Hysterology: a treatise, descriptive and clinical, on the diseases and the displacements of the uterus

Front matter

YALE MEDICAL LIBRARY

HISTORICAL LIBRARY

The Gift of

Preface

Being called upon some twelve years since to fill the chair of clinical Midwifery, in addition to that of Materia Medica and Therapeutics, which I then occupied, I accepted the position with great reluctance and many misgivings. My reluctance arose from the fact that, both in dispensary and private practice, each and every plan of treatment then in vogue had in my hands proven unreliable ; and my misgivings, from the doubt that I should ever be able by any application, however close and unremitting to unravel the mysteries of female diseases ; mysteries which had, in my judgment, foiled others much better fitted than myself to grasp so intricate and complex a subject. However, being overpersuaded, and making the attempt to teach a branch, the general principles of which had not as yet been established, I soon found that it would be necessary, in order to secure a reliable base of operations, to institute a thorough course of clinical study. To do this in a satisfactory manner, and whilst opening the door to all truth, to bar it against all error, I secured the services of a competent assistant, whose duties were, aside from any aid required in making the examinations and carrying out the treatment, to take full notes of each case at every visit. Having followed this plan with the greatest advantage to myself, and thereby gained a clearer insight into the normal and abnormal evolutions of the uterine organs, inasmuch as the eye and the finger are, in this class of disorders, the best of all teachers, I resolved to continue it at my second course of lectures, and bring the students also into direct, personal contact wTith disease in the living subject. The mode of procedure was this : The advanced students being divided into classes of from eight to ten, two of their number acted in rotation as my assistants, whereas the others were not admitted into the private room until the patient had been placed on the operating table, and her person protected from needless exposure. The history of the case now being read, its peculiar features commented upon, the opportunity

VI PREFACE.

of seeing and touching given to as many as practicable, and the treatment conducted in their presence, the class, excepting the two on duty, retired to an adjoining apartment whilst this patient was dismissed, and another admitted and made in readiness for examination. By thus regarding the feelings of these poor women, who were by want obliged to seek aid at a public institution, and yet demanding every facility requisite for the thorough instruction of the students, I fortunately succeeded in giving satisfaction to both parties ; to the one, a happy sense of returning health, and to the other, a solid foundation whereon to build an enduring superstructure in the after years of their practice.

These Cliniques that present the data from which the doctrines, inculcated in the following pages, have been deduced, are represented by the cases and commentaries.

The body of the work, on the contrary, is a reproduction of my lectures on the diseases and displacements of the uterus. These lectures, being designed for the first as well as the second course students, were of a general character, and embodied the results of my observation and experience.

This method of treating my subject, that comprehends both a clinical and a systematic treatise, arranged side by side in the same book, though it necessarily leads to repetition, will, I hope, from the many stand-points from which each and every particular is viewed, insure greater clearness and precision than is otherwise to be attained.

In presenting this volume to my professional brethren, I crave indulgence for those shortcomings to which every human undertaking is liable, seeing that one's ideal is ever far in advance of his accomplishment, and also for the positive, and, as some may think, self-confident manner in which I express my convictions — that to me are vivid and real — even when they run counter to those entertained by the leading hysterologists of the day. My aim, however, has not been to float with the tide and accept on trust every statement found in print ; but rather to question received opinions, and by anew interpreting natural phenomena, to discover, if possible, those general principles which would, when carried into practice, render the treatment of womb-disease more certain and efficient.

I have ventured to coin a new word, hysterology, from vorepa, the icterus, and Xoyog, a description, as a more distinctive title of a monograph on uterine disease than gynecology, that, embracing all the diseases peculiar to the female, is too broad in its

PREFACE. VH

signification. The words vaginocele and rectocele are of a hybrid character, and would, except for the want of better and the common employment of a similar one, vaginismus, be quite inexcusable.

In conclusion, while bespeaking a fair hearing and a careful investigation of the views about to be advanced, it but remains to me to return my hearty acknowledgments to Drs. Skene, Olm stead, Tourney, McMillen, and others, for most efficient services in recording the. cases and conducting the treatment, and to Drs. Yickers, Rockwell, and Sargent, for taking the sketches that were the ground-work of my original drawings. To Dr. Skene, now Professor of Clinical Obstetrics in the Long Island College Hospital, I am especially under obligations for efficient and long-continued assistance in my department.

Brooklyn, July, 1872.

Introduction

Manner of obtaining Materials for this Work ; its Plan — Great Advance of Sciences collateral to Medicine — Slight Advance of Therapeutics — Temporizing Practice — Physical Sciences tested in every new Relation ; those pertaining to Practice, by Actual Trial — Medical Science founded on Observation and Experience, not on Theory and Reasoning — Explorations in Diseases of the Uterus, of the Chest — Objections to Speculum Examinations — Local Treatment of Dr. Bennet — Advocates of the Constitutional and the Local Treatment Partisans — Author's Experience — Defence of the Speculum— Diagnosis by Speculum, Complete ; Treatment effectual, 1

Chapter II. Symptoms And Examinations

Symptoms, Local, General — Symptoms compared — Touch and Sight — Manual Examination— Examination in Recumbent Posture ; English Method ; What can be learned — Examination in Erect Posture ; Method ; What can be learned — Examination in Semi-Recumbent Posture — Examination by Touch and Palpation — Speculum- Examination ; Deportment of Physician—Specula Matricis, Fergusson's, Non-Reflecting, Valvular, Record's, Charriere's, disco's, Segalas' — Uterine Sound; Use; Abuse- Forceps — Probes, Lente's, Budd's — Pocket Sound and Probe — Tenacula — Application of the Nitrate of Silver ; Portes Caustiques, Lallemand's, Lente's — Preparation of Patient for Speculum Examination ; English Posture ; French Posture — Introduction of Speculum, in the Married, in the Unmarried — True Stand-Point for the Physician, . . . .12

Chapter III. Anatomy And Physiology

Anatomy of Mucous, of Erectile, of Muscular, and of Fibrous Coat of Vagina—Anatomy of Mucous Membrane, of Uterus, of Cervical Canal, and of Body of Uterus — Anatomy of Muscular Fibres, of Blood Vessels, and of Nerves of Uterus— Physiology of Menstruation, of Pregnancy, and of Involution, .... 39 x CONTEXTS.

Chapter IV. Pathology And Etiology

Pathological Doctrines of the Older Writers, of Dr. Tilt, of Dr. Bennet, of Prof. Meigs, of Prof. Scanzoni, of Dr. Tyler Smith, of the Author — Cases i.-xiii. Complete — Synopsis of the Author's Pathology and JEtiology — Existence of Congestion and Non-Existence of Inflammation — Modus Operandi of Morbid Actions, in Multiparous Uterus, in Nulliparous Uterus— Classification, Classes I.-VII, 53

Chapter V. Class I. — Nulliparae And Multipara

Congestion of the Cervical Canal, Uterine Catarrh. Symptoms, General, Local— Examination by Touch, by Speculum— Cases *XIV.-XXIV. Complete— Cases XXV.-XCV. Abbreviated, . . .93

Chapter VI. Class II. — Multipara

Congestion of the Cervical Canal, Congested Circle around the Os Uteri, with or without the Loss of Epithelium, and Slight Congestion and Enlargement of the Neck.

CLASS III.— MULTIPARA.

Congestion of the Cervical Canal, Congested Circle around the Os Uteri, toith or without the Loss of Epithelium, and Congestion and Enlargement of the Neck.

Symptoms, General, Local — Examination by Touch, by Speculum — Class II., Cases XCVI.-CVII. Complete— Cases CVIII.-CLXXXIX. Abbreviated—Congestion, Physiological of Uterus, and Pathological of Cervix, Cases CXC, CXCI. Abbreviated— Class III., Cases CXCTI.-CXCVII. Complete— Cases CXCVIII.-CCXVIII. Abbreviated, . . . .13;

Chapter VII. Class IV. — Multipara

Congestion of the Cervical Canal, Congested Circle around the Os Uteri, with or without the Loss of Epithelium, Congestion and Enlargement of the Neck, Congestion and Enlargement of the Corpus Uteri, and Slight Congestion of the Ovaries and Upper Portion of the Vagina.

ACTIVE CONGESTION OF UTERUS.

Symptoms, General, Local — Anteversion, Additional Local Symptoms from ; Examination by Touch, by Sound — Prolapsus, Additional Local Symptoms from ; Examination by Touch, by Sound— Cases CCXIX.-

CONTEXTS. XI

CCXXIII. Complete— Cases CCXXIV.-CCXXXVIII. Abbreviated— Congestion, Physiological and Pathological, of Uterus— Cases CCXXXIX.- CCXLI. Abbreviated.

PASSIVE CONGESTION OF UTERUS.

1. — From Non-Involution — Symptoms, General, Local ; Examination by Touch, by Speculum, by Sound — Cases CCXLII. and CCXLIII. Complete —Cases CCXLIV.-CCLXXXIII. Abbreviated.

II. — From Mechanical Obstruction — Symptoms, General, Local ; Examination by Sight, by Touch, by Sound, by Catheter — Case CCLXXXIV. Complete—Cases CCLXXXV. and CCLXXXVI. Abbreviated, . . .204

Chapter VIII. Class V. — Multipara

Congestion of the Cervical Canal. Congested Circle around the Os Uteri, with or without the Loss of Epithelium, Congestion and Enlargement of the Neck, Congestion of the Erectile Coat of the Vagina, Mucous Inflammation of the Vagina, and Slight Congestion of the Corpus Uteri, and Ovaries.

Peculiarities of Class V. — Vaginismus — Vascular Tumor — Vaginitis — Causation—Symptoms, Genera], Local — Examination by Touch, by Speculum—Cases CCLXXXVII.-CCXCI. Complete— Cases CCXCII.-CCCV. Abbreviated — Congestion, Physiological and Pathological, of Uterus and Vagina — Case CCCVI. Abbreviated — Cases simulating Uterine Disease of the Fifth Class, CCCVII.-CCCX. Complete, 255

Chapter IX. Class VI. — Multipara

Congestion of the Cervical Caned, Congested Circle around the Os Uteri, with or without the Loss of Epithelium, Congestion and Enlargement of the Neck, Congestion and Enlargement of the Corpus Uteri, Congestion of the Ovaries, and Erectile Coat of the Vagina, Mucous Inflammation of the Vagina, and Vaginismus.

Relationship of the Uterus, Ovaries, Vagina, Vulva, Rectum, and Bladder— Nervous and Vascular Supply of Genitalia — Ovarian Congestion ; Symptoms, General, Local ; Examination by Touch, per Vaginam, by Touch, per Rectum, by Touch and Palpation, by Speculum — Hypertrophy and Exfoliation of True Uterine Mucous Membrane — Retroversion, Partial ; Symptoms, General, Local ; Examination by Touch, by Sound, by Speculum — Flexions; iEtiology and Pathology ; Symptoms, General, Local ; Examination by Touch, by Sound, by Speculum — Anteflexion and Retroversion — Retroflexion and . Retroversion — Cases CCCXI.- CCCXVIII. Complete— Cases CCCXIX.-CCCXXVI. Abbreviated— Passive Congestion of Internal Genitalia, from Non-Involution — Cases CCCXXVII. and CCCXXVIII. Abbreviated, 287

Xll CONTENTS.

Chapter X. Class VII. — Nullipar.k

■ stion of the Cervical Canal, Congestion of the Uterus, Ovaries, and Erectile Coat of the Vagina, Mucous Inflammation of the Vagina, and Vaginismus.

Symptoms, General, Local — Examination by Touch prr Vaginam, by Touch per Rectum, by Touch and Palpation, by Sound, by Speculum — Non-Hypertrophy and Non-Exfoliation of True Uterine Mucous Membrane— Retroversion — Flexion — Anteflexion and Retroversion — Retroflexion and Retroversion— Cases CCCXXIX.-CCCXXXVIII. Complete- Cases CCCXXX1X.-CCCLVII. Abbreviated, 343

Chapter XI. Summary

Table of Class I., of Class II., of Class III., of Class IV., of Class V., of Class VI., of Class VII. — Table, General — Aphorisms of Uterine Therapeutics, I.-XL., 396

Chapter XII. Treatment

Congestion, Recent and Active — Cong., Recent and Passive— Cong-., Chronic and Active, Uterine Disease, proper — Cong, of Uterus and Ovaries — Cong, of Cervix and Vagina — Cong, and Mucous Inflammation of Vagina —

, Cong, and Prolapsus — Cong, and Procidentia — Cong., Hypertrophy, and Anteversion — Cong., Hyper., and Retroversion — Cong., Hyper., and Anteflexion— Cong., Hyper., and Retroflexion — Cong., Hyper., and Antero-lateral Flexion — Cong., Hyper., and Retro-lateral Flexion — Cong., Hyper., Anteflexion, and Anteversion — Cong., Hyper., Retroflexion and Retroversion — Cong., Hyper., Anteflexion, Anteversion, and Prolapsus — Cong., Hyper., Retroflexion, Retroversion, and Prolapsus — Cong., Abrasion, Enlargement and Elongation of Cervix — Cong, and Stricture of Inner Cervix — Cong, and Pregnancy — Cong, and Change of Life — Cong, and Vascular Tumor — Cong, and Mucous Inflammation of Rectum — Cong, and Mucous Inflammation of Bladder — Prolapsus Uteri, Vesica3, et Vaginae — Cystocele — Vaginocele — Procidentia — Rectocele — Operations for Prolapsus, Procidentia, Cystocele, Vaginocele, and Rectocele — General Remedies — Prophylaxis, 411

ILLUSTRATIONS.

FIGURE PAGE

1 Section of pelvis, one quarter of life-size — nullipara 17

2 A view of the fundus uteri, fallopian tubes, round ligaments, bladder,

and rectum at the brim of the pelvis 18

3 Fergusson's Speculum 25

4 Cusco's Speculum 27

5 Segalas' Speculum, closed 27

6 Segalas' Speculum, opened 28

7 Uterine Sound 29

8 Uterine Forceps 30

9 Lente's Probe 31

1 0 Budd's Probe 31

11 Pocket Sound and Probe SI

12 Single Tenaculum 32

13 Double Tenaculum, opened and closed 32

14 Lallemand's Porte Caustique 33

15 Whalebone Probang, armed and unarmed 33

1G Pavement Epithelium covering the vagina and outer cervix 41

17 Villi of the Vagina 41

18 Bulbi vestibuli, pars intermedia, etc 42

19 Cavity of the virgin cervix uteri laid open 43

20 Ciliated cylinder epithelium from the canal of the cervix uteri 44

21 Villi of the canal of the inner cervix, covered by cylindrical epithe-

lium, and containing looped blood-vessels 44

22 Villi of os uteri covered with pavement epithelium, and containing

looped blood-vessels 45

23 Villi of the os uteri seen through the epithelial layer 45

24 Villi of os and cervix uteri from which the epithelium has been re-

moved by maceration 40

25 Section of the proper uterine cavity at the commencement of preg-

nancy 50

20 A uterine gland from a primipara, eight days after conception 50

27 Muscular elements of the pregnant uterus, formative, advancing and

developed fibre-cells 51

28 Muscular fibre-cells of the uterus, three weeks after parturition 52

29 Procidentia, vaginocele and cystocele 08

30 Anteversion ; prolapsus vesica? 113

XIV ILLUSTRATIONS.

FIGURE TAGE

111 Hypertrophy ; anteversion ; prolapsus uteri, first degree ; prolapsus

32 Prolapsus uteri, second degree ; prolapsus vesicas 210

33 Prolapsus uteri, changing from, the second to the third degree ; cysto-

cele ; vaginocele 210

34 Prolapsus uteri, third degree ; prolapsus vaginae 211

35 Procidentia, partial ; vaginocele 249

33 Procidentia ; cystocele ; vaginocele 2-50

37 Procidentia ; cystocele ; vaginocele ; erosion 251

38 The uterus, bladder, and vagina as retained in position by the

pessary 253

39 Hypertrophy ; retroversion ; prolapsus vagina? 304

42 Scarificator 436

43 Pocket scarificator , 437

44 Cotton-holder 441

45 Laminaria tents 465

46 Method of preparing sponge tents 466

47 Silver-coated globe pessaries 471

DISEASES AND DISPLACEMENTS

UTERUS.

Chapter I. Introduction

Manner of obtaining Materials for this Work ; its Plan — Great Advance of Sciences collateral to Medicine — Slight Advance of Therapeutics — Temporizing Practice — Physical Sciences tested in every new Relation ; those pertaining to Practice by Actual Trial — Medical Science founded on Observation and Experience, not on Theory and Reasoning — Explorations in Diseases of the Uterus, of the Chest — Objections to Speculum Examinations — Local Treatment of Doctor Bennet — Advocates of the Constitutional and the Local Treatment, Partisans — Author's Experience — Defence of the Speculum — Diagnosis by Speculum, complete ; Treatment, effectual.

It is proper, in presenting to the medical public a work on the diseases and displacements of the uterus, to make known its intent and scope, and perhaps apologize for the boldness and presumption of the undertaking. My purpose, a humble one, is simply the delineation, from personal observation, of the histories, symptoms, pathology, and treatment of the special disorders of the non-gravid uterus. To effect this, I shall attempt the difficult task of drawing my descriptions from the open page of Nature, and discussing the subject independently of the expressed views of hysterological writers ; not that I have an overweening confidence in the acuteness and accuracy of my powers of observation, and hold in light esteem the labors of others, but because it is the privilege, as it is the duty, of each and every author, to go to the original, that he may in reality study the varying and ever-shifting phases of morbid actions, and thus truly transcribe the phenomena presented. This, to most readers, will appear like a work of supererogation, since, in their estimation, the acme of medical knowledge lias at the present day been attained ; so that now, with the wealth of materials at our disposal, little more is required of an author than the compilation of the observations and doctrines of those who already occupy the field of medical literature.

The progress, the last few years, of certain branches of our art, that conspire to aid and improve practical medicine, has been truly wonderful, and has far outstripped the advance of therapeutics ; and although we are ostensibly rich in the variety and abundance of scientific acquisitions, and enjoy every facility and appliance for pushing forward our investigations to still greater lengths, yet it is a matter of grave doubt, whether, by such studies, and in this direction, our knowledge of better and more successful methods of curing disease will ever be proportionately increased. In truth, we have a tacit confession of the fact, in the writings and practice of certain modern physicians of the largest and broadest scientific acquirements, who have refined their treatment of disease to such a degree that it is purely expectant, and amounts simply to doing nothing, and trusting to the unaided natural powers for a favorable result. By their showing, the progress of medical science leads to the conclusion that all efforts on our part to assist the system in its struggle with disease are naught ; that we are powerless for good, but potent for evil, and that our mission as physicians is virtually ended, unless it be to induce our patients to abide their allotted time of deliverance and refrain from active medication.

If it is true that the investigations of medical scholars lead to deductions so startling and so opposed to the doctrines current but a few years since, and at the same time so directly in the face of the general experience of all practical men, it becomes us anew to examine the groundwork — the very foundations — of our art, and, leaving our books at rest on their shelves, to return from our wanderings in the mazes of hypothesis to the study of Nature herself, who, unchangeable from age to age — the same to-day and for all time — is the only standard by which medical doctrines are to be tested, and either proved or disproved.

Every science must come out of the region of the ideal and submit its theories, however specious the arguments by which they are supported, to trial in their actual workings, before its conclusions can be allowed as warranted. Whatever may be the results, attained by chemistry in the laboratory, these must, when applied to agriculture or the arts, be submitted to actual experiment under varied conditions, before the laws regulating chemical action in these new relations can be determined. Hence every science that deals with the material world is constantly being subjected to practical proof, which, confirming or invalidating the problems worked out in the study, establishes the principles of each on a basis as fixed and enduring as the natural laws which they interpret.

The late sad and deplorable war, which called out a host of inventions, both for aggressive and defensive purposes, aptly illustrates the fact that an idea may appear sound and practicable, and yet, when embodied and carried out, be defective and valueless.

In all departments of physics, we reach perfection in proportion to our knowledge of natural laws, and whatever is written in treatises on these subjects, is only of worth, as it sets these laws forth and assists us in comprehending them.

In medicine, the main object of our various studies is, or at least ought to be, the cure of disease, or, this result not being attained, the relief of urgent symptoms and the prevention of ttdary evils. Collateral branches of our art, the aids in this the great work of our lives, should, if of the slightest value, contribute to this end, and conspire to render our efforts more certain and effectual. But should they fail in this particular, and inculcate doctrine- unstable, fluctuating, and ever-shifting, like the sands of the sea ; and above all, should their teachings, when tested practically, be found wanting and not confirmed by experience at the bed -side, we would in duty be bound, by the decisions of this higher and final court, to set their dicta aside without a moment's hesitation, and betake ourselves to the study of morbid actions and the discovery of means for their subdual or mitigation.

Scholastic learning ought to be held in no higher esteem in medicine than in other sciences, and ought even more rigidly to be submitted to like ordeals. Here, least of all, should we give place to abstract thought, since no one has a moral right to venture a human life on a mere theory, however complete the argument by which it is sustained.

That we have a controlling power, greater or less, over the inception, progress, and termination of disease, when observation and experience are the foundations whereon we build the superstructure of our knowledge, no more admits of doubt than that manifest power which we wield in the physical world. Unfortunately for practical medicine, this path — the only one leading to enduring results — which was followed by Hippocrates and Sydenham,- has almost universally been forsaken by medical writers, who wandering in the intricate mazes of speculation, have viewed diseases through colored media, and warped their phenomena in conformity to a certain acquired bias. The prominence given to theory, which enlisting induction and analogy in its service, in accordance with the Baconian philosophy, first assumes a proposition and then strives by logic to demonstrate its truth, has been an incubus upon and the bane of our profession.

The only true plan by which to advance our art and elevate it to the full dignity of a science, is to carefully study the phenomena of disease, and the means found advantageous or otherwise, in its removal or modification. To this, other methods of investigation and other modes of procedure are secondary and subsidiary, as they are only of use to throw additional light on what is observed in the living subject.

Moreover, each writer, instead of his or others' opinions, should rather give a record of his cases, as the basis of his opinions, so that we might be competent judges of the legitimacy of his deductions and the soundness of his doctrines.

When, in the course of time, by the labors of many physicians, observations such as these shall have been made on an extended scale and under every variety of circumstance, and critically sifted for all possible sources of error, then the right will be acquired to reason upon the facts presented, to discuss the nature

INTRODUCTION. O

of the disease, and to indicate the line of treatment and the means required to fulfil the indications.

What a high eminence our profession would occupy to-day, had this humble, painstaking, and despised method — the empirical— been followed by writers, instead of that unreliable one, which delights in parading learning, astonishing by scientific display, weaving systems, inventing theories, drawing analogies, and indulging in speculations — a method peculiarly seductive to an imaginative mind and flattering to the pride of intellect. But now, alas ! we must in all candor confess that our real knowledge is extremely limited. The next, like the present boastful century, will, most likely, vaunt aloud its wonderful advances and great acquisitions, and read with astonishment, perhaps with a smile, the antiquated doctrines of to-day. Hence, to prevent the present from sinking into the oblivion that is enshrouding the past, it behooves us to adopt and follow a medical philosophy that is based upon and arises out of natural phenomena. The histories of direct and actual observations, the details of all the facts within the cognizance of our senses, the records of normal and abnormal manifestations, complete and under every variety of circumstance, will alone give us substantial results, and build up a science of medicine, that will be both progressive and enduring.

The foregoing criticisms, applicable almost universally to the faulty observation and fallacious reasoning which prevailed until of late years in medical inquiries, apply with greater pertinence and stronger emphasis to the subject that more directly concerns us at the present time. The benign diseases of the uterus can, by modern appliances, be investigated by the aid of the sight, and its forms, stages, appearances, and changes, as, also, the results, following different plans of treatment, can be observed, day by day, in the living subject, as distinctly as though they were transpiring on the external surface of the body ; and yet, strange to say, most writers on Hysterology have, whilst either neglecting these advantages for gaining positive knowledge, or only employing them to establish a foregone conclusion, given their whole thought and care to collating, comparing, and digesting the various views extant in the literature of this subject. They transcribe, in a succinct form, the substance of all previous publications, and then attempt, by striking a balance between their authorities, and drawing logical deductions from their assumed facts, to settle beyond dispute each and every mooted point.

As, however, most writers on female diseases were, save the more recent, either ignorant or neglectful of the use of the speculum, by which alone it is possible advantageously to study, properly to understand, and effectually to treat the varying states of the pelvic organs, their teachings deserve to be ranked as ideal, and omitted from a practical treatise, precisely as we are wont to deal with the odd and fanciful notions of ancient authors.

In chest diseases, slight regard would be paid a writer's statement, as to the diverse conditions of the heart and lungs, who knew nothing of or omitted to practise auscultation and percussion ; and yet he might, from the violent and distinctive symptoms attending most disorders of these vital organs, get a tolerably correct idea of the morbid actions in progress, and the medication required to subvert them, and restore the patient's health.

In pelvic diseases, on the contrary, a physical examination is absolutely indispensable, both to a correct diagnosis and an efficient treatment.

Besides, a pleurisy, pneumonia, bronchitis, or pericarditis has a tendency to a spontaneous resolution, a recovery in many instances being: effected, without the aid of medicine, bv the vis medicatrix natures / whereas the disorders affecting the uterus and its appendages have no such tendency, but one rather to perpetuate themselves indefinitely, or to the period when the " change of life" comes to the rescue, and morbid action ceases, because the vital power of the uterus is extinct.

Advocating, as I do, the investigation of the diseased states of the womb by the aid of every sense that can make the diagnosis more positive and complete, and by every appliance that can render the treatment more certain and effectual, it is, perhaps, incumbent upon me to vindicate the propriety of and the necessity for the employment of the speculum, inasmuch as a fierce and acrimonious warfare has been waged against it and its champions by several writers of eminence in the profession. It is said that ulceration of the os uteri is very rare, and then, again, that it is very common, and even general, and yet the women thus affected feel quite well, and are unconscious of any local suffering ; that the so-called ulceration, when present, is. a simple abrasion of the epithelium, which reforms as readily as the cuticle on the derma; that, granting the existence of a grave local disorder, this arose primarily from causes affecting the general system, and is to be subdued by constitutional remedies, or, if topical medication be required, by the same means — cups, leeches, blisters, and sedative, mucilaginous, astringent, or caustic lotions — which are so effectual for analogous states of other mucous surfaces ; that, as inflammation and ulceration of the conjunctiva are treated successfully by collyria of various kinds, so similar conditions of the cervical mucous membrane are equally benefited by like applications ; that, from the importance of the ovaries being recently more fully appreciated, inasmuch as the ova are formed in their stroma, the uterus has taken a secondary place in the sexual system, and its diseases have been found to originate from inflammation of these bodies, and to be incurable, except by a treatment, internal and external, directed to this pathological state ; that the speculum has been most shamefully misused, and'though it may, in extreme cases, be resorted to with propriety, its general employment is highly reprehensible, and not to be tolerated, except in a city of lax and degenerate morals, like the capital of France ; that these examinations tear down the barriers which hedge in chastity, and thus, by blunting virtuous sensibility, open the flood-gates of vice ; that the physician who espouses this specialty, becoming devoid of shame, is scarcely ever without a speculum in hand, and, assuming that ulceration, induration, and hypertrophy of the cervix are the fountain-heads of all female ailments, is certain, on making an examination, to find whatever he has made up his mind to see ; and lastly, that the local treatment succeeds when there is no need of interference, but fails when the womb is actually diseased, and that, too, in cases readily cured by constitutional remedies.

These objections to the general employment of the speculum are, it must be confessed, well urged in several particulars against the energetic and dangerous practice introduced by Dr. Bennet of London, and since followed by most uterine specialists. This practice is based on the assumption that in womb-disease there is first inflammation, and then ulceration, induration, and hypertrophy of the cervix, and that, by eating away the degenerated tissues by escharotics, this inflammation will be removed, and the uterus restored to its original condition. As might have been expected to happen, the physicians, who espoused the new doctrines and ventured into this unexplored field of practice, often committed grievous errors, rarely accomplished much good, and sometimes inflicted great injury.