderick, 
 invented for the purpose of tying a 
 polypus, which some of the Brus- 
 sels surgeons, and even the cele- 
 brated Levret could not extract for 
 him. This knot-tyer, en chapelet , 
 which was used by its inventor in 
 his own case with success, is pre- 
 cisely like that which M. Mayor, of 
 Lausanne, supposed himself to have 
 invented for the same use, some years ago. The constrictor en 
 chapelet of M. Bouchet, of Lyons, and that by M. Levanier, of 
 Cherbourg, are likewise nearly similar to Roderick’s, a drawing of 
 which may be seen in plate 87, fig. 9, of the surgical part of the 
 Encyclopedic Methodique, edited by de Laroche, and Petit-Radel 
 in 1790. 
 
 Whatsoever be the method of applying the ligature, it ought to be a 
 rule to draw it only moderately tight at first, for the purpose of avoid- 
 ing the bad consequences that might follow a too sudden and violent 
 strangulation of the pedicle. It should be afterwards gradually tight- 
 ened so as to cut off the vascular communication between the poly- 
 pus and the womb, and thus cause the tumour to fall off. The sepa- 
 ration takes place at the very point of contact of the ligature, and 
 not at the insertion of the pedicle into the womb, as was supposed by 
 Levret.* That celebrated practitioner, and since his day, Segard,t Gar- 
 dien4 and M. Gensoul, a very distinguished surgeon at Lyons, main- 
 tained the notion that a polypus, like the umbilical cord of a new- 
 born child, is detached at the point of origin, whatsoever may 
 have been the point at which the ligature is made. Although this 
 doctrine, which has been sustained by several cases, published 
 by Levret, Segard, and M. Gensoul, urges nothing contrary to the 
 laws of the animal economy, both Boyer and Dupuytren, whose 
 chirurgical opinions are of such great authority, look upon it as dan- 
 gerous, and admissible only in cases where the ligature has been 
 
 Fig. 41. 
 
 * Jour. m6d., t. xxxii. p. 536. 
 
 f Dissertation inaugur., Nov. 12, Paris. 
 
 * Trait6 d’accouchement, &c., t. i. p. 460. 
 
POLYPUS OF THE WOMB. 
 
 405 
 
 affixed very close to the point of insertion. Though the porlion that 
 is below the ligature falls off, that which is above it often continues 
 to live, to grow, and even to reproduce the tumour. 
 
 Where the pedicle is very slender, it sometimes happens that the 
 ligature cuts through it, the moment it is applied ; but, in general, 
 the tumour does not separate until the fifth or sixth day. In a case, 
 reported by Leblanc, the fall of the tumour was put off for three 
 months. In any case, where there should happen to be an attack of 
 violent pain, attended with sleepiness, agitation, tumefaction of the 
 belly, and intense fever, haste should be made to relax the ligature 
 and not to tighten it again, nor even to apply a new one, provided it 
 be wholly removed, until all the symptoms are completely relieved, 
 either by the relaxation of the ligature merely, or under the influ- 
 ence of baths, injections, emollient applications, or bleeding, whether 
 general or local, which ought to be had recourse to, provided they be 
 indicated by any inflammatory movements. The application of a 
 ligature to polypus uteri, has been seen to produce metritis and peri- 
 tonitis* almost invariably of mortal violence. 
 
 In case the pedicle be hard and of a large size, the first attempts 
 at strangulation do not immediately interrupt the circulation between 
 the womb and the tumour. The latter swells, becomes violet-coloured 
 or blackish; its superficial vessels becoming distended with blood, 
 burst and give rise to haemorrhages that are followed by horribly fetid 
 discharges, the contact of which irritates the genital passages, and 
 may, by their resorption, give rise to fever of a pernicious character. 
 For the purpose of avoiding, or at least, of diminishing the troublesome 
 consequences of the ligature, care should be taken to make frequent 
 use of emollient injections into the vagina, and afterwards, to order 
 injections of bark, or what is still better, injections composed with 
 chlorur. of the oxid. of sodium, diluted with water. Provided these 
 measures should not succeed in lessening the bad symptoms, and par- 
 ticularly in case the pedicle of the tumour could be easily got at, or 
 where, by drawing it gently downwards, it could be brought within 
 reach of the instrument, we ought unhesitatingly to remove, by an 
 incision, either with the probe-pointed bistoury, or the scissors, the 
 whole of that portion of the mass below the ligature. 
 
 The separation of the polypus, which is known to be complete by 
 the coming away of the knot-tyer, with the ligature unbroken, is fol- 
 lowed by a purulent discharge, which yields to the use of the bath, and 
 the common precautions as to cleanliness. In some instances, how- 
 ever, the nervous symptoms, the nausea and vomiting, the pain, and 
 the inflammatory symptoms that often accompany the adjustment of 
 the ligature, continue to be felt even after the removal of the tumour. 
 Notwithstanding the disagreeable circumstances now set forth, as 
 producible by the use of the ligature, we agree with Drs. Siebold and 
 Mayer of Berlin, that it is to be preferred to all the other operations: 
 1 , where we can feel the pulsation of an artery in the substance of 
 the tumour : 2d, where the pedicle is so large as to give reason to 
 fear that it may comprise some large blood-vessels ; but, ill a case of 
 
406 
 
 POLYPUS OF THE WOMB. 
 
 this sort, we think that the tumour should be cut off below the liga- 
 ture, provided it should prove to be too long in separating the poly- 
 pus, or give rise to any of the accidents we have spoken of; in 
 fine, we look upon the ligature as preferable to all other means, in 
 cases where the excision of the pedicle appears to be too difficult of 
 execution ; or where the woman is so much reduced and anaemic as 
 to make us fear the smallest loss of blood. It should be mentioned, 
 that the use of the speculum is of the greatest advantage in most of 
 the operations required for the cure of polypus uteri. 
 
 In consequence of the serious objections to the ligature, and the 
 terrible accidents that sometimes follow its application, M. Dupuytren, 
 and most of the modern practitioners, prefer to remove the pedicle 
 by means of the knife. This preference of excision, as a general 
 method, is fully justified by the anatomical character of the fibrous 
 polypus; for, in fact, M. Hervez de Chegoin (loc. cit.) has proved 
 incontestably, that the pedicle of the tumour is formed at the expense 
 of a layer of the uterine tissue, and that the ligature is generally affixed 
 upon this very layer of muscular tissue, evidently furnished by the 
 womb itself, and whose strangulation gives rise to the symptoms we 
 have described. Hence it may readily be conceived that the section of 
 the pedicle, though it take effect also upon this muscular layer, does 
 not give rise to the bad symptoms, because the cutting instrument 
 acts promptly and instantly, instead of after the slow, continuous, and 
 irritating mode of the ligature; and it produces a simple wound from 
 which nothing is to be feared, especially when we reflect upon the 
 number of cases where the os uteri has been amputated, without any 
 immediate symptoms being occasioned. • 
 
 The excision of a uterine polypus is as simple as it is facile ; the 
 operation, which was adopted exclusively by Dupuytren, and had 
 been recommended by Philotenus, and Moschion, (de mul. affect.) 
 and also successfully practised, according to Levret, by Tulpius, Va- 
 ter, and Frouton, is to be performed in the following manner. 
 
 The patient being placed in the same position as the one recom- 
 mended for the operation with the ligature, the surgeon introduces 
 the jointed speculum, in order first to reconnoitre the tumour, and 
 then to seize it more, effectually in a Muzeux forceps: he then tries to 
 draw it downwards very gently and carefully, exhorting the woman, 
 at the same time, to bear down as in labour. As soon as the pedicle 
 of the polypus becomes accessible, it is cut off with a pair of scissors, 
 curved on the flat, or with a long probe-pointed bistoury, that is 
 somewhat curved both on the flat and edge. Provided the tumour 
 should be found to be soft, and easily torn, the surgeon, in imitation 
 of M. Lisfranc, might seize the cervix itself and pull the uterus in 
 this way downwards, until the operation is concluded. 
 
 For the purpose of getting a firmer hold, and of more easily draw- 
 ing down the polypus, without being obliged to make use of two 
 Muzeux forceps at once, which is not only inconvenient but hazard- 
 ous, and likewise to avoid the necessity of making use of the for- 
 ceps, as advised by Iierbiniaux, Deneux, Murat, Lobstein, Ilervez 
 
/ 
 
 POLYPUS OF THE WOMB. 
 
 407 
 
 de Chegoin, and other authors, an inconvenient 
 and difficult operation, we make use of our quad- 
 ruple erigne, the uteroceps, {see adjoining figure, 
 which needs no explanation ,) which seizes the tu- 
 mour circularly, and never interferes with, nor 
 masks any of the manoeuvres, because the hand 
 that holds it is always placed opposite to the peri- 
 neum. 
 
 Where the polypus resists steady traction, instead 
 of letting it go up again, we hold it down at the 
 same point by giving the quadruple erigne to an 
 assistant. Proceeding along the superior and con- 
 vex surface of the tumour, we then, with the right 
 hand, carry up our probe-pointed bistoury, which 
 is curved both on the fiat and edge, so as to reach 
 and divide the pedicle at its most contracted point ; 
 always guiding the instrument by the left index 
 finger. 
 
 Where the polypus is a small one, we first bring 
 it into view with the speculum uteri, and then, 
 seizing it with our forceps, we withraw the specu- 
 lum, and pulling the tumour down far enough, cut 
 it off. With a view to prevent the patient from 
 suffering unnecessary pain, and to perform the 
 operation with greater rapidity, the pedicle might 
 be divided with the sickle-shaped knife, which we 
 make use of in exscinding at the bottom of a specu- 
 lum the small fungous vegetations that are occasionally 
 to be found growing upon the os tincae. ( Vide the fig. 
 38 .) 
 
 42 . 
 
 Fig. 43. 
 
 In a case where the tumour should prove to be too 
 large to pass readily through the external organs, which 
 is, however, a rare occurrence, it might become necessary 
 to enlarge the orifice by cutting through the perineal 
 membrane, the fourchette. Or the tumour, as in Be- 
 dard’s case,* might be divided into two equal longitudi- 
 nal portions, and removed from the vagina in succession. 
 
 Lastly, where the root of the tumour is still concealed 
 within the uterine cavity, the surgeon might try the semi- 
 inversion, recommended by Baudelocque, for it is well 
 known, that to such a partial inversion of the womb, 
 lasting but for a few moments, there is attached no 
 other inconvenience than that of being, in the case of 
 a virgin, or a woman who has never had children, very 
 difficult, or even impracticable. Under such circum- 
 stances recourse might be had to the ligature, or to the 
 division of the circle of the os uteri itself, by means of the bis- 
 
 * Acad, de Medecine, Jan. 27, 1825. M. Chasagnac, in a similar case, success- 
 fully removed a large fragment of a wedge-shape, from a fibrous polypus. 
 
 / 
 
408 
 
 POLYPUS OF THE WOMB. 
 
 toury, according to the plan practised by Dupuytren and Hervez de 
 Chegoin. The former of these surgeons, in two cases of the sort, 
 made one incision into the posterior part of the cervix, and one on 
 each side, after which the polypous tumours were extracted easily, 
 and with complete success in both cases.* 
 
 Should the polypus have contracted adhesions to the vagina, they 
 ought to be loosened gradually, by means of scissors bent on the flat, 
 before drawing down and cutting off the pedicle. Lastly, should the 
 case be one in which the polypus is separated from the surface from 
 which it springs by a deep or a shallow fissure, or by a very short 
 and thick pedicle, the operation need not, on that account, be re- 
 nounced, but even where the pedicle can not be got at, as muph of 
 the tumour as can be got away, ought to be removed, as was suc- 
 cessfully done by M. Lisfranc ; for a number of instances exist, that 
 go to show that the part left after the operation becomes detached, or 
 undergoes a process of suppuration. In imitation of the example 
 set by M. Recamier, we might likewise divide, by a longitudinal in- 
 cision, the layer of muscular tissue that envelops the morbid fibrous 
 material, and then detach or eradicate the latter with the fingers or 
 with a scalpel handle, just as a kernel is taken out of the fruit that 
 encloses it. The ragged membranous laminae that are left by this 
 process of enucleation, retract and heal over as they return to their 
 natural situations, or they are partially lost in the suppurative opera- 
 tions that ensue. It is right to remark, that when a polypus has 
 formed adhesions to the muscular membrane that covers it, there is 
 almost always a vascular connection established, and hence, if the 
 whole tumour is not taken away, the remainder continues to live, and 
 at length requires the performance of another operation, instances of 
 the kind having been reported by various authors, as Herbiniaux 
 and MM. Recamier and Lisfranc. 
 
 The dread of haemorrhage, which had caused the operation by the 
 knife to be rejected in the case of polypus uteri, in universal prefer- 
 ence of the ligature, is not justified, except, perhaps, by the case 
 related by Zacutus Lusitanus,t who died at Amsterdam in 1642. 
 This celebrated Portuguese who, from fear of the Inquisition, migrated 
 to Holland, informs us that a quack, having removed by incision, a 
 polypus of the size of an almond, lost his patient with the haemor- 
 rhage that followed his operation. However this may have been, it 
 ought to be stated that such a serious consequence was never known 
 to follow the numerous operations performed with the knife by Du- 
 puytren. In only a single case, was some special attention required 
 
 * Revue Medicale, tom. ii. p. 382, 1829, and the Nouvelles Elements de path. med. 
 chirurg. of Mess. Roche and Sanson. 
 
 | M. Berat'd ( Dissertations sur plusieurs points d’anaf. pathol. 14 Feb. 1825), cites 
 the case of a polypus having a primitive insertion at the fundus uteri, but which, in 
 consequence of adhesion to the vagina, was attached to the posterior wall of the 
 vagina, as by a second pedicle. Professor Alibert informed qs that he had seen a 
 patient with a double tumour formed in the recto-vaginal septum, part of which came 
 out at the anus and the other part at the vulva; the two portions, having inflamed, 
 cohered, so as to inclose the perineum in a sort of ring. 
 
POLYPUS OF THE WOMB. 
 
 409 
 
 on account of the loss of blood. The case reported by Herbiniaux, 
 Boyer’s, all those convincing ones by MM. Siebold, Mayer, Lisfranc, 
 Idervez de Chegoin, Villeneuve, Velpeau, Lejeune and a number of 
 operations of the same sort, exempt from consecutive haemorrhage, 
 prove how greatly exaggerated have been the fears entertained upon 
 this point. Besides, if the patient should be attacked with haemor- 
 rhage of an alarming character, it could be treated by means of 
 astringent injections, cold applications to the thighs and hypogaster, 
 and in fine, with the tampon, composed of pledgets of lint, moistened 
 with an astringent preparation, or sprinkled with resin, or where that 
 could not be readily procured, with common ashes. 
 
 In a comparison of the ligature with the excision, the advantage 
 always is on the side of the latter. In fact, if on the one hand we 
 reflect that the ablation by the knife is less painful, that the woman 
 is promptly relieved, and that the fears on the subject of haemorrhage 
 are nearly chimerical ;* and, on the other hand, that the ligature 
 produces severe pain, and the fall of the tumour requires a considera- 
 ble lapse of time ; that the ligature must be tightened every day, that 
 the patient must be visited and examined day after day, and, finally, 
 that fatal inflammation may follow the strangulation of the pedicle, 
 and especially that the patient may be affected with nervous and 
 adynamic symptoms, arising from the putrefaction of the polypus 
 and absorption of the fetid discharges ; when we take into considera- 
 tion the inconveniences and advantages on both sides of these surgi- 
 cal measures, we ought not. to hesitate in looking upon the operation 
 by excision as the general rule, and that by the ligature as the excep- 
 tional case. To conclude, let us add, that both operations are to be 
 regarded as inadmissible, where the tumour is wholly enclosed within 
 the cavity of the womb ; where we are assured that it is not single, 
 and where we have ascertained that there are other tumours in the 
 organ, yet not within reach of the chirurgical means of assistance. 
 
 The cares required by patients, subsequently to the operation, con- 
 sist in the exhibition of injections, at first of an emollient, and then 
 of a detergent and slightly tonic quality ; should any inflammatory 
 symptoms show themselves, and particularly, should the patient be of 
 a plethoric habit, we ought to have recourse to venesection, cautiously 
 administered, and to all the antiphlogistic measures, both general and 
 local. Let it also be said that Dupuytren, for the purpose of obvi- 
 ating the irritation and pain that are often found to follow the re- 
 moval of the polypus, established it as a general rule, that the patient 
 should be bled from time to time, in small quantity at each bleeding, 
 provided she had been long subject to floodings, which are entirely 
 stopped by the operation. 
 
 It remains for us to speak of polypus of the vulva and vagina ; the 
 former are easily recognized, and the treatment of them so simple that 
 
 * The ligature may, in certain cases, be followed by haemorrhage; for M. Monfal- 
 con (Diet, cfes Sci. Med.) says that “ M. Dubois was so unfortunate as, on several 
 different occasions, to lose, by rapid haemorrhage, the patients relieved of polypus 
 uteri by the application of the ligature.” 
 
410 
 
 INFLAMMATION OF THE OVARIA AND TUBES. 
 
 it is only necessary to state that they may be met with in practice. 
 The latter, which are quite analogous to those of the womb, but not 
 so generally of the fibrous sort, are readily distinguished by the. touch, 
 which shows that the os tincse, and the entire surface of the cervix, 
 are completely free, and have no connection with the polypous tumour. 
 Any mistake ought to be regarded as out of the question, where we 
 can touch the pedicle and ascertain the precise point of its insertion on 
 some part of the vaginal walls. All we have to say is that the vaginal 
 polypus produces less frequent haemorrhage than polypus uteri, and 
 that the surgical treatment most generally suitable for the case, is the 
 ligature, which may be most easily applied merely by means of our 
 jointed constrictor. — ( Vide fig. 41 , p. 404 .) Where the tumour is deep 
 seated, it should be brought into view with the speculum uteri, 
 taking care to lodge it in the space betwixt the blades of the instru- 
 ment. 
 
 INFLAMMATION OF THE OVARIA AND FALLpPIAN TUBES. 
 
 Of all the disorders of the ovaries and tubes, the most common, 
 beyond doubt, is inflammation, known under the title of ovaritis or 
 oophoritis. Although these organs, do participate, more or less, in 
 the phlegmasias of the uterine tissue, it happens that they may be 
 separately attacked with inflammation of an acute character, or in a 
 subacute or chronic form. But as the ligaments of the womb, the 
 tubes and the ovaries, are closely united, and are, moreover, deeply 
 seated in the abdomen, the signs of inflammation are common to the 
 whole of them ; for it is almost impossible to distinguish which of the 
 parts is the special seat of the disorder. We add, moreover, that the 
 existence of the lesion generally eludes observation until the morbid 
 development of the uterine appendages becomes sufficiently consi- 
 derable to be felt through the parietes of the abdomen. 
 
 An acute inflammation of the ovaries, chiefly met with in young 
 females, is generally produced by laborious parturition, by a suppres- 
 sion of the lochia, an acute puerperal metritis, and especially by an 
 inflammation of the uterine peritoneal membrane. 
 
 The causes which have been considered capable of producing this 
 disorder, independently of the circumstances of the puerperal condi- 
 tion, are, a blow, a fall, a wound and contusion in the iliac region, a 
 degree of nervous sur-excitement, and all the irritations connected 
 with erotic excitements ; and, in fine, whatever causes may serve to 
 give rise to an attack of metritis, such as sudden refrigeration of the 
 body, the suppression of the menses, or a painful menstruation which 
 is difficult and imperfect ; the abuse of emmenagogues ; the use of 
 substances designed to produce abortion, and such exciting articles 
 as are known under the denomination of aphrodisiacs. 
 
 The symptoms of inflammation of the ovaria are : a sense of heat 
 and a pungent pain in either side of the pelvic excavation. Both the 
 touch and inspection disclose a rounded swelling, resisting, and very 
 sensitive to pressure, situated in the part. The swelling and tension 
 
INFLAMMATION OF THE OVARIA AND TUBES. 411 
 
 are propagated over the whole abdomen, and the pain almost 
 always shoots towards the loins, and also extends down the thighs, 
 which are the seats of an extreme degree of torpor and lassitude. 
 The belly, which, in some cases, is pretty supple to the touch, and 
 may remain so throughout the whole progress of the malady, be- 
 comes more and more sensitive as the disease extends; and it fre- 
 quently happens that the lightest touch of the hand gives rise to 
 spasmodic contraction of the features and convulsive motions of the 
 lower limbs. When both of the ovaries are affected at the same 
 time, which is mostly the case, two tumours are produced, at first 
 distinct from each other, but which gradually approach each other, 
 and at length unite into one swelling, under the median line. To 
 these local symptoms are conjoined frequent pulse, heat and dry- 
 ness of the skin, ardent thirst, extreme disgust, violent agitation, 
 difficult and painful expulsion, both of urine and stool ; and, lastly, 
 nausea and vomiting, showing that the stomach sympathizes in the 
 ovarian phlegmasia. We should observe that all the general symp- 
 toms resulting from this disorder, vary not only according to the 
 individual disposition, but also in proportion to the intenseness of 
 the attack and its complication with acute metritis and peritonitis, 
 which so often coexist with acute ovaritis, and particularly with 
 puerperal ovaritis. 
 
 The progress of the disorder, when acute, is about the same as 
 that of an acute inflammation of the uterine tissue itself. It may 
 terminate in resolution, from the eighth to the eleventh day. In 
 such case, the menses return, and the lochia increase in quantity; the 
 pain, as well as both the general and local symptoms, gradually 
 diminish; the tumour, whether single or double, retires, little by 
 little, and at length disappears entirely. A case of acute ovaritis 
 may also prove rapidly fatal, particularly where it is complicated 
 with an attack of puerperal metro-peritonitis, which is itself so fre- 
 quently mortal. This affection may also end in suppuration, from 
 the twelfth to the fourteenth day. Such a termination is indicated 
 by alternate chills and flushings, by softness of the pulse, an increase 
 of throbbing pain, coincidentiy with the lessening of the general 
 symptoms. Where this happens, the pus escapes by different routes; 
 it has been seen to penetrate into the peritoneal sac, and give rise 
 to an attack of peritonitis, which is almost always the cause of a 
 speedy dissolution. We witnessed a case of this kind at Dupuytren’s 
 clinic: Dr. Seymour* also reports a sample of the kind; and M. 
 Andral cites from Brehm (Die. de Med . , in 24 vols.,t. 16) the case of a 
 girl who, after suffering for fourteen days with a severe pain in the 
 right side of the pelvis, was seized, after some time, with all the 
 symptoms of a peritonitis, that soon proved fatal. In addition to the 
 traces of peritoneal inflammation, it was ascertained by the autopsy 
 that the pus which had filled the right ovary had escaped through 
 two large openings into the peritoneal sac. In some instances, it 
 may happen that the acute inflammation, produced by the purulent 
 
 * Illustr. of the Principal Dis. of the Ovaria, p. 40 . 
 
412 
 
 INFLAMMATION OF THE OVARIA AND TUBES. 
 
 collection, shall act in a salutary manner, and cause the formation of 
 adhesions, which, by preventing the pus from spreading itself abroad, 
 allows of its directing itself to the external surface, or to become one 
 of the means of creating an encysted tumour. 
 
 In most cases, the pus is directed towards the colon or the rectum, 
 and, discharging itself into the intestine, at last passes out at the anus. 
 Facts of this kind are stated by Madame Boivin;* by Messrs. Nau- 
 che,t Dnges,f Martin Solon, § and other practitioners. 
 
 The pus may also find issue from the vulva, either by making an 
 opening into the vagina or by passing along the cavity of the Fallo- 
 pian tube. || The pus has also been observed to move towards the 
 iliac region, and open at that point. 
 
 [I saw a case, a few years since, in a young woman, the mother of two 
 children, who, after her confinement with the third, was seized with the 
 symptoms of ovaritis. The malady was most painful, and extended consi- 
 derably into the peritoneum near the left ovary. A hard and extremely 
 painful tumour gradually formed in the lower part of the left iliac region, 
 which fluctuated and pointed. I opened it with a common lancet, and dis- 
 charged near a pint of pus. The purulent discharge continued for many 
 days, but the patient at length recovered her health very completely. I saw 
 a similar collection that attacked a lady affected with carcinoma of the cervix 
 uteri. The discharge was very great, but the abscess was cured. She 
 ultimately died with ulcerated carcinoma uteri. — M.] 
 
 Some cases are met with, in which the purulent product passes 
 into the urinary bladder, and then escapes through the urethra, as in 
 specimens described by Messrs. Murat, Andral and Duges. In fine, 
 acute ovaritis may terminate in gangrene ; but it most generally 
 passes into a chronic form of inflammation, which is known by a 
 marked diminution of all the symptoms. In this case, the engorge- 
 ment of the ovary may be dissipated in the course of time, longer or 
 shorter, or, what much more commonly occurs, the chronic inflam- 
 mation may be indefinitely prolonged, the ovary becoming indurated, 
 scirrhous or cancerous, or undergoing various alterations, which we 
 shall treat of presently, and whose symptoms differ according to their 
 several kinds. But it is quite true, that although the different vital 
 lesions to which the ovaries are exposed, are almost always produced 
 by an attack of inflammation, either acute or chronic, they may yet, 
 in some instances, arise and make progressive developments, inde- 
 pendently of any appreciable signs of inflammation. 
 
 * Recherches sur une des causes de l’avortemen, 1828. 
 
 f Des maladies propres aux femmes, p. 375. 
 
 * Maladies de l’uterus, t. ii. p. 572. 
 
 § Diet, de med. et chirurg., prat. t. xii. p. 416. 
 
 || Iu the fifth case of the Mem. de l’Acad. des Sciences, for the year 1700, is an 
 account of a woman who had never menstruated, and in whom, after death, was 
 found an abscess of the ovary which emptied itself into the vagina along the cavity 
 of the Fallopian tube, and through the womb. M. Laumonier (Mem. de laSoc. Roy- 
 ale de M6decine, 1782, p. 300,) reports a very similar case. 
 
INFLAMMATION OF THE OVARIA AND TUBES. 
 
 413 
 
 The diagnosis of ovaritis is, for the most part, an obscure one. 
 While we may clearly distinguish it (rorn an attack of metritis, or 
 cystitis, by reference to the situation of the 'affected part, we may 
 very easily confound it with inflammation of the parts about the side 
 of the womb, and particularly with inflammation of the cellular tex- 
 ture, which is so abundant in that vicinity. An ovaritis may also 
 very easily be confounded with inflammation of the Fallopian tube, 
 and can be distinguished from it, during life, only by the absence of 
 the rounded swelling in one side of the pelvis. Fortunately, a mis- 
 take in the diagnosis of these different cases cannot lead to any unfa- 
 vourable consequences ; for the treatment indicated for the one is 
 equally applicable to the other of these affections. Besides, it is an 
 uncommon circumstance for the ovaries and the ligaments of the 
 womb to become inflamed without drawing the relaxed parts into a 
 participation in the malady ; or they are even, most generally, the 
 radiating points of the inflammation. 
 
 The prognosis of acute ovaritis depends upon the extent and 
 intensity of the disease ; it is much more serious when co-existent 
 with puerperal metritis and peritonitis, and when developed like 
 the last named affections, under an epidemic influence. Chronic 
 ovaritis is rarely cured ; it almost always passes into a state of scirr- 
 hous induration, which, however, in many specimens, does not hin- 
 der the patient from drawing out a long-continued existence. 
 
 [I interrupt for a moment the detail, for the purpose of protesting against 
 the plan of our author, of treating as a case of ovaritis, those terrible in- 
 flammations that ensue upon the puerperal state, and commonly known as 
 child-bed or puerperal fever. I apprehend, that in the management of a case 
 of the disorder in question, particularly under an epidemic influence, the 
 practitioner will find it necessary to combat not an ovaritis, (although the 
 ovary is a most common seat of the inflammation,) but a general inflamma- 
 tion of the tissues invested by the peritoneum. The womb, the tubes, the 
 ovaries, the intestines, the spleen, liver and stomach, are all involved in one 
 common inflammation of their serous surfaces; and though it is quite true 
 that we find deposits of pus beneath the ovaric peritoneum, we also find 
 similar depositions below the uterine peritoneum, and within the ligamenta 
 lata, in the veins, and even in the absorbents of the uterus itself. It is dispa- 
 raging the idea of a puerperal fever to call it an ovaritis. — M.] 
 
 Anatomical character. In its acute stage the ovaries are found 
 swollen, red, and more or less injected with blood ; their vesicles are 
 always larger than in the natural state ; sometimes they are found 
 larger than an orange, and their tissue, which is soft and friable, is 
 infiltrated with a yellowish or violet-coloured serous fluid, or in it 
 contains collections of pus, either liquid or in a concrete form; the 
 pus may also be seen collected in one, or in several cysts of various 
 sizes, and then the ovary will generally be found to have formed ad- 
 hesions to the adjacent parts. Finally, when the disorder is of an 
 
414 
 
 INFLAMMATION OF THE OVARIA AND TUBES. 
 
 ancient date, the organ is but littled injected with blood, and is, in a 
 measure, destitute of capillary vessels. 
 
 The treatment of acute ovaritis consists in the employment of 
 venesection, which should be reiterated according to the violence of 
 the symptoms and the strength of the patient ; recourse should be 
 had, from time to time, to the application of leeches to the groin, 
 near the affected part, Cataplasms should also be laid upon the hypo- 
 gastrium ; baths, emollient and slightly narcotic injections, demul- 
 cent and diluting drinks, slightly acidulated, should be prescribed ; 
 lastly, rigorous diet and absolute rest add greatly to the efficacy of 
 the other antiphlogistic measures. 
 
 Should the disease terminate in suppuration, so as to allow us to 
 perceive an evident fluctuation at the groin, or within the vagina, 
 there ought to be no haste to open the abscess and draw oft' the pus ; 
 but we ought to wait, in order to allow of the formation of adhesions. 
 Upon coming to the determination to open the abscess, it would be 
 well, if the groin be the spot selected, to apply a portion of caustic 
 paste to the point chosen for the incision; such a proceeding possesses 
 the twofold advantage of promoting adhesion, and the formation 
 of an eschar through the centre of which the opening can be made 
 with the bistoury. In case the fluctuation should be felt in the va- 
 gina, instead of at the inguinal region, the abscess should be opened 
 with a bistoury or a trocar; the absorption of such portions of the pus 
 as could not be discharged, might be afterwards promoted by the use 
 of diaphoretic drinks, and some gentle purgative doses. When the 
 disease ends in gangrene, recourse might be had to blisters, frictions, 
 and camphorated lotions externally, with the use of antiseptics and 
 chlorurets internally used. 
 
 In those instances where the ovaritis has already passed into the 
 chronic state, or had assumed, from the beginning, a chronic cha- 
 racter, resort should be had to external revulsive measures, such as 
 blisters, issues, moxas, setons established in the iliac region, and fric- 
 tions at the same point, with antimoniated ointment, mercurial oint- 
 ment, or ointment of hydriodate of potash ; douches of the sulphur 
 waters of Aix in Savoy, or of Bareges, to be directed on to the 
 groins, or in the ascending form to the vagina ; lastly, leeches in 
 small numbers ; topical applications of extract of cicuta, of colchicum 
 or opium, and narcotic injections. Such, perhaps, is the entire series 
 of external measures demanded for the treatment of chronic ovaritis, 
 whether primitive or consecutive in its attack. At the same time 
 that we are administering remedies of the kind above pointed out, 
 we should order the internal use of sudorific drinks, composed of 
 saponaria or sarsaparilla ; calomel, aloes and cicuta in small doses ; 
 castor oil ; the mineral waters of Plombieres, of Neris, of Luxeuil, 
 or Bourbon les Bains; and, lastly, we should direct the patient to fix 
 her residence in a dry, warm situation; she should also be directed to 
 wear flannel next to the skin ; absolute rest, followed by moderate 
 exercise, a very light diet, an extreme degree of sobriety in every 
 sense of the term, could not but add to the efficacy of all other thera- 
 
# INFLAMMATION OF THE OVARIA AND TUBES. 415 
 
 peutical agents, on which rest our hopes, if not of curing, at least of 
 checking the progress of the disease. 
 
 The course to be followed incase of the inflamed organ becoming 
 the seat of a collection of pus, would be the same as that pointed 
 out in speaking of the treatment of acute ovaritis. However, we 
 are of opinion that in no case whatever, should resort be had to the 
 extirpation of the ovary, as has by some writers been recommended. 
 
 [I fully concur with the author in his disapprobation of operations for the 
 extirpation of the diseased ovary; and I am free to say, that I look upon 
 operations for the extirpation of the diseased ovary, as not to be justified by 
 the most fortunate issue in any ratio whatever of the cases. 1 apprehend 
 the ratio of success hitherto obtained, as not justifying the operation. In 
 the illustrations of some of the principal diseases of the ovaria, &c., by 
 Ed. S. Seymour, M. D., Lond., 1380, the author, at page 124, makes the 
 following judicious remarks, which appear to me quite applicable to the 
 increasing disposition to prosecute this dangerous surgery. In speaking 
 of the operations by M. Lizars, and other surgeons, Dr. Seymour was not 
 blinded by the success — he says, “If the tumour be not large, and the wo- 
 man’s health unbroken, she may live many years ; as long as is allotted to 
 humanity, in the enjoyment of a tolerable existence. If the health be much 
 broken, the cure of so large a wound in a weakened constitution would be 
 difficult, if not in the great majority of cases impossible. If connected with 
 scirrhus in other parts of the body it is inadmissible ; and if the growth 
 itself be of the nature of fungus hematodes, all experience tells us, that should 
 the operation be survived or the wound healed, the disease will recur in 
 other vital organs of the body.” The statistics of the operation show, that 
 out of some sixty or seventy operations, there have been lost about one-half 
 of the subjects, while the other half have recovered — or, in other words, es- 
 caped a present death, and perhaps, in a few instances, recovered a secure and 
 long life. Let not, however, the ardent and young reader be infatuated 
 with even such success as this, until he shall first have satisfied his con- 
 science and judgment as to the grounds upon which so desperate an opera- 
 tion is instituted. Let him lay to heart Dr. Seymour’s remarks just quoted, 
 and let him assure himself that persons, and many persons, indeed, are 
 known to carry these tumours through a long existence, with even very little 
 inconvenience, and that in some cases they actually diminish in size, while 
 the inconveniences attending them nearly disappear. Let him place these 
 facts in contrast with the frighful incision extending from the umbilicus to 
 the pubis, and the subsequent handling, pulling, tying, and resection of the 
 tumour with the consequent inflammation. As to the opening of the abdo- 
 men, in cases requiring the Cassarian section, I look upon that operation, 
 however dreadful, as inevitable, because it presents the only hope of escape 
 from sudden and imminent death — whereas, in the case of a chronic ovaritis, 
 no matter what may be the particular form with which the malady clothes 
 itself, there remains a great uncertainty as to the future development and 
 
416 INFLAMMATION OF THE OVAFtIA AND TUBES.* 
 
 influence of the tumour. I attended, for example, a lady in several suc- 
 cessive labours, while she laboured under a chronic ovaritis, accompanied 
 with immense developments of the abdomen, from fluid in the ovarian cyst. 
 This stale of things continued some twelve or fifteen years, until at length 
 finding the weight too considerable, she allowed the fluid to be drawn off by 
 an operation for paracentesis abdominis. After the evacuation of the sac, 
 the solid portions of the tumour were distinctly felt in the lower and left side 
 of the abdomen. For five years she continued gradually to fill up the tu- 
 mour again until she was again tapped, and now more than three years have 
 elapsed, and she enjoys very comfortable and active health, though it is pro- 
 bable that within another year she may require a repetition of the operation. 
 It is quite true, that the operation for tapping is a dangerous one, particu- 
 larly a first tapping, and it has been shown by FleetwoodChurchill, of Dublin, 
 that the operation of tapping, in twenty cases, had the following results : 
 “ Thus, fourteen died within nine months after the first operation, four of 
 whom survived it only a few days. Of the remaining six, two died in 
 eighteen months, and four lived for periods varying from four to nearly 
 nine years.” Dr. 0. takes this table from Dr. Southam’s article in the 
 Medical Gazette. It ought to be observed that six of these persons were 
 over forty years of age, and, for aught we know, the operation may have 
 been deferred until the pressure and other disturbing influences of the tumour 
 had utterly ruined the constitution. Indeed, Dr. Blundell’s opinion, that 
 the operation should be performed early, if at all, is worthy of all appro- 
 bation. 
 
 In the United States, the extirpation of the tumour has been repeatedly 
 effected with success, as may be seen in the table to be given on another 
 page ; but it is equally true that frightful disasters, very little creditable to 
 the healing and conservative powers of surgery, have occurred; disasters 
 sufficiently terrible one would think, forever to deter from engagement in 
 the risks of reproducing them. It ought to be remarked, that the ovary, 
 when once fully engaged in the course of morbid changes, that result in the 
 development of what is called ovarian tumour, has already cast off, so to 
 speak, its allegiance to the common government of the economy. Its hyper- 
 trophic, or carcinomatous or hydropic law rules it supremely, and it is far 
 from being a settled point, that the tying up of the root or pedicle of the 
 tumour, can be relied upon, for the total extirpation of those principles of 
 morbid nutrition, or secretion on which the mass depends for its support 
 and growth. In case a female should, by fortunate accident, escape with life, 
 the smallest remaining portion of the diseased structure, a leaven, which 
 leaveneth the whole lump, should be esteemed capable of coming, in time, 
 to be as large and as troublesome as before the extirpating operation. The 
 Dublin Journal of Med. Science , for July, 1844, contains a very interesting 
 paper by Dr. Fleetwood Churchill, entitled Notes on Ovariotomy. Dr. C. 
 has collected the resu ts of sixty-six cases, in which the diseased, or sup- 
 posed diseased ovary, was removed, or attempted to be removed by the sur- 
 
OVARIAN TUMOUR. 
 
 417 
 
 geon. He gives three tabular statements, with the names of the surgeons, 
 the size of the incisions, the results, and the character of each tumour, which 
 we subjoin in the tables. 
 
 Table I. — Cases of Extirpation of the Ovary. 
 
 No. and 
 
 
 
 
 
 
 
 date. 
 
 Operator. 
 
 < 
 
 Incision. 
 
 Result. 
 
 Character of disease. 
 
 Adhesions. 
 
 1, 
 
 L’ Aumonier, 
 
 
 4 inches, 
 
 Recovered, 
 
 Abscess of ovary. 
 
 
 2, 1 80£ 
 
 Dr. McDowell, 
 
 
 9 “ 
 
 44 
 
 Gelatinous matter. 
 
 
 3, 181€ 
 
 4 
 
 <t u 
 
 
 Long, 
 
 “ 
 
 Scirrhous ovary. 
 
 
 5, 
 
 « « 
 
 
 44 
 
 44 
 
 
 
 6, 
 
 44 44 
 
 
 44 
 
 Died, 
 
 
 
 7, 1821 
 
 Dr. N. Smith, 
 
 33 
 
 3 inches, 
 
 Recovered, 
 
 Cyst, fluid. 
 
 Adhesions. 
 
 8, 1825 
 
 Mr. Lizars, 
 
 36 
 
 Long, 
 
 “ 
 
 1 
 
 9, 1825 
 
 “ “ 
 
 35 
 
 “ 
 
 Died, 
 
 
 Adhesions. 
 
 10, 
 
 Dr. A. G. Smith, 
 
 30 
 
 44 
 
 Recovered, 
 
 Cyst, fluid, 
 
 
 11, 
 
 Dr. Quittenbaum, 
 
 44 
 
 About 4 in., 
 
 
 12, 1829 
 
 Dr. David Rogers, 
 
 
 “ 3 “ 
 
 44 
 
 Solid and fluid, 
 
 Adhesions. 
 
 13, 
 
 Dr. Granville, 
 
 44 
 
 44 44 44 
 
 Died, 
 
 
 
 14, 
 
 Dr. Chrysmer, 
 
 47 
 
 Long, 
 
 44 
 
 ( Cartilaginous and 
 \ lardaceous matter, 
 
 Adherent. 1 
 
 15, 
 
 44 44 
 
 38 
 
 44 
 
 Recovered, 
 
 C Honey-like and 
 
 
 
 
 
 C green sanies, 
 
 
 16, 
 
 “ Ci 
 
 
 44 
 
 Died, 
 
 
 
 17, 
 
 Dr. Ritter, 
 
 31 
 
 44 
 
 Recovered, 
 
 Cyst, fluid. 
 
 
 18, 1836 
 
 M r. Kin?, 
 
 57 
 
 Short, 
 
 “ 
 
 44 
 
 
 19, 1833 
 
 Mr. JeafFerson, 
 
 
 44 
 
 “ 
 
 “ 
 
 
 20, 
 
 Mr. DolhofF, 
 
 23 
 
 Long, 
 
 Died, 
 
 Cyst and fluid, 
 
 Adhesions, j 
 
 21, 1836 
 
 Mr. West. 
 
 “ 
 
 Short, 
 
 Recovered, 
 
 
 22, 
 
 a 
 
 44 
 
 “ 
 
 « 
 
 « 
 
 
 23, 
 
 “ 
 
 24 
 
 44 
 
 Died, 
 
 44 
 
 
 24, 
 
 « 
 
 “ 
 
 44 
 
 Not cured, 
 
 “ 
 
 
 25, 
 
 Mr. Hargraves, 
 
 40 
 
 «4 
 
 44 
 
 Multiloc. cysts, 
 
 Adhesions. 
 
 26, 
 
 Dr. Clay, 
 
 46 
 
 27 inches, 
 
 Recovered, 
 
 Cysts, solid and fluid, 
 
 “ ( 
 
 27, 
 
 a 
 
 67 
 
 14 “ 
 
 Ext. adhes. 1 
 
 28, 
 
 
 39 
 
 28 “ 
 
 44 
 
 44 
 
 44 
 
 29, 
 
 u 
 
 40 
 
 14 « 
 
 Died, 
 
 44 
 
 44 
 
 30, 
 
 44 
 
 22 
 
 14 « 
 
 Recovered, 
 
 44 
 
 Adhesions, j 
 
 31, 
 
 a 
 
 40 
 
 14 “ 
 
 Died, 
 
 
 None. 
 
 32, 
 
 a 
 
 43 
 
 14 « 
 
 Recovered, 
 
 44 
 
 Ext. adhes. 
 
 33, 
 
 “ 
 
 59 
 
 16 « 
 
 Died, 
 
 
 « 
 
 34, 
 
 “ 
 
 46 
 
 16 “ 
 
 Recovered, 
 
 “ 
 
 “ 
 
 35, 1840 
 
 Mr. B. Philips, 
 
 « 
 
 2 “ 
 
 Died, 
 
 
 
 36, 1841 
 
 Dr. Stilling, 
 
 “ 
 
 6 « 
 
 “ 
 
 
 
 37, 1842 
 
 Mr. Walne, 
 
 58 
 
 Long, 
 
 Recovered, 
 
 44 
 
 None. 
 
 38, 1843 
 
 “ 
 
 57 
 
 44 
 
 44 
 
 
 «( 
 
 39, 
 
 44 
 
 21 
 
 44 
 
 Died, 
 
 
 | 
 
 40, 1843 
 
 44 
 
 20 
 
 44 
 
 Recovered, 
 
 44 
 
 a 
 
 41, 1843 
 
 Mr. Morris, 
 
 « 
 
 44 
 
 44 
 
 
 
 42, 1843 
 
 Mr. Southam, 
 
 “ 
 
 “ 
 
 44 
 
 Cystic sarcoma, 
 
 “ 
 
 43, 1843 
 
 Dr. F. Bird, 
 
 
 3 or 4 in., 
 
 44 
 
 Cyst and fluid, 
 
 « 
 
 44, 1844 
 
 44 
 
 “ 
 
 44 
 
 44 
 
 Cysts and sol. matter, 
 
 « 
 
 45, 
 
 Dr. Atlee, 
 
 “ 
 
 9 inches, 
 
 “ 
 
 44 44 
 
 Adhesions. 
 
 46, 
 
 Mr. Lane, 
 
 « 
 
 Long, 
 
 44 
 
 Cysts, fluid 
 
 None. 
 
 47, 
 
 Mr. Key, 
 
 19 
 
 Died, 
 
 “ 
 
 48, 
 
 Mr. Greenhow, 
 
 Mr. B. Cooper, 
 
 29 
 
 44 
 
 44 
 
 
 « 
 
 49, J 
 
 32 
 
 44 
 
 44 
 
 
 
 27 
 
418 
 
 OVARIAN TUMOUR. 
 
 Table II. — Cases of Ovarian Disease in which the operation could not he completed. 
 
 Date. 
 
 Operator. 
 
 Cause of failure. 
 
 1 
 
 Result. j Incision. j 
 
 50, 
 
 Dr. M’Dowall, 
 
 Adhesion to bladder 
 and uterus, 
 
 [Recovered, Long. 
 
 1 51, 
 
 Mr. Ligars, 
 
 Solid and very vascular 
 tumour, 
 
 \ " « 
 
 ! 52, 1826, 
 
 Dr. Granville, 
 
 Firm adhesions, 
 
 “ 6 inches. 
 
 ! 53, 
 
 Dr. Dieffenbach, 
 
 Vascularity, 
 
 “ Long. 
 
 ! 54, 1826, ; 
 
 Dr. Martini, 
 
 Solid, fixed tumour, 
 
 jDied, “ 
 
 ! 55, 
 
 Anonymous, 
 
 Fixed tumour, 
 
 | 56, 
 
 Mr. Dolhoff, 
 
 “ 
 
 j “ About 6 ins. 
 
 1 57, 
 
 Dr. Clay, 
 
 Extensive adhesions, 
 
 ! “ (Long. 
 
 58, 
 
 1 i 
 
 Mr. Walne, 
 
 u u 
 
 (Recovered, 5 inches. 
 
 1 
 
 Table III. — Cases in which the operation failed from an error in diagnosis. 
 
 j Date. 
 
 Operator. 
 
 Result. 
 
 Disease. 
 
 1 59, 1823, 
 
 Mr. Lizars, 
 
 Recovered, 
 
 No tumour found. 
 
 | 60, 1834, 
 
 Mr. Kins:, 
 
 
 it « 
 
 I 61, 
 
 Mr. Dolhoff, 
 
 Ct 
 
 U ii 
 
 62, 
 
 Dr. Clay, 
 
 Died, 
 
 Uterine tumour. 
 
 j 63, 
 
 “ 
 
 Recovered, 
 
 Hydatid. 
 
 . 64, 
 
 U 
 
 Died. 
 
 Pelvic tumour. 
 
 1 65, 
 
 
 «< 
 
 Uterine tumour. 
 
 1 66, 
 
 Mr. Heath, 
 
 “ 
 
 ti U 
 
 After making the above statements, Dr. Churchill sums up the whole in 
 the following manner. He says : “ 1. The entire number of cases, whether 
 dropsy or scirrhus of the ovary, uterine disease, or simulated tumours, 
 amounting to sixty-six : of these forty-two recovered, and twenty-four died, 
 or about one in two and three-fourths.” 
 
 “Of the forty-nine cases in which the ovary was extirpated, sixteen died, 
 or one in three and one-tenth. Of the nine cases in which the operation 
 could not be completed, four died, or one in two and one-fourth ; and of the 
 eight cases where the operation was unnecessary, four died, or one in two.” 
 
 Dr. Churchill, among his conclusions, at p. 395, says: “ But, bearing in 
 mind these difficulties, and making allowance for these draw-backs, I think 
 we may conclude that there are cases in which the operation would be justi- 
 fiable ; and on these grounds, — we find the general opinion is against the 
 curability of the disease by medical means ; — that after a time the patient 
 will die from local disease, or accident, or constitutional disturbance, and 
 that mean time she suffers more or less inconvenience; that tapping, in 
 almost all cases, affords but temporary relief ; and that, as far as the limited 
 statistics we have adduced are admissible as evidence, it is attended with 
 great danger; i. e., one in five died of the first operation, and that of twenty 
 
OVARIAN TUMOUR. 
 
 419 
 
 patients, fourteen (more than two-thirds) died within nine months of the 
 first tapping; whilst of the entire number of those who underwent the ope- 
 ration of ovariotomy, about one-half have absolutely recovered so far.” 
 
 I have thus laid before the reader, the results obtained by Dr. Churchill 
 in his paper, but I wish him to reflect upon the value of statistical exhibi- 
 tions of this sort; and to warn him against the seduction of statistics, in 
 cases where we cannot judge of the necessity or the propriety of the risk to 
 which the patient has been subjected. If, instead of ovariotomic ones, Dr. 
 C. had given us the statistics of one hundred cases of Caesarian operations 
 where the antero-posterior diameter of the superior strait w r as known to be 
 not more than two inches, and the foetus alive, there would be no hesitation 
 in agreeing to the propriety of the surgical measure, or even its absolute 
 necessity ; but under all the uncertainty as to the duration of life in chronic 
 ovaritis, I contend, that even the very faint praise and admission of the ope- 
 ration given by Dr. Churchill, are indicative rather of his doubts than his 
 approbation — his fears for the patient rather than his hope for the victim. 
 
 I freely admit that where the tumour has attained a certain magnitude, we 
 have no hope left save that doubtful one, of the possibility that the tumour 
 shall cease to augment, as often happens ; and the reasonable expectation 
 of the ability, under a wise treatment, to retard its progress and obviate its 
 disturbing force in the economy. 
 
 Seeing that it is pretty well understood at present, that the catamenial 
 office depends upon the periodical evolution of the Graafian vesicle, I beg 
 leave to suggest to the reader the propriety of giving a due share of atten- 
 tion to that process in the management of all cases during the mensual life 
 of the female, that have not gone, as to volume, beyond any reasonable 
 hopes of control. For example, a lady from a distant city, aged about 
 twenty-eight years, after suffering for two years after her marriage with 
 very intense paroxysms of hysterical passion connected with irregular and 
 excessive menstruation, gave birth to a child, and within eighteen months to 
 a second, which was born about four years ago, (1840). 
 
 In the course of the winter of 1843, she discovered a small tumour in the 
 lower and left side of the hypogastric region. It appeared upon the taxis to 
 be some two and a-half inches in length by two inches in breadth, and was 
 movable under the finger. The touch and the surpubal palpation, led me to 
 the conclusion that the tumour was a chronic ovaritis of the left ovary. It 
 was not painful, nor did it visibly affect her health in any regard, the men- 
 struation being very regular. 
 
 I gave a written opinion on the case, upon the following grounds : 
 
 The violent hysterical excitements to which this lady was long subject, 
 and from which she is not, even now, wholly free, derive their source from 
 the ovaria and other reproductive organs. As she menstruates regularly, it 
 may be supposed that each catamenial period will be one of affluxion 
 towards these organs, whose hyperaemic condition cannot fail to add con- 
 
420 
 
 OVARIAN TUMOUR. 
 
 siderable force to the morbific tendencies now in actual exercise in the ovary. 
 Therefore, let attention be given to the subduction of the ovaric excitements, 
 especially on the periodic occasions. If the mensual periods, which may 
 be regarded as dangerous, or at least as mischievous crises, can by any art 
 be made to pass by with the least possible disturbance, whether local or 
 general, the tumour may be expected to develop itself very slowly, or, per- 
 haps, even to retreat. 
 
 To this end, let the diet be carefully regulated, as neither too spare, nor 
 too nutritious — let the clothing be warm, especially about the pelvic region 
 and the lower extremities, with a view to avoid any check to the menstruae. 
 Let the bowels be kept in a soluble state. Let the patient take a bath at 
 97° three times a week, and go from the bath to her bed. Leeches suffi- 
 cient to take three or four ounces of blood should be applied to the left 
 groin, over the round ligament, four or five days before each menstrual 
 period, with a view to obviate the then hyperaemic tendencies of the ovarian 
 stroma. Let her not leave the house for three or four days of the period of 
 return. During some months let her make use of proper doses, three to 
 five grains, of the hydriodate of potassa, thrice a day. 
 
 I hoped by such measures to retard, at least, the growth of the tumour ; 
 and I find that after some months, in which the course has been faithfully 
 carried out, there is a positive diminution of the size of the diseased mass. 
 What shall be the result of the case, and what may be the power of the 
 treatment to control or modify that result, must be left to time to disclose; 
 but I conceive that in all such early or recent cases it would be important to 
 fix the views of the practitioner upon the necessity of moderating the periodi- 
 cal hyperaemia of the reproductive organs. 
 
 I have never seen ovarian tumour commence after the cessation of the 
 menses ; and though such a case may have happened, it appears highly 
 probable that the disease is intimately connected with the mensual function, 
 which, by the alternate excitement and repose of the vesicular develop- 
 ment, exposes it evidently to the danger of inflammation, acute or chronic, 
 with all its consequences in the depravation of its texture. — M.] 
 
 OF DROPSY OF THE OVARIES, AND FALLOPIAN TUBES. 
 
 Chronic inflammation of the ovary may give rise to various altera- 
 tions whose existence remains for the most part unknown until dis- 
 covered by a post-mortem examination. Thus, one of those organs 
 has been found to contain a collection of hair, or portions of bones 
 or teeth, which, according to the opinions of some authors, are the 
 relics of an abortive conception, while others regard them as evidence 
 of pregnancy by inclusion, or of an unnatural nisns formativus , inas- 
 much as similar collections have been found in various other parts 
 of the body,* even in the male, and in virgins not yet arrived at 
 
 * Gordon discovered a tumour within the cavity of the thorax containing bones and 
 teeth, surrounded by a substance resembling tallow. Professor Andral discovered 
 
OVARIAN DROPSY. 
 
 421 
 
 puberty, as in the cases reported by Messrs. Baillie,* Seymour,! Cru- 
 veilhier,:}: and Andral.§ 
 
 The preternatural and encysted products in question have been 
 very often met with; as they never grow to a very large size, their 
 existence is rarely suspected during the life of the patient ; besides, 
 it is probable that they are much more frequently the causes than 
 the effects of ovaritis. That disease, when chronic, on the contrary, 
 much more generally ends in scirrhous indurations, in encephaloid 
 softening, in tumours, either homogeneous or filled with hydatids, 
 and especially in an encysted tumour, known as dropsy of the ovary, 
 of which we shall proceed to treat. 
 
 This kind of dropsy is not only the most common of the encysted 
 dropsies, but also the most ordinary form of ovarian disease, and 
 one, indeed, to which the female is most liable. Though it be proba- 
 ble that the formation of the serous cysts which constitute the dis- 
 ease, always takes place in the same manner, it has been divided 
 into several varieties, as, 1st. Uni-locular cysts , that is, where the 
 ovary is converted into a single sac, which is generally polished on 
 the external surface, of a globular shape, though sometimes multi- 
 lobular or pyriform, and attaining so great a size, in some instances, 
 as to distend the abdomen like a common ascites. 2d. Multi-locular 
 cysts , composed of a number of cells, each communicating with the 
 others, or else of several groups of distinct lodges, though their con- 
 stituent parts are connected together. The cysts comprised under 
 this variety are mostly lumpy on the surface. 3. Multiple cysts , or 
 such as, though distinct the one from the other, yet, by their aggre- 
 gation, make up the tumour. Each one of these cysts may be either 
 uni-locular or multi-locular. There is generally one principal cyst 
 which effaces, in a manner, all the rest ; so that the external surface 
 of the mass is smooth, instead of being lumpy. 4th. Areolar cysts , 
 in which the ovarian tissue is divided into areolae, or cells, containing 
 a peculiar gelatiniform matter. According to M. Cruveilhier, this 
 variety of the multi-locular cyst is like the areolar cancer, especially 
 the areolar cancer of the stomach, from which it differs only in the 
 greater size of the meshes. 
 
 5. Acepkalocyst cysts , which rarely become as large as the other 
 serous cysts above mentioned, and are, moreover, distinguished espe- 
 cially by containing hydatids, which we need not again advert to. 
 
 The texture of an ovarian cyst is commonly fibrous, and contains 
 blood-vessels. In some instances, it is found to be very thin ; in 
 
 another between the laminae of the mesentery in a negro woman ; the tumour, which 
 was as large as a festal head, contained, in the midst of a quantity of fatty matter, a 
 collection of hair, some of which was isolated, and the rest in bunches. It should 
 however, be observed that these preternatural collections are most frequently met with 
 in the ovaries, and that here, as well as elsewhere, they are surrounded by a quantity 
 of steatomatous matter, as is shown in the cases related by Portal, Meckel, Logger, 
 Murat, Cruveilhier, Paul Marshall, Andral and others. 
 
 * Anat. Pathol, p. 319. 
 
 f Illustrations, &c. of Diseases of the Ovaries, 83. 
 
 i Essai sur l’Anat. pathol., t. ii. 180. 
 
 § Precis d’Anat. pathol., t. ii. 
 
422 
 
 OVARIAN DROPSY. 
 
 others, on the contrary, it is very thick,* and has a steatomatons 
 appearance. Its internal surface, which may happen to be smooth, 
 is more frequently found to be rugous and uneven. According to 
 Hoopert and M. Cruveilhier,f (loc. cit.,) the walls of the sac are some- 
 times observed to be nodose, and to contain laminae of cartilage and 
 even of bone. 
 
 The fluid contained in the cyst is generally serous ; it may be lim- 
 pid, ropy, like albumen, of a gelatinous appearance, sanguineous, 
 purulent, of a chocolate colour, or like coffee grounds, &c. 
 
 In the multi-locular dropsies, the fluid may differ in the different 
 cells, as to its colour and its nature, and may even undergo putrefac- 
 tive decomposition, giving rise to gases, whose escape through the 
 trocar-canula leads the surgeon to suppose that it communicates with 
 an intestine. 
 
 The quantity of fluid contained in a dropsical ovary varies very 
 much in different specimens. At first, the morbid accumulation of 
 serosity is scarcely perceptible; but, in a more advanced stage, it may 
 be very considerable. Morand had an ovarian cyst which held ten 
 pints, and he mentions§ that Dr. Duret, of Vitry-le-Frangais, reported 
 to the Academy, in 1740, the history of a case of ovarian dropsy, in 
 which the cyst held fifty pints: it had distended the abdomen so 
 much that the woman was obliged to tie her petticoat four finger 
 breadths below the axilla. In fine, according to Munro,|| Wepfer, 
 and other authors, the weight of the serum has been known to 
 amount to one hundred and ten and to one hundred and twenty 
 pounds. 
 
 Where the disease is already of old standing, both of the ovaries 
 are generally found to be affected; but the disease, which began first 
 upon one side, is always less forward, and the tumour smaller than 
 on the side where the lesion first commenced. Under these circum- 
 stances, the belly appears to be uneven, lumpy, and, in many in- 
 stances, divided into different and distinct lobes, just as happens 
 where a scirrhous degeneration has taken place, or where the ovary 
 is divided into several cysts. These multiple cysts, which are per- 
 haps more common than single cysts, exhibit a great variety of cha- 
 racter. Sometimes the tumour, which is susceptible of acquiring a 
 very large size, is divided into two or three portions, unequally deve- 
 loped. Sometimes, on the other hand, the size of each sac is very 
 small ; but, as remarked by Messrs. Munro, Cruveilhier, Delpech, 
 Strambio, Andral, &c., their slight development is generally compen- 
 sated for by their great number, which is very considerable in some 
 of the specimens. It should be added, that in these cases of multiple 
 ovarian cysts, the front one is almost always the largest; that is to 
 
 * Morand (Mem. de I’Acad. de Med., t. ii. p. 426) speaks of two empty cysts, one of 
 which weighed fourteen, and the other twenty-seven pounds. 
 
 t The Morbid Anat. of the Uterus, pi. xx., 1832. 
 
 * Ratio Medendi, t. ii. p. 259. 
 
 § Mem. de l’ Acad, de Chirurg., t. ii. p. 457. 
 
 !| Monro, Essay on Drops}', p. 228; and J. I. Wepfer, Observ. Anat. ou Cadav., 
 &c., 1658. 
 
OVARIAN DROPSY. 
 
 423 
 
 say, the most voluminous and heaviest cyst of the tumour is dragged 
 in front of the others by its own weight. 
 
 The causes and the mode of development of ovarian dropsies are, 
 as yet, but little known. Whether the disorder depends on the new for- 
 mation of a cyst, created de novo within the ovary, under the influence 
 of some inappreciable morbid state, or a cancerous state, as supposed 
 by many writers, as Ledran, Delpech, ( Joe . cit., p. 214,) and M. Cru- 
 veilhier, who compares the multi-locular cyst to the areolar cancer ; 
 or, whether the encysted tumour results from the accumulation of a 
 serous fluid, in one or more ovarian vesicles, the first origin of the 
 evil ought, in our opinion, to be always referred to a chronic inflam- 
 mation. What is more certain, as to the etiology of ovarian dropsy, 
 is this, viz., that it is never found to manifest itself, except at those 
 periods of life during which the genital organs are possessed with 
 their highest degree of activity, which is from the age of twenty years 
 to forty-five years. It is proper to remark, however, that although 
 the disease has been met with in girls not arrived at puberty, and in 
 women beyond the change of life , such as have been the subjects of 
 the sexual embrace, and particularly women who have borne chil- 
 dren, are much more subject to the disease than virgins and women 
 who have never conceived. 
 
 Among the determining causes of ovarian dropsy, have been 
 classed all the causes we have mentioned as giving rise to ovaritis ; 
 such as external violence, a blow, a fall upon the hypogastric region; 
 indeed, all the various abusive causes of irritation and excitement of 
 the genital system, the chief of which is masturbation, and other 
 indecent manoeuvres, which females rarely confess to their physi- 
 cians. However, it must be admitted that the disorder is often deve- 
 loped without any distinguishable provocation. 
 
 The symptoms of this affection are very obscure at first. As in 
 the incipient stage of its existence, it causes very little inconvenience, 
 and, moreover, is developed very slowly; the female who is attacked 
 with it pays very little attention to it, and many of them attribute 
 their feelings to an incipient pregnancy ; a mistake the more easily 
 made, since both the conditions are marked by the same symptoms. 
 For example, the gradual enlargement of the abdomen, as well as of 
 the breasts, the suppression of the menses, the vomiting, the disgust, 
 the queer appetite, &c., as they may be met with in ovarian dropsy, 
 as well as in pregnancy, may contribute to deceive the woman, and 
 mislead, at the same time, the physician, who feels secure, even 
 while under a great error. 
 
 Before the development of the tumour becomes sufficiently con- 
 siderable to admit of its becoming sensible to the external touch, the 
 woman feels a dull, deep-seated and permanent pain in one of the 
 iliac regions, with a feeling of weight in the corresponding hip and 
 thigh. The progress of the tumour is generally very slow ; indeed, 
 it sometimes requires several years to make it perceptible to the ex- 
 ternal touch ; and such is the depth of the situation of the ovary, 
 and so great is the thickness of the abdominal parietes, that it must 
 have attained a considerable magnitude before it can be externally 
 
424 
 
 OVARIAN DROPSY. 
 
 felt. When it does become large enough, a tumour may be felt near 
 one of the groins, which, provided it has contracted no adhesions 
 with the adjacent parts, generally projects most on the side on which 
 the patient lies. As this tumour may be globose, circumscribed, even, 
 or lumpy, indolent or painful, it is often a difficult matter to decide 
 whether it be a scirrhous, an extra-uterine pregnancy or an ovarian 
 cyst. Though the fact of fluctuation in the tumour may be held to 
 dissipate all doubt as to its nature, the absence of the fluctuation is 
 not always to be taken as proving the negative, as the matter of the 
 cyst maybe thick or gelatinous; a mistake is so much the more 
 easily made, inasmuch as a dropsy of the ovary often coincides with a 
 scirrhous state of the same organ. It is, in fact, the frequent coinci- 
 dence of these two affections, that has led different authors to ima- 
 gine that the ovarian cyst is always complicated with a scirrhous 
 state of the organ. In some of the cases, so slow is the progress of 
 the disorder, that many years have elapsed before the tumour has 
 acquired any considerable size. In these instances the women retain 
 their fresh colour and their embonpoint for a long time, and appear 
 to be in the enjoyment of all the attributes of a most perfect health ; 
 some of them, in whom only one ovary is affected, have been known 
 to conceive and bear children with safety. It generally happens 
 that as long as the cyst continues to be of inconsiderable size, and 
 particularly where only one of the ovaries is affected, the functions 
 of the pelvic viscera, such as the excretion of the urine and of the 
 stool, and the mensual evacuation, continue to be performed with 
 great regularity. On the other hand, when the encysted tumour 
 begins to attain a certain magnitude, the viscera in proximity with it 
 being displaced, and more or less inflamed by the pressure, contract 
 adhesions with each other, as well as with the tumour itself. The 
 painful dragging sensations felt by the patient upon any change of 
 position, or on turning upon the side opposite to the diseased one, 
 are the indicias of the morbid adhesions that bind the abdominal 
 viscera together with the cyst. The womb may also suffer various 
 sorts of displacements ; sometimes it is found pressed over to the side 
 of the pelvis ; at. others it is deeply depressed within the excavation 
 by the weight of the tumour resting on the fundus uteri ; the abdo- 
 men, which is most prominent on the side first affected, most generally 
 allows us to detect the existence of a dropsical fluctuation, though 
 the fluid may as yet occupy only a portion of the swelling. 
 
 Where the cyst has become large enough to push the bowels and 
 the stomach upwards against the diaphragm, and thrusts the latter 
 upwards into the confines of the thorax, the powers of digestion are 
 interfered with, and the respiration is embarrassed. Obstinate con- 
 stipation supervenes ; the fluctuation in the abdomen becomes more 
 evident, and the fluid, which now appears to occupy the whole 
 capacity of the belly, often leads to a belief that the case is one of 
 ascites. In certain instances the tumour, after having attained this 
 great degree in its development, becomes stationary as to its progress. 
 Sabatier dissected several subjects in which tumours of this sort had 
 continued during a term of forty-five and even fifty years, without 
 
DROPSY OF THE OVARIUM. 
 
 425 
 
 any evident morbid influence on the general health of the individu- 
 als. Notwithstanding the abdomen was enormously large, their vital 
 powers had been maintained, because the functions of their abdomi- 
 nal viscera had been executed without too much interference of the 
 tumour. It must be said, however, that where the cyst is very large, 
 the patient, as a general rule, is incapable of much motion, and the 
 pressure it exerts on the viscera is sometimes so great that their 
 functions are either entirely disordered, or more or less interrupted. 
 Lastly, let us add, that a distressing dyspnoea, an imminent danger of 
 suffocation, an ischuria .renalis, painful and obstinate constipation, 
 and in the end, a hectical form of fever, are, for the most part, the 
 sad forerunners of the approaching dissolution of the patient. 
 
 The diagnosis of dropsy of the ovary is not always very easily 
 settled, because the disorder exhibits certain general phenomena and 
 local symptoms, that are more or less similar to those of simple preg- 
 nancy, of extra-uterine pregnancy, as was the case in a sample that 
 fell under the notice of Merklin, of ascites, of hydrometra, &c. 
 
 It may be ascertained that the increased size of the abdomen is 
 due to the dropsical state of the ovary and not to a state of pregnancy, 
 by recollecting that in the case of an ovarian cyst, the tumour forms 
 slowly, and commences at first on one side only, that it is circum- 
 scribed, often having an irregular shape, lumpy, and exhibiting cer- 
 tain harder points on its surface, and particularly near its base ; that 
 by means of auscultation, which, in such a case, is merely negative, 
 that is to. say, without any fetal pulsations, or placental sounds, we 
 most generally may discover gurgling sounds at different points of the 
 tumour, which principally occupies one side of the abdomen ; in fine, 
 that the fluctuation , which, in a majority of the cases, may be ascer- 
 tained to exist, is confined within the boundaries of the tumour. By 
 the vaginal touch the cervix uteri is found to be small and thin, 
 while the os tincae is a narrow, regular, transverse orifice, yet by 
 pressing upon the hypogastrium, we do not eause it to move at all. 
 Attention should also be paid to all the circumstances attending the 
 progress of the abdominal swelling, nor should we forget that for the 
 most part, the menses are suspended in dropsy of the ovary as they 
 are in pregnancy, and that in either case, a woman may exhibit 
 general or sympathetic phenomena having the closest analogy to 
 each other. The age of the patient, a state of barrenness protracted 
 through many years of the married life, the unmarried state of the 
 woman, and her social position, may, when considered in conjunction 
 with the other symptoms, lead to the rejection of the idea of preg- 
 nancy. It should also be remarked that the absence of the sponta- 
 neous motions of the child, and the persistence of the abdominal dis- 
 tension to a period beyond the term of utero-gestation, may assist in 
 putting an end to all doubt as to the questions of normal pregnancy 
 or extra-uterine pregnancy. 
 
 To distinguish betwixt an ovarian dropsy and a case of ascites, 
 we should not forget that in the latter disease, the patient’s constitu- 
 tion generally exhibits marks of languor and atony pervading the 
 entire organism, such as excessive paleness, bloating of the face,infil- 
 
426 
 
 DROPSY OF THE OVARIUM. 
 
 tration of the lower limbs, and not unfrequently of the external geni- 
 tals also. In ascites, the discharge of urine is generally diminished 
 in quantity, while in case of an ovarian cyst, the amount of urine 
 produced appears to be more considerable than is usual, especially 
 where the tumour, by compressing the urinary bladder, gives rise to 
 an uneasy sensation that excites the woman to more frequent efforts 
 to discharge its contents. Nevertheless, it does sometimes happen 
 that too strong a compression of the bladder of urine may, in ovarian 
 dropsy, produce a complete incontinence, which constitutes one of 
 the most distressing complications of the malady. In ascites, the 
 swelling of the belly takes place more rapidly and in a more uniform 
 manner, and the fluctuation is perceptible in every part of the 
 tumour. In dropsy of the ovarium, on the contrary, it is dull and 
 circumscribed, the shape of the abdomen is always less regular, its 
 growth does not proceed in every dimension at one and the same 
 time, and, lastly, the tumour which seems to come up from within 
 the pelvis is always largest at the side on which it first made its 
 appearance. 
 
 [I do not think that practice will always prove this diagnostic sign to be a 
 dependable one, since the tumour, provided it have a long and very flexible 
 pedicle, may, by the italic sigma of the colon, be pressed towards and kept 
 on the right side, even though it may come from a depravation of the structure 
 of the left ovary. — M.] 
 
 We add, that as dropsy of the ovarium is formed more slowly than 
 the dropsy of an ascites, the patient is less incommoded by it in the 
 early stages, and some of them preserve their embonpoint, and their 
 healthy complexion for a long time, a circumstance which does not 
 hold good as to ascites, which is generally accompanied with all the 
 marks of a cachectic state, and of a general hydropic diathesis, and 
 particularly with oedema of the lower extremities. The infiltration 
 that is now and then observed as a consequence of ovarian dropsy, 
 is generally confined to the thigh corresponding to the side affected, 
 which may likewise be the seat of a feeling of numbness, arising 
 from the pressure of the tumour upon the crural nerves and blood- 
 vessels. The chief difference between ascites and ovarian dropsy is 
 that the latter, like a hydrocele, is a purely local disorder. 
 
 Where a peritoneal dropsy exists at the same time with a dropsy 
 of the ovary, we discover, by means of palpation, a stratum of fluid 
 separating the abdominal walls from a tumour lying free within the 
 peritoneal cavity. By moderate pressure we can generally succeed 
 in pressing aside the serosity with the hand, and thus get down to 
 the real tumour itself, and clearly appreciate its resistance, size and 
 shape. 
 
 Where the abdominal walls, from being distended both by an 
 encysted ovarium and a peritoneal dropsy, have yielded as far as 
 their natural elasticity will admit of, it occasionally happens that a 
 portion of the ovaric tumour forms a hernial protrusion. l)r. Iluguier, 
 upon the autopsy of a female who died in 1830, at the Hospital St. 
 
DROPSY OF THE OVARIUM. 
 
 427 
 
 Louis, of an ovarian dropsy, complicated with ascites, found a cyst of 
 the ovary larger than a man’s head, presenting the following appear- 
 ances-: the tumour was multilobular and divided into four portions; 
 the first, internal and inferior, filled up the pelvic excavation ; the 
 second, anterior and internal, occupied the corresponding part of the 
 abdomen; the third, superior and external, whose summit touched 
 the under surface of the right lobe of the liver, had detached the peri- 
 toneum from the whole of the right costo-iliac region, and the infe- 
 rior part of the anterior paries of the abdomen, and engaged itself 
 within the crural canal, not only its internal portion where the lym- 
 phatic vessels pass and where hernias are formed, but even through- 
 out the whole length of the canal, folio wing the aponeurotic expansion 
 furnished to the thigh by the fascia iliaca. This portion of the 
 tumour, which contained nothing but serum, was three inches long 
 by two inches in breadth, and situated behind and outside of the 
 crural vessels. It is only necessary to know that a crural hernia of 
 an ' ovarian cyst is a possible case, in order to avoid the errors of 
 diagnosis that such a displacement might give rise to. Lastly, we 
 remark that the general symptoms and sympathetic and hysterical 
 phenomena that accompany most of the maladies of the womb and 
 ovaries, ought, likewise, to aid us in discriminating betwixt an 
 ovarian dropsy and the other serous collections of the abdominal 
 cavity. 
 
 The prognosis of the disease under consideration is always unfa- 
 vourable, especially when complicated with scirrhus of the ovarium, 
 with ascites, a general dropsy, or hydrothorax. Notwithstanding 
 some women have been found to attain an advanced age, though 
 long afflicted with dropsy of the ovary, they almost all fall victims to 
 the progress of their malady, either from a rupture of the cyst, whose 
 fluid is effused into the cavity of the belly, giving rise to a mortal 
 peritonitis, or from the disorders and disturbances produced by the 
 pressure of the tumour upon the abdominal viscera, or, finally, from 
 the accidents which very frequently result from the operations re- 
 quired in order to evacuate the fluid or remove the diseased organ. 
 It sometimes happens that the rupture of the tumour is favourable to 
 the patients, because the serous fluid has been discharged into the 
 cavity of some neighbouring viscus which has been perforated simul- 
 taneously with the cyst*; Denman* saw it escape by the rectum ; 
 Madame Boivin,t by the vagina, in two cases ; Monro , % once, by the 
 same route, and again, through the groin; and Mead and Locock§ 
 through the umbilicus. || Denman’s patient, one of Madame Boivin’s, 
 and the one of which Mead speaks, were entirely cured ; the others 
 relapsed, and death occurred some time after. Sometimes, after rup- 
 ture of the cyst, the effusion into the abdominal cavity has been 
 
 * Med. and Physic. Journal, vol. ii. p. 20. 
 
 f Recherches sur l’avortement, etc., pp. 103,131. 
 
 ± Edinburgh Essays, vol. vi. p. 387. 
 
 § Illustrations, etc. of the Principal Diseases of the Ovaria, p. 53. 
 
 || Doctor Grenville (Med. Physic. Journ., 1822), has published a case of encysted 
 tumours of the right ovarium, some of which, as large as the head of a fetus, opened 
 and gave issue to purulent matters through an ulceration in the walls of the abdomen. 
 
428 
 
 DROPSY OF THE OVARIUM. 
 
 reabsorbed, and a complete cure effected. Doctor Seymour (loc. cit., 
 p. 55,) quotes from Blundell, a case in which absorption took place, 
 after effusion into the abdomen, though the rupture of the ovarian 
 cyst had been occasioned by a fall. We shall conclude our remarks 
 upon the prognosis of dropsy of the ovarium, by adding that the dis- 
 ease ought to be ranked amongst those whose progress may some- 
 times be retarded, but whose complete cure can rarely be obtained. 
 It is wrong, however, to pronounce an unfavourable prognosis too 
 soon ; for Portal,* Petit Radel,t M. Nauche,f Seymour (loc. cit., pp. 
 93, 116 and 119,) and several other practitioners, cite several cases of 
 cure obtained by various means, which we shall point out. 
 
 The treatment of dropsy of the ovarium is far from having been 
 determined with precision; for whatever be the therapeutical methods 
 that have been employed, the examples of failure are infinitely more 
 numerous than those of success. Thus purgatives ; emetics ; sudor i- 
 fics ; diuretics; sialagogues; simple, salt, and sulphurous baths ; per- 
 cussion and compression of the abdomen ; revellents and resolvents, 
 both internal and external ; puncture ; incision and extirpation of the 
 tumour, and a crowd of empirical remedies, have been, turn by turn, 
 employed, and all followed by rare and isolated cases of cure. 
 
 Though we ought not to place much confidence in the means de- 
 rived from medicine strictly so called, we are of opinion that they 
 ought always to be employed before recurring to those afforded as 
 by surgery. Consequently, sudorifics ought first to be prescribed, 
 for example, guaiac, sarsaparilla, and* vapour-baths; resolvents, 
 among others mercurial frictions, successfully employed by Clarke 
 and M. Nauche ; those of hydriodate of potash with the internal use 
 of iodine in small doses ; sea-bathing, or salt-water baths, from which 
 M. Laennec, of Nantes, says he has obtained most excellent effects : 
 the thermal baths of Aix, in Savoy, or of Barege ; antimonial fric- 
 tions, cauteries, moxas, and blisters applied upon the abdomen. 
 Diuretics, such as squills, nitre, etc., which, according to 1 Haller, § 
 were usefully employed by Willis ; a decoction made from ashes in 
 the proportion of a handful to a quart of water, which Petit Radel 
 (loc. cit.,) employed, and from which he obtained a cure, after having 
 punctured the ovarian cyst ; lastly, purgatives in divided doses ; for 
 instance, aloes, rhubarb, croton oil, calomel combined with Castile 
 soap, and sulphate of potash, etc., are other means which, in conjunc- 
 tion with abstinence and compression of the abdomen, may be pre- 
 scribed at the commencement of the disease, for the purpose of 
 assisting the absorption of the fluids at first small in quantity. 
 
 When the cause of the disease can be discerned, we must endea- 
 vour to remove it as early as possible. If it have occurred after a 
 blow, a fall or some engorgement resulting from inflammation, we 
 should resort to the use of baths and to general and local bleedings, 
 especially if the woman be of strong constitution. Should the dis- 
 
 * Observat. sur la nature etle traitement de l’hydropisie, 1. 1. p. 15. 
 
 j- Encyclopedic methodique, chirurgic., t. ii. p. 134. 
 
 \ Maladies des femmes, t. i. p. 174. 
 
 § Disputationes Morborum, vol. iv. 
 
DROPSY OF THE OVARIUM. 
 
 429 
 
 ease have followed suppression of the menses or of a haemorrhoidal 
 flux, appropriate means for restoring these discharges ought to be 
 directed. Lastly, when ovarian dropsy has followed the disappear- 
 ance of a cutaneous eruption, of gout or rheumatism, etc., the irritation 
 must be restored as soon as possible to the place it primarily occu- 
 pied, and then remedies proper for the treatment of these different 
 diseases should be resorted to. 
 
 When these various therapeutical means fail, which, unfortunately, 
 is generally the case, we may resort to the operation of tapping, in 
 order to remove the fluid contained in the cyst. This operation, 
 which is rather a palliative than a curative means, is recommended 
 by Theden, Ledran, Monro, Richard Brown, Chester, Camper, 
 Howship, S. Cooper, and several other surgeons ; it is regarded, on 
 the' contrary, as being more injurious than useful, and as hastening, 
 sometimes, the death of the patient, by Callisen, Denman, Garengeot, 
 Burns, G. Hunter, Richter, Sabatier, Delpech, etc.; some of these 
 writers, though they do not positively forbid tapping, think with good 
 reason, that it ought not to be resorted to except as an extreme 
 measure, and when the life of the patient, exposed to constant danger, 
 has become insupportable in consequence of the inconveniences and 
 sufferings which result from the enormous distension of the ovarian 
 cyst. 
 
 This operation, of which Ledran, Monro, Dehaen, Portal and Dr. 
 Hey, have published cases that have either terminated successfully 
 or prolonged, for a long period,* the lives of the patients, has, most 
 generally, been followed by rapidly fatal accidents, — a statement 
 supported by the cases reported by Johnson, Cleghorn, Denman, 
 Scudamore, Ford, Lizars, Dupuytren, Delpech, Seymour, Madame 
 Boivin,and several other practitioners whom it would be useless to cite. 
 
 Though tapping is sometimes successful, or, at least, renders life 
 more bearable, it ought never to be decided upon hastily ; whether 
 because the uterus or intestines, etc., may be wounded, examples of 
 which we could cite ; because it may determine rapidly fatal inflam- 
 mations and hemorrhages ; or, because it may occasion a debility 
 which increases so rapidly as to carry off the patient in a few days ; 
 or, finally, for the reason that it fails in lessening the size of the abdo- 
 men when the dropsy is formed of several small cysts, or when the 
 substance of the tumour is gelatinous and too consistent to escape 
 externally. There is still another reason which ought to deter prac- 
 
 * In a case of dropsy, supposed by J. Latham to be seated in the ovary, tapping 
 was performed one hundred and fifty-five times, and five thousand seven hundred 
 and twenty pints of fluid evacuated, and, in this way, the life of the woman was pro- 
 longed for several years. (Philosoph. Transact., vol. lxix. part i. p. 54, 1779.) In the 
 same collection, vol. lxxiv. part ii. p. 471, year 1784, is the history of a case of dropsy 
 of the ovarium, communicated by Ph. Meadon, Martineau and John Hunter, which is 
 remarkable for the number of times that tapping was performed, and especially for 
 the quantity of fluid evacuated. The patient underwent eighty operations, in the 
 space of twenty-six years, and furnished six thousand six hundred and thirty-one 
 pints of fluid. In the second volume of the Medical Communications, it may be seen 
 that Ford tapped the ovary forty-one times, at very close intervals, because the col- 
 lection formed with constantly increasing rapidity. These operations furnished two 
 thousand six hundred and eighty-six pints of serous fluid. 
 
430 
 
 DROPSY OF THE OVARIUM. 
 
 titioners from performing paracentesis of the ovarium, except in the 
 last extremity ; which is, that the good which results from it is almost 
 alwa5^s ephemeral, and that the collection reappears after each opera- 
 tion, with a constantly increasing rapidity. 
 
 When compelled to resort to tapping, it should be performed in 
 the following manner : first, after arranging the woman so that the 
 tumour becomes as salient as possible, we must search for the point 
 where fluctuation is most marked, and where the cyst seems to be 
 thinnest, and then the trocar must be introduced obliquely towards 
 the side in which is the diseased ovary, so as to avoid wounding the 
 uterus. 
 
 For the purpose of obtaining a radical cure, by inducing sudden 
 inflammation of the cyst, as for the cure of hydrocele, injections have 
 been recommended; but this method was not followed by the success 
 looked for. Scudamore’s patient, referred to by Lizars,* treated by 
 port-wine injections, died some weeks after the operation. M. Rams- 
 den,t surgeon to St. Bartholomew’s Hospital in London, who had 
 injected the same kind of wine, mixed with water, in two similar 
 cases, saw his two patients perish from the effects of the inflamma- 
 tion ; the woman, mentioned by Denman, died at the end of six days; 
 lastly, vinous injections, employed on a single occasion, under the 
 same circumstances, by Dr. Martini, £ of Lubeck, were not followed 
 by any appreciable result. 
 
 With a view slowly and gradually to inflame the parietes ‘of the 
 cyst, reduced to a small volume, it has been attempted to convert the 
 wound into a fistula, by means of a sound or tent retained perma- 
 nently in place. This method succeeded with Dehaen, [Ratio Me- 
 dendi , t. ii. p. 255,) in a case in which the state of gestation and 
 the more or less considerable size of the womb, kept the pouch, 
 which had been emptied by the tapping, constantly compressed. 
 Portal also relates a successful case, treated by the same method ; 
 lastly, M. Seymour [toe. cit., p. 103) says that of three patients 
 treated in this way by Dr. Key, only one recovered, while the other 
 two died, soon after, of acute inflammation and profuse suppuration. 
 
 When often repeated tappings, or the permanent retention of 
 a catheter in the wound, give reason to fear the development of too 
 acute an inflammation, and also when the tumour contains matter 
 of a gelatinous consistence, Ledran§ proposed treating the disease by 
 incision, in the way Delaporte|| practised it. The latter surgeon, by 
 means of an incision four or five inches in length, succeeded in ex- 
 tracting, from an ovarian tumour, sixty-seven pounds weight of a 
 thick and gelatiniform matter ; the patient dying thirteen days after, 
 other cysts were found filled with the same substance, a portion of 
 which had escaped into the abdomen through certain ulcerations in 
 the principal cyst. The two cases, given by Ledran.are such as to give 
 
 * Edinburgh Medical and Surgical Journal, No. 81. 
 
 f Cooper’s Surgical Dictionary, vol. ii. p. 255. 
 
 * Journal Hebdom. de M£d., t. ii. 1829. 
 
 § Memoires de l’Acad. de Chirurgie, t. xi. pp. 421 and 442. 
 
 | Idem. (loc. citato,) p.452. 
 
DROPSY OF THE OVARIUM. 
 
 431 
 
 greater encouragement to such attempts ; for, in one of the pa- 
 tients operated upon, the wound remained fistulous, and, in spite of 
 a second incision, rendered necessary by an abscess in the hypogas- 
 triurn and a scirrhous affection of the ovary which daily augmented 
 in size and complicated the dropsy of the organ, death was deferred 
 for several years, during which time the patient enjoyed tolerable 
 health. In the second patient, operated upon by the same surgeon, 
 the cure was radical, although a number of accidents occurred; 
 among others, a suppuration, at first abundant and fetid, but which, 
 after diminishing, continued to discharge, through a fistulous open- 
 ing, for two years. Notwithstanding the cases just mentioned, and 
 the complete success obtained in some similar to that of Delaporte, 
 by Dr. Houston, quoted by Monro, (loc. cit., p. 225,) and by Portal, 
 Denman, and MM. Hay and Ramsden, we agree with Richter,* 
 that the laying open of the cyst of the ovary generally hastens the 
 death of the patient by the induction of very extensive inflammation, 
 and that, where the consequences are not immediately fatal, almost 
 all the patients perish, before long, from subacute peritonitis or hectic 
 fever. 
 
 As neither single nor multiple tapping, nor incision, promises ad- 
 vantage, when ovarian dropsy is complicated with scirrhous degene- 
 ration, or when the tumour is multi-locular, and divided into a larger 
 or smaller number of cysts, several practitioners, among others Felix 
 Plater,! Diemerbroeck,f Power and Darwin, §, Vanderhaar, quoted 
 by Logger, {de ovariorum morbis, p. 76,) Delaporte and Morand, 
 [loc. cit..,) Siebold, Lizars, {loc. cit.,) etc., have recommended the 
 extirpation of the whole of the diseased organ, as is done almost with 
 impunity in the females of various animals, for the purpose of render- 
 ing them sterile. 
 
 Notwithstanding these cases, and although the loss of both or a 
 single ovary has happened in women, without fatal results, either 
 after operations performed for ends not medical, || or after a wound, 
 instances of which are cited by Franck of Francknau, Poot, by Las- 
 sus and by M. Deneux, the methodical extirpation has been rejected, 
 in all cases, by Dehaen, {loc. cit., t. ii. p. 88,) by Morgagni, {epist. 38,) 
 by Sabatier, by Gardien, by M. Murat and several other distinguished 
 surgeons. This method, which, in the opinion of the writers, ought 
 to be erased from the list of useful operations, is, to a certain degree, 
 
 * Anfrangs gruende der Wundarzneykunst, th. v. p. 128. 
 
 -j- De Mulier. part, generat. dicatis., 1597. 
 
 \ Anat. corporis huraani, 1679. 
 
 § Zoonomia. 
 
 |] Isbrand de Diemerbroeck, (Opera omnia anat. loc. cit.,) relates that Adrometes, 
 according to Athenseus, and Gyges, King of Lydia, according to Suidas, often caused 
 the ovaries to be extirpated in women of their kingdoms, for the purpose of making 
 them barren. According to some authors, this custom, as barbarous as it is immoral, 
 prevailed among the Egyptians and some other of the eastern nations also. 
 
 Jean Wier, who died in 1588, says (Med. obs. rarior) that a sow-gelder, suspecting 
 the virtue of his daughter, opened her abdomen, drew out the uterus, and cut off the 
 ovaries. The author adds that this cruel operation was followed by complete 
 success. 
 
432 
 
 DROPSY OF THE OVARIUM. 
 
 justified by several cases of cure, obtained by Lemaunier,* by Pa- 
 roisse, and by Dr. Smith, t as well as by thp three cases of Dr. Mac- 
 do well, related by Lizars, ( loc . cit.,) by the extirpation of the ovarium, 
 successfully performed by the last-named surgeon, and another time 
 by Dr. Chrysmer, [Archives de Med., t. xx.) Finally, it is justified, 
 in part at least, by the cases communicated by Delaporte, Lieutaud 
 and Kapser, and by the more or less successful attempts of Lemman, 
 Delpech, Nathan, MM. Lafflize, of Nantes, Ischier, Dzondi, Halles, 
 and of some others. 
 
 We ought to state, moreover, that though the operation has some- 
 times been crowned with success, it has more frequently been fol- 
 lowed by unfavourable results. One of the four women operated 
 upon by Lizars, survived only fifty-four hours. A patient of Dr. 
 Martini’s ( Arch.de Med.,X. xx.,) and two others, operated upon by Dr. 
 Chrysmer, also died a few hours afterwards. We will add, moreover, 
 that the operation has had to be abandoned, in different cases, after 
 the incision of the abdominal parietes, by a surgeon of whom Sir A. 
 Cooperi speaks, as well as by MM. Lizars, Grenville, (/oc. cit.,) Dief- 
 fenbach, (Arch, de Med., t. xx.,) and by Galenzowski, of Wilna. 
 W T hen the cyst was exposed to view, these able practitioners deemed 
 it imprudent to extirpate it, either because of numerous adhesions 
 that had been formed, or because of the great number of large ves- 
 sels which it would have been necessary to divide. 
 
 W r e conclude, from the cases that we have just related, that the 
 extirpation of the dropsical ovarium is an operation which may 
 present great difficulty and always the greatest dangers. Without 
 wishing to proscribe it entirely, we are of opinion that it ought not 
 to be resorted to except as an extreme resource, and only where the 
 mobility of the tumour gives a certainty, in some sort, that it has not 
 contracted adhesions, or that they are at least of small extent. A 
 very large cyst, the least uncertainty in the diagnosis, § a complication 
 with ascites and different indurations, are circumstances which con- 
 tra-indicate the operation. We will add, that it ought not to be 
 attempted, even under the most favourable circumstances, unless the 
 patient earnestly desire it. 
 
 If we determine that the operation offers the only chance of safety, 
 the tumour ought to be exposed, by an incision in the most suitable 
 point of the abdomen, by an incision parallel to the axis of the body, 
 and of as small extent as possible ; that is to say, from three to five 
 or six inches ; then, if the cyst were adherent, it would be necessary 
 to endeavour, after the example of Dr. N. Smith, to empty it with 
 the trocar, and afterwards remove it, taking care to destroy the 
 adhesions, either with the fingers and handle of the scalpel, or by a 
 
 * Mem. de la Societe Royale de Med., 1782, p.296. 
 
 t Edinb. Med. and Surg. Journal, No. 72, 1822. 
 
 * Diet, of Pract. Surgery, by S. Cooper, vol. xi. p. 256. 
 
 § The diagnosis is sometimes so uncertain that M. Lizars (Edinb. Med. Journal, 
 No. 81) acknowledges, with a candour above all praise, that he mistook a swelling of 
 the abdomen, resulting from obesity, for a dropsy of the ovary, and that he did not 
 perceive his mistake until after he had made an extensive incision in the abdominal 
 parietes. 
 
DROPSY OF THE OVARIUM AND TUBES. 
 
 433 
 
 careful dissection, should these means prove insufficient. Either 
 ligature or torsion of the vessels ought likewise to be performed, as 
 they are divided. Should the cyst be free, movable and isolated, 
 and have a narrow pedicle, it is sufficient to tie its root firmly and 
 divide it beyond the ligature, with a bistoury, or with long scissors, 
 curved on their flat surfaces. In case the tumour were fungous, and 
 had a large base, with numerous vessels of a large size, it would be 
 better not to touch it, but to close the wound, as was done by MM. 
 Lizars, Grenville and Dieffenbach. It is well to add, that the edges 
 of the wound, ought to be held together by adhesive strips or with 
 the suture, when the division is very extensive. 
 
 We shall conclude by saying, that since ovarian tumours are 
 rarely composed of a single cyst, since they are often, on the contrary, 
 multilobed, and adherent at several points ; as they contain, in the 
 greater number of cases, something more than serosity, and as, more- 
 over, the dropsy, which almost always ends with attacking both ovaries, 
 is not unfrequently complicated with other lesions which render the 
 diagnosis more obscure and the prognosis more unfavourable, we are 
 tempted to say, with the celebrated Hunter, ( Medical Observ. and 
 Inquiries, vo\. ii.,) that the patients would often be more jikely to 
 prolong their existence, if no attempt were made to deliver them of 
 their disease. 
 
 Dropsy of the Fallopian tubes, being dependent upon the same 
 causes and presenting the same symptoms as that of the ovaries, with 
 which it is almost always complicated, and from which it cannot be 
 distinguished until after death, we shall be content with saying that 
 medical treatment is the same, and that, though tapping has seemed, 
 in some cases, to palliate the disease and prolong the lives of the 
 patients, it has generally been very soon followed by death. We 
 remark, that, the matter they contain is often thick and gelatinous, 
 and that, like the ovaries and uterus, they are sometimes distended 
 by hydatids, and majr acquire an enormous size. Dehaen ( loc . cit., 
 U iii. p. 29) speaks of an enlarged Fallopian tube, which weighed 
 seven pounds, and contained twenty-three pounds of fluid. Frank 
 (de cur. ret., lib. vi. p. 130) saw one which contained thirty-two 
 pounds of serous and gelatinous matter. Finally, Blancard ( anat . 
 prat, rat.) met with a tube distended by one hundred and twelve 
 pounds of serosity. It is true, that the ovary and broad ligament 
 likewise formed part of the same cyst. In women who die of this 
 disease, the tubes are tortuous, thickened, elongated, having the 
 appearance of the large intestines, and being larger in proportion 
 as they approximate to the ovary. Sometimes they enlarge sud- 
 denly, and are pyriform or spheroidal in shape. 
 
 OF CANCER OF THE OVARIUM AND OTHER DEGENERATIONS OF 
 THAT ORGAN. 
 
 The ovarium, like the uterus, may exhibit various morbid growths 
 and degenerations, upon which we shall say but a few words, be- 
 cause any circumstantial details that we might give, would be, in 
 28 
 
434 
 
 CAKCER OF THE OVARIUM, ETC. 
 
 some sort, a mere repetition of what we have said in the preceding 
 chapters. 
 
 Amongst the transformations of the ovaries ought to be ranked the 
 fibrous transformation , which bears so strong an analogy to that of 
 the uterus that it is often impossible to determine the true seat of the 
 tumour, not only during the life of the patient, but even with the 
 anatomical specimens before the eyes. These fibrous productions, 
 which not unfrequently co-exist With those of the uterus, and which, 
 like those of that viscus, may be developed either at the surface, or 
 within the proper tissue of the organ, vary prodigiously in size and 
 weight, since they have been known to weigh from a drachm to more 
 than forty pounds. M. Cruveilhier* lately found, in a woman who 
 died at the Salpetriere Hospital, a tumour of the ovary, weighing 
 forty-six pounds. We ought to state, also, that this organ may, like 
 the uterus, become the seat of cartilaginous,! osseous.! petrous, § 
 tubercular|] and melanic^ transformations, which can be recognized 
 only by autopsical examination. 
 
 Of all the degenerations of the ovary, the cancerous is, beyond all 
 contradiction, the most important to study, because of the frequency 
 of its unfortunate results, and of the terrible pain it almost always 
 occasions. Cancer of the ovary may, like that of the womb, present 
 itself in every form, which are often combined together or with other 
 alterations. Nevertheless, scirrhous and encephaloid cancer, which 
 are always rather hard to distinguish from each other even after 
 death, have been more frequently observed than the other varieties 
 that we pointed out while treating of this disease when situated in the 
 uterus. 
 
 Cancerous ovaria sometimes attain a very large size, and, in that 
 case, alter all the relations of the surrounding parts to each other. 
 Morgagni speaks of a cancerous ovary which weighed twenty-four 
 pounds. M. Velter saw one weighing fifty-six pounds, and M. Caillot 
 another of the same weight. 
 
 The causes of cancer of the ovary are but little known ; every 
 thing, however, tends to make us suppose that the degeneration has 
 the same origin as chronic ovaritis, of which it is often the termi- 
 nation. All that we can say positively is, that cancer of the ovary 
 is met with at least as frequently as that of the breasts, and that it 
 yields in frequency only to that of the uterus, with which it coin- 
 cides sometimes consecutively. 
 
 The symptoms of the disease are very obscure in the early stage 
 of its existence ; later, when the increase of the tumour might lead 
 to the suspicion of a cancer of the ovary, it is difficult to distinguish 
 
 * Dictionnaire de m^decine et de chirurg. prat., t. xii. p. 414. 
 
 t Kluisken, Annales de litter, etrang., t. ix. p. 336. Dupuytren, Bulletin de la Fa- 
 culte de Med., No. 3, 1806. Caillot, Acad^mie de Med., Jan. 13th, 1824. Velter, idem, 
 July 12, 1825. 
 
 * Logger, De ovarior. morb., p. 12. Seymour, loc. cit., p. 56. 
 
 § Haller, Disput. ad morb., t. iv. p. 420, (d’apres, Schleuker.) Saviard, Nouv. reeueil 
 d’ob.serv., 1702. 
 
 I| Seymour, loc. cit. Tonnele, Journal bebdom. de m£d., t. v. 1829. 
 
 1 Morgagni, de sedibus et caus. morb. epist., 21, 22, 31, 39. 
 
CANCER OF THE OVARIUM, ETC. 
 
 435 
 
 it from the other vital lesions Of which we have just spoken ; in 
 proportion as the disease advances, the pain, which i$ felt in one of 
 the sides of the pelvis, and which was dull and not continued at 
 first, becomes more acute, and assumes more and more the character 
 of that belonging to the cancerous degeneration. 
 
 When the disease appears in the scirrhous form, the tumour grows 
 slowly, and it has sometimes been known to augment insensibly for 
 ten and even thirty years, without giving rise to any marked de- 
 rangement of the functions, or to very acute pain; often, the only 
 inconveniences which the patient experiences are sensation of unea- 
 siness, proportioned to the weight and development of the scirrhus, 
 and some disorders of the menstruation, which, moreover, are far 
 from being always present. Encephaloid cancer, on the contrary, 
 grows with rapidity, may become enormous in a few months, and 
 cause the lancinating pains characteristic of the degeneration. When 
 the disease approaches a fatal termination, the tumour, which be- 
 comes irregular, and more and more enlarged, softens in certain 
 points; the shooting pain, which has been compared to the pricking 
 of needles, becomes more and more severe, and extends to the neigh- 
 bouring parts, to the uterus, vulva, loins and thigh corresponding 
 to the diseased side ; haemorrhages, discharges of an ichorous cha- 
 racter and disgusting odour, escape from the vagina, which, by exten- 
 sion of the degeneration, often produces fungous vegetations, of 
 a granulated and livid reddish appearance. The pains extend sym- 
 pathetically to the knees, the legs, the breast and the shoulders ; the 
 stomach, particularly, is affected; the digestion is imperfectly per- 
 formed ; the patient, who acquires an extreme disgust for food, is 
 also troubled with nausea and vomiting, together with obstinate con- 
 stipation of the bowels ; lastly, a state of insomnia, amounting to 
 almost absolute sleeplessness, a permanent condition of hystericism, 
 rapid emaciation, and continual fever, are harbingers of her approach- 
 ing end, the inevitable result of this scene of pain. 
 
 The diagnosis of cancer of the ovary, while in the state of scirrhus 
 properly so called, is always difficult, especially in the early stages of 
 the attack ; but where the disorder is more acute, the hardness of the 
 tumour, the absence of any fluctuation, and lastly, the lancinating 
 pains, sufficiently distinguish it from encysted dropsy, from fibrous 
 tumour of the uterus, and from extra-uterine pregnancy ; we may 
 also avoid confounding the symptoms with those of great masses of 
 faeces accumulated in the caecum, or colon, by remembering that tu- 
 mours produced by the causes last mentioned appear and disappear, 
 and change their situation, according to the posture of the patient ; 
 besides, the Touch per vaginam, and the origin and antecedents of the 
 disorder largely contribute to the dissipation of every doubt. 
 
 The prognosis , although always serious, differs according to the 
 form of the cancer, the volume of the tumour, and the complications 
 of the disease. Encephaloid degeneration is the most serious of all, 
 and the one whose termination is most speedily fatal. But, with 
 regard to the ovary, we make the same remarks as with regard to 
 the uterus ; that is to say, according to the order of gravity in these 
 
436 
 
 CANCER OF THE OVARIUM, ETC. 
 
 varieties, the first to be named is the encephaloid cancer, the one 
 most frequently met with in dissection, next the haematode or blood- 
 cancer, which has been thrice noticed by Hooper,* the fungous 
 cancer, of which Professor Proschaska has given a description, ac- 
 companied by a drawing, {Disc, or g arris mi corpor. human ., plate v,) 
 and lastly, the scirrho-cancer, which is the first stage of the other 
 kinds, and the least unfavourable as regards its diagnosis, for we 
 may often succeed in arresting its growth. We may add, that it 
 frequently co-exists with encysted dropsy of the ovarium, with which . 
 it makes a distressing complication, or of which it may be either the 
 effect or the cause. 
 
 The treatment of the degeneration under consideration, ought to 
 be merely palliative ; for, in spite of the pretended cures published 
 by certain authors, the disease is beyond the resources of medical 
 therapeutics. Small venesections, prolonged bathing, narcotics, de- 
 mulcent and cooling drinks, emollient and anodyne enemata, gentle 
 laxatives, a mild regimen, principally vegetable, — such are the 
 measures, by the prescription of which we may succeed in mo- 
 derating the violence of the symptoms, and retarding the progress 
 of the malady. Where the menses are suppressed, which is often 
 the case, we should endeavour to recall them, or supply the want 
 of them by applying leeches to the vulva or anus, in small num- 
 bers at each time ; or we might equally well establish issues, and give 
 orders for douches of sulphurous or alkaline solutions ; mercurial 
 frictions made upon the tumour, and the internal use of cicuta, and 
 the other so-called anti-scirrhous articles mentioned in our remarks 
 upon cancer of the womb, should be turn by turn attempted, with a 
 view not to cure, but to console the patient. Where the scirrhous 
 tumour has become softened, and taken on the encephaloid character, 
 or any other of the cancerous transformations, the treatment, which 
 ought to be varied according to the nature of the symptoms, should 
 consist of cares accessary and subordinate to the precise kind of 
 inconvenience suffered by the sick person. We further add, that, 
 in this disease, as well as in dropsy of the ovarium, the extirpa- 
 tion of the organ has been proposed, and which, as we have seen in 
 the preceding chapter, has been sometimes crowned with success. 
 We think, however, that the results, as yet obtained, are not sufficient 
 always to justify so grave an operation, and that too much blame could 
 not be cast upon any attempt of the kind in a patient exhibiting the 
 signs of the cancerous diathesis, a degeneration of the same sort affect- 
 ting any other organ, or, in fine, an hereditary disposition to cancer. 
 
 Although the Fallopian tubes are subject to the same diseases as 
 the ovaries, we shall not treat of them here, as any details we might 
 give would be of no avail in enlightening the practitioner as to the 
 treatment, and would be interesting only in a treatise on pathological 
 anatomy, for the different lesions of the tubes can only be determined 
 upon the dead and not upon the living body, and since, also, they 
 almost always coincide with the diseases of the ovarium. 
 
 The Morb. Anat. of the human uterus, pi. xxi. 
 
CANCER OF THE VAGINA AND EXTERNAL GENITALS. 
 
 437 
 
 CANCER OF THE VAGINA AND EXTERNAL ORGANS OF GENERATION. 
 
 Cancer of the vagina may be either a primary disorder, or a mere 
 extension of cancer uteri, or of the same malady, situated in the 
 external genitals. When primary, it may arise from the simple 
 degeneration of' an eroded point, a simple or syphilitic ulcer, a ne- 
 glected or ill-treated cancerous excrescence, or from ulceration of a 
 scirrhous induration situated in the lining membrane, or in the proper 
 texture of the vaginal parietes. Primary cancer of the vagina is a 
 somewhat less serious affection than cancer of the womb, especially 
 when it is situated near the orifice of the vulva. A cancer, conse- 
 cutive of one of the womb, is far more serious, for it is a complication 
 and an extension of the primary malady, whose fatal result is greatly 
 accelerated by it. 
 
 Cancer of the clitoris generally commences like cancer of the 
 penis at the glans. Whatever be the form under which it attacks, it 
 may depend upon an irritation proceeding from syphilitic ulcers, 
 from solitary erotic excesses, from frequent and prolonged frictions 
 and excitation. Under the influence of one or more of these causes, 
 the clitoris has been found to grow to the size of the thumb, and 
 sometimes to give risq to a pediculated fungous tumour of the size of 
 the fist, presenting a softish mass of a whitish livid or reddish colour, 
 covered with bunches of granulations secreting an ichorous fluid. 
 
 Cancer of the meatus urinarius, like cancer of the nymphse, 
 almost invariably arises from degenerated ulcerations, whether of a 
 simple or syphilitic nature, irritated by the permanent contact of 
 the urine, or by improper dressings. The same may be stated as to 
 cancer of the labia pudendi, whose vascular tissue is very irritable, and 
 exhibits, in a high degree, a structure favourable to the development 
 of the cancerous ulceration. The vaginal discharges and the fric- 
 tions from walking, or frequent coitus, may likewise contribute much 
 to the production of cancer of the labia, and the other organs apper- 
 taining to the vulva. We add, that the carcinomatous affections of 
 these parts, like those of the vagina, may also be the disastrous 
 consequences of the gradual spread of the same vice from a pri- 
 mary development of it in the womb. It is well, too, to remember, 
 that the inverse of this proposition may hold good, that is, that the 
 disease may extend from the vulva along the vagina, and thence 
 to the womb itself. 
 
 As there is generally some uncertainty as to the nature of the dis- 
 order, it is always well to begin the treatment by the use of mercu- 
 rials, both locally and internally exhibited, and that conjointly with 
 antiphlogistics, and especially topical bleeding, and emollient and nar- 
 cotic fomentations. Should the symptoms, instead of ameliorating, 
 become exasperated, it might be deemed necessary, in order more 
 certainly to arrest the progress of the evil, to resort to certain surgical 
 operations which we are about to describe. Where the disorder is 
 confined to the vagina, we are restrained to the use of a mere pal- 
 liative treatment ; should it, however, be found to be superficial, and 
 should it appear possible to destroy all the parts affected, recourse 
 might be had to cauterizations, with the liquid acid-nitrate of mer- 
 
438 (EDEMA, VARIX, AND OTHER VULVAR TUMOURS. 
 
 curv, or even with the arsenical paste. Should the mischief, how- 
 ever, not extend beyond the orifice of the meatus urinse, the whole 
 of that point might be removed with the bistoury. The canal of 
 the urethra, be it observed, cicatrizes very readily, and continues to 
 perform its functions, even where it has been curtailed of several 
 lines of its length. The operation is performed with a pair of pin- 
 cers, and a scissors curved Qn the flat, which serve equally well for 
 the incision of the clitoris and of the nymphae. To the bleeding that 
 follows these several operations, the usual haemostatic remedies 
 are directed, but especially the actual cautery, which possesses the 
 additional value of being useful for the utter eradication of the last 
 vestiges of the disease ; should the disease reappear, it should be 
 again attacked either with the knife, the red-hot iron, the nitrate of 
 silver, or the liquid acid-nitrate of mercury. 
 
 The treatment of cancer of the labia is likewise wholly chirur- 
 gical, that is to say, it consists in the extirpation of the parts affected. 
 The operation is in general neither tedious nor difficult, and when 
 the case requires it, we may venture to remove almost the whole of 
 the external genitals, for experience has proven that few very seri- 
 ous inconveniences, and but very little disturbance of the functions, 
 are the consequences of the operation. The bigeynorrhage ought espe- 
 cially to attract our attention ; for, as the blood oozes from almost 
 every part of the wounded surface, we are often obliged to arrest it 
 by means of the incandescent iron. In cases where the cautery 
 might not appear to be indispensable, and with a view to obviate 
 the attack of a secondary htemorrhage, pressure might be made on 
 the bleeding surfaces with small balls of charpie sprinkled with resin 
 or ashes, and covered with several discs of agaric, sustained by 
 compresses and a T bandage. We ought to observe, that previously 
 to commencing the dressing, it is important to introduce and secure 
 a catheter in the bladder, so as to allow a free passage to the urine, 
 and keep the dressings from becoming soaked with it. Care should 
 also be taken to plug up the orifice of the womb with charpie, to 
 hinder any blood that might still continue to flow, from getting 
 within, and remaining within the canal of the vagina. It is hardly 
 requisite to remark, that for the performance of these operations, the 
 woman must be placed in the same manner as for the application of 
 the speculum. 
 
 OF (EDEMA, VARIX, AND OTHER TUMOURS OF THE VULVA. 
 
 (Edema of the labia is generally the extension of anasarca pro- 
 ceeding from ascitic dropsy, or from the state of pregnancy. Some- 
 times it accompanies a local inflammation, especially an erysipelas, 
 but it then becomes a more serious matter than the cedematous en- 
 gorgement from the other causes we have mentioned. 
 
 (Edema of the vulva is known by a certain swelling of the labia 
 externa, which becomes tense, shilling, of a rose colour, transparent, 
 very little sensitive to pressure, and retaining the impression made 
 by the fingers when pressed upon the surface. 
 
(EDEMA, VARIX, ETC., OF THE VULVA. 
 
 439 
 
 This oedematous engorgement of the labia majora looks like a 
 thick and protuberant cushion, which may become so very large as to 
 interfere with the act of walking, become an obstacle to that of par- 
 turition, and also prevent the proper exercise of the Touch per vagi- 
 nam, by hindering the point of the finger from penetrating as far as 
 the os tincse. 
 
 The surgical treatment of oedema of the labia consists in a steady 
 compression of the parts ; but when the swelling is very great, we 
 should attempt to discharge the fluid by means of small, shallow 
 punctures made with the point of a lancet. An inflammatory 
 oedema accompanied with fever, demands the use of antiphlogistics, 
 such as venesection, the application of leeches to the inside of the 
 thighs, and not to the diseased parts; cooling drinks, emollient, nar- 
 cotic and slightly resolvent applications ; and, lastly, dieting, and rest 
 in a horizontal posture ; such are the remedies. 
 
 Varices of the labia constitute a rather rare affection, which differs 
 from all other tumours of the vulva by the following characters: the 
 dilated veins form beneath the skin on one side, and the mucous mem- 
 brane on the opposite side of the labium, certain nodosities or lumps, 
 which are more or less protuberant as they are of an older or 
 fresher date. The tumours are indolent upon pressure, of a bluish 
 colour, and a consistence so soft that they disappear under pressure, 
 to reappear again as soon as the pressure is taken off. In some 
 cases these tumours become irritated, and then they inflame, when 
 they become the seats of fungous ulcers difficult to heal. It should 
 be also stated that what renders the disorder in some instances quite 
 distressing, is the pruritus of the sexual parts with which it is accom- 
 panied. 
 
 The principal causes of varix are too frequent coitus, and particu- 
 larly the violent frictions that may attend it ; pregnancy, too often 
 repeated ; laborious labours, and the repeated and prolonged irrita- 
 tions they give rise to. These circumstances are especially favoura- 
 ble to the development of the disease in females in whom the veins 
 are of a large size, dilatable, and with coats that have but little resist- 
 ing power. 
 
 The treatment of varix of the vulva is very simple; the disorder 
 often disappears spontaneously upon the cause that produced it ceas- 
 ing to act. When the labia are indolent, recourse is mostly had, and 
 with advantage, to cold and astringent topical remedies, such as com- 
 presses moistened with liquid acetate of lead, a decoction of tan, or 
 Provence roses, or a weak solution of sulphate of alumina in a mix- 
 ture of water and claret. To these remedial measures should be 
 added an entire abstinence from the coitus, and a steadily maintained 
 compression of the parts, where that can be effected without too 
 great a degree of inconvenience. Cases of painful and irritative varix 
 should be managed by means of rest, opiated cerates, topical bleed- 
 ings, and, lastly, by using the chloruret of the oxide of sodium as a 
 lotion where the varicose tumours have become the seats of ulcera- 
 tion. 
 
 Encysted tumours of the labia are of sufficiently frequent occur- 
 
440 
 
 (EDEMA, VARIX, ETC. OF THE VULVA. 
 
 rence, and are easily distinguishable from all other tumours of the 
 labia pudendi, by their rounded and circumscribed form ; they occa- 
 sion no alteration in the colour of the skin; their consistence is some- 
 what fluctuating, and their substance, which is neither pasty nor 
 translucent, nor diffused, as in oedema, does not show the hardness 
 and the resistance of the fibrous tumours with which it is not difficult 
 to confound them. Besides, a mistake in the diagnosis is of no very 
 great moment, since the extirpation of the tumour is equally appli- 
 cable to both cases. 
 
 Encysted tumours of the vulva exhibit a resistance to the touch 
 that differs, according to the nature of the material contained within 
 them ; though the cyst, whose parietes are smooth, and of a whitish 
 colour, is mostly distended with a serous fluid, its cavity is in some 
 specimens found to be filled with a thick brown liquid. Cases are 
 seen of a spontaneous opening of this kind of tumour, which gives 
 rise to an inconvenient and constant oozing, which rarely dries up 
 without the assistance of art. 
 
 The treatment of encysted tumours of the labia majora, like that 
 of the fibrous tumours, consists, as we have already said, solely in 
 their extirpation, which is performed as follows : after placing the 
 patient in a proper posture, we seize the labium and turn it over 
 outwards, then fixing the tumour firmly by a finger behind it so as 
 to make it project more, a small incision should be made on the inner 
 surface, whether because the cyst or fibrous tumour is nearer to the 
 surface at that point, or because it is desirable to avoid making a 
 disagreeable scar. When the tumour is fairly uncovered, the sur- 
 geon should endeavour to detach it from all its connections by a 
 minute dissection, and pressing his finger behind it still more strongly 
 so as to make it project, he will remove it as completely as possible 
 with the scissors. Should the cyst happen to be laid open during 
 the operation, it is proper to remove every part of it that can be 
 reached, and then cauterize the whole internal surface of the wound 
 with a view to prevent the reproduction of the disease. In case of 
 profuse haemorrhage, it might be treated by the ligature, but above 
 all, by the incandescent iron. 
 
 The mucous surface of the labia may also, in certain cases, become 
 the seat of small pediculated polypous tumours, distinguishable by 
 their shape from the vegetations of cancer and syphilis, and which 
 are treated by exscinding them with scissors curved on the flat. It is, 
 further, not very rare to see lipomatous tumours growing in the sub- 
 stance of the labia ; they offer the same character as similar tumours 
 in other parts of the body, and require the same curative means, 
 that is to say, as complete a removal and destruction as possible. 
 The incision also suits for the removal of certain vegetations or par- 
 tial hypertrophies of some of the vulvar tissues, such as warts, 
 small cellular tumours filled with serosity, the venereal poireaux , 
 &c. Let it be added, that, when these tumours attain a certain size, 
 they become, though not painful in themselves, very inconvenient to 
 the patient, and give rise to constant dragging pains, extending as far 
 as the inguinal and lumbar regions. 
 
CANCER OF THE BREAST. 
 
 441 
 
 CANCER OF THE BREAST. 
 
 Cancer of the breast, from being very common, easily observable, 
 and moreover most accessible to the surgeon, has been more studied, 
 and has excited a more especial interest than the same malady in 
 any of the other organs of the body. This affection, beyond contra- 
 dictibn the most serious malady to which the breast is liable, is in- 
 comparably more frequent in the female than in the male, notwith- 
 standing the mammary glands are originally precisely alike in both 
 the sexes. It is easy to explain this happy privilege, and this differ- 
 ence in our favour, if we but reflect that the mammae in women 
 have a much more important function to perform than in men, and 
 are more exposed to the contact and influence of external causes, 
 and also suffer from irritations and sympathetic excitements growing 
 out of the state of pregnancy, the mensual periods, and ail the modi- 
 fications, whether normal or pathological, of the functions of the 
 reproductive organs. 
 
 This most serious disorder of the female breast seems preferably 
 to develop itself in the marriage state, after the lactations, in those 
 who have large breasts, and chiefly at the period of life corresponding 
 with that of the final cessation of the menses. Cancer of the breast 
 has been seen, however, at the age of twenty and of thirty, but 
 much more generally betwixt the thirtieth and fortieth year. 
 
 The occasional causes of cancer of the breast are either internal 
 or external ; among the latter are classed blows, falls, contusions, 
 the pressure of tight corsets, adjusted with a view to push the breasts 
 upwards, or, on the other hand, to flatten them, and lessen their appa- 
 rent size ; the bad habit indulged in by some women, of not sup- 
 porting the breasts, but abandoning them to their own weight; 
 the inconsiderate use of discutient and irritating topicals for the 
 breast when inflamed, or affected with simple and chronic engorge- 
 ments ; and lastly, the sudden impression of cold air, especially soon 
 after a confinement, and the astringent applications designed to check 
 the secretion of the milk. These are justly regarded as capable of 
 acting as the occasional causes of scirrhous indurations. We may 
 add, that it is generally agreed that chronic inflammations of the 
 breast, its milk engorgement, its herpetic, scrofulous, syphilitic and 
 other engorgements, may, in some instances, degenerate into cancer. 
 
 The internal causes of the affection under consideration, are, irre- 
 gularities and accidental suppression of the menstruae ; the cessation 
 of a long chronic leucorrhoea, or piles, or profuse habitual sweat; the 
 drying up of an old issue, the repercussion of certain exanthematous 
 disorders, of psoric and herpetic affections ; the metastasis of gout, 
 rheumatism, wandering erysipelas, as in cases of the kind reported 
 by Pouteau ; and a variety of other causes more or less evident ; 
 which, like those now above mentioned, are incapable of giving rise 
 to an attack of cancer, except where they coincide with some occult 
 cause whose essence is unknown, that is to say, a disposition which 
 is interior, and individual for the person who suffers, and which is 
 commonly designated by the term cancerous diathesis. According 
 to some practitioners, this mere disposition to have cancer suffices, 
 
442 
 
 CANCER OF THE BREAST. 
 
 in some instances, to give birth to the malady, while in others it may 
 co-exist with the whole duration of life, without exhibiting itself in 
 any external symptoms. It has further been supposed, that the can- 
 cerous diathesis does not always exist in the same degree of inten- 
 sity, which may explain why a slight irritation may be enough to 
 provoke the development of cancer, whereas, in other circumstances, 
 it requires the concurrent operation of many powerful occasional 
 causes, to give life to the malady. 
 
 Progress arid symptoms. A cancerous- degeneration of the breast 
 most commonly begins as a small tumour, more or less regularly 
 rounded, hard, circumscribed, movable under the finger, indolent, 
 without change in the colour of the skin, and situated, which is most 
 common, in some point of the adipose tissue of the breast, or in the 
 body of the mammary gland itself, whose parenchyma becomes hard, 
 heavy, compact, and more or less voluminous as to its size. 
 
 A scirrhous tumour that has formed in the adipo-cellular tissue of 
 the breast, may be readily circumscribed with the fingers, for it is 
 completely isolated by the cellular layers which surround it like the 
 walls of a real cyst. In the rarer cases, where the morbid indura- 
 tion has commenced by affecting the mammary gland itself, the ab- 
 normal tumour cannot be circumscribed, and runs into the sound, 
 parts in every direction, and is confounded with them. Where the 
 whole gland is invaded, it becomes transformed into an irregular 
 botryoidal mass with the nipple adhering to it, and enveloped in a 
 certain quantity of cellular and adipose tela. 
 
 During the early stages of cancer it often happens not only that 
 the health of the patient undergoes no depravation, but, on the con- 
 trary, it appears that her freshness and embonpoint actually improve. 
 Unfortunately, however, after the lapse of a period of uncertain dura- 
 tion, the progress of the disease comes to cheat all these false hopes. 
 In general, after having received some blow — some pressure, after 
 the natural or morbid suppression of the menses, or even without any 
 known cause, the isolated tumour grows rapidly, spreads in every 
 direction among the neighbouring parts, with which it forms adhe- 
 sions so as gradually to invade the whole breast. A scirrhus that 
 has begun by the mammary gland proper, also, under such circum- 
 stances, takes on a new power of extension, that is to say, after having 
 involved the entire gland, it seizes upon the adipose tissue round 
 about it, and continuing its progress from the centre to the circum- 
 ference, extends its ravages to the textures exterior to the mamma. 
 The patient, who began by feeling a sort of disagreeable itching or 
 tickling sensation in the breast, with a sense of heat and pricking, 
 now experiences deep dull pains, which next become lancinating, 
 and which, felt and lost by turns with the rapidity of lightning, are 
 compared to the thrusts of a needle or a sharp pen-knife, suddenly 
 forced through the breast. The skin covering the scirrhous indura- 
 tion becomes of a rose tint, has a polished appearance, and is tense; 
 the subcutaneous veins become nodose, distended with blood, and 
 perfectly distinct ; the nipple, which is attached to the glands by the 
 galactophorous tubes, and also by a resisting tissue, being unable to 
 follow the growth of the tumour towards the exterior, remains buried 
 
CANCER OF THE BREAST. 
 
 443 
 
 within a sort of pit, and in many instances becomes at last completely 
 effaced as the surrounding parts project more and more. 
 
 The malady, which ceases not its onward progress, soon changes 
 its features, and exhibits itself in its distinctive characters, sapping, 
 more or less furiously, the life of the unfortunate victim of its attack. 
 Now is the period arrived when the pain, becoming more frequent 
 and atrocious, and acquiring increased violence during the evenings 
 and nights, prevents the patient from tasting of repose, and introduces 
 a general perturbation of the economy. The tumour shows some 
 points more raised than the rest, and quite in relief above the surface ; 
 the skin that covers each of these reliefs, and that has taken on a 
 deep red or livid hue, grows thin, cracks, and is covered with fissures 
 which discharge an ichorous serosity, the colour and fetor of which 
 vary, while its acrimony inflames and even ulcerates the neighbour- 
 ing parts. These fissures and ulcerations increase iff size, and 
 gradually approaching nearer and nearer to each other, are at last 
 fused into one horrible ulcer, whose edges roll outwards, while they 
 constantly grow thicker and harder. An ulcerated cancer of the 
 breast that has reached this stage, exhibits a knotty, grayish, wan- 
 looking surface, which, in some instances, overspreads itself with 
 reddish fungous vegetations, secreting a sanious, and generally very 
 foetid fluid. Lastly, frequent attacks of haemorrhage, arising from 
 the erosion of the vessels, sometimes assist in diminishing the severity 
 of pain, but for the most part, these sanguine discharges, instead of 
 doing any good, only serve to exhaust the remaining strength of the 
 patient. 
 
 Upon reaching this stage the disorder is no longer local, and those 
 general phenomena begin now to manifest themselves, whose en- 
 semble constitute the cancerous cachexy. Thus, the patient, who 
 loses her freshness and her embonpoint, and whose skin takes on a 
 yellow straw-colour, is now tormented with a dry and frequent 
 cough, attended with heat arid gnawing pain behind the sternum; 
 she is agitated with febrile paroxysms, suffers under extreme anxi- 
 ety, a distressing oppression, a great disgust for food, obstinate con- 
 stipation alternately with purging, and in fine, she has most of the 
 general symptoms denoting the cancerous cachexy, treated of in our 
 article on cancer of the womb. We should mention, that the sub- 
 clavicular glands begin to swell, and those of the neck and axilla 
 which have also swollen, become knotty and scirrhous. The arm 
 corresponding to the diseased side, in some cases becomes cedematous, 
 tense, painful, and incapable of motion. We have seen a cancerous 
 degeneration of the mammse invade not only the pectoral muscles, 
 but even expose the ribs and extend its ravages to the pleura costalis, 
 which had itself become exposed, thickened and fungous. 
 
 Cancer of the breast does not always pursue the development and 
 march we have here pointed out. Instead of always commencing 
 as a small hard rounded tumour, situated in the true parenchyma of 
 the mammary gland, or in the adipo-cellular tela surrounding it, it 
 invades suddenly, and almost at once, a great part or even the whole 
 of the breast. This form of cancer has been observed in very fat 
 women, who have attained to the period of change of life. The 
 
444 
 
 CANCER OF THE BREAST. 
 
 tumour, which occupied the entire breast, is a little flattened, hard, 
 movable with the rest of the breast, but not rolling. The skin above 
 it is always thicker than natural, and is united to it by so dense a 
 cellular tela, that it is not possible to make it slide over the surface 
 of the induration, or to pinch it up from the surface with the fingers. 
 
 As these changes in the density and size of the breast mostly take 
 place in the beginning, without giving rise to any pain at the time, 
 the woman does not discover it, for the most part, until the size of the 
 breast has considerably augmented, or until a clear bloody serosity, 
 escaping from the nipple, happens to soil her dress. The nature of 
 the evil soon leaves no uncertainty on the mind ; the teguments of 
 the indurated breast, after having, for some length of time, preserved 
 their colour, assume a darker cast, and exhibit certain tortuous emi- 
 nences produced by the blackish varicose veins of the part ; the pain, 
 which was at first tensive, soon grows into lancinating pain. The 
 mammary globe, whose size and density have gone on increasing, 
 exhibits upon its surface those knotty protuberances which, by ulce- 
 rating, give birth to the symptoms of the last stage of cancer. 
 
 The cancerous degeneration of the breast may likewise assume the 
 form designated by writers as soft cancer , which forms either in the 
 gland, or in the adipo-cellular tissue about it. In the commencement, 
 this variety is not only less hard than a scirrhus, but it grows also 
 with much greater rapidity. It is also distinguished from scirrhus 
 by knots that are much larger, softer, and having a sort of fluctua- 
 tion. This, moreover, is the form of cancer that is most likely to 
 retain its indolence, and in which the vessels also are most dilated. 
 When the tumour has attained a certain size it adheres more and 
 more closely to the skin, which grows red and violaceous as to tint, 
 and admits of our perceiving a much more decided fluctuation. If 
 a cutting instrument be plunged into the centre of the softened 
 portion, a bloody serum flows out ; when the tumour opens sponta- 
 neously, there generally springs from the opening a fungus like a 
 mushroom, which sometimes strangulates itself and falls off, which 
 makes the patient suppose herself to be cured, until one or several 
 such vegetations come to dispel her consolatory illusions. 
 
 [I saw such a cancer, which protruded in the breast of a primiparous 
 young lady. The tumour had been noticed eighteen months before her 
 marriage. The lactation developed the malady. It came out like a mush- 
 room, and was removed at the base of a sort of pedicle, by a ligature applied 
 bv my distinguished townsman, Dr. J. Rhea Barton. The cure is complete. 
 She has been confined again, and nurses her child without any menace. — M.] 
 
 It also happens, in some cases, that the tumour is formed by a great 
 cyst, containing from three to six ounces of bloody serosity ; the walls 
 of the cyst, which are generally smooth, resemble a serous surface, 
 and present at some point one or more fungi. This form of encysted 
 degeneration is the least mischievous, and least subject to relapse, 
 because, when the cyst is taken away, the disease is destroyed. 
 Where the cancerous tumour is not encysted, which is incomparably 
 the most frequent case, the diseased tissue, some portions of which 
 
CANCER OF THE BREAST. 
 
 445 
 
 resemble that of the spleen, is blended with the healthy tissues, and 
 this variety, a most dangerous one of mammary cancer, often termi- 
 nates by gangrene. 
 
 We ought still to treat of a variety described by Lassus: this author 
 says, ( Pathol . Chirurg. t. i.,) that there are some women, in whom, 
 at the age of forty or fifty years, the two breasts suddenly become 
 voluminous and as hard as marble. The tumefaction and hardening 
 extend to the shoulders and front of the chest, the skin is reddish 
 and marked with lines, the pain is excessive, the patient experiences 
 considerable difficulty of respiration, and may perish prior to the 
 ulceration of the tumour. It is to this variety that Professor Alibert 
 has assigned the name cancer tburne. 
 
 Finally, in some subjects, it is not the cellular tissue or glandular 
 portion of the mammae, which is primarily affected, but the skin 
 which covers them ; then are developed here and there upon the 
 surface of the integuments of the breast hard, rounded tubercles, of a 
 violet colour, increasing gradually in number and size, and blending 
 together little by little as they approach each other. The skin be- 
 comes hardened and wrinkled, and retracts upon the dried mamma. 
 Lancinating pains come on, the axillary glands become engorged, and, 
 before long, the disease produces its accustomed ravages. This variety 
 is allied to that which, according to Boyer, occurs at the critical age, 
 and in which the breast, instead of being engorged, becomes hardened 
 and shriveled from assuming a firm, compact consistence in one or 
 more points of its circumference. The indurated mamma, in this 
 form, adheres so firmly to the subjacent parts, as to become entirely 
 immovable, and seems attached by a very hard cord to the nipple, 
 which has almost diappeared. Pouteau, ( (Euvres Posthumes, t. i.,) 
 who likewise speaks of this variety of cancer of the breast, regarded 
 it as the most intractable of all. The progress and duration of cancer 
 of the mamma vary greatly in different cases ; we think it should 
 be divided into acute, chronic and stationary cancer ; the first 
 rapid in its progress, and lasting from three to six months ; when a 
 relapse takes place after the operation, it generally shows itself before 
 the cicatrization of the wound produced by the removal of the tu- 
 mour. Fabricius Hildanus states that, in the space of four months, 
 a cancer destroyed the whole of the breast and the neighbouring 
 parts. Professor Roux, ( Melanges de Chirurgie, p. 165,) speaks of 
 having seen the breast of a woman, at the critical period of life, 
 enlarge considerably and become covered with cancerous ulcerations, 
 which caused death in less than three months. Chronic cancer is 
 slow in its progress, and may last several years; it does not, in gene- 
 ral, relapse until after the cicatrization of the wound. Finally, station- 
 ary cancer , which is more rare than the preceding, passes through its 
 stages so slowly, that patients retain it during a greater or less num- 
 ber of years, and sometimes during a lifetime, as they often perish 
 at an advanced age, of some disease independent of the cancer. We 
 may add, that the progress of the mammary degeneration under con- 
 sideration, is more rapid in proportion as the tumour is larger, softer, 
 and more painful, and that those which relapse after an operation 
 have a very rapid course always. Let us remark, lastly, that cancer 
 
446 
 
 CANCER OF THE BREAST. 
 
 of the breast, like the different engorgements of that organ, some- 
 times seems to augment periodically at epochs corresponding to the 
 menstrual function. The pain and the tumour, which augment with 
 each return of the menses, diminish sensibly during the interval. It 
 may be well to remark, that the momentary improvement which 
 takes place at those periods, is generally attributed to the effect of 
 some new treatment, the good effects of which are always too hastily 
 proclaimed. 
 
 The termination of cancer of the breast, when left to itself, is 
 almost constantly in the death of the patient, which is generally de- 
 termined by the general symptoms, constituting the cancerous ca- 
 chexia. The woman may perish, also, before the disease has passed 
 through all its stages, from some complication; such, for example, as 
 acute or chronic pleurisy, hydrothorax, or general dropsy; some 
 dangerous affection of the intestinal canal, and finally gangrene, 
 which often attacks the mammae ; the last complication, which gene- 
 rally renders the prognosis still more unfavourable, may, in some 
 very rare cases, become a mode of cure by separating the diseased 
 from the healthy parts ; unfortunately, this mode of termination does 
 not preserve from relapse, and the hope of radical cure it gives 
 rise to, is often ephemeral. The spontaneous cicatrization of cancer, 
 without surgical treatment, of which MM. Nicod, Bayle and Cayol, 
 cite examples, is a termination still more rare than the preceding. 
 
 The diagnosis of mammary cancer is often obscure, especially at the 
 commencement of the disease ; an encysted tumour, with a hardened 
 base, for example, has sometimes been taken for scirrhus, but this 
 mistake is of no great consequence to the patient ; for, extirpation 
 is equally indicated in both. There have, likewise, been confounded 
 with scirrhus of the breast, not only the fibro-cartilaginous tumours, 
 which are sometimes developed there, but also chronic, venereal, 
 scrofulous, milky, and herpetic engorgements, etc., which, in some 
 cases, undergo the cancerous degeneration. These mistakes might 
 almost always be avoided by referring to the preceding history of 
 the patient, by tracing the march of the disease, and especially by 
 recalling the diagnostic signs which we are about to point out as 
 peculiar to the cancerous induration of the breast! 
 
 We may affirm, without fear of mistake once in a thousand cases, 
 that we have a scirrhous induration of the mamma, when we meet 
 Avith a tumour seated upon some part of that organ which is hard, 
 unequal, indolent, insensible to pressure, which has existed for more 
 than a year, resisted the treatment for chronic inflammations and 
 for scrofulous, milky and herpetic indurations, etc. ; which has 
 become the seat of sudden lancinating pains ; and lastly, which is 
 quite indolent and insensible during the intervals between the pains, 
 which may be compared to the pricking of needles. 
 
 The prognosis depends upon the nature of the disease; the stages 
 through which it has passed; the complications; the age and tempera- 
 ment of the patient; in a word, upon all the circumstances that may 
 exert a favourable or unfavourable influence. When the patient is of 
 strong constitution, young, well regulated, affected with a scirrhus in 
 the first stage, which lias been developed under the influence of some 
 
CANCER OF THE BREAST. 
 
 447 
 
 external cause, the prognosis is as favourable as it can be. The 
 disease resists, with great obstinacy, all curative means, when the 
 patient is irritable, nervous, melancholy or hypochondriacal. When 
 the tumour is voluminous, adherent, extended, irregular, lancinating, 
 softened in some points, and especially when it has been developed 
 spontaneously about the critical age, the prognosis becomes more 
 unfavourable ; but it is still more unfortunate when, to these symp- 
 toms, are added considerable engorgement of the axillary glands, 
 dyspnoea and cough ; and, to conclude, no hope remains when the 
 general symptoms are marked ; when the disease, after having passed 
 rapidly through its stages, still exerts an injurious influence upon the 
 constitution, and the tumour, ulcerated to a great extent, furnishes an 
 abundant sanious and fetid suppuration. 
 
 As the treatment of cancer of the breast has for its object not 
 merely to combat this affection after its development, it ought, there- 
 fore, to be divided into the conservative , curative and palliative. The 
 preservative treatment consists in preventing and combating, by the 
 most suitable means, certain diseases and derangements of the func- 
 tions which, in the opinion of the best practitioners, may prove to be 
 the sources of cancer — amongst others, suppression of the menses, 
 scrofulous, milky, herpetic and venereal engorgements, and the differ- 
 ent acute and chronic inflammations of the breast. The conservative 
 treatment of cancer of the mamma is nothing more, therefore, than 
 the curative treatment of the pre-existing disease. It is by this 
 method that the most distinguished practitioners, having dissipated, 
 by general and local antiphlogistics, and by resolvents, etc., the chronic 
 engorgements of the breast, have asserted positively as to their hav- 
 ing cured tumours of a cancerous nature, when, in fact, they have, 
 in almost all the cases, merely prevented them. 
 
 While, in our opinion, confirmed cancer is incurable by the re- 
 sources of medicine alone, properly so called, we believe, founding 
 upon our own experience, and upon the observations of a great num- 
 ber of physicians, amongst others Hippocrates, Galen, Fearon, Le- 
 dran, Vacher, Pouteau, Hufeland, Marc-Antoine-Petit, of Lyons, 
 Lisfranc, Recamier, and Lallemand, of Montpellier, etc., we believe, 
 we repeat, that it is possible, and when the disease is not of long 
 standing, to obtain the resolution of certain hard engorgements of the 
 breast, which, without our being able to affirm them truly scirrhous, 
 since their dissection cannot be made, offer at least the strongest 
 analogy to tumours of this nature, and often present perfectly identi- 
 cal characters. 
 
 The treatment of scirrhous tumours of the mammae consists in 
 removing the causes which may have produced them, if we can suc- 
 ceed in discovering these causes, and then resorting to the methodical 
 employment of the different means we are about to point out. If 
 the woman be young and plethoric, we should firs! order a general 
 bleeding, which may be repeated several times, if the disease be in 
 the acute stage, and then make applications of leeches about the 
 tumour, which should afterwards be covered with an emollient poul- 
 tice, sprinkled with laudanum. Fumigations of elder-flower water, 
 the bath, demulcent drinks, mild regimen, frictions of the skin, dia- 
 
448 
 
 CANCER OP THE BREAST. 
 
 phoretic infusions, residence in a dry and well-aired situation, gaiety, 
 quiet and agreeable amusements, moderate exercise, with the pre- 
 caution of avoiding violent movements of the superior extremity cor- 
 responding to the diseased gland, and lastly, a perfect execution of 
 all the functions of the economy, will contribute very much to the 
 resolution of the induration. 
 
 After employing these various means for some length of time, 
 should we find that the tumour has ceased to diminish and is no longer 
 painful, it will be well to make use of discutients and resolvents, with 
 the precaution, however, of associating them at first with emollients, 
 lest they determine too acute an inflammation. We should employ 
 poultices of flax-seed and of Windsor- beans, made with simple water 
 at first, and then with elder-flower water, infusion of chamomile, 
 soap and water, in succession, and, finally, with a mixture of Goulard’s 
 lotion, or decoction of roses and red wine. The discutients should 
 be succeeded by other more active agents, such as the ammoniacat 
 liniments, plasters of camphorated soap, of cicuta, vigo cum mercu- 
 rio-plaster, frictions of mercurial ointment or ointment of hydriodate of 
 potash, fumigations of vinegar, ammonia, cinnabar and juniper ber- 
 ries, and, lastly, bags of fine linen, containing muriate of ammonia, 
 thoroughly dried and reduced to powder. We should prescribe, at 
 the same time, the internal use of aperients and bitters, amongst 
 others the expressed juices of succory, of fumitory, and of bugloss, 
 tisans of water-dock, of soap wort, and of scabiosa, to which may 
 be added, from time to time, suitable quantities of sulphate of mag- 
 nesia and of soda, the use of Seidlitz water, or of some other mild 
 laxative, which, producing a transient excitation of the digestive 
 tube, will promote the resolution and concur in augmenting the 
 efficacy of the other remedies. The application of a swan or rabbit 
 skin, is likewise useful in maintaining the breast at a uniform tempe- 
 rature and in a state of moisture usually very favourable. We add, 
 also, that in most of the cases, we may, like M. Lisfranc,* after the 
 antiphlogistics, and in combination with the resolvents and discu- 
 tients, make use of local excitants, such as frequently repeated appli- 
 cations of a few leeches, say from three to six, used alternately with 
 small moxas of three or four lines in diameter, or very small blisters 
 placed about the mamma. 
 
 Compression, brought into use, in France, by M. Biett, after having 
 been employed, first in England, by M. Young, and then by M. Pear- 
 son, and Doctor Ch. Bell, who rejected it, and, in a report which he 
 made in the name of the Medical Committee of Middlesex, de- 
 scribed it as always injurious, — compression, we repeat, is likewise 
 a means which, combined with some of those we have pointed out, 
 constitutes a new mode of treatment fully deserving of the attention 
 of physicians. Though this method, from which M. Recamier has ob- 
 tained good effects, has failed, and could not even be borne by many 
 of the patients, it has, nevertheless, effected cures in several cases 
 that were even despaired of, or has, at least, very much facilitated 
 
 * In the inaugural dissertation, (No. 68, May 1, 1826,) Doctor Corbin has published 
 several cases, proving the efficacy of M. Lisfranc’s method, the happy results of 
 which we have ourselves been able to appreciate. 
 
CANCER OF THE BREAST. 
 
 449 
 
 the extirpation of the disease, either by reducing the tumour to a 
 small size, or by rendering it movable, and isolating it from the parts 
 with which it had formed adhesions. 
 
 This treatment consists in the application of permanent pressure, 
 continued during a certain period, to the mamma affected with cancer 
 in its different stages,— even in the state of ulceration, which, in this 
 case, however, must first be cauterized, so as to produce a slough of all 
 the affected parts, and allow of the subsequent approximation of the 
 edges of the wound with adhesive strips. As it would take too long 
 to describe M. Recamier’s bandage in detail, we shall be satisfied 
 with saying that it is composed of one long roller and of several discs 
 of agaric interposed between each turn, in such a way as to enclose 
 the tumour gently and equally, and form a truncated cone, the base 
 of which covers the whole breast, and the apex corresponds, as 
 nearly as possible, to the centre of the induration. 
 
 In order to avoid compressing the whole circumference of the tho- 
 racic parietes, so generally and violently, and with the view of 
 acting more directly upon the whole tumour, without, in anyway, 
 pressing the healthy breast, we invented, ten years since, a mechani- 
 cal bandage, which may be applied and removed in a few minutes. 
 This compresser, by establishing a local pressure, which the physician 
 and the patient can augment or diminish at will, by means of a key, 
 renders the method much more supportable, and does not require, 
 like the roller bandage, to be entirely removed when the compression 
 becomes painful or when it interferes with the dilatation of the tho- 
 rax, and, consequently, with respiration. Let us add that our mam- 
 mary compresser, which, 
 
 by means of straps, may Fig. 44. 
 
 remain applied while the 
 patient is in bed, as well 
 as when up, requires, like 
 M. Recamier’s bandage, 
 discs of very soft agaric 
 of different sizes. The 
 instrument, when com- 
 plete, is composed as fol- 
 lows : 1, a hollow elastic 
 cushion, ( pelote ,) design- 
 ed to cover pieces of 
 agaric and keep them in 
 place, upon the tumour ; 
 
 2, a girdle, two inches 
 and a half wide and a 
 yard long, arranged with 
 an opening or fenester, 
 to be enlarged or dimi- 
 nished at will, so as to re- 
 ceive the sound breast, 
 and thus entirely avoid 
 compressing it ; 3, a steel 
 29 
 
450 
 
 CANCER OF THE BREAST. 
 
 Fig. 45. 
 
 Fig. 46. 
 
 plate, with a screw upon its external surface, by turning which the 
 cushion may be forced down upon the diseased breast. On one side is 
 a cylinder, with a rachet wheel, by turning which the girdle may be 
 lengthened or shortened, at discretion. On the other side is a six- 
 tongue buckle. The figure (No. 44 ) on the preceding page explains 
 the apparatus adjusted in situ. The circular pad, or 
 cushion, is represented by the figure annexed, No. 45 ; 
 and the form of the steel plate is designated by figure 
 46 , which is also annexed. 
 
 M. Recamier does not always employ compression 
 alone, in the treatment, and exclusively ; for exam- 
 ple, he commences by the application of leeches, by 
 cauterization, by enucleation, and by the ligature, 
 according as the tumour is painful and inflamed, or 
 is affected with ulcerated scirrhous masses and fun- 
 gous vegetations. Though we believe with the dis- 
 tinguished practitioner we have just cited, that com- 
 pression often renders the tumour more movable and 
 more favourable to the success of the operation, we 
 are of opinion that it ought not to be resorted to except 
 when the induration is but slightly painful on pressure 
 and presents no solution of continuity. We ought to remark, also, 
 that there are some women who cannot bear compression in any 
 mode in which it can be applied, and that the constant attention, 
 moreover, which it necessitates during many consecutive months, 
 may lead us to ask whether extirpation would not be preferable, 
 even though the compression were supportable and advantageous, 
 and examples of cure more numerous than those which the science 
 records. For ourselves, we are of opinion that when the patient can 
 support compression, it is well to employ it, as well as all other means, 
 before deciding upon the removal of the cancerous part. 
 
 When the methodical employment of the internal and external 
 means, just pointed out, brings about an evident diminution of the 
 tumour, their use may be persevered in as long as they continue to 
 act favourably ; but, should the induration retain its consistence and 
 size, and, a fortiori , should it augment in size, become painful and 
 irregular, and at length become ulcerated, softened, and present all 
 the characters of confirmed cancer, we ought to renounce the hope 
 of obtaining its resolution, and abstain thenceforth from fatiguing the 
 patient by a treatment, the inutility of which is manifest, and which, 
 if continued for a longer time, would become hurtful, by hastening 
 the progress of the cancerous degeneration. 
 
 We shall not attempt to exhibit the immense list of substances 
 which have been, in turn, set forth for the treatment of ulcerated 
 cancer : their inutility, now generally acknowledged, is a legitimate 
 excuse for thus passing them by. We shall rest satisfied byrecalling, 
 in few words, the therapeutical means which have more particularly 
 fixed the attention of physicians; but we ought to inform our read- 
 ers that we shall pass by, in silence, the internal remedies which 
 
CANCER OF THE BREAST. 
 
 451 
 
 have already been mentioned in onr remarks upon cancer of the uterus. 
 Among the external remedies that have had a more or less deserved 
 reputation, we cite, first, arsenic employed alone or united with other 
 substances, by John Gaddesden, Valescus of Tarentum, Fuchs, Para- 
 celsus, Reusner, Jerome Capivacci, Pierre Alliot, Deidier, Roosselot, 
 Frere Come, Justamont, the celebrated Dubois, Messrs. Zang, Bug- 
 niard of Lyons, Grandpre of Givors,* and a number of others, whom 
 it would take too long to name. 
 
 Lead also has been used in the state of oxide made into a plaster, 
 by Balthazar Timee ; in the state of acetate in solution, by Goulard, 
 Imbert, Fearon, Boyer and Pissier ;t and finally, in the metallic state, 
 by means Qf a plate covered with unguent, diapompholigos , by John 
 Schmidt, (a drying ointment, composed of oil, wax, juice of night- 
 shade, incense, flowers of zinc, and oxide and sulphuret of lead. 
 — M.) Mercury, in the state of proto and deuto-chloride, has also 
 had its partisans; amongst others, Bowman and Norford. The same 
 is true of the carbonate, the phosphate and the arseniate of iron, re- 
 commended by Mr. Carmichael ; of the sulphate of copper and the 
 muriate of baryta; and, finally, of the diluted acids, especially the 
 hydrochloric; and of different gases, as carbonic acid, (Peyrilhe, 
 Evrart and Fourcroy,) chlorine, and the sulphurous, mercurial and 
 arsenical vapours, (Grandpre.) 
 
 The vegetable kingdom has likewise furnished a large number of 
 external pretended anti-cancerous remedies, such as opium, cicuta. 
 (Stork, Kapp,) nightshade, (Vesalius,) belladonna, (Lambergen,) 
 cinchona, (Dietrich,) rasped carrots, (Sultzer,) and a number of other 
 vegetable substances. In the animal kingdom, we find the gastric 
 juice of animals, the blood and flesh of cattle, the infusion of snails, 
 and especially the spawn of frogs, whose marvellous efficacy was 
 vaunted by 0. P. Braun. Cauterization, by means of a hot iron or 
 the solar rays collected by a lens, or, finally, with different escharo- 
 tics, such as arsenical powder, the nitric and hydrochloric acids, chlo- 
 ride of antimony, nitrate of silver, and the acid nitrate of mercury 
 have been likewise included in the immense list of external therapeu- 
 tical remedies f 
 
 * It is particularly in the treatment of superficial carcinomatous ulcers, that M. 
 Grandpre has proved the good effects of arsenic combined with sulphur, and espe- 
 cially with the sulphuret of mercury, (cinnabar,) employed chiefly in fumigations 
 directed upon the affected surface, which is isolated by means of an apparatus to 
 prevent the respiration of the poisonous vapours. Plunket’s remedy for cancer of the 
 breast was also a combination of arsenic and sulphur; but he added a certain 
 quantity of powdered ranunculus, and used the mixture merely as a topical applica- 
 tion. 
 
 f M. Pissier combined the opium with the oxide of lead, and Professor Boyer with 
 the acetate of the same metal. 
 
 4 Of all the caustics employed in the treatment of cancerous affections, there is 
 none whose use has been more general than that of Roosselot, modified by the cele- 
 brated Dubois. This paste is composed, of dragon’s blood, an ounce, sulphuret of 
 mercury, half an ounce, and arsenious acid, half a drachm ; which must be pulver- 
 ized and well mixed. To employ these substances, it is necessary to moisten them 
 to the consistence of paste. Dupuytren employed, with advantage, the nitrate of 
 
452 
 
 CANCER OF THE BREAST. 
 
 Could we localize the disease and confine its action to the degene- 
 rated part, nothing would be easier than to cure cancer of the breast, 
 since it is almost always possible to remove it completely. Unfortu- 
 nately, when the patient decides upon the operation, this is no longer 
 the case, and commonly the whole economy then participates in the 
 cancerous affection. It is from hence that the tumour, when re- 
 moved, is often and early replaced by another, even before cicatri- 
 zation is finished ; and it would seem that the disease has acquired 
 new force, for it now advances with hopeless rapidity. It is, there- 
 fore, important to operate too soon rather than too late, because, 
 when the disease is confined to any induration of small extent, and is 
 not ulcerated, we shall not only have less cause to fear a relapse, but 
 the tumour to be removed, being small and movable, will require an 
 operation of little importance, whilst, by deferring it, the degenera- 
 tion, having increased, constitutes a serious disease, strongly disposed 
 to relapse, and requiring a laborious operation, with extensive and 
 deep incisions. 
 
 Though Celsus,* Archigenes,t Albucasis,f Pierre Cerlata,§ Leonard 
 of Berfapaglia,|| John Tagault,1F Triller,** Monro, tt Reneaulme,l± 
 Boyer, §§ Rouzet,|||| and some modern surgeons, are amongst the 
 antagonists of the extirpation of the cancerous breast, we believe 
 with Galen, 1 IMF Leonidas,*** Aetius,ttt Paul of Egina,f±± Avicen- 
 na, §§§ Rhazes,|||||| Lanfranc/FHf Scultetus,**** de la Vauguyon,tttt 
 Heist.er,±ff± Cheselden,§§§§ Verduc,|||||||| Ledran,11inF1F Lecat,***** 
 
 mercury, prepared in the following proportions : crystallized mercury, four drachms ; 
 nitric acid, an ounce. M. Recamier often makes use of this remedy, or of a concen- 
 trated solution of caustic potash. We think that it is necessary to cauterize deeply, 
 so as to attack the totality of the cancer, which, when not completely destroyed, 
 reappears with great rapidity and with augmented virulence. 
 
 * Lib. v. cap. 18. 
 
 j- Aetius, tetrab. iv. serm. iv. cap. 43. 
 t Chirurg., lib. i. sect. 50. 
 
 § Philos., lib. vii. cap. 33. 
 j| Chirurg., tr. i. cap. 25. 
 t Instit. chirurg., lib. i. cap. 15. 
 
 ** Haller, diss. chirurg., t. ii. p. 475. 
 ij- Edinburgh, trans. supplern., 1752. 
 tt Non ergo mammte, sect, curand. Paris, 1732. 
 
 §§ Traite des malad. chirurg., t. vii. p. 297, 1821. 
 
 y Recherches et observat. sur le trait, du cancer. Paris, 1818, 1 vol. in 8vo. 
 
 ^ * Method, med., lib. xvi. 
 
 *** Aetius, tetrab. iv. serm. iv. cap. 43. 
 ttf Toe. c R-> ca P* 42. 
 ttt Lib. vi. cap. 45. 
 
 §§§ Canon., lib. iv. fen. iii. cap. 2. 
 
 Continens, lib. xiii. cap. 2. 
 
 Chirurgia parva, tr. i. doct. iii. cap. 13. 
 
 **** Armamentarium chirurg., pars i. p. 22, tab. xiv. et tab. xxxvi. 
 fttt Traite comp, des operat. de chirurg. chap. xvii. p. 163. 
 tttt Chirurg., t. ii. cap. 107. 
 
 §§§§ Observ. 1749, and biblioth. chir. of Haller, t. ii. p. 24. 
 
 IRUS Operat. des chirurg. et pathol., t. i. chap. 15. 
 
 Traite des operat. de chirurg., p. 375. 
 
 ***** Biblioth. chirurg. de Haller, t. ii. p. 176. 
 
CANCER OF THE BREAST. 
 
 453 
 
 Garengeot,* * * § Dionis,t J. L. Petite Vacher,§ Siebold,|| Sabatier, 1 
 Camper,** * * §§ Dessault,tt Bell,tt James Hill,§§ and, finally, Scarpa, 
 Dupuytren, MM. Roux, Richerand, Zang, Cloquet, Lisfranc, S. 
 Cooper, Velpeau, Sanson, Begin, Amussat, and a great number of 
 other distinguished surgeons of our epoch, we believe, we say, that 
 the operation should always be attempted when none of the contra- 
 indications, about to be mentioned, exist. 
 
 If it be objected, that out of sixty women, whom Monro (loc. 
 cit.) saw operated upon, four only had no relapse at the end of two 
 years; if we are told, moreover, that the celebrated Boyer (loc. cit.) 
 gives an equally unfavourable diagnosis, since, of one hundred cases 
 of extirpation of cancerous parts, there were only five subjects radi- 
 cally cured, we will oppose the testimony of James Hill, who, in 
 ninety-eight cases of cancer, saw but twelve relapses ; and we might 
 quote, also, Doctor North, who has remarked but few cases of failure 
 in more than one hundred examples. Finally, to a large number of 
 other authentic facts, establishing radical cqres, we might add the 
 observation of Zeller, of Zellemberg,|||| who, in 1810, amputated with 
 entire success, a cancerous breast of more than two feet in diameter, 
 and that not less singular case of F. T. Ochmer,H1[ who likewise re- 
 moved successfully a cancerous mamma, weighing ten pounds, from 
 a pregnant woman who was delivered without accident, and reco- 
 vered perfectly. Finally, we cite the ablation of two mammas, per- 
 formed with success on the same female, by Foubert,*** and the 
 same operation performed a few years since by MM. Thuillier and 
 Thibaultjttf at the hospital of Limoges, on a girl twenty-two years 
 of age, both of whose mammas were attacked with a scirrhous 
 degeneration. These organs were so much tumefied that they 
 weighed about twenty-nine pounds, and had been only four years in 
 attaining this extraordinary size. The mamma removed at the first 
 operation weighed fourteen pounds and a half, and the cicatrization 
 of the wound did not occur until after seventy-five days. The 
 second mamma, the weight of which equaled that of the first, was 
 removed three months afterwards, and union was obtained in fifteen 
 days. 
 
 Without wishing to describe, or even indicate all the methods 
 proposed or employed by authors for the extirpation of cancer of the 
 mamma, we are about to confine ourselves to the description of the 
 operation, as it is performed by most surgeons of our period, but we 
 shall be careful to point out the different modifications which may be 
 
 * Traite des operat. chirurg., t. ii. cap. vii. art. i. 
 
 •j- Cours d’operat. chirurg., dem. v. p. 381. 
 
 t Traite des malad. chirurg., t. i. chap. iv. 
 
 § Dissert, sur le cancer des mammeiles, 1740. 
 
 |j Huermann, chirurg. operat. t. ii. cap. 20. ^ Med. operat. 
 
 ** Gences natur, etc., p. 194. 
 
 •j-f GGuvres chirurg., par Bichat, t. ii. 
 
 Treatise on the Theory and Manag. of Ulcers, part ii. sect. viii. Edinburgh, 1 778. 
 
 §§ Cases in Surgery. Edinburgh, 1772. 
 
 Hl| Abhandlung, ueber, etc. Wien, 1810, p. 194. 
 
 Observ. einer scirrheusen, etc., 1774. 
 
 *** Mem. de l’acad. de chirurg., t. iii. p. 118. 
 
 fff Dissert, sur le cancer, etc., par M. Gaudeix Laberderie, Paris, 9 Juillet, 1827. 
 
454 
 
 CANCER OF THE BREAST. 
 
 Fig. 47. 
 
 required by the mobility, small size, great development, or adhesions 
 of the tumour, or finally, the complete degeneration of the breast, 
 and the different complications which may be met with. 
 
 Mode of operating. In order to obviate the danger of syncope, 
 and that the surgeon may be more conveniently placed during the 
 operation, we think, that instead of seating the patient on a chair, it 
 is better that she should lie on a bed or table, arranged in such a 
 way that the head and thorax may be sufficiently elevated to make 
 the breast project as much as possible. 
 
 When the tumour is circumscribed, movable, and of small size, it 
 is sufficient to make a longitudinal incision in the breast proportioned 
 to the size of the induration, and then with a 
 double hook, or still better with the much more 
 commodious forceps which we have invented 
 for this operation, [vide fig. 47,) we seize, after 
 having separated the edges of the incision, the 
 morbid production, and draw it out with the 
 left hand, while the right, armed with a convex 
 bistoury, finishes its separation and detachment 
 from the cellular and vascular bands to which 
 it adheres. When we have arrested the flow 
 of blood by the ligature or torsion, the edges 
 of the wound are drawn together with adhe- 
 sive straps. 
 
 Where the breast is very much developed, and 
 particularly if the tumour were large, although 
 circumscribed and movable, it would be ad- 
 vantageous, according to the advice given by 
 Paul of Egina,* not to preserve all the integu- 
 ment, but to excise a larger or smaller ellipsis 
 of it. In this way, the operation would become 
 not only easier and more rapid, but would 
 more probably be successful, because the lips 
 of the wound would be in a condition more 
 favourable to nice reunion, than if all the integument had been pre- 
 served. In case the skin itself should be altered, thinned, and ad- 
 herent to the tumour, we should, with still greater reason, follow 
 this precept, that is to say, remove all the affected parts by two 
 semi-elliptical incisions, which ought always to include a certain 
 portion of the healthy tissue. If the entire breast were implicated, 
 it would be necessary, after the precept of Pimpernelle, Verduc, 
 and most modern surgeons, to circumscribe the organ by two semi- 
 circular incisions, in such a way that the large diameter of the wound 
 might be directed obliquely from above downwards, and from without 
 inwards, in the direction of the fibres of the great pectoral muscle, the 
 projection and tension of which should be augmented by causing an 
 assistant to hold the arm upwards and outwards. 
 
 In order to proceed to the operation, the surgeon, after having 
 caused his patient to be arranged in the mode we have just pointed 
 
 * De le rned., lib. vii. cap. 46. 
 
CANCER OF THE BREAST. 
 
 455 
 
 out, should draw the skin of the breast in a direction the contrary of 
 the first semilunar incision, that is to say, the inferior, and then when 
 this is finished, he should draw down with his left hand the parts 
 to be extirpated, and making an assistant tighten the integuments 
 above, he should insert the cutting instrument in the external angle 
 of the first incision, and make the superior incision, which he will ter- 
 minate at the inferior angle of the wound, of which it will complete 
 the ellipsis. When the cancerous mass has been thus circumscribed, 
 he will seize the mass to be removed with our hook-forceps, or with 
 a pair of Muzeux forceps, and then dissect the tumour first from 
 below upwards, and then from above downwards, taking care to 
 leave a portion of healthy tissue about the affected gland; if the 
 depth of the disease require it, he should not fear to go down to the 
 muscular fibres, and even to the ribs. 
 
 With the view of terminating the ablation of the cancerous tu- 
 mour more rapidly, we may dispense with tying the arteries as they 
 spring, closing their orifices by the fingers of an assistant. Should 
 any diseased or suspected portions have escaped the instrument at 
 first, it would be necessary to extirpate them at once ; finally, after 
 having tied the vessels and washed the wound, the operator should 
 approximate the edges and maintain them in contact with the thumb 
 and index finger of each hand, while an assistant applies long ad- 
 hesive strips, beginning with those in the middle. The number of 
 these strips must vary according to the extent of the wound; and 
 small intervals should be left between each, in order to give issue to 
 the pus and other secreted fluids. A pledget covered with cerate, 
 one or two bundles of charpie, and long compresses maintained by a 
 body bandage, complete the dressing apparatus required in this ope- 
 ration. 
 
 Where the loss of substance is so great as to render the approxima- 
 tion of the edges of the incision impossible, or at least very difficult, 
 it would be well, after the precept of M. Lisfranc, to separate each 
 side of the wound from the subjacent parts, to the extent of one or 
 more inches ; by this method, we procure sufficient integument to 
 unite the wound directly. In case we should not wish to resort to 
 immediate reunion, the adhesive strip would become useless, and it 
 would suffice to cover the wound with a piece of linen spread with 
 cerate, and with holes cut in it, and some pledgets of charpie and 
 several compresses. Should there exist any engorgement of the 
 axillary glands of a suspicious nature, we should prolong the upper 
 angle of the wound as far as these glandular indurations, but if too 
 distant, it would be better to effect their extirpation, by exposing them 
 by independent incisions ; finally, if we had reason to fear lesion of 
 some rather large vessels, it would be necessary, after having pro- 
 perly isolated them, to tie the pedicle of the engorged glands, and 
 then divide it in front of the ligature, as advised by J. L. Petit, Des- 
 sault, Dupuytren, Zang, MM. Lisfranc, Velpeau, and other distin- 
 guished surgeons. 
 
 In case the wound should assume an unfavourable appearance a 
 few days after the operation, it might be recovered by applications of 
 chlorinated soda or wine and honey, or cauterization with nitrate of 
 
456 
 
 CANCER OF THE BREAST. 
 
 silver. If symptoms of purulent absorption should suddenly make 
 their appearance, such as nausea, rigors, fever, etc., it would be 
 necessary to destroy, as soon as possible, the adhesions under which 
 the pus has accumulated, and then introduce a tent to prevent the 
 too rapid approximation of the edges of the wound. We should 
 never forget, that it is to the neglect of this important point of surgi- 
 cal therapeutics, that we must ascribe most of the failures in removal 
 of the breasts, and in a number of other operations. 
 
 We shall conclude by saying that, if, after some lapse of time, any 
 vegetations or small tubercles of doubtful nature should appear, it 
 would be necessary, after the example of Lapoterie, of Frere Come, 
 of Zang, and some modern surgeons, to destroy them as soon as 
 possible, either with a cutting instrument, with fire, or some caustic 
 substance, as the arsenical paste, acid-nitrate of mercury, or the lapis 
 infernal is. 
 
 Circumstances that contra-indicate the operation . Two cir- 
 cumstances may, according to M. Richerand, contra-indicate the 
 operation ; the too great extent of the local degeneration, and a gene- 
 ral cancerous infection. The operation ought likewise to be rejected 
 in cases where the breast is immovable, adherent to the ribs, and as 
 it were, cemented upon the thorax; when its progress has been rapid, 
 when the skin is tuberculous for some distance ; and finally, when 
 the glands of the axilla are greatly engorged, even as far as the very 
 neighbourhood of the great vessels. We ought to remark, however, 
 that this latter circumstance may, according to the remark of Dupuy- 
 tren, depend upon a sympathetic irritation, which ceases when its 
 cause has been removed.* We add, that extensively ulcerated can- 
 cer, encephaloid and melanoid cancer, as well as scirrhous cancer, 
 which has suddenly invaded the whole of the breast, are the most 
 disposed to a sudden relapse. On the contrary, movable scirrhous 
 tumours, which are recent and of small size, hydatiform, encysted, 
 and tuberculous cancers, offer the most favourable chances for the 
 success of the operation, and the radical cure of the patient. 
 
 Notwithstanding the example of Foubert, reported by Ledran,t 
 who successfully performed on the same female and on the same day, 
 the amputation of both mammae, one of which was deeply ulcera- 
 ted, and the other scirrhous ; notwithstanding the success of MM. 
 Thuiller and Thibauld, of Limoges, (see page 453,) we regard the 
 simultaneous existence of several cancerous tumours in different 
 organs as being almost always a contra-indication to the operation. 
 There is, likewise, but little to hope for, where the affection is heredi- 
 tary, where general symptoms of cancerous cachexia exist, or where 
 the female has suffered for a long time from considerable derange- 
 ments of menstruation. 
 
 Though several authors assert that a relapse is a circumstance 
 which ought always to remove all idea of a new operation, we think 
 that the chances of a cure cannot be too carefully weighed, before 
 
 * It is in cases of this kind, no doubt, that Louis, Dessault, Assalini, Soemmering, 
 and some others, have successfully extirpated cancerous tumours, without removing 
 the engorged axillary glands. 
 
 t Memoires de l’Acad. de chirurg. t. iii. p. 18. 
 
ENCYSTED TUMOURS OF THE BREAST. 
 
 457 
 
 abandoning the patients to their unfortunate fate ; for, Morgagni, 
 Sabatier, Lacombe, L. M. Pousse, etc., have succeeded in obtaining 
 a complete cure after a second and even a fourth operation. 
 
 Palliative treatment. When cancer of the breast is not, or, at 
 least, is no longer of a nature to be operated upon, or when, the patient 
 refusing to submit to the operation, a radical cure is no longer to be 
 hoped for, the physician ought to seek to render the disease more 
 bearable, and to check its progress by a palliative treatment. This 
 treatment consists in regimen, and in the internal and external em- 
 ployment of various remedies. We must prescribe, with this view, 
 a milk-diet, vegetable substances, white meats, and sedative drinks. 
 As it is a treatment of symptoms that must be instituted, we should 
 seek sometimes to recruit the strength by tonics and bitters, at other 
 times we must ease the pain and oppose the nervous symptoms by 
 narcotics and antispasmodics, administered in the form of potions, 
 pills, enemata, etc. We should also prescribe fomentations and seda- 
 tive applications, especially extract of opium, dissolved in fluid ace- 
 tate of lead or incorporated with a liniment or cerate employed as a 
 topical ; and finally, the use of baths, small general bleedings, appli- 
 cations of leeches around the mamma, and a number of other means, 
 which must vary according to the symptoms, and will aid in conduct- 
 ing the patient to the tomb as gently as possible. Happy, says M. 
 Richerand, if they can add to the oblivion of their ills the sweet 
 illusions of hope. 
 
 OF ENCYSTED TUMOURS, AND OF DIFFERENT KINDS OF CHRONIC 
 ENGORGEMENT OF THE MAMMA. 
 
 There are two kinds of encysted tumour of the breast ; the one con- 
 tains a serous fluid in cells which compose the tumour, the other en- 
 closes globular hydatids. In the beginning, these tumours, which grow 
 very slowly, and which are commonly regarded as being the result 
 of a chronic inflammation of the breast, are not painful except at the 
 approach of the menstrual evacuations. After some time, the cyst 
 becomes fluctuating, while the remainder of the tumour retains its 
 primitive hardness, and we do not observe the skin covering it to 
 change its colour, until it begins to ulcerate ; it is not, indeed, until the 
 period when the ulceration begins to take place, that the health of 
 the patient is slightly disturbed. t 
 
 These tumours, which make their appearance from the age of 
 fifteen to sixty, without our being able to discover the cause, may be 
 either multiple, or may present themselves in the form of a simple cyst. 
 In either case, they are radically cured by extirpation ; yet when 
 there is a simple cyst, Sir A. Cooper* has sometimes confined him- 
 self to piercing it with a lancet, and the cure has then taken place 
 from the adhesive and suppurative inflammation which followed 
 this slight operation. t Finally, we shall add that though these mam- 
 
 * The Lancet, vol. ii. p. 368-370. 
 
 -{-We think that puncturing cannot be followed by cure except when we have to 
 do with an acephalocyst cyst; in the serous cysts, the fluid is always reproduced after 
 
45S 
 
 ENCYSTED TUMOURS OF THE BREAST. 
 
 mary cysts do not constitute diseases of a severely malignant charac- 
 ter, they may in some cases degenerate ; therefore, for this reason, 
 and especially to quiet the patient and satisfy the mind, we should 
 not hesitate to extirpate them, taking** care not to open the cyst, 
 which must be detached from its adhesions by a minute dissection. 
 In case the tumour should have been opened and should have con- 
 tained nothing but a serous fluid, and especially where we are not 
 certain of having removed the whole of the cystic sac, it would be 
 necessary to cauterize the internal surface of the wound, in order to 
 prevent the reproduction of the disease. 
 
 Fibrous tumours developed in the mammas resist all therapeutical 
 means, and also require complete extirpation, by means of the knife. 
 The same is true of a sort of movable, globular tumours, soft to the 
 touch, less distinctly circumscribed than the scirrhous and fibrous 
 tumours, which, like the preceding, are met with most commonly in 
 women having all the appearances of fine health. These tumours, 
 which are a species of lupia, rarely pass into the cancerous state, 
 though they may become rather large, varying between the size of a 
 pea and a large billiard-ball ; they are generally indolent, and do not 
 become painful except at the periods of menstruation. 
 
 The mammae are also subject to other chronic ulcerations, which 
 present more or less analogy to those we have just mentioned, and 
 from which it is important to distinguish them, because it is not 
 necessary to extirpate them in order to obtain a radical cure ; amongst 
 the affections of this class are: 1, engorgement resulting from dis- 
 turbed menstruation; 2, engorgement of the lymphatic vessels; 3, 
 scrofulous engorgement. 
 
 The engorgement which is observed after some disorder in the 
 periodical discharge of the menstruse, occurs in a portion of the 
 breast, and is met with most frequently at the age of from fifteen to 
 twenty-five years ; the induration which results is always very pain- 
 ful to the touch, especially at epochs corresponding to those at which 
 the menstruae were in the habit of appearing. The pain in the breast 
 is then so much augmented that it often extends from the diseased 
 mamma to the arm, and even to the fingers of the same side. This 
 kind of induration, which has been called irritable tumour of the 
 breast , by the celebrated Sir A. Cooper, (loc. cit. p. 405,) never re- 
 quires the extirpation of the breast, and h fortiori as it is resolved as if 
 by enchantment^ so soon as we succeed in restoring the menstrual 
 function. We ought to say, also, that the absence of fluctuation, of 
 febrile symptoms, of throbbing pains, and the commemorative cir- 
 cumstances, will always suffice to prevent our confounding this affec- 
 tion with an abscess of the breast. 
 
 The tumefaction of the lymphatic vessels passing from the breast 
 to the axillary glands, commonly yields without difficulty to bitter 
 and sudorific drinks, to narcotic fomentations, and to mercurial and 
 iodine frictions. Finally, scrofulous tumours, which are sometimes 
 
 it has been evacuated ; the extirpation of the tumour is, therefore, the only means 
 which suits all cases. 
 
DISORDERS OF THE MENSTRUATION, ETC. 
 
 4 53 
 
 followed by ulcers of a cancerous appearance, from which they may 
 be readily distinguished by the absence of shooting pains, by the little 
 sensibility, the nature of the suppuration, etc., rarely resist an anti- 
 scrofulous regimen and treatment, especially the internal and external 
 use of pharmaceutical preparations whose base is iodine. 
 
 We must, in order to conclude what we had to say upon engorge- 
 ments of the mammae, add that those engorgements which we 
 observe after abscesses of these organs, are not long in being resolved 
 under the influence of topical bleeding and an antiphlogistic treatment 
 methodically employed. As we shall treat of abscesses of the breast 
 in speaking of the diseases developed after parturition or during 
 lactation, we shall not dilate any further upon the subject at present. 
 
 SECTION FIFTH. 
 
 CHAPTER IX. 
 
 LESIONS OF THE FUNCTIONS. 
 
 Of derangements of menstruation, of uterine haemorrhages and chlorosis, and of the 
 neuroses peculiar to women. 
 
 In health and disease, in whatever climate she may exist, and 
 whatever may be her social condition, her physical and moral 
 constitution, woman is under the dominion of a physiological and 
 mysterious law, that strong and powerful law which subjects her, 
 during a certain period of her life, to a periodical haemorrhage from 
 the reproductive organs. This function, termed menstruation, which 
 keeps all the others under its empire, and which is in some sort the 
 regulator of all the other apparatuses and systems, because of the, 
 intimate sympathies existing between the uterus and the other 
 organs, constitutes the least equivocal sign of the health and fecun- 
 dity of women. Without this discharge, says Roussel, beauty either 
 appears not, or is lost ; the order of the vital movements is destroyed ; 
 the soul falls into languor, and the body into exhaustion. Though it 
 be true, that serious diseases have been known to pass through all 
 their stages, without any appreciable disorder resulting as to the peri- 
 odical discharge, it most commonly happens that menstruation is 
 notably disturbed when the health undergoes any alteration, and we 
 observe derangements of the function to influence the exercise of all 
 the others, and add its morbid influence to those which already exist. 
 
 [As M. Colombat appears to have omitted nearly all reference, in his 
 pages, to the now received and approved doctrines on the causes of menstru- 
 ation, and its diseases, I shall take advantage of this page to enter a few addi- 
 tional observations, which I consider as a necessary introduction to what he 
 has here written on the subject, though I have already said something on the 
 
460 DISORDERS OF THE MENSTRUATION, ETC. 
 
 subject at p. 25 of this work. I look upon the modem theory as a most 
 important one, and if that doctrine should become regarded by my brethren 
 here as well established, I shall rejoice to have called their attention to it ; 
 since I conceive, that well-founded notions of the physiology of the func- 
 tions are essential to any competent views of their pathological states, or 
 their therapeutical requirements or indications. 
 
 It appears to me, that under the ancient theories, or rather hypotheses, 
 on the catamenia, no sound practical views could ever be acquired, although 
 it is true to say, that the lapse of ages had left in the hands of the profession 
 a variety of remedies and indications, the use of which was rather em- 
 pirical than philosophical, rather customary than useful, and which, though 
 the best that could be commanded, wer^ for the most part found to be incom- 
 petent, uncertain and baffling, as confessed, indeed, by the celebrated Cullen, 
 at the conclusion of his Essay on Emmenagogues, in his work on the Mate- 
 ria Medica. 
 
 # Happily, at the present day, we are better informed upon the nature and 
 'causes of the mensual phenomena, both in health and disease ; and in so 
 far, at least, better prepared to fulfil our duty to the patient. 
 
 De Graaff ’s discovery of the ovarian vesicle rested without therapeutical 
 profit, until Purkinje, by the invention, in the unimpregnated yolk, of the 
 vesicle named after him, laid the foundation, in 1825, for the subsequent 
 revelations as to the nature of the real ovum, by MM. Coste, Wagner, 
 Schwann, Wharton, Jones, Barry, Bischoff, and the other micrographers, 
 who have thrown so much light on the subject within the last ten or fifteen 
 years. 
 
 The result of these beautiful investigations has been the discovery of a 
 physiological law of the sex, under which the embryonic germ is found to 
 be developed, and brought to perfection at stated intervals , corresponding 
 nearly with the revolution of the lunar period of twenty-eight days each ; 
 one ovum being ripened every month. 
 
 The yolk that bears the germ, in all the mammals, is contained within 
 the Graafian vesicle, and it may readily be found, with a good lens, in 
 the drop, or drops of liquid that escape from a ripe vesicle, upon puncturing 
 it with a lancet, or crushing it under the compresser of a microscope. 
 
 The substance of the ovary, or its stroma , is found to contain a vast 
 multitude of small points, disseminated within its structure. Each of these 
 points, discoverable only by the aid of a microscope, is supposed to be a 
 rudimental germ, ready to commence its work of development whenever the 
 proper time may arrive, in its series or turn ; and it proceeds in that work 
 by such degrees, that at least one such will be brought to full and complete 
 maturity, as before said, once a month, as long as the menstrual age lasts, and 
 while the woman enjoys good health. Now, as the microscopic ovum is 
 contained within a double capsule, called the Graafian vesicle, it happens that 
 the containing vesicle expands, and grows with great rapidity during the lat- 
 ter part of the process ; it continues to rise from the central or internal parts 
 
DISORDERS OF THE MENSTRUATION, ETC. 
 
 461 
 
 of the ovary towards the surface, distends the stroma, puts the tunica albu- 
 ginea on the stretch, and finally bursts outwards, discharging its fluid, and 
 the ovum in that fluid, with its accompanying retinacula, or granular matter, 
 into the cavity of the belly, or in case of impregnation, into the fimbria of the 
 Fallopian tube, by which it is conducted to and lodged in the womb, to con- 
 stitute the ovum of a gravid uterus. Now, it clearly appears, from the show- 
 ing of Robert Lee, of London, M. Negrie#, of Angers, M. Gendrin, of Paris, 
 and M. Raeiborski, of the same city, and many others — I have seen it with 
 my own eyes — that if a woman die in menstruating, or soon afterwards, there 
 is found on the surface of the ovary a bloody and ragged opening, leading 
 into a small pit or crypt, in which is frequently found a small clot of blood, 
 and which crypt once contained the fluid, the granules and the ovum of the 
 now broken Graafian vesicle. It also appears, that where the rupture has 
 recently taken place, the entire ovary is found reddened and turgid from the 
 hyperaemia induced in it by the development of the vesicle, just as the gum 
 of a young child, over a large jaw tooth, is found to be reddened and en- 
 gorged from a hypersemic irritation, arising from the pressure of the still 
 uncut tooth. 
 
 Different observers report, that they have found the ovary of the same 
 side, the Fallopian tube, and the uterus, of a bright red colour in patients 
 dying suddenly during their menstruation, and they declare it to be an inva- 
 riable rule to find the evidences of a recent rupture in all such persons, 
 while the numerous pits, depressions and cicatriculae to be noticed upon 
 the surface of every ovary of females, between fifteen and forty-five years 
 of age, are regarded as the vestigia of these periodical stated developments 
 and burstings of the Graafian vesicle, while in every case of the pregnant 
 female, or the gravid mammal, examined after death, the cicatricula of the 
 ruptured Graafian vesicle may be confidently looked for on one or the 
 other of the two ovaries. So firmly does Mr. Raeiborski seem to regard 
 this doctrine as established, that he calls it a regular ponte or laying pro- 
 cess . , whose appearances and laws, as far as ascertained, he has published in 
 his recent work, Be la Puberte , fyc. #*c. 
 
 It is not necessary, nor proper for me in this place, to enter fully upon 
 the discussion of the doctrine set forth on this matter by M. Negrier, in his 
 work; nor of M. Gendrin, in his Philos. Pract.; nor of Dr. Lee, in his 
 midwifery; nor of M. Raeiborski in his volume; I must be content merely 
 to indicate those works and recommend them very warmly to the reader. 
 In those works he will find that the ridiculous notions on local plethora 
 without cause — on general plethora without cause, and on lunar influence, 
 as the proximate cause of the strange and hitherto mysterious phenomena, 
 are all exploded, and that, inasmuch as the ovaries, by their constitution, are 
 liable to the hyperaemic affluxion, as coincident with the stated, periodical, 
 monthly completion of a Graafian vesicle, which hyperaemia relieves itself 
 by the menstrual discharge, we possess in that law the key to all the de- 
 rangements of the catamenial office, not dependent upon some obturation, 
 
462 
 
 DISORDERS OF THE MENSTRUATION, ETC. 
 
 or some sudden shock and diversion of the nervous power to other di- 
 rections ; in short, we have the means in our hands of explaining the non- 
 appearance of the menses at the age proper for their eruption — their post- 
 ponement or anticipation in different women, and their protracted duration 
 in some women, even to fifty or sixty years, or more. The change of life, 
 occurring at thirty or thirty-five years, instead of the legitimate time of forty- 
 five years, is also explained. This doctrine, too, teaches us the importance 
 of so providing for the health of young girls, as to enable them to come up 
 to the puberic age, in a condition fitting them to assume this great office and 
 its after responsibilities, while it directs our therapeutical intervention into 
 the only true path, that of the physiological functions. It is to be believed, 
 that if menstruation is caused by the regular, periodical, stated production 
 and rupture of a Graafian vesicle, the means of treating the disorders of men- 
 struation must be such as are directed to the promotion of such vesicular 
 development, called by Negrier, le travail vesiculaire, and travail ovarique. 
 
 There is reason to believe that in all the mammalia, birds, fishes, insects, 
 and probably in all the vegetable tribes, the development of germs is a 
 stated periodical operation ; and there is little difficulty in conceiving that 
 this may be the case, if we reflect upon the numerous instances of periodi- 
 city, observed in all the varied functions of life. 
 
 Having premised these remarks, in which I re-state some of the points 
 set forth at p. 25, 1 leave to the reader to appreciate M. Colombat’s opinions 
 on the menstrual affections, here following. — M.] 
 
 Menstruation, in order to be truly effectuated, requires, like most 
 of the secretory functions, two principal and distinct actions, which 
 are the exhalation of the menstrual fluid, and its excretion to the 
 exterior. When one or the other of these actions cannot occur, or 
 is but imperfectly accomplished, there result absence, suppression, 
 diminution, or deviation of the menstruae, and all the modifications 
 of menstruation, which can be comprised in two principal classes, 
 which are, amenorrhoea , or failure of the menstrual discharge, and 
 hypermenorrhoea , or excess of the same discharge. 
 
 These two principal heads, of all the lesions of menstruation, pre- 
 sent divisions which may be distinguished in the following manner : 
 
 The first class comprehends: 1, menaphania * or non-appearance 
 of the first menstruae ; 2, dysmenophania ,t or difficult establishment 
 of the first menstruation ; 3, me?iostasis,% or amenorrhoea from re- 
 tention ; 4, amenorrhoea, properly so called, or suppression of the 
 menstruae ; 5, dysmenorrhcea, or incomplete and painful discharge 
 of the menstrual fluid ; 6, menometastasis ,§ or deviation of the men- 
 struae ; 7, menopausis, || or the cessation of the discharge at the criti- 
 cal period. 
 
 * From the Greek /utht, junvoj, month; a privative , and <pavtia, appearance , 
 from <pa t>a , 1 appear. 
 
 f From t u;, with difficulty ; month; and faveta, appearance. 
 
 ± From fxryo; and e-ram, stagnation , retention. 
 
 t) From fxtivo <■ and /unrae-ram. displacement. 
 
 |j From fxry o{ and naum, cessation. 
 
AMESTORRHCEA. 
 
 463 
 
 The second class, or hypermenorrhoea , includes menorrhagia and 
 the different sanguine discharges from the uterus. 
 
 The menstrual disorders that we have now enumerated, instead of 
 forming diseases always distinct, are commonly, like other functional 
 disturbances, nothing more than symptoms, or groups of symptoms 
 resulting from a crowd of latent affections, from different sympathetic 
 reactions, or from some organic alteration which is almost always 
 discoverable by an attentive examination. 
 
 Though the more or less complete absence or suppression of the 
 menstrucB, present very evident differences in relation to the etiology, 
 prognosis and treatment of such disorders, we deem it right to study 
 these various derangements of menstruation collectively, and to com- 
 prise them under the general term of amenorrhoea , reserving to our- 
 selves, however, the power of separating them in the research after the 
 causes which give rise to them, and in the curative indications which 
 suit each more particularly. In this way, we shall avoid the repeti- 
 tions and long details arising from divisions unnecessarily multiplied. 
 
 OF AMENORRHCE A. 
 
 Amenorrhoea, which, in its widest acceptation, embraces all cases 
 in which there is failure in the menstruse, ought to be divided into 
 primitive and consecutive. Primitive amenorrhoea, comprising the 
 non-appearance of the function, at the epoch of puberty, and conse- 
 cutive amenorrhoea, which means their accidental and more or less 
 complete suppression after menstruation has been already established, 
 may depend upon a general condition of the constitution, upon a phy- 
 sical or vital lesion of the uterus, and, lastly, upon the sympathetic 
 reaction of some of the viscera contained in the splanchnic cavities. 
 By founding on these three principal origins of menstrual derange- 
 ments, we have constitutional amenorrhoea , sympathetic amenor- 
 rhoea , and amenor'rhcea from a local cause. 
 
 The causes of primitive constitutional amenorrhoea are predisponent 
 and occasional. Among the former are included, 1, the sanguine tem- 
 perament, which is manifested by a plethoric condition and by exces- 
 sive fulness of the vessels, determining local congestions in different 
 organs, and, in that way, promoting the suppression or diminution 
 of that of which the uterus ought to be the seat ; 2, the lymphatic 
 temperament, characterized by a condition of general debility and 
 by a want of activity in the circulatory system, ought likewise to 
 be ranked amongst the predisponent causes of both primitive and 
 consecutive amenorrhoea. Indeed, do we not daily see that girls 
 of a lymphatic constitution, especially those exhibiting symptoms of 
 scrofulous disease, are regulated later, and with more difficulty, than 
 others? Is it not known, also, that women already regulated, who 
 are placed in similar conditions, find their menstrual discharges dimi- 
 nishing little by little, or becoming entirely suppressed ; the periods 
 of return becoming more and more distant ; the retardations con- 
 stantly more prolonged, until at last a complete amenorrhoea is esta- 
 blished ? 
 
464 
 
 AMENORRHOEA. 
 
 The general debility which is so often the cause and the attendant 
 of amenorrhoea, does not always derive its origin in the primitive 
 constitution of the female ; it is often the unfortunate consequence 
 of a number of debilitating causes, such as living in a low, humid 
 situation, deprived of the light of the sun ; aliment of a bad quality ; 
 warm, watery drinks; insufficient nourishment; want of exercise, or 
 the fatigue produced by labour beyond the strength ; tedious diseases 
 and convalescence ; the abuse of sanguine evacuations ; habitual 
 leucdrrhcea,* disappointment, and all the depressing passions, and, 
 finally, all the causes which impoverish the blood and render it inca- 
 pable of imparting to the organs the energy indispensable for the full 
 exercise of the functions. If the contrary excess, that is to say, the 
 state of plethora, produces an analogous effect, it is because the blood, 
 too rich in fibrine, forms an obstacle to itself and itself opposes the 
 periodical exhalation which constitutes menstruation. 
 
 We agree with MM. Roche and Sanson, t Desormeaux and Paul 
 Dubois , % Louis Delaberge and Monneret,§ that too great an in- 
 fluence has been falsely attributed to the nervous temperament in the 
 development of amenorrhoea. Indeed, observation proves that women 
 in whom the nervous temperament predominates, are regulated both 
 sooner and more copiously than others; and that all the causes which 
 exalt this temperament, such as powerful passions, the culture of the 
 arts, erotic studies, precocious or too often repeated enjoyments, and, 
 finally, excitants of all kinds, far from causing suppression of the 
 menstruse, do but precipitate the age of puberty and increase the 
 menstruation. Besides, is it not known, as remarked in their excel- 
 lent compendium , (loc. cit.) by MM. L. Delaberge and Monneret, that 
 in warm climates, where women are commonly endowed with a ner- 
 vous constitution carried to its maximum, menstruation is very early, 
 very active, and rarely deranged ? Beyond a doubt, the nervous 
 temperament was to be looked upon as a predisposing cause of the 
 affection which engages us, because it is not uncommon in hysterical 
 and epileptic women, etc.; this error would certainly have been 
 avoided, and the effects of amenorrhoea would not have been mis- 
 taken for the cause of this morbid phenomenon, if it had been re- 
 marked that the menstrual flux may be suspended by all sorts of 
 chronic, inflammatory and nervous affections, and that very often, a 
 crowd of neuroses and neuralgias show themselves for the first time, 
 only when the menstrum are suppressed. Finally, chlorosis and 
 anemia have been properly ranked amongst the predisponent causes 
 of constitutional amenorrhoea. 
 
 The exciting causes of constitutional amenorrhoea, are no other 
 
 * Our young fellow-practitioner and friend, Dr. Marc d’Espine, of Geneva, says, 
 in a memoir inserted in the Archives generates de medecine, for the year 1835, that of 
 eighty women observed at Paris, twenty-seven only had never had fluor-albus; he 
 adds that of the fifty-three others, twenty-six had it before puberty, eighteen during that 
 epoch, and nine only after that physiological revolution. 
 
 fNouveaux elements de pathologie, t. ii. p. 492. 
 
 j Diet, de Medecine, t. ii. part, amenorrhee, 2d ed. 
 
 § Compendium de Med. Prat., t. i. p. 57, 1836. 
 
AMENORRHCEA. 
 
 465 
 
 than the predisposing causes we have just enumerated, and which, 
 from having lasted longer, or having progressively reached a higher 
 degree of intensity, may produce a more or less complete amenor- 
 rhoea, which then constitutes a case most obstinate, most rebellious, 
 and most fruitful in accidents. 
 
 The causes both of primitive and consecutive sympathetic amenor- 
 rhoea, ought to be referred to three principal heads, to wit: the moral , 
 physical and symptomatic causes of some visceral disorder, or one 
 dependent upon an acute irritation of any part of the economy. 
 
 Amongst the moral causes , should be ranked the vivid emotions 
 of the soul, as anger, disappointed love, celibacy, despair, jealousy, 
 immoderate joy, profound depression, the sudden reception of bad 
 news, a sudden fright,* extreme fear, or a sudden disappointment. 
 A tuberculous female in the wards of M. Rostan, had her monthlies 
 suddenly suppressed on learning that the application of a seton to 
 the parietes of the thorax had been prescribed for her.t We might 
 cite a large number of cases of the same kind, of the sympathetic 
 influence of the nervous system and of the brain in particular, were 
 they not already so generally acknowledged. 
 
 The physical causes that may still more suddenly arrest the 
 menstrual discharge, are : sudden exposure to cold and damp air, 
 the immersion of the feet or hands in cold water, cold ablutions of 
 the sexual organs, sitting upon the grass, on the ground, or on a stone- 
 bench; the ingestion of ices, of sherbets, and of/ very cold drinks, and 
 especially when taken while the body is in a statoof perspiration; 
 a violent bleeding ; the application of a large blister, of cups, etc.; a 
 wound, a burn, a hsemorrhage; the employment of purgatives, of 
 emetics, or of cinchona in large doses; the action of strong odours, 
 particularly, according to Haller’s assertion, the herb penny-royal ; 
 and, finally, all circumstances capable of suddenly drawing in other 
 directions than towards the uterus, the blood which ought to be 
 exhaled by that organ at this period. 
 
 Amongst the causes of sympathetic amenorrhma, we should also 
 include phthisis pulmonalis, hypertrophy of the heart, the different 
 dropsies, scrofulous and tuberculous affections, softening of the bones, 
 the acute and chronic inflammations of the skin, of the stomach, the 
 pleurae, the lungs, the liver, the spleen, the peritoneum, the brain and 
 its membranes, the spinal marrow, and all the visceral irritations 
 which retain the blood and prevent it from being directed upon the 
 uterus. Finally, the sudden suppression of the perspiration, or a 
 
 *From the report of Baudelocque, (loco citato,) sixty-two women were attacked 
 with hsemorrhage or suppressions upon the occasion of the explosion of the powder- 
 magazine of Grenelle. M. Husson has also collected the case of a woman who, at 
 several different times, was attacked with menstrual suppressions, under the influ- 
 ence of claps of thunder. We ourselves observed, in July, 1830, that the reports 
 arising from the platoon firing and cannon-shot, produced the same effect in several 
 women, amongst others in a young person eighteen years old. 
 
 -j-Some months since, one of our relations, whose menstruation is ordinarily very 
 regular and abundant, was attacked with a sudden suppression, in consequence of a 
 frightful dream, a kind of night-mare. 
 
 30 
 
466 
 
 AMENORRHOEA. 
 
 considerable augmentation of this or of any other secretion,* may 
 also determine the non-appearance, the suppression or diminution of 
 the menstruae. 
 
 The causes of amenorrhoea that are dependent upon a local 
 condition of the genital organs , ought likewise to be referred to 
 three principal heads, to wit : vital lesions, lesions of situation, and 
 lesions of form and development of the uterus and its appendages. 
 
 Amongst the causes depending upon vital lesions of the sexual 
 organs, we ought to mention acute and chronic inflammation, indu- 
 ration, the different engorgements, ulceration, excessive sensibility, 
 and the state of anemia of the gestative organ, and of the ovaries ; 
 and, finally, the presence of false membranes; physometra, hydrome- 
 tra, and uterine hydatids, also produce suppression of the rnenstruae. 
 
 The causes depending on lesions of situation are, anteversions, 
 retroversions, flexions and incomplete prolapsus of the womb. 
 Though these different displacements do not prevent the exhalation of 
 the menstrual fluid, they often constitute temporary obstacles to its ex- 
 cretion, because the os tine® being strongly pressed against the sacrum 
 or pubis, there results from this a more or less complete closure of 
 the uterine orifice. Finally, amongst the causes depending on lesions 
 of form and of development , we range the absence, atrophy, and 
 failure of development of the uterus and ovaries, of which we have 
 given examples at pages 76,88 and 118; imperforation of the os 
 tincse and of the hymen ; obliteration of the vagina and of the 
 mouth of the uterus; primitive or accidental agglutination of the labia 
 majora, and of the walls of the vagina ; and, lastly, the different 
 kinds of atresia of the sexual cavities, of which we treated at pages 
 74 and 119, should, likewise, be included amongst those local lesions, 
 which may prevent the exhalation, or more commonly the excretion 
 of the menstruae. We add that it is often impossible to discover the 
 cause of the non-appearance, or of the consecutive suppression of the 
 menstruation. 
 
 The symptoms of amenorrhoea , which vary according to the 
 causes of the disease, ought to be divided into two series. To the 
 first belong the local symptoms, such as pains and dragging sensation 
 in the lumbar region, and a sense of weight in the pelvis, and espe- 
 cially behind the pubis. Amenorrhoea, owing to engorgement of the 
 womb, comes on with a sensation of a somewhat acute local sensi- 
 bility, which often inclines women to onanism, and especially makes 
 them desire coitus even when it is tfery painful to them. If the non- 
 appearance of the menstruation depends upon a congenital fault of 
 conformation, which, moreover, does not manifest itself until the 
 epoch of puberty, the menstrual blood is accumulated in the vagina 
 or in the uterus, and forms above the obstacle a tumour, whose most 
 marked character is that of increasing periodically each month, that 
 
 * This is the reason, no doubt, that professional danseuses are usually scarcely 
 ever well regulated, as well as all those women, who, from their condition of life, 
 give themselves up to fatiguing labours, which provoke in them abundant and 
 almost constant sweats. Moreover, is it not known that lactation, diabetes, and all 
 the dropsical diseases almost invariably lead to. suppression of the menstruation? 
 
AMENORRHGEA. 
 
 467 
 
 is to say, at the epochs when the menstruse ought to be excreted, 
 and then of remaining stationary during the intervals between the 
 sanguine exhalations. In cases where the retention is due to an acci- 
 dental imperforation or obliteration of the mouth of the uterus, the 
 tumour, or rather the distended uterus appears first on a level with 
 the pubis, and then rising gradually from the hypogastrium to the 
 umbilicus, it simulates pregnancy the more closely, inasmuch as it 
 exhibits most of the sympathetic phenomena, and particularly the 
 swelling of the mammae. If the obstacle is situated at the orifice of 
 the vulva, and it be, for example, an imperforate hymen, that mem- 
 brane, pressed forwards by the blood accumulated in the vagina, 
 forms between the labia majora, a hemispherical, livid or bluish, 
 soft and fluctuating tumour, becoming more prominent when the 
 female is erect. (See our remarks upon this matter, pp. 79 and 89.) 
 In most cases, the exploration of the genital parts, and especially 
 the examination per vaginam, per rectum, and by the hypogastrium, 
 suffice to reveal the nature and seat of the obstacle, and to establish 
 a positive diagnosis. We shall add that the pressure of the tumour 
 on the sciatic nerves, the sacral plexus, the rectum and the bladder, 
 often determines engorgement, cramps and numbness of the inferior 
 extremities, and troublesome weight in the pelvis, and sometimes 
 even difficulty and frequency in the expulsion of the urine and 
 faecal matters. (For fuller details, see p. 89 et seq.) 
 
 Where the symptoms we have just pointed out appear for the first 
 time, and especially where they are not followed by symptoms too 
 serious, it would be prudent to wait for another menstrual period ; for 
 it frequently happens that the sanguine exhalation does not establish 
 itself completely, or fails to reappear after being suppressed, until the 
 second or third term, or even until a more distant period ; neverthe- 
 less, if a real condition of disease should result from the amenorrhoea, 
 it would be important to convince ourselves, as early as possible, 
 whether the organs of generation and the pelvic cavity are properly 
 developed, and, finally, whether the enlargement and sensibility of 
 the mammse, as well as all the local symptoms of menstruation, 
 appear at regular epochs. 
 
 The general symptoms or sympathetic signs, which are often 
 the only ones that announce primitive menaphania , or the accidental 
 suppression of the monthlies, vary by their nature, their modifica- 
 tions, their obstinacy and their termination, according to a great 
 number of individual circumstances, such as age, temperament, 
 ordinary disposition, education, and the kind of life more or less con- 
 trary to the laws of hygiene. Thus, the young woman, heretofore 
 brilliant with freshness, strength and health, suddenly sees her fea- 
 tures assume the impress of feebleness, depression and languor ; the 
 roses upon her countenance fade ; the fire of her eyes is extinguished, 
 and a dark areola surrounds them; finally, the most frequent symp- 
 toms are habitual cephalalgia, dyspnosa, dizziness, oppression, pains 
 in the limbs, especially at the joints, and an excessive susceptibility, 
 which changes her character and renders it impatient and irascible. 
 
468 
 
 AMENORRHCEA. 
 
 The moral alteration is not less considerable than the physical.* 
 The ideas become sad, the imagination is sombre; sometimes, the 
 exaggerated sensibility causes the patient to seek for solitude, and 
 shed causeless tears; sometimes, on the contrary, she becomes pas- 
 sionately fond of music, theatres and amusements of all kinds. 
 
 Though there be a small number of women, never having been 
 regulated, who seem to enjoy moderately good health, the great 
 majority of those who are in this condition, suffer at periodical 
 epochs from most of the symptoms that we have just enumerated, 
 and then, without any menstrual discharge making its appearance, 
 calm returns, and both the general and local symptoms are partially 
 dissipated, until another epoch arrives which occurs every month. 
 Other women reach a certain age without suffering any periodical 
 indispositions, but their health is habitually deranged ; they are subject 
 to leucorrhceal discharges, to cholic, to diarrhoea, palpitations, and 
 headaches ; their tissues are soft, flaccid and colourless, and, finally, 
 every thing about them bears the marks of langour and suffering. 
 They are fortunate, if to all these general symptoms are not added 
 cutaneous affections, vicarious haemorrhages, chlorosis, infiltration of 
 the cellular tissue, ascites, and a crowd of neuroses, such as hysteria 
 nymphomania, epilepsy, mania, convulsions, chorea and the whole 
 train of nervous diseases. 
 
 Women, who have never been regulated, and who enjoy, never- 
 theless, perfect health, are generally more or less unendowed with 
 the attributes of their sex ; in them, the breasts, the womb, and the 
 ovaries, are scarcely developed, and may be entirely absent. Their 
 physical constitution, as well as their moral life, approximates to that 
 of the male, whose form, strength, courage, taste, inclinations, pas- 
 sions, etc., they most commonly represent. t Baudelocque, ( Art . des 
 accouch., t. i., p. 183,) speaks of a woman who was destitute of an 
 uterus ; she loved the chase, horses, arms ; she cultivated belles-let- 
 tres, and had never felt any thing which revealed a retention of the 
 menstrual blood, nor even the want of this evacuation. She was 
 married, and fulfilled, but very imperfectly, the duties of a wife, and 
 without caring for its sweets. 
 
 Amenorrhoea depending upon disease of some viscus, may appear 
 at the commencement of such disease, or at a rather advanced period 
 of it ; and, though it is impossible to statue any thing positively upon 
 this point, we may say, generally, that the menstrual derangement 
 declares itself the sooner in proportion to the degree of sympathy 
 between the disordered organs and the uterus ; for example, when the 
 
 * According to M. Broussais, (Cours de Palhologie, tom. ii. p 230,) this is ex- 
 plained anatomically by the intimate relations of the uterus with the spinal marrow, 
 and consequently with the portions of the brain devoted to the affective passions; as 
 has been demonstrated by M. Ollivier d’ Angers, in his treatise on diseases of the me- 
 dulla spinalis. 
 
 f Might we not ask, whether those heroines, whose lofty deeds vve admire in his- 
 tory, and who differed so wonderfully from other persons of their own sex, whether 
 those heroines, we repeat, who lived only in combats and camps, were not deprived 
 of uterus and ovaries, or whether, at least, those organs had not remained in the 
 inertia in which they are naturally plunged during the early years of life? 
 
AMEN0RJRHG2A. 
 
 469 
 
 stomach, the brain, or the heart, is affected, the amenorrhoea comes 
 on at a very early period, whilst in phthisis pulmonalis, the complete 
 suspension of the menstruse does not occur until the stage when the 
 tubercles begin to soften. We may state, furthermore, that the ple- 
 thoric and nervous constitutions exert a marked influence upon the 
 symptomatic or sympathetic suppressions of menstruation, which 
 often coincide in persons who present the individual conditions we 
 have just mentioned, with inflammation of a viscus or some mem- 
 branous organ. 
 
 Before concluding what we have to say upon the symptoms of 
 amenorrhoea, we shall state, that when accidental, and especially 
 where the suppression has been sudden, the woman immediately feels 
 a sensation of heat, weight and pain in the pelvis; more or less violent 
 uterine colic, and a disagreeable tension in the inguinal and lumbar 
 regions, and the upper part of the thighs ; finally, there are added 
 to these symptoms, enlargement of the abdomen and mammae ; an 
 indescribable feeling of malaise and lassitude ; extreme loathing, 
 nausea, vomiting, headache, vertigo, tinnitus aurium, oppression, fre- 
 quent palpitations, and, in many, a burning pain, during the expulsion 
 of urine. Independently of all these symptoms, which are peculiar 
 almost to the sanguine temperament, we often see arise, when the 
 suppression is of no recent date, chronic affections, such as chloro- 
 sis, leucorrhoea, metritis, engorgements, scirrhus, and cancer of the 
 uterus. We call attention, also, to the fact, that amenorrhoea symp- 
 tomatic of some other disease, especially that which has come on 
 slowly and progressively, sometimes aggravates the disease upon 
 which it depends, whilst, under other circumstances, it is favourable 
 to it. It is useless to say, that in the former case it ought to be 
 treated, while in the latter we should let it alone. 
 
 Among the most curious phenomena following suppression of the 
 menses, should be ranked the haemorrhages and other vicarious evacua- 
 tions, of which a more singular example cannot be found than that re- 
 lated by Gardien, ( Trciitk d’JJccoitch., t. i.,) and observed at the hos- 
 pital La Salpetriere,in a girl who, after suppression of the menses, had a 
 periodical sanguine discharge : 1, during six months, from small ulcers 
 in the legs ; 2, for a year, from ulcers on the arms ; 3, for six months, 
 from the opening of a paronychia of the left thumb ; 4, for two years, 
 from ulcers at the angle of the eye, consequences of an erysipelas of 
 the face ; 5, for five months, from the umbilicus where another erysi- 
 pelas had made its appearance ; 6, for four months, from the internal 
 malleolus of the left foot ; 7, and finally, for two months, from the 
 left ear. When the blood ceased to flow from a fixed point, there 
 occurred attacks of epistaxis and haemoptysis, preceded by convul- 
 sions, headaches, and dizziness. Doctor Chatelain, of Nancy, in his 
 thesis, ( Essai sur la mensh'uation, 1827,) speaks of a prostitute 
 seen by M. Bonfils, at the Magdalen Society of that city, who, 
 in consequence of derangement of menstruation, had sanguine dis- 
 charges successively from the arm-pit, the nipple, the left flank, the 
 back, the epigastrium, and the thigh. M. Chatelain, likewise, cites 
 a case observed by M. Begin, concerning a young person, whose 
 
470 
 
 AMENORRHOEA. 
 
 left index-finger, in consequence of amenorrhoea, swelled, and was 
 covered by an acute herpetic eruption from the surface of which 
 flowed several drops of blood, at a certain period of every month. 
 The herpes and the discharge, which lasted only three or four days, 
 were accompanied by a disagreeable pruritus. It was not until three 
 years later that the womb returned to its regular functions, and the 
 health of the patient was completely re-established. 
 
 The point at which the vicarious hsemorrhage takes place, gene- 
 rally varies according to the age of the female ; during youth, it is from 
 the nose and chest ; later in life, from the haemorrhoidal vessels, the 
 stomach and the bladder. According to Stahl, ( de mensium insolit. 
 viis,) an indigestion or a pulmonary catarrh occurring during men- 
 struation, suffices to provoke the afflux of blood towards these diges- 
 tive and respiratory organs. Yet, though epistaxis, haematemesis, 
 haemoptysis and haematuria, may be the most frequent of these 
 haemorrhages, we could cite other examples of these menstrual de- 
 viations taking place from other fixed points of the economy. Bau- 
 douin Ronssaeus ( OpuscuL med. de morb. mitlier.,) states that a 
 woman having had a molar tooth extracted, had a suppression, and 
 that a discharge of blood, which was renewed every month, was esta- 
 blished from the alveolus of this tooth. Raymond speaks of an un- 
 married woman who, at the age of forty-eight, had a slight haemor- 
 rhage once a month from the alveolus of a tooth which she had lost. 
 The same author adds, that the discharge of blood, which lasted 
 three days, was about three ounces per diem. J. N. Pechlin, ( Ob - 
 serv. physic, med., lib. iii.,) relates a case of menstrual haemorrhage, 
 which took place from an ulcer on the foot. Theod. Kerckring, 
 ( Spiceleginni anat. cont. observ. cinat. rar.,) cites the case of a girl 
 who was periodically regulated from a wound in the right hand. 
 Louis Mercatus, [de morb. mulier. lib. iv.,) mentions a woman that 
 was not regulated, whose cheeks became of a very deep red colour 
 every month. Finally, to the long enumeration of menstrual irre- 
 gularities, reported by Haller, [Element, physiol, corp. human.,) 
 Freind, [Emmenol, cap. viii.,) and Royer Collard, [Essaisur Vame- 
 norrhee, p. 28,) we will add that Baudelocque, ( Traitb des accouch .) 
 who was acquainted with a woman forty-five years old, who had never 
 been regulated, and who was subject, during three days of every 
 month, to a diarrhoea. M. Brera, ( Essai clinique sur Viode ,) mentions 
 a woman who, in consequence of a menstrual suppression, was sub- 
 ject every month, for two years, to a dysenteric flux, which lasted 
 five or six days ; we will add, also, that we saw a similar case in a 
 female, who was in the wards of Fouquier, in 1830. 
 
 The diagnosis of amenorrhoea is not always easy to establish. 
 Therefore, we think that a physician, in such cases, should use the 
 greatest reserve, and behave with the utmost prudence and circum- 
 spection, in order to avoid mistakes, and especially the snares which 
 might be tendered him. In effect, may it not happen that young 
 girls and widows, interested to conceal their pregnancy, shall seek, 
 with criminal intentions, to deceive their physician as to their real 
 condition, in the hope that the remedies, and especially the bleedings 
 
AMENORRH(EA. 
 
 471 
 
 which might be ordered for suppression of the menses, shall lead to 
 the criminal end they seek to attain. Besides, may not women, in- 
 voluntarily, deceive themselves as to their condition of pregnancy, 
 and suppose that they merely labour under a suppression attribu- 
 table to some accidental cause. Is it not, also, true, that women, 
 aware of the arrival of the critical age, by the cessation of the men- 
 strual discharge, seek, by remedies not always unattended with 
 danger, to prolong the marks of a youthfulness which has passed 
 away, by recalling the signs of a fecundity which no longer exist ? 
 To administer remedies in such cases without any precaution, would 
 be to expose ourselves on the one hand to the danger of inducing 
 abortion, and on the other of determining dangerous haemorrhages 
 and inflammations, which may be followed by the most serious 
 consequences. To avoid unhappy mistakes, and the snares held out 
 by the fear of dishonour and the desire of concealing the ravages 
 of years, the physician who feels any uncertainty, should endeavour 
 to temporize, as much as possible, until he can discover the true 
 cause of the suppression, and confine himself to a grave prescription 
 of insignificant remedies, especially in cases where the health no 
 longer requires any therapeutical intervention. This conduct seems 
 the more rational, as there are no positive signs of commencing 
 pregnancy, and as, after the fifth month, ballottement, the sponta- 
 neous movements of the foetus, and the use of the stethoscope, permit 
 us no longer to doubt on this point. 
 
 Supposing, that by a series of questions adroitly asked, we have 
 succeeded in convincing ourselves of the good faith of the patient, 
 who might be, moreover, by her social position and known morality, 
 above all suspicion, the first thing to seek after, would be to dis- 
 cover whether the uterus were primarily or sympathetically affected. 
 By the exploration of the sexual organs, we could always recognize 
 the local lesions that might give rise to amenorrhoea depending on 
 this cause ; we ought particularly to insist upon this means of diag- 
 nosis before commencing any treatment, provided the suppression, 
 already of longstanding, have resisted the ordinary remedies. Never- 
 theless, we ought, as M. Lisfranc* directs, to be careful in the case 
 of the virgin young girl, and rest contented with examining merely 
 by the rectum, the vagina, and the uterus. 
 
 Should the amenorrhoea co-exist with any lesion whatsoever of 
 some other organ, we should try to discover whether that organ is 
 affected primarily and reacts sympathetically on the uterus, or whe- 
 ther, on the contrary, it is a morbid condition of this latter viscus 
 that reflects its unhealthy influence on a part* or the whole of the 
 economy. The origin of the disease may generally be detected by 
 carefully studying the temperament and constitution of the woman, 
 as well as the modifications and sequence of the symptoms. We 
 must acknowledge, however, that there are some very embarrassing 
 cases, in which we can discover neither any lesion nor any cause to 
 clear up the diagnosis. 
 
 * Bulletin clinique, par MM. Piorry, Rameaux, L’hSritier, Thibert, No. 5, 1 Sep- 
 ember, 1835, and compendium de med. pratiq. de MM. Delaberge et Monneret, t. i, 
 p. 62, 1836. 
 
472 
 
 AMENORRHOEA. 
 
 The prognosis of amenorrhoea must necessarily vary according to 
 the causes which have produced it, according to its duration and the 
 severity of the accompanying symptoms. Amenorrhoea connected 
 with a plethoric constitution is not always complicated with serious 
 symptoms ; often, indeed, is it accompanied by mild ones, which are 
 usually readily controlled ; nevertheless, a strongly marked plethoric 
 condition may give birth to acute inflammations, which sometimes 
 resist the most energetic treatment, but which always cease updn the 
 appearance of the menses. When the non-appearance or suppres- 
 sion of the menses is the result of constitutional debility, the progress 
 of the disease is slow, and it assumes a character of languor and 
 inertia, which forms an obstacle to the cure, which is always obtained 
 with greater difficulty than when the disease depends upon a gene- 
 rally plethoric condition. Amenorrhoea, in the year following the 
 first menstrual irruption, at the age of puberty, is not of much conse- 
 quence, and is scarcely ever due to a seriously morbid state of the 
 uterus. That which attacks suddenly, occasions inflammatory symp- 
 toms, which, for the most part, are readily controlled as no doubt 
 rests upon the diagnosis. It even happens, sometimes, that the 
 menses appear at the next epoch, and that this indisposition, which 
 women call retard , yields to simple remedies or to the powers of 
 nature alone. In these cases menstruation often returns with such 
 violence as to constitute a real haemorrhage. 
 
 The prognosis of amenorrhoea from a local disease, must always 
 depend upon the nature of the lesion which has produced it. It is 
 most troublesome, generally, when the menstrual suppression depends 
 upon a simple chronic engorgement, or upon chronic induration o 
 the neck or body of the gestative organ. If sanguine congestion has 
 induced the amenorrhoea, and the physician recognizes the nature 
 of the disease, it is very rare for him to be unable to apply a prompt 
 remedy, unless, indeed, the engorgement be the first stage of some 
 degeneration of the uterus. 
 
 It becomes necessary to pay the strictest attention to the case, 
 where the suppression is of long standing, even though the patient 
 has not suffered from any serious disorder. Although it is very difficult 
 to ascertain what organ was primarily affected in such a case, and, 
 consequently, to establish the basis of a rational treatment, that end 
 may often be attained by studying all the commemorative symptoms, 
 and carefully comparing them with those that actually exist. The 
 older the amenorrhoea, the more difficult is it to overcome it by 
 therapeutical agents : one that has lasted for several years, offers 
 but slight chances of cure ; and it is well known that the father of 
 Medicine gave a still more unfavourable prognosis, which, however, 
 is not supported by experience, when he said, ( De rnorb. rnulier.): 
 “ Sexto mense insanubilis ?norbus redditur , qui antea curari pro - 
 ter at” Women have been known to become habituated sometimes 
 to the loss of the menstrual discharge, and to suffer no consequent 
 inconvenience. In cases of that kind, we ought not to fatigue the 
 patient by useless treatment, but be contented with preventing and 
 combating any symptoms which may arise. In certain cases, where 
 
AMENORRHCEA. 
 
 473 
 
 the most rational treatment has failed, the return of the menses has 
 followed pregnancy. As to the prognosis to be made in amenorrhcea 
 depending on disease of some important viscus, we shall rest satisfied 
 with saying, that it is altogether subordinate to the nature of the dis- 
 ease ; if the suppression be connected with phthisis pulmonalis, or 
 any other profound disorganization, the chances of recovery are the 
 same as those of the primary diseases. As we should be compelled, 
 in order to offer any positive statements on this point, to pass in 
 review the whole nosological catalogue, we shall be content with 
 stating that the prognosis varies according to the importance of the 
 organ primarily or secondarily affected, and according to the more or 
 less favourable general circumstances in which the patient may be 
 placed. 
 
 The prognosis of amenorrhea from non-excretion is not generally 
 unfavourable, because both the vicious disposition and the obstacle 
 which prevent the escape of the menstruae may commonly be cor- 
 rected. The cure, however, is difficult to obtain where the occlusion 
 is deeply situated, and especially when it depends on a more or less 
 extensive adhesion of the walls of the vagina or uterus. Rupture 
 of the Fallopian tubes has been proved to occur in cases of this kind 
 from the accumulation of blood : it is useless to add that the effusion 
 of the fluid into the abdomen has always produced, as its inevitable 
 and almost immediate cause, the death of the patient. In fine, we 
 conclude by saying that we should never interfere with the vicarious 
 haemorrhages and other discharges, which, to a certain extent, are 
 the substitutes of the menses, and that we cannot, be too watchful 
 of the function in a delicate girl, whose limbs are slight, whose chest 
 is contracted, and whose constitution is predisposed to tuberculous 
 affections. 
 
 The treatment of amenorrhoea must be regulated according to the 
 physical and moral circumstances and causes which have brought 
 on or that keep up the disease. 
 
 When the amenorrhoea is simple, and occurs in a girl of a depraved 
 constitution, with a predominance of the lymphatic system, we should 
 direct a prolonged insolation, a fresh and dry air, especially in a 
 mountainous country, the use of nourishing food, principally rich 
 soups and roast meats, largely supplied with ozmazome and fibrine. 
 For drink we may prescribe the old and tonic Burgundy wines, or 
 the Bordeaux and Rhenish, mixed with the mineral waters of Forges, 
 of Passy, of Provins, of Rouen, of Bussang, of Spa, of Bussiares,'* and 
 the various ferruginous waters. It will be well, likewise, to make use 
 of bitter and gently excitant drinks, of dry frictions, flannel next to the 
 skin, and, finally, of cold river-baths, of swimming, exercise on foot 
 
 * Bussiares is a village situated in the department de l’Aisne, three leagues from 
 Chateau-Thierry, and twenty-one from Paris. Its waters, the principal sources of 
 which belong to M. Villacrosse, and of which M. Corriol, a distinguished pharma- 
 ceutist of Paris, has lately made an excellent analysis, are situated in a charming 
 spot, where one breathes the purest air. For this last reason, they are preferable, 
 when taken on the spot, to most of the other ferruginous springs, which, almost with- 
 out exception, are in damp, unhealthy and marshy districts. We have had it in our 
 power, as well as Dr. Eydoux, to witness, on several occasions, the happy effects of 
 the waters of Bossiares, in cases of amenorrhoea, chlorosis, and dropsy, etc. 
 
474 
 
 AMENORRHCEA. 
 
 and in a carriage, riding on horseback, living in the country, mode- 
 rate exercise, the games of battledore, the jumping-rope, the hoop, 
 running, and particularly dancing, are also powerful means of cure, 
 which ought not to be neglected, and which women seldom object 
 to putting in practice. We should also endeavour to remove the 
 melancholy of our patients by relieving, as much as possible, their 
 vexations and moral disorders, which are often the chief causes of the 
 debility of their constitutions. It is to the persuasive eloquence of 
 friendship that we must trust for the restoration of that calm and peace 
 of mind, without which all other means will remain without fruit. 
 
 Though a hygieinic treatment is sufficient, in some simple cases, to 
 remove amenorrhoea depending upoft general debility of the consti- 
 tion, it is in most cases necessary, at the same time, to resort to tonic 
 medicines, whose action influences all the different systems, and 
 especially that of the circulation. Among the therapeutical agents 
 of this nature, we would place in the first rank iron and its various 
 preparations, as the filings, the oxides,- the tartrates, and the carbo- 
 nates of this metal, employed alone, or combined with the bitter pow- 
 ders and extracts, with Castile soap, cream of tartar, or some salt of 
 potash, etc. We ought, however, to remark, that of all the ferrugi- 
 nous salts ,the subcarbonate is the one whose efficacy in overcoming 
 primitive or consecutive amenorrhoea depending upon constitutional 
 debility, is most generally recognized. This remedy, which is pre- 
 scribed in graduated doses, from a few grains up to two or three 
 drachms daily, gives tone to the whole economy, improves the haema- 
 tosis, equalizes the circulation, and by re-establishing, as it were, by 
 enchantment, the equilibrium of all the functions, directs, by a special 
 action, an afflux of blood upon the uterus. We have, in this condi- 
 tion, and always with advantage, used the pills of Doctor Eland, of 
 Beaucaire, composed and administered as we shall describe in treat- 
 ing of chlorosis. We might, also, in the same condition, prescribe 
 WherlofPs pills, made according to the following formula, viz., sul- 
 phate of iron, two drachms ; extract of absinthium, four drachms : 
 syrup of saffron, q s. to make one hundred and fifty pills. If 
 the disease should seem connected with a scrofulous diathesis, it 
 would be well to recur to M. Lugol’s pills : take of protiodide of 
 iron, six grains ; starch, twenty-four grains ; syrup of gum, q. s. 
 to make twenty-four pills, one of which should be taken morning 
 and evening. If the amenorrhoea should be complicated with chro- 
 nic leucorrhoea, which is sometimes a substitute for the menstrual 
 discharge, recourse should be had to vaginal injections of the ferru- 
 ginous waters of Forges, of Spa, of Passy, etc., and at the same time 
 should be prescribed our balsamic, tonic and ferrated troches,* 
 which are perfectly well prepared by M. Corriol, of whom we have 
 already had occasion to speak in this chapter. These troches have 
 the double advantage of being very efficacious in chronic leucorrhoea, 
 and in the amenorrhoea, dependent upon constitutional debility. 
 
 * We shall give, at the end of this work, the composition and mode of preparation 
 of our troches, into which enter, in different proportions, copaiba, the black oxide ot 
 iron, gentian, rhubarb, canella, and magnesia. 
 
AMENORRHCEA. 
 
 475 
 
 There might, likewise, be prescribed with advantage in this case, 
 the internal use of turpentine, united to some tonic substance, the 
 efficacy of which has been established by M. Gibert, [Rev. Med., 
 1837, t. iii. p. 32.) 
 
 For the cure of the amenorrhoea under consideration, there is not 
 only a crowd of other martial preparations, such as the vinum ferri, 
 the martial pills, etc., but also a great number of other tonic and 
 stimulant remedies, among others, cinchona, quassia, gentian, cen- 
 taury, buck-bean, canella, ginger, cardamum, absinthium, mint, balm, 
 sage, etc., etc. Though most of these substances are efficacious in 
 some cases of amenorrhcea, we think they should be resorted to only 
 where it is certain that the alimentary tractus can support their action 
 without injury. 
 
 The means that we have just mentioned should not be employed, 
 where constitutional amenorrhoea depends upon excess of vital power 
 and a state of general plethora. In cases of this kind, we most fre- 
 quently succeed in reproducing the menstrual flux by diminishing 
 the richness and exuberance of the blood and other fluids, by means 
 of a more or less rigorous diet, vegetable regimen, watery drinks, 
 mild purgatives, and especially by the aid of repeated bleedings 
 practised mostly a few days before the presumed epoch of the men- 
 strual exhalation. 
 
 If, after having modified the constitution, as we have described, the 
 menses should fail to thake their appearance, we might resort, but 
 with the utmost circumspection, to the remedies ranged in the class 
 of emmenagogues, such as rue, mugwort, absinthium, saffron, savine, 
 Fuller’s pills, and those of Ruft'us, which are prescribed only at the 
 approach of the menstrual epoch. To the careful use of these sub- 
 stances, it would be well to add the employment of local means 
 capable of inviting the blood towards the uterus, such as foot- 
 baths, hip-baths, warm enemata, aromatic fumigations, fomentations 
 of the same nature applied to the external genital organs, cups about 
 the pelvis, local depletion from the vulva, or general bleedings from 
 the inferior extremities, and finally, a great number of other reme- 
 dies, to which we shall revert haj^after. We merely add, that in 
 order early to accustom the genual organs to a sanguine fluxion, 
 we should make use of the jjbcal means we have just pointed out 
 at the same time that we prescribe a general treatment. In re- 
 fractory cases, it would.be particularly necessary to insist upon the 
 employment of leeches, to the number of four or six, applied to the 
 internal surface of the thighs, or on the outside of the labia majora, 
 taking care to renew the applications several times at the approach 
 of the supposed epochs of the menses. M. Lisfranc, ( Bulletin de 
 clin., No. 5, p. 148,) who advises that the bites should not be allowed 
 to bleed for more than a quarter of an hour, prefers, under these cir- 
 cumstances, a bleeding in the foot of two to four ounces. That able 
 practitioner says, with reason, that to succeed, this treatment must 
 often be employed, at each menstrual epoch, for several months in 
 succession. 
 
 In order to produce, sympathetically, an afflux of blood towards 
 
476 
 
 AMENORRHOEA. 
 
 the uterus, several practitioners have recommended irritating the 
 mammas, either by means of cups, by the use of leeches in small 
 numbers,'* or by the application of sinapisms to the breasts.! Se- 
 veral instances of the successful employment of these means have 
 been published in the journals, and mentioned in the foot note, and 
 in the fourth volume of the Archives Generates de Medecine for 
 the year 1831. 
 
 The treatment of amenorrhoea. dependent upon a particular 
 condition of the uterus , varies according as the menstrual disorder 
 is owing to engorgement, to atony, or to some accidental or some 
 congenital fault of the gestative organ. 
 
 Uterine engorgement , which contra-indicates all the emmena- 
 gogues, and other excitant remedies which we have just mentioned, 
 should be treated by rest, by mild diet, by bleeding from the arm, 
 baths, emollient drinks, poultices, demulcent and narcotic enemata, 
 and finally, by all the remedies which we pointed out at page 297, 
 while speaking of simple engorgement of the uterus. 
 
 When the non-appearance or suppression of the menses depends 
 upon a torpor of the womb, the female, being in other respects 
 well, we might, with the view of exciting them, advise cups to the 
 hypogastrium, the groins and thighs ; warm douches of the Bareges 
 waters, or of those of Aix in Savoy, directed to the outside of the 
 pelvis and into the vagina ; stimulant enemata, medicated pessaries, 
 electricity,! galvanism, ( Andrieux ,) coitus^ flannel drawers, aro- 
 matic hip-baths, bathing of the legs knee deep, the application of a 
 small cup to the cervix uteri, || when the hymen allows of it; we 
 should, at the same time, resort to the methodical employment of 
 the active emmenagogues, as for example rue, savine, saffron, mug- 
 wort, hellebore, aloes, and cantharides, the effects of which must 
 be carefully watched, and which are rendered still more efficacious 
 by association with persons of the other sex, by visiting balls, the 
 theatre, and finally, all the circumstances capable of arousing the 
 genital organs. 
 
 Amongst other remedies proposed for the treatment of chronic 
 amenorrhoea, we ought to cite -igdine, the efficacy of which has 
 been proved by MM. Coindet, Dumeril, Brera of Padua, Magendie, 
 Sablairoles, Recamier and Trousseau, as well as by ourselves. 
 Doctor Carron du Villards, ( Bulletin ther ., Oct. 15, 1835,) speaks of 
 having seen several cases of amenorrhoea yield to the internal em- 
 ployment of cyanuret of gold, prepared in the proportion of three 
 grains to eight ounces of alcoholic water. At first one teaspoonful 
 
 * Ch. Loudon, on the cure of amenorrhoea, 1832. Repert. de clinique, par Carron 
 du Villards, 1834, p. 304. 
 
 f Patterson, Gazett. Med., 1833, p. 866. 
 
 % Sigaud-Lafond,(</e I'electr. med., p.565,) Mauduyt, ( Trait de Veledr.med.) Nauche, 
 p. 659, Ch. Loudon, ( on the cure of amenorrhoea , 1834.) 
 
 § Hippocrates, Plato, (m prax., cap. xiv.) Hoffman, ( med rat. syst., t. iv. p. 401, 
 Cullen, ( Elern . de med., trad, par Bosquillon, t. ii. p. 137,) and several other authors 
 state, that the first appearance of menstruation often takes place after the first con- 
 jugal approaches. 
 
 11 MM. Chaponnier, Piorry, and Amussat, have made use of this remedy, which, in 
 our opinion, is far from being unobjectionable. 
 
AMENORRHCEA. 
 
 477 
 
 is taken morning and evening, fifteen days before the supposed period 
 of the menses, and then two and three progressively. Ergot, also, has 
 been employed advantageously, in a dose of five or six grains daily, 
 (Pauly,) and the watery extract of aconite, (M. West,) in the dose of 
 from one to eight grains progressively. 
 
 Were the amenorrhoea associated with a condition of extreme 
 irritability, or with excessive action of the uterus, we should pre- 
 scribe abstinence from coitus, revulsive bleedings from the arm, in- 
 jections, emollient and narcotic enemata, and poultices, and finally, 
 various kinds of sedatives, and particularly opium. Nervous and hys- 
 terical symptoms, and neuropathic disorders, should be treated by 
 antispasmodics, assafoetida, camphor, musk, castor, and the opiate 
 preparations, administered especially in small enemata. Finally, 
 we conclude what we had to say upon the treatment of amenor- 
 rhoea depending upon a local cause, by adding that, that which is 
 owing to atresia of the uterus, vagina or vulva, or a lesion of situa- 
 tion of the gestative organ, requires operations which we have else- 
 where described.'* 
 
 The treatment of sympathetic amenorrhoea must depend on the 
 causes which have given rise to the suppression. When the amenor- 
 rhoea has been consequent on circumstances which may provoke it in- 
 stantaneously, such as the sudden impression of cold, it is necessary, if 
 we are called at the very beginning, to prescribe the use of warm drinks, 
 slightly excitant and sudorific, as for example the infusions of balm, 
 of mint, of elder flowers, &c., rest in bed, the application of warmth 
 to the thighs and legs, kept up by means of bottles filled with warm 
 water, or still better by a poultice of flaxseed meal, enveloping the 
 whole of the inferior extremities, and renewed as soon as it begins to 
 cool : in cases of this kind, the following potion has always seemed 
 efficacious in our hands ; take of distilled balm- water and of orange- 
 flower water, each two ounces; spirits of Mindererus, three drachms; 
 tincture of saffron, thirty drops ; syrup of tolu and orange-peel, an 
 ounce each, of which a tablespoonful may be taken every half hour. 
 We may, likewise, employ with advantage, dry cupping to the hy- 
 pogastrium and upper part of the thighs, and particularly the 
 veniouses monstres, that is to say, the apparatus of Doctor Sunot,t 
 
 * At the sitting of the 20th March, 1838, Professor Roux read to the Academy of 
 Medicine, the account of his scientific journey in Germany, where reference is had to 
 a curious case observed at Prague, at the clinic of M. Fritz, in a young person twen- 
 ty-six years of age, whose uterus presented a development equal to that of a woman 
 pregnant at seven months; this anormal condition was produced by an accumula- 
 tion of the menstrual blood, which could not be discharged because of a congenital 
 obliteration of the cervix uteri, and absence of the inferior portion of the vagina. 
 Having been consulted by M. Fritz, M. Roux advised the opening of the pouch 
 through the vagina by careful incisions with a bistoury. The advice of the celebra- 
 ted French surgeon was adopted with complete success. Analogous operations have 
 been performed by Professor Flammand, MM. Willaume, of Metz, Amussat, Stoltz, 
 and some other surgeons whom we quoted in Chapter V., First Section, (lesions of 
 form.) 
 
 f Some interesting details upon the application of the ventouses monstres may be 
 found in a memoir published by Doctor Sunot, in the number of the Revue Medicate , 
 for September, 1834, under the title of Physiological and Therapeutical Researches on 
 the effects of the compression and rarefaction of the air , both upon the body and limbs 
 
478 
 
 AMENORRHCEA. 
 
 in which the inferior extremities, as far as the pelvis, should be 
 engaged ; this method is so powerful, that we have seen it, in a case 
 of cerebral congestion, produce uterine haemorrhage in a woman fifty 
 years of age, who had ceased to be regulated for several years. To 
 avoid the inconveniences which might result from the application of 
 this ingenious means, particularly that of .too sudden a derivation, 
 the precaution should always be observed of acting slowly and 
 effecting the rarefaction of the air in a gradual manner. The method 
 of M. Patterson, which had already been usefully employed by M. 
 Velpeau, and which consists in the application of sinapisms to the 
 breasts, might also have some good effect. Where the suppression 
 has resulted from some vivid emotion, antispasmodics and sedatives 
 should be conjoined with these means. 
 
 The treatment of amenorrhoea , , dependent upon a visceral lesion, 
 ought to consist in combating the disease which sustains and has 
 given rise to the suppression or primary non-appearance of the 
 menses. The most successful, and, at the same time, rational mode 
 is first of all to allay the irritation of the organs primarily affected ; 
 we should not, therefore, concern ourselves with the absence of the 
 menstrual discharge, except merely with the view of diminishing the 
 severity which it lends to the existing affection, and to ^pcrease the 
 chances of cure by diverting as much as possible the afflux of blo6d 
 towards the organ, whose lesion is the primitive cause of the ame- 
 norrhoea. Irritation and congestion of the heart, lungs, stomach, 
 liver, etc., require, at first, the treatment appropriate to those differ- 
 ent affections, and afterwards local means proper to recall the men- 
 struae, which should be employed chiefly at the epoch corresponding 
 to the monthly periods. Vicarious haemorrhages, of small amount, 
 not. affecting very delicate organs, and especially those already of 
 long standing, ought to be treated with prudence and circumspection, 
 and perhaps left to the efforts of nature alone ; if, however, they 
 should occur from organs in which congestion might produce fatal 
 consequences, it would become necessary to relieve the patient of 
 them, taking care not to arrest them suddenly: after producing the 
 discharge of the menses by the rational means we have mentioned, 
 all anormal haemorrhages will disappear spontaneously, or they may 
 be suppressed without danger. 
 
 We shall conclude by saying, that the moral condition of the patient 
 merits as close attention as the different means we have discussed, 
 and requires, perhaps, greater sagacity even on the part of the physi- 
 cian. So long as we neglect to attend to the state of the mind, the 
 menstrual disorders depending upon diseased mental conditions, and 
 especially upon profound dejection, resist all the resources of the art ; 
 all the doings in pharmacy are equally powerless to oppose the ame- 
 
 tvhen isolated. We are happy to have the opportunity, in this place, of thanking the 
 ingenious inventor of this apparatus, for the disinterested zeal with which he applied 
 it upon our own person, during an attack of cephalalgia and insomnia, brought on 
 by excessive labour and prolonged loss of rest. This new derivative of the blood, 
 whose happy results we have witnessed, procured for its author the prize of two 
 thousand francs, offered by the Academy of Sciences of the Institute. 
 
DYSMENORRHCEA. 
 
 479 
 
 norrhoea of a young girl, who is tormented by a disappointed or 
 unfortunate love ! 
 
 “Nullis est amor medicabilis herbis !” 
 
 The consolations of a prudent and enlightened mother, the counsels 
 of a kind and indulgent friend, and especially marriage, where the 
 prostration is not gone to such an extent as to give cause to fear for 
 pregnancy and labour, such are the means which, in these cases, can 
 arrest the disease at its source. 
 
 OF DYSMENORRHCEA. 
 
 We understand by dysmenorrhcea a state of thfe menstrual dis- 
 charge, in which it is regularly established, but is preceded or ac- 
 companied by uterine pains, and often by nervous and hysterical 
 symptoms. This anormal condition, which is less a disease than the 
 painful exercise of a function, and which, according to M. Lisfranc, 
 is often hereditary, may be either idiopathic or symptomatic of a 
 chronic metritis, with or without engorgement. 
 
 The causes of idiopathic dysmenorrhoea are but little known ; it 
 has been noticed, however, that those women who furnish the most 
 frequent examples of it, are generally of a nervous or bilious tem- 
 perament, of ardent feelings, and greatly addicted to coitus ; yet 
 constitutions precisely the opposite of this are not exempt from it ; 
 and it has often been observed that changes of climate, of mode of 
 life, of habitation, and various debilitating causes, which, by long- 
 continued action, produce amenorrhcea, are likewise causes of the 
 difficult and painful discharge of the menstrual fluid. 
 
 The symptoms which constitute a case of dysmenorrhoea are : 
 pains in the loins and groins, in the hypogastric region, in the thighs, 
 and a kind of contraction of the uterus, which precede and accom- 
 pany the flow of the menses. To these symptoms, which are always 
 present, are added others which sometimes fail to appear ; such are 
 a condition of hystericismus and anxiety, a sense of constriction 
 in the throat, of lassitude of the limbs, more or less complete insom- 
 nia, and a very variable temper. Most of the patients feel a sen- 
 sation of heat in the neck of the womb, a kind of pruritus of the 
 vagina and spasmodic constriction of the vulva, giving rise to erotic 
 desires. Nevertheless coitus, far from being agreeable, is then very 
 painful and irritating ; moreover, the discharge of blood takes place 
 only drop by drop, and though sometimes abundant, it is always 
 accompanied with a great deal of pain. 
 
 Symptomatic is much more common than idiopathic dysmenor- 
 rhma ; its most frequent cause is engorgement of the neck, and espe- 
 cially of the body of the uterus, which may be ascertained by means 
 of the Touch practised during the intervals between the menstruse. 
 The incomplete and painful discharge of the menses may likewise 
 be symptomatic of some lesion of a distant organ, and like amenor- 
 rhoea, there is no chronic disease which may not give rise to it. 
 
 The treatment of idiopathic dysmenorrhoea, or that which we may 
 
480 
 
 DYSMEXORRHCEA. 
 
 regard as dependent upon a neurosis of the uterus, and excessive 
 sensibility of that organ, presents as the first indication the allaying 
 of the nervous condition by the use of prolonged warm baths, and 
 particularly hip-baths, employed several days before the menstrual 
 epoch ; opiate enemata, narcotic injections of cicuta and henbane, 
 when the pruritus is very severe, or simply mucilage of marshmallows 
 with infusion of poppy-heads, when the heat alone of the parts is 
 augmented ; emollient drinks in large quantity, vegetable diet, mild 
 regimen ; finally, if the female is plethoric, a revulsive bleeding, 
 during the interval of the menses, or still better, two or three days 
 before their appearance ; such are the means whose efficacy in the 
 treatment of the affection under consideration has been tested by 
 experience. In very irritable women, we should add to these means 
 the internal employment of sedatives; amongst others the potions and 
 emulsions, which contain either extract of opium in minute doses, 
 or syrup of white poppies or acetate of morphia, in the proportion 
 of a quarter of a grain to four ounces of fluid, which should be taken 
 in the dose of a tablespoonful every hour. Finally, with the view of 
 producing a more rapid sedative action upon thje uterus, and to 
 overcome the painful tormina which accompany the discharge, we 
 might, after the example of M. Masuyer,* M. J. Cloquet, f Patin, of 
 Troyes , % and some other practitioners, we might, we say, as we have 
 several times done with advantage, give from forty to seventy drops 
 of the acetate of ammonia, ( spirit Minderer.) in a glass of water, 
 taken at two doses. The administration of this remedy allays the 
 pain, and in that way facilitates the flow of the menses. As soon 
 as the malaise and uterine pains are felt, the first dose, (twenty- 
 five to thirty-one drops,) should be administered; half an hour after a 
 second quantity is ordered ; finally, if the symptoms do not improve, a 
 third dose is prescribed, but that should be done with the same reserve, 
 in order to avoid what sometimes results from it, a diminution in the 
 quantity of the menses. We shall conclude by saying, that amenor- 
 rhoea is often rebellious to therapeutical means, especially when 
 hereditary, and in some sort connected with the primary organiza- 
 tion of the womb. Dysmenorrhcea, symptomatic of disease of this 
 viscus, or of a distant organ, offers the same prognosis as the primary 
 affection, and requires, therefore, the same treatment as the last. 
 
 [Here is no notice taken of the very ingenious theory on dysmenorrhoea, 
 by Dr. Mackintosh, in his Practice of Physic, p. 686. Dr. Mackintosh, it 
 seems, as long ago as 1823, had met with much difficulty and embarrass- 
 ment in the treatment of cases of dysmenorrhoea, when, having thought that 
 he perceived in such cases the signs of stricture in the canal of the cervix 
 uteri, he imagined that to dilate that canal with the bougie, might be a method 
 of relieving the pain of the patient. In the course of a few years, from 
 1826 to 1832, he met with twenty cases of dysmenorrhsea, which he treated 
 
 * Gazette de Sante, November, 1826. 
 
 t Archives gen. de Med., t. xii. p. 651. 
 
 * Clinique des hopitaux, t. iii. No. 15 and 16, 1828. 
 
DYSMENORRHCEA. 
 
 481 
 
 by the use of the bougie, and in eighteen of them with a most marked suc- 
 cess ; in two others, without advantage. Ten of the eighteen were married 
 women, of whom seven afterwards fell with child. Eight were unmarried 
 young women or widows. 
 
 As it is well known that strictures of the urethra, if neglected or become 
 inveterate, produce diseases of the bladder and even of the kidneys, it appears 
 reasonable to suppose that too great a constriction, or narrowness of the 
 cervical canal, might come at last to establish a permanent irritation in the 
 womb, laying the foundation for the complaints in question. It is at least 
 certain that instances are met with of great alterations in the form and size 
 of the canal. Dr. Mackintosh says (p. 652) that in 1823, a medical friend 
 presented him with a preparation of the uterus and its appendages, in which 
 the os uteri was so small as scarcely to admit of the introduction of a hog’s 
 bristle, and that he has obtained many preparations taken from the bodies of 
 people dying of different diseases, particularly phthisis, and whose histo- 
 ries prove that they had laboured under dysmenorrhcea during their men- 
 strual lives. Some are so small as scarcely to admit a bristle, and others 
 large enough only for a small silver probe. I exhibited two such specimens 
 to the class in the Jefferson Medical College, in 1841, and I have a cast of 
 one in papier mache , by Mons. Thibaud, of Paris; I have also, on various 
 occasions, carried out Dr. Mackintosh’s suggestions in some of the cases 
 under my care. I cannot boast of success equal to that of Dr. Mackintosh, 
 perhaps because I have not confined myself to the selection of cases so 
 strictly as he may have done. It certainly appears to me, however, that 
 the operation has been productive of advantage in several instances; and in 
 two ladies, who were both married, and who had painful menstruation, the 
 dilatation was followed by relief, and in both of them the health was so 
 much improved that they have continued to be in good health as regards 
 dysmenorrhcea; both of them have had children, one thrice, and the other 
 twice-— though they had never before become pregnant. 
 
 The operation is safe, and not very difficult of performance. 
 
 The woman should lie across the bed, or near the foot of it, with the 
 knees drawn upwards, and separated with a pillow. A flexible block-tin 
 bougie of proper size is next to be conducted along the right index finger to 
 its point, which is placed on the os uteri, and serves to guide the bougie to 
 the canal of the cervix. If the bougie be somewhat curved, its apex enters 
 without difficulty, and passing upwards, slowly, to the distance of one inch 
 and a half to two inches, is left in situ for a minute or two, and then with- 
 drawn, to be followed by one of a larger size. The patient complains of a 
 sense of aching in the region of the uterus if the instrument selected happen 
 to be somewhat of a full size; and I think it undesirable to give any pain 
 whatever, since it will be found that a larger and still larger instrument can 
 be passed at subsequent operations, without distress. 
 
 It is proper to advert in this place again to the new theory of menstrua- 
 
 31 
 
482 
 
 DYSMENORRHCEA. 
 
 lion, which has been the subject of two notes in this volume. Very certainly 
 many women do complain of the dysmenorrhcea-pain as situated in the ovary, 
 sometimes on the right, and sometimes on the left side. I was recently pre- 
 sent during the severe dysmeriorrhcea-pain experienced by a patient, which 
 she referred to the left ovarian region — and she told me that she was in the 
 habit of suffering sometimes on one, and sometimes on the other side, but 
 never in both iliac regions at once. I should think there could be little 
 doubt that the pain in such case is the result of the exalted sanguine and 
 nervous force of one of the ovaria and tubes, coincident with the mensual 
 hyperaemia, and completed development and rupture of a Graafian vesicle. 
 In such a case, the therapeutical treatment indicated would be the subduc- 
 tion of such vital augmentations — to be effected by venesection, by cooling 
 aperients, by baths, fomentations, cataplasms, by the application of leeches 
 along the region of the round ligament, and by a blister in anticipation. 
 This method, with the calming and restraining influence of the anodyne 
 enemata or suppository would suffice, together with the proper hygieinic pre- 
 cautions as to dress, diet and exercise, probably to overcome the morbid 
 tendency of the functions. I shall take advantage of this opportunity to set 
 forth a few laws upon the subject of menstruation and reproduction, as laid 
 down by M. Pouchet, of Rouen, in his Theorie Positive de la Fecondation 
 des Mammiferes, 4"C. Paris, 1842, 8vo. p. 161. I have not had an oppor- 
 tunity to see M. P.’s work until to-day. He lays down certain fundamental 
 physiological laxvs, as follows : 
 
 Law I. There is no exception in favour of the human race ; the pheno- 
 mena of human generation obey laws analogous to those of the mammals. 
 
 Law II. In all animals, generation is effected by means of ova : some 
 inferior creatures furnish exceptions to this law. 
 
 Law III. In all the animal series, ovula pre-exist to fecundation. 
 
 Law IV. Physical obstacles prevent the seminal fluid from coming into 
 contact with the ovula while within the Graafian vesicle. 
 
 Law V. In the entire series of animals, the ovary incontestably emits 
 ova independently of fecundation. 
 
 Law VI. In all animals, the ovary emits ova at determinate epochs con- 
 nected with a periodical sur-excitement of the genital organs. 
 
 Law VII. Fecundation never takes place in a mammal, except where the 
 emission of ova coincides with the presence of the seminal fluid. 
 
 Law VIII. The emission of the catamenial discharges in women corre- 
 sponds with the phenomena of excitation observable in the mammalia during 
 the rut of the zoological species, and particularly in the females of the mam- 
 malia. 
 
 Law IX. Fecundation has a constant relation to the discharge of the 
 menses. It is, moreover, easy to point out the inter-menstrual period, 
 wherein conception is physically impossible, and also that wherein it is 
 probable. 
 
IMMODERATE FLOW OF THE MENSES. 
 
 483 
 
 Law X. There are certainly no ovarian pregnancies, properly so called. 
 
 Additional physiological laws. 
 
 Law L Fecundation in mammals, when normal, occurs in the womb. 
 
 Law II. Abdominal and tubal pregnancy do not prove that fecundation 
 takes place in the ovary, nor that this is what determines the emission of the 
 menses. 
 
 Law III. The Fallopian tubes do not normally contract, except from the 
 interior towards the exterior of the body, for the transmission of the ovu- 
 
 lum. — M.]* 
 
 OF IMMODERATE FLOW OF THE MENSES AND OTHER UTERINE 
 HAEMORRHAGES. 
 
 We ought to comprehend, under the terms floodings or uterine 
 haemorrhages only the excessive or immoderate sanguine discharges 
 which take place from the external orifice of the uterus, either in its 
 non-gravid state, or during pregnancy and labour. As our intention 
 is to treat, in this work, only of the haemorrhages connected with the 
 diseases, properly so called, of the uterus, we shall pass by, in silence, 
 those occurring during gestation and delivery, but propose noticing 
 them in another treatise, independent of this, to be published after a 
 time. 
 
 Uterine haemorrhages occur in women who are still regular and 
 also in those who have ceased to be so when connected with the 
 appearance of the menses ; that is to say, when the loss of blood is 
 nothing more than menstruation itself, carried beyond the healthful 
 point, the discharge is specially designated untler the term menor- 
 rhagia , while it takes that of metrorrhagia , when it appears at any 
 other epoch than that of menstruation: in menorrhagia or hyperme- 
 norrhoea, the blood flows at each menstrual period in greater abun- 
 dance than natural : there are some cases in which the quantity of 
 blood remains the ^me during a given period ; but, nevertheless, the 
 discharge becomes superabundant, because it lasts a greater or less 
 number of days. In some women, the periods of menstruation 
 approximate to each other to such an extent that there remains 
 scarcely any interval between them. In others, the different varie- 
 ties of hypermenorrhoea are blended together, so that the menses 
 recur not only more frequently, but also more abundantly, and re- 
 main during a longer period than usual. Finally, there is another 
 kind of menorrhagia that Aetius has designated by the title of stilli- 
 cidium uteri; and other authors, by that of menorrhagia stillati - 
 tia, which consists of a sanguine excretion, small in quantity, but 
 prolonged to such an extent as to become in some sort continual, so 
 that the epochs corresponding to the menstrual periods are no longer 
 distinguished except by the greater abundance of the discharge and 
 by the redder colour and firmer consistence of the fluid thrown off. 
 
 While women of considerable embonpoint ordinarily lose but 
 little, those who are thin and delicate generally have abundant men- 
 struse, and are more disposed to menorrhagia than the strong and 
 
4S4 
 
 IMMODERATE FLOW OF THE MENSES. 
 
 sanguine : there are some, indeed, who might be traced by the marks 
 which they leave for several days, even when provided with napkins 
 and cloths. The blood, which escapes in a full, free stream, as it were, 
 compels them to remain in bed, and this the more, as the loss reduces 
 them to a condition of extreme feebleness. Women of this kind of 
 constitution are in the habit of calling themselves very sanguine, 
 because they judge of their temperament by the exuberance of their 
 menstruation. 
 
 A consideration of the amount of blood lost by a female at each 
 periodical epoch, is a faulty mode of judging whether the uterine 
 exhalation is in a normal condition, or whether, on the contrary, 
 hypermenorrhcea is commencing. It is impossible to have a certain 
 standard, and we think that the quantity of the sanguineous discharge 
 is a measure the more inexact, because a considerable loss often pro- 
 duces no unfavourable symptom in a plethoric female, while a men- 
 strual discharge of moderate* quantity is sometimes sufficient to 
 debilitate a feeble person. Nevertheless, we should regard as mor- 
 bid, the uterine haemorrhages which appear at any other epoch than 
 that of menslruation, as well as all the sanguine exhalations from 
 the womb, which, far from alleviating and inducing well-being, pro- 
 duce feebleness, paleness, malaise, and which, lasting longer than the 
 ordinary time, are followed by coldness of the extremities, syncope, 
 and convulsions. The guide to direct the physician, in judging of 
 immoderate flow of the menses, is therefore less the quantity of 
 blood that flows, than the strength or languor of the patients. We 
 therefore should not regard a menstrual discharge as morbid, which, 
 though very abundant, exerts no unfavourable influence upon the 
 health of the womarf. 
 
 [Nothing can be more various than the quantity of blood lost by different 
 women, in their menstrua. There are many females who enjoy the most 
 perfect menstrual health, and who never find themselves obliged to wear any 
 napkin for the reception of the discharge, but suffer it to fall on their ordi- 
 nary dress; but this could not be, without the most glaring exposure, were 
 the quantity to be considerable. On the other hand, I am told by many 
 females, that the discharge for them requires, from first to last, some, fifteen, 
 and some even as many as twenty napkins ; so that I infer that some women 
 are sufficiently regulated with three ounces, while others require a depuration 
 amounting to fifteen ounces, or even twenty ounces, at each catamenial 
 period. Hence it appears that each woman obeys a law of her own consti- 
 tution, and that the object of the physician should be to learn what is her 
 particular rate. Having done so, he becomes a fitting judge of what is devi- 
 ation, by excess, or by diminution. I have seen a girl of fifteen aetat. use 
 sixty napkins, soaked full, for each menstruation, without appearing to be 
 rendered unwell by the loss. — M.[] 
 
 As metrorrhagia, properly so called, often assumes the periodical 
 character of menstruation, and may be blended with it, it is difficult 
 to distinguish certainly these two sanguine discharges ; some authors 
 
IMMODERATE FLOW OF THE MENSES. 
 
 485 
 
 regarding the distinction as very important, and resting, moreover, 
 upon the opinions of Celsus, of Hunter, of Dionis, upon the experi- 
 ments of MM. Mojon, Davy, Brande, Lavagna, Julia Fonteneile, 
 etc., have asserted that the menstrual blood does not coagulate, and 
 is destitute of fibrin. Though the works of modern chemists and 
 physicians seem to leave no doubt as to the permanent fluidity of 
 the menstrual blood, we are far from believing all that has been said 
 upon this subject ; for all the females in good health, whom we have 
 consulted upon this matter, have told us that they have sometimes 
 expelled clots ; besides, M. Lecanut ( Etud . chim. sur le sang., 1837) 
 has proved that menstrual blood differs from ordinary blood merely 
 in the respect that it contains some mucus. 
 
 [Dr. Donne examined some menstrual blood for Dr. Brierre de Boismont, 
 and found ordinary natural blood corpuscles in great quantity, and epithelium 
 scales from the vaginal mucous membrane. 
 
 Mr. Denis gives this analysis of the blood of a girl of twenty-seven aetat. : 
 
 Water, 
 
 Globules, 
 
 Albumen, 
 
 Extractive, 
 
 \ 
 
 825.00 I Fatty matters, . . . 3.90 
 
 64.40 I Saline “ ... 12.00 
 
 48.30 I Mucus, .... 45.30 
 
 01.10 | 
 
 Apud. Brierre de Boismont, op. cit., p. 172. 
 
 M. Bouchardat, in a patient of 35 set., found 
 
 Water, .... 
 These solids were — 
 Fibrine, albumen and colouring 
 matter, .... 
 Extractive, 
 
 90.08 1 Solids, 
 
 Fatty matter,’ 
 75.27 Salts, 
 
 0.42 Mucus, 
 
 Idem, 
 
 6.92 
 
 2.21 
 
 5.31 
 
 16.79 
 
 M.] 
 
 As it is not always easy to make the differential diagnosis of im- 
 moderate flow of the menses and of metrorrhagia, and, moreover, as 
 these two uterine haemorrhages, which are confounded by most 
 authors, may be referred to the same points of doctrine, and require 
 nearly the same therapeutical indications, we deem it proper not to 
 separate them in the description, in order to avoid the constant repe- 
 titions that would occur were we to devote to each a particular 
 chapter. We shall therefore confine ourselves to stating that women 
 who wish, to moderate a too great abundance of the menstruae, 
 should abstain, during the period of their flow, from all violent exer- 
 cises, and sometimes even maintain a horizontal position, in such 
 a way that the pelvis may be rather more elevated than the head 
 and trunk : those of strong constitution should make use of a milk and 
 vegetable diet ; of diluent, cooling and acidulated drinks, as currant 
 water, whey, weak lemonade, decoctions of barley or of dog’s grass 
 with nitre, mucilage of gum arabic, flavoured with lemon syrup or 
 with vinegar. Women of a ner vo-lymphatic temperament must 
 be nourished with tonic aliments, principally roast meats, and they 
 ought to use as drinks, during their repasts, water mixed with a little 
 generous Rhenish or Bordeaux wine. There might also be directed 
 for them, with advantage, narcotics and antispasmodics, administered 
 
4S6 
 
 METRORRHAGIA. 
 
 in minute doses during the continuance of the function ; the use of 
 cool, or, if the season forbids, of warm baths, in the interval : in either 
 case, small revulsive bleedings from the arm, a few days after the 
 menstrual discharge, to be repeated between each periodical epoch, 
 will contribute powerfully to moderate the discharge of blood from 
 the uterus. 
 
 OF METRORRHAGIA. 
 
 For the reasons just given while speaking of excessive flow of the 
 menses, we shall comprehend, under the denomination of metror- 
 rhagia, all the sanguine discharges of the uterus which take place at 
 other times than during pregnancy or labour, and which we divide 
 into essential , sympathetic and symptomatic haemorrhages. 
 
 The two first classes include all discharges of blood that take 
 place without wound, erosion or appreciable rupture of tissue, and 
 in the latter are found those which constitute secondary phenomena, 
 or accidental complications of some more serious disease which 
 ought particularly to fix the physician’s attention. 
 
 Essential or idiopathic metrorrhagia, that is to say, that which, 
 like menstruation, is effected by the mysterious influence of an un- 
 known physiological law, may appear at any time of life ; for it has 
 often been observed to occur in women of very advanced age, in 
 girls who were not yet regulated, and even in children of seven 
 years of age, (Delamotte;) of three years of age, (Bourjot Saint- 
 Hilaire;) of nine months, (Clarke, Nonv. Bibliot. Med., t p. 92, 
 1829 :) of three months, (Comarmond ;) and of a few days, (Mallat, 
 Gazette Med., September, 1832.) We should remark, however, that 
 the sanguine exhalations from the uterus, which appear at other times 
 than during the fecundative period of the life of the female, are very 
 rare exceptions. 
 
 Essential uterine haemorrhage may be active or passive. The 
 former, or active metrorrhagia, which accompanies plethora, and 
 occurs during the mature period of life, has, for predisposing causes, 
 excessive heat, extreme cold, residence in large cities, the inhabitation 
 of elevated situations, the abuse of stimulating dishes, of alcoholic 
 liquors, and of too nourishing food, violent passions, indolent mode 
 of life ; beside all those that are common to other haemorrhages, we 
 range amongst those which are peculiar to active metrorrhagia, the 
 epoch of the menses and principally those two at which this discharge 
 is either first established, or should finally cease; excessive sensibility 
 of the womb, whether primitive or acquired by the abuse of coitus, 
 of masturbation, or from any other cause ; finally, frequent child- 
 bearing, the use of foot-stoves, the abuse of emmenagogues, of acrid 
 purgatives, and of warm baths, all properly regarded as being pre- 
 disposing causes of active metrorrhagia. It is not uncommon to see 
 an abundant loss of blood follow a suppression of the menses, or 
 occur in newly-married persons, especially if the first conjugal ap- 
 proaches take place a few days before the epoch of menstruation. 
 
METRORRHAGIA. 
 
 487 
 
 The exciting causes of active metrorrhagia are : violent exercises, 
 such as running,’ dancing, riding on horseback, the jolting of a car- 
 riage, a fall on the feet, on the knees, and especially on the buttocks; 
 excitants applied to the genital parts; the efforts and concussions 
 which result from lifting a burthen, from crying, singing, sneezing, 
 coughing, etc. We ought to remark, however, that all these circum- 
 stances act most powerfully where the gestative organ has been for 
 a long time the seat of an excess of vital force or of a local plethora. 
 
 The causes of asthenic, or passive metrorrhagia, are all such as 
 may cause general or local debility, such as excessive labour, late 
 hours, the depressing passions, grief, immoderate or too frequent 
 menstruation, diseases of long duration, protracted lactation, the 
 habitual use or abuse of aliment of improper nature, relaxing, un- 
 wholesome or mucilaginous drinks; warm mineral waters, warm 
 baths, and emollient or warm injections ; finally, passive uterine 
 haemorrhage, which may be a consequence of labour or abortion 
 repeated in quick succession, has frequently been the termination 
 of an often-renewed active metrorrhagia, or has even been the 
 result of a treatment for this affection, in which bleedings, refrige- 
 rants, astringents and narcotics have been improperly used. We 
 add, that women of feeble constitution, of lymphatico-nervous tem- 
 perament, and those who have laboured under some scorbutic disor- 
 der, are more liable than others to the sanguine exhalation of which 
 we are speaking. 
 
 Sympathetic uterine haemorrhage depends upon causes which 
 are equally worthy of arresting the attention of practitioners. Those 
 causes, whose action first falls upon other organs, produce in them 
 disorders which, reacting upon the womb, occasion uterine haemor- 
 rhages, which are really sympathetic. This species of metrorrhagia 
 is the more readily produced in proportion as the organs, first dis- 
 eased, have a more intimate sympathy with the uterus ; wherefore, 
 inflammations of the stomach, of the brain, heart, lungs, liver, intes- 
 tines, etc., are frequent causes of uterine haemorrhages. Stahl, [Med. 
 prat., lib. iii., p. 29 ,) states that during the bilious constitution, 
 which prevailed in 1778 , uterine haemorrhages were very com- 
 mon. Tourtelle, also, makes mention of meningo-gastric fevers, 
 which were accompanied by an abundant serous discharge from the 
 vagina. Fincke, in the history which he has given of the epidemic 
 of Techlenbourg, says that menorrhagia was very common, and that 
 menstruation experienced an unfavourable influence from the bilious 
 affection. Ziegert [Dissert, sur Vemploi despurg. dans la mlnor- 
 rha<ri.e), has seen an intestinal irritation produce sympathetically a 
 sanguine exhalation from the uterus; Vander Bosch has also ob- 
 served, that the same effect was produced by the presence of worms 
 in the digestive tube ; finally, the irritation of the breasts caused by 
 a sinapism, the application of leeches, or even the suckling of the 
 child, has brought haemorrhages from the uterus, and has repro- 
 duced the suppressed menstruee. Moreover, all circumstances capa- 
 ble of imparting a sudden shock to the innervation, such as joy, grief, 
 
488 
 
 METRORRHAGIA. 
 
 anger, * fright, the sudden announcement of bad news, have often 
 been the causes of sympathetic metrorrhagia. 
 
 It is well to say, that the losses resulting from these last causes, 
 are met with more particularly in nervous women, who allow them- 
 selves to be agitated by the slighest events, and who are, as Hoffman 
 says : “ activae et sensibilioris naturae, vet etiam hypochondriasis et 
 hystericis passionibus obnoxiae 
 
 However numerous the causes we have just mentioned, they are 
 not those, nevertheless, which most frequently produce haemorrhage 
 from the uterus. Indeed, haemorrhages from the gestative organ 
 are, in the great majority of cases, the symptoms of a local affection, 
 such as acute or chronic metritis, simple hypertrophy, scirrhous en- 
 gorgement, and especially sanguine engorgement, polypous tumours, 
 simple, scrofulous, tubercular, venereal, carcinomatous, and fungous 
 ulcerations; finally, inversion of the uterus, and a number of other 
 lesions of the organ, which have been discussed in this work. Symp- 
 tomatic metrorrhagia is also, in some cases, the unfortunate result of 
 scorbutic, eruptive, typhoid, and pestilential diseases, and of malig- 
 nant intermittents. 
 
 The course and precursory phenomena of uterine haemorrhages 
 vary according to the causes which have produced them. Those 
 which are the effects of predisposing causes pursue a slow progress, 
 and are generally established either by a successive augmentation in 
 the quantity and duration of the menstrual discharge, or by the ap- 
 proximation of the menstrual periods. In some cases, the haemor- 
 rhage reappears a few hours after its cessation ; in others, it returns 
 every day, every two days, every three days, and assumes the quo- 
 tidian, tertian or quartan type ; finally, there are cases in which 
 the returns appear only every eight days, once a month, and every 
 three months. The influence of habit is so powerful, that essential 
 uterine haemorrhages are often renewed in the same order, and with 
 the same conditions that first gave rise to them. 
 
 When the metrorrhagia has been produced by a violent exciting 
 cause, the discharge appears either immediately, or which is most 
 common, a few moments after the action of that cause. In either 
 case, the uterine loss may take place with such violence, that the life 
 of the female is soon exposed to the greatest danger, especially if the 
 accident has happened at the epoch of menstruation. This metror- 
 rhagia, which may be called accidental, does not commonly return 
 after it has once been overcome. 
 
 Although, in some cases, the precursory symptoms of essential me- 
 trorrhagia are confined to a few uterine pains, like those felt at the 
 menstrual epochs, it happens, most frequently, that the sanguine 
 flow is preceded by various phenomena; amongst others, by a sense 
 of tension, of fulness, of heat, of weight, and pain in the pelvis and 
 hypogastrium ;• these symptoms ordinarily coincide with swelling of 
 the breasts, frequency and fulness of the pulse, obstinate constipa- 
 
 * Doctor Rondelou, ( Dissert . inaug.) quotes from M. Alibert, the case of a female 
 endowed with very great sensibility, who, every time that she gave way to transports 
 of anger, was attacked with violent haemorrhage from the uterus. 
 
METRORRHAGIA. 
 
 489 
 
 tion and general lassitude ; finally, paleness of the face, coldness of 
 the extremities, shrinking and horripilation of the surface, heat and 
 pruritus of the genital parts, are signs which indicate the approach 
 of active haemorrhage. The flow of blood, which soon follows 
 these last symptoms, at first restores calm and quiet ; but, where the 
 amount is greater than the state of the strength permits, the woman 
 experiences a sensation of sinking in the region of the stomach, the 
 pulse becomes feeble, and soon hardly perceptible, the lips become 
 white, the face pale, vision is obscured, the hearing more and more 
 obtuse, respiration is embarrassed, and death, the approach of which 
 is heralded by lipothymia and convulsions, often comes to close this 
 startling scene. 
 
 Far from following the march and order which we have just 
 traced, consecutive nervous symptoms sometimes make their ap- 
 pearance very early, and we see them arise even before the loss of 
 blood has been very abundant. There is one quite frequent conse- 
 cutive phenomenon in particular, which is sometimes extremely in- 
 tense, and persists for a long time after the haemorrhagic discharge 
 has been arrested. In cases in which the losses of blood, without 
 reaching this point, are frequently renewed, and last longer than the 
 usual period, the digestion becomes more and more deranged, the 
 appetite is lost, the pallor of the skin resembles that which is met 
 with in chlorosis, the eye-lids are swollen and surrounded by a dark 
 areola, the inferior extremities become oedematous, serous collections 
 are found in the pleuric and peritoneal cavities, and there are gene- 
 rally added to the unfavourable symptoms which we have just men- 
 tioned, dull pains in the stomach, and various nervous disorders. 
 We should remark, however, that the convulsions and syncope 
 which occur, are sometimes advantageous in producing a general 
 spasmodic condition, which throws the blood upon the interior of the 
 economy. 
 
 In passive metrorrhagia, the blood escapes without precursory 
 signs, and flows little by little and for a long time. The sanguine 
 exhalation is not preceded by any symptoms which show that the 
 action of the uterine vessels is increased. Finally, the frequent 
 return of the haemorrhage, the presence of an abundant leucorrhoea 
 in the interval of each new appearance of the discharge, and espe- 
 cially the persistence of the loss, the pale and serous, and sometimes 
 blackish colour of the secreted fluid, will indicate sufficiently the 
 passive and asthenic character of the sanguine flux. 
 
 Though the diagnosis of metrorrhagia is commonly readily made 
 out, since the disease declares itself by the escape of blood and the 
 effects produced upon the economy, it is not always easy to ascertain 
 the causes which give rise to it, and which keep it up. Nevertheless, 
 we may most generally succeed in recognizing them by an attentive 
 examination of the patient, and by carefully weighing the symp- 
 toms along with the commemorative circumstances. As the uterine 
 haemorrhage is most generally the symptom of a more serious disease, 
 it is to the discovery of this latter that the physician should especially 
 devote himself. It becomes, therefore, indispensable in the majority 
 
490 
 
 METRORRHAGIA. 
 
 of cases, to proceed to the examination of the sexual organs, by means 
 of the Touch and the speculum uteri ; but we should never resort, 
 in the very commencement, to this kind of exploration, when the 
 female is very nervous and easily irritated, although the diagnosis 
 ought, in most cases, to direct the practitioner in his choice of means; 
 we shall add nothing to what we have said upon the particular cha- 
 racters of each kind of metrorrhagia. 
 
 The prognosis of uterine haemorrhages ought to be based upon 
 the causes that have produced them, the severity of the symptoms, 
 the constitution and strength of the subject, and finally, the duration 
 of the disease. The passive metrorrhagias are more unfavourable, 
 more difficult to overcome, and more liable to relapse than those 
 which are active. Those that depend upon transient causes cease 
 commonly of themselves, or at least are readily cured ; if they ever 
 appear with some severity, it is only when they are very abundant. 
 Ancient haemorrhages, which seem in some sort to have habituated 
 the economy to frequent losses, are the most rebellious to the cura- 
 tive means which are opposed to them. Those which come on 
 during the early part of puberty, almost always insensibly cease as 
 menstruation becomes regular. It is the same with the attacks of 
 metrorrhagia, which announce the critical period; they generally 
 disappear spontaneously so soon as the woman has reached the 
 normal term of her menstruation. Finally, metrorrhagia sympto- 
 matic of a local condition, as well as that which results from irrita- 
 tion of a distant organ, reacting sympathetically upon the uterus, is 
 dependent upon the severity of the disease which produces them. 
 Let us add, in order to terminate what we had to say upon the 
 prognosis, that active, intermittent, and often-repeated haemorrhages, 
 are usually unfavourable, rather because they become the source of 
 a number of very serious lesions of the womb, than because they 
 make the whole economy feel their pernicious influence. Finally, 
 we remark that the critical metrorrhagias generally announce a 
 favourable termination of acute diseases, but that in eruptive dis- 
 eases, as in adynamic fevers, they are the indices of great prostration 
 of the strength, and augment the gravity of the prognosis. 
 
 The treatment of uterine haemorrhages presents three principal 
 indications to be fulfilled, which are : I, to remove the causes, if they 
 be still present, and will yield to the powers of art; 2, to arrest, the 
 discharge in severe cases ; 3, to prevent the return of the haemor- 
 rhage. 
 
 It is useless to recapitulate all the causes of metrorrhagia, in order 
 to point out the means of removing or overcoming them ; there are 
 some, however, upon which we deem it proper to insist by devoting 
 to them a particular examination. 
 
 Active uterine haemorrhage, which depends upon general plethora, 
 and which often finds a remedy in itself by the mere fact of the loss 
 of blood, requires, in the majority of the cases, one or two revulsive 
 bleedings from the arm. The local plethora, which often exists, 
 independently of the general plethora, likewise demands the same 
 means, but we ought not to be in too great haste to arrest the flow 
 
METRORRHAGIA. 
 
 491 
 
 of blood, which is sometimes of great use in preventing inflamma- 
 tion of the womb. We should, however, in all cases, prescribe 
 absolute rest on mattresses of hair or straw, arranged in such a way 
 that the pelvis may be somewhat higher than the rest of the body. 
 The patient, who should be kept in perfect quiet and in the greatest 
 tranquillity of mind, ought to be lightly covered, and should breathe 
 fresh air ; but it is always well to avoid coldness of the extremi- 
 ties; the efficacy of these means may be much increased by ordering 
 at the same time strict diet, or at least, forbidding any aliment 
 except some fruit jellies, or rice-milk, or barley or some other amy- 
 lacious substance, prepared with milk or water. There should be 
 prescribed, at the same time, the abundant use of some refreshing 
 drink, taken cold, such as whey or a decoction of dog-grass with 
 nitre, or of rice, of apples, green apples, oranges sweetened, of syrup 
 of currants, of mulberries, cherries, vinegar, of quinces, etc. Were 
 these means insufficient, we should prescribe a tisan, made with 
 an ounce or two of comfrey-root, or an ounce of rhatany-root, and 
 sweetened with some sedative syrup ; finally, by means of emol- 
 lient enemata with honey, of suppositories of beurre cle cacao , and 
 especially by mild laxatives, such as the pulp of tamarinds, or of 
 cassia fistula, or cream of tartar, (potassse bitartras, from one to four 
 drachms,) we should combat the constipation, which is hurtful from 
 the expulsvie efforts which it necessitates, and from the state of gene- 
 ral irritation which it gives rise to. 
 
 If the means we have just mentioned should fail in arresting the 
 haemorrhage ; if, especially, the flow of blood, by its quantity or dura- 
 tion, exposes the life of the patient to imminent danger, we should 
 seek to draw towards some other point the fluxionary movement 
 and the haemorrhagic effort directed towards the uterus; it would 
 be well, at the same time, to overcome, as far as possible, the 
 spasms upon the periphery of the body, which keep up the concen- 
 tration of vital movement towards the gestative organ, and, in certain 
 cases, to act directly and immediately upon the vessels which throw 
 off the blood, by determining their shrinking and constriction. We 
 can fulfil these different indications by means of re vel lents, antispas- 
 modics, narcotics and astringents; amongst the revel lents, bleeding 
 ought, with good reason, to be placed in the first rank, especially in 
 essential active metrorrhagia, and in that which is accidental or 
 which depends upon a general condition of the constitution. The 
 bleedings, which in these cases ought to be made from the arm, 
 should always be of small amount, a palette more or less. To obtain 
 a more powerful revulsive effect, we might, after the example of 
 Riverius, allow the blood to flow little by little only, and at several 
 different times, by occasionally keeping the finger upon the orifice 
 in the vein. Where bleeding from the arm appears difficult, as often 
 happens in women, we might substitute for it either the repeated 
 application of three or four leeches to the anterior and upper surface 
 of the fore-arm, or beneath the mammae, or, as Sennertns advises, and 
 as is frequently done in Italy, by practising bleedings from the hand 
 in the vena salvatella or cephalica. It would likewise be well to 
 
492 
 
 METRORRHAGIA. 
 
 determine a powerful revulsive effect, by applying cups or a sina- 
 pism between the shoulders ; in this position we should not have to 
 fear the inconveniences that are charged, of increasing the haemor- 
 rhage when they are applied to the breasts, as Hippocrates recom- 
 mends, (Aphoris. 50, sect, v.), or underneath the same organs, accord- 
 ing to the precept of Galen. The ventouses monstres of Dr. Junot, 
 applied to both the arms, produce a very energetic revulsion, which, 
 in our opinion, should render their employment preferable to the 
 warm manuluvia recommended by F. Hoffman ( De hsemorrhagiis 
 gen. orig. et curat., 1697 ; Lordat), ( Traite des Hsemorrhagi.es, 1806; 
 Desormeaux), (Diet, de med. t. xiv); it is well understood that 
 these different revellents, applied to the superior extremities or any 
 point whatever of the chest, ought to be rejected, or, at least, em- 
 ployed with the greatest circumspection, where the lungs are feeble 
 and disposed to become the seat of a sanguine congestion ; vomiting, 
 provoked by ipecacuanha, and recommended by Hippocrates, Stoll, 
 Fincke, Cullen, Alphonse Leroy, Gardien, Osborn and some others, 
 produces a kind of perturbation and derivation which may be advan- 
 tageous in some cases, principally where the metrorrhagia is con- 
 nected with some gastric disorder; but as it is impossible clearly to 
 determine the circumstances under which emetics ought to be pre- 
 scribed, we think that they should not be resorted to except with great 
 prudence and discrimination. In case the metrorrhagia depended upon 
 sympathetic reaction with some disorder of a distant organ, the first 
 indication would be to attend to that disorder; but we ought first to 
 resort to the employment of narcotics and antispasmodics,* should 
 the uterine haemorrhage have succeeded some vivid emotion or 
 shock of the nervous system. 
 
 To the employment of the means we have just pointed out, should 
 be added, at the same time, in obstinate cases, the use of astringents, 
 amongst others injections and decoctions of the bark of the pomegra- 
 nate, or oak, of tormentil, or of bistort, and particularly that of rhatany 
 root, solutions of alum, and, also, cold drinks, acidulated with the 
 aqua Rabelliana. In cases where chronic haemorrhages had resisted 
 the operation of a variety of remedies, we have always employed 
 with advantage the following potion, taken in tablespoonful doses, 
 every half hour : viz., take of orange-flower water, eight ounces; ex- 
 tract of rhatany, two drachms ; syrup of comfrey, two ounces ; aqua 
 Rabelliana, thirty drops; Rousseau’s laudanum, twenty-five drops. 
 
 [I beg leave to take this occasion for the purpose of recommending the 
 trial, in some perverse cases of metrorrhagia, of a remedy that has often 
 proved useful in my hands; and where the use of astringents is indicated, 
 as in the instances here discussed by M. Colombat, I should make use ot it 
 with no little confidence. The remedy in question is a decoction of the 
 
 * It is in the form of enemata that antispasmodics and narcotics have always 
 seemed to us to prove most efficacious, especially in the following formula; assafee- 
 tida, fifteen grains, suspended in the yolk of an egg: flaxseed mucilage. eight ounces; 
 Sydenham’s laudanum, thirty drops ; tincture of castor, twenty drops, for an enema of 
 half the common size. 
 
METRORRHAGIA. 
 
 493 
 
 roots of the common black currant, ripe, and the roots of the dewberry. A 
 handful of each of these articles is to be boiled in two quarts of water, and 
 after straining the liquor, the patient should take half a cupful occasionally 
 for a dose. The draught is by no means disgusting, and I venture to say 
 that the effect of the administration has often been a very sensible diminu- 
 tion of the discharge. I should deem such a formula very useful in country 
 places, where every facility cannot be enjoyed in varying the more scien- 
 tific prescriptions repeatedly, upon the failure of such as may have been 
 tried without success. — M.] 
 
 The drinking of large quantities of iced water, advised by Hoff- 
 man and Leake; very cold enemata of the same fluid, which Bezold 
 speaks of having seen used successfully ; and, finally, cold hip-baths, 
 the uterine injections employed by Prosper Alpinus; the application of 
 compresses wet with iced water, with vinegar and water, or with 
 vinegar, to the vulva, thighs, loins and hypogastrium, can be justifia- 
 ble only by a terrific haemorrhage, and should never be used except 
 in despair of all else, in evidenti morbis pericvlo . 
 
 In metrorrhagia primarily passive , or assuming this character 
 after having been active , the first thing to be done is to try to 
 restore the strength of the patient by suitable regimen, and by the 
 employment of various tonic substances. To attain this end, we 
 should advise some; kind of food which is nourishing without being 
 stimulant, amongst others, roast meats, jellies, farinaceous substances, 
 and the flesh of young animals, and certain fish. Amongst the 
 tonic medicines, should be placed in the first rank the ferruginous 
 preparations, especially the subcarbonate of iron administered in 
 pilular form; the dose, which at first should not exceed three or 
 four grains twice a day, to be gradually increased. We may also 
 employ with benefit the ferruginous mineral waters, the decoctions of 
 catechu or kino, extract of cinchona, or of columbo, and diascordum; 
 finally, we should put in requisition all the resources of hygieine, and 
 with the view of preparing the constitution for the cessation of a dis- 
 charge which has become in some sort necessary to it, we should 
 practise small revulsive bleedings of from half a palette to two palettes 
 at most. When, by its excessive quantity or protraction, the haemor- 
 rhage has induced a state of debility which favours the relaxation of 
 the mouths of the exhalent vessels, and, consequently, the effusion of 
 the sanguine fluid, it sometimes becomes necessary to sustain the vital 
 forces in order that the uterine fibres and the walls of the vessels may 
 recover their power of contraction; for this purpose, we might pre- 
 scribe, from time to time, a spoonful of generous wine, rendered 
 aromatic with a few drops of essence of canella; by this means, we 
 arrested, as if by magic, a ha3morrhage which had lasted nearly a 
 month, in the person of the Baroness of Car * * *, authoress of seve- 
 ral charming literary productions. 
 
 Guided by the special action of ergot on the uterus, and even on 
 the general circulation, MM. Sparjani, Pignana, Cabini, Negri, Reca- 
 mier, Duparcque, Trousseau and some other writers, have recom- 
 
494 
 
 METRORRHAGIA. 
 
 mended this substance in doses of from five to fifteen grains, repeated 
 two or three times in the twenty-four hours. Lastly, in haemorrhages 
 of long duration, M. Vedekin has proposed savine, whose action, 
 however, we fear, would be too energetic and stimulating, though 
 Doctor Sauter speaks of having used it with the greatest success. 
 
 To prevent the return of the haemorrhage, we should remove, as 
 far as it may be possible, the causes which have given rise to it, and 
 direct, at the same time, light food, of easy digestion. Hoffman 
 recommended asses’ milk, diluted with Seltzer water, chiefly for 
 women of very delicate and sensitive constitutions, who are more 
 liable than others to uterine haemorrhages. The patient, who should 
 take moderate exercise in the intervals of each menstrual period, must 
 remain in a state of repose at their approach and during their pre- 
 sence. A visit to the country should be recommended; she ought 
 to retire at an early hour, rise betimes in the morning, and avoid 
 all vivid emotions, and especially the use of coitus and all circum- 
 stances capable of giving rise to erotic desires. It will be well, like- 
 wise, to institute small revulsive bleedings from the arm, especially 
 a few days before the epoch of the menses. Revellents, employed 
 with discrimination, and particularly the wearing of a flannel chemise 
 next to the skin, will also be useful in the majority of cases. 
 
 In passive metrorrhagia, we should recommend a diet which is 
 succulent and tonic without being stimulating, and at the same time 
 the use of rough wines, and of beer rendered medicinal by the infu- 
 sion of bitter plants. Tonics, in particular the preparations of iron, 
 ferruginous waters, river and sea bathing, tonic and astringent douches 
 and injections into the vagina ; douches of the same kind to the lum- 
 bar and hypogastric regions, and, finally, aromatic fumigations will 
 often be useful, especially if local debility exists. 
 
 The treatment of sympathetic and symptomatic haemorrhages is 
 the same as that of the diseases upon which they depend; it should 
 be modified, however, according to the degree of curability of the 
 principal disease, and according as the uterine flow is connected with 
 an incurable local lesion, or a serious disorder of some other viscus. 
 
 When the metrorrhagia depends upon an incurable disease of the 
 womb, it is almost always, unless it be excessive, beneficial to the 
 patient, since it diminishes engorgement and allays pain ; commonly 
 when the sanguine flux is arrested, whether spontaneously or by the 
 assistance of art, the symptoms soon become aggravated ; in cases of 
 this kind, it is therefore quite rational to respect the anormal discharge, 
 so long as it is not profuse enough to endanger life ; though the 
 haemorrhage is most frequently advantageous, the contrary may be 
 the case, that, is to say, the pain and other symptoms may increase 
 during the flow of blood, which then becomes the sign of a new 
 engorgement, which it is necessary to oppose in particular by re- 
 vulsive bleedings. Finally, if the sympathetic or symptomatic uterine 
 haemorrhage co-exist with a visceral disease liable to aggravation, 
 and to become dangerous by the suppression of the discharge of 
 blood, we ought to be content with moderating the discharge, and 
 
CHLOROSIS. 
 
 495 
 
 should scrupulously abstain from such general and local means as 
 might entirely suppress it. Nevertheless, should the haemorrhage 
 become dangerous and threaten the life of the patient, all other con- 
 siderations must be put aside, that we might recur as soon as possi- 
 ble to the most powerful measures, and especially to the tampon, 
 adjusted, howeyer, only at the depth of an inch in the vagina ; or else 
 to the use of simple compression applied to the outside of the vulva, 
 and maintained by the hand and an appropriate bandage. By ob- 
 serving these precautions, which are those recommended by M. Lis- 
 franc, we need no longer fear irritating, by the contact of the appara- 
 tus, the altered tissues of the vagina or cervix uteri, whose sensibility 
 is greatly augmented by their morbid condition. In those happily 
 rare cases in which the slightest loss of blood may prove mortal, we 
 must plug the vagina as far as the cervix, by means of a small gauze 
 bag filled with common ashes; this method, which is the more effi- 
 cacious because it acts both physically and chemically, was employed 
 by us, with entire success, in an apparently desperate case. 
 
 We conclude by observing that after an uterine haemorrhage has 
 become chronic, it is imprudent to suppress it suddenly; in such 
 cases, we should always commence the treatment by the establish- 
 ment of one or two issues upon the inside of the thigh, in order to 
 replace or reproduce the point, of irritation, of which the pelvis has 
 been for a long time the seat. 
 
 OF CHLOROSIS OR GREEN SICKNESS. 
 
 There is generally understood by the term chlorosis * * * § a set of symp- 
 toms, the principal of which are, a pale greenish tint, and puffi- 
 ness of the face ; loss of colour and dryness of the skin, coinciding 
 with general debility and derangement of most of the functions, espe- 
 cially those of the circulation, the digestion and the menstruation. 
 
 Chlorosis was known to the highest antiquity, for it is mentioned in 
 the works of Hippocrates,! of Galen, f of Aetius,§ of Paul of Egina,|| 
 and of Avicenna. IT Authors who have written upon the disease 
 have assigned different names to it, derived from the symptoms which 
 accompany it, from the period of life at which it is most frequently met 
 with, and the causes which they supposed gave rise to it. Taking 
 the chronological order, the sage of Cos calls it z^poa/u a; Avicenna, 
 illisis: L. Mercatus,/e5r?.s alba et virginum obstruction.es ; Baillou, 
 fsedi colores; Roderic a Castro and Daniel Sennertus, morbus virgi- 
 neus; Ranchin and Varande, chlorosis; Ettmuller, icteria alba ; Sy- 
 denham, pallidi-colores; J. Langiusj/e^ns amatoria; Savage, white 
 jaundice; Tissot, opilations; and to conclude, nearly all the authors of 
 the present time designate by the name of chlorosis , the disorder 
 which we are now considering. 
 
 * From the Greek xx«po'c, green. 
 
 flab. de morb. virginum. 
 
 t De causis symptom., lib. i. cap. 7. 
 
 § Tetrab. iii. serm. 1. cap. 23. et tetrab. iv. serm. 4, cap.10. 
 
 U De remed. lib. i. 
 
 ^ Canon Med., lib. iii. fen. 21. tract iii. 
 
496 
 
 CHLOROSIS. 
 
 The different denominations of chlorosis afford ns a kind of abridged 
 history of the disease, and prove, at the same time, the uncertainty 
 which has always prevailed as to its nature. Though ancient and 
 ♦modern authors generally agree in classing chlorosis amongst asthenic 
 diseases, they are far from holding the same opinion as to its location 
 and point of departure in some diseased organ. As it would require 
 too much time to enter upon the discussions which this question has 
 raised, we shall rest content with recapitulating the principal opinions 
 and grouping together those which are identical or bear some analogy 
 to each other. 
 
 Some, with Galen, Hoffman, Gardien, and Hamilton, consider 
 chlorosis to be the result of an adynamic condition of the digestive 
 tube. Others, again, see in this disorder merely an asthenia of the 
 genital organs, and a morbid state consecutive to suppression of the 
 menses. This opinion has been sustained by Forestus, Roderic a 
 Castro, Sennertus, Mercatus, Primrose, Freind, Cullen, Tissot, Pinel, 
 Cabanis, Desormeaux, MM. Roche, Duges, Blache, and a great 
 number of others ; finally, according to MM. Boisseau, Andral, 
 Brachet, of Lyons, Bouillaud, Blaud, Trousseau, Bonnet, and Brueck, 
 chlorosis is dependent upon asthenia of the circulatory system and 
 vicious sanguification. 
 
 We do not believe that atony of the digestive organs ought to be 
 regarded as the point of departure of chlorosis, since the affection 
 sometimes precedes the derangement of the digestive function, and 
 since even the stomach sometimes retains its normal condition. Be- 
 sides, atony of the gastro-intestinal surface always co-exists with 
 that of other important functions. An asthenic condition of the 
 genital organs, with amenorrhoca, can, with no better reason, be 
 regarded as the primary sources of the chlorotic condition, since it 
 may make its appearance in well-regulated girls, who do not cease 
 to be so throughout the disease ; the disease has likewise been ob- 
 served in women perfectly and abundantly menstruated, in pregnant 
 women, in women who have passed the critical age, in children of 
 both sexes, and finally in men, instances of which have been cited by 
 Sauvages, Cabanis, Chambon, Franck, Rahn, Blayn, Desormeaux, 
 MM. Roche, Blaud, Pujol, of Montpellier, Tanquerel des Planches,* 
 and some others. While it is allowable to infer, from these facts, 
 that atony of the organs of generation is not the primary cause of 
 chlorosis, we still acknowledge that the womb plays some part, but 
 only a secondary one, in the disorder. 
 
 The theory which supposes the chlorotic condition to depend 
 upon sanguine asthenia, producing vicious haematosis, with increase 
 of serum, and diminution of fibrous colouring matter and iron, 
 does not state the true nature of the malady, nor does it indi- 
 cate under what pathological influence the disorders of the circula- 
 tion. digestion, menstruation, etc., make their appearance. To go 
 back to the probable origin of the disease, and explain all the de- 
 rangements of the disease, which together constitute chlorosis, we 
 
 * Lancette Fran^aise, 18 July ,1837. 
 
CHLOROSIS. 
 
 497 
 
 believe the primary cause of the affection to be nothing more than 
 a general asthenia of the nervous system, and especially of the nerves 
 of the ganglionic system, or of organic life presiding over the digest- 
 ive, circulatory, nutritive and genital functions; in a word, it is faulty 
 innervation, and imperfect action of the trisplanchnic nerve, that 
 give rise to the group of symptoms constituting chlorosis. 
 
 [M. Colombat, in this paragraph, has properly stated that in chlorosis 
 there is a vitiated hsematosis, which has a strong influence upon the malady; 
 and he continues his remarks upon the condition of the blood, in his two 
 subsequent paragraphs. It has been recently shown by M. Andral, in his 
 work on Hsematosis, that the constitution of 1000 parts of healthy blood is 
 as follows, namely, water 790 parts, albumen 80 parts, blood-discs 127 parts, 
 and fibrine 3 parts = 1000 ; and he shows that, in plethora, the quantity of 
 the solid material increases, carrying up the figure for the disc to 130 and 
 even to 150, the albumen to 90 or 100, and reducing the figure for the water 
 in proportion to the rise of the figures for the solids. In the opposite 
 or anaemic state, the figure for water may rise from 790 to 850, or even to 
 near 900, while the disc descends, in some cases, to 100, to 60, to 30, and 
 even as low as 20. 
 
 It appears to me to be very clear that these mutations in the quantity of the 
 constituents of the blood, cannot exist without carrying great disorder into all 
 the varied functions of life. It is to be believed that the power of the brain, 
 and of the whole cerebro-spinal axis, has the closest relations to the consti- 
 tution of the blood, and the momentum or rate of its motion in the vessels of 
 the brain and the system at large, and that a healthful and natural state of 
 that fluid will produce a due and exact innervation, while a feeble, watery 
 and unhealthy blood must produce a feeble, irregular and imperfect innerva- 
 tion of all the organs of the body, which, under such circumstances, not only 
 exert their secerning, accretive, and development-powers feebly and imper- 
 fectly, but by the very fact of their own failure, extend the derangements to 
 all the parts on which they can exert any sympathetic force. But the deve- 
 lopment of the Graafian vesicle is one among the transcendental and extraor- 
 dinary powers of the economy : one, requiring for its execution the attainment 
 of the womanly age and the enjoyment of a sufficiently good health. Hence, 
 when anaemia is considerable, it is common to find a failure in the vesicular 
 development, an amenorrhoea, and a consequent exhibition of morbid symp- 
 toms, which grow cumulatively, one being drawn in after another until the 
 whole health is depraved or even totally lost. 
 
 M. Colombat very judiciously refers the first cause of chlorosis to a gene- 
 ral asthenia of the nervous system, but principally of the ganglionic part of 
 it. This is doubtless true ; but what is the precise point at which dwells 
 the proximate cause of the disorder? It is, I suppose, seated in the textures 
 that have the most immediate relation to the hsematosis. If we go back to 
 first principles, we shall be obliged to admit that the fault in the hsematosis 
 32 
 
498 
 
 CHLOROSIS. 
 
 is a fault of innervation, but yet that fault must be traced to the innervation 
 not of an abstract constitution, but of some special membrane or tissue, 
 as the membrane commune , as Bichat calls it, of the sanguiferous apparatus. 
 Here is the seat of the power by which the chyle is converted into blood. 
 The elaboration of the blood into its constituents of fibrine, discs, albumen, 
 and water, depends on the vital force of the lining membrane of the blood- 
 vessels ; it is there alone that the fluid poured into the vascular cyst, from 
 the great chyle tube, has any contact or connection with the living body. 
 Have we not a just ground, then, to believe that the proximate cause of the 
 anaemic malady is one sealed in this blood-vessel tissue? It is probably true, 
 as M. C. observes, that an inefficient action of the trisplanchnic nerve gives 
 rise to the symptoms that constitute chlorosis; and yet it is quite as probable 
 that disorders in the vessels themselves may, in many cases, originate the 
 diseased state of the blood, which, as I have already said, implicates such 
 great and extensive vices of the innervation. It cannot have escaped the 
 most careless observation, that a violent excitement of the circulation is 
 rapidly productive of vitiations in the constitution of the blood, which, in 
 order to its attaining its real normal character, demands a momentum or rate 
 not varying greatly from some seventy pulsations per minute for the adult. 
 I regard some vitiation of the constitution of the blood as one of the true 
 elements of the chlorotic condition, and even as one of the chief of the pa- 
 thological characteristics of the malady. It is true that a merely watery or 
 hyperhvdrsemic state (as M. Colombat calls it) of that fluid will not consti- 
 tute the malady in question; for it is clear that the symptoms of the affection 
 depend upon the failure, more or less complete, of many vital functions, 
 arising from the imperfect extrication of the nerve power of the whole cerebro- 
 spinal system, including the ganglionic apparatus. These derangements will 
 exhibit themselves in disordered respiration, circulation, secretion, digestion 
 and nutritious absorption ; all of which must receive a due share of regard in 
 making out a method of treatment. Among the disordered secretions, those 
 of the reproductive apparatus are not the first in order of importance, and 
 are generally the last to resume their healthful rate and character; a return to 
 which is the sign, rather than the cause, of restoration to full and vigorous 
 health. 
 
 From this I deduce the inference that, in chlorosis, one of the great desi- 
 derata should be to give to the sanguine circulation its just number of pulsa- 
 tions, to restore to the vascular membrane its healthful metabolic force, and, 
 by re-establishing the normal figures for the several constituents of the blood, 
 restore to the constitution all its powers of innervation and development. The 
 means within our power, for the attainment of this end, are numerous and 
 energetic, of undoubted efficacy, and requiring only to be understood in 
 order to render the intervention of the physician as useful in these myste- 
 rious and hitherto misunderstood affections, as are the lancet in the treatment 
 of croup or pleurisy, or the Peruvian bark in the cure of intermittents. — M.] 
 
CHLOROSIS. 
 
 499 
 
 The experiments recently made by M. Dupuy,* member of the 
 Academy, militate in favour of the opinion we have just expressed, 
 and seem to prove positively, that chlorosis is a nervous affection, 
 inducing secondarily excess of serous blood, a sort of aqueous hsema- 
 tosis, which might be designated by the term hyper hy dr semi a. t This 
 opinion, it seems to us, explains not merely the various derangements 
 of the circulation and imperfect performance of other functions, but 
 is also in perfect harmony with the mode of development, the pro- 
 gress of the symptoms, and the nature of all the consecutive pheno- 
 mena. We ought to say, however, then, as chlorosis is confined 
 almost exclusively to the female, and, moreover, as the uterus is de- 
 ranged, in the majority of cases, it seems very probable that a diseased 
 state of that organ may be the most common point of departure of 
 the vicious innervation of the organism which constitutes the chlo- 
 rotic disorder. 
 
 Though chemistry has revealed to us the presence of iron in the 
 blood , X and though this element seems to exist in smaller quantity 
 in the blood of chlorotic persons, we cannot admit, with M. Pujol, § 
 that the affection under consideration is the result of a deferrugina- 
 tion of the sanguine fluid ; even if a want of the iron were found 
 to be the material condition of chlorotic blood, which is far from being 
 proved, it would still be necessary to seek out the primary causes, and 
 ascertain the source of this change. 
 
 The predisposing causes of chlorosis, which we prefer to call hy- 
 perhydrsemia , are numerous and various. Some of them are gene- 
 ral, and others peculiar to individuals. Amongst the former, we 
 rank the female sex ; the age of puberty ; hereditary predisposition ; 
 rapid and premature growth ; a feeble, melancholic constitution ; a 
 lymphatic, scrofulous or nervous temperament ; the privation of 
 the physical enjoyments of love, or their abuse ; the state of widow- 
 hood ; onanism ; sudden and continued suppression of the menstruae, 
 and their too great abundance; frequent haemorrhages, and finally, 
 any circumstances which may interfere with a proper innervation, 
 as for example, depressing moral emotions, disappointments, grief, 
 sadness, captivity, and the melancholy which accompanies unfortu- 
 nate love ; 
 
 Palleat omnis amans, color hie est aptus amanti, (Ovid.) 
 
 The general causes of chlorosis are living in low, damp, and cold 
 
 *z At the meeting, held October 31, 1837, M. Dupuy communicated to the Academy 
 of Medicine that, in experiments which he has made upon horses, the division of the 
 pneumogastric nerve always enabled him to observe a progressive diminution of the 
 fibrine of the blood, during the few weeks that the animals survived the operation. 
 
 j- We just now observe, in Mess. L. Delaberge and Monnerefs excellent compen- 
 dium, that Doctor Copland, (Diet, of Prad. Med., p. 317,) also regards chlorosis as 
 the result of asthenia of the great sympathetic nerve. 
 
 t M. Barruel conceived the ingenious idea of making a medal from the iron 
 which might be collected from the blood of a subject. The wife of one of the cele- 
 brated members of the Ecole de Medecine of Paris, wears a ring made of iron, which 
 was extracted from blood taken from her husband, during the course of a severe 
 disease. 
 
 § Memoire surla chlorose ; Seance de Tacadetnie de Medecine, 31 Octobre, 1837. 
 
500 
 
 CHLOROSIS. 
 
 situations, secluded from the solar rays, as in quarries, mines, dun- 
 geons, the cellars of weavers, in low workshops, in valleys of great 
 depth, which are shaded by wood, and in the sombre, narrow, and 
 badly-ventilated streets of large cities. Periods of famine, continued 
 use of heavy indigestible and decomposed food; the indulgence in 
 warm aqueous drinks, or in the excessive use of vinegar, of green 
 fruit, and all crude articles; excessive fatigue, and finally, the want 
 of exercise, and a sedentary, lazy and voluptuous mode of life, are 
 all causes of the nervous asthenia, which gives rise to the derange- 
 ment of the functions constituting chlorosis. 
 
 Symptotns. No disease inspires more tender interest, or more 
 touching compassion, than the state of paleness, suffering and lan- 
 guor, observed in a young chlorotic girl ; like some delicate plant, 
 deprived of the beneficent rays of the sun, she is a flower which 
 withers and droops away even before its blossoming. 
 
 The approach of chlorosis is marked by a state of habitual inertia 
 and melancholy ; the patient becomes sombre and taciturn, weeps 
 without cause, and sighs involuntarily ; the face becomes bloated ; 
 the expression is, as it were, veiled ; the eyes sad and languishing ; 
 the eyelids, which are swollen, especially in the morning, are encir- 
 cled by a blackish areola, strongly contrasting with the pearl-white 
 colour of the sclerotic coat and the pallor of the lips ; the skin, parti- 
 cularly of the extremities, is dry and cool ; the pulse frequent, rather 
 large and less easily compressed ; the respiration is difficult ; diges- 
 tion is deranged ; the alvine dejections become white, hard, and 
 sometimes fluid ; palpitations and fits of pandiculation make their 
 appearance, while debility, lassitude, a desire for sleep, or rather for 
 repose, as well as the whole collection of symptoms, augment from 
 day to day. 
 
 The patient feels frequent inclination to make deep and very 
 strong inspirations, a symptom which is excited and increased by 
 walking, by ascending, by slight exercise even, and finally by any 
 mental emotion. Auscultation generally shows the impulse of the 
 heart to be stronger than natural. The carotid arteries, which beat 
 with great force, are the seat of certain anormal sounds. Sometimes 
 we have a simple bellows-sound, or a bellows-sound & double cou- 
 rant ; at other times it is a prolonged vibration and a kind of hum- 
 ming, described by M. Bouillaud, under the name of bruit de diable y 
 from its resemblance to the noise produced by the child’s toy, called 
 the dictble. These anormal sounds, which are symptomatic of chlo- 
 rosis, and which become more evident whenever the patient makes 
 any exertion, may be perfectly heard in the carotid and subclavian 
 arteries, and sometimes to a less degree in the crurals. By com- 
 pressing these vessels slightly, taking care not to interrupt the circu- 
 lation entirely, we are enabled to hear a kind of roar, that is dis- 
 agreeable to the ear. If the patient make a lengthened effort, the 
 sounds suddenly cease, just as they diminish and at length disappear 
 in the cervical arteries, when we push aside the larynx from near 
 the vessel in which they are produced. The bruit de diable to 
 
CHLOROSIS. 
 
 501 
 
 which M. Bouillaud* first called the attention of the profession, has 
 been explained in a very ingenious manner by Doctor Beau,t in a 
 memoir inserted in the Archives Generates de Medecine , for the month 
 of February, 1838. This young physician, who has devoted himself, 
 with the utmost zeal, to the pursuit of science, has ascertained, as we 
 ourselves have been enabled to do, likewise, that in well-marked chlo- 
 rosis, that is to say, chlorosis accompanied by arterial sounds, the 
 volume of the arteries is in proportion to the intensity of the chloro- 
 sis and to that of the sound ; the size of the vessels diminishes as the 
 disorder is approaching to a cure, and as the humming noise becomes 
 less sensible. The pulse seems, in some cases of chlorosis, to be 
 small because it is soft and very compressible. It is soft, because 
 the blood is watery and very gently impelled by the action of the 
 heart, which organ is not duly stimulated ; it is full and well deve- 
 loped, however, from the fact that the sanguine fluid is in excessive 
 quantity, though serous, pale and deficient in fibrine. It is the aug- 
 mentation of the serous portion of the blood in chlorotic patients — it 
 is the aqueous plethora, so to speak, called by us hyperhydrsemia — 
 that produces all the plethoric symptoms, and the turgor lympha- 
 ticus which accompany chlorosis. 
 
 Blood drawn from the venous system, and from leech bites, is pale 
 and aqueous ; the clot is soft and diffluent ; the animal heat is dimi- 
 nished ; the lips, nose, hands, and all the organs situated at a dis- 
 tance from the centre of circulation are cold and almost icy; the 
 general cellular tissue becomes the seat of a serous turgescence, 
 which is especially observable about the eyelids and face. The 
 
 * Recherches sur les divers bruits du coeur et des arteres, Journ. hebd., t.ix.,p. 560, 
 1833. 
 
 j- Doctor Beau supposes the bruit de diable, observed in chlorosis, to be caused by 
 the shock of the blood against the arterial walls, and the want of due proportion be- 
 tween the exaggerated sanguine wave and the size of the vessel. This plethora, 
 mi generis, which seems the more paradoxical, because it is acknowledged that there 
 is diminution in chlorosis of the mas;? of blood or anaemia, becomes explicable, 
 nevertheless, when we reflect that most of the chlorotic sy mptoms belong to plethora, 
 as for example the vertigo, the dazzling of the eyes, the tinnitus aurium, the cepha- 
 lalgia, the dyspnoea, the palpitations, the turgescence of the face, somnolence, etc. 
 The superabundance of the sanguine fluid coinciding with paleness, languor, arrest 
 of nutrition, and other anaemic symptoms, is nothing more than an increase of the 
 serous parts of the blood, which fluid is impoverished and deprived of its nutritive 
 qualities. If we admit an augmentation of the mass of the blood, in consequence 
 of the excess of serosity which it contains, it is easy to understand how, from the 
 calibre of the vessels being no longer in due proportion to the volume of fluid which 
 passes through them, there must result a shock and friction against the walls of the 
 arteries, which give rise to the different sounds symptomatic of chlorosis. The idea 
 of a serous plethora, which we have denominated by the term hy perky dr aemia, was 
 maintained by Berner, {de plethora cum cacohymid complicatd,) by Gcelicke, ( de caco- 
 hymid plethorse pedisequd,) and by Buchner, (de crebiore sanguinis missione fecunda 
 plethorae getiitrice.) M. Beau also quotes a passage from Boerhaave, (de morb. ner- 
 vorum, t. i., p. 158,) which proves, that that illustrious physician regarded chlorosis 
 as the result of a superabundance of serous blood. “ The fluids are in excess over 
 the solids, and their motion is retarded, because the mass to be moved is augmented 
 while the moving force remains the same. The body soon becomes inactive ; the 
 young girl becomes swelled, and grows pale ; for, to speak truly, she does not lose the 
 red portion of her blood, but acquires more of the white than is necessary, in propor- 
 tion to the red.” 
 
502 
 
 CHLOROSIS. 
 
 inferior extremities, particularly the ankles, become oedematous, a 
 condition which is most marked towards evening, and which, accord- 
 ing to Gardien, differs from that of common anasarca, in not retain- 
 ing the impression of the finger. 
 
 As the disease progresses, the functions of the stomach are more 
 and more deranged ; the strangest and most depraved tastes manifest 
 themselves ; the patients prefer the most sapid substances, such as 
 salt, vinegar, green fruits ; they often seek, with avidity, indigestible 
 substances, and such as are in no way nutritive, as charcoal, chalk, 
 plaster, earth, ashes, spiders, flies, and other equally disgusting in- 
 sects. The appetite gradually diminishes until complete anorexia is 
 established ; at other times, on the contrary, it is increased beyond 
 measure, while the ingestion of food is followed by a sensation of 
 weight at the epigastrium, by malaise, and sometimes by vomiting. 
 The tongue is generally large and covered with a mucous coat ; acid 
 regurgitations, and frequent nausea occur, especially in the morning ; 
 a feeling of heat and weight in the epigastric region, and sometimes 
 nervous pains in the course of the oesophagus, and extending through 
 to the shoulders, make their appearance. Finally, the patients expe- 
 rience alternations of constipation and watery diarrhoea. The alvine 
 dejections are white, while the urine small in quantity, is pale and lim- 
 pid, as in all the nervous affections. 
 
 The sexual organs are commonly affected with an abundant leu- 
 corrhceal discharge ; most generally there is failure or suppression of 
 the menstruse; at other times they persist and last longer than natural; 
 but far from alleviating the sufferings of the patients, the return of 
 the menses is accompanied by the most diverse nervous disorders, by 
 uterine cholics, by pains in the loins, and great depression; by a 
 kind of stupidity even. When menstruation continues, the secreted 
 fluid, which is pale and watery, separates upon the napkin, into two 
 distinct portions, and forms spots, which lose their colour by drying. 
 The nervous system participates in the general languor of the func- 
 tions ; the patient is sad, melancholy and indifferent to all enjoyments. 
 She seeks solitude, sighs involuntarily, and weeps without cause ; she 
 is often tormented by sinister ideas ; her temper is capricious, odd 
 and irascible ; for her, all thought of happiness is gone, and in her 
 despair she often speaks of suicide ; finally, the night, far from pro- 
 curing repose, brings her only broken slumbers and frightful dreams. 
 
 To these disorders of the intellectual and sensitive apparatus, there 
 are sometimes added the most discordant nervous symptoms, such as 
 tinnitus aurium, vertigo, partial loss of sight, tremors of the limbs, 
 cephalic, cervical and dental neuralgia, peculiar palpitations in the 
 epigastrium, and, in some rare cases, hysterical symptoms even. 
 
 When the progress of the disease is not arrested, the symptoms 
 become more and more aggravated ; the head becomes the seat of 
 severe pain, felt mostly in the occiput; the skin assumes a greenish 
 or earthy hue ; the abdomen is hard and tumid ; thirst arises ; the 
 dyspnoea, faintness and palpitations are increased ; diarrhoea, as well 
 as hectic fever, creep in ; daily exacerbations occur, and the emacia- 
 tion makes rapid progress. Finally, incipient general infiltration, 
 
CHLOROSIS. 
 
 503 
 
 extreme feebleness, invincible repugnance to all kinds of exertion, 
 alteration of the features, and a pale, violet colour of the lips, fore- 
 bode approaching death, which comes at last without shock and 
 almost without pain, surprising the patient under a complete state of 
 marasmus. We shall close by stating that the duration of chlorosis 
 has no fixed limit, but that when properly treated, it commonly ter- 
 minates by a return to health in from one to two months. Yet of 
 twenty-eight patients treated by M. Bland, of Beaucaire, one-third 
 recovered in less than twenty days, and a single case only was pro- 
 tracted to the thirty-second. {Revue Med., t. i. p. 387, 1832.) 
 
 Differential Diagnosis. Though the symptoms of chlorosis are, 
 generally speaking, well marked, the diagnosis of the disease is not 
 devoid of all sources of error ; we shall proceed to mention the chief 
 pathognomonic characters of the diseases which, from the paleness 
 and general loss of colour which accompany them, bear in that 
 respect some resemblance to chlorosis. 
 
 Of all morbid conditions, anaemia is the one which most resembles 
 chlorosis; the analogy existing between these two affections is so 
 great that M. Andral, {Anal. Pathol ., t. i) , regards them as one and 
 the same disease ; amongst the symptoms common to both, are 
 classed: paleness and decoloration of the skin, conjunctiva, lips and 
 buccal mucous membrane ; shrinking and disappearance of the sub- 
 cutaneous veins ; muscular debility; fainting on the slightest exer- 
 cise ; oedematous engorgements ; derangements of the gastro-intestinal 
 functions, and identical auscultative phenomena. Although these 
 symptoms exist both in chlorosis and anaemia, we can distinguish 
 those belonging to the former disorder, from thair being always car- 
 ried to a higher degree and accompanied by nervous symptoms so 
 marked as to form one of the essential characters of the malady. 
 We can detect differences that will enable us to form a correct diag- 
 nosis by a reference to the causes and by a consideration of the 
 course of the disease. The progress of chlorosis is generally slow; 
 it occurs almost exclusively in women at the epoch of puberty, and 
 often takes its rise without known cause or appreciable lesion. 
 Anaemia, the source of which is almost always easily discernible, 
 commences, on the contrary, rather suddenly, especially when it suc- 
 ceeds to spontaneous or secondary losses of blood. Moreover, it is 
 met with in both sexes, and at any age. The chemical analysis of 
 the blood might also assist in clearing up the diagnosis : in chlorosis, 
 there is superabundance of serous blood, whilst in anaemia properly 
 so called, which is a transient condition, we have simple diminution of 
 the mass of the blood. The former disease causes paleness, because 
 the sanguine fluid itself is deprived of colour, while the same phe- 
 nomenon occurs in the latter only because the vessels are almost 
 empty and in some sort exsanguineous. 
 
 [I have been accustomed to confide, in a good measure, in a mode of diag- 
 nosis which I beg leave here to suggest as an useful one. 
 
 Every instance of anaemia is not discoverable always upon inspection of 
 the tint of the skin, nor upon a survey of the stale of the patient as to her 
 
504 
 
 CHLOROSIS. 
 
 embonpoint, since, in some anaemic individuals, the cheek and lips retain 
 a considerable degree of freshness and vivacity of colour from a natural exu- 
 berant vascularity of the tissues composing them ; and there are not a few 
 anaemic patients who even grow fat during the malady. Now I should in 
 such a case test the state of the lungs by asking the patient to make several 
 forced inspirations, in order to discover whether the capacity of the lungs for 
 atmospheric air were at all lessened by disease — and should she appear to be 
 able to inhale fifty or sixty cubic inches at an inspiration, I should have a 
 right to conclude that the air-cells of the lungs were free from pressure or 
 obstruction, and duly expansible. This view might be confirmed by per- 
 cussion and by auscultation of the chest. Still the respiratory difficulties 
 remain to be accounted for, especially those proceeding from every muscular 
 effort. 
 
 I should next examine the frequency of the pulse, which, in a state of rest, 
 might be sufficiently quiet — as at 70, or 80, or 90 beats per minute. If 
 now the patient be requested to walk to the head of the stairs, and return 
 immediately to her seat, she will, if anaemic, be found to have the pulse 
 greatly accelerated and beating in the most troublous manner, to the number 
 of 120, and even 160 pulsations per minute, while her respirations may 
 amount to 40 and even 60 per minute. This fact serves to disclose the 
 existence of the anaemic state, which, in order to effect any powerful innerva- 
 tion as exercise, &c., requires this great and extraordinary precipitation in 
 the movements of the heart. 
 
 M. Colombat is for |he most part so correct and so philosophical in his 
 opinions, that it might be considered in some degree unsafe to controvert the 
 inferences which he makes, and always surrounds with a strong fortification 
 of arguments and well-selected facts. In the opinions he sets forth in some 
 of the preceding paragraphs, he opposes the belief that an altered crasis of the 
 blood plays a prime important part in the maladies grouped under the head 
 of chlorosis, and that anaemia is not chlorosis — and vice versa. But, seeing 
 that no case of chlorotic disorder can well exist without implicating the con- 
 stitution of the blood, I am tempted still to defend an opinion that regards 
 that fluid as greatly, or even principally, concerned in the production of the 
 malady. 
 
 Nothing is truer than that the lining membrane of the sanguiferous system 
 is liable to alterations both functional and physical. These alterations are 
 frequently met with in endocarditis, and it is a well-established truth that 
 most extensive disease of the membrane commune of the veins is met with 
 in some forms of puerperal disease, as in uterine and crural phlebitis, for 
 example. It is also common to observe the membrane commune of the 
 great arterial trunks presenting the signs of disease in the form of engorge- 
 ment thickening and red inflammatory injection. 
 
 If, then, it be admitted that this membrane commune be capable of patho- 
 logical modifications, it follows that all the life-powers of that membrane 
 
CHLOROSIS. 
 
 505 
 
 must also be liable to modifications. Now, what are these life-powers — 
 what are the offices or functions of the membrane commune? No man at 
 the present day can propose to limit those powers to the mere physical 
 agency of containing the blood! On the contrary, it cannot be denied that 
 the constitution of the blood is some how intimately connected with, and 
 probably in immediate dependence upon the biological state of this very 
 tissue. All the products of the nutritive digestions, after passing along the 
 lacteal tubes and trunk, are poured as chyle, ( not as blood,) into this mem- 
 brane, and as that chyle never afterwards touches any other tissue, it is clear 
 that in the contact or nerve-influences of that tissue resides the faculty of 
 converting the chyle into blood and of converting it into healthy normal 
 blood, or of failing so to convert it; whence it appears that the sponta- 
 neous and pathological modifications of the blood, as to its crasis, are to be 
 sought for in the agency of this very membrane ; and that, whether the 
 mutation be into the state of plethora or into that of anaemia. 
 
 It is hardly necessary to follow, even were it possible, to its most recon- 
 dite and hidden depths in the innervative powers, the sole unique principle 
 of that power which ought to give to the body in health a blood consisting 
 of discs 147 — albumen 80 — fibrine 3, and water 790 = 1000 parts. The 
 anatomist will never, perhaps, succeed in unraveling the real nerve filaments 
 that endow this membrane with its biological forces; but should he attempt it, 
 he will doubtless seek to trace them from the nerves that supply the various 
 organs, viscera or parts throughout which the membrane is distributed, as in 
 the spleen, the kidneys — in the stomach, the eye, &c., wherever a vessel 
 runs there also is a nerve fibril, which constitutes not only a part of the 
 organ, but also a part of the vessel itself. Wherefore, every organ plays 
 its part or contributes of its peculiar influence to modify the vitality of its 
 own membrane commune , and thereby to modify the crasis of the blood while 
 within its limits, and for the time a part of its nature. See, therefore, what 
 an immense, and what a varied influence is that the blood is subject to as it 
 courses among the tissues, of which it is always the bond that unites them to 
 the organs with which they stand connected throughout the entire economy. 
 
 These observations, which are offered in brief, may suffice to show why 
 I cannot accede to M. Colombat’s views as to the trifling nature of the role 
 played by the fluid in question in the chlorotic affections. They show that 
 (supposing my opinion well founded) the blood may be greatly in fault in 
 these cases, and it must be quite unnecessary to advance arguments to prove 
 that with a weakened, dilute, pale, ill-animalized blood, we must look for 
 all the results of that feeble innervation which attends the presence of a 
 weak blood in the vessels. 
 
 There can be no sound normal healthful innervation without a normal equa- 
 ble lateral pressure of a healthy blood. Muscular weakness is one of the first 
 manifestations of its presence, and organic or visceral debility follows in rapid 
 succession; development goes on slowly, or reluctantly and imperceptibly — < 
 
506 
 
 CHLOROSIS. 
 
 all the powers of the economy are devoted, under such circumstances, to 
 carry on the more important actions in the scheme of life, while the lesser 
 ones, the outposts, are overlooked or abandoned. 
 
 What more need I say — the travail ovarique is suspended ; no more 
 development of Graafian vesicles; one viscus after another becomes involved 
 in disease, and the patient falls, at length, the victim of a malady whose 
 prime seat and throne were in the membrane commune of the common vas- 
 cular sac which contains all the blood of the body. — M.] 
 
 Jaundice may readily be distinguished from chlorosis, by the yel- 
 low colour of the skin and by the nature of the stools and urine ; by 
 the yellow tint of the sclerotic coat of the eye, which is always pearl- 
 white in chlorosis, and finally, by the absence of nervous symptoms, 
 of palpitations, and particularly of anormal sounds in the arteries. 
 We may avoid mistaking anasarca for the affection under considera- 
 tion, by recollecting that the cedematous turgescence, observed in the 
 feet and legs, and sometimes over the whole surface of the body, is 
 but momentary in chlorosis, and that though observable in the even- 
 ing, it disappears in the course of the night. In addition, the oedema- 
 tous swelling, the turgor chloroticus , does not retain the impression 
 of the fingers as does anasarca, unless the disease has reached a very 
 advanced stage. The paleness, the dyspnoea, the palpitations, the 
 anormal sounds in the heart and arteries, the dizziness, and the oede- 
 matous enlargement of the limbs which we meet with in chlorosis, 
 are so many symptoms of organic disease of the heart. In this con- 
 dition, a mistake may have serious consequences, for the treatment 
 is essentially different. Nevertheless, the appearance and sudden 
 cessation of the phenomena, especially of the anormal sounds of the 
 heart, and the symptoms of cerebral congestion occurring at intervals, 
 will prevent our believing in the existence of a permanent organic 
 lesion. Moreover, the connection of the symptoms, the age, sex and 
 temperament of the patient, the character of the pulse, the march of 
 the disease, and finally, the amelioration which follows the use of 
 martial preparations and tonics, will suffice, in the greater number of 
 cases, to establish a correct, diagnosis. It is well, furthermore, to 
 recollect, that in diseases of the heart, the skin is less altered, that the 
 cheeks generally retain their colour, that the face is sometimes tume- 
 fied, and, finally, that the lips are livid and swollen, which is not the 
 case in chlorosis. We deem it useless to speak of the differential 
 diagnosis of this disease from degeneration and chronic affections of 
 the stomach, from gastritis, tympanitis, intestinal irritation, etc., which 
 often occasion paleness, bearing some resemblance to that which fol- 
 lows the affection forming the subject of our chapter. We shall 
 likewise pass by in silence the different cancerous and tubercular 
 degenerations which, at a certain period of their progress, have as 
 one of their symptoms a yellow straw colour. All these diseases 
 reveal themselves to the observe^’ by their pathological localization, 
 and they exhibit distinctive characters and corroborative circum- 
 stances, which may prevent us fr.om confounding them with the 
 affection now under consideration. 
 
CHLOROSIS. 
 
 507 
 
 The prognosis of chlorosis, when the attack is simple and of recent 
 date, is favourable ; it is not at all dangerous in itself, and often dis- 
 appears upon a mere change of air and regimen. When the patient 
 can be placed under favourable hygieinic and moral conditions, it is 
 surprising to see the rapidity of the cure. Under the influence of a 
 well-directed therapia, we often see a life, which seemed about to be 
 extinguished, almost instantaneously reanimated. But when the dis- 
 ease is left to itself, or combated by irrational treatment, it often 
 becomes complicated with organic lesions of the stomach, heart, 
 lungs, liver, spleen, and with various dropsical affections, which 
 speedily conduct the patient to the tomb. As there is no definite 
 duration for the periods of the disease, the prognosis can be based 
 only upon the length of the attack, and the nature of the complica- 
 tions. We ought, also, to take into account the constitution of the 
 subject, and her mode of life, occupations, and hygieinic circum- 
 stances. Chlorosis, appearing after the establishment of menstrua- 
 tion's more unfavourable than when it occurs in a young girl not yet 
 regulated. It is generally believed, that chlorotic women are almost 
 always sterile, or at least give birth to feeble and sickly children 
 only, but we think that this opinion is correct only in regard to per- 
 sons in whom the disease presents great intensity, and when it has 
 been of long standing. 
 
 The treatment of chlorosis includes two principal indications to 
 remove, as far as possible, the predisposing causes and appreciable 
 morbific influences which have produced or maintain the disease, 
 and, at the same time, to resort to measures calculated to impart 
 energy to the functions of nutrition and sanguification. For these 
 reasons, we divide the treatment into the hygieinic and pharmaceu- 
 tical. 
 
 Whatever may have been the cause that has brought on the chlo- 
 rosis, we should remove the patient from all exposure to cold and 
 humidity ; she should breathe a dry, pure and moderately warm air, 
 and it is for this reason that spring and autumn are most favourable 
 to the cure of the disease. A dry, breezy situation, in a sunny 
 exposure, ought to be recommended. Clothes which, by the nature 
 of their tissue, slightly irritate the skin, are to be preferred to any 
 others. Flannel worn next to the skin, and especially alcoholic and 
 aromatic frictions of the whole surface of the body should likewise 
 be proposed, with the view of exciting the action of the capillary 
 vessels, of inviting the blood into them and promoting perspiration. 
 The food must consist of roast meats, fresh eggs, farinaceous vegeta- 
 bles, ripe fruits, and bitter and aromatic plants, for example, succory, 
 and celery. As a drink during meals, we may employ with advan- 
 tage a mixture of chalybeate water, with Bordeaux, or still better, 
 with Burgundy wine, which contains a large quantity of astringent 
 matter.* Between the repasts the patient may allay her thirst with 
 some refreshing, slightly acidulated drink. Nevertheless, though a 
 
 * We might prepare the gaseous eau fcrree, with Doctor Quenesville’s powder. 
 This solution, which is of easy administration, is generally taken by the patients 
 with pleasure. 
 
508 
 
 CHLOROSIS. 
 
 careful regimen ought to be strictly observed, it is not well to be too 
 exclusive; if we meet with great reluctance in giving up the injurious 
 articles which the patients desire, it would be necessary, at first, to 
 respect their longings, however strange they might seem, and even 
 to satisfy them, unless they were directed to substances evidently 
 hurtful. We should always commence by regulating the meals, by 
 forbidding fruit, salad and all crude articles ; we ought, moreover, 
 to consider the digestive functions, and wholly proscribe nothing but 
 known indigestible articles. 
 
 Whatever be the aversion to exercise felt by chlorotic persons, we 
 ought invariably to insist upon its employment, regulating it, how- 
 ever, by the state of the strength. Should the muscular debility be 
 so great as to prevent the patient from walking, we must resort to 
 mixed and passive exercises. Riding in a carriage, or still better, on 
 horseback, especially if a man’s saddle is used, in open and elevated 
 places, when the air is pure, are proper modes of exercise, particu- 
 larly if pleasant conversation can be added to the charms afforded 
 by diversity of views and landscapes. Boating-excursions, which 
 exert a favourable effect upon ail the organs, and which unite to all 
 the advantages of exercise, that of being agreeable to young per- 
 sons, and of producing an useful stimulation by the presence of 
 individuals of the opposite sex ; music, which occasions a salutary 
 excitation in lymphatic persons, and finally, sea-bathing, and swim- 
 ming in running water, are different hygieinic means which it is well 
 to recommend to nervous, sad, melancholy women, and to those of 
 great moral sensibility. Travelling cannot be too strongly recom- 
 mended to persons in whom the disease is kept up by acute sorrow, 
 or by any moral affection whatsoever ; the use of mineral waters 
 taken at the springs, offers, in this respect, incalculable advantages, 
 not only from the medicinal action of the waters themselves, but 
 also, because the patients enjoy at such places the various charms of 
 a numerous and brilliant society, and attractions which are con- 
 stantly changing. The springs, which have been most strongly 
 recommended, are those of Spa, Plombieres, Vichy, and Pyrmont. 
 
 The use of very tight corsets ought to be forbidden ; sleep should 
 not be protracted beyond eight or nine hours, and care must be taken 
 that the patient’s bed be neither too warm nor too soft, because 
 such beds often increase the feebleness and constipation of very 
 sensitive women, especially those in whom the chlorotic state has 
 been developed, and maintained under the influence of disappointed 
 love. We should forbid exciting drinks, the use of wine, and highly 
 nutritious food ; vivid emotions ; the frequenting of balls and shows; 
 the reading of high-wrought romances ; the examination of lascivious 
 pictures, and finally, we should, as far as possible, suppress all cir- 
 cumstances capable of disturbing the sensibility, or of exciting the 
 passions too strongly. It is in such cases as these especially that 
 we ought to insist upon sedative drinks, warm baths, and especially 
 upon some means of diversion to be kept in constant action. 
 
 The pharmaceutical treatment of chlorosis, whether accompanied 
 by derangements of the menstrual flux or not, consists in restoring 
 
CHLOROSIS. 
 
 509 
 
 ihe tone of all the functions, by means of a tonic and excitant medi- 
 cation. Of all the therapeutical agents, iron is the one which should 
 be placed in the first rank, on account of its constant efficacy. This 
 metal, regarded with good reason as a specific in chlorosis, has been 
 employed alone, and associated with a number of other remedies, 
 such as the extracts of succory, parsley, absinthium, gentian, blessed- 
 thistle, cinchona, rhubarb, etc. It has also been prescribed in com- 
 bination with emmenagogue substances, as, for example, saffron and 
 aloes, etc., or with canella, conserve of roses, anise, tartrate of potash, 
 lemon-juice, chocolate, white wine, (and vinum ferri.) Finally, it 
 has been ordered infill its different forms ; in the minutely divided 
 metallic state, in the state of oxide, (gethiops martial,) in the state of 
 salt, sulphate of iron, (green vitriol,) tartrate of potash and iron, 
 (boule de Nancy,) and subcarbonate of iron, which is at present 
 preferred, either incorporated with syrup, into an electuary, or admi- 
 nistered in the form of pills, of pastilles, of powders, etc., and in doses 
 of from six or eight grains to half a drachm, or a drachm, two or three 
 times a day.* 
 
 Doctor Blaud, of Beaucaire, supposing that the subcarbonate of 
 iron does not exert all its curative properties, unless so modified 
 as not to be rejected by the absorbent orifices, and unless given in 
 sufficient doses, has proposed the following formula as best fulfilling 
 these two essential conditions. R. Sulphate of iron, and subcarbo- 
 nate of potash, each half an ounce ; reduce them separately to a 
 very fine powder; then mix very thoroughly, little by little; add a 
 sufficient quantity of mucilage of gum tragacanth ; beat strongly in 
 a mortar, and make a mass to be divided into forty-eight boluses. 
 “ There results, from this mixture, a mutual decomposition of the 
 two salts. The subcarbonate of iron thus formed, being in a state 
 of extreme division, becomes more readily absorbable, while at the 
 same time it acquires from its chemical composition, greater activity. 
 The sulphate of potash, which is also present, greatly favours its 
 absorption by determining its movement along the mucous mem- 
 brane of the digestive tube by the contraction it produces, and by 
 exciting the lymphatic absorbents situated upon it.”t 
 
 M. Blaud directs a pill to be taken early in the morning, and in the 
 evening upon retiring, during the first three days. On the fourth, 
 fifth, and sixth days, he adds a pill at mid-day ; the seventh, eighth, 
 and ninth days, two pills in the morning and two in the evening ; 
 the tenth, eleventh, and twelfth days, two more in the middle of the 
 day ; the thirteenth, fourteenth, and fifteenth days, three pills in the 
 morning and three in the evening ; the sixteenth, and following days, 
 four pills three times a day. He continues this dose long enough to 
 dissipate the symptoms of the disease, and then returns gradually to 
 the smaller doses, as at the commencement. 
 
 * The English physicians, particularly Doctor B. Hutchinson, have found great 
 benefit from the use of the subcarbonate of iron, carried to the dose of from one to 
 three drachms daily, taken at three different periods. Edinburgh Journal, vol. 18, pp. 
 
 321 and 411. 
 
 f Mem. sur les Malad. Chlorotiques, Revue M6d. t. i., p. 337, 1834. 
 
510 
 
 CHLOROSIS. 
 
 Scarcely, says M. Blaud, is the remedy introduced into the eco- 
 nomy, whatever be the duration and violence of the disease, before 
 a sensible improvement is observed; this appears sometimes on the 
 second, or even on the first day of the treatment, after years of suffer- 
 ing, and most singular, without the aid of any auxiliary treatment. We 
 have but to note a progressive, and generally a rapid amelioration, 
 whose course nothing suspends, even in individuals labouring under 
 cardialgia, diarrhoea, etc., symptoms which would seem to contra- 
 indicate all tonic medication. At first a light rosy tint appears upon 
 the cutaneous surface, chiefly upon the face, and the eyes assume the 
 lustre which they had lost. At the same tim%, or a little later, the 
 symptoms of nervous disturbance, the gastralgia, which nothing 
 could calm, the insomnia, the buzzing in the ears, the cephalalgia, 
 which had resisted all remedies, sensibly diminish, and before long 
 disappear. The respiration, also, becomes freer, the pulse less fre- 
 quent, the palpitations less severe and more rare, the infiltration of 
 the limbs is dissipated, the muscular force is re-established, appetite 
 returns, the moroseness vanishes, a feeling of general comfort suc- 
 ceeds to the wearing misery which rendered the life of the patient 
 so deplorable, and all the organic functions soon return, as if by a 
 miracle, to their normal state. 
 
 [The author appears to have confined himself solely to the recommenda- 
 tion of Blaud’s pill, as a chalybeate remedy in chlorosis ; and perhaps 
 that preparation does in fact combine all the activity and convenience desira- 
 ble in any ferruginous formula. Nevertheless, as not a few persons are to 
 be met with, who appear insuperably opposed to the use of pills, and as his 
 pills are of ten grains weight each, it is highly convenient to have other 
 formulae that may suit their tastes or prejudices, which, in medical practice, 
 ought, to a certain extent, to be respected. M. Raciborski, in his ingenious 
 and most valuable work, Be la Puberte , &c., gives high praise to the com- 
 binations of the oxyde of iron with weak acids, under the supposition that 
 they most readily yield their place to the new combination of principles 
 that ought to take place in the stomach. With this view, he recommends 
 strongly the citrate of iron, &c. 
 
 I have made most advantageous use of a citrate of iron conjoined with sul- 
 phate of quinia; as in the following formula, which I subjoin as a very con- 
 venient and successful one, in the disorders dependent upon anaemia: 
 
 Take of citrate of iron, 2 drachms; 
 
 Sulphate of quinia, £ drachm: , 
 
 Water, 1 fluid ounce; 
 
 Mix, and direct from 20 to 30 drops for the dose, in syrup and water. 
 
 Agreeably to M. R ’s method, I advise the patient to take the draughts 
 after each meal, within half an hour of the breakfast, dinner or supper, so 
 that it may be carried with the chyle along the course of the bowels. 
 
 The addition of the quinia to the ounce of water, renders the citrate and the 
 sulphate perfectly soluble, as does also the addition of a few drops of ammo- 
 
CHLOROSIS. 
 
 511 
 
 nia to a solution of the citrate alone ; without some such addition, a part of 
 the citrate of iron is not dissolved. Vallet’s mass of the carbonate of iron is 
 also worthy of much confidence ; it is a most convenient and active ferrugi- 
 nous medicine. Made into pills of two to five grains each, it is found, in 
 numerous instances, to remove, with great rapidity, the disorders of the cir- 
 culation, connected with the anaemic and chlorotic states. 
 
 M. Raciborski highly recommends, as endowed with the two chief desi- 
 derata of great therapeutic activity and absolute insipidity, a metallic iron 
 or impalpable powder. It is prepared by heating protoxyde of iron in a 
 gun barrel, to redness, and then passing through it a stream of hydrogen. 
 In the process, the hydrogen combines with the oxygen of the protoxyde to 
 form water, and passes off, leaving the iron reduced to a purely metallic 
 state, and impalpably fine. This is much used in France, in the form of 
 lozenges, and is greatly admired for its curative power. 
 
 I have, on many occasions, directed my patients to purchase one or two 
 ounces of Vallet’s mass, and to take a piece as large as a pea, after each 
 meal. This may be done with persons who are averse to the use of pills, 
 and is a means of saving trouble, and even of avoiding the disgust and feel- 
 ing of constraint apt to follow the prolonged use of a regular medical formula. 
 M.] 
 
 The dose, to which the subcarbonate of iron should be gradually 
 increased, is a drachm daily, but it is very important not to stop the 
 treatment suddenly, just when a return to health is about to take 
 place. M. Blaud advises a continuance of the treatment as long as 
 may be necessary to dispel the symptoms, and he considers a gradual 
 return to the earlier doses as very important in establishing the cure. 
 At the same time that we subject the patient to this treatment, we 
 should prescribe for her drink, during meals, either the natural ferru- 
 ginous waters, as Spa, of Passy, or of Forges water, mixed with wine, 
 etc., or simply water, into which has been plunged a piece of hot 
 iron, or which has been prepared with the chalybeate powder of 
 Dr. Quenesville.* To increase the efficacy of this treatment, or of 
 any other of the same kind, it will be well to prescribe, at the same 
 time, alcoholic frictions over the whole body, and the use of some 
 slightly stimulating tisan, as an infusion of balm, of mugwort, of 
 hyssop, of lungwort root, etc. 
 
 Other tonics might likewise be added to the iron, such as tisan of 
 hops, of gentian, of the lesser centaury, of blessed thistle, etc. 
 
 In his thesis, No. 51, 1803, M. Ballard speaks of having derived 
 good effects from the tan of the oak bark, or of the horse-chestnut. 
 Tannin, extolled by Dr. Pezonni, is likewise an excellent therapeutic 
 
 * A gaseous chalybeate water may be prepared in the following manner: Take 
 of crystallized sulphate of iron, 2 drachms; white sugar, 3 drachms; pulverize and 
 make into twelve powders. Take of bicarbonate of soda, 2 drachms; white sugar, 3 
 drachms; pulverize, and divide into twelve powders. One paper of each of these 
 powders is dissolved in half a glass of water; then the two portions of water are 
 mixed and swallowed during the eifervescence. 
 
512 
 
 CHLOROSIS. 
 
 means in chlorosis ; it may be administered either combined with 
 opium, with iron, or in aqueous or vinous decoction ; or else, which 
 is preferable, in the pilular form, from sixty to one hundred grains 
 being taken in the twenty-four hours, at different times. 
 
 Constipation, a symptom as constant as it is troublesome, must 
 be treated by enemata and laxatives. Purgatives might also be 
 employed with the same end ; they often produce a stimulation 
 which greatly assists the cure. Dr. Hamilton, who regarded consti- 
 pation as the principal cause of the disease, recommended pills of 
 aloes and gamboge, as well as the powder and the tincture of jalap. 
 Rhubarb, in doses of from six to fifteen grains, taken just before 
 eating, seems to us the most suitable remedy, from its tonic and 
 purgative properties. Drastics should be resorted to with great re- 
 serve, and only where rhubarb and enemata have failed to relieve the 
 constipation. They should be rejected in toto where the disease is far 
 advanced, or complicated with a lesion of the stomach, liver or other 
 viscera. Emetics, which were first proposed by Mercatus, physician 
 to Philip II., King of Spain, (Gynoeciorum, sive de mulierum , etc., 
 1554 ,) may be appropriate for cases in which the disease is compli- 
 cated with some gastric disorder. Baillou ( de virgin, et mulier. morb ., 
 1643 ,) relates that all the remedies employed for the cure of the 
 daughter of a goldsmith, aged eighteen years, and affected with chlo- 
 rosis, proved unsuccessful: but he adds that the young patient was 
 thrown from a carriage, which caused her great fright, and brought 
 on a very abundant vomiting of bile : from that moment her appetite 
 returned, her face resumed its natural colour, and her health was 
 perfectly restored in a short time. Should it be thought necessary 
 to resort to an emetic, ipecacuanha ought to be preferred above all 
 others, because of its less violent action and for the tonic properties 
 which it possesses. 
 
 Electricity, recommended by MM. Sigaud - Lafond, Manduyt, 
 Nauche, Loudon, and others, ought not to be employed, we think, 
 except with great circumspection, and after we have restored to 
 the blood and other fluids their physiological qualities. Without 
 this precaution, electricity would be not only useless but dangerous, 
 by increasing the disorders which depend upon the hyper hydrsemia, 
 or serous plethora, especially in those accompanied with determina- 
 tion of blood to the head or chest. 
 
 Though bleeding was prescribed by Van Helmont, Hoffman, Sy- 
 denham, Gardien, Desormeaux,and several other distinguished prac- 
 titioners, we are of opinion that a small revulsive bleeding may be 
 useful, where there is uterine engorgement with haemorrhage, and in 
 cases where the patients are tormented with violent palpitations 
 and symptoms of very marked serous plethora. We conclude by 
 stating that the nervous symptoms, the gastralgia, cephalalgia, facial 
 neuralgia, melancholy, etc., commonly disappear very rapidly under 
 the administration of iron and by attention to hygieinic indications, and 
 do not require any special prescription. Furthermore, an attempt to 
 recall the menses, when they have not returned spontaneously, should 
 never be made until after the chlorosis is cured, and we are convinced 
 
NYMPHOMANIA. 
 
 513 
 
 that the organs of assimilation have resumed their functions. For 
 this purpose, we should combine emmenagogues, such as saffron, 
 aloes, mugwort, etc., with the filings or with the subcarbonate of 
 iron. Rufus’s, and particularly Fuller’s pills, in doses of twenty 
 grains every morning, might also be prescribed conjointly with pedi- 
 luvia, hip-baths, cups to the thighs and about the pelvis; and, indeed, 
 most of the remedies which we mentioned when speaking of the 
 treatment of amenorrhoea. 
 
 Should we discover, as Erasistratus did at the court of Seleucus, 
 King of Syria, an amorous inclination to be the cause of the dis- 
 ease, we ought always to consent to marriage, not immediately, but 
 where a well-directed treatment has restored the health, which would 
 be fully established by following the precept given by Hippocrates: 
 " Equulem virginibus suadeo, quibus tale quid accidit, at citissime 
 cum viris conjungantur ; si enim conceperint ,sanse evadwit.” (Lib. 
 de morb. virgin.) 
 
 To complete, as far as possible, what we had to say upon the 
 disease which forms the subject of this chapter, we deem it proper 
 to subjoin the only analyses that have been made of the blood of 
 chlorotic persons.* By taking, as the point of comparison, the blood 
 of a healthy female, and experimenting on one thousand parts, the^e 
 analyses, due to MM. Foedich and Lecanu, have furnished the fol- 
 lowing results : 
 
 Analysis of M. Foedich : Cruor. 
 
 Blood of a healthy woman, 124.00 
 
 Idem, .... 144.00 
 
 Blood of a chlorotic patient, 91.41 
 
 Idem, .... 85.90 
 
 Serum. 
 
 Fihrine. 
 
 Water. 
 
 Iron. 
 
 86.01 
 
 25.11 
 
 756.87 
 
 S.01 
 
 89.20 
 
 25.01 
 
 732.73 
 
 9.01 
 
 93.61 
 
 6.40 
 
 826.28 
 
 3.30 
 
 92.21 
 
 6.31 
 
 830.75 
 
 5.01 
 
 • Analysis of M. Lecanu.— Blood from a chlorotic patient: water, 
 862.40 ; globules, 55.15 ; albumen, fixed, fatty and extractive matters, 
 82.45; total, 1.000. We see, from the results obtained by these able 
 experimenters, that no doubt remains as to the increase of the water 
 and the proportional diminution of the globules and iron in the blood 
 of chlorotic persons. 
 
 OF NYMPHOMANIA, OR FUROR UTERINUS. 
 
 By nymphomania , or furor uterinus,\ is now understood an 
 exaggerated, irresistible and insatiable desire urging the woman to 
 the venereal act. This affection, upon which most of the authors of 
 antiquity, amongst others Hippocrates, Galen, Celsus, Aretaeus, Oriba- 
 sius, and Paul of iEgina, observe entire silence, was first described by 
 Soranus, under the title of ^tpoyavia, ( Be utero et mulieb. pudendo;) 
 and from this author, by Aetius, under that of furor ulerinus , and 
 by Moschion, ( De affect, mulieb., cap. 28,) under the denomination of 
 satyriasis. The physicians who have written upon this neurosis, 
 disagree as to its seat: some have placed it in the genital organs, while 
 others fix it in the encephalon. The former opinion is maintained 
 
 * [Vide Andral’s Pathol. Haematol., Phil., 1844, pp.43, 52.— M.] 
 f This disease is also designated by the terms metromania, andromania, erotomania, 
 hysteromania, clitorimania, lypatia , etc. 
 
 33 
 
514 
 
 NYMPHOMANIA. 
 
 by Soranus, Aetius, Moschion, Sennertus and Louyer-Villermay, 
 and the latter by Willis, Sydenham, Boerhaave, Georget, Duges, etc. 
 Finally, some modern authors, amongst others MM. Soby and Rech, 
 professor at Montpellier, in whose opinion we ourselves agree, regard 
 nymphomania as resulting from a simultaneous irritation of the brain 
 and sexual organs. This morbid exaggeration of the venereal appetite, 
 this cestus eroticus , is less a disease than a symptom for the manifesta- 
 tion of which is required the concurrence of the brain and the organs to 
 which erotic sensations are referred. The point of departure is some- 
 times in the brain, and sometimes in the uterus and its appendages. 
 In the former case, the disease is developed under the influence of 
 moral causes which secondarily irritate the genital parts, and in the 
 latter, it is a primary irritation of the organs of generation reacting 
 sympathetically upon the brain, and especially on the cerebellum. 
 
 The affection, which may appear at all ages, generally attacks 
 women of an original uterine temperament, which is determined by 
 the predominance of the sanguine system, and extreme irritability of 
 the abdominal viscera. Women of this constitution have some of 
 the characteristics of Sappho ; their stature is small, their skin dark, 
 and their complexion highly coloured ; in them the breasts, and all 
 the attributes of puberty, have been developed at an early period ; 
 the clitoris and the nymphm, which are generally of anormal length, 
 are endowed with exquisite sensibility. Young widows, who have 
 to regret frequent engorgements, public girls who have been sud- 
 denly deprived by forcible seclusion of venereal pleasures, to which 
 they had abandoned themselves to excess, ardent women, married 
 to men whose cold and feeble constitutions prevent often-repeated 
 sexual connection, and finally, those who are attacked with some 
 chronic cerebral affection, are most exposed to this frightful disorder, 
 especially when they inhabit warm climates, in which the passions 
 are most vivid and the imagination most exalted. 
 
 There are some women, whose genital organs acquire such a pre- 
 ponderance, as to make it almost impossible for them to control the 
 erotic flame that devours them ; such was the young girl of whom 
 Buffon speaks. “ I have seen, and I have regarded her as a singular 
 phenomenon, a girl of twelve years of age, a dark brunette, of a bright 
 and highly-coloured complexion, of small stature, but already fully 
 formed, with a rounded neck and embonpoint, perform the most 
 indecent action at the simple appearance of a man ; nothing could 
 control her in this, neither the presence of her mother, nor remon- 
 strances, nor punishments. Yet she did not lose her reason, and the 
 attack, which was carried to such a point as to be frightful, ceased 
 the moment that she remained alone with women.” ( Histoire Na- 
 turelle de Vhomme , de la puberte.) Such, also, was the famous 
 Messalina, of whom Juvenal, and Pliny the naturalist, give us the 
 shameful and disgusting history. She escapes, during the night, from 
 the bed where sleeps the Emperor Claudius, her stupid lord, and 
 disguised in the dress of the courtezan Lycisca, hastens to encounter 
 the brutality of the vilest debauchees : 
 
 “ Et lassata viris, sed non satiata recessit.” 
 
NYMPHOMANIA. 
 
 515 
 
 Amongst the causes which act primarily on the brain and second- 
 arily on the sexual organs, should be included all conditions capable 
 of producing an accession of excitement in the centre of sensation, 
 and of augmenting the exaltation of the senses and ideas ; such as 
 disappointed love, a concentrated affection, the reading of lascivious 
 and impassioned works, the sight of licentious paintings, erotic and 
 romantic conversations, intimate communion with governantes or 
 corrupt companions, frequent visits to balls or theatres, the too 
 assiduous cultivation of the fine arts, accidental sight of amorous 
 interviews and the influence of imitation which, in this case, as in 
 most of the nervous affections, is followed by consequences as de- 
 plorable as they are frequent. As equally capable of producing 
 nymphomania are regarded the abuse of what are styled aphrodisiac 
 remedies, or of spirituous liquors, the immoderate use of aromatics, 
 and perfumes which, by exciting the brain and the general sensibility, 
 arouse and exalt the venereal appetite. 
 
 The causes whose action is felt primarily and directly upon the 
 uterus and its appendages, and which may afterwards react sympa- 
 thetically upon the brain, are solitary pleasures, the abuse of coitus, 
 an herpetic affection or prurigo of the vulva, irritation of the clitoris 
 and nymphae, inflammation of the cervix uteri, and of the ovaries; 
 we may add, that the age of puberty, and that of the physiological 
 cessation of the menses, as well as the epoch of their flowing, are 
 circumstances the most favourable to the development of the disease, 
 which now occupies our attention. There is another frequent and 
 not less powerful cause of exaggerated erotic exaltation, which is 
 nothing more than the presence of ascarides, which, by irritating the 
 rectum, the nymphae, the clitoris, the labia majora and vagina, induce 
 in the genital apparatus an excitement and pruritus, which compel 
 the patients to scratch themselves to such a degree as to give rise to 
 the most violent erotic desires. Finally, the use of drastic purga- 
 tives, haemorrhoidal fluxions, and especially the internal or external 
 employment of cantharides, have sometimes brought on an exagge- 
 ration of genital excitation. 
 
 Symptoms . — In the beginning of the disease, the female expe- 
 riences venereal desires, which are strongest at the menstruating 
 periods, but which shame compels her to conceal. The care which 
 she takes to hide the obscene ideas that constantly disturb her imagi- 
 nation, as well as the illusions of platonic love which has irresistible 
 charms for her, exalts her imagination, renders her sad, taciturn and 
 melancholy ; she loses her appetite and sleep, and seeks solitude in 
 order not to be distracted from the thoughts with which her imagina- 
 tion is constantly preoccupied. After the disorder has made some 
 progress, far from seeking to hide her irresistible passion, the patient 
 employs all her address to make it known by frequent sighs, by encou- 
 raging proposals, by voluptuous attitudes, and finally by complete for- 
 getfulness of all modesty. At the sight of one of the masculine sex the 
 pulse of the nymphomaniac is agitated, her face becomes redder and 
 more animated, her respiration tumultuous, her senses are obscured, 
 
516 
 
 NYMPHOMANIA. 
 
 she makes indecent proposals, and often indecent gestures ; finally, 
 when the irritation reaches the highest point, she strikes, and tears 
 every thing that opposes her, and at last falls into furious delirium. 
 In addition to these essential and characteristic symptoms of the 
 disease, there are commonly certain symptoms of insanity which 
 may be remittent or perhaps intermittent, until some new causes 
 reproduce them. The female, who is always affected with a general 
 or local spasmodic condition, experiences lassitude of the extremi- 
 ties, and a sensation of pruriginous heat in the loins, hypogastrium 
 and mammes ; the urine, variable in quantity, is always clear, and 
 the genital parts, which are red, swollen, and constantly irritated 
 by handling or illicit manoeuvres, are commonly the seat of a sani- 
 ous, fetid, and sometimes even a purulent discharge. Lastly, hur- 
 ried respiration, fatiguing palpitations, ardent thirst, grinding of the 
 teeth, spasm of the oesophagus, and, in some cases, hydrophobic 
 symptoms are other phenomena attending erotomania. The termi- 
 nation of the disease is sometimes fatal, especially when coexisting 
 with organic affections of the ovaries, uterus and its appendages, of 
 which examples are cited by Blancard, by Gesner, and by Mor- 
 gagni. In some cases, the attacks of furor uterinus follow each other 
 with great regularity, and terminate as unhappily as pernicious in- 
 termittent fever. Doctor Jolly, ( Diet . de Mbd. et eh. pr., t. xii. p. 96, 
 1834,) reports a case of this kind from Jauzion. It is well known 
 that Eusebia, wife of the Emperor Constantine, son of Constantine 
 the Great, died in an attack of furor uterinus. ( From Zonaras, hist, 
 grascum. annul., t. iii. p. 23.) Nicolas Blegny, who founded the Aca- 
 demy of recent discoveries in Medicine, in 1678, relates the case of a 
 woman who, after several paroxysms of furor uterinus, had one so 
 violent, as to cause death by apparent suffocation. Paul of iEgina, 
 likewise cites the case of a beautiful woman of Delphos, who pe- 
 rished in a paroxysm of the same kind. Though marriage has 
 sometimes been known to put a stop to nymphomania,* it is a means 
 which should not be resorted to until we are fully assured of the 
 etiology of the disease, and of the proper time for the remedy. 
 Suffice it to say, that we cannot be too reserved and prudent, when 
 called upon to give advice on so delicate a point. 
 
 The treatment of nymphomania must depend upon the causes 
 and primary seat of the disease, that is to say, the therapeutical 
 means are to be applied sometimes to the brain, and at other times 
 to the genital organs, in which is seated the venereal appetite which 
 overpowers the patient. In the former case, which, in our opinion, 
 is much the most frequent, we ought, especially if the erotomania be 
 incipient, to repose greater confidence in hygieinic measures than in 
 drugs, which are generally inefficacious in opposing a disease whose 
 source lies in some moral cause. We must begin, therefore, by de- 
 vising for the patient some means of distraction, capable of diverting 
 
 * Swenck relates that an Italian woman, who, in a paroxysm of erotic insanity, 
 had escaped from her house, and gone to a house of ill-fame,, where several men sati- 
 ated their passions on her, recovered her health in the midst of their brutal caresses. 
 
NYMPHOMANIA. 
 
 517 
 
 her imagination from lascivious thoughts, for which purpose we may 
 recommend constant occupation, travelling, and exercise by walking. 
 
 “ Otia si tollas periere Cupidinis arcus.” {Ovid.) 
 
 Every thing capable of producing erotic excitement, as the view 
 of statues and images, the reading of romances; balls, shows, the 
 society of men, etc.; should be avoided with the greatest care. We 
 should always seek to occupy their thoughts with objects foreign to 
 their passion, and to contrive that they may associate only with per- 
 sons of their own sex; we must, at the same time, prescribe the use 
 of prolonged warm baths, with cold affusions to the head, while 
 the patient is in the bath. Emulsion of almonds, with addition of 
 nitrate of potash ; sedative and cold drinks, sweetened with syrup of 
 orgeat, of currants or marshmallows ; those made with the distilled 
 waters of lettuce, cucumber, melon, pumpkin, or water-lily, and ene- 
 mata of the same nature, with addition of a few grains of camphor ; 
 finally, whey ; broths made of beets and sorrel, and of chicken or 
 veal, with nitre ; lemonade, a milk and vegetable diet ; general 
 bleeding ; applications of leeches behind the ears, and especially to 
 the nucha, are all useful methods of treatment, when the point of 
 departure of the disease is seated in the brain. 
 
 If the nymphomania depends upon some local cause of venereal 
 excitement, such as masturbation, some herpetic affection, prurigo, 
 leucorrhoea, the presence of worms, etc., we must try to allay the 
 pruriginous sensation which stimulates the patient to the revolting- 
 excesses so hurtful to her, by combining with the various means 
 already indicated various tonics; for example, emollient and narcotic 
 injections, and applications to the genital parts of cloths wet with 
 decoction of poppy-heads, of lettuce, of henbane, of cicuta, etc. We 
 might, also, with the same view, resort, to inunctions of cucumber 
 ointment with opium, or of a liniment made of lime-water and olive 
 oil. Small enemata of milk with addition of a few grains of cam- 
 phor, and the internal employment of camphor, strongly recom- 
 mended by Ettmuler ( De mnrb. mnlier ., cap. 2), in a dose of five to 
 fifteen grains in a 'mixture, are means whose efficacy has been recog- 
 nized from the highest antiquity, and is consecrated by the old adage : 
 
 “ Camphora per nares castrat odore mares.” 
 
 To diminish the venereal orgasm, some authors have proposed 
 cicuta, but the anti-aphrodisiac virtue of this plant is far from being 
 proved, although Saint Basil has said, ( Homil . v. supra hexaemer :) 
 “ Se vidisse quasdam foe minus, qux potione cicutse extinxerint rabio- 
 sas cupiditates Finally, for the purpose of quelling the erotic de- 
 sires, Doctor Coster has proposed the employment of tartar emetic 
 in small quantities, one or two grains in a pint of water, to be taken 
 in teacupful doses every hour, so as to excite nausea without occa- 
 sioning vomiting. According to this physician, the nausea and mus- 
 cular prostration which result from the use of this potion, scarcely 
 ever fail to produce the desired effect. It is well to remark, also, 
 that every thing capable of exciting the genital organs must be re- 
 moved from the bed upon which the patient lies. For example, very 
 
518 
 
 NYMPHOMANIA HYSTERIA. 
 
 soft mattresses, feather beds, and beds made of down must be for- 
 bidden, and one made of straw is to be preferred instead, or else it 
 should consist of a simple hair mattress. We should reject, also, as 
 dangerous and immoral, the titillation of the clitoris, advised by some 
 authors, particularly by Varande, (De morb. rrnilier ., lib. i. cap. 5 .) 
 Excision of the clitoris, likewise, would be useless in gpposing true 
 erotomania, in the treatment of which Levret and some other authors 
 have vainly employed it. This operation, performed several times 
 by MM. Dubois the elder, by Richerand (Nosog. chir ., t. iv.), and 
 by Grsefe ( Nouv . bibl. Med., t. ix., p. 256 , 1825 ), etc., has served 
 merely to arrest the vicious habits, which might often be remedied 
 by means of the tincture of M. Gerentel, or the ingenious apparatus 
 of Professor J. Cloquet, which consists of a sort of wire-work whose 
 meshes are so close as to prevent the passage of the finger. To the 
 employment of the various means we have mentioned, should still 
 be added a Pythagorean regimen, a milk and vegetable diet, absti- 
 nence from stimulating drinks and food, while in the intervals of calm 
 we must remind the patient of her duty to herself and family, which is 
 dishonoured by her shameless practices. Finally, where the nympho- 
 mania has reached the highest degree of violence, the disease, which 
 in that form is generally incurable, would simply require the treatment 
 proper for mania. We refer our readers to Pinel’s treatise upon mental 
 alienation, 1809 , and to the work just published by M. Esquirol, 
 entitled Des Maladies Meat., etc. t. ii. p. 32 , 1838 . We cannot too 
 strongly recommend, likewise, the excellent work of M. F. Voisin, 
 whose title is : Des causes Morales phys. des Maladies Meat, et de 
 quelques autres affect, new., idles que Vhyst'erie , la nymphoma - 
 nie, etc., 1836 . 
 
 OF HYSTERIA AND OTHER SPASMODIC DISEASES OF WOMEN. 
 
 From the earliest periods to the present time, most authors who have 
 written on the disease designated by the term hysteria ,* have involved 
 themselves in vain arguments, in specious explanations and rash 
 theories upon its nature, seat and causes. Without wishing to recall 
 all that has been said upon the subject, we shall proceed to state in 
 a few words the opinions that have been put forth by different 
 writers. We ought, however, to inform our readers that, in order to 
 avoid digressions and repetitions, and especially with a view to a 
 more methodical arrangement, we have preferred to proceed by ana- 
 logy rather than to follow the chronological order, that is to say, to 
 group together the opinions bearing the strongest resemblance and 
 relations to each other. 
 
 The various opinions which have prevailed as to the seat of hys- 
 teria, may be reduced to four: 1 . Some have placed the seat of the 
 disease in the uterus, whether it were the effect of change of position, 
 
 * This disease has been called by various denominations, amongst others, vs-rcpi^v 
 hysterica, hystencia, hysterical spasm; suffocation of the womb, hysterical vapours, 
 maux de nerfs, attaques de nerfs, metronervie, mal de la mere, hystericism, encepha- 
 lie spasmodique, etc., etc. * 
 
HYSTERIA. 
 
 519 
 
 or of alterations of the organ, as believed by Hippocrates, Plato, 
 Aretaeus, Caelius-Aurelianus, Soranus, Primrose, Haller and Duret; 
 whether it depended upon a retention or alteration of the sperm or 
 of blood retained in the viscus, and whence arise malignant vapours, 
 afterwards dispersed through the whole body, as supposed by Galen, 
 Ahrun,Fernel, Pitcairn, Charleton,Zacutus-Lusitanus, Forestus, Guil- 
 laume de Baillou, Thomas Burnet, Mercalus, Sennertus, N. Chesneau 
 and Laz Riviere ; or, lastly, whether the disease were the consequende 
 of some modification of the uterine nervous system, acting sympathe- 
 tically on the general nervous system, as set forth by Aetius, Astruc, 
 Cullen, Pinel, Lieutaud, Vigarous, Beaumes, Louyer-Villermay, Ra- 
 pon, Duges, Foville, Dubois, of Amiens, and by most modern authors. 
 Pujol, of Castres, and M. Lisfranc, who are of this opinion, admit, 
 nevertheless, that chronic inflammation of the uterus or ovaries* 
 may often be the primary cause of hysteria. 
 
 2. Other writers have supposed the disease to be seated in the 
 general nervous system ; of these some see nothing in the disease but 
 irritation or irregular movements of the nerves ; others think that the 
 disease should be attributed to an alteration of the nervous fluid, or 
 to some vitiation of the animal spirits. We must refer to this class 
 the opinions of Dutnoulin, de Loob, Boerhaade, Alberty, Neuter, 
 Gorter, Sauker, Raulin, Pomme, Lory, Tissot, Ridley, F. Hoffmann, 
 Blackmor, Pressavin, Whytt, Viridet, Sauvage, Perry, Linnaeus, Gar- 
 dien, etc. We may attach to the same class, also, the atony of the 
 spirits (ata^a spirituum anirnaliam) of Sydenham, the lesion, what- 
 soever it be, of the ganglionic system of Bichat, and the prostration of 
 the whole system of strength of the vital principle, to which Barthez 
 assigns so important a part. 
 
 3. Among the physicians who have referred the point of departure 
 of hysteria to the brain, are included Ch. Lepois, Willis and Geor- 
 get: Barbeyrac thought it was the effect of an acid and bilious prin- 
 ciple conveyed to the brain ; Schacht supposed it .to depend upon a 
 disturbed course of the spirits, whose source is in the semorium com - 
 mttne and in the nerves: again, M. Amard has referred the origin of 
 hysteria to the inferior portion of the medulla spinalis. M. Brachet, 
 of Lyons, [Recherches sur 1' hysteric, etc. p. 143, 1832,) thinks that 
 the disease has its seat in the central nervous system, and that it con- 
 sists of a peculiar mode of excitation and perversion of this system, 
 Gardien has imagined that the starting-point of the evil might very 
 well be in the pulmonary and cardiac plexuses. 
 
 * Vesalius (de hum. corp. fabr. lib. v. cap. 15), speaks of having found the ovaries 
 of hysterical women larger than a trap-ball, and filled with a yellow fluid. Riolan 
 (Anthropol., lib. ii. p. 55), asserts that he saw an ovary larger than the fist, in a female 
 affected with the same disease. Diemerbroeck (Anat.lib.de ventre inferiore, cap. 24), 
 also states that he found around the uterus of a person who died in a hysterical parox- 
 ysm, a tumour filled with a yellow liquid; finally, S. N. Binninger (Observ. et curat. 
 Med. Aut. ii., obs. 90). likewise speaks of having seen the ovaries and Fallopian 
 tubes of a woman who died with the same disease, enlarged and infarcted with a white 
 thickened tumour. Riverius (loc.cit. cent. i. obs. 60), found an ovary of a dark colour, 
 and of the size of a small egg; again, Morgagni (epist. 65, No. 21) met with two ova- 
 ries in a scirrhous condition, and M. Rullier (dissert inaug.) discovered that they 
 were tumefied in a girl who had perished in an attack of hysteria. 
 
520 
 
 HYSTERIA. 
 
 4. Some authors have fixed the origin of the affection which 
 engages our attention in the stomach and its neighbourhood, (Parcel, 
 Hunault, Pitcairn, Vogel); in the bowels and stomach, (Jean-Maria, 
 Hamilton); in the lungs and heart, (Hyghmore); in the abdominal 
 nervous system, and, especially, the- vena portas, (Stahl). 
 
 As most of these opinions rest upon mere hypotheses, errors and 
 isolated facts, or such as have been observed with preconceived 
 ideas, as, moreover, the physiological inductions which gave rise to 
 them, were not illuminated by the lamp of pathological anatomy, 
 we deem it proper to abstain from discussing their value, and to con- 
 tent ourselves with saying that if a more accurate knowledge of the 
 seat of the disease is ever to be attained, it can only be by more care- 
 ful analysis of the symptoms, and by seeking to discover which of 
 the organs receive the principal influence of the various pathogenic 
 causes. Nevertheless, we must add that most physicians of the 
 present day regard the uterus as the starting-point of the different 
 phenomena whose sum constitutes hysteria. Some practitioners, and 
 amongst them, M. Boisseau, suppose the disease to be the effect of a 
 simultaneous irritation of the uterus and encephalon. If it is allow- 
 able for us to put forth an opinion as to the probable sources of the 
 disease, founded upon the cases which have fallen under our own 
 observation, and which we have compared together, and with a great 
 number of others reported by different authors, we should say that 
 hysteria, properly so called, has its principal seat in the nervous sys- 
 tem of the uterine apparatus, and that it consists of a special and 
 sui generis mode of excitation and perversion of this system reacting 
 sympathetically upon the general nervous system ; we state farther, 
 that this peculiar excitation, this morbid modification of the uterine 
 innervation, may itself have for its origin, either a local irritation, 
 often inappreciable, or a sympathetic one, resulting from a moral 
 cause, or from the pathological condition of some organ or different 
 apparatus with which the uterus has bonds of union more or less 
 direct. 
 
 As the characters of hysteria are too numerous and variable to 
 allow of our giving a short and precise description of it, we shall 
 rest content with saying, that it consists of a lesion of the uterine 
 apparatus, giving rise to paroxysms devoid of fever, which are ma- 
 nifested less by local symptoms than by a sense of suffocation and 
 strangulation, followed by more or less complete loss of conscious- 
 ness, and accompanied by convulsive and spasmodic phenomena in 
 the orgahs of organic life, and the life of relation. 
 
 [It might, perhaps, have been deemed better to rest content with the ex- 
 position above given of the author’s views, as to the essential seats of the 
 hysteric malady ; the more particularly, as notwithstanding the respectable 
 opposition of many distinguished writers, I agree with him, that it is to be 
 sought for in lesions of the nervous apparatus of the uterine system. Yet, I beg 
 leave to say, that notwithstanding the existing and past dissidence of profes- 
 sional opinions on this point, it would, one should think, suffice for the con- 
 
HYSTERIA. 
 
 521 
 
 vincement of an unprejudiced mind, to examine even cursorily Dr. Tiede- 
 mann’s plates, in his Tabulae nervorum uteri humani; and the recently pub- 
 lished engravings of the same series of nerves, in Dr. Robert Lee’s work on 
 Midwifery. The vast complicity of the reproductive nerves with the entire of 
 the ganglionic system and the cerebro-spinal nerves therein displayed, would 
 seem sufficient to remove all doubt as to the disturbing power, which, when 
 modified by disease, that system could exert on the other members of the 
 ganglionic innervation, as well as on the brain-nerves, and those of the spinal 
 cord. It is scarcely to be deemed philosophical to look upon the working 
 of the organisms, as a mere concurrence of a given catalogue of organs in 
 carrying on the business of general life, by contributing each its part in the 
 grand scheme of the hasmatosis, the calorification, the innervation, the assi- 
 milation, and secretion merely, and without reference to the constitutional 
 influence that each member of the confederacy exerts on its co-members. It 
 is like looking at the results of the operations of a great commercial part- 
 nership, in which each partner does his part in the correspondence, the 
 buying and selling merely, when, in fact, each such partner exerts a power 
 to modify the activity of every other member of the concern, beyond and 
 besides his special routine of daily toil. Now, in a community of vital organ- 
 isms, the nature, whether physical or physiological of the substance called 
 liver , is so special, so peculiar, that throughout the whole range of the tissues, 
 there is no other substance at all like it — it has a peculiar power, a peculiar 
 metabolic or changing power, which it exercises for the conservation of 
 various other parts of the economy. The same holds good as to brain , 
 spleen, the stomach, the kidneys, &c. Each one enjoys not an inde- 
 pendent, but a special life, and therein possesses the power to modify and 
 control, to a certain extent, all other special lives ; and this, too, without rela- 
 tion to the mere secerning and circulating power it enjoys, but in a more 
 extended degree, by virtue of that special and peculiar life, since doubtless 
 the life even of every cytoblast is peculiar and special, and then a fortiori is 
 it so as to the organic products of the cytoblasts that compose all our phy- 
 sical frame. 
 
 But it cannot be disputed, that the organs exercise each a special influ- 
 ence on the blood, that pabulum of the life and common bond of the mem- 
 bers of it. The entire vascular system is lined with a membrane, called by 
 Bichat, the common membrane of the sanguiferous system. But that mem- 
 brane is by no means a unit. As the mucous membrane is not a unit, but 
 is different, as it serves in different places to line organs wholly unlike in 
 their nature and offices, so the common membrane of the blood-vessels is 
 everywhere different, as in the vessels of the brain, the liver, the stomach, 
 the reproductive organs, &c. 
 
 Let that membrane be regarded as constituting one single cavity or cyst, 
 the angeiotenic cyst, containing, as in a simple single sac, all the blood of the 
 subject, computed to amount to six hundred ounces. Let it, fur the argu- 
 
522 
 
 HYSTERIA. 
 
 ment sake, be conceded, that the blood in this cyst, as is the fact, is perpe- 
 tually changing its place of contact with the surface, so that the discs come 
 to be placed in succession, in contact with the interior surface of every 
 organ of the body ; brain, lungs, stomach, womb, &c. Can we reasonably 
 then doubt, that each one of these organs, so different in nature and power, 
 taking out from, and depositing in the sanguine mass the materials for its 
 accretion, and the detritus of its substance, can we doubt, I say, of the 
 powerful influence each one of them can exert on the constitution of the 
 blood ? Is it not true, that each organ can and does then modify the crasis 
 of the blood, influence the hsematosis, and thereby rule and domineer when 
 diseased, over the law of the life of the organisms, by this single power. 
 
 Yet this is not the sole power they can exert, and it is specified merely as 
 one single one, and to show that it is not impossible to trace the steps by 
 which diseased actions spread themselves abroad through the constitution. 
 
 There are other powers to disturb and to preserve beyond this one, and 
 even exceeding it. Such are the nervous relations and connections, which, 
 like the radii and circles of the spider’s web, awaken, when touched, the 
 sensibility of every limitrophic organ, of every fibre to which they are distri- 
 buted. Of these nervous influences, I have here no time to speak, nor is 
 it necessary for my purpose to do so; but I beg leave to ask the attention 
 of the reader, to the remarkable case related at page 83, as exhibiting an 
 instance of peculiar power in a system of tissues, even over the morbid 
 products of those textures themselves. In that case it is shown, that the 
 tissue of which the clitoris is composed, could preserve free from putridity, 
 and almost from decomposition, a quantity of blood, amounting, at least, to 
 more than twenty ounces, for fourteen or fifteen years, precisely in the same 
 manner as blood is often preserved for months and years, in the cavity of 
 the obturated womb and vagina, in cases of imperforate hymen, and other 
 atretism of the passages, as in the case I have related, also, at p. 102, of 
 this work. 
 
 Is there any other tissue, save the reproductive tissue, that possesses this 
 power ? Certainly aneurismal sacs do not possess it, and, so far as I know, 
 none others. 
 
 But there is another consideration that I desire to lay before the reader; 
 on which account I add, that the great reproductive force of all living beings, 
 going from the top of the scale down to the lowest infusory monas or vorti- 
 cella, is dependent on a reproductive tissue or substance, implanted some- 
 where within the constitution of the individual. That great force is one of 
 the first necessity in the world, and, existing as it does, it could only be set 
 in motion by an aphrodisiac or erotic sense and appetency. This it is, 
 that in all the tribes of beings, constantly provokes them to fulfil the great 
 ordinance to go forth, increase and multiply, and fill the whole earth. This is 
 binding, not only on the mammals, but even on the hermaphrodite annelides 
 and molluscs. This law is so general, so indispensable, that without its provi- 
 
HYSTERIA. 
 
 52 3 
 
 sions, the genera and the species would, without exception, in a few years 
 be annihilated, leaving the globe a vast desolation, and without a living wit- 
 ness to the glory and power of its Divine author. 
 
 It is true, then, that this great force exists, but it exists in the reproduc- 
 tive substance, in the ovaries and womb, and there alone in the female ; yet, 
 so influential and diffusive is it, that through the nerves, it irradiates every 
 part of the economy ; the senses, and the innermost recesses of the organisms 
 feel and obey its provocations on the eye, the lip, the tactile surface, and 
 even in the simple consciousness of presence and power, or in the imagina- 
 tion itself. The faintest perception of the erotic odour is sufficient to wake 
 it from the sleep of days or weeks, and an internal and pervading sense, 
 which is irradiated by the reproductive tissues, fills and influences the whole 
 community of the organisms. Is it not then a pervading vital force ? Is it 
 not a constitutional sense ? Is there any other one amongst the whole system 
 of organs that enjoys a power equally urgent, when it becomes excited by 
 disease; or when disordered by whatsoever cause, it becomes capable of 
 carrying confusion into every department where it may rave and rage in its 
 caprice or fury? Is there any serious difficulty, then, or want of ratiocination 
 in arriving at the conclusion, so much disputed, that disordered and modified 
 states of the reproductive structures may, and indeed do, excite all the won- 
 derful and mysterious phenomena, whether physical, physiological, or psy- 
 chological of the hysteric malady. — M.] 
 
 The causes of hysteria may be divided into predisposing and de- 
 termining. Though the former class is exposed to some objections, 
 it is generally admitted, that hereditary transmission mentioned by 
 Willis and Pomme, a feeble constitution, residence in large cities, 
 idleness, an effeminate moral and physical education, exquisite 
 nervous sensibility, ardent temperament, and erotic idiosyncrasy, 
 are causes which favour the development of the disease. It is pro- 
 per, also, to remark, that the affection is most common between the 
 epoch of puberty and the cessation of the menses; nevertheless, it has 
 sometimes been observed in young girls before menstruation, and in 
 women who have passed the critical age. Chambon relates, in his 
 Treatise upon the diseases of women, that one of his relations be- 
 came hysterical at the age of eighty-three years. We add, that 
 it more particularly attacks girls who are on the point of being 
 regulated, young widows, women who have had no children, those 
 who are approaching the critical period, and finally, those who are fat, 
 plethoric, and sanguine, and in whom the menstrual function is com- 
 monly painful and irregular. 
 
 The determining causes of hysteria are : the menstrual effort at 
 the epoch of puberty ; suppression of the menses,* or their difficult 
 
 * Suppression of the menstruse is often a precursory or coincident phenomenon, 
 and not the cause of hysteria; this is proved by the fact, that the disease has been 
 known to persist without the slightest amendment, in a great number of eases, even 
 after the periodical discharge has been successfully restored. We also remark, 
 that suppression of the lochia, which has been regarded as an occasional cause of 
 
524 
 
 HYSTERIA. 
 
 discharge ; uterine plethora ; forced continence ; abuse of coitus ; 
 masturbation, and all circumstances capable of producing, main- 
 taining, or increasing irritation of the uterus, and especially of the 
 ovaries. The disease may, also, have as determining causes, the in- 
 stinct of imitation,* the vivid emotions of the soul, such as transports 
 of anger, fright, violent and sudden disappointment, the uneasiness 
 produced by love, the reading of highly wrought works, erotic con- 
 versation, the sight of some ghastly and bloody spectacle, or of a 
 licentious scene ; the impression produced by a tragical representa- 
 tion, by sombre, mysterious, pathetic, or too animated music ; finally, 
 all the circumstances that produce violent movements in the eco- 
 nomy, or suddenly recall painful and lasting impressions. 
 
 Whatever be the causes of hysteria, women affected with, or pre- 
 disposed to the disease, generally exhibit all the signs of a very 
 excitable temperament ; their characters are commonly marked with 
 a shade of levity, frivolity, or remarkable obstinacy ; they are com- 
 monly capricious and irascible; their temper is uncertain and wa- 
 vering, and the most trivial circumstances make them pass from 
 immoderate joy, from the most noisy laughter, the most affection- 
 ate caresses, to melancholy mingled with sighs, tears, sobs, and the 
 bitterest reproaches ; finally, they experience, in the highest degree, 
 that state of anxiety, of indefinable melancholy and suffering, of 
 which eminently nervous persons complain. 
 
 The symptoms of hysteria are as variable as the causes which 
 produce them. An entire volume would not suffice, were it neces- 
 sary for us to describe and trace all their varieties as mentioned by 
 authors, for we should be in some sort compelled to describe nearly 
 every form of disease, and thus justify what was said by F. Hoff- 
 mann, when treating of hysteria : non est morbus unus , sed potius 
 morborum cohors. Is it not known, moreover, that the number and 
 variety of the symptoms, and various forms of the disorder, led to their 
 being compared by Sydenham, to the metamorphoses of Proteus, 
 and to the changing colours of the chameleon. We shall, therefore, 
 confine ourselves to a description of the phenomena which the disease 
 most frequently presents at its commencement, and during its pro- 
 gress. 
 
 Though the hysterical paroxysm sometimes attacks suddenly, and 
 without precursory signs, it is generally preceded for several minutes, 
 an hour or two, or even for days, by some derangement of the eco- 
 nomy, by feelings of malaise, depression and uneasiness ; to these 
 prodromic phenomena, are added frequent yawning, pandiculation, 
 
 hysteria, is itself nothing more than a symptom of a puerperal affection, complicated 
 with nervous symptoms. 
 
 * M. Andral relates in his course, the case of a young girl, who, at a boarding- 
 school, fell into a paroxysm of hysteria in the presence of her companions; soon 
 after, so large a number were attacked with the same disease, as to make it necessary 
 to close the school for a considerable period. Thouret and Bailly cite an analogous 
 case, which happened upon the occasion of a first communion at St.Ruch. A young 
 girl was attacked with an hysterical paroxysm, and the same accident soon happened 
 to several young persons who were witnesses of it. It is probable that these attacks 
 were the result of a cerebral spasm, of which we shall soon speak, and not of true 
 hysteria, which scarcely ever appears before the age of puberty. 
 
HYSTERIA. 
 
 525 
 
 flashes of heat, redness of the face, paleness and coldness of the ex- 
 tremities, palpitations, numbness and cramps of the limbs, intense 
 cephalalgia, a state of moroseness, and sadness accompanied by tears, 
 and sighs which alternate in certain cases, with immoderate and 
 causeless laughter. * 
 
 At the commencement of the paroxysm, the patients feel a sensa- 
 tion of obscure tension and spasmodic constriction, analogous to that 
 produced by the movement of some globular body, which, after 
 having performed various circumvolutions in the cavity of the abdo- 
 men, ascends chiefly on the left side, towards the stomach and thorax, 
 and following the course of the oesophagus, produces a sense of 
 tightening in the throat, which, in very severe cases, occasions dread 
 of suffocation. 
 
 This sort of mysterious ball, which mounts, by an oscillating 
 movement, from the hypogastrium to the throat, gives rise to a feeling 
 of weight in passing through the epigastric region, and to painful 
 constriction and fatiguing palpitations at the praecordia. When the 
 paroxysm is a mild one, slight convulsions, and not unfrequently 
 impaired hearing, and a momentary feebleness of the intellectual 
 faculties, are observed. When, on the other hand, it is more violent, 
 partial, or even complete attacks of syncope occur, which last but a 
 few moments, after which the paroxysm sometimes ceases. In some 
 cases, convulsive movements of the muscles of the limbs and trunk 
 appear, which are generally so violent as to make it difficult for 
 several persons to hold the most delicate woman, who, in spite of the 
 efforts of the assistants, struggles, rolls and twists herself upon her 
 bed* When not pevented, they meet with terrible falls, strike 
 themselves upon the breast, tear out their hair, and forcibly thrust 
 aside any object they encounter. The body, which is stiffened, 
 bends forwards, backwards, to the right and left, just as in epilepsy. 
 The jaws are shut, and the eyelids, which almost always cover the 
 whole globe of the eye, during the attack, are contracted and agitated 
 with rapid and continual tremors. The nostrils are wide open, but 
 the cheeks and other portions of the face commonly experience no 
 other movements than those in co-ordination with the cries and 
 forced respiration of the patients. 
 
 While the attack lasts, the head is almost always carried back- 
 wards; the anterior part of the neck is the seat of a tension, which 
 causes the woman to apply the hand frequently against the region of 
 the larynx, which she presses and scratches as though she wished to 
 remove some obstacle. If the patient is thin and of feeble constitution, 
 the cheeks, the lips and the alse nasi are pale and cold: in some cases, 
 especially where the female is fat and plethoric, the face is florid, 
 warm and red, particularly on the cheek bones. The abdomen and 
 thorax are distended or contracted in a permanent or alternate man- 
 ner, and the edge of the false ribs is commonly the seat of a painful 
 constriction, which depends upon contraction of the diaphragm. 
 Some patients retain their consciousness and intellectual faculties 
 throughout the paroxysm ; others, on the contrary, lose them only 
 for a few moments ; whilst, in some, their functions are suspended 
 
526 
 
 HYSTERIA. 
 
 until the attack is completely over. Different parts of the body are 
 often the seats of very acute pain. Some women say that it seems 
 to them as though the head were squeezed in a vice or broken by 
 the blows of a hammer ; others complain of violent epigastric pain, 
 and of terrible cramps and anguish about the region of the heart. 
 
 Though it most frequently happens that the action of the senses 
 and of the intelligence is momentarily enfeebled or even suspended, 
 it nevertheless happens, in some cases, that the sensitive faculties are 
 extremely developed ; indeed, hysterical women have been observed, 
 in whom the senses of smell, touch, sight and hearing were more 
 delicate during the attack than in a state of health, and who hear all 
 that is said, even in a low tone, and see all that passes about them. 
 Amongst such, are some who answer questions addressed to them ; 
 others, on the contrary, cannot speak, but indicate, with the hand, 
 what they suffer, and after the paroxysm, describe all that they have 
 heard, seen and felt, without omission of the slightest circumstance. 
 Often, after these various symptoms, a period of quiet occurs, which 
 leads to the belief that the paroxysm has reached its termination. If 
 we interrogate the patient on this point, she answers, without ever 
 scarcely deceiving herself, that it is or is not terminated. In fact, 
 so long as the patient fails to assert that the paroxysm has passed, 
 the symptoms generally reappear: it is rare that women deceive 
 themselves, even in their first attack ; and, d fortiori , when they 
 have already had several. We will add, that in the most marked 
 cases, the patients, from the opening of the attack, utter piercing, 
 rapid cries, which have something peculiar in them, and which leads 
 us at once to recognize the disease, if we have already had occasion 
 to observe it. 
 
 After each violent fit, there is commonly an emission of inodorous 
 gas from the mouth, preceded by noisy borborygmi, and accompanied 
 by vomiting. The respiration is high, frequent, laborious and inter- 
 rupted, and sometimes seems to cease, even. The pulsations of the 
 heart are generally tumultuous, hurried and painful. The state 
 of the pulse is very variable ; it is small, contracted, frequent, irregu- 
 lar, and, in some cases, effaced by the convulsive movements of the 
 muscles and the subsultus of the tendons. We ought, however, to 
 remark, that the arterial pulsations differ according to the region of 
 the body ; for even when the pulse presents the different modifica- 
 cations we have just mentioned, the carotids beat with vehemence, 
 and the jugular veins are felt to be very much enlarged. The patient 
 often feels an acute and poignant pain in a fixed and circumscribed 
 portion of the head, which authors have designated under the title 
 of clavus hystericus. In some, expectoration is frequent, and some- 
 times the saliva is even slightly frothy, but without froth in the 
 mouth. These different phenomena are accompanied by noise in the 
 ears, by vertigo, confusion, the sensation of dazzling and sparks, 
 which float before the eyes, or a kind of thick mist, which impairs 
 and sometimes entirely obscures vision. Most of the patients utter 
 frightful cries and howls, which can be compared only to those of the 
 wolf j they abandon themselves also to immoderate laughter, alter- 
 
HYSTERIA. 
 
 527 
 
 nating with sobs and tears. These last symptoms, which are often 
 the precursors of an attack, also show that the fit is approaching its 
 termination. We ought to add that, while in the greater number of 
 cases, the patient continues panting, and agitated at the slightest noise 
 or shock, during the remission of the symptoms, it sometimes hap- 
 pens that she remains immovable, as though in a kind of ecstacy or 
 somnambulism. 
 
 When the hysteric paroxysm has passed through all its periods, 
 the patient regains the use of her intellectual and sensitive faculties; 
 she opens her eyes, and utters deep sighs and plaintive moans ; the 
 action of the different functions is re-established little by little ; the 
 pulse becomes soft, undulating and regular ; the respiration assumes 
 its normal rhythm; a gentle warmth and moisture appear upon the 
 surface; the neck of the womb, the vagina and vulva, which were 
 dry and spasmodically contracted during the paroxysm, then become 
 more dilatable and are lubricated by an abundant secretion: finally, 
 after the paroxysm, which commonly terminates by involuntary 
 tears, by sardonic laughter, by eructations, and sometimes by press- 
 ing desire to expel the urine, which is abundant and limpid, there 
 remains nothing but a sensation of fatigue in the limbs, and a sort of 
 general lassitude and despondency. 
 
 As each of the morbid phenomena we have just described, may 
 be either very mild or very severe at different periods, whether 
 in the same patient, or in different persons, we regarded it as useless 
 to divide, as has generally been done up to the present time, the 
 progress of the symptoms into different stages, which, not being 
 precise, would render any limitations we might assign to each degree 
 of the hysterical attack arbitrary and inexact. We must inform our 
 readers, also, that we deem it best to dispense with treating, at 
 present, of two other forms of spasmodic disorder, which we shall 
 speak of hereafter, as we desired to separate them altogether from 
 hysteria, with which they are often associated, but from which they 
 differ in several essential characters. From careful study, and ana- 
 lysis of the symptoms at the bed-side of the patient, we have been 
 led to conclude, that the spasmodic affections to which we refer, and 
 which, like hysteria, are not confined exclusively to the female , 
 though by far the most frequenrin them, emanate from two primary 
 sources, to wit : the encephalon, and the stomach and upper part of 
 the intestines. In order to establish a more rational system for the 
 application of remedial agents, and still more to introduce more 
 correct language, and avoid confusion of ideas, we designate these 
 lesions, which have been improperly considered as varieties of hys- 
 teria, by terms which suggest at the same time their nature, and the 
 viscera which we suppose to be primarily affected : they are cere- 
 hrospasm and gastrospasn\ , which we shall treat of after concluding 
 our remarks upon hysteria, properly so called, or metrospasm. 
 
 The symptoms of hysteria, as we have just said, do not always 
 present the same degree of intensity. Sometimes the attacks are very 
 slight, and limited to constriction of the throat and spasmodic visceral 
 movements, without the convulsions and other secondary symptoms 
 
52S 
 
 HYSTERIA. 
 
 which alarm the attendants. It even happens, in some cases, that cer- 
 tain characteristic signs do not appear, while in others very unusual 
 phenomena may be observed, such as a desire to bite, hydrophobia, 
 frequent hiccough, etc. The duration of the paroxysms, also, is very 
 irregular; they vary from a few moments to one or two hours, or 
 even days. The epoch of the attacks, also, is almost always uncer- 
 tain ; nevertheless, they have been observed, in certain cases, to recur 
 in a periodical or intermittent manner. Their number, likewise, 
 is very variable ; while some persons are subject to them every 
 week only, or every month or two, others, again, have them once, 
 or even several times a day ; we ought to state, moreover, that the 
 attacks diminish in violence and frequency with the progress of age. 
 During the interval between the paroxysm, the health seems to be 
 perfect ; some patients, not only preserve their embonpoint, but even 
 become fatter and fresher. In the greater number of cases, however, 
 hysterical women feel a sort of painful tension about the pelvic 
 cavity, and wear upon their features a dejected expression, which is 
 augmented by a constant leucorrhoea. 
 
 The termination of hysteria is preceded by a progressive dimi- 
 nution in the number and violence of the attacks, but we cannot rely 
 upon the entire disappearance of the disease, until the patient has 
 been well for several years. If we fail to remove the predisposing 
 and occasional causes, and especially if the hygienic and pharma- 
 ceutical treatment be badly directed, the disease continues to ad- 
 vance ; it becomes rebellious to all curative means that may be 
 opposed to it, and may be indefinitely prolonged, unless it degene- 
 rates into different lesions, which, by their progress, shorten the term 
 of life. The principal diseases which may follow or complicate 
 hysteria are : hypochondriasis, epilepsy, chronic metritis, amenor- 
 rhoea, nymphomania, and all the organic lesions of the uterus and 
 ovaries. It is in cases of this kind only, that the disorder proves fatal.* 
 We may add, that it has sometimes ceased spontaneously after a 
 single attack, and at other times after many. It has been known to ter- 
 minate by sweating, by profuse leucorrhcea, by diarrhoea, and finally 
 by the appearance of furunculi, and various cutaneous eruptions. 
 According to Georget, the cessation of the paroxysms has been 
 known to follow a sudden fright. 
 
 When the attacks are of long duration, and especially when the 
 patients remain for a long period immovable, it so much resembles, 
 in certain cases, the appearances of death, that the most unfortunate 
 mistakes! have resulted from it. In order to avoid so unhappy an 
 
 * In his Inaugural Thesis, (Paris, 1808,) Rullier details the interesting case of a 
 young girl, who died from an hysterical affection, occurring after a violent frightdur- 
 ing the menstrual period. As this disease presented, in conjunction with the hyste- 
 rical symptoms, different phenomena which might be referred to hydrophobia, such 
 as horror of fluids, inability to swallow drinks, violent pain in the throat, desire to 
 bite, perfect integrity of the intelligence, etc., it cannot be affirmed whether it was 
 really due to an uterine spasm or not. 
 
 -f- The Journal des Savants for the year 1745, reports the case of Lady Russel, whose 
 body remained for eight days without giving the slightest appearance of life, or the 
 least sign of alteration. This person, who lived a long time alter, was aroused by 
 
HYSTERIA. 
 
 529 
 
 error, we should follow, not only the wise counsel of Klein ; pro 
 mortuis habit x ante diem tertiam terrx non sunt mandandx ; but 
 likewise forbid the inhumation of hysterical women in a state of 
 apparent death, until the commencement of decomposition shall have 
 afforded a certainty that a return to life is impossible. 
 
 The diagnosis of hysteria is not generally difficult, though it has 
 been mistaken for epilepsy, hypochondriasis, syncope, catalepsy and 
 apoplexy. Several authors, amongst others, Ch. Lepois, Hyghmore, 
 Boerhaave, Sydenham, Sylvius, Van-Swieten, Whytt, Lorry, Tissot, 
 Pomme and Alberti, confound hysteria with hypochondriasis, and 
 consider them to be identical diseases. Physicians of the present day 
 commonly agree in considering the two affections as entirely differ- 
 ent indeed, the two diseases possess characters so distinctive as to 
 make it impossible to confound them. Hypochondriasis rarely occurs 
 before an advanced age, and almost exclusively in men, while hyste- 
 ria often shows itself even before the epoch of puberty, and never 
 affects others than women. The latter disease always commences 
 by paroxysms which, to a considerable extent, derange nearly the 
 whole economy, whose functions are again executed as in a state of 
 health, as soon as the attack is over; in hypochondriasis, the invasion 
 is slow and gradual, and the chief characters of the disease are to be 
 found in the induction of derangements of the digestive functions, in 
 its being continuous, or presenting only slight remissions, and finally 
 in its giving an unsound direction to the ideas. Moreover, in the last- 
 named affection, we do not find the spasmodic and convulsive con- 
 tractions, and especially the weeping, laughter, sighing; the expulsion 
 of inodorous gases, or the eructations which precede the close of the 
 paroxysms in hysterical patients. Besides, after death in persons 
 who have perished from hysteria, we rarely meet, as in hypochon- 
 driasis, with extensive visceral alterations, especially of the stomach, 
 intestines, liver, and spleen. 
 
 the sound of the bells of a neigbouring church, whilst her husband, who vehemently 
 opposed her inhumation, was holding her hand and bathing it with his tears. Joseph 
 Raulin, ( Traite des affect, vapor. 1758,) speaks of an hysterical girl, whose funeral he 
 postponed, because her colour had not entirely changed. The author adds, that in 
 the course of a few hours the supposed corpse recovered her consciousness. A. Pare, 
 (liv. xiv. p. 992, chap. 54,) says, that a celebrated anatomist, “ lequel estant pour lors 
 resident en Espagne, fut mande pour ouvrir une femme de maison, qu’on estimait 
 estre morte par une suffocation de matrice. Le deuxieme coup de rasoir qu’il donna, 
 commen§a la dite femme d se monvoir et demontrer qu’elle vivait encore.” This 
 mistake, which was made in 1564, by Vesalius, who was invited to the court of Spain 
 by Charles the Fifth, gave rise to a criminal proceeding against that illustrious ana- 
 tomist, who was condemned by the Holy Inquisition, to an ignominious punishment, 
 which the king, Philip II., commuted to a pilgrimage to the Holy Land. We ought 
 to say, that those conditions of protracted apparent death, of which Aretaeus, Aetius, 
 Diogenes Laertius, Pliny, the naturalist, J. M. Lancisi, etc., cite examples, are ex- 
 tremely rare, particularly after attacks of hysteria. 
 
 * M. Dubois, of Amiens, of all authors, whether ancient or modern, is the one who 
 has best pointed out the differences, and distinctive characters of hysteria and hypo- 
 chondriasis. The labours of this young and able physician, which have been 
 crowned by the Royal Society of Medicine of Bordeaux, deserve this honourable dis- 
 tinction on every account, from the judicious criticism, the philosophical arguments, 
 and the vast erudition which they display. The work of M. Dubois, is entitled : 
 Histoire philosophique de l' hypochondrie et de I'hysterie , 1837. 
 
 34 
 
530 
 
 HYSTERIA. 
 
 Epilepsy differs from hysteria in several strongly-marked particu- 
 lars. In epilepsy there are sudden loss of consciousness and complete 
 suppression of the action of the senses; the face is always of a deep 
 red, violet or livid colour ; the saliva escapes from the mouth and 
 forms froth upon the lips. The pulse is strong and accelerated, the 
 respiration accompanied by loud and jerking rhonchus : the eyes are 
 turned upwards, convulsed, deadened and protruding; the pupils 
 dilated, and the lips hideously swollen ; finally, the aura epileptica 
 seems to arise in some point or other of the body, generally in one 
 of the fingers or toes, and simultaneously with these symptoms, 
 which are absent in hysteria, occur convulsive movements, ordina- 
 rily more violent upon one side than the other, and chiefly affect- 
 ing the muscles of the trunk and face. Besides, in epilepsy, we 
 never observe the sighs, cries, sobs, tears, explosions of laughter, 
 the sensations of strangling, and the globus commencing in the hy- 
 pogastrium, as we do in hysteria. These distinctive characters were 
 pointed out long since. Celsus (lib. iv. cap. xx.,) traced them in a 
 concise and exact manner, when he said, “ neque oculi vertuntur, 
 nec spumse projluant, nec nervi distenduntur , sopor tanturn est.” 
 Cselius Aurelianus, who was the cotemporary nearly of Galen, in 
 speaking of the differences between epilepsy and hysteria, thus ex- 
 presses himself: “ Frequenter simile pati epilepticis et d matricis 
 prsefocatx mulieres inveniuntur ; siquidem non aliter sensibus 
 privantur , sed discernantur quod in ultima accessionis parte per 
 os atque nares spurn arum Jluore non afficiantur .” (De morb. 
 acut., lib 2.) 
 
 Syncope differs from' hysteria in the complete cessation of the pul- 
 sations of the heart and arteries ; in the paleness of the face ; the icy 
 coldness of the extremities; the absence of convulsive movements, 
 and the short duration of the attack, which, if prolonged, would 
 produce inevitable death. 
 
 Apoplexy may be distinguished from uterine spasm, by the para- 
 lysis of one half of the body, or of a limb ; by that of the tongue ; 
 by the distortion of the mouth ; by the remarkable fulness of the 
 pulse and great difficulty of respiration, accompanied by a kind of 
 snoring. These different phenomena are not met with in hysteria. 
 
 Finally, in catalepsy , the eyes are open and fixed, the limbs 
 are stiffened and immovable, and retain the position they were in at 
 the moment of the attack. If the paroxysm, however, is not a severe 
 one, the limbs may be flexed or extended, but even then retain the 
 attitude which is given to them. 
 
 It sometimes happens that females have some motive that leads 
 them to simulate hysterical paroxysms, either to induce the belief 
 that they have been maltreated, to obtain the consent of their parents 
 to a union which they desire, or to protract their stay in a hospital, or 
 to obtain assistance from the attendants, etc. Should we suspect them 
 of malingering, we may avoid being duped by the trick, by inform- 
 ing ourselves first of the persons around the patient, whether she has 
 any motive for feigning disease ; we should then study the symptoms 
 attentively, and during both the paroxysms and the intervals, ques- 
 
HYSTERIA. 
 
 531 
 
 tion the woman, in order to discover whether she does not experience 
 some phenomena incompatible with those she presents, and which 
 are essential to the nature of the disease. We should endeavour to 
 make her contradict herself; finally, we almost always feel certain 
 that the attacks are simulated, if the patient refuse to submit to treat- 
 ment, because really hysterical persons are generally importunate 
 for the prescription of remedies fit to remove their disorder. It is 
 proper to remark, also, that we should avoid, with the greatest care, 
 showing the slightest doubt as to the reality of the disease ; for, in 
 case it truly exists, not only is the patient exceedingly affected by 
 the doubts she is allowed to perceive, but her condition is almost 
 always aggravated thereby. 
 
 The prognosis of hysteria depends upon an infinitude of circum- 
 stances ; yet, it is not usually regarded as dangerous, and persons 
 are astonished to see the most frightful symptoms, and a species of 
 agony, so to speak, give place in a few moments to perfect calm, and 
 all the signs of health. Indeed, the disorder is more alarming than 
 dangerous ; wherefore, Sennertus ( Prax . Med., lib. iv., 1632,) says, in 
 speaking of hysteria : “ Malum quidem plerumque feminis lethale 
 non est ; ” nevertheless, he adds, “ aliquando tamen , superveniente 
 syncope , aut gravibus convulsionibus aut calore nativo extincto , 
 segrss £ vi/a tolluntur The same prognosis was made by Riviere, 
 who followed Sennertus, step by step, and often copied without citing 
 him; this author thus expresses himself in his treatise, [Prax. Med., 
 lib. xv., cap. 6, 1640) : Raro hie affect us inter ficit segrot antes. In 
 his dissertation, ( De malo hysterico,) Frederick Hoffmann, like the 
 authors we have just cited, has presented a not very unfavourable 
 prognosis, when he said : “ Vera passio hysterica, ut valde dira et 
 terribilis videatur, in se non adeo periculosa sit.” When the dis- 
 ease is recent, especially if the person be young and not very irrita- 
 ble, if the determining cause be a transitory one, or if it is capable 
 of being removed; or finally, if the attacks take place at some distance 
 of time from each other, and are of short duration, and if all the 
 functions are properly executed during the intervals, it is almost cer- 
 tain that an entire cessation of the attacks will take place before long. 
 On the contrary, where the female is aged, and of feeble and very 
 irritable constitution; where the attacks are frequent, of long duration, 
 and accompanied by violent symptoms, the treatment will be long, 
 and the cure doubtful ; though we ought not to despair of effecting 
 it. The prognosis is likewise rather unfavourable when the hysteria 
 is complicated with epileptic symptoms, which have the additional 
 inconvenience of frequently obscuring the diagnosis. Should the 
 disease seem to be connected with some chronic irritation, or organic 
 alteration of the uterus and ovaries, the affection, which would then 
 be secondary, would require a prognosis relative to that of the pri- 
 mary disease. Nevertheless, in certain cases where hysteria seemed 
 to depend upon amenorrhoea, or some derangement of the menstruse, 
 the hysterical symptoms have been known to continue with the same 
 violence, even after the menstrual flux has been re-established and 
 regulated. The same has been observed in regard to suppression of 
 
532 
 
 HYSTERIA. 
 
 the lochia, which, like that of the menstruae, is perhaps as often the 
 consequence as the cause of the affection that forms the subject of this 
 chapter. The slight, and nearly permanent spasmodic state, desig- 
 nated by M. Louyer-Villermay, hystericism , and which commences 
 chiefly by a peculiar sensation of constriction in the throat, and a sort 
 of general malaise experienced by some women whose menstruation 
 is difficult, or who are affected with an uterine lesion, constitutes a 
 secondary phenomenon not deserving of our attention, except as 
 being a pathognomonic sign. It suffices to say, that the spasm con- 
 fined to the uterus alone, is commonly of short duration, and seldom 
 appears except during the flow of the menses, or a few days before 
 their appearance. 
 
 The treatment of hysteria presents two fundamental indications : 
 una in paroxismos , altera extra paroxismum , say Sennertus and 
 Riviere. The first indication consists in acting during the attack so 
 as to diminish, as far as possible, its force and duration ; the second, 
 in preventing during the interval a renewal of the attack by combat- 
 ing the disease itself, that is to say, by seeking to destroy the action 
 of its causes, effects, and complications. 
 
 In treating the paroxysms, and with a view to shorten their dura- 
 tion, we must, above all, observe the precaution of taking off the 
 clothes and removing every thing binding, as, for example, corsets, 
 girdles, garters and collars, which embarrass both the respiration and 
 circulation, and obstruct the motions of the neck and thoracic and 
 abdominal cavities. We should then make the patient lie down on a 
 bed or large couch, taking care to arrange her with the head higher 
 than the trunk and inferior extremities, and to confine her so that she 
 may not strike her head, wound herself in any way, tear her hair, bite 
 herself, or be exposed to falling. When the attack is violent, it will 
 require at least four persons to hold her limbs, whose movements 
 should be followed without being entirely prevented, for the more 
 closely the patients are confined, the more exhausted and fatigued 
 are they when the attack is over. In hospitals a straight jacket is 
 used, which alone suffices to secure the patient; but we ought to 
 observe that this apparatus seems to have something in it humiliating 
 to them, and affects them painfully and unfavourably. During the 
 attack visitors should be excluded, leaving those persons only in the 
 room whose aid and presence are indispensable: it is also very im- 
 portant to avoid making remarks aloud upon the state of the patient, 
 as this may irritate or alarm her ; for, very often, in the strongest 
 paroxysm, she does not entirely lose the use of her senses, but hears 
 perfectly all that is said around her. 
 
 To abate the violence of the attack and shorten its duration, the 
 patient should be freely exposed to the air, and made to respire 
 strong and penetrating odours, as ether, acetic acid, liquid ammonia 
 or the heated vapours disengaged from quills, horn, old leather or 
 wool thrown upon burning coals. We have employed, with some 
 advantage, fomentations or lotions of a mixture of eight parts of water 
 to one of Cologne-water or vinegar, applied to the temples and fore- 
 head. Small enemata of cold water, especially with the addition of 
 
HYSTERIA. 
 
 533 
 
 three grains of camphor and eight or ten of assafoetida suspended in 
 the yolk of an egg, and from fifteen to twenty drops of Sydenham’s 
 laudanum, have always appeared to us to produce good effects, 
 especially where the attack is mild and the spasm in some sort concen- 
 trated upon the organs contained within the pelvis. A means which 
 often serves to arrest an attack, consists, when we can separate the 
 jaws, in the introduction into the mouth of a tablespoonful of very 
 cold water, to which has been added two or three drops of ammonia. 
 We have also used with good effect, the following potion : R — distilled 
 water of balm, three ounces ; orange-flower water, one ounce ; syrup 
 of valerian and poppy-heads, each, one ounce ; tincture of musk and 
 castor, each, twenty drops ; sulphuric ether, fifteen drops. Mix and 
 give at first two tablespoonfuls at once, and then one every hour. 
 
 In -very violent attacks, it is well to employ dry or stimulating 
 frictions of the whole body, and particularly of the limbs and verte- 
 bral column ; the last may be made of camphorated alcohol, or still 
 better of the following liniment : R. olive-oil, two ounces ; camphora- 
 ted alcohol and spirits of turpentine, each one ounce ; liquid ammonia 
 and Sydenham’s laudanum, each one drachm. To the employment of 
 these measures may be added dry cups, and especially flaxseed poul- 
 tices sprinkled with mustard, and applied to the hypogastric region, 
 to the thighs, and even to the arms. Should the symptoms be very 
 intense, pure mustard, and even Gondret’s ointment may be used.* 
 Though several authors speak of having seen hysterical paroxysms 
 quelled by bleeding, we think that it ought not to be resorted to except 
 when the female is either plethoric or irregular in her menstruae, or 
 when she is threatened with congestion of some important organ ; for 
 we have known it to increase the intensity and frequency of the at- 
 tacks ; should the latter return at certain hours, and be preceded by 
 premonitory signs, we should endeavour to prevent their return by 
 the use of some of the means just mentioned, and especially by irri- 
 tating pediluvia and the application of sinapisms to the thighs. 
 
 Amongst the great number of remedies that have been brought for- 
 ward for the purpose of arresting hysterical paroxysms, we may cite 
 narcotic injections! and antispasmodic suppositories introduced into 
 the vagina; aromatic or fetid fumigations of the genital parts; a 
 sudden jet of cold water upon the face ; and also, for the purpose of 
 suddenly arresting the fit, by a violent shock, some have made use 
 of reproaches, or of threats, and of the most indecent manoeuvres. 
 The precept of the father of medicine : Nubat ilia et morbxnn ejfa- 
 giet , has led to the proposal of consummating the venereal act during 
 an attack of hysteria ; Duret {In enarrat. ad , etc., cap. 59), speaking 
 of a husband, thus expresses himself: Jussi ut rem cum uxore sua 
 haberet : rem habuit , indlque statim convaluit. iEtius, also, 
 
 * Made by mixing together an ounce of suet and lard; and two ounces of liquid 
 am mon i a. — Trans. 
 
 f Bichat successfully treated three hysterical girls by means of injections which he 
 caused to be retained in the vagina, and to which he added from one hundred to one 
 hundred and fifty drops of laudanum. 
 
534 
 
 HYSTERIA. 
 
 tells us of a practice which was employed with the same view by 
 certain matrons : (s Excrelo multo crasso viscosoque semine ex digi- 
 torum contrectatione” etc. A Pare says in his unaffected style (lib. 
 
 24, chap. 55,) “A plusieurs d’icelles il s’evacne dehors une 
 
 grosse sentence principal ement cl celles d qui les matrones titil- 
 
 lent le col de leur rnatrice Finally, Jerome Capivaci (Med. pr act. 
 lib. iv. Be morh. mulier,) dares to give still more extraordinary and 
 indecent advice ; this idea, destructive of both morals and health, 
 ought always to be rejected with horror, notwithstanding the opinion 
 of Sauvages, who speaks of a woman in whom “clitoridis titillatio 
 a barhi-tonsore impudico instituta paroxysmum solvebat .” To 
 prove the falsity of the doctrines upon which the immoral practices 
 we have just mentioned repose, it is sufficient to state that there are 
 at least as many hysterical persons in houses of prostitution as in 
 convents, and that married women are more exposed than virgins, 
 to uterine spasm. Far from calming the attack, coitus, which is the 
 most direct excitant of the uterine system, could, in general, only in- 
 crease its violence. 
 
 Though the treatment of hysteria during the paroxysm may be 
 almost purely empirical, that which we ought to employ during the 
 intervals, that is to say, the radical treatment cannot be successful 
 unless it assume as its first principle the removal of the cause of the 
 disease, nor unless it is based upon the nature of that same cause. 
 Thus, if the hysteria co-exist with amenorrhoea, we must endeavour 
 to restore the menses by the means pointed out in the chapter de- 
 voted to menstrual suppression : if, on the contrary, the attacks occur 
 at the moment of the periodical discharge, we must try to prevent 
 them by the use of baths, by emollient drinks, by antispasmodic and 
 narcotic enemata, and by small revulsive bleedings between each 
 menstrual epoch. The same plan should be followed, if the uterine 
 spasm coincide with engorgement of the neck, the state of which 
 ought always to be ascertained (at least in women who have had 
 sexual intercourse), before commencing the curative treatment. 
 
 For the purpose of combating the spasm itself and preventing the 
 return of the paroxysms, recourse has been had to a great variety of 
 therapeutical agents, principally antispasmodies, narcotics, tonics, 
 antiphlogistics and revellents. The antispasmodies which have been 
 most frequently employed with advantage, especially in very irritable 
 persons, and those of exquisite sensibility, are : the distilled waters of 
 balm, mint, cherry-laurel, orange-flowers, linden-flowers, and peony: 
 infusions of valerian, mug wort and chamomile ; musk, castor and 
 assafoetida, in tincture or substance ; amber, camphor, myrrh, frank- 
 incense, gum ammoniac, spiritus mindereri, carbonate and muriate of 
 ammonia, Dippel’s animal oil, the ethers, syrup of ether, Hoffman’s 
 anodyne, and finally, the oxides of zinc and bismuth, and the car- 
 bonate of potash ; these different remedies, which are administered 
 either in draughts, in the form of enema, in pills, or by friction, are 
 often usefully combined with the preparations of opium, cicuta, 
 hyoscyamus, aconite and lactuca virosa ; we ought to remark further 
 
HYSTERIA. 
 
 535 
 
 that narcotics* prescribed alone, and the medicinal prussic acid even, 
 in the dose of one or two drops daily in an ounce of water, have 
 sometimes produced favourable results. 
 
 Where the patient is of a broken constitution, thin, feeble and 
 cachectic ; when she is badly regulated ; if she has lost much blood, 
 or if she inhabits a low, damp, badly ventilated and marshy situa- 
 tion, great advantages may often be obtained from the employment 
 of tonics; such as the preparations of iron; cinchona; rhubarb; 
 gentian; and infusions of the lesser centaury and Virginia snakeroot. 
 If, on the contrary, the patient were strong, plethoric, very fat, and 
 especially if she were at the same time affected with amenorrhoea or 
 dysmenorrhoea, we should resort to general bleeding, to scarified cups, 
 and to applications of leeches to the thighs, which at the same time 
 act as derivatives. General baths ; vapour baths ; hip-baths ; pedi- 
 luvia ; emollient and sedative drinks ; broth made of veal, chicken 
 or frogs ; whey ; milk diet ; poultices to the hypogastrium ; enemata 
 and injections of olive oil, regarded as specifics by Pomme and Pres- 
 savin ; and, finally, all the means capable of producing general and 
 local relaxation, are proper in cases where hysteria seems to depend 
 upon a state of plethora. 
 
 Revellents are indicated chiefly in women of lymphatic or lym- 
 phatico-nervous temperament, and sometimes in those who are ple- 
 thoric; but they should never be resorted to in cases of the last 
 kind before having first employed one or more bleedings. These 
 various means, which comprise cutaneous irritants; sulphurous dou- 
 ches, and baths of the same kind; ammoniacal, alcoholic, aromatic 
 and dry frictions; sinapisms; blisters; setons; issues; moxas; the 
 cauterizations transcurrent es upon the abdomen, successfully em- 
 ployed by M. Lisfranc; and, finally, all agents used with the view 
 of displacing the morbid action of the organs primarily disordered, 
 are likewise suitable when hysteria has followed an herpetic, arthritic 
 or rheumatic affection. It is for the purpose, also, of producing a 
 revulsive effect, or to remedy some gastric derangement or habi- 
 tual constipation, that purgatives and emetics have sometimes been 
 advantageously employed. Should the disease seem to depend 
 upon a state of torpor of the genital organs, marriage may be recom- 
 mended ; while, if the hysterical attacks were dependent upon im- 
 proper excitation of the genital organs, no hope of cure can be enter- 
 tained unless the manners are reformed and more or less absolute 
 continence enjoined. 
 
 The curative means we have just mentioned generally require to 
 be employed with the greatest circumspection, because as the dis- 
 ease is usually of long duration, their abusive and protracted use 
 could not be borne by the patients. It is proper to remark, also, that 
 the action of the therapeutical agents cannot be followed by good 
 
 * We observe in the 11th vol. of the Revue Medicate, p. 31 1, that Doctor Ch. Coindet 
 did not hesitate to inject a preparation of opium into the veins, in a case of hysteria 
 assuming the form of tetanus. The momentary success which followed the employ- 
 ment of this rash measure, did not last, for the disease reappeared at the end of six 
 weeks. 
 
536 
 
 HYSTERIA. 
 
 results, unless aided by dietetic and moral means. The regimen must 
 be modified according to the constitution of the patient. Thus, for 
 strong and plethoric persons should be prescribed a diet consisting of 
 thin soups, milk, herbaceous vegetables, a moderate use of ripe or 
 well-cooked fruits, and some of the white meats ; those, on the contrary, 
 in whom feebleness and languor keep up extreme sensibility of the 
 organs, should be subjected to a restorative diet; to the use of nutritive 
 aliment, and especially of the white meats which are of easy digestion. 
 Finally, a residence in some healthy situation ; a pure and temperate 
 air; walks in the country in the morning and evening during the fine 
 season^ travelling ; river, and especially sea-bathing ; agreeable occu- 
 pations ; domestic cares ; useful and amusing reading ; bodily exer- 
 cises ; riding on horseback ; means for employing the mind, and select 
 society ; such are the moral and hygienic means capable of efficaci- 
 ously assisting the other therapeutical agents, and even of preventing 
 the development of hysteria in persons showing a predisposition to 
 contract the disease. We conclude by stating that those who desire 
 to examine more thoroughly the nature, seat, literary history, etio- 
 logy, and therapeutical treatment of the disease under consideration, 
 would do well to consult the late works of Mess. Louyer-Villermay, 
 Georget, Ch. Gerard, Brachet, of Lyons, Foville, and Dubois of 
 Amiens. 
 
 HYSTERIFORM ATTACKS. 
 
 V 
 
 Though the vapoury or spasmodic affections to which women 
 are liable generally have their point of departure in the uterine 
 apparatus, the analysis of the phenomena which constitute them and 
 of the causes under whose influence they are produced, leaves no 
 doubt in our mind that they may have their source, either in the 
 encephalon, as supposed by Ch. Lepois, Willis and Georget ; or in 
 the stomach and intestines, as supposed by Purcel, Pitciarn, Hunault, 
 Jean Maria, Vogel, Hamilton and some others. 
 
 We have one peremptory reason to prove that the uterus is not 
 always the commencing point of the spasmodic affections of females, 
 which is, the existence of hysteriform paroxysms in men, as observed 
 by Ch. Lepis, F. Dubois de le Boe, Morgagni, Boerhaave, Raulin, 
 F. Hoffmann, Pomme, Leroy, Cullen, Haller, Gardien, Georget, 
 Louyer-Villermay, Mess. Recamier, Trolliet and Brachet, of Lyons, 
 Casimir Broussais, and twice by ourselves* and by several other phy- 
 sicians. Besides, the study of the pathogenic causes, the progress of 
 the disease, the analysis of the symptoms and their comparison with 
 those of hysteria properly so called, would alone be sufficient to 
 prove that spasmodic disorders may likewise have, as their primary 
 source, some particular irritation of the encephalon or stomach. 
 Spasm of the former of these organs or cerebral spasm^m^ be desig- 
 nated by the title of encephalospasm or cerebrospasm, while we may 
 
 * We saw a case of hysteriform spasm in 1833, in a boy who sold lemonade in the 
 streets, and a second, a few days since (April 15, 1838), in a young type-founder 
 employed by M. J. Didot. 
 
HYSTERIFORM ATTACKS. 
 
 537 
 
 distinguish spasm of the stomach under the denomination of g astro- 
 spasm . 
 
 [I do not perceive the force of the argument here advanced against the 
 hysterical nature and origin of the hysteric paroxysm, or passion. Not 
 only the celebrated case mentioned by Sydenham, but numerous published 
 cases of the disorder occurring in males, show that the affection is not con- 
 fined to women alone ; and yet, even admitting that the womb itself, or the 
 ovary, is not at the foundation of the malady, nor the disturbing force in the 
 malady, we may readily conceive it is in the reproductive tissue, and the 
 reproductive influence or power, that is situated the fons et origo of the 
 evil. I conceive the question to be, not so much whether hysteria arises 
 from a disturbing power of the womb, as from a disturbing power of the 
 reproductive agencies implanted in the economy; and I conceive that devia- 
 tions of that power, or those agencies, whether in the male or the female, 
 may alike be regarded as ipsissimas causas in these maladies. 
 
 Read, in Trousseau and Pidoux’s article, Medication Antispasmodique , 
 their exposition of the phenomena of the genital act, for a description of the 
 hysteriform state, in its most exquisitely marked features. — M.] 
 
 The predisposing causes of encephalospasm independent of hyste- 
 ria, are : a nervous temperament ; the feminine sex ; the culture of 
 belles-lettres and of the arts, especially of poetry ; a vivid imagina- 
 tion ; careful education ; great development of the intellect ; habitual 
 cephalalgia ; the abuse of perfumes, of alcoholic liquors, and of exciting 
 drinks, especially coffee ; and, finally, all circumstances capable of 
 producing frequent and protracted excitement of the encephalon. 
 
 The exciting causes are : anger ; sudden fright ; the unexpected 
 receipt of bad news ; the sight of some painful spectacle or sanguinary 
 scene ; the view of another female in a convulsive paroxysm ; the 
 departure of some dearly loved person ; the sad impressions of me- 
 mory, and strong and unexpected sensations, as, for example, the 
 sound of thunder, of cannon, etc. ; a penetrating odour, and espe- 
 cially one for which antipathy* is felt ; the hearing of certain pieces 
 of music, or of cries announcing imminent danger ; acute physical or 
 moral suffering ; a conflagration, and any great misfortune, &c. We 
 attended, a few months since, a female, twenty-eight years of age, 
 who, having previously suffered from nervous disorders, was sud- 
 denly taken with a violent paroxysm of hysteriform cerebral spasm, 
 on seeing an only son, five years old, fall from the third story. M. 
 Th * * *,jr., ex-prosector of the Faculte de M&decine , fell, deprived of 
 
 * M. Orfila cites the instance of a young lady who could not be present where a 
 decoction of flaxseed was preparing without fainting. M. H. Cloquet has observed 
 the same thing. Aretaeus saw epilepsy caused by certain odours. M. Rostan says 
 that attacks of hysteria, loss of voice, and even suffocation, have been caused by the 
 colour of the flower of the malva moschata, of the lobelia longijlora, of the magnolia 
 tripetala. , etc. We knew a lady who was instantly thrown into a nervous paroxysm 
 by the smell of orange-flowers; One of our connections, wife of a deputy, Madame B. 
 de C * * *, experienced the same accident from the odour of violets. That of the lily, 
 tuberose, musk, and especially of frankincense, often produces as unpleasant effects, 
 not only in women, but likewise in men. 
 
538 
 
 hySteriform attacks. 
 
 consciousness and with convulsive movements, at accidentally meet- 
 ing the procession of the physician Cast in, on his way to the scaffold. 
 M. Brachet, of Lyons, quotes the case of a washerwoman, regular as 
 to her menses, and enjoying good health, who was suddenly attacked 
 with cerebral spasm, accompanied with loss of consciousness, with 
 convulsive agitation and with a feeling of strangulation. She had 
 let fall a bundle of linen that she had just washed, while crossing the 
 shore plank of a boat used for washing. M. B * * *, one of the most 
 distinguished of our young composers, is seized w T ith an hysteriform 
 paroxysm whenever he hears the beautiful finale of the second act 
 of the opera la Vestale. Doctor Vautre in his thesis cites the case 
 of a young woman, seventeeen years of age, who was attacked with 
 a cerebral spasm as soon as she heard the hour of five strike on the 
 clock in the apartment ; the hour was that at which her father had 
 died. We could, were it necessary, quote a number of other cases 
 of the same kind. 
 
 Symptoms . — Like the paroxysms of hysterical spasm, those of 
 cerebral spasm appear suddenly or are preceded by a few prodromes, 
 such as vertigo, tinnitus aunum, obstinate insomnia, absence of 
 mind and even ecstacy, inability to sustain any long-continued intel- 
 lectual labour, and, finally, profound sadness, alternating with exces- 
 sive gaiety and causeless laughter. After the precursory phenomena 
 have lasted a longer or shorter period of time, the patient falls with- 
 out consciousness, and loses, more or less completely, the exercise of 
 the sensitive and intellectual faculties. This condition often lasts during 
 the whole of the attack ; nevertheless, in some cases, the suspension of 
 the functions of intelligence is only momentary, and it may happen 
 even that they shall become more energetic, and the external senses 
 be sharpened and more delicate than in the normal state. The 
 limbs and trunk are stiffened and affected as in hysteria, with con- 
 vulsive movements of flexion and extension ; but it is rare for the 
 patient to complain of the sensation of globus hystericus. If the 
 last phenomenon appears at all, it commences in the epigastrium 
 only : finally, the pulse, the respiration, the heat and the phenomena 
 which precede the termination of the paroxysm, are nearly the same 
 as in the attack of hysteria. We ought to remark, however, that 
 during the paroxysm of cerebral spasm, there is rarely any disengage- 
 ment of gas from the mouth and never any borborygmi and meteor- 
 ism, as so often seen in hysteria. Cerebrospasm often terminates, after 
 a single spasm, which rarely lasts more than a few hours ; in other 
 cases, as happens in hysteria, it reappears a greater or less number 
 of times, or is combined with that affection, according as the organic 
 predispositions change. When the paroxysms are frequently re- 
 newed or long protracted, there may follow loss of memory, mania, 
 mental alienation, partial paralysis, and strong tendency to apoplexy. 
 
 OF GASTRO-INTESTINAL SPASM. 
 
 Gastrospasm chiefly attacks persons who make frequent use of 
 aromatic substances, of highly-seasoned salt and exciting dishes, such 
 
GASTROINTESTINAL SPASM. 
 
 539 
 
 as truffles, mushrooms, salt meat and fish, alcoholic drinks, tea, 
 coffee, chocolate with vanilla, etc. The frequent administration of 
 purgatives, narcotics, bitters, astringents, tonics and emetics also dis- 
 pose to this affection. Nervous and melancholy women, those in 
 whom the stomach is feeble, delicate, irritable and subject to nervous 
 cramps, and, finally, those subjected to protracted low dieting, are 
 likewise more liable than others to gastrospasm. 
 
 The determining causes of gastrospasm are : the ingestion of iced 
 drinks, sherbet, orgeat syrup, or lemonade into the stomach, particu- 
 larly after eating; heavy and indigestible food, especially food for 
 which repugnance is felt ; the administration of an emetic ; a drastic 
 purge; or some remedy whose perturbing action is very powerful, 
 have often given rise to nervous phenomena, which together consti- 
 tute gastrospasm. M. Brachet [toe. cit., p. 135) relates the case of a 
 lady, twenty -six years old, who was suddenly taken with an hys- 
 terical paroxysm, after having eaten, without knowing it, of a dish 
 seasoned with cheese, for which she had a strong antipathy. We 
 saw, last year, a lady who was generally regular and enjoyed good 
 health, suddenly attacked with gastrospasm, after taking a few tea- 
 spoonfuls of vanilla ice-cream: we also knew orgeat syrup, taken by 
 a lady thirty-one years of age, and tartar-emetic lotions, used by 
 another twenty-three years of age, to produce the same effect. It is 
 proper to state that these ladies were not then at the period of their 
 menstruse, which appeared as usual, without presenting any thing 
 singular. 
 
 The prodromes of hysteriform gastrospasm are, general malaise, 
 lassitude of the inferior extremities, and sense of oppression at the 
 epigastrium. To these precursory symptoms, succeed intense gas- 
 tralgia, a kind of painful torsion and dragging pains in the stomach, 
 accompanied by gurgling and by emissions of large quantities of 
 gas, with efforts at vomiting and sensation of constriction in the 
 throat. In this kind of paroxysm, convulsive movements of the 
 limbs, and sometimes general convulsions, are observed ; the beating 
 of the heart is strong and tumultuous ; the respiration difficult, inter- 
 rupted, loud and even stertorous ; the face, which is extremely pale, 
 and particularly the region of the stomach, which is the seat of some 
 swelling, are covered with a cold and viscid sweat, which is replaced 
 by a warm, soft perspiration, when the paroxysm approaches its ter- 
 mination. 
 
 The persons most exposed to these sorts of attack, are commonly 
 subject to cramps of the stomach, to derangements of the digestive 
 functions, to chronic gastritis, and to engorgements of the abdominal 
 organs. These different phenomena, and the absence of all nervous 
 symptoms in the region of the uterus, indicate, in our opinion, with 
 sufficient clearness, that such attacks have their point of departure in 
 the stomach. It must be evident that we have devoted ourselves to 
 the study of the causes and to the analysis of the symptoms, in order 
 to establish the distinction that we have made, and to discover the 
 different sources of the spasmodic, disorders of females. 
 
 The last variety of gastro-intestinal spasm yields either to the em- 
 
540 
 
 HYSTERALGIA. 
 
 ployment of antispasmodics and tonics, or to that of antiphlogistics, 
 local bleedings, general baths, warm poultices, derivatives, and espe- 
 cially to frictions upon the epigastrium with tartar-emetic. Cerebral 
 spasm requires moral means, warm baths, with cold applications or 
 affusions to the head, leeches to the neck, and laxatives, and deriva- 
 tives to the limbs and digestive canal. We add, that the employment 
 of these different therapeutical agents ought to be modified according 
 to the causes, symptoms and complications, and that their use should 
 be continued a long time after the attacks have ceased ; that is to 
 say, until the constitution shall have been modified in such a way 
 that we need no longer fear a relapse. This fortunate result will be 
 the more certainly attained, if the patient uses proper care in avoiding 
 the causes which might bring on the attacks.* 
 
 We shall conclude by saying, with Th. Willis, ( Be. morbis con - 
 vulsiuis, cap. x., Pathol, cereb. et nerv., 1667,) that the hysterical 
 affection has so bad a reputation, ( passio hysterica pessimae adeo 
 famae ex is tit,) that it is made to answer for every thing that is trou- 
 blesome amongst women. When unable to discover the cause and 
 treatment of any disorder which seems extraordinary, we imme- 
 diately accuse the evil influence of the womb, which is most fre- 
 quently innocent, ( pleurumque insons est,) and gravely assert that 
 there must be something hysterical in it, ( aliquid hystericum snbesse 
 pronunciamus ;) then we prescribe some form of treatment depend- 
 ent on the evasive and convenient explanation which veils our igno- 
 rance, ( qui saepe tantum ignorantiae subterfiigium est.) 
 
 We have still to treat of uterine neuralgia, to which M. Louj^er- 
 Villermay has given the name of hysteralgia. 
 
 OF HYSTERALGIA. 
 
 By this term, derived from the vampa, uterus , and axyo s , pain , is 
 usually meant any pain in the gestative organ, independent of in- 
 flammation of that viscus. This affection, which is for the uterus 
 what gastralgia is for the stomach, scarcely ever appears except 
 during the period of the sexual existence, say from fifteen to forty- 
 five years of age. It has been observed, that many girls, before 
 reaching the age of puberty, and even some married women, are 
 subject to it at each return of the menses. In some cases, hysteralgic 
 pains are brought on by the first conjugal approaches, and they fre- 
 quently succeed to the sensation of voluptuous spasm which occurs 
 during sexual union. Without being the effect of leucorrhcea, of 
 displacement, or of rheumatism of the uterus, etc., hysteralgia is a 
 
 * L’Histoire de l’Academie des Sciences, (year 1752, p.73,) mentions several cases 
 of hysteria and other spasmodic disorders cured by the employment of rapid, abrupt 
 and unexpected music. Pomme and Tissot relate several examples of it. Goubelly, 
 who is the author of a learned dissertation, ( An hystericis insu/tibus prxcavendis 
 musice, Paris, 1771, collection de theses erolico-medicales,) has derived great advan- 
 tage from the employment of music in the treatment of hysteria and all the vapoury 
 affections of women. We shall dwell at some length on this subject, in a work 
 which we purpose publishing, and which is to have for title, Del' histoire philosophiqut 
 de la musique et de I'injluence de cel art sur les passions et sur la santc de I'/iomme. 
 
HYSTERALGIA. 
 
 541 
 
 symptom which often accompanies those different disorders, but; 
 which, instead of being like them, continuous, has longer or shorter 
 periods of perfect calm. Hysteralgia, also, sometimes coincides with 
 paroxysms of intermittent fever; during the apyrexia, there often 
 remains slight sensibility merely of the hypogastrium, which might 
 lead us to suspect the presence of a slight metritis, a condition, more- 
 over, which has been known to arise when the nervous affection of 
 the uterus has lasted a great length of time. 
 
 The symptoms of uterine neuralgia are more or less violent pain, 
 with sensations of pricking and twisting, and often a burning heat 
 even, seated in the centre of the pelvic excavation, and irradiating, 
 in some cases, to the rectum, anus, groins, and loins, and especially 
 to the vagina and vulva. Exploration by the Touch and speculum, 
 shows that the genital organs present neither redness, swelling, nor 
 abnormal sensibility. The pain, however, may reach such a degree 
 of severity, that the patient is thrown into a state of agitation and 
 despair, capable of giving rise to a suspicion of her being attacked 
 with mental alienation. 
 
 The treatment of hysteralgia consists in the use of baths ; of 
 emollient and narcotic enemata and injections ; and of cataplasms, 
 and liniments of the same nature applied to the hypogastric region ; 
 finally, repose, continence, demulcent drinks, caustic issues on the 
 thighs or arms, and especially frictions of the hypogaster with tartar- 
 emetic ointment, are additional means that ought not to be neglected. 
 Should the disease assume a periodical form, either with or without 
 fever, recourse must be had to the preparations of cinchona, and espe- 
 cially to the sulphate of quinia, in combination with opium. If the 
 hysteralgia were a symptom of some other affection of the uterus, 
 we should seek, above all, to overcome the primary disease. 
 
 With this, we conclude our remarks upon the diseases peculiar to 
 females ; we have passed by, without notice, those that are relative 
 to reproduction, and that are classed in the Sixth Section of our 
 synoptic table, because, on the one hand, they do not enter into the 
 plan of the work, and on the other, because they are sufficiently 
 numerous and important to induce us to devote to their consideration 
 a particular treatise, which will be independent of this, and which we 
 purpose publishing after some time. 
 
 Though it is evident from the sad picture we have just traced in 
 lengthened detail, that the diseases peculiar to women are for the 
 most part extremely serious, it is also evident, that we may generally 
 hope for their prevention and cure, by opposing them in good time, 
 by the various prophylactic and therapeutical agents, which have 
 been tested by experience, and which justify, day by day, the old 
 adage : 
 
 Principiis obsta; sero medecina paratur 
 Cum mala per longas invaluere moras. 
 
 Ovid. Remedia amoris, ver. 91, 92. 
 
542 
 
 HYGIENIC RULES — PUBERTY AND MENSTRUATION. 
 
 CHAPTER X. 
 
 SPECIAL HYGIENE OF WOMEN. 
 
 Pluris est labantem sustinere, quam lapsum erigere. — Sejteca. 
 
 After treating of the diseases peculiar to women, we naturally 
 come to speak of the means of avoiding them as far as possible, and 
 of the precautions to be taken, in order to render less difficult and 
 laborious the important functions assigned them by nature. The 
 object we propose to ourselves, in this chapter, is, therefore, to guide 
 them through the midst of the dangers which threaten them during 
 those stormy periods, and physiological transitions that mark the chief 
 phases of their life. Though the counsels we give them are far from 
 having the power of always preventing their diseases, we have, at 
 least, the certainty that they will constantly weaken the morbific 
 influences which produce them. 
 
 To proceed with greater method in the application to women of the 
 hygienic precepts which belong to their sex, we have thought best 
 to follow the physiological order in which the principal periods of 
 their existence succeed each other, and not to restrict ourselves to 
 the six divisions adopted by modern authors, except when we shall 
 be occupied with what concerns them chiefly in general hygiene. 
 
 HYGIENIC RULES CONCERNING PUBERTY AND MENSTRUATION. 
 
 When a young girl shows, by the unfolding of her physical facul- 
 ties, that she is approaching the completion of her full development, 
 she needs the closest watching, and a management having a different 
 object from that towards which her childish constitution tended. 
 Whereas before puberty she existed but for herself alone, having 
 reached this age, the spring-time of life, when all her charms are in 
 bloom, she now belongs to the entire species which she is destined 
 to perpetuate, by bearing almost all the burthen of reproduction. 
 
 During infancy, the vital forces tend to act equally upon all her 
 organs, but at the epoch of puberty, the chief efforts of the organ- 
 ism are in some sort concentrated upon the sexual parts, whose func- 
 tions are executed only during the second period of life. 
 
 As at this period, the instinct of modesty often leads young girls to 
 conceal their first menstrual haemorrhage, it becomes the duty of 
 mothers to inform them of the revolution they are about to undergo, 
 and to announce to them that the sanguine discharge, which they are 
 to become subject to, is a natural function upon which their health 
 will henceforwards depend. Young persons, kept in entire ignorance 
 upon this point, and taking their new condition for some shameful in- 
 firmity, have been known to oppose the salutary efforts of nature, by 
 
HYGIENIC RULES — PUBERTY, MENSTRUATION. 543 
 
 means of lotions, injections, and other equally dangerous agents. 
 The exact truth, therefore, should be told to girls just arrived at pu- 
 berty, because, though it is dangerous to know too much, it is more 
 dangerous to be entirely ignorant. 
 
 The general attention required by women at entering the brilliant 
 and stormy crisis, which is terminated by the appearance of the 
 menses, consist in fulfilling two principal indications : l,to moderate 
 the excitement and disorder resulting from the momentary plenitude 
 of the circulatory system ; 2, so to direct the efforts of nature, that 
 they may exert their chief action upon the sexual organs, in which 
 the vital forces ought, so to speak, to centre and terminate. 
 
 A carefully regulated regimen is of all means the most appropriate 
 one for fulfilling the first indication ; the food of a young girl at 
 puberty ought to consist principally of vegetable substances, of pre- 
 parations of milk, of the tender meats, and of light and easily diges- 
 tible substances. Water, with very small quantities of wine, cooling 
 drinks, and light beer, should form the chief part of her drink ; solid 
 and highly seasoned meats, sour and unripe fruits, stimulating arti- 
 cles, alcoholic liquors, and coffee, as well as the daily use of tea, must 
 be carefully avoided ; warm baths, taken from time to time, will con- 
 tribute, together with the regimen, to produce a general detergent 
 effect, and will have the advantage, moreover, of softening the skin 
 and dispersing the cutaneous eruptions to which girls are particularly 
 subject at the period of puberty. Sanguine evacuations, particularly 
 general bleedings, are almost always contra-indicated at this time, 
 and their employment becomes justifiable only in case there should 
 exist some acute and dangerous inflammation of an important organ. 
 Issues and derivatives, likewise, should never be employed, except 
 with great care, and in cases when the indications for their use are 
 very positive. 
 
 To fulfil the second indication, to wit, to place the genital organs, 
 especially the uterus, in a condition favourable to their becoming the 
 seat of the irritation which precedes the menstrual exhalation, we 
 should advise gymnastic exercises, walking and riding, running ; 
 the games of battledore, the jumping rope, the hoop, and riding 
 on horseback ; lastly, frictions about the pelvis and inferior extremi- 
 ties, the use of flannel-drawers, etc., are additional means very 
 useful for inviting the flow of the menses. If the important function 
 delays its appearance too long, and particularly if the girl suffers 
 any of the evil effects of amenorrhoea, we should resort to very warm 
 hip-baths and pediluvia ; to aromatic fumigations ; to applications 
 of cups to the thighs, and leeches to the vulva ; and finally, to the 
 various means pointed out under the head of essential amenorrhoea. 
 At this period, in particular, we must, forbid the wearing of corsets 
 with busks and whalebones, and tight clothing, which obstruct the 
 free development of the pelvis, of the thorax, and of the neck, and 
 which might prove the origin of most of the diseases whose sad 
 picture we have just sketched. 
 
 It will be well, at the same time, to pay attention to the moral 
 condition of the patient, and for this reason, it is of the highest im- 
 
544 HYGIENIC RULES — PUBERTY, MENSTRUATION. 
 
 portance to remove young girls from boarding-school, when they 
 approach the age of puberty, in order to exercise a constant watch 
 over them. We should prevent, as far as possible, the false emotions 
 produced by the reading of licentious books, especially of the highly- 
 wrought romances of the modern school, which are the more inju- 
 rious, as all the faculties become, as it were, overpowered by the 
 desire to experience the sentiment which these works always repre- 
 sent in an imaginary and exaggerated strain. Frequent visits to the 
 theatre ought to be carefully avoided, because they, also, may give 
 rise to sensations conformable to the moral condition, which is natu- 
 rally, at puberty, already too much exalted. These powerful exciting 
 agents, and still more frequently, the violent intimacies formed at 
 boarding-school, tear the veil of modesty, and destroy, for ever, the 
 seductive innocence which is the most charming ornament of a 
 young girl. Endowed with an organization eminently impressiona- 
 ble, she soon contracts improper habits, and constantly tormented by 
 an amorous melancholy, becomes sad, dreamy, sentimental and lan- 
 guishing. Like a delicate plant, withered by the rays of a burning 
 sun, she fades and dies under the influence of a poisoned breath. The 
 desires for happiness and love, so sweet and attractive in their native 
 truth, are in her converted into a devouring flame, and onanism, that 
 execrable and fatal’evil, soon destroys her beauty, impairs her health, 
 and conducts her almost always to a premature grave ! 
 
 Comme une flear dessechee 
 Tombe, la tete penchee, 
 
 Feuille a feuille, sur le sol: 
 
 Ainsi meurt la pauvre fille. 
 
 En elle plus rien ne brille, 
 
 Que les perles de son col. 
 
 (L. A. Bekthaxd.) 
 
 It often happens that, in spite of all the care and precaution of a 
 tender and prudent mother, the imagination of a girl becomes exalted 
 to such a point, as to silence the voice of reason and shame. In this 
 unequal contest, where nature often gains the victory over social 
 institutions, we should resort to the use of means which may, by a 
 powerful diversion, counterbalance and destroy the erotic exaltation. 
 Experience has proved, that among these means, severe occupation 
 of the mind, and bodily exercises carried so far as to induce fatigue, 
 are more efficacious than all the drugs of the apothecary ; the Fable 
 which represents the chaste Diana as the goddess of the chase, is 
 an ingenious allegory, which seems to prove that the ancients had 
 discovered, in corporeal exercises, the power of blunting, and even of 
 extinguishing the stings of love. A strict superintendence ; a milk 
 and vegetable diet ; the study of history, geography, and belles-let- 
 ters ; counsels founded upon religion and morality ; the frequent use 
 of bathing ; the precaution never to leave young persons alone, and 
 especially to make them retire late and rise early ; such are the means 
 to which we may almost always resort with success. 
 
 A directly opposite plan should be adopted for girls who, though 
 arrived at the nubile age, are cold, apathetic, and indifferent ; and, it 
 
HYGIENIC RULES FOR WOMEN. 
 
 545 
 
 is to such only that the culture of the fine arts, the frequenting of 
 balls, of theatres, of crowded assemblies, and even the reading of 
 certain 'imaginative works and romances, will not be hurtful, and 
 might even prove useful in exciting their sensibility, and thus inviting 
 the menstrual exhalation. 
 
 From the epoch of puberty % to the critical age, the menstrual dis- 
 charge requires certain cares and precautions, which it is important 
 to understand. While the haemorrhage is present, women ought to 
 refrain from taking baths, and from washing the hands and genital 
 organs with cold water; they should also avoid cold feet; they should 
 not remain with the arms or neck uncovered, and must abstain from 
 iced, exciting and alcoholic drinks, such as sherbets, coffee, tea, 
 liqueurs, etc.; coitus, also, ought to be proscribed, because the excite- 
 ment determined by it in the genital organs, may occasion either 
 metrorrhagia, or more or less complete suppression, and secondarily 
 a utero-vaginal inflammation. It is well, also, to avoid sitting upon 
 cold and damp places, for example the earth, a stone bench, a grassy 
 bank, etc. The napkins, or chaitffoirs , employed to receive the 
 fluid of the menses, as it escapes from the genital parts, ought 
 always to be well aired, and in winter warmed before being applied. 
 If the discharge is too abundant, it may be remedied by a vegetable 
 and milk diet; by repose; by the horizontal position; by cooling 
 and -sedative drinks, as barley water, whey, weak lemonade, etc.; if 
 the female is of lymphatic temperament, she must use, on the con- 
 trary, a tonic diet, composed chiefly of roast meats, feculent sub- 
 stances, and rich soups. When menstruation is entirely or partially 
 suppressed, in consequence of some imprudence or unexpected occur- 
 rence, it is necessary to endeavour to recall it, by means of a warm 
 infusion of balm and orange flowers. Rest in bed, warmth to the 
 thighs and legs, maintained by bottles filled with warm water, are 
 other means which should not be neglected. 
 
 We ought to remark, moreover, that during the flow of the menses, 
 except some absolute necessity arises, it is proper to abstain from the 
 use of bleeding, of purgatives, of emetics, and all the therapeutical 
 means which act energetically, and which might occasion an impres- 
 sion capable of disturbing the salutary efforts of nature. In general, 
 women may escape most of the disorders of menstruation, either by 
 exercising, to a greater extent, the muscular system, which they 
 too often condemn to dangerous inaction ; by abstaining from excit- 
 ing!:, salted, or highly-seasoned food and from stimulating drinks ; or 
 lastly, by taking care to clothe themselves suitably during the winter; 
 and especially by wearing flannel drawers, some days before, and 
 during the epoch of the menses principally. It is, likewise, very im- 
 portant that they should abstain, during the presence of the discharge, 
 from all intellectual labour, and from severe study, which, by esta- 
 blishing a high cerebral excitement, determine an unequal distribution 
 of the vital forces, and cause an afflux towards the brain of the blood 
 which ought to flow towards the genital apparatus. Before conclud- 
 ing what we had to say upon the attention to hygiene that men- 
 struation requires, we will add, that so long as the function lasts, 
 35 
 
546 
 
 HYGIENIC RULES FOR MARRIAGE. 
 
 women ought to be the object of the most attentive kindness, and of 
 a solicitude capable of preserving them, as far as possible, from the 
 unhappy influences of the physical and moral causes which affect 
 them then more strongly than at any other period. It is well to say, 
 also, that if some amongst them become subject at these periods to 
 caprices, to sadness, and unequal te paper, we should always bear 
 these transient humours with indulgence, because they depend upon 
 the action of the body upon the mind, and upon an active irritation, 
 which is radiated from the uterus towards the other organs, and espe- 
 cially towards the brain. 
 
 HYGIENIC RULES IN RELATION TO THE UNION OF THE SEXES. 
 
 If, on the one hand, as M. Virey* says, the condition of virginity, 
 in our civil institutions, is a state of violence against the impulsions 
 of nature, v§ry different from the free state of the young females of 
 animals who are subjected, at the period of their loves, to the yoke 
 of passion ; if, on the other hand, it is generally admitted that mar- 
 riage is the state most favourable to the happiness, well-being, and 
 health of man, it is important to respond to the call of nature, as 
 soon as the complete development and perfect conformation of all 
 the organs allow. In the infancy of the world, the sexes obeyed in 
 their union only the natural sentiment which attracted them to- 
 wards each other; but philosophers, physicians and legislators, made 
 of marriage one of the chief objects of their meditations. Seeking 
 to determine the more 01; less advantageous influence which might 
 result from it to the people, whose happiness they sought to assure, 
 all agreed that the most serious inconveniences might flow from the 
 premature union of the two sexes. In order to prevent the evil effects 
 of marriage before the full development of the constitution, legislators 
 have determined its epoch. Lycurgus and Plato fixed it at seven- 
 teen years for girls, and Aristotle at eighteen. Among the Romans, 
 women were authorized by the Poppcean law, to marry at the age of 
 twelve years; lastly, the Athenians, less scrupulous, permitted mar- 
 riage as soon as individuals believed themselves fit to fulfil its end. 
 This law, fatal to population in general, and especially dangerous for 
 women, accorded with the customs and warlike policy of the people 
 of Athens. As it would be both useless and fastidious to cite all the 
 laws and opinions relative to marriage, we shall confine ourselves to 
 saying, that the period ought to vary tvith the difference of place, of 
 climate, of people, and with the degree of civilization, since these 
 several circumstances may hasten or retard the first appearance of 
 the menses and the age of complete nubility. 
 
 The French laws, before the Revolution, forbade legal union, for 
 girls, before the age of twelve years ; but, by the present code, they 
 cannot enter into the conjugal tie until they have reached the age of 
 fifteen years complete. The French legislators have permitted mar- 
 riage at this early period after birth, because they deemed it neces- 
 
 * De la femme, sous les rapports physiologique, moral et litteraire, ch. xi.p. 78. 
 
HYGIENIC RULES FOR MARRIAGE. 
 
 547 
 
 sary for the interest of good manners, inasmuch as accidental con- 
 nections between the sexes might occur at that period, to leave 
 some means by which to repair a fault, and legitimatize children 
 who, but for this provision, would have a false and unhappy posi- 
 tion in society. Moreover, if it be recollected that marriage is the 
 most effectual means of removing the evils resulting from the violent 
 desires which are often excited in young girls, at an early period, by 
 the education they receive and by the prevailing customs of society, 
 it will be agreed, undoubtedly, that the civil code has been digested 
 with the utmost wisdom. Nevertheless, regarding woman only in 
 her physiological aspect, we think that from eighteen to twenty-five 
 is the age at which women may marry most advantageously for 
 themselves and for their children. Besides, there is a rule by which 
 we may always guide ourselves, which is, to place at least two years 
 between the time of marriage and the first appearance of the menses. 
 It is rare for the constitution to have acquired, before this period, the 
 development necessary for the reproduction of the species. “ If,” as 
 remarks M. Lachaise, in his Hygiene , “ the indispensable processes 
 of nature, occupied with the completion of its organization, are 
 broken in upon by the premature enjoyments of marriage, the 
 female will be exposed to a thousand risks, in her new position. 
 Become pregnant, she will be unable to support, without the great- 
 est difficulty, and at the expense of her health, the innumerable and 
 unavoidable inconveniences of that condition : she will be liable to 
 abortions and haemorrhages, and the pangs of childbirth may cost 
 her, perhaps, her life. Become the mother of delicate and sickly 
 infants, she will pass her youth in uneasiness and tears; give to the 
 offspring of her love an impoverished milk ; yield herself, in order 
 to rear them, to cares and watchings beyond her strength ; hasten 
 for them the approach of old age, and tear herself, perhaps, from life 
 at a period when she is ordinarily strongest and most active.” 
 Though premature marriages are not invariably followed by such 
 fatal consequences, we may say that they always influence, more or 
 less, the physical and moral condition, and hasten the termination, 
 already too precipitate, of youth and beauty. 
 
 In women who are well formed and fully developed, the first 
 enjoyments generally produce a favourable impression upon the 
 constitution : nevertheless, it sometimes happens that the generative 
 organs become the seat of inflammation, or that newly-married per- 
 sons suffer from some spasmodic disorders which readily yield to 
 absolute repose of the organs, to the employment of general baths, 
 sedative drinks, and narcotic and emollient enemata and lotions: 
 lastly, to general depletion, where the pulse is full and the reaction 
 very violent. 
 
 While a moderate indulgence in the venereal act generally pro- 
 duces useful effects, when too often repeated, it occasions lassitude, 
 feebleness, and general depression ; the beauty is soon destroyed, the 
 grace and freshness of youth are withered ; finally, when the abuse 
 of coitus is kept up, it may determine inflammations and ulcerations 
 of the vagina and uterus, leucorrhoea, uterine haemorrhages, disorders 
 
548 
 
 HYGIENIC RULES FOR MARRIAGE. 
 
 of the digestive and nervous apparatus, acute and chronic gastritis, 
 attacks of hysteria and nymphomania, feebleness of all the senses, 
 loss of memory, stupidity, moral inferiority, caries of the vertebrae, 
 aneurisms, especially of the heart, phthisis pulmonalis, marasmus 
 and death. 
 
 Under all circumstances, young married persons ought to proportion 
 their pleasure to their forces, and should recollect that the first conjugal 
 approaches require certain cares and precautions, the forgetfulness of 
 which might lead to the most unhappy results. When the consum- 
 mation of the marriage meets with too great resistance, especially 
 when there is disproportion between the organs, the husband, young, 
 full of vigour and sometimes inexperienced, instead of abandoning 
 himself to all his transports, should seek to overcome the obstacles 
 with care and circumspection. In general, the difficulties which the 
 first essays of marriage present, are least during the period of the 
 menses and for some days afterwards. We may remark, also, that the 
 use of unctuous substances, of emollient fomentations, and of general 
 baths, and that the effusion of blood, even, which generally follows 
 the first attempts, may determine a useful relaxation in cases of dif- 
 ficulty. Nevertheless, if too great a resistance should be met with, 
 far from making violent efforts that might endanger the life of the 
 woman, some unnatural conformation ought to be suspected, and the 
 assistance of the surgeon be invoked against an obstacle which he 
 alone can surmount without risk. 
 
 As conception is the most natural consequence of the genital act, 
 and though the reproduction of the species is the chief end of the 
 institution of marriage, there are yet certain circumstances, which, 
 however imperious the tone of the senses, and however powerful the 
 laws of the social condition, should be held as authoritative enough 
 to forbid the sexual approach, as regards some women, in whom it 
 threatens to become the fruitful source of dangerous diseases, and 
 often, indeed, the cause of death itself. Among the number of de- 
 formities which contra-indicate marriage for such persons, we should 
 place in the first class those which are capable of preventing the act 
 of generation, or that of parturition, such as absence of the vagina or 
 insufficient capacity of the pelvis. The latter-named fault of con- 
 formation would place the woman under the cruel alternative of 
 undergoing the Caesarian operation, or that for the section of the 
 symphysis; or, at least, of seeing her offspring sacrificed and ex- 
 tracted piecemeal. 
 
 In general, we may presume that there is vicious conformation of 
 the pelvic cavity, whenever we find a curve in the vertebral column, 
 which allows the last lumbar vertebra to sink in towards the poste- 
 rior and upper part of the pelvis, where the haunch bones are not 
 very apparent, and are very much elevated on one side ; where the 
 thighs are closely approximated towards each other, and, in fine, 
 where a curve in the long bones and swelling of their articular 
 extremities indicate a general rachitic condition. It is true, how- 
 ever, that we have seen some horribly deformed women, with a 
 well-formed pelvis, and lying-in very easily, while there are others 
 
HYGIENIC RULES FOR MARRIAGE. 
 
 549 
 
 who, with all the appearance of a regular conformation, cannot 
 bring their children into the world, and almost inevitably perish, 
 because they have the superior strait of the pelvis with an antero- 
 posterior diameter of not more than two inches. Parents who should 
 suspect the existence of such pelvic deformity in their children, ought 
 never to consent to their marriage, without first taking the opinion 
 of a capable physician ; for though an examination into the facts of 
 such a case gives a shock to the modesty of the female, such a senti- 
 ment ought not to be put in balance against the life both of a mother 
 and her child. 
 
 Among the disorders that ought to be admitted as obstacles to a 
 legal union, we place pulmonary consumption, aneurism of the heart 
 and of the large arterial trunks, idiocy, insanity, and even epilepsy, 
 where that disease continues after the age of puberty. 
 
 In following out the order in which the various physiological 
 phases of the life of the female succeed each other, we ought not to 
 speak of the hygienic precautions applicable to the functions and 
 various states of the female, having relation to the reproductive 
 faculty ; we pass them by in silence, because we intend, as we have 
 stated both in the preface and in the last chapter, to speak of them 
 very fully in another and independent treatise, which we propose to 
 publish, upon the diseases and accidents connected with conception, 
 pregnancy, parturition and lactation, but which do not constitute a 
 part of the plan of this work. 
 
 On account of the reasons now set forth, we shall at once pro- 
 ceed to contemplate the prophylactic, hygienic and therapeutical 
 measures applicable for the prevention of those disorders to which 
 women are obnoxious at the change of life, under the influence of 
 a final cessation of the catamenial office. 
 
 HYGIENIC RULES RELATIVE TO THE CHANGE OF LIFE. 
 
 The period of the final cessation of the menses exhibits a less flat- 
 tering and often a no less stormy prospect than that of their first 
 appearance. Compelled to yield to the power of time, women now 
 cease to exist as for the species, and henceforward live only for 
 themselves. Their features are stamped with the impress of age, 
 and their genital organs are sealed with the signet of sterility. This 
 great revolution, this remarkable epoch of life, which most commonly 
 happens between the age of forty and fifty years, but which is sub- 
 ordinate to the influences of climate, constitution and mode of life, 
 to the social position and the healthful or morbid condition of the 
 patient, requires such cares and precautions, of a hygienic nature, as 
 may serve, as far as possible, to prevent the evils to which women 
 are then known to be liable. 
 
 The first advice they ought to receive, is an advice to reject all 
 sorts of drugs and preparations to which are attached such titles as 
 health-pills, elixir of long life, or elixir of propriety, and all the 
 receipts that are loudly proclaimed by ignorance, puffed by charla- 
 tanism and old-womanism, accredited by the attractions of a vogue and 
 
550 
 
 HYGIENE — OF CHANGE OF LIFE. 
 
 by millions of so-called miraculous cures : the approach to the critical 
 period less, perhaps, than any other epoch, admits of any infractions 
 as to regimen, dress, bodily exercise, sleep and watching, the various 
 excretions and also the affections and passions of the soul. The diet, 
 which ought not to be too nutritious, may be composed of white 
 meats, veal, chicken, fresh-water fish, vegetables, such as succory, 
 spinach, acidulous fruits, cooked, and rdw fruits very ripe. Such a 
 person should reject all sorts of spiced dishes, ragouts, black and 
 salted meats, coffee, tea, spirituous liquors, and, in fine, all stimulating 
 and indigestible food. Plethoric women, who are subject to copious 
 menstrual discharges, should renounce late suppers, should drink 
 whey, cooling beverages, infusions with succory, and acidulous mine- 
 ral waters. All such women ought to make it a rule to take moderate 
 exercise, with a view to distribute, throughout the entire system, the 
 excitability which is thus withdrawn from the reproductive system. 
 Exercise, taken in attending to household affairs, is so much the more 
 favourable, as it is proportioned to the physical strength, and super- 
 adds, to the natural effects of toil, the internal satisfaction arising from 
 the fulfilment of duty. Lastly, riding out in the country, where one 
 may go to inhale the bracing air of the morning; the cares demanded 
 for the proper culture of flowers; short excursions into pleasant 
 regions of country, where the land is high and dry, especially in 
 agreeable company, also constitute the kinds of exercise from which 
 may be derived the happiest results. 
 
 Women who have reached their critical period of life, should, with 
 more than usual care, withdraw themselves from the influences of 
 atmospherical vicissitudes, and especially from that of a cold, damp 
 atmosphere,* which often gives rise to catarrhal disorders, leucor- 
 rhoeas, &c. They would also do well to avoid, especially at those 
 periods at which they were accustomed to menstruate — they would 
 do well, we say, to avoid large assemblies, theatres, heated, close 
 rooms, where only impure air can be breathed : they ought also to 
 eschew all low and damp situations, to give up the use of foot- 
 warmers; they ought not to sleep upon feather beds, nor in any bed 
 that is too soft and too warm, for such are attended with the disadvan- 
 tage of promoting plethoric accumulations, and disposing the system 
 to attacks of uterine haemorrhage, of causing constipation of the 
 bowels, and exciting the generative organs, which should henceforth 
 be left, as far as possible, in a state of inaction. Sleep, if prolonged 
 beyond six or seven hours, long watchings, too much exercise of the 
 mental faculties ; sensations, whether too acute or too profound ; 
 wrath, love of play, and all sorts of passionate sentiments, — these 
 are especially hurtful to a woman about the close of her menstrual 
 life. 
 
 Love, a sentiment so gentle and so natural to the female, a pas- 
 sion which is, so to speak, the sole dominant passion of the sex, may, 
 
 * Among washerwomen and other females habitually exposed to damp cold, the 
 cessation of the menses is, for the most part, distressing and tempestuous: such 
 women, likewise, are more liable than others to leucorrhceal discharges, chronic 
 inflammations, and cancerous affections of the womb. 
 
HYGIENE FOR CHANGE OF LIFE. 
 
 551 
 
 at the critical age, produce the greatest disturbance in the nervous 
 system ; on this account, the use of venery could not be too mode- 
 rate at this period of life, and should, in case of the appearance 
 of any signs, be placed under a complete interdict. Under si^ch cir- 
 cumstance, it is the dictate of prudence to avoid all such circumstances 
 as might tend to awaken any erotic thoughts in the mind, and re- 
 animate a sentiment that ought rather to become extinct, such as the 
 spectacle of lascivious figures, the reading of passionate novels, and 
 in fine, every thing calculated to cause regret for charms that are 
 lost, and enjoyments that are ended forever. 
 
 Most women exaggerate to themselves the dangers of the critical 
 age, representing the future in the most sombre hues ; they should be 
 reassured upon this point, and disabused of the false idea they gene- 
 rally form that their menses are designed to purge the body of some 
 virus or impure principle, and that the cessation of the flow is about 
 to become the source of numerous disorders. They should be re- 
 minded, that when this short period is once past, their sex has a 
 better chance of long life than ours. The persons who live with 
 ijiem ought to turn aside their sad thoughts, and avoid all occa- 
 sions of strong feelings, and seek, indeed, to inspire them with none 
 but complacent affections : assisted by the counsels of medicine and 
 of friendship combined, and arming themselves with courage for 
 the conflict, the sex may hope to spend many happy days far beyond 
 an age at which they suppose there is no further hope of happiness 
 for them. 
 
 How great soever may be the advantages of the hygienic mea- 
 sures we have just proposed, the health of many different females 
 still demands the rigorous observation of many precautions, and the 
 employment of certain therapeutical agents, among which we may 
 mention venesection, issues, enemata baths, and purgative medi- 
 cines ; bleeding is indicated, on account of the plethora which gene- 
 rally succeeds the final cessation of the menses. Recourse should 
 be had to it at an early period, and it should be repeated from time 
 to time, and at intervals, greater or less, according to circumstances. 
 Bleeding at the arm is always to be preferred, because it should be 
 rather derivative than spoliative. Bleeding in the foot ought to be 
 rejected in these cases, as well, likewise, as the application of leeches 
 to the.vulva and thighs. This last method of abstracting blood is 
 objectionable, as tending to increase the local irritation and plethora 
 which it is so desirable to remove. However, there are cases, very 
 rare ones to be sure, in which leeches may be advantageously 
 applied to the hypogaster, and even to the vulva ; such are the cases 
 where the lower belly and the pelvic viscera are affected with acute 
 pain, that venesection at the arm, even when several times repeated, 
 has been found incapable of alleviating. 
 
 Constipation ought to be combated by the use of injections sweet- 
 ened with honey, or prepared with the addition of a teaspoonful of 
 olive oil. Suppositories of beurre de cacao , the use of the plunge 
 bath and of gentle laxatives, such as Seidlitz water, tisans with 
 prunes, tamarind whey, veal broth or vegetable broth, infusion of 
 
552 
 
 GENERAL HYGIENE OF FEMALES. 
 
 wild succory, and other drinks of the same sort, containing a weak 
 solution of sulphate of soda, are proceedings to be instituted with 
 advantage to the patient. Drastic cathartics, especially aloetic pur- 
 gatives, ought always to be rejected, for they excite the viscera of 
 the pelvis, especially the womb and the rectum too much, accumu- 
 lating in that direction congestions that frequently lead to attacks of 
 metrorrhagia and obstinate haemorrhoidal disorders. For similar 
 reasons, we ought to abstain from purgative injections irivariably, as 
 well as from hip-baths, nor have recourse to common injections with- 
 out care in the employment of them, and only in cases of absolute 
 necessity. 
 
 Those women who, in early life, may have been subject to swel- 
 lings of the joints, or of the lymphatic ganglions, to ophthalmias, and 
 to cutaneous eruptions ; and those, lastly, who happen to labour 
 under chronic, mucous, or parenchymatous inflammation, &c., will 
 act prudently by establishing some point of derivation upon the skin 
 by an issue, and especially by a blister. Petit Radel has justly re- 
 marked, ( Notes on Fothergill ,) that the last-named exutory is pre- 
 ferable to the former kind, because it acts upon a more extended 
 surface, and the irritation produced by it may be easily increased 
 or diminished. Let us close by remarking, that the cessation of the 
 menses, which is a physiological phenomenon, as natural as the first 
 appearance, would almost terminate well, were it not that former 
 excesses, careless dieting, and a treatment not unfrequently foreign 
 to the principles of the art, intervene and oppose its progress. We 
 cannot, therefore, too loudly proclaim to the sex, that infractions of 
 the laws of hygiene may lead them into the arms of death at a 
 period which would have been for them the commencement of a 
 more tranquil life, and an existence exposed to much fewer dangers. 
 
 GENERAL HYGIENE OF WOMEN. 
 
 Though the male and female are subject to the same laws of life, 
 to the same wants, the same passions, although the act of living 
 ought to be in common as to the two sexes, there are, nevertheless, 
 in the application of the general hygiene of the female certain shades 
 of difference, and pecular modifications, in regard to which we con- 
 sider it a duty to offer a few remarks. 
 
 To proceed with a more regular method, and particularly that we 
 may avoid any important omissions, we shall review, in succession, 
 the six classes that constitute the substance of hygiene. 
 
 1. Circumfusa, or surrounding circumstances. If it be true, as 
 the sage of Cos observes, that air is the aliment, the pabulum of life, 
 it also happens that it may become the aliment or cause of death, 
 in the disorder of which it is frequently known to be the pernicious 
 cause ; as women are by nature more sensitive and impressionable, 
 and possess smaller lungs, that, are more irritable, and more liable to 
 phthisis, they are of course more injuriously affected than men are 
 by the influence of atmospheric vicissitudes. Precautions in regard 
 to the respiratory organs deserve, in an especial manner, to fix our 
 
GENERAL HYGIENE OF FEMALES. 
 
 553 
 
 most particular attention at the approach to puberty, during the act 
 of menstruation, at the change of life, and in fact, at all the epochs of 
 the life of the female that are characterized by an increase of the 
 general susceptibility. 
 
 Women, particularly those in whom luxury and ease have given 
 additional acuteness to their impressionability, ought, as far as possible, 
 to inhabit elevated apartments ; they should avoid crowded saloons, 
 where the air is both too hot and unwholesome ; they should be par- 
 ticularly careful not to pass carelessly from a high to a low tempera- 
 ture ; when compelled to do so, or to remain for some time with a 
 part of the person unprotected, they might greatly lessen the risk of 
 injury from the sudden transition of temperature and from the per- 
 nicious tendency of sudden cold, by stopping for a while in a cooler 
 apartment, or by keeping up an artificial warmth by walking, or any 
 other brisk motion ; those who are of a delicate constitution, and 
 prone to catarrhal and tuberculous disorders, would act very wisely 
 by rendering their parenchymatous organs and their whole mucous 
 system, and especially the bronchial and genital mucous membranes, 
 less impressionable, by keeping up a gentle excitement on the skin 
 by wearing flannel jackets and drawers ; they may also weaken the 
 evil powers of dampness and cold, by using mild tonic drinks, and 
 food both nutritious and easy of digestion. 
 
 The changes that the constitution of the air may undergo are some- 
 times extremely hurtful, especially to women. They ought, as far 
 as possible, to interdict for themselves all places of resort where great 
 numbers are assembled, such as balls, shows, concerts, &c. Without 
 dwelling in extenso upon the effects of exhalations and gaseous efflu- 
 via, we shall be satisfied with saying, that the habit indulged in by 
 some females of surrounding themselves with odours, deserves to be 
 mentioned, on account of the accidents and the real dangers which 
 accompany such habits. Nervous persons should, therefore, not only 
 shun the impression of powerful odours, and perfumes even the most 
 delicate, but they ought not to have in their chambers flower-pots 
 and vases filled with flowers, which are attended with the double 
 inconvenience of affecting the nervous sensibility too powerfully, 
 and of decomposing the air by the exhalations of carbonic acid gas. 
 Among the numerous cases in point that we have it in our power to> 
 cite, we shall confine ourselves to the case related by Cromer, that of 
 the daughter of Nicholas I., Count of Salin, who died after having 
 inhaled the odour of a rose ; in 1774, a woman in London was found 
 dead in her bed in consequence of having breathed the odour of 
 several full-blown lilies that she had placed in a small chamber. 
 Triller, ( Clinotechnia Medic, sive de diversis xgrot. lectis , 1774,) 
 saw a violet give rise to a distressing accident : under nearly similar 
 circumstances, the emanations from some lilies in blossom very nearly 
 proved fatal to the wife of Saumonier, the distinguished Rouen sur- 
 geon ; lastly, on the night of the 10th August, 1837, Mad. , the 
 
 Duchess d’Ab**'*, was upon the point of being asphyxiated from 
 having slept for several hours in her bed-room where her friends and 
 
554 
 
 GENERAL HYGIENE OF THE SEX. 
 
 the admirers of her literary talents had deposited their presents of 
 flowers on the eve of her birth-day. 
 
 From the facts above related, it is easy to judge that women ought 
 to abstain from perfuming their apartments with flowers, essences or 
 oriental pastilles, and from carrying about their persons, perfumery 
 and sweet-scented bags, which are capable not only of powerfully 
 afl’ecting the nervous sensibility, but even of acting as the occasional 
 causes of syncope^ of asphyxia, and a variety of spasmodic disorders 
 to which the sex are peculiarly prone. 
 
 Let us add that the abuse of perfumes is attended with the objec- 
 tion that it may exalt or depress the power of the sense of smelling, 
 and that Montaigne has judiciously remarked, “que la plus exquise 
 senteur dhine femme , c’est de ne rien sentir” bene olet quae nihil 
 olet. 
 
 Among the most mischievous habits indulged in by females we 
 ought to signalize the use of foot-stoves, which disengage a quantity 
 of carbonic gas, and likewise excite the genital organs and predis- 
 pose to fluor albus, and uterine haemorrhage, to piles, varix, ulcers 
 on the legs, &c. Persons whose avocations expose their feet to cold, 
 would do well to substitute for the foot-stove a chancelliere [a small 
 box, lined with bear skin, to put the feet in. — M.] or a tin vase filled 
 with warm water. 
 
 2. Applicata, or things applied to the surface of the body; 
 clothing , attention to cleanliness , cosmetics , fyc. 
 
 Inasmuch as there is attached to our clothing the precious advan- 
 tage of guarding the body from the immediate impression of the 
 atmosphere, and thus of annulling, to a certain extent, the influences 
 of atmospherical vicissitudes, it is very important that all parts of the 
 female dress should be constructed with reference to their manner of 
 life, the circumstances in which they are placed, and the prevailing 
 temperature of the air. In winter, they should wear woollen stuffs, 
 or silken stuffs wadded, or doubled, which, while they are both sup- 
 ple and light, yet keep up a good degree of warmth about the person, 
 from their being bad conductors of caloric. Although furs are pos- 
 sessed of the same property, they are inconvenient, because, upon 
 leaving them off merely for a short time, the person becomes sensible 
 to the slightest cold. In summer, they should make use of linen or 
 hemp, whereas, in the fall and spring, the variableness of the season 
 requires the use of dresses that are moderately warm. Lastly, at all 
 seasons of the year, females ought not, without great care, to lessen 
 the number of their garments, or suddenly change them for others less 
 preservative against sudden changes of the weather. It is equally 
 important for them at all times and seasons to keep the bosom and 
 the arms covered, and most especially is it important during the act 
 of menstruation. 
 
 The form of the female dress also deserves attention ; it should 
 always be large enough not to interfere with a perfect freedom of 
 motion, and not to exert any compressing power on the several parts 
 of the body ; the corset, especially, when badly constructed, or too 
 
GENERAL HYGIENE OF THE SEX. 
 
 555 
 
 tight, interferes with the motion of the body, prevents the expansion 
 of the lungs, and favours a stagnation of blood in the internal parts 
 of the body, disposing them to be attacked with inflammation, and 
 in consequence thereof, with consumption. Moreover, they painfully 
 compress the breasts, and act as causes of cancerous engorgements 
 and indurations. It is but just, however, to state, while the corset, 
 when too small, too tight, and supplied with strong whalebone and 
 a steel busk, is almost always hurtful, the elastic corset, well fitted 
 to the shape, furnished with ample gussets to receive the breasts 
 without compressing them, and besides unprovided with the busk 
 and applied moderately tight, lends grace to the figure, gives a useful 
 support to the bosom, increases the energy of the muscles on the 
 chest and abdomen, and, in fine, obviates a disposition to divide, met 
 with in some of the muscles, prevents the escape of the abdominal 
 viscera from the cavity of the belly, as well as the deviations of the 
 womb, in pregnant and lying-in women. It should be said, further- 
 more, that a corset, when well made, ought to adapt itself to the hips 
 and other parts of the body, and not these latter to the corset, as the 
 fashion required a few years since. The use of whalebones, far from 
 being injurious in all cases, as most authors consider them, is, on the 
 contrary, useful, provided they be made very thin and flexible, for 
 they prevent the numerous folds that the various motions of the 
 wearer would make in the corsets, and which, as well as the pain 
 that attends them, could be no otherwise prevented than by making 
 the corset fit much tighter than when provided with whalebones; it 
 is right to remark, also, that the shoulder-pieces ought to be very large, 
 and especially very elastic, but, that although we recommend to full- 
 grown women the use of a corset not too tight, we look upon their 
 use, before the age of puberty, as very hurtful. 
 
 Frequent changes of clean linen, and strict attention to cleanliness, 
 deserve the most scrupulous attention of the female ; she ought to 
 take a tepid bath at least once a month, the effect of it being to 
 cleanse the skin, render it supple, promote the peripheral circulation, 
 excite perspiration, and thus assist nature in one of her proposed 
 ends. The temperature of the bath ought to be so adjusted as to excite 
 a sensation neither of heat nor cold ; it should simply be agreeable. 
 This last is always to be preferred to that of the thermometer, which, 
 although it does indicate the temperature of the water, yet it does 
 not indicate what may happen to suit the state of the bather. River 
 or sea bathing, in the summer season, most generally agrees with the 
 constitution of the sex, but hip-baths, which tend to produce a con- 
 gestion of the pelvic viscera, should always be forbidden, except 
 under some special indication, of which a skilful physician alone is 
 the fitting judge. 
 
 Among the attentions to cleanliness, we ought to place in the first 
 rank those that refer to the cure of the sexual parts. The only liquid * 
 that a woman ought to use for her toilet , at all seasons of the year,, 
 except winter, is fresh water ; in the winter season it ought to be 
 tepid, that is, it should be made as warm as it is in the warm season. 
 Very cold water might produce inflammation of the vagino-uterine 
 
556 
 
 GENERAL HYGIENE OF THE SEX. 
 
 mucous membrane, and thus bring on the whites, whereas, the fre- 
 quent employment of tepid water is attended with the risk of relaxing 
 the genital organs, and giving them a disposition to be affected with 
 haemorrhage. 
 
 For the purpose of injecting the vagina, it is best to make use of 
 a syringe with a curved canula ending in an olive, with several 
 holes in it ; by such an arrangement of the canula, the woman is 
 not subject to too violent an impulsion of the liquid against the os 
 tincae. It is just to state, moreover, that all those toilet vinegars, 
 those essences, the astringent compositions, and all those mysterious 
 waters that the perfumers have the talent to produce, under a variety 
 of picturesque titles, should be proscribed by females who attach 
 any importance to the conservation of their health ; it is, at the same 
 time, useful for them to know, that certain preparations invented by 
 the corruption of the public manners, and which are the occasional 
 resources of mere libertinism, are far from equaling the precious 
 character of true innocence. 
 
 A desire to please, and to conquer all hearts by her beauty, has, in 
 all countries, and in all ages, been one of the most important occu- 
 pations in the life of the female ; to attain this end, her imagination, 
 fruitful in inventions of the sort, has suggested to her various means, 
 in the first rank of which is the cosmetic. These articles, which, 
 as their name shows, are designed to embellish the skin, have fallen 
 into the hands of a set of charlatans, who have transformed them 
 into a thousand shapes, more or less prejudicial to the health, and 
 always useless, “ pour reparer des arts V irreparable outrage 
 
 If there really are any cosmetics, which are unattended with inju- 
 rious effects upon the skin, such as the aromatic distilled waters, &c., 
 the greater proportion of them, especially the different sorts of rouge , 
 and among others, the red and the white, compounded of metallic 
 preparations, such as lead, mercury, antimony, bismuth, arsenic, 
 &c. &c., are extremely hurtful, and are, at the present day, wholly 
 abandoned to the use of players, courtesans, and a few old co- 
 quettes. Far from producing the effects so much wished for, these 
 various preparations are fit for nothing but to precipitate the appear- 
 ance of age ; they deepen the wrinkles, ruin the skin, arrest the per- 
 spiration, bring on tetter of different sorts, pimples, and erysipelas. 
 It is true, that some of them succeed in dispersing spots, and some 
 forms of cutaneous eruptions, but then they are generally followed 
 by metastasis and repercussion, that are mostly very dangerous. 
 Salivation, tremors, palsy, convulsions, colica pictonum, ophthalmias, 
 inflammation of the stomach, of the liver, and the lungs, have been 
 the miserable consequences produced by the application of various 
 metallic preparations to the skin. It is a duty, however, to observe, 
 that the rouge , called vegetable rouge, prepared from the carthamus, 
 as well as that extracted from red sanders wood infused in alcohol, 
 from cochineal, from the root of the alkanet, Brazil wood, and other 
 •vegetable substances, is attended with little danger, provided it be 
 seldom employed, and in moderation. According to Professor Chaus- 
 sier, the steatite may be made use of, without much inconvenience, 
 
HYGIENE FOR THE SEX. 
 
 557 
 
 for the purpose of whitening and polishing the skin, and even as a 
 preservative against certain contagious disorders. 
 
 Where fresh water, the best and most efficacious of cosmetics, will 
 not suffice to cleanse the skin, or restore its brilliancy and suppleness, 
 lost by the abuse of pleasures, prolonged vigils, the use of paint, the 
 action of the air, and the solar rays, &c., the ladies may successfully 
 employ a balsamic lotion, prepared by mixing ten drops of balsam 
 of Mecca, a drachm of sugar, the yolk of an egg, and six ounces 
 of distilled rose water or fleurs de feve. She might, likewise, make 
 use of the cucumber ointment, beurre de cacao ointment, or sweet 
 almond ointment, taking care to get them fresh, and without any 
 combination with the metallic salts, that certain perfumers are in the 
 habit of mixing with them. 
 
 Cucumber ointment, or the salve made with the same vegetable, 
 and coloured with alkanet, and perfumed with a drop of essence of 
 roses, is the only article that can be safely employed, either for 
 protecting the lips from the irritating action of cold weather, or for 
 giving them the vermilion tint which disease had deprived them of. 
 A woman ought always to refuse to employ the different sorts of 
 vinegars and spirituous preparations that are often recommended for 
 the same end. She will do well, also, not to use, without great 
 circumspection, most of the so-called treasures of the mouth, into 
 the composition of which various acids are known to enter, and the 
 presence of which renders them quite injurious to the teeth;* the 
 tincture of guaiacum, the vinous tincture of bark, and the spirit of 
 cochlearia, are the best dentrifices for the preservation of the mouth. 
 A mixture of water and alcohol, with a few grains of sal ammoniac, 
 may also be very beneficially employed, and the powder of Peruvian 
 bark, or charcoal, or burnt bread incorporated with honey, compose 
 an opiate which is very suitable for whitening the teeth, removing 
 the tartar that encrusts them, and thereby for preserving them from 
 the attacks of caries.t This opiate ought to be used at least once a 
 week, and it is right to rinse the mouth after each meal, with cool 
 wine and water, and to do the same thing every morning, with water 
 containing a portion of some one of the liquid dentrifices we have 
 mentioned, or merely a little eau de Cologne; no one should ever 
 clean the teeth except with a soft brush, nor should they take cold 
 drinks immediately after taking their food very hot. 
 
 The cosmetics prepared for the hands, and all the cutaneous sur- 
 faces, with a view to their neatness, consist of pastes and flour of 
 sweet and bitter almonds, of fecula, and of aromatic soaps. We 
 think it a duty, however, to say, that the Windsor and Palmyra soaps, 
 which are in most general use, are but ill suited to preserve the soft- 
 ness and suppleness of the skin, because they always contain an 
 
 * Dr. Regnard, ( Recherches sur la curie dentaire , 1838,) has proved, that the action 
 of acids on the teeth is the most common, and almost sole cause of caries. 
 
 ■f M. Taveau, a skilful dentist at Paris, and author of an excellent treatise on the 
 hygiene of the mouth, makes a most successful use of a ciment obliterique, for the 
 purpose of arresting caries, and curing pains of the teeth ; it is composed of anhy- 
 drous sulphate of alumine, and an alcoholic and etherial extract of the pistachia len- 
 tiscus, of the isle of Ohio. 
 
558 
 
 HYGIENE FOR THE SEX. 
 
 excess of alkali, which dries, and at last cracks it. None of these 
 objections are chargeable against the liquid soap, called Oleine , pre- 
 pared by M. Guerlain, Perfumer, at Paris. 
 
 The caustic substances that enter into the composition of depilato- 
 ries should be sufficient motive for rejecting their use ; not only may 
 they give rise to serious symptoms, but there is the further objection 
 that they do not fulfil the end proposed, for the hair which they cause 
 to fall soon grows again. All those metallic substances also, that are 
 used for dyeing the hair should be banished from a lady’s toilet as 
 being very dangerous articles. They mostly consist of nitrate of sil- 
 ver, or a mixture of sulphuret of lead and quick-lime, to be diluted 
 with water at the time of using it. We add, as to what relates 
 to the care of the hair, that she ought to confine herself to the 
 use of the comb ; to wash it from time to time with water, and to 
 detach the dandruff occasionally with a brush, and, lastly, she should 
 tress it with a grace, and perfume it occasionally with some perfumed 
 oil. We shall close by reminding the ladies that too frequent dress- 
 ing of the hair with hot curling tongs dries and makes it early turn 
 gray; that metallic combs cut it, and that the various pomatums 
 recommended for improving the growth of the hair, have no other 
 effect than to cover it with a coat of grease consisting, for the most 
 part, of coloured tallow, perfumed and occasionally mixed with oil 
 or beef’s marrow. Let us observe, moreover, that cleanliness and 
 native elegance, the graces of the body as well as those of the mind, 
 and, in fine, good temper and modesty, are the most powerful of 
 cosmetics. 
 
 Ingesta. Food , drinks , &c. — Although it be difficult, not to say 
 impossible, to trace out the rules of alimentary regimen applicable to 
 all women alike, we may state that their food ought to be propor- 
 tioned to their constitution and to the exercise they undergo, as more 
 or less fatiguing. Their taste naturally inclines them to prefer such 
 dishes and beverages as are easy of digestion, and most of them like- 
 wise are very fond of fruits — preparations of milk and all the lighter 
 kinds of food, or such as are taken from the vegetable kingdom. Yet 
 some there are who, giving way to a false appetite, have the habit 
 of overloading the stomach with food ; but it generally happens that 
 their exaggerated digestive power leads them to a state of corpulency 
 and excess of embonpoint which, by depriving the body of its sup- 
 pleness, its activity, and all its natural proportions, are as unfavoura- 
 ble to its beauty and its health, as leanness itself. There are also 
 many women to be met with who are extremely addicted to the use 
 of high-seasoned food and to spirituous and aromatic drinks ; but 
 most of those who thus transgress the laws of hygiene are found to 
 be barren, lean, of a bilious temperament, and subject to attacks of 
 uterine haemorrhage, disorders of the menstruae, cutaneous eruptions, 
 and also to inflammation of the womb and bowels. Women who 
 desire to retain, during the longest possible period, the advantages 
 of youth, of beauty, and above all, of health, should wholly abstain 
 from liquors, stimulating, acrid and spicy dishes, from fat meats, 
 pastry, and in one word, from all kinds of food artfully prepared to 
 
HYGIENE OF THE SEX. 
 
 559 
 
 exaggerate the limits of the appetite, and create factitious wants. 
 Light kinds of food, derived from the vegetable kingdom, meats of 
 easy digestion, boiled or roast meats, fish, birds and game plainly 
 dressed, milk in its various preparations, fruits, herbaceous vegeta- 
 bles, and lastly, water, either pure, or with a little red wine — such 
 should be the constituents of diet for a woman from puberty to the 
 change of life. We, moreover, give it as our opinion that the frequent 
 use of tea and coffee is in general hurtful to very nervous women, 
 and especially to those who shine less by their intellectual qualifica- 
 tions than by their beauty and all the perfections of their merely 
 physical nature. 
 
 4. Excreta. Excretion of the menses , the faeces, the urine and, 
 sweat , 8?c. — Our bodies so often waste and repair the materials of 
 which they are constituted that we may compare one of them to the 
 vessel of Theseus, which was so often repaired that at length not one 
 piece of its original t imbers was left. As the condition of health chiefly 
 depends upon the perfect harmony of this double action, it is easy to 
 understand why it is of importance to promote, and sometimes to 
 moderate the different secretions of the animal machine. Women 
 should not only follow out the hygienic rules we have traced for 
 them in reference to their menstruation, but they ought to pay a 
 special attention to the excrementitia! evacuations, to see that they are 
 effected in due proportions, at the periods, and by the routes assigned 
 for them by nature. Their attention is chiefly required as to the 
 urinary and fascal evacuations, that is to say, they ought to yield to 
 the first solicitations of the one, and facilitate the expulsion of the 
 other, by mild food, cooling drinks, and occasionally by means of 
 emollient enemata, and by suppositories, where there happens to 
 arise a state of obstinate costiveness. It is needful, also, to watch 
 with the same scruples, the state of the perspiration, remembering 
 that on the one hand, too much perspiration brings on general debi- 
 lity, and renders the skin susceptible to the vicissitudes of the weather, 
 whilst on the other hand, a sudden suppression of the sweat occasions 
 an infinity of disorders of a nature more or less severe. To keep up 
 a gentle perspiration of the whole skin ; to keep the person perfectly 
 clean ; to dress moderately and suitably as to the season ; to abstain 
 from all immoderate exercise, and, lastly, to avoid sudden transitions 
 from heat to cold ; such are the means by which they may keep up 
 a constant regular exercise of the functions of the economy. 
 
 5. Gesta. Exercise , late hours, sleep, rest, fyc . — To keep her- 
 self in a state of health as perfect as may comport with the mobility 
 of the organization, the female should addict herself to a moderate 
 amount of exercise, which should end, however, as soon as it becomes 
 fatiguing. All the world knows that the celebrated Tronchin, when 
 he was called to the court of Louis XVI. and consulted by nervous 
 ladies as to their disorders, never recommended any thing but exer- 
 cise, sustained and varied by all sorts of dissipation. He pushed the 
 rigour of his orders so far as to prescribe for them the very duties 
 their valets had been accustomed to perform for them; and the 
 
560 
 
 HYGIENE OF THE SEX. 
 
 coquettes and high dames of the court were seen polishing the inlaid 
 floors, which they had before scarce deigned to press with their feet. 
 
 We ought, also, in this relation, to bring to mind the inestimable 
 value of rural pursuits. The aroma of plants and flowers exhaled 
 at sunrise, the oxygen which is set free in torrents under the influence 
 of light, the ravishing aspect of nature, the melodious song of the 
 birds, all serve to procure the most delicious sensations, and impart 
 to the organs an incredible amount of strength and health. 
 
 Among the exercises to be regarded as most suitable for females, 
 are those connected with house-keeping, walking, as an amusement, 
 or as a prescription, riding on horseback, jumping, and above all, 
 dancing, provided it be not continued to a late hour of the night, 
 nor indulged in immediately after a repast or during the catamenial 
 flow. The waltz, which has on very good grounds met with many 
 opponents, conjoins with the disadvantage of fatiguing too much, 
 the greater one of propelling the blood too strongly towards the 
 principal internal organs, and especially the 'heart, lungs and brain. 
 Speaking, reading aloud, and, above all, singing, contribute more 
 powerfully than might be supposed to the conservation of the health, 
 and the prevention of many affections of the lungs and stomach. 
 Moderate exercise, moreover, increases the appetite, facilitates the 
 digestion of the food, energizes the circulation of the fluids, promotes 
 the secretions and the excretions, and augments the power and 
 activity of all the systems of organs. When carried to excess, it is 
 far from producing such salutary effects ; for it then exhausts the 
 organs, reduces the strength, and renders all the functions languid. 
 In fine, leisure, indolence, luxurious habits, the soft and sedentary 
 tone of life which are the very vices of education among the wealthy, 
 leave the body in a state either of debility or of lymphatic embon- 
 point, and frequently constitute the chief causes of a thousand nervous 
 affections and that excessive sensibility which renders even the gen- 
 tlest impressions absolutely painful. 
 
 It is impossible to repeat too often, that exercise is the surest anti- 
 dote to the continued state of suffering complained of by many ladies 
 in high life. Let a languishing coquette, pale and vapoury, keep 
 company with strong, healthy village girls, and participate in their 
 labours as well as their amusements, for awhile ; she will soon find in 
 herself a most admirable metamorphosis ! Her digestion, which was 
 disordered, will be gradually restored ; her strength will return in 
 company with the freshness and bloom of her complexion ; indeed, 
 her whole nervous system will be corroborated, and the desperate 
 languor and mobility which constituted a continued state of suffering, 
 will soon give place to a stable and brilliant condition of health. 
 
 Rest, which is as needful as exercise, should be enjoyed in proper 
 proportion. Late hours are always prejudicial to the health of the 
 sex, because they cannot repair, in the morning, the losses of sleep at 
 night, nor with impunity invert the invariable order of nature. With 
 those among them, who, as they say, turn night into day and day into 
 night, all the organs suffer, the functions are deranged, the nutrition 
 is very imperfect, the physical constitution loses its energy entirely, 
 
HYGIENIC RULES FOR THE SEX. 
 
 561 
 
 and the appearance and bloom of youth soon depart and give place 
 to wrinkles and old age. 
 
 Although sleep is a means of restoration, with which nature 
 endows us, it ought not to exceed certain bounds, that is, it ought 
 not to be prolonged beyond from seven to nine hours. Sleep solicited 
 by too soft a bed, plunges the nervous system into a sort of stupor, 
 induces debility rather than procures strength, and brings about a 
 fulness of the vessels, followed by torpor of the circulation, and not 
 rarely by haemorrhage. Upon the whole, the female ought to retire 
 early to bed, be up betimes in the morning, and pass her waking 
 hours in occupations that may exercise without fatiguing the organs. 
 
 Percepta, passions , intellectual labours , fyc . — Helvetius says 
 “that the passions are the celestial fire that vivifies the moral world ; 
 it is to them that the arts and sciences owe their discoveries, and man 
 the elevation of his position.” It is true, however, that, while some of 
 them are useful to him, the greater proportion of them agitate the cur- 
 rent of his existence, fill it with storms, and curtail its duration. Their 
 influence upon his health is questioned by none, whether they act 
 slowly or whether they burst forth with impetuous violence : in the 
 former, they are like a concealed poison that destroys ; in the latter, 
 like a devouring flame. Notwithstanding that each one of the passions 
 possesses a character peculiar to itself, and discloses itself by charac- 
 teristic signs, they all have this in common, that they pervert the 
 habitual order of the organs. The concentrated passions, such as 
 jealousy, hate, fear, envy, grief, and its varied forms, direct their 
 action principally upon the diaphragm, the stomach, liver and womb, 
 all whose functions they are capable of disturbing. 
 
 The intense passions, as well as emotions, whether agreeable or 
 painful, felt in excess, impart shocks so violent that the most alarm- 
 ing symptoms, and even death itself, may be brought on by them. 
 Tissot knew a female at Lausanne, who fell into convulsions when- 
 ever the name of her rival was mentioned in her presence. In the 
 annals of France, we see that a princess of Conde died of jealousy, 
 on hearing that her husband had attached himself to a lady of 
 honour to Catherine de Medicis. Valerius Maximus speaks of an 
 Athenian lady who lost her speech in an excess of rage; and Buchan 
 reports the case of a woman who died suddenly with cerebral hae- 
 morrhage, produced by a similar cause. Lastly, Professor Rostan 
 saw a lady perish in the course of two days, with an attack of peri- 
 pneumonia, with which she was seized upon reading a letter that 
 announced the death of her son. Let us further add, that a sordid 
 interest led to the sudden death of Leibnitz’s niece. That cele- 
 brated philosopher had scarcely yielded his last sigh, when his ava- 
 ricious heiress caused his trunks to be opened, and, upon seeing the 
 piles of gold he had bequeathed to her, was so filled with delirious 
 joy, that she expired before she could count them, (Elo<*e de Leib- 
 nitz, by Fontenelle.) We also observe that Cromwell’s daughter, 
 after the execution of Charles I., was so indignant at having for her 
 father the assassin of her king, that she died of despair. Although 
 the lively emotions and impetuous movements of the soul do not 
 36 
 
562 
 
 IMPOTENCE AND STERILITY. 
 
 always produce such fatal effects, they always act in an injurious 
 manner upon the economy, and principally among women whose 
 sensibility and imagination are commonly of an exalted cast. 
 
 We conclude with remarking, that literary labour, abstract studies, 
 protracted meditations, which, in a manner, concentrate all the vital 
 forces upon the organ of thought, are also very prejudicial to females. 
 Conflicts of the mind are especially hurtful to them, at the period 
 when nature calls upon them to fulfil the important functions of their 
 sex, and at an age when they ought to shine rather by the advan- 
 tages and graces of youth, the art of pleasing and the charms of their 
 conversation, than by a scientific or literary reputation, which men, 
 even, never purchase but at the expense of both their health and 
 their happiness. 
 
 ’SECTION sixth* 
 
 CHAPTER XI. 
 
 LESIONS RELATIVE TO REPRODUCTION. 
 
 Lesions and sympathetic phenomena produced by conception, pregnancy, labour and 
 
 lactation. 
 
 In the female, the lesions relative to reproduction may refer to her 
 as in a state of conception, pregnancy, labour or lactation. 
 
 Among the lesions connected with conception, we may name im- 
 potence and sterility, false pregnancy, moles and extra-uterine preg- 
 nancy, which we shall here proceed to consider ; and, first, 
 
 OF IMPOTENCE AND STERILITY. 
 
 With a view to establish what we conceive to be a useful distinc- 
 tion betwixt impotence and sterility, let us make such a definition as 
 to prevent their being confounded together. 
 
 By impotence in the female, we should understand an inaptitude 
 for conception, dependent on a fault of the physical condition, render- 
 ing the accomplishment of the reproductive act more or less impos- 
 sible. 
 
 Sterility, on the other hand, is an incapacity, in any woman, to con- 
 ceive, notwithstanding that copulation may, in her case, take place 
 in a natural manner, and be accompanied with all the apparent 
 
 * This is the commencement of the third volume, or supplementary volume, which 
 appeared in the year 1843. It was M. Colombat’s intention to close his labours with 
 the last paragraph; but I am happy to think that he has been enabled to bring his 
 task to a later conclusion by the following fine essays on the Diseases of the Pregnant 
 and Lying-in Woman. 
 
IMPOTENCE AND STERILITY. 
 
 563 
 
 conditions of fecundation. From the distinction now set up, it follows, 
 that a woman may be impotent without being sterile, and vice versa. 
 
 Among the causes of impotence, all of which are connected with 
 some deformity of the genital organs, we may enumerate absence of 
 the vagina, primary or accidental obliteration of that tube, excessive 
 contraction or undersize of it, produced by a deformity of the bones 
 of the pelvis, or by a tumour that cannot be removed ; and, lastly, 
 cohesion of the labia or nymphse ; persistence and firmness of the 
 hymen, or any other membrane in the vagina ; excessive magnitude 
 of the clitoris, and all other deformities of structure preventing the 
 accomplishment of the genital act, and which may, often, be reme- 
 died by various operations that were treated of in the fifth chapter 
 of this work. Let us add, that prolapsus of the womb or vagina, a 
 communication of the vagina with the rectum, as well as a very 
 great amplification of the size of the vagina, produced by a lacera- 
 tion of the perineum, do not constitute absolute causes of impotence. 
 
 The causes of sterility, a case difficult and often impossible to ascer- 
 tain, are, absence of the womb, inclination, incurvation and occlu- 
 sion of the womb ; chronic inflammation of its texture and of its 
 internal membrane ; its spasms, its atony and its haemorrhages ; also 
 the absence of all uterine cavity, absence of the ovaries, specific dis- 
 eases of the ovaries, accompanied with degeneration of their struc- 
 ture, obliteration and chronic inflammation of the Fallopian tubes, 
 and all the disorders of the genital organs which yet give no signs 
 leading to a suspicion of their existence during the lifetime of the 
 woman. 
 
 [I saw, a few years since, a lady who was attacked with symptoms of 
 iiiaca passio. Nothing relieved her, and she died with the appearance of 
 a person labouring under strangulated intestine. Upon examination, after 
 death, a knuckle of intestine was found to have passed under a band within 
 the pelvis, and to have become fatally strangulated there. This was one of 
 numerous bridles which had been produced many years before, when this 
 lady was about thirteen years of age, and suffered from an attack of perito- 
 nitis, to which she had nearly fallen a victim. Her Fallopian tubes were 
 adherent, so as to render their physiological function impossible, and, indeed, 
 she had passed many years in wedlock, without having conceived. I sup- 
 pose that young girls attacked with peritonitis, ought to be held very liable 
 to the accidental destruction of their reproductive power, by this very adhe- 
 sion of the tubes. — M.] 
 
 There are two kinds of sterility that may be called physiological, 
 since they are natural to all women : the first is that which exists in 
 young girls previous to puberty, and the second takes place in women 
 who have passed beyond the change of life. Women giving suck 
 are also very often found to be barren, and particularly during the 
 early months that follow the birth of the child, because the vital 
 forces are then concentrated upon the organ of lactation. 
 
 Sterility seems also to be more common in hot than in temperate 
 
564 
 
 IMPOTENCE AND STERILITY. 
 
 and high northern latitudes: the abuse of baths and of venereal plea- 
 sures are perhaps the causes of it. There is not any doubt that 
 women who abuse these pleasures are like the whole class of prosti- 
 tutes, very subject to sterility, which, moreover, is far more common 
 in women than among men. It is, therefore, not without some show 
 of reason that when a couple, of proper .age, continue to be without 
 offspring, it is the woman who is generally accused of barrenness. 
 
 Generally speaking, sterility proceeds from some congenital affec- 
 tion ; and, in a multitude of cases, the cause has been supposed 
 to be discovered. Among the most common and indubitable of 
 these causes, is absence and irregularity of the menstruation. 
 Notwithstanding, we have reported some instances of women con- 
 ceiving, though they had never menstruated, and of others who had 
 never menstruated except during their pregnancy, it nevertheless 
 holds true, notwithstanding such rare facts, that the menstrual dis- 
 charge is the most certain indication of the aptitude of a female for 
 conception. 
 
 A habit of excessive menstruation has also been regarded as the 
 cause of non-fecundation in some cases; also, profuse leucorrhoea, 
 when habitual. A painful sensation, durante eoitu ; absence of the 
 exterior attributes of the female sex, and of voluptuous desires and 
 sensations, at the conjugal approaches ; a considerable embonpoint, 
 or want of consonance betwixt the husband and wife, as to tempera- 
 ment : m fine, too violent and too frequently repeated transports, as 
 well as a constitution as to the female, that resembles too closely that 
 of the male ; such as we observe in tall women, with small mammae, 
 strong eoarse voice, and brown skin, covered with hairs in places 
 usually destitute of them, in the sex. 
 
 While compelled to admit that in certain cases, some of the circum- 
 stances we have now particularized really constitute conditions that 
 are unfavourable to conception, ought we not, at the same time, to 
 confess that almost all the theories, as well as the cases on which 
 they are founded, are diminished as authority, by other facts that 
 greatly lessen the value assigned to them by writers. Indeed, do we 
 not daily observe that women bring forth children, notwithstanding 
 they may have been subject to profuse menstruation, or have had 
 copious discharges of whites, but who are in fact more liable to abor- 
 tions and premature delivery than other women are? Is not the 
 same true, as to the supposed contrast betwixt the two spouses, sus- 
 tained with so much vigour by Lucretius, and especially by Bernardin 
 de Saint-Pierre, with all the power of his poetical style and his bril- 
 liant imagination. Though certain women are known not to have 
 been impregnated by one husband, though they have borne children 
 to another one, ought we to count for nothing the greater generative 
 power of the last husband ; and, besides, is it not often the case, 
 that a woman shall be sterile for a certain time only, and that many 
 of them have become pregnant after being several years married, yet 
 without any change of husbands? Anne of Austria gave birth to 
 Louis XIV. after twenty-two years of barrenness, and Catherine de 
 Med ids brought forth the first one of her ten children after she had 
 
IMPOTENCE AND STERILITY. 
 
 565 
 
 been married ten years to her husband, Henry II. Is it not also 
 known that women, even such as manifest the greatest indifference 
 for their husband’s embraces, or who have been very fat, could yet 
 be impregnated by the embraces of men of character, age and tem- 
 perament, the most various? Farther, are there not many who 
 become mothers, without taking the least voluntary part in the geni- 
 tal act, inasmuch as they had been surprised by force, or had been in 
 the lethargy of the profoundest narcotism ? 
 
 [I have attended, during many years past, a considerable number of cases 
 of leucorrhcea, in which the discharge consists of a small quantity of viscid 
 mucus, coming away from the genital organs at intervals, and not escaping 
 by a steady or continuous flow. In most of the cases, the mucus is thick, 
 translucent, or even transparent, or only slightly opaque, and amounts to 
 about a teaspoonful. In certain persons, I have observed that but one dis- 
 charge took place per diem, and that in the afternoon, leaving the patient 
 free from discharge during all the rest of the day. By using the speculum 
 uteri, I have repeatedly seen this mass or lump of phlegm sticking in the 
 os uteri, and have removed it from there with a bit of sponge : it is cohesive 
 and ductile, so that if caught upon the points of the sponge, the whole mass 
 seems to be drawn out from the cervix. 
 
 I am of opinion that this substance is produced by the mucous glandules 
 and follicles just within the os uteri; the same that so abundantly secrete it 
 in the beginning of labour. Indeed, the mucus of this leucorrhcea is pre- 
 cisely like that of the dilating cervix uteri in labour. I believe that all women 
 thus affected are sterile ; at least, the disorder has been invariably accompa- 
 nied with sterility, in my patients. The treatment by nitrate of silver, by 
 leeches to the os uteri, by alteratives, astringents, tonics, and, indeed, by 
 whatever measures, is in general very unsatisfactory. I have, in two cases, 
 removed the symptoms by means of the dilating bougie, as recommended 
 by Dr. Mackintosh, in his Practice of Physic , under the head “ Dysme- 
 norrhcea but my success, in the use of the bougie, has not equalled the 
 expectations raised by his publication. 
 
 For such a case, the occasional cauterization of the canal of the cervix, 
 with nitrate of silver, or a pencil of sulphate of copper, in a proper caustic- 
 holder ; astringent injections, bath^, and the total change of the constitu- 
 tional state produced by a long voyage, a journey and change of climate, afford 
 the most probable grounds of hope to effect the cure. — M.] 
 
 From the foregoing, we ought to conclude that much doubt rests 
 upon questions concerning the causes of sterility, and, of course, that 
 we should put numerous restrictions upon all the circumstances that 
 are looked upon as giving rise to it, and which must always continue 
 to be very obscure, for want of a rigorous examination and from the 
 impossibility that generally obtains, of ascertaining the real state of 
 the internal genital organs of the female. There are, therefore, no 
 certain signs by which to distinguish a barren from a fruitful woman. 
 
566 
 
 IMPOTENCE AND STERILITY. 
 
 Hippocrates, indeed, remarks that fruitful women are small, of dark 
 complexion, menstruating freely ; that they have well-developed and 
 projecting breasts, with the womb dry, neither contracted nor too 
 low. He adds that, on the other hand, sterile women are pallid, do 
 not menstruate well; they are fat and fleshy, too ardent or too cold in 
 love, and are generally troubled with leucorrhcea and with headache. 
 
 He also says, (Aphor. v. 62 ,) that those who have the womb cold 
 and dense, as well as those who have it moist, do not conceive; in 
 them the embryo perishes : such as have a very dry womb are like- 
 wise unfruitful, because the semen is destroyed for want of nourish- 
 ment. Notwithstanding all these assertions of the father of Medicine, 
 and a multitude of other assertions of the same sort, what numerous 
 exceptions do we not find to these general rules ; since we meet with 
 fruitful women of all the various temperaments, while we also observe 
 a great many who are barren, but who yet enjoy the most perfect 
 health, and the most regular conformation. 
 
 Seeing, then, the great uncertainty as to the causes of sterility, we 
 may readily comprehend how inefficacious must often be the reme- 
 dies proposed for its cure. The success of these measures in some 
 cases cannot even go to prove their utility, even in those very cases, 
 inasmuch as we often observe that sterility disappears in women 
 long barren, without having it in our power to appreciate the cir- 
 cumstances which may have restored the aptitude for fecundation. 
 
 Although, strictly speaking, sterility is not a disease, it may be 
 accompanied by such serious moral consequences, that it is important 
 to set forth in this connection the chief measures that have been em- 
 ployed for its removal under various circumstances. 
 
 Treatment . — When the barrenness depends upon faulty confor- 
 mation, and upon diseases of the womb, we may hope to combat it 
 by remedying its deformities and curing its diseases, either by means 
 of the different operations we have pointed out, or by medical treat- 
 ment appropriate to the disease, all of which have been treated of in 
 this work. It must be unnecessary to state that in some cases sterili- 
 ty is wholly incurable. 
 
 If we suppose in a case, that non-fecundation depends upon an 
 inclination, and particularly upon an anteversion of the womb, we 
 might recommend the coitus more ferarum^quadr'u'pedumque ritu , in 
 accordance with the advice given by Lucretius. Further it would be 
 proper in all cases to recommend the sexual approach just before and 
 after the mensual apparition. This is the moment when the mouth 
 of the womb is open, and when the organ has the greatest amount of 
 action, and is therefore most apt for conception. It was by giving to 
 Henry II. the counsel, previously imagined for such cases by Hippo- 
 crates, that Fernel was so fortunate as to procure for France a Dauphin, 
 and to put an end to the sterility of the Queen Catherine de Medicis. 
 
 If it be supposed that an excessive degree of ardour in the genital 
 act, is the cause of the sterility, it might be useful to prescribe an 
 emollient regimen, baths, light food and cooling drinks, and especially 
 the use of cold milk, containing a teaspoonful of lime-water to every 
 cupful. Long walks and journeys could not but be useful. In 
 
STERILITY. 
 
 567 
 
 contrary circumstances, that is, where the woman is of a lymphatic and 
 cold constitution, and remains indifferent to the conjugal caress, we 
 might recommend country air, tonic and stimulating baths, especially 
 the sea bath, chalybeate and sulphurous waters, such as those of For- 
 ges, of St. Alban, Vichy, Aix la Chapelle, Bareges and Aix in Savoy. 
 The patient would be the better, likewise, for a substantial diet, as 
 black meats, eggs, a glass of generous wine, chocolate, salep, sago, 
 celery, mushrooms, truffles, vanilla, and the various analeptic and ex- 
 citing articles. In fine, where there exists a complete state of ana- 
 phrodisia, we might advise the frequentation of the ball-room, the 
 theatre, and even the reading of romances and other works of a some- 
 what erotic character. 
 
 Where the female is excessively fat, attempts might be made to 
 add to the energy of the entire system, and to reanimate the action 
 of the womb, by prescribing the internal use of mint, balm, garden 
 rocket, saffron, aloes or nutmeg. These substances might also be 
 used in enemata and in injections, which should also be recom- 
 mended, as well as frictions of the loins, thighs and hypogaster with 
 a hot flannel, impregnated with oil of petroleum, of saffron, or rue, or 
 with vapour of amber, benzoin, or the volatile and spirituous sub- 
 stances. In women of too strong a constitution, recourse should be 
 had to venesection, to tepid baths, to a half-diet, to milky acidulous 
 and cooling drinks. Let us further say, that where the sterility may 
 be supposed to arise from any excess of venereal indulgence, the 
 parties ought to be separated for some time, or at least learn to have 
 some moderation as to their sensual gratifications ; after this let trial 
 be* made of tonics, sedatives and an analeptic regimen. It is unne- 
 cessary to say that cantharides or phosphorus should never be em- 
 ployed for these ends, but with the greatest reserve and the most 
 scrupulous attention. 
 
 [_ Although not absolutely apposite to the subject, I cannot refrain from 
 contrasting with the cases of special impotence and sterility, the remarkable 
 productiveness of the human female after the great epidemic of the 14th 
 century, called the Black Death. Dr. J. F. C. Hecker, in his work, “ The 
 Epidemics of the Middle ages,” states, at page 31, that “ After the cessation 
 of the Black Plague, a greater fecundity in women was everywhere remark- 
 able — a grand phenomenon, which, from its occurrence after every destruc- 
 tive pestilence, proves to conviction, if any occurrence can do so, the preva- 
 lence of a higher power in the direction of general organic life. Marriages 
 were, almost without exception, prolific ; and double and treble births were 
 more frequent than at other times,” &c. Dr. Hecker computes the mortality 
 in Europe during the three years of the prevalence of the Black Death at 
 25,000,000 souls. 
 
 It seems to me that M. Colombat might have spared himself much 
 of the foregoing articles upon the nature, causes and treatment of sterility, 
 had he been fully acquainted with the novel doctrines on the ovum of 
 the mammalia to which we have so often referred. Doubtless the tra - 
 
568 
 
 FALSE PREGNANCY. 
 
 vail ovarique fails in many women to produce the perfect ovule, although 
 the development of the Graafian cell may go on, and, indeed, in some ab- 
 normal condition of the vesicle, as, for example, where it becomes twice or 
 thrice as large as it ought to be, we might well suppose the elements of a men- 
 struating power even greater than the healthful one ; yet without developing 
 a healthful ovule, germinal vesicle, or germinal macula. M. Pouchet, as 
 has been seen at p. 482, is of opinion that the precise time wherein the act of 
 fecundation is impossible, can be correctly indicated, while it is most proba- 
 ble that the period during which it is most practicable cannot be so well 
 determined, since observation has not, as yet, settled the question as to the 
 date of the rupture and discharge of the Graafian vesicle ; as, whether 
 antecedent to, in the midst of, or at the close of the menstrual phenomena. 
 This, perhaps, can never be settled ; and it is even probable that it is a varia- 
 ble, not a constant period. — M.] 
 
 OF FALSE PREGNANCY. 
 
 The term false pregnancy comprehends a variety of affections that 
 may simulate true pregnancy ; some of them are always products of 
 conception, and others are independent thereof. Among the former, 
 we include moles ; and, among the latter, we class the cases of hy- 
 drometra, of tympanitis, of hydatids of the womb, polypous, scirrhous, 
 and cancerous tumours of that organ, collections of pus, blood, me- 
 senteric or epiploic tumours, ascites, and scirrhus and dropsy of the 
 ovarium. 
 
 Inasmuch as we have, in separate chapters, traced the history of 
 the disorders that may be confounded with true pregnancy, we shall 
 here be content succinctly to recapitulate the common considerations 
 they present in their resemblance to normal pregnancy, to which 
 they for the most part conform only in regard to the distensjon of the 
 abdomen. It is true that in many of the instances these affections 
 are coincident with suppression of the catamenia, a suppression 
 which they may either cause, or follow ; and it is also unquestionable 
 that the suppression of this evacuation may give rise to other symp- 
 toms of pregnancy, such as enlargement of the breasts, nausea, 
 vomiting, &c. Under these circumstances to commit an error is so 
 very easy, that there are, perhaps, few medical men who have not 
 witnessed, or even been subject to such mistakes. Desormeaux re- 
 lates a case of a gross mistake, but of an inverse sort. 
 
 “ A female living in the Faubourg St. Marceau was pregnant; 
 certain impudent quacks asserted that she laboured under dropsy, 
 and plunged a trocar into her abdomen, which killed her.” The 
 same author adds that he was called in consultation to decide as to 
 the necessity of the Caesarian operation for a woman who was sup- 
 posed to have been several days in labour. She was labouring 
 under an attack of intense peritonitis, of which she recovered, but 
 she also had a scirrhous ovarium, of which she died some months 
 later at the Alaison Roy ale c/e Sante. 
 
FALSE PREGNANCY. 
 
 569 
 
 Roussel speaks of a woman in whom all the signs of pregnancy 
 were found, but who, after the lapse of nine months, was delivered 
 of them by a flooding. Mauriceau recites the case of a woman, fifty 
 years of age, who believed herself pregnant, and engaged a midwife 
 to stay in the house with her, and had the baby-clothes ready — but 
 whose supposed pregnancy ended in a discharge of gas. Schmidt, 
 Lamotte, M. Lefevre and many other persons tell us of similar cases. 
 In fine, we refer the reader as to the diagnosis of the diverse affec- 
 tions that simulate real pregnancy, to our remarks in the chapters 
 on physometra, hydrometra, hydatids, calculous concretions, uterine 
 polypus, and on inflammation, dropsy, cancer and other degenera- 
 tions of the ovarium. 
 
 The collection of symptoms known as nervous pregnancy , or hys- 
 terical pregnancy , which generally depends upon some spasmodical 
 affection of the abdominal viscera, and which sometimes depends 
 upon a chronic inflammation of those organs, is the form of false 
 pregnancy most commonly met with, and moreover, the one that 
 most generally gives rise to mistakes. For the most part it is met 
 with among women approaching the change of life ; in women 
 affected with accidental suppression of the catamenia, who are ner- 
 vous, irritable, hysterical, and particularly in the unmarried ; further, 
 in widows, who imagine themselves pregnant by a second husband ; 
 and in those who, having lost their first children, are extremely 
 anxious to have them replaced. 
 
 With all these women, the abdomen swells; the menses cease to 
 appear ; nausea, disgust, enlargement of the breasts, and in many of 
 the cases, all the rational signs of pregnancy supervene, so as indeed 
 to impose upon the most skilful accoucheur, as happened in fact to 
 Professor A. Dubois. 
 
 Under such circumstances, as well as the others that we have 
 described, an exact appreciation of the positive signs of real preg- 
 nancy, and of the signs peculiar to each of the affections that might 
 simulate it, ought to enlighten the physician, and place: him in a 
 position to decide as to what kind of lesion the case submitted f m his- 
 opinion belongs. Furthermore, the diagnosis is of still greater diffi- 
 culty where pregnancy is complicated with some one of the affec- 
 tions above pointed out; yet, from the fifth month onwards, the 
 careful exploration of the womb serves to remove every doubt, in 
 whatsoever case of false pregnancy, and to dispel every illusion upon 
 the subject. In fine, the treatment of these various affections is in 
 substance pretty much the same as the treatment of hysteria, to 
 which we now refer the reader. 
 
 ♦ 
 
 [M. Colombat thinks that from the fifth month forward the difficulty of 
 diagnosis is greatly lessened, if not removed. I have to say that in cases of 
 ascites and anasarca, the greatest embarrassment is likely to befall any man 
 who may be called upon to decide the question of pregnancy, provided there 
 be a dead foetus in utero, floating in an excessive quantity of liquor amnii, 
 while the womb itself is drowned in a vast ascitic effusion. The utmost 
 precaution should be used by the medical practitioner, in making the diag- 
 
570 
 
 MOLES. 
 
 nosis. He ought not to omit either the Touch, the abdominal taxis, or the 
 stethoscopic exploration, nor should he leave out of view the commemorative 
 and the rational signs of pregnancy connected with the particular case, while 
 contemplating the sensible signs of the supposed pregnancy. Still, under cir- 
 cumstances like those above proposed, the difficulty is sometimes extreme. 
 For my own part, I have but one rule of action ; and that is, to admit very can- 
 didly my inability to decide, where I have not the clear and undeniable signs of 
 a pregnant womb. Dr. Evory Kennedy, in his valuable work on pregnancy 
 and auscultation, informs us that the stethoscope and other means of ausculta- 
 tion sometimes reveal the heart’s action of the fcetus before the expiration of 
 the fourth month ; yet, when he has detected the sounds, they have been “ so 
 delicate and feeble as to render it necessary for the individual exploring, to 
 have an ear well trained to stethoscopic sounds. In general, therefore, we 
 may look upon it, that this phenomenon is not to be detected until after the 
 period of quickening, when the uterus has risen out of the pelvis, and allows 
 of one coming more immediately in contact with that part of it where the 
 embryo is contained.” — p. 101. I may add, that Dr. Kennedy’s book is 
 worthy of the perusal of every medical or obstetrical practitioner. — M.] 
 
 OF MOLES, OR DEPRAVED CONCEPTION. 
 
 There are other kinds of false pregnancy which arise from a con- 
 ception natural at the commencement, but the product of which has 
 become changed as to its nature, under the influence of some mor- 
 bific cause, and has still further changed after the death of the 
 embryo. 
 
 The productions that result from these depraved conceptions, have 
 received the denomination of moles, which are distinguished as of 
 three kinds, and, of course, constitute three kinds of false pregnancy, 
 to wit, 1, False germ or embryonal mole ; 2, Fleshy mole ; 3, Hyda- 
 tid mole. 
 
 By the word mole, from the Latin mola , and the Greek \io or 
 from moles , mass, is meant an organized fleshy insensible body, 
 generally softish, sometimes hardish, of variable and indeterminate 
 shape, which, after having begun and having been developed within 
 the womb is, instead of a foetus, sooner or later expelled from the 
 cavity of the organ. 
 
 Moles have been confounded with polypus and with the various 
 other tumours that are produced within the womb ; yet there is 
 one very important difference that distinguishes them, which is that 
 moles are always the results of depraved conception, and products of 
 generation disturbed in its formation and altered in its composition ; 
 while other tumours are parasitic bodies, developed spontaneously, 
 and without any clearly appreciable causes. 
 
 Fernel, the physician of Henry II., was the first author to repro- 
 duce the idea that a genital act is necessary for the formation of a 
 mole. Nusquam visa est mulier molarn sine mare concepisse. 
 This opinion was, at a later date, maintained by Mauriceau, who 
 
MOLES. 
 
 571 
 
 « 
 
 rested the opinion upon a number of facts, which have never since 
 been successfully controverted. Hippocrates, Galen, Aristotle, Mos- 
 chion, Mercurialis and Roderic a Castro, supposed the mole to consist 
 in a mass of flesh developed in the womb in consequence of an imper- 
 fect conception ; yet Hippocrates speaks of certain bodies that grow 
 within the womb, in strong, robust young girls ; and Galen avers 
 that in the same way as the hen may lay her eggs without the tread 
 of the cock, so some women may produce moles without the inter- 
 vention of the husband. Lastly, Mercurialis ( De morb. mulierum , 
 lib. i. cap. 4. p. 24 . 1597,) pretends that a voluptuous dream has often 
 sufficed to give rise to a mole in the womb of a young girl. Wein- 
 rich, of Breslau, thought that a mole might be formed in the uterus 
 of a virgin, or even of a castrated woman, [Comment, de monstris , 
 1595.) In fine, Stalpaart Van der Wiel described a virginal mole, 
 ( Obs . rariores medicinal ., 1687,) and Hanneman published a memoir 
 on the moles of young girls, [Ovum Harv. gener. 1678); this opinion 
 is partly admitted by M. Velpeau, who recognizes the possibility of 
 the mole in a virgin, but regards them as very rare. 
 
 With a view to reconcile all these different opinions, Lamzeweerde 
 [Hist. Nat. Molarum Uteri , 1686,) distinguished them into moles 
 of generation and moles of nutrition. The same author victoriously 
 opposed all the ridiculous prejudices which prevailed in his day 
 on the subject of moles, and which some medical men promoted 
 by their marvellous histories of vital moles, and fantastic animals, 
 living or dead, such as screech-owls, frogs, lizards, bats, dragons, 
 apes, &c., brought into the world by women. Some authors also 
 have admitted the existence of true and false moles ; that is to say, 
 they supposed some to be the result of abortive conception, while 
 others had formed spontaneously and without any appreciable cause ; 
 among the latter they classed the wind-mole, the water-mole and the 
 humoral mole, which were neither more nor less than the disorder 
 we have described under the heads of hydrometra and physometra 
 or uterine tympanitis. 
 
 Whatever may be the supposed value of these opinions, it is at 
 present generally admitted by the pathologists and accoucheurs, that 
 a mole is the result of a conception that has become depraved from 
 some cause, and which is called a false germ, or embryonal mole, 
 where the product does not remain more than two or three months in 
 the womb, and besides, exhibits the usual envelopes of the ovum, 
 which, though always thicker and more dense than the healthy ones, 
 are yet filled either with a transparent or a bloody fluid, amid which 
 are discovered the early lineaments of the embryo. False germs, 
 then, differ from fleshy moles, only as to the longer sojourn of the 
 latter in the womb, and as the membranes are both thicker and more 
 consistent. 
 
 Fleshy moles are sometimes hollow and sometimes compact or 
 solid. In the former the size varies from that of a goose-egg to that 
 of a foetal head ; the cavity is polished and full of water, while the 
 external surface is fungous, uneven, rounded, and sometimes lobular 
 and angular. In the latter case, which is where the mole is solid, it 
 
57 2 % 
 
 HYDATID MOLES. 
 
 consists of a more irregular and larger mass ; they are sometimes 
 met with of enormous dimensions, but for the most part do not 
 exceed the size of the double-fists. Their texture is composed either 
 of a filamentous and spongy tissue, like that of the placenta, or of a 
 fleshy parenchyme mixed up with clots of fibrinous blood, amid which 
 are often found incorporated the remains of embryos, bones, and 
 even whole limbs. 
 
 The last circumstance proves that a twin pregnancy may coincide 
 with a fleshy-mole ; but it is very uncommon for both the products 
 to be affected at the same time, and for two moles to be simulta- 
 neously formed within the womb. On the contrary, a mole has often 
 been found to co-exist with the natural product, and at the conclusion 
 of the term of gestation, the exclusion of the mole has immediately 
 followed that of the living foetus, or at least it has come away in the 
 course of a few days after the birth of the child. In certain cases, 
 such a mole produces abortion, or indeed, which is still more rarely 
 observed, it is expelled at some period of the pregnancy earlier or 
 later, and the pregnancy then goes on through all its stages, the 
 woman reaching the full term and giving birth to a perfect child. 
 It is proper to say further, that moles have been known to remain 
 for years within the womb ; Pierre Rideux, grandson to the Regent 
 of the Montpellier Faculty, cites in the Mem. de l’ Acad des Sci. for 
 1735, the case of a woman who discharged a very large mole at the 
 age of seventy-seven years. 
 
 It remains for us to speak of the third sort of moles, that is to say, 
 the hydatid mole, which consists in a degeneration of the placenta, 
 and, like the fleshy mole and the false germ, is a product of conception. 
 This diseased affection is nothing more than the development within 
 the placenta, of a certain number, greater or less, of cysts, — either 
 separate or united together like the berries of a bunch of grapes. 
 This kind of mole, which is very common, in general attains a size 
 greater than the other sorts, and sometimes sojourns for a great 
 while in the uterus, whence it escapes either in mass or in broken 
 masses. For fuller particulars we refer to our remarks on degenera- 
 tion of the placental tissue at p. 378 of this volume. 
 
 The causes of moles, of whatsoever species, are always very ob- 
 scure ; but it is ordinarily supposed they may be produced by any 
 cause capable of disturbing the development of the new being. 
 Among these causes may be classed a sudden fright or a lively emo- 
 tion experienced during the genital act, or in any of the early days 
 of the embryonal life. A bad quality of the semen, and the usus 
 coitus during the catamenial excretion, have also, by some, been 
 looked upon as capable of giving rise to this depravation of the pro- 
 duct of generation. It is unnecessary to say that all such hypotheses 
 are wholly without foundation. 
 
 The diagnosis of the different species of moles, is extremely diffi- 
 cult, especially in their earlier stages in the uterus, because the symp- 
 toms characterizing them at that period, are equally characteristic of 
 true pregnancy. In fact, as happens in real pregnancy, a molar con- 
 ception is announced by suppression of the menses, swelling of the 
 
MOLES. 
 
 573 
 
 breasts, tumefaction of the belly, disgusts, nausea and disorder of 
 most of the functions. 
 
 The obscurity becomes much less, when the mole has remained 
 for several months within the womb. Under such circumstances, the 
 size of the abdomen is greater than it is at the corresponding stage 
 of real pregnancy ; it is generally more painful, harder, and more 
 equably distended. There is no ballottement, and no spontaneous 
 motion of a foetus. The weight of the womb appears to be greater 
 and more fatiguing than when it contains a foetus, and the woman, 
 who suffers from pain in the loins, from dysuria and from lassitude, 
 more than she does in an ordinary pregnancy, also feels something 
 like a ball falling about within her as she turns from side to side. 
 To all the above symptoms should be added the shrinking of the 
 breasts, which were at first enlarged; the secretion of a serous fluid 
 in place of milk ; and lastly, frequent, irregular attacks of uterine 
 hasmorrhage. Generally speaking, after the first five months of 
 gestation, where the signs of true pregnancy are not to be found, 
 and where the local uneasiness, as well as the floodings, continue to 
 increase, we are authorized to suppose the symptoms derivable from 
 the presence of a foreign body within the womb. 
 
 Previously to concluding what we had to say upon the diagnosis 
 of moles, we shall offer a few remarks upon the distinguishing cha- 
 racteristics of the fleshy and hydatid mole. 
 
 In the first place, the hydatid mole is much more rarely seen to 
 coexist with a normal embryo than the fleshy mole, and a hydatid 
 pregnancy is almost always longer than one from a fleshy mole. 
 The belly is also larger, although the womb is in common not so 
 heavy or hard as when occupied with a solid and compact fleshy 
 substance. Lastly, the hydatid is more frequently expelled in frag- 
 ments or shreds, and at different times, and the pains are stronger 
 and more lasting than in the fleshy mole, while there is also greater 
 and consequently more dangerous flooding. 
 
 Where the mole has attained its maturity, which is generally the 
 case from the fourth to the seventh month, the patient has pains like 
 those of real labour; the womb contracts, its orifice becomes dilated, 
 and the mass is expelled. The breasts then fill with milk, the lochia 
 follows in course, and all the other secondary symptoms take place 
 as in a common lying-in. 
 
 The treatment of moles was formerly very complicated; thus, 
 some of the authors, under an impression that every thing ought to 
 be done in order to terminate its sojourn in the womb, were in the 
 habit of prescribing a host of remedies designed to effect its detach- 
 ment and discharge. In order to come at this end, they practised 
 bleeding in the foot and arm, emetics, sternutatories and drastic 
 cathartics, baths, emmenagogues, fumigations and stimulating ene- 
 mata. They provoked the uterine contraction by means of pessaries 
 containing savine powder, rue, hellebore, or aristolochia, which they 
 also administered internally. In fine, in order to expedite the escape 
 of the mole, they advised the patient to leap, to walk about, and to 
 go up and down stairs. 
 
574 
 
 EXTRA UTERINE PREGNANCY. 
 
 The employment of such measures as the above is so much the 
 more dangerous for the female, as the signs of a mole are not inva- 
 riably sufficiently marked to remove ail risk of mistaking a true 
 pregnancy for it. 
 
 The treatment, then, for the most part, requires nothing particular ; 
 we should wait until nature expels the foreign body, and then we 
 extend the same care, and make use of the same precautions as in 
 an ordinary accouchement. Nevertheless, if in any case the os uteri 
 were to be sufficiently open to enable us to touch the mole, or see it 
 by using a speculum, it would perhaps be useful to arouse the con- 
 tractions of the organ by administering doses of secale cornutum. In 
 case a profuse flooding should come on, or be frequently renewed, we 
 ought to act as in cases of abortion, or of placenta previa ; that is to 
 say, provided the dilatation would not admit of the introduction of 
 the hand or a proper instrument, we should apply the tampon ; and 
 should the mole appear at the os uteri, we might seize it with a pair 
 of Levret’s pi nee a faux Jerme , or with our uterocep pincers, repre- 
 sented at fig. 38, p. 350. Where there is no urgency, the opening of 
 the os uteri might be favoured, if possible, by applying some bella- 
 donna ointment, and could the fingers be introduced within the cer- 
 vix, we ought to try to get hold of the mole and withdraw it in that 
 way. In fine, in those very rare cases, where the tumour is too 
 voluminous to be able to pass through the orifice of the womb, it 
 might be exposed by means of the speculum, and then seizing it with 
 a hook forceps, we should divide it into several distinct fragments. 
 
 For the most part, all the symptoms disappear when the mole has 
 been extirpated or expelled ; and beyond that, the treatment is the 
 same as that appropriate for a lying-in woman. 
 
 OF EXTRA-UTERINE PREGNANCY. 
 
 The development of a foetus and its appendages outside of the 
 womb, is called extra-uterine pregnancy, which is divided into tubal, 
 ovarian, peritoneal and interstitial pregnancy, accordingly as the pro- 
 duct of the conception is found in the tube, the ovary, the peritoneal 
 sac, or in a cavity formed at the expense of the texture of the womb 
 itself. 
 
 All the ancients were ignorant, of these different species of preg- 
 nancy, the history of which does hot go back beyond two hundred 
 years ; and, indeed, most of the writers of that period looked upon 
 the first published cases of the kind as chimerical. 
 
 The commonest and most anciently understood form of extra-ute- 
 rine gestation is the tubal pregnancy ; for, according to Riolan, Pro- 
 fessor of Anatomy in the reign of Louis XIII., a surgeon saw a case 
 of the kind in 1590, though not much attention was paid to it at the 
 time. The same author, who himself had an opportunity of seeing 
 a case of the sort in the body of a washerwoman, in the service of 
 Anne of Austria, says further that a surgeon, one of his cotempo- 
 raries, had met with another case, in the year 1640. But, soon after 
 this period Regnier De Graaf, Duvernoy, Bussiere, Bianchi, Louis 
 
EXTRA-UTERINE PREGNANCY. 
 
 57 5 
 
 Leger de Gouey, Runge, Bruyer, of Leipzig, J. Clark, Wilson, Martin, 
 Petit, Chaussier, and Messrs. Bry de Bouillon, Bonnie, Vallerand and 
 a crowd of others, published cases of tubal pregnancy that could 
 leave no doubt upon the subject. 
 
 After the numerous experiments that have been made to explain 
 the mechanism of conception, and the almost positive knowledge 
 now acquired as to that important question, it becomes easy for us 
 to understand how the arrest may happen of an ovule in some point 
 of one of the tubes, and so to comprehend the formation of a tubal 
 pregnancy. It is also easy to conceive that if the germ may stop at 
 any point of the tube, it is precisely in the fimbria that it will be 
 most likely to stay, and that, after the lapse of some short time, it 
 will be difficult to determine whether the pregnancy is tubal, ovarian, 
 or abdominal, because the tumour will be seen to be confounded 
 with the circumjacent tissues. 
 
 Ovaric , or ovarian pregnancy , is extremely rare, and, by some 
 authors, is not admitted to exist; M. Velpeau, for example, who 
 thinks that the published cases have not been sufficiently well de- 
 scribed or studied incontestably to establish the existence of these 
 kinds of pregnancy. Other persons have asserted their impossibility, 
 on the ground that, at the moment of fecundation, the membrane of 
 the ovary gives way, and that, besides, in the quite ancient cases 
 that have been published, it was an easy matter to confound these 
 cases with cases of peritoneal pregnancy, inasmuch as the science 
 of morbid anatomy was not in that day so well understood as at 
 present. Be this, however, as it may, the first authentic case men- 
 tioned in the annals of the science is one published in 1682, by St. 
 Maurice, a physician in Perigord, in Mangetus’s Bibliotheca Ana- 
 tomica , t. i. p. 623. The second case was reported by Vieussens,* 
 who tells us that Montanier, a physician at Lambesc, in Provence, 
 being called to a woman who died suddenly, with violent pain in the 
 abdomen, examined the body for the purpose of ascertaining the 
 cause of so strange a death. He found a foetus, of about two months, 
 in the lower belly, surrounded with a quantity of blood, but without 
 any lesion of the womb or Fallopian tubes; but he observed the 
 right ovary to be very much enlarged and lacerated at its lower 
 side, whence it was clear that the fetus had escaped. 
 
 In the Memoirs of the Academy of Sciences, \ Littre assures us 
 that he found, in the left ovarian, a vesicle containing a foetus about 
 three lines and a half in length. He adds, that this fetus was 
 attached to the inner part of the membranes of the vesicle, where it 
 was held by an umbilical cord, a third of a line thick and a line and 
 a half in length. 
 
 Lastly, the fourth case is due to Varoquier, anatomical demonstra- 
 tor at Lille, who communicated it to the Academy of Sciences in 
 1756. Upon opening the body of a girl, thirty years of age, who 
 died with a fixed pain in the left iliac region, he found the ovary 
 
 * Verheyen’s Anatomy. De structura, et usu uteri et placentae, 
 j- Memoires de l’Academie des Sciences, annee, 1701, p. 109. 
 
576 
 
 EXTRA-UTERINE PREGNANCT. 
 
 on that side, of the size and shape of a hen’s egg. Upon opening 
 the tumour, about an ounce of a lymphatic fluid, resembling whey, 
 escaped, in which was floating a foetus, somewhat withered, but with 
 its umbilical cord and placenta still entire. The placenta was at- 
 tached to the top of the substance of the ovary, with which it Avas 
 confounded. The foetus was two inches long, from the top of the 
 head to the knees. As some cases have been published, since those 
 now above mentioned, it follows that very few practitioners of the 
 present day entertain any doubts as to the fact that ovarian preg- 
 nancy has existed and may exist. 
 
 [It seems no longer deniable, that the spermatozoid may, on some occa- 
 sions, actually reach the ovary. Both Bischoff and Martin Barry have dis- 
 covered the animalculac lying on the surface of the organ, where they could 
 have been transported only through the Fallopian tube. Bischoff, in his 
 Entwickelung' s Geschicte , & c., p. 21, states that it was his good fortune to 
 make the first discovery of the kind. Diese beobachtung zumachen, ist 
 mir endlich zuerst gegluckt. The first occasion of seeing this pheno- 
 menon, was June 22, 1838. He exhibited the fact to many of his friends, 
 and made a communication, relative to it, to a scientific congress, assembled 
 at Fribourg in the fall of 1838 ; since which time, he has had other oppor- 
 tunities of witnessing the same occurrences. The proofs advanced by M. 
 Colombat, and the clear and undeniable case by Dr. Granville, accompa- 
 nied with a beautiful engraving, in the Lorul. Phil. Trans., 1820, suffice to 
 set the question at rest. There ought, moreover; to be no reluctance to 
 admit the fact of ovarian fecundation, for those wdio believe in the ponte 
 periodique of the mammals. It is quite easy to suppose that an ovisac in 
 the ovary may be opened in the steps of the ponte , without discharging the 
 ovule which is retained by its tunica granulosa or retinacles. Such an 
 ovule, being fecundated through the rent or aperture, afterwards closed by 
 being hidden, in some change of place of the ovary, against an intestine or 
 the anterior lining of the broad ligament — the fecundated ovule readily forms 
 its mesenteric attachment there — and we have, in consequence, a case of 
 ovarian gestation. The ovule, when detected in the tube, even long after the 
 sexual conflict, is found surrounded by zoospersms. M. Bischoff represents 
 them in several of the figures given in his elegant Atlas. — M.] 
 
 The third species of extra-uterine pregnancy is the peritoneal or 
 abdominal , which is produced when the fecundated ovule falls into 
 the abdomen, instead of entering the Fallopian tube. It is probable 
 that this accident is not very uncommon, and that the reason why the 
 abdominal pregnancy is not more frequent is, that the greater part of 
 the germs which escape in this way, perish before forming their 
 attachment upon the serous membrane destined to receive them. 
 
 One of the most authentic cases of pregnancy of this kind was 
 published by Courtial, professor of medicine at Toulouse.* The 
 
 * Nouvelles Observ. sur les os. Observ r . x. 
 
EXTRA-UTERINE PREGNANCY. 
 
 577 
 
 foetus of which he speaks, which was of nine months, was found in 
 the left side of the abdomen, situated with the head downwards, and 
 the feet above, connected by the umbilical cord with the placenta, 
 which was itself attached to the omentum and stomach. It was ascer- 
 tained, by examination, that the uterus, the ovary and the Fallopian 
 tubes were free from any laceration, so that no doubt could be enter- 
 tained as to the pregnancy being abdominal. 
 
 The case by Jouy, surgeon to the Hotel-Dieu at Paris, and re- 
 ported by Dionis,* is nearly similar to the preceding. The fetus, 
 as in that case, was of nine months; it was likewise in the left side 
 of the abdomen, in a cavity filled with sanguineous fluid ; its cord, to 
 which it was still connected, was attached to the placenta, situated 
 between the mesentery and colon ; no rupture or cicatrix of the 
 womb, tubes or ovary was discovered. 
 
 In 1748, two physicians of Soigny communicated to the Academy 
 of Sciencest a nearly similar case. It concerned a fetus which had 
 been carried by the mother, in her abdomen, for thirty years. It was 
 found in the right side of the abdomen, covered by its membranes, 
 which were attached to the peritoneum and mesentery, outside of 
 the uterus. The foetus was well formed, provided with hair, and had 
 two incisor teeth ready to protrude. Besides, as in the preceding 
 cases, the womb, the tubes and the ovaries bore no traces of lesion. 
 
 Cases anterior to those we have just cited, have already been pub- 
 lished ; amongst others, by Egide Hertogf and Achilles Pirminius 
 Gassarus,§ physician at Augsburg, and by Steph. Manialdus.|| 
 Other cases of abdominal pregnancy have also been inserted in dif- 
 ferent journals or general treatises upon medicine, by Abraham 
 Cypriaan,1T by Solingen,** by James Brodie Birbeck,tt by Cop- 
 ping, If by Ch. Delaunay, §§ and a number of others, whom it would 
 take too long to cite. 
 
 Though frequently observed, the existence of abdominal pregnancies 
 has been denied by some physicians, who pretend that the peritoneum 
 is not sufficiently vascular to carry on the development of the ovum, 
 and that supposed peritoneal pregnancies had no doubt been con- 
 founded with tubal pregnancies. We reply to these arguments, that the 
 human ovum, provided with a simple epichorion, generally adheres to 
 the peritoneum by numerous vascular filaments, constituting a kind of 
 placenta formed of a collection of vessels united to a mass of spongy 
 material, in every respect similar to that which characterizes the 
 human placenta. We may add, that this species of placenta was 
 found inserted upon the ovary and broad ligament, by Kelni and 
 
 * Anatomie de fhomme, c. vi. p. 2.23. 
 f Mem.de TAcad. des Sciences, p. 108, annee, 1748. 
 t Dodon. Exemp. Med. Observ., 1520, p.321-328. 
 
 § Gassarus died in 1577. 
 
 || Comment, in Hipp., in- 8 , 1619. 
 
 Epist. ad Thomas Millington, 1700. 
 
 ** Manuale Med. Oper.,p. 234. 
 tt Philosoph. Transactions, t. i. p.224. 
 
 44 Leshe Auszuge, t.ii. p. 321. 
 
 §§ Nouveau Systeme sur la Generation, p. 270, 1726, 
 
 37 
 
57S 
 
 EXTRA-UTERINE PREGNANCY. 
 
 Lallemant ; upon the mesentery and peritoneum, by Weinhard and 
 Weinknecht ; upon almost all the abdominal viscera, by. Turnbull ; 
 upon the stomach, by Courtial ; upon the colon, by Fern ; in the iliac 
 fossa, by Romieux ; on the sacrum, by Baudelocque ; on the front of 
 the spinal column, by M. Arnault : and, finally, on the kidneys and 
 intestines by M. Bricheteau. We remark further, that the difference 
 between the organization of the peritoneum and that of the womb 
 is no reason for supposing that the peritoneal serous membrane may 
 not serve as point of attachment to the placenta. The ovum forms 
 adhesions to all the viscera with which it is in contact ; it is a part 
 supplied with vital forces, and which unites itself with another part by a 
 kind of action bearing some resemblance to the adhesive inflammation. 
 Changes similar to those which occur in the uterus, after conception, 
 take place ; for, by the intervention of the placenta, a communication 
 is established between its vessels and. those of the neighbouring parts, 
 which become sensibly dilated. 
 
 The fourth species of pregnancy, called, by M. Mayer, intersti- 
 tial, has not been mentioned by- the ancients. In this form, the foetus 
 is developed in the midst of the fibres of the uterus. Though it has 
 been observed by Messrs. Schmidt, Albers, Hederich, Cams, Chit, 
 Bellemain, Lartet, Dance and Moulin, Meniere and Dujardin, it has 
 been carefully studied only by Messrs. Mayer and Meckel, and 
 especially by M. Breschet, who collected all the authentic cases in 
 an excellent memoir, which he published in the Repertoire cTAna- 
 tomie et de Physiologie Pathologiques, 1826 , p. l er . The mode of 
 formation of interstitial pregnancy resting entirely upon hypothetical 
 suppositions, is still quite unknown : wherefore we deem it right to 
 pass over all the anatomical and physiological explanations of it 
 which have been given. Lastly, according to some modern authors, 
 there is a fifth kind of extra-uterine pregnancy, called utero-tubal , 
 because, in this case, a portion of the ovum is developed in the ute- 
 rine cavity, and a portion in the Fallopian tube. Some cases of this 
 kind have been reported by Patuna, Hay, Herbin, Hoffmeister, Lau- 
 gier and Moudot. 
 
 The causes that produce these different species of extra-uterine 
 pregnancy, are very difficult to ascertain ; nevertheless, though they 
 rest upon hypotheses merely, which are therefore of no practical 
 utility, either in regard to the prophylaxis or diagnosis, we shall 
 bestow a few words upon them. It has been the custom to regard 
 all deformities of the Fallopian tubes as capable of producing extra- 
 uterine pregnancy ; their obliteration, spasm, or faulty direction ; any 
 excess or diminution of their length ; their anti-peristaltic movement, 
 and all anomalies which they may present as to their situation or con- 
 formation. There have also been classed amongst the causes of this 
 affection, thickening and anormal density of the investing tissue of 
 the ovule and of the membranes of the ovary; too strong an adhesion 
 of the germ, and its being situated too deeply or too near to the liga- 
 ment of the ovary. Astruc thought that unmarried women, and 
 especially those who pretend to be chaste, were more liable than 
 others to pregnancies of this kind. Kruger, who is of the same opin- 
 
EXTRA-UTERINE PREGNANCY. 
 
 579 
 
 ion, maintained that the ovule either remains in the ovary, is arrested 
 in the Fallopian tube or falls into the peritoneum, because some vivid 
 emotion, a sudden fright, or surprise, seizing a woman during the 
 coitus, or immediately after it, imparts a shock which reacts upon the 
 sexual organs especially. A case by M. Lallemant and another by 
 Baudelocque seem to confirm this idea of Astruc and Kruger. In 
 fact, in one of these cases, the extra-uterine conception seems to have 
 been produced at the moment when one of the women was seized 
 with terror, at hearing the turning of the key which she had impru- 
 dently left in the lock, while she was in the arms of her lover ; in 
 the other case, the same accident seems to have occurred at the 
 woman’s hearing a sudden noise which caused her to fear being 
 taken in flagrante delicto. Further, we ought to remark that, as 
 nothing of the kind was observed in the other cases, these various 
 explanations can only be regarded as more or less plausible hypo- 
 theses. 
 
 The signs of extra-uterine conceptions are, in the early months, 
 very difficult to appreciate, since all the signs of true pregnancy are 
 extremely doubtful during the early periods. Thus, the persistence 
 of menstruation, the nausea, the mere frequent vomiting, the mere 
 acute pains in the hypogastrium, can have but little value, since they 
 are often absent and not unfrequently accompany true pregnancy. 
 The same is true of the want of changes of the breasts, of the non- 
 secretion of milk; of the irregular shape of the abdomen; of its more 
 rapid development, especially on one side ; of the movements of the 
 foetus at an earlier date, and felt, too, through parietes which seem to 
 be thinner than common, and of the small size of the uterus ; lastly, 
 several other signs of extra-uterine pregnancy, which are often 
 absent in this condition, and which are met with still more frequently 
 in natural pregnancy. In general, there is scarcely a doubt as to the 
 existence of an anormal conception, when the abdominal tumour 
 has risen earlier than usual, above the superior strait, and when it 
 is found to be in one of the iliac fossae ; when the tumour seems 
 irregular and varicose; when it is the seat of pulsations, and when 
 it is easy to detect the movements of the foetus through the parietes 
 of the abdomen, while we ascertain by the Touch, that the weight 
 and volume of the womb are very slightly increased, and that the 
 neck of the organ is but little shortened, though it has changed its 
 position, direction, density, and even form. Moreover, there is one 
 constant sign, which is, that when the- woman has already borne 
 children, she recognizes, by the symptoms, that the pregnancy is differ- 
 ent from the preceding ones. In some cases, a blunt probe, carefully 
 passed into the cervix uteri, which is generally considerably open, or 
 even the finger introduced into the same cavity, would indicate 
 whether the size of the womb was enlarged. The Touch by the 
 rectum would also furnish valuable information, as also the applica- 
 tion of the stethoscope over the tumour, which would enable us to 
 hear the placental and foetal circulation. 
 
 As to the symptoms which may serve to point out the nature of the 
 extra-uterine pregnancy, they are more uncertain even than those we 
 
5S0 
 
 EXTRA-UTERINE PREGNANCY. 
 
 have just described. Nevertheless, when the foetus is developed ill 
 the ovary, the uterus is more movable than when it is seated in the 
 Fallopian tube. When the tumour is large, whether situated in the 
 ovary, Fallopian tube, or peritoneum, the uterus is equally immova- 
 ble, and suffers the same displacements. In peritoneal pregnancy, 
 however, the tumour is more elevated, more movable, and is gene- 
 rally fixed in one of the hypogastric regions. Lastly, we add that 
 the diagnosis becomes still more difficult when the foetus is dead, 
 and especially when it has remained a long time in the abdominal 
 cavity, of which we shall relate several examples. 
 
 Extra-uterine pregnancy commonly terminates before the fifth 
 month; Turnbull, Baudelocque, Arnault, Novara, Delisle and Pa- 
 tuna, however, have known it to go nearly to the term of gestation. 
 Canonico has seen it at the first month, Treviranus at six weeks, 
 Verheyen, Baudelocque and Vallerand, at the second month; Bres- 
 chet and Mayor at the third, Blizard, James, Ramsbotham and 
 Cruveilhier at the fourth, Barbaut from the fifth to the sixth, and, 
 lastly, Starke at the seventh. In all the cases, the patients have 
 been carried off by hsemorrhage, either suddenly, or after a few days 
 of suffering. Accidents of this nature are characterized by acute 
 pain, rapid debility, paleness and syncope. At the examination after 
 death, the foetus is found in the abdomen, amidst clots and fluid blood, 
 and with the placenta in the middle of the broken cyst. It should 
 be remarked that the women generally experience pains like those 
 of labour, and accompanied with all its symptoms, such as the dila- 
 tation of the cervix uteri, discharge of sanguineous glairy mucus, and 
 very evident contractions even of the womb and tumour. 
 
 The rupture of the cyst may be regarded as a sort of abortion, and 
 the escape of the foetus from the cavity in which it is contained being 
 the inevitable consequence, the death of the mother and child is 
 almost certain to follow, because the latter can be extracted only 
 through an artificial opening : the interstitial pregnancy alone some- 
 times allows of the removal of the foetus by the natural passages. 
 
 The death of the foetus takes place most frequently in the early 
 months, and when this occurs, the health of the female has been 
 known to be re-established, and to continue for a considerable 
 length of time, although bearing in her abdomen the product of con- 
 ception, during a longer or shorter period of years. The annals of 
 science contain a great many cases of this kind. Abraham Cypriaan* 
 speaks of a foetus which had remained twenty-nine months in the 
 abdominal cavity. Runget cites another case in which the foetus 
 had remained eleven years in the cavity of the Fallopian tube. 
 Spoering,± a Swedish physician, makes mention of a female who re- 
 tained her child for thirteen years in the abdomen, and Thomas Bell§ 
 cites a case of twins which were carried for twenty-one months in 
 
 *Epist. ad Thomas. Lug. 1700. 
 
 f Hamburgher, etc., t. ix. cap. 1, pp. 1 — 18. 
 
 * Abhandlungen, etc., 1744, p. 91. 
 
 § Edinb. Med. Comment., t. ii. p. 71. 
 
extra-uterine pregnancy. 
 
 581 
 
 the abdomen of the mother. M. Mojon* found in the pelvic excavation 
 of a female seventy-eight years of age, who died of decrepitude, and 
 who was the mother of three children, a tumour depending from the 
 uterus, and adherent to the vagina and bladder ; it was composed 
 of a cartilaginous cyst containing a foetus completely ossified, which 
 seemed to have lived to the third month. Lastly, M. Blauchef lately 
 received into his wards a woman of seventy years of age, who had a 
 large tumour in her left iliac fossa, which dated from more than thirty 
 years back. For some time before she came in, the pain was very 
 severe, the abdomen tense and painful to the touch. The patient had 
 had one child, when at the age of twenty-seven years ; the tumour 
 made its appearance at forty years of age, and the menses ceased at 
 fifty. She was supposed to have an ovarian cyst, but having died on 
 the 25th of September, 1841, it was found at the autopsy that the 
 tumour was composed of the remains of a foetus. Almost all the 
 bones were still united by ligaments, and the skeleton was rolled 
 up ; the pelvis and inferior extremities occupied the posterior part of 
 the tumour, the occiput the anterior, while the head formed the 
 principal portion of the mass. 
 
 In all the cases we have now cited, the foetuses had undergone dif- 
 ferent alterations ; in general they become shriveled, dried and mum- 
 mified, and the cyst in which they are contained thickens, becomes 
 fibrous and fibro-cartilaginous, and may remain in the abdomen with 
 the rest of the product of conception for a long time without endan- 
 gering the life of the woman. Sometimes, however, the foetus be.- 
 comes covered with a sort of incrustation and with a substance like 
 plaster, and this it is that caused foetuses of this kind to be formerly 
 designated by the name of lilhopedia or petrified foetuses. Such 
 was that at Sens in 1582, or lilhopedium Senonense , which had 
 been carried by its mother for 28 years; that of Pont-d-Mous - 
 son , in 1659, which remained for 30 years in the body of the female 
 who had conceived it; that of Dole in 1661, which remained for six- 
 teen years in the abdominal cavity where it had been developed, and 
 for the account of which we are indebted to Francois Bouchard, pro- 
 fessor of medicine at Dole; lastly, that at Toulouse, in 1678, which 
 had remained for twenty-five years in the abdomen of its mother, 
 and which is described in a letter by F. Bayle, published in 1678. 
 
 In other cases, the cyst is converted into a true purulent abscess ; 
 the foetus is decomposed, and putrefied, the sac forms adhesions 
 with the surrounding parts, and opens into the bladder, caecum, colon, 
 small intestine, rectum or through the abdominal parietes or perineum. 
 When this happens, dangerous symptoms almost always follow, 
 and an inflammation which, extending to the neighbouring organs, 
 gives rise to violent fever, which is more or leks rapidly followed 
 by the death of the patient. It sometimes happens that the female 
 falls into a hectic condition, in consequence of abundant suppu- 
 ration, while in other cases the foetus is expelled in portions, the 
 
 * Diction, des Sciences Medic., t. xxvii. p. 42. 
 t Supplement & la Gazette des hdpitaux, 16 Juin, 1842. 
 
582 
 
 EXTRA-UTERINE PREGNANCY. 
 
 cyst empties itself little by little, the suppuration gradually ceases, 
 and the wound cicatrizes, or at least diminishes to a fistulous ulcer, 
 less dangerous than inconvenient. Be it as it may, extra-uterine 
 pregnancy is always extremely dangerous, both for the mother and 
 child, and its most natural termination is the rupture of the cyst and 
 the death of the child. 
 
 The treatment and conduct to be pursued in cases of extra-uterine 
 pregnancy, present no positive rules, because of the impossibility of 
 detecting them with certainty in the early months, and from the 
 dangers incurred from the different means that might be employed. 
 In extra-uterine pregnancies just commencing, and as to whose exist- 
 ence there is considerable uncertainty, the employment of any active 
 or dangerous means should be rigidly interdicted ; we should confine 
 ourselves to treating the symptoms and to relieving the abdominal 
 pain by means of strict diet, by a demulcent regimen, by baths, by 
 enemata, and by emollient poultices and fomentations. It is impro- 
 per, generally, to do any thing before the infant is viable , that is to 
 say, before the seventh month of gestation, especially when the preg- 
 nancy passes through its stages without producing dangerous symp- 
 toms. 
 
 But when the motions of the child have become sensible both to the 
 surgeon and the mother; when the form of the foetus can be distin- 
 guished through the walls of the abdomen ; when by auscultation and 
 the touch, it has been almost positively ascertained that the tumour is 
 formed by a foetus, ought we to interfere, that is to say, perform gas- 
 trotomy, or should we wait for the spontaneous rupture of the cyst ? 
 In the last case, the uterine haemorrhage and consecutive inflamma- 
 tion expose the woman to the greatest dangers. The only remedies 
 we can oppose to these accidents are diet and absolute rest, refri- 
 gerants to the abdomen, sedative and cold drinks, and some other 
 means which are of but slight avail. As to the inflammation, must 
 we not fear increasing its intensity very much by operating in such a 
 case and by incising the walls of the abdomen to extract the foetus. 
 It is difficult to know what to advise under such circumstances, but 
 we believe that the operation ought not to be resorted to untif after 
 the symptoms of internal haemorrhage have disappeared ; it would be 
 still more prudent, perhaps, to wait until the cyst and other foreign 
 bodies, naturally carried towards the lowest part of the abdomen, 
 should have contracted inflammatory adhesions, so that the seat of the 
 disease, being better circumscribed, it might the more readily be unco- 
 vered by an incision, which would also cause the woman to be ex- 
 posed to less risk. 
 
 Nevertheless, if the pregnancy, having nearly reached its term, were 
 accompanied by very severe pains, and especially if the rupture of 
 the cyst had taken place or were about to occur, and if, moreover, it 
 were certain that the foetus was still alive, it would become necessary 
 to perform gastrotomy, which, notwithstanding the great dangers by 
 which it is attended, does not augment those which the mother runs 
 when left to herself, while it offers some chance of safety to the child. 
 With the operation, the death of both is but too probable, and with- 
 
GASTROTOMY. 
 
 583 
 
 out it nearly inevitable. Desormeaux and M. Velpeau think, with 
 good reason, that gastrotomy would offer a much better chance 
 of success, were it not deferred until the symptoms of peritonitis, 
 itself a fatal disease, become developed. M. Velpeau adds, that 
 by resorting to it earlier, the operation offers the greater chance 
 of success in proportion as the pregnancy is less advanced, and 
 that in this condition, the probability of the life of the child is too 
 slight to be considered and to be placed against that of the mother. 
 The authors who are in favour of waiting, and who think we should 
 leave to nature the care of relieving herself, cite in support of their 
 opinion, the not unfrequent examples of foetuses having remained for 
 a long period in the abdominal cavity, and even where their presence 
 has given rise to inflammation, they bring not less numerous cases of 
 women in whom the pus has escaped exteriorly, carrying with it the 
 remains of the foetus. Gastrotomy has been objected to, moreover, 
 on account of the danger of the operation, which requires a large 
 opening in the abdomen, and especially on account of the inevitable 
 haemorrhage and escape of the waters which result from it. Those 
 who are of a contrary opinion, and who approve of the operation, say 
 that if not performed, the child is surely sacrificed, and the mother 
 exposed to the greatest danger ; that gastrotomy may save the former, 
 while placing the female in a more favourable position than when 
 left to herself; and lastly, that when the cyst is opened by an inci- 
 sion, the effusion is to be feared less than when the rupture occurs 
 spontaneously. 
 
 However it may be in regard to the different opinions we have just 
 mentioned, we believe that the operation ought to be performed, 
 even after the rupture of the cyst, and that in general we ought not 
 to wait until the symptoms of peritonitis shall have declared them- 
 selves, because in that case we are almost sure to see the mother and 
 child perish, when, by operating earlier, we might, perhaps, have 
 saved both. 
 
 OF GASTROTOMY. 
 
 Gastrotomy, which is not the Csesarian operation, properly so 
 called, since the uterus is not laid open, consists in incising the in- 
 teguments of the abdomen to an extent sufficient to allow of the ex- 
 traction, through the opening, of a living or dead child. The place 
 of choice is to be determined by the situation of the tumour, observing 
 the precautions, however, rendered necessary by the presence of ves- 
 sels. The incision is made by cutting layer after layer, first the skin, 
 the muscles, the aponeuroses and peritoneum, and then the cyst which 
 contains the foetus. The extraction of the foetus is to be made by 
 seizing it by the feet. The waters and blood which may have 
 escaped into the peritoneum must be removed as far as possible, and 
 the placenta then taken away, particularly if it be separated. A 
 portion of the wound is to be united by means of the quill-suture, in 
 such a way as to leave an opening at the lower angle sufficient for 
 the discharge of the pus and blood, and even for the escape of the 
 
584 
 
 GASTROTOMY. 
 
 placenta, if it has been impossible to extract it. After the operation 
 is concluded, a suitable position should be given to the woman ; the 
 wound is to be dressed with a piece of fine linen, having portions of 
 charpie and long compresses placed over it, the whole to be kept in 
 place by means of a moderately tight bandage around the body. The 
 subsequent treatment consists in preventing as much as possible the 
 inflammation which follows this dangerous operation by the use of 
 general and local bleedings, by emollient applications, by mucilagi- 
 nous and sedative drinks, by strict diet, and lastly, by promoting the 
 discharges by means of frequent injections. If fortunate enough to 
 save the child, the female should be requested to suckle it, in order 
 to produce a determination towards the breasts, which is a powerful 
 means of derivation. 
 
 If the head of the foetus should have become engaged in the exca- 
 vation of the pelvis, so as to make a distinct projection and seem to 
 be nearly bare, or covered at least with so few integuments as to 
 allow us to distinguish the sutures and fontanelles, the vagina ought to 
 be incised at that point, and the child extracted through the passage. 
 This operation, which was performed by Colomb, of Lyons, at the 
 fifth month of pregnancy, and which terminated in the death of the 
 patient, is less dangerous than gastrotomv, because the cyst is opened 
 without uncovering the intestines, and without fear, therefore, of effu- 
 sion ; besides, the dependent position of the wound always allows 
 of a free escape of the liquid matters. To add a few more words in 
 favour of gastrotomy, we will remark, that the operation has been 
 performed with success in cases in which the foetuses were dead, by 
 Abraham Cypriaan ( loc . cit.), by Solingen ( loc . cit.), by Thomas 
 Bell (loc. cit.), by Breyer (loc. cit.), by Weinhardt (loc. cit.), 
 and by some others. We shall conclude by saying that as to 
 extra-uterine pregnancies in which the presence of the cyst has 
 brought on inflammation or suppuration, we should rest content 
 with combating the accidents that may occur ; with treating symp- 
 toms; laying open deposits of pus; and enlarging the orifices of 
 those which have opened spontaneously ; we must assist the escape 
 of the portions of soft parts or of the osseous fragments which may pre- 
 sent themselves at the opening, or have formed themselves a passage 
 in the vagina, rectum or bladder, an instance of which is related by 
 Josephi. Lastly, the retention of pus or decomposed matters must 
 be prevented, by means of baths, injections, enemata, by a rigid 
 diet or an analeptic regimen, according to circumstances. 
 
 If we have to do with a case of stationary extra-uterine pregnancy, 
 without complications, which can occur only after the death of the 
 foetus, any attempt can but aggravate the position of the patient, and 
 endanger her life, which may sometimes be otherwise prolonged 
 through many years. 
 
 OF DISEASES CONNECTED WITH PREGNANCY. 
 
 The diseases connected with pregnancy are either seated in the 
 gestative organ or depend upon the influence of that organ on the 
 
ABORTION. 
 
 585 
 
 different functions of the organism ; that is to say, they are either 
 idiopathic or symptomatic. 
 
 Amongst the former we rank retroversion, anteversion, obliqui- 
 ties, prolapsus, hernia, immobility, wounds, haemorrhages and abor- 
 tions. As we have already spoken of all these disorders while 
 treating of the pathological history of the genital organs of the female, 
 we refer our readers to the chapters which are devoted to them, in 
 order to take up the subject of abortion, of which we have not yet 
 treated. 
 
 OF ABORTION OR MISCARRIAGE. 
 
 By abortion, ought to be understood the expulsion of the foetus 
 from the mother’s organs before it has attained the degree of develop- 
 ment necessary to render it viable. What distinguishes abortion 
 from premature labour is, that in the latter, the foetus, though born 
 before term, has acquired an organization sufficiently perfect to ena- 
 ble it to live when severed from its mother. 
 
 According to Madame Lachapelle, abortion is more frequent at 
 six, at five, and at three months, than at any other period of preg- 
 nancy. 
 
 Desormeaux, agreeing in that respect with the observation and 
 opinion of almost all authors, thinks, on the contrary, that the 
 accident is the more common as the pregnancy is less advanced. 
 Morgagni has observed that a larger proportion of aborted em- 
 bryos were male than female, and, in this opinion, coincides with 
 most of the authors who have written upon the subject. 
 
 The causes of abortion are divided into efficient and determin- 
 ing. The efficient causes are nothing more than the contractions of 
 the uterus and the muscular efforts of the parietes of the abdomen ; 
 the determining causes ought to be divided into predisposing and 
 exciting. In some women the former causes act with so much force 
 that abortion occurs spontaneously, without appreciable exciting 
 causes. 
 
 Women most liable to abortion are those of a nervous, hysteri- 
 cal or irritable constitution ; those who have abundant or irregular 
 menses, or who are affected with leucorrhcea, syphilis, scurvy, rickets, 
 dropsy, cancer or organic disease of the womb ; women who have 
 too much embonpoint, who are lame, in whom the pelvis is badly 
 formed, in whom the womb is too yielding or not sufficiently so, or 
 who have become pregnant too early in life; and, lastly, those hav- 
 ing improper or insufficient nourishment, are also more exposed than 
 others to abortions : the same is true of those who have an heredi- 
 tary disposition to, or who have already had several miscarriages^ 
 and, to conclude, those who compress the trunk too violently with 
 corsets, or who make use of very tight clothing. 
 
 Amongst the predisposing causes of abortion should be ranged 
 also, residence in marshy districts of country, and certain consti- 
 tutions of the atmosphere which are mentioned by Hippocrates, and 
 which have rendered abortions really epidemic at certain periods; 
 
5S6 
 
 ABORTION. 
 
 Grown-Hann speaks of an epidemic of this kind which occurred in 
 the year 1685; Berthold and Beherens observed a similar one in 
 1695, and A. Genselius another in 1712, and lastly, Stoll has described 
 an epidemic of abortions which prevailed at Vienna in 1778 and 1779. 
 We observed, likewise, that the cholera proved a frequent cause of 
 abortion in Paris in 1832; we ought, however, to remark that we 
 took care during that period of two pregnant women attacked with 
 cholera, who were several times bled at the commencement of the 
 disease, and who gave birth, in due time, to strong and healthy 
 children. 
 
 To the predisposing causes just mentioned must be added those 
 which are connected with the foetus and its appendages; for exam- 
 ple, abortion may be a consequence of debility, of disease, or of 
 monstrosity of the foetus ; it may also depend on slight adhesions of 
 the placenta to the internal surface of the uterus, on placenta praevia, 
 on scirrhous, hydatid, varicose or aneurismal degeneration of that 
 organ ; on want of proportion between it and the foetus, or atrophy of 
 its tissue, on too short or too long a cord, and, finally, on any of the 
 diseases that might prevent the proper development of the embryo 
 or foetus. 
 
 [In most of the cases of abortion that I have seen, the embryo had been 
 long dead; whence I conclude that in a majority of the cases of the acci- 
 dent, the cause of the abortion was to be found in the death of the em- 
 bryo. — M.] 
 
 Although the predisposing causes just pointed out by us may in 
 most of the cases determine by their single action the expulsion of 
 the product of conception, constituting spontaneous abortion , it is 
 customary to attribute the accident almost always to particular circum- 
 stances, which in general pass for the principal and exciting causes. 
 Amongst these, some of which are insignificant, are yawning, the act 
 of having a dejection, of voiding urine, and of coughing ; different im- 
 pressions, as joy, sorrow, anger, disappointment ; that produced by 
 a strong odour, by a candle just extinguished, by coitus, and by a 
 number of other circumstances which act more powerfully ; such, 
 for example, as the violent movements and succussions which occur 
 in dancing, in riding in a carriage or on horseback, in running, leap- 
 ing, crying, coughing, sneezing, vomiting, and, to conclude, all sudden 
 movements of the body, and falls or blows upon the abdomen, but- 
 tocks or loins. 
 
 To the exciting causes just mentioned, we must also add all acute 
 diseases, . such as fevers and inflammations, especially those of the 
 womb ; diarrhoea, dysentery, colic, constipation, strangury, convul- 
 sions and attacks of hysteria and epilepsy. 
 
 Amongst the exciting causes of abortion, are to be ranged, more- 
 over, the use of baths, especially hip and foot-baths, emetics, drastic 
 purgatives, particularly those of which aloes forms the basis ; emme- 
 nagogues, such as rue, savine and saffron, etc.; blood-letting, espe- 
 cially from the foot; and, lastly, the employment of mechanical means, 
 of acupuncture and certain manoeuvres acting directly upon the ovum, 
 
ABORTION. 
 
 587 
 
 which have been recommended in cases of deformity of the pelvis, 
 but which, unfortunately, are but too often resorted to by infamous 
 people. 
 
 In general, when there is no* disposition to abortion, the greater 
 part of the abortive remedies and occasional causes we have just cited 
 fail to produce the expected result and do not prevent the pregnancy 
 from passing through all its periods. Thus writers are filled with 
 cases which prove the inefficacy of baths, pediluvia, bleeding from 
 the foot and general bleeding. Mauriceau relates the cases of two 
 pregnant women, one of whom was bled ten times without aborting: 
 the other also reached the full term of pregnancy, notwithstanding 
 a frequent use of emetics and bleeding. We took care of a young 
 woman in 1839 who, in the hope of inducing abortion, had caused 
 herself to be bled several times by a sage-femme, and whom we 
 found lying without consciousness, in a pool of blood escaped from 
 a varix which she had intentionally opened in one of her legs. But 
 far from obtaining the result she hoped for, the pains in the loins from 
 which she suffered before this guilty attempt disappeared entirely, 
 and she was brought to bed at the proper time of a perfectly well- 
 formed boy. Puzos speaks of the wife of an attorney who was deli- 
 vered of a healthy child, although she had been bled fourteen times in 
 the arm and seven in the foot ; Janot bled a woman forty-eight times, 
 which did not prevent her giving birth to a healthy child at term. 
 Lastly, Mauriceau also speaks of a brother physician who likewise 
 bled his wife ninety times during a pregnancy. Astruc remarks 
 with good reason that if bleeding, especially from the feet, caused 
 abortion, there would be fewer foundlings in the hospitals. 
 
 [I saw a lady at the middle of the third month, who had uterine haemor- 
 rhage to the amount of more than twenty ounces, without losing the embryo. 
 I delivered her of a healthy child at full term. — M.] 
 
 The same is true of the other causes of abortion ; Mauriceau re- 
 lates the case of a woman pregnant at seven months, who, in order 
 to escape from a fire, let herself slide from a third story ; but losing 
 her hold from fright, she fell upon some stones and fractured her 
 forearm, which did not prevent her pregnancy from reaching its term. 
 Madame Lachapelle cites the case of a young sage-femme, pregnant 
 and affected with a contracted pelvis, who threw herself down a stair- 
 case in order to bring on abortion, and thus avoid the Csesarian opera- 
 tion; she died a few days afterwards, from the effects of the fall, but 
 abortion did not take place. We took care of a washerwoman preg- 
 nant at six months, who had contused her whole body in a fall which 
 she met with while carrying clothes; the accident did not prevent her 
 from reaching her term of pregnancy. The employment, for a criminal 
 purpose, of drastic purgatives, of emetics, of the most powerful em- 
 menagogues, as well as the most violent exertions, has often caused 
 different acute diseases and even death, without provoking the expul- 
 sion of the foetus. Pregnancy has been known to go on, notwith- 
 standing the presence of a polypus in the uterus, of the existence 
 of a cancer of the neck, or even of a wound of that organ. Since 
 
588 
 
 ABORTION. 
 
 causes of this kind act so readily in some cases, while they exert 
 no action in others, we ought to admit that in the former there 
 existed predisposing causes of abortion. We must remark, more- 
 over, that there is a predisposition common to all women, that which 
 corresponds to the menstrual periods, an epoch when a fluxion 
 towards the womb is established which disposes the ovum to become 
 detached. This explains why, in the early months of pregnancy, 
 miscarriages are never more frequent than at epochs coinciding with 
 those of menstruation. 
 
 Periodical abortion, or that which takes place at nearly the same 
 period of pregnancy, in the same women, is one which seems to 
 depend most clearly upon the spontaneous or menstrual molimen. 
 This kind of abortion may be the result also of a special condi- 
 tion of the uterus, and especially of one in which the cavity of 
 the organ cannot extend beyond certain limits. Moreover, this acci- 
 dent of gestation is the more to be feared in proportion as the female 
 has already had a considerable number of them. As to mechani- 
 cal causes and criminal manoeuvres, those who employ them gene- 
 rally fail in their purpose, and succeed only in wounding the uterus 
 and bringing on disorders that may have the most unhappy con- 
 sequences to the unnatural women who demand them. 
 
 The symptoms of abortion vary according to the stage of the preg- 
 nancy and the nature of the causes which have produced it. When 
 the result of some disease and during the two first months of gestation, 
 it often happens that the ovum, then of small size, is suddenly ex- 
 pelled almost without pain or haemorrhage. This kind of miscarriage 
 scarcely diflers from a slight attack of haemorrhage or from a some- 
 what difficult menstruation. At a later period, the expulsion of the 
 foetus may produce most of the phenomena of an ordinary labour, 
 but it is generally preceded by malaise, lassitude, rigors, languor, 
 sadness, syncope, sensations of cold about the pelvis, paleness of the 
 face, palpitations, fetid breath, swelling and dark*colour of the eye- 
 lids, anorexia, nausea, thirst, pains in the loins, and sensation of 
 weight about the external genital organs and towards the funda- 
 ment. To these phenomena should be added elevation of the pulse ; 
 falling of the breasts, which now secrete only a serous liquid ; the 
 discharge from the vulva of a humour at first sanious, and then san- 
 guineous, to which succeeds liquid or grumous blood ; diminution or 
 absence of the movements of the child; lastly, falling of the abdomen ; 
 uterine pains becoming gradually stronger and more frequent ; the 
 progressive dilatation of the os uteri and protrusion of the mem- 
 branes; the expulsion of the liquor amnii, and after a time the expul- 
 sion of the product of conception, which generally puts an end to the 
 haemorrhage. 
 
 When abortion is the result of a powerful disturbing cause, it hap- 
 pens sometimes that the action of this cause is immediately followed 
 by an abundant hmmorrhage, which does not cease until after the 
 expulsion of the foetus and its appendages, which expulsion is always 
 accompanied by lancinating pains felt chiefly in the direction from 
 the umbilicus to the vulva. We should remark that in general the 
 
ABORTION. 
 
 589 
 
 , symptoms of abortion resemble those of labour the more closely in 
 proportion as the pregnancy is more advanced ; the same is true 
 as to the sequelae, that is to say, the lochial discharge and milk- 
 fever. In some cases, however, the effusion of blood produced by 
 abortion depending upon an exciting cause is preceded by pains, by 
 weight in the loins, by malaise, by rigors and by a sensation of unu- 
 sual weight in the sexual organs. 
 
 Although the escape of blood, and more especially that of the waters, 
 is always a symptom of threatened-abortion, the first of these phe- 
 nomena has often been seen, and the second even has been observed, 
 without abortion taking place. We attended, in the month of Sep- 
 tember, 1S39, the Baroness of Chab * * *, pregnant at seven months, 
 who, after a fall, was attacked with pains extending from the umbi- 
 licus towards the vulva, and with a considerable hemorrhage, fol- 
 lowed by the discharge of the waters ; in spite of all these precursory 
 phenomena, the lady reached the term of her pregnancy, and gave 
 birth to a healthy child. A bleeding at the arm, repose, cold and 
 sedative drinks, an antispasmodic and astringent mixture, restored 
 every thing to order and dissipated the symptoms of threatened 
 abortion. 
 
 Morlanne cites the case of a female who was not delivered until six 
 weeks after the waters had escaped. M. Velpeau relates, by the 
 authority of another physician, the case of a female pregnant at six 
 months, in whom the bag of waters was formed, and then broke* so 
 that the arm of the child engaged in the vagina ; after this the labour 
 was arrested, the foetus resumed its position, and the pregnancy pur- 
 sued a regular course. M. Velpeau adds that the author both saw 
 and touched, and that he ought to be believed. It is proper to know, 
 also, that the serous fluid which escapes from the cervix uteri may 
 come from an hydatid cyst or from between the membranes ; it may 
 also come from a double pregnancy, in which one ovum is broken 
 while the other remains perfect. Nevertheless, rupture of the mem- 
 branes and discharge of the waters indicate, almost always, approach- 
 ing abortion, or at least the death of the foetus. 
 
 It is likewise necessary to know how to distinguish the haemorrhage 
 which precedes a miscarriage from that which is the result of a re- 
 turn of the menses; — in the former case, the blood is seldom so abun- 
 dant or so apt to clot, and especially to escape in this form from the 
 genital organs, as when it is the product of an uterus occupied by a 
 foetus about to be detached. 
 
 It is also very important to distinguish uterine pains from the 
 colics produced by difficult menstruation. In abortion, the pains 
 follow the discharge of blood, while, on the contrary, they precede it 
 in menstruation. We should remark, moreover, that the touch will 
 often greatly assist in making the diagnosis, and especially in esta- 
 blishing the fact of pregnancy. 
 
 If the foetus has ceased to live, it is generally soon expelled from 
 the uterus ; in some cases, however, its expulsion does not occur until 
 after a longer or shorter period of time. If the membranes remain 
 unbroken, and especially if no air has penetrated the uterus, the 
 
590 
 
 abortion. 
 
 foetus may remain unchanged for several months, and even years ; 
 sometimes it becomes decomposed, and passes into the state of adi- 
 pocire, as happens in extra-uterine pregnancy. In the early months, 
 it often becomes atrophied, and offers the dimensions of an embryo of 
 a month or six weeks only, though the female be pregnant at several 
 months. In some cases it is macerated in the fluids, and the hard and 
 soft parts of the embryo have been known to disappear completely, 
 and the ovum to be transformed into a true mole. 
 
 It sometimes happens, when the fetus is expelled from the uterus, 
 that the secundines are retained by adhesion, and continue to live 
 and be developed. It is precisely in such cases that fleshy moles are 
 formed. Most generally, especially in the early months, the ovum is 
 expelled entire ; it has, however, been known to be expelled, un- 
 broken, at the fifth, and even at the sixth month ; but in the greater 
 number of cases, its size will not permit of its escape entire after the 
 second month. 
 
 [I have met with many instances in which the embryo has been retained 
 for several months in the womb, after the cessation of its life. In some 
 other cases I have found the placenta, with what had been chorion and am- 
 nion, but greatly changed by long residence in the uterus after the death 
 of the embryo, which had taken place so early as to be subject to macera- 
 tion and solution in the waters. Upon searching for it no trace of it has 
 been discoverable. I should not look upon such, as a specimen of the true 
 mold, but as a really depraved ovum. That these ova, (without embryo,) 
 continue to live, and to a certain extent develop themselves, I have no 
 doubt, since upon examining them, certain portions clearly appear to have 
 enjoyed a sanguine circulation, small, it is true, but yet sufficiently consi- 
 derable, to maintain a low vegetative sort of life for several consecutive 
 months. 
 
 I have added this note for the purpose of remarking on the very great 
 difficulty of the diagnosis, and the doubtful nature of the therapeutical indi- 
 cations thereon depending. 
 
 I have many times been consulted by persons, who, having had symp- 
 toms of pregnancy, had unexpectedly found themselves not advancing in the 
 uterine development pari passu with the lapse of time. The only duty in 
 such cases is to collect with care the history and dates of the mensual periods, 
 to weigh the circumstances that led to the opinion that conception had taken 
 place, and then, by means of the taxis of the hypogastrium and the vaginal 
 examination, to learn accurately the form and size of the womb, the state of 
 the cervix and os uteri, and also to inquire into the actual and past condition 
 of the mammary glands and nipples. 
 
 Should the form and size of the uterus lead to the opinion that a fetus, of 
 an age conformable to the rest of the history of the case, is still contained in 
 the organ, there need be very little hesitation in announcing such an opinion, 
 or in establishing upon it a course of treatment. Care should be taken to 
 
ABORTION. 
 
 591 
 
 compare the actual development of the womb with the rate at which a fibrous 
 tumour or any other morbid growth might have proceeded; and thus we 
 shall be enabled to judge between the doubtful points of the diagnosis. The 
 doubts would be on the questions — 1st, is it pregnancy, with arrest of de- 
 velopment? 2d, is it merely engorgement and hypertrophy of the womb? 
 3d, is it a tumour within the organ ? For the most part, by making a clear 
 statement of the various circumstances capable of presenting phenomena like 
 those of the case under consideration, and by examining the grounds for de- 
 ciding in favour of either, by the method of exclusion, we shall rarely be 
 led into serious mistakes. — M.] 
 
 The prognosis of abortion regards both the mother and the child ; 
 for the female it is generally more dangerous than labour, because 
 the latter is the performance of a natural function, while miscar- 
 riage is a disease. Moreover, its prognosis varies according to the 
 causes which have produced it and the accidents by which it is 
 accompanied. The least dangerous is that which is produced by 
 disease of the ovum ; the most dangerous that which has been occa- 
 sioned by a violent exciting, without any predisposing cause. Spon- 
 taneous abortion is always less to be dreaded than forced abortion, 
 and its effects are the less unfavourable in proportion as it occurs 
 more slowly. We remark, also, that the danger is less in pro- 
 portion as the date of the pregnancy is earlier, as the neck of the 
 womb is more yielding, and as the accident has occurred under the 
 influence of a well-marked molimen. Moreover, the abortion is 
 always of very bad augury when accompanied by convulsions, 
 diarrhoea, or dysentery, and when it occurs in the course of an inflam- 
 mation, of a fever, or of an eruptive disease. The prognosis in rela- 
 tion to the foetus is still more unfavourable ; for it almost always 
 perishes either from the slowness of the labour, or because of its pre- 
 mature expulsion ; we ought to remark, however, that there are to 
 be found amongst authors several examples of aborted children 
 which have survived, although the conception dated only from four 
 to six months. It is generally acknowledged at present that the pro- 
 bability of survival is less in proportion to the distance from full term. 
 It is, therefore, without any good reason that Hippocrates has said 
 that a child at seven months was more likely to live than one at 
 eight. He founded this opinion, indeed, mainly upon the doctrine of 
 numbers. As to the particular condition of the female, abortion is 
 most dangerous for primipara, because the genital organs are less 
 yielding and less disposed to give passage to the product of concep- 
 tion. 
 
 The treatment of abortion presents two indications: first, to prevent 
 it by every possible means, and, secondly, if unable to prevent it, to 
 hasten its termination, and to remedy the accidents which accom- 
 pany it. To fulfil the first indication, it is necessary to modify the 
 individual and the predisposing, and to remove the exciting causes. 
 
 If the female is nervous, and especially if her uterine system is in 
 a state of unusual spasm, we must resort to the use of warm baths, 
 
592 
 
 ABORTION. 
 
 assisted by a demulcent regimen. When she is of plethoric constitu- 
 tion, we may with advantage bleed several times in the course of the 
 gestation, especially at periods corresponding to those at which men- 
 struation had occurred. 
 
 It will be useful also to relieve, as far as possible, the fatiguing 
 coughs, the vomiting and constipation, which often accompany preg- 
 nancy. We should recommend strengthening food, repose, slumber, 
 and always moderate exercise for delicate persons : we should forbid 
 all violent movements, especially those of the arms, leaping, long 
 walks, the lifting of weights, and riding on horseback, or in a car- 
 riage; they should be advised not to expose themselves to intemperate 
 weather, to avoid tight dressing, not to use indigestible aliments, 
 and to avoid, as much as possible, all the vivid emotions and affec- 
 tions of the soul. Should there exist any affection of the uterus 
 or other organ, it must be treated by a suitable medication ; while 
 we should have recourse to the employment of mercurial prepara- 
 tions, if the pregnancy were complicated with syphilitic disease. 
 
 Though bleeding is generally one of the most powerful means for 
 preventing abortion, it ought not to be indiscriminately resorted to in 
 all cases ; wherefore we know not how to condemn too strongly the 
 habit which some physicians have of always bleeding in the course 
 of the pregnancy, without first distinguishing the circumstances 
 which call for its employment, which is as hurtful, in some cases, as 
 it may be advantageous in many others. 
 
 When haemorrhage occurs, the patient should be made to lie 
 down immediately upon a hard and fresh bed, and be directed to 
 maintain absolute rest. We should make use of cold acidulated 
 and astringent drinks, especially of rhatany, of external revellents, 
 of iced applications, injections and enemata ; and if there are symp- 
 toms of nervous agitation or convulsions, antispasmodic and anodyne 
 preparations ought to be employed. Moreover, bleeding is one of 
 the best means we can recur to, but it must be used with reserve 
 and precaution; for, as it is often powerless against abortion, the 
 accident which it failed to prevent might be ascribed to it. In gene- 
 ral, so long as there is any hope of opposing abortion, we should 
 avoid the employment of foot-baths, of manuluvia, and of full baths. 
 In a contrary condition, their use might be advantageous. 
 
 Should the haemorrhage become so great as to endanger the life of 
 the patient, recourse must be had to the tampon, which has the 
 advantage of arresting the haemorrhage and often the abortion, or 
 else, by the accumulation of blood, which it causes in the uterus, of 
 determining the contractions of the organ, separating the placenta, and 
 assisting in the expulsion of the product of conception. Under these 
 circumstances, ergot might prove useful, but it should be employed 
 with care, and only after having tried all the other means, precau- 
 tions the more necessary as it almost always favours the expulsion 
 of the ovum. 
 
 When the means we have just pointed out fail to arrest the pains 
 and haemorrhage, and especially when the cervix begins to relax and 
 dilate, abortion is inevitable. The physician, under these circum- 
 
ABORTION. 
 
 593 
 
 stances, has nothing to do but assist the delivery, and aid the 
 woman in ridding herself of the foetus and its appendages. If the 
 patient is strong, we must recur to venesection ; opium must be 
 administered internally, when the pains are very acute; an ointment 
 of belladonna and opium may be applied to the cervix uteri, if it be 
 sensitive and firmly contracted, and emollient and narcotic injections 
 might also be used under like circumstances. Moreover, should the 
 ovum be detained a long time in the cervix, it would be advan- 
 tageous to introduce the finger, and, in this way, assist its escape ; 
 but the membranes must not be ruptured until the orifice of the 
 womb is fully dilated, and the foetus properly engaged. When pos- 
 sible, the placenta ought to be extracted, by pulling upon the cord, 
 taking care, however, not to break it. We might, at the same time, 
 administer ergot and use frictions over the hypogastrium to excite 
 the uterine contractions. If it could be done without using too much 
 force to penetrate the cervix, we should endeavour to separate 
 the placenta with the aid of the finger. When this is impracti- 
 cable, its separation must be abandoned to the vital forces of the 
 organism. The sequelae of the escape of the foetus are generally the 
 same as those of an ordinary labour ; that is to say, the lochia and 
 the milk-fever require the same attention. 
 
 [I believe that the most successful mode of treating persons who are pre- 
 disposed to abortion, before the period of quickening, is one which I have 
 long employed, and with a most satisfactory success. It was indicated to 
 me, many years ago, by the late Dr. Physick, as one which he had been 
 much accustomed successfully to employ. If the patient has had repeated 
 miscarriages, I advise her to use an anodyne enema, consisting of a wine- 
 glassful of boiled starch, mixed with forty drops of laudanum, to be taken 
 at bedtime, and to be repeated every night, until quickening takes place. 
 Perhaps the influence of the laudanum may be useful in suppressing or 
 lessening the act, or the effect of the vesicular developments in the ovaries 
 or at least it may deprive the uterus of an abnormal degree of sensibility, 
 the persistence of which might lead it to the early contraction of its walls 
 and the consequent expulsion of the foetus. 
 
 Dr. Dewees gives, in his work on Midwifery, p. 404, 2d edition, the 
 
 Fig. 48. 
 
 adjoining drawing of what has been here long denominated Dewees’ pla- 
 centa-hook, and which is sold by the surgeons’ instrument-makers of this 
 city. The figure is one-third less than the usual size of the instrument. Dr. 
 D. gives the following directions as to the use of it: 
 
 “ The forefinger of the left hand is placed within, or at the edge of the os 
 tincae ; with the right we conduct the hooked extremity along this finger 
 38 
 
594 
 
 ABORTION. 
 
 until it is within the uterus; it is gently carried up to the fundus, and then 
 slowly drawn downwards, which makes its curved point fix in the placenta : 
 when thus engaged, it is gradually withdrawn, and the placenta with it.” 
 — ( System of Mid., p. 404.) 
 
 The distinguished writer speaks of the success he has met with in using 
 this instrument; but I cannot say that, in the various occasions of trying 
 the hook, I have been so fortunate. In fact, I have learned to believe that 
 where the cervix and os uteri are dilated, or dilatable, the ovum, whether 
 entire or broken, in abortions, comes readily to the os uteri, from whence it 
 may be taken with the point of the forefinger; and that, where the passage 
 is not dilated, all attempts to pull it away by force are both unnecessary and 
 dangerous. 
 
 In abortions, there is no hazard in the use of the tampon, where it is re- 
 solved that all hope of saving the pregnancy is to be abandoned. Perhaps 
 some reflection and hesitation might be proper, as to the tampon, at five or 
 five and a half months of gestation ; but, up to the period of four or four and 
 a half months, I look upon the tampon as the means of security in all haemor- 
 rhages from abortion ; and I very confidently expect, in general, that upon the 
 withdrawal of the tampon, after its purposes have been 
 subserved, I shall find the ovum in the cervix and os 
 uteri, whence I can take it with the finger. Dr. 
 Dewees* placenta-hook would be very convenient un- 
 der such circumstances, no doubt ; yet, where the 
 dilatation of the passages is incomplete, the hook 
 would be very apt to tear out of the soft and often 
 semi-putrid mass of the placenta. 
 
 My friend, Dr. Henry Bond, a highly esteemed 
 practitioner of our city, has lately published, in the 
 Jlmer. Jour, of the Med. Sciences for April, 1844, 
 an article on the “Extraction of Retained Placenta in 
 Abortion.” 
 
 Dr. Bond, in the very sensible paper in question, 
 examines the pretensions of the various instruments 
 in use for the purpose, and, after weighing their se- 
 veral merits and defects, he proposes a new instru- 
 ment, which he calls the placental forceps , of which 
 the adjoining cut gives a good idea. “The instru- 
 ment is ten inches long, curved laterally on a radius 
 of about twelve inches, and the blades are about an 
 inch and a half longer than the handles. The blades 
 terminate in an oval expansion, nearly half an inch 
 wide,” &c. 
 
 I have had, hitherto, no occasion to make use ol 
 
ABORTION. 
 
 595 
 
 Dr. B.’s placental forceps; but I feel assured that it is the most convenient, 
 safe and useful implement that has as yet been proposed for the purpose. 
 
 A good many cases of abortion, in the early stage, as from the sixth 
 week to the tenth, have fallen under my notice, in which the uterus was 
 unable to expel the remains of the ovum, and in which I could not extract 
 it. The patient, in such instances, has always recovered, without the 
 ovum having been visibly discharged, except with here and there a shred 
 or a lump of macerated organic matter. In these samples there is a nearly 
 constant excretion of dark grumes and offensive sanies, sometimes bloody, 
 and often of a rust colour. I presume that the remains of the ovum un- 
 dergo a slow maceration and decomposition, so as to escape imperceptibly. 
 I consider it better to leave the ovum, in such cases, to the care of nature, 
 than to reiterate attempts to extract it by force; there is as great danger 
 of exciting inflammation of the womb, by such attempts, as by leaving the 
 placenta to the process of gradual maceration and discharge. I am not dis- 
 posed to deny that the presence of a putrefying substance, even of a small 
 size, in the womb, is capable of developing violent inflammation and fever; 
 but it has not happened so with me; and I have given advice to some of 
 my younger medical friends, when consulted on such occasions, to abandon 
 the attempt ; it being always understood that reasonable efforts ought to be 
 made to get the placenta away. — M.] 
 
 OF NAUSEA AND VOMITING. 
 
 Diseases of pregnancy depending upon the sympathetic influence of the womb upon 
 the different functions of the organism. 
 
 Nausea and vomiting are phenomena which so frequently accom- 
 pany pregnancy, that their presence is ordinarily its first symptom, 
 and is sufficient to make us infer its existence. 
 
 Nausea, which may be regarded as the first stage of the vomiting, 
 sometimes exists alone, and is more distressing, even, when it persists, 
 than the latter. Some writers have supposed that these accidents of 
 pregnancy were owing to the pressure of the womb upon the sto- 
 mach, and of the thrusting of that viscus up into the oesophagus. This 
 opinion is inadmissible, especially in the early months, for the nausea 
 and vomiting often appear immediately after fecundation, and gene- 
 rally become less frequent in proportion as the womb increases in 
 size, and ascends in the abdomen. For the same causes, the early 
 signs of pregnancy can with no better reason be ascribed to plethora, 
 as supposed by Boerhaave and Smellie. They are evidently, there- 
 fore, due to the sympathetic action of the gestative organ upon the 
 stomach. Besides, this influence is further demonstrated by the 
 derangement of the digestive functions, where the uterus is the seat 
 of any disease whatever. 
 
 The nausea and vomiting generally cease after the third or fourth 
 month. In some cases, however, they last until the onset of 
 labour, while in others they cease at first at the ordinary time, but 
 reappear in the later months, which seems to depend upon the pres- 
 sure which the womb then exerts upon the stomach. 
 
596 
 
 NAUSEA AND VOMITING. 
 
 The sympathetic phenomena also vary exceedingly as to their fre- 
 quency, and the periods of the day at which they make their appear- 
 ance. Most commonly, the vomiting occurs in the morning., and 
 then consists merely of a viscid fluid. It often occurs, also, in the 
 course of the day, and especially just after meals. The solid and 
 liquid food are both rejected ; and there are some women who 
 scarcely retain a few spoonfuls of sweetened-water, or of broth or 
 coffee, while in others, again, the vomiting is calmed by the ingestion 
 of food into the stomach. 
 
 In some cases, where the vomiting is very frequent and painful, 
 it may bring on abortion, especially where a predisposition to it 
 exists. Though not always followed by unfortunate consequences, 
 the violent succussions which it occasions, and the diminution in the 
 amount of nourishment produced by it, necessarily cause emaciation 
 and debility in the patient. 
 
 [I have met with but one case of abortion that could be attributed to 
 the vomiting, whence I conclude that nausea and vomiting are rarely causes 
 of abortion. — M-3 
 
 The sickness appears to be connected sometimes with a gastric 
 derangement, characterized by a bitter taste in the mouth, by a yel- 
 low colour of the tongue, and by bilious vomiting. It is very im- 
 portant to distinguish cases of this kind from those which depend 
 upon a sympathetic influence of the uterus upon the stomach. The 
 diagnosis is generally easy when no doubt exists as to the fact of 
 pregnancy. 
 
 Though the vomiting is exceedingly distressing in some women, the 
 prognosis is not generally unfavourable. We have often known 
 pregnancy to pass happily through all its stages, though accompa- 
 nied, during its whole course, by vomiting, giving rise to very violent 
 general spasms and excessive pain in the epigastric region. 
 
 The treatment of vomiting varies according to its violence and 
 frequency, and the nature of the causes whose action produces it. 
 
 When sympathetic, we generally recommend a mild regimen, and 
 especially one composed of the articles most easily digested by the 
 patient. In many women, the most indigestible, and least suitable 
 in appearance, are the only ones which the stomach will bear : it is 
 better, when such is the case, for them to take improper food than 
 none at all. 
 
 Some women likewise find it useful to take, after meals, a small 
 glass of Madeira or Frontignac wine, or of pure brandy even, or of 
 cherry-brandy, or of rum alone or mixed with water. Good effects 
 have been obtained from Riverius’s draught, also from Seltzer- 
 water, from Columbo root, from a few drops of laudanum, or ether, 
 from mint-water, from syrup of poppy-heads, from two or three ipe- 
 cacuanha troches, and, lastly, from extract of cinchona or sulphate of 
 quinine, especially if the vomiting and epigastric pain are accompa- 
 nied by slight febrile movement, and seem to assume a periodical 
 character. Some practitioners have also recommended, when the 
 vomiting is obstinate, the application of a large cup over the region 
 
PTYALISM. 
 
 597 
 
 of the stomach, after each meal. The use of an opium plaster, or of 
 a poultice, sprinkled with Sydenham’s laudanum, has likewise been 
 tried. Finally, in two cases of purely nervous vomiting, M. Joubert, 
 of Lyons, cured the patients immediately, by the application of a 
 mustard plaster over the last dorsal vertebrae. 
 
 We have obtained the same result, on several occasions, by means 
 of frictions upon the epigastric region, with Autenrieth’s antimonial 
 ointment. 
 
 If the vomiting coincides with a saburral condition and with gastric 
 derangement, we resort to the employment of some mild purgatives, 
 as, for example, a Seidlitz powder, manna, castor oil, cassia, tama- 
 rinds, rhubarb, infused in the proportion of four grains, and to 
 emetics, even. We combine, with these means, a properly regulated 
 regimen, or a rigid diet; the use of acidulated and gummy drinks, 
 lemonade, gooseberry syrup, baths, and emollient enemata and cata- 
 plasms. 
 
 If the sickness coincide with a plethoric condition, especially if 
 the woman have been abundantly regulated before pregnancy, we 
 must resort to bleeding from the arm and to the application of 
 leeches to the epigastrium, especially when that region is painful and 
 exhibits some signs of inflammation. We might, at the same time, 
 make use of diluents, and subsequently of antispasmodics. It is 
 proper for us to remark, moreover, that, in some women, pregnancy 
 is unaccompanied by either nausea or vomiting, and that none of the 
 sympathetic phenomena we have yet to notice, occur in them. 
 
 OF PTYALISM. 
 
 Ptyalism, which constitutes one of the first signs of pregnancy in 
 many women, is characterized by an excessive secretion from the 
 salivary glands, far more inconvenient than dangerous. This exu- 
 berance of salivation generally appears soon after conception, and 
 ceases commonly towards the fourth month; but, in some cases, lasts 
 until the end of gestation, or does not even make its appearance 
 until a short time before labour. 
 
 The ptyalism, which is, in some sort, a precursory symptom 
 merely, and a primary degree of the nausea and vomiting, seems to 
 depend, like them, upon the increased vitality of the uterus during 
 pregnancy, and upon the sympathetic relations existing between the 
 gestative organ and the salivary glands. 
 
 When the salivation is slight, it is to be left to nature; but though 
 it is dangerous to arrest the secretion suddenly, especially when the 
 quantity is very great, it is wise to moderate it should it produce 
 debility of the patient and derangements of the digestive functions. 
 To attain this end, all that is commonly necessary is to keep the 
 bowels soluble by diluent and laxative drinks, by fluid magnesia, 
 by enemata and by a substantial and digestible regimen. 
 
 We may recommend, also, the use of sulphur troches, of opiate gar- 
 gles, of draughts with balm, mint, and canella water, taken by spoon- 
 fuls throughout the day. Should these means fail, we may employ 
 bleeding, or make applications of leeches to the angle of the jaw. 
 
598 
 
 TOOTHACHE. 
 
 [I recently had a lady under my charge, who had ptvalism throughout 
 the whole pregnancy; for many months she discharged at least a pint of 
 saliva daily, and was not very sensibly weakened by the discharge. — M.] 
 
 OF ODONTALGIA. 
 
 The odontalgia of pregnant women may depend on different causes, 
 which require particular plans of treatment. 
 
 The affection is generally a dental neuralgia, which commences 
 with more or less violent pains, confined generally to the lower jaw. 
 When this is the case, all the teeth of one or both sides of the jaw are 
 painful, while, if the odontalgia depends upon caries, the pain is con- 
 fined to the diseased tooth. The aching is sometimes so violent, that 
 it extends to the whole face and in the course of the branches of the 
 seventh pair of nerves. It is proper to remark, also, that there is 
 neither swelling, heat, throbbing, nor any trace of change of tissue in 
 toothache of this kind, as happens when the dental pain depends upon 
 an inflammatory condition. 
 
 To relieve the neuralgic affection, Meglin’s pills are used, in doses 
 of four or six pills daily; the sub-carbonate of iron combined with 
 rhubarb ; emollient and anodyne lotions, and, also, cataplasms of 
 the same kind. To these means are added the application of a 
 plaster of extract of opium over the course of the diseased nerve, and 
 that of a blister behind the ear on the affected side ; in some cases, 
 the application of four or five leeches to the gums cannot but be 
 advantageous, and assist the action of the other remedies. When 
 the neuralgic pains are intermittent, which is often the case, sulphate 
 of quinine united with opium is prescribed ; lastly, should all these 
 means fail, we may make trial of the following, recommended by 
 Guide meau : 
 
 Take the whites of two eggs, common pepper in powder gii, beat strongly together 
 and spread the preparation on tow, which is to be applied to the cheek of the affected 
 side. 
 
 If the odontalgia depend upon an inflammatory state of the gums, 
 the patient experiences heat and throbbing at the diseased point; an 
 abscess sometimes forms in the alveolus, which suppurates around 
 the tooth and gives rise to swelling and pain that often extend to 
 the eye and even the ear of the same side. The pain, which is kept 
 up in the case by plethora, generally yields to the employment of 
 bleeding from the arm and to the application of leeches to the gums. 
 It is advantageous to add to these means the use of foot-baths, of 
 enemata, of diluent drinks, rigid diet, and lastly, attention to keeping 
 the head warm, and the employment of emollient vapours directed 
 to the mouth. 
 
 When the toothache depends upon caries of a tooth, it must be 
 promptly extracted, unless the female is so irritable as to make us 
 fear abortion; then we should combine with the employment of in- 
 ternal and external antispasmodics the application of a blister behind 
 the ear of the affected side. If the dental pains be caused by gas- 
 tric derangement, the treatment ought to consist in the use of laxa- 
 tives, and amongst others of fluid magnesia. 
 
LOSS OF APPETITE. 
 
 599 
 
 OF ANOREXIA. 
 
 Anorexia , or the disgust inspired by food, is a phenomenon often 
 observed in pregnant women, especially in the early months. In 
 some cases it exists in regard to certain kinds of food only, but gene- 
 rally includes all descriptions. Like the affections already described., 
 the anorexia may be caused either by a nervous condition of the 
 stomach, by gastric derangement, or by a state of plethora which is 
 met with principally in women of strong and sanguine constitution. 
 
 When of a nervous character, it may be recognized by the absence 
 of the signs which characterize the other varieties ; it is to be treated 
 by antispasmodics and sedatives ; among others, emollient fomenta- 
 tions to the epigastric region, general baths, enemata, weak infusions 
 of linden-flowers, of orange-flowers, of chamomile, and of valerian, 
 sweetened with ether syrup, and with the addition of a few drops 
 of Sydenham’s laudanum. 
 
 We may join to these means the use of Seltzer- water with or 
 without lemon juice, and sometimes that of the ferruginous prepa- 
 rations, among others, the subcarbonate of iron. 
 
 If anorexia occurs in a female in whom a hard pulse, strong throb- 
 bings of the heart, swelling of the veins, general numbness, and 
 redness and puffiness of the face, show that there is evident plethora., 
 rigid diet, bleeding at the arm, and even leeches to the epigastrium 
 are indicated, especially during the fourth and fifth months of gesta- 
 tion. Finally, when the loss of appetite depends upon gastric de- 
 rangement, with bitter and pasty mouth and yellowish or whitish 
 fur upon the tongue, it becomes proper to prescribe diluent drinks., 
 and lemonade ; moreover, if there is no pain at the epigastrium, 
 the saburral state of the stomach may be more directly treated by 
 means of ten or twelve grains of ipecacuanha or by a mild saline 
 purge, in case no intestinal disorder be present. Anorexia depend- 
 ing upon debility of the stomach generally yields to the employment 
 of tonics, bitters and ferruginous waters. 
 
 We may add that it is generally unnecessary to do much for ano- 
 rexia, as it commonly ceases after the fourth month of pregnancy ; 
 when it lasts longer, it becomes in some cases a means employed by 
 nature to prevent plethora. Besides, the want of appetite seems to 
 have but little influence in some women, who bear well-formed chil- 
 dren, and retain their embonpoint and freshness through the whole 
 of the gestation. 
 
 OF BOULIMIA. 
 
 Though we generally find that pregnant women lose their appetite 
 and take complete disgust to all kinds of food, there are some also who, 
 during pregnancy, have an extraordinary appetite. This species of 
 boulimia, which often gives rise to gastritis, to vomiting and to diffi- 
 cult digestion, and which becomes sometimes a necessity so impe- 
 rious as to amount to delirium, often yields to the employment of 
 some nourishing liquids, such as broths, rice-milk, chocolate, or else 
 
600 
 
 BOULIMIA, DYSPEPSIA, THIRST. 
 
 to the use of other substances containing a large amount of nutriment 
 in a small space, among others the animal jellies, feculent substances 
 or eggs in the shell. We may likewise cheat the hunger by means 
 of some morsels of chocolate or sugar ; and we may modify the ab- 
 normal nervous state of the stomach with the gaseous and ferrugi- 
 nous waters and with some of Darcet’s troches. 
 
 OF DYSPEPSIA AND POLYDIPSIA. 
 
 Though the difficulty of digestion called dyspepsia is in some cases 
 symptomatic of an affection of the stomach, it is ordinarily idiopathic 
 in pregnant women, and constitutes a neurosis of the digestive appa- 
 ratus. The patients experience, after eating, a sensation of fulness 
 and distension at the epigastrium, ordinarily accompanied by general 
 uneasiness, by more or less thirst, and sometimes by nausea, vomit- 
 ing and cardialgia. 
 
 The prognosis of the affection is generally good, for it commonly 
 begins with pregnancy and disappears after the fourth or fifth month. 
 Sometimes, however, it does not appear until the latter months, but 
 ceases in that case with the gestation. In all cases it seems to exert 
 but little influence upon the development and health of the child. 
 
 The treatment of the disorder is very simple : it consists in the 
 employment of the bitter medicines, such as the infusions of gentian, 
 of the lesser centaury, of absinthium, of mint, rhubarb, and especially 
 of chamomile. The action of these remedies is assisted by the use 
 of the ferruginous and gaseous waters, mixed with a little wine ; and 
 by wholesome food composed of articles of easy digestion, such as 
 meat soups, white meats and very ripe fruits. Finally, the digestive 
 powers of the stomach are sustained by Vichy troches, by some 
 alcoholic liquor, among others, Bordeaux anisette, cherry brandy, 
 and Garus’s elixir, or by the use of coffee or tea. It is proper to 
 remark that in some cases, we may resort with advantage to the 
 employment of antispasmodics, given conjointly with tonics. If the 
 dyspepsia be brought on by polydipsia , or excessive ingestion of 
 liquid's into the stomach, it may be remedied by the use of baths, of 
 a few grains of nitre in lemonade, taken frequently and in small 
 quantity at a time, or else by means of ether and water, according to 
 the recommendation of Baron Larrey. 
 
 OF CAPRICIOUS APPETITE (PICA, MALACIA.) 
 
 The longings of pregnant women are as variable as they are 
 numerous. Some are tormented with a desire not only to eat sub- 
 stances which are not included in the list of aliments, but which are 
 of the most disgusting character even. This constitutes the pica, 
 while by the term malacia is meant the exclusive desire for a sub- 
 stance belonging to those used as food. We have seen women who, 
 though completely fastidious, were affected with one of these depra- 
 vations of taste, and who longed to swallow chalk, plaster, cinders, 
 charcoal, green fruits, vinegar, strong liquors, suet, caterpillars, flies, 
 opiders, and even excrement. Anomalies of this kind, which are 
 
PICA, MALACIA, ETC. 
 
 601 
 
 also observed in hysterical and chlorotic women, and in those who 
 have suppressed or irregular menstruation, are quite frequent in the 
 early months of pregnancy, and commonly cure themselves. In 
 general, it has been remarked that, whatever be the substances that 
 are introduced into the stomach in this condition, no evil has resulted 
 to the female from it, which to a certain extent permits us to suppose 
 that it is nature which inclines her to introduce into her economy 
 materials necessary to her new physiological condition. 
 
 Without believing in the marvellous effects of the spots {naevi ab 
 imaginatione) and deformities of the foetus occasioned by the caprices 
 of pregnant women, we are of opinion that there is no reason for 
 denying them any thing, or for refusing to yield to a well-marked 
 appetite, unless, indeed, the substances longed for are evidently hurt- 
 ful. It is readily conceivable that a disappointed wish and an un- 
 gratified longing carried to a certain extent may produce dangerous 
 consequences to the mother, and thus interfere with the formation 
 and development of the embryo. 
 
 The treatment of capricious appetite is nearly the same as that of 
 the other neuroses of the stomach ; that is to say, we prescribe eme- 
 tics and purgatives, where the affection coincides with a gastric de- 
 rangement; bleeding, if there is plethora; and, finally, antispasmodics, 
 syrup of ether, and laudanum, as well as the bitter infusions of the 
 lesser centaury, of balm, and of rhubarb, and the martial prepara- 
 tions, should the first means not suffice. We shall add that the dis- 
 ease is often left to itself, because it almost always yields after the 
 first months of pregnancy, and generally bears upon substances, 
 that do not prevent the female from taking other aliment, and enjoy- 
 ing comfortable health. 
 
 OF PYROSIS, DYSPHAGIA AND HEARTBURN. 
 
 Pyrosis is an affection which consists in a sense of burning pain 
 in the stomach, with eructation of an acrid fluid that produces a very 
 painful feeling of heat throughout the oesophagus, and even in the 
 mouth. 
 
 The causes of the affection are almost always inappreciable ; 
 nevertheless, they commonly occur in persons who make use of food 
 that is heavy and difficult of digestion, as fried dishes, salt meats, 
 old cheese, and alcoholic liquors. In pregnant women, it generally 
 occurs in the first months of pregnancy, without our being able to 
 ascribe it to any other cause than the sympathetic influence of the 
 uterus upon the stomach. 
 
 Idiopathic pyrosis, or even that which is symptomatic of pregnancy, 
 is generally a disease of which the prognosis is not unfavourable; for 
 when it occurs in the early periods of conception, it ceases towards 
 the fourth month, or else, when it comes on in the latter period of 
 pregnancy, it terminates at the period of the delivery. 
 
 The treatment of a pyrosis in pregnant females generally consists 
 in the administration of magnesia, and of lime-water combined with 
 antispasmodics and anodynes, such as extract of valerian, syrup of 
 
602 
 
 PYROSIS, DYSPHAGIA, GASTRALGIA. 
 
 ether, and especially opium, given in the paroxysms. To these 
 means are added a milk and vegetable diet, and demulcent and muci- 
 laginous drinks. Sometimes the employment of the martial prepara- 
 tions, among others, the subcarbonate of iron and the ferruginous 
 waters, are found to answer well. Good results have also been 
 obtained from the internal use of nux vomica in powder, in the dose 
 of from one to three grains, twice a day. Finally, when the disease 
 attacks periodically, the latter are advantageously treated by means 
 of sulphate of quinine combined with a little opium. 
 
 Dysphagia, or difficulty of swallowing, characterized by spasmodic 
 contraction of the oesophagus by the sensation of a body arrested in 
 the throat, is a phenomenon often produced by the sympathetic in- 
 fluence of the uterus in pregnancy. Though the nervous symptom, 
 under these circumstances, is commonly transient and unimportant, 
 it nevertheless sometimes requires a treatment consisting in the 
 employment of antispasmodics, and frictions of the lateral and ante- 
 rior portions of the neck, with balsam of Fioraventi and ban me 
 tranquille. We have found the following ointment to answer a 
 very good purpose in our hands: 
 
 R. — Extract Belladon., grs. xl vii. 
 
 “ Stramon., grs. xv. 
 
 Cerati, 3i. 
 
 Olei Limon., gtt. xii. 
 
 To be applied by friction, to the neck, morning and evening. 
 
 We have cured the dysphagia also by giving to the patient a little 
 cherry brandy, rum, or Bordeaux anisette mixed with water. 
 
 Heartburn is a very common indisposition in pregnant women, 
 especially in blondes and those of a lymphatic temperament. It is a 
 frequent symptom of dyspepsia, but, in the greater number of cases, 
 results from an aberration of taste, since the patients find all their 
 food to be acid, or else, which is still more common, it is produced 
 by acids actually existing in the stomach. 
 
 The acid sensation, which is more inconvenient than dangerous, 
 and which generally ceases towards the fourth month, commonly 
 coincides with paleness of the face, heat in the region of the stomach 
 and along the oesophagus, and with risings and even vomiting or 
 eructations of acrid matters. 
 
 For the treatment of this affection are recommended tonics, espe- 
 cially cinchona, gentian and rhubarb. We prescribe also, in order 
 directly to neutralize the acids of the stomach, alkaline substances, 
 magnesia, the subcarbonates of soda and potassa, Darcet’s troches, 
 and especially a spoonful or two of lime-water in half a cup of milk, 
 taken two or three times a day. To these means should be added 
 a tonic regimen, roast meats, nourishing soups, moderate exercise, 
 and residence in the country, or, at least, in a dry and temperate air. 
 
 OF GASTRALGIA. 
 
 The gastralgia, to which pregnant women are subject, is charac- 
 terized, like other forms of the same disorder, by acute pain, and by 
 
GASTRALGIA. 
 
 603 
 
 a, feeling of dragging and laceration at the epigastrium. This kind 
 of gastralgia, vulgarly known by the name of nervous colic or 
 cramp of the stomach , may, in some cases, suddenly disappear, and 
 not return. When momentary merely, the functions undergo no 
 sensible change; but where it continues with full violence, the patient, 
 more and more oppressed, is obliged to sit down, to keep the body 
 inclined, and bend herself forward while pressing upon the epigas- 
 trium. We can distinguish nervous pains of the stomach from those 
 produced by inflammation of that organ, by observing, that in gas- 
 tralgia there is always absence of fever ; that the tongue presents its 
 natural colour, and that the pains, which have intervals of paroxysm 
 and repose, are not aggravated, but are even relieved, sometimes, by 
 pressure. The contrary occurs in gastritis, which occasions less 
 severe, but always more constant pain. 
 
 We have seen attacks of gastralgia occur in some women, as soon 
 as the stomach became empty, while the pains ceased immediately 
 upon taking some solid or liquid substance. In others, again, they 
 recur immediately after eating, or after the slightest impression of 
 cold upon the arms, shoulders, and especially the feet. 
 
 The treatment of the disorder, which differs but little from that of 
 the preceding, presents two fundamental indications. The first con- 
 sists in acting during the paroxysm, so as to lessen its severity and 
 duration, and the other in preventing, as far as possible, the return. 
 
 During the paroxysm, a large flaxseed poultice should be applied 
 to the epigastrium, as hot as the patient can bear it. It is well to 
 sprinkle the poultice with a little mustard; but, when this is done, it 
 must be kept applied a shorter time. It is good also to prescribe 
 several tablespoonfuls of some antispasmodic mixture. We have 
 always found the following to answer extremely well: 
 
 R. — Of orange and linden-flower water, each two ounces; of syrup of ether and 
 of valerian, each an ounce; of syrup of poppy-heads, half an ounce. Of this, a tea- 
 spoonful is to be given every quarter of an hour. 
 
 To prevent the return of the paroxysm, we should prescribe the use 
 of baths, enemata, diluent drinks, and warm applications to the epi- 
 gastrium ; or else frictions of that region with tartar-emetic ointment. 
 We may also use, with advantage, infusions of linden-flowers, of 
 orange-flowers, or of chamomile, sweetened with a little syrup of 
 poppy-heads or of ether. There have been recommended, also, the 
 subnitrate and white oxyde of bismuth, in the dose of four to six 
 grains, administered at two or three different times in the day, in a 
 spoonful of sweetened water or syrup. We have always prescribed, 
 with greater advantage, the extract of valerian and subcarbonate of 
 iron in the pilular form. We have likewise obtained good results, 
 sometimes, by directing the internal use of ice, or else of a small 
 quantity of Garus’s elixir, especially for the purpose of diminishing 
 or dispelling the paroxysms. Finally, we must associate with the 
 employment of these means a regimen composed of aliments of easy 
 digestion, and the use of tea after the meals, and of the gaseous 
 waters of Seitz or of St. Albans, mixed with wine and taken with the 
 food. 
 
604 
 
 ENTERALGIA, CONSTIPATION. 
 
 OF ENTERALGIA. 
 
 There is another form of neuralgia, to which pregnant women are 
 subject; that which is known by the name of enteralgia or nervous 
 colic. This affection, which depends upon a spasmodic and sym- 
 pathetic condition of pregnancy, generally prevails in the early 
 months, in the form of intermittent, shifting pains, unaccompanied 
 by febrile movements, however severe they may be, and which are 
 not increased by pressure upon the abdominal parietes. 
 
 This kind of colic, which may also be occasioned by cold, requires 
 nearly the same treatment as gastralgia, that is to say, we must 
 oppose it by baths, poultices, fomentations, and emollient and ano- 
 dyne enemata, as well as by infusions of linden-flowers, of chamo- 
 mile, and of tea sweetened with syrup of ether and of poppy-heads. 
 Barthez recommended, in such cases, a bolus composed of camphor, 
 nitrate of potash and assafoetida. If flatulence accompany these 
 symptoms, we might relieve it by frictions with the baume tran- 
 qiiille , or by warm poultices sprinkled with oil of hyoscyamus or 
 chamomile, upon the abdomen. Lastly, should there be any symp- 
 toms of plethora or inflammation, bleeding must be resorted to. 
 
 OF CONSTIPATION. 
 
 Constipation is very common in pregnant women, especially to- 
 wards the end of pregnancy : it is generally caused by the pressure 
 of the enlarged womb upon the colon and rectum, whence results 
 difficulty in the passage of the fecal matter. It may depend also 
 upon a vital lesion or intestinal neurosis connected with the spasmo- 
 dic irritation of the uterine system. Whatever be the cause of the 
 difficulty, when it is carried to some extent, it produces anorexia, 
 renders the digestion difficult, causes restlessness, insomnia, cephal- 
 algia, sadness and capricious temper. The efforts made by the female 
 to expel the abundant and hardened fecal matter, may become a 
 source of uterine haemorrhage, and even of abortion ; while the con- 
 tinual pressure of the excrements upon the extremity of the intes- 
 tine, may determine, at that point, inflammation and haemorrhoidal 
 tumours. 
 
 Moreover, the constipation exists in different degrees. When it 
 does not last more than three days, most women are little disturbed 
 by it ; but when the stools occur at longer intervals, it may give rise 
 to all the inconveniences we have pointed out. 
 
 It is of the utmost importance, therefore, to prevent or dissipate, 
 or at least to diminish the unfavourable effects of constipation in 
 pregnant women. It must be treated by various means, except the 
 drastic purgatives, the use of which may occasion the most danger- 
 ous accidents. It is, however, upon a mild and relaxing regimen that 
 we should chiefly rely : thus we may with advantage prescribe the 
 white meats; dressed vegetables, particularly sorrel, lettuce and spi- 
 llage ; cooked or very ripe fruits, such as cherries, melons, grapes, 
 prunes, strawberries and oranges. It is well to add to these dietetic 
 
DIARRHOEA, DYSENTERY, TENESMUS. 605 
 
 means, the employment of warm baths, the use of vegetable or veal 
 soup, lemonade, cream of tartar, milk weakened with water, decoc- 
 tions of tamarinds, cassia fistula, or of prunes, and barley-water 
 sweetened with honey, according to the taste of the patient and the 
 effects produced. 
 
 Should these measures not be sufficient, we must recommend emol- 
 lient and laxative enemata, prepared with brown sugar, honey, senna, 
 French mercury, oil or butter. We may likewise employ the mild 
 purgatives, such as manna, castor oil, Seidlitz water or phosphate of 
 soda. We have treated the obstinate constipations of pregnant 
 women successfully, 'by means of suppositories of benrre de cacao , 
 employed three times a day, and a grain of calomel taken at night, 
 on going to bed, in half a tumbler of sweetened water. Finally, in 
 some bad cases, when the fecal matters are so impacted in the 
 intestine as to make it impossible to expel them by enemata and 
 purgatives, it becomes indispensable to extract a large portion of 
 the mass with the finger or a scoop. The impossibility of intro- 
 ducing a canula or of injecting fluids into the rectum, indicates the 
 accidental occlusion of the intestine, and should decide the physician 
 to remedy it as soon as possible, by the use of the finger. It is proper 
 to remark, further, that in some subjects, frictions of the abdomen, 
 the application of a cold body, as ice, to the soles of the feet, just as 
 the use of beer or coffee, especially if a glass of water be taken after- 
 wards, almost immediately produce an evacuation of the fecal mat- 
 ters. 
 
 OF DIARRHOEA, DYSENTERY AND TENESMUS. 
 
 The diarrhoea of pregnant females, which consists of a more or 
 less frequent evacuation of mucous, serous or bilious matters, depends 
 almost always upon a nervous cause, that is to say, it depends upon 
 the sympathetic influence of the uterus upon the digestive canal. In 
 some cases, however, the diarrhoea is produced by an intestinal irrita- 
 tion, which betrays itself by sensibility of the abdomen, by heaviness 
 of the head, by a saburral condition, by a mucous coat upon the 
 tongue, by difficulty of digestion, and elevation of the pulse. In the 
 sympathetic or nervous diarrhoea, the patients are without fever, or 
 colic; the mouth, tongue and appetite retain their normal condition. 
 
 When the evacuations are mixed with blood, it takes the name of 
 dysentery, which is always the result of an irritation of the intestines, 
 and which is generally accompanied by fever, colic, tension and 
 sensibility of the abdomen. Lastly, the disease receives the title of 
 tenesmus, when it consists of a constant, painful and nearly unavail- 
 ing desire to go to stool, and when accompanied by burning heat at 
 the fundament. The last-named affection generally occurs towards 
 the end of pregnancy ; and the straining which results from it has 
 been known to produce abortion. The compression exerted upon the 
 rectum, and the constipation thereby produced may sometimes give 
 rise to tenesmus; but this affection commonly depends upon the 
 diarrhoea or dysentery. 
 
606 
 
 DYSPNOEA. 
 
 A diarrhoea occurring at the commencement of pregnancy, is com- 
 monly of little consequence ; as the woman retains her appetite 
 and strength, it may be left to nature, or, at least, treated simply by 
 careful diet, rice water, and emollient enemata. Should there be 
 symptoms of gastric or intestinal irritation, and especially if the 
 tongue be coated and give evidence of a saburral condition, resort 
 must be had to the employment of demulcent and anodyne enemata, 
 drinks of the same kind, baths, fomentations and poultices; and 
 even to an application of leeches ^about the anus, particularly in 
 women of strong and plethoric constitutions. In some cases, evacu- 
 ants also are prescribed ; ipecacuanha in a dose of several grains, 
 and infusion of rhubarb, with addition of four drachms of sulphate 
 of soda. If, notwithstanding the use of these means, the diarrhoea 
 should persist, and especially if the woman loses her strength, we 
 must resort to the bitters, such as gentian, the lesser centaury, rhu- 
 barb, infusion of chamomile, and, after a proper time, to wine of ab- 
 sinthium, to Bordeaux wine, to diascordium, to theriac., and to opiates. 
 It will be well, also, to use tonic and sedative enemata, prepared with 
 a weak decoction of cinchona and a few drops of laudanum. 
 
 In the treatment of dysentery, we must recur to opiate prepara- 
 tions chiefly ; for example, opium is to be prescribed in all its forms. 
 For ordinary drink, the patients should make use of rice water with 
 gum, with the addition of fifteen drops of Sydenham’s laudanum; 
 they should use, two or three times in the day, enemata of decoction 
 of althaea or flaxseed, with twenty-five drops of laudanum. Lastly, 
 there is a remedy which has always succeeded in our hands, consisting 
 of a mixture of the whites of six eggs, beaten in a quart of water, 
 to be taken both as a drink and as enemata. Care must be observed to 
 use enemata, of small size only, several times a day; and they ought 
 to be retained, if possible. The portion of the same liquid which is 
 used as drink, ought to be sweetened with sugar, or, still better, with 
 half a tablespoonful of syrup of poppies, to every glass. The two 
 last means are particularly useful when the dysentery is complicated 
 with tenesmus, which requires nearly the same treatment as dysen- 
 tery. 
 
 The power of these remedies may be assisted by dieting, or by an 
 analeptic regimen, composed principally of moderately rich soups, 
 feculent substances, animal jellies, white meats, fresh eggs in the 
 shell, and of substances of easy digestion. 
 
 OF DYSPNCEA. 
 
 Affections of the Respiratory Organs during Pregnancy. 
 
 Several sorts of dyspnoea often accompany the pregnant state. 
 The first, which is a nervous dyspnoea, generally appears in the 
 early periods of the gestation, and, for its principal character, has 
 intermissions, and returns in regular or irregular paroxysms. 
 
 The second species of dyspnoea, which is generally more painful 
 than the first, and which has been looked upon as the result of pie- 
 
DYSPNCE A. 
 
 607 
 
 thora, occurs more particularly towards the fifth month, and is 
 without intermissions. Finally, the last species, observed towards 
 the end of pregnancy, depends upon the size of the uterus, which 
 presses up the diaphragm, and thereby lessens the capacity of the 
 chest. This difficulty of respiration is remarked principally in women 
 who have narrow chests and contracted pelvis; in primipara, in 
 those who are rather under size, and lastly, in those affected with 
 some deviation or deformity. In this condition the oppression is 
 so great sometimes as to produce a state bordering upon suffocation. 
 The patients are always obliged to maintain a nearly vertical posi- 
 tion, or to place themselves on their knees upon cushions, with the 
 elbows resting upon other and more elevated cushions, in order, in 
 this way, to obtain a little sleep, or at least repose. Desormeaux, 
 who relates the case of a lady who was deformed and was affected 
 with this species of dyspnoea, adds that she was threatened with 
 suffocation whenever she leaned backwards or quitted the position 
 we have just described. The same author says that the above 
 patient, who always had imperfect respiration, swelled face, and 
 bluish lips, was forced to remain standing during the whole of the 
 labour, which was long and painful, and could not be terminated 
 until the head of the child had been opened and the brain evacuated. 
 Moreover, she died three days after the labour without pain or 
 fever, and seemed to perish by a slow asphyxia. At the autopsy, 
 the lungs were found to have been forced into the superior part of 
 the thorax, to be of compact consistence, of a brownish-red colour, 
 and crepitant in a very small portion only. 
 
 The treatment of nervous dyspnoea or that which occurs in the 
 early months of pregnancy, consists in the employment of antispas- 
 modics and sedatives, amongst others the infusion of orange-flowers 
 and linden-flowers, syrup of poppies, cherry laurel water, and the 
 medicinal hydrocyanic acid ; camphor, assafoetida, musk, and castor 
 in mixture or pill ; lastly, sulphate of quinine combined with opium, 
 should the difficulty of respiration affect an intermittent type. 
 
 The plethoric dyspnoea is to be treated by bleeding, to the amount 
 generally of eight or ten ounces, which is sufficient to relieve the 
 lungs and facilitate the entrance of the quantity of air necessary for 
 respiration. There should be prescribed, at the same time, a more 
 severe regimen, and some laxatives and enemata in order to keep the 
 bowels soluble. 
 
 To oppose the last species of dyspnoea, the patient must be recom- 
 mended to take a position most favourable to respiration, which con- 
 sists in maintaining a nearly erect posture, with the head and chest 
 sustained by means of cushions disposed in the way found to be most 
 agreeable. A bleeding from the arm is generally employed for the 
 purpose of preventing vertigo and a sense of suffocation, and to 
 relieve as much as possible the pulmonary vessels. Finally, the 
 patient should be subjected to a mild diet, she should be allowed 
 small quantities only of food at each meal, in order to avoid distension 
 of the stomach, while substances difficult of digestion, especially those 
 which produce extrication of gases, must be forbidden. The size of 
 
60S 
 
 DYSPNCEA. 
 
 the abdomen is to be diminished as much as possible, by means of 
 enemata and laxative drinks, and all articles of clothing that com- 
 press the thorax and abdomen, and prevent their expansion during 
 respiration, ought to be removed. It is proper to remark, also, that 
 if the dyspnoea depend upon an organic affection of the lungs exist- 
 ing before conception, but which has been aggravated by gestation, 
 the treatment must be directed towards the affection which is the 
 cause of it, remembering, however, its complication with the preg- 
 nant state. 
 
 [I have met with many cases of dyspnoea in pregnant females ; and ex- 
 cept in those instances where the oppression of the chest is derived from the 
 pressure against the diaphragm from below, I think they are always worthy 
 of a close and most careful scrutiny — since it is dangerous to permit the 
 difficulty to continue, when it is possible to obviate it, under the very 
 loose general idea of its being one of the diseases of pregnancy. 
 
 The pressure of the gravid womb upon the abdominal aorta, and the branches 
 of the cceliac and the mesenteric arteries, as well as its intrusive interference 
 with the descent of the diaphragm, are all highly provocative of excessive 
 determination of blood to the head, the superior extremities and the thoracic 
 viscera. Hence we very frequently meet with the cephalalgia, the convul- 
 sion, the mania, and the altered temper of the pregnant female, in dependence 
 mainly on simple excessive determination of blood to the superior parts 
 of the body, from pressure on the aorta. But the same disposition also 
 exists as to the pulmonary circulation, and is shown in the engagements, the 
 dyspnoea, and the altered colour of the cheeks, lips and fauces, in the cough, 
 and mucous rale, in the palpitation, and also in the vascular reaction conco- 
 mitant of such conditions. 
 
 Where a patient under gestation makes complaints on the subject of her 
 respiration, it requires but little time carefully to auscult every part of the 
 lungs and the heart, and pericardium. This, and the test of the capacity of 
 the lungs for air, obtained by causing the patient to make a forced inspira- 
 tion, may clear up the diagnosis and leave us assured that nothing is to be 
 feared ; or direct us to the prosecution of vigorous measures for the cure. I 
 have for the most part found that a patient attacked with inflammation of the 
 lungs, is not very easily cured, if, in an advanced stage of pregnancy, until 
 after her delivery shall have taken place. Upon the withdrawal of the 
 pressure and the distension, the restoration of a free excursus to the blood 
 enables the disordered lung to recover rapidly, provided no mischief has been 
 done to the organ in the mean time. But as there is great danger that such 
 mischief may be done, a patient so complaining ought to be made aware of 
 the risk, and put at once under a regular clinical treatment. 
 
 Many women complain of a difficult respiration in pregnancy, and of vio- 
 lent palpitation and unusual disorder of the heart, in consequence of their 
 having become anaemic during the last months or weeks of the gestation. 
 
 I am quite certain that pregnancy is a not unfrequent cause of the anaemic 
 
COUGH. 
 
 609 
 
 malady — and where the anaemia proceeds to an aggravated state, the conse- 
 quences are often most distressing — for during the existence of a great dimi- 
 nution of the crasis of the blood, the patient is liable to troublesome and 
 even very dangerous effusions of serum into the chest, the pericardium and 
 the abdomen. A mistake on the part of the practitioner would be very un- 
 fortunate for the patient, by misleading him in the method of treatment. 
 Let him therefore carefully discriminate betwixt the effects of a pure inflam- 
 mation, and those often similar ones that arise out of the feeble and irregu- 
 lar innervation proceeding from a state of the blood, in which that fluid 
 has lost a large portion of its power to excite the brain and nervous sys- 
 tem, leaving them subject to the utmost incompetency to fulfil their office. 
 Where the blood has become imperfect by the loss of a quota of its discs or 
 its albumen, it is not possible that the brain and nerves should steadily and 
 properly innervate the heart — the respiratory organs, nor indeed any portion 
 of the organisms. — M.]| 
 
 OF COUGH. 
 
 The cough, like the dyspnoea which attacks women in the early 
 months of pregnancy, depends upon a nervous condition which is 
 the result of the sympathetic influence of the womb upon the pul- 
 monary organs. The nervous cough, though the least dangerous of 
 all, must be distinguished from that which is the result of a bron- 
 chitis or of a pulmonary congestion, for the therapeutical means which 
 it requires are totally different. In the nervous cough, there is no 
 expectoration, and the cough is always dry, unless complicated by a 
 cold ; the catarrhal cough produced by cold, is on the contrary accom- 
 panied by mucous expectoration, coryza, often by soreness of the 
 throat, by dull pain in the head, and by a slight rigor in the evening 
 with or without fever; none of these symptoms occur in the nervous 
 cough. 
 
 That which is produced by a pulmonary engorgement generally 
 appears towards the end of the pregnancy. Its exciting cause is the 
 augmentation of size of the uterus, which presses up the diaphragm 
 and intestines, and, by consequence, lessens the thoracic cavity. Un- 
 der these circumstances, the pulse of the patient is hard and full, the 
 countenance red and animated ; she complains of headache, of un- 
 easiness and oppression, especially after eating, and some are subject 
 to nasal or bronchial haemorrhages. 
 
 In general, be the character and cause of the cough what they 
 may, it is a symptom which ought to command the attention of the 
 physician, because the violent shocks which it imparts to the abdomi- 
 nal viscera may become the causes of uterine haemorrhage and abor- 
 tion, or be extremely inconvenient, at least in some cases, by exciting 
 sudden and involuntary expulsion of the urine. • Moreover, the 
 cough, whose violence is generally increased by the phenomena ot 
 gestation, may, by its prolongation, determine pulmonary inflamma- 
 tion, or have the inconvenience at least of increasing in severity after 
 39 
 
610 
 
 HEMORRHAGE IN PREGNANCY. 
 
 the labour, which does not generally occur in regard to the other 
 complications of pregnancy. 
 
 The treatment of the nervous cough consists in the employment 
 of opiates when it is slight, and of bleeding when violent and con- 
 tinued. To these means may be added tinctures, mucilaginous 
 drinks, the bechic infusions of violets, calf’s foot, hyssop, wild poppy 
 or borage, sweetened with syrup of gum, of erysimum or maiden- 
 hair, sinapisms to the limbs, laxative enemata, and, lastly, frictions 
 with Autenrieth’s antimonial ointment upon the sternum. The 
 same means, and particularly the bleeding, may be opposed to the 
 cough which depends upon a pulmonary engorgement : the same is 
 true of the catarrhal cough, which less frequently requires sanguine 
 emissions, and which is generally treated successfully, when chronic, 
 by means of a tisan of Iceland moss, taken with a little milk or 
 sweetened with syrup of maiden-hair or erysimum. 
 
 OF HEMORRHAGES OCCURRING DURING PREGNANCY. 
 
 Uterine Haemorrhages. 
 
 Amongst the losses of blood to which pregnant women are sub- 
 ject, there is none more frequent and dangerous than that from the 
 uterus. This haemorrhage, whose predisposing causes are all the 
 circumstances that we assigned to the other metrorrhagias independ- 
 ent of pregnancy, may be occasioned by any of the causes capable 
 of producing abortion, amongst others, by the criminal manoeuvres 
 which some persons make use of, by means of puncturing instruments 
 introduced into the uterus, or by making use of violent emetics 
 and purgatives, by emmenagogues, hip-baths, bleedings, leeches, etc. 
 Blows upon the abdomen; falls on the feet, knees or breech; violent 
 movements of the limbs, forced walking, dancing ; abuse of coitus, 
 and all efforts and sudden or violent shocks may also give rise to it. 
 The uterine haemorrhage of pregnant women is particularly caused 
 by separation of the foetal membranes from the internal surface of 
 the womb, and by vicious insertion of the placenta over the cervix 
 uteri. The haemorrhage due to this cause generally appears without 
 precursory symptoms from the sixth to the seventh months of preg- 
 nancy, because about this period the cervix uteri begins to diminish 
 in length and to enlarge its orifice. 
 
 This metrorrhagia may be apparent or concealed, that is to say, 
 external or internal. In the former case, it is recognized by the 
 escape from the vulva of a larger or smaller quantity of blood ; and, 
 unless it depend on anormal insertion of the placenta, is preceded by 
 dull pain, by weight in the hypogastrium, and by dragging in the 
 loins and groins. In the second case, the diagnosis is more diffi- 
 cult; for the blood may be retained by occlusion of the cervix, by 
 adhesions which confine the liquid behind the foetal membranes, 
 and, lastly, by the placenta, which, separated at the centre and not 
 at the edges, forms a sort of sac in which the sanguine effusion 
 accumulates. , Under these circumstances, the haemorrhage can be 
 
UTERINE HAEMORRHAGE. 
 
 611 
 
 suspected only from the internal phenomena showing congestion of 
 the uterus, such as increased size of the abdomen and deep-seated 
 pains in the pelvis and loins, to which after a time are added pale- 
 ness of the face, faintness, feeble pulse and vision, tinnitus aurium, 
 general sensation of coldness and often syncope. Hemorrhages of 
 this kind take place without being preceded by prodromic symptoms; 
 they are at first slight and of short duration, but, after a longer or 
 shorter period of time, they reappear in larger and larger quantity 
 and last longer. The finger carried into the os uteri, finds it filled 
 with the thick, unequal and spongy substance of the placenta, always 
 easy to distinguish from the clots of blood which may be detained 
 there, and which are always of softer consistence and smoother sur- 
 face ; lastly, by means of ballottement, we discover that there is 
 some intermediate body, more or less thick, between the finger and 
 the foetus. Moreover, the successive haemorrhages exhaust the 
 patient, render the muscles oedematous, and soon produce white- 
 ness of the lips and puffiness of the face, whose colour becomes yel- 
 low and dull like wax. 
 
 Metrorrhagia occurring in the early months of pregnancy, is gene- 
 rally less dangerous for the female than for the fetus, for it is very 
 often followed by abortion. In the latter months, on the contrary, 
 the mother runs more risk than the child. Internal haemorrhage is 
 always more dangerous than external; just as the loss of blood, 
 which occurs from the placenta or cord, exposes the fetus to greater 
 danger than the woman ; the contrary is true where it is due to an 
 uterine exhalation. It is proper to remark, also, that in haemorrhage 
 depending upon a plethoric condition, the flow of blood, by destroy- 
 ing the molimen, arrests the disorder itself. It thus becomes its 
 principal remedy. 
 
 The treatment of uterine haemorrhages of small amount, and 
 which have occurred accidentally in the early months of pregnancy, 
 consists in moderating the general circulation and diminishing the 
 afflux of blood towards the uterus. This double indication is 
 answered by placing the woman in a horizontal position on a hard 
 bed, and adjusting the pelvis in such a way that it shall be 
 higher than the rest of the body. Fresh and pure air, repose of 
 the body and mind, rigorous diet, and cold acidulated drinks are 
 indispensable. If the patient be strong and of sanguine constitution, 
 we may resort to bleeding, taking care to make a very small orifice 
 in the vein, so that the blood may flow as long as possible. The 
 same result might be obtained by applying the finger to the wound, 
 and then removing it from time to time in order to let the blood 
 escape. If the haemorrhage should continue, in spite of these means, 
 we must resort to refrigerants and to applications of compresses, wet 
 with cold water or oxycrate, to the abdomen and inside of the 
 thighs. We might employ, likewise, the large dry cups under the 
 breasts, mustard hand-baths, and mustard poultices between the 
 shoulders, according to the advice of M. Velpeau. There should be 
 prescribed, also, especially for feeble women, a sedative mixture, 
 composed of lettuce water, extract of rhatany and syrup of comfrey, 
 
612 
 
 UTERINE HAEMORRHAGE. 
 
 which ought to be substituted by syrup of opium and ether if the 
 patient be very nervous and irritable. 
 
 Should the haemorrhage persist and threaten to prove fatal, not- 
 withstanding the employment of these means, which are proper 
 principally in the early months, the only chance of saving the patient 
 that remains, is to empty the uterus. The moment which calls for 
 this proceeding, is that when the constantly increasing paleness and 
 debility, the small size of the pulse and faintings, indicate a pressing 
 danger and one beyond the other resources of the Art. But as the 
 womb is often not sufficiently developed to allow of the introduction 
 of the hand into its cavity, the membranes ought not to be rup- 
 tured. It is then only that the tampon is useful, by permitting the 
 blood to accumulate in the uterus, the os uteri to be dilated and soft- 
 ened, the ovum to detach itself, favouring in this way the expulsion 
 of the foetus. If the sanguine discharge persist, notwithstanding 
 the presence of the tampon, we must endeavour to bring on con- 
 tractions of the uterus by means of irritating enemata, and act after- 
 wards as in ordinary cases of abortion. Lastly, if, on the contrary, 
 the dilatation and thinning of the cervix permit, first one, then two, 
 and then three fingers must be carried into the os uteri, and, as 
 soon as the bag of waters is formed, without waiting for complete 
 dilatation, the membranes are to be perforated and the expulsion 
 of the foetus to be trusted to nature, assisted by means of titiilations 
 of the os uteri and frictions to the hypogastrium. Should the child 
 be in a bad position, it would be necessary, after the rupture of the 
 membranes, to carry the hand into the uterus, search for the feet, 
 and turn the child. Ergot might often be useful in cases of this 
 kind, to prevent inertia of the uterus, which is to be apprehended 
 after too rapid a delivery. 
 
 [In one of the sentences of this paragraph M. Colombat says, that in 
 uterine haemorrhage, in the pregnant woman, when the cervix is not suffi- 
 ciently dilated to admit the hand, the tampon becomes useful, and only 
 then , ( settlement alors.) 
 
 I am much gratified with the appearance of carefulness with which the 
 author has pronounced this opinion, settlement alors. I add this note 
 for the sole purpose of endeavouring to impress the value of this direc- 
 tion more deeply upon the mind of the young practitioner, f have, in 
 another note, given my opinion, that the tampon is a resource of the 
 greatest value in uterine haemorrhages of the pregnant woman who has not 
 passed much beyond her fourth month ; but I have a feeling amounting 
 almost to horror, of the practice of introducing the tampon in an advanced 
 stage of gestation — since when blood is effused from the vessels it can 
 never be reabsorbed by them, and the sooner it is removed from the cavity 
 the better. I disapprove of the tampon even in placenta praevia ; and I 
 am glad to find that Robt. Lee, in his beautiful little volume, Clinical Mid- 
 wifery , is of the same opinion. — M.] 
 
 The uterine haemorrhages occurring during labour, generally depend 
 
UTERINE HAEMORRHAGE. 
 
 613 
 
 upon the same causes as the preceding, particularly upon a plethoric 
 condition of the female and on placenta prasvia ; to these should be 
 added, more or less serious lacerations of the uterus and vagina and 
 rupture of the umbilical cord. Moreover, the haemorrhages which 
 appear during labour, are so much the less dangerous as this is more 
 advanced, for when the uterus is emptied it generally contracts, and, 
 in this way, the flow of the blood is arrested ; the treatment ought 
 to consist, therefore, in the employment of means proper to accele- 
 rate delivery. The accoucheur must determine, in these cases, 
 between the ergot, the tampon, the rupture of the membranes, the 
 forceps and version. Haemorrhage during labour is one of the most 
 dangerous forms of that accident, especially if it depend on inertia 
 of the womb. It may be occasioned, also, by plethora, by vivid 
 emotions, by the presence of the placenta, by a portion of that body 
 or of any other substance in the uterus, by more or less complete 
 inversion of the organ, and, finally, by laceration of the cervix. 
 These hemorrhages may be either internal or external, like those 
 which appear during pregnancy or labour. We call attention to the 
 fact merely, that internal uterine haemorrhage is never more frequent 
 or more dangerous than after labour. 
 
 The treatment of flooding varies according to the cause which 
 produces it. If it be the placenta, a clot of blood or any other body 
 preventing the contraction of the womb, it must be extracted. — 
 If the haemorrhage depend upon laceration of the cervix, it may be 
 arrested by means of a tampon of charpie, sprinkled with pow- 
 dered alum and resin, carried up to the seat of the mischief. Again, 
 bleeding must be used in cases determined by a plethoric state, and 
 the reduction of the womb in those produced by inversion of that 
 organ. Finally, we may join to the other means, especially to the 
 external refrigerants and derivations indicated for the arrest of 
 haemorrhage during pregnancy, the introduction of a peeled lemon 
 into the cavity of the uterus, and compression of the aorta above 
 the sacro- vertebral angle, either by acting upon the uterus through 
 the walls of the abdomen, by means of a hand carried into the 
 uterus so as to compress the aorta against the vertebral angle, or, 
 lastly, by making the compression above the uterus, by means of 
 the fingers acting through the abdominal parietes. As to haemor- 
 rhages dependent upon inertia of the womb, we refer to the chapter 
 which treats of them. The same applies to the inversion of the 
 organ. 
 
 [In the treatment of uterine haemorrhages, it is of the utmost importance 
 to understand the uses and value of position, as a means of diminishing or 
 suppressing the flooding. 
 
 In all floodings at or near the full term of utero-gestation, the woman 
 should lie upon the bed, with the head but slightly raised, while the 
 shoulders are upon the same plane with the rest of the trunk. If the 
 haemorrhage be an alarming one, it might be that the medical attendant * 
 should find a full and bounding pulse, with a decided heat of the skin 
 
614 
 
 UTERIXE HAEMORRHAGE. 
 
 and flushing of the face. In such a case he ought, without hesitation, to 
 let blood at the arm, provided the general state of the patient’s health 
 would warrant such a proceeding. In some of the cases of uterine haemor- 
 rhage the necessity for using the lancet is as great as that which exists in 
 haemoptce or other arterial haemorrhages. But it will be his duty carefully 
 to discriminate between the cases from nisus and those simpler effusions 
 of blood that proceed from an accidental detachment of a portion of the 
 placenta, in which the blood escapes as in a wound, and not by a nisus 
 haemorrhagicus . 
 
 It is highly expedient, in all serious cases of uterine haemorrhage, for 
 the attendant to demand the privilege of Touching, without which I con- 
 ceive it impossible for him to enjoy the light that should guide his ministry 
 — but let him not resort too frequently to the operation, which is so loudly 
 condemned by Dr. Dewees, as both mischievous and useless ; let him 
 acquire the desirable information as fully and completely as possible, and 
 rest satisfied with that until some evident necessity arises for a new 
 research. 
 
 A woman flooding should be kept profoundly still: she ought not to be 
 permitted to rise, for the urine or stool — and should be advised to move her 
 arms and lower limbs as little as possible. The apartment ought to be 
 ventilated, whether in winter or summer; and at either season, I am accus- 
 tomed to open the windows and doors if the danger be imminent. The re- 
 frigerant power of cloths wrung out of cold spirit and water, or vinegar and 
 water, is to be availed of. Such napkins, not dripping, but wrung as hard 
 as possible, ought to be applied to the hypogastrium and thighs. All 
 exciting conversation should be suppressed ; the attendants should be no 
 more numerous than necessary, and their movements ought to be gentle 
 and considerate, without hurry or appearance of alarm. 
 
 Fortunately, in most cases, where the extravasated blood is allowed to 
 flow freely away, not being checked or dammed up in the passage, the 
 flooding mostly ceases as soon as the loss has been sufficient to bring on a 
 slight feeling of faintness ; and the check once obtained, the loss is not 
 renewed if the woman lies perfectly still; but is very apt to recommence, 
 if she tosses herself too much on the bed. 
 
 Styptic medicines are of very little avail here. Opium is of very great 
 value, and may be given in full doses; but it should never be forgotten, 
 that the haemorrhage, when the placenta is detached, may never cease until 
 life has escaped along with the last drops, unless the uterine cavity be 
 allowed to contract. And this contraction of the womb is what we can 
 almost always command. 
 
 If the membranes are as yet unruptured, let them be broken ; so that, 
 upon the escape of the waters, the parietes of the womb may become con- 
 densed ; in doing which, the bleeding vessels will be constringed, or even 
 
UTERINE HEMORRHAGE. 
 
 615 
 
 effectually closed to such a degree that from that moment all danger is at 
 an end. This is what is called Louise Bourgeois’s method. 
 
 Should the flooding, however, continue, after the rupture of the ovum 
 and the discharge of the waters, to such a degree as to endanger the 
 mother’s safety, the time will have arrived, or will soon be at hand, to place 
 her in a state of complete security, by emptying the womb — that is, by 
 removing the child. This may be done by what is called Puzos’ method, 
 which consists in turning it and delivering it by the feet; or, if the occa- 
 sion should present, by Levret’s method, which consists in delivery by 
 the forceps. As soon as practicable after the child is removed, let the 
 placenta be taken away, when no obstacle is left in the way of those 
 effective contractions, by which the uterine tissue is entirely condensed, 
 its arteries compressed in every dimension, and the orifices as well closed 
 nearly as if shut by the ligature. These are the true and reliable prin- 
 ciples on which uterine haemorrhage ought to be treated — it being under- 
 stood to be the province of the physician, and his alone, to decide as to the 
 time and method of acting. To trust the gravid womb, under flooding, to 
 the efficacy of a coagulum, is what few practitioners of experience would 
 approve. They all know that the cure lies in a contracted and well con- 
 densed womb. 
 
 It frequently happens, that when a woman has been well and safely 
 delivered, she shall have the uterus well contracted, firm and small in the 
 hypogastrium — and expresses herself as comfortable , but within an hour, 
 more or less, she shall suddenly faint away, and be without pulse or 
 motion. In such a case, the hand, when placed upon the hypogaster, finds 
 the womb now raised up almost to the navel — or it may be, that it is but 
 slightly enlarged or expanded again. 
 
 Such an occurrence always gives rise to a panic in the lying-in room ; 
 and, indeed, there is reason to fear she may never recover, unless proper 
 measures be taken. A direction should be given to open all the windows 
 and doors, no matter what may be the state of the weather. The bed 
 clothes should be lightened. One hand should be pressed upon the ex- 
 panded uterus, while, without moving the patient and with the least possible 
 delay, the other should be gently passed upwards into the vagina, (the 
 whole hand,) where will be found some 8 or 10 ounces of coagulated 
 blood, which should be turned out by a proper motion of the fingers — after 
 which, while by a reasonable pressure and frictions or grasping manoeuvre 
 with the other hand, the womb is pushed downwards into the strait, the 
 fingers — two or more of them — are conducted within the os uteri ; there 
 they will encounter a very firm coagulum, which fills and distends the 
 womb. This clot should be broken up by the points of the fingers, and 
 turned out of the womb into the vagina, and so until the womb is ascer- 
 tained to be empty and well contracted. When the womb' and vagina 
 are perfectly freed from the burden, the danger is over for the present, 
 
616 
 
 UTERINE HAEMORRHAGE. 
 
 and the success ought to be insured by means of a thick compress and 
 binder for the lower belly. 
 
 If the woman be weak, some wine, some brandy and water, some vola- 
 tile alkali or other convenient cordial ought to be administered at once, and 
 a proper nourishment should be prepared as hastily as possible. For a 
 great many years, I have had the custom of prescribing for women very 
 much sunken with flooding, a nutriment prepared as follows : — Take a slice 
 of bread cut thin; pare off the crust; then lay the bread in a soup-plate, 
 and sprinkle it with salt ; pour upon it half a pint of boiling milk, and it is 
 ready for use. I think that a few spoonfuls of this diet will afford the 
 lightest, most nutritious and speediest preparation that can be got for such 
 emergencies. It was the custom of Dr. Clarke, of London, to make use of 
 it, and I rarely have ordered any thing else under such circumstances for 
 many years past. The patient likes it, and, so far as I know, it is unob- 
 jectionable in every respect. 
 
 When a patient has thus been rescued from visible danger, let the medical 
 attendant not leave her bed-side until she is quite safe — for such is the state 
 of the womb after labour in some women, that it will give way and fill two 
 or three times ; for, where the contractile power is but feeble, the blood of 
 the lochia coagulates and stops the mouth of the womb like a tampon — 
 whereupon the parietes begin to yield, and the more the vessels bleed, the 
 more rapidly will they bleed, until the cavity becomes enormously dis- 
 tended and the woman faints and dies. 
 
 I have repeatedly been compelled to turn out the clots as much as three 
 times in the same patient. If one were very watchful, he should not permit 
 the coagulum to be formed. 
 
 The nurses, when they give a napkinto the patient, should tell her that 
 the cloth is for receiving the discharge and not for the purpose of stopping 
 it, and that it should not be jammed close to the genitalia. When the nap- 
 kins are packed close up to the patient’s person, they act as a tampon does ; 
 they stop the blood in the vagina, which first fills, and then backs it into 
 the womb. 
 
 Where the case has a critical appearance, the surgeon’s hand should be 
 insinuated beneath the compress and binder, so as to enable him to touch 
 the uterine globe, and irritate it by pressure and friction, or, at least, inform 
 himself of its actual state and disposition. I have thought fit to offer these 
 remarks as supplementary to those of the author, which I deem to be less 
 copious than is demanded by the importance of the subject. — M.] 
 
 OF HAEMOPTYSIS, H.EMATEMESIS AND EPISTAXIS. 
 
 Haemoptysis, or spitting of blood, is one of the most dangerous 
 complications of the pregnant state. This haemorrhage, which 
 escapes from the lungs during more or less frequent paroxysms of 
 
HAEMOPTYSIS, HiEMATEMESIS, EPISTAXIS. 
 
 617 
 
 cough, is met with particularly in women of sanguine or nervous 
 temperament, and in those who wear very tight clothing. The 
 exciting causes of the affection in pregnant women, are all con- 
 nected with their condition, because the uterus becomes more volu- 
 minous, and, pressing upwards the abdominal viscera and diaphragm, 
 diminishes the capacity of the thorax, whence follow first embarrass- 
 ment of the pulmonary circulation, and then a cough and rupture of 
 some of the bronchial vessels. 
 
 The prodromes of the affection are dry cough and sensation of 
 heat in the chest, which commonly appear towards the fourth and 
 fifth month. There are felt praecordial anxiety, pains about the dia- 
 phragm, accompanied by horripilation and coldness of the extremities. 
 Finally, respiration becomes difficult, expectoration of bloody and 
 frothy sputa appears, particularly after eating, and is increased by 
 exercise, by remaining in too warm an atmosphere or in a very warm 
 bed, and by all circumstances capable of exciting the circulation. 
 
 The prognosis of the affection is always unfavourable during preg- 
 nancy, when before conception, there had been disposition to cough, 
 pain between the shoulders, and especially when the patient has a 
 narrow chest, projecting cheek-bones, hollow temples, and a weak, 
 feeble constitution. In some of the cases, however, haemoptysis is 
 attended with but little danger ; such is that in which it is the result 
 of a slight sanguine exhalation from the bronchial mucous membrane, 
 produced by some disorder of the pulmonary circulation, or by an 
 engorgement or any kind of obstacle to the passage of the blood. 
 Under these circumstances, the sanguinolent sputa, which occur with- 
 out effort or fever, are small in quantity, do not reappear, and almost 
 always yield to a small bleeding. 
 
 To avoid confounding haemoptysis with haematemesis or vomiting 
 of blood, to which pregnant women are much less subject, we need 
 only recollect that in the latter haemorrhage, the blood which comes 
 from the stomach is black, grumous, often mixed with the food, 
 mucosities or bile, and generally expelled without cough. The blood 
 which escapes from the lungs is, on the contrary, vermilion in colour, 
 frothy and without mixture with other fluid, and escapes generally 
 in a paroxysm of coughing ; it is important, moreover, to ascertain 
 whether the effusion may not depend upon pneumonia or some dis- 
 ease of the heart. 
 
 The treatment of the affection consists first in the employment of 
 bleeding, to relieve the local plethora; and then in calming the irri- 
 tation of the lungs by opiates and antispasmodics, amongst others 
 the infusions of orange and linden flowers, sweetened with syrup of 
 poppies. To these means may be added derivatives to the limbs 
 and digestive canal, bechic and astringent drinks, strict diet, and 
 quiet of mind and body ; lastly, in some cases, we may have resort 
 to cold applications about the chest, and to iced mineral lemon- 
 ade. We will add that the treatment of hsematemesis is the same 
 as that of haemoptysis, except in case an attack of colic, which the 
 patient sometimes experiences, makes us suppose that there are accu- 
 
618 
 
 EPISTAXIS; PLETHORA. 
 
 mulations of blood in the intestines, when its escape may be assisted 
 by means of emollient enemata and light laxatives. 
 
 Epistaxis, or nasal haemorrhage, occurs in pregnant women more 
 frequently even than haemoptysis and hsematemesis ; but this haemor- 
 rhage, whose return can seldom be prevented by bleeding, ought to 
 be regarded rather as a useful evacuation than as a real diseaes. 
 For this reason, its prognosis is much less unfavourable than that of 
 the preceding diseases, though like them, it is generally the result of 
 plethora or of obstruction of the pulmonary circulation. In general, 
 the haemorrage is left to itself, when slight, but should the discharge 
 become too frequent or too abundant, it is proper to arrest it, by 
 placing the patient in a cool air, and by keeping the head elevated 
 and covered with compresses, wet with cold vinegar or sulphuric 
 ether. If these means are insufficient, we must resort to bleeding, 
 to mustard manuluvia, and even to plugging the nasal fossa. We 
 ought to remark that there is a means that has succeeded in our 
 hands in a number of cases, which consists in keeping the arms ele- 
 vated, and in the application of a cold body between the shoulders. 
 
 DISORDERS OF THE CIRCULATION DURING PREGNANCY. 
 
 Of Sanguine Plethora. 
 
 The physiological changes that take place in pregnancy very well 
 explain the derangements of the circulation which accompany that 
 condition. Some physicians have supposed plethora to be almost 
 the sole cause of the diseases of pregnant women ; this opinion, be- 
 come at last a vulgar one, is true, particularly for the haemorrhages 
 of which we have just spoken, and for other lesions of the circulation 
 of which we are about to treat. 
 
 Plethora , or anormal increase of blood, occurs mostly in women 
 of strong and sanguine constitution, and particularly in those who 
 were abundantly regulated before pregnancy. The causes which 
 concur to produce plethora are, independent of the menstrual flux, 
 the increased activity of nutrition during gestation, and often a want 
 of exercise and food of too succulent a character. 
 
 The phenomena which reveal the state of predominance of blood 
 in pregnant women are fulness and hardness of the pulse, and a sen- 
 sation of swelling in the limbs, which interferes with their move- 
 ments. The surface is warm and highly coloured ; there is a taste 
 of blood in the mouth ; the gums are painful ; the eyes, lips and nos- 
 trils are red and injected ; the veins are swollen and projecting ; the 
 head is heavy, with disposition to sleep ; there are tinnitus aurium, 
 giddiness, epistaxis, and signs of congestion about the pelvic region. 
 
 Though the symptoms of plethora may show themselves at any 
 period of pregnancy, it is generally towards the sixth or seventh 
 month that they are most marked. In some cases, though always 
 inconvenient and even insupportable, they may exist for a long time 
 without greatly deranging the health ; but there occur haemorrhages 
 which sometimes produce the most dangerous consequences. 
 
PLETHORA, PALPITATION. 
 
 619 
 
 The prophylactic and therapeutical treatment of plethora consists 
 in the use of a regimen containing but little nourishment, and com- 
 posed principally of vegetables ; in diluent drinks, emollient enemata, 
 laxatives, moderate exercise, and especially in the employment of 
 bleeding. The period of the pregnancy at which blood ought to be 
 taken cannot be determined; in general, bleeding should be em- 
 ployed when it is necessary, and only then. The quantity of blood 
 must be sufficient to remove the plethoric condition, and never so 
 copious as to enfeeble the patient. We ought to remark, however, 
 that a great many physicians are in the habit of bleeding in all cases 
 between the fourth and fifth months of the pregnancy. This method, 
 which is good in some cases, is irrational and injurious in many 
 others. We should abstain from bleeding when the women expe- 
 rience slight symptoms merely of increased activity of hsematosis. 
 
 OF PALPITATION. 
 
 In the pregnant state, the heart is sometimes agitated with palpi- 
 tations, that is to say, with tumultuous movements and with stronger 
 impulse than ordinary. Nervous women are more subject to them 
 than others; yet those of robust and plethoric temperament are like- 
 wise exposed to them ; but in this condition the disordered action 
 of the heart is the result of plethora. The affection is recognized by 
 the violence and irregularity of the pulsations of the heart, which 
 are sometimes so strong as to arouse the patients suddenly from sleep. 
 The heart, which strikes against the parietes of the thorax with great 
 force, suspends its palpitations at irregular intervals, and follows the 
 movements of the pulse, which are unequal and intermittent. 
 
 The cause of the palpitations depends generally upon a nervous 
 condition and sympathetic irritation of the uterus; it may be con- 
 nected also with plethora, and in some cases, perhaps, with the pres- 
 sure exerted upon the abdominal vessels by the gestative organ 
 whose volume is much increased. We must confess, however, that 
 the intermissions of the symptoms and their disappearance, or at 
 least diminution, towards the approach of labour, when the womb 
 has acquired a greater development, should throw some doubts upon 
 the last cause we mentioned. 
 
 In general, the palpitations of pregnant women constitute less a 
 disease than a painful and troublesome inconvenience, from which 
 they ought to be relieved. 
 
 When the affection is of a nervous character, it is treated by anti- 
 spasmodics, opium, ether, assafoetida, syrup of asparagus shoots, 
 cherry-laurel water, tincture or powder of digitalis, syrup of lactuca- 
 rium, and lastly, by the medicinal prussic acid, and even by bleeding. 
 To these means are added baths, demulcent enemata, and moderate 
 exercise in the open air. If the disorder of the circulation occurs in 
 a strong and sanguine female, and seems to be connected with ple- 
 thora, it is to be treated by bleeding and suitable regimen. Care 
 should be taken, moreover, to advise the patient to sleep with the 
 
620 
 
 PALPITATION. 
 
 head elevated, to eat moderately, especially at night, and to abstain 
 from wine, coffee, liquors and all exciting articles. 
 
 [In a note at page 608, I have expressed an opinion as to the im- 
 portance of making out a correct diagnosis of the cases of palpitation, and 
 have said that pregnancy is for some constitutions a cause of anaemia. Let 
 a careful discrimination be made, then, between the cases of palpitation 
 arising from slow inflammation of the pericardium, and such as spring from 
 a similar affection of the endocardium, and those that proceed from an anae- 
 mic state. The latter are exceedingly distressing and dangerous, yet 
 not so much so as the former, for they recover after the termination of the 
 pregnancy, while the former are often followed by violent aggravation of 
 the distress in the post-puerperal condition. Where the endocarditis exists 
 during the labour, the process of parturition, which generally, and in this 
 case almost inevitably, provokes a high degree of vascular excitement, is 
 sure to aggravate the malady of the heart, and we have then the most fright- 
 ful hurry and irregularity of the pulse; — but such a state of disorder of the 
 vascular circulation is to the last degree hazardous for the puerperal or 
 lying-in woman. I have had occasion to observe not a few such instances. 
 In one of them, the lady, who had long been subject to disorder arising from 
 attacks of endocarditis, got very well through her labour, and continued to be 
 pretty well for three or four days — when she was suddenly seized after 
 breakfast with palpitation of the heart, which soon made her feel and look 
 so ill that 1 was sent for. I found her pale and feeble, and without power 
 to move, for upon the least attempt to change her position, (she was lying 
 on the back,) she appeared ready to expire. I could by no means count 
 the pulse; it was so rapid as to go far beyond my power to count it by the 
 second-hand of my watch. I can with considerable accuracy count the 
 pulse at 180 in the minute — and I judged, after much reflection, that the 
 heart beat at least 240 strokes per minute. Thus it continued to do from 
 half-past eight in the morning until near eight in the evening — more than 
 eleven hours. Now her pulse ought to have amounted to 46,200 pulsations 
 of the heart in the eleven hours, but the real number of beats was 158,400, 
 which is 112,200 beats more than natural — more than are required for the 
 wants of the healthy constitution. It is easier to imagine than to describe 
 the frightful fatigue of this lady during all those eleven hours — in which 
 death seemed to be close at hand, for there was the greatest probability that 
 the heart would cease to beat altogether, unless some measures could be 
 adopted to arrest its wild career. There was no extra heat of the body — 
 no delirium — but, on the contrary, the temperature was nearly natural, and 
 the mind calm — the countenance clothed with a melancholy and distressed 
 expression, which excited the greatest sympathy of the beholders. The 
 respiration was quick and very short. The impulse of the heart upon aus- 
 cultation was neat and clear, and there was not the least intercurrence of 
 
PALPITATION. 
 
 621 
 
 the first and second sounds. I was convinced that no effusion existed — her 
 complaint, in a scarce audible voice, was of excessive fatigue about the 
 breast, and the greatest debility. My desire was to take blood from the 
 arm, supposing that I might thus affect the sources of her innervation, so as 
 to arrest the flight of the pulse. All the other remedies, in the shape of 
 antispasmodics, counter-irritants, &c., &c., which I persevered to apply, 
 completely failed ; and such was the condition of the circulation that I could 
 not venture to open a vessel in the arm, for 1 felt sure that a fainting fit 
 would terminate her existence. The heart was so exhausted, that had she 
 fainted badly, I conceived nothing would be able to restore its full motion 
 again. Near eight o’clock in the evening, I told her friends that I should 
 open the vein, but under the greatest apprehension she might faint and die, 
 but convinced of the necessity of doing it in order to prevent an otherwise 
 fatal termination. I accordingly had a strong light thrown upon her face, 
 in order to be able to detect the first symptoms of a change in the innerva- 
 tion about to be produced — I being quite sure, that under the circumstances, 
 the pulse would not be a safe guide, for I expected that when it should fall, 
 it would give way instantly. The vein bled well, and I had not to take 
 more than four ounces before I discovered a change of the expression about 
 the mouth, when she admitted also that she was a little sick. Upon binding 
 up the arm, I took the wrist, and found the rapidity undiminished. 'While 
 feeling the pulse, it suddenly stopped, and the head was rotated to the right 
 side, as if in spasm ; she uttered a prolonged groan, and I supposed her 
 dead ; but, after a suspension of several seconds, the heart resumed its rapid 
 flight for some ten or twenty seconds, then stopped again, so long that I 
 thought it would never beat — it then fluttered for a moment — and from that 
 moment her pulse was as gentle, and regular, and orderly as if in the finest 
 health. She recovered afterwards, having subsequently complained only of 
 debility. During these eleven hours I scarcely left her bed-side, and have 
 not had, in a long course of practice, occasion to pass a day of more thrilling 
 interest in relation to one to whom I had no ties other than those of the 
 medical adviser to his patient. Nor can I now well conceive of a case more 
 exciting than one in which an organ, the very centre and source of motion 
 and life, was in so extraordinary a predicament. Let the reader imagine the 
 organic fatigue, if such an expression be allowable, which the heart must 
 have endured, under 112,200 extra-pulsations in that space of time. — M.] 
 
 OF SYNCOPE. 
 
 If inordinate contractions of the heart constitute one of the acci- 
 dents of the pregnant state, the same is true of the suspension of 
 the contractions of the organ, which may, in pregnant women, occa- 
 sion syncope : this condition consists in a complete and generally 
 sudden loss of sensation and motion, with suspension of respiration. 
 This sort of temporary death, which generally lasts only four or five 
 
622 
 
 SYNCOPE, VARIX. 
 
 minutes, recurs periodically in certain women, once a month, once a 
 week, once in every two or three days, and even oftener. During 
 the attack the countenance and skin, as well as the adnata of the 
 eyes, the lips and mouth, lose their colour, and resemble the paleness 
 of death ; the senses are paralyzed, ( suspended , M.,) the sensations 
 nullified, and there is a complete loss of consciousness. The attacks 
 come on with yawning, tinnitus of the ears, and a dull pain at 
 the epigastrium; they terminate by an insensible return of the 
 respiration and pulse, and frequently by throwing up the contents of 
 the stomach. 
 
 The predisponent causes of syncope in pregnant women depend 
 on a disturbing force, connected with the pregnant state, which 
 influences all the functions of the body. The determining causes 
 are sometimes found to be the sudden brisk motions of the foetus, a 
 vertical posture, a kneeling posture, particularly one long continued, 
 the sight of certain objects, strong emotions, a sudden sound, the 
 odour of certain sorts of plants, or certain substances; and, lastly, a 
 state of plethora or one of anaemia, may likewise bring on attacks of 
 syncope in pregnant women. 
 
 Syncope is generally a more serious affair as regards the foetus 
 than as regards the mother, whose life is less endangered by a some- 
 what protracted fainting fit than is that of the infant. 
 
 The treatment of this accident of pregnancy consists in recalling 
 the functions of life, chiefly those of the respiration and circulation. 
 We generally succeed very readily in effecting this result by placing 
 the woman in a horizontal position, by relieving her of those parts 
 of her dress that might obstruct the motions of her breast, abdo- 
 men, neck and limbs ; by making her inhale strong odours, such as 
 the odour of liquid ammonia, pure acetic acid, or burnt feathers, 
 and, further, by making frictions on the region of the heart, either 
 dry or with cloths wrung out of brandy, or cologne or balm water. 
 Care should likewise be taken to expose her to fresh air, to sprinkle 
 cold water on the face, and to apply sinapisms to the arms and legs, 
 which may also be wrapped in cloths wrung out of very warm 
 water. When the patient recovers her consciousness, she should 
 swallow a portion of Garus’s Elixir, or a little wine, or any other 
 alcoholic liquor diluted with water. 
 
 For the purpose of preventing as far as possible a return of the 
 attack, the woman, if plethoric, should be bled, take moderate exer- 
 cise, and make use of some sort of antispasmodic medicine. 
 
 OF VARICES. 
 
 Among the complications of pregnancy none is met with more 
 frequently than a varicose state of the veins. For the most part, 
 they begin to grow towards the close of the pregnancy, and affect 
 most especially the lower extremities, and particularly the saphena 
 vein; they are, however, found to invade all the superficial branches 
 of the legs and thighs, the labia, vagina and cervix uteri. Pregnant 
 women have been seen even, in whom all the veins were swollen 
 
VARICOSE VEINS. 
 
 623 
 
 and knotty without excepting even those of the upper extremities, 
 exhibiting, indeed, a general varicose diathesis. We should remark, 
 however, that it mostly happens that one side is more affected than 
 the other, probably because the womb presses most upon that side. 
 
 Wherever they happen to be formed, these varices appear under 
 the form of small lumps, like a string of beads, or like a bunch of 
 leeches twisted together, or they look like oblong, round, uneven, 
 indolent knots, which generally disappear under pressure, and return 
 upon withdrawing the pressure, diminishing by rest in bed, and 
 increasing upon resuming a vertical posture : they are without any 
 pulsation, and generally exhibit a sort of arborescent appearance. 
 
 Although the rupture of a small varix is, in most cases, a slight 
 accident, readily cured by compression, it does happen that such an 
 accident becomes promptly fatal, especially where there is a varicose 
 diathesis, and where the rupture occurs in a large vessel, such as the 
 internal iliac or superior cava. 
 
 The causes of this dilatation of the veins may depend upon a 
 natural or accidental weakness of the vessels, and a certain disposi- 
 tion in them to allow themselves to be easily distended with the 
 blood, whose circulation is obstructed by the pressure of the womb 
 upon the iliac veins. 
 
 In order to prevent this unmeasured distension of the veins, and 
 the rupture of the tumour thus formed, we should recommend the 
 patient to keep a soluble state of the bowels ; a horizontal posture, 
 rest, and, lastly, compression of the limbs by means of the roller 
 or a laced stocking, which should be applied in the morning before 
 rising from bed, because the veins are then less distended with blood. 
 In plethoric women bleeding is one of the useful remedies to which 
 recourse ought to be had. The resources of surgery have never been 
 emyloyed in varix in the pregnant female, for they always disappear 
 after the lying-in, except in cases where they have been renewed by 
 numerous and rapidly succeeding pregnancies. 
 
 Varices of the cervix uteri may interfere with labour, as they are 
 liable to burst during the throes, and give rise to a considerable 
 haemorrhage. We should endeavour to prevent their rupture by sus- 
 taining and gently repressing them with the ends of the fingers. In 
 case, notwithstanding these precautions, one of the varices should 
 give way, we ought to tampon the orifice of it with linen soaked in 
 alum water or any other suitable styptic liquor. 
 
 [M. Colombat has omitted to notice an important item in the consider- 
 ation of the varices of pregnant women. They are often, it is true, only 
 troublesome during the pregnancy, and that evil may be, in general, very 
 readily obviated by the use of the roller and the other measures recom- 
 mended by the author. 
 
 I fear, however, that an insufficient degree of attention is paid to the more 
 severe and extensive samples of varix, both by the patient and the physi- 
 cian. In some such instances I have had to contend with dangerous crural 
 phlebitis coming on after labour, and clearly taking its rise in the already dis- 
 
624 
 
 HEMORRHOIDS. 
 
 eased and distended state of the veins of the leg; and I had the misfortune, 
 about two years since, to witness the loss of one of my patients, in whom 
 the enormous varicose veins of the right leg and thigh were attacked, after 
 her confinement, with phlebitis terminating in the production of pus and all 
 the distressing consequences of the pyogenic fever. I merely desire, at this 
 point, to call the attention of the reader to the propriety of taking all due 
 precautions against the development of that dangerous malady, after the 
 delivery of the patient, who is so unfortunate as to have very bad varices of 
 the legs. — M.] 
 
 OF HAEMORRHOIDS. 
 
 The occurrence of haemorrhoids in the pregnant woman has gene- 
 rally been assigned to the same causes that give rise to varix of the 
 lower extremities. It is at least certain that costiveness, to which 
 women with child are very subject, is one of the most common and 
 undeniable causes of piles. We may, also, it is true, depend on the 
 volume of the womb, whose pressure upon the veins within the 
 pelvis, obstructs the circulation and provokes an engorgement of the 
 hssmorrhoidal vessels. Be this as it may, the disorder in question 
 may be met with at any period of gestation, rarely in the early 
 months, more frequently towards the middle, and still more fre- 
 quently near the term, especially in women of a costive habit. 
 
 Where the hsemorrhoidal tumours are indolent, and not very 
 painful, they constitute a mere inconvenience, which the female 
 submits to in silence without consulting her physician ; but in cer- 
 tain cases they cause an active inflammation, with very acute pains, 
 a great obstruction ; inability to sit, tenesmus, fruitless efforts at stool, 
 and, in some instances, even a prolapsus of the rectum; inflam- 
 mation, suppuration and ulceration of the hasmorrhoidal mass ; and 
 even uterine contraction and abortion. To these symptoms should 
 be added dyspnoea, insomnia, restlessness, headache and a fever of 
 greater or less violence. 
 
 From the above sketch, it may be perceived that the consequences 
 of haemorrhoidal attacks may be very serious; yet these tumours do 
 not, in general, prove injurious in pregnancy, particularly if they 
 bleed, and the bleeding be not too profuse. On the other hand, 
 where the loss of blood is abundant and long-continued, exhaus- 
 tion of the mother and the death of the child may be the con- 
 sequences. 
 
 Where the hsemorrhoidal tumours are red, tense, painful and in- 
 flamed, it is customary to order the bath ; emollient and narcotic 
 fomentations ; oleaginous injections, suppositories of beurre de cacao , 
 opiated cerate, unguent, populeum, a cooling regimen, and bleeding at 
 the arm, where the woman is plethoric, and the turgescence and pain 
 considerable. When the piles are internal ones and inflamed, warm 
 milk, with a few drops of laudanum, may be injected into the rec- 
 tum ; and the bowels can be kept free by gentle laxatives and emol- 
 
CEDEiMA. 
 
 625 
 
 Jient enemata. Should the hemorrhoidal tumours bleed moderately, 
 the discharge ought not to be interfered with; but in case it should 
 become too profuse, we ought to endeavour to arrest, or at least to 
 moderate it by using astringent fomentations, made with decoction of 
 pomegranate rind, bistort root or nut-galls, to which is added a little 
 alum or sugar of lead : in fine, for the more serious cases the rectum 
 may be plugged with a roll of linen, introduced into the bowel. ]t 
 should be remembered, however, that the presence of the tampon, 
 which is always distressing, may provoke the womb to abortion; 
 and that the measure, which is never to be resorted to but in extreme 
 cases, might allow an accumulation of blood to take place within 
 the bowel, and thus fail of arresting an internal haemorrhage, which, 
 although it no longer appears to be discharged from the bowel, 
 might still prove sufficiently profuse to deprive the patient of life. 
 
 OF (EDEMA. 
 
 Most of the modern medical authorities attribute the oedema of 
 pregnant women to a fault of the venous and lymphatic systems; we, 
 also, have not hesitated to class it among those lesions of the cir- 
 culatory apparatus that are dependent upon pressure on the ves- 
 sels. Indeed, it is observed that the disorder under consideration is 
 mostly found to occur in the latter stages of pregnancy, that is to 
 say, at a time when the volume of the womb is greatest ; that it 
 generally affects the lower extremities, especially in true pregnancies; 
 and farther, that it diminishes while the woman maintains a recum- 
 bent posture, and increases by standing up or walking. Be this as 
 it may, women of a feeble and lymphatic habit of body, those 
 whose vascular system has little vigour, or who have a narrow pelvis, 
 are most exposed to attacks of oedema of the lower limbs, a disorder 
 which first manifests itself in the feet and legs, and then extends 
 upwards on the thighs, and even to the vulva, the groins and the 
 parietes of the abdomen. 
 
 (Edema sometimes consists in a diffuse indolent whitish swelling, 
 which pits upon pressure, increases towards night and diminishes 
 towards morning ; sometimes, again, it is a more or less extensive 
 engorgement, accompanied with pain, heat, and, occasionally, red- 
 ness, and a sort of elasticity which prevents it from retaining the 
 impression of the finger, or pitting. 
 
 (Edema, arising from a state of pregnancy, is mostly not at all 
 dangerous, and disappears spontaneously after the lying-in. Where 
 it is not extensive, it gives rise merely to an uneasy sensation and a 
 troublesome feeling of weight. W~hen it extends to the thighs and 
 genitalia, it not only interferes with walking and sitting down, and 
 occasions much pain and uneasiness, but when the skin becomes 
 excessively distended, it is liable to inflame and be covered with ery- 
 sipelatous patches. Cases, indeed, have been met with, where the 
 subcutaneous cellular tela has been affected with inflammation ter- 
 minating in gangrene of the skin. Moreover, a simple cedematous 
 swelling may become sufficiently extensive to obstruct the move- 
 40 
 
626 
 
 (EDEMA. 
 
 merits of the body, interfere with the respiration, and even offer 
 serious obstacles in labour. It ought, however, to be understood 
 that oedema, how considerable soever it may become, is generally not 
 a serious affection for pregnant women. Delamotte assures us that 
 he never saw a female perish from these swellings, even the most 
 extensive of them, and that those who do suffer from them are ordi- 
 narily not troubled with vomiting. 
 
 [It may be very true that Delamotte did not see fatalities as a direct result 
 of oedema gravidarum, but, in his great experience, it is probable that not a 
 few cases of severe malady, such as eclampsia, for example, might have been 
 more or less intimately connected with oedema of the limbs. — M.] 
 
 Should the oedema be accompanied with symptoms of plethora, 
 and the tumefaction be red and elastic, venesection is the most appro- 
 priate remedy, and should be prescribed conjointly with mild purga- 
 tive and diuretic medicines, which alone ought to be ordered when 
 no plethora exists, and where the oedema consists in a mere infiltra- 
 tion of serosity into the cellular tela. In such circumstances we 
 might also, with propriety, advise the patient to use dry friction, 
 aromatic lotions, a gentle compression by a roller bandage, and the 
 maintenance of a horizontal posture. Should this situation, however, 
 give rise to a considerable degree of oppression, it would be better 
 for the patient to remain seated in an arm chair, and especially 
 on a sofa. In fine, should these proceedings prove to be inefficacious, 
 and the swelling become very extensive, slight punctures may be 
 made with the point of a lancet, in the legs, and then followed by a 
 blister applied, according to Levret’s advice, on the space betwixt the 
 thigh and the labium pudendi. In all cases, the bowels should be 
 kept soluble, by injections and gentle purgatives ; the dresses should 
 be warm, and the woman should be sure to wear flannel; and, to 
 conclude, let the strength, as to feeble, lymphatic persons, be sus- 
 tained by a good diet and a glass of good Bordeaux claret at meal 
 times. 
 
 [Notwithstanding the favourable prognosis in this case, offered by Dela- 
 inotte, and confirmed by M. Colombat, I do not think that the younger 
 practitioner ought to found thereon a careless confidence as to the safety of 
 either the patient or foetus. It is true that a simple oedema may not offer 
 the least obstruction to the escape of the foetus in labour; and it is in fact 
 found that many women, very considerably infiltrated, do pass through the 
 several stages of parturition with the greatest facility; but I wish to warn 
 he younger portion of our readers, that if the patient be in a first pregnancy, 
 and if the tumour of the limbs and body be of the elastic sort mentioned by 
 M. Colombat, the medical attendant should take good heed as to the circula- 
 tion, the innervation, the state of the patient’s temper, her sleep, &c., for she 
 ought to be esteemed as highly liable to attacks of eclampsia. In a woman 
 who has already borne several children, I deem the danger of eclampsia 
 to be less imminent, under these circumstances, in consequence of the 
 greater laxity of fibre which, in such persons, admits of freer distension of 
 
CEPHALALGIA AND VERTIGO. 
 
 627 
 
 the cellular tissue, and that, without too great a development of nervous irri- 
 tation and susceptibility. I offer these remarks additional to M. Colombat’s, 
 under a sense of the deeply distressing and alarming cases of puerperal con- 
 vulsions that I have met with in my own practice and in consultations; 
 cases which I deemed clearly traceable to a close connection with an exces- 
 sive distension of the cellular tela and skin, arising from the oedema or ana- 
 sarca of pregnant women. 1 know not why the mere infiltration of the cellular 
 tissue should produce so great a tendency to attacks of puerperal convulsion, 
 but I feel very confident that the primiparous female, who is affected with 
 the more firm and elastic sort of oedema, is very prone to suffer in this way. 
 The pressure on the veins and absorbents producing oedema, coincides with 
 pressure on the aorta producing determination to the head. — M.] 
 
 OF CEPHALALGIA AND VERTIGO. 
 
 Affections of the brain occurring during pregnancy. 
 
 Cephalalgia and vertigo are frequently found to complicate preg- 
 nancy, in consequence of a state of nervous excitement or of a ple- 
 thoric condition. The first-named variety of cephalalgia is principally 
 to be observed in women of a delicate habit of body, and may arise 
 under the influence of vivid impressions on the mind, such as grief, 
 disappointment, rage, &c. The second, which is common in women 
 of a sanguine temperament and robust constitution, appears to depend 
 upon whatsoever tends to augment the nutritive materials and the 
 abundance of the hsematosis. 
 
 There is*a third species of cephalalgia ; it is that which depends on 
 the state of the stomach, or on some gastric disorder, evinced by bit- 
 terness of the mouth, a whitish or yellowish induitus of the tongue, 
 and a more or less decided want of appetite. In these cases the head- 
 ache is lancinating, and increased after each meal ; but there are 
 intervals of calm between the attacks. 
 
 Those pains that depend upon nervous irritation, are met with 
 chiefly in the earlier months of gestation, and grow less and less 
 severe as pregnancy approaches towards the full term. Further- 
 more, where the headache is connected with a state of plethora, it 
 does not commonly come on before the fourth month, and it then 
 begins with a pain above the brows, and a sort of stupor and heavi- 
 ness of the head, accompanied with pain in moving the eyelids and 
 eyes, which seem to be more sparkling than usual, and which, be- 
 sides, are not at ease in their orbits. 
 
 The treatment of these different kinds of pain ought to vary 
 according to the causes that give rise to them. To the nervous head- 
 aches, for example, we should oppose the sedative, soothing articles 
 of the materia medica, antispasmodics, baths, enemata; the t hr id ace ; 
 opium and camphor, administered internally; the inspiration of 
 ether, of Cologne water, and eau des carmes; and, lastly, rest and 
 sleep. A plethoric headache may be advantageously met by vene- 
 section, and especially by arteriotomy. The effects of these measures 
 may be seconded by a mild regimen, more especially a vegetable 
 
628 
 
 SLEEPLESSNESS. 
 
 one, by dilating drinks, and the employment of injections and laxa- 
 tives, for the purpose of keeping the bowels in a soluble state. In 
 fine, we should direct the use of lemonades, vegetable broths, saline 
 cathartics, Seidlitz or Pulna water, and, in some cases, ipecacuanha, 
 with the design to combat the cephalalgia and vertigo, seemingly 
 dependent upon a disordered stomach. 
 
 [Let the physician be aware of the danger of headache in women in ad- 
 vanced stages of gestation. A severe headache, and especially one accom- 
 panied with a sense of weight on the crown, or a severe pain that can be 
 covered with the thumb, is but one step removed from eclampsia. Such a 
 person ought to be bled freely at the arm, if it be possible to do so without 
 flying in the very face of powerful counter-indications. I have not spared the 
 lancet in many such ; but I mav confidently assert that where I have done 
 so, I have had cause most bitterly to regret it. 
 
 A severe headache in a woman advanced in pregnancy, should be taken 
 as the sign that she ought to be let blood — almost, I was about to add, with- 
 out inquiring of the pulse. — M.] 
 
 INSOMNIA, OR AGRYPNIA. 
 
 Sleeplessness is one of the most distressing affections to which the 
 pregnant female is liable. Women of a nervous and delicate consti- 
 tution are much more liable to such an affection than the plethoric 
 sort, who, on the contrary, are sometimes disposed to sleep or be 
 drowsy all the time. 
 
 The insomnia that occurs in pregnancy is most generally a neurosis, 
 which depends upon cerebral exaltation arising from sympathy with 
 the uterine system. In some instances, however, both the sleepless- 
 ness and the drowsiness of pregnant women are owing to a plethoric 
 condition, evinced by the high colour of the face and eyes, the gene- 
 ral agitation of the system, and the strength and hardness of the 
 pulse. 
 
 In slight cases of insomnia, the treatment consists in moderate 
 exercise of the body, a soothing regimen, anodyne enemata, syrup of 
 thridace, but where the agitation is greatly prolonged, it should be met 
 by opiate-emulsions, syrup of diacodiiun, syrup of white poppies, and 
 particularly by acetate of morphia, in doses of a centigramme for 
 each potion. Should the patient be constipated, the bowels should 
 be freed, by enemata or laxatives, and tonics combined with seda- 
 tives and antispasmodics are adapted for women who are debilitated, 
 and who have a naturally feeble constitution. 
 
 For those cases of insomnia that are coincident with a plethoric 
 habit of body we should direct a venesection, which. is, under such 
 circumstances,, the first and the best of sedatives. 
 
 QNot merely to cure the vigil, but, what is far more important, to ward 
 off the attack of convulsion or apoplexy, which should be held as a threatened, 
 and even as an imminent danger for persons in whom the insomnia has 
 arisen to a considerable height. — M.] 
 
AFFECTIONS OF THE SENSES. 
 
 629 
 
 The beneficial influence of a blood-letting may be powerfully 
 seconded by the use of the bath, of diluent drinks, and by almond 
 emulsions, and lemonade. 
 
 LESIONS OF THE SIGHT, THE HEARING, THE SMELL, &c. 
 
 The various ophthalmic neuroses, as amaurosis, diplopia, nycta- 
 lopia, hemeralopia, and sparkling lights in the eyes, are often observed 
 to affect pregnant women. These disorders, that are particularly 
 prevalent in nervous women, may be continued, or may cease for 
 awhile, and then reappear, and afterwards cease altogether, which 
 for the most part happens after the accouchement. Thus, there are 
 women who, after being for several months affected with amaurosis, 
 recover their sight as soon as they are confined. The same may 
 be said as to all the disorders of vision, such as those in which 
 objects are seen double, or under changes of shape or colour, or ' 
 where they are magnified or lessened in size. 
 
 Sometimes these ocular neuroses come on towards the close of ges- 
 tation, and especially is it the case in plethoric persons ; they are then 
 caused by a sanguine congestion of the head. In others, they depend 
 upon a nervous cause, and an extreme degree of sensibility of the 
 nerves of the eye, particularly of the retina. Neuroses of this sort, 
 come on without pain, redness or fulness of the eyes. The former 
 kind, such as are complicated with sanguine congestion, are attended 
 with uneasiness, pain, redness, swelling of the eyes, turgescence of 
 the features, stupor or drowsiness. Furthermore, in both these kinds 
 of ophthalmic neuroses, there is blindness more or less complete, 
 or perhaps simple flashings of light in the eyes, and optical illu- 
 sions, which create imaginary objects, or change the shape, size, and 
 volume of real ones In some instances, likewise, the engorgement 
 of the eyes may merely produce an ecchymosis, or a real inflamma- 
 tion of the conjunctiva, as in the instances reported by Bartholin and 
 several other authorities. 
 
 The treatment of these affections differs according to their several 
 causes and the constitution of the individual. Ophthalmic neuroses 
 of a nervous origin require to be corrected by antispasmodics, opiates 
 and tonics, such as pills of cynogloss, syrup of valerian, and cinchona, 
 or these two last-named articles in powder. Where the woman is ple- 
 thoric, and the neurosis seems connected with a cerebral engorgement, 
 recourse is to be had to blood-letting, dieting, a diluting regimen, 
 enemata, derivatives to the inferior extremities, and gentle purga- 
 tives, especially calomel, in doses of three or four grains daily. 
 
 Like the neuroses above treated of, the neuroses of the sense of 
 hearing attack nervous females, and those who are of a plethoric con- 
 stitution. The patients first hear a buzzing noise in the ears, and sup- 
 pose they are hearing real sounds of different kinds, or they suppose 
 they have increased or diminished auditory power, or there is some 
 discordance betwixt the perceptions and the sounds. 
 
 The treatment, like that of the neuroses of vision, consists in the 
 use of antispasmodics and opiates, provided the affection is due to a 
 
630 
 
 AFFECTIONS OF THE SENSES. 
 
 nervous condition, and in venesection and derivatives when it is con- 
 nected with a state of plethora. 
 
 As to the neuroses and anomalies of the senses of smell and taste, 
 to which pregnant women are obnoxious, they generally require no 
 regular treatment ; for they almost always disappear spontaneously 
 soon after the confinement, for they are results of a sympathetic in- 
 fluence of the womb. 
 
 [I cannot agree with M. Colombat in all this opinion, since the affections of 
 the hearing, notwithstanding they may in some instances arise from a mere 
 sympathy with the womb, yet cannot be known to do so except by the 
 event. The sudden abolition or extraordinary mutation of power as to one 
 of the senses, like similar changes as to the activity or obedience of a muscle, 
 should be regarded as evidence of pressure or of irritation at the source of 
 the nerve power in question, and in the event of either of the theories being 
 adopted, the case becomes one of startling interest. I had a young lady 
 under my care during her pregnancy, in which she suffered with attacks of 
 headache, for which she received the appropriate treatment. On one occa- 
 sion, when about eight months and a half gone with child, she went to a 
 drawer of her bureau to look at some papers, and while standing before it 
 thought she heard a loud explosion, and received a violent blow on the head. 
 She informed me that the sound was like that of a heavily-charged musket, 
 and the blow felt as if some one had struck her head with an axe. She 
 was stunned for a moment, and when the painful sensation had disappeared 
 she could only see half of the paper, and half of any thing that she looked 
 at. I was called to her, and upon arriving, learned that she could see only 
 the right half of my face, half a bed-post, window-blind, or whatsoever ob- 
 ject she looked at. I need not say that I felt very great concern for the 
 internal affection that had given rise to these symptoms, and that I imme- 
 diately bled her copiously, after which she recovered. 
 
 fl'he late distinguished surgeon, Dr. Physick, was called to a gentleman 
 here who suddenly lost his hearing — it was absolutely gone — the sense 
 being for the time completely abolished. Dr. P. looked upon him as suffer- 
 ing from pressure at the sources of the auditory nerves, and treated him by 
 the most liberal venesection, after which his hearing immediately returned. 
 He died some years afterwards, of a series of paralytic attacks, terminating 
 at length in apoplexy. 
 
 If a woman in labour should say, Sir, I cannot see you — the room has 
 been darkened, or should she say, I see every object doubled, or only half 
 of any object, I esteem it far more prudent to look upon the complaint as 
 one exigent of immediate treatment, than to say, along with M. Colom- 
 bat, that it arises from sympathy with the womb, and pass it lightly by. 
 
 A woman in labour said to me, “ Doctor, what is the matter, sir, I cannot 
 see you.” “ Give me a bandage and basin,” said I to the nurse, “quick, 
 quick,” — but before I could tie up the arm she was in eclampsia. — M.] 
 
631 
 
 DISORDERED INTELLECT, ETC. 
 
 DISORDERS OF THE INTELLIGENCE AND OF THE MORAL INCLINA- 
 TIONS AND AFFECTIONS. 
 
 Although the modifications that gestation introduces into the intel- 
 lectual faculties and the moral inclinations and affections, have been 
 greatly exaggerated, it is nevertheless true that, insanity, certain forms 
 of monomania, and certain disorders of the understanding often come 
 on during gestation. It is very certain that pregnancy exalts the 
 sensibility and the susceptibility, and disposes the person to nervous 
 disorders. 
 
 We shall pass over, in silence, the antipathies and the sympathies, 
 the queer temper, the headstrong character, the melancholy, perverse 
 or irascible humour that displays itself of a sudden, in females of the 
 mildest and most even temper. Women have been known to be- 
 come thievish, poetical or musical, from being pregnant, while others 
 in that situation lose all intellectual activity, and some have all their 
 intellectual powers either elevated or depressed in force. Goubellv 
 speaks of a woman who never had a sound judgment except when 
 she was pregnant ; but she then lost her memory, which, after her 
 delivery, she recovered, but at the expense of no judgment. Baude- 
 locque mentions a pregnant woman who ate nothing with so much 
 pleasure as the articles of food that she had stolen, while going to 
 market for her provisions. Roderick a Castro tells us of another 
 female who wanted to eat a piece of the baker’s shoulder, and Lan- 
 grus, of another who, longing to eat a piece of the flesh of her 
 husband, whom she tenderly loved, assassinated him to satisfy her 
 ferocious appetite, and then salted down some parts of the body, 
 with a view to prolong the pleasure. Vives speaks of a woman who 
 would, perhaps, have miscarried, had she not been allowed to bite a 
 young man’s neck, one of her acquaintances. In 1816 , a woman at 
 Mons threw three of her children into a well, and then plunged to 
 the bottom herself. She had two other children, one at boarding- 
 school and the other with a wet nurse : happily for them, the young- 
 est had not been sent to her in time, agreeably to her order, and the 
 elder child did not take any of the poisoned cake that she sent it. 
 
 Generally speaking, all these caprices, all these oddities and ma- 
 niacal states, disappear after delivery: insanity, however, which, 
 besides, does not come on until after the parturition, (puerperal in- 
 sanity,) sometimes continues throughout the lifetime of the patient. 
 The therapeutical treatment, under such circumstances, is almost 
 always impotent, and consists, indeed, almost wholly in a few 
 bleedings, some counter-irritants to the skin, and derivatives applied 
 through the intestinal tube. 
 
 [M. Colombat says truly, that puerperal mania does, in some instances, 
 last as long as the life of the patient; but it would be wrong to assume from 
 this, that the cases of non-recovery are few. On the contrary, the cases of 
 recovery are numerous, while those of persistent mental alienation are very 
 few, and those in which death occurs are very rare, indeed. Dr. William 
 Hunter, of London, was asked what opinion he had formed as to the pros- 
 
632 
 
 PUERPERAL CONVULSIONS. 
 
 pect of recovery of a lady who had been brought to London to see him. 
 “Ah, that’s not the question in these cases,” replied he; “the question is 
 not whether the patient is to recover, but when?” If Dr. Hunter ever made 
 the above remark, it should be deemed a consolatory item in the budget of 
 distress connected with such cases, since his great judgment and experience 
 have been almost universally acknowledged ; yet it is true to say, that not 
 a very few persons, seized with the symptoms of puerperal mania, perish, 
 sooner or later, from lesions of the encephalon, consisting of softening, or 
 effusion or even extravasation of blood within the parietes of the cranium. 
 M.] 
 
 OF ECLAMPSIA, OR PUERPERAL CONVULSIONS. 
 
 By the term eclampsia, eclampsia parturientium, from the Greek 
 fX^pL^is,Jiash of light, is understood the epileptiform attack of con- 
 vulsions depending upon the puerperal state, that is to say, those 
 that are met with in pregnant women, in women in labour, or those 
 who have been recently delivered. Although the convulsions may 
 exhibit themselves in the puerperal state, under the form of hysteria, 
 tetanus and catalepsy, we esteem it best to say but a few words on 
 them, in order to afford space for fuller detail on the subject of the epi- 
 leptiform cases, since the former sort are always less serious, exhibit 
 much less alarming symptoms, and require pretty much the same 
 treatment as the epileptic kinds. Furthermore, cases of cataleptic and 
 tetanic puerperal convulsions are so rare that even M. Dubois him- 
 self has never had an opportunity to meet with a case. 
 
 The frequency of eclampsia, or epileptiform puerperal convulsions, 
 cannot be accurately established ; for the statistical results obtained 
 in various countries, and at different periods, show the most enor- 
 mous discrepancies amongst themselves. In fact, from the statistical 
 statements, extending from 1829 to 1S42, at the Paris Mat emit 6 and 
 at the Clinique d’ Accouchement s, the disease occurred only ten 
 times in 12,500 women, or once in 1250 cases ; while, at Dublin, the 
 statistical report shows thirty cases in 1600, that is to say, one in 
 every 53 women; an enormous difference, which no circumstances 
 can explain or account for. 
 
 The causes of eclampsia ought to be divided into predisponent 
 and occasional causes. Amongst the number of the former, there is 
 one that ought to be deemed essential, and as occupying the first 
 rank, to wit, the. puerperal state, which lends energy and power to 
 all the other causes, which, in the common course of life, may give a 
 predisposition to convulsive disorders. It should be stated, however, 
 that the puerperal state does not constitute a predisposition to 
 eclampsia, except when accompanied by other conditions that de- 
 velop the predisposition in a still higher degree. The first in order, 
 of these conditions, is undoubtedly the primiparous state ; for, 
 according to a statement made by Dr. Collins, of Dublin, there were 
 seventy-five primiparous women in eighty-five cases of convulsive 
 attack during pregnancy and lying-in. Nevertheless, women who 
 
PUERPERAL CONVULSIONS. 
 
 633 
 
 have had children are* also liable to convulsion ; but they are so 
 under the influence of other causes, that we shall make known, and 
 which exert a direct influence on the production of the accidents. 
 Women in their first pregnancy are more liable to eclampsia, only 
 because in them the uterus enjoys a higher degree of susceptibility, 
 and the labour, moreover, is longer and more painful. Among the 
 predisponent causes of the disorder, we ought also to class the dis- 
 tension of the womb by twins, or by an unusual quantity of water, 
 which almost always coincides with a serous diathesis and considera- 
 ble infiltration of the inferior extremities. The sanguine tempera- 
 ment, and particularly the lymphatic temperament, with general or 
 partial oedema of the cellular tela, are rationally, by many authors, 
 regarded as conditions essential to the production of eclampsia. 
 The isolated influence of the nervous temperament is less marked 
 than that of the other states above mentioned ; but a decided rachitic 
 condition seems to have a very decided influence in the production 
 of the disease for eclampsic convulsions, and are more frequently 
 noticed in rachitic females, than in such as are well formed. 
 
 [M. Colombat appears to me to beg the question here; and he atlributes 
 to the disease what should more fairly be assigned to the influence of the 
 products or consequences of the disease. A woman may enjoy the most 
 robust and vigorous health, notwithstanding she may, in early life, have 
 suffered great distortion of the spine, the pelvis, and of other parts of her 
 osseous structure. She was rachitic, as a child ; but, as a woman, she 
 is in sound health. Such a woman is exposed to the extremity of nervous 
 perturbation by the opposition of her rickety pelvis to the delivery of her 
 foetus, in labour; and, in so far, may be regarded as liable to convulsions. 
 It may be true that she is so ; but I have not met with convulsions in 
 any one of the cases of labour, with distorted pelvis, that has been under 
 my care. M. C. goes on to say that: — M.] 
 
 A deformity of the pelvis, a bad position of the child, a dispropor- 
 tion between its parts, and the passages it is to traverse, and, indeed, 
 an excess of sensibility of the womb, are likewise so many circum- 
 stances that predispose the patient to the puerperal convulsion. 
 
 Particular states of the atmosphere have also been classed among 
 the predisponent causes of eclampsia. Smellie, Desormeaux, Mad. 
 Lachapelle, M. Bouteillier, and some others have remarked that 
 the disorder sometimes prevails epidemically. It may, likewise, be 
 brought on by the power of imitation, or by fright from seeing a 
 woman seized with convulsions, which has often been clearly ob- 
 served in the lying-in wards of a hospital. One may also perceive 
 that whatsoever tends to excite the general irritability of the con- 
 stitution, may constitute a predisposition ; it is in this way that we 
 discover the effects of imprudence in eating, and disorders in the 
 exercise of other functions of the economy ; the use of high-sea- 
 
 * Women have been seized with eclampsic convulsions in the second, third, fourth, 
 fifth, and even in the eleventh pregnancy. 
 
634 
 
 PUERPERAL CONVULSIONS. 
 
 soned food, a depraved appetite frequently gratified, attacks of indi- 
 gestion, the abuse of coffee, drunkenness, abuses of coitus, especially 
 in the latter months of pregnancy, the abuse of alcoholic drinks, the 
 impressions made by odours, the use of tight dresses or corsets, and, 
 in fine, the effect of the passions, whether of joy or grief — and all the 
 more powerful emotions of the soul. 
 
 It would appear, from a considerable number of observed cases, 
 that eclampsia is less common with poor country women than with 
 the easier classes of cities, who are, generally, more excitable and of 
 a more nervous and active temperament. It is right, however, to 
 remark, that puerperal convulsions are principally to be met with in 
 the hospitals of large cities, and^ of course, among the more wretched 
 classes, who, in fact, partake of the same nervous predominance as 
 appertains to the wealthier females, and is, moreover, connected with 
 most unfavourable hygienic conditions. 
 
 The operation of the predisponent causes does not, necessarily, 
 result in the production of the epileptiform convulsion, and, as it 
 serves merely to place the economy in an attitude favourable to the 
 development of the attack, some occasional circumstance must of 
 necessity intervene, in order that the disease may make itself mani- 
 fest. 
 
 Among these occasional circumstances we ought to place in the 
 first rank the pains of labour. In fact, the attack of eclampsia does 
 most commonly take place just as the head is escaping from the 
 circle of the os uteri, or from the vulva, or, in other words, at the 
 period when the labour pain has reached the summum of its inten- 
 sity. It happens, especially where the pains are protracted an inor- 
 dinate length, in consequence of some obstacle, such as rigidity, 
 hardness, or spasms of the cervix, unusual tenacity of the mem- 
 branes, a cancer of the womb, an occlusion or extraordinary con- 
 traction of the os tineas, a calculus in the bladder, or an extremely 
 distended state of the bladder, a polypus or any tumour within the 
 pelvic cavity, a rupture of the womb, or the laceration of its cervix ; 
 in fine, a disproportionate size, or the death of the foetus; a bad 
 position of the child ; twin pregnancy, and the various manoeuvres 
 required in the operation for turning the child or delivery by the 
 forceps. It should be added farther, that strong moral impressions, 
 such as anger, vexation, fright and joy may at this period become 
 determining causes of eclampsia. 
 
 Dr. Burns, an English physician, thinks that the compression of 
 the sacral nerves, either by the child’s head or by the forceps, should 
 be regarded as an immediate cause of the disorder under consider- 
 ation : a circumstance that might be considered as proof of the 
 soundness of this opinion as to some of the instances, is this, namely, 
 that in eclampsia the head is very frequently in an occipito-posterior 
 position. However, it is our opinion, that the determining cause of 
 eclampsia occurring during the course of pregnancy is a result of 
 exaggerated sympathetic reaction of the womb upon the nervous 
 system. It is to be remarked, that convulsions occurring during the 
 progress of gestation may cause abortion to take place, or they 
 
PUERPERAL CONVULSIONS. 
 
 635 
 
 may occasion the death of the foetus and a premature confinement. 
 Labour under such circumstances goes on more rapidly than in ordi- 
 nary cases, and almost always without the consciousness of the 
 patient, who appears to feel no pain, or at least gives no sign of suf- 
 fering beyond a low grunting sound. 
 
 Puerperal convulsion may be also caused after delivery, by the 
 presence of coagula in the womb, or by remnants of the placenta, 
 or of false membranes, retained within the cavity. In such cases 
 the convulsive paroxysms succeed the expulsive efforts; they may 
 also be brought on by lesions and lacerations of the womb, by 
 exposure to cold, and by walking about too soon after delivery, and 
 sometimes by metritis and peritonitis, which produce suppression of 
 the lochia, itself a mere symptom that has been erroneously regarded 
 as a cause of eclampsia. The same may be said as to flooding 
 after delivery, which brings on convulsions, that are, however, of a 
 nature different from those in question. The precursory signs of the 
 disorder are numerous and varied, but sometimes so slight that they 
 excite little attention. They consist in a fixed pain in the head, 
 with disordered intellect, sensibility and mobility; an extreme degree 
 of uneasiness; flashing of light in the eyes, vertigo, hallucinations; 
 diminished power of sight and hearing ; confusion of ideas and of 
 the speech. The eyes are by turns fixed and rolling, their pupils 
 are dilated ; there is shuddering of the limbs, accompanied by slight 
 convulsive twitchings of the muscles of the face, which appears some- 
 what swelled and flushed; these prodromes are often followed by 
 vomiting, involuntary discharge of the faeces, and likewise by violent 
 pains at the epigastrium ; sometimes, however, the attack comes on 
 without any apparent precursory sign. 
 
 The attack is announced by symptoms peculiar to it; the wo- 
 man is excessive^ agitated and uncontrollable, the countenance 
 assumes a bluish or violaceous tint, the look becomes fixed, the 
 globe of the eye turns up under the upper lid, the nostrils are 
 distended, the angles of the mouth are drawn backwards, the chin 
 seems sharpened, and the features resemble those of a satyr. At 
 the same time the trunk becomes rigid, and the hands are con- 
 vulsively clenched, the head turns over backwards, and through 
 the half-open mouth the tongue is projected forth. The forearms 
 acquire a very rigid tension and are excessively pronated, the legs 
 are extended upon the thighs, the feet and toes are strongly flexed ; 
 the body, which is bent backwards, often seems to rest only on the 
 heels and the occiput, like two ends of a bow ; and the jaws are so 
 forcibly clenched that the tongue, in many of the examples, is deeply 
 wounded. One remark on this subject is, that, in general, one side 
 of the body is more convulsed than the other ; but the motions are 
 limited in all the cases, consisting of little more than a sort of trem- 
 bling, which serves to distinguish the puerperal from the hysterical 
 kind of convulsions ; the latter sort being characterized by extensive 
 and violent motions. 
 
 During the attack the respiration, which is at first rapid and 
 jerking, becomes suspended, while the muscles refuse to dilate the 
 
636 
 
 PUERPERAL CONVULSIONS. 
 
 thorax, or while the glottis is closed by spasm ; when the air, how- 
 ever, escapes from the lungs, the breathing, which is suspirious and 
 loud, produces a hissing sound, owing to the rush of the air betwixt 
 the clenched teeth, carrying with it abundance of the saliva, which 
 inundates the whole mouth. The circulation is also very irregular, 
 and the arterial pulse becomes so feeble and disordered that, at 
 times, there is a real suspension of the motions of the heart. 
 Further, throughout the whole duration of the attack, the sensibility 
 of the patient is completely nullified, the intellection wholly disap- 
 pears, and sight and sound are no longer perceived, while the skin 
 fails to perceive even the most violent excitants that can be applied 
 to it. All these symptoms last during some few minutes, and the re- 
 spiration and circulation then gradually resume their natural rhythm; 
 the close of the attack is announced by a return of warmth to the sur- 
 face, and by a general perspiration, and, above all, by diminution of 
 the convulsions, which, though they are more violent, yet recur after 
 longer and still longer intervals. 
 
 The convulsions are followed by a state of stupor, complete relax- 
 ation of the limbs, loss of sense, feeling and memory, and apoplectic 
 somnolency, accompanied with stertorous breathing, interrupted by 
 moanings, and a complete forgetfulness of all that has transpired 
 during the attack. 
 
 The duration of the attack varies from three to five and even to 
 ten minutes ; but we doubt whether it can exist during ten hours 
 out of the twenty -four, as in a case mentioned by Levret. It almost 
 always happens that the attacks are repeated, but after each attack 
 the torpor and the sleep are more prolonged and decided, and they 
 become more so in proportion as they are more frequently repeated ; 
 in some cases they may be found to recur at determinate periods. 
 Baudelocque speaks of a lady whose attacks occurred twice a day 
 for twelve consecutive days ; he adds, that the attacks always lasted 
 three hours and a half, which leads us to suspect that the distin- 
 guished accoucheur may possibly have been mistaken as to the 
 nature of the convulsion, as attacks of eclampsia could not be very 
 greatly prolonged without destroying the patient. In fine, the con- 
 vulsions may come on at intervals of five minutes consecutively, or 
 every fifteen minutes, and they may be separated by intervals of a 
 whole day, or of several days. 
 
 Generally speaking, the disorder terminates fatally in half the 
 cases; or it may be followed by restoration to perfect health— or it 
 may result in the development of some other disease, of greater or 
 less severity. 
 
 [M. Oolombat says that one-half of the cases of puerperal convulsions 
 prove fatal. I am very sure that such is not the case in this country. I 
 have met with upwards of twenty cases of the affection, of which not more 
 than three have proved to be mortal cases ; so that, instead of 50 per cent, 
 of fatalities, I am confident that the fatalities will not reach beyond 14 or 
 15 per cent, under a judicious management of the attack. By a note, 
 dated August 31, 1844, from my colleague, Prof. Huston, of the Jefferson 
 
PUERPERAL CONVULSIONS. 
 
 637 
 
 Medical College, I learn that his results are very similar to mine, he having 
 lost two only out of thirteen cases of puerperal eclampsia, the amount 
 of his personal experience in hospital, in private practice and in consult- 
 ations, which is a mortality of not quite 15 percent., instead of 50 per 
 cent., as stated by M. Colombat. 
 
 Dr. Collins, of Dublin, says, that thirty cases of puerperal convulsions 
 occurred in the lying-in hospital during his mastership, and that five of the 
 women died, giving a mortality of between 16 and 17 per cent. — M.] 
 
 Death sometimes takes place during the convulsion, or in the stupor 
 that follows it ; women have been seen to perish in the first or the 
 second paroxysm. History informs us that the Duchess of Beaufort 
 died in the second paroxysm of puerperal convulsions, with which 
 she was seized while writing to Henry IV. 
 
 The return to health may be more or less rapid, but it is generally 
 gradual ; however, an attack may take place without leaving any 
 symptoms whatever after it is over. 
 
 Lastly, the diseases which may be complicated with, or which may 
 become sequelse of eclampsic attacks, are rupture of the womb, a 
 speedily fatal accident, metro-peritonitis, paralysis, or simple numb- 
 ness of the limbs, disordered understanding, and diseased sensations, 
 mania, dementia, amaurosis, deafness, cephalalgia, and a loss of 
 memory more or less absolute. It should be understood that these 
 several disorders may be only transitory, or that they may be indefi- 
 nitely prolonged. 
 
 The prognosis of the case is very serious, both as to the mother 
 and her offspring. It is more serious in primiparous women than in 
 such as have had children before, and it is particularly unfavourable 
 for first labours in women somewhat advanced in life, for women 
 not subject to convulsions, as hysteria, epilepsy, catalepsy, &c. The 
 prognostic is more serious in women whose limbs are infiltrated, and 
 it has been found more fatal in hospitals than in private practice ; 
 and that the same is true as to cases occurring before the full term of 
 pregnancy, because the disorder is complicated with all the hazards 
 that attend abortion. 
 
 An attack coming on at term, but before the commencement of 
 labour, is also more dangerous than one that comes on during the 
 progress of a labour, or towards its conclusion, and this latter is more 
 hazardous than one that succeeds to the birth of the child or the deli- 
 very of the secundines. Lastly, the prognosis will be more or less 
 grave in proportion as an attack is made at a period less or more 
 advanced of gestation, inasmuch as in such a case the attacks might 
 continue until the pregnancy should be brought to its close. How- 
 ever, the disease is so much the more to be dreaded as the attacks 
 are nearer to each other, more numerous, more intense, longer in 
 duration, and as the stupor is profound and enduring. We add, that 
 it is a good sign when lucid moments appear after the coma in the 
 intervals of the convulsions. 
 
 The death of the child is also a very frequent consequence of 
 
638 
 
 PUERPERAL CONVULSIONS. 
 
 eclampsia, and its danger is enhanced as the attacks are more vio- 
 lent and reiterated. Its life, however, is less endangered when the 
 convulsion comes on before the commencement of the labour. Besides, 
 children born of eclarnpsic mothers are more liable than others to 
 die of convulsions, for they come into the world with symptoms of 
 cerebral congestion, and are in a condition closely allied to that of 
 infants born with compression of the umbilical cord. 
 
 Examinations post mortem rarely give any satisfactory explana- 
 tion of the severity of the symptoms ; in a great majority of cases, no 
 lesion is discovered to explain the profound disorder of the nervous 
 system. In women who have perished during the attack, there are 
 sometimes discovered the traces of a cerebral congestion, engorgement 
 of the encephalic veins and sinuses, and sanguine, but more generally 
 serous effusions where life is closed in the stupor of the disease. The 
 viscera of the other splanchnic cavities exhibit no alterations attribu- 
 table to the malady. In these cases, then, as in all the neuroses, the 
 material change escapes our cognition. 
 
 The diagnosis of eclampsia is easily established, for, according to 
 the symptoms which we have recognized as belonging to the epilep- 
 tiform sort, &c.,it would always be possible to distinguish them from 
 other affections exhibiting analogous symptoms. Thus the eclamp- 
 sic convulsion is characterized by movements of small extent, con- 
 centrated, occurring in slight jerks, and always ending in stupor and 
 coma. With these characteristics, it cannot be confounded with hys- 
 teria. It is true that there is sometimes confusion of these two orders 
 of symptoms, but the gravity and the indications are always the same, 
 for in this case the hysterical symptoms are transformed into those 
 that are characteristic of eclampsia. Paroxysms of hysteria ordi- 
 narily begin with sobs, a feeling of constriction at the throat, and they 
 consist in violent movements of the body, they terminate in weep- 
 ing, and in loud cries, but without frothing of the mouth, change of 
 the countenance, or stupor. Cataleptic attacks are marked by mus- 
 cular rigidity, without any convulsive motions, without consecutive 
 stupor, or any disorder of the understanding after the attack. More- 
 over, catalepsy is more common in pregnancy than in labour, during 
 which it is suspended ; besides, it compromises neither the mother 
 nor the child. Attacks of tetanus are signalized by painful and per- 
 manent muscular rigidity of one or more parts or of the whole sys- 
 tem, but without alteration of the intellectual or sensorial powers. 
 These attacks are extremely rare in labour, only one woman having 
 been seen to perish with it. 
 
 Epilepsy is the disease that bears the closest resemblance to 
 eclampsia; indeed, there is no difference between them except in 
 the closing of the paroxysm. In eclampsia the stupor is much more 
 decided and lasting. Besides, the pregnant state, and the non-exist- 
 ence of epilepsy previous to the conception, which generally suspends 
 an epilepsy, are circumstances that show the case to be one of eclamp- 
 sia. The eclarnpsic stupor, moreover, should not be confounded 
 with apoplexy, which is not ushered in with convulsion, and is 
 attended by a persistent paralysis. Let us further add that it is 
 
puerperal convulsions. 
 
 639 
 
 quite as easy to distinguish the puerperal convulsion from those that 
 follow violent flooding. 
 
 The treatment of eclampsia should be modified accordingly as the 
 attack takes place during the progress of the pregnancy, coincidently 
 with labour, or after the birth of the child. 
 
 During pregnancy . Should the physician arrive during an attack, 
 instead of remaining a passive spectator of the scene, he should see 
 that the patient be properly held by intelligent assistants, so as not 
 to repress her movements too much; then when the mouth opens 
 and shuts with violent force he ought to push the tongue, whenever 
 it is thrust forth, back into the mouth, and retain it there with his 
 fingers, lest it might be seriously lacerated. For fear of being bitten, 
 a piece of fine cork might be made use of for this purpose ; but a 
 spoon ought never to be introduced into the mouth, as is done by 
 most physicians. It is proper, also, to compress the carotids, and to 
 pour cold water on the face, especially if the attendant be present 
 during the prodromes of a paroxysm, to which, also, he ought to 
 oppose a venesection, and leeches to the throat, the temples and epi- 
 gastrium, which is in general the seat of some disease. 
 
 But it is particularly after the attack is over that the physician 
 may act with the greatest advantage. Blood-letting is proper in true 
 eclampsia, not only where the patient is plethoric, but also in those 
 who are infiltrated, with this difference, however, that it should be 
 more abundant in the former sort. Bleeding from the arm is always 
 to be preferred to bleeding from the jugular vein or the temporal 
 artery, for these require a subsequent compression that obstructs the 
 return of the circulation; it is also to be preferred to bleeding in the 
 foot, which is generally impracticable, on account of the infiltration 
 of the lower extremities. The quantity of blood to be taken away 
 is from twenty to forty ounces, twenty-five to thirty for the mean, 
 twenty for the minimum, and forty as the maximum quantity. Al- 
 though Hamilton and Dewees carry the quantity to be withdrawn 
 up to fifty, and even to one hundred ounces, the quantity we have in- 
 dicated ought rarely to be exceeded. Should the symptoms not be 
 lessened, the bleeding might be repeated a second, or even a third 
 time in the course of the day ; but these abstractions of blood should 
 be much more limited than the first one. Abstraction of blood by 
 leeches to the nucha, the throat, and the temples, will also be useful ; 
 yet they should be had recourse to only as an auxiliary measure, and 
 as substitutes for a second or third general bleeding, but never as a 
 
 PRIMARY MEASURE. 
 
 It is useful to associate with the venesection the use of derivatives 
 to the intestinal canal, by means of mild cathartics, such as castor 
 oil, calomel, alone or in combination with jalap, in a dose of from 
 five to ten grains, and also the sulphate of soda or of magnesia. 
 Mauriceau used senna with the juice of an orange; Delamotte 
 recommended rhubarb, manna, the syrup of nerprun , and Merri- 
 man prescribed a pill of five grains of calomel, followed by a solu- 
 tion of some purgative salt, the doses being repeated every third or 
 fourth hour, the operation being solicited by laxative enemata. Should 
 
640 
 
 PUERPERAL CONVULSIONS. 
 
 the stupor be so great as to hinder the opening of the mouth, these 
 purgatives ought to be administered by injection. Emetics ought 
 not to be prescribed except where the attack should coincide with an 
 overloaded stomach, or where the disorder seems to have some con- 
 nection with gastric derangement. 
 
 Derivative applications to the skin appear to be not less beneficial 
 than the other measures of relief; but their employment ought to be 
 wisely managed. We should confine ourselves to the application of 
 warm cataplasms to the feet and legs, where the attacks are fre- 
 quently repeated ; but in case the convulsions return at intervals of 
 several hours, sinapisms may be advantageously placed on the legs 
 and blisters to the inside of the thighs and to the nape of the neck. 
 These counter-irritants are most especially useful where the stupor is 
 of long duration ; but the blisters ought to be removed as soon as 
 the rubefacient effect shall have been produced. 
 
 Cold applications to the head, such as ice or cold water in a blad- 
 der, may likewise be very useful. Under such circumstances we 
 ought not to hesitate to cut off the hair. Should the stupor be per- 
 sistent and more decided, care ought to be taken to remove the cold 
 applications. Let us add, that Merriman recommends the following 
 mixture : — 
 
 R. — Liquid acetate of Ammonia, 3iv 
 
 Spirit of Rosemary, 3ij. 
 
 Water, 3j. 
 
 Mix. 
 
 Baths, also, afford a very useful remedy ; but they are suitable only 
 in cases where the paroxysms are separated by considerable intervals, 
 during which the patient recovers her senses. Tepid baths are par- 
 ticularly valuable as remedies in this case, where care is taken to 
 direct cold aspersions to the head, or to keep a bladder of ice upon 
 it ; they are injurious if the convulsions are frequent, and the stupor 
 very great. It would be useful, in such a case, to introduce the 
 catheter and empty the bladder, whose excessive distension, and the 
 suppression of urine, which are common occurrences during the 
 stupor, might tend to excite renewed attacks of the convulsion. 
 
 The antispasmodics, as opium, musk, assafoetida, camphor, &c., the 
 effect of which is slow, will not often be resorted to in this form of 
 convulsions; opium especially should be made use of only with great 
 reserve, when there is cerebral congestion and stupor ; nevertheless, 
 Dr. Collins, of Dublin, informs us that he met with great success in 
 the use of this article combined with emetic tartar, which, after pre- 
 mising the other remedies, he prescribed as follows : — 
 
 R. — Water, 3viij. 
 
 Tartar Emetic, gr. viij. 
 
 Tincture of Opium, Tltxxx. 
 
 Syrup, 3ij. 
 
 Mix. 
 
 To be taken in doses of a tablespoonful every half-hour. M. Vel- 
 peau, also, asserts that he was successful in the use of acetate of 
 morphia, in doses of a quarter or half grain every second or third 
 
PUERPERAL CONVULSIONS. 
 
 641 
 
 hour, mixing it in a tablespoonful of water. We believe that the 
 sedative remedies have been useful chiefly in cases other than 
 eclampsia. 
 
 [I am much pleased with M. Colombat’s bold and vigorous employment 
 of the lancet in his cases of puerperal eclampsia, and perhaps he has gone 
 far enough in his recommendation of venesection. Yet the late Dr. De wees, 
 Dr. Chapman and most of the practitioners here, would scarcely feel them- 
 selves warranted, in a young, vigorous female in convulsions, if in a first 
 pregnancy, to take less than forty to sixty ounces of blood, provided the 
 repetition of the attacks should serve to show that the hyperaemic state of 
 the brain, leading to the first convulsion, was not overcome by the first 
 bleeding of twenty or thirty ounces. 
 
 I am not so well satisfied as to his abjuration of opium in the treatment. 
 I believe it has become a very general practice here, to give opium freely in 
 almost all the cases where full blood-letting has been premised, and after the 
 unloading of the bowels by very active enemata. I should make it almost 
 invariably a rule, to give from twenty to forty drops of laudanum, to be 
 repeated even several times, and at no very distant points of time, where I 
 could no longer entertain any doubts as to whether I had been sufficiently 
 attentive to relieve the brain by free use of the lancet, and of cups or 
 leeches. It appears to me, that I have seen several women pass gradu- 
 ally from the stupor or coma of eclampsia into the quietest sleep under the 
 soporific and anodyne power of opium — a practice that has proved not 
 only safe but most efficacious. Indeed, the nervous excitability left after 
 the convulsion, the labour, the blood-letting and other treatment, seems 
 loudly to call for the hypnotic power of this most beneficent drug. It is 
 quite true, that a treatment undertaken without reference to the predis- 
 posing causes and influences might lead the practitioner to be too soon 
 satisfied with his prescription of venesection, and permit him to hasten the 
 exhibition of the opiate sooner than the state of the patient would really 
 warrant. If we reflect but a moment upon the facts, we shall be com- 
 pelled to admit that puerperal convulsion is far more common in primi- 
 parous women than in women who have already undergone the fatigues 
 and excitements of gestation and labour. But why should this be the 
 case, seeing that the health and strength of the patient should be, cseteris 
 paribus, better than that of the woman who has already been racked with 
 the pains and all the accidence of the gestative and parturient state ? Iam 
 fully of the opinion set forth by Puzos, at p. 173 of the Traite ties Re- 
 concilements, who says: “If the blood-lettings and other remedies do not 
 calm the convulsions, and should they, on the contrary, become more fre- 
 quent, the measure most indispensable is to deliver the woman as soon as 
 possible ; for, by freeing the womb of such a burthen, we emulge the great 
 vessels that run along the course of the spine, and allow the blood to flow 
 equally to every part, whereas, before the delivery, the excessive pressure 
 41 
 
642 
 
 PUERPERAL CONVULSIONS. 
 
 of the child upon the great trunks of the descending aorta, compelled the 
 blood to flow upwards to the superior parts and to inundate, so to speak, 
 the mass of the brain.” 
 
 This sentiment of Mons. Puzos has been reiterated by writers, but it 
 appears to be one so just and apposite, that proper occasion ought always 
 to be taken to enforce it and promulgate it. The strong, healthful, resisting 
 muscles of the woman who has not borne children, cannot fail to compress 
 the womb with considerable more force than the weak, flaccid muscles of the 
 female who has been already confined. Under such compression the blood 
 tends to accumulate in the head and superior extremities, and to develop 
 there a more active and powerful nutrition. In many such the hands are 
 swollen and stiff upon rising in the morning, and the face becomes bloated 
 or swelled — the old notion, that a woman who has conceived cannot measure 
 the circumference of her neck with a thread that was quite long enough to 
 go round it before, has some foundation in fact, then. 
 
 Non illam nutrix, oriente sole revisens 
 
 Hesterno poterit circumdare collum filo. 
 
 The rapid development of the mammae in pregnancy is also, in part, attri- 
 butable to the inundation of the superior parts of the body with the blood, the 
 source, the cytoblastem of all nutritive absorption. In primiparous females, 
 then, the brain, ipso facto , is to be held as in a hyperaemic state for some weeks, 
 or even months before the commencement of the labour. Let the labour- 
 pains be violent, long ones and for a long time repeated — how can it happen, 
 that the solid, contracted globe of the womb shall be pressed violently and 
 repeatedly against the descending trunk of the aorta, without more or less 
 impeding the flow of blood in the tube, and, consequently, compelling the 
 carotids a!nd superior branches to carry a preternatural quantity. This ex- 
 cessive sanguine determination, which so frightfully engorges the face and 
 bosom of the female in her throes, is generally rendered harmless by the 
 floods of perspiration which deluge the superior parts, while the legs and 
 feet remain dry. The salutary diversion thus effected, saves many women 
 from apoplexy and from eclampsia. I look upon it as a dangerous state, 
 when a woman in strong labour does not sweat freely from the head and 
 thorax. She is generally in danger of convulsion. 
 
 It is with me a rule, not to allow a primiparous female to lie long upon 
 her back while in strong labour, for fear that the weight of the womb super- 
 added to the pressure of the abdominal muscles, might check the aortic cir- 
 culation too considerably — and the more particularly would I forbid a dorsal 
 decubitus in case she should make any complaint of headache, dizziness, 
 flashings of light, or tinnitus, or manifest any other symptoms of excessive 
 sanguine determination to the head. 
 
 M. Velpeau, in his monograph on puerperal convulsions, speaks of the 
 value of blood-letting as inestimable in the treatment of the malady, and yet 
 admits that the most eradicative abstractions will not suffice in all cases to 
 
PUERPERAL CONVULSIONS. 
 
 643 
 
 secure the patient’s recovery. So, likewise, Dr. Robt. Lee [Led. on the 
 Theory and Pract. of Mid ., p. 400) advises, in energetic terms, the use of 
 the lancet: “Copious blood-letting in puerperal convulsions is the first 
 remedy now employed by all practitioners in this country,” [loc. cit.,) 
 and, though he admits the impracticability in some cases, to abstract a suffi- 
 cient quantity to save the patient, he evidently looks upon it as the sheet- 
 anchor of hope. 
 
 I need not extend this note for the purpose of reiterating directions as to 
 enemata, cathartics, cups, leeches and sinapisms, shaving the head, &c. • 
 these are too obvious to require any notice from me, but I desire to say, 
 that the practice here at present is, so far as I know, nearly universal, to 
 give full doses of opium as soon as the practitioner is satisfied that he has 
 carried his venesections to a sufficient extent. Robt. Lee, loc. cit., says : 
 “Opium has been almost universally condemned in puerperal convulsions, 
 and I consider it improper before blood-letting has been employed to a suffi- 
 cient extent, and delivery has been completed, either spontaneously or arti- 
 ficially. In some of the most severe cases which I have seen, after copious 
 venesection and delivery, large doses of the liquor opii seditivus, have ap- 
 peared to produce very powerful effects in arresting the fits ; in others, no 
 benefit whatever resulted from the employment of sedatives of any kind,” 
 402. The caution of the distinguished writer, as to the exhibition of 
 opium before delivery, is, I think, a case of excessive caution, since I have 
 seen women recover, undelivered, under very liberal exhibitions of opium ; 
 but never until the venesections had been carried to a great extent. Indeed, 
 I do not perceive that delivery or non-delivery has any thing to do with the 
 therapeutical principle of the case, as to the exhibition of the drug. 
 
 M. Colombat coincides with every body in the opinion, that the brain, 
 when examined after death, generally yields no pathological lesions to 
 explain the violence of the disorder. We have a legitimate right then to 
 infer, that the disorder is one of extreme cerebral excitement from hyperse- 
 mia, and from sympathy of the brain with the irritated organs below. — 
 What could then be more reasonable than the exhibition, after abundant 
 depletion and evacuation, of full doses of the anodyne, the only one that 
 can be expected to remove from the encephalon its excessive perceptivity 
 of distant irritations. — M.] 
 
 If it be agreed that the state of plenitude of the uterus, is one of 
 the most powerful causes of the eclampsic convulsion, does it not 
 appear to be reasonable to arrest those convulsions by emptying the 
 womb? When the attacks come on before the sixth month, we ought 
 to make every effort to overcome them, without provoking delivery; 
 but there is no necessity for such precautions where the viability of 
 the foetus is already possible, that is, where the pregnancy has nearly 
 reached its term, and especially where the cervix is soft and dilata- 
 ble, and where the attacks, after resisting the venesections, baths, &c., 
 threaten to prove speedily fatal. Under circumstances like these we 
 
644 
 
 PUERPERAL CONVULSIONS. 
 
 should be justified in rupturing the membranes, or detaching them, 
 and should those steps fail, we could properly proceed to a forced 
 premature, delivery. It is true that cases where such measures are 
 required are very rare ; they would be useful only in women who 
 have already borne children, and not in cases of primiparous women, 
 who are precisely those most liable to puerperal convulsions, and in 
 whom the os uteri is almost always rigid and not readily dilatable. 
 In fine, where the paroxysms are very violent, they commonly excite 
 uterine contractions, which often effect the expulsion of the child. 
 Besides, we must never despair of seeing the attacks disappear, 
 never to return, allowing the woman to come to her bed without 
 any disaster. 
 
 During the labour the assistance of art may be demanded, either 
 when the os uteri is undilated, or where the dilatation is completed. 
 In the former case, after the employment of the measures now pointed 
 out, them is a better chance of success, the pregnancy being at term, 
 by resorting to the means proper to facilitate the natural expulsion, 
 or even to terminate the delivery artificially. In order to assist the 
 natural delivery we should order emollient fumigations by means of 
 a funnel, the nozzle of which being covered with a piece of linen, 
 should be directed towards the womb; by injections of the same 
 kind ; by the employment of belladonna mixed, in equal parts, with 
 cerate, or pure in the form of extract, say two or three grains, which 
 should be placed on the os uteri by the index finger. But prudence 
 is necessary here, for the drug being promptly absorbed, might prove 
 dangerous in the convulsions, particularly, were the coma very much 
 prolonged. The introduction of the fingers with the design to dilate 
 the os uteri, ought not to be considered proper in the major part of the 
 cases; for the irritation it excites provokes to repetition of the pains 
 at improper intervals, and thereby tends to bring on attacks of con- 
 vulsion. The same principle applies to the administration of the 
 spurred eye, the action of which is not to be doubted of, but which, 
 by bringing on powerful and permanent contractions, might probably 
 give rise to the eclampsic paroxysm. However, the use of this 
 remedy might be resorted to in desperate cases. 
 
 The measures now indicated having been put in execution without 
 any happy effect, and the convulsions increasing in frequency and 
 violence, in such a way as clearly to compromise the lives both of 
 the mother and her child, the practitioner should endeavour to con- 
 clude the labour by rupturing the membranes by means of a catheter, 
 by incising the os uteri, or by turning the child and delivering it foot- 
 ling. There are cases that go to show the advantage of rupturing 
 the membranes, where dilatation has already commenced, and where 
 the excessive distension of the uterus appears to act as a cause of the 
 obstinacy of the attacks, and especially where the presentation of the 
 foetus is natural and favourable. It ought not to be done, however, 
 under opposite circumstances; for it might then be followed by the loss 
 of the child, from pressure on the umbilical cord, or it might render the 
 delivery by any manual or instrumental operation, far more difficult. 
 Were the os uteri somewhat open, soft and very dilatable, we should 
 
PUERPERAL CONVULSIONS. 
 
 645 
 
 be justified in resorting to compulsory delivery by the hand, which 
 is passed up to the child’s feet, which are brought down until the 
 child is completely turned, and so delivered. But the time required 
 for this operation, and the pain it gives, appear to us reasons for pre- 
 ferring the incision of the os uteri, which gives occasion to less lacera- 
 tion, less pain, and fewer accidents of any sort than forced delivery 
 by turning. This operation, proposed by Simson and Lauverjeat, 
 under the title of vaginal Caesarian operation, is done with a probe- 
 pointed bistoury that should be a little falciform. The blade, applied 
 flat along the finger, should be carried up to the cervix and applied 
 to the anterior margin of the circle of the os uteri, which should be 
 then cut or divided by a forward movement of the bistoury. One 
 incision might, perhaps, prove sufficient, but it is better to make twc 
 or three of them of a smaller size. Such an operation as this, be it 
 understood, ought not to be ventured upon, as long as there is any 
 other chance of success in the treatment. For the most part, after 
 this chirurgical relaxation of the cervix, nature provides for the deli- 
 very^ — where her power proves incompetent, it is our business to 
 bring it to a conclusion. 
 
 In cases where convulsions come on at an advanced stage of la- 
 bour, there ought to be no hesitation about terminating the labour by 
 turning, should not the head be sufficiently engaged in the superior 
 strait of the pelvis ; in other circumstances, we should make use of 
 the forceps, which is fraught with less danger to the mother than the 
 version delivery. Where the attack of convulsion comes on after 
 the woman is delivered of the child, the prime indication would be 
 to remove the placenta and free the womb from any coagula that 
 might be found within its cavity; should the attacks still come on, 
 we ought to have recourse to blood-letting, to counter-irritants, to 
 baths, to cataplasms to the abdomen, to emollient and detergent 
 injections ; and in a case where a flooding should threaten to pro- 
 duce an eclampsic attack, it should be checked by cold astringent 
 applications to the hypogastrium, and even by the tampon, should 
 the measures first recommended fail of success. 
 
 [It is difficult for us to imagine a haemorrhage as menacing the woman 
 with puerperal convulsions, as M. Colombat appears to suppose it might do. 
 On the contrary, every additional ounce of blood that should drain off from 
 the body might be expected to relieve the brain of its sanguine or hyperae- 
 mic determination. It is true that haemorrhage, when excessive and on the 
 point of proving fatal, brings upon the patient a short, quick, rapid convul- 
 sion, but such a convulsion is free from the very nature and character of the 
 eclampsia. I protest likewise against the author’s doctrine as to the arrest 
 of the supposed haemorrhage by the tampon; that is, as a proposition per 
 se, without those modifications of precept which ought to accompany all 
 directions as to the use of the tampon. I have had so many and such vexa- 
 tious occasions to remember of tampons consisting of coagula of blood in 
 the vagina, which I always make haste to turn out, that I feel little inclined 
 to pass over an unmitigated prescription of so dangerous a remedy. 
 
646 
 
 PUERPERAL CONVULSIONS. FALLING. 
 
 When a woman is not yet delivered, a tampon can in general only serve 
 to enhance any danger from the haemorrhage, on account of which it is em- 
 ployed, and that, by blocking up the blood that continues to pour from the 
 uncovered vascular orifices in the womb, until the cavity of the uterus be- 
 coming filled, it gradually yields to the pressure, and dilates more and more. 
 As the superficies of the uterus augments, the patulous orifices of the vessels 
 become more and more open, and the torrent of effusion becomes greater 
 and greater ; so rapidly, indeed, that many women have bled and died with- 
 out discharging any considerable quantity from the vulva. The tampon 
 cannot save a woman by causing the blood to coagulate — nor can it return 
 into the veins the fluid already extravasated. When blood is once out of 
 the vessel, it should get out of the body as soon as practicable — and the 
 woman’s safety can only be considered as absolute, when it is procured by 
 means of a firm contraction and condensation of the womb. I agree with 
 Robt. Lee, who says in his Clinical Midwifery , that upon the whole, the 
 tampon, even as used in the cases of placenta praevia under his care, has 
 done as much harm as good. — M.] 
 
 In fine, should the mother have breathed her last during the pro- 
 gress of the labour, the Caesarian operation ought to be performed, 
 notwithstanding the slight chance of success in such an attempt to 
 rescue the life of the child. We remark further, that an attack of 
 eclampsia might often be obviated by a preventive treatment, con- 
 sisting of venesection, baths and purgative medicines, which would be 
 indicated in cases of women infiltrated, or suffering under cephalal- 
 gia, disordered vision, vertigo and other significant symptoms. As to 
 attacks of hysterical convulsion, of an hysterical, cataleptic or tetanic 
 character, which are almost always innocuous as to the female, as 
 well as to the child, they should be combatted by means of blood- 
 letting, particularly where the patient is plethoric, and by antispas- 
 modics and derivatives, taking great care always to follow out the 
 true indication as it may be developed. 
 
 DISPOSITION TO FALL. 
 
 It is undeniable that pregnant women are much more liable to fall 
 than non-gravid females; this peculiarity may depend upon the great 
 prominence of the abdomen, preventing the person from seeing the 
 stumbling-blocks that lie in her path, or upon the reversed position 
 she is obliged to take in order to keep up her equilibrium, or, indeed, 
 upon the rapid increase of the weight of the body, and the unfa- 
 vourable distribution of that weight. It has, likewise, been supposed 
 that the pressure of the womb upon the crural and sciatic nerves 
 gives rise to a debility and sort of incomplete paralysis of the inferior 
 extremities. 
 
 These falls, which are both frequent and dangerous in the gravid 
 female, are, however, much less common among countrywomen, 
 who retain their strength and activity better than the women of 
 large cities do; it is true, however, that these accidents are much 
 
DISORDERS OF THE URINARY ORGANS. 
 
 647 
 
 more rare than they were before the absurd and ridiculous fashion 
 of wearing narrow high-heeled shoes was abandoned. All we can 
 do is to advise our patients to be doubly careful of their gait, so as to 
 lessen, as far as practicable, the awkwardness concomitant on the 
 pregnant state. 
 
 DISORDERS OF THE URINARY ORGANS DURING GESTATION. 
 
 Situated betwixt the pubes and the womb, the urinary bladder 
 undergoes several modifications during pregnancy. Being more and 
 more compressed as the womb augments in size, its expansion is 
 obstructed, whence arises a necessity frequently to discharge the 
 urine. When the pressure acts on the neck of the bladder and the 
 meatus urinarius, ardor urines will follow, and strangury likewise, 
 should the pressure by the womb irritate the mucous membrane of 
 the parts, and excite any inflammation of the tissue. 
 
 These disagreeable effects of the pressure of the womb on the blad- 
 der are met with, chiefly, at two periods. First, betwixt the fourth 
 and the fifth month, especially where the pelvis is spacious enough 
 to allow the womb to remain within it after the period mentioned ; 
 next, during the three last months of pregnancy, especially in women 
 with decided anterior obliquity of the uterus, allowing it after rising 
 above the plane of the superior strait, to compress the body of the 
 bladder against the anterior parietes of the abdomen, or the neck of 
 the bladder against the posterior surface of the symphysis pubis. 
 The bladder is then drawn along by the womb, which is attached to 
 it by the utero-vesical septum, whence it happens that the neck of the 
 bladder is bent like a retort, making it impracticable to introduce 
 the catheter, except with a sound very much curved, like those used 
 for the male urethra. Under such circumstances the affection con- 
 tinues until after the accouchement of the patient, whereas, in the 
 first-mentioned sort, it ceases as soon as the uterus rises above the 
 strait. 
 
 Dysuria and strangury may also depend upon a degree of dis- 
 placement of the womb, especially upon a retro verted position of the 
 organ ; upon a calculus in the bladder, or on a catarrhal inflamma- 
 tion, or on inflammation produced by haemorrhoids. These diseases, 
 whose chief symptom is retention of the urine, demand a peculiar 
 treatment, to which it is urgently necessary to have recourse as early 
 as possible, for the excessive distension of the bladder might lead, 
 not to its inflammation only, but to its absolute rupture. 
 
 A retention of urine occasioned by compression from a womb that 
 has become too voluminous, is developed gradually, unless, indeed, 
 some error of regimen should happen to impart to it a suddenly violent 
 intensity. In all sorts of cases there are two principal indications to 
 be taken up ; one of which consists in promptly evacuating the blad- 
 der, and the other is to hinder, as far as possible, the accumulation 
 of fluid in its cavity. For the fulfilment of the first indication, a 
 curved catheter should be used, after which the faulty position of the 
 womb, giving rise to the suppression, ought to be corrected. The 
 
648 
 
 DYSURIA. VARIOUS PAINFUL AFFECTIONS. 
 
 employment of these measures may be always usefully preceded by 
 the warm bath, by emollient fomentations, and even by venesection, 
 provided the early remedies should have been deferred. 
 
 To fulfil the second indication, which consists in repositing and 
 supporting the uterus, all that is requisite is to raise the womb up- 
 wards by the hands placed on the abdomen, or likewise to bend the 
 body very strongly forwards, so that the womb may be got out of the 
 superior strait. Where these attempts fail, we may readily obtain 
 the discharge of the urine by lifting the uterus upwards by one or 
 two of the fingers introduced within the vagina. The woman her- 
 self should be taught to effect this purpose for herself. Further, the 
 effects of the uterine pressure may be lessened by keeping the patient 
 in a horizontal posture, and by the use of a binder with which to 
 support the abdomen. Where the difficulty of passing the urine 
 depends upon hsemorrhoidal swellings, leeches ought to be applied 
 to the anus, and the patient should go into the bath, and be after- 
 wards kept perfectly at rest. 
 
 A frequent necessity to urinate, and even an incontinence of urine, 
 constitute less a disease than an inconvenience, which besides is likely 
 to continue until the delivery of the child, when it cures itself. 
 
 Notwithstanding our art can boast of but few resources against 
 this affection, we can recommend demulcent drinks, and emollient 
 baths, to lessen the irritation of the meatus urinse, and to subdue the 
 sort of vesical tenesmus that is occasionally conjoined with it. But, 
 should the incontinence of urine arise from atony of the neck of the 
 bladder, coming on after strong compression by the womb, injections 
 ought to be made with Barege waters, or the waters of Balarac or 
 Cauterets. Lastly, paralysis of the bladder should be combatted by 
 injections of soap, or Passy- waters, or Forges-waters, or the waters 
 before mentioned. It seems proper to state that, generally speaking, 
 all the maladies of which we have now been speaking do not obtain 
 a radical cure until after the delivery of the patient, and that all treat- 
 ment up to that consummation is therefore little else than palliative. 
 
 PAINS IN DIFFERENT PARTS DURING PREGNANCY. 
 
 Women at all stages of pregnancy are subject to pains whose seats 
 vary very much. There are in the early months some women whose 
 breasts, under the sympathetic influence of the womb, become pain- 
 ful, and swollen, as happens at the menstrual periods: in others, 
 towards the conclusion of pregnancy, there come on pains from the 
 excessive distension of the skin, and from the secretion of milk which 
 begins to take place. In general, these pains require no medical 
 treatment ; but in more serious cases, we are compelled to combat 
 them by moderate warmth, emollient cataplasms sprinkled with 
 laudanum, and, above all, by venesection. 
 
 Those pains in the lumbar and sacral regions that women com- 
 plain of as backache, and which are aggravated by walking about 
 and standing on the feet, may depend, perhaps, on compression of 
 the lumbar or renal nerves, or the stretching of the broad ligaments, 
 
AFTER-PAINS. 
 
 649 
 
 or, perhaps, upon engorgement of the pelvic blood-vessels, or the 
 uterine vessels, or on the excessive distension of the womb. Pains 
 in the back are also produced, in some instances, by fatigue of the 
 muscles of the spine. 
 
 We may relieve a patient of pain arising from compression of the 
 lumbar nerves or from stretching of the ligamenta lata, by rest and 
 the horizontal position; while such as are dependent upon distension 
 of the womb, or plenitude of the pelvic vessels, are subdued by 
 blood-letting. In the former, the pains are characterized by the 
 volume, sensibility and tension of the womb ; in the latter, by a feel- 
 ing of fulness at the hypogaster, weight within the pelvis, and heat in 
 the parts, as well as by the signs of a general plethora. Pains pro- 
 duced by fatigue of the spinal muscles, and which, in addition to 
 their precise locality, are marked by increased soreness from pressure 
 on these muscles, generally give way to alcoholic and aromatic fric- 
 tions on the parts affected. 
 
 To speak generally, the chief treatment for these pains, as well as 
 for the cramps and numbness caused by Uterine compression of the 
 nerves of the sacral and lumbar plexuses, consists in rest, in baths, 
 opiate injections, and a flannel bandage to support the abdomen, and, 
 lastly, patience, a remedy sovereign in all the disorders whose term 
 is almost always that of the gestation. 
 
 DISEASES CONNECTED WITH THE LYING-IN. 
 
 Those disorders that may follow the accouchement of the woman, 
 are situated either in the organs of generation or in any other system 
 of the organism. 
 
 Among the former ought to be classed lacerations and contusions 
 of the genital parts, inversion of the womb and vagina, inflammation 
 of these organs, already treated of in former chapters, to which we 
 refer the reader. The other diseases of parturition, most of which 
 affect other systems of the economy, are, suppression of the lochia, 
 milk-fever, peritonitis, uterine and crural phlebitis, metritis, phlegma- 
 sia dolens, phlegmonous abscess, cutaneous eruptions, &c., which we 
 shall proceed to treat of in succession. 
 
 AFTER-PAINS. 
 
 The first symptoms that are observed immediately after the deli- 
 very of the woman in labour, are the after-pains and the discharge 
 of the lochia. The after-pains are owing to the contractions of the 
 womb, and mainly occur whenever the cavity of the viscus is filled 
 with coagula, or with some broken remains of the secundines, from 
 which, by this means, it endeavours to free itself. It generally hap- 
 pens that primiparous women are not affected with these after-pains, 
 which are found to be more and more violent, with each consecutive 
 confinement. They are likewise more violent after an easy labour 
 than after a long and difficult one. However, where the parturition 
 has been extremely painful, the after-pains are often very distressing, 
 
650 
 
 AFTER-PAINS. 
 
 in consequence of the great fatigue that the womb has suffered. 
 They generally commence a few moments after the delivery of the 
 placenta, soon become more and more intense, and then go on les- 
 sening in frequency and violence, until the milk-fever comes on, at 
 which period they often disappear completely. It is proper to re- 
 mark, however, that, in some instances, they are prolonged beyond 
 the term of the milk-fever, only diminishing during its existence. 
 
 After-pains may be distinguished from other kinds of pain, by 
 their recurrence at considerable and regular intervals, and by observ- 
 ing that, while they are active, the uterus contracts and becomes 
 hard, so as to expel any clots along with a portion of fluid blood. 
 An after-pain, moreover, is often brought on by the pain that the 
 infant gives when it seizes the nipple. We deem it scarcely worth 
 while to say any thing against the ridiculous prejudice that the more 
 griping the child has, the less after-pain is to be expected by the 
 mother, and vice versa. After-pains, of sufficient violence to prevent 
 the patient from sleeping, may be relieved by anodyne injections, 
 enemata of tepid water, warm cataplasms to the hypogaster, or by a 
 liniment composed of olive oil one ounce, and laudanum one drachm. 
 
 [The reader will pardon me for here suggesting the necessity there is for 
 the greatest caution, in deciding what is, and what is not, after-pain. This 
 it is not always very easy to do, since, in many women, the uterus remains 
 very sore and sensible to the touch, for several days after delivery. Under 
 such circumstances, the patient suffers extreme distress, from the frequent 
 recurrence of the uterine contractions, and, not unfrequently, fever is lighted 
 up in the system, as a reaction against the local disorder. 
 
 It is my custom, in these cases, to take what I conceive the safest course, 
 viz., to lessen the force of the circulation by a blood-letting proportioned 
 to the exigency. Certainly, as an anodyne, or pain-queller, the lancet, in 
 many circumstances, transcends the efficacy of all other sedatives. 
 
 I repeat it, there is great danger of overlooking, under a false security as 
 to the diagnosis, a dangerous attack of metritis. I am well convinced that 
 the dangerous attacks of metritis often coincide with what is usually sup- 
 posed to be merely violent after-pain ; and I think it difficult to conceive of 
 pure after-pain as the sole pathological state of those females, in whom the 
 after-pains continue to recur, with distressing violence, during several con- 
 secutive days, leaving the uterine globe, and the whole of the hypogastric 
 region, indeed, very sensitive and sore to the touch. Even supposing that 
 such a stale can coincide with complete absence of inflammatory nisus , 
 there is always accompanying it, a just ground to dread the development of 
 some of those disastrous forms of inflammation to which the uterus is held 
 always liable, and to which it should be regarded as excessively prone, 
 under the acute and irritating anguish communicated by these post-puerperal 
 contractions. After-pains are well worthy of a careful supervision. — M.] 
 
MODIFICATIONS OF THE LOCHIA. 
 
 651 
 
 ACCIDENTS RELATIVE TO THE LOCHIA. 
 
 Notwithstanding some women have been known to have no 
 lochia, and yet do quite well in their lying-in, yet the absence of this 
 excretion is fit to excite the solicitude of the accoucheur, for it may 
 mostly be attributed to some serious disorder, either actual or immi- 
 nent. Generally speaking, the lochial discharge is most abundant in 
 women who are in the habit of menstruating freely, in those who 
 have had many children, or who take too nutritious a diet, and like- 
 wise in women who do not give suck. 
 
 While it is quite true that the diminution of the lochial discharge 
 is ordinarily the symptom of some disease, such as peritonitis, metri- 
 tis, &c., it also happens, in some cases, that it may be a primary 
 affection, and not the sympathetic consequence of an existing dis- 
 order, as might be the case after some violent and sudden moral 
 impression, the impression of cold air upon the genital organs or on 
 the lower extremities, and of ablutions and astringent injections into 
 the vagina or womb itself. This primary affection is most commonly 
 followed by the development of very serious affections, such as 
 metritis, peritonitis, congestion, or nervous disorders. All these dis- 
 orders are so much the more dangerous, and their attacks so much 
 the more to be dreaded, in proportion as the lochia was at first free, 
 and as the suppression may have occurred at a period nearer to that 
 of the recent delivery. Sometimes, also, it is true that the suppres- 
 sion is followed by no bad consequences, and the health of the woman 
 is not at all affected by it, whether the discharges return again fully, 
 whether they disappear entirely, or whether they return in a mode- 
 rate way. 
 
 The treatment of a primary suppression of the lochia consists in 
 the employment of a hot foot-bath with mustard ; in directing the 
 vapour of hot water upon the sexual parts ; in the application of 
 emollient cataplasms to the lower part of the abdomen and to the 
 vulva ; in injections and enemata of the same sort ; and, lastly, in 
 blood-letting from a vein in the foot, the application of leeches to 
 the superior and inner portion of the thighs, or to the inner surface 
 of the labia pudendi, and in cups and blisters to the thighs, and sina- 
 pisms to the feet and legs. In all cases, the state of the patient’s con- 
 stitution will furnish indications that must not be disregarded : thus, 
 in strong women, we ought chiefly to rely upon blood-letting ; in 
 nervous women, we should combine antispasmodics with the mea- 
 sures before pointed out; and in patients of a feeble constitution, 
 where the pulse is not frequent nor the temperature of the skin much 
 elevated, recourse might be had to stimulating and tonic infusions 
 prepared with the periwinkle, the soap- wort, the cane-root, or Vir- 
 ginia snake-root $ but it should not be forgotten that the suppression 
 of the lochia generally tends to the production of most dangerous 
 inflammatory diseases. 
 
 The symptomatic cessation, or diminution of the lochial discharge, 
 that constitutes an immediate consequence of any disease, and which 
 is justly looked upon as a very unfortunate circumstance, ordinarily 
 
652 
 
 LOCHIA. MILK-FEVER. 
 
 requires no treatment beyond that appropriate to the disorder of 
 which the suppression constitutes a sign. It is worthy of remark, 
 however, that a suppression of the lochia is much more frequently 
 a symptomatic than a primary disorder ; that is to say, it is much 
 more commonly the effect than the cause of disorders with which it 
 happens to coincide. 
 
 The immoderate lochial discharge which may serve to reduce a 
 woman to a state of great debility and prostration, and which may 
 happen at any stage of the secretion, requires no other treatment 
 than one applicable to a case of metrorrhagia or leucorrhcea, accord- 
 ingly as the discharge may be sanguineous, serous or puriform. A 
 discharge, of a serous nature, ought to be respected, whenever it 
 coincides with a rapid diminution of a dropsical collection affecting 
 the patient during her pregnancy, for it is then the route which 
 nature employs to evacuate the superabundant serosity that consti- 
 tuted the ascites or anasarca. 
 
 Changes in the colour of the lochia, in their odour and consist- 
 ence, as they are mostly the results of some malady that ought to 
 command- the attention of the practitioner, do not constitute a very 
 important symptom. In some cases, however, the lochia, when 
 already puriform, assume a blackish tint, and acquire a fetid odour, 
 without producing any apparent consequence as to the health of the 
 functions. These changes, which are referable to the decomposition 
 of some clot, or a portion of the placenta that may have been left in 
 the womb, require nothing beyond the use of emollient and cleansing 
 injections into the vagina. 
 
 OF MILK-FEVER. 
 
 Milk-fever is not so much a real disease as a febrile movement 
 requisite to determine the secretion of the milk, in a woman recently 
 brought to bed. 
 
 The development of this fever is announced by shooting pain and 
 aching in the breasts, which become swollen ; a swelling that is often 
 found to extend as far as the axillary glands, so that there are some 
 women who, when thus affected, are unable to bring their arms 
 together, but are obliged to keep them far apart. Yet it is true that 
 there are cases in which the milk-fever comes on without any tension 
 of the breasts, and almost without any febrile action. 
 
 The symptoms that characterize the formation of the milk-secre- 
 tion are generally to be observed about the third day after the birth 
 of the child : in certain cases, as early as the first day, or the second, 
 and even as late as the sixth. The pulse then becomes full and fre- 
 quent ; the temperature rises, the skin becomes dry, the face is 
 flushed, the breasts swell and become painful, the thirst increases, 
 the tongue is covered with a whitish fur, the urine is more scanty, 
 and higher-coloured than usual ; and all these appearances are pre- 
 ceded or attended by a state of general agitation and a headache 
 without rigors. The febrile condition increases by degrees, and 
 
MILK-FEVER. 
 
 653 
 
 goes off, in most instances, in about twenty-four hours, and, in some 
 instances, in the course of six, eight, or twelve hours. 
 
 While the milk-fever lasts, the lochial evacuation diminishes, or is 
 temporarily suspended; but a diminution or a suppression of the 
 flow ought not to excite any solicitude, for they are occasioned by 
 the febrile action that brings about the milk secretion. In most cases, 
 calm is restored after the flowing of an abundant perspiration, and 
 the lochia then become as free as they were previously to the attack. 
 
 Women who nurse their children have little or no milk-fever, espe- 
 cially when they take care to let the child suck very soon after its 
 birth. The same may be correctly stated of those women who per^ 
 spire very copiously, who are ordinarily free from the attack of this 
 form of fever, or, at least, who generally have it very slightly. 
 
 The treatment of a milk-fever ought,* in some sense, to be purely 
 hygienic. When the secretion of milk is very considerable, and the 
 woman does not give suck, she ought to be subjected to a severe 
 diet, to take demulcent and slightly diaphoretic drinks, such as infu- 
 sion of mallows and linden, of violets and orange flowers, with gum- 
 arabic. Should the fever prove to be too violent, it might be 
 moderated by a small bleeding at the arm, yet, in general, it requires 
 merely the care above indicated. 
 
 In cases where the breasts are too much swollen and painful, 
 attempts should be made to empty them by allowing the infant to 
 draw them, and where the woman does not nurse, by rubbing them 
 gently with warm olive-oil, and covering them with fine tow, or a 
 lawn handkerchief, kept on with a soft napkin. Care ought to be 
 taken to change the dressing as soon as it becomes moistened. The 
 flow of the lochia ought, at the same time, to be promoted by means 
 of fumigations to the vagina, or, what is still preferable, with emol- 
 lient narcotic injections, prepared with mallows and poppy-heads. 
 These measures ought to be put in force, especially where the lochia 
 is suspended, either before or subsequently to the coming of the milk. 
 
 After the milk-fever, the tongue is white, yellow or greenish, the 
 mouth bitter and clammy. Should there be, likewise, a loss of appe- 
 tite, the medical adviser might advantageously order a mild purgative 
 dose, such as manna, castor oil, Seidlitz water, sulphate or phosphate 
 of soda, and even the sulphate of potash, which, whether well or 
 ill founded, enjoys a very long-standing reputation as an antilactic 
 article. In cases where the tongue is red and lanceolate, with indu- 
 bitable signs of a gastro-enteritis, the action of these purgatives will 
 always be noxious, and they should be therefore proscribed. In like 
 manner, they are not of any value where the strength and appetite 
 return rapidiy and manifestly. 
 
 The other kinds of supposed antilactic articles, such as the peri- 
 winkle, which quickens the pulse and weakens the stomach, ought 
 to be forbidden; nevertheless, we might allow the patient to take a 
 tisan of the arundo donax, provided she have some confidence in its 
 powers, for its action is nearly insignificant and inoffensive. 
 
654 
 
 PUERPERAL FEVER. 
 
 OF PUERPERAL PERITONITIS. 
 
 This inflammation of the peritoneum differs from other kinds of 
 peritonitis only in the circumstance of its following the delivery of 
 the woman. 
 
 Notwithstanding this malady must have existed in all ages of the 
 world, it seems to have been wholly unknown until the time of Hip- 
 pocrates. That illustrious observer, in the second book of his trea- 
 tise on the diseases of women, has presented us with a pretty good 
 description of it, which proves that the principal characteristics of the 
 malady had not escaped his notice, but that he regarded it as an 
 acute affection of the uterus, brought on by the suppression of the 
 lochia, or by a laborious labour. This opinion of the Coan sage 
 was reproduced by Galen, Celsus, Aetius, Aretseus, Pouteau, Bos- 
 quillon, and Lamothe. 
 
 Chaussier, Messrs. Cayol. Chomel, Velpeau, and many other 
 writers justly suppose that puerperal peritonitis is very often a con- 
 secutive of metritis. Weikard and Horn, agreeably to the doc- 
 trines of Brown, look upon the disorder which, by Strother and 
 Willis, was described under the vague title of puerperal fever, as 
 being in its nature essentially asthenic. Vigaroux, Etmuller, Puzos, 
 Levret, and especially Doublet, having noticed that the lochia were 
 not suppressed in all cases, while, according to their view, the milk 
 secretion is invariably arrested, came to the conclusion that a perito- 
 nitis is merely a metastasis of milk to the abdominal cavity. Mi- 
 chaelis endeavours to prove, in his memoir, published about the 
 beginning of the present century, that both the cause and the gravity 
 of the disease depend solely, in recently-delivered women, upon the 
 accumulation of the lactic principle in the mass of the blood. 
 
 There is no doubt, at present, that nearly all the cases designated 
 by authors, under the appellations of puerperal fever, inflammation 
 of' the bowels, metastasis of the lochia, or metastasis of milk to the 
 abdominal cavity, were real cases of puerperal peritonitis, a denomi- 
 nation under which modern physicians designate an inflammation of 
 the peritoneum coming on after parturition. 
 
 A very great number of recorded cases go to prove, that although 
 this disorder is often simple, yet in many instances it is complicated 
 with metritis or with uterine phlebitis ; that is to say, the peritoneal 
 inflammation is a secondary occurrence, and takes place only by 
 contiguity or continuity. We shall, hereafter, point out the means 
 of distinguishing a simple peritonitis from an attack of metro- 
 peritonitis. 
 
 The causes of peritonitis ought to be divided into predisponent and 
 occasional causes; among the former ought to be classed the state of 
 pregnancy, errors in diet, a sedentary life, domestic anxiety, too 
 exciting a diet, or diet of a bad quality; prolonged inhabitation of a 
 dark, damp, cold house, where the air does not circulate well; the 
 abuses of coitus; lastly, a plethoric temperament, a very great mo- 
 bility of the vascular system; a delicate constitution, which has been 
 weakened and rendered easily liable to become disordered, are also 
 
PUERPERAL FEVER. 
 
 655 
 
 looked upon as predisponent causes of the disease at present under 
 consideration. 
 
 Among the determining causes we must place the energetic contrac- 
 tions of the muscles of the abdomen, concurring in the power to expel 
 the foetus, the action of cold, the influence of a tampon made use of 
 in arresting haemorrhage after delivery; a long and difficult labour; 
 an extreme degree of confidence inspired by a happy delivery ; the 
 remaining of the lochia within the womb for too long a period ; too 
 much company and conversation soon after delivery ; imprudence in 
 rising too soon from bed after the birth of the child, and engaging in 
 any exercise too soon, and before the womb can have resumed its 
 ordinary position and recovered its non-gravid volume ; moral im- 
 pressions of too severe a character, which are the more dangerous 
 on account of the augmented impressibility of the newly-delivered 
 woman; the too sudden suppression of some usual evacuation, as the 
 insensible perspiration, the lochia or the milk ; cold applied to the 
 whole body, and chiefly to the breasts, the vulva, and the abdominal 
 muscles. It should be added, that the impression of cold and damp 
 is one of the most frequent causes, and that, according to the cases 
 published by Delaroche, more women die in child-bed in winter 
 than in the warm seasons. Savary assures us, that puerperal peri- 
 tonitis is a very rare disease in Egypt; and Dr. Solly says, that he 
 saw no case of it in South America, where he resided for about 
 three years. 
 
 Puerperal fever sometimes becomes epidemic in hospitals devoted 
 to lying-in women. Although the causes that give rise to it are per- 
 haps unknown, they appear to be absolutely local, and to be con- 
 nected with the influence of a vitiated atmosphere, for, in general, 
 such epidemics do not extend among females in the same city, nor 
 among women inhabiting private houses, or among such as are in 
 other hospitals. Several epidemics of this sort have occurred at 
 Paris, at the Hotel Dieu, at the Maison d’Accouchements, and also 
 at the Hopital de PEcole. Broussais says, he met with an endemic 
 peritonitis in certain parts of Holland and Belgium. 
 
 [The history of the epidemic at Aberdeen, by Gordon, and that at Leeds, 
 by Hey, as well as the Sunderland epidemic, described by Dr. Armstrong, 
 are very conclusive as to the power of the malady over patients in private 
 houses. It is well known, also, that puerperal fever has been epidemic in 
 various parts of the United States for the last three or four years. — M.] 
 
 The symptoms of puerperal peritonitis are pretty much the same 
 as those of other forms of the malady, for they only differ as to the 
 suppression of the milk and the lochia; although this pathognomonic 
 symptom is not invariably present, and may, indeed, occur in other 
 maladies coming on not long after delivery. Indeed, the lochia may 
 continue to flow in abundance, and we, as well as White, Leake, 
 Chaussier, Dubois, Deneux and others, have seen the breasts con- 
 tinue swollen and full of milk up to the last moments of existence. 
 
 The invasion of puerperal peritonitis generally takes place from 
 
656 
 
 PUERPERAL FEVER. 
 
 the second to the 5th day after the accouchement ; it may, however, 
 come on at a much later period, as the tenth, fifteenth or twentieth 
 day. Pinel speaks of a nurse, who was seized with it at the end of 
 her thirteenth month. It may also happen, that the disorder comes 
 on immediately after the termination of the labour; we saw a patient 
 who gave birth to twin children, in whom the attack of the malady 
 was made several hours previously to the commencement of labour. 
 Be these circumstances as they may, an assault of puerperal fever is 
 announced by a general sense of lassitude, uneasiness and weak- 
 ness; by headache, vague horripilation, intermittent chills, attended 
 with tremors and numbness of the limbs, and followed by that 
 burning and internal heat, which is almost always felt in inflamma- 
 tion of the serous membranes. These signs are soon followed by 
 pains in the abdomen, that are more or less sharp, and that are felt 
 at various points in the belly, which will not tolerate the least pres- 
 sure ; the patient compares her pain to a feeling of twisting, burning 
 and laceration, which is increased by motion, coughing, hiccough, 
 sneezing, and especially by the action of vomiting, and any motion 
 that disturbs the relations of the peritoneum. The patient lies on 
 the back, and likes to have the head weil raised on pillows, and 
 instinctively seeks to have the knees drawn up so as to relax all the 
 muscles. All these pains are attended with ardent heat, excessive 
 thirst, cephalalgia, and piercing and broken cries; the respiration is 
 short, laborious, plaintive, costal, incomplete ; hiccough is inevitable, 
 provided the portion of peritoneum that invests the diaphragm is 
 affected with inflammation ; the skin is sometimes moist, but more 
 generally it is dry ; all these symptoms coincide with diarrhoea, or 
 constipation, with vomiting, with meteorismus, tumefaction, and ten- 
 sion, greater or less, of the belly, and frequently with a contraction 
 of the anus. The countenance, which is altered, pale, and down- 
 cast, becomes covered with a cold sweat, and always bears the im- 
 press of suffering. All the features seem to be drawn upwards, and 
 towards the median line, and give the true type of the facies desig- 
 nated under the title, [face grippe,) contracted countenance. The 
 lochia becomes suppressed or diminish in quantity, and the flaccid and 
 occasionally painful mammae contain either no milk or but a very 
 small quantity of it; the pulse is small, contracted, frequent, concen- 
 trated, and often irregular and intermittent ; however, in some rare 
 cases, the circulation is almost undisturbed, and becomes accelerated 
 only on the approach of dissolution. The urine is red, turbid, 
 scanty, and comes off with smarting pain. The pituitary membrane 
 is dry and blackish; the tongue, after becoming fuliginous, pointed, 
 tremulous and fissured, loses its normal characters of form and colour. 
 The mental faculties frequently remain sound until the death of the 
 patient; but in almost all the patients we observe a feeling of con- 
 sternation, discouragement and moroseness, and sometimes delirium, 
 extreme agitation, convulsions and subsultus of the tendons. In 
 fine, the eye, whose mucous membrane is often observed to be dry 
 and brownish, with the pupil gradually dilating, does, in some cases, 
 exhibit the appearance of death, and remains motionless, and some- 
 
PUERPERAL FEVER. 
 
 657 
 
 times upturned. Should all the symptoms here enumerated, when 
 taken separately, not characterize a case of peritonitis, the physician 
 should found his judgment only upon the whole of them together; 
 and he should never forget this precept of the father of medicine, 
 “ Non ex uno signo,sed ex concursu omnium 
 
 In the progress and termination of puerperal peritonitis there is 
 great variety. Yet it mostly runs through its periods with rapidity, 
 and in some instances is so intense, as to carry off the victim in two 
 or three days. It is true, however, that in some cases it is protracted 
 through a period of from, five to ten or even twelve days, and has 
 even been known to last beyond the fourteenth day. 
 
 The disease may terminate in resolution, suppuration, or gangrene, 
 or it may pass into a chronic state, [he ought to have added the termi- 
 nation by adhesion. — M.] The termination by resolution, which is 
 the rarest, the most favourable, and, consequently, the most desirable, 
 is announced about the fourth day or up to the sixth, by diminution of 
 the pains and other symptoms, by softness, slowness and fulness of the 
 pulse, by re-establishment of the lochia, and of the secretion of milk, 
 
 . and by the ability of the patient to lie with ease either on the back 
 or side. 
 
 The termination by suppuration, which is one of the most com- 
 mon, and, unfortunately, too often disastrous results of the disease, 
 occurs where the pain and tension of the belly become less, where 
 the pulse, though still frequent, becomes soft ; where the patient has 
 slight irregular chills, with coldness of the extremities ; and, lastly, 
 where there comes on a feeling of weight in the hypogaster. No 
 doubt as to the existence of fluid remains, when it escapes through 
 some opening, or when its fluctuation becomes evident through the 
 parietes of the abdomen. 
 
 The termination in gangrene, which is the rarest, and which in- 
 volves the inevitable death of the patient, may be suspected where 
 the sensation becomes dull, where the pains cease suddenly, where 
 the abdomen becomes smaller, though the discharges be not rein- 
 stated, and lastly, where a sense of coldness takes the place of the 
 burning heat, while the pulse at the same time grows weak and inter- 
 mittent, and the features become more decidedly altered. Attacks of 
 vomiting come on, attended with delirium ; the sphincters relax, and 
 admit of the escape of insufferably fetid matter, accompanied by a 
 treacherous calm, in the midst of which the patient expires. 
 
 Where an attack of peritonitis does not increase in violence, but 
 yet continues to prevail, it passes into a chronical form. This is a 
 sort of imperfect termination, which may be known by the following 
 signs : the abdomen continues painful to the touch, and somewhat 
 tumid, or else it becomes more and more tympanitic. Sometimes 
 there are intervals of calm, which lead to the supposition that the 
 cure is at hand; but the pain, nausea and vomiting recur from time 
 to time ; the loss of flesh, and emaciation, become extreme ; at length 
 a colliquative diarrhoea comes on, attended with a low continued 
 fever, with consumption and marasmus ; the effusion goes on, and 
 42 
 
658 
 
 PUERPERAL FEVER. 
 
 the patient becomes gradually extinct. In fine, cases are to be 
 observed where dropsy, which often becomes general dropsy, is de- 
 veloped, and sometimes, towards the close, the disease becomes exas- 
 perated, and again assumes the acute character. 
 
 We ought to observe, likewise, that a chronic peritonitis may 
 manifest itself upon a lying-in, without being preceded by any acute 
 symptoms; in such a case, it is evolved slowly and insensibly; the 
 abdomen is painful only upon pressure, or when startled by some 
 considerable shock. However, there are cases where the patient 
 suffers fixed pain, attended with heat, elevation of the pulse, which 
 is accelerated, especially towards evening. In fine, she has dyspnoea 
 and cough, particularly when lying down. Under such circum- 
 stances, there is reason to suspect that effusion is taking place in the 
 abdomen. 
 
 The diagnosis of puerperal fever is, beyond contradiction, the most 
 important item in its history. The disease may be distinguished 
 from metritis, in respect that in the latter the pain is dull, gravative, 
 and confined to a small space in the hypogastrium. Where this is 
 the case at first, yet the pain afterwards extends over the whole sur- 
 face of the abdomen, the metritis is complicated with peritonitis; the 
 interior of the vagina communicates to the finger, as it does in metri- 
 tis, the sensation of an acrid and burning heat ; the os tineas is swol- 
 len, tense and very sensitive. A case of peritonitis may, likewise, be 
 distinguished from one of uterine phlebitis, which often complicates 
 it, by the acuteness of the pains, and by their extending to all parts 
 of the abdominal cavity. (Edema of the lower limbs, and especially 
 a considerable development of the external and superficial veins of 
 the abdomen, are signs that best characterize the case of uterine 
 phlebitis. 
 
 The prognosis of puerperal peritonitis generally leaves little to 
 hope for; yet, notwithstanding the dangers to which it exposes the 
 patient, it may be considered as favourable, where the volume of the 
 belly grows less and less, where the lochial discharge returns, where 
 the secretion of the milk is restored, and, lastly, where some of the 
 symptoms are absent, where the pain becomes less acute, where it is 
 felt over a smaller extent of surface, and where the pulse loses its 
 frequency. In general, the disease is the more dangerous as the 
 inflammation is more extensive, and as the period of its development 
 approximates to the moment of labour. It is always mortal when it 
 commences before the pains of parturition, and, particularly, when 
 the female has a twin pregnancy. The prognosis again is generally 
 favourable, if the affection present no remarkable sympathetic phe- 
 nomenon, for a prompt and energetic treatment usually arrests its pro- 
 gress. In any case, it is difficult to make a positive prognosis before 
 the fifth, eighth or tenth day of the disease, since before that period 
 we cannot ascertain its probable course or duration. As to the prog- 
 nosis of chronic peritonitis, it is always unfavourable, in consequence 
 of the disorganizations which it occasions ; nevertheless, cases have 
 been observed which prove that it may be cured; but then its true 
 character has been recognized early, and moreover, it is of a simple 
 
PUERrERAL FEVER. 
 
 659 
 
 form, without complication, and without considerable effusion ; and 
 if fever exists, it is accompanied by hectic phenomena. 
 
 The anatomical characters of puerperal peritonitis are the follow- 
 ing : if the female have died from a very. acute attack, one severe 
 enough to destroy life in thirty-six or forty- eight hours, which is rare, 
 the serous membrane often presents no trace of alteration, either in 
 its colour or organization. The peritoneum may even seem to be 
 entirely healthy, or to be merely slightly dry and red ; but when 
 death has been less sudden and prompt, that is to say, when it has 
 not occurred until the third or fifth day, the intestines are retracted 
 upon themselves ; the vessels which ramify upon the peritoneum are 
 red and congested, particularly at the points where the inflammation 
 has been most active. Non-organized false membranes and small ab- 
 scesses and collections of serum are sometimes met with in the uterus, 
 broad ligaments, Fallopian tubes and ovaries. Often, also, the cellu- 
 lar layer which unites the peritoneum to the abdominal walls and 
 viscera is distended by a gelatinous fluid and by a limpid, thick, or 
 reddish and more or less abundant serosity, in such a way as com- 
 pletely to isolate the serous membrane. Lastly, in some cases, arc 
 found lactiform collections, in which float whitish flocculi, resembling 
 whey that has not been strained. It was the colour and milky 
 appearance of this fluid, indeed, which caused Willis, Puzos, Levret, 
 Doublet, and some others, to fall into the error of regarding these 
 collections as the result of a deviation and metastasis of milk into the 
 peritoneal cavity. They supposed that the lactescent urine and 
 whitish matters which some women, affected with peritonitis, pass 
 by stool, must have come from the same source. 
 
 In chronic peritonitis, the congested membrane is thickened and dot- 
 ted over with whitish granulations; the intestines are glued together, 
 as it were, and united so as to form a mass, and, between the folds 
 of the peritoneum is found a yellowish, muddy, purulent and green- 
 ish fluid, holding fragments of false membrane in suspension. Lastly, 
 in some cases the peritoneum has a lardaceous and cancerous appear- 
 ance, and the inter-peritoneal tissue of the epiploon is often the seat 
 of ulcerations more or less numerous. 
 
 The prophylactic treatment of peritonitis consists in removing 
 recently-delivered women from the influence of the causes which 
 produce it. Those, for example, who are deprived of the happiness 
 of nursing their own children, ought to be subjected to a rigid diet ; 
 they should avoid, as much as possible, the visits of friends, cold, 
 excessive heat, noise, odours, and we should endeavour to prevent 
 the vivid emotions of the soul, which make an impression the more 
 unfavourable to women in childbed, because their nervous mobility 
 is at that time greatly augmented. Lastly, the disease may often be 
 prevented by advising women to suckle the child. 
 
 The curative treatment of this acute disease ought to be the more 
 prompt, energetic and skilfully conducted, because its symptoms are 
 formidable, its. progress rapid, and its clanger always great. The 
 treatment ought, therefore, to be essentially antiphlogistic, and to 
 consist, first, of a large bleeding, to be repeated more or less fre- 
 
660 
 
 PUERPERAL FEVER. 
 
 quently, according to the intensity of the inflammation, the hardness 
 of the pulse, the pathological sympathies which occur, and the 
 strength of the patient. This first indication fulfilled, there should 
 be applied to the abdomen, at one, two, or three different times, from 
 forty to one hundred and fifty leeches, according to the constitution 
 of the patient and the violence of the disease. Leeches to the vulva 
 are likewise very useful in relieving the engorgement of the uterus 
 and recalling the lochia ; but it is necessary, in all cases, to precede 
 their application by one or two large bleedings at the arm. It is by 
 the energetic employment of these means especially, that we must 
 endeavour to regulate the disease at its very beginning, because, in 
 a few days, sanguine emissions are no longer so efficacious, and when 
 there is complete prostration of the strength, may even augment 
 this condition and render the death of the patient more rapid. We 
 must resort, at the same time, to emollient and narcotic fomentations, 
 to mucilaginous, acidulated and tepid drinks, and, lastly, to the most 
 rigorous diet. The iced applications and aspersions, and the cold 
 baths recommended by Van Swieten and Broussais, seem to us to 
 be dangerous, and likely to produce 'gangrene. Warm baths are 
 rarely endowed with the utility attributed to them, and their action 
 often turns against the patient. In fact, the weight of the liquid, the 
 impression of the cold, the painful position and the displacement 
 which they require, seem to us motives sufficient for their rejection. 
 Enemata of decoction of marsh-mallow, of flax-seed or of poppy- 
 heads, may assist the treatment ; but they ought not to be used in the 
 first days of the disease, as they increase the pain, and the greatest care 
 should be taken, in administering them, not to disturb the patient, and 
 to inject only a small quantity into the large intestine at once; that is 
 to say, to use only a fourth, or, at most, half of the usual quantity. 
 
 Should the patient be so irritable that the drinks, even when taken 
 in very small quantity, are rejected by vomiting, we must, in order 
 to avoid, as much as possible, the violent succussions so produced, 
 allay the thirst by means of slices of orange, or by a few spoonfuls 
 of Seltzer water. It is well, also, to promote, as much as possible, 
 the secretions from the mucous membranes, by means of warm sudo- 
 rific drinks ; and we should endeavour, in particular, to excite the 
 action of the skin by vapour-baths, which were successfully em- 
 ployed by Chaussier. 
 
 The injurious effects of epispastics applied to the abdomen, in the 
 acute stage of peritonitis, should lead us to avoid their use ; they 
 should be employed only when the disease has become chronic, or in 
 the second stage of the acute form. 
 
 To remove the constipation, we may resort to the use of enemata 
 of oil, or to mild laxatives ; especially, after the example of Chaus- 
 sier, to castor oil, mixed with equal parts of syrup of succory or 
 rhubarb. The use of drastic purgatives, recommended by the Eng- 
 lish writers, ought to be proscribed in all cases ; they, however, 
 employ, with advantage, calomel in divided doses. 
 
 The use of emetics, principally ipecacuanha in emetic doses, re- 
 commended by Doublet and Doulcet, can be beneficial ouly during 
 
PUERPERAL FEVER. 
 
 661 
 
 the earliest stages of the disease ; given later, they aggravate the symp- 
 toms by the efforts at vomiting which they occasion. The method 
 of the above physicians consisted in giving, at the appearance of the 
 earliest symptoms, twelve grains of ipecacuanha in two doses, and 
 repeating the emetic several times, according to the obstinacy of the 
 case. We ought to remark, that the success of this mode of treatment 
 has not been proved, and that most of the physicians of the present 
 day have renounced it. 
 
 We have still to speak of a most valuable therapeutical agent, to 
 wit, mercury, employed first by Armstrong, Vandeusande, and, more 
 recently, by Professor Velpeau, who has shown all the advantages 
 of frictions of the abdomen with mercurial ointment in the proportion 
 of from one to two drachms, repeated every two or three hours.* 
 Eight or ten grains of calomel, daily, may be given at the same time, 
 while continuing, with great exactness, the mercurial frictions, up to 
 the disappearance of the morbid symptoms, which generally diminish 
 when the salivation begins to be established. 
 
 The spirits of turpentine also has been recommended, both inter- 
 nally and in the form of enemata, by Douglas Kinneir and Mayer. 
 It may be prescribed in mixture, prepared in the following manner: 
 
 Take Spirits of Turpentine, an ounce and a half; Narbonne honey, two drachms; 
 water, two ounces. One-third to be taken at intervals of two hours. 
 
 When peritonitis terminates by resolution, the physician has merely 
 to watch the disease and encourage the favourable actions which 
 may tend to make their appearance. In the termination by suppu- 
 ration, the patient is destined to certain death, unless, what is unfor- 
 tunately very rare, the pus escapes externally. Therefore, as soon 
 as fluctuation becomes evident, we should endeavour to imitate 
 nature, by performing the operation of paracentesis. Again, when 
 the disease passes into the chronic form, the employment of leeches, 
 of rubefacients, of dry frictions to the skin, of vesicatories to the 
 thighs and abdomen, of mercurial frictions, and of baths of different 
 kinds, may assist in the treatment, and bring about a cure, which. is 
 rare, but not always above the resources of the art. When the 
 serous effusion becomes considerable, diuretics ought to be prescribed, 
 and tapping should be performed at an early period, if the fluid is 
 not absorbed. It is well to add that, in cases of acute peritonitis, we 
 may assist the flow of milk in the breasts by keeping them warm, by 
 covering them with cups, and especially by frequent drawing. We 
 might also endeavour to remove the meteorism, by means of a large 
 gum-elastic catheter, kept a longer or shorter time in the rectum, so 
 as to give issue to the gases that distend the intestines. 
 
 OF UTERINE PHLEBITIS. 
 
 Of all the diseases which occur after labour, uterine phlebitis is 
 certainly one of the most frequent and most dangerous. Obscure in 
 its symptoms, insidious in its progress and complications, it was mis- 
 
 * Revue Medicate, January, 1S37. 
 
662 
 
 UTERINE PHLEBITIS. 
 
 understood by the ancients, who, being destitute of the aid of patho- 
 logical anatomy, could have only uncertain ideas as to the nature of 
 the affection. Though partially understood by Leake, Chaussier, 
 Schwilgai, Clarke, Wilson, Meckel, M. Ribes, and Husson, it had 
 nearly been forgotten when Dance, and, after him, M. Tonnele, 
 recalled the attention of physicians to it by publishing several cases, 
 which render its history complete. Since then, all the cases have 
 been more than confirmed, by the labours of MM. Breschet, Andral, 
 Louis, Cruveilhier, Perreau, Garget of Pampeluna, and some others. 
 
 Amongst the causes of uterine phlebitis, should be ranked a long 
 and difficult labour, during the expulsion of the foetus, and certain 
 individual predispositions; long-continued pressure of the head of the 
 child against the neck of the uterus ; cold and humid temperature, 
 especially during winter ; crowded lying-in wards ; lastly, tractions 
 exerted upon the placenta, immediately after delivery, in such a way 
 that the uterine veins, separated too suddenly from the parts with 
 which they are in contact, remain patulous and in direct communica- 
 tion with an inflamed surface, with the lochia, or with clots of decom- 
 posed blood, and sometimes with putrefied and softened portions of 
 placenta. In all these cases, the uterine veins are nearly in the same 
 circumstances as when they are near an ill-conditioned wound, and 
 consequently in a state to invite inflammation. 
 
 To these causes of uterine phlebitis, we will add the injection of 
 iced and astringent fluids, into the cavity of the uterus, to arrest a 
 dangerous hsemorrhage ; suppression of the milk ; compression of the 
 hypogastric region ; indulgence in improper diet ; premature exer- 
 cise ; the excessive susceptibility of recently-delivered women ; and, 
 lastly, any imprudence committed by them, after delivery, and parti- 
 cularly latent inflammation of the mucous tissue, or of the proper 
 tissue of the gestative organs. 
 
 Progress and seat. Inflammation of the veins of the uterus 
 generally commences at the orifices of the uterine sinuses, exposed 
 by the separation of the placenta, as an amputation exposes the veins 
 of one of the limbs. The inflammation soon extends to the veins, 
 into which the uterine sinuses empty, which, by contiguity, transmit 
 the inflammation to the proper tissue of the uterus, which constitutes 
 a parenchymatous uterine phlebitis, complicated with metritis. We 
 ought to remark, however, that the last affection may precede the 
 phlebitis, and that this may extend beyond the limits of the walls of 
 the uterus, follow the direction of the uterine veins furnished by the 
 hypogastrics, and often extend along the ovarian veins to the inferior 
 cava. It is proper to add, moreover, that the phlebitis may exist 
 upon one side of the uterus only, and that it is generally the right 
 side which is affected, probably because the insertion of the placenta 
 takes place more frequently on this side than on the left. 
 
 The symptoms of uterine phlebitis vary according to the stage of 
 the disease; in the first stage, the disease, which is purely local, 
 ordinarily manifests itself from the second to the third day by the * 
 symptoms of metritis, that is to say, by irregular rigors, by constant 
 feeling of weight in the lumbar region, and by pain confined to the 
 
UTERINE PHLEBITIS. 
 
 663 
 
 hypogastrium and iliac fossse, often on one side only, which is that to 
 which the insertion of the placenta upon the womb corresponds. To 
 these symptoms must be added sudden suppression of the lochia, 
 shrinking of the breasts, smallness and frequency of the pulse, dry- 
 ness of the skin, redness and dryness of the tongue, engorgement of 
 the uterine tumour, which augments, instead of diminishing, as the 
 inflammation advances ; lastly, a discharge of puriform, thick, and 
 generally fetid matters from the vulva ; tumefaction and pain of the 
 cervix uteri, and sensibility of the hypogastrium, which is more acute 
 than that which is usually present after delivery. 
 
 The second stage, which is that in which suppuration takes place, 
 is marked by diminution of the local pain and by the development in 
 the digestive tube of gaseous products; lastly, the third stage, marked 
 by the absorption of pus into the torrent of the circulation, presents 
 general symptoms of a more dangerous character; for there is at 
 that time excited imagination, and generally delirium; the skin as- 
 sumes an earthy hue; the eyes are sunken, and the pupils dilated; 
 the face is pinched and covered with a cold sweat, and, moreover, 
 there occurs a sort of insensibility, which renders the patient uncon- 
 scious of pain ; sometimes the limbs become the seat of sudden swell- 
 ing, of evident fluctuation and painful induration, bearing all the 
 marks of a deeply-seated abscess. Later in the disease, all the symp- 
 toms become aggravated, the extremities grow cold, the pulse more 
 frequent and compressible, and to these various symptoms are added 
 loquacity, a constant sardonic laugh, picking at the bed-clothes, sin- 
 gultus, fainting, and death, which terminates the scene. 
 
 The diagnosis of phlebitis in the first stage differs but little from 
 that of metritis, and it is by the symptoms which denote the introduc- 
 tion of pus into the circulation alone, that the existence of phlebitis 
 can be demonstrated. The extension of the disease to the large 
 venous trunks may be inferred, when oedema of the lower extremi- 
 ties, and a peculiar pufliness about the pelvis, exist. Again, there is 
 a sign of considerable value in the diagnosis of phlebitis, which is the 
 development of the external and superficial veins of the abdominal 
 walls ; moreover, venous inflammation is distinguished from perito- 
 nitis, by the acuteness of the pains in the latter disease, and especially 
 by their extension to the whole abdominal cavity. To conclude, in 
 phlebitis the delirium is greater, and the rigors which precede suppu- 
 ration in the uterine veins are more marked, and return periodically, 
 as in an attack of pernicious fever, which is not the case in perito- 
 nitis. 
 
 The prognosis of the disease under consideration is as uncertain 
 as its duration; nevertheless, it may be regarded in general as being 
 very unfavourable, though in many cases we might arrest its pro- 
 gress at first with as much facility as in ordinary phlebitis. But the 
 uncertainty of the diagnosis in the early stage, and especially the 
 failure of the patients or their friends to ask for advice, render the 
 prognosis almost always unfavourable. In general, when the inflam- 
 mation is confined to the veins of the uterine walls, we may hope for 
 much from the resources of the art and the efforts of nature ; but 
 
f 64 
 
 UTERINE PHLEBITIS. 
 
 when it extends to the spermatic veins, purulent absorption and its 
 consequences are much to be apprehended. This phlegmasia, in a 
 word, is always more dangerous than simple metritis. It usually 
 terminates during or towards the end of the third week ; but it may 
 also last a much longer time, and prove fatal four months after its 
 commencement, as is proved by the tenth case reported in the essay 
 of M . Dance. 
 
 The cadaveric lesions vary according to the duration of the 
 disease. When it has lasted but a short time, the point of inser- 
 tion of the placenta is red and covered with a blackish putrescent 
 matter ; the uterus is always larger than it ought to be at the time 
 which has elapsed since the delivery, and the uterine veins are pustu- 
 lous and contain more or less pus. If the phlebitis has existed for 
 some time, the tissue of the uterus is softened, and when cut into and 
 squeezed, drops of pus are seen to exude ; pus is often found, also, 
 in the spermatic, and in the external and internal iliac veins, and 
 sometimes the cavity of the abdomen is the seat of a sero-purulent 
 effusion, and the muscular interstices of the superior and inferior ex- 
 tremities and the articulations even, likewise present extensive puru- 
 lent deposits. Lastly, the brain is more or less congested, and in 
 some cases the spleen, liver and lungs are also involved in the suppu- 
 ration. 
 
 The treatment of phlebitis must vary according as the disease is 
 in the first period of the symptoms or in the two others, to wit, in 
 that of suppuration or of the passage of pus into the torrent of the 
 circulation. 
 
 The treatment of the first period consists in the use of general 
 bleedings, in the application of leeches to the vulva, to the inside 
 of the thighs, and to the anus, and in the energetic employment of 
 all the antiphlogistics, such as frequently-repeated emollient injec- 
 tions, baths, poultices sprinkled with laudanum for the hypogastrium, 
 rigorous diet, demulcent and sedative drinks and mixtures, and, last- 
 ly, the withdrawal of all causes which might irritate or disturb the 
 patient. 
 
 During the period of suppuration even, general bleeding is some- 
 times useful ; but it is the administration of tartar emetic and ipeca- 
 cuanha in large doses, which promises the best chances of success. 
 We once had occasion to observe the good effects of tartar emetic, 
 as MM. Nauche and Nouat had done before us. To these means 
 might be added vaginal injections of some solution charged with 
 chlorine, and if symptoms of purulent absorption were present, it 
 would, perhaps, be proper to attempt transfusion of the same liquid 
 into the veins in the neighbourhood of the affected part, in order to 
 endeavour to snatch the patient from certain death. We might like- 
 wise resort to the employment of powerful revellents, to sinapisms, 
 to blisters applied to the thighs and legs, or to sudorifics and all the 
 excitants of the cutaneous system, especially to the acetate of ammo- 
 nia, in the dose of five or six drops in a cup of tisan ; it would be 
 proper to associate with these means remedies having a sedative 
 action upon the nervous system, as, for instance, camphor, assafoetida, 
 
PUERPERAL PHLEBITIS. 
 
 665 
 
 cinchona or any of the bitters ; lastly, if the uterine phlebitis were 
 complicated, the treatment should be modified according to the nature 
 of the complications. It is well to add, moreover, that, notwithstand- 
 ing the prostration and feebleness of the pulse, general bleeding may 
 sometimes prove useful, for it has been proved by experiments upon 
 animals, that sanguine evacuations were one of the best means to 
 modify the evil effects of the introduction of putrid matters into the 
 circulation. 
 
 OF OTHER KINDS OF PUERPERAL PHLEBITIS. 
 
 Phlebitis occurring after delivery has also been observed in the 
 hypogastric, external iliac, and primitive iliac veins, in the crurctles 
 and in the inferior cava. The disorder may be known by the swell- 
 ing and pain discovered along the track of the inflamed vein, by the 
 swelling of the adjacent cellular tela, and which in some instances 
 extends over the whole limb ; and likewise by a sensation resembling 
 that produced by feeling a sort of cord running in the direction of the 
 vessel, and which rolls under the finger. The causes of the different 
 kinds of puerperal phlebitis are the same as those that give rise to 
 uterine phlebitis; they are therefore to be treated by like measures, 
 such as general blood-letting, the application of leeches to the hypo- 
 gaster, which should be resorted to immediately upon the appearance 
 of the symptoms, and repeated until the pain ceases ; by emollient 
 cataplasms, and protracted use of the bath, continued as long as three 
 or four hours ; by irrigations into the womb, by means of a* proper 
 syringe, and, finally, by the employment of gentle purgatives. 
 
 [1 have deferred until the present occasion, the addition of any note upor 
 the subject of puerperal fever, and perhaps I might have spared the reader 
 the present addition, were it not that I feel very desirous to place in as clear 
 a light as possible the therapeutical considerations that flow out of the view 
 of these affections which regards them as diseases of an inflammatory type. 
 
 Among the numerous individuals who have made public their opinions, 
 and the experience on which they were founded, great discrepancies are 
 found to exist. One party pushing the use of the most vigorous antiphlo- 
 gistics to the utmost; another recommending their very cautious use, while 
 others seem afraid of them, except under the most guarded limitations. 
 
 So far as I can learn, a discrepancy, equally as great as that among foreign 
 writers, exists in the profession on this side of the Atlantic. The question 
 as to the nature and treatment of childbed fever being a most important one, 
 we believe that we shall confer a benefit upon the public at large, and upon 
 our brethren in particular, by calling their attention anew to the subject. 
 
 So rapid and fatal in their course have been the epidemic and even the 
 sporadic forms of puerperal fever, and so evident and early have been the 
 signs of great prostration, or exhaustion and mortal proclivity of the vital 
 powers, that we have no room for surprise at the tendency of mankind to 
 view them as ataxic or typhous in their very nature ; and so requiring, on 
 
666 
 
 PUERPERAL FEVER. 
 
 that account, a careful avoidance of strong antiphlogistic or debilitating mea- 
 sures. The idea of typhus is inseparably connected, in many minds, with 
 that of great muscular weakness, tremors, dry tongue — with stimulants and 
 cordials, and all the means of rapid reparation. In such persons it is enough 
 to know that to-morrow the patient will be weaker, in order to lead them to 
 obviate that fearful debility to-day by opium and brandy, and an alexipharmic 
 course, and beef tea, &c. <fcc. Dr. Win. Hunter, who saved but one case 
 out of thirty-two, persisted to the last, according to Dr. Mackintosh, in be- 
 ginning the treatment with a generous glass of brandy; and there are many 
 gentlemen who, having repeatedly seen the belly filled with the fluid depo- 
 sits of extensive peritoneal inflammations, and the veins gorged with pus, 
 the product solely of inflammation, still contend that the employment of 
 venesection is very dangerous , and requires great consideration of the con- 
 stitution and habits of the patient, and is to be practised only on the most 
 favourable subjects. Not only are there to be found respectable brethren 
 holding these views, but even of those who preach the opposite doctrines, 
 there are many who, though bold in recommending the lancet to others, yet, 
 in their own practice, stop short of the free use of this measure. 
 
 The mischievous effects of error are continued long after the error itself 
 is overthrown : a man who has been trained, by bad teaching, to look upon 
 a grave disorder as of a typhous nature, and therefore to be treated by stimu- 
 lating means, finds it very difficult to liberate himself from the rules of 
 action imposed by his early prejudices, which continue to bias his practice 
 even long after his judgment has been fully enlightened. 
 
 At the present day, we know that women in childbed are liable to attacks 
 of chills or rigors, followed by pain in the region of the womb, with a very 
 frequent pulse, rising speedily to 120 or 150 beats per minute; and soon 
 after by distension of the abdomen, pain, and other symptoms, which mark 
 the childbed fever. This fever proves fatal to many of the patients attacked 
 with it; and the examinations of the bodies of those who die reveal either 
 extensive inflammation of the peritoneum alone, or of the womb alone, — or 
 of the womb and peritoneum both. In some of the cases the womb is 
 proved to have become gangrenous or softened by inflammation ; and in 
 others, and many of them, its veins, and the veins returning its blood, are 
 greatly inflamed and filled with inflammatory deposits of lymph, or gorged 
 full of pus. Deposits of pus are also, in some of the cases, found in the 
 ligamenta lata, in the womb, in the thorax, or in remote parts of the body; 
 to such extent, indeed, as to have given rise to the idea of a pyogenic or 
 pus-creating fever. The absorbent vessels are also found to be affected in 
 a manner similar to that of the veins. 
 
 Diseases of childbed like these have been noticed from time immemorial 
 by writers of great ability. Faint and imperfect views of their nature, and 
 some approaches to good sense in their treatment, as by Strother, had been 
 obtained, but lost sight of again and again, until a great reformer of doctrine, 
 
GORDON ON PUERPERAL FEVER. 
 
 667 
 
 as regards them, appeared in Scotland. I allude here to Dr. Alexander 
 Gordon, of Aberdeen.* This gentleman, who enjoyed an extensive prac- 
 tice there, and in the country round about it, encountered a severe epidemic 
 of puerperal fever, which, from December, 1789, to March, 1792, prevailed 
 epidemically at and near Aberdeen. The first cases he treated without 
 energy and without success. Taught by woful experience the inadequacy 
 of his method, and enlightened by dissections of a few of the early victims, 
 he adopted a more energetic practice, which was founded on the substantial 
 proofs of inflammation revealed in the dissections. It consisted of free 
 bleeding from the arm, aided by the use of purgative medicines. The re- 
 sult, to use his own language, was as follows : “ When I took away only 
 ten or twelve ounces of blood from my patient, she always died; but when 
 I had the courage to take away twenty or twenty-four ounces at one bleeding, 
 in the beginning of the disease, the patient never failed to recover, as was 
 the case in No. 23, 28,” &c. &c. In another place he says, after citing 
 the results of practice in other countries — “ In my practice, of seventy-seven 
 women who were attacked with puerperal fever, twenty-eight died ; so that 
 very near two-thirds of my patients recovered, which proves that I have 
 been much more successful than any other practitioner. But it will be pro- 
 per to mention that I was too late in being called to many of the cases, and 
 that I had a fair trial only in fifty of the above number: of these fifty, only 
 five died.” 
 
 Dr. Gordon’s volume is small, and is written without arrogance or great 
 pretensions. It is a plain and, doubtless, a candid detail of his concern with 
 that epidemic ; and has so convincing and truthful an air in every page and 
 line, that I cannot imagine any thing more fitted to impress the mind of a 
 reader with the warm and irresistible convictions of the author. Fifty 
 years have elapsed since its publication. It is always quoted or referred to 
 in treatises on the same topic, and still retains its good name. Every medi- 
 cal practitioner ought to read it, and I was almost ready to say that its peru- 
 sal ought to be regarded as indispensably necessary to a right understanding 
 of the history and treatment of puerperal fever. Whatever critics may say 
 as to Dr. Gordon’s performance, and however wofully several eminent 
 writers and practitioners may have erred in their theories and practice, Gor- 
 don will be regarded as the reformer of the therapia of puerperal fever; for 
 it can scarcely be denied that, since his publication, there is a more perfect 
 and understood conviction of the inflammatory character of this disorder, 
 and of the little regard to be paid to the state of the pulse in making np 
 one’s mind as to the necessity for treating it boldly in the first stage. The 
 work, precious as it is, has long been out of print; and I cannot conceal the 
 satisfaction I feel at the fact of its having been placed at a cheap rate in the 
 hands of numerous practitioners in our country. M. Legouais, in his admi- 
 rable and spirited treatise on the subject, pays a just tribute to the merits of 
 
 * Author of the History of the Puerperal Fever of Aberdeen. London, 1795. 8vo. 
 
668 
 
 PUERPERAL FEVER. 
 
 this author; and, as he had the most abundant and fortunate opportunities, 
 by a residence of several years in the Maternite at Paris, to witness the 
 practice and carry out the directions of Chaussier, in the malady, I should 
 conceive that his experience alone, unaided by the fine arguments of his 
 volume, should constitute him a high authority. -When I read Legouais’s 
 excellent work, I am disposed to thank Gordon for it, as I am for every other 
 valuable rule of practice in this most distressing disease. Nothing since 
 Gordon’s work, that I have seen, detracts from his merit by comparison. 
 Few American physicians yet possess it. 
 
 Gordon had not the leisure or the privilege requisite to make very nume- 
 rous and elaborate dissections. This task, however, has been well fulfilled 
 by Robert Lee, of London, in his Treatise on Puerperal Fever and Phle- 
 bitis ; to that degree, indeed, as to leave but little to be desired. All these 
 researches have but added strength and assurance to the conviction derivable 
 from Gordon’s essay. These new and more minute inquiries, which pro- 
 ceed so much farther than he had gone, ought to be fully known by the 
 medical fraternity. But it will not suffice to know only the later productions 
 of the press. I do not believe that the writings of Hey, of A. Baudelocque, 
 of Armstrong, Mackintosh and Lee, studied alone, could carry such a weight 
 of argument to the mind as their perusal after Gordon would do; he is the 
 first in the series, and the others wait on him, and honour themselves by 
 illustrating him. Palmam qui meruit ferat. 
 
 It is obvious that the death of a puerperal patient is, in general, more 
 to be deplored than the ordinary fatalities met with in practice. A wo- 
 man, under these circumstances, appears to have a stronger claim on life; 
 and the disruption of the ties which bind her to society, and to her friends, 
 is more painful, from the new relations just established with them. If the 
 child survives, it suffers, during the long period of infancy, childhood and 
 puberty, the bitter fruits of this terrible privation ; while the breaking up 
 of the domestic establishment, which usually follows that event, appeals, 
 with irresistible power, to the public sympathy. Each family is a little patri- 
 archate, state or kingdom ; and the domestic catastrophe has, within its 
 proper pale, all the importance of a great political overthrow. It is a great 
 misfortune to lose a patient in childbed. 
 
 Those diseases, therefore, which, by their attacks, expose women to an 
 imminent danger of death in childbed, ought to be carefully studied by 
 medical men ; and the physician should be deemed inexcusable, who under- 
 takes the management of them without a due, nay, an unusually careful 
 preparation for the enterprise. He ought not to confide alone in his own 
 keen perceptions at the clinic, nor in the results of his own most imperfect 
 experience. He is obliged, by his vocation, to take up a position which he 
 ought fully to examine and render secure before he enters into the conflict 
 with so dangerous an enemy. 
 
 I refer to the statements in the volume of Robert Lee, for accounts of the 
 
puerperal fever. 
 
 669 
 
 mortality produced in some parts of Great Britain, and on the Continent, 
 by puerperal fever. Those gentlemen who, in our own country, have had 
 occasion to observe it either as an epidemic or sporadic disease, will require 
 no further incitement to a perusal of the volumes recently published by 
 Barrington & Haswell. They will see Gordon’s success, who, by the 
 antiphlogistic treatment, was able to save forty-nine out of seventy-seven 
 cases; or, rather, forty-live out of fifty; Hey, who met with a most en- 
 couraging success by the same method ; and Lee, who lost fifty-nine only 
 out of one hundred and seventy-two cases ; while Armstrong saved all but 
 five of his patients. In bespeaking so great a share of attention to these 
 writers, I do not mean to disparage the opinions of others who act upon 
 the same practical principles. I would refer, with especial satisfaction, to 
 the opinions and experience of Dr. Legouais, of David D. Davies, of Dr. 
 Mackintosh, and .the younger Baudelocque, for confirmation of the views 
 of the gentlemen whose works are now republished in this country. 
 
 Let us briefly consider the nature of the disorders usually comprised 
 under the term childbed fever, after taking a view of the organs and tissues 
 known to be affected in its different varieties and complications. 
 
 In the first place, the gravid womb is a hollow muscle, supplied with a 
 vast profusion of veins, arteries, absorbents and nerves. It would hardly be 
 deemed the stretch of a prurient imagination, to compare it, on account of 
 its great vascularity, to an enormous aneurism by anastomosis, furnished with 
 a sufficient quantity of muscular fibres to reduce back and compress, within 
 safe and natural limits, the luxuriant production of sanguine tissues, of which 
 it is chiefly constituted, and which afford a proper nidus for the germ, which 
 derives from so abundant a source the materials of its new development. Its 
 nerves, abundantly distributed through its substance, and having the most 
 intimate and complex connection with the hypogastric, sacral and renal 
 plexuses, and, indeed, the whole sympathetic system, endow it with a nor- 
 mal and pathological sympathy, coextensive with the body, and a keen 
 sensibility to both intrinsic and extrinsic causes of excitement. 
 
 Under the circumstances of such a physical constitution, we need feel 
 no surprise at observing the extent of disturbing force which, when diseased, 
 it exerts upon the whole economy ; nor, indeed, at the rapid destruction it 
 brings upon the living system, whenever it happens to become the seat of 
 disorganizing inflammation. 
 
 The violent exertions of its contractile power, in labour, are often alone 
 sufficient to rupture or lacerate its tissues, and, a. fortiori , to injure or disease 
 them. It is also liable to be forcibly and injuriously compressed by the 
 tenesmic action of the accessory muscles; to be subject to contusions by the 
 projecting angles of the foetus ; or by the bony sides of the pelvis ; and to 
 be stimulated by the putrid discharges and absorptions incident to its lochial 
 state. It is connected by its vagina in a bond of contiguous sympathies 
 propagated along that canal ; which, even more than itself, is subjected to 
 
670 
 
 PUERPERAL FEVER. 
 
 accidents in the parturient act. It is attached to the ovaries, which seem to 
 carry throughout pregnancy, and even for many months after delivery, an 
 invitation to disease in the uncured remains of the corpora lutea, and the 
 continued travail ovarique, and in which, it is plausibly supposed, the first 
 germs of some of the puerperal inflammations take their rise. It is at- 
 tached by the broad ligaments to the sides of the pelvis. These ligaments 
 are occupied with an abundant cellular tissue, liable to infiltrations and the 
 consequences of pressure and contusion and disruption in labour. It is in- 
 vested by a peritoneum and a vascular membrane, in which superficial in- 
 flammation spreads, with the rapidity of erysipelas, over extended surfaces. 
 This peritoneum is a component part of the womb — it is its investing 
 membrane — its coat; and it is also common, as a tissue, to the whole ali- 
 mentary tube, as well as to the liver, the spleen, thq diaphragm, the bladder, 
 and the abdominal muscles. Inflammation of the intestinal, gastric, or 
 hepatic peritoneum, is also inflammation of those several organs; and, in 
 fine, a peritonitis attacking a childbed patient, which becomes at all exten- 
 sive, radiating from the surface of the womb, soon involves, in its disastrous 
 embrace, every important abdominal viscus. Hence the tympanites; hence 
 the constipation or the diarrhoea ; and hence, at last, and as closing pheno- 
 mena, the nausea, the eructations of incipient gastritis, and the last fatal 
 regurgitation of the puerperal black vomit.* 
 
 But not only are the reproductive organs liable to be attacked by a simple 
 peritonitis destined to extend far and wide ; they are the not unfrequent 
 seats of phlebitis after labour. Nor should this liability excite any wonder 
 or suspicion in the mind. Who that has ever listened to the rush of the 
 blood in the uterine veins, under a powerful contraction of that organ in 
 labour, but must admit that the compression of them in each pain must do 
 violence, in a greater or less degree, to their structure; since, at every return 
 of the pain, a major part of the blood contained in the veins and sinuses of 
 the organ, is hastily and forcibly driven out into collateral vessels, to return 
 as soon as the contraction ceases, and to be expelled, again and again, for 
 the fiftieth or the hundredth time.f 
 
 The placental superficies of the womb, generally the most vascular part 
 of the organ, is frequently left in a state comparable to that of a wounded 
 organ. Portions of the texture are slightly torn, or small shreds of the pla- 
 cental lobules are left adhering, and even the mouths of uterine vessels are, 
 
 * Some of the older writers have been sneered at for supposing that childbed fever 
 was really an inflammation of the viscera of the abdomen. What else does it prove 
 to bel 
 
 j- A stethoscope, or the immediate auscultation of the womb, during a labour pain, 
 gives a very strong perception of the violence and haste with which the blood in the 
 uterine veins is squeezed out from their cavities ; and so great is the apparent rush 
 that the sound is extremely disagreeable; on account, I suppose, of the conviction 
 that it is so violent as to compromise, to a certain extent, the safety of the tissues 
 concerned. 
 
ri’ERPERAL EEVER. 
 
 671 
 
 for days in succession, found discharging the lochial fluids. Under such 
 circumstances, the veins inflame as do the veins in an amputated limb — the 
 frequent cause of death from that surgical operation ; and when inflamed, 
 their mucous, or common membrane, like the mucous surface of the larynx 
 or trachea, soon begins to be covered with inflammatory or plastic exudation; 
 it becomes thickened, and is the seat of a pyogenic irritation. Under such 
 circumstances, the future drainage of the blood thrown into the organ by the 
 arteries is impeded or wholly suspended. The blood injected into the 
 womb through the ovarian and uterine arteries, can no longer freely pass off 
 by the uterine or ovarian veins, whose lining membrane becomes the seat of 
 hasty and plastic inflammation, which either wholly obstructs the tubes, or 
 so far diminishes their calibre as seriously to interfere with the passage 
 through the capillary and even the larger vessels. 
 
 The observations that I have had opportunities to make, have led me to 
 the conclusion, that the process of inflammation, obstruction, and destruction 
 of the lining membrane of veins, may be hurried on with a celerity equal 
 to that of the most rapid croup. But these changes of structure in organs 
 indispensably necessary to the constitution of the womb, imply as a conse- 
 sequence its own inevitable destruction with that of the patient. 
 
 The numerous absorbents of the womb may be viewed under the same 
 light, and as being placed in the same category. 
 
 Besides the above too abundant sources of danger and evil, there is a great 
 liability to inflammation of the womb alone, and not extending beyond its 
 proper texture. This inflammation, like that in some other tissues, reduces 
 the womb almost to the state of a pulp, in certain cases, so that it may be 
 pierced through with the point of a knife, or torn with the slightest force.* 
 We have seen instances, in which considerable portions of the inner, extend- 
 ing nearly half way through to the peritoneal surface, have been converted, 
 within seventy or eighty hours, to a soft and gangrenous material, almost fit 
 to be described as a colluvies or liquamen. 
 
 Such diseases as these are to be cured soon, or not at all. It is like a 
 battle — “Quid est! Concurritur, et momento horae, aut cita mors venit, aut 
 loeta victoria.” If the nurse allow the precious moments of the forming 
 stage to elapse before the alarm is taken ; or if the physician, through inat- 
 tention or failure in making the diagnosis, pursues, in the beginning, a feeble 
 or erroneous practice, no human skill, sagacity or devotion, can be relied 
 upon to rescue the victim, who has already begun to die before the first hand 
 is extended for her rescue. 
 
 We hear and read of numerous cases in which prompt measures have 
 been taken, of the very class we would recommend, but in vain. We 
 admit it has been so, and it must be so often in future ; for, unhappily, the 
 greatest watchfulness is sometimes incapable of detecting the existence of a 
 
 * Robert Lee gives samples of this ramollissement, or softening, of the uterine 
 texture. 
 
672 
 
 PUERPERAL FEVER. 
 
 disease destined to destroy, because the forming stages — the curable ones — 
 are already overpast before the patient herself, much less the nurse or the 
 physician, has perceived the least cause for alarm.* Inflammation of the 
 lining membrane of a vein is not painful in its commencement; nor is 
 inflammation of the bronchus painful in its commencement, to a degree at 
 all commensurate with its dangerous tendency; so that it happens, in bad 
 epidemic cases, that the attempt to cure fails, because the aid is presented 
 too late. Unquestionable authority exists to prove, that uterine inflamma- 
 tion, in some cases, has already gone far beyond any curable stage long 
 before the delivery of the child had permitted its existence to be even sus- 
 pected. 
 
 Under the above recited circumstances, the question is brought up — 
 What shall we do for the saving of the life committed to our care, humanly 
 speaking ? 
 
 Can we safely abandon the philosophy of medicine, and, relying upon 
 some vague and ill-defined notion of a constitutional depravation, undertake 
 to counteract these vivid and almost electric movements of life, local in their 
 origin and domain, by means of a few drugs applied to the mucous mem- 
 brane of the stomach or bowels; by some cataplasms or liniments, or 
 fomentations to the belly; or, at most, by dozens or hundreds of leeches 
 fixed on the cutis of the abdomen ? What are great inflammations, that 
 they can be overcome by such means; especially inflammations concealed 
 in the very recesses of the body, remote from the surfaces, and deriving 
 their source, their impetus, their proximate cause, their ipsissima 'causa 
 from the injecting power of arteries springing directly from the emulgents, 
 the aorta, or the hypogastric tubes ? It would appear to me to be mere 
 dawdling with the malady, in comparison with the vigorous and masterful 
 influences of blood-letting, which is perfectly obedient to the will of the 
 physician, goes directly to its object, and stops short at the desirable point: 
 which reduces the injecting force of the systemic ventricle, and brings it to 
 such a state as to leave the necessary equipoise between all the parts of the 
 angiotenic apparatus: a therapeutic agent, which, wisely and well directed 
 to the exigencies of the case, surpasses all other modes of relief or cure. 
 
 In the application of this great measure for the cure of these puerperal 
 inflammations, I might feel content to refer to the exhortations of Gordon, 
 to be firm and decided; and I trust that every one of my medical brethren 
 who may read his book, will give due weight to his energetic expressions 
 on that point. But I cannot resist the desire I feel to remark, that a feeble 
 
 * I am disposed to believe, from opportunities recently enjoyed, that even the con- 
 stitution of the patient does not take the alarm in some examples of phlebitis, until 
 the disease has already reached a certain, stage of development, at which it is in- 
 curable. This is undoubtedly the case in certain cases of crural phlebitis — where 
 our attention is called to a state of the limb, just discovered by the patient, and 
 which must have already existed many hours before she herself detected or even 
 suspected any disorder. 
 
PUERPERAL FEVER. 
 
 673 
 
 and timid employment of the measure will be likely, not only to fail of 
 success, but even to give additional impetuosity to the disorganizing forces 
 of the malady.* The pulse, under certain circumstances of constitutional 
 irritation, is found to be in the state which Dr. Rush characterized as the 
 oppressed pulse, — a pulse in which the beat is apparently feeble, and ren- 
 dering it doubtful whether a safe recourse is to be h-ad to the lancet; but 
 
 which, after the abstraction of a certain quantity of blood, rises and bounds 
 
 like the full synochus fortis action. To raise the pulse to this condition, and 
 leave it so, is to disengage the heart — the injecting power — from something 
 that obstructed and embarrassed its action; and to enable it, by setting it at 
 liberty, as it were, to force new and greater torrents of blood into the 
 inflamed parts, impacting it there, and extending the inflammatory engorge- 
 ments and obstructions into the collateral capillaries in every direction. 
 Hence it is apparent, that in using venesection' as a remedy, it will not 
 
 suffice to stop as soon as the pulse has risen : it must be carried to the 
 
 extent of subduing and reducing down within safe limits the power which 
 it is instituted to control. 
 
 If there be any thing true in medical philosophy, it is that all the nervous, 
 muscular, and nutritive functions, have a very close dependence upon the 
 circulation of the blood. An increase of the momentum of the blood tends 
 to augment the development of the nervous force ; every organ is stimulated 
 and brought to a higher degree and expression of vital power by increased 
 rapidity, within certain limits, of the blood’s motion. On the contrary, 
 diminished intensity of its motion tends to diminish the innervative force, 
 with all the action of all the organs dependent on that force. To bleed in 
 fevers and inflammations, is to lessen them. But the question is, not as 
 to bleeding; it is as to how much? by what sign shall we know when to 
 stop? Is there a safe limit? 
 
 What is that safe limit? The practitioner is the sole judge. It is easy to stop 
 short of its attainment: it is by no means difficult, nor perhaps uncommon, to 
 go beyond it ; and thus render most injurious a means designed only for good. 
 Experience is the only teacher : the physician must have acquired that fami- 
 liarity with the condition of the pulse, in health and disease, that can alone 
 enable him to say — this is sufficient ; the movement of the circulation is now 
 no longer destructive or dangerous ; the columns of blood driven through the 
 arterial tubes upon the inflamed tissues, reach them with a force sufficiently 
 moderate to permit them to recover. Experience, habit, tact, sagacity, these 
 
 * There is great difficulty, except in the clearest cases of violent reaction, in 
 bringing one’s mind to the point of courage so anxiously inculcated by Gordon, and 
 which it seems he himself found it hard to attain. Let the reader of his book 
 ponder well his directions; and if they meet the concurrence of his judgment, let 
 him bear them in mind at the clinic . — “ Jugulare febrim ” should be the motto in 
 such cases. 
 
 43 
 
674 
 
 PUERPERAL FEVER. 
 
 will govern him, and show him that he can go no further with safety. Gor- 
 don insists upon twenty-four ounces as the quantity to be drawn in the early 
 stage — within twenty-four hours of the attack — and he looked with confi- 
 dence to a cure when that quantity could be drawn. I find no objection to his 
 standard, which is concurred in by Hey, with- certain exceptions. It is pro- 
 bably sufficiently large to effect the desirable degree of reduction in most 
 cases, but I should not be willing to adopt it as a universal rule, since 
 there are many constitutions that would bear a greater abstraction than he 
 proposes without injury, while others would not endure to lose near so 
 much without a fall of the rate of circulation below the desirable point: 
 the same point, in a word, being attainable in some by twenty-four ounces, 
 in others by not less than thirty, and in others, again, by twelve or fifteen. 
 Let the pulse declare; let the breathing declare; let the cessation of pain 
 declare; let the general sensations of the patient declare: while her voice, 
 gesture, decubitus , and physiognomonic expression, concur in indicating 
 that enough has been done, and not too little, nor too much. 
 
 There is not, and there cannot be, any safety in practising physic by a 
 rule. The state of the case ought always first to be made out and under- 
 stood ; the physiological rate of the parts concerned in disease should be 
 detected, as well as the epiphenomena which the prime disorders have 
 superinduced ; and from this knowledge should be collected the indications 
 of cure, and the precise agents to be used in the process determined upon. 
 The innervation, the circulation, and the respiration, compose the great triad 
 of the offices of the constitution: all constitutional disorders must implicate 
 one or more of them. Let the physician take care that these suffer no material 
 detriment in the case, and the remaining functions, that are of greater or less 
 vital importance, will be all the safer for the wise precautions he may take 
 as to these principal ones. Death must, in every instance, depend upon the 
 cessation of vital action, either in the brain, or heart, or lungs, according to 
 the beautiful exposition of Bichat; no man can die but by one of these 
 powers. Let the medical attendant, then, in his plan for the treatment of 
 such grave disorders as those under consideration, adapt his measures to 
 the conservation or rectification of these functions. I say again, then, let 
 the pulse declare; let the breathing declare; let the pain, the decubitus , the 
 expression, &c., all concur in declaring what he ought to do, and teach him 
 that he is about to do, or has done, right ; neither too little, nor too much. 
 
 There is a valuable work by Dr. Legouais, published in 4to., Paris, 1820. 
 It is entitled, “ Reflections and Observations on the Employment of Bleed- 
 ing and of Purgatives in the Treatment of Puerperal Fever." This 
 gentleman appears to have had a very enlarged field for observation on the 
 subject in question, and claims, with apparent justice, to be heard on the 
 topic. He sets forth (p. 12) the evidences which go to prove that the dis- 
 ease is an inflammation. 
 
 He says: — To acknowledge that the disorder most common to lying-in 
 
PUERPERAL FEVER. 
 
 67 5 
 
 women is an inflammatory one, is to admit that sanguine evacuations must 
 constitute an essential part of its treatment. We cannot avoid the adoption 
 of such a proposition : its truth is demonstrated to us ; and we have on this 
 point the highest degree of conviction that can be attained in medicine. 
 But we are far from admitting this without qualification ; and, however great 
 may be the acknowledged utility of venesection in puerperal peritonitis, as a 
 general proposition, it appears to us equally important that its employment 
 should be subjected to certain rules in order to ensure its success : without 
 such rules even venesection, instead of proving useful, becomes injurious in 
 the disease, (p. 17.) 
 
 Dr. L. thinks, that venesection is applicable to the first stage, or stage of 
 irritation ; and that, when the inflammatory movement has gone so far as 
 clearly to indicate to what termination it tends, the use of blood-letting 
 serves only to derange the action or hasten that result, whatever it may be. 
 He admits that the duration of this stage may be very different in different 
 subjects: the medical attendant is to judge of the duration, (p. 17-18.) 
 
 He contends that this stage does not extend beyond twenty-four hours, 
 and that he has never seen any good result from it at a later day, except in 
 a very small number of cases ; and even in these the abstractions have 
 been so small in quantity as to leave room to doubt of their influence, if 
 any. (p. 19.) 
 
 The paragraph commencing at p. 21 is devoted to the question, as to the 
 quantity of blood to be taken ; which, Dr. L. insists, should be large enough, 
 jugulare febrim , as Galen says, to destroy it at a blow, and not merely to 
 weaken the force of the disease for a short period, in order that it may 
 rise with greater power in a system weakened and not saved by the first 
 operation. He finds the fault, generally found with Leake, who, under- 
 standing the nature of the case well, and urging early and free blood-letting, 
 yet did not himself go beyond eight or ten ounces. 
 
 Again: — “We believe, then, that in treating puerperal fever by blood- 
 letting, the object should be to abolish the disease entirely by the powerful 
 and energetic use of the remedy. It is the fabulous hydra, which can only 
 be destroyed by cutting off at a blow all the heads. If a single one be 
 spared, it is sufficient to keep alive a vital principle, which soon reproduces 
 the monster more terrible than before.” (p. 23.) 
 
 In a paragraph, at p. 24, he regards the quantity needful as eighteen, 
 twenty, or twenty-four ounces at the first operation ; less than this rarely 
 produces an advantageous and sure result. 
 
 The student of the history of childbed fever will not have, failed to ob- 
 serve, that many individuals of the profession who have been called upon to 
 encounter the disease in question, when it prevailed as an epidemic, have 
 trusted to the use of remedies, which, although not successful in curing the 
 disorder, or saving the patient from death, yet could not be accused of mis- 
 chievous or pernicious action in the case. This arises from the less obvious 
 
676 
 
 PUERPERAL FEVER. 
 
 or less evident nature of the operation of drugs than of venesection, which 
 produces effects so sudden and palpable upon the great vital functions, as to 
 render them intelligible to the ordinary by-standers and friends. A patient 
 taking large doses of calomel or James’s powder, or ipecacuanha, or purga- 
 tives, if she grows worse and worse in childbed fever, will be readily sup- 
 posed to do so, notwithstanding the salubrious tendencies of their operations: 
 Post hoc , sed non propter hoc. Whereas, should she decline as rapidly 
 under the use of the lancet, that decline is apt to be charged directly to the 
 loss of blood. Dr. Robert Collins, of Dublin, in his Practical Treatise on 
 Midwifery * says, that of the eighty-eight cases which he had under his 
 care while Master of the Dublin Lying-in Hospital, thirty-two recovered, 
 and fifty-six died. (p. 190.) 
 
 Dr. Collins, in this important work, discourages the use of venesection 
 in the epidemic forms of the disorder. Let it be observed, however, that he 
 had eighty-eight cases, of which fifty-six died, and thirty-two recovered. 
 He says, “In fifteen only of the eighty-eight did we deem it advisable to 
 bleed generally; seven of the fifteen recovered.” Notwithstanding this, the 
 doctor gives the following summary : — “ The result of my observations upon 
 the treatment of puerperal fever is, that general bleeding, except when there 
 is a strong, full pulse, and the symptoms are of a highly inflammatory cha- 
 racter, is injurious. On the contrary, local depletion, by the application of 
 three or four dozen leeches, followed by the warm-bath and stuping, all of 
 which should be repeated according to circumstances, and as often as the 
 strength will permit, seemed most beneficial. These means, together with 
 the active employment of calomel, conjoined with hippo or opium, offer the 
 best prospect of relief. Blistering the whole abdomen, after leeching had 
 been pushed as far as could be, was found serviceable. In some cases the 
 debility was so excessive as to induce us to apply the blister at once, using 
 calomel and stimulants at the same time.” (p. 396.) 
 
 Dr. Collins evidently entertains the opinion, adverse to my own, that 
 puerperal fever is a something over and above the local disease, and consti- 
 tutional affection resulting therefrom. In this opinion he has many sup- 
 porters. But, accustomed to look for causes sufficient, and not more than 
 sufficient, for the production of certain effects, I find myself still unable to 
 believe that he and those who think with him are right. Phlebitis of the 
 recently-discharged womb is alone sufficient to produce all the frightful 
 rapidity of which Dr. Collins speaks — so is gangrenous inflammation of the 
 inner paries of the organ ; and equally capable of causing a rapid, a most 
 sudden overthrow of all the functions, is an inflammation of the whole peri- 
 toneum ; by which is implied, as I have before explained, a disease of every 
 organ which receives an investment of the peritoneal membrane as part and 
 parcel of its own nature and texture. 
 
 I cannot but avow, that so great is the respect I feel for Dr. Collins, of 
 
 * Select Medical Library, February, 1838, Philadelphia, Barrington & Haswell. 
 
PUERPERAL FEVER. 
 
 677 
 
 Dublin, on account of the very valuable services he has rendered to man- 
 kind, and particularly to the medical profession, in giving to them the work 
 above quoted from, that it is with much reluctance I find myself compelled 
 to dissent from his opinions on puerperal fever. Acknowledging, therefore, 
 his great authority as a medical teacher, I disavow it for his article on puer- 
 peral fever; in which neither does his reasoning take captive my judgment 
 by its force, nor his practice overcome my prejudices by its success; in 
 fact, its success was very bad — he having lost nearly two out of three cases ; 
 and his reasoning not better, since it is founded on the bare postulate, that 
 the disease was something more — something beyond inflammation of tissues ; 
 an opinion which, were it even proved to be true, could not alter my views 
 of the urgent necessity to reproduce the reciprocity of force betwixt the 
 receiving or inflamed tissues and the injecting agent, viz., the heart and 
 arteries. 
 
 I am further compelled to dissent from Dr. Collins’ authority, and that of 
 those who agree with him, in regard to the preferableness of leeching to 
 direct blood-letting from veins. I have never yet perceived the full force of 
 the reasoning which induces many medical practitioners to prefer local to 
 general bleedings in such great cases. The mere fact that the leech draws 
 blood from the cutis of the abdomen, ought not to be taken as proof that it is 
 capable of exhausting a system of non-collateral vessels in the interior of the 
 body. What direct connection can be asserted to exist betwixt the capillaries 
 of the skin and those of the intestinal peritoneum; or the uterine veins, or 
 absorbents, or the proper texture of the womb ? The abdominal peritoneum 
 and the intestinal peritoneum are in all probability equally exempt from the 
 charge of originating or setting on foot the first movements of the inflamma- 
 tion in childbed fever. But the womb and its annexed organs are supplied from 
 the ovarian and the uterine arteries. This circulation is in nowise directly re- 
 lated to the circulation in the skin. Hence I infer, if the leeching is useful in 
 this case, it is through its power on the action of the heart alone, and not by an 
 immediate depletion of the inflamed parts. But if the object in truth be, to 
 modify the injecting power of the heart, by diminishing the quantity of the 
 blood and changing its crasis, why not take it from a vein at once, where 
 you can control the operation? where you can take one ounce or twenty? 
 where you can go on or stop at the slightest warning? and where you avoid 
 all the fatigue and exposure to cold and dampness inseparable from the ope- 
 ration of leeching? A patient who can bear leeches can, in general, much 
 better tolerate the lancet. I shall be glad, therefore, when the day arrives 
 in which the therapeutical employment of the leech should be understood 
 as nearly confined to local disorders ; while the lancet should be esteemed 
 as applicable for both the local inflammations and engorgements, and the 
 constitutional derangements either arising out of them, or originating them. 
 
 Dr. Baudelocque, the younger, in his Traite tie la Peritonite Puerperale , 
 cites opinions from the Diet . des Scien. Med. unfavourable to the use of 
 
678 
 
 PUERPERAL FEVER. 
 
 general bleeding except in special cases, but highly laudatory of the employ- 
 ment of leeches as a means of cure. Dr. B. opposes the sentiments of that 
 party as follows : — 
 
 “ It has been further alleged in favour of leeching, that in drawing blood 
 from the capillary system they are also able to abstract it directly from the 
 diseased organ, by means of vascular connections existing betwixt the skin 
 and the subjacent parts. This communication seems to me to be remote 
 even in the case of inflammation of that portion of the peritoneum that lines 
 the anterior parietes of the abdomen ; and it must be absolutely null when 
 the inflammation is seated in the broad ligaments, upon the womb, upon 
 the intestines, &c., which is most commonly the case.” (p. 330.) 
 
 “ I do not participate in the fears of MM. Gasc and Marat, as to the dis- 
 advantages of general bleedings ; and cannot place the same confidence that 
 they do in topical depletion. Whenever a loss of blood is indicated, and 
 properly administered, a venesection is not more likely to promote the deve- 
 lopment of an adynamia than a leeching; if, on the contrary, the loss of 
 blood is contra-indicated, the employment of leeches, it is true, will do less 
 harm than that of the lancet, but we ought not to select one remedy in pre- 
 ference to another because it will do less injury to the patient than that other.” 
 
 A little further on he speaks in the following terms : — “ In my opinion, 
 bleeding from the arm is, in the majority of cases, to be preferred to leeching; 
 and that the latter should be resorted to only where, after having obtained 
 by venesection a considerable diminution of the symptoms, there remain 
 several painful points in the abdomen. These points should be covered 
 with leeches, which will then dissipate a disorder for which general bleeding 
 would have been much less efficacious. In weakly persons it would be 
 proper to use the leeches at once, especially if the inflammation should be 
 partial, of small extent, and accompanied with but little fever. But they 
 should be used in pretty great numbers : it is not by applying eight or ten 
 leeches that advantage may be expected ; — twice or thrice this number 
 should be put on. A fortiori , the number should be much more considera- 
 ble, where, from peculiar circumstances, we are obliged to abstain from 
 general bleeding in a robust person, and confide in leeches alone for the 
 cure of the peritonitis ; in such case we ought to use fifty or sixty each 
 time.”* (p. 333.) 
 
 In the above views of M. B. I do not perceive how any one can fail to 
 eoncur. It seems to me that, except for purely local affections, the loss of 
 blood ought to be effected from a vein of considerable size, in order to bring 
 about a state of the whole circulation favourable to the termination by reso- 
 lution. I have had, as I think, many occasions of observing, that where 
 leeches were applied for the relief of great and extensive inflammations, 
 
 * The reader will bear in mind the greater powers of the French over the Ameri- 
 can leech. 
 
PUERPERAL FEVER. 
 
 679 
 
 attended with much constitutional perturbation, they rather served to weaken 
 the patient than to diminish the force of the disorder. 
 
 Nor is it at all apparent to me, that even in those cases where leeching is 
 practised to the extent of bringing on a disposition to syncope, any advan- 
 tages superior, or even equal, to those derivable from venesection, can be 
 claimed. The debility occasioned by leeching ad deliquium animi has 
 always, under my observation, been alarming, and even dangerous. It is 
 much less easily recovered from than in the case of its following phlebotomy. 
 
 Dr. Mackintosh, a writer of great reputation, in his Principles of Patho- 
 logy and Practice of Physic gives a few pages to the subject of puerperal 
 peritonitis; and it is true that, at p. 201, edition of 1834, he bestows much 
 praise on the employment of leeches in the case. Nevertheless, his views 
 are conformable to those of Gordon, Hey, Armstrong, &c., in regard to 
 the greater dependence to be placed on venesection, as may be seen in his 
 summary at p. 202, and in his critical and sarcastic remarks upon Dr. 
 Hamilton. It is perhaps useless to multiply citations here; and, indeed, 
 I am quite willing to leave the decision to the judgment of any practitioner 
 who will give due regard to the arguments drawn from the nature and ex- 
 tent of the disorder, the indications of treatment, and the comparative powers 
 and facilities of the several remedies. 
 
 There are writers who disapprove of frequent repetitions of venesection in 
 the treatment of puerperal fever ; as, for example, Legouais, above quoted. I 
 have already said that it is not difficult for the approvers of venesection to 
 carry the abstraction of blood too far. I know that in some cases, when it has 
 been deemed needful to bleed very copiously for the cure of an inflammatory 
 attack, the latter part of the case has been rendered very unmanageable by 
 the supervention of a state of the pulse, which may be qualified by the epi- 
 thet soap-bubble, from its slight resistance to pressure, notwithstanding the 
 considerable remaining volume of the radial artery. Such a pulse is fre- 
 quently met with after very violent uterine haemorrhages ; and is not unapt 
 to mislead the inexperienced by its apparent vehemence, when, in fact, it 
 arises from the insufficient stimulation of the heart and brain, the conse- 
 quence of a diminished crasis of the blood. The blood, for its healthful 
 constitution, requires a due proportion of crassamentum, from which it 
 derives its proper crasis. While I am aware, on the one hand, that the 
 constitution of the blood may be seriously changed by the imprudent repe- 
 tition of phlebotomy, I am not afraid to repeat the venesections in peritoni- 
 tis, &c., until I feel assured, both from the state of the crassamentum and the 
 signs presented by the patient, that no more can be taken with prospect of 
 benefit to the patient. To show what can be borne in certain cases, let me 
 relate the following observation. In the course of the present year a case 
 fell under my care, of which the following is a correct statement: — A young 
 married lady, at the end of her fourth pregnancy, was attacked about 3 A. M. 
 with pains of labour and flooding. I did not see her until mid-day. Upon 
 
G80 
 
 PUERPERAL FEVER. 
 
 arriving at the house, I judged, upon careful inspection of the napkins and 
 sheets, &c., that had been removed from about her person, that she had lost 
 fifty ounces of blood ; an opinion strengthened by an examination of her 
 pulse, her muscular strength, and her skin, which was excessively pale. 
 Upon making an examination I found the haemorrhage still active; and, in 
 order to check it, resolved, as the placenta was not in jeach, and the os uteri 
 one-third dilated, to rupture the membranes, according to the method, as it 
 is called, of Louise Bourgeois. As soon as the water had gone off, the 
 haemorrhage was stayed ; and she, not long afterwards, gave birth to a 
 healthy child. The young lady was very weak. I saw her late in the 
 evening, and she was comfortable, but extremely pale. During the course 
 of the next day and night she was comfortable, and was kept carefully in 
 bed, being without other complaint than debility. But at 4 o’clock in the 
 morning she was attacked with intense rigor, amounting to ague, accompa- 
 nied by excessive pain and soreness of the belly, with a pulse at 150 per 
 minute, rising at times to 160 beats; she presented, indeed, all the pheno- 
 mena of a violent attack of puerperal fever. I did not see this patient until 
 as late as 1 1 a. m. 
 
 Upon making out the diagnosis, I again made inquiries of her mother, a 
 most intelligent person, who convinced me that the first estimate, as to the 
 quantity lost in the haemorrhage, was far too small ; and I have not, at this 
 moment, any doubt of her having lost, on that day, full seventy ounces of 
 blood. As puerperal fever was prevailing considerably at the time, I felt 
 deeply concerned as to the line of my duty in the actual circumstances. It 
 appeared to me more than probable, considering the violence of the attack 
 after so great a haemorrhage, that it would prove fatal under any treatment 
 that might be adopted. I thought it certainly would have a fatal result, 
 should I allow the heart to continue beating at so violent a rate. 150 pulsa- 
 tions per minute will give 115,200 pulsations per diem over and above the 
 number required for the healthful rate of the circulation; which, at seventy 
 per minute, gives a little over 100,000 per day. Let any one conceive the 
 amount of danger and mischief concomitant upon the long continuance of 
 such an excessive rate of a vital function. But the patient had already lost 
 profusely of her blood ; and hence, with due regard for my own reputation, 
 or the credit of a most invaluable remedy, could I venture to increase this 
 loss by bleeding her, whose death, probably, under such treatment, would be 
 boldly charged to malpractice? It was a severe struggle; but I had convic- 
 tion enough to compel me to follow the suggestions of mv judgment; and 
 having bled her as freely as I dared to do, I had the satisfaction to find that 
 the pulse soon fell to a more moderate state, and in forty-eight hours my 
 patient was out of danger, and is now enjoying health, and a life which, 
 I sincerely think, would have been destroyed by metro-peritonitis, but for 
 the correct decision I made as to the use of the lancet. 
 
 I have recited the above case as evidence of the propriety of bleeding a 
 
PUERPERAL FEVER. 
 
 681 
 
 patient, notwithstanding she has already lost freely of her blood ; and 
 numerous instances have fallen under my notice where venesection has been 
 reiterated during successive days after the attack was fully formed. In the 
 winter of 1840, I visited the wife of a gentleman at Concord, twenty miles 
 from the city, who had been three days ill, under the care of a neighbouring 
 physician. The latter had bled her once, but sparingly, on the second day, 
 though she was labouring under severe peritoneal fever. Upon arriving in 
 the night, at her residence, where I met the medical gentleman, we con- 
 curred in opinion as to the propriety of another venesection, which was 
 promptly effected, and repeated the next day, and then followed by cupping 
 of the belly ; so that she perfectly recovered after a very narrow escape. In 
 the lying-in wards of the Pennsylvania Hospital, I have seen seven women 
 recover from the most alarming attacks of metro-peritonitis, under the vigor- 
 ous employment of the lancet, carried to the full extent of Gordon’s views; 
 not a single death has taken place there, under this treatment, within my 
 notice. I shall recite the following sample from my note-book, which may 
 suffice to show more clearly my views of the plan that ought to be followed. 
 
 Mrs. W. G., aged about twenty years; first pregnancy; was delivered 
 on Thursday, the 4th November, 1830, of a female child, after a labour of 
 four hours. 
 
 She was very comfortable on Friday and Saturday. There was already 
 a small quantity of milk in the breasts, but they were neither full nor pain- 
 ful. The bowels were opened on Saturday by a dose of castor oil, a table- 
 spoonful and a half, which operated through the day and night ten or twelve 
 times. She has had, for her diet, tea and bread, and oatmeal gruel. There 
 was no fever on Friday nor Saturday. 
 
 Sunday , November 7th. — I did not call to see her until past 10 a. m. She 
 had had a chill in the night, rested badly, and now suffers pain and soreness 
 in the right flank and iliac region. The parts were very tender on pressure, 
 distended and resonant under percussion ; the fundus uteri , above the sym- 
 physis pubis, sore to the touch ; lochia bright and free; urine abundant; 
 tongue whitish, soft, moist and broad; headache, thirst, dorsal decubitus; 
 motion of thighs gives pain in abdomen; any attempt to rise or turn also 
 gives pain; pulse 148, with a vigorous stroke. She was bled eighteen 
 ounces from a large orifice, when faintness came on, and the arm was bound 
 up. In a few minutes after the bleeding, the pulse was 112, but it soon rose 
 again to 152. Although the bowels had been moved so often, I thought 
 their flatulent state indicated an arrest of the peristaltic movement from in- 
 flammation of their peritoneal coat; and, to re-excite them, she took a com- 
 mon enema, which operated twice with relief. A flannel bag, filled with 
 wheat bran soaked in boiling vinegar and water, after being well pressed, 
 was laid warm on the belly : it was changed occasionally. 
 
 At 20 minutes past 3, p. m. The pulse 145, with a smart stroke; the 
 tenderness of the belly neither less nor greater. I took twelve ounces of 
 
682 
 
 PUERPERAL FEVER. 
 
 blood from the arm, in a large stream. I was obliged to stop, on account of 
 faintness, though I had first drawn the pillows from under the head, in hopes 
 of getting a larger quantity. In fifteen minutes afterwards, pulse 144. 
 
 At 4£ p. m. Calomel, gr. viij .; Opium, gr. iss. The powder was taken 
 for a dose. To drink gum water. 
 
 At 6| p. m. Has slept, and feels decidedly less pain and soreness ; but, 
 as the pulse is frequent and strong, I took twenty-two fluid ounces of blood, 
 which was carefully measured. It made a firm clot, and had a thick coat of 
 size. She took Manna, ^ss.; Sem. anise, 3b; Magnes. carb. ^ss.; Aq. bulli- 
 ent. ^vi. An infusion was made of the anise and manna in the boiling water; 
 which, when cool, was strained : after which, the magnesia was added, to 
 make a proper mixture. A fluid ounce was taken for a dose every hour, 
 until the bowels were moved. 
 
 At 10§ p. m. Pulse 136, full and strong; the right mamma filling and 
 hardening, the left soft and flaccid, but the gland is developing favourably ; 
 no headache ; thirst ; the soreness and pain, on pressure, (carefully exa- 
 mined,) are very much lessened ; lochia free ; decubitus still dorsal. 
 
 Monday , 8 a. m. Has slept a good deal; pulse 130, and softer; no pain 
 except by firm pressure on abdomen ; thirst lessened ; both mammae full 
 and hard. 
 
 3 p. m. Pulse 120, full and strong; no pain, not even from pressure; 
 tongue clean ; had several stools ; not thirsty. 
 
 9£. Same. 
 
 Tuesday , 9th November, 9 a. m. Pulse 124, and strong; tongue some- 
 what furred ; plenty of milk ; breasts soft ; no pain ; bowels moved again. 
 
 9 p. m. Pulse 111; sore nipples. 
 
 Wednesday , 10 a. m. Has been sitting up ? no pain ; pulse 126. 
 
 In a few days after this last date, she was perfectly well. 
 
 This young woman had a healthy and strong constitution. In her case, I 
 took away, between 11 and 6 o’clock on the first day of the attack, fifty-two 
 ounces of blood, without which, I think, she must have died. 
 
 I have related the above case from my note-book. I present it as a fair 
 specimen of the mode of practice, in such attacks, which I have for years 
 been in the habit of pursuing. I have treated cases in the Pennsylvania 
 Hospital and in private houses upon the same principle; and I have the 
 satisfaction to say, that my just expectations of success, founded on the 
 doctrines of Gordon, have rarely been disappointed. — M.] 
 
 OF PAINFUL (EDEMA. 
 
 By this title, or by that of phlegmasia alba dolens , is understood 
 an acute and very painful swelling of the inferior extremities, which 
 sometimes affects women in the lying-in. This inflammatory swell- 
 ing, which rarely involves both limbs at once, is attended with fever 
 
MILK-LEG. 
 
 683 
 
 of considerable violence, which in some instances takes on an adyna- 
 mic or typhoid character. 
 
 This disease, which the earlier writers designated as milk-leg, 
 (d£pot Iciiteux ,) or metastasis of milk, has been well investigated of 
 late years only, and particularly by M. Velpeau, in his Recherches 
 et observations sur la phlegmasia alba doleiis , in the Archives 
 Generates de Medecine, for Oct., 1824. 
 
 Among the causes that give rise to it, should be comprised all those 
 circumstances that obstruct the venous circulation of the lower ex- 
 tremities, by causing, to a certain extent, the blood to coagulate 
 within the vessels that happen to be attacked with inflammation; 
 thus, pressure exerted upon the nerves and veins in the pelvis, the 
 traumatic inflammation of labour, uterine phlebitis and phlebitis of 
 the veins of the pelvis, suppurative inflammation of the symphyses, 
 and also inflammation of the sciatic and obturator nerves, are so 
 many circumstances under the influence of which the disorder may 
 be brought on. It should be further observed, that even if an in- 
 flammation of the lymphatics of the limb be not the cause of the dis- 
 order, it may, nevertheless, contribute to produce the phenomena that 
 constitute the malady. Moreover, a sudden chilling of the body, 
 following the copious perspiration that almost every woman in labour 
 has, is one of the commonest among the determining causes of phleg- 
 masia dolens. 
 
 The malady generally comes in with a chill, followed by intense 
 fever and by sudden pain in the groin and thigh, which gradually 
 swells from above downwards, and mostly upon its inner and ante- 
 rior surface. 
 
 [I shall interrupt the paragraph in order to protest against M. C.’s ac- 
 count of the onset of the disorder; or rather to aver that in the many cases 
 I have met with, the swelling is in a great majority perceived first in the calf 
 of the leg, which becomes painful and hard and swollen before the woman 
 suspects that she has any pain at the groin and in the thigh. When I hear 
 a lying-in woman complain of pain of the limb, my first attempt at diagnosis 
 is to compress the calf of the leg — and I feel always reassured, as to any 
 danger from phlebitis, when she permits such pressure to be made without 
 complaining of it as painful. — M.] 
 
 The limb soon becomes infiltrated completely, the skin is white, 
 glistening, tense, and exceedingly sensitive to the touch, but the oede- 
 ma is not really serous and does not pit upon pressure, except upon 
 the points that are not painful. The disorder, which ordinarily lasts 
 from four to seven weeks, most commonly ends by suppuration, in 
 enormous ulcers, and sometimes in death. 
 
 The treatment consists in blood-letting, both general and topical, 
 in cataplasms, both emollient and narcotic, cooling drinks, absolute 
 diet, baths, which are most suitable after the fever is broken, and, 
 lastly, in the internal use of antiseptics, when any adynamic symp- 
 toms begin to be exhibited. 
 
 [I disagree here, also, as to the liability to suppuration. In the greater 
 
684 
 
 MILK-LEG, NEURITIS, PHLEGMON. 
 
 portion of my cases, the patient has effected resolutive cure of the inflam- 
 mation, and even where the malady has resulted in the death of the patient, 
 of which I have witnessed two instances only, the suppurations did not ap- 
 pear externally, and were confined to the membrane commune of the veins. 
 I differ with Mr. C. as to the necessity of treating separately phlebitis 
 and phlegmasia alba, since they constitute an identical case. Of this no 
 person could doubt, I should suppose, who had read the observations on 
 phlebitis by Dr. David D. Davis, late Professor of Midwifery in the Lon- 
 don University, and those of Dr. Robt. Lee, of London, in his writings on 
 crural phlebitis, for which see the volume on puerperal fever, published by 
 Hasweli and Barrington, of this city. — M.] 
 
 PUERPERAL NEURITIS. 
 
 This designation is applied to the inflammations of the crural and 
 sub-pubal nerves, brought on by pressure during labour. The dis- 
 ease, which until lately was confounded with phlebitis and neuralgia, 
 is characterized by pain that is highly exasperated by pressing upon 
 the inflamed nerve, which becomes red and swollen, and forms a 
 hard, uneven cord. In some of the cases phlegmons are formed over 
 the tractus of the nerve, which suppurate, and in other instances, the 
 neuritis gives rise to painful cedema. 
 
 The treatment of this affection consists chiefly in topical bleeding, 
 carried to a proper extent, according to circumstances, and frequently 
 repeated, according to the violence and obstinacy of the pain. It is 
 well, in some specimens of the malady, to make use of general bleed- 
 ing; but it is mainly by the use of bathing, emollient cataplasms and 
 the energetic application of antiphlogistics, that we may hope to 
 subdue the extreme pain, and even completely to cure the patient. 
 
 OF PHLEGMONOUS ABSCESS IN LYING-IN WOMEN. 
 
 It sometimes happens that the cellular tissues of the pelvic muscles? 
 as well as the articulations of the symphyses, are the seats of isolated 
 inflammation, giving rise to abscesses and phlegmon, called milk- 
 boils, which appear in different parts of the body in lying-in women 
 recently delivered. 
 
 When these abscesses form around the psoas and iliac muscles, 
 purulent collections often follow, which may open at the groin, in 
 the lumbar region, and even in the texture of the labia pudendi ; 
 when, on the other hand, these collections find their way into the blad- 
 der of urine, into the rectum, or into the cavity of the womb, the acci- 
 dent is so much the more unfortunate, as it very often causes the 
 death of the patient. It is, therefore, of the highest importance to 
 prevent and to combat, as early as possible, the development of 
 these inflammatory symptoms by the prompt and energetic applica- 
 tion of the antiphlogistic method of treatment, and where we cannot 
 succeed in preventing suppuration, to give speedy issue to the matter, 
 by opening the abscess conformably to the rules of the art; that is to 
 
INERTIA OF THE WOMB FLOODING. 
 
 685 
 
 say, by means of the bistoury or the caustic, according to the circum- 
 stances of the case. 
 
 INERTIA OF THE WOMB, AND FLOODING DEPENDING THEREON. 
 
 By inertia of the womb is understood the diminution or cessation, 
 more or less entire, of the contractions of the organ, so that it has no 
 farther power to expel the foetus or placenta, or to contract itself after 
 being freed from the fruits of the conception. The disorder may, 
 therefore, be met with either during or after labour. 
 
 The causes of inertia of the womb vary accordingly as the affec- 
 tion occurs at the commencement, during the progress, or after the 
 termination of a labour. An attack of uterine inertia, that takes place 
 at the onset of labour, generally depends upon weakness of the 
 patient, and is chiefly met with in women of a lymphatic tem- 
 perament, of a constitution debilitated by trouble, or by antecedent 
 attacks of disease, and by haemorrhages that may have occurred 
 during the pregnancy. Sometimes inertia is caused by the excessive 
 distension of the womb in twin pregnancy, and in dropsy of the 
 uterus, and in certain cases it is produced by a vivid emotion, such 
 as an exaggerated feeling of modesty, and the presence of an ac 
 coucheur, or of some other person or persons. 
 
 Inertia coming on during labour almost always depends upon 
 fatigue of the uterus, where contractions have been both too vio- 
 lent, and too frequently reiterated, or too long continued. It may, 
 also, be occasioned by a premature rupture of the membranes, 
 which, when the waters are gone off', leaves the contractions much 
 less energetic and useful. Indeed, an attack of inertia of the womb 
 coming on after labour may be caused, not only by the circum- 
 stances we have mentioned, but may, likewise, result from a san- 
 guine congestion of the brain, which no longer receives any nervous 
 influx. 
 
 Where the inertia of the womb comes on early in a labour, the 
 uterine contractions are feeble and few, and the dilatation of the 
 cervix takes place very slowly. It often happens that, after many 
 days of suffering and of useless efforts, the woman falls into a state 
 of extreme exhaustion, her strength disappears, and the labour 
 comes to a full stop ; there is a complete cessation of the pains, and, 
 where the foetus is already engaged in the pelvis, it stops and makes 
 no further progress. The pulse is now found to be small, irregular 
 and scarcely perceptible, and when we Touch, the neck of the womb 
 is found to be in a state of atony, of softness and relaxation. Haemor- 
 rhage often comes on, too, which renders the condition of the patient 
 still more alarming. 
 
 An attack of inertia, coming on in the course of a labour already 
 advanced, exhibits nearly the same symptoms, with tins difference, 
 however, that they have succeeded to contractions, energetic, fre- 
 quent and prolonged, and to severe pains that have now completely 
 ceased, often have grown weaker and weaker, and less and less fre- 
 quent. In cases of this kind, both the mother and the child are in 
 
686 
 
 INERTIA — FLOODING. 
 
 the greatest danger of being lost, unless succoured both promptly 
 and wisely. 
 
 In the form of inertia that comes on after the termination of the 
 labour, the womb fails to contract, and does not exhibit that hard, 
 spherical globe which we find in the hypogaster, when the womb 
 contracts naturally. The os uteri being in a state of complete 
 inertia, remains open, and the patient feels no after-pains from the 
 contractions of the womb — which, under such circumstances, becomes 
 inverted under the slightest provocation thereto by tractions made 
 upon the cord. This state of affairs almost always brings on serious 
 haemorrhage. The blood escapes in torrents from the genitals, or it 
 is retained within the cavity of the womb, which constantly enlarges 
 more and more under the influx. In either case the countenance of 
 the patient assumes a cadaverous pallor; the pulse grows weak ; she 
 has tinnitus aurium, flushings, and very soon faints away. In fact, a 
 rapid, inevitable death follows this haemorrhage, provided there be 
 the least delay in applying the proper remedies. If the woman dies, 
 the parietes of the uterus are found thin and collapsed together ; 
 indeed, the inertia is dangerous in proportion to the violence of the 
 haemorrhage with which it is complicated. 
 
 The treatment of this sort of paralysis of the womb varies ac- 
 cordingly as it is simple or complicated with flooding, and, likewise, 
 according to its dependence upon some general debility in the 
 patient. -Under circumstances such as those last alluded to, particu- 
 larly where hemorrhage comes on, we should first endeavour to 
 improve the strength of the female, by a few spoonfuls of Madeira 
 or Frontignan, or a cordial draught with mint or canella waters, 
 with a few grains of sulphate of quinine, and a few drops of tincture 
 of saffron or mug wort, which exert a more special power over the 
 womb. Prof. Lobstein, of Strasburg, was in the habit of prescribing 
 borax with advantage ; he gave a few grains for the dose. But 
 should the labour, notwithstanding these attempts, prove to be lan- 
 guid and slow, and especially should the strength of the patient 
 become more and more exhausted, the delivery should be accele- 
 rated, either by means of the ergot, of which ten grains may be 
 given every ten minutes, in a glass of sweetened water ; by turning 
 and delivering by the feet; or, lastly, by the forceps, where the head 
 has already become engaged in the pelvis. 
 
 In case the inertia should be complicated with uterine haemor- 
 rhage, it is our duty to act still more promptly in the way just 
 pointed out ; and where the flooding does not attack until after the 
 birth of the child, and before the delivery of the placenta, our first 
 indication is to hasten the expulsion of the placenta, by pulling it 
 downwards by the umbilical cord, with proper care, by exhibiting a 
 dose of ergot, and especially by carrying a hand into the womb to 
 take it way.- 
 
 Where the haemorrhage persists after the discharge of the after- 
 birth, we should make haste to apply cloths wrung out of a mix- 
 ture of cold water and vinegar to the lower belly and upper part of 
 the thighs ; and at the same time inject a similar mixture into the 
 
FLOODING FROM INERTIA MILIARY ERUPTION. 687 
 
 womb itself, or pass a hand np into the uterine cavity, with a view 
 to excite its contractile power. The spurred rye is one of the most 
 uniformly successful agents in cases of this kind. In all cases, before 
 we proceed to any action whatever, we should satisfy ourselves that 
 the womb is not inverted. In case we should find it inverted, the 
 first indication would always be to reposit the organ, and recur to 
 the modes of treatment just now pointed out, should the haemor- 
 rhage continue after the restoration of the organ to its natural posi- 
 tion. With a view to sustain the womb, by means of an internal 
 mode of compression, a bladder, to be afterwards inflated, might be 
 introduced into the cavity, while pressure is made with a hand upon 
 the exterior through the integuments of the abdomen, according to 
 the plan proposed by M. Rouget.* In fine, transfusion of blood, 
 taken from another person, into one of the veins of the patient’s 
 arm, is to be looked upon as one of those last resources to which 
 we might turn in the most desperate cases, as a means of remedy- 
 ing the extreme debility consequent upon flooding. 
 
 OF MILIARY ERUPTION. 
 
 Lying-in women are subject to a miliary eruption, which takes 
 place without any fever. This disorder, which is announced by 
 pricking sensations and itching, comes on during abundant perspira- 
 tion, whether spontaneous or provoked, and exerts itself chiefly on 
 the neck, breast, abdomen and wrists. It is characterized by white 
 pimples, that are followed by transparent vesicles filled with colour- 
 less serous fluid. Yet it sometimes happens, that the vesicles are sur- 
 rounded with a reddish areola more or less deeply tinted. The disor- 
 der, which commonly lasts from four to six days, in most instances 
 goes off by degrees ; but in some of the examples, by a slight desqua- 
 mation of the cuticle. However, it may be a complicated disorder, 
 as, for example, with mucous inflammations, such as bronchial 
 catarrh, angina, gastritis, &c. 
 
 Where the malady exists without any complication, we should 
 confine ourselves to guarding the patient from cold air, and to the 
 prescription of demulcent drinks, and an antiphlogistic regimen. 
 Where the heat or itching, or sensation of heat, prove troublesome, 
 relief may be obtained from tepid baths. Lastly, where the erup- 
 tion is complicated, we must act according to the requirements of 
 the concomitant disorder ; that is to say, recur to demulcent and 
 diluent drinks, to blood-letting, and all the antiphlogistic measures 
 calculated to combat the various phlegmasias, and, on the other 
 hand, employment is demanded of the cinchona, of tonics, and seda- 
 tives or excitants in cases where the eruption is complicated with 
 adynamic or ataxic fever. 
 
 Melanges de M6d. et de Chirurgie. Paris, 1810. 
 
6SS 
 
 AGALACTIA. 
 
 LESIONS RELATIVE TO LACTATION. 
 
 When the milk-fever is passed, the breasts have become to the 
 greatest degree distended, and the secretion of milk goes on con- 
 stantly, as is proved by the slow and gradual swelling of the mam- 
 mas, in the intervals between the giving of suck to the child. 
 
 The quantity of milk secreted varies very much, for there are 
 some women who cannot support one child at the breast, while 
 others can nurse several ; in certain cases, there is even an exube- 
 rance of the secretion, which constitutes what is called galactir- 
 rhcea ; in other instances, on the contrary, the secretion fails either 
 wholly or in part, a state which has received the appellation aga- 
 lactia. In some women, the milk is retained within the breasts; 
 in others, it flows involuntarily: in some, it is so thin, and so little 
 consistent, that it cannot suffice to sustain the child : and, lastly, the 
 milk is liable to modifications of colour, consistence and savour that 
 render it more or less unfit for the purposes of nutrition. We 
 shall proceed to speak of the different anomalies of the milk in suc- 
 cession. 
 
 A case of agalactia is one in which the mammary gland either 
 secretes none, or very little milk. In the former case, it is said to be 
 total ; in the latter, partial. This fault may be either primary, or 
 merely accidental, according as whether the secretion does not come 
 on after the birth of the child, or whether the secretion becomes sup- 
 pressed or lessened by the influence of some accidental cause. The 
 causes that may produce agalactia are, atrophy of the mammary 
 gland ; its being either very little or very much developed ; its want 
 of vital energy, and all its organic diseases. Among the causes of 
 agalactia are alike arranged a nervous temperament ; an extreme 
 degree of emaciation, or its opposite; a state of debility and languor 
 of the ordinary kind, or one produced by starvation ; a long pro- 
 tracted disease, a painful pregnancy, profuse haemorrhages or other 
 evacuations ; bad digestion, leucorrhoea, abuse of venery, phthisis, 
 grief, and the depressing passions of the mind ; and the too early or 
 too advanced age of the patient. Lastly, the application of topical 
 astringents or narcotics to the breasts, acute diseases, gestation, and 
 menstruation, occurring during the lactation, are likewise causes that 
 may lessen or completely suppress the secretions of the mammary 
 glands. 
 
 Though it be always easy to establish the diagnosis of agalactia, 
 upon the sole indication of the patient herself, it is not so always 
 with mercenary nurses, who have some interest in concealing the 
 truth. The want of the milk secretion may always be verified by 
 the following characters : the breasts do not swell and become hard 
 during the intervals of giving suck; the child is always hungry, 
 even when he has just been nursed ; it often asks for the breast, lets 
 it go, and cries as soon as he has taken hold ; his urine is scanty and 
 infrequent, he sleeps but little, grows thinner, and soon wastes away. 
 
 Notwithstanding that a case of agalactia is beyond the power and 
 resources of our art in many instances, there are some instances in 
 
polygalactia; milk-consumption. 
 
 689 
 
 which we determine, augment, and sustain the secretion of milk : 
 thus in pregnant women who are weak and emaciated to such a 
 degree as to give reason for fear lest no milk should be formed, the 
 difficulty may, in many instances, be prevented by means of a tonic 
 and nutritious diet, and by frictions on the breasts with flannel, 
 either dry or saturated with aromatic substances. At the same 
 time, we ought to endeavour to remove those causes we have men- 
 tioned, and to cure the diseases with which the woman may happen 
 to be attacked. The sucking of the child, and the frictions we have 
 pointed out, have often proved sufficient to establish the secretion, 
 by exciting the mammary gland; but where this cannot be effected, 
 the woman ought certainly to abstain from nursing her child. The 
 use of what have been denominated galacto-poietic substances has 
 fallen into disuse, with the exception, perhaps, of the anise, the fen- 
 nel and lentils, which, in some women, seem to increase the milk- 
 secretion; but it is proper to observe, that in most women these articles 
 are quite inefficacious. 
 
 While agalactia is more promptly injurious to the child than to its 
 mother, she may likewise, having lost her milk, be attacked with 
 a kind of hectic, attended with a dry cough, and a sense of heat in 
 the chest, which bring on rapid emaciation, if the woman does not 
 wean as soon as these symptoms become manifest. Let us add, that 
 the secretion may be either lessened, suspended, or completely dried 
 up, from the effects of violent grief, fright or anger. Very young 
 women, under eighteen years of age, or those who are too old, above 
 forty, give milk that is not so good, and in smaller quantity, than 
 others. The secretion, also, is generally less plentiful after a first 
 than after the subsequent confinements. But there are some women 
 who have less and less milk after each consecutive lying-in, and who 
 at last have none at all for the second or third child, as if the mam- 
 mary gland became exhausted by the repetition of its action, instead 
 of becoming stronger and stouter by the exercise of its powers, as 
 generally happens with other organs. This is particularly apt to be 
 the case in women who have very small breasts. 
 
 POLYGALACTIA, AND MILK-CONSUMPTION. 
 
 Under these terms, and under that of galactirrhoea, is designated 
 a too abundant secretion of milk, which, however, does not con- 
 stitute a morbid condition, unless the discharge of the liquid affects 
 the woman’s health. This exuberance of the milk is generally ac- 
 companied by insomnia, pains of the back and loins, and lassitude 
 in the lower limbs; the milk becomes limpid, and without any con- 
 sistence ; the child profits but little by its nursing, throws off what it 
 takes, digests it badly, and grows thinner and thinner. 
 
 A galactirrhoea, which mostly is merely an inconvenience, and not 
 a disease, and which may be caused by too succulent a diet, by 
 too frequent application of the child to the breast, or by irritation of 
 the nipple, in general requires, as to the treatment, nothing more 
 than exercise, a vegetable diet, the use of pure water, a less fre- 
 44 
 
690 
 
 POLYGALACTIA. 
 
 quently-repeated application of the child to the breast, and some 
 slight revulsion to the skin, the mucous membranes of the digestive 
 system or the urinary organs, by means of some sudorific doses, 
 small saline doses, Veiss’ whey and diuretic drinks. 
 
 Though galactirrhoea generally affects the health of females but 
 slightly, it may, in some cases, give rise to the symptoms of milk - 
 phthisis , which is preceded by loss of appetite or by constant desire 
 for food, by a burning sensation in the pharynx and stomach, and 
 by pain in the chest, and, lastly, by emaciation and loss of strength, 
 from which more or less speedily death may result. This disease, 
 which has been designated also by the title of nurse's phthisis , 
 ( tabes nutricum,) and which Morton has described so well, some- 
 times appears in women who continue to nurse too long, or who 
 persist in suckling when their constitution is unfit for it. 
 
 The treatment of this kind of phthisis demands, above all, that 
 the child should be weaned, after which the health is soon established 
 if we resort to the employment of food of easy digestion, and pro- 
 portioned to the powers of the stomach ; to moderate exercise, ac- 
 companied by agreeable means of distraction : a milk diet, a tisan of 
 Iceland moss; rhubarb in small doses; effervescing mineral waters, 
 acidulated: blisters to the interior of the thighs, and cups to the 
 back, are likewise very useful in some cases; at the same time, 
 good effects are obtained from the internal and external use of seda- 
 tives, from syrup of white poppies, or from that of lactucarium. M. 
 Rauque recommends the following liniment : 
 
 R. — Cherry laurel water, two ounces; extract of belladonna, two scruples; ether, 
 an ounce. 
 
 We might, moreover, prescribe frictions of the mammae with cam- 
 phorated oil of chamomile, or opodeldoc ; vapour baths, with addi- 
 tion of juniper berries, gum benzoin, and other aromatic substances. 
 
 Involuntary discharge of the milk, which is due to atony or ex- 
 cessive sensibility of the nipple, requires, in the former case, exter- 
 nal and internal excitants, and, in the latter, sedatives. We should, 
 at the same time, resort to astringent applications to the nipple, and 
 to a tonic regimen. M. Nauche speaks of having recommended, 
 with good effects, a weak decoction of rhatany, to overcome invo- 
 luntary flow of the milk. 
 
 Retention of milk in the breasts. In some women it happens 
 that there is excessive secretion of milk, without the excretion of the 
 liquid being thereby augmented. When this is the case, the breasts 
 are distended, painful, and contain indurated points, arranged in lines 
 which extend even to the arm-pits, and give rise to a true inflamma- 
 tory engorgement, if means are not taken to prevent it. In this con- 
 dition, the first indication is to have the breasts emptied by a vigorous 
 child or by an adult, or else by a young puppy, whose feet should be 
 wrapped in linen before he is applied to the breast ; or, lastly, by 
 means of breast-pumps. Care must be taken to keep the breasts 
 warm, at the same time that we endeavour to diminish the secretion 
 of milk, by restricting the patient to a moderately close diet, of sub- 
 
POLYGALACTIA. 
 
 691 
 
 stances not containing a great deal of nutriment, and by insisting 
 upon nearly absolute rest, and especially upon inaction of the upper 
 extremities. We should endeavour, moreover, to encourage perspi- 
 ration and the urinary secretion, by means of weak diaphoretic and 
 diuretic substances ; as, for instance, decoction of the root of the 
 Arundo donax, with the addition of ten or twelve grains of nitrate 
 of potash, or an infusion of borage or tilia-flowers, with a few drops 
 of the spiritus Mindereri. It would be well, at the same time, to act 
 upon the digestive canal, by prescribing an ounce of phosphate of 
 soda or sulphate of potassa, for which might be substituted Weiss’s 
 whey. Should there be inflammation or spasm of the breasts, they 
 might be relieved by means of emollient or narcotic poultices. In 
 case the child should be too weak to nurs.e freely, another nurse, 
 whose milk flows more easily, ought to be chosen. Lastly, if the 
 female prove to be entirely incapable of suckling, she should be sub- 
 jected to more rigorous diet, and some mild purgatives ought to be 
 prescribed. 
 
 We shall add, moreover, that retention of the milk is incurable 
 when it depends upon vicious conformation of the nipple, such as its 
 absence and its congenital or accidental imperforation. If this ano- 
 maly exists in both breasts at the same time, the woman ought 
 always to give up the attempt to nurse the child. The obstruction 
 of the galactophorous ducts is sometimes the result of flattening or 
 induration of the nipple ; in other cases, it may depend upon turge- 
 scence of the mammas ; it often coincides, moreover, with depression 
 of the nipples, which may generally be remedied. 
 
 Alterations of the milk. Under the influence of certain circum- 
 stances, the milk is subject to different alterations in its colour, con- 
 sistence and taste. For example, after nervous diseases, it becomes 
 thin, like water, or of a greenish colour. It assumes a yellowish 
 colour, in inflammations of the mammae, a saltish and disagreeable 
 taste in inflammatory diseases, and, lastly, a sour smell, after labour 
 particularly. It contracts an odour like that of garlic in persons who 
 eat that substance, a reddish colour in those who make use of mad- 
 der, and, lastly, a bluish colour in women who work in indigo manu- 
 factures. To discover whether the consistence of the milk is too thin, 
 or too thick, it is necessary merely to put a drop on one of the nails. 
 If it adheres to it at first, and then spreads without running, it is in 
 the natural condition ; in the contrary case, it is not sufficiently con- 
 sistent ; while it is too thick, if the drop adheres to the nail without 
 spreading. This happens generally in women who have too much 
 embonpoint. In nervous women, the milk is thin, not very nutri- 
 tious, and subject to slight alterations after the slightest vexation. 
 To conclude, very young and very aged women have milk, of quality 
 inferior to that of middle-aged persons. 
 
 Menstruation during lactation renders the milk thin and serous. 
 Pregnancy renders it thick and unfit for the nourishment of children. 
 Different kinds of food, amongst others salt meats, highly-seasoned 
 dishes, mealy vegetables, salad and fruits, make the milk more abun- 
 dant, but thinner ; spirituous drinks, late hours, excessive sleep, and 
 
692 
 
 DISEASES OF THE BREAST. 
 
 all abundant excretions, diminish, on the contrary, the quantity of 
 the fluid, the least alteration of which may have an unfavourable 
 effect upon the child. It is, therefore, of the highest importance, on 
 account of the latter, as soon as possible, to remove these faults, 
 which destroy a large number of children in ail classes of society. 
 
 The treatment of the different alterations ought to consist simply 
 in the removal of the causes which have produced them, either by 
 changing the diet of the nurse, or by curing the affections of the 
 mammae or the other diseases which give rise to them, or else by 
 changing the nurse or by weaning the child when of suitable age. 
 
 DISEASES OF THE MAMMJ3. 
 
 It. sometimes happens, especially in a first lactation, that the nipple 
 becomes the seat of excoriations and fissures that are generally ex- 
 tremely painful. This condition may be produced by the too fre- 
 quent or violent sucking which the infant is forced to use, principally 
 where the nipple is badly shaped, or, if the organ is in the normal 
 state, by the acrid character of the saliva of the child, and by the 
 force with which it draws. 
 
 This state of phlogosis of the nipple may often be prevented by 
 keeping it clean and avoiding any exposure of it to the air and to 
 the contact of the clothes, and especially of the corsets. If it has 
 been impossible, in spite of these precautions, to prevent the deve- 
 lopment of the inflammation, it should be treated by means of emol- 
 lient fomentations or poultices. When ulcerated cracks or fissures, 
 which generally give rise to intolerable pain during suckling, make 
 their appearance, we must combine, with the means we have pro- 
 posed, frictions of cerate containing opium, and not permit the child 
 to nurse until the nipples have been covered with shields made of 
 caoutchouc, softened by plunging them into boiling water for a few 
 minutes, and which should be sweetened with a little honey, after 
 they are applied, in order to tempt the child to seize them. 
 
 Should the ulcerations oi\the nipples be of venereal character, that 
 is to say, forming an ulcer \^ith irregular, perpendicular edges, dis- 
 charging an acrid, ichorous matter, and especially if me female pre- 
 sent other syphilitic symptoms, recourse must be had to a general 
 anti-venereal treatment, and, for the dressings, an equal portion of 
 strong mercurial ointment might be added to the cerate, containing 
 opium. 
 
 To conclude, depression or imperfect development of the nipple 
 may be remedied, by having the breasts gently drawn, for some time 
 before delivery, either by the woman herself, with the aid of a pipe, 
 or by some other person. This result is attained still better by apply- 
 ing over each nipple the mouth of a phial previously warmed, and 
 the mouth being wide and well rounded off. The application of 
 this species of cup generally elongates the nipple and solicits the 
 escape of a greater or less quantity of milk. The operation should 
 be repeated two or three times a day, and care must be taken to 
 wash the nipple each time, with sweetened wine and a little oil of 
 
INFLAMMATION OF THE BREAST, OR WEED. 
 
 693 
 
 sweet almonds. It is proper to add that, in cases where the nipple, 
 after delivery, seems short and small, merely because of the swelling 
 and tension of the breast, it is necessary to suspend the lactation, 
 and feed the child with the bottle, until the tumefaction has sub- 
 sided to such a degree as to render the lactation practicable. 
 
 OF INFLAMMATION OF THE MAMMJE, OR THE WEED. 
 
 Inflammation of the breast is generally developed in lying-in 
 women, or in those who have been recently delivered, and sometimes 
 during lactation, or at the period of weaning. The affection, vulgarly 
 denominated weed , may be the result either of engorgement of milk, 
 the excretion of which occurs with difficulty, of the action of cold or 
 excessive heat, of compression of the glands, of astringent applica- 
 tions, or violence done to the organs, or, again, of the acute pain and 
 irritation which some women experience when the child seizes the 
 nipple. The disease makes its appearance generally on the fourth or 
 fifth day after delivery, and principally affects persons who do not 
 wish to nurse, those who have a great flow of milk and suckle a 
 feeble child, or who wean suddenly, or, lastly, those who have the 
 nipples either too little or too large. Generally, the engorgement is 
 seated in only one breast; but, in some cases, both are diseased at 
 the same time, and sometimes the inflammation passes from one into 
 the other. 
 
 The symptoms of the affection, which may also be produced by 
 violent passions and any acute and sudden emotion, vary as the 
 engorgement is simple or complicated with inflammation. In the 
 former case, which is a milk congestion, merely, the disease is pre- 
 ceded by rigors in the back, followed by heat; but the fever does 
 not generally last more than twenty-four hours, unless the en- 
 gorgement pass into the inflammatory state. The breasts, which 
 were soft and even, become hard, and unequal, but preserve their 
 normal colour. Nevertheless, it sometimes happens that the dis- 
 ordered mamma becomes the seat of indurations, and the secretion 
 of milk is always diminished or completely suspended, while the 
 patient feels a more or less painful sensation, which affects the whole 
 breast, and, in some cases, extends even to the arm-pits. 
 
 In the second condition, that is to say, when the engorgement 
 becomes inflammatory, the mammae, which gradually augment in 
 size, and whose form varies according to the seat of the inflam- 
 mation, become very painful and hard ; are excessively hot and 
 tense, and assume a reddish colour ; the female experiences, at the 
 same time, lancinating and pricking pains ; fever, which is always 
 proportioned to the engorgement, arises; the headache increases 
 more and more, and is acute ; the face flushes, the urine diminishes 
 in quantity, and deposits a whitish sediment; the fecal matters ex- 
 hale an acid odour; lastly, the inflamed breast acquires a consider- 
 able size and tension, which extend even to the arm-pits and to the 
 neck; and sometimes the pains become so acute that cerebral symp- 
 toms and delirium are manifested. 
 
694 
 
 INFLAMMATION OF THE MAMMJE. 
 
 The simple and mild engorgement terminates generally by resolu- 
 tion, whilst suppuration is the most common termination of the inflam- 
 matory and really phlegmonous engorgement. This affection, how- 
 ever, which sometimes passes into the state of induration and scirrhus, 
 very often terminates by resolution, especially if the female clothes 
 herself warmly, and follows a suitable treatment. This fortunate 
 termination is preceded by rapid diminution and disappearance of 
 the inflammatory symptoms, and by gradual softening of the affected 
 gland, which, in some instances, is covered with small drops of per- 
 spiration. It is proper to remark, that there often occur critical 
 evacuations, amongst others sweats, alvine dejections, and abundant 
 and sedimentary discharges of urine. 
 
 We ascertain that suppuration is taking place by the continuation 
 and progressive augmentation of the inflammatory symptoms. The 
 diseased breast constantly increases in size, and becomes, throughout, 
 the seat of throbbing pains and intolerable shootings. The patient 
 has vague and irregular rigors, the skin becomes dry, the fever 
 assumes a marked intermittent character, with evening exacerbation, 
 and sometimes with delirium. At length the existence of fluctua- 
 tion in some portion of the mamma leaves no doubt as to the forma- 
 tion of a purulent collection. We deem it proper to add, that when 
 the engorgement terminates in induration, the progress of the disease 
 is very slow, and the hardness augments by insensible degrees. 
 
 The prognosis of the engorgement under consideration is not un- 
 favourable in itself; but the accidents which may accompany it are 
 often troublesome, for there may result from it abscesses, fistulas and 
 indurations, which dispose to new engorgements in other layers. 
 
 The preventive treatment of the disease consists in the early 
 application of the child to the breasts, in order to empty them as 
 soon as they are filled; and in removing, as far as possible, the causes 
 which give rise to engorgement. The curative treatment, in the be- 
 ginning of milk congestion, consists in the disengorgement of the 
 breast by means of natural or artificial suckling, and by abstinence 
 from very nourishing food or by rigorous diet, while, at the same 
 time, we endeavour to increase the flow of the lochia, or to produce 
 revulsion to the skin or alimentary canal. It is useful, also, to cover 
 the breast with a lamb’s, a rabbit’s or a swan’s skin, and to anoint it 
 with a liniment of oil and liquid ammonia, in proper proportions, 
 especially when there is little or no pain. We might also employ a 
 poultice of flax-seed meal and water, containing soap, with the addi- 
 tion of ten or twelve grains of subcarbonate of potash ; and frictions 
 of oil and lime-water, or of two drachms of camphor dissolved in the 
 yolk of an egg. 
 
 If the engorgement passes into an inflammatory condition, that is 
 to say, if the breast becomes tense and extremely painful, with fever, 
 heat, restlessness, cephalalgia, etc., prompt recourse should be had to 
 bleeding from the arm, then to the application of leeches upon the 
 breast, to the use of emollient and narcotic poultices, to rigorous diet, 
 to sedative drinks, to rest in the horizontal position, to the employ- 
 ment of fumigations to the seat of the disorder, and, lastly, to that of 
 
INFLAMMATION OF THE MAMMiE, 
 
 695 
 
 antispasmodics and sedatives, where the pains are very acute, and 
 especially if the female be nervous. In case the disease should have 
 appeared after a suppression of the lochia, the means proper to 
 recall the discharge ought to be employed ; cups should be applied 
 to the groins, loins and thighs, and calomel in small doses, or some 
 other mild purgatives, must be administered. It is proper to remark, 
 that the female ought not to suckle with the diseased breast, until it 
 has been somewhat disengorged. 
 
 If the engorgement, inclining towards resolution, diminishes, soft- 
 ens and becomes less painful, we should resort to emollient poultices, 
 sprinkled with a few drops of solution of acetate of lead, or red wine, 
 or with a solution of muriate of soda or carbonate of potash. We 
 might also employ, towards the close of the inflammation, the pulp 
 of the hemlock, chervil or parsley, applied very warm to the breasts. 
 Liniments composed of a solution of carbonate of potash, of muriate 
 of ammonia, or of soap in equal parts of water or milk, have also 
 been used with advantage in these cases. Moreover, the effect of 
 these means ought to be seconded by mild purgatives, by suitable 
 regimen, and by careful movements of the arms, so as to bring the 
 pectoral muscles into action, and thus hasten the resolution. 
 
 To conclude, when the engorgement passes into the state of sup- 
 puration, we ought to insist upon emollient topical applications, to pro- 
 mote the formation of pus, which may be much assisted by means of 
 poultices of sorrel and hog’s lard, or of lily-roots roasted in the ashes. 
 When the purulent collection is fully formed and fluctuation distinct, 
 we ought, if the abscess is small, to allow it to open of itself; but if 
 the collection is extensive, and especially if the mammary gland is 
 less affected than the cellular tissue, which may be known by the 
 slight depth of the suppuration, it becomes necessary to give issue to 
 the pus, by means of a vertical incision, made with a narrow lancet 
 or bistoury, in the most dependent part of the tumour; then, after 
 the purulent matter has been evacuated, a little plug of linen is to be 
 introduced into the opening, to prevent it from closing too soon. 
 The dressing should consist of a compress pierced with holes, and of 
 charpie, and the mamma must be enveloped in an emollient poultice, 
 until the heat, pain and induration of the tumour have disappeared. 
 If the breast is very large, it is to be supported by a proper bandage, 
 and we should make use of the revellents indicated above. If fistu- 
 las, discharging small quantities of serous pus, remain, and which 
 heal up slowly, the breast is to be covered with emollient and revel- 
 lent poultices, and it must be washed with soapy and alkaline solu- 
 tions, made gradually stronger and stronger. It is proper to remark, 
 moreover, that the engorgement which terminates by induration, 
 ought to be treated by frictions, repeated several times daily, with 
 some volatile liniment, and by mild purgatives; and, if the tumour is 
 entirely indolent, by plasters of soap, of conium, or by that of vigo. 
 It is always useful to keep the breasts very warm, by covering them 
 with flannel, or with swan or rabbit-skin. 
 
 Our remarks upon the diseases peculiar to females are here brought 
 to a conclusion. While it appears, from the sad picture we have 
 
696 HYGIENE OF THE PREGNANT AND THE PARTURIENT. 
 
 drawn, that the different affections to which they are subject are, for 
 the most part, extremely dangerous, it also appears that it is possible, 
 in most cases, to prevent and to cure them by an early resort to 
 the different prophylactic and therapeutical agents, of which expe- 
 rience proves the efficacy and daily verifies the truth of the old 
 adage : 
 
 Principiis obsta ; sero medecina paratur 
 Cum mala per longas invaluere moras. 
 
 Ovid. — Remedia Amoris. Y. 91 and 92. 
 
 HYGIENE OF PREGNANT AND LYING-IN WOMEN. 
 
 While a pure atmosphere is of the highest importance to health at 
 all periods of existence, it is during the pregnant state especially that 
 it becomes indispensable. Hippocrates, Baillou, Bartholin, Stoll, 
 Lepecq-de-la-Cloture, and several other observers, have remarked 
 the bad effects of a damp or too dry an atmosphere, upon pregnant 
 women, and assert that it predisposes to abortions and to premature 
 labours. They ought, therefore, as far as possible, to breathe an 
 atmosphere which is pure and exempt from all extremes of cold or 
 heat, dryness or humidity. 
 
 Their clothing should be loose, and so arranged as to avoid all 
 pressure upon the breasts, chest, abdomen and stomach. Pressure 
 upon these organs may interfere with the growth of the mammae and 
 the development of the nipples ; it may augment the embarrassment 
 of the respiration, prevent the enlargement of the uterus and its 
 ascent in the abdomen ; and, lastly, become a cause of abortion, or of 
 displacement of the gestative organ, as has been remarked by White 
 and Doering. Pregnant women should especially avoid the use of 
 corsets with busks or whalebones, which are very hurtful, while the 
 pressure which they exert from above downwards acts upon the 
 uterus, forces it to develop itself in a dependent situation, and be- 
 comes a powerful cause of prolapsus uteri, and, according to some 
 authors, a cause of deformity of the foetus, even. They ought to 
 wear, therefore, elastic and very large corsets only, for which should 
 be substituted, after the fifth month, an equally elastic binder, 
 which, embracing the abdomen in every direction, maintains the 
 uterus in a normal position, and, as far as possible, prevents the 
 wrinkles and cracks which are generally the results of pregnancy. 
 During winter, pregnant women ought to take care to wear flannel 
 drawers, in order to escape the action of the cold upon the thighs 
 and sexual organs, which are the more exposed to it because of the 
 prominence of the abdomen, which shortens the petticoats and 
 pushes them forwards. They ought to endeavour likewise to protect 
 the mammae, the shoulders and the superior extremities, from cold. 
 Inattention to this precept has sometimes occasioned very extensive 
 inflammation of the breasts, followed by abscesses, which has not 
 generally been cured until after the delivery. Circular compression 
 of the inferior extremities is no less dangerous, especially towards 
 the latter months of the gestation, for, by retarding the flow of the 
 
BATHING, BLOOD-LETTING, ETC. 
 
 697 
 
 fluids, they produce (Edematous engorgements and varicose dilata- 
 tions of the inferior extremities. 
 
 The use of warm baths, which were always proscribed by the 
 ancients, in pregnant women, is nevertheless very useful. As they 
 promote the cutaneous perspiration, relax the tissues and cleanse the 
 skin, they are suitable for primiparous women, and especially for those 
 of advanced age, whose soft parts are hard and resisting, and whose 
 uterine and abdominal parietes are distended with difficulty : they 
 are prescribed also for the purpose of relaxing the symphyses of the 
 pelvis, of softening the external parts of generation, of preventing 
 lacerations, and to facilitate labour. The use of baths is suitable 
 also for nervous and irritable women, who are very subject to colics 
 and convulsions; they are injurious in those who have much embon- 
 point, in those of lymphatic temperament, and who are subject to 
 oedema and haemorrhages. Persons of the latter description should 
 make use of them only for purposes of cleanliness, therefore, and 
 should remain in them as short a time as possible. The best time for 
 the employment of baths is at the commencement and at the end of 
 the pregnancy ; about the first month, in order to allay the spasm and 
 excitation of the uterus, and in the last, in order to dispose the genital 
 organs to the distension which they are about, to undergo. If we 
 prescribe, or if we consent to the use of baths by plethoric women, 
 it will be most prudent to precede their employment by a bleeding 
 at the arm, performed some days beforehand. In some cases, cold 
 river-baths may be proper ; but the women ought to be careful not 
 to expose the abdominal parietes against the current of the water, 
 which, in that position, would act like a douche. Foot-baths are 
 generally forbidden ; nevertheless, they ought to be allowed for the 
 purposes of cleanliness, with the precaution, however, of keeping 
 the feet in the water only so long as is strictly necessary to cleanse 
 them. 
 
 Bleeding, likewise, ought to be avoided, unless some accident 
 happens, and unless called for by some particular indication. It 
 becomes necessary, on the contrary, to recur to its employment at all 
 periods of pregnancy, in plethoric women, in whom the pulse is 
 strong, full and accelerated, and who suffer from insomnia, from 
 excessive agitation, from cephalalgia, or from nasal, pulmonary or 
 uterine haemorrhages. Bleeding at the arm ought always to be pre- 
 ferred to bleeding from the foot, although the latter, in the greater 
 number of cases, is not followed by any accidents. 
 
 The derangements of the digestive functions and the state of san- 
 guine plethora, which are the general results of pregnancy, suffix 
 ciently indicate that pregnant women ought, especially during the 
 early months, make use only of light food, containing but little nutri- 
 tious matter, of easy digestion, and selected chiefly from amongst 
 the vegetables. Nevertheless, towards the middle of the gestation, 
 the period at which the appetite reappears and the digestive functions 
 are generally re-established, it becomes proper to relax the severity 
 of the regimen, and allow of more food at each repast ; with the 
 precaution, however, of renewing the latter often enough to sup- 
 
69S 
 
 DIET, EVACUATIONS, EXERCISE. 
 
 ply sufficient nourishment, without overloading the stomach. The 
 custom of making pregnant women eat for two , as it is vulgarly 
 expressed, is the more pernicious, because it occasions a super-exci- 
 tation of the digestive organs, which is generally followed by more 
 or less obstinate vomiting, colic or diarrhoea. We must remark, 
 however, that the tastes and desires of the patient should be re- 
 spected, provided they do not concern articles evidently injurious. 
 Though it is wrong to yield to all their caprices of appetite, it is also 
 wrong to resist desires which often persist in spite of them, and 
 which are sometimes the indications of nature itself. It is proper to 
 remark, moreover, that the excessive use of warm drinks may be 
 hurtful, by debilitating and relaxing the stomach ; and that the abuse 
 of fermented drinks, of liqueurs, of coffee and tea, and of irritating 
 condiments, is equally pernicious, by increasing the already too 
 great excitation of pregnant females, from which may result convul- 
 sions. uterine haemorrhages and abortions. The use of iced drinks, 
 which is often one of the best means of allaying gastralgia and 
 vomiting, may also become a cause of abortion ; examples of which 
 are reported by Mauriceau and other authors. 
 
 In some women, we find disorders of the urinary secretion and 
 intestinal excretions. Emollient enemata will be useful to calm not 
 only intestinal and vesical irritations, but also to facilitate digestion, 
 to prevent and overcome vertigo and cerebral congestions, and even 
 to aid, in the primipara, the dilatation of the genital parts, at the 
 moment of delivery. Nevertheless, their habitual use should be re- 
 stricted to the well-ascertained cases that require them ; for they 
 may lead to constipation and intestinal torpor, and an abnormal 
 relaxation of the genital organs. One ought especially to be very 
 circumspect as to the use of purgative injections, which, in conse- 
 quence of the relations existing betwixt the rectum and the womb, 
 may bring on contractions of that organ, and thus give rise to miscar- 
 riage. As a general rule, purgatives ought to be rejected upon the 
 same considerations; and the conduct of those practitioners who 
 prescribe what are called precautionary purgatives, cannot be too 
 much condemned. The use of emetics ought likewise to be pro- 
 scribed; and notwithstanding they are often taken, without effect, 
 by women who desire to make a criminal use of them, still they 
 should never be resorted to except in cases of absolute necessity. 
 
 Exercise, which ought never to be carried to the extent of fatigue, 
 is very useful for pregnant women ; it maintains a regular action 
 of all the functions, prevents the attack of many diseases, and is 
 often a means of cure. The most suitable mode of exercising for 
 such persons is walking, both morning and evening, during the fine 
 weather, and at noon, during the winter. The lengih of the walks 
 should be calculated agreeably to the state of the strength and habits 
 of the woman ; yet there are women who cannot go out their full time 
 except on the condition of keeping perfectly still, and in a horizontal 
 posture. Riding on horseback, or in a carriage, and dancing, expose 
 her to shocks that are the frequent causes of haemorrhages and abor- 
 tion. Moreover, women in a state of pregnancy ought to enjoy 
 
VIOLENT MENTAL IMPRESSIONS. 
 
 699 
 
 protracted sleep, which, in that state, they require more than at any 
 other period of their lives. We ought, therefore, to treat the case of 
 insomnia and agitation to which they are liable, especially in the 
 last months of pregnancy, by baths, exercise and blood-letting, and 
 by some gentle narcotic, such as distilled lettuce-water and orange- 
 flower water, the syrup of thridace, or with certain of the potions 
 into which these articles enter as their basis, and to which may be 
 added some drops of sulphuric ether. The narcotics, properly so 
 called, especially the opiates, do not succeed so well. 
 
 The exalted state of the sensibility in pregnant women, rendering 
 their sensations more acute, and their emotions more energetic, they 
 ought, with equal care, to shun the . occasions of violent impressions 
 upon the physical and upon the moral constitution ; and all objects 
 capable of affecting the imagination should be cautiously kept out of 
 their way; such as tragical spectacles, tlie sight of mutilated people, 
 of the lame, and of all persons affected with loathsome diseases. As 
 they are, in general, persuaded, however erroneously, that the sight 
 of such an object may give rise to a similar deformity in the child in 
 utero, they are violently agitated whenever they meet with it. Be- 
 sides, the records of disease are full of cases of serious disorders, 
 as convulsions, hsemorrhages and abortions, brought on by the sight 
 of some repulsive object, by fright, by a paroxysm of anger, a fit of 
 joy, of hate, of jealousy, or other acute emotion of the soul. From 
 among the numerous histories of this sort, we shall quote one only, 
 from the writings of Sue. It is the case of a woman who was so 
 much affected by the prediction of a gipsy, who foretold that she 
 would die, that she made her will, and died in the eighth month. It 
 is ridiculous to believe in the injurious effects of longings and desires, 
 and the prejudices which pretend that the woman’s imagination may 
 exercise a powerful influence upon her child, and that when she longs 
 for any thing, or is powerfully affected by any object, there is esta- 
 blished a deformity resembling the object of her fright, upon that part 
 of the infant’s body that corresponds to the part of her own surface 
 which she happens first to touch with her finger, after experiencing 
 the sensation. However, as these various causes may produce violent 
 agitation in credulous females, and exert an injurious influence upon 
 the foetus, it is requisite to pay great attention to the state of her 
 mind, so that she may be treated with gentleness and respect, and 
 especially with indulgence as to her caprices and oddities, which 
 are for the most part involuntary. As abortion is often the conse- 
 quence of the voluptuous and tumultuous ecstasies of the venereal 
 indulgence during pregnancy, the conjugal embrace ought to be in- 
 terdicted during the early months, particularly to newly-married wo- 
 men, and to those who have already been subject to abortion. In 
 case, however, of excessive desire in both parties, there might be 
 more inconvenience in resisting, than danger in gratifying it, with 
 moderation. As, during the last six months of gestation, the danger 
 is much less than in the first three months, the indulgence of the 
 habit may be enjoyed with less restraint. 
 
700 
 
 HYGIENE OF PARTURIENT WOMEN. 
 
 HYGIENE OF THE LYING-IN WOMAN. 
 
 The term of pregnancy having arrived, it is important, as soon as 
 the first signs of labour are manifest, to free the woman from such 
 parts of her dress as might prove troublesome, and to order her to 
 take one or two small emollient injections, with a view to empty 
 the large intestines and the rectum; the matters of which, being accu- 
 mulated in their cavities, might render the labour more difficult. It 
 would be likewise useful to introduce the catheter, should the pres- 
 sure exerted by the womb on the neck of the bladder, hinder the 
 patient from discharging the urine. Without trying to prevent her 
 from crying out with the pains, it is proper to advise her to save her 
 strength ; while, under some pretext, we should get rid of all persons 
 who might tease her by their mere presence, — even her mother, her 
 sister, or husband. 
 
 If, notwithstanding the frequency and strength of the pains, the 
 dilatation of the womb progresses very slowly, the patient may be 
 bled, particularly if she be of a strong constitution, and complains of 
 headache and a sense of heaviness of the limbs. As a means of 
 relief for the rigidity of the genital organs, recourse may be had to 
 emollient tepid fumigations to the parts, or to the use of baths and 
 of mucilaginous injections made of marsh-mallows or flax-seed tea, 
 or to the application of some unctuous material to these parts, and, 
 above all, to belladonna ointment. Where the labour is suspended, 
 and the pains become languid, the spurred rye ought to be adminis- 
 tered, yet not until we feel assured that the mouth of the womb is 
 sufficiently dilated. On the other hand, we ought always to reject 
 as hurtful and dangerous, all purgative emetics, irritating injections, 
 and sternutatories, prescribed with a view to arouse the pains and 
 augment the activity of the labour. In fine, when the neck is suffi- 
 ciently open, the bag of waters may be ruptured by gently pressing 
 the finger-nail against the protruding membranes, or by making use 
 of the point of a pair of scissors, guided by the index-finger. 
 
 To avoid, as far as possible, the laceration of the perineum, when 
 that part is distended by the head of the child, which has reached 
 the vulva, we ought not only to support the perineum, by pressing 
 the palm of the hand against the perineum, but we should direct the 
 woman to refrain from bearing-down efforts, and to separate her 
 thighs and not flex them too much on the pelvis, so that the parts 
 being put less upon the stretch, may mould themselves better upon 
 the head of the child. 
 
 [I must caution the inexperienced practitioner not to incur the hazard of 
 rupturing the membranes in primiparous women, except under some well- 
 considered necessity for that act. It is difficult, in such persons, to foretell 
 the precise amount of resistance to be encountered by the child before it 
 can escape from the organs ; and an early rupture of the ovum is not very 
 rarely followed by increased delay in the delivery of the head, — but, as the 
 child is thenceforth subjected to the unmitigated pressure of the womb, 
 
DELIVERY OF THE SECUNDINES. 
 
 701 
 
 which is irritated by the contact of the child’s body, from around which the 
 waters have thus been removed, the woman is exposed not only to the mis- 
 hap of giving birth to a still-born child, but she runs some risk of being 
 afterwards subjected to a forceps or an embryulcia operation for her delivery. 
 I may make the additional remark, that the reasons for supporting the peri- 
 neum are the following: — Professor Carus’s curve consists in an arc of a 
 circle whose radius is two and a half inches, and which may be described 
 as follows : — Cut a pelvis in two, vertically, from front to rear, with a saw. 
 Set one leg of a pair of compasses upon the posterior edge of the bisected 
 symphysis pubis ; open the other leg two and a half or two and three- 
 quarter inches ; then describe a circle through the pelvis, from top to bot- 
 tom, and carry the curve up in front of the pelvis. This curve of Professor 
 Carus is the curved axis of the pelvis, — and the centre of the child’s ence- 
 phalon, in the act of being born, moves coincidently with this curved 
 line. Now, when the accoucheur supports the perineum, he does so with 
 no other view than to compel the head to move coincidently with this 
 curve, or, in other words, to prevent it from descending at a tangent to the 
 arc ; in doing which, it must carry away the perineum or rupture it. I do 
 not think that when the womb is thrusting the head downwards, we ought 
 to prevent the descent of the head ; for, in so doing, we oppose an obstacle 
 so great that we expose the patient to the risk of laceration of the womb or 
 vagina, or both. If we compel the head to move along, in the direction of 
 Carus’s curve, and exhort the patient not to bear down, we do all that it 
 behoves us to do for her interest and safety in the premises. — M.] 
 
 When the child is born, we should next attend to the delivery of 
 the after-birth, which is generally effected by a few pains, and which 
 may be facilitated by taking hold of the umbilical cord and gently 
 pulling it downwards. After this operation, which the accoucheur 
 commonly need not attend to until after he shall have given some 
 attention to the child, the vulva must be cleansed, as well as all the 
 parts that are soiled with the discharges, either by washing them, 
 with pure warm water, or a mixture of wine and water, where the 
 parts appear much relaxed. 
 
 The woman may with propriety be left upon her cot, as long as 
 fluid blood continues freely to flow from the organs ; but we should 
 not too long delay putting her into the bed that she is Vo use for the 
 rest of her lying-in, unless some haemorrhage, convulsion or other 
 accident, the consequence of extreme weakness, should intervene. 
 In such case, we ought to wait awhile, to give time to the functions 
 to recover their natural rate ; yet, be the woman ever so well, she 
 must be forbidden to rise and walk to her bed, for, by doing so, she 
 exposes herself to the danger of having some displacement of the 
 womb, and to a thousand other accidents ; it is well, even, to bring 
 the two beds side by side, so that she can be made to slide from one 
 into the other, almost without moving her body, by pulling the sheet 
 on which she laid to be delivered. 
 
702 
 
 PUTTING TO BED — THE BREASTS. 
 
 Previously to transferring her to her bed, we ought always to 
 direct the nurse to put clean linen on the patient, taking care that it 
 be well aired first and moderately warmed, and never follow the 
 absurd prejudice that pretends that a woman ought not to change 
 her linen until the seventh day or the ninth day after her delivery. 
 
 When the patient is comfortably put to bed, which, in cool or 
 damp weather, ought to be warmed, her breasts are to be covered 
 with a soft napkin or muslin handkerchief, folded in eight ; but the 
 breasts ought never to be compressed, nor kept immoderately warm, 
 nor ought we to allow any repercussive or astringent poultice, with 
 a view to hinder the coming of the milk. The same rule holds 
 as to the binder for the belly, which ought to be lightly applied, so 
 as to be merely a contentive bandage. It commonly consists of a 
 napkin, folded into a triangle, the point being directed towards the 
 vulva ; the bandage to cover the hypogastrium, is a napkin folded in 
 three, lengthwise, and which is used as a body bandage, to pass 
 round the abdomen, and comprehending the hips. To prevent this 
 bandage from slipping, or becoming uncomfortable, it should be 
 secured to straps passing over the shoulders, like a pair of suspenders. 
 It should also be kept down by attaching to it the two ends of the 
 napkin , to be used by the woman as her T bandage, with a view to 
 receive the lochial discharges. 
 
 [Let me again caution the younger reader against M. C., with whom I 
 cannot here agree. The napkin is to be used as a receiver. If it be too 
 strongly pressed against the genital fissure, by the method indicated by our 
 author, there is reason to fear that it may act as a tampon, and by prevent- 
 ing the escape of coagula, or of fluid blood, may give rise to a concealed 
 haemorrhage. — M.] 
 
 Inasmuch as when, speaking of milk-fever, of the lochia, and of 
 inflammation of the mamma;, we treated of other cares required, as 
 to the woman, we shall rest satisfied here, to prevent repetition, with 
 saying that the woman ought to be in a large chamber, well venti- 
 lated, warmed in the winter season, but with the air renewed once 
 or twice a day, by opening the windows, after carefully covering the 
 patient and closing her curtains. A calm state of mind, and rest for 
 the body, are indispensable. The ancients were so well convinced 
 of the usefulness of this precept, that, at Rome, even the magistrate 
 had no right to enter the house of a lying-in woman, to execute a 
 sentence. Juvenal says, that in order that all the citizens might 
 respect this asylum, it was necessary merely to suspend a garland at 
 the door. 
 
 Foribus suspende coronas, 
 
 Jam pater es 
 
 The visits of friends, neighbours and acquaintances, ceremonious 
 visits, and calls of relatives, are among the frequent causes to which 
 may be attributed a variety of diseases of the lying-in woman, that 
 lead to the most serious consequences. 
 
 The time that a woman ought to remain in bed, is necessarily very 
 
DIES MUNDINiE. 
 
 703 
 
 variable ; and the fixed term of nine days, adopted by the vulgar, 
 can only be so as a mean and general term. In some instances, six 
 days are sufficient ; whereas, in other cases, fifteen, and even twenty 
 days, are indispensable, particularly where the symphyses have been 
 strained, where the womb is disposed to prolapsion, and where the 
 general health is precarious. Furthermore, the first trial of sitting 
 up should not be protracted beyond half an hour, or an hour at most, 
 upon a couch or sofa ; but women ought never to consecrate their 
 first going out to a visit to the church, to perform what is called their 
 relevuilles. The cold damp air of a church, the kneeling posture in 
 which they place themselves, expose them to dangerous attacks. 
 Enlightened and true religion would forbid such imprudences, and 
 ordains rather, that previously to proceeding to the church to return 
 thanks to God for her recovery, the lying-in woman should first 
 recover her strength at home, and go out only during the fine 
 weather, and not until she is satisfied she can venture into the air 
 without hazard. There is another custom that requires the strict 
 care of the physician, to wit, the baptismal feast, at which the lying- 
 in woman ought not to be present, unless it take place after the tenth 
 day, and even then she should take great care lest the days of re- 
 joicing should be followed by days of mourning. 
 
INDEX 
 
 OF 
 
 AUTHORS REFERRED TO. 
 
 Aetius, 65, 74, 80, 81, 121, 152, 154, 165, 
 284, 293, 381, 384, 400, 452, 483, 495, 
 513, 514, 519, 529, 533, 654. 
 
 Ahrun, 519. 
 
 Albers, 578. 
 
 Alberti, 519, 529. 
 
 Albinus, 381, 493. 
 
 Albucasis, 65, 74, 82, 134. 
 
 Alibert, 309, 320, 322, 343, 408, 445, 488. 
 Aliiot, Pere, 451. 
 
 Amard, 519. 
 
 Ameline, 155, 169. 
 
 Amussat, 382, 453, 476, 477. 
 
 Andral, 107, 381,411,412,420,421,422, 
 496, 497, 503, 513, 524, 662. 
 Andrieux, 476. 
 
 Ane, 177, 182. 
 
 Antillus, 121. 
 
 Antipater, 400. 
 
 Archigenes, 65, 452. 
 
 Aretaeus, 121, 307, 513, 519, 529, 537, 
 654. 
 
 Aristotle, 24, 31, 87, 121, 571. 
 
 Armstrong, 286, 655, 661, 668, 679. 
 Arnaud, 77, 113. 
 
 Arnault, 578, 580. 
 
 Arronssohn, 360. 
 
 Asdrubali, 220. 
 
 Aspasia, 121, 154, 165. 
 
 Assalini, 456. 
 
 Astruc, 25, 32, 152, 284, 313, 314, 368, 377, 
 519, 578, 579. 
 
 Atlee, 417. 
 
 Avenel, 348. 
 
 Avicenna, 65, 74, 82, 90, 307, 452, 495. 
 Aumonier, 417. 
 
 Babin, 198. 
 
 Bache, F., 183. 
 
 Baer, 381. 
 
 Baglivi, 314. 
 
 Baillie, 238, 421. 
 
 Baillou, 313, 314, 495, 512, 519, 696. 
 Bailly, 524. 
 
 45 
 
 Ballard, 511. 
 
 Banks, 44. 
 
 Barbaut, 55, 261, 580. 
 
 Barbeyrac, 519. 
 
 Barlet, 157. 
 
 Barnes, 243. 
 
 Barret, 198. 
 
 Barruel, 499. 
 
 Barry, 28, 460, 576. 
 
 Barthelemi, Emile, 220, 223. 
 
 Barthez, 519. 
 
 Bartholin, of Copenhagen, 76, 215, 235, 
 282, 696. 
 
 Barton, J. Rhea, 263, 266, 444. 
 
 Basil, St., 517. 
 
 Baudelocque, 32, 118, 155, 162, 169, 177, 
 179, 182, 190, 193, 203, 219, 233,346, 
 367, 370, 395, 407, 465, 470, 578, 579, 
 580, 668. 
 
 Baudelocque, the younger, 669, 677, 678. 
 Bauhin, 75, 93, 143. 
 
 Baumes, 519. 
 
 Baumgarten, 168. 
 
 Bauner, 364. 
 
 Baxter, 152. 
 
 Bayle, 335, 446, 581. 
 
 Baynham, 167. 
 
 Bazin de Basseneville, 155. 
 
 Bazoni, 322. 
 
 Beau, 501. 
 
 Beaujon, 258. 
 
 Beaulieu, 143. 
 
 Beauregard, 234. 
 
 Beckerus, 76. 
 
 Bedard, 407. 
 
 Begin, 453, 469. 
 
 Beherens, 586. 
 
 Behling, 234. 
 
 Bell, Benjamin, 314, 370,453. 
 
 Charles, 448. 
 
 Thomas, 580, 584. 
 
 Bellanger, 163, 164. 
 
 Bellemain, 578. 
 
 Bellini, 247, 365. 
 
706 
 
 INDEX OF AUTHORS REFERRED TO, 
 
 Bellon, 80. 
 
 Benedicti, 368. 
 
 Benevenius, 88, 152. 
 
 Benevoli, 105, 114. 
 
 Beniveni, 77. 
 
 Benoiston de Chateau-Neuf, 42. 
 
 Berard, Auguste, 26, 147, 151, 214, 408. 
 Berner, 501. 
 
 Bernhard, 152. 
 
 Berthelot, 353. 
 
 Berthold, 586. 
 
 Bertholini, T., 211. 
 
 Bertrand, 353. 
 
 Bertze, 65. 
 
 Bessiere, 198. 
 
 Bianchi, 574. 
 
 Bichat, 29, 54, 308, 381, 386, 519, 521, 
 533. 
 
 Bicknell, 207. 
 
 Biett, 448. 
 
 Billard, 198, 199. 
 
 Binninger, 519, note. 
 
 Birbeck, James B., 577. 
 
 Bird, 155, 417. 
 
 Bischoff, 26, 28, 34, 460, 576. 
 
 Blache, 496. 
 
 Blackmore, 519. 
 
 Blancard, 375, 382, 433, 516. 
 
 Blandin, 354, 355, 386. 
 
 Blasius, 165. 
 
 Blaud, 474, 496, 502, 509, 510. 
 
 Blanche, 581. 
 
 Blayn, 496. 
 
 Blegny, 516. 
 
 Blizard, 580. 
 
 Blundell, 241, 364, 416, 428. 
 Bobe-Moreau, 131. 
 
 Bochard, 233. 
 
 Bocquet, 322. 
 
 Boehmer, 127. 
 
 Boer, 158, 169, 225. 
 
 Boerhaave, 280, 381, 501, 514, 519, 529, 
 536, 595. 
 
 Boisseau, 496, 520. 
 
 Boivin, Mad., 65,68, 79, 132, 155, 156, 163, 
 164, 169, 170, 172, 176, 188, 191, 193, 
 198, 324, 374, 412, 427, 429. 
 
 Bond, H., 594. 
 
 Bonfils, 355, 469. 
 
 Bonnet, Theoph., 234, 307, 375, 382, 496. 
 Bonnie, 575. 
 
 Bordeu, 29. 
 
 Bosquillon, 654. 
 
 Bouchard, 581. 
 
 Bouchardet, 485. 
 
 Bouchet, of Lyons, 189, 404. 
 
 Boudet, 217. 
 
 Boudon, 245, 390, 395, 400. 
 
 Bouillaud, 496, 500, 501. 
 
 Bourgeois, Louise, 615, 680. 
 
 Bourjot, St. Hilaire, 486. 
 
 Bousquet, 54. 
 
 Bouteillier, 633. 
 
 Bouvet, 385. 
 
 Boyer, 99, 114, 118, 143, 145, 150, 168, 178, 
 195, 201, 214, 246, 355, 388, 404, 409, 
 445, 451,452,453. 
 
 Boyle, 386. 
 
 Brachet, 496, 519, 536, 538, 539. 
 
 Brainerd, Daniel, 98, 99. 
 
 .Brande, 485. 
 
 Brasador, 401. 
 
 Braun, 451. 
 
 Brem, 411. , 
 
 Bremser, 381. 
 
 Brendelius, 228. 
 
 Brera, 470, 476. 
 
 Breschet, 52, 54, 355, 381, 385, 386, 578, 
 580, 662. 
 
 Breyer, 584. 
 
 Bricheteau, 578. 
 
 Brierre de Boismont, 22, 33, 39, 485. 
 Brodie, 148. 
 
 Bromfield, 382. 
 
 Brouard, 144. 
 
 Broussais, Casimir, 468, 536, 655, 660. 
 Broussonnet, 310. 
 
 Brown, R., 429, 654. 
 
 Brueck, 496. 
 
 Brugnatelli, 382. 
 
 Brunninghausen, 142, 155. 
 
 Bruyer, 575. 
 
 Bry de Bouillon, 575. 
 
 Buchan, 561. 
 
 Buchner, 501. 
 
 BufFon, 514. 
 
 Bugniard, 451. 
 
 Buisson, 54. 
 
 Burnet, Tho., 519. 
 
 Burns, of Glasgow, 203, 208, 330, 429, 634. 
 Bussidre, 574. 
 
 Cabanis, 496. 
 
 Cabaret, 113. 
 
 Cabini, 493. 
 
 Cabrol, 86, 88, 113. 
 
 Caignoux, 355. 
 
 Caillot, 54, 118, 434. 
 
 Callisen, 158, 429. 
 
 Camerarius, 76. 
 
 Campbell, 233. 
 
 Camper, 147, 198, 429, 453. 
 
 Canella, 355. 
 
 Canonico, 580. 
 
 Cappivacci, 451, 534. 
 
 Capuron, 132, 150, 241. 
 
 Carget, of Pampeluna, 162. 
 
 Carron de Villards, 100, 342, 476. 
 Carmichael, 451. 
 
 Carpue, 189. 
 
 Carpus, 152. 
 
 Carus, 218, 578, 701. 
 
 Castro, Rod. a, 38, 154, 309, 314, 495, 496, 
 571. 
 
 Cayol, 335, 446, 654. 
 
 Cazeaux. 287, 291. 
 
 Celsus, 74, 89, 90, 92, 385, 400, 452, 485, 
 513, 530, 654. 
 
INDEX OF AUTHORS REFERRED TO, 
 
 707 
 
 Cerlata, 452. 
 
 Chailly, 244, 287. 
 
 Chambon, 77, 93, 523. 
 
 Chapman, 641. 
 
 Chapponnier, 476, note. 
 
 Chardin, 80. 
 
 Charleton, 307, 313. 
 
 Charriere, 65, 341. 
 
 Charlton, 314, 519. 
 
 Chassaignac, 407. 
 
 Chassagne, Dufresne, 259. 
 
 Chatelain, 469. 
 
 Chaussier, 201, 202, 226, 285, 556, 575, 
 654, 655, 660, 662. 
 
 Chelins, 249. 
 
 Chesneau, 519. 
 
 Chester, 429. 
 
 Cheselden, 452. 
 
 Chevalier, 92. 
 
 Chit, 578. 
 
 Chomel, 654. 
 
 Christian, of Liverpool, 201, 202. 
 Christophe de Vega, 152. 
 
 Chrysmer, 417, 432. 
 
 Churchill, 174,418, 419. 
 
 Fleetwood, 321, 416. 
 
 Cigna, 276. 
 
 Civatte de Siteron, 52. 
 
 Clarke, 152, 155, 401, 486, 575, 616, 662. 
 Claubry, 396. 
 
 Clay, 417, 418. 
 
 Cleghorn, 429. 
 
 Clifton, 25. 
 
 Cloquet, Jules, 127, 144, 146, 209, 390, 453, 
 480, 518. 
 
 M. H., 381,537. 
 
 Cocke tt, 155. 
 
 Coelius Aurelianus, 519, 530. 
 
 Coindet, 476, 535. 
 
 Colin, 390. 
 
 Collineau, 233, 325. 
 
 Collins, of Dublin, 632, 637, 676, 677. 
 Colomb, of Lyons, 584. 
 
 Colombus, 118. 
 
 Columella, 31. 
 
 Comarmond, 486. 
 
 Come, 188, 451, 456. 
 
 Condon, 105. 
 
 Cooper, Sir Astley, 201, 202, 204, 208, 209, 
 432, 457, 458. 
 
 B., 417. 
 
 Samuel, 201, 429, 453. 
 
 Copping, 577. 
 
 Copland, 499. 
 
 Corbin, 448, note. 
 
 Cormick, 107, 108. 
 
 Corriol, 473, note. 
 
 Coste, Baer, 28, 460. 
 
 Coster, 517. 
 
 Courtial, 576, 578. 
 
 Crantz, 232. 
 
 Cromer, 553. 
 
 Crosse, J. Greene, 184. 
 
 Crouzit, 268. 
 
 Cruveilhier, 332, 355, 377, 381, 390, 391, 
 
 421, 422, 423, 434, 580, 662. 
 
 Cullen, 460, 476, 492, 496, 519, 536. 
 Cullerier, 26, 178, 263, 315, 325. 
 
 Curade d’Avignon, 201, 202. 
 
 Cypriaan, 575, 580, 584. 
 
 Daillez, 175, 179, 182. 
 
 Dance, 277, 578, 662, 664. 
 
 Darwin, 431. 
 
 Duverney, 54. 
 
 David, of Rouen, 401. 
 
 D., 684. 
 
 Davies, D., 669. 
 
 Davis, John, 396. 
 
 Davy, 485. 
 
 De Cordibus, 367. 
 
 Deganosse, 355. 
 
 De Graaff, 25, 28, 122, 307, 313, 381, 385, 
 460, 574. 
 
 Dehaen, 32, 107, 204, 205, 206, 429, 430, 
 431,433. 
 
 D’Huc, 203. 
 
 Deidier, 451. 
 
 Dejours, 107. 
 
 Delaberge, Louis, 464, 471, 499. 
 
 De la Corde, Maurice. 
 
 De la Croce, Andreas, 65. 
 
 Delamotte, 134, 179, 220, 232, 367, 486, 
 626, 639. 
 
 Delaporte, 430, 431, 432. 
 
 Delaroche, 655. 
 
 Delaunay, Ch., 577. 
 
 Deleau, 143. 
 
 Deleurie, 189. 
 
 Delisle, 580. 
 
 Delloir, 151. 
 
 Deloob, 519. 
 
 Delpech, 113, 153, 176, 219, 247, 362, 366, 
 
 422, 423, 429, 432. 
 
 Demarchais, 80. 
 
 Deneux, 169, 198, 199, 218, 225, 227, 373, 
 406, 431, 655. 
 
 Denis, 485. 
 
 Denman, 157, 169, 170, 178,219,232,386, 
 427, 429. 
 
 Dessault, 188, 190, 227, 245, 246, 386, 391, 
 401,453, 455, 456. 
 
 Deschamps, 153, 250, 262. 
 
 Desgranges, 113, 155. 
 
 Desmarais, 377. 
 
 Desormeaux, 143, 162, 165, 169, 177, 210, 
 219, 231, 381, 464, 492, 496, 512, 583, 
 585, 633. 
 
 Devaux, 128,228. 
 
 De Vega, 368, 370. 
 
 Deveux, 367. 
 
 Deventer, Henry, 173, 174, 232. 
 
 Dewees, 165, 186, 187, 271, 593, 614, 641 
 Deyber, 65, 250. 
 
 Dezeimeris, 287. 
 
 Diemerbroeck, 78, 224, 431, 519. 
 
70S 
 
 INDEX OF AUTHORS REFERRED TO, 
 
 Dieterich, 451. 
 
 Dieffenbach, 213, 220, 223, 252, 418, 433. 
 Diogenes Laertius, 529. 
 
 Dionis, 82, 284, 401, 453, 485, 577. 
 
 Divoux, 201. ' 
 
 Dobson, 32. 
 
 Dodonceus, 367. 
 
 Daering, 196. 
 
 Doloeus, Jean, 309. 
 
 Dolhoff, 417, 418. 
 
 Donatus Marcellus, 76, 235, 376, 382. 
 Donne, 275, 315, 316, 321, 485. 
 
 Doublet, 654, 659, 660. 
 
 Douglass, 234. 
 
 Doulcet, 660. 
 
 Dowman, 451. 
 
 Dubois, A., 65, 179, 190, 356, 401, 409, 451, 
 464, 518, 569, 632, 655. 
 
 Dubois de la Boe, 536. 
 
 Dubois, Paul, 26. 
 
 Thibaud, 237. 
 
 d’Amiens, 529 note , 536. 
 
 Dubled, 365. 
 
 Ducreux, 127, 150. 
 
 Dufrenois, 322. 
 
 Duges, '25, 79, 80, 132, 143, 150, 151, 156, ; 
 163, 167, 169, 170, 171, 172, 176, 188, j 
 190, 191, 192, 193, 209, 252, 324, 330, ! 
 374, 376, 386, 412, 496, 514, 519. 
 Dumeril, 476. 
 
 Dumoulin, 519. 
 
 Dunn, John, 235. 
 
 Dunus, 367. 
 
 Duparcque, 232, 233, 241, 299, 300, 302, 1 
 303, 304, 305, 330, 339, 493. 
 
 Dupuys, 499. 
 
 Dupuytren, 77, 93, 116, 118, 147, 201,213, ! 
 219, 220, 222, 246, 247, 258, 261, 267, ! 
 323, 344, 349, 354, 355, 373, 386, 387, | 
 389, 390, 392, 401, 404, 406, 408,409, 1 
 411,529, 451,453, 455, 456. 
 
 Duret, 422, 519, 533. 
 
 Dussaussoy, 164. 
 
 Duval, 128. 
 
 Duvernoy, 574. 
 
 Pzondi, 432. 
 
 Egge, 232. 
 
 Ehrmann, 250. 
 
 Emett, 25. 
 
 Engel, 54, 118. 
 
 Erasistratus, 513. 
 
 Ergot, 341, 477. 
 
 Esqnirol, 518. 
 
 Ettmuller, 318, 495, 517, 654. 
 
 Evratt, 451. 
 
 Eydoux, 473, note , 474. 
 
 Fabre, 355. 
 
 Fabricius ab Aquapendente, 88. 
 
 Faivre, 153, 189. 
 
 Fallopius, 401. 
 
 Fatio, 249. 
 
 Fearon, 339, 447, 451. 
 
 Feburier, 243. 
 
 Fern, 578. 
 
 Fernel, 309, 314, 376, 519, 570. 
 
 Ferrand, 176, 185. 
 
 Ferrin, 107. 
 
 Fincke, 487, 492. 
 
 Fitzgerald, 32. 
 
 Flamand, 91, 92, 93, 105, 113, 114, 477. 
 Fodere, 30, 69, 107, 110, 118. 
 
 Foedich, 513. 
 
 Fonseca, 318. 
 
 Fontenelle, Julia, 485. 
 
 Ford, 429. 
 
 Forestus, 220, 318, 496, 519. 
 
 F othergill, 42. 
 
 Foubert, 453, 456. 
 
 Fourcroy, 451. 
 
 Foville, 519, 536. 
 
 Fox, George, 182, 186. 
 
 Franck, 113, 367, 368, 431, 433, 496. 
 Freind, 32, 308, 470, 496. 
 
 Fresart, P., 314. 
 
 Fritz, 477. 
 
 Fritzel, 237. 
 
 Fronton, 406. 
 
 Fuchs, 451. 
 
 Gaddesdex, 451. 
 
 Gall, 24. 
 
 Galen, 25, 32, 75, 81, 284, 305, 307, 318, 
 339, 347, 354, 355, 373, 385, 386, 387, 
 389, 390, 392, 401, 404, 406, 408,409, 
 411, 429, 447, 451, 453, 455, 456, 495, 
 496,513, 519, 571, 654, 675. 
 Galenzowski, 432. 
 
 Gardien, 54, 168, 178, 182, 431, 469, 492, 
 496, 502, 512, 519, 536. 
 
 Garengeot, 65, 205, 429, 453. 
 
 Garin, 127. 
 
 Garthshore, 155. 
 
 Gasc, 678. 
 
 Gattinaria, Marcus, 152. 
 
 Gauthier, 113. 
 
 Gendrin, 25, 26, 27, 28, 34, 365, 461. 
 Gensoul, 404. 
 
 Genselius, 586. 
 
 Georget, 514, 519, 528, 536. 
 
 Gerard, Chs., 536. 
 
 Gerdy, 386. 
 
 Gerentel, 518. 
 
 Gesner, 516. 
 
 Gilbert, 83, 475. 
 
 Girardin, 151. 
 
 Giroud, 132. 
 
 Goldson, 234. 
 
 Goliken, 318. 
 
 Gooch, 189. 
 
 Gordon, of Aberdeen, 286, 420, 655, 661, 
 672. 679, 681. 
 
 Gorter, 32, 519. 
 
 Goulard, 178, 215, 451. 
 
 Goubelly, 540. 
 
 Gradibus, J. Math, de, 367, 370. 
 
 Graaff, 31. 
 
INDEX OF AUTHORS REFERRED TO. 
 
 709 
 
 Grsefe, 518. 
 
 Grainger, 386. 
 
 Grammont, 134. 
 
 Grandpre, 451. 
 
 Granville, 189,417,418, 576. 
 
 Gregoire, 154. 
 
 Greenhow, 417. 
 
 Grenier, 148, 267. 
 
 Grenville, 427, 432, 433. 
 
 Grownhawn, 586. 
 
 Guerin, 266. 
 
 Guenee, 354. 
 
 Guersant, 223. 
 
 Guerbois, 262. 
 
 Guillemeau, 93. 
 
 Guillon, 65, 143, 356, 360. 
 
 Gutberlat, 362. 
 
 Hagendorix, 211. 
 
 Hahnemann, 341. 
 
 Hall, Marshall, 151. 
 
 Halle, 320, 432. 
 
 Haller, 32, 38, 59, 119, 126, 135, 198, 428, 
 465, 470, 519, 536. 
 
 Hamilton, 496, 512, 520, 536, 679. 
 Hanneman, 571. 
 
 Hargraves, 419. 
 
 Hatin, Jules, 100, 322, 355, 356. 
 
 Hay, 263, 264, 431, 578. 
 
 Heath, 418. 
 
 Hecker, J. F. C., 567. 
 
 Heidenrich, 578. 
 
 Heister, 76, 110, 113, 211, 222, 339, 401, 
 452. 
 
 Helvetius, 561. 
 
 Heming, 213. 
 
 Herbin, 578. 
 
 Herbiniaux, 179, 386, 398,401,406,408, 
 409. 
 
 Hertry, 577. 
 
 Hervez de Chegoin, 115, 136, 155, 386, 
 389, 406, 408, 409. 
 
 Heurnius, 307. 
 
 Hey, 286, 429, 655, 668, 674, 679. 
 Hildanus, 88, 91, 196, 239, 241, 244, 245, 
 445. 
 
 Hill, James, 453. 
 
 Hilscher, 245. 
 
 Hippocrates, 31, 32, 42, 87, 93, 94, 121, 
 154, 176, 276, 305, 307, 312, 317, 318, 
 38 1,385, 400, 40 1 , 447, 472, 476, 492, 
 495, 513, 519, 533, 566, 571, 585, 654, 
 696. 
 
 Hoechstetter, 367. 
 
 Hoelscher, 363. 
 
 Hodge, 183. 
 
 Hoffman, 25, 227, 284, 307, 318, 385, 389, 
 476, 488, 492, 493, 496,512. 
 
 T., 519, 525, 531, 536. 
 
 Hoffmeister, 578. 
 
 Hoin, 188, 203, 205, 213. 
 
 Holt, Ths., 233. 
 
 Home, SirEverard, 198. 
 
 Hooper, 155, 330, 422, 436. 
 
 Horace, 72. 
 
 Horn, 127, 131, 654. 
 
 Horner, 95. 
 
 Howship, 429. 
 
 Huerman, 377, 453. 
 
 Hufeland, 305, 339, 447. 
 
 Huguier, 395, 396, 426. 
 
 Hunalt, 520, 536. 
 
 Hunter, G., 429. 
 
 Wm, 59, 631, 632, 666. 
 
 Jno., 141, 155, 157, 167, 168, 384, 
 
 429, 433, 485. 
 
 Husson, 465, 662. 
 
 Huston, B. M., 103, 207, 636. 
 
 Hutchinson, 509. 
 
 Hygmore, 520, 529. 
 
 Imbert, 451. 
 
 Irving, 151. 
 
 Ischier, 432. 
 
 Itard, 376. 
 
 Jacquemin, 325. 
 
 Jadelot, 53. 
 
 Jahn, 155, 168. 
 
 James, 182, 186, 580. 
 
 Janot, 587. 
 
 Jauzion, 516. 
 
 Jeafferson, 417. 
 
 Jean Maria, 536. 
 
 Jewel, 116, 118. 
 
 Jobert, 324. 
 
 Johnson, 429. 
 
 W. P., 151, 189. 
 
 Jolly, 516. 
 
 Jones, 28, 460. 
 
 Josephi, 584. 
 
 Joubert, 30, 65, 368, 370, 382, 597. 
 Jourdan, 26. 
 
 Jourel, 167. 
 
 Jouy, 577. 
 
 Junot, 492. 
 
 Justamont, 451. 
 
 Juvenal, 514. 
 
 Kaetschmxtt, 386. 
 
 Kapp, 451. 
 
 Kapser, 432. 
 
 Kelni, 577. 
 
 Kempel, 341. 
 
 Kennedy, Evory, 70, 570. 
 
 Kerckring, 127, 476. 
 
 Kergaradec, 69. 
 
 Key, 417, 430. 
 
 King, 417, 418. 
 
 Kinneir, Douglas, 661. 
 
 Kirshner, 155, 156. 
 
 Klein, 155, 529. 
 
 Koeller, 385. 
 
 Kravel, 346. 
 
 Kruger, 578, 579. 
 
 Labare de Benzeville, 182., 
 
 Labarraque, 273. 
 
 Lachaise, 547. 
 
710 
 
 INDEX OF AUTHORS REFERRED TO. 
 
 Lachapelle, Mad., 193, 219, 225, 5S5, 587, 1 
 633. 
 
 Lacombe, 457. 
 
 Laennec, 378, 381, 428. 
 
 Lafflize, of Nantes, 432. 
 
 Lagneau, 314, 355. 
 
 Lallemand, 163, 164, 241, 257, 258, 447. 
 Lallement, 54, 194, 195, 198, 578, 579. 
 LambaUe, J. J. de, 260. 
 
 Lambergen, 451. 
 
 Lambron, 237. 
 
 Lamothe, 654. 
 
 Lamoite, 280, 569. 
 
 Larnzweerde, 386, 571. 
 
 Lancisi, 529. 
 
 Lane, 417. 
 
 Lanfranc, 452. 
 
 Langenbeck, 153, 362, 363, 364. 
 
 Langius, 152, 227, 495. 
 
 Lankrisch, 385. 
 
 Lapeyronie, 346. 
 
 La Pitie, 63. 
 
 Lapoterie, 456. 
 
 Largus, Scribonius, 400. 
 
 Laroche, 143, 404. 
 
 Laroux, 182. 
 
 Larrey, 212, 298, 344, 600. 
 
 Lartet, 578. 
 
 Lassus, 198, 199, 200, 431, 445. 
 
 Latham, 429. 
 
 Latour, 92, 114. 
 
 Laugier, 259, 401, 578. 
 
 Laumonier, 412. 
 
 Lauvariol, 346. 
 
 Lauverjeat, 188, 198, 645. 
 
 Lavagna, 485. 
 
 Leake, 662. 
 
 Leblanc, 131, 177, 203, 205, 206, 404. 
 Lecat, 25, 401, 452. 
 
 Lecanut, 485, 513. 
 
 Lecieux, 235. 
 
 Leduc, 366. 
 
 Ledran, 305, 423, 429, 430, 447, 452, 456. 
 Lee, 21, 25, 27, 28, 34, 286, 461, 521, 643, 
 646, 669, 671, 684. 
 
 Lefevre, 567. 
 
 Leger de Gouey, 575, 612. 
 
 Legouais, 667, 668, 669, 674. 
 
 Lejeune, 409. 
 
 Lemman, 432. 
 
 Lemaunoir, 432. 
 
 Leonard de Bertapaglia, 552. 
 
 Leonidas, 452. 
 
 Leo Africanus, 80. 
 
 Lepecq-de-la-Cloture, 696. 
 
 Lepine, 261. 
 
 Lepis, Chas., 536. 
 
 Lepois, 519, 529, 536. 
 
 Le Roux, 54, 175. 
 
 Le Roy, 492, 536. 
 
 Lesne, 249. 
 
 Lesueur, 44, 341. 
 
 Levaillant, 44. 
 
 Levannier, 404. 
 
 Leveille, 131. 
 
 Levis, 183. 
 
 Levret, 82, 107, 134, 155, 158, 162, 166, 
 169, 174, 175, 179, 213, 232, 386, 389, 
 394, 395,401, 404, 406, 518, 615, 654, 
 659. 
 
 Lewzinski, 249, 250. 
 
 L’Heritier, 471, note. 
 
 Liebaud, 314. 
 
 Lieutaud, 54, 107, 118, 281, 382, 432, 519. 
 Linnaeus, 32, 519. 
 
 Lisfranc, 24, 45, 46, 47, 49, 50, 52, 54, 57, 63, 
 65, 122, 147, 295, 297, 299, 305, 323, 
 333, 336, 339, 341, 344, 345, 347, 348, 
 350, 357, 358, 359, 361, 370, 401, 406, 
 408, 409, 447, 448, 450, 453, 455, 471, 
 475, 495,519, 535. 
 
 Littre, 575. 
 
 Lizar.s, of Edinburgh, 364, 415, 417, 418, 
 429, 430, 432, 433. 
 
 Lobstein, 25, 406. 
 
 Locock, 427. 
 
 Loder, 127, 211. 
 
 Loefler, 401. 
 
 Logger, 421. 
 
 Lordat, 492. 
 
 Lory, 519, 529. 
 
 Loudon, 476, 512. 
 
 Louis, 381, 382, 456, 662. 
 
 Louyer Villermay, 514, 519, 532,536,540. 
 Lugol, 474. 
 
 Lycurgus, 546. 
 
 Macdowei, 432. 
 
 Mackenzie, 237. 
 
 Mackintosh, 480, 481, 565, 666, 668, 669, 
 679. 
 
 Magendie, 32, 476. 
 
 Mahon, 110. 
 
 Major, 69. 
 
 Malagodi, 251. 
 
 Malgaigne, 341, 386, 387, 391, 399. 
 
 Mallat, 486. 
 
 Mainaldus, 577. 
 
 Manning, 234. 
 
 Marat, 678. 
 
 Marcus Aurelius. 
 
 Maret, 194. 
 
 Marignes, 126, 150. 
 
 Marjolin, 153, 324, 345, 355, 389. 
 Marshall, 152,213, 421. 
 
 Martial, 82. 
 
 Martin, M. H., 383, 418, 432. 
 
 , 114, 575. 
 
 Martineau, 429. 
 
 Martini, of Lubeck, 430. 
 
 Masuyer, 480. 
 
 Mathias, 82. 
 
 Mauduyt, 476, 512. 
 
 Maune, 390. 
 
 Maunsel, Wm., 124. 
 
 Mauriceau, 81, 82, 88, 122, 126, 127, 131, 
 132, 148, 150, 176, 281, 284, 314, 315, 
 367, 376, 389, 570, 587, 639, 698. 
 
INDEX OF AUTHORS REFERRED TO. 
 
 711 
 
 Mayer, of Bonn, 52, 386, 409, 578, 661. 
 Mayor, of Berlin, 405, 580. 
 
 Mayor, of Lausanne, 298, 360, 401, 404. 
 McDowell, 417, 418. 
 
 Mead, 24, 427. 
 
 Meckel, 46, 157, 421, 578, 662. 
 
 Meckren, 88, 213, 215. 
 
 Meisner, 401. 
 
 Menier, 578. 
 
 Mercatus, 315, 470, 495, 512, 519. 
 Mercurialis, 284, 571. 
 
 Merklin, 425. 
 
 Merriman, 155, 157, 639, 649. 
 
 Metzer, 118. 
 
 Meudon, 429. 
 
 Michaelis, 654. 
 
 Miguet, 344. 
 
 Miller, 337, 339. 
 
 Millot, 188. 
 
 Mcehring, 183. 
 
 Mojon, 485, 581. 
 
 Monneret, 464, 471, 499. 
 
 Monfalcon, 409. 
 
 Monro, 122, 376, 377, 422, 427, 429, 431, 
 452, 453. 
 
 Montaigne, 262. 
 
 Montain, 220. 
 
 Montana, 235. 
 
 Montanier, 575. 
 
 Monteggia, 246, 346. 
 
 Montpelier, 170. 
 
 Morand, 108, 135, 211, 381, 422, 431. 
 Moreau de la Sarthe,31, 41, 131, 218, 287. 
 Morlane, 235. 
 
 Morland, 114. 
 
 Morgagni, 89, 91, 92, 105, 107, 110, 113, 
 116, 119, 193, 281, 307, 309, 310, 339, 
 381, 431, 434, 457, 516, 519, 536, 585. 
 Morris, 417. 
 
 Morton, 690. 
 
 Morus, Michael, 382. 
 
 Moschion, 82, 88, 386, 406, 513, 514, 571. 
 Mott, Valentine, 266. 
 
 Moudot, 578. 
 
 Moulin, 231, 232, 233, 578. 
 
 Muratt, Jean, 88, 194, 198, 406,412,421, 
 431. 
 
 Murey, 52. 
 
 Murel, 42. 
 
 Murray, 155. 
 
 Musa, Anthonius, 400. 
 
 Mutter, 116, 219. 
 
 Muzeau, 448, 450. 
 
 Naboth, 110, 113. 
 
 Nsegele, 250, 370, 376. 
 
 Nathan, 432. 
 
 Nauche, 70, 126, 166, 172, 237, 376, 382, 
 412, 428, 476,512, 690. 
 
 Negri, 322, 493. 
 
 Negrier, 25, 26, 27, 28, 34, 461, 462. 
 Neuter, G. P., 309, 519. 
 
 Neuville, 237. 
 
 Newnham, 152, 189. 
 
 Nicholson, 21. 
 
 Nicod, 446. 
 
 Nicoton, 119. 
 
 Noel, 220. 
 
 Nollet, John, 147. 
 
 Norford, 451. 
 
 Norris, George, 83. 
 
 North, 453. 
 
 Novarra, 580. 
 
 Nysten, 401. 
 
 Ochmar, 453. 
 
 Ollivier d’Angers, 26, 468. 
 
 Orfila, 39, 261, 537. 
 
 Oribasius, 198, 284, 513. 
 
 Osborn, 492. 
 
 Osiander, 25, 30, 134, 149, 189, 342, 346, 
 347. 
 
 Ovid, 499, 517, 696. 
 
 Palella, 241, 245. 
 
 Pallas, 381. 
 
 Papen,. 198. 
 
 Paracelsus, 25, 451. 
 
 Pare, 65, 75, 93, 128, 152, 339, 346, 368, 
 370, 386, 529, 534. 
 
 Paroisse, 432. 
 
 Pasta, 32, 284. 
 
 Patterson, 476, 478. 
 
 Patin, 480. 
 
 Patuna, 578, 580. 
 
 Paulus JEginetta, 65, 75, 80, 82, 152, 293, 
 452, 453, 495, 513, 516. 
 
 Pauly, 24, 49, 54, 305, 333, 341, 477. 
 
 Pe, Lazare, 314. 
 
 Pearson, 448. 
 
 Pechlin, 470. 
 
 Pecquet, 382. 
 
 Pelletier, 251. 
 
 Percy, 379, 381. 
 
 Peron, 44. 
 
 Perreau, 662. 
 
 Perry, 519. 
 
 Petit Radel, 404, 428, 552. 
 
 , J. L., 197, 243, 249, 453, 455, 575. 
 
 , M. A., 107, 190, 305, 447. 
 
 Peu, 234, 241. 
 
 Peyrille, 152, 451. 
 
 Philips, B., 417. 
 
 Philotenus, 385, 401, 406. 
 
 Philoxenes, 400. 
 
 Physick, 141, 593, 630. 
 
 Pidoux, 537. 
 
 Piesch, 211. 
 
 Pignana, 493. 
 
 Pimpernelle, 453. 
 
 Pinault, Severin, 307. 
 
 Pinel, 308, 314, 496, 518, 519, 655. 
 
 Piorry, 471, 476. 
 
 Pirminius Gassarus, 577. 
 
 Pissier, 451. 
 
 Pitcairn, 313, 519, 520,536. 
 
 Planchon, 228. 
 
 | Plato, 57,476,519, 546. 
 
712 
 
 INDEX OF AUTHORS REFERRED TO, 
 
 Plater, 76, 431. 
 
 Flazzoni, 107, 224. 
 
 Plenck, 110, 114. 
 
 Pliny, 25,31,38,74,514. 529. 
 
 Plunket, 451, note. 
 
 Pomme, 519, 523, 529, 536, 540. 
 
 Poot, 431. 
 
 Portal, 54, 126, 127, 150, 368, 392, 421, 428, 
 429,430, 431. 
 
 Potts, 198, 200,347. 
 
 Pouchet, 482, 568. 
 
 Pousse, L. M., 457. 
 
 Pouteau, 147, 234, 305,441,445, 447, 654. 
 Powel, 237. 
 
 Power, 431. 
 
 Pressavin, 519. 
 
 Preuner, 143. 
 
 Primrose, 314, 496, 519. 
 
 Prochaska, 436. 
 
 Pujol, of Castre, 519. 
 
 , of Montpellier, 496, 499. 
 
 Purcel, 168, 530, 536. 
 
 Purkinje, 28, 460, 460. 
 
 Puzin, 233. 
 
 Puzos, 178, 376, 587, 615, 641, 642, 654, 
 659. 
 
 QuARijr, 322. 
 
 Quenesville, 507, 511. 
 
 Quettenbaum, 417. 
 
 Raciborski, 21, 26, 28, 29, 461, 510, 511. 
 Radamet, 287. 
 
 Radel, 428. 
 
 Radford, 234. 
 
 Rahn, 496. 
 
 Rameaux, 471, note. 
 
 Ramsden, 430, 431. 
 
 Ramsbotham, 580. 
 
 Ranchin, 495. 
 
 Randolph, Jo., 102. 
 
 Rapon, 519. 
 
 Raspail, 381. 
 
 Rast, of Lyons, 318. 
 
 Rauque, 690. 
 
 Raulin, 310, 519, 529, 536. 
 
 Raymond, 313, 470. 
 
 Recamier, 65, 67, 143, 152, 259, 305, 333, 
 341, 344, 347, 354, 355, 361, 364, 365, 
 366, 400, 401, 408, 447, 448, 452, 476, 
 493, 535. 
 
 Rech, 514. 
 
 Rega, 58. 
 
 Regnard, 557. 
 
 Reichard, 227. 
 
 Renauldin, 54. 
 
 Renaulme, 452. 
 
 Reusner, 451. 
 
 Reuss, 381. 
 
 Rey, 190, 225. 
 
 Rhazes, 452. 
 
 Ribes, 662. 
 
 Richerand, 314, 390,453, 456, 457, 518. 
 Richter, 155, 205, 211, 213, 429, 431. 
 
 Ricord, 65, 262, 276, 314, 315, 321, 322. 
 Ricque, 65. 
 
 Rideux, 572. 
 
 ! Ridley, 519. 
 
 | Riolan, jun., 76, 106, 519, 574. 
 j Ritter, 417. 
 
 Riverius, 318, 491, 519, 596. 
 
 Robert de Lille, 201, 202, 203. 
 
 Robouham, 252. 
 
 Roche, 201, 464, 496. 
 
 Roderick, 404. 
 
 Roederer, 232. 
 
 Rogers, D., 417. 
 
 Rognetta, 135, 136, 145, 166, 201. 
 Romieux, 578. 
 
 Rondelet, 30. 
 
 Rondelou, 488. 
 
 Rondet, Mad., 136, 201. 
 
 Ronseeus, 470. 
 
 Roonhuysen, 76, 88, 249. 
 
 Rooselot, 451. 
 
 Rostan, 465, 537, 561. 
 
 Rouget, 687. 
 
 Rougemont, 198. 
 
 Rousseau, 492. 
 
 Roussel, 24, 37, 134, 189, 227, 459, 569. 
 Rousset, 152, 197, 198, 452. 
 
 Roux, 135, 220, 221, 222, 223, 250, 252, 
 366, 382, 386, 391, 445, 453, 477. 
 
 , A., 147. 
 
 Royer Collard, 470. 
 
 Ruan, 91,271. 
 
 Rufus, 513. 
 
 Rullier, 519, 528. 
 
 Runge, 580. 
 
 Rungius, 234, 575. 
 
 Rush, 673. 
 
 Ruysch, 46, 88, 91, 127, 150, 153, 193, 197, 
 198, 203, 262, 381, 382, 389. 
 
 Ryan, 241. 
 
 Sabatier, 131, 134, 147, 148, 164, 237, 
 383, 394, 529, 431, 453, 457. 
 Sablairoles, 476. 
 
 Saisard, 54. 
 
 Salathe, 287, 288. 
 
 Salmuti, 235, 368. 
 
 Sanctorius, 379. 
 
 Sandifort, 201, 202. 
 
 Sanson, 201, 244, 453, 464. 
 
 Saucerotte, 220. 
 
 Sauker, 519. 
 
 Saumet, 107. 
 
 Sauter, of Constance, 362, 364, 365, 494. 
 Sauvages, 176, 315, 368, 496, 519, 534. 
 j Savage, 495. 
 
 Savary, 655. 
 
 Saviard, 88, 122, 127, 128, 131, 143. 
 Saxtorph, 155, 197. 
 
 Scarpa, 201, 208, 209, 453. 
 
 Schacher, 211, 212, 386. 
 
 Schacht, 519. 
 
 Schenck, John, 88, 382. 
 
 Schenck, of Nuremburg, 375. 
 
INDEX OF AUTHORS REFERRED TO, 
 
 713 
 
 Schlessing, 346. 
 
 Schmidt, 155, 156, 451, 569, 578. 
 Schmucker, 227. 
 
 Schneider, 156. 
 
 Schreger, 244, 251, 255. 
 
 Schultz, 76. 
 
 Schulzius, 245. 
 
 Schwann, 460. 
 
 Schweighauser, 155, 156. 
 
 Schwilgai, 662. 
 
 Scudamore, 429, 430. 
 
 Scultetus, 65, 452. 
 
 Sedillot, 220, 262. 
 
 Segalas, 101. 
 
 Segard, 404. 
 
 Segrot, 168. 
 
 Seguin, 204. 
 
 Seneca, 542. 
 
 Sennerlus, 93, 196,491, 495, 496,519, 531, 
 532. 
 
 Serres, 45. 
 
 Seymour, 411, 415, 421, 428, 429, 430. 
 Sibergundi, 158. 
 
 Siebold, 363, 405, 409, 453. 
 
 Sigaud Lafond, 476, 512. 
 
 Simmons, 228. 
 
 Simpson, 25, 391. 
 
 Sims, 201. 
 
 Simson, 113, 386, 645. 
 
 Sinibaldus, 78. 
 
 Smellie, 32, 157, 158, 206, 280, 281,595, 
 633. 
 
 Smith, A. G., 417. 
 
 , N., 417. 
 
 Soemmering, 381, 385, 456. 
 
 Soby, 514. 
 
 Solenander, 368. 
 
 Solingen, 88, 577, 584. 
 
 Solly, 655. 
 
 Solon, M., 412. 
 
 Sonnini, 80. 
 
 Soranus, 88, 121, 152, 198, 513, 514, 519. 
 Sorbait, 77. 
 
 Southam, 416, 417. 
 
 Spachius, 65, 154, 386. 
 
 Sparjani, 493. 
 
 Sparmann, 44. 
 
 Spaering, 580. 
 
 Stahl, 25, 320, 476, 487, 520. 
 
 Stark, 580. 
 
 Stein, 198. 
 
 Steelier, 385. 
 
 Stilling, 417. 
 
 St. Maurice, 57 5. 
 
 Stoll, 492, 586, 696. 
 
 Stoltz, 107, 108, 112, 113, 118, 287, 288, 
 370, 477. 
 
 Storck, 322, 451. 
 
 Strambio, 422. 
 
 Strother, 654. 
 
 Sue, 227. 
 
 Suidas, 82, 431. 
 
 Sultzer, 451. 
 
 Sunot, 477, 
 
 Suret, 143. 
 
 Swammerdam, 381. 
 
 Swenck, 516, note. 
 
 Sydenham, 318, 492, 495, 512, 514, 519, 
 524, 529, 533. 
 
 Sylvius, 25, 309, 529. 
 
 Syme, 155, 158, 164, 167. 
 
 Tackard, 44. 
 
 Tagault, 452. 
 
 Talenta, J. V. de, 370. 
 
 Tanqueret des Planches, 496. 
 
 Taranta, 367, 370. 
 
 Tarral, 365. 
 
 Taveau, 557. 
 
 Teallier, 333, 335, 339, 344. 
 
 Theden, 54, 401, 429. 
 
 Then-Rhine, 44. 
 
 Thevenot, 80. 
 
 Thibert, 471. 
 
 Thiebault, 453, 456. 
 
 Thompson, 65. 
 
 Thoumain, 395. 
 
 Thouret, 524, 
 
 Thuillier, 453, 456. 
 
 Tiedemann, 59, 521. 
 
 Timaeus, 451. 
 
 Tissot, 495, 496, 519, 529, 540, 561. 
 
 Toilet, Fr., 203. 
 
 Tonnele, 662. 
 
 Toulmouche, 113. 
 
 Tourtelle, 487. 
 
 Trainel, 220. 
 
 Trallianus, 293, 400. 
 
 Treviranus, 580. 
 
 Triller, 452, 553. 
 
 Trolliet, 536. 
 
 Tronchin, 559. 
 
 Trousseau, 270, 271, 476, 493, 496, 537, 
 Tulpius, 346, 406. 
 
 Turnbull, 578, 580. 
 
 Turnebus, Adrian, 198. 
 
 Ulmanst, 342. 
 
 Vacher, 305, 447, 453. 
 
 Valerius Maximus, 561. 
 
 Valescus, de Tarenta, 38, 451. 
 
 Vallerand, 575, 580. 
 
 Vallisnieri, 54, 381. 
 
 Valsalva, 91, 339. 
 
 Vander Bosch, 487. 
 
 Vanderhaar, 431. 
 
 Vandoeveren, 158. 
 
 Vanderwiel, 213, 234, 571. 
 
 Vandeusande, 661. 
 
 Vanhelmont, 24, 42, 59, 512. 
 
 Vanswieten, 280, 313, 381, 529, 660 
 Varande, 495, 518. 
 
 Vargas, 21. 
 
 Varoquier, 575. 
 
 Vater, 406. 
 
 Vauguyon, 452. 
 
 Vaulre, 538. 
 
714 
 
 INDEX OF AUTHORS REFERRED TO. 
 
 Vedekin, 494. i Walter, Wall, 154, 155. 
 
 Veidmann, 191. j Walther, 381. 
 
 Velpeau, 52, 67, 112, 214, 249, 258, 259, Warner, J. S., 141. 
 
 262, 263, 321, 355, 381, 409,453, 455, Warrington, 183. 
 
 478. 571, 575, 583, 589, 611, 640, 642, Weikard. 310. 654. 
 
 654, 661, 683. 
 
 Velter, 434. 
 
 Ventusa, 113. 
 
 Verheyen, 31, 580. 
 
 Verdier, 198, 199, 205. 
 
 Verduc, 452, 453. 
 
 Vesalius, 375, 451, 519, 529. 
 Veslingius, 226. 
 
 Viardel 91. 
 
 Vidal di Cassis, 220, 260, 261, 272. 
 Vieussens, 575. 
 
 Vigarous, 178, 519, 654. 
 
 Vigny, 341. 
 
 Villars, Caron du, 322. 
 
 Villeneuve, 409. 
 
 Villerme, 143. 
 
 Villette, 92. 
 
 Virey, 546. 
 
 Viricel, of Lyons, 167. 
 
 Virgil, 113. 
 
 Viridet, 519. 
 
 Vogel, 520, 536. 
 
 Voigtel, 157. 
 
 Voisin, 112, 518. 
 
 Wagner, 127, 128, 150, 460. 
 Waille, 107, 116. 
 
 Waller, 370. 
 
 Walne, 417, 418. 
 
 Walter, 59, 249, 385. 
 
 Weinhard. 578, 584. 
 
 Weinknecht, 578. 
 
 Weinrien, of Breslau, 571. 1 
 
 Wepfer, 422. 
 i WerlhofF, 24. 
 
 West, 417, 477. 
 
 Wharton, 28, 460. 
 
 White, 655. 
 
 Why tt, 519, 529. 
 
 Widman, 211, 215. 
 
 Wierus, 88, 431. 
 
 Willaume, 113, 477. 
 
 Willis, 91, 428, 514, 419, 423, 536, 540. 
 654, 659. 
 
 | Wilson, 270, 575, 662. 
 
 I Windsor, 152, 153, 189. 
 j Wirer, 377. 
 
 Wizezech, 155. 
 
 } Wlesling, 80. 
 
 | Wrisberg, 189, 346. 
 
 [ Young, 448. 
 
 Zacchias, 30, 82, 118. 
 
 ! Zacutus Lucitanus, 408, 519. 
 
 Zang, 377, 541, 453, 455, 456. 
 
 Zeller, 143, 453. 
 j Ziegert, 487. 
 
 Zimmermann, 82. 
 
INDEX 
 
 OF 
 
 DISEASES OE FEMALES. 
 
 Abscess of the ovarium, vide Ovarium 
 
 of the womb, vide Uterus 
 
 Abortion, 585 
 
 causes, 586 
 symptoms, 588 
 prognosis, 591 
 treatment, 591 
 cases, 587, 589 
 
 After-pains succeeding delivery, 649 
 treatment, 650 
 Agalactia, 688 
 
 treatment, 689 
 Agrypnia, or insomnia, 628 
 treatment, 628 
 Amenorrhoea, 463 
 causes, 463 
 symptoms, 466 
 diagnosis, 470 
 prognosis, 473 
 treatment, 473 
 Anorexia, 599 
 
 treatment, 599 
 
 Anteversion of the womb, vide Uterus 
 Anteflexion of the womb, vide Uterus 
 Atresia of the Fallopian tubes, vide Fallo- 
 pian Tubes 
 
 Boulimia, 599 
 
 treatment, 600 
 
 Calculi of the Womb, 381 
 causes, 382 
 treatment, 384 
 Cancer of the uterus, 328 
 varieties, 328 
 causes, 331 
 symptoms, 333 
 diagnosis, 336 
 prognosis, 337 
 treatment, 338 
 extirpation of, 360 
 
 of the breast, 441 
 
 causes, 441 
 symptoms, 442 
 
 Cancer, diagnosis of, 446 
 prognosis, 446 
 treatment, 447 
 case, 444 
 
 of the ovarium, 433 
 
 causes, 434 
 symptoms, 434 
 diagnosis, 435 
 prognosis, 435 
 treatment, 436 
 
 of the vagina, 437 
 
 treatment, 438 
 Cephalalgia, 627 
 
 varieties, 627 
 treatment, 627 
 
 Cervix uteri, occlusion of, 113 
 remedy, 114 
 Chlorosis, 495 
 
 causes, 499 
 symptoms, 500 
 diagnosis, 503 
 prognosis, 507 
 treatment, 507 
 Chronic metritis, 293 
 
 without engorgement, 294 
 
 with engorgement, 295 
 
 Clitoris, unnatural development of, 82 
 cases, 83 
 excision of, 83 
 
 Compression, in case of cancer in the 
 breast, vide Cancer 
 Constipation, 604 
 
 treatment, 605 
 
 Contusions of the vagina, vide Vagina 
 
 of the mammae, vide Mammae 
 
 Convulsions, puerperal, vide Eclampsia 
 Cough, 609 
 
 varieties, 609 
 treatment, 610 
 
 Cystocele, vaginal, vide Hernia 
 
 Dropsy of the womb, vide Hydrometra 
 
 of the ovarium, vide Ovarium 
 
 Diarrhoea, 605 
 
716 
 
 INDEX OF DISEASES OF FEMALES. 
 
 Diarrhoea, treatment of, 606 
 Dysentery, 605 
 
 treatment, 606 
 Dysmenorrhoea, 479 
 causes, 479 
 symptoms, 479 
 treatment, 480 
 Dyspepsia, 600 
 
 prognosis, 600 
 treatment, 600 
 Dysphagia, 601 
 
 treatment, 602 
 Dyspnoea, 606 
 case, 607 
 treatment, 607 
 
 Eclampsia, 632 
 
 causes, 633 
 symptoms, 635 
 treatment, 639 
 
 Encysted tumours of the vulva, 440 
 
 labia majora, 439 
 
 treatment, 440 
 
 mammae, 457 
 
 varieties, 458 
 treatment, 458 
 
 Engorgement, chronic metritis, without, 
 294; with, 295 
 
 of the uterus, 297 
 
 treatment, 298 
 
 with haemor- 
 rhage, 30 1 
 
 treatment, 302 
 
 with indura- 
 tion, 363 
 
 . treatment, 304 
 
 scirrhous, 305 
 
 symptoms, 304 
 treatment, 305 
 
 uterine, 476 
 
 treatment, 476 
 Enteralgia, 604 
 
 treatment, 604 
 
 Extirpation of cancerous uterus, 360 
 Sauter’s method, 362 
 Recamier’s, 364 
 Tarral and Gendrin, 365 
 Dubled’s, 365 
 
 of the ovary, vide Ovary 
 
 Fallopian Tubes, atresia of, 115 
 
 inflammation of, 410 
 
 causes, 410 
 symptoms, 410 
 diagnosis, 413 
 prognosis, 413 
 treatment, 414 
 case, 412 
 
 dropsy of, 420 
 
 causes, 423 
 symptoms, 423 
 treatment, 428 
 Fever, milk, 652 
 puerperal, vide Peritonitis 
 
 | Fistula, vesico-vaginal, 238 
 
 treatment, palliative method, 243 
 tamponnement, 245 
 cauterization, 246 
 the suture, 249 
 the author’s method, 252 
 Lallemand’s, 257 
 Dupuytren’s, 258 
 Laugier’s, 258 
 Recamier’s, 259 
 Jobert de Lamballe’s, 260 
 Vidal’s, 260 
 
 recto- vaginal, 261 
 
 cases, 262, 263, 264 
 treatment, 263 
 
 Dr. J. Rhea Barton’s method, 
 264 
 
 Furor uterinus, vide Nymphomania 
 
 Gangrenous Inflammation of the Labia 
 Majora, 273 
 Gastralgia, 602 
 
 treatment, 603 
 Gastro-intestinal spasm, 538 
 causes, 539 
 varieties, 539 
 treatment, 540 
 
 Heartburn, 602 
 
 treatment, 602 
 Hernia, uterine, 194 
 
 1. Inguinal 
 cases, 194, 195 
 
 2. Crural 
 cases, 195, 196 
 
 3. Ventral 
 case, 197 
 treatment, 197 
 
 ovarian, vide Ovarium 
 
 — of bladder in the vagina, 201 
 
 causes, 201 
 cases, 202 
 treatment, 203 
 
 vaginal, 205 
 
 causes, 205 
 treatment, 206 
 case, 207 
 
 vulvar, 208 
 
 treatment, 209 
 Haemoptysis, 616 
 
 prognosis, 617 
 treatment, 617 
 Haemorrhage, uterine, 483 
 varieties, 486 
 causes, 487 
 diagnosis, 489 
 prognosis, 490 
 treatment, 490 
 
 during pregnancy, 610 
 
 treatment, 613 
 Haemorrhoids, 624 
 
 treatment, 625 
 Hydatids of the womb, 378 
 causes, 779 
 
IftDEX OF DISEASES OF FEMALES. 
 
 717 
 
 Hydatids, diagnosis of, 379 
 treatment, 380 
 
 Hydrometra, 374 
 causes, 374 
 symptoms, 375 
 diagnosis, 375 
 prognosis, 376 
 treatment, 377 
 
 Hypersemia of the womb, vide Uterus. 
 
 Hysteralgia, 540 
 
 symptoms, 541 
 treatment, 541 
 
 Hysteria, and other spasmodic diseases, 
 518 
 
 causes, 523 
 symptoms, 524 
 treatment, 532 
 
 Hysteriform attacks, 536 
 causes, 537 
 symptoms, 528 
 treatment, 541 
 
 Hysterocele of the womb, 194 
 inguinal, 195 
 crural, 195 
 ventral, 196 
 treatment, 197 
 
 Hysterotomy, 351 
 
 cases, 353, 354, 355 
 author’s method, 356 
 after-treatment, 358 
 
 Hygienic rules in relation to Puberty, 542 
 Menstruation, 545 
 Union of the sexes, 546 
 Change of life, 549 
 
 Hygiene of women, 552 
 
 1. Circumfusa, 552 
 
 2. Applicata, 554 
 
 3. Ingesta, 558 
 
 4. Excreta, 559 
 
 5. Gesta, 559 
 
 6. Percepta, 561 
 
 of pregnant and lying-in women, 
 
 696 
 
 bathing and blood-letting, 697 
 diet, evacuations, exercise, 698 
 violent mental impressions, 699 
 labour, 700 
 
 Impotence and Sterility, 562 
 causes, 563 
 treatment, 566 
 
 Immobility of the womb, vide Uterus 
 
 Inclination, or obliquity of the womb, 
 vide Uterus 
 
 Inertia of the womb, 685 
 causes, 685 
 treatment, 686 
 
 Inflammation, acute, of the vagina, vide 
 Vagina 
 
 of the uterus, vide Uterus 
 of the ovaria, vide Ovaria 
 of the Fallopian tubes, vide Fallopian 
 Tubes 
 
 of the mammae, vide Mammae 
 
 Inversion of the womb, vide Uterus 
 Insomnia, 628 
 
 treatment, 628 
 Invagination of vagina, 214 
 Inversion of vaginal mucous membrane, 
 209 
 
 causes, 210 
 symptoms, 210 
 prognosis, 21 1 
 treatment, 212 
 
 Jaundice, 506 
 
 Labia Majora, union of, 76 
 case, 76 
 treatment, 78 
 contusion of, 216 
 treatment, 216 
 phlegmon of, 272 
 gangrenous inflammation of, 273 
 treatment, 273 
 
 Lactation, lesions relative to, 688 
 polygalactia, 689 
 galactirrhcea, 689 
 alterations of the milk, 691 
 Leucorrhoea, 307 
 causes, 308 
 acute, 310 
 subacute, 311 
 passive chronic, 311 
 prognosis, 316 
 treatment, 320 
 Lochia, 651 
 
 treatment, 651 
 
 Malacia, 600 
 
 treatment, 601 
 Mammae, diseases of, 692 
 treatment, 692 
 inflammation of, 693 
 symptoms, 693 
 prognosis, 694 
 treatment, 694 
 
 contusions and wounds of, 229 
 treatment, 230 
 Menstruation, 22 
 
 commencement of, 23 
 derangements, 459 
 immoderate flow during pregnancy, 
 483 
 
 cessation, 37 
 absence of, 30 
 case, 30 
 
 hygienic rules concerning, 542 
 Metritis, puerperal, 277 
 treatment of, 284 
 acute, 284 
 
 treatment of, 284 
 chronic, 293 
 
 with engorgement, 295 
 Metrorrhagia, 486 
 essential, 486 
 sympathetic, 487 
 symptomatic, 493 
 
718 
 
 INDEX OF DISEASES OF FEMALES. 
 
 Metrorrhagia, treatment of, 493 
 Metrorrhage, 610 
 
 treatment, 611 
 Milk-fever, 652 
 
 symptoms, 652 
 treatment, 653 
 Miliary eruptions, 687 
 treatment, 688 
 Moles, 570 
 
 causes, 572 
 diagnosis, 572 
 treatment, 573 
 
 Nausea and Vomiting, 595 
 treatment, 596 
 Neuritis, puerperal, 6S4 
 treatment, 684 
 Neuroses, ocular, 629 
 treatment, 629 
 cases, 630 
 
 Nymphas, cohesion of, 79 
 cases, 79 
 remedy, 80 
 
 excessive development of, 80 
 excision of, 82 
 case, 83 
 
 Nymphomania, 513 
 causes, 515 
 symptoms, 515 
 treatment, 516 
 
 (Edema of the Vulva, 438 
 treatment, 439 
 of pregnant women, 625 
 treatment, 626 
 painful, 682 
 treatment, 684 
 Odontalgia, 598 
 
 treatment, 598 
 
 Os tincae, eruptions upon, 323 
 treatment, 324 
 
 chancres, 325 
 
 treatment, 326 
 
 scrofulous ulcers, 325 
 
 treatment, 326 
 
 Ovaria, inflammation of, 410 
 causes, 410 
 symptoms, 410 
 diagnosis, 413 
 prognosis, 413 
 treatment, 414 
 case, 412 
 
 Ovarium, hernia of, 198 
 causes, 199 
 treatment, 200 
 
 dropsy of, 420 
 
 varieties, 421 
 causes, 423 
 symptoms, 423 
 diagnosis, 425 
 prognosis, 427 
 treatment, 428 
 
 extirpation of, 417 
 
 cases, 417 
 
 Palpitation, 619 
 causes, 619 
 treatment, 619 
 case, 620 
 
 Perineum, rupture of, 217 
 treatment, 217 
 cases, 219, 221, 223 
 Peritonitis, puerperal, 654 
 causes, 654 
 symptoms, 655 
 diagnosis, 658 
 prognosis, 658 
 treatment, 659 
 
 Pessaries in prolapsus uteri, 133 
 uses of, 150, 151 
 j Phlebitis, uterine, 661 
 symptoms, 662 
 treatment, 664 
 
 other kinds of puerperal phlebitis, 665 
 Plethora, sanguine, 618 
 symptoms, 618 
 treatment, 619 
 
 ' Physometra of the womb, 366 
 causes, 366 
 case, 369 
 symptoms, 370 
 prognosis, 373 
 treatment, 373 
 Polygalactia, 689 
 
 treatment, 690 
 Polypus of the womb, 385 
 varieties, 386 
 causes, 392 
 symptoms, 392 
 prognosis, 399 
 treatment, 400 
 Dessault’s instruments, 401 
 Dupuytren’s operation, 406 
 Pregnancy, false, 568 
 symptoms, 569 
 treatment, 569 
 
 extra-uterine, 574 
 
 cases, 577 
 signs, 579 
 treatment, 582 
 Prurigo of the vulva, 269 
 symptoms, 270 
 treatment, 271 
 
 Puncture in ovarian abscess, 167 
 Pyrosis, 601 
 
 causes, 601 
 treatment, 602 
 
 Recto-vaginal Fistula, vide Fistula 
 Retroflexion of the womb, vide Uterus 
 Retroversion of the womb, vide Uterus 
 Rheumatism of the womb, 286 
 causes, 287 
 symptoms, 287 
 prognosis, 292 
 treatment, 293 
 Rupture of vagina, 224 
 treatment, 225 
 I of uterus, 230 
 
INDEX OF DISEASES OF FEMALES. 
 
 719 
 
 Rupture of uterus, cases of, 231 
 treatment, 236 
 
 Scirrhous Engorgement of the Womb, 
 vide Uterus 
 
 Sight, lesions of, vide Neuroses 
 Speculum uteri, manner of using it, 64 
 Superficial inflammation of the vulva, vide 
 Vulva 
 
 Syncope, 621 
 
 causes, 622 
 treatment, 622 
 
 Tenesmus, 605 
 
 treatment, 606 
 Touching per vaginam, 60 
 by the rectum, 62 
 at the hypogastrium, 63 
 Tubercular induration of uterus, 305 
 treatment, 306 
 
 Tympanitis of the womb, vide Physometra 
 
 Urethra, imperforation of, 85 
 case, 86 
 remedy, 87 
 
 Urinary organs, disorders of, 647 
 remedies, 648 
 Uterine haemorrhage, 610 
 Uterine phlebitis, 661 
 symptoms, 662 
 diagnosis, 663 
 prognosis, 663 
 treatment, 664 
 cases, 679, 681 
 
 Varix of the Vulva, 439 
 causes, 439 
 treatment, 439 
 Varices, 622 
 
 causes, 623 
 treatment, 623 
 Vagina, absence of, 116 
 case, 116 
 remedy, ] 17 
 imperforation, 87 
 cases, 91, 92 
 remedy, 90 
 narrowness, 94 
 case, 95 
 
 Vagina, narrowness, remedy for, 96 
 obliteration, 100 
 cases, 101, 102 
 remedy, 105 
 obturation, 106 
 cases, 107, 108 
 remedy, 111 
 hernia in, vide Hernia 
 rupture of, vide Rupture 
 foreign bodies introduced into, 266 
 cases, 267, 268 
 cancer of, vide Cancer 
 Vertigo, vide Cephalalgia 
 Vesico-vaginal fistulas, vide Fistulas 
 Vulva, superficial inflammation of, 269 
 prurigo of, 269 
 treatment of, 270 
 acute inflammation of, 274 
 treatment of, 275 
 
 oedema, varix, and other tumours of, 
 438 
 
 treatment, 439 
 Vulvar enterocele, 208 
 cystocele, 208 
 
 Uterus, prolapse of, 122 
 symptoms, 123 
 case, 126 
 causes, 128 
 treatment, 129 
 ante version of, 154 
 symptoms, 156 
 retroversion of, 154 
 symptoms, 154 
 treatment, 163 
 anteflexion of, 169 
 retroflexion of, 170 
 treatment, 171 
 inversion of, 175 
 symptoms, 179 
 treatment, 185 
 cases, 182, 183 
 rupture of, vide Rupture 
 acute inflammation of, 277 
 causes, 277 
 symptoms, 278 
 diagnosis, 282 
 prognosis, 283 
 treatment, 284 
 
 THE END. 
 

 
 
 
 
 
 
 
 
 4 
 
] 
 
 ) 
 
 WORKS 
 
 IN THE VARIOUS DEPARTMENTS 
 
 0 F 
 
 MEDICINE AND SURGERY*. 
 
 PUBLISHED 
 
 BY 
 
 LEA & BLANCHARD. 
 
 ANATOMY. 
 
 ANATOMICAL ATLAS, illustrative 
 of the Structure of the Human Body ; with 
 over Six Hundred Illustrations ; the most 
 complete work of the kind ever issued, — 
 beautifully executed, in One Volume Im- 
 perial Octavo ; by H. H. Smith, M.D., un- 
 der the supervision of Professor W. E. Hor- 
 ner. 
 
 HORNER’S Special Anatomy and His- 
 
 tology ; 6th edition, much improved. 2 vols. 
 8vo., 1114 pages. 
 
 WILSON’S Human Anatomy; anew 
 edition (the second! revised, with additions 
 by Dr. Goddard : 207 beautiful cuts. 8vo., 
 60S pages. 
 
 WILSON’S Dissector, or Practical and 
 Surgical Anatomy ; with additions by God- 
 dard — 106 cuts. Royal 12mo., 444 pages. 
 
 PHYSIOLOGY. 
 
 CARPENTER’S Human Physiology; 
 with notes and additions by Meredith Cly- 
 mer, and over 100 cuts — in 8vo., 618 pages. 
 
 DUNGLISON’S Human Physiology; 
 the fifth edition, with numerous additions 
 and 300 cuts — in 2 vols. 8vo., 1304 pages. 
 
 HARRISON on the Nervous System; 
 8vo., 292 pages. 
 
 MULLER’S Elements of Physiology 
 by Baly, arranged by Bell — Svo., 886 pages. 
 
 ROGET’S Outlines of Physiology — 
 8vo., 516 pages. 
 
 PATHOLOGY. 
 
 / 
 
 f 
 
 i 
 
 \ 
 
 ABERCROMBIE on the Brain. 3d edit. 
 
 on the Stomach. 4th edit. 
 
 ALISON’S Outlines of Pathology. 8vo., 
 424 pages. 
 
 ANDRAL on the Blood in Disease. 130 
 pages, 8vo. 
 
 BELL on the Teeth, with plates — 8vo., 
 350 pages. 
 
 BERZELIUS on the Kidneys and Urine. 
 8vo., 178 pages. 
 
 BARTLETT on the Fevers of the 
 United States — 8vo., 394 pages. 
 
 BILLINGS’ Principles of Medicine — 
 8vo., 304 pages. 
 
 BRODIE on the Urinary Organs. 8vo., 
 214 pages. 
 
 BRODIE on the Diseases of the Joints. 
 8vo., 216 pages. 
 
 CHAPMAN on Thoracic and Abdomi- 
 nal Viscera. 8vo., 384 pages. 
 
 CHAPMAN on Eruptive Fevers, &c. 
 8vo., 448 pages. 
 
 HOPE’S Treatise on the Diseases of the 
 
 I Heart and Great Vessels, with additions by 
 Pennock. 8vo., 572 pages. 
 
 JONES and TODD on the Diseases of 
 the Ear, edited by Dr. Hays ; with numer- 
 ous cuts. 8 vo., pages — preparing. 
 
 LAWRENCE’S Treatise on the Dis- 
 eases of the Eye, with additions by Hays, 
 and numerous cuts. 8vo., 778 pages. 
 
 PROUT’S Treatise on Stomach and Re- 
 nal Diseases, with coloured plates. 8vo., 
 < 466 pages. 
 
 > PHILIP’S Treatise on Protracted Indi- 
 jgestion. 8 vo., 240 pages. 
 
 | RICORD’S Treatise on Venereal Dis- 
 eases. 8vo., 256 pages. 
 
 WALSHE’S Diagnosis of the Diseases 
 | of the Lungs. 12mo., 310 pages. 
 
 | WILSON on the Diseases of the Skin. 
 I 8vo., 370 pages. 
 
 1 WILLIAMS’ Principles and Pathology, 
 with additions by Clymer. 8vo., 384 pages. 
 
 WILLIAMS on the Respiratory Organs, 
 edited by Clymer. 8vo., 508 pages. 
 
 PRACTICE OF MEDICINE. 
 
 ASHWELL on the Diseases of Females, | CHURCHILL on the Diseases of Fe- 
 by Goddard. 1 vol. 8vo., pages — near- j males, including those of Pregnancy and 
 ly ready. | Childbed ; with additions by Huston. 8vo., 
 
 CONDIE’S Practical Treatise on the | 596 pages. 3d edition. 
 
 Diseases of Children. 1 voL8vo., 650pages. < COATES’PopularMedicine. 8vo.5J4pp. 
 
LEA AND BLANCHARD'S PUBLICATIONS. 
 
 DEWEES on the Diseases of Children. 
 8th edition; 8vo., 548 pages. 
 
 DEWEES on the Diseases of Females. 
 8vo., with plates, 532 pages. 
 
 DUNGLISON’S Practice of Medicine. 
 Second edition, in 2 volumes 8vo., 1322 
 pages. 
 
 TWEEDIE’S Library of Practical Me- 
 dicine. Second edition, revised ; in 3 vols. 
 large 8vo., 2016 pages. 
 
 OCrAny one of the five volumes of the 
 first edition can be had separate. 
 
 WATSON on the Principles and Prac- 
 tice of Physic. 8vo., 920 large pages. 
 
 SURGERY. 
 
 COOPER’S (Sir Astley) Treatise on 
 Hernia, with lithographic plates. Imperial 
 8vo., 428 pages. 
 
 COOPER (Sir Astley) on the Testis and 
 Thymus Gland, with lithographic plates. 
 Imperial 8vo., 1 vol. 
 
 COOPER (Sir Astley) on Dislocations 
 and Fractures, with numerous cuts, and a 
 Memoir and Portrait. 8vo., 500 pages. 
 
 DRUITT’S Modern Surgery. Second 
 edition, with 153 cuts; 8vo., 568 pages. 
 
 FERGUSSON’S System of Practical 
 Surgery, edited by Norris, with 246 cuts. 
 8vo., 630 pages. 
 
 HARRIS on the Maxillary Sinus. 8vo., 
 164 pages. 
 
 LAWRENCE’S Treatise on Ruptures. 
 } 8vo., 480 pages. 
 
 MAURY’S Dental Surgery, with nu- 
 merous plates and cuts. 8vo., 286 pages. 
 
 ROBERTSON on the Teeth. 8vo., 
 230 pages. 
 
 THERAPEUTICS AND MATERIA MEDICA. 
 
 DUNGLISON’S Therapeutics and Ma- 
 teria Medica; a new work.. 2 vols. 8vo., 
 1004 pages. 
 
 DUNGLISON’S Treatise on New Re 
 medies. Fifth edition, 8vo., 616 pages. 
 
 ELLIS’ Medical Formulary, by Morton. 
 Seventh edition, 8vo., 262 pages. 
 
 PEREIRA’S Elements of Materia Me- 
 dica and Therapeutics ; edited by Carson, 
 with 280 cuts. 2 vols. 8vo., 1566 pages. 
 
 OBSTETRICS. 
 
 CHURCHILL on the Theory and Prac- 
 tice of Midwifery, by Huston; 116 cuts. 
 8vo., 520 pages. 
 
 DE WEES’ System of Midwifery, with 
 plates. Tenth edition, 8vo., 660 pages. 
 
 RIGBY’S System of Midwifery, with 
 cuts. 8vo., 492 pages. 
 
 RAMSBOTHAM on Parturition, with 
 figures in lithography. Imperial 8vo., 458 
 pages. 
 
 CHEMISTRY, MEDICAL PHYSICS AND HYGIENE . 
 
 ARN OTT’S Elements of Physics, with ? second edition revised, with additions. 8vo., 
 numerous cuts. One volume 8vo., 520 j 464 pages. 
 
 P a S es * | GRAHAM’S Elements of Chemistry, by 
 
 DUNGLISON on Human Health; a j Bridges, with numerous cuts. 8vo. ,750 pp. 
 
 MEDICAL JURISPRUDENCE AND MEDICAL EDUCATION. 
 
 CHITTY’S Medical Jurisprudence. — ? TRAILL’S Medical Jurisprudence. — 
 8vo., 510 pages. s8vo., 234 pages. 
 
 DUNGLISON’S Medical Student; a < TAYLOR’S Medical Jurisprudence, by 
 new edition, large 12mo. $ Griffith. 1 vol. 8vo., 540 very large pages. 
 
 DICTIONARIES AND JOURNALS. 
 
 AMERICAN JOURNAL OF THE 
 MEDICAL SCIENCES; edited by Dr. 
 Isaac Hays, published Quarterly at Five 
 Dollars a Year. 
 
 CYCLOPAEDIA OF PRACTICAL 
 MEDICINE ; comprising Treatises on the 
 nature and treatment of Diseases, includ- 
 ing those of Women and Children , Materia 
 Medica , Therapeutics, Medical Jurispru- 
 dence , &c., &c. Edited by Forbes, Twee- 
 die, Conolly and Dunglison. 4 large Su- 
 
 per-Royal Octavo Volumes. About 3000 
 pages in double columns. 
 
 DUNGLISON’S Medical Dictionary; 
 4th edition, containing over 40,000 words 
 and synonymes ; large 8vo., of 772 pages, 
 double columns. 
 
 MEDICAL NEWS AND LIBRARY. 
 Published Monthly at One Dollar a Year. 
 
 SELECT MEDICAL ESSAYS, by 
 Drs. Dunglison, Chapman and others. — 2 
 vols. 8vo., 1150 pages. 
 
 V 
 
NEW WORKS AND NEW EDITIONS LATELY PUBLISHED BY LEA AND BLANCHARD. 3 
 
 HORNER’S ANATOMY, 
 
 NEW EDITION— NOW READY. 
 
 SPECIAL ANATOMY AND HISTOLOGY. 
 
 BY WILLIAM E. HORNER, M.D., 
 
 PROFESSOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, &C., &C. 
 
 • Seventh edition. 
 
 With many improvements and additions. In two octavo volumes, with illustration 
 
 on Wood. 
 
 This standard work has been so long before the profession, and has been so ex- 
 tensively used', that; in announcing the new edition, it is only necessary to state, that 
 it has undergone a most careful revision ; the author has introduced many illustra- 
 tions relating to Microscopical Anatomy, and has added a large amount of text on 
 these various points of investigation that are rapidly advancing and attracting so 
 much attention. This new edition has been arranged to refer conveniently to the 
 illustrations in Smith and Horner’s Anatomical Atlas. 
 
 “ A comparison of the present edition with its antecedents, will, therefore, the 
 Author hopes, show to the student an improved state, in many respects, in regard 
 both to Descriptive Anatomy and to Histology ; much of the latter, especially, having 
 been remodelled and written anew since the last edition. 
 
 “The present edition has also the advantage of additional illustrations from the 
 best authorities, through numerous figures inserted in its pages ; and it is placed in 
 a more immediate relation with the plates of Dr. H. H. Smith’s Anatomical Atlas, 
 they having been selected expressly as an elucidation of its text. This connection 
 has been made by specific references at the foot of the page to the plates in question. 
 
 “ That all has been said that belongs to the science of Anatomy, no one fully 
 acquainted with the subject will admit ; but the author trusts that no well-established 
 fact of leading importance has been omitted ; and that a sufficient expansion has been 
 given to the subject to realize the principal object, that of furnishing an elementary 
 Text Book for the use of students of Medicine .” — Preface to Seventh Edition, Sept. 1846 
 
 HORNER’S DISSECTOR. 
 
 man upwzwn® 
 
 BEING A NEW EDITION, WITH EXTENSIVE MODIFICATIONS, 
 AND ALMOST REWRITTEN, OF 
 
 “IIOKJYERPS PRACTICAL AJYATOAIW 
 
 IN ONE VERY NEAT VOLUME, ROYAL 12mo. 
 
 With many Illustrations on Wood. 
 
 The numerous alterations and additions which this work has undergone, the im- 
 provements which have been made in it, and the numerous wood-cuts which have 
 been introduced, render it almost a new work. 
 
 It is the standard work for the Students in the University of Pennsylvania. 
 
4 
 
 NEW WORKS AND NEW EDITIONS JUST PUBLISHED BY LEA AND BLANCHARD. 
 
 NOW READY,— A NEW EDITION OF DDNGLISON’S PHYSIOLOGY. 
 
 HUMAN PHYSIOLOGY, 
 
 WITH THREE HUNDRED AND SEVENTY ILLUSTRATIONS. 
 
 BY ROBLEY DUNGLISON, M.D., 
 
 PROFESSOR OF THE INSTITUTES OF MEDICINE IN THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA, ETC., ETC. 
 
 Sixth edition, greatly improved. — In two large octavo volumes, containing nearly 1350 pages. 
 
 “ It is but necessary for the Author to say, that all the cares that were bestowed on the preparation 
 of the fifth edition have been extended to the sixth, and even to a greater amount. Nothing of import- 
 ance that has been recorded since its publication, has, he believes, escaped his attention. Upwards 
 of seventy illustrations have been added ; and many of the former cuts have been replaced by others. 
 The work, he trusts, will be found entirely on a level with the existing advanced stale of physiological 
 science.” 
 
 In mechanical and artistical execution, this edition is far in advance of any former 
 one. The illustrations have been subjected to a thorough revision, many have been 
 rejected and their places supplied wilh superior ones, while numerous new wood- 
 cuts have been added wherever perspicuity or novelty seemed to require them. 
 
 “Those who have been accustomed to consult the former editions of this work, know with how 
 much care and accuracy every fact and opinion of weight, on the various subjects embraced in a 
 treatise on Physiology, are collected and arranged, so as to present the latest and best account of the 
 science. To such vve need hardly say, that, in this respect, the present edition is not less distinguished 
 than those which have preceded it. in the two years and a half wdiich have elapsed since the last or 
 fifth edition appeared, nothing of consequence that has been recorded seems to have been omitted. 
 Upwards of seventy illustrations have been added, and many of the former cuts have been replaced 
 by others of better execution. These mostly represent the minute structures as seen through the 
 microscope, and are necessary for a proper comprehension of the modern discoveries in this depart- 
 ment . — The Medical Examiner. 
 
 NOW READY. 
 
 THE SIXTH EDITION OF DIINGLISON’S MEDICAL DICTIONARY. 
 
 MEDICA L_L EZIGOrr. 
 
 A Dictionary of 
 
 MEDICAL SCIENCE, 
 
 CONTAINING A CONCISE ACCOUNT OF THE VARIOUS SUBJECTS AND TERMS: WITH 
 THE FRENCH AND OTHER SYNONYMES; NO HOES OF CLIMATES AND OF 
 CELEBRATED MINERAL WATERS; FORMULAE FOR VARIOUS OFFICI- 
 NAL AND EMPIRICAL PREPARATIONS, &c. 
 
 BY ROBLEY DUNGLISON, M. D., 
 
 PROFESSOR OF THE INSTITUTES OF MEDICINE, ETC., IN JEFFERSON MEDICAL COLLEGE, PHILADELPHIA. 
 
 Sixth edition, revised and greatly enlarged. In one royal octavo volume of over 800 very large 
 pages, double columns. Strongly bound in the best leather, raised bands. 
 
 “ We think that ‘the author’s anxious wish to render the work a satisfactory and desirable — if not 
 indispensable — Lexicon, in which the student may search without disappointment for every terra 
 that has been legitimated in the nomenclature of the science,’ has been fully accomplished. Such a 
 work is much needed by all medical students and young physicians, and will doubtless continue in 
 extensive demand. It is a lasting monument of the industry and literary attainments of the author, 
 w r ho has long occupied the highest rank among the medical teachers of America.”— The New Orleans 
 Medical and Surgical Journal. 
 
 “ The simple announcement of the fact that Dr. Dunglison’s Dictionary has reached a sixth edition, 
 is almost as high praise as could be bestowed upon it by an elaborate notice. It is one of those standard 
 works that have been ' w’eighed in the balance and (not) been found weanling. ’ It lias stood the test of 
 experience, and the frequent calls for new editions, prove conclusively that it is held by the profession 
 and by students in the highest estimation. The present edition is not a mere reprint of former ones; 
 the author has for some time been laboriously engaged in revising and making such alterations and 
 additions as are required by the rapid progress of our science, and the introduction of new terms into 
 out vocabulary. In proof of this it is stated ‘ that the present edition comprises nearly two thousand 
 five hundred subjects and terms not contained in the last. Many of these had been introduced into 
 medical terminology in consequence of the progress of the science, and others had escaped notice in 
 previous revisions.’ We think that the earnest w’ish of the author has been accomplished; and that 
 ne has succeeded in rendering the work ‘a satisfactory and desirable— if not indispensable— Lexicon, 
 in which the student may search, without disappointment, for every term that has been legitimated in 
 the nomenclature of the science.’ This desideratum he has been enabled to attempt in successive 
 editions, by reason of the work not being stereotyped ; and the present edition certainly offers stronger 
 claims to the attention of the practitioner and student, than any of its predecessors. The work is got 
 up in the usual good taste of the publishers, and we recommend it in full confidence to all who have 
 not yet supplied themselves wilh so indispensable an addition to their libraries.”— The New York Jour- 
 nal of Medicine. 
 
NEW WORKS AND NEW EDITIONS LATELY PUBLISHED BY LEA AND BLANCHARD. 5 
 
 Now Ready, — Carpenter’s New Work. 
 
 A MANUAL, OR ELEMENTS OF FmrSZOZiGGHT, 
 IJVCJL UJ&IJTG FMJT SIOI.®aiCJlL JV Jl T O JfS Y , 
 
 FOR THE USE OF THE MEDICAL STUDENT. 
 
 BY WILLIAM B. CARPENTER, M. D., F. R. S., 
 
 FULLERIAN PROFESSOR OF PHYSIOLOGY IN THE ROYAL INSTITUTION OF GREAT BRITAIN, ETC., 
 
 With one hundred and eighty illustrations. In one octavo volume of 566 pages. Elegantly printed 
 to match his “ Principles of Human Physiology.” 
 
 This work, though but a very short time published, has attracted much attention from all engaged 
 in teaching the science of medicine, and has been adopted as a text book by many schools throughout 
 the country. The clearness and conciseness with which all the latest investigations are enunciated 
 render ii peculiarly well suited for those commencing the study of medicine. It is profusely illustrated 
 with beautiful wood engravings, and is confidently presented as among the best elementary text 
 books on Physiology in the language. 
 
 “The author has shown singular skill in preserving so marked a line of distinction between the 
 present Manual and the ‘ Principles of Physiology’ previously published by him. They are both on 
 precisely the same subject; but the one is neither a copy, nor an abstract, nor an abridgment of the 
 other. In one thing, however, they are exactly alike— in their general excellence, and in their per- 
 fect adaptation to their respective purposes. The reputation of Dr. Carpenter as a physiologist is too 
 well established throughout the whole medical world to admit of increase from any commendation of 
 ours; but we should be doing injustice to our own feelings if we did not here express our admiration 
 of his great intellectual powers, of his extensive learning, of the comprehensiveness of his views, of 
 the quickness with which he seizes the important points and bearings of each subject, of the logical 
 order in which he arranges his facts, and of the clearness and precision with which he explains and 
 exposes his doctrines. Dr. Cavpenter’s various treatises are in fact models in their respective depart- 
 ments. It is their great and varied excellence which accounts for their unrivalled popularity. We 
 can pay no higher compliment to the work before us, than to say, that it is equal in merit to the former 
 productions of the author. This is equivalent to saying that it is, without question, the best manual or 
 short treatise on physiology extant. Although designed for the student, and framed expressly to meet 
 his wants, it is a work, we will venture to say, that may be consulted with advantage by most physi- 
 cians and surgeons, however learned.”— The British and Foreign Medical Review. 
 
 The merits of this work are of such a high order, and ils arrangement and discussion of subjects so 
 admirably adapted to the want of students, that we unhesitatingly commend it to their favorable no- 
 tice. This work studied first, and then followed by the more elaborate treatise of Dunglison. or Muller, 
 or others of similar character, is decidedly the best course for the student of physiology.” — The Western 
 Lancet. 
 
 Simon’s Chemistry of W£an. 
 
 ANIMAL CHEMISTRY. 
 
 WITH REFERENCE TO THE PHYSIOLOGY AND PATHOLOGY OF MAN. 
 
 BY Dr. J. FRANZ SIMON. 
 
 Translated and edited by George E. Day, M. A. & L. M., Cantab., &c. 
 
 With plates. In one octavo volume of over seven hundred pages, sheep, or in two parts boards. 
 
 This important work is now complete and may be had in one large octavo volume, Those who 
 obtained the first part can procure the second separate. The very low 'price at which this is offered, 
 in comparison with the cost of the English edition, should secure for it a large demand. 
 
 “Phis excellent work, the most complete on animal chemistry that has ever appeared, has recently 
 been issued by the publishing house of Lea and Blanchard, after the Sydenham edition of London. No 
 physician, who desires to keep pace with the improvements in our science, or to be prepared at all 
 points for the successful treatment of disease, can remain ignorant of physiological and pathological 
 chemistry ; and he will seek in vain for as complete and accurate work on the subject, as he will find 
 in the elaborate and finished treatise of Dr. Simon The work is replete with facts of the highest interest, 
 calculated to reflect a broad blaze of tight on the pathology and treatment of many diseases hitherto 
 involved in obscurity. We trust it may have a universal circulation among the profession in this 
 country. — The New York Journal of Medicine. 
 
 Now Ready— A New Edition of 
 
 COMDIE O N CHILDREN. 
 
 BROUGHT UP TO 1847. 
 
 In one octavo volume of over 650 pages. 
 
6 NEW WORKS AND NEW EDITIONS LATELY PUBLISHED BY LEA AND BLANCHARD. ’ 
 
 A NEW EDITION— JUST READY. 
 
 Dunglison on Mew Remedies. 
 
 JVE !»’ REMEDIES, 
 
 BY ROBLEY DUNGLISON, M.D., &c., &c. 
 
 Fifth edition, with extensive additions. In one neat octavo volume. 
 
 The numerous valuable therapeutical agents which have of late years been introduced into the 
 Materia Medica, render it a difficult matter for the practitioner to keep up with the advancement of 
 the science, especially as the descriptions of them are difficult of access, being scattered so widely 
 through transactions of learned societies, journals, monographs, See. & c. To obviate this difficulty, 
 and to place within reach of the profession this important information in a compendious form, is the 
 object of the present volume, and the number of editions through which it has passed show that its 
 utility has not been underrated. 
 
 The author has taken particular care that this edition shall be completely brought up to the present 
 day. The therapeutical agents added, which may be regarded as newly introduced into the Materia 
 Medica, together with old agents brought forward with novel applications, and which may therefore 
 be esteemed as “New Remedies,” are the following Benzoic Acid, Chromic Acid, Gallic Acid, Nitric 
 Acid, Phosphate of Ammonia, Binelli Water, Brocchieri Water, Atropia. Beerberia, Chloride of Car- 
 bon (Chloroform,) Digitalia, Electro-Magnetism, Ergotin, Ox-gall, Glycerin, Haemospasy, Haemostasis, 
 Hagenia Abyssinica, Honey Bee, Protochloride of Mercury and Quinia, Iodoform, Carbonate of Lithia, 
 Sulphate of Manganese, Matico, Double Iodide of Mercury and Morphia, Iodhydrate of Morphia, 
 Iodide of Iodhydrate of Morphia, Muriate of Morphia and Codeia, Naphthalin, Piscidia Erythrina, 
 Chloride of Lead, Nitrate of Potassa, Arseniate of Quinia, Iodide of Quinia, Iodide of Cinchonia, 
 Iodide of Iodhydrate of Quinia, Lactate of Quinia, Pyroacetic Acid, (Naphtha, Acetone) Hyposulphate 
 of Soda, Phosphate of Soda, Iodide of Iodhydrate of Stry r chnia, Double Iodide of Zinc and Strychnia, 
 Double Iodide of Zinc and Morphia, and Valerianate of Zinc. 
 
 Massed Pathological Anatomy. 
 
 AN ANATOMICAL DESCRIPTION OF THE DISEASES OF THE 
 
 ORGANS OF CIRCULATION AND RESPIRATION. 
 
 BY CHARLES EWALD HASSE, 
 
 Professor of Pathology and Clinical Medicine in the University of Zurich , <$-c. 
 
 Translated and edited by W. E. Swaine, M. D., &c. 
 
 In one octavo volume. A new work, just ready, — October, 1846. 
 
 •• The advantages which Professor Hasse has possessed for the preparation of such a work as the 
 present, appear to have been considerable, and of these he has manifestly availed himself to the 
 utmost. As a diligent student in the hospitals of Paris and Vienna, and subsequently as clinical 
 assistant to Professor Carus, and pathological prosector in the principal hospital at Leipsic, he pos- 
 sessed the means of observing and collecting materials for himself, whilst at the same time he was 
 forming that ‘ pathological collection,’ which, under his auspices, has grown into a most interesting 
 and valuable museum. The present treatise, therefore, differs essentially from what is commonly 
 called a compilation. For although he has ‘not relied solely on his own investigations, but has 
 largely availed himself of facts recorded by others,’ he has been chary in making use of other men’s 
 experience. The estimation in which the book is held in Germany, is sufficiently attested by the fact 
 that since its publication the author has had the offer of the chair of Clinical Medicine in five Universi- 
 ties, and holds that vacated by Professor Schoenlein, at Zurich.” — The Medico- Ckirurgical Review. 
 
 A NEW WORK.— PHILLIPS ON SCROFULA.— JUST READY. 
 
 TS NATURE, ITS 
 
 l(D 3R (Q) IF W 3Li A 
 
 PREVALENCE, ITS CAUSES, 
 PLES OF ITS TREATMENT. 
 
 AND THE P RINCI 
 
 BY BENJAMIN PHILLIPS, M.D., F. R. S., ETC. 
 
 In one neat octavo volume, with a plate. 
 
 •The work of Mr. Phillips is immensely in advance of all others that have ever been written on 
 Scrofula. 
 
 “The author has extended his researches over a wide and most interesting field. It has been a 
 fault with preceding writers, that they have not enjoyed a very extensive sphere of observation, or 
 extended their inquiries so as to comprise the influence of the many causes which are supposed to be 
 capable of producing the disease. 
 
 ‘•He has even extended his inquiries to Russia, Austria, Prussia, Bavaria, Portugal, Holland, 
 France, Switzerland, Belgium and America, to China and the East Indies, Egypt. Syria and Greece ; 
 .n short, we have fully presented to us. a body of authentic statistics bearing upon this disease, — col- 
 lected with care, and arranged and classified in a philosophical manner.” — The N. Y. Journal of 
 
 Medicine. 
 
NEW WORKS AND ^EW EDITIONS LATELY PUBLISHED BY LEA AND BLANCHARD. 7 
 
 Ellis’s Medical Formulary, 
 
 NEW AND IMPROVED EDITION. 
 
 THE MEDICAL FORMULARY; 
 
 Being a collection of Prescriptions, derived from the writings and practice of many of the most 
 eminent physicians of America and Europe. To which is added an appendix, containing the usual 
 , dietetic preparations and antidotes for poisons. The whole accompanied with a lew brief pharma- 
 ceutic and medical observations. 
 
 BY BENJAMIN ELLIS, M. D., 
 
 LATE PROFESSOR OF MATERIA MEDICA AND PHARMACY IN THE PHILADELPHIA COLLEGE OF PHARMACY. 
 
 Eighth edition, with extensive alterations and additions. By SAMUEL GEORGE MORTON, M. D. 
 In one neat octavo volume. 
 
 This popular work has been too extensively and favorably known to the profession in the United 
 States to require any remarks in introducing a new edition, except to state that the improvements in 
 it will be found to be numerous and important. Great care has been taken in its passage through the 
 press to insure the utmost accuracy, and it is confidently presented as worthy the increased confidence 
 of physicians and apothecaries. 
 
 HOPE ON THE HEART. — New Edition, just published. 
 
 A TREATISE ON THE DISEASES 
 
 OF THE HEART AMD GREAT VESSELS, 
 
 AND ON THE AFFECTIONS WHICH MAY BE MISTAKEN FOR THEM. 
 
 Comprising the author’s view of the Physiology of the Heart’s Action and Sounds as demonstrated by 
 his experiments on the Motions and Sounds in 1830, and on the Sounds in 1834—5. 
 
 BY J. HOPE, M. D., F. R. S., &c. &c. 
 
 Second American from the third London edition. With Notes and a Detail of Recent Experiments. 
 BY C. W. PENNOCK, M. D., &c. 
 
 In one octavo volume of nearly six hundred pages, with lithographic plates. 
 
 fS WATMLi m®©SE3 ®sr ©HUgA 1 ® STSriSS’ZMSB'So 
 
 Under the title of “ Small Books on Great Subjects,” there has lately appeared in London a series of 
 works which have attracted much attention from their originality, strength and conciseness. Not- 
 withstanding their very high price, they have commanded a large circulation in England, while that 
 cause has limited the demand in this country. In placing them, therefore, before the American public 
 in a neat form, and at the very low price of twenty-five cents each, the American publishers hope to 
 meet with an extended sale. The following have appeared : — 
 
 No. 1. Philosophical Theories and Philosophical Experience; No. 2. On the Connection between 
 Physiology and Intellectual Science; No. 3 On Man’s Power over himself to Prevent or Control 
 Insanity; No. 4. An Introduction to Practical Organic Chemistry, with reference to the works of 
 Davy, Brande, Liebig, &c. ; No. 5. A Brief View of Greek Philosophy, up to the age of Pericles ; No. 
 6. A Brief View of Greek Philosophy, from the Age of Socrates to the Coming of Christ ; No. 7. Chris- 
 tian Doctrine and Practice in the Second Century; No. 8. An Exposition of Vulgar and Common 
 Errors adapted to the year of Grace MDCCCXLV ; No 9 An Introduction to Vegetable Physiology, 
 with References to the Works of De Candolle, Lindley, &c. No 10. On the Principles of Criminal 
 Law. No. 11. Christian Sects in the Nineteenth century. 
 
 To be Continued. 
 
 NOW READY.— PHILOLOGY OF THE EXPLORING EXPEDITION. 
 
 The Ethnography and Philology 
 OF THE U. S. EXPLORING EXPEDITION, 
 
 Under the Command of Captain Wilkes, during the years 1838, 1839, 1840, 1841 and 1842. 
 
 BY HORATIO HALE, Philologist to the Expedition. 
 
 In one large imperial quarto volume, done up with great strength in extra cloth, price only $10. 
 
 This is the only edition of this volume, of which but few copies have been printed Early ap- 
 plication is therefore necessary to secure it. It is printed and arranged to match the Congress 
 copies of the “Narrative,” and is confidently presented as the most beautiful specimen of typo- 
 graphy ever executed in this country. 
 
 This work forms the seventh volume of the Publications of the Exploring Expedition. The next 
 volume, by Professor Dana, on Corals, with an Atlas of colored plates, will shortly be ready, to be 
 followed by the remainder of the scientific portion. 
 
8 
 
 LEA & BLANCHARD’S NEW PUBLICATIONS. 
 
 THE GREAT SURGICAL LIBRARY 
 
 (NEARLY COMPLETED). 
 
 CHEUUS’ SYSTEM OF SURGERY. 
 
 A SYSTEM OF SURGERY. 
 
 BY J. M. CHELIUS, 
 
 Doctor in Medicine and Surgery, Public Professor of General and Ophthalmic Surgery, etc. etc. in the 
 
 University of Heidelberg. 
 
 TRANSLATED FROM THE GERMAN, 
 
 AND ACCOMPANIED WITH ADDITIONAL NOTES AND OBSERVATIONS, 
 
 BY JOHN F. SOUTH, 
 
 SURGEON TO ST. THOMAS’ HOSPITAL. 
 
 Orbited, toil!) Reference to American ^ntlicriiies, 
 
 BY GEORGE W. NORRIS, M. D. 
 
 To be complete in Three large Octavo Volumes of about Six Hundred very large pages each , or 
 in Seventeen Numbers at Fifty Cents. 
 
 The completion of this great work has been delayed by the very numerous and important 
 additions of the translator: it is now, however, in a state to enable the publishers to pro- 
 mise its conclusion by the first of March, 1847. 
 
 It is unnecessary to call the attention of the profession to this important work. The 
 names which are associated in it, and the unanimous testimony borne by the medical press 
 to its excellence are sufficient to prove its great value. For fullness and completeness it is 
 unapproached by any work of the kind now before the profession, and it may, indeed, be 
 said to be the only real System of Surgery, embracing both the Principles and Practice, that 
 has appeared since the days of Hunter. The consideration which it has long enjoyed , abroad 
 may be estimated from the fact of its having passed through six editions in Germany, and its 
 having been translated into no less than seven languages. 
 
 “Judging from a single number only of this work, we have no hesitation in saying that, if the re* 
 maining portions correspond at all with the first, it will be by far the most complete and scientific Sys- 
 tem of Surgery in the English language. We have, indeed, seen no work which so nearly comes up 
 to our idea of what such a production should be, both as a practical guide and as a work of reference, 
 as this; and the fact that it has passed through six editions in Germany, and been tran«lated into seven 
 languages, is sufficiently convincing proof of its value. It is methodical and concise, clear and accu- 
 rate; omitting all minor details and fruitless speculations, it gives us all the information we want in 
 he shortest and simplest form .”— New York Journal of Medicine. 
 
 DRUITT’S SURGERY. New Edition-- Now Ready. 
 
 THE 
 
 PRINCIPLES AND PRACTICE OF MODERN SURGERY, 
 
 By ROBERT DRUITT, Surgeon. 
 
 THIRD AMERICAN FROM THE THIRD LONDON EDITION. 
 ILLUSTRATED WITH ONE HUNDRED AND FIFTY-THREE WOOD ENGRAVINGS. 
 
 WITH NOTES AND COMMENTS 
 By JOSHUA B. FLINT, M.D., M.M., S.S., &c. &c. 
 
 In One very neat Octavo Volume of about Five Hundred and Fifty Pages. 
 
 In presenting this work to the American profession for the third time, but little need be 
 said to solicit for it a continuation of the favor with which it has been received. The me- 
 rits which have procured it this favor, its clearness, conciseness, and its excellent arrange- 
 ment, will continue to render it the favorite text-book of the student who wishes in a 
 moderate space a compend of the principles and practice of Surgery. 
 
LEA & BLANCHARD’S NEW PUBLICATIONS, 
 
 9 
 
 JONES ON THE EYE, Now Ready, 
 
 THE PRINCIPLES AND PRACTICE 
 OF OPHTHALMIC MEDICINE AND SURGERY. 
 
 By T. WHARTON JONES, F.R.S., &c. &c. 
 
 WITH ONE HUNDRED AND TEN ILLUSTRATIONS. 
 
 EDITED BY ISAAC HAYS, M. D., &c. 
 
 In One very neat Volume , large royal 12 mo., with Four Plates , plain or colored, and 
 Ninety-eight well executed W oodcuts. 
 
 This volume will be found to occupy a place hitherto unfilled in this department of medi- 
 cal science. The aim of the author has been to produce a work which should, in a mode- 
 rate compass, be sufficient to serve both as a convenient text-book for students and a book 
 of reference for practitioners. Thus, by great attention to conciseness of expression, a 
 strict adherence to arrangement, and the aid of numerous pictorial illustrations, he has been 
 enabled to embody in it the principles of ophthalmic medicine, and to point out their prac- 
 tical application more fully than has been done in any other publication of the same size. 
 The execution of the work will be found to correspond with its merit, the illustrations have 
 been engraved and printed with care, and the whole is confidently presented as in every 
 way worthy the attention of the profession. 
 
 VOGEL’S PATHOLOGICAL ANATOMY. 
 
 THE 
 
 PATHOLOGICAL ANATOMY OF THE HUMAN BODY, 
 
 By JULIUS VOGEL, M.D., &c. 
 
 TRANSLATED FROM THE GERMAN, WITH ADDITIONS, 
 
 By GEORGE E. DAY, M.D., &c. 
 
 EUustrate'O bp uptoavUs of <©ne ^unbreU $latn anti (Eoloreti Hngrabtngs. 
 
 In One neat Octavo Volume. 
 
 The entire absehce of any English work on Morbid Anatomy, embracing the recent dis- 
 coveries effected by chemistry and the microscope, affords a sufficient reason for the ap- 
 pearance, in the present form, of “Vogel’s Pathological Anatomy of the Human Body.” 
 It forms in itself a complete treatise on General Morbid Anatomy, and will shortly be fol- 
 lowed by a second volume devoted to the consideration of pathological changes affecting 
 special organs. This translation has been made with the approbation and assistance of the 
 author, who has examined a considerable portion of the volume and expressed his satisfac- 
 tion at the manner in which it was executed. 
 
 A PRACTICAL TREATISE 
 
 ON 
 
 INFLAMMATION, ULCERATION AND INDURATION OF THE NECK OF THE UTERUS: 
 WITH REMARKS ON THE VALUE OF LEUCORRHCEA AND PROLAPSUS 
 UTERI AS SYMPTOMS OF THIS FORM OF DISEASE. 
 
 BY J. HENRY BENNET, M.D., 
 
 In One Duodecimo Volume, cloth. 
 
 “The descriptions of disease are throughout clear and concise, the arrangement of the subject is 
 judicious and the remarks are thoroughly practical, and calculated to improve the treatment of a fre- 
 quent and troublesome class of diseases. In recommending Dr. Bennet’s volume, therefore, to our 
 readers as an excellent essay upon the subject, we only convey the impression which its perusal has 
 left upon us .” — Dublin Medical Press. 
 
10 
 
 LEA & BLANCHARD’S NEW PUBLICATIONS. 
 
 ROYLE’S MATERIA MEDICA. 
 
 MATERIA MEDICA AND THERAPEUTICS; 
 
 INCLUDING THE PREPARATIONS OF THE PHARMACOPOEIAS OF 
 
 LONDON, EDINBURGH, DUBLIN, (AND OF THE UNITED STATES.) 
 
 WITH MANY NEW MEDICINES. 
 
 BY J. FORBES ROYLE, M.D., F. R. S. f 
 
 Late of the Medical Staff in the Bengal Army, Professor of Materia Medica and Therapeutics, 
 King’s College London, &c. &c. 
 
 EDITED BY JOSEPH 'CARSON, M.D., 
 
 Professor of Materia Medica in the Philadelphia College of Pharmacy, Jcc. &c. 
 
 WITH NINETY-EIGHT ILLUSTRATIONS. 
 
 In one large octavo volume of about 700 pages. 
 
 Being one of the most beautiful Medical works published in this Country. 
 
 No apology is requisite for re-issuing the book in this country. By the student attending 
 upon lectures, as well as by practitioners, a full and large manual like this cannot but be re- 
 ceived with favor, and notwithstanding the large and valuable works that have of late been 
 presented to the profession, its merit will insure for it a favorable reception. The illustrations 
 are superior to those heretofore given in works of the kind, every care having been taken 
 both in the engraving and printing. The labors of the editor have been confined to the su- 
 pervision of the work in passing it through the press, and the addition of such matter in con- 
 nection with the Pharmacopoeia and indigenous Materia Medica of the United States, as 
 would render the work fitted for American students and practitioners. 
 
 WILSON’S ANATOMY. New Edition— Now Ready. 
 
 A SYSTEM OF HUMAN ANATOMY, 
 
 GENERAL AND SPECIAL, 
 
 BY ERASMUS WILSON, M.D., 
 
 Lecturer on Anatomy, London. 
 
 THIRD AMERICAN FROM THE THIRD LONDON EDITION. 
 
 EDITED BY P. B. GODDARD, A.M., M.D., 
 
 Professor of Anatomy in the Franklin Medical College of Philadelphia. 
 
 WITH TWO HUNDRED AND THIRTY-FIVE ILLUSTRATIONS BY GILBERT. 
 
 In one beautiful octavo volume of over SIX HUNDRED large Pog-M, 
 
 Strongly Bound and sold at a low price. 
 
 Since the publication of the second American edition of this work, the author has issued 
 a third in London, in which he has carefully brought up his work to a level with the most 
 advanced science of the day. All the elementary chapters have been rewritten, and such 
 alterations made through the body of the work, by the introduction of all new facts of inte- 
 rest, illustrated by appropriate engravings, as much increase its value. The present 
 edition is a careful and exact reprint of the English volume, with the addition of such other 
 illustrations as were deemed necessary to a more complete elucidation of the text; and 
 the insertion of such of the notes appended to the last American edition as had not been 
 adopted by the author and embodied in his text; together with such additional information 
 as appeared calculated to enhance the value of the work. It may also be stated that the 
 utmost care has been taken in the revision of the letter-press, and in obtaining clear and 
 distinct impressions of the accompanying cuts. 
 
 It will thus be seen, that every effort has been used to render this text-book worthy of a 
 continuance of the great favor with which it has been everywhere received. Professors 
 desirous of adopting it for their classes may rely on being always able to procure editions 
 brought up to the day. 
 
 This book is well known for the beauty and accuracy of its mechanical execution. The 
 present edition is an improvement over the last, both in the number and clearness of its 
 embellishments ; it is bound in the best manner in strong sheep, and is sold at a price 
 which renders it accessible to all. 
 
LEA & BLANCHARD’S NEW PUBLICATIONS. 
 
 It 
 
 SUPPLEMENT TO THE ENCYCLOPEDIA AMERICANA, UP TO TOE YEAR 1847. 
 
 ENCYCLOPEDIA AMERICANA- -Supplementary Vol, 
 A POPULAR DICTIONARY 
 
 OF ARTS, SCIENCES, LITERATURE, HISTORY, POLITICS 
 AND BIOGRAPHY. 
 
 VOL. XIV. 
 
 Edited by HENRY VETHAKE, LL. D., 
 
 Vice-Provost and Professor of Mathematics in the U niversity of Pennsylvania, Author of “A Treatise 
 
 on Political Economy.” 
 
 In One large Octavo Volume of over Six Hundred and Fifty double columned pages. 
 
 The numerous subscribers who have been waiting the completion of this volume can now 
 perfect their sets, and all who want a Register of the Events of the last Fifteen Years, for 
 the Whole World, particularly embracing interesting scientific investigations and discover- 
 ies, can obtain this volume separately, price Two Dollars uncut in cloth, or Two Dollars 
 and Fifty Cents in leather, to match the styles in which the publishers have been selling sets. 
 
 Subscribers in the large cities can be supplied on application at any of the principal book- 
 stores; and persons residing in the country can have their sets matched by sending a volume 
 in charge of friends visiting the city. 
 
 Complete sets furnished at very low prices in various bindings. 
 
 “The Conversations Lexikon (Encyclopedia Americana) has become a household hook in all th 
 Intelligent families in America, and is undoubtedly the best depository of biographical, historical, geo- 
 graphical and political information of that kind which discriminating readers require. There is in the 
 present volume much matter purely scientific, which was all the more acceptable to us that it was 
 unexpected.” — Sillimari’s Journal. 
 
 THE CHEMISTRY OF THE FOUR SEASONS— A NEW WORK. 
 
 THE CHEMISTRY OF THE FOUR SEASONS, 
 
 SPRING, SUMMER, AUTUMN AND WINTER. 
 
 AN ESSAY PRINCIPALLY CONCERNING NATURAL PHENOMENA ADMITTING OF 
 ILLUSTRATION BY CHEMICAL SCIENCE, AND ILLUSTRATING PASSAGES 
 OF SCRIPTURE. 
 
 BY THOMAS GRIFFITHS, 
 
 Professor of Chemistry in the Medical College of St. Bartholomew’s Hospital, &c. 
 
 In One very neat Volume , royal 12 mo., of Four Hundred and Fifty large pages, extra cloth , 
 illustrated with numerous Woodcuts. 
 
 “The title-page copied at the head of this article sufficiently expresses the objects of the work, and 
 the subjects of which it treats. It is a token from the laboratory, designed for the parlor. The dis- 
 courses are adapted to the comprehension of those not familiar with the technicalities and details of 
 chemistry, and are written in a pleasing style. The mechanical execution of the work is neat and 
 tasteful. Altogether it is a beautiful volume .” — Buffalo Med. Journal. 
 
 YOUATT ON THE DOG. 
 
 THE DOG. 
 
 BY WILLIAM YOUATT. 
 
 WITH NUMEROUS AND BEAUTIFUL ILLUSTRATIONS. 
 
 EDITED BY E. J. LEWIS, M.D., &c. &c. 
 
 In One beautifully printed Volume. Crown Octavo , with Twenty-four Plates , done up in 
 rich crimson extra cloth. 
 
 “With this explanation of his connection with the work he leaves it, in the hope that it 
 may prove of value to the sportsman from its immediate relation to his stirring pursuits; to 
 the general reader from the large amount of curious information collected in its pages; and 
 to the medical student from the light it sheds on the pathology and diseases of the dog, by 
 which he will be surprised to learn how many ills that animal shares in common with th© 
 human race.” — Editor’s Preface. 
 
 A 
 
12 
 
 VALUABLE WORKS PUBLISHED BY LEA AND BLANCHARD. 
 
 Valuable Works for Sportsmen, &c, 
 
 THE HORSE, 
 
 BY WILLIAM YOCATT. 
 
 A NEW EDITION, WITH NUMEROUS ILLUSTRATIONS. TOGETHER WITH A 
 
 HISTORY ©F THE [MIO^SIEb 
 
 A DISSERTATION ONTHE AMERICAN TROTTING HORSE 
 
 HOW TRAINED AND JOCKEYED. AN ACCOUNT OF HIS REMARKABLE PERFORMANCES ) 
 
 AND AN ESSAY ON THE ASS AND THE MULE, 
 
 BY J. S. SKINNER, 
 
 ASSISTANT POST-MASTER GENERAL, AND EDITOR OF THE TURF REGISTER. 
 
 This edition of Youatt’s well-known and standard work on the Management, Diseases and 
 Treatment of the Horse, has already obtained such a wide circulation throughout the country; 
 that the Publishers need say nothing to attract to it the attention and confidence of all who 
 keep Horses or are interested in their improvement. 
 
 STABLE TALK AND TABLE TALK, 
 
 OR SPECTACLES FOR YOUNG SPORTSMEN. 
 
 BY HARRY HIEOVER. 
 
 In one very neat duodecimo volume, extra cloth. 
 
 THE SPORTSMAN’S LIBRARY, 
 
 OR HINTS ON HUNTERS, HUNTING, HOUNDS, SHOOTING, GAME, DOGS, GUNS, FISHING, 
 
 COURSING, Ac., Ac. 
 
 In one well printed volume, duodecimo, extra cloth. 
 
 EVERY MAN HIS OWN FARRrER ; 
 
 CONTAINING THE CAUSES, SYMPTOMS AND MOST APPROVED METHODS OF CURE OF THE 
 
 DISEASES OF HORSES. 
 
 BY FRANCIS CLATER, 
 
 AUTHOR OF “ EVERY MAN HIS OWN CATTLE DOCTOR.” 
 
 AND HIS SON JOHN CLATER. 
 
 First American from the twenty-eighth London edition, with notes and additions, by J. S. Skinner In one 
 
 l*2mo. volume, cloth. 
 
 EVERY MAN HIS OWN CATTLE DOCTOR. 
 
 CONTAINING THE CAUSES, SYMPTOMS AND TREATMENT OF ALL DISEASES INCIDENT TO 
 OXEN, SHEEP AND SWINE; AND A SKETCH OF THE ANATOMY AND PHYSI- 
 OLOGY OF NEAT CATTLE.— By FRANCIS CLATER. 
 
 Edited, Revised, and almost Rewritten, by William Youatt. With numerous Additions, embracingan Essay 
 on the Use of Oxen, and the Improvement in the Breed of Sheep, by J. S. Skinner, Asst. P. M General. 
 
 In one duodecimo volume, cloth, with numerous illustrations. 
 
 Kirby and Spence’s Entomology, for Popular Use. 
 
 AN INTRODUCTION TO ENTOMOLOGY; 
 
 OR, ELEMENTS OF THE NATURAL HISTORY OF INSECTS; COMPRISING AN ACCOUNT OF 
 NOXIOUS AND USEFUL INSECTS, OF THEIR METAMORPHOSES, FOOD. STRATAGEMS, 
 HABITATIONS, SOCIETIES, MOTIONS, NOISES, HYBERNATION, INSTINCT, Ac., Ac. 
 
 With Plates, Plain or Colored. 
 
 BY WILLIAM KIRBY, M. A., F. R. S. AND WILLIAM SPENCE, Esa., F. R. S. 
 From the sixth London edition, which was corrected and considerably enlarged. In one 
 large octavo volume, extra cloth. 
 
 We have been greatly interested in running over the pages of this treatise. There is scarcely, in the wide 
 range of natural science, a more interesting or instructive study than that of insects, or one that is calculated 
 to excite more curiosity or wonder. 
 
 The popular form of letters is adopted by the authors in imparting a knowledge of the subject, which ren- 
 ders the work peculiarly fitted for our district school libraries, which are open to all ages and classes.— Hunt's 
 Merchants' Magazine. 
 
VALUABLE WORKS PUBLISHED BY LEA AND BLANCHARD. 
 
 13 
 
 CAMPBELL’S LORD CHANCELLORS. 
 
 JUST PUBLISHED. 
 
 LIVES OF THE LORD CHANCELLORS AND KEEPERS OF THE 
 GREAT SEAL OF ENGLAND, 
 
 FROM THE EARLIEST TIMES TO THE REIGN OF KING GEORGE IV., 
 
 BY JOHN LORD CAMPBELL, A. M., F. R. S. E. 
 
 First Series, forming three neat volumes in demy octavo, extra cloth. 
 
 Bringing the work to the time of Lord Jeffries. 
 
 The second series will shortly follow in three volumes to match. 
 
 It is sufficient for us to thank Lord Campbell for the honest industry with which he has 
 thus far prosecuted his large task, the general candor and liberality with which he has 
 analyzed the lives and characters of a long succession of influential magistrates and min- 
 isters, and the manly style of his narrative. We need hardly say that we shall expect with 
 great interest the continuation of this performance. But the present series of itself is more 
 than sufficient to give Lord Campbell a high station among the English authors of his age. 
 — Quarterly Rev. 
 
 The volumes teem with exciting incidents, abound in portraits, sketches and anecdotes, 
 and are at once interesting and instructive. The work is not only historical and biographi- 
 cal, but it is anecdotal and philosophical. Many of the chapters embody thrilling incidents, 
 while as a whole, the publication may be regarded as of a high intellectual order. — Inquirer. 
 
 A work in three handsome octavo volumes, which we shall regard as both an ornament 
 and an honor to our library. A History of the Lord Chancellors of England from the insti- 
 tution of the office, is necessarily a History of the Constitution, the Court, and the Jurispru- 
 dence of the Kingdom, and these volumes teem with a world of collateral matter of the live- 
 liest character for the general reader, as well as with much of the deepest interest for the pro- 
 fessional or philosophical mind . — Saturday Courier. 
 
 A work of enduring interest, as well from the signal ability with which it is written, as 
 from the great names whose personal history and official acts it enumerates . — Richmond 
 Whig. 
 
 HAWKER ON_ SHOOTING. 
 
 INSTRUCTIONS TO YOUNG SPORTSMEN IN ALL THAT RE- 
 LATES TO GUNS AND SHOOTING. 
 
 BY LIEUT. COL. P. HAWKER. 
 
 From the enlarged and improved ninth London edition. 
 
 To which is added the Hunting and Shooting of North America , with Descriptions of Animals and Birds. 
 
 Carefully collated from authentic sources. 
 
 BY W. T. PORTER, Esq., Editor of the N. Y. Spirit of the Times. 
 
 In one large octavo volume, rich extra cloth, with numerous Illustrations. 
 
 “ Here is a book , a hand-book, or rather a text-book— one that contains the whole routine of the science. It is 
 the Primer, the Lexicon, and the Homer. Every thing is here, from the minutest portion of a gun-lock, to a 
 dead Buffalo. The sportsman who reads this book understandingly, may pass an examination. He will know 
 the science, and may give advice to others. Every sportsman, and sportsmen are plentiful, should own this 
 work. It should be a “ vade mecum.” He should be examined on its contents, and estimated by his abilities 
 to answer. We have not been without treatises on the art, but hitherto they have not descended into all the 
 minutiae of equipments and qualifications to proceed to the completion. This w r ork supplies deficiencies, and 
 completes the sportsman’s library.” — U. S. Gazette. 
 
 PHILOSOPHY IN SPOUT MADE SCIENCE IN EARNEST. 
 
 BEING AN ATTEMPT TO ILLUSTRATE THE FIRST PRINCIPLES OF NATURAL 
 PHILOSOPHY, BY THE AID OF THE POPULAR TOYS 
 AND SPORTS OF YOUTH. 
 
 From the Sixth and greatly improved London Edition. 
 
 In one very neat royal 18mo. volume of 432 large pages with numerous wood-cuts, crimson extra cloth. 
 
 “ One of the most entertaining, and to a large class of persons, most instructive volumes that we have lately 
 met with. We think we can do a service to our juvenile readers by recommending it to their study, though it 
 may be read profitably by many of either sex who wear beards or bishops .” — Richmond Times. 
 
 “ It shows the young reader why his present toys enact such wonderful pranks, and how new ones may be 
 constructed even more remarkable ; and contains matter enough within its cover to amuse a household profit- 
 ably for a twelvemonth.” — Neal's Saturday Gazette. 
 
PUBLISHED BY LEA & BLANCHARD. 
 
 Brought up to 1847. 
 
 ENCYCLOP/EDIA AMERICANA, 
 
 THE ENCYCLOP/EDIA AMERICANA: 
 
 A POPULAR DICTIONARY 
 
 GF ARTS, SCIENCES, LITERATURE, HISTORY, POLITICS & BIOGRAPHY. 
 
 In Fourteen Large Octavo Volumes of over Six Hundred double columned 
 
 pages each • 
 
 For Sale very low, in various styles of Binding. 
 
 “ The publishers of the Encyclopaedia Americana conferred an obligation on the public when, fourteen years 
 ago, they issued the thirteen volumes from their press. They contained a wonderful amount of information, 
 upon almost every subject which would be likely to occupy public attention, or be the theme of conversation 
 in the private circle. Whatever one would wish to inquire about, it seemed only necessary to dip into the En- 
 cyclopaedia Americana, and there the outline, at least, would be found, and reference made to those works 
 which treat at large upon the subject. It was not strange, therefore, that the work was popular. But in four- 
 teen years, great events occur. The last fourteen years have been full of them, and great discoveries have been 
 made in sciences and the arts ; and great men have, by death, commended their names and deeds to the fide- 
 lity ofthe biographer, so that the Encyclopaedia that approached perfection in 1832, might fall considerably be- 
 hind in 1846. To bring up the work, and keep it at the present point, has been a task assumed by Professor 
 Vethake, of the Pennsylvania University, a gentleman entirely competent to such an undertaking; and with 
 a disposition to do a good work, he has supplied a supplementary volume to the main work corresponding in 
 size and arrangements therewith, and becoming, indeed, a fourteenth volume. The author has been exceed- 
 ingly industrious. and very fortunate in discovering and selecting materials. U3;ng all that Germany has pre- 
 sented, and resorting to every species of information of events connected with the plan of the work, since the 
 publication of the thirteen volumes. He has continued articles that were commenced in that work, and added 
 new articles upon science, biography, history and geography, so as to make the present volume a necessary 
 appendage in completing facts, to the other. The publishers deserve the thanks of the readers of the volume, 
 for the handsome type, and clear white paper, they have used in the publication.”— U. S. Gazette. 
 
 THE SUPPLEMENTARY VOLUME, 
 
 (VOL XIV.) 
 
 Bringing the work up to 1847. 
 
 Edited by HENRY VETHAKE, LL.D., 
 
 Vice Provost and Professor of Mathematics in the University of Pennsylvania, Ac.; Author of a Treatise on 
 
 Political Economy, Ac. 
 
 May be had separate and in any style of binding. 
 
 “This volume is worth owning, by itself a most convenient and reliable compend of recent History, Bio- 
 graphy. Statistics, Ac. Ac. The entire work forms the cheapest and probably now the most desirable Encyclo- 
 paedia published for popular use.” — N. Y. Tribune. 
 
 MURRAY’S ENCYCLOPAEDIA OF GEOGRAPHY. 
 
 THE ENCYCLOPAEDIA OF GEOGRAPHY, 
 
 COMPRISING 
 
 A COMPLETE DESCRIPTION OF THE EARTH, PHYSICAL, STATISTICAL, CIVIL AND 
 
 POLITICAL. 
 
 EXHIBITING 
 
 ITS RELATION TO THE HEAVENLY BODIES, ITS PHYSICAL STRUCTURE, THE NATURAL HISTORY 
 OF EACH COUNTRY, AND THE INDUSTRY, COMMERCE, POLITICAL INSTITUTIONS, 
 
 AND CIVIL AND SOCIAL STATE OF ALL NATIONS. 
 
 BY HUGH MURRAY, F.R.S.E., &c. 
 
 Assisted in Botany, by Professor HOOKER— Zoology, Ac., by W. W. SWAINSON — Astronomy, Ac., 
 by Professor WALLACE — Geology, Ac., by Professor JAMESON. 
 
 REVISED, WITH ADDITIONS, 
 
 BY THOMAS G. BRADFORD. 
 
 THE WHOLE BROUGHT UP, BY A SUPPLEMENT, TO 1843. 
 
 In three large octavo volumes. 
 
 VARIOUS STYLES OF BINDING. 
 
 This great work, furnished at a remarkably cheap rate, contains about 
 
 .VIA E TEEJY H UJYU RED LARGE IMPERIAL PAGES, 
 
 AND IS ILLUSTRATED BY 
 
 EIGHTY-TWO SMALL MAPS, 
 
 And a colored Map ofthe United States after Tanner’s, 
 
 Together with about Eleven Hundred Wood Cuts executed in the beat Style* 
 
MISCELLANEOUS WORKS 
 
 PUBLISHED BY 
 
 LEA AND BLANCHARD. 
 
 Acton’s Modern Cookery, 420 large pages, 
 with many cuts, 12mo., neat extra cloth. 
 
 American Ornithology, by Prince Charles 
 Bonaparte, in 4 vols. folio, half bound, many 
 colored plates. 
 
 American Military Law, by Lieut. O’Brien, 
 U. S. A., 1 vol. 8vo., cloth or law sheep. 
 
 Addison on Contracts, at press. 
 
 Arnott’s Elements of Physics, new edition, 
 1 vol. 8vo., sheep, many cuts. 
 
 Boz’s Complete Works, 8 parts, paper, cheap- 
 est edition, containing Pickwick, 50 cents ; 
 Sketches, 37^ cents ; Oliver Twist, 25 cents ; 
 Nickleby, 50 cents ; Curiosity Shop, 50 cents ; 
 Barnaby Rudge, 50 cts. ; Martin Chuzzlewit, 
 50cts. ; and Christmas Stories and Pictures 
 from Italy, 25 cts. — Any work sold separately. 
 
 Boz’s Works, in 3 large vols., extra cloth, good 
 paper, price 83.75. — N. B. A fourth vol. is 
 preparing, to contain Dombey & Son, Christ- 
 mas Stories, and Pictures from Italy. 
 
 Boz’s Works, in 8 vols., imperial 8vo., extra 
 cloth, with 136 plates and 140 cuts. 
 
 Benthamiana : Extracts from Bentham, in one 
 large vol., 12mo. 
 
 Browne’s Religio Medict, and Christian Mo- 
 rals, 1 vol., 12mo., extra cloth. 
 
 Bolmar’s French Series, consisting of— A Se- 
 lection of One Hundred Perrin’s Fables, with 
 a Key to the Pronunciation ; a Series of Collo- 
 quial Phrases ; The First Eight Books of Fe- 
 nelon’s Telemachus ; Key to the same; a 
 Treatise on all the French Verbs, Regular and 
 Irregular. The whole forming five small vol- 
 umes, half bound to match. 
 
 Butler’s Atlas of Ancient Geography, with 
 an Accentuated Index, 8vo., half bound, 27 
 colored maps. 
 
 Butler’s Geographia Classica, 1 vol., 8vo. 
 
 Brigham on Mental Excitement and Culti- 
 vation, &c., 12mo., cloth. 
 
 Bird’s Natural Philosophy, 1 vol., 12mo., 
 many cuts, [at press.] 
 
 Bridgewater Treatises. — The whole complete 
 in 7 vols., 8vo., various bindings. 
 
 Brougham’s Historical Sketches of States- 
 men, 3d Series, 1 vol., 12mo., cloth. 
 
 Barnaby Rudge, by “ Boz,” paper or cloth. 
 
 Browning’s History of the Huguenots, one 
 vol., 8vo., cloth. 
 
 Brewster’s Treatise on Optics, 1 vol., 12mo., 
 
 cuts. 
 
 Buckland’s Geology, 2vols., 8vo., cloth, many 
 plates. 
 
 Complete Cook, paper, price only 25 cents. 
 
 Complete Confectioner, paper, price 25 cents. 
 
 Complete Florist, paper, 25 cents. 
 
 Complete Gardener, do. do. 
 
 Campbell’s (Lord) Lives of the Lord Chan- 
 cellors of England, in 3vols. neat demy 8 vo. 
 
 Second and concluding series, 3 vols.8vo. at press. 
 
 Curiosity Shop, by “ Boz,” paper or cloth. 
 
 Christmas Stories, containing the Chimes, the 
 Carol, the Cricket on the Hearth, and The 
 Battle of Life ; together with Pictures from 
 Italy. By “Boz.” Neat 8vo., price 37£cts. 
 
 Campbell’s Complete Poetical Works, in 
 one vol., crown 8vo., cloth gilt or white calf, 
 plates. 
 
 Cooper’s Naval History of the United 
 States. 
 
 Cooper’s Novels and Tales, in 23 vols., sheep 
 gilt, 12mo., or 47 vols., paper, price 25 cents 
 per vol. 
 
 Cooper’s Sea Tales, 6 large vols., royal 12mo., 
 extra cloth. 
 
 Cooper’s Leather Stocking Tales, 5 large 
 royal 12mo. vols., extra cloth. 
 
 Clater’s Horse Doctor, l vol., 12mo. cloth. 
 
 Clater’s Cattle and Sheep Doctor, one vol., 
 12mo., cuts. 
 
 Carpenter’s Popular V egetable Physiology, 
 1 vol., 12mo., extra cloth, many cuts. 
 
 Carpenter’s Comparative Physiology, one 
 vol., large 8vo., many plates, [preparing.] 
 
 Carpenter’s Elements of Physiology, one 
 vol., 8vo., with many cuts. 
 
 Dana on Corals, &,c., 1 vol. imp. quarto, with 
 an Atlas of colored plates, being vols. 8 and 9 
 of the U. S. Exploring Expedition, [preparing] . 
 
 Davidson, Margaret, Memoirs of and Poems, 
 in 1 vol., 12mo., paper 50 cents, or extra cloth. 
 
 Davidson, Lucretia, Poetical Remains, 1 
 vol., 12mo., paper 50 cents, or extra cloth. 
 
 Davidson, Mrs., Poetry and Life, in 1 vol., 
 12mo., paper 50 cents, or extra cloth. 
 
 Dombey &, Son, by Dickens, to be complete in 
 20 Nos., with 2 plates each ; price 8 cts. each. 
 
 Dog and Sportsman, by Skinner, plates, 1 vol., 
 12mo., cloth. 
 
 Dunglison on Human Health, 1 vol., 8vo., 
 cloth or sheep. 
 
 Encyclopedia of Geography, in 3 vols., 8vo., 
 many cuts, various bindings. 
 
 Encyclopedia Americana, 14 vols. 8vo., various 
 bindings. The supplementary volume (14th), 
 by Professor Henry Vethake, is just published. 
 To be had separate, price 82.00 uncut in cloth, 
 or $2.50 bound. 
 
 East’s Reports, edited by G. M. Wharton, in 
 8 vols., large 8vo., law sheep. 
 
 Education of Mothers, 1 vol., 12mo., cloth or 
 paper. 
 
 Electro-Magnetic Telegraph, by Vail, 8vo., 
 sewed, many cuts. 
 
 Frederic the Great, by Campbell, 2 vols., 
 12mo., extra cloth. 
 
 Fielding’s Select Works, in 1 vol. large 8vo., 
 cloth, or in 4 parts paper, price $1.25. 
 
 Francatelli’s Modern French Cook, in 1 
 vol., 8vo., fancy cloth, with many cuts. 
 
 Fownes’ Elementary Work on Chemistry, 
 
 1 vol., 12mo., many cuts, cloth or sheep. 
 
 Grahame’s Colonial History of the United 
 States, 2 vols., 8vo., a new edition. 
 
 Grote’s History of Greece, 8vo., cloth, [pre- 
 . Paring.] 
 
 Giesler’s Ecclesiastical History, 3 vols. 8vo. 
 
 Griffith’s Chemistry of the Four Seasons, 
 
 1 vol., 12mo., extra cloth, cuts. 
 
 Hawker on Shooting, Edited by Porter, one 
 beautiful 8vo. vol., rich extra cloth, plates. 
 
2 MISCELLANEOUS WORKS PUBLISHED BY LEA AND BLANCHARD. 
 
 Hale’s Ethnography and Philology, impe* ) 
 rial 4to., being 7th vol. of the U. S. Exploring i 
 Expedition. 
 
 Herschell’s Treatise on Astronomy, 1 vol., 
 12mo., cuts. 
 
 Hemans’ Complete Poetical Works, in 7 
 vols., 12mo. 
 
 Hemans’ Memoirs, by her Sister, 1 vol., 12mo., 
 cloth. 
 
 Hilliard on the American Law of Real 
 Estate, 2 large vols., 8vo., law sheep. 
 
 Hill on Trustees, Edited by Troubat, 1 targe 
 vol., 8vo., law sheep. 
 
 Holthouse’s Law Dictionary, with large ad- 
 ditions, 1 vol., royal 12mo. 
 
 Ingersoll’s History of the Late War, 1vol., 
 8vo. 
 
 Irving’s Columbus, in 2 vols., 8vo. 
 
 Irving’s Beauties, in 1 vol., 18mo. 
 
 Irving’s Rocky Mountains, 2 vols., 12mo., 
 cloth. 
 
 Johnson’s Gardener’s Dictionary, edited by 
 Landreth, 1 vol., 12mo., with cuts, [at press.] 
 
 Keble’s Christian Year, in 32mo., extra 
 cloth, with illuminated title. 
 
 Kirby on Animals, 1 vol., 8vo., plates. 
 
 Kirby and Spence’s Entomology, 1 large 8vo. 
 vol., with plates, plain or colored. 
 
 Life of Thomas Jefferson, by Judge Tucker, 
 
 2 vols., 8vo. 
 
 Language of Flowers, 1 vol., 18mo., colored 
 plates, extra crimson cloth, gilt. 
 
 Loves of the Poets, by Mrs. Jamieson, 12mo. 
 
 Landreth’s Rural Register, for 1847, royal 
 12mo. ; price only 15 cts., about 100 cuts. 
 
 Lover’s Rory O’More, royal 12mo., with cuts, 
 paper, price 50 cts., or extra green cloth. 
 
 Lover’s Legends and Stories of Ireland, 
 royal 12mo., with cuts, paper, price 50 cts v 
 or in extra green cloth. 
 
 Lover’s Songs and Ballads, royal 12mo., 
 paper, price 25 cts. 
 
 Marston ; or the Soldier and Statesman, by 
 Croly, 8vo., sewed, 50 cts. 
 
 Mackintosh’s Ethical Philosophy, 1 vol., 
 8vo. 
 
 Medical Botany, by R. E. Griffith, M. D., 
 with 400 illustrations (at press). 
 
 Moore’s History of Ireland, complete in 2 
 vols., 8vo., cloth. 
 
 Martin Chuzzlewit, by “Boz,” cloth orpaper. 
 
 Millwright’s and Miller’s Guide, by Oli- 
 ver Evans, 1 vol. 8vo., many plates, new ed. 
 
 Mills’ History of the Crusades and Chi- 
 valry, 1 vol., 8vo., extra cloth. 
 
 Mills’ Sportsman’s Library, 1 vol., 12mo., 
 extra cloth. 
 
 Narrative of the United States Exploring 
 Expedition, by Captain Charles Wilkes, U. 
 
 S. N. In 6 vols., 4to., $60; or 6 vols. imp. 
 8vo., $25 ; or 5 vols. 8vo., $10. 
 
 Niebuhr’s History of Rome, complete, 2 vols. 
 8vo., extra cloth. 
 
 Nicholas Nickleby, by * ‘Boz,” cloth or paper. 
 
 Oliver Twist, by “Boz,” cloth or paper. 
 
 Picciola, — The Prisoner of Fenestrella, 
 12mo., illustrated edition, [preparing.] 
 
 Pickwick Club, by “Boz,” cloth or paper. 
 
 Philosophy in Sport made Science in Ear- 
 nest, 1 vol, royal 16mo., with many cuts, 
 
 Rush s Residence at the Court of London, 
 new series, 1 neat vol., 8vo., cloth. 
 
 Ranke’s History of the Popes of Rome, 1 
 vol., 8vo., cloth. 
 
 Ranke’s History of the Reformation in 
 Germany, to be complete in one vol., 8vo. 
 
 Ranke’s History of the Ottoman and Span- 
 ish Empires. 
 
 Rogers’ Poems, a splendid edition, illustrated, 
 imperial 8vo., extra cloth. 
 
 Roget’s Outlines of Physiology, one vol., 
 8vo. 
 
 Roget’s Animal and Vegetable Physiology, 
 2 vols., 8vo., cloth, with about 400 wood- 
 cuts. 
 
 Roscoe’s Lives of the Kings of England, a 
 12mo. series to match the Queens. Vol. 1 
 now ready. 
 
 Strickland’s Lives of the Queens of Eng- 
 land, 9 vols., 12mo., cloth or paper, [to be 
 continued.] 
 
 Select Works of Tobias Smollett, 1 vol., 
 large 8vo., cloth, or 5 parts, paper, $1.50. 
 
 Siborne’s Waterloo Campaign, with Maps 
 
 1 vol., large 8vo. 
 
 Stable Talk and Table Talk, for Sports- 
 men, 1 vol., 12mo. 
 
 Small Books on Great Subjects — No. 1 , “Phi- 
 losophical Theories and Philosophical 
 Experience.” No. 2, “On the Connection 
 between Physiology and Intellectual 
 Science.” No. 3, “On Man’s Power over 
 himself to Prevent or Control Insanity.” 
 No. 4, “An Introduction to Practical 
 Organic Chemistry.” No. 5, “A Brief 
 View of Greek Philosophy up to the Age 
 of Pericles.” No. 6, “A Brief View of 
 Greek Philosophy from the Age of So- 
 crates to the Coming of Christ.” No. 7, 
 “Christian Doctrine and Practice in the 
 Second Century.” No.'S, “An Exposi- 
 tion of Vulgar and Common Errors, 
 adapted to the Year of Grace 1845.” No. 
 9, “An Introduction to Vegetable Phy- 
 siology, with References to the Works 
 of De Candolle, Lindley, &c.” No. 10, 
 “On the Principles of Criminal Law.” 
 No. 11, “Christian Sects in the Nine- 
 teenth Century,” &c. — each work sold 
 separate for 25 cents, or handsomely done up 
 in volumes, in cloth, forming a neat series. 
 (To be continued.) 
 
 Spence on the Jurisdiction of the Court of 
 Chancery, 1 vol., large 8vo., law sheep. 
 Vol. 2, on the Practice, preparing. 
 
 Thomson’s Domestic Management of the 
 Sick Room, 1 vol., 12mo., extra cloth. 
 
 Tokeah, by Sealsfield, price 25 cents. 
 
 Trimmer’s Geology and Mineralogy, one 
 volume of large 8vo., extra cloth, many cuts. 
 
 Walpole’s Letters, in 4 large vols., 8vo., 
 extra cloth, with a portrait. 
 
 Walpole’s New Letters to Sir Horace 
 Mann, 2 vols., 8vo., extra cloth. 
 
 Walpole’s Memoirs of George the Third, 
 
 2 vols., 8vo., extra cloth. 
 
 Walpole’s Journals, never before published, 
 [preparing.] 
 
 White’s Universal History, a new and im- 
 proved work for schools, colleges, &c., with 
 Questions, by Professor Hart, in 1 vol., large 
 12mo., extra cloth, or half bound. 
 
 W heaton’s Elements of International Law, 
 1 vol., large 8vo., law sheep or extra cloth, 
 third edition, much improved. 
 
 Wraxall’s Posthumous Memoirs, 1 vol., 
 8vo., extra cloth. 
 
 Wraxall’s Historical Memoirs, 1vol., 8vo., 
 extra cloth. 
 
 ( Youatt on the Horse, &c., by Skinner, 1 
 ( vol., 8vo., many cuts. 
 
 ( Youatt on the Dog, in one beautiful volume, 
 ( crown 8vo., extra cloth, with plates. 
 

 • . * 
 
 • i 
 
 * 
 
 «• # w 
 
 
 
 
 . 
 
 
 
 
 
 
 * * 
 
 
 
 
 
 
 
 
 
 
 *>• • 
 
 ■ 
 
 
 
 
 * 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 
 
 ■ 
 
 
 > 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 , 
 
 
 
 
 
 
 
 
 X * 
 
 
 
 
 
 
 
 *V‘ 
 
 
 
 
 
 
 
 
 
 - • ' ‘ 
 
 • - • 4 
 
 
 
 ' 
 
 <i 
 
 & . 
 
 
 
 •- 
 
 
 
 4 
 
 
 
 
 
 
 
 
 
 
 
 
 
 * # 
 
 •- * %> 
 
 
 
 * 
 
 
 
 
 
 
 
 
 
 
 
 3 * 
 
 J V' 
 
 . * 
 
 
 
 * ■'' 
 
 iJF. " * v - 
 

 ' 
 
 
 
 
 
 
 ' 
 
 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 • * 
 
 
 % 
 
 yii