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OBSERVATIONS
                ON THOSE



 DISEASES OF FEMALES


                WHICH ARE


    ATTENDED BY DISCHARGES.


               ILLUSTRATED BY


  COPPER-PLATES OF THE DISEASES, &c.

                  BY

      CHARLES MANSFIELD CLARKE,

UZHBER OF THE ROYAL COLLEGE OF SURGEONS J SURGEON TO THE QUEEN'S
   LYING-IN HOSPITAL; AND LECTURER ON MIDWIFERY IN LONDON.
Helleborum frustra, cum jam cutis aegra tumebit,
Poscentes videas; venieoti occurrite morbo.
                       Pers. 3 Sat
        PHILADELPHIA:

H. C. CAREY AND I. LEA—CHESNUT STREET,
      AND WELLS &• LILLY, BOSTON.

            183f. 
C b^c










    GltlC 
TO
                  DR. BAILLIE.

DEAR SIR,
  In dedicating the following Work to you, I am per-
forming an act of duty to a Physician who has greatly
illustrated the nature of disease by investigating morbid
structure.   I entertain  a  hope also, that the imperfec-
tions of this Work will Bnd  some shelter under your
protection:  but I have especial pleasure in  thus pub-
licly testifying the obligations which I owe to you for
many acts of kindness, undeserved, but uot unremem-
bered by,

           Dear Sir,

                Your most faithful  Servant,
                  CHARLES MANSFIELD CLARKE.
Saville Row, February 10, 1814. 
 
               CONTENTS.
                                               Page
Preface,    .....      i
                     chapter i.
Remarks Introductory to the Consideration of the
  Diseases of the Sexual Organs,      -           7
                    CHAPTER II.
Prqfluvium  Vaginale,       -       -      -      13
                    CHAPTER III.
General Observations on Sexual Diseases, and on
  the Necessity and Mode of making an Exami-
  nation per Vaginam, -       -       -       -  20
                    CHAPTER IV.
On Sympathies,    .       .       .      ,      22
                     CHAPTER V.
Procidentia Uteri,      -       -       -       -  27
                    CHAPTER VI.
Treatment of Procidentia  Uteri,    -      -      35
                    CHAPTER VII
On the mode of supporting (he Uterus,  -       -  44
                    CHAPTER VIII.
Procidentia Vesicae,                             51
                    CHAPTER IX.
Procidentia Vaginae,   -       -       -       -55
                     CHAPTER X.
Inversio Uteri,     ...      -      58
                    CHAPTER XI.
Haemorrhoids, or Piles, -       -       -       -  63 
vi                  CONTENTS.
                    CHAPTER XII.                Page
JLscarides in the Rectum,   -       -       .      67
                    CHAPTER XIII.
Carcinoma Recti,    *           -       -       -  69
                    CHAPTER XIV.
Carcinoma Uteri,                                78
                    CHAPTER XV.
Treatment of Carcinoma Uteri,  -       -       -  84
                    CHAPTER XVI.
Polypus of the Uterus,     ...       88
                   CHAPTER XVII.
Fleshy Tubercle of the Uterus,  -       -       -  97
                   CHAPTER XVIII.
Verrucce, or Warty  Tumours, arising from the
   Vestibulum,      -      -       -             103
                    CHAPTER XIX.
Vascular Tumour of the  Orifice of the Meatus
   Urinarius,    -       -        -       -       .105
                    CHAPTER XX.
Thickening  of the  Cellular Membrane surround-
   ing the Urethra throughout  its  whole Extent,
   accompanied by a Varicose State of the Vessels
   of the Parts,     -       -       -       -      107
                    CHAPTER XXI.
On the Transparent Mucous Discharge from the
   Vagina, not accompanied by any Alteration of
   the Structure of the Sexual Organs,  -       - 109
                   CHAPTER XXII.
On the Case of Transparent Mucous Discharge
   depending upon Debility,   -    -       -      113

Explanation of the Plates,      -       -       - 117 
CONTENTS.
   OF

PART II.
T                                           rage.
INTRODUCTORY REMARKS,      -       -       - 129
                  CHAPTER XXIII.
White Mucous Discharge,   -     -       .     131
  Inflammation of the Cervix Uteri,    -  131 et seq.
  Inflammation of the Substance of the unimpreg-
    nated Uterus,    -            .       _     140
  Remarks upon Amenorrhoza,       -       -  144
                  CHAPTER XXIV.
Watery Discharge,   -            -       -     150
  Cauliflower-Excrescence of the  Os Uteri,     151
  Symptoms of Cauliflower-Excrescence,       - 160
  Treatment of Cauliflower-Excrescence,   -     163
  Hydatids of the Uterus,       -       .       . 17s
  Oozing Tumour of the Labium,  -       -     177
  Involuntary Discharges of Urine,    -       - 181
                  CHAPTER XXV.
Purulent Discharge,       -       -       -     184
  Inflammation of the Mucous Membrane of the
    Uterus, terminating in Secretion of Pus,    187
  Inflammation of the Mucous Membrane of the
    Vagina,     -     -       .       .       .192 
viii                CONTENTS.
                                              Page.
  Abscess of the  Vagina,  -       -       -     196
  Ulceration of the Os Uteri and Cervix Uteri,  199
  Corroding Ulcer of the Os Uteri,    -      - 300
  Symptoms of Corroding Ulcer,   -       -     201
  Treatment of Corroding Ulcer,      -      - 203
  Ulcerated Carcinoma of the Rectum,    -     206
  Ulcerated Carcinoma of the Uterus,  -      - 209
  Treatment of Ulcerated Carcinoma,     -      212
Explanation of the Plates, -      -       -     SIS 
PREFACE.
  The author has had two objects in view in laying the follow-
ing observations before the public.  In the first place, it appeared
to him to be desirable to make some arrangement of the sexual
diseases of the female.  In the  second, to  shew that diseases
having some symptoms  in common, are nevertheless very dis-
similar in their character,  and  require very different treatment;
to demonstrate the impropriety of designating diseases by names
which do not convey a true idea of their character; and to point
out the dangerous consequences of treating symptoms instead of
diseases.
  Having been during many years a teacher of midwifery in
the school founded by  Dr. Denman and Dr. Osborn, and con-
tinued by his brother, Dr. Clarke, the author's attention has
been naturally and necessarily led to contemplate the diseases of
the sexual organs, and to consider  the best  mode of explaining
them, so as to make the description profitable to those whom it
was his duty to instruct. In preparing his notes, a question arose
in his mind; whether any classification of them would assist the
memory in retaining, or the judgment in discriminating and cur-
ing  them. The  opportunities which the author  has had of  at-
tending to these  diseases, and of observing the very general and
careless manner  in which they are sometimes treated, have  in-
duced him to attempt to illustrate them by  a  plain, unadorned
history of their  nature  and symptoms, and to point out  what
appears to be the best mode of treatment. In this work, no more
hypothetical reasoning has been  admitted, than was absolutely
necessary. The author has endeavoured to  confine himself to
             A 
11
PREFACE.
 facts, and the simple narration of them: he  has no new  theory
 to offer, no new medicine to propose, the  virtues of which he is
 desirous of establishing.
   How to arrange these diseases became  an important subject
 for consideration:  they are numerous, and dissimilar; arise from
 various causes, and produce different effects. Some are attended
 by no discharge from the vagina; others, on the contrary, never
 occur without  discharge,  and the nature of this discharge va-
 ries.—Here appeared to be a path to follow.  Here, at any rate,
 was presented a mode of making  something like a division of
 these  complaints,  which  might prove serviceable  to the prac-
 titioner: for, supposing him not to be very conversant with these
 disorders, and to be at fault respecting  the disease; supposing,
 for example, that he is not quite sure whether a tumour in the
 vagina is a soft polypus, or a cauliflower excrescence; if he knows
 that one of these  diseases  is  attended by a  mucous  discharge
 and the other by a discharge of water, he will have nothing to do
 but to inquire into  this circumstance, and the question is imme-
 diately solved.
  The First Part of this  work,  now respectfully offered to the
 medical profession, contains those diseases which are attended
by mucous discharges. Many other important diseases  remain to
be described under the head  of purulent, watery, and white
opake discharges; and there are others of equal consequence, in
which no discharge of any kind is present.  These  will fall un-
der consideration in a future part of this undertaking.
  The author entreats that the reader will make allowances for
many inaccuracies in  this  work. He has endeavoured to write
clearly rather than elegantly: he has not wilfully misled any one;
and if these observations shall prove in  the smallest  degree use-
ful, in diffusing information upon the subject of them, or in miti-
gating the sufferings of human nature, the author will not consider
his labour thrown away, nor his time misemployed. 
OBSERVATIONS,

              &c.
            INTRODUCTORY REMARKS.

  The diseases of the sexual organs in females, although so
various, so distressing to those who labour under them, and not
infrequently so fatal in their consequences, are  perhaps less
generally known and understood by practitioners, than any other
complaints to which the human body is subject.  They are of-
ten neglected by women during the early stages of them, con-
cealed from a sense of delicacy during their progress, and are
often only made known to practitioners,  when they have pro-
ceeded so far as to be beyond the  reach of remedy.  In these
latter stages, a  disease  becomes complicated with many symp-
toms not originally belonging to it, which are the consequences
of high irritation, of great debility, or of the general disturbance
of the constitution.
  In many of these diseases, when physicians or surgeons are
consulted,  the  patient  mentions some  prominent symptom,
which  is to her  the apparent  cause  of annoyance; and this  is
often considered as the disease, and treated as such.
  With as much reason it  might  be expected to remove  asca-
rides from the rectum by making applications to the nostrils, or
to diminish the  effects of pressure upon the brain by medicines
applied to the stomach to relieve sickness, one of the symptoms
of such pressure, as to cure a woman  of an uterine disease in
the manner alluded to above.  Yet  many instances are  to be
found where strangury has been treated as an  idiopathic  affec-
tion  of the bladder, when it has in  fact been symptomatic of a
morbid state of  the uterus; and also, where an itching of the
external organs  of generation  has been attempted to be cured by
a sedative lotion, when  it depends upon the presence of an or-
ganic disease in the neighbouring parts: or, lastly, where local
astringents, and  internal tonics and  stimulants,  have been  pre- 
4
INTRODUCTORY  REMARKS.
scribed for a case of fluor albu?,—the symptom  only of a dis-
ease; and that disease  perhaps of an  inflammatory character,
which the discharge produced by the disease would be more
likely tp relieve than such remedies.
  Upon almost all the other subjects connected with  medicine,
information may be obtained from a variety of sources: but upon
the subject of the diseases of the female organs,  many systems
of physic and surgery, otherwise of deservedly high estimation,
are entirely without information, and are often more apt to mis-
lead than to instruct. Valuable observations are scattered through
the works of  different writers, and some detached papers upon
the subject may be found in collections and  transactions of dif-
ferent Societies; but the student does  not know  where to look
for them: they require  to be collected  with much labour,  and a
great sacrifice of time;  and  it is almost impossible for a student
to separate that which is valuable from that which is useless.
   Another  reason why  the information of the medical student
must be defective on this subject is, that in the course of medi-
cal education, very few, if any, opportunities of  witnessing  any
of the diseases of the female parts occur; there being no hospi-
tal  into which these complaints are expressly received: and from
many public institutions they are excluded, being generally chro-
nic diseases; in some instances incurable, and only admitting of
palliation.*  A student  would even gain little  if such cases were
admitted; for it could not be expected that a patient would sub-
mit to  be  exposed  to  the  manual examination  of a  number of
students; and  without such examination, little good could arise,
except in cases of disease in the external organs, which  bear a
very small proportion to those of the internal or remote parts.
   To give a history of the diseases of the female organs of ge-
neration, to describe with accuracy their symptoms, to shew by
means of engravings the alteration of structure which the parts
undergo, and  thereby  to familiarize  the  mind to them, so that
when the  diseases are  met with, they may be known and dis-
tinguished, and to point out the mode of treating them—is the
 intention of this work.  Owing  to an imperfect knowledge, all the
 discharges from these parts, which are not of a red colour, have
been classed  under the title of fluor  albus,  and treated  as  that

   *  It may appear at first sight, that the exclusion of chronic diseases of this
 kind from hospitals, is an improper regulation; but upon considering the mat-
 ter more closely, it will be found, that though an individual may suffer, the
 public is a gainer. As the funds, and consequently the means of relief are li-
 mited, it becomes important to extend those  means to as great a number as
 possible. The occupation of a bed in an hospital  by one patient labouring un-
 der phthisis or an old ulcer of a leg for six  months,  will prevent assistance
 from being given to many labouring under acute diseases which might be cur-
 ed in that period. 
INTRODUCTORY REMARKS.
5
disease;  and various diseases in which there exists  pain with a
fetid discharge have been denominated cancer.  To this confu-
sion of the diseases of the female organs of  generation, are to
be  attributed those errors in practice which are frequently ob-
served.
  That engravings of morbid structure are likely to prove ser-
viceable, in  leading to the knowledge of disease in the living
body, particularly when connected with a history of the disease,
is the opinion of one of the first physicians of the present day,
to whom medical  science is indebted for a very valuable work
upon morbid anatomy:—that they are really so, is demonstrated
by  the estimation in which that work is held.*
  If, then, engravings taken from internal parts of the body, af-
ter  death are likely to prove serviceable, it may not  be presum-
ing  too much, to nope that those which the  author  proposes to
lay  before  the  public will not be useless; as every practitioner
ought to  be well acquainted with the diseases of the female or-
gans of generation, in order to enable him by his sense of touch
to discriminate between them.  By the frequent employment of
this sense, it becomes very acute, so as  to convey with  great
correctness to the mind the impressions made upon it: but much
time is required to perfect  this sense.  Many cases of  disease
must  have presented themselves to  the practitioner, before he
will have obtained much knowledge  respecting them: but  if an
engraving of the appearances of each disease is brought before
his  eye; if this  is accompanied by a correct history of the symp-
toms, and a description of the  peculiar nature of the discharge
from  the vagina,  when such discharge accompanies  the  com-
plaint; if it can be shewn that some diseases are characterized
by  discharges of a watery kind, others by those of  mucus, oth-
ers  by those of pus, or of blood,—he will meet the first case
which  occurs to  him  with a confidence  founded upon  know-
ledge: and judging, by that which  he has  seen described in
plates, of that which he feels, he will form a better opinion re-
specting  the nature of the complaint,  will  be able to  give a prog-
nostic more likely to be verified, and will direct such measures
to be pursued as will tend to its alleviation or removal.
  To further this latter view, it is proposed also to give engrav-
ings of such instruments as  may be  necessary for the perform-
ance of the operations required  in some of the diseases, and of
such machines as may be serviceable in applying local remedies
to them.
  In attendance upon the poorer class of patients, when suffer-
ing  under  the  diseases of the  external organs, the author has
* Dr. Baillie's Morbid Anatomy. 
6
INTRODUCTORY  REMARKS.
been able to make drawings, shewing the appearances of some
of these diseases in the living body.
   The other engravings are made from a collection of  morbid
preparations in the possession of Dr. Clarke and of the  author;
and occasionally from those of his friends, where he has found
it necessary. 
7
                     CHAPTER  I.

Respecting the Sexual.  Organs  in  the Female, as far as their
                  Secretions are concerned.

  It is not the intention of the author to increase the size of
this work by giving an anatomical description of the female or-
gans of  generation,  the dissecting-room furnishing a sufficient
opportunity  to the student  to  inform  himself  of their natural
structure; but it must be remarked, that  it is  highly important
that  the  anatomy of these parts  should  be well  understood.
Without  this  knowledge, diseases cannot be known, nor the de-
gree of them; for as disease is a deviation from health, the natu-
ral structure  must be known before those deviations from  it can
be ascertained which constitute disease. It is also especially ne-
cessary to be acquainted  with  the relative situation of  these
parts, and with the effects which arise out  of this relation:  this
leads to  a comprehension of the manner in which the disease is
produced, frequently accounts for many symptoms which  could
not otherwise be  explained, and gives a direction to  the  appli-
cation of those modes of treatment which may prove serviceable
in restoring the parts to health.
   As an accurate knowledge of the  different  secretions  from
these parts will very materially assist the practitioner in his in-
quiries, some remarks will be made here respecting them.
   All the discharges from these parts come away from the os
externum; but they spring from various sources, and  are of dif-
ferent kinds.  The parts from which these secretions  arise, are:

   1. The internal surface of the uterus and of the fallopian tubes.
   2. The inner membrane of the vagina.
   3. The lacunae about the os externum.
   4. The mucous membrane of the urethra.*

   These will be  separately considered.
   1.  The secretions from  the uterus.  These are:
   «. The inenstruous secretion.
   fi.  The secretion from the mucous  membrane of the uterus,
which extends to  the cavities of the fallopian tubes.
   y.  The secretion from the glands in the  neighbourhood of the
cervix of the uterus.
  » These are (lie surfaces from which the natural secretions arise: but dis-
charges from  the os  externum  may originate from the surfaces ot  newly-
fonued tumours, as the cauliflower excrescence.; or they may be the contents
of cysts of hydatids. 
8
RESPECTING THE  SEXUAL
                «.  The Menstruous Secretion.

  The menstruous secretion is a fluid of a red colour, possess-
ing very  little tenacity, which does not coagulate, poured out by
the arteries of the uterus, once  every lunar month in healthy
women, if  they are neither pregnant nor suckling;* it begins at
puberty,  and generally continues till between  the age of forty
and fifty  in this country: so that calculating the age of puberty
to be the fifteenth year, and the  duration of life to be seventy
years, it  may be said that the menstruous secretion is performed
during three-sevenths of it.
  A case is related in the Transactions of the Medical and Chi-
rurgical Society of  London, by  Dr. Martin Wall,  professor of
clinical medicine in the  University of Oxford, of a child, aged
nine years, having menstruated  regularly from the age of nine
months;  in whom also all the symptoms, which attend puberty,
were  present before she was two years old.
  It is of consequence  for practical purposes to observe, that
menstruation  is a secretion, and  not an  effusion  of pure  blood
either from arteries or veins.  All blood from  the  sanguiferous  *»
vessels (with very few morbid exceptions) coagulates; whilst the
fluid of the catamenia does not, whether it comes away in a stil-
latilious manner, or is retained in large quantity as in  the case
of imperforate vagina.
  The quantity of the menstruous fluid is greater in warm than
in cold climates: so,  if  a woman lives in an atmosphere artifi-
cially warmed, the same effect is produced.
  At each  period of  menstruation, the average quantity lost in
England, and  perhaps in other countries in the same degree of
latitude, may be reckoned at four ounces, which takes up about
four or five days in coming  away:  in  some  women it lasts a
week; in others not  more than  two or three  days. Plethoric
women are more liable to the first, and women of delicate health
to the last,  occurrence.
  Whatever is capable of increasing the determination of blood
to the vessels of the  uterus, may increase  the quantity of this
secretion; and if this determination of blood is increased  above
a certain  point, the  orifices of the vessels give way, and  blood
is mixed  with the secreted fluid:  but if, in consequence of this
determination of blood to the uterus, inflammation  takes  place,
then coagulating  lymph is thrown out, as from other inflamed
mucous membranes, and the  secretion is diminished till the la-
mina of coagulating lymph is separated.
  From  the  definition above  given of the menstruous fluid, it '

    * Some women who give suck do menstruate, but it is not usual. 
ORGANS OF THE  FEMALE.
9
 will be seen that it does not possess the coagulating part of the
 blood, and instances have occurred where the red colour  has
 been wanting; but  from the  quantity of which, a woman  has
 been obliged  once in a month to take the ordinary precautions
 of a menstruating woman.

  ft.  The Secretion from the Mucous Membrane of the Uterus,
                 and of the Fallopian Tubes.

   The uterus is lined  throughout with a mucous membrane,
 which also is  spread along the fallopian tubes.  The secretion
 from this membrane is permanent, and  continues during  the
 whole of life,  with the exception of the period of pregnancy. At
 this time the  internal structure of the uterus undergoes a great
 change, and forms the outer membrane of the ovum,  called tin)
 Membrana Decidua, by Dr. William Hunter. This  mucus re-
 sembles, in consistence and appearance, the uncoagulated white
 of an egg, and does not differ from mucus in other parts of the
 body.* A very small quantity of this mucus is secreted; its use
 being  simply  to  lubricate the  sides of these passages, so as to
 prevent the cohesion of them; and for this purpose very  little is
 sufficient. In  the other passages  which have external openings,
 the mucus is to be considered likewise as a defence  against sti-
 mulating bodies which pass through and into them.

 y. The Secretion from  the Glands in the  Cervix of the Uterus.

   The structure  of the  uterus itself is very simple.  Its sides are
 muscular, and the muscular fibres are capable of great exertion;
 and it is principally owing to the contraction of these fibres that
 uterine hemorrhage in the impregnated state is restrained.
   The structure of the cervix of the uterus is more complicated;
 more nerves are sent to this than  to any other part of the viscus;
 on which account the dilation  of this part  is attended with great
 pain in labour, and diseases affecting it are productive of great
 distress and suffering.
   The cervix  of the  uterus is also beset with a number of glands.
 These glands  are more  readily discernible in  women  who have
 died pregnant; and in some bodies they are probably much more
 numerous than in others.
   The mucus secreted  by these glands contains a smaller pro-
 portion of water than any other mucus in the body, approaching
 nearer to the nature  of a solid than to that of a fluid body: it is

  • According to the experiments of Mr. William  Brande, mucus consists of
albumen and soda.—See a paper in the Philosophical Trausactioni, on albu
 men aud some other secreted fluids.
B 
10
RESPECTING  THE
SEXUAL
semi-transparent, and possessed of a great degree of tenacity :
it adheres to the fingers like bird-lime; but the attraction of co-
hesion between its  parts is so  strong, that it may be generally
drawn away entire  from any body to which it has adhered.  If
the uterus of a  pregnant woman is examined after  death, this
mucus may  be  drawn out of the orifices of the glands which se-
crete  it.—These glands, in a state of health, perforin the office
of secretion in  pregnancy  only;  or, if  at any other time,  the
matter secreted is of a very different kind, so resembling com-
mon mucus  as not to be distinguished from it.
  It is probable that the  secretion of this viscid substance is
confined to the  commencement of the state of pregnancy; for if
the body of a woman, in the third month of ulerogestation, is
examined after  death, the  quantity of mucus filling  the cervix
uteri will be found to be quite as considerable as at the close of
pregnancy.  The intention  of this mucus has been supposed to
be, to prevent  the  escape  of the  ovum  in  its early state;  and
that when it has  answered this  purpose, the  secretion  ceases;
but it is probable that it has some other use,  at present  not un-
derstood.
  It is known that the uterus prepares for the  reception of the
ovum, before the ovum reaches its cavity, by the formation of
the decidua: the cervix uteri also  performs the secretion of this
viscid  substance immediately  after  impregnation  has taken
place.*

  2.  The Secretion from the inner Membrane of the Vagina.

  This membrane  presents a very large  surface for secretion,
which is constantly going on.  The quantity of this secretion is
liable to  great alterations, from causes which will be hereafter
enumerated.  This  mucus  is thinner  than that formed by the
mucous membrane  of the  uterus;  for the finger, when with-
drawn from the vagina of  a healthy woman, after an examina-
tion,  is merely  moistened  with a  fluid, evidently containing a
much  larger quantity of water than mucus  generally,  or  that
formed by the  uterus, contains;  for if, in a  case of  procidentia
uteri, where from the extent of the disease the os uteri  has be-
come visible, the finger be applied to that opening, the mucus
from it may be drawn out in  thin  filaments.  The inner mem-
brane of the vagina (the surface  which secretes this mucus) is
generally thrown into a vast number of folds, which do not fol-

  * Vide Medical Commentaries; and a paper, by Dr. Clarke, in vol. i. of the
Transactions of a Society for the Improvement of Medical and Chirurgical
Knowledge.—The  parts referred to are  preserved in the collection of Dr.
Clarke and the author;  and in the preparation both  these facts are demon-
strated. 
ORGANS OF THE  FEMALE.
11
low any regular arrangement, like those within the cervix of the
uterus. This corrugation of the  membrane is greatest in the fe-
tus and in young children: in maiden women it is very conside-
rable ;  but in  married women, particularly  in those who have
borne many children, it is less observable.  A number of mus-
cular fibres surround the vagina; and  by the action of these
fibres the capacity of the vagina is diminished, and the number
of the rugae increased.  By means of volition these  fibres may
be excited to a stronger action: but this is temporary, and con-
tinues only whilst  the will is directed to produce this effect.  A
woman from whom one of the drawings of procidentia  of the
uterus was taken, had the uterus returned  to its situation  within
the body, and was enabled to  retain it for a short time  in that
position by the exertion of her will; but in a short time the tu-
mour came down  again, the mere tone or permanent contrac-
tion of the fibres  being inadequate to produce the same  effect.
—The number of rugae in the vagina  is in proportion  to the
strength of the woman: for when this  has  been greatly  dimin-
ished, the lining of the vagina becomes more and more smooth,
by the rug.ie being diminished in  number; till at last, in those cases,
when from the effect of long diseases,  or great age, the powers
of the body are nearly exhausted, the rugae are quite obliterated,
making the inner part  of the vagina perfectly smooth.  If the
body of a woman  who has died of hemorrhage after a labour is
examined, this will be evidently seen.  The secretion from this
membrane is least in  quantity when  the wrinkling is the  great-
est:—for example, it is very trifling  in  children and in maiden
women ;* but  is formed in the  greatest  quantity, and more fre-
quently,  in married  women who have borne  many children,
whose  vagina  has been most  frequently dilated.  In cases  of
great debility,  from any cause,  this discharge almost always at-
tends;  but as  the system acquires strength  the discharge  dimin-
ishes, liil it ceases altogether.-]-
  If the vessels of the uterus  and the  vagina  are injected by
coloured wax  thrown into the hypogastric arteries, several ves-
sels of a  considerable size may be seen running from the hypo-
gastric  arteries along the sides of the vagina towards the  os ex-
ternum^  and partly by these vessels and partly by some branches
of the  pudica  artery  this  secretion  is performed.  When the
muscular fibres which surround the vagina contract, the small
branches of these vessels  will be pressed upon, and  their diam-
eter will  be diminished: in consequence of this  diminution of
  ' Virgines rnr5 hoc malum (fluor mulicbris) infeslat, frequentius adullior^
— St-nriurtus, lib.  4, part i2, sect. 2, cap. 12.
  t «P*»ff ft XfUKDf  t» TIKTI yfgXlTSfflTi Till yVVSHXi'V (MKMl yMTOU » S» TWJ Vtfc'TtflWI.
'iTTixf T'fl ymxixtivi, SiCk £ ) 
IS
SEXUAL ORGANS
OF  THE FEMALE.
their diameter, the stream in them will be lessened,  and less
blood will be sent to the parts which they  supply; but if the
power of contraction in  the muscular fibres surrounding the va-
gina be lessened or lost; then,  no restraint being laid  upon the
vessels, more blood rushes through them, their diameter  being
increased; and the parts, to which they go, will be supplied more
plentifully. So likewise  if the canal is very much dilated by any
cause, this muscular band being  put upon the stretch will be un-
able to act at all; and a like effect will  be produced upon the
blood-vessels which furnish fluids for secretion.
   In moist countries and climates also, where it is to be  expected
that the tone of the body would  be diminished, this discharge is
found to be  very  common.*

  3.  The Secretion from the Lacuna seated in the  Vestibulum.

   The term vestibulum  has been  given to that part of the pas-
sage leading to the uterus  which lies upon the outside of the hy-
men:  beyond this membrane the canal is called the vagina.
   Between  the clitoris and the  meatus urinarius are to be seen
small openings, which pour out  a glutinous mucus. Two other
openings of  the  same  kind are situated upon each side of the
vestibulum, at about an  equal distance from the fore  and  back
part of the passage: these are large enough to admit the end of
a bristle.  There are also several Fittle orifices very ne;ir to the
carunculae myrtiformes. All of these openings pour out a glutin-
ous mucus which has a  peculiar odour.

 4. The Secretion from the Mucous Membrane of the  Urethra.

   The urethra is lined  throughout with a  mucous membrane
which secretes a  viscid  mucus:  this shields the membrane, and
prevents the salts of the urine from stimulating it.  If,  however,
the urine is rendered particularly  acrid  from  substances taken
into the stomach, or from improper actions going on in the sto-
mach, the mucous membrane may be irritated through this mu-
cus by such increased acrimony ; which, though it  may be equal
to defending it  from ordinary stimuli, may be incapable  of pro-
tecting it from others which  are stronger.  This is the case also
in other mucous  membranes.    Mucus  secreted in  diseased
states of the bladder escapes occasionally  in large  quantity from
the orifice of the meatus urinarius, so as to make  the urine of a
ropy consistence.
  "" In Holland, fluor albus is frequent, and in a manner peculiar to the place,
from the dampness of its situation. I have attended more women labouring
under fluor albus in autumn, than at any other season of the year, especially
when the weather was extremely moist and cold. Most of them were cured by
change of diet, increased perspiration, and the proper use of Peruvian bark
and aromatics."—Leake's Medical Instruction?, vol. i. 
13
                    CHAPTER  II.

        Projluvium Vaginale, or Vaginal Discharge.

   Under the above  term, it is proposed to comprehend those
morbid discharges from  the vagina which have been variously,
and perhaps improperly, named by writers.
   If a practitioner is capable of removing  that assemblage of
symptoms which attends a disease, it is very immaterial  what
name he gives to it, or whether he affixes any name to it at all.
On the other hand, the adaptation of a proper name to a disease
will not always  lead to the successful  treatment of  it.  For ex-
ample, if a surgeon is called to a patient who, having been sub-
ject to giddiness, is attacked by a sudden privation of sense and
the power of voluntary motion,  whose pulse is full and slow,
whose face is red, and whose breathing is stertorous; if he takes
away a large quantity of blood, such a patient  will  be as much
relieved as if the surgeon knew that  the complaint was called
apoplexy.  And if a surgeon should be able to attribute certain
symptoms to an aneurism of the aorta, the disease will be as
much beyond the reach of remedy, as if no name  was conferred
upon it. Nevertheless, it is necessary for the purpose of descrip-
tion, to  designate every  disease by some appellation; and great
care should  be  taken  that it should be an appropriate one, or at
least that it should not mislead.
   Hippocrates  calls  the morbid discharges  from the vagina
which are not menstruous " yvmiMix Xsvku."
   Sydenham gives to these discharges the name of " fluor mu-
liebris."  He considers the complaint to depend upon  debility,
and to be allied to diabetes, respecting which he observes: "Cu-
rativae indicatione ad  sanguiuem  invigorandum corroborandum-
que."  Then follow some prescriptions for medicines of a tonic
and stimulating kind.  After this  he concludes by saying: "Ea-
dem fere methodo atque iisdem remediis contumax iste, et diu-
ttunus affectus  fluor tnuliebris sanatur ac diabetes modo dictus;
nam ulrobique  indicaliones curativae  eaedem sunt quantumcun-
que inter se hi  duo morbi dissidere videantur."—Vide Epist. 1.
de morb. epidemic, ab anno 1G75 ad annum 1680.
   Dr. Mead describes the disease under the name of "fluor al-
bus:"—"Foedus morbus est tetra ista colluvies quae colore albo
ex fueminarum naturalibus interdum profluit: hunc autem humo-
rem modo profundunl canales uterini, modo ex glandulis quibus
ronsita est vagina erumpit.  In utraque mali specie  corporis ha-
bitus  pra?cipue  habenda est ratio :  ab illius enim  vitio  tam hie 
14
VAGINAL DISCHARGE.
quam iste morbus orii:inem trahit:  ubi autem in ipsa vagina se-
dem fixit externa etiam  opus sunt."—Mead's Monita et Prae-
cepta, cap. 19, sect. 3. The mode of cure recommended con-
sists of the exhibition of an emetic of Vin. Ipecac, of purgatives
of rhubarb with occasional closes of mercury six times sublimed:
and if the fibres are lax and require to be strengthened, steel is
to be exhibited. Astringent injections are recommended by him
to be thrown into the vagina, which is also to be fumigated with
a powder consisting of some gum  resins  and cinnabar of anti-
mony.
   Dr. Cullen treats of the disease under  the  title of Leucor-
rhaea:—"Every serous or puriform discharge  from the  vagina
may be,  and has  been, comprehended under  one or other of
these appellations—Leucorrhaea, fluor albus, or whites.  Such
discharges may be various, and may proceed from various causes
not yet well ascertained: but 1 confine myself here to treat of
those discharges alone which  may be presumed to proceed from
the same vessels which in their natural state pour  out the men-
ses."...." As the Leucorrhaea generally depends  upon  a great
loss of tone in the vessels of the uterus, the disease  has been
relieved,  and sometimes cured, by  certain  stimulant medicines,
which  are commonly determined  to  the  urinary passages, and
from the vicinity of these  are often communicated to the uterus:
—such for example are cantharides, turpentines, and other bal-
sams of a stimulating nature."—Cullen's Practice of Physic.
   By Dr. Denman, in his valuable Introduction to the Practice
of Midwifery; and by Dr. Ileberden, in his Commentaries, pub-
lished  after  bis death by  his  son; the disease is named fluor al-
bus: and both have given very accurate descriptions of it.
   "A  mucous, ichorous,  or  sanious discharge from the vagina
or uterus, is called fluor  albus: these discharges are  various in
their degrees as in their kinds; from a simple increase of the
natural mucus of the part, to that which  is of the  most acrimo-
nious quality;  but the first is not esteemed a disease, unless it is
excessive in its degree.  It  is the  most  frequent  complaint to
which  women are liable, and  is by them  suspected  to  be  the
cause of every disease which they may  at the time suffer;  but
it is generally a symptom of  some local disease, or a conse-
quence of great debility of the constitution, though when  pro-
fuse it becomes a cause  of yet greater weakness."—Dr. Den-
man's Introduction to the Practice of Midwifery, chap. 3,  sect. 6.
   " Humor iste, quamquam  plerumque  albus  ut vulgo appella-
tur, et aquae similis, interdum tamen glutinosus est, et coloris
subflavi,  item  subviridis et mali odoris, atque  tarn acris ut  nisi
partes  in quas descendit saepe eluantur levis inflammatio fiat cum
prurigine et dolore: cuticula quoque deteralur, et urina reddi 
VAGINAL DISCHARGE.
15
nequeat sine sensu pungentis caloris."—Heberden's Comment.
cap. 41.
   By la Motte, in his work entitled Traite complet des Accou-
chemens, the complaint is called " Les fleurs blanches."
   Dr. Hamilton,  in his Treatise on Female Complaints,  consi-
ders the  disease  under the head of "Sexual Weakness"  and
amongst  women  above  the  lower class  of life in this  coun-
try the  discharge is called " a weakness." The most vulgar de-
nominate  the discharge " the whites."
   In reviewing these names, we shall find that they are all ob-
jectionable, with the exception of that employed by Sydenham,
" fluor muliebris," which is as applicable to the menstruous dis-
charge  as to any  other.
   The  term " a weakness" deserves particularly  to be repro-
bated; because it may, and actually does, very often become the
reason for prescribing tonic medicines, which may be most de-
trimental  to the  patient.  Indeed,  women  often spontaneously
have recourse to strengthening medicines and  to food in many
cases in which both are injurious.
   The  author has prefixed the expression  "vaginal discharge"
to this chapter; but he wishes  it to be considered as a symptom,
and not treated as a disease.   The most simple definition of it
appears to be, that it is a discharge of a fluid flowing  from the
vagina, varying  in its consistence, quantity, and  colour; either
produced  by weakness of the constitution, or by a change  in the
structure, position, or actions of the neighbouring parts,  such
change being the effect of natural or morbid causes.
   It is very important  to inquire into the cause  of these dis-
charges; by the  knowledge of which, the judgment of the prac-
titioner  will be directed to the  best mode of treatment.
   If the discharge is the effect of weakness, and if by its contin-
uance the original weakness is  increased, tonics will be  required.
If it depends upon some tumour in the vagina, the removal or
support of this will also  remove the discharge. If it arises from
inflammatory action,  this must be removed before any endeavour
to restrain it is employed; for as the discharge during its contin-
uance lessens the violence of the disease which produced it, it
should not be checked till such inflammatory action is diminish-
ed. Nothing can be more injurious  under such  circumstances,
than the exhibition of tonics and stimulants, as cantharides,  tur-
pentine, and steel.
   In many cases it is as injurious to restrain the discharge from
the parts,  as it would be to put an end to the natural salivation of
a teething child whilst the determination of blood  to the head
continues,  or to  heal an ulcerating surface in a constitution 
1(3
VAGINAL  DISCHARGE.
which has been long accustomed to it, without substituting some
other secretion for it.
   In  many complaints of the female organs the patient is liable
to discharges,  and these are of different kinds: but all the varie-
ties of discharge are not met  with in one patient  at  the  same
time; since in one case the discharge is  mucous, in another pu-
rulent, and in another watery.
   The  author hopes that  some  advantage will be  gained  by
classing these diseases according to the  peculiar nature of the
discharge which accompanies them.—It  must be allowed, that
there are mixed cases, where the discharges vary  from their usu-
al appearance; moreover, a discharge of one kind will  mark one
stage of a disease, and a discharge of another kind a different
stage. As happens in  diseases in  other parts of the  body, one
disease also is sometimes blended with  another, and the dis-
crimination of these  modifications and irregularities  constitutes
no small part  of the  skill of the  practitioner.—A scirrhous tu-
mour of the uterus may have been attended  (for years perhaps)
by an increased  secretion of simple mucus;  but upon this dis-
ease becoming active, by inflammation attacking  the tumour, so
as to convert it into cancer, the discharge becomes purulent and
highly irritating.  The period of this conversion is indicated by
the alteration in the nature of the secretion.
   In the cauliflower excrescence  of the os uteri,* the discharge
consists of little more  than a clear watery fluid: blood, however,
is sometimes mixed with it, or perhaps comes  away alone in
large  quantities.  Nevertheless, the discharge of blood forms no
part of  the peculiar character of this disease, but it is generally
produced by violence or improper exertion.
   The discharges from the vagina may be comprised  under the
following heads:

   1. Transparent Mucous Discharge.
   2.  White Mucous Discharge.
   3. Watery Discharge.
   4. Purulent Discharge.
   5. Sanguineous Discharge.

              Transparent Mucous Discharge.

   By transparent mucous discharge is meant that which is gela-
tinous, nearly transparent, and capable of being coagulated.

  * See a paper by Dr. Clarke, in vol. iii. of the Transactions of a Society
for the Promotion of Medical and Chirurgical Knowledge. 
VAGINAL DISCHARGE.
17
                    White Mucous Discharge.

    The white mucous discharge is opake, of a perfectly white
 colour;  and it  resembles,  in  consistence, a  mixture  of starch
 and  water made without heat; or thin cream.
    This discharge is easily washed from the finger after an exa-
 mination; and it is capable  of being diffused through water, ren-
 dering it turbid.—A morbid state of the glands in the cervix of
 the uterus probably gives rise  to  this  discharge; at least,  the
 cases in  which it comes away are those in which the symptoms
 are referred to  this  part; and when  pressure is made  upon it,
 the woman complains of considerable pain.


                       Purulent Discharge.

    The  term purulent discharge  needs  very little  explanation,
 meaning simply  that,  in which the fluid resembles pus secreted
 by the surface of an ulcer.


                       Watery Discharges.*

    Under the head of watery discharges are comprehended those
 which resemble  clear water, having no colour, and which  con-
 tain very little glutinous matter; sometimes  none at all.
    If the discharge  of blood (the quantity of which is sometimes
 very great) be excepted, the watery discharge exceeds in quan-
 tity any other which these  parts furnish.  The linen of the pa-
 tient will  often  appear  as if drenched with water, and  no care
 (so long as the disease continues which gives rise to it) will pre-
 vent the patient being rendered uncomfortable by it. By a stea-
 dy perseverance in a proper plan,  in one,case  of disease   in

  * It is not intended  under the present head to  nclude  involuntary dis-
 cbarges of urine, arising from paralysis of the neck of the bladder, or commu-
 nications between the  bladder ana the vagina. The unfortunate subject uf
 these accidents deserves every  attention; and whatever can be suggested by
 the invention, or formed by mechanical means, for the purpose of adding to
 the comfort of the sufferer, should be employed. The cases just mentioned
 may not admit of cure;  but muth may be done in the way of alleviation.
 There will be no difficulty in distinguishing between urine and any other wa-
 tery fluid, if a moderate degree of attention be given .•—the smell itself will
 be in most cases sufficient to  detect the difference: but where (as in 9ome hy-
 sterical cases) the urine possesses little colour or odour, the nature of the fluid
 may be readily ascertained by some inquiries made of the patient  respecting
 the commencement of the disease, the supposed cause, and the accompanying
 symptoms; especially whether, in addition to the constant discharge of a fluid,
 the patient is at any  time enabled to retain much urine in the bladder: for in
 no case of palsy of the neck of the bladder, or destruction of the parts be-
 tween its cavity and that of the vagina, can much urine be retained; and it
generally runs off as fast as it is secreted—Obvious as the diagnostics are, it
has occurred to the  author to witness an instance where the  mistake was
made, and it may often bare  happened.
                       C 
18
VAGINAL DISCHARGE.
which it arises, it may be much moderated; whilst in another,*
no remedy will produce any effect upon it.

                  Sanguineous Discharge.

  The sanguineous discharge is that of which blood forms the
principal part, or perhaps the whole, of the matter evacuated.—
The appearance of blood is too well  known to be mistaken; but
in proportion to the quantity evacuated, or the length of time
which it takes up in escaping, will be its fluidity or form. When
the quantity is considerable, when it escapes from large vessels,
or is quickly forced out by the  energy of the action of the heart
and  arteries, it comes away in a fluid state: when  it escapes
more slowly, and the exit of it is for a while  retarded, being in
a state  of rest, it coagulates, assuming the figure of the parts in
which it lies: where very little is poured out, not enough to form
a stream, or a coagulum, of much thickness, it simply covers the
surfaces over which it flows, and becoming solid, escapes  from
the external parts,  either in the form of hollow casts of the ca-
vities in which it has been retained; or sometimes, spreading it-
self over the surfaces of tumours, it comes away in  the form of
circles of coagulated  blood.  In this  latter case, the shape of
these rings of blood escapes observation generally; for being re-
ceived upon the linen of the patient,  by collapsing they lose
their proper form:  but  if they are  placed in water, or  if they
come away with the urine, they fall into the vessel which con-
tains it, and demonstrate the  manner of  their formation.—By
the action of the surrounding parts upon these coagula of blood,
the serum is squeezed out of them; and the coagula themselves,
having acquired a  greater firmness  than usually belongs to co-
agulated blood, are sometimes regarded by patients as diseased
tumours which had,,;een formed in the parts.  The coagulating
lymph of the blood sometimes comes away  unmixed with the
colouring matter or the serum: this happens  in inflammation of
the mucous membrane of the vagina and uterus. Many cases of
this  kind are mistaken for  abortions: since  the substance dis-
charged resembles  decidua, both in colour and thickness; and
the pain which attends  them makes the resemblance between
the  two  cases greater.  Periodical  returns of the pain are met
with in both occurrences. The difference  between the two cases
consists in this—The transparent membranes of the ovum will
be wanting if the case is not abortion; and  in inflammation of
the mucous membrane of the uterus and vagina, although there
will be occasional pain in the attempts to  expel the adventitious
matter, there will  remain a permanent pain, arising from the
" Hydatids of the uterus. 
VAGINAL DISCHARGE.
19
continuance of the morbid action  of  the parts, which will be
wanting in abortion.
   Of some diseases of the  uterine system, the white mucous,
and the  watery discharge  are  pathognomonic symptoms; but
ihe sanguineous belongs to none  exclusively, being met with
occasionally in  most of them:  in some  it appears with more vi-
olence than in others: its quantity may  not exceed a few drops;
or it may be so profuse as  to bring the life of the patient into
immediate hazard.—It is unnecessary  in this place to consider
sanguineous discharges, because they will be described in the
history of those diseases to  which they  belong.
   An evacuation of blood from the uterus takes  place in some
cases of  disordered menstruation, without any alteration of the
structure of the parts.—These cases may perhaps be the subject
of future consideration.
   There are some diseases of the  female organs  which are un-
attended with any discharge from the vagina.—These will also
be described at some future period.
   Of all the discharges which come away from the vagina, those
of mucus are the most frequent, as they are capable of being
produced by several complaints of the parts: besides which, the
mucous discharge is that which takes place  frequently (in those
women  whose constitutions have been  much weakened) from
debility alone. 
20
EXAMINATION NECESSARY
                   CHAPTER III.

General Observations on Sexual Diseases, and on the Necessity
     and Mode of making an Examination per Vaginam.

  There are no diseases which  excite in  the mind of the pa-
tient a greater degree of anxiety and  distress than those affect-
ing the sexual organs,  both male and female. The first appear-
ances of disease are marked with attention, inquiries respecting
them are made  with earnestness, and their progress is watched
with the most unremitting care. This is not only observable  in
persons of weak  minds and  fearful dispositions;  but in  those
who possess the  strongest  understandings, whose  minds have
been used to contemplate danger, and fortified by religion and
morality.
   So connected is the happiness of mankind with the well-being
of these parts, and so diffused is the influence which these parts
have upon the functions of others essential to health, that  it ex-
cites no surprise that the anxiety respecting them should be  so
great.
   The diseases of these parts affect either the external or the
internal organs, of which complaints the latter are by far the
most numerous.
   The existence  of these diseases and their  kind  can only  be
known by an examination per vaginam: and this should  be  al-
ways proposed and performed, whenever there is  reason to be-
lieve from the symptoms, that they depend upon any local cause.
If it should be found, upon examination, that no such local dis-
ease exists, the state  of the constitution is to be inquired into,
and remedies applied for its relief.  If, on  the  other hand, it
should appear that the parts are altered in structure or situation,
such local remedies are to be used as will either cure or palliate.
   It should also be recollected, that it is no inconsiderable com-
fort to a patient who believes herself to be affected by some  fa-
tal complaint, to  be  informed, after such  examination, that  no
such complaint exists.
   The human mind is prone to look upon the dark side of ob-
jects;  and for the sacrifice  which  on  this occasion the woman
makes of her feelings to her health, she often is amply compen-
sated by the information acquired.
   In making such examination, the person of the woman should
 on no account be exposed, and as  much care as possible should
 be taken to avoid giving pain.—Even when, as in the case of a
 tumour in the parts, it becomes desirable to know whether that 
TO ASCERTAIN DISEASE.
CM
tumour is sensible, this should  be ascertained with the greatest
tenderness.  The finger should  be covered with some unctuous
substance, in order to avoid giving any unnecessary uneasiness.
After the examination has  been made, the finger is to be wiped
upon a clean napkin, which will shew what is the  nature of the
discharge.
  It is notorious that many practitioners prescribe for complaints
of these organs, from a mere history of the symptoms given by
the patient.  It is quite impossible in many complaints to depend
upon such descriptions;  and daily experience demonstrates the
futility, and in  some cases the injury, arising to  patients from
medicines prescribed upon such vague information.
  From  the general disinclination of practitioners to make an
examination, arises in part their want of success in  the treatment
of these  complaints; and from this omission  proceeds the dislike
which many patients have to an examination being  made by a
second practitioner, when it had not been proposed by the  first.
In considering the complaints of these organs, it does not appear
that they are more easily  discovered than those in other situa-
tions.  They require as much and as attentive investigation;  they
are  not less numerous, or more simple, than those of other parts;
and by conjecture truth  is not likely to be elicited.
   But let it be granted that they are simple. Is it not customary
in other instances to pay a nice attention to simple complaints?
Is it usual to prescribe for a sore  throat, without  looking at the
fauces?  If a patient has a purulent discharge  from the anus.it
is the business of a surgeon to examine whether fistula be pre-
sent.  If a  man advanced in life  has a mucous discharge from
the  urethra, the practitioner would suspect disease of the pros-
tate gland, and would not be satisfied without making the neces-
sary examination.  These instances need not be multiplied.  If
all this be so, it is equally right for the practitioner to examine
a female patient, whenever he  believes that disease is present.
   But the nature of his  other avocations may not  lead him very
often to  meet  with  uterine diseases; and he may be  too little
 acquainted  with the state of the parts to draw any just conclu-
 sions from  this investigation. If this is an excuse for not making
 the examination himself, he should take  care that this very ne-
 cessary  duty should be performed  by another who is compe-
 tent, and accustomed to make it, and who possesses  ability to
 describe with accuracy what has been found on examination. 
22
                    CHAPTER IV.

                   ON SYMPATHIES.

   Between different parts of the body  sympathies of various
 kinds exist; some of which are indicative of healthy actions, and
 others of morbid  changes. On the subject of these sympathies
 every practitioner should be informed, as the knowledge of them
 is involved in almost every case respecting which a surgeon or
 physician may be consulted.
   Among the most common of the healthy sympathies may be
 mentioned that between the testicle and  the organs of voice in
 the male; that between the uterus and the stomach, and between
 the uterus and the breasts, in  the female; and that between the
 skin and the internal cavities in both sexes.
   The  morbid sympathies are very  numerous.—By morbid
 sympathy is meant that consent between one part  of  the  body
 and another, which arises in consequence of a part  having un-
 dergone some alteration in structure or actions, which excites
 sympathy in another.
   Morbid sympathy is found to exist between those parts af-
 fected by the sympathies of health; but it is also  met with in
 parts  between which, in health, there is no evidence of sympa-
 thy at all. For instance; a pain in the shoulder  attends a dis-
 eased state of the liver: but no one, whilst the liver is in a  heal-
 thy state, and performing its natural functions,  would be led to
 think  that any such sympathy between these parts existed.
   Morbid sympathy may be divided  into the single or simple
 sympathy, the compound, and the reciprocal.—Of the single or
 simple sympathy,  many examples present themselves:  that be-
 tween the liver and the shoulder has been mentioned above.
   When the functions of the stomach are disordered, and some-
 times  when only in a very trifling degree,  the breasts  become
 softer and more flaccid,  and the gland  itself seems altogether
 gone; and this too when the tone of the system generally is not
 much diminished, nor the size of the other parts at all  shrunk.
 In this case, the return of the firmness and size of the gland be-
 comes the strongest mark of the returning health of the stomach.
   An exception to the above statement, respecting the sympa-
thy between the stomach and the breasts, is observable in preg-
nancy;  in which  state, notwithstanding the functions of the
stomach are  greatly deranged, the  breasts continue firm  and
hemispherical, and become even harder and larger than at other
times; but this is  to be regarded in another way, and is part of
a process for the maintenance of the child to be born. 
ON SYMPATHIES.
23
  When the lower part of the intestinal canal is irritated by as-
carides, there is frequently an itching of the nose.
  The whole constitution appears in some cases to sympathize
with a part, since in large  external  and  particularly in internal
inflammations a shivering fit sometimes comes on.
  But it is to be observed, that these sympathies are single, and
pot mutual; for when the nostrils are irritated by polypus, or in-
flammation of the  membrane which lines them, no increased
irritability of the anus is excited,  neither is any uneasiness in the
region of the  liver produced when the shoulder is  affected  by
disease.
  There  are some sympathies  which are reciprocal; that is,
when the parts  mutually sympathize with  each other.
  In certain affections of the brain, there  is sickness of the sto-
mach ;  and in a disordered state of the stomach, pain is felt in
the head.
  If a man receives a blow  upon the testicles,  sickness of the
stomach comes on: on the other hand,  when the functions of
the stomach are deranged, the passions connected with and de-
pendant upon the testicles are dormant.
  There are other cases in which the  sympathies are of a com-
pound  nature;  as where a diseased  uterus produces sickness of
the stomach,  and  the  latter organ being disordered, pain in the
head  comes on:  here the sympathy is nnt direct between the
uterus  and the head, but  the head  is  affected through the  me-
dium of the stomach;  for  the same disease not being attended
by any  complaint of the  stomach, the bead does not suffer. A
lady between  fifty and sixty years of age  was attacked with
pain in the back and at the bottom of  the belly,  attended by a
purulent discharge  from  the vagina:  there was nausea and vom-
iting, spasmodic pains were referred to the epigastric region, and
there was pain over the anterior part of the head. An examina-
tion being made, the uterus was found extremely sensible to the
touch, but it was not enlarged; at least no enlargement could be
ascertained by examination: recourse  was had to the hip bath
and other remedies, and at the end of a few days the pain in the
back and  belly  ceased,  the sickness went off,  and the patient
was no longer troubled  by head-ache.  At various  times since
the first attack,  this patient has been liable to the  same symp-
toms, which have come on in the same order of succession; and
they have yielded to the same means.  The uterus appears to be
a very  fertile source of sympathy, and many symptoms referred
to other parts arise from it.  On this subject Sennerlus has the
following passage:  " llibet prceterea haec pars cum  multis aliis
partibus consensum, unde varii morbi et symptomata varia exci-
tari possunt." 
&1
ON SYMPATHIES.
   The influence of the uterus upon the stomach is one of  the
 most remarkable of all the sympathetic  affections between this
 organ and any other.  " Uteri affectus fere omnes ventriculo no-
 cent." Heberden. Commentaria de Historia Morborum, cap. 97.
   In cancer of the uterus, the stomach is always more  or less
 affected with vomiting.  When the uterus has been  ruptured,
 vomiting comes on; and the matter rejected is of a black colour,
 resembling coffee grounds.
   In amenorrhcea, the symptoms which  belong to the stomach
 constitute a very important part of the disease.
   In dysmenorrhoea, or painful menstruation, sickness and vom-
 iting are  present during the acute stage,  and the effects of im-
 paired digestion or disease of the chylopoietic viscera  distress
 the woman in the intervals between the periods of menstruation.
   The bladder and the  rectum sympathize with the uterus; and
 hence strangury and tenesmus attend many of its complaints, as
 well as the process of labour. Frequently, however, these symp-
 toms are produced by mechanical causes, as by tumours of the
 uterus pressing upon the rectum or the  meatus urinarius.  It is
 highly important to investigate these cases fully, as from the re-
 lative situation  of  these parts,  and  the existence of sympathy
 between  them,  mistakes may otherwise take place.
   A tumour attached to the posterior part of the uterus may  so
 compress the rectum between the os sacrum and itself, as to al-
 low the fasces to pass with great difficulty, or to obstruct the
 passage of them entirely,  unless when they are of a very small
 size.  This has  led practitioners often to suspect stricture of the
 rectum;  and  upon carrying  the finger into the rectum, this sus-
 picion is confirmed: not only the size of the faeces passing through
 the sphincter ani is rendered much smaller, but a resistance is
 offered to the passage of the finger.
   A pain in the back is present in many  diseases of the uterus;
 arising perhaps  partly from sympathy, and partly from the origin
 of the sacral nerves.*
   Pain in the lower extremities attends some uterine affections:
 previously to  the appearance of the menses, and before the com-
 ing on of each period of  menstruation, it is experienced by many
 women.  It has been observed  as a precursor of puerperal ma-
nia.—This pain in the legs is very different from cramp in the
lower extremities, produced by pressure upon the sciatic nerve

  * At the moment at which the author is writing this, he has a patient who
has been taking medicines for a considerable time, under a supposition that
she laboured  under stone in the bladder.—She has a tumour projecting from
the anterior part of the cervix of  the  uterus, upon which all her  symptoms-
depend; and there is  every reason to believe that the  bladder is perfectly
 healthy.                                               r 
ON SYMPATHIES.
25
of one or both sides; and it takes place in cases where no such
pressure is, or can be made.
   The abdominal muscles sympathize with the uterus; but not
unless the muscular fibres of the uterus are in a state of con-
traction.  If there is any substance  to be expelled from the ca-
vity of the uterus, the abdominal vessels lend their assistance in
expelling it; as when an ovum, a  bunch of hydatids, or a poly-
pus, are  protruded through the cervix of the "uterus. The abdo-
minal  muscles  assist also in expelling  the contents of the sto-
mach, the intestines, and the bladder.
   The diaphragm is apt to be affected in  some diseases of the
uterus, so that the patient becomes subject to hiccough.
   The mind  also sympathizes with  the uterus.  This it does al-
most always when the  stomach is affected by disease: but this
is to be  considered as one  of the  compound  sympathies: for
both in men and  in  women,  when the digestive organs are dis-
ordered, the faculties of the mind are apt  to be enervated; and
occasionally to so great a degree, as to incapacitate  the patient
for attending  to common business, or for enjoying  the  ordinary
pleasures of life.
   But besides  this  affection of the mind, induced  through the
medium  of the stomach, many cases are found where  the con-
nexion subsisting between the uterus and  the brain  appears to
be more direct: as in furor uterinus, puerperal convulsions, and
in those cases of madness which succeed parturition, when  there
is little of bodily disorder. This connexion  between the uterus
and  the  sensorium  may account  for the  greater number of in-
stances of madness  which occur in females than in males; it ap-
pearing that the number of women, compared with that of men,
affected by madness in this country, is in the proportion of five
of the former to four of the latter.*
   The same  author observes, " The natural processes  of  men-
struation, parturition, and preparing  nutriment for the infant, to-
gether with  the  diseases to  which  they  are  subject  at  these
periods,  and  which are frequently  remote causes of  insanity,
may perhaps  serve  to  explain  their greater disposition to this
malady."—"That the  peculiar states of  the  uterus have fre-
quently a share in producing  madness, appears from the fact,
that between  the years 1784 and  1794 eighty patients were ad-
mitted into Bethlem Hospital,  whose disorders followed shortly
the puerperal  state.  It is also to  be remarked, that in this spe-
cies of madness,  the secretion of the  menstruous discharge is
interrupted, but its  regular flow generally precedes recovery;
and  that some cases are met with, when the  madness is con-

       * See Haslam's Observations on Madness aDd Melancholy.
                    D
F 
26
ON SYMPATHIES.
nected with the menstruation, and has lasted for years, in which,
upon the cessation of the uterine discharge, the patient has com-
pletely recovered."
  The inferences to be deduced from these facts  are; that the
functions of the uterus  being duly performed, the mind is  very
little apt to be affected: that a disordered state of the reasoning
faculty is attended by an interruption to the performance of these
functions: that a parturient state of the uterus is a frequent cause
of madness: and that, lastly, when the functions of the uterus
are at an end, when it no longer secretes menstruous fluid, and
when consequently it is no  longer capable of being impregnated,
the disposition to mental disease generally terminates.*
  The mind sympathizes  with the uterus in different degrees;
from the case of the slightest  hysterical  affection, to  absolute
madness.  Great despondency, dread of the future, ungrounded
apprehension of some great misfortune, are to  be looked upon
as states of mind frequently originating in uterine disease.  The
last-mentioned mental symptoms seem most frequently to attend
those cases  in  which  there is a languor in the uterine system;
whereas  the more  violent kinds  of mania attend those cases
where the uterine system is highly  excited.  This, however, is
by no means universal:  but the author's  experience does not
furnish him with a single  case of violent  madness  connected
with amenorrhcea  attended by debility; whereas those accom-
panied with dread and  melancholy  are exceedingly  common.
These states of mind form by far  the most distressing part of
the disease; and there are few patients who would not exchange
these feelings for bodily suffering, if they could choose between
them.
  There is a sufficient  evidence of a  disordered state of mind in
many uterine affections in  the gestures of the patient, which are
hurried; the patient is almost constantly in  motion.   There is a
restlessness of manner, a hesitation in her speech;  sometimes a
remarkable solicitude in her mode  of interrogatijig  the practi-
tioner. She prefers solitude to society; although when her mind
is fully engaged in  the latter, she becomes less restless and dis-
turbed.

  * The author has kept no exact register of the number of patients whom he
has seen labouring under puerperal mania: but his recollection furnishes him
with nearly as many cases of this disease in single as in married women; not-
withstanding the proportion of  single women who fall into labour, compared
wilb those who are married, is very small.
i 
87
                     CHAPTER  V.

 On certain Diseases attended by a Mucous Discharge from the
                          Vagina.

   Some of  these  complaints consist of  the displacement of
parts; as
                   Procidentia Uteri.
                   Procidentia Vesicae.
                   Procidentia Vagina;.
                   Inversio Uteri.


                PROCIDENTIA  UTERI.

   The nature of this disease may  be understood  from the name
given to it: it has also been called vrrtpicTwris, Prolapsus Uteri,
and Descensus Uteri; the latter term being used to express the
minor degrees of the disease, the  former that in  which  the ute-
rus has fallen out of the body through the  external parts.  By
women the disease is called "a falling of the womb," or simply
"a bearing down."
   In  the healthy unimpregnated state of these parts, the uterus
is situated nearly in the centre of the cavity of the pelvis, the
distance of the  os uteri from the  os externum being about four
inches.  The  os uteri is not a continuation  of the same line with
the vagina, but it terminates in the vagina  by projecting into it,
the outer surface of this  projection  being  covered by a portion
of the inner membrane of the vagina tightly spread over it.  In
the generality of subjects the distance from the opening of the
os uteri, to the part  where the inner membrane of the vagina
begins to be reflected over it, may be nearly an inch. This dis-
tance will of course be increased in  procidentia uteri, the angle
of reflection being made nearer to the os externum.*
   Every  degree of procidentia uteri  may be met with; from
that case in which  the  os uteri descends  a little lower than its
natural situation, to that in which the uterus projects through the
external parts, dragging with it the vagina, and forming a large
tumour between the thighs of the woman, equal in size to a large

  * In  the most trifling case of procidentia uteri there must be some inversion
of the  vagina, and the degree  depends upon the extent to which  the prod
dentia  uteri has proceeded.—" Nam in descensu quoque vagina taritum se in-
vertat  quantum  uterus descendit."—Morgagni de Sedibus  et Causis Morbo-
rum, Epist. sir.
• 
28
PROCIDENTIA UTERI.
 melon. This will cause an alteration  in  the relative situation of
 the parts within the pelvis and of the abdominal viscera, both
 regarding each other and also the containing parts, as the pari-
 etes of the abdomen, and the bones of the pelvis.  The bladder,
 instead of being contained in the  pelvis, falls down into the ex-
 ternal tumour, dragging with it the meatus urinarius; so that in
 order to introduce a catheter  into the bladder, the point of the
 instrument  must be turned  towards the knees of the woman;
 for, being placed in the usual  manner in which that instrument
 is introduced, it will enter the passage,  but cannot be made to
 pass into the bladder in that direction.
   The rectum,  instead of taking  the sweep of the sacrum, first
 dips down  into the posterior part  of the  tumour, and afterwards
 ascends into the pelvis. The  fallopian tubes and ovaria will of
 course be dragged down with the uterus,  and the centre of the
 tumour will be filled  up by the small intestines which hang
 down into it (the mesentery  being stretched;) whilst the omen-
 tum will occupy any vacant  space which may be left.
   Many months or even years may  elapse whilst the uterus is
 making this descent; for when the uterus has descended  so far
 that it can  rest upon the perinaeum, there it not infrequently re-
 mains, resting upon it as upon a shelf, the violence of the symp-
 toms abating; for the parts which  suspend the uterus  above, al-
 though much lengthened, are no longer put upon the stretch.
   The number and violence of the symptoms are by no means
 proportioned to  the degree of the descent of the uterus; for when
 it has descended but little, the round  ligaments are put upon the
 stretch, and the  symptoms also which depend upon  sympathy
 attend the minor cases of the complaint.
   When the tumour is external, much inconvenience  is felt by
 the woman in consequence  of the situation  of it  between the
 thighs,  which obliges her to straddle, in order to prevent pres-
 sure upon it. The external surface of the tumour presents a near-
 ly equal surface; for as the uterus  descends, the ruga? of the va-
 gina are obliterated, except where the upper part of the tumour
 is joined to the body; and even here they are lost,  when the
 bladder contains much urine; but  in proportion as it empties it-
 self, the rugae begin to  form again.
   When the tumour becomes very large, the skin  of the labia is
 drawn down,  so that these parts are no  longer distinct projec-
 tions; but the tumour begins  close  to the upper part of the thighs
 being covered by the cuticle  of the labia, and the greater part by
 the membrane which,  under natural circumstances,  lines the
 vagina.
   The vagina, being exposed to the  action of the air upon it,
loses its florid colour, and acquires that of the skin of the  body! 
PROCIDENTIA UTERI.
29
It also loses its peculiar sexual irritability; not indeed becoming
insensible to pressure,  but its sensations being  by no means so
acute as they are in the natural state. The anterior part of the
abdomen, instead of possessing  its usual convexity, becomes
flatter, from the viscera of the abdomen having left  its cavity.
When the uterus and its appendages only have fallen out of the
external parts, but before the other viscera have fallen into the
inverted vagina, the tumour has a lengthened  form, which, ta-
ken together with its situation and the opening at the lower  part,
has made it sufficiently resemble the male organ to impose upon
the credulous; and such persons have been exhibited as herma-
phrodites. The difference between  this disease and the  male
organ is too obvious to be mistaken by any one who will  pay
attention to it. The long diameter of the opening of the urethra
in the latter is from before to behind; whereas that of the os
uteri in  females is from side to side; and this alone is enough to
mark the  difference. After some time the breadth of the tumour
increases, so that it becomes of a globular form.  The situation
of the viscera  being thus changed,  they become liable to pres-
sure in a greater degree than when  they maintained their natu-
ral situation in the cavity of the abdomen; and  inflammation is
sometimes the effect of this pressure.  Coagulating lymph  is in
such cases thrown out, which unites the parts; and if either the
omentum, or a portion of intestine, be thus connected with the
lower part of the tumour, pain may  and will be felt in those situ-
ations of the belly from which such parts proceed.  In the young
woman  from whom one of the drawings was taken,* where the
omentum adhered to the fundus of the uterus, pain was felt in
the region of the stomach,, and became a cause of great distress.
   The immediate causes of this  disease are:

   1.  Relaxation of the broad and round ligaments above.
   2.  A want of due tone in the vagina below.

   By the first, the uterus is permitted  to fall;  by the second,
the uterus is allowed to be received into its cavity.
   Whatever is capable of producing a lengthened state of the
ligaments, or a relaxed state of the vagina, may become the oc-
casional cause of the complaint.
   Weakness of the system may be looked upon  as a cause of
this complaint; and therefore after long diseases, which have di-
minished  the patient's strength, it is occasionally met with.  Pro-
fuse hemorrhages taking place from any  part of the body may
acf in the same way.
   But the most common cause of procidentia uteri is the  long
continued erect posture of the body at an early period after de-
* Vide Plate. 
30
PROCIDENTIA UTERI.
livery, and in some cases after abortion.  To this cause the ma-
jority of the cases is to be attributed: for at this time not only the
immediate causes  of the disease are present,  but the  uterus
weighs eight or ten times more than  an  unimpregnated  uterus,
and it is carried down by its own weight. The long confinement
of a patient to a warm bed after oelivery may be  productive of
considerable debility ; but sitting  up in the erect posture is more
injurious.  The use of the chair is now very much laid aside, and
the best practitioners direct their patients to remain in the re-
cumbent posture upon a sofa, or  on the outside of the bed: the
advantages of a horizontal posture and coolness are thus com-
bined. This posture should be  observed  until  the uterus has
nearly regained its unimpregnated size,  which will be between
the third and fourth week after delivery, at which lime it may be
presumed that the ligaments and the  vagina have acquired  their
former strength.   In this place a question may arise: What be-
comes of a women in the lower ranks of life, who  have not the
means of giving  up this time to the recovery of their local
strength?  These women are liable to this complaint,  and suffer
from  its effects very frequently. Because they are  not generally
found to complain, it is  not to be supposed  that they have not
cause for  complaint;  nor,  because  they are not seen confined
to a bed,  is it  to be thought  that there is  no necessity for con-
finement.  They  are often  great sufferers;  but their sufferings
are frequently unknown, and their  humble  station  often pre-
cludes them from  obtaining  relief.  Women liable to  violent
coughs during the time of their confinement  after childbirth are
especially the  subjects  of procidentia, from the pressure made
by the abdominal  viscera upon the uterus in the  occasional
strong action of the diaphragm and the abdominal muscles, when
the vagina can afford no resistance.

                        SYMPTOMS.

  These arise partly from the effects produced upon the cir-
cumjacent parts by the change in the  situation of the uterus, and
partly from sympathy.
  It may  be  a matter of surprise, that a very trifling change in
the situation of the uterus should  produce those inconveniences
which attend some of the cases of this disease; but this surprise
will be lessened by the recollection, that in other  parts  of the
body, any derangement of the natural order or structure occa-
sions much distress. A small tumour  upon the inside of the eye-
lid will cause great  pain, and produce  a plentiful effusion of
tears; a trifling obstruction in the lacrj mal duct will be attended
with a constantly weeping eye; a  polypus  of the nostrils will 
PROCIDENTIA
UTERI.
31
occasion suffocation, interfere with  the power of smelling and
swallowing,  and produce a considerable  discharge  of  mucus;
one tooth projecting beyond the rest will irritate the  cheek, and
sometimes render the speech inarticulate; and a relaxed or elon-
gated uvula  will sometimes produce a permanent sensation of
choking.
  At the commencement of this ailment the women complains
of pain in the back, and this symptom sometimes continues for
a great length of time  without any other: pain is also felt in the
groins, extending towards and terminating in the labia:  there is
a sense of fulness in the parts, and  an increased  discharge of
transparent  mucus from the vagina.  As the disease proceeds,
the pain in the back is described as the pain of dragging:  the
patient now has a sense of bearing down, or of weight; feeling,
as she expresses it, as if every thing was dropping through her.
The discharge increases  in quantity.  The pain in the groins
arises probably  from  the round  ligaments  being stretched,  and
that  in  the  back perhaps from an elongation of the parts con-
necting the uterus behind. As soon as the erect posture is chang-
ed for the recumbent position, these symptoms go off.
  Strangury, although  not a constant attendant,  sometimes is
present, and annoys the patient until the procidentia is cured.—
A lady, whose constitution was weak, and who had borne seve-
ral children, was attacked by pain in the groins; she had a  dis-
charge of mucus from the vagina, and was affected by a frequent
desire to make water,  voiding very little at each attempt.  She
had  employed poppy fomentations and opium, and had taken
some oily purgatives, without experiencing the least good effect.
Upon further inquiry it appeared, that the  pain in the groin3
left the patient at bedtime, and  that at the same  time the  fre-
quent inclination to make water went off. This led to an exam-
ination of the parts, by which a procidentia uteri was discover-
ed. The whole  plan of treatment was now changed. She used
an astringent injection, took some cinchona with sulphuric acid,
and confined herself to the  sofa.  By pursuing these means, the
strangury and  all the  Other symptoms left  her as her strength
was restored, without  the use of any mechanical means.
  The  pain in the back which attends procidentia of the uterus,
should be distinguished from that which is  met with in  cases of
separation of the joint  between the os ilium and the os  sacrum,
after some cases of labour.  It has been remarked, that the  pain
in the  back arising from procidentia is greatest when the patient
is erect, and that it subsides in the horizontal posture.  In the
case of separation of the joints alluded to, the patient has a great
difficulty in standing,  or perhaps cannot stand  at all, is uneasy
even in the  recumbent posture, and  incapable of moving in  bed
without great pain. 
B2
PROCIDENTIA UTERI.
  Procidentia  uteri and separation between the bones  of the
pelvis may exist together  in the same patient, as is exemplified
in the following case.
  A young lady was delivered of her first child after  a very
good labour, which was very well managed by  a sensible prac-
titioner. The child was large. Being well  after her labour, she
sat up, walked about early, and considered herself  remarkably
well. She soon, however, became subject to a pain  in the back
and groins,  uneasiness in the region of the  stomach, and her di-
gestion was impaired.  She was very hysterical, and never free
from a mucous discharge  from the vagina.  By the use of a pes-
sary and an astringent injection, and  the employment of some
bitter tonic  medicines, these symptoms diminished, and the sea-.
bath completed the cure.  She  fell  with child  again in a few
months, and was delivered of twins.  During and after  this la-
bour, there was a considerable discharge of blood;  but in other
respects she was well.  At the end of a fortnight she found her-
self incapable of standing, and  all the symptoms  returned as
after her former labour.   By the use of the means above  men-
tioned, the  fresh-water bath being used (from necessity) instead
of the sea-bath, the symptoms all left her, excepting the pain in
the back, and the incapability of standing for half a minute unless
supported on each side.  Whenever she  made the attempt to
Stand, she placed  her hands upon the sides of her hips.  This
led the author to make a firm pressure there with his own hands;
and as long as this was firmly applied,  she could stand, but as
soon as this support  was withdrawn she was in danger of fall-
ing. Upon this information being gained, a leathern  belt was
made, of about the breadth of an inch and a half, or somewhat
more, which was  applied round the pelvis as tight as it could be
borne without producing pain.  The comfort  arising from this
belt was felt immediately;  and by  the  permanent  use  of the
bandage the complaint was cured, but  some time elapsed be-
fore she completely recovered.
  In procidentia uteri, the symptoms arising from the sympathy
between the stomach and the uterus are  very distressing.   The
appetite becomes  irregular, or is totally lost; the stomach and
bowels lose their tone, and there is  a great sense of distention
in the belly arising from air, which may  be heard when  moving
from one part to  another; the spirits flag; every employment
becomes irksome, and life itself is considered as scarcely desir-
able. The diaphragm  is sometimes affected by  spasm, and hic-
cough is produced.
  The quantity of the discharge from the vagina varies; in some
cases being very profuse, in  others slight.  The appetite  being
diminished, the  digestion impaired, and the secretion from the 
PROCIDENTIA UTERI.
33
 parts being greatly increased, considerable weakness of the sys-
 tem is produced, and the vessels of the uterus, partaking of the
 general debility of the frame, permit blood as well as menstru-
 ous fluid  to escape from their cavities: so that the patient may
 at the same moment labour under two diseases, one  being the
 effect of the other; viz. menorrhagia and procidentia  uteri; the
 former not admitting of relief by the usual means, unless atten-
 tion be paid to the latter.
   When the uterus has fallen out of the body, so as to become
 an  external tumour covered by  the vagina, the surface of the
 tumour (i. e. the membrane of the vagina) ceases to secrete, al-
 though it  did so before in very considerable quantity, whilst the
 tumour was contained within the os externum.  This circum-
 stance will account for a fact observable in the disease, viz. that
 those cases of descent of the uterus in which the tumour is not
 external,  are attended  with a much greater degree of bodily
 weakness than when the tumour is  external; in which latter
 case, all that strength is saved to the woman, which would have
 been expended if the tumour  had continued in the body. But
 if the parts are returned to their natural  situation, if that which
 is the covering of an external  tumour is converted into the lining
 of an internal cavity, the mucous membrane of the  vagina be-
 gins again immediately to resume its  functions.*
  It seldom happens that the vagina remains  long  exposed  to
 the action of the air, without  ulceration taking place upon its
 surface. This ulceration does not attack the whole of the expos-
 ed surface at once; but small spots or patches inflame and ul-
 cerate, and these sometimes run into each other, but the whole
 surface is  seldom covered by them. These ulcerations are gene-
 rally not deep, and they have the appearance of healthy sores.
  Whenever these  ulcerations are met with, the os uteri seldom
 escapes being attacked by one of them.
  Slight degrees of procidentia uteri can only be ascertained by
 great attention to the state of the parts, together with a know-
 ledge of the  common size and length of that part of the uterus
 which hangs down  into the  vagina.
  There is then,  in this disease, a tumour, either in the vagina,
 or hanging out of the external parts. But every tumour in these
 parts is not a prolapsed uterus. The mark which always charac-
 terizes procidentia of the uterus, is the existence of the os uteri
 at the lower part of the tumour. This being wanting,  the dis-
 ease is proved not to be procidentia uteri.

  " This the author has frequently had an opportunity of  demonstrating to
some of the pupils attending the lectures, in the person of a poor  woman la-
bouring under an external prolapsus, who occasionally came to the lecture-
room.
i: 
31
PROCIDENTIA UTERI.
  If a woman labouring under this complaint observes a hori-
zontal  posture,  she experiences none of the symptoms so long
as this posture is continued, but they return in the erect posture;
the cause of which is, that in the recumbent posture the  uterus
does not fall into the vagina, and therefore the parts above are
no longer stretched, nor those  below distended. Any  examina-
tion made only  whilst the patient  is lying down,  will, for  this
reason, give little information to the practitioner.  She should be
examined  in the erect attitude also.  By  this  means, if the  dis-
ease is procidentia, the uterus  is not only made to fall  lower,
but the degree of the disease is also ascertained. 
35
                   CHAPTER  VI.

               Treatment of Procidentia Uteri.

  If nothing were done in the way  of  treatment for a patient
labouring under this disease, she would become much distressed
by all the symptoms which  have been described: she might die
from weakness, induced by the large  discharges and the disor-
dered state of the stomach; or she might die from inflammation
taking place in the parts contained in  the inverted vagina, which
are  more liable  to pressure  than when in their  usual place, the
cavity of the pelvis and abdomen.  This really occurred in the
young woman who died of  an external procidentia in the work-
house at Kensington,  and  whose body  was  inspected  by Mr.
Thomson junior, and the author: coagulating lymph was thrown
out, and the contents of the tumour were cemented together by
means of it.  There was also,  as is usual in cases of peritonoeal
inflammation, a considerable quantity of serous fluid in the ca-
vity of the  abdomen. Such  fatal terminations are uncommon; it
much more frequently happens, that the  patient drags on an un-
comfortable life for a number of years, till she is destroyed by
accident, or by some other disease.
  Few cases admit of relief more readily than procidentia  uteri
in the early stages of it, and the  remedies  should be applied as
soon as the disease is  discovered; for the size of the  support
which is to sustain the uterus must be in proportion to the de-
gree of dilatation of the vagina.  If a  woman having this disease
should again become  pregnant,  and  will consent, after her la-
bour, to a confinement for  some weeks in  a horizontal posture,
the parts may regain their tone, so  as to  render any artificial as-
sistance unnecessary: but as the woman  may not again be preg-
nant, and as, if she should, her patience may  not hold out dur-
ing  the length .of time necessary for the natural cure of  the dis-
ease, the next subject of inquiry will be into the mode by which
the complaint may be cured by art.
  It has been already remarked, that in this complaint the va-
gina and the ligaments  which suspend the uterus have had their
tone diminished or destroyed, in  consequence  of which the ute-
rus has fallen lower than its natural situation.  From this view
of the case, the curative intentions appear to be, to  increase the
strength of the parts which  are weak, and to afford a support to
the tumour, the descent of  which produces the symptoms. In
every case, these two objects are never  to be lost sight of; but
as in many cases  the powers of  the constitution are weakened. 
36
TREATMENT OF
and as we can give strength to particular parts by adding to that
of the whole, those means usually employed to strengthen the
constitution are not to be neglected.
  The tone of the weakened parts is to be restored,
  ].  By the application of cold.
  2.  By the application of astringents.
  Cold applied to the surface of the body produces an increase
of the tone of the body, or increases the  permanent contraction
of the moving fibres.  Thus, after the  immersion of the body in
the  cold bath the  muscles  will be found firmer and harder, and
will adapt themselves more closely to  the  parts which they co-
ver; the scrotum, although before relaxed, becomes shorter in
consequence of the increased tone of the muscular fibres, and
the  skin is consequently thrown into folds or rugae.  Cold pro-
duces also the temporary contraction  of muscular fibres.  Ap-
plied  suddenly to the body previously heated, it is known to
produce contraction of the bladder, as may be instanced in peo-
ple  who come out of hot rooms and theatres: and this happens
before the bladder is much distended; so that it is not the mere
distention of the bladder which produces this effect, but simply
the  application of cold to the surface of the body.
  Cold produces contraction of parts in the  immediate neigh-
bourhood of its application in a greater degree  than in those at
a distance. If the hand of a man be dipped in cold water, it will
shrink in size, the skin of it will become paler, and the vessels
which ramify near the surface will be diminished in diameter, so
as perhaps to be no longer visible, whilst the  other  hand will
undergo no change.  The application  of cold to the outside of
the  head  of a patient labouring under  the effects of pressure
upon  the brain, will diminish  these  effects by taking off the
pressure;  and that it does so actually, is demonstrated by the
vessels of the tunica conjunctiva  becoming smaller in size, the
face paler, and the pupil capable of contraction.
  But the application  of cold to a small  part of the body, and
this too at a distance, will  sometimes  cause a temporary strong
action of parts, particularly of internal cavities: the immersion
of the hands in cold water may  occasion contraction of the blad-
der and the expulsion of its contents.
  The application of ice  to  the neighbourhood of the uterus,
i. e. to the back  or belly, is useful in  uterine hemorrhage, by
producing the contraction  of  the uterus itself;  and the size of
the  uterus may be felt to diminish under the hand; whereas the
application of ice to a surface  equally large  at a distance, will
not  produce this effect at all,  or not in the same degree.
  Whatever produces  an  increased determination of  blood to
any part of the body, will occasion an  increase of secretion from 
PROCIDENTIA UTERI.
37
 the neighbourhood of that part.  If the surface of the  body is
 kept warm, the skin  becomes red, and the quantity of the per-
 spiration is increased. If a larger quantity of blood is sent to the
 salivary glands by the exhibition of mercury, salivation in great-
 er quantity follows:  and innumerable other instances might be
 brought, demonstrating the same fact.
   On the other hand, whatever diminishes the flow of blood to
 any part of the body, will produce a diminution of the secretion
 from the neighbourhood  of that part.  If the skin of the body is
 kept cold, the surface becomes pale, and a check is given to the
 perspiration: if the breasts of a woman are kept cool, the quan-
 tity of milk may be greatly diminished.
   Of the knowledge of these  facts the practitioner is to avail
 himself in the treatment of the disease  under consideration. It
 is desirable to increase the tone of the vagina, and so, by dimin-
 ishing  its diameter,  to prevent the descent of the uterus: it is
 also important to lessen the quantity of the mucus secreted: 1st,
 because it becomes a cause of weakness;  and, 2dly, because
 the passage of a warm gelatinous fluid over the parts will relax
 them still more.
   The  canal of the vagina is surrounded by a number of mus-
 cular fibres,  capable  of being made  to contract by some appli-
 cations or to relax by others, subject to the same laws by which
 muscular  fibres in other  parts are governed. When these mus-
 cular fibres contract  with force, the rugae of the vagina are great-
 ly increased in number;  when their tone is diminished  or lost,
 the ruga? of the vagina are diminished in number. If the vagina
 of a woman in perfect health and vigour be examined, the in-
 ternal surface of it will be corrugated strongly;  but the reverse
 will happen in proportion as the woman  becomes  weak;  and
 therefore  in some cases of extreme  debility the vagina will be
 so much relaxed, as readily to admit the whole hand  : the rugae
 will be obliterated, the surface of the vagina will present no  in-
 equalities, but be perfectly smooth.
   Cold  substances applied to the vagina, or to the parts in the
 neighbourhood, will produce a contraction of the muscular fibres
 which surround it, a  corrugation of the internal membrane, and
 a diminution of the diameter of the canal itself.
   Cold  applied  to  the vagina will produce contraction of the
 blood-vessels which are in its neighbourhood, and the secretion
 from it will be diminished. Women  subject to a mucous dis-
 charge from the vagina are sometimes inclined to employ some
 addition of clothing,  so as to absorb it, and to keep  their per-
sons comfortable; although they remark at the same time, that
if they have not recourse to such additional clothing, the quan-
tity of the discharge is diminished.  The explanation of this is, 
38
TREATMENT  OF
that the action of the parts is increased by the addition of what-
ever tends to increase the warmth.
  Further: It is to be  observed, that cold not only produces a
diminution  of secretion, by causing an increased contraction of
the blood-vessels, but  also by  throwing the vagina into folds;
for in this state of the parts the blood-vessels which supply the
lacunae must run in a more  tortuous direction, and a resistance
must be offered in a greater degree to the flow of blood through
them;  and  this is perhaps  the reason why  it will generally be
found, that  the quantity of the secretion from the membrane of
the vagina will be proportionate  to the number of rugae within
it, as  was  remarked in describing the discharges  from these
parts.
  In procidentia uteri,  cold  water ought  to be  applied to the
female  parts,  to  the  belly, and  to  the back, by  means of a
sponge, three or four times a day; and  the  water for this pur-
pose should  be used  as  soon as it has been drawn from the
spring.  The water may be rendered still colder by the addition
of some matter which is passing from a solid to a fluid state, as
ice or salt.  Cold water may also be thrown into the vagina by
means  of a  syringe,  or a piece of ice may be introduced into
the vagina,  and suffered to dissolve there.  In very slight cases
of the disease, when the symptoms are just beginning, and when
they are known to proceed  from  the  causes which have  been
mentioned, they will  be  removed by attention to  these rules,
assisted by  the horizontal posture. Whenever it is found neces-
sary to inject  fluids  into the vagina,  and important that they
should remain there for any time, the operation should be per-
formed  when the woman is in  a recumbent position;  and if a
pillow is previously placed under the  hips, in order  to  raise
them a  little, the fluid  will be less likely to escape.
  The syringe to be employed should be  capable of holding as
much fluid  as will fill the vagina;  it should be furnished with a
curved pipe, and the piston should play readily in the cylinder:
this is a very material point, as the following case will shew.
  A lady whilst throwing some  injection into the vagina found
that great force  was necessary to make the  fluid pass, and she
incautiously applied it.  Instead of pushing the piston lower in
the cylinder, she pushed the point of the  pipe violently against
the anterior parts. Inflammation of the  bladder came on, which
extended to the peritonaeum, and  spread over great part of it;
symptoms of the most  alarming kind came on, and it was only
by frequent bleedings,  the use of diaphoretics, and  a long con-
finement, that  the disease was subdued.
  There are two great defects in the construction  of  many of
the syringes  made for  female use: one is, that they have one 
PROCIDENTIA UTERI.
39
large hole, or so great a number of holes at the extremity, that
the fluid passes out too quickly. The other defect is in the situ-
ation of those holes, which are frequently placed at the sides as
well as at  the point of the instrument, so that the fluid escapes
at the lateral holes,  and little or none perhaps reaches the upper
part of the vagina. But if the holes are all  placed at the extrem-
ity of the pipe,  the injection will be  thrown to the upper part of
the vagina, and will be sure of returning by the sides.  In by far
the greater number of  cases the vagina will be found too much
relaxed  to have its tone restored by cold alone, and it will re-
quire the additional aid of astringents.
   Astringent substances, applied to an animal solid, increase the
force of the cohesion between the parts of it, or render it firmer.
   The same  substances  applied  to  the living fibre increase its
power of contraction, and thus a shortening of the fibre  is pro-
duced.  On these  accounts they become very valuable applica-
tions in many cases of disease depending upon a laxity of mus-
cular fibres. They  often become the cause of the restriction of
hemorrhage from  small  vessels, by producing a diminution of
their cavities.   Stimulants will produce the same effect,  but are
by no means so safe or so efficacious.
   In procidentia of the uterus, astringent applications to the va-
gina become very serviceable, by diminishing its diameter, and
thus rendering  it less disposed to receive the displaced  uterus;
and also by restraining the mucous discharge.
   The mineral and vegetable  kingdom furnish a number of as-
tringent substances, differing from each other much in power;
and certainly not all equally applicable  to every case.
   Sulphate of zinc.—This substance is more useful in cases  of
relaxation of the orifices of mucous glands, than where tone  is
required to be given to muscular fibres, as in the case of proci-
dentia: for in order to this latter effect a very strong solution of
it must be employed, and  this  will  be apt to irritate the mem-
brane of the vagina:—few persons can continue to apply it long
on this account.
   The same observations apply to the compound of silver and
nitric acid, and of copper and sulphuric acid.
   The superacetate  of lead does  not possess much power in
contracting the  vagina; and few cases of  this  disease  will  be
benefited by  its use, unless  where  inflammation has attacked
the vagina.
   Solutions of alum  will  be found to be a much  more powerful
remedy; and even when very strong, they are little apt to irri-
tate the mucous membrane.  It has  been the custom, from the
earliest ages of medicine, to make a combination  of those medi-
cines, which fulfil the same intentions; and experience confirms 
40
TREATMENT OF
the propriety of the practice.  It may reasonably be supposed,
that a part not liable to be acted  upon by one substance may be
acted upon by another of the same  class: thus one patient will
be purged by senna, another by jalap, and another by salts, and
either  of them may be more active with one patient than the
other two;  but-a more certain effect will be produced by a com-
bination of the three medicines and  by any of them singally, or
even by two of them.
  This fact is not confined to medicines  for internal use, since
we  find that an indolent ulcer will sometimes be more benefited
by one stimulating application than by another, and  that a com-
bination  of stimulating substances will sometimes agree better
than any one applied singly.
  A mixture of alum and sulphate of zinc in such 'proportions
as the  nature of the case may seem  to require, will sometimes
fulfil the  intentions of the practitioner better than either employ-
ed alone; and so of all the other mineral  astringents  which have
been in use.  The varieties in the  shades of disease  require a
variety in the remedies employed; and this must be left to the
skill and  the judgment of the practitioner, who must accommo-
date his measures to the peculiarities of each case;  and who, if
he expects to find  all cases alike, will be much disappointed
when he  is called  upon to treat them. In the last Pharmacopoeia
published by the London College of Physicians,  there is a for-
mula for  a solution of sulphate of zinc and alum, under the title
of Liquor Aluminis Compositus,* which  however will require to
be diluted with different proportions of  water, so as to adapt it
to different cases;  for the irritability of the mucous membrane
of the vagina varies in different women, as well as in the same
woman at different  periods of time.  This may make  it neces-
sary to begin with the application of weak astringents, and to
increase their strength gradually.
  Amongst the vegetable astringents applicable to the  case un-
der consideration, may be reckoned Thea viridis, Petala Rosae
rubrae, Cortex Quercus, Cortex Granati,  Gallae.
  The two former do not possess the same degree of astringen-
cy with the last-mentioned substances. The three last possess a
great degree of astringency.  They give out their astringent pro-
perties to water more readily by boiling than by infusion, and
therefore the decoctions of them are to be preferred: they may
be used alone, or some of the mineral astringents may be dis-

                  * Liquor Aluminis Compositus.
    R Aluminis
      Zinci sulphatis singulorum unciam dimidiam;
      Aqua? ferventis octarios duos:
     Alumen et zinci sulphatem in aqua simul liqua; dein per chartam cola. 
PROCIDENTIA UTERI.
41
solved in them.  By these means are procured astringent fluids
of such  strength that the  vagina  may be so much  contracted as
even to render the introduction of the pipe of the female syringe
difficult.
   Astringent injections should be thrown into the parts twice or
three times a-day, or oftener; and they should be  used cold.
   In addition to the good effects produced upon the  parts by
the local application of astringents, the views of the practitioner
may  be forwarded  by exhibiting tonics internally. Substances
of this kind applied to the stomach have the effect of increasing
the lorce of the contraction of parts at a distance, and therefore
will  prove useful in many cases of this disease.  From the nu-
merous class of bitter tonics may be selected, according to the
judgment of the practitioner, one or more which may be exhib-
ited, such as gentiana, coluinba, quassia, anthemis, humulus; and
the combination of two or more of these proves more useful than
one  only, and is besides more grateful to the stomach.*
   A combination of a bitter and  an astringent may be  more use-
ful than a bitter medicine given  alone.  The sulphuric acid may
be exhibited in any of the bitter infusions; but as  the cinchona
contains both of these principles in a great degree, it  is perhaps
to be preferred to any other medicine: this too  may  be advan-
tageously combined with the sulphuric acid.
   It has been before remarked,  that the stomach sympathizes
with  the uterus in this complaint; and  that all its functions will
sometimes  be impaired,  and its tone greatly diminished.  In
cases where both the stomach and the general  system are weak-
ened, but in which  the stomach has more than its  proportion of
weakness, the simple bitters will be found  better fitted to the
purpose  of giving strength than  the combinations of bitters and
powerful  astringents: it  may indeed  be judicious to combine
these medicines with  stimulants,  in order to excite the stomach

  * " Bitter medicines which tend to strengthen the system,  as far as my ex-
perience has gone, sit easier on the stomach, and tend more to strengthen the
system when  mixed together, than when any one of them is employed sin-
gly "—See a paper, by the late Dr. George Fordyce, in the second volume
of the Transactions of a Society tor the Improvement of Medical and Chirur-
gical  Knowledge.
  The snme observation had been made above a century before, by the expe-
rienced Sydenham. Speaking of medicines for strengthening lh«  stomach, he
says:—" Eorum species aliquot affabre permislae humoribus concoquendis
rrctius, ut mihi videtur, quam simplex  quodlibet ex eorum tribu  desumptum.
Quumlinet enim quoties specifica medicamenti cujuslibet virlute  opus est no-
bis, regula tenet, Quo simplicius en, melius:—Tamen cum id habemus propo-
siti ut huic illive iudicationi satisfaciendo aegrum sanenius, singula ingredien-
tia symbolum pro morbo curando quasi conferunt. Atque in hoc  casu, quanto
major est simplicium numerus, tanto potcntius medicamentnm opeiabitnr.—
E praedictis itaque et reliqu& ejusdem farina? materia inedica. varix remedio-
rum formulae ad hunc scopuin tendentes concinuari posnint."
F 
42                  TREATMENT  OF
quickly to a more vigorous  action.  The spicy barks, the aro-
matic seeds, and  volatile alkali, will be found well  adapted to
this purpose.
  In  all  complaints it is highly important  to  have a well-regu-
lated state of the stomach and bowels, but  in none more than in
this; for the two extremes of diarrhoea and costiveness will great-
ly retard the progress of the cure.  The straining attendant upon
tenesmus will act  upon the  uterus; and  the endeavour to expel
a costive stool has frequently displaced a pessary. The purga-
tives adapted to this case are those which  increase the  peristal-
tic motion of the intestines; such as rhubarb, or senna, to which
some aromatic water or essential oil may be added, or a drachm
or two of the compound  tincture  of rhubarb may be added to
each dose of the bitter medicine.
  Oily purgatives are apt to offend the stomach; those  of a sa-
line nature diminish the strength of the system, by lessening the
quantity of circulating blood: and the resinous class of purga-
tives stimulate the lower part of the intestinal canal, and thereby
increase the action of the vessels of the neighbouring parts. All
these therefore are improper.
  Mention has been already made of the application of cold to
the parts concerned; but it yet  remains to be stated,  that the
cold-bath is a valuable auxiliary in the cure  of the  disease.  It
increases  the  strength of the  muscular fibres  throughout the
whole body, and greatly invigorates the system;  but the same
observation  which was made  respecting other tonics is no less
applicable  to cold-bathing; namely, that when  the  stomach is
weakened more than any other part of the frame, the use of it
will be detrimental to the patient.   In like manner,  when a pa-
tient labours under any inflammatory affection of  the chest, the
cold-bath should not be recommended on any account; although
it should appear  probable  that the employment of  it might be
beneficial in the  other complaints  under which the patient la-
bours.
   Women whose strength  has been much exhausted,  should
employ this remedy less frequently than those who are not so
much debilitated, beginning with it twice  a-week only,  and  at
length using it daily.  There  certainly is  a difference  between
the effects of bathing in fresh and  salt water in many complaints.
It is also observable in this. Women who have used the fresh-
water bath with little or no advantage, have derived great bene-
fit from sea-bathing; but as the situation in life, or the  conveni-
ence of every person, does not  admit of a journey to the sea,
it may not  be amiss to  mention a plan which the author  has
found in some measure  to compensate for the want of a sea-
bath.  It is  observed by persons  who  have  used both salt and 
PROCIDENTIA UTERI.
43
fresh-water bathing, that after the former a glow diffuses itself
all over the body, which glow is not felt after the latter.  The
shock  applied to the constitution  increases  the strength of the
action  of the  heart, and the stimulus of the salt upon  the skin
invites the blood to the surface.  Let two pounds of salt be dis-
solved in a gallon of water; let some coarse towels be immersed
in this water, and afterwards wrung out and dried. After  bath-
ing, let the patient be dried with these towels, using  some fric-
tion at the same time.  In this way a degree of warmth will be
given to the body, which will  be  both  useful  and agreeable to
the patient. A solution of sea salt in water, employed  as a show-
er-bath, is a good substitute for bathing in the sea.
  In every case of procidentia much may be done by  posture:
the patient should lie  as much as possible upon a bed or upon
a sofa; and a mattrass,  as presenting a flatter surface, and being
less likely to debilitate, is preferable to a bed of down or fea-
thers.  The rooms which the patient inhabits should be kept cool.
  Great care should be taken to guard against every thing which
may produce strong action of the abdominal  muscles; which, by
pressing upon the parts contained in the abdomen or pelvis, may
prolong the disease:  besides, if a pessary is employed, it may
be expelled or  displaced by these efforts.
  The diet of the patient should  be nutritious, and a moderate
quantity of wine may be allowed; but  the stomach  and intes-
tines should never be loaded, lest the weight in the pelvis should
keep up the complaint. The bladder should never be suffered
to contain a large quantity of urine, for the same reason.
  All  flatulent  food,  all the  wines of this country,  (amongst
which  beer is included)  should be avoided, as being liable to
undergo another fermentation in the body, and to inconvenience
the patient by flatulency. 
44
ON THE MODE OF
                   CHAPTER VII.

           On the Mode of supporting the Uterus.

  Different modes have been employed, at various times, of
supporting  the weight of the uterus. Some of these possess  ad-
vantages over the rest. The support intended for this purpose is
called a pessary.  Those in common use have been made of
wax, cork,  cork  covered with  wax, sponge, and wood.  All  the
above-mentioned substances, except the last, are liable to some
objections.
  Wax being soft, and  readily  formed into  any shape  which
may be required, would seem  to be a very good material for a
pessary; but in the heat of the body  its shape becomes altered,
and it no longer bears upon the parts on  which it was intended
that it should rest.
  Cork, although from its lightness it seems  well adapted for
the purposes of a pessary,  is objectionable,  from  being  porous
and liable to imbibe the moisture of the parts;  from which  cir-
cumstance  it becomes offensive and irritating.
  Pessaries have been  made  of cork covered with wax;  but
they soon lose the wax, which either becomes soft and is rub-
bed off, or it peels off in flakes.
  Sponge is the worst material which can be employed for pes-
saries;  for it is porous, and will very quickly imbibe the mois-
ture of the parts.  The piece of sponge must be large, compar-
ed  with the size of the vagina, or it will be useless; and if it is
large, the vagina, (the  dilated state of which was  one  of the
causes of the disease,) will be still farther  dilated: and although,
whilst the sponge is worn,  the uterus will rest  upon it, and  the
symptoms-may be relieved;   yet, when  it is removed, the  dis-
ease will return with double violence. It  is a matter of surprise
how such a substance could  have been  recommended  for the
purpose of curing the disease;  since in  fistulous  sores,  where
the object of a surgeon is to increase the  size of the opening by
dilatation, this substance has been selected for the purpose.
   A good  pessary should combine firmness, lightness, and close-
ness of texture:—firmness, that it  may not yield to pressure;
lightness, that it may not incommode by  weight; and closeness
of texture, that it  may not imbibe the secretions of the vagina.
   Those made of box wood possess all these  advantages;  and
this wood, not being scarce, can be easily procured.
   Pessaries are made  of  various shapes  as well as of different
materials, adapted to different  cases and circumstances. For the 
SUPPORTING THE UTERUS.
45
majority of cases, a circular or an oval pessary answers suffi-
ciently  well; but the circular pessary can  only be safely used
in those cases where the  disease has  not made great progress,
and where the tone of  the  vagina  is not much  impaired:  for if
the canal of the vagina has been much  dilated, no pessary of a
small size can be sustained in it; and  one of a larger size, and
of a circular form, might  do mischief,  by compressing the mea-
tus urinarius and rectum,  and so preventing the  discharge of the
faeces and urine.
  It will seldom be safe  to introduce a circular pessary the di-
ameter  of  which  exceeds two  inches  and a  half: below this
size there can be no impropriety in using it; for it is certainly
less liable to be displaced  than the oval pessary.  The efficacy
of a pessary depends upon the nice adaptation of its size  to the
state of the parts:  the  practitioner  ought therefore particularly
to attend to this.  It should be large  enough to keep the situ-
ation  in which  it is placed, else it  will slip away; but it should
not be so large as to distress the woman, or to injure the parts
by its pressure.
   If, after the first introduction of the  instrument, it should be
found that it is not adapted to the state and size of the parts, its
size or form should be changed.
   No instrument of this kind should measure in thickness at its
external edge less than one-third of an  inch, lest it should in-
jure the parts by its edge:   it should  become gradually thinner
as it approaches  the centre, in which  there should be an oval
opening large enough to hold  the end of the  forefinger of the
surgeon, in order to enable him to place the instrument. A num-
ber of holes may be pierced through  the instrument in different
parts, by means of which it is . rendered much  lighter, and the
secretions from the upper  part of the vagina, as well menstru-
ous  as  mucous, can  more readily pass through it.—Whatever
may be the shape of the instrument employed  as a support, it
should be removed occasionally for the  purpose of cleaning  it,
lest the secretions of the  parts  should  attach  themselves to it,
and by  retention become acrimonious and irritating. Occasion-
ally also the pessary should be changed for one of a smaller
size.  In consequence  of omitting  to  withdraw the pessary, the
surface  of it has sometimes become  coated with gritty matter,
which has brought on irritation, inflammation, and ulceration  of
the neighbouring parts. Instances too  have occurred where parts
of the instrument have  been destroyed by a  spontaneous change
taking place in it, and angular portions of it have been left, which
have produced  similar  bad effects.
   A lady, seventy-five years of age,  who had borne children,
came under the care of the author, on account of considerable 
46                 ON THE MODE OF
pain in the vagina, attended by a  very offensive discharge: the
pain was  constant, and was compared  to that produced by a
sharp instrument.  Thirty-five years before, she  bad a prolapsus
uteri, for which a pessary  had been introduced, and had never
been removed. The author having reason to fear that some dis-
eased structure existed, examined  the  patient, and found that
the pessary had lost its original form, being corroded in several
places, and that many irregular portions of it were left, which
pressed upon the vagina, and had  produced ulceration of its in-
ternal surface.  This lady having, as  she said, suffered  exceed-
ingly  in the introduction of the instrument (because perhaps it
was incautiously performed,) would not consent to its removal,
particularly after some of her symptoms had been relieved by
fomentations  and injections.*
  The pessary of an oval form is  best adapted to those cases in
which the tone of the  vagina is so very much diminished as to
make a large support necessary; because  in this case  the  oval
pessary rests by its two extremities upon the sides of the vagi-
na; but lying with its long diameter applied to the short diame-
ter  of the lower aperture of  the female  pelvis,  it neither inter-
feres with  the rectum nor with the urinary passage.
  If the case should require it, an oval pessary may be used, of
a size so large  that it may measure three inches and three quar-
ters in its long  diameter, without any injury to the  parts: and a
case will scarcely occur, where  the perinaeum is  not injured, and
where the  uterus  has not descended out of the external parts,
in which a pessary of  this kind will not afford  a sufficient sup-
port.  There is however an objection  to the use of this  instru-
ment; which is, that it is more likely to be displaced  in the sex-
ual intercourse than a circular pessary. It may be here remark-
ed, that if the patient has not passed the child-bearing age,  such
intercourse should not be prohibited; for if the woman should
become pregnant, the  disease will be  naturally  cured after the
fourth month, by the ascent of the uterus into the cavity of the
abdomen.

      Mode of introducing the circular or oval Pessary.

  The woman should  be placed upon her left side, close to the
edge of a bed, and her knees should be drawn  up towards the

  *  Dr. Clarke  related to the author a case to which he was called, in  a wo-
man advanced in life, who on account of similar symptoms had been exam-
ined by another practitioner, who found what he considered to be a schirrous
tumour surrounding the os uteri. Dr. Clarke found that the supposed schirrous
tumour was a cork pessary, introduced many years  before, and rendered very
rough by calculous matter deposited on its surface.  It was withdrawn, and all
the  symptoms subsided in the course  of a week. 
SUPPORTING THE UTERUS.
47
abdomen: the practitioner is then (having previously examined
the size of the vagina) to select a pessary, according to his judg-
ment, of a proper size.  This instrument is then to be covered
with some simple unctuous matter; and if its form  is  circular, it
is to be placed  between the labia, so that one edge  will be turn-
ed towards the  os pubis, and the other to the rectum: it is then
to be moved in a circular direction on  its own  axis,  pressing it
at the same  time towards the perinaeum, till it has fairly entered
the vagina.  As the instrument passes  the edge of the external
parts, some little uneasiness is always felt by the  woman; but
this  ceases  as  soon as it has reached  the vagina,  to the  upper
part of  which it is to  be carried; and it is to be so placed  that
the uterus may rest upon one of the broad surfaces of it.  The
instrument is now to  be left in the vagina, and a syringe full of
some cold astringent  injection should be thrown into the parts,
to give  tone  and contraction to the  dilated os externum; as in
cases where the vagina is very  much relaxed, it may make a
smaller pessary answer the purpose of support than would  be
required if no such means were resorted to. Whatever may  be
the shape of the pessary introduced, the woman should continue
for some minutes in the recumbent posture.
   An oval pessary requires great care  in the  mode of introduc-
tion; and is either a very good or a very bad instrument, accord-
ing as it is well or ill  applied.  In the choice of it, the present
size of the vagina is to be first considered, with the diameter of
which the long diameter of the instrument should correspond.
The extremities of the instrument should not be too acutely
pointed, lest they should injure the parts.
   The instrument being covered with some unctuous substance,
one end of it is to be placed between  the labia, with  the short
diameter running from before to behind; and in this direction it
is to be carried up into the vagina.  Thy practitioner is then to
insert the point of his forefinger  into the opening in the centre
of the  instrument, and to place it across the vagina, so that the
extremities may be turned towards the spinous processes of the
 os ischium.  If the direction of the opening  in the pessary is
 made to correspond with that of the long diameter of the instru-
 ment itself, this will be easily accomplished. The pessary is now
 to be passed as high  into the vagina as it can be without giving
 pain, and to be left there.
    Procidentia uteri sometimes occurs in women whose perinae-
 um  has been  lacerated to a great  extent in labour:  in such a
 case, neither the circular nor the oval  pessary can be retained;
 but the sacrosciatic ligaments and the os coccygis will sufficient-
 ly contract the lower aperture of the pelvis to enable a globular
 pessary to  be  retained. This pessary, pressing equally in all di- 
48
ON THE  MODE  OF
rections, is very conveniently borne; and it may be used in wi-
dows who have lost the catamenia, with great advantage.  The
size of the instrument being adapted to the capacity of the parts,
its surface is to be covered with unctuous matter, and  it is to be
placed  between the labia;  by a gentle pressure  it is to be car-
ried  into the vagina, giving a degree of rotatory motion to it as
if passes along, which  greatly facilitates the introduction.
  A form of instrument has been made for these  cases with a
stalk, to enable the woman to secure the instrument in the parts:
but this stalk is very apt to  irritate the labia; and the author has
hardly known a case in which it could be employed with advan-
tage.
  Hippocrates, in the  second  book weg* yvvxiKtioi, describes ex-
ceedingly well some  cases  of procidentia uteri.  Amongst the
causes of the disease, he  mentions fatigue after delivery,  carry-
ing heavy burthens, fright, cutting wood, or being connected t»
etvtfi tt ry texiy xct6«£<ret.  Speaking of the treatment of the dis-
ease, he recommends  the application of cold water and  astrin-
gents to the parts, the moderate use of food and  drinks, a pos-
ture of body in which the feet are  to be placed higher than the
head;  and, as a means of supporting the uterus, he desires that
a globular  pessary should  be  worn; and  perhaps a better one
could not be suggested,—very light, and possessing  astringent
power—a pomegranate steeped in wine.  This (he directs) is to
be chosen of a fit size, and to be carried  into the parts, so that
it may not  come away, but remain.*
   In those degrees of this disease where  the  uterus quits the
cavity  of the  pelvis and falls out of the body, forming occasion-
ally a tumour between the thighs of  the  woman, it is obvious
that the parts must be returned to their natural situation  before
any support can be applied with much advantage.   How far it
 may be prudent to attempt this reduction, and what degree of
force  it may be justifiable  to employ for the purpose, must de-
 pend  upon many circumstances into which inquiry  should  be
made.
   Particular care should be taken to ascertain, whether inflam-
 mation has at any time attacked the internal parts of the tumour;
because if this should have happened, and  if the parts should be
 connected  with each other by coagulating  lymph, the force ne-
 cessary to accomplish the return of the- tumour may separate the
 adhesions, or tear the parts with which they are connected; and
 the  life of the patient may be brought into imminent hazard.

   • T«v poiuv ii*  tov OfV»<x\ov TgrxravTX fU<rov, fv oiva) ^Xiwvavra, ins ag/uA%» /uxtXia-ra,
u ft* ti kuXvei, xgovrtiii oi(.c(rccTaTa, ut  ocvaJWai TaiKw TXaTEi), n.cu av«Xa£f»y, aif fit
omctQxvoi axxa /avoi.—'Inrto^. xtgi yvvctMiu*, lib. ii. cap- 41. 
SUPPORTING  THE UTERUS.
49
Whenever therefore acute pain, which has been lasting, has oc-
curred in the tumour, particularly when this has  been accom-
panied by other marks of peritonaeal inflammation,  such as thirst,
white tongue, small quick pulse, tenderness of the abdomen, and
vomiting, no attempt should be made to replace the uterus with-
in the  body.  So also when the  attempt is  attended with great
pain, all efforts to return  the parts should be abandoned.  Bands
of organized coagulating lymph may compress some parts of the
intestinal canal when the tumour has been reduced, and the pa-
tient may  be exposed to  all the hazard of a  strangulated hernia.
  If it is determined that the tumour should be returned great
caution is  necessary;  for when  the parts have been long  dis-
placed, and the centre of the tumour is filled by the intestines,
omentum, &c, the operation may be difficult, if not impossible.
The vagina, when dragged down by the uterus, sometimes un-
dergoes such a degree of distention, that its diameter will be
greater than that of the  pelvis itself.  In the case of Watkins,
who died in Kensington workhouse, the tumour measured more
than fifteen  inches  in circumference, and  its length was six
inches and a half.
   As the size of the tumour will "be much increased by the dis-
tended state of the bladder and rectum, they should be previ-
ously  emptied.  The body  of  the patient  should then be so
placed that the pelvis may be much higher  than the  head: this
will  prevent the weight of the abdominal viscera from interfer-
ing with the return of the parts.  The patient being now directed
not to  strain, or  in any way to act with her  abdominal muscles,
the practitioner  is to apply his fingers and  thumb to the lower
part of the tumour, where the os uteri is situated, and by a gen-
tle pressure this  is to be carried  up into the centre of the tumour
itself.  This done, the same pressure is to be continued, and the
parts are to be returned into their proper place in  the pelvis. A
pessary is then to be introduced into the vagina, and the patient
should continue  to lie upon an inclined plane, with the hips ele-
vated,  for several hours.
   In almost all the  cases in which the degree of the disease is
so considerable,  every pessary which can be introduced will be
forced away by the slightest efforts of the woman: even the glo-
bular pessary  (which is the best) will not  be  retained, neither
can it be kept in the vagina  by any common bandage.  But by
the following contrivance the globular pessary may  be kept in
the vagina.  In the first  place, a pessary is  to be chosen of the
size which the case requires, and a small slip of  brass is to be
attached to it by its two  ends, leaving a space between  the in-
strument and the centre of this piece of brass: a belt of leather,
long enough to  go round the patient's body, is also to  be pre-
                     G 
90
SUPPORTING THE  UTERUS.
pared: to the centre of which behind, a brass wire, as thick as a
common quill, is to be attached  by a screw.  This wire is now
to be properly bent; and  the pessary being introduced into the
vagina, the wire is to be passed  between the  pessary  and the
piece of brass attached to  it; and being brought up between the
thighs, it is to be  attached to the fore part of the circular strap.
The reduced parts are by this means  supported by a pessary,
and this is kept in its place by the unyielding piece of metal.
   By this contrivance a disease of a most distressing nature may
be relieved, and the patient's  situation changed from a state of
the greatest distress to  one of comparative comfort.
   Before  this history  of procidentia uteri  is closed, it will be
right to observe, that cases of this disease  are  sometimes  pro-
duced  by the pressure of  tumours of various kinds upon the
uterus, and also by tumours of the uterus itself, which  by their
weight displace it.  The symptoms in such cases will be some-
times of a compound nature, arising partly from the tumour, and
partly from  the altered situation of the uterus.  Great circum-
spection is  here  required; and it should  be well considered,
whether it is advisable to recommend to the patient to bear the
inconvenience arising from the two diseases, or to have recourse
to a support.
   Wherever there  is reason to believe that the tumour is of a
character likely to assume an active form,  it will  be best to do
nothing which can  possibly add to the disorder, but to  advise
the  patient  to submit to her present complaints, rather than to
incur the  hazard of rendering them worse, by experiments in-
tended to relieve one of them which is not hazardous, but only
inconvenient. 
51
                    CHAPTER VIII.

                PROCIDENTIA VESICA.

   This  disease being attended with some of the symptoms of
procidentia  uteri, has  been confounded with it, and  treated as
such:  in a few instances the patient has been relieved, but in
the majority of cases she receives no benefit. As in procidentia
vesicae the vagina  falls  down  before the tumour, the case has
been  denominated  by some  writers procidentia vaginae;* al-
though by others this term has been applied to the case where
the posterior part of the vagina has failen, so as to be exposed
by protruding through the  os externum. By some writers  upon
the diseases of the female  organs, this complaint has not  been
noticed at all; and by none, within the author's knowledge, has
the symptom which  generally attends it been pointed out.
   The term procidentia vesicae is given  to  this disease:  first,
because  it is really  the bladder which falls, and which  carries
the vagina  with it, in  the  same  way in  which a falling uterus
does;  and secondly, because the name directs the mind of the
practitioner to an important part of the treatment.
   The bladder may descend a little lower than  its natural situ-
ation, or  it may fall  so low as to become an external tumour
projecting between the labia.
   This disease, like the former, will be  most likely to  occur
when the vagina is relaxed, as after childbirth; but it may hap-
pen at any period of life.  It is the posterior  part of the bladder
which descends, or that which lies behind the entrance of the
urinary passage.
   The.greater  number of  patients whom  the author has  seen
labouring under this disease have been subject to violent coughs,
which may therefore probably have had some share  in its pro-
duction.
   The symptoms of the disease in some respects resemble those
of  procidentia  uteri; but some of the latter are wanting, and
others not present in procidentia uteri  are met with in this ail-
ment.  The weight of  the  part induces the woman to complain
of a bearing down; not however to the  same extent as in proci-
dentia uteri. When any urine is contained in the bladder, the

  * " De procidentia vulvae seu vagina uteri. Non ab imperitis tantum ob-
stetricibus  alque aliis mulieribus, sed ab ipsis quoque medicis atque chirurgis
viris ceterum satis expertis et doctis, identidem vagina procidentiam cum uteri
procidentia confundi, eodem utplurimum nomine utrasque designari, manifes-
lum est experientia."—Institutiones Chirurgica;, Laurent. Heister. cap.  clviii. 
52
PROCIDENTIA VESICiE.
patient is much more uncomfortable, as the size of the tumour
is much increased when the bladder is full; and vice versa. The
tumour seldom goes away entirely, because some urine gene-
rally remains in the bladder, even immediately after the woman
supposes that she has emptied it; it appearing that these  mus-
cular  fibres  of the  bladder, which form the pouch or tumour,
have not the  power of contracting so as to expel  the whole of
the urine.
  A mucous discharge often attends the disease: but the quan-
tity varies. In some cases it is very profuse.
  The peculiar symptom which marks this complaint is a pain
referred to the navel, with a sense of tightness there.  This pain
is the greatest when the bladder contains the largest quantity of
urine; and as it parts with its contents the uneasiness diminishes,
till at last when it is empty, or nearly so, the symptom goes off
altogether.
  The superior ligament of the bladder runs from  the fundus of
the bladder to  the  navel,  to which  it is attached;  and perhaps
some elongated stale of this  ligament (the remains of the umbi-
lical arteries), or the effect produced by the dragging upon  the
navel itself, may account  for this symptom.
  This pain at the lower part of the belly extending to the  na-
vel, has been considered as symptomatic of disorder in the bow-
els, and the  disease has been treated by purgatives.  This class
of medicines for a time relieves, because  during  the action of
these remedies the bladder is  nearly emptied of its contents:
moreover, less urine is secreted by the  kidneys.  The  good
effect  of  these medicines is, however, only temporary, as  the
symptoms will be re-produced when the purging is discontinued.
  The distinguishing mark between procidentia vesicae and pro-
cidentia uteri, is the absence of those stomach  symptoms which
attend the latter; for although the stomach  sympathizes with the
bladder under many states of disease arising from  altered struc-
ture or disordered  actions, it is  by no  means  so frequently af-
fected by disorder of the  bladder as by that of the uterus, and
very rarely,  if ever, is affected by the mere displacement of the
bladder: but if in  consequence of the displacement, the bladder
should  become affected  by disease, then  the complaint is  no
longer to be considered as a simple case of procidentia of  the
bladder.
  A distinctive mark  occurs on examination.  In  procidentia
uteri an opening is perceptible at the lower part of the  tumour,
which is not the case in procidentia of the bladder.
  In examining patients labouring under this disease, a tumour
will  be found in the vagina; and upon tracing this to its origin,
it may be felt lying between the os pubis before and the uterus 
PROCIDENTIA VESICA.
53
behind; and a practitioner can  hardly fail to discover  that it is
formed  by a fluid.  Encysted  tumours forming in the  cellular
membrane of the parts, although rare occurrences  may likewise
be mistaken for a prolapsed bladder, or a prolapsed bladder for
them; but tumours of the  above description will not be lessened
in size by the expulsion of the  contents of the bladder, as is the
case in procidentia vesicae.
  In the case under consideration, there is also an altered state
of the cervix of the uterus, which deserves particular attention.
In examining the structure of the sexual organs of the female in
the dead body, it is to be observed, that the cervix of the uterus
and  the cervix  of the bladder are very firmly connected by a
strong cellular membrane; so  that if the  cervix of the  bladder
rises high into the cavity of the abdomen, the cervix of the ute-
rus will  follow it; and in this manner (it is known) retroversion
of the uterus is produced.
  In procidentia of the bladder of long standing, the pressure of
the posterior part of this viscus (when containing some urine)
upon the cellular membrane connecting it with the anterior part
of the cervix uteri, elongates this cellular membrane: but as it
does not yield readily, the anterior lip of the  os uteri is dragged
down with it, so as to be  very  much lengthened. In this altered
state of the parts, the os uteri, instead of being found in the cen-
tre of the  pelvis, opens directly backwards,  and  lies in contact
with the posterior part of the vagina; so that  the space between
the elongated anterior lip  of the os uteri and the posterior part
of the vagina is very  small.
  The author has been consulted several times in cases of  this
kind, where the practitioner has been led to believe that the ute-
rus was diseased, when, in  fact, the parts had only undergone
this change from an altered situation of the bladder. This length-
ening of the cervix  uteri  may  exist without  any, or very little,
alteration of the situation of the fundus of the uterus, as the  fol-
lowing examination of the body of the woman, related by Mor-
gagni, will shew.
   " In ventre summum uteri fundum aliquanto inferiorem quam
par esset obtinere sedem  animadvert]', nee tamen tanto ut posse
ejus osculum illuc quo dicam pervenire suspicarer: Extra natu-
ralis multum  dilatati labia corpus tres quatuorve transversos di-
gitos longum prominebat  cylindri forma, valde crassum factum
ex substantia, ligamenti simili nisi  qua ad imum exulcerabatur;
esse vaginam inversam facile agnovi. Itaque ad summam inte-
riorem partem ejus corpus urethrae erat osculum, et sub hoc sin-
gula ab singulis lateribus satis  patentia lacunarum  foramina.  In
medio autem partis infimae orificium erat mox abiens in uteri os-
culum per quod specillum ad summos usque caveae uteri parie- 
54
PROCIDENTIA VESICJE.
tes nullo negotio trajiciebam. Miratus insolitam  longitudinem
vaginam incidi, atque intra ipsam conclusam  reperi uteri cervi-
cern permulto quam soleat longiorem factam."
   This alteration of the cervix uteri being once produced,  con-
tinues, although the bladder be emptied; and if the proper mode
of curing the disease is not resorted to the anterior lip of the os
uteri acquires additional length.  The parts gradually return to
their original state, if a support adapted to the  nature of the case
is  applied and worn for a length of time.
   Procidentia vesicae admits of remedy by the use of a  support
introduced into the vagina; and the hollow pessary of a globular
form before  mentioned, is more serviceable than any other.
   Hollow pessaries made of the shape of an egg are worn by
some women more comfortably than the globular pessaries: par-
ticularly in those cases  where the  diameter of the vagina is but
little increased by relaxation; where the length of the pessary,
from the perinaeum to the falling portion of the bladder, must of
course be sufficient to support the  latter; and where, if the in-
strument were globular, unnecessary pressure and pain would
be the consequence.
   The globular and the oviform instrument should be provided
with four holes (in the latter, at the broad extremity),  through
which two pieces of silk can be passed, by means of which the
instrument  may be  occasionally withdrawn  by the woman or
practitioner.   Two holes would  be sufficient for this purpose, if
the strength  of the silk  could be depended upon;  but as it may
happen to break by the force employed in withdrawing the in-
strument, the remaining sound piece affords the means of bring-
ing it away.  For want of this precaution, women who have worn
the oval pessary have had  some difficulty in  removing it when
the tape has  been broken.
   Solutions  of astringent substances should be thrown  into the
vagina often in the day. Particular care should be taken  to avoid
straining, as  every exertion of this kind must affect the displaced
part, and may force away the instrument. The woman  should
therefore avoid lifting heavy weights; and the bowels should be
kept in such a relaxed  state, that the faeces can be passed with-
out any great exertion:  the  woman may  therefore eat freely of
fruit and vegetables; and if any  assistance is  required from me-
dicine, the  mildest  purgatives are  to be preferred. As the uri-
nary bladder, at different periods, contains very different  quan-
tities of urine, and as the degree of the procidentia will depend
upon the degree of distention of  the bladder, especial regard
should be had to prevent the accumulation of urine, by desiring
the woman to make water frequently. 
55
                   CHAPTER IX.

               PROCIDENTIA VAGINiE.

  Medical men are not so frequently consulted respecting this
disease as concerning  procidentia of the uterus  or bladder;  for
it is not attended with the constitutional symptoms of the for-
mer, nor the local inconveniences of the latter disease.
  The term " procidentia vaginae" is here  meant to imply a re-
laxation of the  posterior part of the vagina, so that this  part is
lower than the natural defined edge of the  peririaeum.
  Lacerations of the  perinaeum, in labour, may certainly have
some share in producing the complaint.
  The anterior part of the os sacrum is of a concave  form, and
in this concavity the rectum  lies.  In the  ordinary state of col-
lapse, or emptiness of this intestine, and even when the quantity
of faeces in it is not very considerable, the space  at the back part
of the pelvis will be sufficiently  large to receive it without incon-
venience:  but  partly from the  state of constipation into which
the generality of women are disposed to fall, from habits of false
delicacy, and partly perhaps from the sedentary life which they
too often lead,  the lower part of the intestinal canal becomes so
distended sometimes as to make the posterior part of the vagina
approach nearer to the anterior part of the pelvis, and  in  this
way the diameter of the vagina may be much diminished. This
extreme distention of the gut at length diminishes or takes off
the power of contraction  upon its contents, and the strength of
the  sphincter muscle is increased by its frequent resistance to
the  contraction of the  intestines  and  abdominal  muscles: at
length, when by the operation of purgative medicines, or by the
natural strong  efforts of the  intestines, or  by manual assistance
(which is sometimes required)  the lower bowel is emptied of its
contents, the  pouch formed  by it and  the posterior part of the
vagina continues so as to form  procidentia vaginae.  If the fore-
finger of the surgeon is passed into the anus, under such circum-
 stances, and carried forwards, it will be directed into the pouch
 so formed. This disease appears sometimes to be  produced by
 piles acting in  the same manner as habitual costiveness.  Such a
 state of parts being once produced will continue, unless proper
 means are employed  to cure the disease.
   The complaint may also be produced  by cysts  belonging to
 diseased ovaries falling down into the hollow between  the  rec-
 tum and the posterior part of the vagina.  In one case where this
 happened in labour, the author was consulted, under a supposi- 
56
PROCIDENTIA VAGINJE.
tion that the prolapsed  part was the bag of membranes formed
by the amnion and  chorion, and attempts had  been made  to
break them.  The case was terminated by opening  the child's
head, by means of which operation the  life of the woman was
saved. After the labour the cyst went up  again into the cavity of
the abdomen, and the vagina being no longer pressed down re-
gained its natural situation.
  No effect in this disease is produced upon the  shape of the
os uteri, because the cervix of the  uterus is hardly  at all con-
nected to the rectum, and the  cellular membrane between the
vagina and rectum is very loose, and  readily admits of the va-
gina projecting.
  When the patient is  in  the horizontal  posture, the tumour
made by the  prolapsed vagina is somewhat smaller  than when
she is erect; but it never goes away altogether. Its size is some-
times as large as a hen's egg.
  Very few symptoms attend the complaint. Some  pain in the
back is present, but this is not considerable; some  transparent
mucus comes away  from the vagina, and the woman complains
of a relaxation in the parts, and of  something projecting from
them.
  In  curing  this  disease, the practitioner  is to direct proper
means to keep the rectum empty, and thus to remove one of its
causes: afterwards he is to endeavour  to restore  the tone  of the
gut.  Without attending to the first of  these objects,  the second
cannot be accomplished; and unless the tone of the bowel is re-
stored, the  mere emptying of it will  be useless.
  Purgatives given by the mouth, and glysters thrown into the
rectum, are the means  by which  the first of these objects  is to
be attained. If piles are present, the class of resinous purgatives
is to be avoided.  Castor oil, or solutions of some saline purga-
tive in infusion of senna, should be given in  frequently repeated
doses, till the intended effect is produced. The glysters may  be
made of any of the  farinaceous decoctions, or broth, and some
expressed oil.
  As in some instances the gut is  so much distended as entirely
to have lost its power of action, neither  glysters nor purgatives
will be of  any avail; for the  glyster-pipe, as it  passes into the
rectum, will be blocked up by faeces: and  purgatives will  only
bring a larger  quantity  of faeces  down, which will add to  the
bulk,  already too  great.  Nothing remains  in this case, but to
empty the rectum by manual  operation; in doing which, all de-
licate feelings of a  practitioner are to  be sacrificed to the patient's
good;  and  however disgusting the  operation to be performed
may be, if it is necessary, the practitioner is bound to  perform it.
The following is the mode of doing it.  The patient being placed 
PROCIDENTIA VAGINAE.
57
upon  her left side on a bed, her knees being drawn  upwards,
the forefinger of  the  right hand of the surgeon, covered with
oil, is to  be introduced into the vagina: a marrow-spoon, or the
small end of a common table-spoon, covered with oil and warm-
ed, is then to be introduced into the rectum; and  by means of
it, assisted by the finger in the vagina, the faeces are to be scoop-
ed away.  A  large glyster is then to be thrown up; and if any
faeculent  matter should be lying in the sigmoid  flexure of the
colon, it  will  be brought down  into the rectum,  whence it may
be easily removed.*
  For the purpose of giving tone to the rectum, the same means
are to be employed as are calculated  to produce similar effects
in other  parts of the body. Bandages are not applicable to this
case.  The object is to give support to the posterior part of the
vagina, and to the weakened rectum.  A globular  pessary an-
swers both of these purposes very  well, and it should be care-
fully adapted to the size of the vagina.
   Solutions of alum,  in a  decoction of oak bark, may be thrown
into the vagina several  times in a day;  or it may be applied to
the part  affected by means of a sponge.  Cold water applied to
the loins and to the external sexual parts  will also assist the re-
covery of the patient, by giving strength.
   Cosliveness in  future is to be carefully  prevented.

  * An ounce of soft soap dissolved in a pint of warm water forms as good a
glyster for the purpose as can be employed.
H 
58
                    CHAPTER X.

                   INVERSIO  UTERI.

  This complaint consists, as the name imports, in an inversion
of the cavity of the uterus, so that the fundus comes through the
os uteri: consequently that part which formerly was the inside
of a cavity is converted into the outside of a tumour, either con-
tained in the vagina, or projecting  from  it.
  In  the present improved state of the art of midwifery, this
disease is very seldom met with, because it  is generally a con-
sequence of mismanagement of the placenta.
  In labour, the child and the placenta  are expelled partly by
the abdominal muscles, but  chiefly  by the  contraction  of the
uterus;  and no alteration  in the  situation  of the parts  of the
kind about to be described follows:  but if, through ignorance,
haste, or carelessness, the practitioner  is induced to pull with
much force by the funis umbilicalis before the placenta is sepa-
rated, if the placenta should be firmly attached to the fundus of
the uterus, and if the funis should be strong,  the uterus being in
a relaxed state at the time, the placenta will be pulled down;
but the  uterus will come with it, and will be  inverted.
  Women who do not bear children are, for the  most part, ex-
empt from this complaint; but it is said that it may be produced
by  the weight of a polypus attached to  the fundus of the uterus.
This cause may of course render unmarried  women the sub-
jects of the disease;  but it will be  rarely met with:  first, be-
cause polypus itself is infrequent; secondly, because the poly-
pus must be very large and heavy, that it  may have the power
of drawing down the uterus; thirdly, because an unimpregnated
uterus is unyielding and firm;  and fourthly,  because the poly-
pus, to  produce  the effect, must be attached  exactly to the fun-
dus of the uterus. In labours which have been badly conducted,
the uterus is in a much more relaxed state than when the man-
agement has been judicious.
  The immediate consequences of an inverted uterus,  when it
takes ptace after delivery,  are  hemorrhage,  faintness, and  a
sense of fulness  in the vagina.  The woman  in this case com-
pares the feeling with the  sensations which she experienced just
before the child  was born. If the nature of the accident is disco-
vered early, it will admit of a ready cure, by the return of the parts
to their  original state. This is to be effected by making pressure
upon the lower part only of the tumour, so as to cause this
part to be received into that above it: a continuance of the same 
1NVERSI0  UTERI.
59
 pressing force will in some cases quickly reduce the tumour. If
 the uterus has not been long displaced, and is much relaxed by
 loss of blood, the operation will be proportionably less difficult.
 The  author has been called by  other practitioners to cases of
 this kind, where the patient has expired, in consequence of he-
 morrhage, before the nature of the accident has been ascertain-
 ed. In such cases, he has found very little difficulty in replacing
 the uterus, all resistance  being removed by the weakened  state
 of the patient previously to  death.  It sometimes happens,  that,
 when a second  practitioner is called in to a patient, he finds the
 uterus inverted, and  the placenta still adhering.  It is requisite
 that two things should here  be done.   The uterus  is to be re-
 duced, and the placenta is to be detached and removed.
  The uterus is to be first  returned to its  usual state and natu-
 ral  situation; and the case then becoming simply one of a re-
 tained placenta, is to  be treated as such:  but if,  neglecting this
 order  of proceeding,  the  placenta should be first removed, a
 number of bleeding  vessels are exposed before the uterus can
 contract so as to restrain the hemorrhage;  and the chance is,
 that die patient may die from its effects.
  As inversion of the uterus is (strictly speaking) to be consid-
 ered as one of the immediate consequences of delivery,  no ad-
 mission would have been given to it in this work, if it were not
 that it is occasionally  met with, in the  chronic state, attended by
 a mucous discharge.
  The symptoms of  the chronic state resemble those of proci-
 dentia uteri;  and an examination being made, a tumour is found
 either in the vagina or hanging out of the  external  parts. Such
 a tumour may be mistaken for polypus: but in the latter disease
 the os uteri encircles the tumour; in inversion of the uterus, the
 os uteri forms a part of the tumour itself. Moreover, the  invert-
 ed  uterus  is sensible; polypus  tumours, on  the contrary, are
 void of feeling.
  The tumour  may be mistaken for procidentia of  the  uterus;
 but the difference may be detected  by observing that there is no
opening at its lower part.  It is distinguished from procidentia of
the  bladder by being much more resisting, by its size continuing
always  the same, and by the impossibility  of finding the uterus
 behind it.
  If an inverted uterus should project from the external parts,
and the woman should continue to menstruate, the fluid of men-
struation may be observed  coming from the  whole surface of
the  lower part of the tumour—of the lower  part of the tumour,
because in the greater number of instances  the uterus will drag
down the vagina with  it:  in which case the  external tumour will
consist of two parts;  one  above, which is  the inverted vagina, 
60
INVERSIO  UTERI.
another below, which is the inverted uterus.  Where the vagina
terminates and the uterus begins, there will be found a contracted
part, which is the os uteri.  As the uterus alone secretes the men-
struous fluid, the lower part of the tumour only will be moistened
by it; the upper part being an inversion of the vagina, which does
not secrete menstruous fluid, having a glossy surface, which is dry;
or if moist, covered with mucus, and not with menstruous fluid.
  Whilst the inverted uterus remains in the vagina, the discharge
(excepting at the periods of menstruation)  will be of a mucous
kind;  but if the uterus falls lower, so as to protrude beyond  the
external parts,  the  exposure of that surface, which in a natural
state  lined the cavity, to  air, as well as to  occasional injuries,
may induce inflammation and ulceration over a part or the whole
of its  surface; and the mucous  discharge  may be changed to
one of a purulent kind, so considerable in quantity as to debili-
tate the constitution, and to cause  all the common symptoms of
weakness.  If there are any  ulcerations upon the surface of the
upper part of the tumour formed by the  inversion of the vagina,
they will be circumscribed, and rarely cover its whole surface.
   The size of an inverted  uterus  will vary  in different  cases,
owing to the length of time which has  elapsed since the labour,
and the degree  to  which  the  parietes of the uterus  have con-
tracted. An inverted uterus will always be larger than an unim-
pregnated uterus in its  usual state, because the appendages of
the uterus (as the ovaria and the fallopian tubes) will be contain-
ed in  the centre of the tumour.
   In a case where the uterus has been long inverted, and lies in
the vagina, (the latter cavity having undergone no change except
from distention,) it will not be advisable  to recommend any oth-
er remedy than the injection of some very mild astringent fluid,
three  or four times a-day,  into the vagina.   Some restraint will
thus be placed upon the quantity of the discharge, and the parts
will be kept clean by it.
   Pessaries are  useless; for the vagina is already so filled, that
 nothing more-can be retained in it.
   There is an extreme  degree of the disease, where the uterus
 (previously inverted) falls  out of the body, drawing down with it
 the vagina ;  and where the woman is every day becoming more
 and more  weak from the quantity  of the discharge.  If this case
 is left to itself, the woman either drags on a miserable existence
 for  a number of years,  or her life is cut short by the constant
 drain.
   Cases of this kind can receive very little  benefit from exter-
 nal applications;  and it is obvious that nothing is to be expected
 from internal medicines.  Powdered chalk, or lapis calaminaris
 sprinkled  upon  the part,  may check the discharge a little; the 
INVERSIO  UTERI.
61
oxide of zinc  may  in  some  measure abate its quantity, but it
will not remove it altogether:  and the same observation will ap-
ply to astringent applications generally.   Besides, it is to be re-
collected, that  the uterus is an organ supplied  with  blood  most
amply, by a double set of vessels; and therefore it deserves
consideration how far a discharge, which has subsisted for some
time, can be stopped without  injury to the viscus which secretes
it, and  to which the usual  determination  of blood continues to
be made. However, it may be considered more prudent, if the
discharge diminishes in consequence of such applications,  to
persevere with them, rather than to risk  any danger which may
arise from an operation.  In those cases  of inversion of the ute-
rus, where the woman  has passed the menstruating age, where
her comfort is destroyed by the disease,  and where the profuse-
ness of the discharge threatens her with death, from the debility
which it produces; it may be  advisable to recommend  the per-
formance of an operation, which has been attended with success,
and from which  the author has  known  a patient recover after
she had attained the age of sixty:—this operation  is  the removal
of the  inverted uterus itself.
   When the uterus  has been inverted  many years, the ovaria
and the fallopian tubes, which are inclosed in it, become con-
solidated with it, (perhaps by inflammation having taken  place)
and the operation becomes less hazardous, because the cavity
of the abdomen is not exposed.  How far it may  be right to  re-
sort to this operation during the menstruating part of a woman's
life, the  author has  no means of judging.
   Cases are upon record, where the  removal of  the uterus has
been performed  with  safety.  Ambrose Pare*  relates a case,
where he, with Mauriceau and another surgeon, cut away  the
womb of a woman thirty  years of age, who survived the opera-
tion; but she died of a pleurisy three  months afterwards. There
could be no doubt that the tumour which was removed was  the
uterus; for  the ovarium was  removed also, and  upon opening
the  body after death no uterus was found. This  case occurring
during the menstruating part of the woman's life,  shews that  the
operation may be done with  impunity;  unless it be considered
that the woman would not have had  the inflammatory attack if
she had continued to menstruate.
   The following case occurred to the author some  years ago:
   A poor woman, sixty years of age, complained of a tumour
 which  hung down  from the external parts between her thighs,
 attended by a discharge  of mucus and of pus, so profuse in
quantity as to make her exceedingly  weak.  Upon  an examina-
* Lib. xiiv. cap. 42. 
62
INVERSIO UTERI.
 tion of the  tumour, it appeared  to  be an inverted uterus,  the
 whole surface of which  was in a state of ulceration. Above this
 tumour was the vagina,  also inverted, having partial ulcerations
 upon it.  The circumstances in life of the  patient obliged her to
 apply to  a  dispensary for relief:  her sufferings,  although  not
 acute, were sufficient  to interfere with her comfort; and her in-
 creasing weakness made her readily consent to the performance
 of an operation for the removal  of them, which  was performed
 by Mr. Chevalier, surgeon to the Westminster General Dispen-
 sary.  A ligature was  applied round  the contracted part of the
 tumour; that is, where the uterus terminated and the vagina be-
 gan.  It was tightened daily until about the eleventh or twelfth
 day, when the parts included  in the ligature were absorbed, and
 the uterus fell off.  During this time  the patient complained of
 very little pain.  Adhesions had  taken place between  the  sides
 of the vagina, so as to prevent the exposure of the  cavity of the
abdomen; and the woman recovered.  After an operation of this
kind, the vagina should  be returned to its  natural situation, and
it should  be kept there by a hollow globular pessary.  In  all
probability this support will be required during  the remainder
of the patient's life, as the vagina may otherwise fall down and
project between the labia. 
63
                    CHAPTER XL

On Mucous Discharge produced by an increased Determination
               of Blood to the Sexual Organs.

  The  diseases which  have been hitherto described, and of
which an increased mucous discharge is symptomatic, are to be
considered as consisting of the  displacement of certain parts.
But these diseases are not the only causes of such  discharges;
for if an increased determination of blood is made to these parts,
from any natural  or  morbid cause,  an increased secretion of
mucus will be produced by it.
  Those diseases which produce an increased  determination of
blood to the sexual organs of females, or parts  in their vicinity,
will be next considered.
             HEMORRHOIDS, OR PILES.

   This disease is a dilatation of the hemorrhoidal veins, and is
 exceedingly common in both sexes; but more so in women than
 in men; and it becomes a source of great inconvenience to both.
   Hemorrhoidal  tumours are sometimes  contained within  the
 gut; at others they project from the anus:  the first are called in-
 ternal, the last,  external  piles.  Piles, when external, increase
 very rapidly in  size, in  consequence of the contraction of the
 sphincter ani upon the  trunk of the vessels; and if the coats of
 the vessels do not inflame from distention (a circumstance which
 frequently happens), the circulation  in the vein  being  arrested,
 the blood contained in  them coagulates, forming those indolent
 tumours often found round the verge of the anus.
   Sometimes  the  size of hemorrhoidal tumours is  quickly di-
 minished by the rupture of their coats, and the  escape of their
 contents;  and  in this way inflammation is prevented or cured.
 The quantity of blood lost upon these  occasions  is sometimes so
 considerable as to weaken very much.  Nevertheless, upon  the
 cessation of these discharges of blood,  which sometimes become
 habitual, diseases of the neighbouring parts or of the constitution
 arise, which prove of difficult management, and  perhaps do not
 yield till the hemorrhoidal veins  again pour out their blood.  In
 some constitutions there has been remarked a regularity of in-
terval between these discharges.  When hemorrhoidal tumours
 become external, ulceration frequently takes place upon the sur-
face of them, and they  discharge a puriform fluid. 
64
HEMORRHOIDS  OR  PILES.
  Upon inspecting these sores, they  resemble in appearance
those of a venereal kind; and as they may be  such, practition-
ers should be very guarded in their prognostic till  they are cer-
tain.
  Similar sores are also observed upon  the sides of the anus,
to the distance  of two inches or more;  and they likewise  are
formed  sometimes within the labia*
  Patients who have  been exposed at any part of their lives to
the cause of veneral disease,  are very apt to fear that their com-
plaints originate in such diseases; whilst  the  more virtuous, but
suspicious woman, may be led to attribute her disease  to  the
inconstancy of  her husband.  It is to be lamented, that  many
well-meaning practitioners are themselves too  apt to fall  into a
habit of considering almost every discharge from the  neighbour-
hood of the sexual organs to be of a specific nature, and  every
ulcer near  these  parts to require the use of mercury.  But it is
degrading to an honourable profession to witness  the infamous
attempts made to impose upon the unwary and credulous, by
describing in the  public prints diseases as the effects of vicious
propensities, which spring from causes to which all  are equally
exposed.  The  authors of such impositions make it an invariable
rule to  call every complaint about which they are  consulted ve-
nereal,  or to give an opinion couched in obscure or unintelligi-
ble  language, in  order to intimidate  those who  consult  them.
Such persons would do well to heed  the observations of the ex-
cellent  Sydenham, who, speaking of those who think that the
venereal disease  ought not to be cured, in order that others may
be  deterred from falling into the cause of it, says: " His ego non
assentior, utpote qui existimem nullum fere locum charitati atque
operae mutuae relictum iri nisi ea quae sibi sua ipsorum culpa im-
providi  accersunt mala humaniorum officiis sarciantur. Omnipo-
tentis Dei est  sontes castigare, nostrum vero miseris  pro virili
succurrere atque  aegris opem ferre, non autem curiosa causarum
indagatione illos  acrius  urgere, aut censorio vexare fastu."—
Sydenham. Epislola respons. 2da de Morbo  Venereali.
  The  ulcers on the outside of the anus resemble venereal sores;
for  the  cellular membrane is absorbed more quickly  than the
skin, which gives an appearance of high  edges  to  them.  They
also become very difficult to heal:  but these ulcerations differ
from venereal sores, in not having  their  surfaces  covered with
that thick  yellow film which is met with in chancres;  and al-
though  the sores  do sometimes run into each other, yet they do

  *  " Tertium autem ani vitium est, ora venarum tanquam  capitulis quibus-
dam turgentia qua? saepe sanguinem fundunt.  hl/jLoppoi&us  Graeci vocant. Idque
etiam in  ore vulva? fceminarum incidere consuevh."—Celsus, lib.  vi. cap. 18. 
HEMORRHOIDS  OR PILES.
65
not spread with the same  rapidity as chancres. Besides, chan-
cres will heal  by  the use of mercury:  This will rather be inju-
rious in the other  ulcer, which will heal by the  application of
simple stimulants, such  as solutions of  sulphate of copper or of
nitrate of silver.
   A discharge of mucus from the vagina is a concomitant symp-
tom of the piles; for the internal iliac  artery supplies both the
hemorrhoidal  vessels  and  those  about the vagina with blood;
and it will be  found difficult to restrain  this  discharge whilst the
hemorrhoidal  tumours continue.
   The labia and  the nymphae are also  apt to be more swelled,
from their vessels being distended.
   Women who have been  frequently pregnant, and whose bow-
els are disposed to be constipated, are most liable to this disease.
   The surface of the piles being covered with the  internal mem-
brane of the rectum, such tumours are  at first very irritable and
tender: by degrees, however, from exposure to the air and to
pressure,  this  irritability goes off.
   The treatment of this disease depends upon the accompany-
ing symptoms, upon the  state of the  tumour, and  the cause
which induces it.   If the disease should arise in a plethoric ha-
bit, and if blood  should occasionally escape, it will be right to
weigh  whether the  patient will suffer more  by the continuance
of the disease, or by putting a stop to the evacuation  of blood.
In such habits the discharge answers a salutary  purpose; and
whilst it is kept within moderate limits, it may be  suffered to go
on; but if its profuseness should  induce debility, astringents and
pressure may  be  safely  applied.
   In all cases of  the disease, but especially where the vessels of
the system are too full of blood, the bowels should  be kept open;
and  this  should be effected  by  those  purgatives  which do not
stimulate  the lower part of the intestinal canal:—all the class of
resinous purgatives should be avoided. Expressed oils and  man-
na will be found  most  serviceable.  Sulphur  is also  by many
considered to  be useful  in these cases.   Sublimed  sulphur may
be given in the form of electuary mixed with honey, or the sul-
phur praecipitatum  may be taken in milk.  The only objection
to its use  is the smell attending it.
   Although a  confined  state  of  the bowels is injurious, active
purging is not required, but proves detrimental.
   Cold applied to the anus is useful, and the size  of the tumour
will  be diminished by it. Cold spring water may be applied by
means of a sponge, or powdered ice may be applied between folds
of linen.  These applications may be repeated often in the day.
   Solutions of astringent substances will, by producing contrac-
tion of the coals of the veins,  be  likewise beneficially employed,
                     I 
66
HEMORRHOIDS  OR  PILES.
  If external piles become painful, they should be  returned
within the anus by careful pressure, and some cold lotion should
be applied to the anus, or even thrown up into the rectum, after
the reduction of them: this will produce contraction of the dis-
tended vessels, by which the blood will be driven out of them;
and it will also iucrease the contraction of the sphincter ani, by
which a support  will be given  to the vessels, and their future
descent perhaps prevented.
  If inflammation should  exist (which will  be known by  the
constancy and the violence of  the pain, and perhaps by febrile
symptoms),  local  bleeding will  be proper, and this will relieve
the symptoms. The blood  may be taken away by leeches, or by
puncturing the piles with a lancet. If the febrile or inflammato-
ry symptoms should be violent, general bleeding will be proper.
  When a tumour in the cavity of the pelvis occasions the dis-
ease, the symptoms will continue till the tumour rises  into  the
cavity of the abdomen. If that tumour should be a  pregnant
uterus, quickening will cure or relieve the patient, when the piles
occur in the  early part  of pregnancy; and labour, when they
appear in the more advanced stages. But if the pressure should
be caused by any morbid  tumour, as  the progress of  it is very
uncertain, as it sometimes  proceeds very rapidly and sometimes
very slowly, it will be difficult to foretell how long the  pressure
will continue.
   When the hemorrhoidal disease  is conquered, the discharge
from the vagina will  cease; but it will  be advisable, during  the
employment of the measures which have  been recommended,
to throw cold astringent solutions  into  the vagina, which  may
not only restrain  the discharge, but, from  the vicinity of the
parts, may have  some  influence upon  the hemorrhoidal  com-
plaint.
  In cases where  chronic  indolent tumours surround the verge
of the anus, it is sometimes advantageous to rub them lightly
with a mixture consisting of camphor and simple cerate, in the
proportion of one part of the former to twenty of the  latter, by
weight. If they become very troublesome, they may be removed
by  the knife or by ligature:—the ligature  seems least formida-
ble; but it will  be found upon employment to  be much more
painful  than the  knife, with which  the operation is quickly fin-
ished.   If the extremity of the gut is relaxed, the surfaces to
which the tumours were attached may be touched with argen-
tum nitratum. The  subsequent inflammation will be  useful in
producing a thickening of  the  parts, and an obliteration of the
cavities of some small veins, thereby materially assisting in pre-
venting a return of the disease. 
67
                   CHAPTER  XII.

           ASCARIDES IN THE RECTUM.

   Whoever has attended to the diseases of the sexual organs,
must have  seen repeated instances of disease in one part pro-
ducing symptoms in  another, which symptoms  have been re-
garded as the  primary disease.  Mucous  discharges  from  the
urethra of men are indicative of  disease in  the  prostate  gland
and  in the testicle; and yet they are sometimes mistaken for,
and  treated as,  a morbid state of  the urethra, often with  mani-
fest injury to the patient. So, likewise, discharges of mucus from
the vagina have been considered as originating in disease of that
passage, or of the uterus, when the  irritation arising from asca-
rides in the rectum has produced all  the symptoms.
   Ascarides are  endowed with a  power of very rapid motion,
and  have a pointed extremity, which is nearly transparent, with
which they probably irritate  the sides of  the rectum.  An  ex-
treme and an insufferable itching,  almost worse than pain,  is oc-
casioned by them.
   A larger quantity of blood in the vessels of the neighbouring
parts is the effect of being so stimulated; and from the increased
circulation arises an increase  of secretion.
   Ascarides will also  travel from the rectum across the perinae-
um into the vagina, the  membrane of which will be itself stimu-
lated by the presence  of these animals there.
   Some care is required in investigating this case; for both  the
mucous discharge and  the pruritus attend many other complaints,
requiring very opposite modes of treatment.
   Although children are seldom attacked by mucous discharge
from the vagina, yet it  sometimes appears, and may depend upon
this cause.  Irritation in the gums, at the time of dentition, will
also  excite  it.
   As the rectum is especially the  seat of the ascaris, or thread-
worm, the complaint may be cured by glysters. These act partly
mechanically, by washing out  the  intestine and  so  removing
them, and partly by being obnoxious to the ascarides.  Solutions
of bitter substances in  water, as decoct, anthemidis, decoct,  ab-
sinthii, or a mixture of aloes  and  milk, are found to be useful
in removing them; but a strong decoction of the semen santonici
is the most efficacious of all the injections in  use. With this  the
rectum should be filled;  but the quantity thrown up should  ne-
ver be so great as to produce great distention of its cavity, lest the
coats of the bowel being stimulated, it should contract hastily 
68            ASCARIDES IN  THE RECTUM.
and expel the glyster, which acts with more certainty if it re-
mains for some time. This operation repeated for a few succes-
sive days will seldom fail to remove for a time the ascarides and
the symptoms which they produce.
  Purgatives employed alone are of little service; but during the
use of  the  glysters they ought  to be occasionally exhibited.
Those of  a  stimulating kind should be preferred,  as  jalap, or
scammony with calomel.  Generally, no remedies will be requir-
ed to put  an end  to the discharge from  the vagina,  which is
merely symptomatic; and when the ascarides are removed from
the rectum,  the mucous secretion from the vagina will  cease.
  If the rectum should remain irritable after the removal of the
ascarides,  it  may be tranquillized by the injection of two ounces
of decoctum amyli, or decoctum  semin. cydonii,  with forty or
fifty drops of tinctura opii, or by a suppository containing  two or
three grains  of opium mixed with starch. 
69
                  CHAPTER XIII.

                 CARCINOMA  RECTI.

  It has been proposed by Mr. Abernethy, in his Treatise upon
Tumours, that  those tumours which  have  been  designated
" scirrhus," and which have  in their  more  active  state been
termed  " cancer," should  be  included  under the general head
of Carcinoma, dividing the stages of the disease into,
                1.  Carcinoma.
                2.  Ulcerated Carcinoma.
  This  he considers to be advisable,  because other tumours
which are hard, although indolent, have been entitled scirrhus.
  To be clear and precise in terms is important in all sciences;
but in none  more than in physic, which  has for its object the
preservation of human life.   Of less, but still of considerable
consequence, is the soothing the minds of those who are afflicted
with disease. All tumours which have the character of hardness
have been called  scirrhus, and scirrhus has been considered as
the forerunner  and first stage of  cancer.  But many  tumours
which are scirrhous, that is to say hard, have  no disposition to
acquire an ulcerating state, or at least have that disposition only
in a trifling degree. It is the intention here to follow the distinc-
tion above alluded to, and to consider  the first stage of cancer,
under the head of Carcinoma.
   Carcinoma recti is not a disease of frequent occurrence; but
as it sometimes happens, and as in some of its symptoms and in
its termination it resembles carcinoma  uteri, it deserves a place
here, being attended by a mucous  discharge from the vagina.
   The  lower part of the rectum being of a more glandular struc-
ture than some other parts of the  intestines, renders it perhaps
more liable to this disease than they are.* The whole circum-
ference of the gut is most commonly affected; and the parts be-
coming thickened in consequence of the  disease, the capacity of
the canal is diminished, and the passage of the faeces through it
is impeded.  The resistance produced  by this cause makes the
discharge of the faeces very painful: and as piles are a very com-
mon  disease, and are  generally supposed by  patients to be the
 cause of any pain or difficulty in  voiding the faeces, this  com-
plaint has been mistaken for  them, and the patient has suffered
the inconvenience without being aware of any danger.
   In consequence of this narrowness and obstruction in the rec-
* Vide Dr. Baillie's Morbid Anatomy. 
70
CARCINOMA RECTI.
turn, the colon becomes gradually more and more distended;
and upon an inspection of the body after death, it has been found
to contain several  pints of fluid, resembling a mixture of faeces
and water.
   This disease has also been mistaken for stricture of the rec-
tum;  and the  patient has been much injured by the mode of
treatment pursued  in that disease, and her death has been accel-
erated.  Bougies introduced into the constricted part have pro-
duced a great degree of inflammation in the neighbourhood; and
thus, by adding to the thickening of the gut, increased the symp-
toms which they were intended to alleviate.
   The pain attending the complaint is of the darting or lancinat-
ing kind; and being referred to the neighbourhood of the uterus,
has led to a supposition that the uterus was the diseased  part.
This error with regard to the seat of the complaint, if its true
nature is understood, is  not very important;  because, whether
the complaint is in one viscus or the other,  the  principles upon
which it is to be treated are the same.
   In carcinoma of the rectum the pain will  be greatly increased
by the passage  of  the  faeces, and the pain  will be such as the
patient would feel  upon the rough handling of any external tu-
mour of a similar character; whereas in the common stricture of
the rectum, although there may be pain, it will be by no means
so acute, being occasioned merely by the resistance offered to
the passage of the  contents of the gut.
   In  carcinoma of the rectum, acute pain is  occasionally felt
when no endeavour is made to expel.  In stricture  of the rec-
tum, the pain is felt only at this  time, or for a short time after-
wards.
   The constitution also is more likely to be affected in carcino-
ma than in stricture of the rectum; and the sympathies between
the part diseased and other parts will be more  likely to be ex-
cited in carcinoma than in stricture.
   The  hemorrhoidal veins are  apt  to  become enlarged, and
sometimes to bleed.  The bleeding may have some effect in re-
tarding the progress of the complaint. Small oedematous tumours
about the anus are  also very liable to be formed; but both of
these symptoms are likely to be  met with in other diseases.
   When the uses of the  rectum  are considered, and its liability
to be stimulated, it will appear probable that carcinoma of the rec-
tum will advance with greater rapidity to the more active stages
of the disease,  than when it attacks parts less exposed to pres-
sure or disturbance; but upon this subject it will  be difficult to
form any precise opinion, because it is impossible to know how
long the disease may have existed  before the  practitioner was
consulted; and it frequently happens that he is  not consulted at 
                   CARCINOMA RECTI.                 71

all until the inflammatory action has commenced, which attends
the conversion of the complaint into the ulcerated state.  More-
over, the disease not being frequent, opportunities of collecting
information respecting it will not often occur.
  That the mesenteric glands are affected in  the latter  stages,
may be learned from writers  on morbid  anatomy.  Dr.  Baillie
states, that when a portion of the intestinal canal becomes can-
cerous, some of the absorbent glands in the mesentery also  be-
come affected with the same disease, in  consequence of the mat-
ter  of cancer being conveyed to them by  the absorbent vessels.
This explains the great emaciation which  commonly attends the
disease.  The mere irritation and pain, and the quantity of  the
mucous discharge from the vagina, during the first stage  of  this
disease, may in  some  measure account for it;  but if the parts
concerned in the conveyance of the chyle into the blood have
their structure  likewise altered,  it is reasonable to expect that
the emaciation  and loss of strength will be more quickly pro-
duced.
  An opportunity has never occurred to the author  of examin-
ing the body of a patient in the first stage of the complaint,  be-
fore ulceration has commenced;  but as absorbent glands in  the
vicinity of carcinoma  in other parts of the body, occasionally
appear to enlarge before matter forms,  and consequently  before
it can be absorbed, it is probable that they may do so here, and
the mesenteric glands may have undergone an  alteration in  the
early stages of the disease.
  Few other symptoms  attend  this disease;  and this state of
things may  continue  for  a long period, under proper manage-
ment, producing no symptoms of a more alarming nature.
   When the  disease  becomes cancerous, the symptoms begin
to be more formidable, the mucous discharge  is converted into
one of a purulent kind;  but  the history and  treatment of  this
stage will be considered under the head of Purulent Discharges.
It  may here however  be  remarked, that occasionally in  the ul-
cerated stage a communication is made between the  rectum  and
the vagina, in consequence of the destruction of the parts which
naturally separate these cavities from each other; that the pain
becomes more acute; that the  stomach  is apt to be affected with
vomiting; and that hectic fever sometimes supervenes.

                        TREATMENT.

   When, in the latter  part of the preceding section,  the term
" proper management" was used, it was  by no means intended
to convey a notion, that the complaint would be cured ; for car-
cinoma does not admit of this by any medical  treatment. That 

CARCINOMA RECTI.
species of tumour which is found to degenerate into cancer, can
be removed only by the excision of the part.  Even when this
operation is resorted to, it is doubtful whether much  benefit is
often obtained; since the part where the incision was made,  or
parts in the neighbourhood, are very apt to continue the disease.
Admitting,  however, the utility of the operation  where the dis-
ease is seated in other parts of the  body,  it must be wholly in-
applicable in this part.  As the disease does not admit of cure, it
is of great importance that no injury should be done by  unne-
cessary interference or  irritation: the endeavour to do  much in
such cases  is worse than doing nothing.
  To look on and to watch a disease,  to  know  when to assist
nature in her operations and when  to do nothing, are among the
greatest qualifications of practical men, and the  lot of  but  few:
and it should never be  forgotten, that  the natural resources  of
the constitution are equal to  a great deal, if they are not  inter-
rupted by the interference of art.
  Perhaps in other parts of the body, when tumours of this de-
scription arise, and when it is not thought right to remove them
by operation, on account of the age of the patient, of the state of
the constitution being unfavourable to the  healing of the wound,
or because glands in  the neighbourhood  are diseased, the  most
simple applications are  the best.
  Stimulating applications,  to  promote  absorption of such tu-
mours, should  never be  employed; as they  produce  no  good
effect, and may do irreparable mischief.
  All plaisters which adhere strongly to the surface of the skin,
notwithstanding that the ingredients of which they may be com-
posed are of a sedative nature, should be avoided;  for  by the
warmth  which they produce they may be injurious,  and in the
removal of them the  skin may be injured and a breach of sur-
face produced.  Thus  any good effect which might have  been
expected from their sedative quality will be defeated. As a de-
fence against external injuries, when the skin is very lender, the
common soap plaister,  spread upon thin linen, may be applied;
and whilst  care is taken to prevent the part from suffering  by
any improper exposure to cold, it  should also be  a particular
object of regard, that it should not  be kept too warm.
  Most patients who consult  medical men on  account of dis-
eased tumours have applied flannel to the part, " in order to
keep the cold from them." The practitioner should endeavour
to explain to the patient the  erroneous principle of her conduct,
and advise her equally  to avoid the extremes of heat and cold.
   Another object of importance is  to  prevent the  unnecessary
action of  those parts near which the disease is situated.   Thus,
if a tumour should form in the breast, the  arm of that side should 
CARCINOMA RECTI.
73
be kept as quiet as possible, lest the exercise of it should  pro-
duce a larger determination of blood to the disease, as well as
render it more liable to be injured.
  It is well deserving of inquiry, how far pressure made upon
vessels carrying lymph or blood has a tendency to produce and
increase the size of carcinomatous tumours. It cannot be unsafe
to caution a woman labouring under carcinoma of the breast, to
let her dress make no pressure on the shoulder,  but particularly
on the axilla of the side diseased.  It is found to be advantage-
ous in retarding the growth of carcinomatous tumours, to apply
leeches often to the  surface of  them, if  the tumour is not very
near to the surface of the body.  Such a mode of treatment is
very serviceable, by  emptying the blood-vessels, and diminish-
ing any increased action in the vessels of the part.  But when
the tumour lies very near to the surface, more harm than good
has been done by the application of leeches;  for the coagulum
of blood which is always left in the opening formed by the mouth
of the leech, sometimes irritates the parts and produces itching,
which the patient endeavours to appease by rubbing: this ex-
cites great superficial inflammation, which cannot but be.hurtful.
  Whenever a carcinomatous tumour becomes so large as to
stretch the skin covering it so as to make it appear  glossy, the
application of leeches will always be improper; because a breach
of surface once made, may not  heal again. If in such a case the
application of leeches should be thought advisable, they should
be placed on the outside of the circumference  of the tumour,
where no such effect will be produced upon the skin; and when
this is attended to, they will be nearly as efficacious in diminish-
ing the fulness of the tumour, by emptying the supplying ves-
sels, as if applied upon the tumour.
  In  some carcinomatous tumours of the breast, there are points
elevated above the plane of the tumour,  which put the skin co-
vering them much upon the stretch, and which projecting points
at length occasion absorption of the skin lying over them. Every
remedy therefore which tends to relax  the  neighbouring  skin
may be usefully employed. To prevent the conversion of car-
cinoma into the ulcerated state  ought to  be the especial care of
a practitioner.
  In  those cases where the tumour lies near the surface of the
body, there is a state intermediate between these two stages,—
the scabbing stage; and during the continuance of this stage the
patient may live for a number of years, perhaps with less incon-
venience and pain than that which was suffered during the latter
part of the  carcinomatous stage.
  After the skin has been very much  stretched it often gives
way, and a portion of the tumour is exposed: from this portion.
                     K 
74
CARCINOMA RECTI.
small oozing of serous  matter  escapes, and forms a film upon
the surface: the aqueous part evaporating, this becomes a scale.
This small oozing, if the patient attends to proper rules of diet,
will so far relieve the vessels below it, that the sense of pain and
of tightness will be greatly mitigated.  By degrees, however, the
oozing goes on, till that which was a thin scale becomes a scab,
the extent  of which increases, till at length it covers a great part
of the neighbouring sound surface, and even projects very much
above the skin.  As long as the scab  remains attached, the pa-
tient's situation is far less dangerous than when a separation of it
has taken place.*
   During the time of the formation of this scab, any fluid which
may be effused  should  be absorbed, by sprinkling the surface
with some light dry powder, such as oatmeal, or a mixture of
starch and  oxyde of zinc. The part should also be  left exposed
to the air, in order that evaporation  may go on more quickly,
and the film harden.
   If the fluid poured out can be dried in this way, so as to pre-
vent the escape of it over the neighbouring  sound parts, it is
preferable to the application of any powder;  which, by  adding
to the weight and thickness of the scab, will render it more lia-
ble to be displaced. To prevent the occurrence of this accident,
all possible care should  be taken.  For this purpose, a thin me-
tallic case  may be worn over  the breast affected, in  order to
secure it from any injury during  the  day, and from accidental
pressure during the night.  Such metallic case should be very
thin; and it should  be pierced with  holes  throughout, in order
to diminish its weight, and to prevent the retention of the  heated
air between the  breast and itself.  It should of course  make no
pressure upon the scab.
   If the height of the  scab  should render it very liable to be
detached, small  portions of it  may be carefully removed from
its upper surface by very gentle means; care being taken not to
carry the removal of the dried matter too far.      *"
   The author hopes that he shall be excused  for this digression
from the subject of  carcinoma recti.  But as external diseases
often throw much light on internal complaints, as they are more
the objects of the senses, he was led into it, not merely on its
own account, but to  illustrate a similar disease of parts which
are less so.
   No intermediate stage  is met  with  between  carcinoma and
ulcerated carcinoma, when it occurs  in internal  parts; so that

  * A very good account of the scabbing state of this disease is to be met
with in a posthumous work of the late Mr. John Howard, surgeon to the Mid
dieses hospital, edited by Dr. Gower, physician to the same hospital. 
CARCINOMA RECTI.
75
 when once the inactive state is over, the active state immediately
 commences, and in many cases quickly destroys the patient.
   In treating carcinomatous  tumours, every thing  should be
 avoided which can stimulate the diseased part,  or increase the
 force of the circulation.  If there should appear to be too great
 strength of the constitution, or too great  vascular action in the
 part itself, these are to be subdued by the  removal of blood from
 the region of the os sacrum, by cupping-glasses, or by leeches:
 this should never be omitted; and the operation  may be repeat-
 ed as often  as the  urgency of the symptoms may  demand it.
 The  lancet  also  may  be  used,  if the  symptoms should be
 violent, and the patient strong.  Great attention should likewise
 be paid to the state of the constitution; and we should be  care-
 ful whilst pursuing those measures which diminish strength,  not
 to produce the opposite  danger of debility.  There are very few
 constitutions  which will  not bear the loss of a small  quantity of
 blood from small vessels; wherever therefore much pain is pre-
 sent,  this should always  be had recourse to.
   If  the  hemorrhoidal veins  should  spontaneously  bleed, this
 may supersede the necessity of taking away blood by artificial
 means.
   Great attention should be  paid  to  the state  of the  bowels,
 which should not be suffered to accumulate hard faeces; because
 in passing they will irritate the diseased part, and cause pain to
 the patient which might  be avoided.
   The purgatives adapted to this case are expressed oils, sul-
 phur, and manna:  whenever  relief can be afforded by  these
 means, they  are to be preferred to all others;  but if they should
 not be sufficiently active, some senna may be joined  with them,
 or some  saline purgative may  be taken separately.  The objec-
 tion to saline purgatives is, that they  may irritate the mucous
 membrane.   They have, however the advantage of rendering
 the motions more fluid.
   In whatever part a  carcinomatous tumour may be situated, it
will  be right that the  patient should live as much as possible
upon vegetable food, it being less nutritious and  less stimulating
 than animal  food.  It  is especially  proper  when  the  disease at-
tacks the rectum;  such nourishment being most likely to pass
readily through the bowels, and  to keep them  in  that open state
 which is  so much to  be  desired.  Fermented liquors,  distilled
spirits, and spices, will be very injurious: they should therefore
be avoided.
  From  the vicinity of the rectum to the vagina, this latter part
should not be subjected  to any cause of irritation.  And if the
patient should be married, she should be cautioned against sex- 
7Q
CARCINOMA RECTI.
ual intercourse. If the lower part of the rectum should be the
seat of the disease, the sufferings of  the woman upon these oc-
casions would be alone sufficient to deter her from it.
  If the bladder should become irritable, the immersion of the
hips in tepid water will be found to afford  relief.  Opium,  al-
though so useful in relieving pain, should  never be employed
except when  absolutely necessary, as a time may  come when
the patient may be indebted  to it for all her comfort.  It should
not therefore  be  used before it is wanted.   It  is perhaps the
most  powerful of all the medicines in use for relieving pain;
and when the stomach has  been  long accustomed to it, will
produce but little, and the other milder sedatives, no effect.   It
also renders the bowels more torpid.
   The mucous discharge should by no means be restrained by
the use of astringents; because, if  suffered  to continue, it will
retard the progress of the disease.  If it should  be hastily or in-
cautiously checked,  the  symptoms will quickly increase, the
pain will become very violent, and  the disease  altogether very
sensibly aggravated.
   Tepid water may  be thrown into  the vagina  several times a-
day, with a female syringe, and  the external parts may be fre-
quently washed with it.  This will prevent  the discharges from
becoming irritating,  or excoriating  the parts over which they
run, and the neighbouring parts will  be much soothed  by it.
   The temperature of the  water employed should be below
that of the body.
   When means have been employed to diminish the discharge
from  the vagina, it is not unusual for the patient immediately to
observe an increase in the violence  of the symptoms; and this
remark leads  sometimes to the knowledge of the state of the
uterus, or of the neighbouring parts,  which might otherwise have
escaped observation.
   The attention of  the practitioner being  called to the proba-
bility of the existence of some organic disease, he ought to sa-
tisfy himself by an examination. Perhaps  the  disease may be
out of reach, either by the rectum or the vagina, and the nature
of the complaint may not be ascertained:  yet, if upon a return
to the use of astringent injections there should  be an augmenta-
tion of pain,  it will  be prudent to act as if such  disease  was
known to exist.  By such conduct no harm can be done: from
the reverse much mischief may  ensue.
   Women who do not manage  the syringe dexterously, some-
 times affirm that their complaints have increased after the em-
 ployment of an injection, even when warm water only has been
 injected.  In such cases it may  reasonably be  suspected, either 
CARCINOMA RECTI.                77
that  the  instrument employed  has been badly constructed, or
that the woman has not used sufficient caution in the introduc-
tion of it. This should be inquired into; and the  practitioner
should instruct the patient in the best mode of using it, and not
hastily give  up a remedy which,  if judiciously used, will  add
much to her comfort. 
78
                   CHAPTER XIV.

                  CARCINOMA UTERI.

   The disease which has been  last  described as attacking the
 rectum, exists much more frequently in the uterus: and although,
 in the commencement, there will  be marks  distinguishing the
 two diseases from each other; yet  in the latter  stages both are
 attended by similar symptoms, both  commit  the  same ravages
 upon the neighbouring parts, and both are equally fatal.
   In Dr. Baillie's excellent work on Morbid Anatomy are given
 three plates:  One containing two  figures of scirrhous enlarge-
 ment of the uterus, which  disease sometimes  acquires a very
 considerable size, so as to become  as  large as the uterus at the
 sixth month; and this (he says) is very little liable to ulcerate. The
 author has never  met with a case in which ulceration has taken
 place in  this kind of tumour: indeed, Dr. Baillie's expression
 proves that this is very rare.  A  second, containing two  figures
 of fleshy tubercle of the uterus: and  the third plate, containing
 three engravings of malignant ulcer of the uterus, which  always
 begins at the cervix of the uterus, and which is very fatal.
   The author means to include  the  hard tumour which arises
 from the cervix of the uterus, and the case where a hard thick-
 ening of the cervix of the uterus takes place, (both of which are
 disposed to ulcerate) under the name of carcinoma uteri.
   There is an ulceration of  the  os uteri of a distinct kind  from
 that just mentioned, although equally fatal.  This will  be de-
 scribed in a future part of this work, under the head of purulent
 discharges, by the name of the corroding ulcer of the os uteri.
   The cases described by Dr. Baillie under the title of Scirrhus
 Uteri and Tubercle of the Uterus, the author means to consider
 together, under that of the Fleshy  Tubercle of the Uterus; for
 the uterus in both has tubercles, either arising from  its surface
 externally or internally, or imbedded in  its substance. In both,
 few except mechanical symptoms,  are present:  in neither  does
 ulceration take place.  In both, the  tubercles are found at a dis-
 tance from the cervix of  the  uterus,  and both sometimes con-
 tinue for many years without producing  much inconvenience.
  The principal reason for classing the  diseases in this way, is
to enable a practitioner to know  what to expect from the pre-
sence of certain symptoms and certain appearances, and  to give
such a prognostic  as will be likely to be  verified.
  Carcinoma uteri is far more  common than carcinoma recti,
and cases of  it occur very frequently in practice.  Very young 
CARCINOMA  UTERI.
79
women  are seldom  the  subjects of this disease; but it mostly
attacks women of middle age, attended by symptoms which are
not very violent at first,  but which, as in cases of carcinoma in
other parts of the body, become more violent afterwards.
  By carcinoma uteri is  meant that disease where there is a
tumour  near to,  or a thickening of, the  cervix of the uterus,
which tumour or thickening are disposed to ulcerate.
  This  disease attacks only,  in the first instance, the cervix of
the uterus.  All  other tumours, although  hard  in their texture
(scirrhous as they have been called,)  are  of a different charac-
ter, have different  symptoms and  terminations.  In  the  dead
body they may have some resemblance to carcinoma, but they
are never found ulcerated.  Inflammation  may take place in or
near them, and matter may form; but when the first takes place,
they suppurate  from  their  centre, and  not from their surface;
and when they appear to ulcerate upon the surface, it will pro-
bably be found that the ulceration is confined to the parts in the
immediate neighbourhood, upon which pressure has been made
by the tumour itself.
  Carcinoma particularly affects glandular parts;  and the cervix
of the uterus being the most glandular part of it, is probably the
reason  why  it becomes more  liable to  this disease than any
other part of this viscus.*
  When  carcinomatous  tumours are cut through with a knife,
they offer a good  deal of resistance, and appear sometimes as
hard as cartilage.  The  cut  surface  presents an appearance of
white lines, which run pretty regularly with regard  to each oth-
er,  but the directions of which vary according to  the shape of
the tumour.f
  Tumours  with  irregular surfaces  are often liable to become
active :  but all tumours having unequal surfaces are not necessa-
rily of this kind; and  certainly  are not, when distant from the
cervix of the uterus. The fleshy tubercle of the  uterus has not
uncommonly a ragged surface; but this tumour never ulcerates.
  Tumours of a large size  have frequently been called scirrhous,
because they are hard in their texture;  but the  true carcinoma
seldom becomes very large.  In the collection belonging to Dr.
Clarke  and the author there  is a  tumour of the uterus of a very
hard structure, which weighed fourteen pounds;{ but such tu-

  * " Etsi cancer etiam ipsi uteri substantiae accidere potest, tamen hoc rari-
us accidit, et vix turn satis cognoscitur, multo minus curatur; frequenter vero
in cervice uteri generatur, quapropter hoc loco de eo agemus:  Isque nunc est
sine ulcere, nunc exulceratus."—Sennertus, lib. iv. de Morbis Mulierum, cap.
11.
  t Vide Dr. Baillie's Morbid Anatomy.
  t A section of this tumour is preserved in the Museum in Windmill-street 
so
CARCINOMA UTERI.
mours do not possess, even  in their advanced stages, the char-
acter of cancer; neither are they attended in their early state by
the symptoms characterizing carcinoma, nor by those corres-
ponding changes  of structure in  the neighbouring  parts  by
which that disease is attended.
  Two varieties of this disease are to be observed in the early
stage.
  1. There is a firm tumour, of a rounded form, springing from
the surface of the cervix uteri, or imbedded in it, whilst the
other parts of the uterus are perfectly healthy, except  that its
parietes are thickened as the disease advances, and that its cav-
ity becomes  larger than that of an healthy unimpregnated uterus.
  2. Instead of any distinct tumour, the whole of the cervix of
the uterus becomes  larger  and  harder; and  if  this  thickened
part is examined by cutting into it, it puts on the same appear-
ance which a regular carcinomatous tumour possesses.
  The two cases  proceed differently. In addition to the usual
symptoms of carcinoma, there will sometimes be found in  the
first variety of the disease some mechanical symptoms, depend-
ing on the pressure made by the tumour upon the neighbouring
parts; which symptoms will be more or less severe, according
to the size and situation of the tumour itself.
  In the second variety of the disease these symptoms do not
exist; because the carcinomatous thickening of the cervix uteri
rarely acquires a sufficient size to produce them.
  In women  who live temperately the disease may continue for
a long time without producing many symptoms, if any judgment
can be formed from the cases of patients who apply for medical
aid on account of symptoms under which  they have  not long
laboured.  On examination,  there is often found in such women
a considerable alteration  in the structure of the parts, which
most probably could not have happened in a short time.
  There is  reason to believe that carcinomatous tumours make
a very rapid progress when any violence has been done to them,
as the  following case  will  shew.  A woman, about the age of
forty, fell into labour: the head of the child presented;  and  lit-
tle progress  being made, a consultation was thought necessary,
and the author  was desired to see her. Upon examination, the
os uteri was found dilated  to  the size of a half-crown, the cer-
vix of  the uterus was  greatly thickened in every part, and felt
like cartilage; it was also very tender. Upon inquiry, it appear-
ed that the woman  had been liable, during  the  latter part of
her pregnancy, to a profuse discharge of mucus, and to occa-
sional attacks of pain in the lower part of the abdomen.  Two
days elapsed before the os uteri was completely dilated, and the
dilatation  was performed with greater pain  than usual.  The 
CARCINOMA UTERI.                81
 head of the child at length passed through it.  After the labour,
 the pain and discharge were  greatly increased,  and the woman
 died in a few days. Upon examining the cavity of the abdomen
 after death,  the  body of the uterus  was found contracted as
 much  as it generally is at the same period of time after delive-
 ry; but the cervix was very much thickened,  and  had begun to
 ulcerate. The parts are preserved in the collection  of the author.
 It  is to be presumed, that the disease formed  after the com-
 mencement of the pregnancy, and that it became more active
 in consequence of the violence done to it  in labour. Comparing
 this case with others in the progress of which  occasional exami-
 nations are made, it is probable that it must have proceeded
 with great rapidity.
   A sense of weight in the  vagina  is a  symptom  attending all
 tumours which  are moveable in the pelvis, when they have be-
 come large.  This, however, is so frequently felt on less impor-
 tant occasions, that unless it is accompanied by other symptoms,
 it is often disregarded.
   A mucous discharge from the vagina is a  very constant at-
 tendant upon the complaint; and by the local evacuation it in
 some measure checks the  progress of it.
   This mucous  discharge is sometimes tinged with blood, and
 particularly when the patient indulges  in eating and drinking, or
 where  the food taken has been of a stimulating quality. If the
 woman uses much exercise, pure blood sometimes comes away,
 and in  such  large quantity as to produce great weakness, and
 occasionally fainting.  Generally  whilst there  are  discharges of
 blood in moderate quantity,  the tumour remains almost station-
 ary, increasing little in size, and producing little or no uneasiness.
 The author has seen many instances of women,  with a diseased
 uterus  attended by distressing symptoms, who, after having been
 attacked by large bloody discharges, so as to make them faint,
 in any other than the horizontal posture, and  to bring on gene-
 ral  anasarca, have continued  free  from every symptom  of the
 specific disease for many  months. In some instances where the
 woman has died, it  has been  from weakness  and  the dropsical
 symptoms, and  not from the symptoms belonging to the origi-
 nal disease.  This is the reason why many cases of menorrha-
 gia ending in dropsy are unmanageable;  because they depend
 upon  organic disease of the  uterus,  which  is  never  perhaps
 known, or, if known, baffles  the art of medicine.
  In carcinoma uteri,  if menstruation has not ceased, it becomes
 for the most part  irregular,  and is  more profuse than it ought
 to be.
  The mechanical symptoms produced by tumours in the pel-
vis sometimes attend carcinoma; but the patient seldom suffers
                     i, 
82
CARCINOMA UTERI.
much from them, since the size of the carcinomatous tumour is
not often great enough to cause them.  CEdema of the lower ex-
tremities sometimes attends; but this is not generally the effect
of pressure upon the trunks of the absorbents;  for it does not
appear until the frame has been much weakened by the long
continuance of the disease, and the disposition  to anasarca  is
general.
  Difficulty of passing urine rarely occurs in this complaint; but
strangury, arising from the consent  between the uterus and the
bladder, is seldom  wanting.  In some  instances  it accompanies
the disease from the  beginning, but in others it ushers in the
symptoms  which immediately  precede the conversion of the
disease into the state of ulceration.
  The inner membrane of the bladder is found to secrete,  in
some cases, a larger quantity of transparent mucus, which comes
away with the urine, and falls to the bottom of the urinal.
  The seat and the course of the pain, resembling the passage
of a calculus from the kidney to the bladder, have led to a mis-
taken idea of the disease; and in some instances the false opi-
nion has been strengthened  by another symptom which  attends
both diseases; namely, urticaria or nettlerash.
  This  disease of the skin originates in the presence of acid  in
the stomach and intestinal  canal; and it may be produced  by
the food taken, by  a want of tone in  the stomach, a deficiency
of the biliary secretion, or sympathy between the uterus and the
stomach.
  Cardialgia, or heartburn, arising from the  same causes,  be-
comes sometimes also very  troublesome to the patient.
  If the delicacy of the patient should prevent  her mentioning
the symptoms belonging to the sexual organs, if she objects  to
an examination, or if the  practitioner is content to prescribe for
the patient without ascertaining the nature of the disease, it is
probable that the medicines will consist of alkalies, bitters, to-
nics, and aromatics: it is also likely that small  doses of mercury
may be  given, to increase the biliary secretion.  Such a mode
of practice cannot fajl to aggravate the  symptoms, and to accele-
rate the progress of the disease, by increasing the activity and
the strength of the  circulation.
  A woman, about thirty-five years of age, who had experienced
for  some  time  constant pain in her groins  and a mucous  dis-
charge from the vagina, whose stomach was weak, and who was
much distressed by hysterical symptoms, consulted a practition-
er,  who recommended that she should take five  grains of pilula
hydrargyri at bed-time, and  twice in the course of the day a
cupfull of chamomile tea.  She. pursued this plan for more than
a fortnight, at the  end  of which time she became worse; the 
CARCINOMA UTERI.
83
discharge increased, and the hysterical feelings were unabated.
When the author was consulted, the seat of the disease induced
him to make an examination, when there was found a thickened
state of the cervix of the uterus, which was tender to the touch.
A horizontal posture, the injection of tepid water into the vagi-
na, and  small doses of saline purgatives, after some time removed
the complaints, which were only symptomatic of the disease of
the uterus.
   Even in  the early stages of this disease the stomach will be
liable to be, in some degree, affected;  though the more severe
affections of this organ do not geneially attack the patient till the
ulcerating stage  has commenced.  The stomach is much more
disposed to  be affected in some cases than in others; and a mild
degree of the disease will  strongly excite  the  sympathy of the
stomach in one patient, whilst in another it will hardly be brought
on by the most violent forms of the  disorder.  As in hernia, so
in carcinoma uteri, the sympathetic action is occasionally more
distressing  than the disease itself.
   Upon an examination, if the disease  should be carcinoma, the
cervix of the uterus will either be found thickened, and with a
resisting feel resembling that of gristle, or  a distinct tumour will
be perceived arising from some part of the  cervix uteri, the other
parts remaining  healthy. In either case,  pressure upon the dis-
eased parts produces pain of a lancinating kind.
   The  os uteri will be found also to have undergone a change.
It becomes larger than natural, still however retaining its original
shape.  This open or gaping state of the  os uteri sometimes is
sufficient to admit the extremity of a finger, which, when intro-
duced into it,  feels as if surrounded by a  firm  ring.  The parts
will  sometimes  have  undergone  all  the  changes of structure
above related, when  no local  symptoms  have  been  apparent,
and  when the disease  has only  been  ascertained by an exami-
nation,  suggested by the failure of remedies in relieving the sup-
posed disease  of the stomach or kidney.
   It is unusual for patients to be cut off during the carcinoma-
tous state  of the disease: when, however, this does happen, it is
from the excessive discharges of blood bringing on a dangerous
degree  of debility. 
81
                   CHAPTER XV.

               Treatment of Carcinoma Uteri.

  In the case of patients who labour under this disease, the ob-
jects contained in the last chapter are to  be constantly kept  in
view.
  There is a disease of importance  in an internal  part, produc-
ing symptoms,  some of which are local, whilst others depend
upon the sympathy between the part affected and  parts at a dis-
tance.  These symptoms are not all dangerous, but they are very
distressing to the patient.
  This local disease may remain stationary, or it may have  its
symptoms alleviated, so that the patient's life may be prolonged
and her comforts increased; or it may be converted into another
form, in which the constitution may be affected, either by the
absorption of matter, or by an extension of the disease to neigh-
bouring parts,  in which case  all  the original symptoms will  be
aggravated, and many new and dangerous symptoms will be pro-
duced.
  Much regard is  likewise to be paid to the constitution of the
patient in the management of this complaint.  If the system is
plethoric, some blood should be taken  from the arm, the quan-
tity being regulated  by the circumstances existing at the  time.
This is done to diminish the force and  the frequency of the cir-
culation.  Sennertus recommends bleeding in this case, but  for
another reason: " Nimirum si sanguis  sirnul  peccat, is cum  ex
vena  in cubito, turn in crure et  pede, aperta evacuandus."—
Sennertus, de Uteri Scirrho et Cancro.
   Blood may  also be  taken away from the hypogastric  region
or  from the loins, by cupping or  by leeches; and from  time to
time, upon any increase of uneasiness, this operation  should be
resorted to;  since the  most watchful attention must be given to
this disease, when it is proved to exist, as long as the woman
lives.
   The relief produced by topical blood-letting is great, and  of-
ten immediately felt:  blood is generally procured more  easily
when  the cupping-glasses are  applied to the back, than when
they are placed upon the abdomen.
   Purging is of essential service, and should never be omitted.
 For this purpose some saline purgatives should  be chosen; as
 magnesia; sulphas, potassae tartras, sodae  sulphas, or soda tarta-
 rizata.  Whichsoever of these may be employed, it should   be
 dissolved in a  large quantity of some  watery menstruum; and 
CARCINOMA  UTERI.
85
by means of it a permanent increased secretion from the intes-
tinal glands should be kept up.
  When saline purgatives do  not agree with the stomach, but
excite vomiting, an additional  quantity of  acid  may  be given
with them: thus,  to a dose of sulphate of magnesia, eight or ten
drops of diluted sulphuric acid may be added with advantage.*
  No  attempt should be made to  stop the  mucous discharge;
but if  it should  be secreted in  large  quantity, it should  be fre-
quently washed away, by injecting tepid  water into the  vagina.
The heat of the water should  be  accurately regulated:  if it is
employed too cold, the secretion from the parts will be  greatly
checked by it; and if too hot, increased action of the local ves-
sels will be excited. The temperature may vary from eighty-six
to ninety-four degrees of Fahrenheit, according to the sensations
of the  patient. The frequent ablution of the  parts renders it less
necessary for the woman to take any precautions for absorbing
the  discharge, which generally tend to heat the parts, and must
be hurtful.  The  water  should  be injected by a female syringe
several times in a day.  If the woman continues  to menstruate,
the temperature of the  water should be nearly that of the body
at the  periods of the discharge, lest it should be  checked.
  The woman  should be clothed warmly: First,  because if
there is much blood upon the surface, less  will  circulate in the
interior of the body:  and Secondly, because the chance of in-
flammatory action being  produced, by any sudden change  of
temperature to which the body may be exposed,  will be  dimin-
ished,  and the uterus  will be less likely to suffer.  Every day's
experience presents instances of visceral diseases being produced
by cold in the first instance;  and many cases occur where this
cause will reproduce the symptoms, after they have been for a
considerable time quiescent.
  All local stimuli should of course  be avoided. The sexual in-
tercourse must therefore be improper.
  The necessity  for abstemiousness in diet  should be  strongly-
inculcated: no animal food should be allowed; fish, however, is
less objectionable than any other. No wine  or spices should be
mixed with the food, which should  be as plain and as little heat-
ing as  possible.
  The quantity of the food taken should be moderate; lest, not
being digested, it should disturb the functions of the alimentary
canal,  and become the cause of fever; or lest, being digested, it
should add to the quantity of blood, and improperly increase the
vigour of the system.

  * Sodae phospbas, first recommended by  Dr. George Pearson, (being nearly
tasteless) is a useful medicine in cases where other saline purgatives would be
rejected. 
86
CARCINOMA UTERI.
   It has been observed above,  that  urticaria is not an uncom-
mon attendant  upon this  disease, from the  sympathy between
the uterus and the stomach. Whenever there is a disposition to
this complaint, it  will be  increased  by vegetable matter taken
into the stomach.
   Urticaria very often excites great  irritation in the system, and
increases the frequency of the pulse; on both of which accounts
measures should be taken to relieve it.  External  applications do
no good: the author has seen sedative lotions used without any
effect, and unctuous  applications  rather increase than diminish
the irritation.  All those internal medicines which have the cha-
racter of cooling and allaying irritability, will be  found to be in-
jurious, or at least inefficacious: such are nitre, saline draughts,
antimony, saline purgatives, and opium.
   The patient should by no means be kept in  bed.
   The mode of treating the  case is to empty the  bowels by a
purgative of rhubarb, carbonate of magnesia, compound spirit of
ammonia, and peppermint water. Afterwards, some  light bitter
infusion  should be given,  three  times in  twenty-four hours, as
infusum  gentianae comp., infusum calumbae,  or infusum humuli.
To any of these may be added a few grains of subcarbonate of
soda or of potash, and  a drachm or two of some aromatic water.
   If a constipated state  of bowels  should  render any farther
opening  medicine necessary,  some  magnesia  may be added to
each  draught.
   Water containing supercarbonate of soda  may  be given as
common beverage with great advantage. During the continuance
of this plan, the quality of the  food must  be a  little changed.
Very small  quantities of animal food may be allowed  once a
day;  and nothing  should  be  taken  into the stomach which is
likely to run into the acetous fermentation.—The following case
will shew the necessity of attending  to the state of the stomach,
in diseases of the uterus which are disposed  to become active.
   An unmarried lady,  about thirty years of age, had an enlarged
uterus, in which,  at different times, imflammation  had taken
place, which was subdued by local bleeding, purging, abstemi-
ousness, and quiet. Some time  after she  had pursued this  plan
in the country, she came  to the house of her father in London,
and was attacked  with cardialgia and urticaria to a very great
degree.  The skin in many parts of the  body was  attacked by
the latter disease,  but  especially  the face and  the lower part of
the abdomen.  Considerable  itching was present, accompanied
by irritability of the  whole system.   The" disease of  the uterus
also, which had been in a quiet state during several months, re-
turned with great violence. Local bleeding in  some degree les-
sened the pain: purging with neutral salts increased the  urtica- 
CARCINOMA  UTERI.
87
ria. Nearly  all vegetable food was abstained  from: she  took
nothing but  soda water and mint tea for  beverage,  with a  little
thin dry toast for food. Once in four hours a draught was exhi-
bited, consisting of carbonate of  magnesia,  compound  spirit of
ammonia, and an infusion of dill seed.  Under  this plan all the
symptoms subsided,  and uterine disease  at that time  gave no
farther alarm.
   For some months this lady continued well; but having at sup-
per eaten freely of fruit pye, and drunk at the  same time some
sweet  wine, the urticaria returned in the night, and with it the
pain in  the region of the uterus.  Some bitter infusion, with  rhu-
barb and volatile alkali, was now given, and soda water for com-
mon drink;  and again all was put to rights. She  now carefully
avoids such food as is likely readily to ferment;  and, watching
the first attack of heartburn, has not for some time been visited
by her  troublesome complaint.
   If discharges of blood should  take  place, the patient should
be kept in a horizontal posture, and the case should be attentive-
ly watched. If the quantity of the discharge should be moderate,
it should be recollected that it is the effect of the increased ac-
tion, and fulness of the vessels of the neighbouring parts, which
maybe carried off by it:  it ought not therefore to be hastily
checked.  But  if the quantity of blood  lost should be so consid-
erable as to be immediately hazardous, or to lay the foundation
of future danger, it should be restrained by the  usual means em-
ployed  for the restriction of hemorrhage; such as the  applica-
tion of cold and local astringents to the parts.
   In the management of carcinoma uteri, the  observation  and
regulation of the discharges which come away  in the course of
it require great attention.
   Iron has  been recommended by some practitioners as a reme-
dy for this disease; but the author has not seen any good effects
produced by its use.  In some hard scrofulous tumours,  and also
in some foul ulcerations of the skin supposed to be cancerous, it
has been  useful; but  in carcinoma it is very doubtful whether its
exhibition has  ever been  productive of advantage. When the
author has given this medicine,  or  seen it exhibited by the di-
rection of others, in cases of carcinoma, it has  produced injuri-
ous effects,  by increasing pain, and in some instances the quan-
tity  of bloody  discharge: the  preparations  used  were  the ferri
carbonas,Yerrum ammoniatum, and the tinctura ferri muriatis.
   In treating this disease, as no cure is known  for it, the practi-
tioner must be satisfied with palliatives, and not be  anxious to
restore the vigour of the body, which  might aggravate  the  dis-
ease again. 
88
                   CHAPTER XVI.

             POLYPUS OF THE  UTERUS.

   In the disease which is next to be considered, the symptoms
 are of a mixed kind; such as would be naturally expected  to
 arise out of the circumstance of both the uterus and the vagina
 being affected by it.  The uterus gives  rise to the tumour, which
 descends into the vagina, and there excites  irritation, as well  as
 all the other inconveniences which an  extraneous body placed
 in the same situation would produce.  Polypous tumours have
 been known to arise from all the  cavities  of  the  body which
 have external openings,  although some of these  cavities are
 more liable to them than  others.   The most usual seat of  poly-
 pous tumours is the  cavity of the  nostrils,  where,  before they
 have acquired a large size, they will greatly impede the respi-
 ration, and after some time they  will cause a great alteration  in
 the appearance of the face; for the cartilages of the nostrils will
 be much distended, and sometimes the ossa  nasi themselves dis-
 placed by them.
   Polypus of the uterus is an insensible tumour attached to the
 internal part of this viscus by a small neck, forming a disease  of
 a very important character.
   These tumours are various, as to their appearance, shape, and
 degree of hardness.  They are sometimes nearly white, at other
 times of a brown colour:  they are sometimes very hard and re-
 sisting, in other cases so soft and  yielding that they will not ad-
 mit of the  application of a ligature  without  breaking to pieces.
 Polypi of a hard kind will in some cases take on the form of the
 parts in which they lie:  in the upper part of the nostrils, there-
 fore, they are flattened;  when they  descend as far as  the carti-
laginous part of the nose, (less restraint being laid upon them)
 their diameter is increased. In polypus of the uterus, the neck
 of the tumour, which is surrounded  by the os uteri, is contract-
 ed;  it spreads out below, because it has sufficient space for en-
 largement in the yielding vagina.—In the preparation from which
 the engraving of this disease is taken, a longitudinal indentation
 may  be observed, the effect probably of the pressure which the
meatus urinarius made upon the anterior part of it.
   The  soft polypus  is by no means so frequent as  the hard
kind. The  following case  will demonstrate its very yielding na-
ture.
   A  woman between the  age of sixty and seventy laboured un-
 der all the  symptoms of poly pus of the uterus; and upon exam- 
POLYPUS  OP  THE UTERUS.
89
ination a polypus in the vagina was detected, as large as a small
orange, which, by the discharge occasioned by it, had produced
great weakness. The operation was  recommended, and  was
readily consented to. The author passed a ligature into the va-
gina by means  of a brass rod; but upon attempting to carry it
round the neck of the tumour, a small piece of the tumour came
away. In different attempts the same thing happened. At length it
was found to be impossible, from the tenderness of the tumour, to
apply the ligature. By means of a finger, the tumour was brought
away from the vagina, and  upon examination it had much the
appearance and texture of the cerebellum.—The preparation is
preserved in the author's collection.
   Single and married women are subject to polypus of the uterus.
   If a section is made of a polypous tumour, the appearance of
the cut surface does not  differ from that of the exterior  of the
tumour.  When a polypous tumour has acquired such a size as
to fill the cavity of the uterus, the os uteri begins to dilate, so as
to permit the descent of the tumour into the larger cavity of the
vagina below.—The author has in his possession a polypous tu-
mour which resembles in size the cavity of the unimpregnated
uterus (of course a very small one), which nevertheless produced
symptoms of great uterine irritation.  These  went off upon the
removal of the tumour by the finger.
   A polypus sometimes increases in bulk very slowly. The au-
thor had opportunities, in the course of several weeks, of  exam-
ining the polypus last mentioned, which  during that period had
received very little addition to its size. In some cases, the cavi-
ty of the uterus will be greatly distended by the tumour,  before
the dilatation of  the os uteri takes place.  The tumour in some
instances becomes so  large as to fill the cavity of the pelvis:  it
is generally of a rounded form; but  sometimes it is elongated,
or flattened. In one case which th'e author met with, the tumour
was an inch and a half long, but the breadth of it did not exceed
one-third of an inch.—The preparation is preserved.
   Nothing certain is known  respecting  the  cause of these tu-
mours:  they arise  sometimes  in  women  otherwise  healthy,
whose uterus has suffered no violence.
   The symptoms which attend  the disease are, first, a mucous
discharge in considerable quantity, mixed at different times with
blood; and in some  instances the  constitution becomes  debili-
tated to an extreme  degree by this symptom, before there is the
least suspicion respecting the cause of it. Sometimes, instead of
the mucous discharge being mixed with blood, large coagula of
blood will be voided;  and sometimes pieces of a ring-like form
come away, produced by a small quantity of blood attaching it-
self to the surface of the tumour, and there coagulating; it at
                    M 
90
POLYPUS OF  THE UTERUS.
 length slides off, and comes away. In other instances, the blood
 poured  out becomes putrid in the vagina, and  tinges the dis-
 charges of a brown colour, rendering them at the same time very
 offensive. This fcetor of the discharges induces in the mind of
 the patient, and sometimes of  the practitioner, a belief that the
 disease is cancer; and this opinion is confirmed by the sickness
 which generally attends the disease.
   The discharges from cancerous sores are foetid, if great atten-
 tion is not paid to cleanliness: but fetor of the discharge is by
 no means peculiar to cancer; for whenever blood  is retained and
 becomes putrid, this circumstance  must attend: and if such
 rings of blood form upon the  surface of polypous tumours, as
 have been  alluded to above,  there will be a difficulty in  their
 sliding over the lower part of the tumour, because it is generally
 larger than  the upper part, or that nearest  to its neck.  In this
 manner  may  be explained probably  the reason why  the  dis-
 charges  are so  generally and  necessarily offensive in this  dis-
 ease.*
   A sense of pressure  and of  bearing  down are  also found in
 this complaint; and these symptoms are proportioned in degree
 to the size and weight of the tumour.  Pain is likewise  referred
 to the back and groins.
   If the tumour should be large enough to  fill the cavity of the
 pelvis, it  may, by pressing upon the rectum and  upon the mea-
 tus urinarius, prevent both  the free evacuation of faeces and of
 urine. Such cases are, however, uncommon. It more frequently
 happens that strangury attends the complaint, from the sympa-
 thy  between the os uteri and the bladder.
   The sympathy between the stomach and  the uterus is some-
 times excited,  and frequent vomitings  distress the patient ex-
 ceedingly.
   Here  then, from one cause, are three  symptoms  producing
 great weakness; an increased secretion of mucus, hemorrhage,
 and vomiting, with derangement  of  the  digestive powers, by
 which alone the strength can be recruited.
   But the true character of the disease can  only  be ascertained
 by an examination.  This will discover an insensible tumour pro-
jecting through the os uteri, by which its neck is entirely encir-
 cled, so that the finger can be completely  passed round it.
   The only diseases  which can be mistaken for polypus are an

         ■* " Quid tibi vis, mulier nigris dignissima barris?
             Munera cur mini, quidve tabellas
           Mittis, nee firmo juveni, neque naris obesac?
             Namque sagacius unus odoror,
           Polypus, an gravis hirsutis cubet hircus in alis,
             Quam canis acer, ubi latest sus."—Hor. lib. v. Carta. 12. 
POLYPUS  OF  THE  UTERUS.
91
 inverted uterus, and the cauliflower excrescence of the os uteri.
 The history of the case from  its commencement, and the insen-
 sibility  of polypus,  will  distinguish it from the  first:  besides
 which,  unless  the  uterus is only partially inverted, (a very rare
 occurrence)  the  tumour will  not be  encircled  by the os uteri.
 The irregularity of the surface of the cauliflower excrescence,
 the circumstance of  its originating from the substance of the os
 uteri, with a broad base, and not coming through it, and  the wa-
 tery discharge  which attends this disease, will prevent the prac-
 titioner from confounding it with polypus.
   There  is, however,  a tumour which has been looked  upon
 and  treated  as polypus, which ought to be distinguished from
 it, on account of the prognostic to be given respecting its termi-
 nation, and also because it does not admit of the same success-
 ful mode  of treatment  as polypus.
   This disease consists of a tumour, which is insensible, which
 has an unequal ragged  surface, which  comes down from  the  ca-
 vity of  the uterus into the vagina,  surrounded  by  the os uteri,
 and without a narrow neck.
   Upon an  accurate examination,  this tumour is found to  be
 made up of a  number of  irregular  portions, which  lie  parallel
 with each  other.
   All the symptoms of polypus uteri attend this complaint, and
 at length will end  in  the destruction  of the patient.   In this dis-
 ease the  uterus undergoes a great  degree of enlargement, and
 its muscular sides  become greatly thickened; a change not usual
 in polypus, even when  it is of a very large size.
   In an exceedingly good  work upon  the  subject of polypus of
 the  uterus, written  by  M. Herbiniaux, a  surgeon at Brussels,
 published in  1782,* an  account is given of this  disease,  (which
 had been  mentioned before by Levret) in the Memoires de 1'-
 Academie.f

      * Traitc sur les Polypes de la Matrice.
      t " II nait quelquefois, taut dans la matrice que dans le vagin, des  ex-
 crescences que M. Levret appelle Vivaces, qui ne' doivent pas etre confohdues
 avec les polypes, puisqu'elles ne sont recouvertes d'aucune  membrane, et qu'-
 elles n'ont q'un p£edicule imparfait. Ces sont des especes de champignons plus
 ou moins gros qui naissent a des points variqueux ou ulcerees dans ces orga-
 ries, et dont la cause primitive  les rend ordinairement incurables. M Levret
 dit mcme, que coinmc il est  presque  impossible de parvenir a en detruire la
 cause immediate, e'est peine inutile de travailler a les retraucher. Je suis as-
 sez de cet avis; car quelques benignes qu'elles paroissent, on ne les a  pas plu-
 tot emportces par la ligature, qu'elles reviennent. Ces excrescences produi-
 sent peu de douleurs, et souvent aucunes; les ccoulemens sanieuxen sont mc-
 diocres; mais elles procurent des hemorragies  frequentes,  qui  tuent a la fin
 celles qui en sont affligees.
  Cette espece de tumcur ne vient pas seule, comme le polype uti-rin; il en
nait ordinairement plusieurs  a la fois  qui sont distribucs en  me me temps quel-
quefois dans la matrice et dans la vagin. Ces dernieres sont faciles  a recon- 
92
POLYPUS OF THE  UTERUS.
  Polypus of the uterus admits of cure only by means of an op-
eration, which consists of the application of a ligature round the
neck of the tumour.  If the true nature of the  disease is not as-
certained  by an examination, if the practitioner is content with
treating symptoms, the  patient becomes  gradually weaker, and
at iength dies from want of skill in  her medical attendant; as no
medicine  can be exhibited with the least prospect of advantage.
  In the author's  notes, amongst several cases in which he has
successfully performed  the operation for  polypus, four are re-
lated where  the patients had been  under the care of practition-
ers, who, without being  at all acquainted with the  complaint,
prescribed for its effects. Two of the patients had tried blister-
ing and bleeding; one had  taken mercury;  and  all had under-
gone a variety of treatment in  no  respect adapted to the com-
plaint  which produced the mischief.
  The prognostic in  cases of polypus of the uterus  may gene-
rally be favourable, since the operation is not dangerous; and
even where the  debility induced is very considerable,the patient
generally recovers.  But  this assertion applies only  to the true
polypus.  The tumour  which resembles it, and which  has been
described by Levret and by Herbiniaux by the  name of  " Vi-
vace," although admitting of removal by the ligature, is disposed
to return; other newly formed irregular portions shooting down
into the vagina, and this with a rapidity of growth not belonging
to polypus.
   It is not here intended to prohibit the application of a ligature
round such tumours: their size, and the  inconveniences arising
out of it,  their disposition to become in part putrid, may render
such removal advisable;  but the patient  should be prepared for
disappointment, and  the  friends should be made fully aware  of
the essential difference between the two diseases.
   Polypus of the uterus  has been  separated in a  few rare cases
during the act of vomiting, and thus the disease has  been cured
without operation.  Probably in these cases the polypous tumour
has jjeen pushed during the efforts of vomiting out of the os ex-
ternum; and upon the  retiring of the uterus, after the abdominal
muscles have ceased to act upon it, the neck of ihe tumour has
been  broken.   Such a favourable  mode  of cure  is hardly to  be

noitre par le toucher; mais on peut se meprendre facilement aux premieres.
Voici la meilleur methode, selon moi, pour les  distinguer des polypes uterins.
La tumeur est presque toujours dans la matrice, parceque son attache  n'etant
pas un  pedicule, elle ne  lui permet guere d'en sortir, surtout si elle nait aux
environs du col de ce viscere. L'orifice de la matrice est plus ou moins ouvert,
et la tumeur qui y reVide int^rieurement paroit au toucher molleet moins unie
qu'un polype.  La matrice est si volumineuse qu'elle forme tumeur a I'hypo-
gastre,  et durant toute la  maladie, cette tumeur exterieure est fort doloureuse,  *
pendaut que la Vivace, que Ton touche par l'orifice, ne Test pas du tout. 
POLYPUS OF THE UTERUS.
93
expected; certainly not to be depended upon. Spontaneous vo-
miting may not  arise, and it may be dangerous in a debilitated
state of the patient to excite it by artificial means.
  Previously to performing the operation, the rectum of the pa-
tient should be emptied by a glyster, or the intestinal canal may
be cleared in its  whole extent by a mild purgative. For a short
time before the commencement of the  operation, the patient
should be kept in the  upright posture, that  the  neck of the tu-
mour may be more within reach.
  As the tumour possesses different degrees of convexity in dif-
ferent cases, and as the distance of its neck from the os exter-
num is very various, the practitioner must be  provided with two
or three rods of different lengths, made of a flexible  metal, so as
to be capable of being adapted to the shape of the tumour.  The
author's  brother, Dr.  Clarke, has contrived a brass  rod, which,
being received  into a hollow handle, is capable  of having its
length altered as each  case may require; and  by this means the
multiplication of instruments is rendered unnecessary.
  A silver canula, of a length sufficient to reach from the neck
of the tumour to the  distance of an inch or an  inch and a  half
from the os externum, should be  prepared; and near the extre-
mity which is to hang out of the external parts  there should be
placed two  small  shoulders, round which  the ends of the liga-
ture may be twisted. A sort of windlass has been recommended
for this purpose  in the canula; but this is quite unnecessary, and
renders the instrument more complicated.
  The ligature should  be made of waxed silk, of such a thick-
ness, as neither to cut the neck of the tumour, nor to break, nor
to block  up the canula.  In order to pass the ligature through the
canula, a long piece of thin brass wire should be ready. This is
absolutely necessary;  because, when the ligature  becomes slip-
pery and  pliable, it will  not be possible to push it through the
canula. The patient should be placed upon a bed.  She should
lie upon  her left side, and  her  knees should be drawn up to-
wards the abdomen. If the external parts should not be readily
dilatable, they should  be dilated. Afterwards the forefinger of
the  practitioner's  left hand, (previously oiled) is  to be carried
through  the vagina to the neck of the tumour.  The brass rod
(previously prepared with the ligature, and its curvature adapted
to the shape of the tumour) is now to be passed up  by the  right
hand to that part of the neck of the tumour where the forefinger
of the other hand is placed. The ligature is then to be secured
by the finger, and the  brass rod  is to be carried carefully round
the neck of the tumour, till it comes to that part where the liga-
ture was secured.  The practitioner is now to secure also under
his finger that part of the ligature which has been carried round 
01
POLYPUS OF  THE UTERUS.
 the neck of the tumour, and the rod is to be Carefully withdrawn.
 In some cases, it will be found more convenient to steady a part
 of the ligature with the rod, and to carry the other part of the
 ligature round the neck of the tumour with the finger.  In doing
 this part of the operation, great care is to be taken not to include
 any part of the os uteri. Before the ligature is tightened, the pa-
 tient is to  be desired to inform  the operator if she feels pain;
 because  if the tumour only is included  in the ligature, no  pain
 will be felt.
   The two extremities of the ligature which  hang out of the os
 externum are now to be drawn through the canula, by the piece
 of wire (which had been previously doubled, and carried through
 the canula, so as to form a noose projecting  from it),  and after
 the canula has been gently passed up to the neck of the tumour,
 they  are to  be drawn tight, and are then to be twisted round the
 shoulders of the canula, where they are to be  made secure. The
 ligature,  therefore, should be long enough to encircle the neck
 of the tumour, to be carried through the canula, and a sufficient
 length of it should remain  to be  affixed  to the shoulders of it.
 Mure than  one ligature should always be prepared, lest  that
 which is first used should  become  too slippery to  be managed.
   After threading the eye of the  rod, one extremity of the liga-
 ture is to be twisted once or twice round the  instrument, whilst
 the other hangs loose. The patient should  be made acquainted
 with  the shape  and the  situation of the  instrument which is to
 be left in the vagina, that it may not be liable  to be moved when
 she gets  up to make water.  She  is  also to be desired to remain
 constantly upon her side, and should not  be allowed  to move
 from  one side to the other, unless when the practitioner is pre-
 sent.   For want of attention  to this  caution,  there is reason to
 believe that the canula has been  inadvertently pressed against,
 and its extremity pushed through the uterus  of the patient, so
 as to  occasion her death.—In the engraving given  of the poly-
 pus canula, there may be seen a contrivance, by means of which
 this accident may be prevented. The canula is made of the same
 diameter from  the one  end to the  other, and a spiral screw is
 cut upon it.  To this spiral screw is adapted another screw, placed
 in the centre of a kind of shield,  which (when the  ligatures are
 fastened) is to be placed  in contact with the external parts.  The
 shield in  the plate is of a circular form;  but in women who are
corpulent it may be  more convenient that its shape should  be
oval.
   The patient is now to  be left;  and great care is to be taken
by the nurse  that the canula is not moved when the contents of
the bladder are expelled.
  Every  day the practitioner is to examine  the state of the liga- 
TOLYPUS OF  THE UTERUS.
95
ture;  and as often  as it is found to be  at all  slack, it is to be
tightened.  The  mode of tightening it requires particular atten-
tion.  If  the canula  should  happen to be long, the practitioner
should not hold the  end  of it whilst he tightens the ligature; lest
with the  force used  the ligature should cut through the neck of
the tumour, and the  other extremity of the canula should be sud-
denly and forcibly pushed  by the left  hand against the internal
parts of the woman.  In order to avoid this accident, the  canula
should be firmly held close to the parts of the woman, which
prevents  the  possibility of mischief being done.  If the  canula
with  a shield  is employed, it is next to impossible that this acci-
dent should happen.
  A syringefull of warm water should be thrown into the vagina
every day when  the ligature  is tightened, in order to wash away
the putrid discharge.
  The time at which the ligature will come away, will depend
upon  the thickness and firmness of the neck of the tumour, and
the tightness with which the ligature is at first applied. The neck
of the tumour sometimes is cut  through in four days; sometimes
ten or twelve days will elapse between the application of the lig-
ature  and the removal of the tumour.
  The neck of the  tumour being destroyed, the tumour itself is
to be brought away by the  practitioner.  This will  be accom-
plished in some  cases with  ease, by  one or two fingers  intro-
duced into  the vagina. If the  polypus is large, or the external
parts  contracted, a  single blade of  a pair of midwifery forceps,
or a pair of stone forceps, may be  used.  If the size of the tu-
mour should be such as not to be easily removed by these means,
the crotchet  may be fixed  into it, and  in this way  it may be
brought along.  The palm of the hand should always be kept
opposite  to the beak of the instrument; so that if it should slip,
the parts of the woman may not be injured by  it.
  The cavity of the vagina should afterwards be cleansed by
injecting  some tepid water, and this should be repeated  for se-
veral days.
  The mucous and bloody discharge seldom continues long af-
ter the extraction of the polypus; but if any should remain after
a week or ten days, some astringent injection should  be thrown
into the vagina three or four  times in a day.
  As the ligature is  applied round the neck of the tumour, a part
of the latter may remain between  the ligature and  the uterus.
In consequence  of the application of the ligature, this part pu-
trifies and comes away mixed with the discharges. In one case
in which the author extracted a polypus from the  uterus, he
found that the os uteri had  nearly  recovered its natural  size at
the end of five days from the time at which the ligature came 
96
POLYPUS OF  THE UTERUS.
away; that at the end of fourteen days it was  impossible to as-
certain that any disease had existed in the parts;  and upon  the
sixteenth day, the patient menstruated.
  It has been recommended, after the application of the liga-
ture, that the tumour should be cut off with the knife; but there
does not appear to be any necessity for doing  this, particularly
as no harm arises to the patient from  suffering it  to remain  till
it falls off.
  It sometimes happens, that the ligature and the  canula fall out
of the vagina when the practitioner is not with  the patient;  for
which event she should be  prepared, lest  this occurrence should
create alarm. Whenever this happens, it is clear that the neck
of the tumour is destroyed.
  The food of the patient  should be simple, easy of digestion,
and nutritious.  If the bowels should  be confined, a glyster of
warm gruel  may be thro.wn into the  rectum.   If the stomach
should be irritable, a saline  draught  in a  state of  effervescence
may be given, with a few drops of laudanum; and if the  patient
should complain of pain from long confinement to  the same pos-
ture, a sufficient dose of opium should be taken to procure rest.
  The cause of the debility being removed, the  patient gene-
rally quickly recovers her strength;  but as an auxiliary, a draught
consisting of  decoction of bark with sulphuric acid, may be  ta-
ken three times in a day. 
97
                 CHAPTER XVII.

      FLESHY TUBERCLE OF  THE UTERUS.

   Dr.  William Hunter, who first described the true charac-
 ter of this disease, called it the Fleshy Tubercle. It is a hard,
 whitish  tumour,  sometimes nearly as firm as cartilage, situated
 sometimes upon the surface of the uterus, between the muscular
 and the peritonaeal coat, sometimes projecting into the cavity of
 the uterus, and occasionally imbedded in its substance.
   In some cases there is only one tumour; in others there are
 several. Their form differs very much: they are most common-
 ly spherical or  hemispherical,  but  sometimes they  take on an
 irregular shape.  When they project into the cavity of the uterus,
 their surface is smooth:  the contrary is generally the case when
 they form upon  the outer surface of the uterus, the tumour hav-
 ing a granulated  appearance. These  tumours are sometimes not
 larger than a pea;  sometimes they  weigh  several  pounds, and
 occupy  a great part of the cavity of the abdomen.
   In general, when the  tumour is large, the texture is less firm
 than when it is  of a smaller size. It appears to be  composed of
 distinct  parts, connected by a close cellular membrane, the dis-
 eased tumour itself being opake, and the connecting  membrane
 more or less transparent.  If coloured injection be thrown  into
 the vessels of the uterus, so as to make the substance of the  ute-
 rus quite red, none of it passes to the tumour of fleshy tubercle.
 In the collection of Mr. Abernethy, assistant surgeon to St. Bar-
 tholomew's Hospital, there is a  very  good preparation shewing
 this fact.
   In examining  a great number of preparations of this disease,
 the tumours were found  to be  situated  at  a distance from the
 cervix of the uterus.  It sometimes  happens that ossified parts
 are found in these tumours.
   The fleshy tubercle of the uterus has been mistaken for  hy-
 drops ovarii and  for pregnancy: the  first is an error of little  im-
 portance, as both of the diseases have few  except mechanical
 symptoms; and  neither interfere with  life, unless  by  pressing
 upon parts in their neighbourhood: however, the cases by care
 may be generally distinguished. Although both tumours may be
traced to the pelvis, and are circumscribed, the fleshy tubercle of
 the uterus is much more resisting than  the  cyst of an ovarian
 dropsy.  In a dropsical ovary, fluctuation  may be felt by striking
the abdomen gently with the hand;  but no such  fluctuation is
 felt in fleshy tubercle of the uterus.
                     N 
98
FLESHY  TUBERCLE
  It is only in the early  stages of fleshy tubercle of the uterus
that it can be mistaken for pregnancy; because when the tumour
of pregnancy rises above the brim of the pelvis, the motion of
the  child may be felt.  The tumour of pregnancy after this time
increases quickly; that of the fleshy tubercle slowly. The growth
of the fleshy tubercle  is always slow, having sometimes  in the
course of several years increased very little  in bulk  Besides,  if
the  tumour should have been felt for a longer time than is allot-
ted  to the period of uterogestation in  woman, this becomes an-
other diagnostic.
  In pregnancy the stomach  becomes affected, and the breasts
enlarge and are painful,—changes not occurring in  tubercle of
the uterus.
  No dependence is  to be placed  upon  the state of the men-
struation; because in  pregnancy  coloured discharges occasion-
ally take place, and in fleshy tubercle of the uterus the menstru-
ation is sometimes wholly obstructed.
  Fleshy tubercle of  the uterus is by no means an uncommon
disease,  and it attacks  women  at all periods of life: however,
the author has never met with or heard of an instance of  its oc-
currence before  the twentieth year of age.  Married  and unmar-
ried women are alike liable to the disorder.
  These tumours have no disposition to ulcerate, neither does
suppuration take place in the substance of them.  Inflammation
sometimes attacks the neighbouring parts,  and this may proceed
to the formation of matter; but the tubercle remains the same.
  The os uteri may at the same time be affected  by the  corro-
ding  ulcer;  but this is independent of the tubercle, which may
be  at a considerable  distance from it, and have no  tendency to
inflammation.
   In many cases of this malady the  appendages of the  uterus
are also found  diseased;  and it is by no means uncommon to
find dropsical tumours of the ovaria, or  of the broad ligaments,
existing at the same time.*
   Nothing is known respecting the cause of this disease.
   An increased discharge  of transparent mucus from the  vagina
attends many cases. The other symptoms are for the most part
mechanical,  such as  would  be produced by any other equally
hard and large tumour in the same situation.
   The early symptoms are,  a frequent disposition to make wa-
ter and to empty the  rectum.
   Retroversion  of the uterus and suppression of urine may oc-

  * The author has several preparations shewing the co-existence of fleshy
 tubercle with dropsy of the ovary. He also possesses one preparation in which
 fleshy tubercle, the corroding ulcer, and dropsy of the ovary are conjoined. 
OF  THE UTERUS.
99
cur in this disease, and may last for a long time if the growth of
the tumour should be slow.
   Cramp in one or both of the lower extremities, oedema of one
or both feet, are symptoms attending those cases where the sci-
atic nerve or trunks of the  absorbents are pressed upon.
   When the tumour becomes so large as  to fill the cavity of the
pelvis, there may be great difficulty in passing the faeces, and a
total inability of emptying the bladder.  The weight of the  tu-
mour,  and  its pressure upon the parts at the lower aperture of
the pelvis, will occasion a  sense of bearing down ; and this will
not be so much relieved by the horizontal posture, as in simple
cases of procidentia arising from relaxation:  by degrees  the  tu-
mour accommodates itself to the parts in which it lies.
   If an examination be made, a  hard, large, resisting  tumour
will be felt; but the os uteri will have undergone no change. It
will not gape as in carcinoma,  neither will the patient complain
of pain when the tumour is pressed  upon.  The menstruation will
be very variously affected; being sometimes regular, more fre-
quently in increased quantity, or occurring with shorter intervals,
and occasionally, though seldom, wholly obstructed.
   The constitution is seldom  affected; and  when  it is  so, it is
merely from the effects arising out of pressure made  by the tu-
mour upon others.
   This disease does not appear  to be influenced by  medicines
internally exhibited, or by external applications.  If in the pro-
gress of it any symptoms should arise likely  to interfere with the
safety of the patient,  they should be immediately attended to.
Although no medicine can remove the  tumour, there is reason
to believe that these tumours have been spontaneously absorbed.
   A lady had laboured for some time under a very profuse dis-
charge of blood from the vagina.  Upon  an examination, a  tu-
mour, consisting of several irregular portions, was found des-
cending into the vagina from the cavity of the uterus.  A large
tumour as big as a child's  head could be felt through the pari-
etes of the  abdomen just above the pubis. Upon the surface of
this tumour could be felt two smaller ones,  one of which was of
the size of a man's fist, and the other twice  this  size.  A variety
of means were employed for the relief of this case for about two
years;  upon examining the abdomen at the end of this period,
the  tumours could not be  discovered.  At length the  patient,
worn out by pain and by discharge, died. Her body was exam-
ined in  the presence  of Sir Walter Farquhar, Mr. Chilver, and
Dr. Clarke. The uterus was found as large as that of a woman
at the end  of the fifth  month  of pregnancy. Upon the anterior
part of it, near the fundus, were  found  two small  tumours as
large as peas,  which  were probably the same tumours before 
100
FLESHY  TUBERCLE
felt, of the size above mentioned, as there  was no other vestige
of them.  These tumours  were of a  hard  and resisting nature,
and were lying between the muscular part of the uterus and the
peritonaeum covering it.*
   Cramp of the lower extremities in this disease may be dimin-
ished  by certain changes  of posture, which  a knowledge of its
causes will enable the practitioner to recommend.  If the rectum
should be filled with faeces, it  should be emptied by glysters,
assisted by purgatives which produce watery stools.  This being
done, more room will be made for the enlarged tumour of the
uterus, and less pressure  will be made upon the nerves and ab-
sorbents.
   If the hollow of the sacrum should be filled  by the tumour,
and the rectum be  compressed, advantage may arise from the
introduction of a finger  into the rectum; by means of which, as-
sisted, if necessary,  by  another in the vagina, the tumour may
be very gently pushed  up above the projecting angle of the sa-
crum.  If this should succeed, it will  immediately relieve all the
symptoms; and the tumour, being once in the cavity of the ab-
domen, will probably no  more descend into the pelvis.
   The author has succeeded in effecting this  in a lady who was
incapable of making water in consequence of pressure made by
the tumour upon  the meatus urinarius.  A catheter, which passed
into the bladder with great difficulty before the attempt to push
up the uterus "was made,  afterwards passed into the bladder with
so much ease that the nurse of the lady was enabled to introduce
the instrument. This was done twice a-day till the bladder had
regained its tone, which it had lost by being over-distended; af-
ter which the patient was capable of iffaking  water herself.
   Friction with liniments containing  opium may be usefully em-
ployed in cases where much uneasiness is excited in the parts
surrounding the tumour.
   Above all  things, the state of the bladder is to be attended to,
and care should  be taken to empty it by the catheter, if there
should be retention of urine.   A difficulty in  making  water is a
much earlier symptom attending  the disease than a difficulty of
passing the faeces:  therefore  the practitioner should never fail
to inquire into  the   quantity  of urine  voided even  before any
complaint is  made of constipation.  After the tumour has risen
into the cavity of the abdomen, its pressure upon the upper part
of the os pubis may produce a retention of urine. In such cases
the patient will be capable of voiding small quantities occasion-
ally,  if she lies upon her back with the pelvis raised a little from
the bed.
   * Vide a paper by Dr. Clarke, in the Transactions of a Society for the Im-
provement of Medical and Surgical Knowledge, vol. Hi. 
OF  THE UTERUS.
101
  Why inability of making water  should  come on before the
woman becomes costive from  pressure;  and why, in some ca-
ses where the disease has acquired a large size, she never be-
comes costive at all;  may be  understood from considering the
shape of the upper  aperture of  the  female pelvis.  It is of an
oval form, and the long diameter is from side to side:  conse-
quently any tumour, the shape of which does not exactly cor-
respond with  this form,  will  (if it should be too large to enter
the upper aperture of the  pelvis) rest upon the upper and inner
part of the os  pubis,  and the projecting angle of the sacrum.
The sigmoid  flexure of the colon terminating in the rectum, in-
clining towards the left side of the cavity of the pelvis,  will thus
lie secure from any pressure.
  In drawing off the urine, the catheter should be curved very
much before it is introduced, and should  be carried  up with its
concave side  towards the os  pubis;  otherwise it will not pass in-
to the cavity of the bladder, which is made  by the tumour to lie
more forward than the symphysis pubis. If the catheter so curv-
ed will not pass readily, no violence should be used, lest it should
break, or lest injury should be done to the  urinary passage by
it:  but the forefinger should  be introduced  into the vagina, and
the tumour should be so raised that  room may be made  for the
passage of the instrument between it and the os pubis. For want
of due attention to all these circumstances,  many practitioners
have failed in drawing off the  urine, which  will rarely  happen
otherwise.
  A flexible catheter may be tried,  if the practitioner  cannot
succeed with the common instrument; and  if by no means  the
urine can be drawn off, the bladder  must be punctured.  The
author never  saw or heard of such a case; but it is nevertheless
possible. It may be necessary, occasionally, to have  recourse to
those medicines  which diminish irritability;  but the proper mo-
ment for employing  them, as  well  as the choice of that best
adapted to the case, must  be left to  the discretion of the  practi-
tioner. Hyoscyamus may be considered  in such cases  a very
valuable medicine; as although its sedative powers are not very
great, they will  generally be sufficient for the purpose, and the
medicine produces none of the astringent effects of the poppy
tribe. Here it becomes necessary to caution the practitioner not
to  mistake the  symptoms of peritonaeal inflammation  (which
sometimes, though rarely, arise,) for symptoms of irritation.  If
peritonaeal  inflammation should be produced in the progress of
the disease, it will be marked  by the constant acute pain, in-
creased by the pressure of the hand or by breathing; by  a crea-
my whiteness of the tongue, which is nevertheless moist; by in-
tense thirst; by  a  small, frequent, and sometimes hard pulse; 
102
FLESHY TUBERCLE OF THE UTERUS.
and sometimes, but not always, by vomiting. The great remedy
for this case is  bleeding, which ought to be  immediately per-
formed.  The blood should be taken from a large orifice in large
quantity; and the operation should be repeated again and again
if necessary. The bowels being once emptied, the patient should
take some medicine which will be likely to diffuse the circula-
tion, to determine to the skin, and to allay irritation;  such as
small  doses of antimonials with opium; or the  pulvis ipecacuan-
ha? compos, may be taken, in the  dose of four or five grains, in
the form  of a pill  (lest it should increase the sickness,) once in
four or five hours,  swallowing afterwards a saline  draught made
with lemon juice and  vegetable alkali.  If the bowels should in
the course of the disease require any farther opening medicine,
the mildest should  be  chosen, or perhaps glysters only employ-
ed. The drink should be barley water.  Fomentations, the hip
bath,  local bleeding, may also be called into use, if the symp-
toms should  make them necessary. 
103
                 CHAPTER XVIII.

  Verruca, or Warty Tumours, arising from the Vestibulum.

  Warty tumours not uncommonly form in the vestibulum, of
various sizes.  When they are large or numerous, they will  be
attended by a mucous discharge from  the vagina, proportionate
to the number, size, and situation of them.
  These tumours are for the most part insensible, and pressure
made upon them causes little or no uneasiness. They seldom pos-
sess any regularity of appearance; but  each  warty tumour looks
as if a number of small parts were connected so as to make  up
one large tumour.  Their colour generally resembles that of the
part upon which they grow;  so that when situated on the labia,
their colour will be  lighter than when  they arise higher up, as
upon  the vestibulum, or amongst the carunculae myrtiformes.  In
such situations they are  generally of a flesh-colour, or inclining
to red; but when any part of  them is  exposed, they appear of
the colour of the external skin.
  The labia, the nymphae, the vestibulum,  and the carunculae
myrtiformes, are liable to these excrescences; from which, how-
ever,  they may be readily distinguished.  The number of these
tumours varies very much: sometimes they are solitary, whilst
in other instances they are. so numerous as to occupy the whole
of the vestibulum, and their growth is often very rapid. It is not
unusual for tumours of this kind to arise in parts which have re-
cently been the seat of chancres, particularly when mercury has
not been employed in sufficient quantity to destroy the venereal
poison; and chancres themselves, instead of healing and  leaving
a smooth surface, sometimes terminate in a thickened state of
the cuticle, from which  warts  arise. It is not  necessary to the
formation of these tumours, that the part should have been the
seat of any syphylitic  complaint, for  they  may arise in parts
which have never been so affected.
  The attention of the patient is for the most part called to the
disease  by a  mucous discharge, or by the application of the
hand  to the part to  allay the irritation which the excrescence
will produce upon the  opposite side of the vestibulum; and in
doing.this the tumours are discovered. The irritation in this case
is often extreme.
  The mode of treating the disease must be varied, according
to the circumstances of their cause, situation, number, and mode
of attachment.  If there should not be more than two or three
warty tumours, and these seated upon the labia, and  if they 
104        VERRUCA, OR \VARTY TUMOURS.
should adhere by a narrow neck, a ligature of waxed silk may
be tied round each of them, sufficiently tight to interrupt the em-
ulation through them: the ends of the ligature may then be cut
off close to the neck of the tumour, and it will drop off in a few
days.  If they should be more numerous, they may be cut off
with a pair of scissors, and the bleeding may be restrained  by
touching the surface with argenti nitras. Perhaps this latter mode
of treatment is the best in all cases where the carunculae myrti-
formes are the seat of the disease; as the ligature, if the tumours
are large, may excite spreading inflammation in the vagina.
   If the warty tumours  are very numerous,  and lie very close
to each other, the most ready  and the least painful way of ex-
tirpating them is to include the skin on which they grow in the
grasp of a pair of scissors, and by one stroke of the instrument
to take them off.  The pain attending this operation  is momen-
tary, and must be much less  than where,  each excrescence is
removed singly.  Any common dressing may be applied to the
sore,  which generally heals  quickly:  the tumours, however,
sometimes shoot up again.
   Inflammation taking place in the neighbouring parts will some-
times remove these warts without any application being made to
them.  Upon this  principle, stimulating applications of various
kinds are useful; and in that form of the complaint where there
is a general warty disposition of the labia, the application of such
stimulants is to be preferred to every other mode of treatment.
Amongst such applications may be reckoned, a solution of ar-
genti nitras, hydrargyri murias, cupri  sulphas, or ammoniae car-
bonas. Either of these may be applied by means of a piece of
lint, which may be occasionally wetted and laid upon the parts.
A powder composed of  equal  parts of  pulvis sabinae and cupri
sulphas, may also be sprinkled upon the parts with considerable
advantage.
   In the  use of all these  applications care should be taken to
regulate their strength properly; and it is better that the absor-
bents should be very slightly stimulated,  than that any  injury
should be done to the parts by too violent applications.
   If the tumours should be connected with syphylis, mercury
must be employed; and it is particularly recommended, that in
the management of chancres the use  of mercury should not  be
discontinued till the whole of the thickening left by  them is re-
moved.
   The mucous  discharge, and the itching connected with this
disease, will cease upon  the  removal of its cause:  if it should
not, washing the  parts very profusely and frequently with  the
coldest water, will be generally sufficient to stop it. 
105
                   CHAPTER XIX.

   Vascular Tumour of the Orifice of the Meatus Urinarius.

   This disease, although an excrescence from  the  parts, de-
 serves  particular notice in this place; both on account of the
 alarm which it creates, and the great pain attending it, and also
 because it differs from  the preceding case.
   Like the warty  tumour already described, this disease is at-
 tended by a mucous discharge.
   There is in most women a degree of projection round the ori-
 fice of the meatus urinarius; and  from this part sometimes the
 tumour arises, to which the above name of the vascular tumour
 of the meatus urinarius has been  applied. The texture of this
 tumour is seldom firm: it is of a florid scarlet colour, resembling
 arterial  blood; and if violence is offered to it, blood of the same
 colour is effused: its surface is somewhat granulated.  It is ex-
 quisitely tender to  the touch;  and if an accurate examination is
 made, it appears to shoot from the inside of the urethra. It sel-
 dom acquires a large size. Upon  separating the  labia and the
 nymphae, the excrescence is immediately exposed. Its attach-
 ment is so slight, and  it is so moveable, that it appears  almost
 like a detached body lying upon the parts.
  The disease is common to the single and married woman. In
 all the  instances which the author has met with, the  patients
 have been under the middle age, and they have been  chiefly in
 young women.
  The  disease is not of common  occurrence: the author has,
 however, very lately seen  three cases of it. One was in a young
 woman who had been married three months, and was  pregnant:
 in this case the pain was so intense, from the sensibility of the
 tumour, that the patient could not bear any intercourse with her
 husband.  Another case occurred in a young single woman of a
 full habit, in whom all the symptoms of puberty were  present at
 an early age. The  third case was in a young woman  who  had
 recently been delivered, and who  was living very profligately.
 An exquisite degree of tenderness of the part is a constant symp-
 tom of the disease. This  tenderness is confined to the  tumour
 itself, and does not extend to the neighbouring parts.
  Instances sometimes occur of great pain and tenderness to the
touch in the region of the  meatus  urinarius, accompanied by a
 thickening of the part;  so that if the finger is passed into the
 vagina, considerable uneasiness is produced: but upon exposing
the parts, no disease is  visible.  This also is attended  by a mu-
                    o 
106
TUMOUR  OF THE  ORIFICE,  &C.
cous discharge. How far such a symptom may render it proba-
ble that this disease is going on in the cavity of the  urethra, it
may be difficult to determine.  In a patient under the care of Sir
James Earle, in St. Bartholomew's Hospital, this symptom was
present; and upon exposing the parts, a tumour of a scarlet co-
lour, nearly filling up the orifice of the urethra, was brought into
view.  In such cases, relief is obtained by the introduction of a
large bougie, and suffering it to remain in the urethra for some
time.
  Patients labouring under the vascular  tumour of the meatus
urinarius experience sometimes great pain in making water; most
probably from  the pressure of the fluid upon the tumour, and the
impediment which it may offer to the passage of it. The author
has never  known or heard of a case in which it was  necessary
to draw off the urine with a catheter.
  The vascular tumour of the meatus urinarius requires removal
by a ligature, or by the  scissors and caustic.  The ligature is to
be preferred, as  the tumour is less likely to return  than  when
other means are employed.
  The ligature employed should always  be so thick as to press
upon a large surface, and it should never be drawn so'tight as to
cut through the neck at  once. The intention  of the ligature is to
destroy the life of  the  tumour, and to cause  the  absorbents to
throw it off  as an extraneous  body. This   may be effected in
twenty-four hours; and the operation being thus concluded, the
tumour may not return. Notwithstanding all the care of the prac-
titioner, the parts will sometimes give rise to  the reproduction of
the disease.
  If, however, the  neck of the tumour should be cut through in
the application of the ligature, or if the scissors should be em-
ployed, the tumour will be especially likely to  regenerate. When-
ever the tumour is removed by the scissors, the part from which
it arose should be  touched with caustic, and the potassa cum
calce, applied once  lightly, will be more efficacious than repeat-
ed applications of argenti nitras.  A piece of lint should be laid
upon the part afterwards,  and the patient should remain for a
few hours in a state of rest. If there should appear any disposi-
tion in the disease to return, the timely use of the potassa cura
calce will prevent its increase. 
107
                   CHAPTER XX.

A thickening of the Cellular Membrane surrounding the Ure-
   thra throughout its  whole Extent, accompanied by a varicose
   State of the  Vessels of the Part.

   The existence  of  this disease is ascertained  sometimes by
pain and difficulty  in the sexual intercourse;  but  in many cases
the constant uneasiness experienced by the woman leads to the
knowledge of it.  On examination, a bulbous tumour will be
found situated  behind  the pubis; and if much pressure is made
upon it, pain will be produced, but not of a severe kind.
   A mucous  discharge always attends  this  disease,  secreted
probably in  part by the membrane of the urethra,  and in part
by that which  lines the vagina.
   If the parts are exposed, and the patient presses down, the
diseased part will be brought into view, putting on the appear-
ance of a tumour,  but which  is nothing else  than a thickening
of the urinary passage.  On the surface of this thickened part
blood-vessels  ramify,  of a size  large enough to admit of  being  •
opened by the point of a lancet.
   When the patient is in an erect posture, the size of these ves-
sels  increases, and she complains of a sense of fulness in the
parts: when she lies down,  the vessels carry less  blood, and the
sensation of fulness is  diminished. If pressure is made upon the
part, the swelling and redness subside for a  time, but both re-
turn directly upon  the pressure being discontinued.  Sometimes
a pouch forms in the  posterior  part of the urethra, in which  a
few drops of urine lodge, and from  which situation it may be
pressed out  by the finger applied to the part. If a catheter is
introduced into the urethra, it may be  carried backwards to the
part where this lodgement of  urine is  found.  Upon this  cause
depends perhaps one of the most troublesome symptoms of the
disease,—a frequent desire to make water, both in the night and
during the day, so as to interfere with the patient's rest.  When
the disease is removed, this symptom subsides. In a case of this
kind, which the author attended with the late Dr. Reynolds, the
general health  of the patient suffered exceedingly;- and this  was
thought to be greatly owing to the disturbed state of rest.  In an-
other case of the same kind, which Dr. Bain and the author at-
tended, this circumstance was  very distressing;  but the chief
symptom was  a great  degree of soreness of the membrane cov-
ering the tumour, which symptom does not generally occur in
the disease.  This soreness was explained by an attentive exami- 
108
MORBID STATE  OF THE  URETHRA.
  nation: The  mucous  membrane covering the tumour  had be-
  come very thin and shining; and upon the least oblique pressure
  being applied, it wrinkled and peeled off, leaving the parts be-
  low exposed.
    The disease  occurs principally in married women who have
  bad children; and the cases which the author has seen of this
  disease, as well as of that treated of in the  preceding  chapter,
  have been chiefly in women with red or light auburn hair  and
  fair complexions.
    The disease seems to consist of an enlargement of the blood-
  vessels of the part; because when the vessels are emptied of
  their contents, the size of the tumour diminishes.  Judging from
  the colour of the tumour, there is reason to believe that the en-
  larged vessels are principally veins.
    Warm applications (although they may afford temporary re-
  lief) will  be found eventually to increase the complaint, as they
  produce a greater relaxation of the blood-vessels of the part.
    The most speedy and effectual mode of relieving  the patient
  is  by emptying the vessels, either  by puncturing them with a
  lancet,  or by  the application of leeches: either may be  employ-
  ed, according to circumstances.  The size of the vessels and of
• the whole tumour will be diminished  by these  means, and its
  colour will be changed from a deep red to the proper colour of
  the part.
    The fulness of the vessels being removed, lotions composed
  of solutions of lead may  be applied cold to the parts, and these
  should  be changed as often as they become  warm.  After a day
  or two, weak solutions of muriate of ammonia or of sulphate of
  zinc may be used: at first, the openings made by the leeches or
  by the  lancet would be inflamed  by them.  Pressure is service-
  able, and may be applied either  by introducing a piece of  wax
  candle, or a small roll of linen which may be previously dipped
  in the lotion.
    It may be necessary to repeat the  bleeding from time to time,
  if  the symptoms  should continue, or if having subsided they
  should  return. The bowels of  the patient should  be kept in a
  relaxed state  by some mild saline purgative, and the food of the
  patient should consist principally of vegetables.  The horizontal
  posture should always be enjoined. 
109
                   CHAPTER XXI.

On the Transparent Mucous Discharge from  the Vagina, not
   accompanied by any  Alteration of Structure of the Sexual
   Organs.

   This part of the subject includes two very distinct  and dis-
similar cases;  whether the cause be considered, the symptoms,
or the treatment.  The first is that which originates from, and is
accompanied  by, increased action of the vessels of the  parts.
The second,  that which arises from  debility: in which latter
case, the former may  terminate.
   The case of transparent mucous discharge  from  the vagina
attended  by weakness, more frequently occurs  than that which
is  accompanied  with  increased action;  because many cases  of
the latter kind terminate in the former.  A separate  considera-
tion will  be given to each case.
 on transparent mucous discharge from the vagina, aris-
         ing FROM INCREASED ACTION OF THE VESSELS.

   Women of  naturally  plethoric  habits, who  possess great
 strength  of constitution,  are  more liable to profuse  secretions
 from  these  parts than women of ordinary strength.  This fact
 may be ascertained in investigating the complaints of such wo-
 men,  although the quantity of the discharge is rarely so conside-
 rable  as to induce the patient  to make it the subject of particular
 complaint; there is, however,  a state of the system in which such
 discharges are so very profuse as to demand attention. Women
who in the middle of life indulge  much in the pleasures of the
table, (particularly if they drink too  freely of wine or  spirits)
whose habits of life are sedentary, and who take very little ex-
ercise in the open air, are liable to become suddenly corpulent.
They form a larger quantity of blood, as may be known by at-
 tending to the blood-vessels.  The  pulse  becomes full, and the
superficial vessels, which  were hardly visible before, become  in
different parts of the body so large as to be easily traced  by the
naked eye. This may be remarked upon the cheeks.  Such wo-
men are  generally weak,  although  they may have the appear-
ance of strength; they can take very little exercise without fa-
tigue, and are overcome by a very moderate degree of exertion;
the habits which at one time were sedentary by choice, become
so now from necessity; for the woman neither possesses  energy 
110              MUCOUS  DISCHARGE
enough to exert herself, nor, if she has the inclination, can she
indulge it, from the inconveniences attending such exertion.
  In many of these cases a slow enlargement of the liver takes
place, which may be felt by applying the hand to the side.  Gen-
erally a very small quantity of bile is mixed with the stools; and
sometimes these become  not only of a clay colour, but perfectly
white.  The fcetor of these  stools is usually greater than that of
stools in general, and it resembles more the smell of putrefaction
than that of faeces. As the quantity of bile which passes into the
bowels becomes smaller,  the woman  becomes  more and  more
constipated, and the  obesity increases.  The vaginal  discharge
increases in  quantity, the fluid of menstruation also is secreted
more plentifully, and the  intervals between the  periods are gen-
erally shorter than natural: and  these symptoms for  the most
part lead the patient to apply for professional advice.  Upon in-
quiry it will be found, that fits of giddiness  and of sleepiness
have attacked the woman; that there has been pain in the head,
perhaps indistinct vision,  such as a waving appearance when the
eyes are open, or a sensation of sparks when  they are closed.
These symptoms are sometimes relieved by spontaneous bleed-
ing from the nose. In  this  way the case  proceeds, in some in-
stances  disregarded by the  woman, until the urgency of  the
symptoms demands attention.
  Many years may elapse  before any danger is apprehended;
and then all at once the woman may be attacked by a fit of ap-
oplexy, or some great internal  hemorrhage, which may quickly
destroy her; or she may  gradually become weaker and dropsi-
cal, and at length die.  The symptoms will be diminished after
each period  of menstruation.  The mucous discharge probably
is, in some degree, useful: hence, if a check be given to it with-
out employing any means of unloading the blood-vessels, the vi-
olence of the symptoms generally increases.
  The author has examined the bodies of women whom he has
sten during  life with such  symptoms as have  been  described.
He has found  the uterus somewhat, but  very little,  enlarged,
and the liver sometimes increased to more than twice its natural
size. It has been uniformly harder than a healthy liver, but there
have not been any particular parts of the viscus more diseased
than the rest: upon cutting into its substance, it has commonly
appeared remarkably yellow.
  The objects in the treatment  of this case are, to unload  the
vessels, by removing at once a large quantity of blood; to pre-
vent its too quick formation in future; to restore, if possible, the
Itver to a healthy state: afterwards, to moderate the vaginal dis-
charge, or to diminish the inconveniences attending its continu- 
FROM  INCREASED  ACTION.           Ill
ance: and, lastly, to lay down proper rules for the patient's con-
duct, in order to prevent a return of the symptoms.
   If any  local symptoms, arising from fulness, should be pre-
sent, the blood should  be taken from the neighbourhood of the
affected part, by scarifications, and  cupping-glasses applied  be-
tween the shoulders, to  the lower part of the abdomen,  to the
loins, or to the region of  the liver, when there is  reason to sup-
pose it affected.  If no such  symptoms should  be present, the
lancet may be used. Small quantities of saline purgatives, given
three or four times a-day, eminently relieve, by increasing the
secretion from the mucous glands of the intestines, and also by
stimulating the extremities of the biliary ducts in  the duodenum,
so that a larger  quantity  of bile  may be poured out by them.
Whilst this plan is pursued, the diet of the patient should be
regulated,  She  should live chiefly  upon fruits,  vegetables,  and
light puddings.  By slow degrees, the quantity of exercise may
be  increased, till at length it can be taken so as to counterba-
lance any drsposhion which there may be to form  too large  a
quantity of blood.
  The patient should be prohibited from taking fermented li-
quors and spirits.  If the functions of the stomach should have
been much impaired,  by being long accustomed to stimulants,
it may not be  proper  to withdraw  them altogether: but even
here, spices,  the  aromatic seeds, and volatile alkali, will super-
sede the use  of ardent spirits.
  Until the plethoric state of the system shall have been remov-
ed, tepid water alone may be thrown into the vagina; but when
the symptoms arising from this state have subsided, a weak so-
lution of sulphate of zinc may be injected into the vagina seve-
ral times in a day.
  Local increased action may become  the cause of the disease.
Frequent  sexual intercourse may give rise to this case, which is
therefore very frequently met with in women of  dissolute lives.
This case may occur either in weak or in plethoric habits.,
  Women who have frequently miscarried, or who  have  borne
many children, are more liable to the complaint than women who
have not been pregnant.  ,.
  Where  inflammation of a common or specific kind has attack-
ed the mucous membrane of the vagina, and purulent secretion
has  long existed, when this inflammation subsides, the  matter
secreted becomes gradually less yellow and more tenacious, and
at length is found to be merely mucus. This case is sometimes
very difficult of cure.
   In the treatment of the case of discharge  of transparent mu-
cus from the vagina, produced by increased action of the  vessels
of the parts alone, local  remedies will  be principally required. 
Ii2
MUCOUS  DISCHARGE, &C.
These should consist of the application of leeches or of cupping-
glasses, (the parts being also scarified) to the lower part of the
abdomen, or to the back; and it may be necessary to repeat this
operation.
  The bowels should be kept in a relaxed state, by the exhibi-
tion of manna, castor oil, or some other mild purgative.
  The food of the patient should be of the most simple kind, all
salted and high-seasoned meats and spices being very improper.
Whatever tends to irritate the  sexuai  organs will keep  up the
disease:  all sexual communication should therefore  be omitted.
  The external parts may  be frequently washed with cold wa-
ter, and  solutions of superacetate of lead may be injected  by
means of a female syringe into  the vagina*
  When the secretion  of mucus continues after  the local in-
creased action  has been allayed, astringent injections will be ad-
vantageously employed.

  *  Dr. Latham informed the author that he had seen several cases of dis-
charge from the vagina, where the use of this application had been productive
of itaore benefit than any other; and the author believes that these have been
principally cases arising from increased action of the vessels of the sexual or-
gans, as in many  other cases ot local  increased action this remedy  is known
to be eminently serviceable. 
113
                  CHAPTER XXII.

   On the Case of Transparent Mucous Discharge depending
                      upon Debility.

   That women whose vagina has lost its tone become liable to
this disease, has been before remarked in that part of this work
where some general observations upon the nature of vaginal dis-
charge were made.  Whatever tends  to produce  debility of the
system may lay the foundation of this complaint; such as long
diseases, profuse hemorrhages, or anxiety of mind.
   Women who live in a moist atmosphere, who keep bad hours,
who spend much of their  time in bed, or who inhabit hot room?,
(being generally weak women,  and  having  a relaxed vagina)
will be apt to be affected  by the  complaint.
   It sometimes arises in  women who suckle their children for
too long a time, and  it will  often subside spontaneously upon
the child being weaned.
   The quantity  of discharge, and  also its consistence, is very
various in different cases.  It sometimes comes away in a liquid
form: at other times it is ropy.
   A pain in the back attends many cases  of  the  disease. This
symptom is, however, frequently found where great debility of
the system is present.
   The continued drain from the system  increases the original
weakness; and the quantity of blood remaining  is by degrees
so much reduced, that the surface of the  body becomes every
day paler, till  at length the cutaneous  vessels are  completely
emptied of their contents, and at this time the skin assumes an
appearance resembling that of a dead body.   The colour of the
sebaceous glands of the skin is evident through the cuticle; so
that to the paleness of the skin is superadded an appearance of
yellowness, which is not the  effect of  absorption of bile, for the
urine will be found clear  and colourless, and the tunica sclero-
tica of the eye will retain its pearl-coloured  appearance.  The
exact balance between the secreting arteries and the absorbents
being destroyed, the  cellular membrane becomes filled with flu-
id, and the integuments acquire a doughy  look  and feel.  This
fluid effused pervades the cells of the cellular membrane through-
out the body; the legs and feet swell towards night, and in the
morning this swelling subsides, and  the face becomes puffed;  a
shortness of breathing succeeds, which is increased by the hori-
zontal posture, and  is rendered  most distressing when the pa-
tient is going Up an ascent, or  endeavours to read aloud.  Vio-
                     p
# 
114
MUCOUS DISCHARGE
lent palpitations of the heart occasionally give the woman great
uneasiness;  and this  symptom sometimes increases to so con-
siderable a degree, that the action of the heart may be heard by
a bystander.  During  the continuance of these palpitations, the
patient  becomes  very faint, and  often considers herself to be
dying.*
  The circulation  in  the extremities  is very languid, and the
hands and feet are almost always cold; the pulse is feeble, some-
times very quick. The digestive organs not only partake of the
general  debility, but have  more than their proportion of weak-
ness.  The  appetite for food is lost;  the power of digestion is
diminished;  and from the spontaneous changes which the food
undergoes in its passage through the stomach and intestines, the
patient becomes much annoyed by flatulence.
  Bile is  secreted  very  irregularly, and sometimes this secre-
tion  is suspended.  Costiveness is a general attendant on this
state of disease.—In the  farther progress of the case, hectic fe-
ver comes on, the difficulty of breathing becomes more extreme,
and  the patient  dies with the symptoms of  water in the chest.
Although these symptoms are of the most formidable kind, and
threaten the life of the patient, they frequently yield to the em-
ployment  of proper means, which  must be directed with skill,
pursued with energy, and continued with patience.
  The first care of the practitioner should be to remove, if pos-
sible, the causes of the disease. If the  patient has been living in
a moist unhealthy situation, she should  be removed to one which
is more dry and salubrious: without  attention to this very im-
portant circumstance, all the resources of art will be useless.
  It has been stated, upon good  authority,  that the disease is
frequent in Holland, and that it is epidemic in wet autumns.—
The author has repeatedly seen  the complaint attended  by the
worst symptoms in women who live in damp situations, and in
the crowded  parts of London, in whom they have  quickly dis-
appeared upon a removal to a more healthy spot.  The woman
should neither be permitted to breathe a confined  air.  When
the weather permits,  she should  go out; and the apartments in
which she lives and sleeps should  be  large and well ventilated.
Her habits of life should be regular. She should rise betimes in
the morning, and retire  to rest early in  the  evening.  If she is
too weak to sit up during the  whole of the day, a sofa is to be
preferred to a bed.

  * The symptoms attending this case of vaginal discharge are admirably de-
scribed by Hippocrates.
  " Otvvn i^(t t»v vtiaipov yaa-rsgx xa« roc( t%vecf xai thj xwava;. Kai oi$np<tT* tuv t£
cxtXiav xai tuv ^fifwv, xai toc xoiXa algtraf xai ol op6a\/uoi vxgoi, xai i? x?°"l MTigutHSt
nai Aswxu yntrsu' K3i omtxv XogivriTou «?6/ttuv(fi"-~IIefi yvnuMW jwjoj. 
DEPENDING UPON  DEBILITY.
115
   Persons who are weak are much disposed to sleep.  This pre-
vents that exhaustion of the powers of the frame which would
otherwise take place.  Exercise  proportioned to  the strength
and  to the means of the patient should be recommended: when
the weather permits, it should  be taken in the open air.  Exer-
cise  in an easy carriage is preferable to walking, and  that taken
on horseback to both.  The chamber-horse or elastic plank may
be employed when  exercise out of doors cannot be used.
   The food should be of the lightest kind, such as animal broths
and jellies, vegetable jellies, bread properly fermented and well
baked. It will be better that the patient should not eat solid ani-
mal  food until the powers of the stomach  are in some  degree
restored, lest fever should  be excited  by it.  When the powers
of the digestive organs  become  more vigorous, recourse may be
had  to animal food, which should be taken in small  quantities,
once only in the twenty-four  hours, and in the middle of the
day.  Tender meats and such  as will not be likely to disagree
with the  stomach should be selected.  Wine, either pure or mix-
ed with water, as may  best suit the palate or the stomach, may
be allowed  in moderate quantities. All wines which have not
undergone a complete  fermentation will  give  occasion  to flatu-
lency,  and are therefore improper.
   The medical  treatment is to consist of the employment of
means to invigorate the stomach and the constitution, and to re-
strain the vaginal discharge, which, as  long as it continues, must
increase  the debility.
   If steel and the other metallic tonics are exhibited  in the first
instance, they will either be rejected,  or they will  increase the
frequency of the pulse and the general  heat of the body; and
thus by wearing out its  powers, exhaust that strength which they
were intended to augment.
   Instead of this plan the patient should take, two or three times
in the day, a draught of infusion of calumba or some other light
bitter, with the addition of a few grains of carbonate of ammonia.
   At the end of two or three weeks, it is to be expected that
the stomach will  have received an increase  of strength; and
then, instead of the volatile alkali, fifteen or twenty drops of
tincture of muriate of iron, or of ammoniated  iron,  may be add-
ed to the draught.
   Sulphuric acid is a useful tonic in  these cases,  and  may be
given in  an infusion or decoction of bark.
   A mixture  of myrrh, steel,  and alkali, with some aromatic
water in  some cases where  the  stomach will bear it, becomes a
valuable  remedy.
   Under a continuance of these or similar  means, the patient's
health  will be gradually re-established. 
116
MUCOUS DISCHARGE, &C.
  Care is to be  taken to regulate the functions of the  bowels,
until they have acquired sufficient strength to carry down their
contents without assistance: for this  purpose the pilula ex aloe
cum myrrha, or the pil. gambog. compos, of the last Pharmaco-
poeia are well enough adapted.
  It is advantageous in some cases, where the  biliary secretion
is sluggish, to exhibit occasionally a few grains of pil. hydrarg.
at bed-time; and in the morning following a rhubarb draught.—
The strengthening  remedies will produce a better effect when
this is attended to than  when it  is omitted.
  A solution of sulphate of zinc or of alum may be thrown into
the vagina by a syringe, three or four times a-day; and if these
should not be sufficiently powerful, such injections must be era-
ployed as possess a greater degree of astringency.
  Cold sea-bathing will be found very useful,  when  no symp-
toms  are  presem forbidding it: the system, however,  should
have first rallied a little.  Those patients who  cannot bear  the
shock of a cold  bath, will occasionally derive  great  advantage
from a shower-bath.—The temperature of the water  may be
raised  to sixty or  seventy degrees,  if the cold water does not
agree with  the patient. 
r   "'    f
Drawn, from Jiff, byJLfr J for. oh&lden
ful. f,y SX.Cirr,, A-lLea  fluL,
A.__* 
 
EXPLANATION OF THE PLATES.
                      PLATE I.

  In this plate is shewn a view of Procidentia Uteri taken from
the living subject. The tumour had become external, and hung
pendulous between the woman's thighs. The bladder was situa-
ted in the upper and anterior part of  it, and in consequence of
having recently expelled its contents, the rugae of the vagina be-
came very numerous.
  A. The nymphse.
  B. The orifice of the meatus urinarius.
  C. The ruga? in the inner membrane of the vagina (now the
      outer coat of the tumour,) very numerous near the upper
      part of the tumour.
  D. The body of the tumour: the ruga? becoming less nume-
      rous.
  E. The os uteri surrounded by an ulceration.
  Upon the sides of this plate are to be seen engravings of the
oval  and circular pessary, which are adapted to the greater num-
ber of the cases of procidentia uteri. 
118
EXPLANATION  OF THE  PLATES.
                       PLATE  II.

   A View of another case  of Procidentia Uteri also taken du-
ring life. The shape of the tumour in this case is more oval than
in the case Plate I.  This will  be  explained upon considering,
that in the centre  of this tumour are contained the  uterus, the
ovaria, the fallopian tubes, the rectum, the bladder, a large quan-
tity of the small intestines, and the  omentum; the weight of all
which upon  the  lower part  of  the tumour, might be naturally
expected to elongate it.  This elongation of the tumour, it will
be seen, has nearly obliterated all the ruga? of the vagina.
  A. The os uteri  surrounded by ulcerations.
  B. B. Two large ulcerated patches.
  C. The labia.
  D. The orifice of the meatus urinarius.
  E. The nymphae.

  N. B. The size of this tumour is  reduced in the drawing. 
 
 
 
 
EXPLANATION OF  THE PLATES.
119
                      PLATE III.

  The patient  from whom the former drawing was made, died
in Kensington  workhouse.  This plate is an outline of the parts
in the dead body.
  A. The os uteri.
  B. B. Ulcerations.
  C. Rugae of the vagina.
  D. Orifice of the meatus urinarius, into which a bougie is in-
       serted.
  E. The nymphae.
  F. The other end of the bougie in the cavity of the bladder,
       which viscus occupied the anterior part of the tumour. 
120
EXPLANATION OF THE PLATES.
                      PLATE IV.

  This  plate contains a very accurate representation of Proci-
dentia Vesicae. It is here to be particularly remarked, that there
is no opening at the lower part of the tumour.
  A. The nymphae.
  B. The orifice of the meatus urinarius.
  C. The tumour formed by the procidentia vesicae, on the sur-
      face of which the rugae of the vagina may be seen.
  Fig. 1. The globular pessary. Fig. 2. The oviform pessary.
      These are the  forms of pessary best adapted to the cure
      of this disease. 
 
^w
ran
D
Fuh. h, ff.i\:„: 
EXPLANATION OF THE PLATES.
121
                       PLATE V.

  This plate sliews the Carcinomatous Thickening of the Rec-
tum. A longitudinal section has  been made of the gut, which
displays the disease, and also the narrowed part of the intestine,
which the firm and unyielding nature of the disease renders per-
manent.
  A. The cavity of the intestine in a healthy part.
  B. A healthy part of the intestine.
  C. The  cut surface of  the carcinomatous tumour, in which
       may be perceived some  spots of a darker  colour: these
       are  not unusual in such tumours.
  D.  Another cut surface, in  which those white lines described
       by Dr. Baillie are very evident.
« 
EXPLANATION  OF THE  PLATES.
                      PLATE  VI.

  A very distinct view of Carcinoma Uteri, and of the changes
which take  place in that viscus in  consequence of this disease.
  A. The carcinomatous tumour seated at the posterior part of
       the cervix of the uterus.
  B. The os uteri much enlarged, which forms one of the prin-
       cipal characters of this disease, especially when the sides
       of the opening are hard and resisting. A small portion of
       the vagina is left surrounding the opening.
  C. The cavity  of the uterus near the cervix.
  D. The cavity  of the uterus near the.fundus.
  E. The fundus of the uterus.
  The sides of the  uterus are kept asunder by two pieces of
quill placed transversely across the preparation. 
jjra.WnbyMrAU.r  Sh*l<l*»
fUb. to, HXCarajXL^x FkOad. A-, 
 
 
rwm
Fl.-t
durn _Aj _A SJlstJAnr^ 
EXPLANATION OF THE  PLATES.
123
                     PLATE VII.

  A posterior view of the same preparation.
  A. shews a section of the  carcinomatous tumour, a part of
       which only could be exposed in Plate VI.
  B. The fundus of the uterus.
  As the size of this drawing does not exceed the actual size of
the  preparation, it is obvious that all the parts of the uterus have
undergone some degree of enlargement. 
124)        EXPLANATION  OF THE  PLATES.
                   PLATE VIII.

This engraving shews a Polypus of the Uterus.
A. The polypus, in which may be perceived a longitudinal
     depression made probably by the meatus urinarius. It is
     attached to the  fundus of the uterus by a small neck.
     The tumour  has descended  out of the uterus into  the
     vagina, which has been slit open to bring it into view.
B. The vagina;  a few rugae remaining  below the tumour.
     Higher  up they are obliterated by the  distention of  the
     parts.
C. The fundus of the uterus, by which the preparation is sus-
     pended.
D. One of the round ligaments.
E. A part of the left ovarium. 
PI. 8.
<&&*&■/&* tiW*
3715 
«££*.
F1.9.
 
EXPLANATION OF THE PLATES.
125
                     PLATE IX.

            Fleshy Tubercle of the Uterus.
A. The edge of the tubercle.
B. An incision  made  from  the fundus of the uterus to the
     cervix, which shews that the sides of the uterus are not
     thickened.
C. The surface of the tubercle, having several  irregularities
     upon it.
D. The os uteri, having undergone no change: indeed its ap-
     pearance,  together with that part of the uterus which
     projects a little into the vagina, may  be looked  upon as
     a specimen of a perfectly healthy os  uteri.
E. The vagina slit  open: the rugae,  and the very irregular
     manner in which they are disposed,  are also very cor-
     rectly shewn. 
126        EXPLANATION  OF THE  PLATES.
                       PLATE X.

  At the lower part of the plate there is a rod for passing a liga-
ture round a polypus of the uterus. The handle is made follow,
so as to admit a part of the rod, which  is secured by a spring in
the handle.
  At the upper part of the plate is a wire, by means of which
the ligature can be drawn through the canula.
  Immediately below this is the canula, furnished with a shield,
to prevent the instrument being pushed into the vagina higher
than intended by the operation.
  In the centre of the  plate is a  drawing of a hip-bath, the di-
mensions being given in inches.  On the left side of the plate is
described the best form of a female syringe.
END OP PART I. 
PI. JO
 
 
i^mx ssaKosru)* 
 
OBSERVATIONS,

           &c.
            INTRODUCTORY REMARKS.

   Impressed with a belief that the diseases affecting the female
organs of generation were not generally known to practitioners,
and  that they were consequently imperfectly understood, and
flattered  by the hope that some advantage might be derived from
an attempt to classify them, and to describe them  more fully,
the author was led some years since to offer to the profession
the former part of this work, comprehending such a division of
the subject as appeared to  be likely to place it in a clearer point
of view than any  which had been before attempted. The pro-
fession having been pleased to receive the undertaking favoura-
bly,  and  to overlook  its errors in consideration of the good in-
tention with which it was composed, the author  now produces
this Second Part of his work.
  In  the first volume many diseases were treated of, which,
from  their  frequent occurrence, were  familiar to practitioners;
whilst others were described, which more rarely take place, and
to remedy which no mode  of treatment had been suggested.
  The vascular tumour, or  excrescence of the  meatus urinarius,
is an example of a disease  most distressing to the patient, pass-
ing wholly without notice by writers on this branch  of surgery.
The symptoms of this malady being now known, and the prac-
titioner put upon  his guard  respecting it, the disease may be ea-
sily ascertained, and readily removed.  Many  cases of this dis-
ease have come to the knowledge of  the author, in which  the
mode of treatment which he recommended has been carried into
effect by  other surgeons, and the patient thereby cured.
  In the  present volume  it  is intended to enter into the conside-
ration of a number of diseases, which have hitherto been little
distinguished from each other, and which have  been  treated with
little regard to any principles. It is to be lamented that many of
                    u 
130
INTRODUCTORY REMARKS.
them proceed invariably to a fatal termination; but whether this
progress is to be  accelerated or retarded,  depends  upon the
knowledge of the  practitioner.  The situation of the  patient is
still more to be deplored, because many of  them are attended
by great pain; but whether  that  termination is to be  hastened
or postponed, whether that pain is to be aggravated or subdued,
whether the patient is to be allowed to expire in torture, or to
slide into eternity with moderated suffering, will be determined
by the information of the medical attendant, and by his acquain-
tance with  those means of diminishing the physical ills of hu-
manity with which Providence has  been pleased to bless the
practitioners of the healing art.
I 
131
                  CHAPTER XXIII.

   The author has comprehended all the discharges from the
 vagina under the following heads:—                *

   1.  Transparent mucous discharge.
   2.  White mucous discharge.
   3.  Watery discharge.
   4.  Purulent discharge.
   5.  Sanguineous discharge.

   The first of these, Transparent Mucous Discharge, has alrea-
 dy fallen under consideration.  It has been seen that it accom-
 panies a variety  of  morbid states, and that it forms a leading
 symptom of many,—that in  itself it  becomes, although unat-
 tended by any change of structure, or alteration of the  relative
situation of parts, a  very important disease.

   The os  externum is an opening out of which all discharges
 from  the vagina  must flow; but their  sources are as various as
 their  peculiarities of appearance.

   The next variety which will be here described is the


           WHITE MUCOUS DISCHARGE.

   "This discharge is opaque, of a perfectly white colour; and
 it resembles in consistence, a mixture  of starch and water made
 without heat, or  thin cream: it is  easily washed from the finger
after  an examination; and it is capable of being diffused through
water, rendering it turbid."*
   The discharge, of which the above definition is given, belongs
to  one morbid state of the uterus only; but it  characterizes that
state with marked constancy.
   " A morbid state of the glands of  the  cervix of the  uterus
probably gives rise to this discharge; at least the cases in which
it comes away are those in which the  symptoms are referred to
this part; and when pressure is made  upon it, the woman com-
plains of considerable pain."*
   Upon a reference to the above  definition, it will be seen that
the discharge is easily washed  from the finger after an examina-
tion, and it  is capable of being  diffused through water, rendering
it turbid. To  all these circumstances attention must be paid.
"Vide Vol. I. 
132          WHITE MUCOUS DISCHARGE.
The investigation of the discharge must be made when the pa-
tient has remained quiet for  some time, in order to draw a just
conclusion from the appearances; for it is to be observed, that
even the transparent mucus of the vagina,  when secreted in suf-
ficient quantity to run down over the labia, (which have some
motion  upon each other in the act of walking) becomes also
opaque  and white. This  change is attributable  to the entangle-
ment of air with the mucus. A similar circumstance may be ob-
served in the angles of the mouth of hasty  speakers, from the
saliva entangling small bubbles of air.  These have the appear-
ance of whiteness; but if suffered to remain at  rest, the air will
be disengaged, and the saliva  will regain its transparency. Such
a mixture of  mucus and  air will not render the water  turbid,
with which it may be combined; and this  forms a distinguishing
mark between it and the white mucous discharge which stands
at the head of this chapter.
  In many instances, the white mucous discharge is much thick-
er than cream, having  the tenacity of glue; and, perhaps, this is
the  state in which it comes away from the  cervix  uteri.  This
corresponds with  the mucus which  is separated from the cervix
uteri at  the commencement of labour.  Usually when the white
opaque  mucus possesses the tenacity just  mentioned it does not
flow spontaneously, but it remains in the vagina, either until the
exertions  employed to empty the  rectum squeeze out, at the
same time, the contents of the vagina; or, perhaps, by remain-
ing  in the vagina,  it may, by mixing with the mucus of that part,
become attenuated.
  The white mucous discharge is never met with in large quan-
tity; as might be  expected, on considering the small surface of
the  part by which it is poured out.  In women of strong passions,
there is reason to believe  that the white mucous discharge is al-
ways mixed in  greater or less quantity with the mucus of the
vagina;  because in such women, when they are led to consult
medical men, on account of profuse secretion from these  parts,
(to  which they  are very liable)  it will be found that  the dis-
charges have a milky hue.  It is probable, that in  many cases,
when the white  milky  discharge is  present,  no symptoms are
produced which call for remedy, where the discharge, eventually
relieving the increased  action of the vessels which produced it,
spontaneously ceases; but in all cases it is desirable to know the
precise nature of the discharge, which has sometimes been mis-
taken for pus; and both  the  practitioner  and the patient have
been led to fear that some formidable disease has existed. Wo-
men are the most liable to the white opaque  discharge between
the  age of twenty and  the  period at which the menses  cease.
How far it may be a forerunner of important disease in the cer- 
WHITE MUCOUS DISCHARGE.          133
vix of the uterus, the author is not prepared to say, partly from
the few occasions on which women are inclined  to mention the
early stages of disease in these organs; and partly, perhaps, from
a blamable inattention on his own part  to  take notes of such
cases, so as to enable him to speak with confidence; but reason-
ing upon the subject, and  knowing the fact, that the discharges
generally from  these  organs  are found to  be  increased at the
commencement of such complaints, it is not an improbable con-
jecture, that this secretion from the glands of the cervix of the
uterus constitutes a part of them, especially as it is the cervix of
the uterus which is the seat of carcinoma.  In the greater num-
ber of cases of white mucous discharge few symptoms are pro-
duced; but this is not always  the case; the  patient being attack-
ed by an  uneasy sensation in the  back and lowest part of the
abdomen, which gradually becomes converted into pain.  The
pain is increased by whatever tends to  call the neighbouring
parts  into  action, such as riding; or, by whatever produces pres-
sure upon the part  affected.  In this way the passage of a hard
and large  portion of faeces causes  much  distress;  for,  not only
are the blood-vessels filled in the  act of expulsion, but, during
the evacuation, constant, and sometimes  considerable  pressure
is made upon the cervix of the uterus; and if the  stool be ex-
amined afterwards, a  quantity of the white mucus will be found
clinging to it, which the patient, unless she be very attentive, is
apt to consider has passed from the bowels; but in very many
cases, when care has been taken  to ascertain  this fact, it has
been  demonstrated that no part of such mucus has escaped from
the anus.  Irritation about the rectum is occasionally an attendant
upon  the  complaint,  but not so frequently as irritability of the
bladder. The close connexion between the neck of the bladder
and the neck of the uterus will account for this, independently
of the sympathy which is known to exist between these parts.
The  desire to make water frequently, it must  be  observed, is
also an attendant upon the early stages of pregnancy; in  which
state  the glands of the cervix of the uterus undergo a change of
action, and the symptom ceases so soon as this part becomes
quiet  again; that is to  say, at the  end of  the  eighth or tenth
week, at which time the cervix of  the uterus is perfectly block-
ed up, the quantity of the gelatinous mucus not increasing after
that period.
  The constitution is rarely affected in this complaint, the ac-
tion of the heart and arteries is not increased, and the functions
of health are seldom interrupted.
  The menstruation is seldom affected, but it proceeds  as it was
accustomed to do in such persons.  In some instances painful
menstruation has been present.  Where an examination per vagi- 
134
WHITE MUCOUS  DISCHARGE.
nam has been made, the external parts and the canal of the va-
gina have not possessed a more than ordinary degree of sensi-
bility, but upon the finger reaching the cervix uteri  the patient
has complained of pain, and the uneasiness has been compared
to that which has been experienced upon the passage of an eva-
cuation from the rectum; pressure in both cases being the cause
of the pain. There is, however, no alteration of structure in the
part; no  thickening, no peculiar enlargement of the os uteri, nO
breach of surface; the  portion of the vagina which  is reflected
over the cervix uteri possessing its usual polished and smooth
state.
   Several  cases  had occurred  to the writer, attended  by the
syptoms  above mentioned, before he ascertained the nature of
the disease; but he has now no hesitation in stating,  that where-
ver the white mucous discharge is present, there will be found,
on examination, a tenderness of the cervix of the uterus, which
will be removed or relieved  by the mode of treatment hereafter
to be mentioned.  It deserves to be remarked, however, that
some cases resist all treatment, continuing until at  length they
appear to wear themselves out; and during their continuance, in
many cases,  impregnation is prevented.
   A lady,  about twenty-five years of age,  who had been  mar-
ried two or three years,  but who had never fallen with child,
complained of a considerable degree  of uneasiness at the extre-
mity of the back, near the os coccygis; on this account she in-
dulged much in the  horizontal posture. She had also been lia-
ble  for some years to a discharge from the vagina,  which, on
investigation, was ascertained to put on a white appearance: the
general health was tolerably good, excepting that at the periods
of menstruation great pain was felt at  the  bottom of the belly,
which  lasted for twenty-four hours, during which time the men-
•slruous discharge did not flow  freely,  but was pale, and occa-
sionally mixed with portions of a stringy substance.  On account
of the  discharge, astringent injections  had been employed by a
practitioner, who had been consulted, but without any effect upon
the complaint or its symptoms. Tonics had also been exhibited
without any advantage.  An  examination being allowed, the ute-
rus  was found  unusually low, and the neck of it possessed a
much  greater  degree  of sensibility than  is common; so that,
pressure being made upon it, the patient complained much; but
this increased  sensibility did  not extend  to  the neighbouring
parts, neither was  there any alterations in  the structure of the
parts.  This  lady  had  been in the habit of taking much riding
exercise, and it is more than probable, that to this cause tvas to
be attributed both the tenderness of the cervix uteri, and the de-
scent of the whole organ. Prolapsus uteri being a very infrequent 
WHITE MUCOUS DICHARGE.
135
disease in women, who bave not borne children, the patient was
desired to lose  several ounces of blood  from the loins, to live
temperately,  to avoid riding exercise, to  take only  a sufficient
quantity of walking exercise to keep herself in health, and to in-
ject some tepid water into  the  vagina. Sexual intercourse was
of course interdicted.  Soon  after this  plan  was instituted the
symptoms diminished. On account of the painful menstraation,
some diaphoretic medicines, with opium, and the use of the hip-
bath, were recommended, and the sufferings at the periods were
subdued. At  the end  of  three or four months, the complaints
were removed; but the patient did not become pregnant.
  In the above case it is  to be presumed, that violent  exercise
was the cause of the disease, which was  complicated with pro-
lapsus uteri.
  In some cases the increased action of the neighbouring parts
is excited, and co-exists with  the disease under consideration.
•  A young woman, aged twenty-two, whose habits of life had
been very irregular, but who had borne one child at the age of
eighteen, was gradually attacked with pain at  the bottom of the
abdomen, which extended towards the back:  although not con-
stantly violent,  she never was wholly free from it, but it was al-
ways increased upon sexual intercourse, which had been attended
with some difficulty in the last three months:  a milky discharge
attended these symptoms.  On  making an examination, the en-
trance of the finger was  impeded by an encysted tumour, con-
taining a fluid upon the right side of the vestibulum, and extend-
ing upwards  towards the  vagina. The tumour was  as large  as a
pigeon's egg, and was insensible: on carrying the finger towards
the uterus, the  neck of this organ was found exceedingly lender
upon pressure.  As the  patient was very desirous to have this
tumour removed, and as  it  was to  be apprehended that  some
hemorrhage  might attend  the operation, the  author was deter-
mined to ascertain how far  this loss of blood  would prove  a re-
medy for the inflamed state of the cervix  of the uterus.  Accord-
ingly he made an incision into the parts covering the tumour,
and  dissected  it  out, being  assisted in  the  operation by Mr.
Hewit, the apothecary of St.  George's  Hospital. The bleeding
which followed the removal of the tumour was excessive, and
syncope was produced.  By plugging up the parts, however, the
hemorrhage was at length restrained, the wound granulated, and
the sore healed. All the  former discharge ceased, and the ten-
derness of the cervix of the uterus subsided.
  The author lost sight of this patient from the year 1813, when
the operation was performed,  until the month  of October, 1819,
when he was consulted, together with Dr. Maton, respecting her.
The pressing symptom, at this time, was a  distended bladder 
13(3
WHITE MUCOUS DISCHARGE.
 without the power of expelling its contents; the urine was drawn
 off with a catheter; and on carrying the finger into the vagina,
 the uterus was enlarged to the size of a large orange, which hav-
 ing fallen  backwards into  the hollow of the sacrum, had, by
 means of its cervix, made pressure upon the meatus  urinarius.
 This disease had taken place since the year  1813,  and indeed,
 in consequence of the continuance of former intemperance, chro-
 nic enlargement of the liver was present, and the  skin of the pa-
 tient had assumed a dirty appearance.  Profuse menstruation had
 come on, which had farther debilitated the powers of the  sys-
 tem; and the probable termination of such  an  assemblage of
 maladies can hardly  be doubted.
   In the preceding history may be traced the progress of a  dis-
 ease at first shown only  by increased action of  vessels, which
 was removed by blood-letting and by rest, for a  time : but the
 flame,  though  subdued, was  not extinguished:—ready to be
 lighted  up, upon  the  application  of those exciting causes, de-
 bauchery and intemperance, it was rekindled; and, in all proba-
 bility, at a period not very distant, will consume the frame which
 engendered it.
   In a young woman who laboured  under this  complaint two
 years since, and who was seen by Sir Henry Halford, and by
 the writer, the attacks of pain referred to the back and to the
 abdomen were  very violent;  and the  bladder  was so  much af-
 fected, that a great degree of  retention of urine was present, so
 as to require, on several occasions, the use of the  catheter.  The
 intensity of the pain in this patient was greater than in any other
 case of the kind which the author has  witnessed.
   It is  not uncommon to meet  with encysted  tumours in the
 neighbourhood of parts where increased action is  going on.  The
 author  has several times met with such in the labia, and in the
 cellular membranes about the vagina, when local inflammation
 has existed in the vicinity. The following case is  a further illus-
 tration of this fact in  the complaint under discussion.
   A young healthy woman, who had been married nine months,
 consulted Mr. Freeman, of Spring-Gardens.  Since the period
 of her marriage, her health  had declined, and her strength had
 diminished.  Her menstruation, too, had become irregular;  the
 intervals between the  periods being much longer than is natural.
 Much difiiculty attended sexual intercourse, which  was always
 attended with pain. The patient had been liable,  also, since her
 marriage, to a discharge of a whitish mucus  from the vagina, at
 the upper part of which a constant uneasiness was felt. On  ex-
amination, which was very painful, there was found a tumour as
large as a  French walnut on  the  left side of the vagina; and
upon the patient being made to strain,  it could be  brought much 
WHITE MUCOUS  DISCHARGE.
137
lower.  The finger being carried up to the uterus, the pain was
greatly increased when pressure was made upon the neck of that
viscus, even in a very moderate degree. The constant irritation
produced by this uneasiness had  accelerated the circulation;
which circumstance had produced  some degree of emaciation.
   As this tumour evidently contained  a fluid, it was determined
to  evacuate its  contents; which was  effected by puncturing it
with the point of a  lancet. About an ounce of a clear, colourless
fluid escaped. The sides of the cyst collapsed, and the canal of
the vagina of course became more capacious.  A plan of treat-
ment was directed, with  a view to  diminish the local increased
action, and perfect  rest was enjoined.  When the author, at the
end of a few days,  saw the patient again, the tenderness of the
cervix uteri  was nearly gone; the-milky discharge  had ceased;
no  farther accumulation of fluid had taken place in the cyst, and
the patient shortly returned to health.
  In the two cases last related, it appears that the action of the
parts had been greatly increased.  In  the first, by the notorious
irregularity of the patient's life: in the second, by the difficulty
attendant upon  connexion.   Perhaps, also, the parts  might be
more likely to take on  inflammatory  action, in consequence of
the interruption  to the monthly secretion.
  Although the author has stated, that, generally, the constitu-
tion does not sympathize with the  local irritation, the following
case will prove an exception  to this rule; it being manifest, that
great disturbances of the system took  place upon the attack of
the disease, which diminished as the complaint subsided.
  A married lady,  between thirty  and forty years of age, who
was attended by the  late Sir Walter Farquhar, Sir  Gilbert
Blane, Mr. Chilver, and the writer, had for some time been suf-
fering from pain at  the bottom of the back and abdomen, which
continued to increase for some days, at the end of which a vio-
lent paroxysm of fever took  place; the rigour was very conside-
rable, and of long duration;  and  the  hot fit which  succeeded,
was in proportion to it. A repetition of these febrile paroxysms
took place at the end of some hours.   The pulse was very fre-
quent,  and, at the same time, hard.  It was thought right to bleed
the patient, and twelve ounces of blood were removed from the
arm, which, upon standing, put on the  usual  appearances of
blood taken under the influence of inflammatory action.
  A solution of sulphate of magnesia,  in infusion of senna, was
given, and a number of evacuations were procured, upon the
surface of each of which the patient observed a small quantity
of a substance which looked like a  solution of isinglass.   At first
it was thought that this substance came from the rectum; but it
was afterwards ascertained, beyond a doubt, by the patient, that
                    s 
138
WHITE MUCOUS  DISCHARGE.
it was  squeezed out of the vagina  immediately after the faeces
had escaped from the anus.  After the bowels had been freely
evacuated, small doses of  antimony and mercury were  exhibit-
ed, and the  patient was kept in bed  upon an  abstemious diet.
Soon after the removal of blood, and the action of the purgative
medicines, the pain abated; and, although it did not entirely dis-
appear for many days, the glutinous  discharge from the vagina
ceased immediately, and the excitement of the system subsided.
   In this case, it is  true, no examination was  made; but as the
usual symptoms of the complaint were present, and as  both the
pain and the discharge of the white  glutinous matter ceased upon
the employment of the means employed, there can be little doubt
that here, as well as in the former cases, the complaint consisted
of inflammatory action of the cervix of the uterus, accompanied
by its constant attendant, the  peculiar white discharge.
   The introduction of a few cases  tends greatly to illustrate the
history of diseases;  and it  is hoped that enough has been said to
prove, that  the  presence of the white mucous discharge  is at-
tended by pain referred to the lower part of the abdomen and
back;  that, on examination, the cervix of the uterus is  found to
be unusually susceptible of pressure, whilst the neighbouring vis-
cera are in a healthy  state, and that  the anti-phlogistic  mode of
treatment is adapted to the removal of the symptoms.
   In ordinary cases, the most successful mode of treatment is to
take away some blood, either by cupping, or  by leeches applied
to the  groins,  or to  the back; and it may be necessary to repeat
the local blood-letting several times. If symptomatic fever should
be present,  as in the case last related, it will be prudent to open
a large vessel;-but  this is seldom requisite; and all useful pur-
poses  are answered by local blood-letting. The hip-bath proves
a useful remedy, and the patient  may sit in it twice a-day, the
water  being heated to about ninety degrees. Where the hip-bath
cannot be conveniently procured,  fomentations of warm water,
or of decoctum papaveris, to the  back or to the abdomen will
be found serviceable; and even during their application, the pa-
tient is frequently made much more comfortable. Tepid water,
thrown into the vagina with a syringe, constitutes a direct fomen-
tation  to the part affected, and it may be recommended with ad-
vantage.
   It is very useful to keep the bowels in a relaxed state; and,
for this purpose, small doses of sulphate of magnesia will answer
exceedingly well in plethoric habits, and it may be exhibited in
any agreeable vehicle. In languid  habits, it may be advisable to
substitute expressed oil in its stead.  Half an  ounce of ol. ricini
may be given in the  morning, or two drachms in the  morning 
WHITE MUCOUS  DISCHARGE.
139
and at noon, with a drachm of manna.  All the purgatives which
irritate the lower part of the bowel should be carefully avoided.
   Every night, at bed-time, it is an object to exhibit some me-
dicine which will determine the circulation to the surface of the
body, and produce a general tranquillity of the system. For this
purpose, the following formula may be ordered:

   R  Pulv. ipecac, compos, gr. v.
      Camphorae gr.  iii.
      Confect. ros. canin. gr. iii. M.
Div. in pilulas tres, omni node sumendas, cum hoc haustu;

   R  Succ. limonis ^fl.
      Amnion, carbonat. gr. xv.
      Syr. cort. aur. %\.
      Aquae menth. sativ. £i$.  M.
Fiat haustus.

   If  strangury should be considerable in degree, the exhibition
of a larger dose of opium will be found to afford the most ready
and certain  mode of procuring relief; and for this purpose sixty
or eighty drops of laudanum ought to  be given.  Smaller doses,
frequently repeated, may be necessary afterwards. Mucilaginous
drinks of  different kinds may be taken, and indeed will  suggest
themselves to the mind  of every practitioner.
   In  all cases where  the bladder cannot expel its own contents,
and when distention  of its coats is produced, recourse should be
had to the use of the catheter; for, in addition to the  great dis-
tress attending this circumstance, the  patient  may be  placed in
hazard by inflammation  of  this part.  It is usual with some per-
sons to employ diuretics in  this case, and to content themselves
with exhibiting nitric asther, and placing their patient over the
steam of warm water; but nothing can  excuse such a useless
practice, and no professional man is warranted in  leaving such
cases, when  he can  draw off the urine,  an operation, which, if
properly performed,  is attended with neither pain, difficulty, nor
exposure of the person.
   It is seldom requisite to keep the patient in bed; but the hori-
zontal position should be persisted in for some time, and all new
causes of irritation avoided. After the  removal of the complaint,
great  care should be taken  by the patient not to expose herself
to those circumstances which were supposed to lay the founda-
tion for the original  production of the  complaint, lest  a renewal
of it should be caused by  such means; and  perhaps  the parts
take on a  disposition to  permanent increased action. 
140
WHITE MUCOUS DISCHARGE.
  The disease which  bears  the  greatest resemblance to that
above described, is

INFLAMMATION OF THE  SUBSTANCE OF THE UN-
               IMPREGNATED UTERUS,

respecting which a few observations will  here be made.  It will
be observed that, although the pain in both complaints is refer-
red to the same part; in inflammation of the unimpregnated ute-
rus, there will  be found not only the pain arising from local in-
flammatory action, which is of course permanent, but also  occa-
sional pains which come on and retire after the manner of early
labour pains.  Besides, a milky  discharge from the vagina does
not accompany inflammation of the substance of the  uterus, in
which complaint pressure above the pubis greatly aggravates the
pain.
   Inflammation of the substance of the  uterus, is not
an unfrequent disease; it is not  attended by symptoms so  acute
as might be expected, when the unyielding texture of the mus-
cular fibres of the uterus is considered:  but on  the other  hand,
it is to be recollected  that the uterus, with the exception  of its
cervix, is not a very sensible part; and that is not only defended
from external pressure by the circle formed by the bones of the
pelvis, but that no solid parts lie immediately  in contact with it.
In the violence of the pain, there appears to be a great  differ-
ence  between  the inflammation of  this organ  in its impreg-
nated state, or soon after delivery, and in its usual unimpregnat-
ed state. A very ready explanation of this fact presents  itself.
The viscus, in pregnancy, and soon afterwards, is larger, and
therefore there  is a greater extent  of inflammation; added to
which, the nerves and blood-vessels of the uterus become  larger
in pregnancy, and this part is constantly under  the influence of
pressure from the muscular parietes of the abdomen,  and  of the
diaphragm in breathing. The complaint  is more frequently call-
ed into action  by local violence than  by any other cause: it is
not an uncommon consequence of marriage.  The  application of
cold may excite it; but the viscera of the abdominal cavity are
 much  more likely to suffer from this cause than the uterus. The
 inflammation of the substance of the unimpregnated uterus is at-
 tended by a constant  uneasiness referred to the pelvis, and this
 gradually increases,  seldom becoming  intensely violent,  but
 greatly interfering with the comfort of  the  patient, who com-
 plains of pain  sometimes at the bottom of the abdomen, and
 sometimes in the back.  Superadded to the permanent pain, vio-
 lent pains occur by paroxysms, with irregular  intervals: these
 are of short duraliSn.  It appears that these  pains are present 
WHITE MUCOUS  DICHARGE.
141
whenever inflammation  attacks muscular parts, or parts in the
immediate neighbourhood of muscular fibres.  In inflammation
of the stomach they are met with, sometimes causing a sudden
pumping up of its contents.  In inflammation of the bladder, they
are also present, causing one of the great annoyances of that dis-
ease—strangury.
  In  these instances, the inflammatory action becomes a stimu-
lus  to the muscular fibres of the organ; and they are made to
contract, as upon the application of any other exciting cause. If
pressure be made by the hand immediately above the pubis, the
uneasiness of the patient will be increased.
  A rejection  of the contents of the stomach, in very irritable
habits, accompanies the disease, but, like all  the other sympa-
thies, the frequency of its occurrence will have reference to the
disposition to be acted upon, which the patient may possess.
  Numerous instances present themselves, in which parts, whose
functions  are  not immediately necessary to the continuance of
life, undergo a considerable degree of morbid action,  without
producing much constitutional  disturbance: provided  there is no
tension  of the  parts covering them, and that such morbid action
does  not interfere with the due performance of functions in the
vicinity.
  Every one  at all accustomed to examine dead bodies, must
have  seen a variety of examples of disease  in the kidneys, and
in* the ovaria,  where no symptom of such complaints was dis-
played in the life-time of the patient. The author has met with
large  abscesses in them, and in other parts, where no evidence
had existed that such complaints were present. Thus, in inflam-
mation of the substance  of the unimpregnated uterus, the circu-
lation is seldom found much accelerated, neither is much  hard-
ness communicated to the coats of the artery in feeling the pulse.
The heat of the body is not  much, if at all, increased  beyond
the  natural standard; and, although the tongue may not be clean,
it does not possess that slimy whiteness which is so constant an
attendant upon peritonaeal inflammation.
  The disease sometimes lasts a great length  of time, if no at-
tention be paid to it;  the violence of the symptoms always in-
creasing before each  period of  menstruation, and diminishing
after the period has passed by.
  When the disease has continued for some time, the function
of menstruation becomes suspended in some women; an occur-
rence which might be expected from  the existence of disease in
the  organ which performs it: and, under such circumstances, the
symptoms of the complaint are aggravated.
  When inflammation of any of the viscera of the abdomen or
pelvis is found to exist, it commonly happens that practitioners, 
142
WHITE MUCOUS  DISCHARGE.
anxious to combat and subdue so important a malady, resort to
the use of the lancet; but, in inflammation of the substance of
the unimpregnated uterus, unless the peritonaeum  has partici-
pated in the disease, the blood drawn seldom possesses the in-
flammatory crust. Neither will the relief obtained in consequence
of the operation, be commensurate with the activity of the means
employed, nor  be answerable to the expectations of the pre-
scriber.  Much  more advantage  will be derived from  topical
blood-letting. Scarifications may be made upon the sacrum, and
cupping-glasses  afterwards applied, or a dozen leeches npy be
applied to each groin, or across the pubis, and the bleeding may
be solicited by the immersion of the hips in warm water, imme-
diately after the  leeches have fallen off.
  At the end of a week or ten days, the local  bleeding may be
repeated, and it  will be found useful to apply a dozen leeches to
the neighbourhood, in the intervals between the periods of men-
struation.
  Fomentations, consisting of a mixture of tinctura opii, and de-
coctum anthemidis, in the  proportion of an ounce of the former
to a  quart of the latter, should  be used twice or thrice in the
twenty-four hours; and if the symptoms should not be disposed
to yield, the patient should be kept in bed,  and  small  doses of
antimony may be given in a saline  draught,  once in four or six
hours,  with three or four drops of tinctura opii, or 3i of syrupus
papaveris.
  Purging is known to be  so eminently useful in allaying inflam-
matory action, that it  should  by all means be employed; and,
for this purpose, a full dose of magnesiae sulphas, or of soda tar-
tarizata, may be  given in a draught of infusum sennae every other
morning. The diet of the patient should be light,  and  not stimu-
lating;  but as many of these cases occur in persons of irritable
habits, who are  seldom found to  be  strong,  it will  be desirable
not to reduce the powers of the system too considerably.
  As, in many cases of inflammation of the substance of the un-
impregnated uterus, the symptoms are found to  diminish  after
each period  of menstruation; and as in others the complaint has
succeeded to an interrupted state of this function, it will be de-
sirable, when the urgency  of the symptoms shall  have subsided,
to endeavour to  restore this secretion to its natural state.
  With a view to effect this intention, the state  of the general
health  of the patient is to  be accurately observed; for nothing
can be more unwise  and  empirical than to subject all  patients,
under such circumstances, to a similar mode of treatment; and
yet such practice is too often pursued, frequently  to the increase
of the disorder, -and on many occasions to the manifest  injury of
the patient. 
WHITE MUCOUS  DISCHARGE.
143
  There is a class of medicines (formerly called emmenagogues)
which were supposed to be capable of exciting a specific influ-
ence  upon the uterus;  and of these, the  greater number are ei-
ther general or local stimulants. It is evident to common sense,
that such medicines cannot be exhibited justifiably in all  the va-
riety  of cases of obstructed menstruation, even were they capa-
ble of effecting what is proposed. On no subject, perhaps, have
there been more  erroneous  notions entertained, or more injuri-
ous directions given than on that of diseased menstruation. Pre-
judice has occupied the place of science, and a popular nostrum
has been  exhibited, often without, and sometimes with, the con-
currence of the practitioner.
  Cases of suppressed menses having been regarded as arising
from  debility of the system or of the local vessels, it has been
too frequent a practice to resort in  all cases  indiscriminately to
the same supposed means of relief,—to the exhibition of chaly-
beates, gum resins, irritating purgatives, and cantharides.  No
diseases admit of being treated so generally; even the most sim-
ple complaints require care in their management; in the  cure of
the itch  by brimstone, the skin of one patient will be  inflamed
by  a  preparation  of this  drug, which will produce no mischiev-
ous effects in  another.  If there are cases of obstructed or sup-
pressed  menses,  where  the  fluid  is tardily secreted, in  conse-
quence of general or local  debility, there are many others in
which an opposite state of the frame becomes the cause of their
production. The reason is obvious:—the function of menstrua-
tion, like the other functions of the body,  is best performed when
the system is in health.  Now, health is not constituted by excess
of fulness, or by the performance of violent actions, any more
than  by debility,  or enfeebled action; consequently, the  exhibi-
tion of stimulants will not influence this secretion, unless atten-
tion be given to the restoration of the general health of the  pa-
tient, even in cases of debility.  Still less will such a mode of
treatment be applicable to cases of interrupted menstruation oc-
curring in plethoric habits, where the presence of the plethora
itself is the cause of the interruption of the due performance of
the natural secretions.
  Instead then of resorting to such measures, to the employ-
ment of the whip and of  the spur in such cases, (where  if they
do any thing, they do mischief) let the morbid peculiarities of
the constitution, and the habits of life of the patient be taken into
consideration; let the first be counteracted, the second  be  im-
proved;  let the sanguine have her excess of fulness diminished,
let the debilitated have her powers  augmented; in short, let the
general health  be amended, and the functions of health  will be
restored. 
144
WHITE MUCOUS  DISCHARGE.
   The different secretions of the body are governed by the same
laws, are affected by the same causes; a derangement of one of
them can  seldom exist  long without  being  attended  by a dis-
turbance of the rest; and constitutional derangement will inter-
rupt almost all of them.
   Every day's experience  shews that when  the secretions of
those organs, which are esteemed of the greatest importance to
health and life, are duly  performed, other secretions, which ap-
pear to be in unison with them,  proceed also with the greatest
regularity; and vice versa.   When the liver becomes indolent,
and no bile is secreted, the  mouth becomes clammy, the urine
scanty, the skin dry, and, perhaps from the latter  circumstance,
hot; a harsh skin being an almost constant attendant upon a dis-
eased state of the secretions  subservient to the  process of diges-
tion. But  let  means be taken to restore the function of the liver;
with the increased secretion of bile will be found a return of sa-
liva, a more abundant discharge  of urine, and a soft skin. So, in
that constitutional affection called fever, the secretion from the
skin, the mouth, the liver, and the kidneys,  is  interrupted;  but,
the febrile  action having  subsided, they one  and all return.  No
man in his senses would  think in such a case  of giving his pa-
tient diuretics to excite the  kidneys;  mercury, the liver; pyre-
thrum, the  salivary glands; or of  applying heat to produce sweat-
ing;—no man in possession  of reason would attribute the pre-
sence of the  fever to the want of one or the other of these se-
cretions: but  let the case be changed;  let obstructed menstrua-
tion be a feature of it; the patient and her friends are possessed
with a notion, that this circumstance is the cause of all the other
ills; a similar impression  is made too frequently upon  the mind
of the  medical attendant, who, from that moment, directs all his
attention to the uterus, and  subjects  his patient  to a course of
myrrh  and  steel.
   Accidental circumstances, as  the  application of cold or fa-
tigue, may  have proved the original cause of interruption to the
menstrual  discharge by exciting an attack of fever: In this case
let the patient remain quietly in  bed; let her  be  supplied with
cool  drinks; let her bowels be kept free; and, if any medicine is
to be given, let  it be  a saline draught occasionally: the effect of
such a mode of treatment will be to remove the febrile symp-
toms;  when,  health being restored, the functions  of  health will
be performed.
   It is by no means uncommon  to meet with  cases of amenor-
rhasa produced  by a disproportion between the wear and tear of
the system, and the supply of food.  Luxurious living, or a very
sedentary life may  have  produced a plethoric unhealthiness of
the constitution incompatible with the performance of the natu- 
WHITE MUCOUS  DISCHARGE.
145
ral functions:  in such a subject, abstemiousness with increased
exercise will of themselves prove  advantageous remedies;  and
although no regard be paid to the menstruation, it will frequently
spontaneously return.
  If however  these remedies should  not of themselves  be suffi-
cient to remove this state of the system,  recourse must be  had
to venaesection and the employment of saline purgatives. It
should here  be  remarked  that  full  bleedings  are  in this case
much more useful than the frequent  removal of small quantities
of blood.  The patient should not lose less than from sixteen to
twenty ounces of blood  at once. Under ordinary circumstances
it is  very  immaterial from  what part of the body  the  blood  is
taken,  provided the vessel is  large and the orifice  in  the  vein
sufficiently so to allow the blood to escape rapidly; but if there
should  be any evidence of local  congestion, it will be right to
remove the blood from the neighbourhoodof that part, as from
the external jugular vein when there is pain in the head and gid-
diness.
   If, lastly, in consequence of confinement, breathing an impure
air, or low living, the patient's general health should have suffer-
ed, and debility attended by obstructed menstruation should have
been produced, constituting the true case of chlorosis,  it will be
necessary to invigorate the frame by every means in our power.
   The efforts of the art should be first directed to strengthen the
stomach  by the lighter  bitters, and by food of  the most digesti-
 ble  kind, proceeding  by slow degrees to the use of tonics ot
 greater power, such as  bark and steel.                      .
   The constitutional  weakness having been  removed and its
 powers renovated, if the menstruation should not return, then and
 not till then,  should stimulants be substituted for,  or added  to,
 the remedies before employed.
   It is probable that there are no medicines which exert a spe-
 cific effect upon the uterus, and that those which have been em-
 ployed with this view have either been wholly inert, or that they
 have acted either as general  stimulants, or  as stimulants  upon
  those parts in the  immediate  neighbourhood of the uterus.
   Volatile alkali, spices, essential oils,  and wines are the  gene-
  ral  stimulants in use; to which may be added  the  use of the
  cold bath when not contra-indicated. Cold bathing is, however,
  very obnoxious to particular  constitutions, and it is never advi-
  sable when  the stomach has  more  than its proportion of weak-
  ness*                                                  *  i
    The stimulants which exert their influence upon parts  in ttie
  vicinity  of the uterus are sabina,  lytta, helleborus n.ger,  many
  of the resinous gums, electricity, and horseback-exercise.      ,
    The most convenient mode of exhibiting the  savin is that ot 
14G
WHITE MUCOUS  DISCHARGE.
the tinctura sabinae  composita, of which 3i may be given three
times a day in some aromatic bitter  draught.

              R Infus. cascarillae, 5i.
                Aquas pimentae, ;*{$.
                Tinct. sabinae comp. 3L
                Syrup, zingiber: 3i M.
   F. haustus ter die sumendus.
   The quantity of the tinctura sabin. compos, may be increased
to 3$. or 3ii.

   The internal exhibition or the external  application of lytta
causes irritation of  the urinary passages, with which the uterus
sympathizes.  The knowledge of this circumstance (sometimes a
great inconvenience when blisters are applied) is available in the
case of obstructed menstruation.  A blister may be applied oc-
casionally to the region of the sacrum.
   The safest mode of exhibiting this medicine internally is  in
the form of the tincture.  The patient may commence with ten
drops, which dose may be increased to  thirty;  the vehicle may
be infusion of cascarilla, or any other warm tonic.
   Black hellebore is a drastic purgative, and, when given as  an
emmenagogue, should be employed in such a dose as will  pro-
duce an effect upon the bowels. The  uterus is probably affect-
ed from juxtaposition.   It  may  be substituted for the tinctura
lyttae in the last prescription, and it  may be given in the dose of
5i. or more.
   Myrrha, thus, galbanum, aloes, the last especially, possess the
power of stimulating the  lower  part of the rectum, and unless
they are given so as to produce this effect, they will be found of
little service beyond that of causing the expulsion of the con-
tents of the alimentary canal; but even with this intention, they
become more useful than purgatives of any other class;  as the
bowels are unusually torpid, and yield to the action of such med-
icines more readily than to that of either the oily or the saline
kind.
   If  the patient should  be distressed  by excessive  irritation
about the anus, an ounce of infus. lini may be  injected once  or
twice daily, and  the medicines intermitted for a  few days, or un-
til these symptoms shall have subsided.
   In cases of  dyspepsia  in either sex, which are not accompa-
nied by organic disease  of the viscera, riding on horseback  is
acknowledged  by all practitioners to be a valuable auxiliary  in
the treatment of the disease, as it enables the patient to take ex-
ercise  without much  fatigue;  whilst at the same time  the de-
scent of the contents of the stomach and bowels is favoured by 
WHITE MUCOUS  DISCHARGE.          147
 the agitation of  these parts, and by the action of the abdominal
 muscles upon them.  Not so when organicchanges are suspect-
 ed to exist:  as  these have inflammation for their basis, it is evi-
 dent that whatever excites action in such parts will augment the
 mischief, which  will indeed manifest itself by an increased ten-
 derness of the part or by an accelerated circulation.
   The same observation may be made respecting  the  uses of
 tonics and  stimulating purgatives,  which, however useful  they
 may prove in cases, where the powers of the stomach have been
 weakened by fatigue, watching, or  anxiety, never fail to aggra-
 vate that embarrased state  of the  chylopoietic viscera which is
 symptomatic of  active disease of the uterus, or attendant upon
 the altered organization of the viscera themselves.
   Under a treatment of a mild character, the occasional appli-
 cation of a few leeches, the  administration of a little manna, oil,
 or magnesia and  small  doses of hemlock,  and  under a diet at
 once soft and nutritious, but by  no  means  stimulating, the au-
 thor has known  several instances of patients living many years,
 even  where emaciation had taken place  to a great degree;
 when, after death, disease (the result of slow  inflammatory ac-
 tion)  was discovered, and  that to a considerable extent, in the
 pylorus,  the small intestines, and  the liver.  Physicians have of
 course much  more  frequent  opportunities  of witnessing such
 cases.
   The  remaining emmenagogue  is electricity,  the  powers of
 which are very considerable in exciting the  uterus to vigorous
 action. By means of it, a great number of cases of amenorrhcea
 have been cured, when no  other means had been successful.
 The muscular fibres of the  uterus, like those in other parts of
 the body, are probably stimulated by it, and  the circulation of
 blood through the  organ carried  on  with greater energy, and
 perhaps the secreting extremities of the arteries are themselves
 excited;  but as the author has known many instances of its good
 effect, and  two or three when the patient has menstruated upon
 the insulated stool,  the modus medendi is of little consequence.
Like many other of the emmenagogue remedies, it can never be
useful, until the  powers of the system have been restored, and
 until the  general  health  has been  established. Even were this
otherwise, it would be imprudent to employ them, as every loss
 which the constitution sustains, is a loss of so much power, and
 this at a moment when it is as great  an object to save strength,
 as to give it.
   The electrical shock is the only advantageous mode of apply-
 ing the remedies; sparks are of no service. The patient should
therefore have several shocks passed through  the  pelvis daily,
both from before to  behind, and from side to side. The strength
• 
148
WHITE MUCOUS  DISCHARGE.
of the shock should be increased as the patient may be enabled
to bear it, and it should be resorted to at those times, especially,
at which any indications of the menstruating function should pre-
sent themselves.
   The author has been induced to make these few observations
upon the subject of interrupted menstruation, in  the hope that
they may prove useful to the younger members of the profes-
sion, who are compelled to collect their information and experi-
ence upon these subjects very slowly.
   To return to the subject of Inflammation of the Cervix of the
Uterus.
   These  cases  occur frequently  in those habits, in which the
blood is distributed through the different parts of the body very
unequally, and in such cases it will generally be found that the
system  is unusually weak;  there appears here to  be  a  resem-
blance between  inflammation of the cervix uteri, and those cases
of inflammation  of glands met with in different parts of the body,
as in the  neck, the axilla, the groins,  and especially in the me-
senteric glands of children.
   These cases do not admit of being treated by  antiphlogistic
remedies, or by low diet; on the contrary, they will be usually
accompanied by a slow formation of  bone> or by  thickening of
their extremities in the long bones; by a flabbiness of the mus-
cles;  by a want of tone in the integuments; by symptoms which
demand the employment both of medical and culinary means of
restoring the failing powers of the constitution.
   The cervix of the uterus is a glandular part:  its secreting or-
ganization can be demonstrated. It is  subject  to the diseases of
glands in other parts of the body,  and, in all .probability, will be
particularly liable to  take on disease  in habits which  are prone
to other glandular complaints, namely, in weak habits.
  The majority of cases of disease in the breast and in the tes-
ticle arise in such persons.
  It will accordingly be right, whenever inflammation of the cer-
vix of the uterus occurs in such a frame, to endeavour to invigo-
rate the system, and to equalize the balance of the circulation:
an  object  frequently attainable by  the  exhibition  of tonics,
amongst which, the Peruvian bark and  some preparations of iron,
are the most serviceable.   Of the former, the  decoctum cincho-
na?; of the latter, the  tinctura ferri muriatis, will generally best
fulfil the intentions of the practitioner.
  It must, however,  be  confessed that cases of unequal distri-
bution of blood,  whether the determination be made to the head,
the chest, the uterus, or any other organ,  are very unmanagea-
ble,  and  often  baffle all the endeavours of the practitioner to
regulate or remove them. 
WHITE MUCOUS  DISCHARGE.
149
  In conclusion it must be observed, that a great point is gained
in ascertaining the true nature of this disease, of which the milky
discharge is symptomatic; for thereby the physician or surgeon
is led to direct  such measures as may tend to remove its cause,
instead  of those astringents too often employed in such cases;
besides which it should be recollected that the cervix of the ute-
rus is the most  sensible part of the whole viscus;  and  that it is
the cervix of the uterus which carcinoma always selects as its
point of attack.  Surely,  then, it  is not too much to  apprehend
that slow  inflammation in the glands,  seated  in this part, may
lay the  foundation for the  commencement of carcinoma; or,
perhaps, for other alterations of structure  in its neighbourhood.
On all of these accounts, it is prudent and desirable to endea-
vour to remove as quickly  as possible  any  of its diseases, but
especially one in its  own nature so important as  inflammation. 
100
                 CHAPTER XXIV.

               WATERY DISCHARGE.

  By the above term is meant that form of discharge which re-
sembles clear water, having no colour, and which contains very
little glutinous matter, sometimes none at all.  •
  The variety in the thickness of these discharges probably de-
pends  upon the greater or less quantity of albumen diffused
through them.
  It is intended to comprehend the  history of three different
diseases under the head of "Watery Discharge."

  cauliflower-excrescence of the os uteri.

  hydatids of the uterus.

  the oozing excrescence of the labia.

  These three are the only diseases which, in the knowledge of
the writer, are attended  by watery  discharge of the character
described above.
  It is true that women are Hable to an escape of water from
the  os externum; but such fluid will, upon examination, be found
to possess the sensible and chemical properties of urine. A few
observations will be made hereafter respecting these cases. 
WATERY  DISCHARGE.
151
     CAULIFLOWER-EXCRESCENCE OF THE
                      OS UTERI.

  Perhaps no organ in the body is liable to a greater variety of
diseases than that which forms the residence of man during the
first nine months of his existence.  In consequence of affording
this nidus to the ovum, and of sustaining and expelling it when
labour comes on, it became necessary  that its structure should
be very complicated. It accordingly is found to consist of many
parts, possessing different kinds of organization adapted  to  the
purposes for which they  were intended.  Its outer membrane,
therefore, becomes liable to diseases of the peritonaeum: its mus-
cular structure to irregular actions, and  to the formation of tu-
mours in that structure, as well as in the cellular membrane con-
necting the packets of fibres  to each other.  Its internal mem-
brane, performing the double  office of the  permanent secretion
of mucus, and the occasional secretion of the menstruous fluid,
by the  extremities of small arteries  which terminate  upon its
surface, becomes subject to the diseases of mucous membranes;
and  it is, perhaps, more liable to  attacks of inflammation than
any mucous membrane in the body.
  The cervix of the uterus differs from the structure  of the
other parts of the organ in being glandular, and  thence it be-
comes subject to the diseases of glands; whilst the termination
of this part in the vagina, at the os uteri, where it is covered by
the inner membrane  of the vaginal canal, is disposed to take on
different forms  of disease,  one  of which  forms  is that which
stands at the head of this chapter.
  A more appropriate name could not have been given to this
disease, than "the  cauliflower-excrescence." There is a striking
resemblance between itself and a portion of the upper surface of
a cauliflower, or a head of brocoli.  The surface is granulated,
and it consists of a great number of small projections, which may
be picked off from the surface, as the granules may be detached
from the vegetable.  The  firmness of the tumour agrees also
with that of the plant—here the granules will be large and irre-
gular, there small and equal.
   A membrane, very fine in its texture, is spread over the sur-
face of the tumour, and from  this  membrane is poured out that
aqueous  secretion which  characterizes, in a  marked  manner,
this disease.
   As the tumour occupies the upper part of the vagina, it is of
course concealed from view; but in three or four cases, in which
the size of the tumour was so large as  to fill the whole canal, 
■152
WATERY DISCHARGE.
and to protrude between the labia,  the author was enabled to
see the disease, and the colour of the tumour was found to be
that which may be called a bright flesh-colour.
  If the membrane covering the  tumour has been injured in an
examination, the blood-vessels immediately beneath it pour  out
their contents, which appear to be florid red blood, resembling
that which is  contained in  the  arteries of the body generally*
The quantity of blood which so escapes  will be proportioned to
the extent of the injury inflicted upon the tumour.  Similar dis-
charges of  blood  sometimes  spontaneously take place in those
habits  in which plethora exists, or  where the circulation has
been hurried by any exciting  cause.
  The cauliflower excrescence is not endowed with sensibility,
the patient never complaining when pressure is made upon it.
Its attachment is to the surface of the os uteri, and to that alone;
it never can be traced into the  cavity of the uterus.  A small
part of the os uteri may give  rise to the disease, or the whole
circumference of the  opening  may be occupied by it.
  The growth of the tumour  is  sometimes very rapid; but the
enlargement seems to be much influenced by the power of con-
traction of the vagina;  so that when this canal is very dilatable,
as in married women  who  have  borne  many children,  the tu-
mour  will very quickly increase  in size; whereas, the pressure
of the sides of a less  capacious vagina, as in single women, will
greatly tend to control  its  enlargement, acting like a bandage
upon it. The knowledge of this fact is available in the treatment
of the disease.
  When the tumour is of so large a size as to protrude beyond
the labia, it branches out on either side,  and, by pressing and
irritating the surfaces between which it lies, it not unfrequently
causes ulceration of them.
  Hitherto it has not been ascertained what circumstances pro-
duce  in the parts  a disposition to take on the  formation  of  this
disease.'  It might be conjectured, that an  injury inflicted upon
the os uteri in labour, either by the head of the child, or  by vio-
lent attempts made to dilate it, might become an exciting cause;
but many examples are to be  met with, in which such injury has
been done to the  os  uteri, and no such  disease has followed.
Married women who have never  been pregnant, nay, single wo-
men,  are liable to the complaint,  in whom no violence can have
been offered to the os uteri.
  It cannot be traced to any syphilitic cause. The common pros-
titutes of this metropolis are by no means more liable to it thaq
any similar number of women in different  stations of life.  The
disease arises  as often in the strong and  robust as in the weak;
in persons who live in the country, as in those  who inhabit large 
WATERY  DISCHARGE.
153
towns; in those whose situation in life obliges them to labour, as
well as in those who, from their rank in society, sometimes con-
sider themselves privileged to be useless members of it.
  No period of life, after the age of twenty, seems to be exempt
from the disease.  The author has known it fatal at the age of
twenty; and he has met with the disease at different periods of
life up to old age. The complaint may arise, perhaps, before the
woman  has reached her twentieth year, but  no such case  has
occurred in the experience of the author.
  It has  been observed above, that arterial blood escapes from
the tumour when injured; indeed the tumour appears to be made
up of a congeries of blood-vessels, and these  blood-vessels are
arteries; the infinitely  small branches of these  vessels, terminat-
ing upon the surface of the tumour, exhale  in the  most abundant
manner an aqueous fluid.
  Perhaps some small arteries near the os uteri may undergo
that  morbid  dilatation  of their coals, which is analagous to aneu-
rism in larger trunks, and thus the disease may be  produced.
Something similar to this takes  place in the  arterial, or blood-
red naevus, but here the surface,  being covered by cutis and cu-
ticle, no moisture of the  part is met with; but if the surface of
such a naevus should be injured,  arterial blood escapes.
  May such a state of blood-vessels  exist at  the time of birth,
remain concealed in early life from the very small  quantity of
blood which  circulates in the organs of generation  at this age,
and  be developed at that  period  at which  blood rushes with
greater force  and in  greater quantity, to enlarge these organs,
and in the female to render them fit for the performance of new
duties?
  It may be  that the increased  circulation which is  present at
puberty,  may not be  sufficient to elicit  the phenomena  of the
complaint; the stimulus of marriage may be  required in some,
whilst in  others, the further developement of the organs in preg-
nancy, or the exertions of labour may be necessary to call forth
the morbid symptoms of such  hitherto dormant disease.
  In a paper upon the subject  of the cauliflower-excrescence of
the os uteri, contained in  the third volume of the  " Transactions
of a Society for the Improvement of Medical and Surgical Know-
ledge," by the author's brother, the late Dr. Clarke, it is stated
" that he had never been enabled to find a specimen of the dis-
ease in any collection  of anatomical preparations; he sought for
it in vain in  the collections of the late Dr. William Hunter and
of the late Mr. John Hunter;  and  in all the inquiries which he
had  made amongst those who had the  best opportunities of find-
ing it in the dead body, he was  never able to procure a speci-
men of it."
                     u 
154
WATERY DISCHARGE.
   No one had seen a tumour resembling a cauliflower-excres-
cence in the dead body: why they had not will presently appear.
   Some years ago a lady died of this disease: she had been ex-
amined a short time before her  death; and in the vagina a tu-
mour of the cauliflower-excrescence kind was found, arising from
three-fifths of the circumference  of the os uteri: on the day fol-
lowing  that  upon which  she died, an examination of the body
was  made by the author in the presence  of his brother, and of
Mr. Alexander Sneddon.*
   Upon dissecting out the uterus and its  appendages, and slit-
ting open the vagina, no  tumour was found there; although, in
the last examination which was made in the life-time of the pa-
tient, an excrescence was discovered nearly as large as a hen's
egg: but, from  that part of the os uteri to which the tumour for-
merly  adhered, a soft, flaccid, slimy, whitish  substance,  hung
down,  which looked  like the faetal portion of the placenta of a
calf, after it has been macerated in water.  The body and fundus
of the uterus were sound.
   An attempt was afterwards made to inject this flocculent sub-
stance  with  size and vermilion, thrown into  the arteries of the
uterus;  but although the blood-vessels of the uterus itself were
abundantly filled with the injection, and although the flocculent
mass itself received the injection, the fluid escaped from its sur-
face as fast as it was thrown in from the  pipe of the injecting
syringe.
   The author has  the preparation at present in  his collection:
the flocculent mass is heightened in  colour by the small  quan-
tity of injection which remained in its vessels; but it floats lightly
in the  spirit  in  which the preparation is suspended, as it did in
the water in  which it was at first macerated.
   Margaret Pole, the mother of  eight children, discovered that
she was pregnant in  the beginning of the  year 1810.  From the
commencement of the pregnancy to  its termination, she  had a
profuse watery discharge  from the vagina, which was, upon any
trifling exertion, mixed with blood.
   The practitioner who was called to the patient on the first of
July, found  her in  labour, and  made the usual examination:
upon carrying his finger into the vagina, he found a large tumour
there, resembling placenta; and as, upon endeavouring to  ascer-
tain its extent, a large discharge  of blood  followed, it was deter-
mined  that the author should be called  in.  In  addition to the
hemorrhage,  the patient was constantly vomiting; from the con-
currence of which two circumstances a state of great exhaustion
was produced: the  pulse was very feeble and frequent, and oc-

  *■ An ingenious surgeon, to whom the writer is indebted for the drawings of
many of the diseases described in the first volume  of this work. 
WATERY DISCHARGE.
155
 casionally appeared to be lost, when an effort to vomit, or a vi-
 olent  struggle of the frame, which threatened to terminate  the
 existence of  the poor woman, again  excited  the  action of the
 heart, and a sort of half-existence was thus carried on.
   When the  author examined the patient, he found within the
 vagina a substance which nearly filled  it, and which felt like the
 placenta; but upon tracing this upwards, he ascertained that, in-
 stead  of coming down  through the os uteri,  as in presentations
 of the placenta, it actually  constituted a portion of it, so that
 there  was scarcely any part of the circumference of this opening
 to which the tumour was not attached. At this time the os uteri
 was not much dilated. It was agreed that the patient should be
 supplied frequently with nourishment,  and that the usual local
 modes of restraining uterine  hemorrhage in labour, with the ex-
 ception of delivery, should be resorted to.
   When the  patient had  passed  over a few  hours, the os uteri
 was more open, the uterus was in occasional  action, and there
 was a  profuse discharge  of a watery fluid, tinged with blood.
   Under this lamentable combination of circumstances, the ex-
 istence of a formidable  and fatal disease, and the presence of
 labour, the great question was, how the patient should be treated.
 The head was too low in the pelvis to admit  of the child being
 turned; to open the head would have been to destroy the child,
 supposing it to be still alive,  to afford  no  advantage to  the wo-
 man;  to perform the Cesarean operation, would have caused, in
 the deplorably weak state of the mother,  her  immediate death,
 and that when it was doubtful whether  the child was alive or not.
   As the tumour was evidently of the cauliflower-excrescence
 kind, and as it was  probable that, being  so,  it would  be dimi-
 nished in bulk by the pressure of the child's head in its descentt
 the contents of the blood-vessels being thus squeezed out, it was
 determined  to wait, and to  watch the progress of the labour, the
 friends of the  patient having been  informed of her perilous situ-
 ation.  Eventually,  that which was anticipated happened; the
 contents of the tumour were  squeezed  out; the child passed na-
 turally through the vagina;  but  the woman  was  attacked with
 other symptoms of a sinking frame; apthae appeared  upon the
 tongue and the inside of the cheeks, and she sunk upon  the third
 day after her delivery.
   The body was examined; and upon cutting open the vagina,
 the tumour had wholly disappeared, there remaining in  its stead
loose irregularly-shaped  flocculent portions  of matter,  which
arose from every part of the circle of  the os  uteri.  There was
nothing else found remarkable; and the uterus was as much con-
tracted as it is usually found to be  about three days after deli-
very. 
156
WATERY DISCHARGE.
  An attempt was made in this case also to inject the tumour;
but all efforts to do so were unavailing: the fluid escaped from
the surface, and from the interstices of the flocculent mass, as
quickly as it was thrown in by the injecting syringe.
  The  above cases  contain histories of a tumour  arising from
the os uteri, possessing a firm texture during life, but losing this
firmness after death.  The circumstances of the disease resem-
bling a portion of  the placenta, so as to  be  mistaken for it at
first, is too remarkable to pass without further notice.  A carci-
nomatous thickening  of the os uteri may exist during labour, and
the patient has been  destroyed very shortly afterwards, by ulce-
ration taking  place.  The author has  a preparation of this kind;
but a carcinomatous  thickening of the os uteri bears no resem-
blance to the cauliflower-excrescence, and its size  remains un-
altered by pressure, and undiminished by death.
  Why then  do the cauliflower-excrescence and a portion of
the placenta  resemble each other so closely, that the one has
been mistaken for the other?  They differ only in name; the
structure is the same. The placenta consists of blood in blood-
vessels; the cauliflower-excrescence  consists of blood in blood-
vessels. In a  presentation of the  placenta there is hemorrhage;
so there is when the cauliflower-excrescence  is injured.
  Nothing can be better marked than this similarity; and if there
was no  further evidence  to prove  that the nature of the disease
was a distended set of blood-vessels, it would be rendered suffi-
ciently probable from this resemblance alone.
  The vessels of the pia mater, in the dead subject, resemble  a
flocculent mass, when drawn out of the  interstitial  spaces be-
tween the convolutions of the brain where they ramify, and they
scarcely put on the  appearance of having been blood-vessels;
but, let injection be thrown into them, they readily become dis-
tended, and their real structure is  rendered immediately evident.
  In other parts of the   body, small blood-vessels,  very visible
during life, are emptied  of their  contents into the larger trunks
when death  takes place; nay, in fainting, which is a near ap-
proach to death;—for example,  in the membrana  conjunctiva,
the lips, the skin, and in  most parts of the body where the rami-
fication of small vessels  can be distinguished.
  If, in an examination, a small  portion  of the cauliflower-ex-
crescence be detached,  and if it be pressed between the fingers,
or macerated  in water, its volume will be found to decrease very
rapidly; in the one case  blood will be squeezed from the blood-
vessels, and in the other diffused through the water; and in both
a flocculent mass will remain, resembling the appearance of the
cauliflower-excrescence after death.
   That the  blood-vessels so distended in this disease, consist 
WATERY DISCHARGE.
157
principally,  if not wholly, of arteries, is to be collected from
their  contents, the colour of which  resembles that of arterial
blood, which is not returned into the general circulation  by the
termination of these vessels in small veins, but is carried off prin-
cipally in that profuse watery secretion which  causes  such  ex-
penditure of the powers of the frame.
   In  the case of  Margaret  Pole, last related, the tumour was
large  enough to fill the cavity of the vagina entirely, which may-
be accounted for by the greater determination of blood made to
the uterus in pregnancy by the hypogastric arteries. Reasoning
upon  this circumstance, il may be fairly presumed, that as what-
ever tends to increase the flow of blood to the uterus, aggravates
the symptoms of the disease, by increasing its volume;  so, what-
ever has the effect of rendering the circulation less active in this
organ, will diminish the growth of the tumour.
  Various attempts had been  made  by the writer to procure a
specimen of this disease,  which might illustrate its nature, in his
lecture-room; but  all his  efforts were fruitless.  The uteri taken
from the patients whose cases have  been described, and which
are in the  collection of the author, show the pulpy mass, but by
no means  demonstrate the appearance of the tumour during life.
  In  the removal  of some of these tumours by ligature, it has
been  hoped  that, upon the coming away of the ligature,  the tu-
mour would  have  been found in the  vagina; but this  hope has
not been realized; the supply of blood having been cut off by
the ligature, the blood has oozed from the tumour, and  all which
has been left has been a  small pulpy mass.
  The following case will serve as a correct picture of the  dis-
ease in its progress; its diminution by astringents; its  arrest by
the ligature;  its  ultimate termination in the destruction of the
patient, and  the appearances found after death.
  A lady, sixty years of age, the wife of  a physician  at  Bath,
had suffered under great  debility for some months, during which
time she had been liable to a profuse watery discharge.  The
symptoms increasing, and threatening her life, she came to Lon-
don, and was placed under the care of the author.  She was ge-
nerally anasarcous; had great difficulty of breathing, being inca-
pable of lying down, from an apprehension of suffocation.  The
pulse was very weak and irregular, and the lips and tongue were
bleached by the constant drain from the blood. The appetite
was nearly lost, and the powers of converting the small quantity
of food which was taken into nourishment were almost wholly
gone.
  These symptoms commenced six years before, and had gra-
dually increased to their  present degree. On examination, a tu-
mour of the  cauliflower-excrescence kind was found in the vagi- 
158
WATERY DISCHARGE.
 na, nearly large enough to fill that cavity.  By the frequent use
 of strong astringent fluids poured in the vagina, the discharge
 was in some degree controlled in the year 1811; but  in the sum-
 mer of 1812, alarming hemorrhage came on, which  lasted  dur-
 ing many days. These discharges of blood took place very sud-
 denly, (to use the patient's  expression) as  if some  vessel had
 broken.
   In  July, 1813, small  pieces of  granulated flesh came away,
 mixed with blood;  and the  wate y discharge was then so  con-
 siderable, that more than twenty napkins were required daily, to
 keep  the patient even tolerably  comfortable. Hectic fever  took
 place; astringents ceased to  produce any effect; the  tumour be-
 gan to project through the external parts; by the straining efforts
 of the patient at stool, splashes of arterial blood  came away; and
 the symptoms of weakness  now became so formidable, that it
 was evident the patient would quickly sink  under them, unless
 some additional mode of treatment was employed.
   As the danger depended upon the profuseness of  the watery
 discharge poured out by so large a surface, which was no longer
 controllable by even the strongest astringents, it was  proposed
 to the patient that a ligature  should  be applied round  the  base
 of the tumour, so as to remove it.  The patient was  willing to
 accede to this suggestion: a ligature, consisting of about a dozen
 threads of waxed silk, was passed round the excrescence, close
 to the origin of it.  On the seventh  day after the application of
 the ligature, it came away, but  no tumour  came away with  it.
 On examining the silver canula, by means of which the ligature
 had been applied, a small piece of  a  flocculent  substance was
 found adhering  to it.
   From this moment all discharge ceased, the dropsical swell-
 ings were absorbed, and the  patient  recovered  her health suffi-
 ciently to return again into society. . She was even well enough
 to undertake a long journey.
   It had, however, been explained to her, that the disease might
 return; and in the summer of 1815, the originally diseased sur-
 face gave rise to another tumour  of a similar kind, which at length
caused the return of the former  symptoms.
   The patient became very solicitous that  the operation, from
which  she  had derived so much  temporary benefit, should be
repeated, which was accordingly done.
   A ligature was applied round  the  tumour, which was  now
about the size of a  hen's egg, and it was tightened so as to in-
terrupt the circulation,  but not so as to cut through the tumour
at once.  On the second  day the ligature was drawn yet  more
tight;  and upon tightening it upon the third day, it came away.
On introducing  the finger into the vagina, the tumour was found 
WATERY  DISCHARGE.
159
loose:  it was turned out of the vagina by means of the finger;
and it was immediately placed in alkohol, so as to coagulate its
contents perfectly, and, by hardening it, to preserve its shape.
  By these means a specimen of the disease was procured, from
which  the engraving in this work has been made. It is the only
preparation which  the author has seen of the disease  as it ap-
pears during life.  The engraving consists of the half of the tu-
mour only, as the author was desirous to place a portion of it in
some national collection of anatomical preparations.  The tumour,
when it was  separated, was  of a brownish  red colour. Relief
was again  afforded to the patient by the second operation: the
watery discharge ceased, as might have been expected, its source
being removed.
  A new set of symptoms, at the end of a few months, present-
ed themselves;  pain in the  hips  came on, with  cramp at the
lower part of the abdomen, vomiting, and a discharge of muco-
sanguineous fluid, sometimes mixed with matter; and shortly af-
terwards the  patient died.
  It was evident that some new disease had formed.   The ex-
amination made of the body after death will show what it was:
—An incision being made through the parietes of the abdomen,
the intestines were found perfectly healthy, and unconnected by
adhesions; but there was in  the left hypogastric region an oval
tumour, of the size of a large melon; this was connected to the
loins on each side by a separate adhesion, and at its upper part
it adhered to the omentum.  On attempting to make an incision
into this tumour, it was found that the knife would not pass deep-
er than an inch and a half, and in some parts not deeper than
half an inch, as it met with obstruction from bony  matter.  The
substance which surrounded this bony matter was  dissected off,
and it was found to resemble layers of coagulating lymph. Upon
sawing through the rest of the tumour, it was found to consist of
a thin  layer of osseous matter, encasing a substance similar to
that  which covered its external surface. There was no connex-
ion of this tumour with the uterus, except what must have been
the effect of former inflammation, in consequence of which co-
agulating lymph had been thrown out, so as to glue the surfaces
together: a very small quantity of flocculent matter appeared to
project from the surface of the os uteri. The cavity of the uterus
was larger than natural. The fallopian  tubes and ovaria were
perfectly healthy. 
160
WATERY  DISCHARGE.
 On the Symptoms of Cauliflower-Excrescence of the Os Uteri.

  One of the first notices of this disorder is in the patient find-
ing the parts more moist than usual; little attention, however, is
paid to this circumstance, till the quantity of the discharge be-
coming more considerable, the patient is obliged to employ some
means of  absorbing it, and  resorts, perhaps, to the more abun-
dant use of cold water, or to the usual family receipt of isinglass
and milk.  Still the discharge becomes more abundant; but being
unattended by pain or by fastor,  the complaint is neglected, until
at length  a quantity of blood comes away with it, or the patient
finds  that the  colour of  her cheeks is fading, or the strength  of
her frame diminishing; then all at once she takes alarm, and  flies
to medical assistance.  Perhaps  the entire absence of pain, and
of other symptoms, leading the woman to treat the disease lightly
at first, is the  reason why so  few opportunities are afforded  of
examining the tumour when of a small size.  The quantity of the
discharge  is in  proportion to the superficies of the tumour, and
the action of the  blood-vessels of the uterus and  neighbouring
parts: it may only be in quantity sufficient to render the woman's
person uncomfortable, or it  may require the change of twenty  or
thirty napkins  daily.  A small blood-vessel now and then allows
some of its contents to ooze out, which, mixing with the  dis-
charge, gives a shade of colour to it, or perhaps a faintish odour;
but when  no blood is mixed with the discharge, or when the
quantity of the watery discharge is so great as to run  off as fast
as it is secreted, there is little or no smell attached to it.  If the
patient should be a married woman, living with her husband, it
will be found that  hemorrhage always succeeds intercourse;  and,
indeed, in some instances the slightest  exertion of the body,
coughing, sneezing, or straining when at stool,  will produce a
discharge  of blood from  the blood-vessels of the tumour, which
sometimes becomes  very  profuse.  When  a  large quantity  of
blood has been thus lost, it is frequently observed, that the wa-
tery discharge diminishes, the distention of the vessels of the tu-
mour being taken off'. As the disease proceeds, the system be-
comes weakened  from loss of blood,  and the stomach partakes
of this weakness.  The digestion  is performed imperfectly, spon-
taneous changes take place in the food,  and air is either thrown
up in frequent eructations, or the belly becomes tympanitic.  In
some measure the disturbance of the stomach may be the effect
of sympathy of that organ with the  uterus, but the symptoms
very much resemble those met with  after  large hemorrhages.
Hysterical symptoms are produced, and  all  that host of inexpli-
cable symptoms which accompany cases of impaired digestion. 
WATERY DISCHARGE.
161
increasing the patient's stock of bodily and mental misery.  As
the weakness  increases, the action of the  absorbent vessels di-
minishes, and depositions of fluid form in  different parts of the
body, obeying the laws of gravitation, producing oedema of the
feet at night,  and puffiness of the  face and eyelids in the morn-
ing, the particular effects  produced  by such accumulations of
fluid being regulated by their quantities, and determined by the
situations in which they are deposited.  So that the patient may
be destroyed by water in the chest long before she would have
been exhausted by the disease itself.  In some cases an alarming
hemorrhage  takes place,  producing a state of syncope, from
which the patient may not rally.
  Dr. Clarke has remarked, that he never met witii a single in-
stance in which the tumour, upon examination,  was Igss than a
blackbird's egg: this has been before accounted  for; it produces
at first so few symptoms.
  In  many cases, too, the  practitioner overlooks  the  disease,
contenting  himself with treating symptoms without thinking of
their cause.
  In one case, which was attended by the late  Dr. Clarke and
the author, the patient, a lady about forty years  of age, lost her
sense of vision a few days  before her death.  No change in the
appearance of the eyes was visible. It rarely happens that great
emaciation attends the complaint, the patient being drained to
death by the  profuse secretion, or suddenly destroyed by hemor-
rhage,  long before all her fat will have been absorbed.
  On inspecting  the  bodies of several women,  who have been
destroyed  by this disease,  a layer of fat of considerable  thick-
ness has been found covering the  abdominal muscles. How dif-
ferent this  from the case of a patient destroyed by ulcerated car-
cinoma of the uterus, in whom scarcely a  bone can be found, in
which  it is not easy to see the form and processes, nearly as well
as in a skeleton!  Yet, as in this  complaint, a discharge is pre-
sent, as now and then it is foetid, as a tumour is  found upon ex-
amination,  and as the disease has always, sooner or later, a fatal
tendency, it has  been too frequently confounded  with carcinoma.
The prognostic, as to the ultimate event, it is true, must be the
same;  but the terms  sooner or later admit of considerable lati-
tude, and it is a great comfort to be enabled to lengthen life un-
der  such  circumstances.  It is not here, as in  carcinoma, that
whilst life is lengthened by art, distress and suffering is eked out
with it.  A patient labouring under the cauliflower-excrescence
may pass,  nay, she may enjoy, several years of life, if she will
be content to make some sacrifices.
  As the enlargement of vessels in other  situations is much in-
fluenced by pressure, so it will be found, that the compression
                     x 
162
WATERY DISCHARGE.
of the sides of the vagina will greatly retard the growth of this
tumour.  Now as the quantity of the watery discharge depends
upon the extent of the surface of the tumour, and as the danger
of the patient is in  proportion to the quantity of the discharge, it
follows that whenever the vagina  has lost  its  tone, and  the tu-
mour has thereby been  little subject to compression, the prog-
nostic to be given to the friends of the patient, as  to the proba-
ble  duration of life, should be less favourable, than when  the
sides of the tumour are  supported by the  sides of a more con-
tracted canal.  Added to this, the very pressure of a contracted
vagina is an evidence that the constitution still  possesses a con-
siderable degree of vigour: so  that the  capacity of the vagina
forms, in  this, as well as in many other  cases, by no  means a
bad  criterion of the strength remaining in the constitution.*
   When the  tumour occupies only a small part of the os uteri,
the opinion to be given  should  be more favourable, than when
the whole  circumference of the opening is involved in the dis-
ease. The danger may also be increased by any violence inflict-
ed upon the part,  as  by the  pressure of the child's head in la-
bour, or by any increased action  going on  in the vicinity, as by
pregnancy. The symptoms in some cases  of the disease are di-
minished more easily than in others, of which circumstance no
knowledge can be  obtained till  the experiment has been made;
the  greater the effect, therefore, which local remedies produce
in controlling the discharge, the longer will the disease continue,
ceteris paribus, without destroying the  life of the patient.

  ' Thus in cases of great uterine hemorrhage in labour, the vagina will some-
times be so dilated as readily to admit the hand.  Practitioners avail them-
selves also of the knowledge  of this fact, in those cases of difficulty in labour,
which depend upon a contracted and  unyielding vagina. In  this case the loss
of a large quantity of blood by the lancet affords great relief to the patient, the
vagina dilating  afterwards so quickly that the labour is often very speedily
terminated. 
WATERY DISCHARGE.               163
          Treatment of the Cauliflower-Excrescence.

   If a woman labouring under the above disease is left to her-
self, or if the symptoms do not meet with attention, the  tumour
will increase in dimensions, and partly by the perpetual watery
discharge, and partly  by the occasional attacks of hemorrhage,
will shortly prove fatal.
   The enlargement of the tumour will  be greatly retarded, by
diminishing the action of the fulness of the blood-vessels of the
neighbouring parts.  There is reason also to believe, that the size
of the tumour will shrink under judicious management, which is
more than can be expected in most instances of chronic  morbid
enlargements of the viscera, when the tumour is  composed of
more solid materials;  and if the patient has the good fortune to
take notice of the earliest symptoms of the complaint, it is pro-
bable that, by a steady perseverance in that kind of management
which will form the subject of this chapter, the farther progress
of the disease may be put a stop to.
   Local  blood-letting is a most valuable remedy, and great reli-
ance is to be placed upon it.  The region of the sacrum and the
hips may be scarified, and cupping-glasses afterwards applied;
the quantity of blood to  be taken away must be regulated by the
size and  degree of resistance in the tumour, and by the quantity
of the watery discharge, (which is always a measure of the ex-
tent of the disease) regard being paid at the same time to the
strength of the patient. At the same time it must be recollected,
that if, by the loss of  eight or ten ounces of blood by cupping,
the quantity of the watery discharge can  be diminished from four
ounces to  two ounces  daily,  the patient will, at the end of a
fortnight, possess more power than if she had lost four ounces of
blood by cupping,  and  the quantity of watery discharge  had
been diminished to  three ounces daily.
  By unloading the vessels of the tumour, they will also be less
likely to  burst spontaneously,  in which case no estimate can be
formed of the quantity of blood actually lost.
  But, although local  bleeding is so valuable a remedy in many
cases, it may, when employed  injudiciously, hurry the patient's
dissolution. Great circumspection, therefore, is necessary in the
direction of it.  It should not  be employed when  much  oedema
of the feet is  present, or during the continuance of any symp-
toms indicating great  debility.  Neither should blood-letting in
any case be carried farther than is just necessary to produce the
intended effect, particularly when il is considered that the art  is
in possession of many other powerful auxiliaries in curbing the
progress  of this malady. 
16-1!
WATERY DISCHARGE.
  If the patient should be a strong woman, and if  the disease
has not been of long duration, twelve or fourteen ounces of blood
may be taken  away: if she should possess less strength of con-
stitution, it may be sufficient to order the removal of six or eight
ounces only; and  to repeat this once in three weeks or a month.
The application of leeches is to be very little depended upon.
  All general  and local stimuli are to be carefully shunned, or
the intention of the bleeding will be defeated.  The diet should
be of the mildest  kind, such as puddings, white fish, or vegeta-
bles. Wine should be absolutely proscribed.  If the patient should
be married, she should be separated wholly from the bed of her
husband, to which she  should never return.
  The state of the bowels should  be carefully watched, and, if
possible, they  should be so regulated that the patient may have
one motion daily,  of such a consistence as will be voided without
the least attempt  at straining.  This is a very important caution
in many diseases  of the uterus; but in none does it deserve the
same strict attention as the cauliflower-excrescence.  The author
has known several instances where a profuse discharge of blood
has followed the expulsion of a costive motion. Fruit taken be-
fore breakfast, honey eaten instead of butter, a little manna eaten
with a few blanched almonds, or a tea-spoonful of electuary  of
cassia taken occasionally, will commonly obviate any inconveni-
ence which may arise from costiveness.  If a more powerful me-
dicine should  be required, the following may be tried.

            R Magnes. sulphat. 3vi.
              Infus.  rosae  giii.
              Aquae carui giift.
              Syrupi  £tf.
              Acid, sulph.  dil. 3fl.  M.
Sumat cochl. ii. vel iii. mane quotidie.

  The enlargement of the tumour may be greatly diminished,
and  the discharge consequently lessened, by the  application  of
cold to the outside of the pelvis,  and  by the injection of  cold
fluids into the  cavity of the vagina. Cold water may be applied
to the external parts of generation, to the pubis, and to the loins,
by means of a sponge; and this may be done,  not once or twice
only in the twenty-four hours, but several times: by keeping the
parts  in  this way constantly chilled,  the  blood-vessels will  be
contracted, and the  advantages  resulting from such a mode of
treatment will  soon be made  evident, in the diminution of the
quantity of the discharge, and in the improvement of the  consti-
tutional health.
  The recumbent posture ought always to be insisted upon; and 
WATERY DISCHARGE.
165
the utility of it should be explained to the patient by familiar il-
lustrations, as by adverting to the  different size of the  veins of
the hand when held up and in a depending position.
   All medical men at all conversant with human nature  are well
aware, that patients who will  readily submit to an operation, or
to a long continued course of medicine, will very reluctantly yield
to any privation, or be governed by moral directions, the imme-
diate tendency of which they  do not understand.
   The applications to be made to  the tumour itself, with a view
to cause  contraction of its blood-vessels, and to influence the se-
cretion from its surface, should consist of astringent substances
in different forms, as may be best adapted to the variety  of cases
which occur.
   In the history which has been given of the cauliflower-excres-
cence, it has been observed that the tumour increases more ra-
pidly in those cases where the tone of the vagina is the least, and
vice versa; so that  the vagina acts as a supporting  bandage in
varicose  veins of  the legs, or as pressure upon those  tumours
called naevi materni.*
   For the purpose of applying astringent fluids to the vagina,
under ordinary circumstances, the  common female syringe (vide
Part I. plate) is sufficiently useful;  but patients labouring under
the cauliflower-excrescence, as well as  those in whom  there is
any abrasion  of surface,  should be very careful how they use
this instrument.
   A woman who had a cauliflower-excrescence of the  os uteri,
was very much weakened by  the watery discharge attending it.
The author  recommended an  astringent injection, which was
used for  some time, but afterwards discontinued in consequence
of the patient observing  that  it always produced a discharge of
blood: upon inquiring into the manner in which it was  employ-
ed, it appeared that  the pipe of the syringe  was carried up so
high as to injure the  tumour,  in consequence of which blood fol-
lowed.  A cylindrical syringe, the diameter of which  is about
three quarters of an inch, the  extremity being rounded  off, may
be used  for this  purpose, and the  patient should be cautioned
not to introduce it farther than an  inch, or an  inch and  a half.
   Even  if the tumour should be touched with this form of  in-
strument,  it  will be less likely to be injured by  the  diffused

  * The author has not been so fortunate as Mr. Abernethy, in removing many
of these congenital  marks by pressure, although he  has frequently retarded
their growth by means of a compress and strips of adhesive plaister; but they
have always returned when the pressure has been discontinued; and in many
situations the parts beneath the nsevus are not sufficiently resisting to allow of
the pressure being carried  to any great extent.  Nevertheless the  suggestion
was worthy of the mind of that humane and intelligent surgeon, whose vera-
city has never been suspected, and  whose integrity has never been  shakcu. 
166
WATERY DISCHARGE.
pressure made by so large a surface, than by the  partial  pres-
sure caused by the extremity of a small one. The common fe-
male syringe may be used with less risk, if a handkerchief or a
piece of linen is previously wrapped round it at the distance of
about two inches from its point.
  In that aggravated form of the complaint in which the tumour
nearly reaches the  external parts, the patient should lie  down
upon her bed with her hips  raised, and a small quantity of the
astringent fluid should  be poured in between the labia;  a  com-
mon earthen  butter-boat may be used for the purpose, and  there
can scarcely  be found a belter instrument.
  When the  tumour has  actually protruded,  compresses dipped
in an astringent fluid may be  applied, or the  surface  may be
lightly touched with a soft sponge wetted with it.
  A few formulae of astringent injections applicable to tfiis case
are  subjoined.

            R Zinci sulphat. $$.
               Aquae rosae, ^iv.
               Aquae distillat. 5xvi.  M.

            R Aluminis, ~iii.
              Aquae distillat. 5xv.
              Mucilag. gum. acaciae, 5i. M.

  The addition of a small quantity of mucilage  renders the ap-
plication sometimes more  useful,  by enabling a portion of the
fluid to be  longer retained.

       Or—R Infus. lini, ^xv.
               Aluminis, 3ii»
               Tinct. kino,  5i. M.

            R Cupri sulphat. gr. x.
               Aquae flor. Samb.
               Mist, camphorae, ^vi.  M.

  Solutions of the mineral astringents in decoctions of astringent
vegetables, constitute applications possessed of great power; as3

            R Cort. granat. contus. 5$.
               Aquae distillat. ixiii.
coque per sextam partem horae et  cola, dein adde  liquori  colato
aluminis, ^ii.

            R  Gallarum, Jf?.
               Aquae distillat. |xviii.
coque ad ^xvi. 
WATERY  DISCHARGE.
167
            R  Liquoris colati, jxvft.
               Sp. roris marini, £$.
               Aluminis, 3iii- M.

            R  Decocti quercus, fci.
               Tinct. catechu, ^{j.
               Aluminis, 3ii*
               Zinci sulphat. ^i.  M.

   The efficacy of the latter formulae in a great measure depends
upon  the tannin. As this principle has the power of coagulating
albumen, so as to form an insoluble precipitate, it becomes ne-
cessary to  prepare  the  patient for a circumstance which may
Otherwise occasion great alarm in her  mind,—the appearance of
thin, whitish, or ash-coloured flakes which will  come away from
time to time. These are frequently thought to be portions of the
body, and the agitation of the patient's mind has been  very con-
siderable, until it has been quieted by some explanation.
   In some patients the membrane of the vagina is so irritable,
that it will  not bear the application of the mineral astringents. In
such cases a mixture of decoction of oak-bark and linseed tea
will form a less irritating lotion.  The  principles of management
being laid down, the means  must be  variously modified, as the
circumstances  of each  individual case may require,  or  as the
skill of the medical attendant may suggest.
   The  foregoing directions  have  for their object the diminution
ofthe expenditure of the powers  of the frame;  but those powers
may require to be recruited; the disease may not have been dis-
covered until great exhaustion of these powers may have taken
place; and it will be necessary to have recourse to the employ-
ment of some light tonic. The muriatic and sulphuric acids are
here very appropriate medicines.  Indeed, custom has so  autho-
rized  the employment of the latter in  cases of bloody discharges
from the uterus, that they are frequently given by ignorant per-
sons indiscriminately, blended in  such a manner with medicines,
possessing directly opposite properties, as  to  constitute ineffi-
cient, or perhaps very injurious compounds.*

  * In abortion, many practitioners do  not allow themselves time to inquire
what object they have in view: whether the accident is threatened by prema-
ture inordinate action  ofthe muscular fibres of the uterus, or by a separaUoa
of a part of the ovum from the uterus; whether the ovum be living, and may
remain, or whether il be dead, and must come away; whether the patient be
strong, or whether she be weak. Whatever be the concomitant circumstances
of the case, the only thing thought about is that a woman is miscarrying who
ought not to miscarry; and this is the signal for the exhibition of sulphuric
acid and infusion of roses, joined to laudanum; so that there is one ingredient,
the sulphuric acid, (a tonic) which increases the power of the muscular fibres
ofthe uterus to expel its contents, and another ingredient, opium, the known 
108
WATERY DISCHARGE.
            R Acid muriatici, gult. viii.
              Aquae distillat. 5i{$.
              Syrupi cort. aur. 3i. M.
  Fiat haustus ter die sumendus.

            R Acid sulphurici, gutt. vi.
              Infus. rosae, jig.
              Aquae  carui, 5$.
              Syrupi, 3i. M.
  Fiat haustus ter die sumendus.

  Sulphate  of zinc may be  usefully employed; but care should
be taken not to exhibit this  medicine  so as to produce vomiting,
which might be highly injurious, by accelerating the circulation.
It should be given in combination with some essential oil, which
will  reconcile the stomach  to its  use, when it might otherwise
disagree;  and it will be found to agree better in substance than
in solution.

            R Zinci sulphat. gr. xv.
              Extr. humuli, 3i.
              Ol. cinnamomi, gr. iii. M.
Dihgenter et divide in pilulas xv. aequales,  e quibus sumat unam
bis die.

  Decoction of bark may form the vehicle for the acids which
have been before recommended, or it may be taken in the form
of draught after the pill.

            R Decocti cinchonae, 5i$.
              Syrupi cort. aur. 3,i. M.

  The author is justified in repeating, that by a strict attention
to, and compliance with, the rules above suggested, nearly every
case of this  disease may be made  more tolerable; and, perhaps,
such a change wrought in the size or the actions of the excres-
cence, in a  few instances, as to remove all the symptoms.
  A lady, apparently about  two-and-thirty years of age, (a friend
of Mr. Cooke, a respectable surgeon  at Brentford) laboured un-
der a continued  profuse watery discharge, mixed occasionally
with blood: her constitution appeared greatly weakened, she be-
came very pale and emaciated, and together with a slight degree

effect ot which is, to take off the contraction of muscular fibres, with which
view it is exhibited in the passage of a gall-stone, or of a piece of urinary cal-
culus, and also in cases of strangulated hernia, to render the return of the in-
testine more easy. 
WATERY  DISCHARGE.              169
 of swelling of the ankles, she was liable to great palpitation of
 the heart and shortness of breath. As her weakness increased,
 she sought relief from tonics and  a stimulating diet, under which
 plan the disorder increased. An examination being made, a mass
 was found to project from the surface of the os uteri, from which
 a  quantity of blood issued when  it was pressed by the finger.
 Syncope took place in consequence of this discharge of blood,
 although the quantity was very trifling. The tumour had no re-
 gular form, and as far as the author could ascertain, the whole of
 it  could have been contained  in half a walnut shell. The patient
 was desired to confine herself strictly to the sofa, to use cold wa-
 ter in a lavish manner to the pelvis, and to  throw a strong astrin-
 gent injection into the  vagina; she was directed to give up the
 use of wine, to  live upon farinaceous food  and vegetable jellies,
 and to lose five ounces of blood from the  sacrum by cupping,
 when she had recovered from the effects of her journey to the
 author's house.
   Some weeks elapsed  before the author again  saw the patient;
 her watery discharge was considerably lessened, and the bloody
 discharge had entirely ceased: the ankles were no longer swell-
 ed, and the general health was improved.  The patient was de-
 sired  to repeat the cupping, and to continue the former  system
 of management.  Once in about  six weeks or two months the
 author has seen the patient, who has followed up the same mode
 of treatment, occasionally losing some blood from the sacrum by
 cupping.
   At  the termination of about  two years from the time at which
 the author first  saw the  patient, and after an interval of three or
 four months, she again called upon him, when, so great was the
 improvement in her appearance, that he hardly knew her. There
 had been no watery discharge during many months,  and  the
 menstruation, which had been interrupted by the weakness of
 the frame, had now become perfectly regular; the only medicine
 which had been taken  during the latter part of  this period, was
 half a drachm of pulv. cinchonae twice a-day. As the case was al-
 together a very extraordinary one, it became very desirable that
 an examination  should  be made. The vagina was  so much con-
 tracted by the continued use of the astringents, that it admitted
 the finger with difficulty; on carrying  the examination farther, no
 difference could be felt  between the os uteri of  the  patient and
that of a woman in  perfect health.  Such  are  the facts of this
case:  in reviewing it, every one conversant with diseases of the
uterus, must acknowledge that it was very extraordinary in its
termination. No mystery of treatment hangs over it; very little
 medicine  was given, except what has  been mentioned: a few
grains of hyoscyamus or conium to allay irritability, a little Ep-
                    Y 
170
WATERY DISCHARGE.
som salt to regulate the bowels; and when little else than weak-
ness remained, a few drops of tincture of muriated iron twice a-
day.  To the local  blood-letting, the horizontal posture, and the
use of  astringents,  then, must be attributed the removal of this
disease, which had all the characters of the cauliflower-excres-
cence.
  A lady, about forty years of age, who was a patient of Mr.
Tegart, was much  reduced by a perpetual drain of a watery hu-
mour from the vagina. Whenever she took exercise, blood came
away mixed with the other discharge. The skin of the patient
was perfectly blanched:  until she fell under medical manage-
ment, she had eaten meat, and drank wine, suspecting that the
weakness  of constitution produced the discharge.
  An  examination was  made, and,  as was  expected, a  cauli-
flower-excrescence was found as large as a hen's egg: similar
means  to those recommended in the former case were employ-
ed, and with a similar diminution of this discharge.
  The patient now thinking  herself recovering, determined,
against the advice  given to her, to go into the country. The mo-
tion of the carriage, during a journey of sixteen miles, produced
hemorrhage, which continued;  and the  patient  was thankful
when she found herself again upon the sofa in  London.  Aware
ofthe  imprudence of having made the experiment, she then be-
came rigidly attentive to all  the  rules laid down, which had for
their object the intentions contained in the history of the treat-
ment of this  disease.   The  discharge has greatly diminished;
during the space of several weeks  there was no loss of blood;
the patient has been allowed to take a little light animal food,
and a  small quantity of claret;   and there is reasonable ground
for hope that some favourable change has taken place in the tu-
mour,  either as to  the membrane which covers it, or the blood-
vessels which compose it.
   In some instances of patients who labour under cauliflower-
excrescence, all the  resources  of the medical art are futile; no
check  can be imposed  upon the discharge by astringents, how-
ever powerful as to strength: still,  even in such cases, the liga-
ture holds out a prospect of relief, which has now and then been
realized.  The diseased surface of the os uteri  may, and proba-
bly will,  regenerate the fungus;  but a considerable  length of
time may elapse before a tumour of a large size may form; and
in the  interim,  by  the removal of the secreting surface, the dis-
charge will be restrained, and time will be afforded for the pow-
ers ofthe woman  to be recruited.
   A case has been related  where the utility of such a mode of
treatment has been proved in the person of the widow of a phy-
sician  at Bath. 
WATERY DISCHARGE.
171
  The operation is the s^me as that recommended  for polypus
of the uterus, and  described  in the first volume of this work.
More care is required in  applying the ligature round the base of
a cauliflower-excrescence than round the neck of a polypus, be-
cause the cauliflower-excrescence is so likely to bleed upon the
least rough treatment.
  The shield which the  author recommended to be attached to
the polypus  canula, is not so necessary  in performing the ope-
ration for this disease,  because the  tumour will  be  cut through
in a much shorter time, and it will hardly be necessary to tight-
en the ligature often.  The objection to the use ofthe shield in
this operation, is the possibility that the weight of it may tear
through the tumour, before the  blood has coagulated in the  ves-
sels above.
  After the removal ofthe disease, it is  recommended that the
vagina should be washed out with cold water, and that a solu-
tion of alum in a strong decoction of oak-bark should be thrown
into the vagina twice or  three  times a day, the  external orifice
being blocked up  with a dossil of  lint, so  as to prevent the too
sudden escape of the fluid.
  A weak solution of nitrate of silver, or of sulphate of copper,
may be preferable in some cases to  any  other injection:  it  may
be used in the following  proportions:—

            R Argenli nitrat. gr. xii.
               Aquae distillat. ixii.
                           or,
            R Cupri sulphat. gr. xviii.
               Aquae rosae, ^xii.

  In some cases it may  be useful, especially when  the vagina is
irritable, to introduce a  piece of lint wetted  with  this solution
into the vagina, and to carry it up to the diseased part of the os
uteri.  By such means  a slight degree of inflammation may be
excited in the blood-vessels, so as to produce a consolidation of
the parts  diseased; and  thus the regeneration ofthe  tumour may
be more  tardy.
  However favourable appearances may be in that part of the
uterus which can  be examined by the  finger, there may  exist
out of reach, and  consequently  without the  knowledge of the
practitioner, morbid changes of structure,  which may of them-
selves  prove  fatal. 
172
WATERY DISCHARGE.
            HYDATIDS OF THE UTERUS.

  In the cavity of the uterus  small vesicles containing a limpid
fluid are sometimes met with, constituting the disease called Hy-
datids of the Uterus.  These vesicles vary considerably in size,
from that of a small currant to that  of  a large grape. They are
connected with  the uterus,  and  with each other, by small fila-
ments; and  portions of a  substance  resembling partly blood,
and partly coagulating lymph, are frequently mixed with  them.
A similar substance is attached to the internal  part of the ute-
rus, from which the  footstalks of  the hydatids grow.  As the
number of these hydatids increases, the cavity of the uterus be-
comes more capacious; and when, at length, the uterus has ac-
quired a large size, it seems to be offended by its contents, and
contracts upon them.
  The cause of this complaint has not been ascertained: it some-
times appears as a morbid condition of the opake membranes of
the ovum; and  in such cases interfering with  its functions, it
destroys the vitality of that body, and thus produces abortion.
  It is probable that  the existence  of pregnancy is not necessa-
ry for the production of this disease; it has  been believed to
exist independently of this state;  and  perhaps a morbid condi-
tion  of organized coagulating lymph  may have the power of
originating  this  disease under certain circumstances, but what
these circumstances are, is not known. Hydatids are met with
in other parts of the  body, but no very probable conjecture has
been offered for their production. In many cases these vesicles
possess a power of contraction; but whether this power has ever
been observed in the hydatids of the uterus, the author does not
know; he believes that it has not. It may  admit of a doubt
whether, in  consequence of a morbid condition of the  ovaria,
some separation of the corpora  Graffiani may not induce  the
complaint.  It  has been  suggested, that diseases of the ovaria
may originate in consequence of the excitement of the  genital
system, and the opinion seems to be entitled to some regard.
  Hydatids  of the uterus do not appear to produce any peculiar
symptoms, with the exception of one to be  mentioned hereafter.
The greater number  of the inconveniences attending  the dis-
ease arise out of the pressure made by the enlarged uterus upon
the circumjacent parts, such as retention of urine from compres-
sion of the meatus urinarius; constipation of the bowels from
compression of the rectum; oedema and cramp ofthe lower ex-
tremities. These symptoms, however, are  not  necessarily pre-
sent ; and instances have occurred in which they have been alto-
gether wanting. 
WATERY DISCHARGE.
173
  When the cavity of the pelvis can  no longer contain the en-
larged uterus,  that viscus will  rise into the cavity of the  abdo-
men, and may be felt as a circumscribed  tumour through the
parietes.
  The function of menstruation is usually interrupted.   This
might be expected upon the supposition that the complaint was a
disease of pregnancy: but it  will probably be found that, when-
ever  the mucous membrane of the  uterus is  disposed to  throw
out an opake membrane, resembling coagulating lymph, such as
the decidua in pregnancy, or those flakes which are separated in
painful menstruation, the secretion of the  menstruous fluid is in-
terrupted. In painful menstruation,  during  that period at  which
such flakes are separated, the secretion is  very scanty; but after
these flakes  (which sometimes form perfect casts of the  cavity
of the uterus) have been separated, which usually  happens  about
the  second day of the period, the menstruation  becomes more
abundant.
  In  the examination of a patient labouring  under  hydatids of
the  uterus, the body of this viscus will be  found  enlarged, and
suddenly bulging out from the upper part of the cervix.  All
these symptoms attend other enlarged states of the uterus; but
there remains to be mentioned one other symptom which serves
to distinguish this disease from all others, and  from  pregnancy,
—and this symptom is the discharge of an almost colourless wa-
tery fluid. This watery discharge is to be distinguished  from that
which attends the  cauliflower-excrescence, by the  irregularity
and suddenness of its appearance and cessation; being produced
by a rupture of one or more of the coats of  these hydatids, in
consequence of the occasional  contraction  of  the uterus   upon
them, or of  any sudden violence, as in the act of coughing or
sneezing; whereas the  discharge from the cauliflower-excres-
cence, being a secretion from its surface,  is constantly escaping.
The  fluid watery discharge may be  distinguished from  those
splashes of urine which sometimes come  away  from  pregnant
women, by being wholly inodorous.
  In  some cases, the size  of the uterus  increases rapidly, in
others slowly; but in all, sooner or later, the parietes of the ute-
rus, being irritated  by the distention of the cavity, are excited
to contraction.
  From this period of time, a process resembling labour com-
mences;  the os  uteri is dilated; the hydatids are expelled by
periodical pains; and then, for the first time, danger presents it-
self in the form  of  alarming  hemorrhage.  This hemorrhage is
more frightful  than  that which  follows the removal of the pla-
centa from an uncontracted uterus; and  the  reason is obvious,
the  placenta covered only a limited space of the internal surface 
174
WATERY DISCHARGE.
of the uterus, whereas  the  hydatids spring from every portion
of the cavity.
   No means have  been hitherto discovered of curing this dis-
ease artificially, or of arresting its progress towards  its  natural
termination. The patient is to be informed of the nature of this
disease, and the event  is to be patiently waited for.  As symp-
toms arise, they are to  be treated as.their nature  demands; and
the practitioner will best perform his duty  by watching over the
complaint, and by  doing no  more than is absolutely required.
But when  the period  arrives at which the uterus is striving to
unload itself of its contents, then all his skill and  energy  will be
wanting, and all  his efforts will  be called forth to control the
hemorrhage, and  to sustain  the powers ofthe constitution.  With
this view, the patient should be kept perfectly quiet in the  hori-
zontal posture; she  should not be allowed  to take any stimulat-
ing food, or drink.  Cold applications, such as cloths dipped in
vinegar  and water, or in iced water, are to  be made to the  loins,
abdomen, and external organs; and portions of ice  (their  acute
edges being rounded off by being held in  the hand) may be in-
troduced into  the vagina, or into the  uterus.  Let it not, howe-
ver, be  forgotten, that the great  remedy for uterine  hemorrhage
is uterine contraction, and every possible  mode of exciting this
is to be put in practice. The application of a bandage round the
abdomen has sometimes the power of exciting this contraction;
but if the hemorrhage should continue profuse, and if any portion
ofthe hydatids should  remain in the uterus, an attempt should
be made to remove these, in order to produce  complete con-
traction of the muscular fibres.
   Two or three fingers, or the whole  hand, should be covered
with pomatum, and carefully introduced into the uterus, and car-
ried up between the sides of the uterus and the hydatids, which
are to be detached  from the part to which they adhere by the
most gentle efforts.   The mass being  now included in the hand
of the operator,  is to be brought out of the uterus,  the surgeon
recollecting always, in the  performance of this  operation, that
the degree to which the os uteri is dilatable without laceration,
is in proportion to the size of the whole uterus, both in pregnan-
cy, as well as in this disease.   So that, supposing the uterus in
this disease to be enlarged  to the size of that viscus in the sixth
or seventh month of pregnancy, the whole hand  of the operator
may be, if necessary,  introduced through  the cervix; whereas,
in smaller dimensions  of the  uterus, if any  attempt is made to
introduce the whole hand through the  cervix, however carefully
it may be attempted, a laceration of it may ensue, and thus the
patient may be involved in  a new danger.
   The contents of the  uterus being naturally expelled, or  artifi- 
WATERY DISCHARGE.
17^
cially removed, and the hemorrhage being restrained, the strength
is to be restored, by allowing the patient a nutritive diet, and by
the exhibition of such medicines as tend to increase the tone of
the system: amongst which the mineral acids and cinchona may
be  accounted the most serviceable;  these, or other medicines
possessing similar properties, should be from time to time exhi-
bited, until the vigour of the system shall have been entirely re-
stored.
  The usual cautions given to women after delivery, should be
here impressed   upon  the patient, such as  confinement to  the
horizontal posture until the uterus and the vagina shall have ac-
quired  their usual size and tone.
  There is another variety of hydatid of the uterus, in which
the uterus is distended by one single  cyst and its contents to an
enormous size.  The author has  never seen an instance of this
form of the disease; but it appears, from the accounts  given of
it,  that the symptoms are  all  purely mechanical.  Although  the
uterus  may be equally and  greatly enlarged, it will be  difficult
to  determine whether  such increase  of bulk is  produced by a
single hydatid, or by a deposit of solid matter in the substance
of the uterus. The fluidity of the contents of the tumour does
not necessarily cause a sensible fluctuation of these contents. A
full bladder felt  above the pubis does not give to the hand  the
sensation of a fluid being contained within it.  The discharge of
a watery fluid in large quantities is, in this variety of the disease,
the first announcement of the existence, and the presage of its
speedy removal.
  The water having escaped, the cyst is expelled, and the dis-
ease is terminated without the occurrence of any of those dis-
tressing symptoms which threaten the  patient's life, in the disease
first described. The abdomen of the patient will require the sup-
port of a bandage.
  This last variety of the uterine hydatid is a very uncommon
disease;  so that the practitioner will  hardly be  prepared for its
occurrence.  The patient  will, therefore, probably be led to  ex-
pect a disease of long continuance, and will be  agreeably sur-
prised to find her complaints terminated so expeditiously.
  Fleshy tubercle of the uterus, being a disease of slow growth,
and offering to the finger, in an examination, a considerable  de-
gree of resistance, may perhaps be  readily distinguished from
the single  hydatid; but,  after all, it  is only with a view to  the
prognosis, that the discrimination between them is at all impor-
tant; the symptoms which arise in both of them  admitting of si-
milar modes of relief,—fulness of the  bladder by the use of the
catheter, constipation by  the  employment of those purgatives
which  are  found to diminish the consistence of the  faeces, and 
176
WATERY DISCHARGE.
pain arising out of pressure, by the administration of conium,
hyoscyamus, and other sedatives.
   As watery depositions are found to take place into different in-
ternal cavities, constituting dropsies of such parts, as ofthe tho-
rax, abdominal cavity, he, so it has been supposed that a simi-
lar circumstance may take place into  the cavity of the uterus,
which has been  mentioned  by many writers under the title of
dropsy of this viscus.  The uterus, however, possessing an open-
ing at its lower part communicating with an external outlet, it is
difficult to understand  how any accumulation of fluid can  take
place within it; for, although the sides of the cervix  uteri  may
be agglutinated  by its proper mucus, or by adhesion in conse-
quence of inflammation, such  an occurrence is  not very likely
to take place; and even if it  did  happen, a deposit of watery
fluid into its cavity would  be  an extraordinary  concurrent cir-
cumstance.
   It is more than probable that the cases described as  dropsy of
the uterus have belonged to the class of hydatids; or if there be
any such disease, in fact, as dropsy of the uterus, the author has
never met with a case of it. 
WATERY  DISCHARGE.              177
      THE OOZING TUMOUR OF THE LABIUM.

   There is yet another disease attended by a watery discharge,
to which the writer has given the above name. In the first part
of this work a description has been given of  warty  tumours of
the labia, and of the vestibulum;  but there is no similarity be-
tween those diseases and the tumour now  under consideration.
In the warty tumour, there is an  increase of the  mucous dis-
charge from the vagina, arising simply  from  the increased cir-
culation; but in the oozing tumour ofthe  labium, the discharge
arises from the  surface of the  tumour, or rather from interstices
in the tumour.  The fluid which escapes is of a  watery charac-
ter, and it is sometimes very abundant in quantity, being renew-
ed almost immediately after the surface has been made dry by a
napkin.
   The  author has never known blood to escape from this tu-
mour, even when  roughly handled,  so that the complaint is not
by any means analogous to the cauliflower-excrescence.  More-
over, when removed from the body, the oozing  tumour  retains
its form and firmness, which the cauliflower-excrescence does not.
   The tumour sometimes is so large as to leave scarcely any
part of the  labia free from it, and to extend to the mons veneris.
It seldom projects far  above the plane  of the surrounding skin,
often not more  than a line or two,  and rarely above one-third of
an inch.
  The colour of the tumour varies little from that ofthe cuticle
of the neighbouring parts;  and* a  projection, very much resem-
bling it, might  be made by the firm  application of a piece of
fine  netting to an oedematous part  during a few seconds, the sur-
face being unequal, consisting  of irregular depressions and emi-
nences, from the former of which the fluid oozes. In the imme-
diate neighbourhood of the tumour oedema is occasionally met
with, but the tumour itself is not oedematous;  soon after the sur-
face of the tumour has been wiped quite dry, a watery fluid be-
gins to ooze from it, and to form  drops, which, having become
large, at length  run off, and keep the surrounding parts in a state
of constant humidity;  sometimes soreness  and excoriation take
place, as upon the upper lip, when the  secretion from the nos-
trils  is increased, but the tumour itself is seldom  rendered more
sensible.
  The secretion from  this  tumour  corresponds in  appearance
with that from the cauliflower-excrescence. Its quantity may be
influenced by a variety of circumstances, but it  always bears a
proportion to the extent of  the disease.  In damp weather, and
                     z 
178
WATERY  DISCHARGE.
in debilitated states of the  system, it will be found more abun-
dant than when the atmosphere is dry, and the constitution vigo-
rous. It will be seen hereafter that it is controllable by art.  The
disease having once  began, continues to enlarge, and insulated
patches of it appear in the neighbouring parts, so that at length
they will be found to run into each other.
   At first sight the complaint may be mistaken for that  form of
erysipelas which is  denominated  shingles; but, upon  a more
careful inspection, it will be found that the  projecting parts are
solid, and that they do not,  as in the disease called shingles, con-
tain a fluid.  The trifling degree of vitality  which the labia in
some cases possess, renders them liable to attacks of erysipelas,
and therefore the practitioner should be careful in discriminating
between the two diseases.
   In women who are fat and weak (by no means an  uncom-
mon combination,) the cuticle will  sometimes peel off between
the labia and the nymphae, and between the labia and  the thighs,
and an oozing will take place until a new cuticle  shall  have  been
formed; but there is little chance of any mistake  in this  case.
The latter circumstance is very usual; the oozing tumour of the
labium of rare occurrence.
   Fat women  are the most frequent subjects of  the  oozing tu-
mour of the labium, especially if they have borne many  chil-
dren, or  have had their constitution  much  impaired.  In such
habits the complaint seems  to arise  spontaneously,  or at least
the author is ignorant ofthe cause producing it.
   Within the author's knowledge, the complaint does not attack
young women; indeed he has never met with it, unless in that
bulky state ofthe labia more common after middle life.
   It  is more than probable  that many women labour under the
disease without making it the subject of complaint; and amongst
those who do ask advice respecting it, little  regard is paid to it,
unless the neighbouring parts  have been  much excoriated, or
considerable weakness produced by the discharge.
   In one patient, a poor woman, who owes much to the kind-
ness  of Dr.  G. G. Currey,  so much inconvenience and general
distress was caused by the disease, that after she had  been con-
fined during some months in the hospital in the  Borough, and
had afterwards received no  benefit  from the author, she con-
sented to have the labia themselves removed, and thus the dis-
ease  was cured.
   When the structure of  a  part  has been greatly  altered, or
when the vital energy of it is greatly exhausted, a disease form-
ing in its substance is not capable of being cured by the ordinary
resources of art.  No applications of any kind  having  the power
of reproducing, and maintaining healthy actions;  stimulants may 
WATERY DISCHARGE.
179
 excite; pressure may control growth;  but  a relaxation in  the
 employment ofthe means is followed by a return of the malady.
 How often this is the case in old ulcers of the legs is to be found
 in the experience of every surgeon.
    The labia, being endowed with feeble powers of life, become
 liable to some  irreparable  alterations of structure. The oozing
 tumour attacking one labium sometimes produces irritation upon
 that ofthe opposite side: but in no other way than any extrane-
 ous body similarly situated would do.
    The chief inconveniences of this disease are, itching of the
 parts, sometimes a preternatural sense of heat, and a watery dis-
 charge; which, if it should be considerable,  may greatly annoy,
 or even weaken the patient. Relief is seldom sought for in these
 cases  until the  disease has acquired a considerable size, and even
 then it would probably often be concealed, unless the apprehen-
 sions of the patient were called  forth.
   When excoriations of the neighbouring parts  are present, or
 an erysipelatous blush appears upon them, more advantage  will
 be derived from the internal exhibition of the cinchona in sub-
 stance, than  from any other  medicine;  but  no impression  will
 be made upon  the  disease  itself by this  valuable remedy, and
 even the symptoms above mentioned will frequently recur, and
 call for the employment  of the same remedies.
   As  it has been observed that  in most instances the  vis vitae
 was impaired, the patient should be  desired  to live upon a nu-
 tritious diet, and to take  a moderate quantity of wine.
   As  heated rooms and  warm  seats will  always aggravate the
 symptoms, they should be  avoided.
   Much good may in many instances be done by external  ap-
 plications;  by several the discharge may be  greatly controlled,
 and even  cease for a time;  but  the writer has never known the
 disease cured by  them, or even  diminished in size; the vessels
 which  exhale the fluid have  their orifices either clogged up or
 strengthened, so that  less fluid is poured out.
   Common starch-powder sprinkled upon the parts again  and
 again,  so as to form a cake upon them, is a very efficient reme-
 dy ; but it will  be necessary to keep the patient  in the horizon-
 tal posture during its use; and the posture itself has in all cases
 an influence upon  the discharge, even  when no application is
 made to the parts themselves.
   A mixture of starch-powder  and cupri sulphas, very finely
 levigated, has been  found serviceable; or a solution of  cupri sul-
phas, or of argentum nitraturn, may be used.  A solution of gum
arabic  in decoctum  quercus may  be tried. Cold water is also a
valuable remedy,  and  there are  no cases in which it will not
afford  much temporary comfort. 
180
WATERY DISCHARGE.
  Perhaps of all the preparations which may be suggested, none
is so effectual as spirit.  Strong new port wine has afforded great
relief; but, when this has  failed, brandy, or  arquebusade may
be employed, and even alcohol will be useful when the weaker
spirits are in no respect beneficial in controlling the discharge.
  Although the author has made use ofthe terms "frequently,"
and "in  several cases," he wishes it to be understood that he
has had but little experience in this disease, which he considers
as one of the most uncommon complaints affecting the organs of
generation in women. The author has never seen the  oozing
tumour in the scrotum or prepuce of men, or upon the skin in
any other part of the body.
  In one instance the writer has removed the labia at the earn-
est solicitation of the patient.
  A woman, about forty  years of age, who had been in  St.
Thomas's hospital on account of this disease, applied to Dr. G.
G. Currey, who referred her to the author.  A variety of appli-
cations were made to the  parts,  some  with  a little advantage,
others with none at  all; and at length,  the  poor  woman,  being
very anxious to get  rid  of  her disorder, a lodging was provided
for her, and the labia were removed by the scalpel. The sores
granulated and healed  without any trouble, and the patient  got
perfectly well. Such a remedy should hardly be advised until all
other means of relieving the patient have been tried without ef-
fect; nor even then if the inconveniences are at all sufferable. 
WATERY  DISCHARGE.
181
     INVOLUNTARY  DISCHARGES OF URINE.

  In investigating the complaints attended by watery discbarges,
the nature of the discharge itself should always be subjected to
examination. It may happen that they may consist of urine alone,
which, in the adult, may always  be  distinguished from every
other watery discharge by the peculiarity of its smell, especially
when the cloths  upon  which it has been received have been
dried.  The passage of urine over the  labia,  and over the skin
covering the inside of the thighs, will also produce heat, redness,
and inflammation of those parts, circumstances less frequently
attended the other watery discharges.
  Involuntary discharges of urine from  the bladder  may be
either constant or occasional, and they may exist with or with-
out destruction of parts.  These  cases become distressing, be-
cause they  render the  patient very uncomfortable, and  some-
times lay the foundation of troublesome ulcerations in the parts
over which the urine passes. The space allotted to  the bladder
in a healthy state of these parts, is the cavity ofthe pelvis; and,
as the  bladder becomes full, it rises into the cavity of the abdo-
men. If the pelvis and the cavity of the abdomen should be en-
croached upon by any large tumour,  there will be no space for
the reception of the full bladder; and therefore,  at the close of
pregnancy, and in other kinds  of enlargement of the uterus, the
bladder will be capable of containing small quantities  of urine
only;  and, lying between the uterus and  the recti abdominis, it
will  be acted upon by every  sudden and strong contraction of
these muscles, and a part of its contents will be  expelled,  as in
coughing, laughing, straining, &c.  For this case  there is no re-
medy. Flat sponges sewed into the folds of a napkin should be
constantly  worn; and if  the urine should have  stimulated the
neighbouring parts,  they  may  be defended from its action upon
them by being smeared with the following cerate :

            R Ung. cetacei, ^ij.
              Emplastr. plumb. 3ii.  M. fiat ceratum.
                                            •
   In consequence of age, and sometimes from other causes, the
neck of the bladder and the  meatus urinarius will sometimes
have so entirely lost their tone, that the urine will flow away as
fast as it is secreted by the kidneys, forming a constant discharge.
If,  however, the patient remains perfectly still, lying at the  same
time upon  her back, the  bladder will be enabled to retain seve-
ral ounces  of urine.   This  loss of tone  may be  total, or partial 
182
WATERY DISCHARGE.
only, in which latter case the urine will not escape, unless upon
the employment of some slight exertion.
   An examination should  first be made of the parts, by means
of the catheter, in order to ascertain whether any communication
exists between the neck ofthe bladder and the upper part ofthe
vagina; if no such communication is found, the cause ofthe ma-
lady is to be farther investigated.  If general debility or a tedious
labour should have produced the disease, relief is to be sought
for in those remedies which give local and constitutional strength.
Large quantities of cold water may be dashed against the parts
twice or thrice  daily, and  the use of the cold bath  may be re-
commended. Decoction of bark and the  mineral acids may  be
employed three or four times daily; and if these should not pro-
duce any good effect, advantage may be taken of the knowledge
of the occasionally  injurious effects  produced by the exhibition
ofthe cantharis on  the neck of the bladder; and this remedy
may be cautiously exhibited  twice or three times  daily.  The
tinct. Iyttae of the present pharmacopoeia being a good prepara-
tion  of this medicine, it may be given in the quantity of twenty
drops, and the dose gradually and cautiously increased:  blisters
may also be applied to the neighbourhood of the sacrum, or of
the pubis. Electricity may also prove a serviceable remedy, and
should, therefore, not be withheld. Discharges from the Leyden
phial may be passed through  the pelvis, from before to behind.
Should all these plans  fail of producing a good effect, recourse
may then be had to the employment of those means which,  by
compressing the urethra, may produce a retention of the urine;
and here the mechanical talents of the surgeon  may be profita-
bly employed. The introduction of a globular pessary of a large
size into the vagina may, by its pressure against the back part of the
meatus urinarius, effect the intended purpose; and, when the blad-
der becomes full, the pessary may either be removed by means of
a noose of silk attached to it,  or, if the patient should have any
difficulty in accomplishing  this, it may be pushed backwards  by
the finger introduced on one side of the ossa  pubis;  or the pa-
tient may be instructed in  the method of introducing a catheter.
The globular pessary in this  case is thus  made to produce  the
same effect, which the pressure of the child's head in labour oc-
casionally and accidentally causes. In some cases it  may be ad-
visable to construct  an  instrument, consisting of a  small steel
spring, (in a manner similar to that used  to confine letters) to
cover it with  soft leather, and to introduce one part into the va-
gina, so as to press  upon the back part of the  meatus, whilst the
other end of  the  spring lies upon the anterior part  of the ossa
pubis.  By such a contrivance, the strength of the spring being
properly regulated, the urethra may be so compressed as to pre- 
WATERY DISCHARGE.
183
vent the perpetual discharge of the urine, and the patient may
be enabled to remove or to apply it as the state of the bladder
may render necessary.
  The  most distressing  case of involuntary discharge of urine,
is that which is produced by the existence of a communication
between the  posterior part of the neck of the bladder, and the
anterior portion of the vagina.  This state of parts may have been
produced by violence at the time of labour; or by the long con-
tinued pressure ofthe child's head, in cases where artificial means
of delivery had not been timely resorted to:  and there are few
inconveniences to  which the human body is liable greater than
this; but if the destructive ulceration of carcinoma should  have
spread  itself towards the bladder, pitiable, indeed, will  be the
state of the patient; for, in addition to the misery attending such
communication, there will be present  the excruciating  pain of
this disease.  When ulceration is actually present, and extending
itself, little assistance  can be afforded  to the patient; but when
the mischief, has arisen from  laceration or sloughing, it may be
worth while  to introduce into the vagina a large thin globular
pessary, made either  of wood or (which is better) of silver, per-
forated  by a great number of holes, capable of containing  a large
piece of sponge.  At the lower part of this pessary there should
be a circular opening, through which  sponges may be removed
occasionally; and  for this -purpose a piece of  string  may be at-
tached to the sponge, which, being emptied of the urine contain-
ed in it, may be again introduced  into  the  cavity of the pessary,
without  the removal of  it from the vagina.  Both  women  and
men, liable to incontinence of urine, should take especial  care to
drink small quantities of fluid only; and the surface of their body
should be kept warm, in order to  diminish the determination of
blood to the  interior,  as it will  be found that  such patients are
less distressed by their disease in summer than in winter, which
is explicable  only on this principle. 
181
                 CHAPTER XXV.

         ON THE PURULENT DISCHARGE.

  The characters  of  this discharge  are a heavy, yellowish,
opake fluid, possessing little tenacity.  With the exception of a
few cases, the quantity of it is seldom very profuse, and never
so considerable as that  ofthe  watery discharge; and yet the se-
cretion of pus is sometimes the cause of so great a degree of de-
bility, that the powers of the constitution are quickly expended,
of which a variety of instances are to be  met with in different
parts of the body; perhaps, large  purulent  secretions may be
equally injurious to the  frame, with evacuations of blood in simi-
lar quantity.  Pus may  be secreted by membranes in a state of
inflammation, and also by  ulcerated surfaces; and in the former
case, when a part of a membrane is disposed  to pour out  this
fluid, the inflammation  which produces it spreads usually to the
continuous parts of the  same membrane. So long as the disease
exists without any breach  of surface, pus alone, or mixed with
mucus, is secreted;  but when pus is  secreted  by an  ulcerated
surface, the least violence  will cause an admixture of blood with
the pus; or, no violence  being inflicted, the act of absorption
alone will not uncommonly expose bleeding vessels: so that the
fluid discharged will be a mixture of pus and blood:  and  this
becomes a tolerably fair criterion, as to whether the pus is se-
creted by a membrane in a state  of inflammation,  or  by an ul-
cerating surface.  The  irritation arising from the long continued
residence of an old pessary  in the vagina  produces a purulent
discharge, and sometimes  a discharge  of pus mixed with blood;
but, in this latter case,  if there is no other disease present, it will
be invariably found, that ulceration of the vagina has been  pro-
duced by pressure; and the finger of the practitioner introduced
into it will be capable of detecting inequalities and depressions
on its surface.
   As many cases of purulent discharge are  thus attended by a
mixture of blood, it will be impossible to make a nice distinction
between them. It is the intention, therefore, of the  author to de-
scribe first  the  cases of purulent discharge appearing to arise
from the mucous membranes ofthe female organs  of generation
in a state of inflammation, and afterwards to point out those other
cases in which the  pus is secreted by an  ulcerating surface, it
being  occasionally mixed  with blood. 
              THE  PURULENT  DISCHARGE.          185

  Mucous membranes in different parts ofthe body are liable to
different degrees of inflammatory  action.  In some the appear-
ance will consist simply  of an enlargement of the blood-vessels
of the part, and this enlargement arising from the distention of
the vessels, will continue for a considerable  length of lime, and
at length the  inflammation will  retire, the symptoms gradually
subsiding, and no other action taking place; an example of which
is frequently  found in inflammation of the  tunica conjunctiva.
Another mucous membrane, taking on inflammatory action, will
be attended by a great  secretion  of  mucus, as  the membrana
Schneideriana; although, sometimes pus may also be secreted
by it, but this occurrence is rare. The mucous membrane, which
lines the trachea and the cells of the bronchiae, when inflamed,
is sometimes attended by an extravasation of coagulating lymph,
as in the disease called croup; whereas, in others, it will secrete
pus, which will be expectorated in large quantity. The mucous
membrane of the intestines, when inflamed, as in dysentery, will
separate from its surface  tubular flakes of coagulating lymph; and-
but in  few instances will pus  be secreted. The  mucous mem-
brane, by which the vagina,  the cavity of the  uterus,  and the
Fallopian tubes are lined, seems to be very differently affected
during the existence of  inflammation. In the two latter cases,
coagulating lymph is almost always  extravasated, when the in-
flammatory action is violent. In painful menstruation, (or inflam-
mation ofthe mucous membrane ofthe uterus)  flakes of coagu-
lating lymph are almost always thrown off: in some instances pos-
sessing an irregular shape, in others forming accurate casts of the
cavity which gave rise to  them: and it has happened, when the in-
flammatory action has extended itself to the Fallopian tubes, that
casts of their cavities have also been voided; sometimes in de-
tached portions, in others connected with the superior angles of
the triangular portions of the same  substance,  which lined the
cavity  of the uterus.  In a case of a young lady, under the care
of the late Dr. Reynolds and  the author, a considerable number
of these casts of the uterus and Fallopian tubes was voided dur-
ing the  space of twenty-four hours.  Sometimes, however, the
mucous membrane of the uterus being inflamed  will secrete pus;
and, probably in many cases,  this  fluid will  escape from the va-
gina, it being  doubtful whether it  was formed by the uterus, or
by the vagina. In other  cases of inflammation of the membrane
lining the uterus, a retention  of the pus  secreted will  be pro-
duced, in consequence of the adhesive inflammation  having at-
tacked the lining membrane  of the cervix uteri, so as to oblite-
rate its cavity. The mucous membrane of the vagina, when un-
der the influence of inflammation, rarely gives  rise to the pro-
                     2  A 
186          THE PURULENT DISCHARGE.
duction of layers of coagulating lymph; but a very slight degree
of inflammation will excite purulent secretion.  Pus, sometimes,
also  escapes from  the meatus  urinarius in women, either gra-
dually, or mixed with the urine. In the first case, it is probably
secreted by the membrane of the meatus;  in the second, by the
bladder. 
THE PURULENT  DISCHARGE.          187
 On Inflammation of the Mucous Membrane of the Uterus, ter-
                 minating in Secretion of Pus.

   In this case, when the pus secreted can  readily find its way
 into the vagina, few symptoms will be found to exist, excepting
 heat and uneasiness experienced in these passages;  and, as the
 fluid escapes out ofthe external parts, it may be doubtful whe-
 ther it was secreted by the vagina or  by  the uterus.
   In some cases, however, the vagina is wholly free from inflam-
 mation.  But the patient is attacked by pain of an acute kind in
 the back, and at the bottom ofthe abdomen. The constancy of
 this pain is as great as its severity; and its continuance inducing
 the  practitioner to make  an examination per vaginam, he finds
 the uterus tender to the touch, and its  bulk increased, resembling
 the viscus when  in a state of impregnation; the parietes of the
 uterus  gradually yielding, its bulk  becomes very considerable.
 Still, however, from the unusual occurrence of the disease, the true
 nature of the case is involved in conjecture, until the  occurrence
 of another symptom, which unravels the  mystery. Suddenly, a
 burst takes place; the patient being sensible that something has
 given way within  her, and a large quantity of pus of a very of-
 fensive  odour escapes, when the symptoms are immediately re-
 lieved.  For some days small  quantities of pus are evacuated,
 and at length the patient returns to health; and if an examination
 of the uterus  be made after the discharge of the matter, it will
 be found greatly  reduced in bulk.
   An  unfavourable opinion is usually formed of these cases in
 their  progress: the practitioner fearing, and  with reason, that
 some important morbid alteration of structure in the uterus is
 taking  place; under this  impression,  (the prognostic leaning to
 the unfavourable side)  the termination of the case, in the manner
 above  described, is an  agreeable surprise  to the subject of  it.
 And, although, the practitioner may derive  credit for  the  ma-
nagement of it, to which, notwithstanding he is not entitled, an
 impression will be left on the mind of the  patient unfavourable
 to his skill in the art of prognosticating.
   The duration of this disease will depend upon the degree  of
 the inflammation, and  the disposition  which exists in the  sides
of the uterus to yield.  The retention of the matter in the uterus
may be  produced  either by the adhesive  inflammation  taking
place between the sides of the cervix uteri, or by the glands  in
its neighbourhood secreting a tough mucus, filling up its cavity
as in pregnancy;  or by a great degree of contraction  ofthe cer-
vix uteri itself. 
188
THE PURULENT DISCHARGE.
  On the 12th of January, 1812,  the  late Dr. Clarke visited
Mrs. A. B., about sixty-five years of age, who had  ceased to
menstruate many years. A few weeks before he saw her, she
had informed  Mr. Brande, who attended  her, of a small san-
guineous discharge from the pudenda.  The discharge was not
attended by any pain;  but  as she was rather heated, he  gave
her occasionally some sulphate of magnesia in infusion of roses,
from which she considered  that she experienced relief.  After
this she  had, as she  informed Dr.  Clarke, a discharge, at  first
like fluor albus, and  small, but which  afterwards became of a
brownish colour, offensive to the smell, and greater in quantity.
A very short time before Dr. Clarke saw her, she had  experi-
enced a more  considerable  sanguineous  discharge, but  without
any pain. She readily agreed to an examination per vaginam;
when the os uteri was found  ragged,  and much harder than usual.
The cervix was ofthe common length, but was hard to the touch.
From the upper part of the cervix, a tumour bulged out in all
directions, so as to occupy nearly the whole space from the os
pubis to the os sacrum.
   No urgent  symptoms were present; but towards  the end of
the month the patient sent in haste to Mr. Brande, to whom she
stated, that she had  been  suddenly seized with violent pain in
the lower part of the  abdomen, attended  by a sensation,  as if
something had suddenly given way  there, and that she was still
in great pain.  She had passed her urine  at four in the morning.
After the attack of pain, however, she could pass no more; but
had a frequent desire,  attended with uneasiness, to empty the
bladder. She  was now in a state of extreme weakness and faint-
ness, having a small thread-like pulse, and  the extremities being
cold. Cordial remedies being administered, the pulse was im-
proved, and the state of faintness diminished.  About half a pint
of urine was drawn off from the bladder,  and the patient became
more easy.  In the evening of the  31st of January, the day on
which these symptoms appeared, the patient died, having retain-
ed the faculties of her mind  nearly to the  last.  The  body was
examined; and on opening the abdomen, about seven or eight
ounces  of a most offensive  purulent fluid were found in its cavi-
ty. When this was cleared away, the part of the small intestines,
which presented itself, shewed very strong marks of preceding
inflammation.  On raising  the intestines to expose the  contents
of the pelvis,  a tumour appeared in a gangrenous state, with an
opening in the upper part of it, through which, on the slightest
pressure, a quantity of offensive pus issued, similar to that which
was found in the cavity ofthe abdomen.
   About five ounces more of matter were removed from the bag
 which contained it, and which was  afterwards discovered to be 
THE PURULENT  DISCHARGE.
189
the uterus in a distended state.  Both its external  and internal
surfaces were of a dark colour, exhibiting nearly the appearance
of a mortified part. On the internal surface there was an appear-
ance like half-coagulated lymph, but there were no  traces of any
cyst; so that the fluid was contained in the cavity of the uterus
itself.  The  internal surface of the uterus had a honeycomb-like
appearance.  The orifice between the cavity and the cervix'was
closely contracted, so as not to have allowed the contents ofthe
uterus to be  discharged through it.
   The above case proves that  matter  may be retained in the
cavity of the uterus by a contraction of the cervix uteri alone;
-it being stated, in  addition to the  above  history, that a probe
could be readily passed from the vagina into  the cavity of the
uterus after  death.
   Eight or ten years ago, the author was consulted respecting a
patient, about forty years of age, who laboured under symptoms
of inflammation  of the uterus. It is hardly necessary to detail all
the particulars of this case. It may be sufficient to state, that the
inflammatory symptoms ran very high; and  that,  on  examina-
tion, the uterus was found to be so  much enlarged, as to fill the
cavity of the pelvis. At the end of  several weeks, after the pa-
tient had been considerably emaciated, and  a disposition to hec-
tic fever had taken place, a  sudden  and spontaneous  discharge
of pus issued from the vagina, after which the symptoms ceased,
and the patient recovered.
   In the  year 1819, a lady, aged  about forty, who had  been
married to a second husband about six weeks, was  attacked  with
symptoms of inflammation  of the uterus. The disease was treat-
ed in the usual way, by bleeding, purging, warm bath, Sec. The
powers of the  constitution were gradually diminished  by the
great degree of symptomatic fever, and the  patient  became daily
more and more debilitated, without any mitigation of the pain,
except that  which was produced by the exhibition of large doses
of  opium.  Inability of making water, and  of  voiding the faeces
next  presented  itself.   The  former  was  repeatedly relieved by
the use of the catheter.  Saline purgatives, in  some degree, ob-
viated the latter inconvenience.  An examination, per vaginam,
being again  made, the pelvis was found completely filled by an
enlarged uterus, which was  also  perceptible  above the  pubis.
There was no reason to believe  that the enlargement of the ute-
rus depended upon pregnancy.  From this period of the com-
plaint, the patient had  the  additional assistance of Dr. Scuda-
more.  Sedative injections, repeated doses of opium, and the
warm bath, constituted  the chief part of the treatment.  After
some  time,  whilst  in  the  act of voiding a stool, a sudden dis-
charge of pus took place through the rectum, of a most offensive 
190
THE PURULENT  DISCHARGE.
kind.  On each succeeding day a quantity of similar pus was
mixed with the faeces;  and at length the  discharge of matter
ceased altogether. The uterus returned to its original size, men-
struation took place;  and when the author last saw the patient,
the constitution had acquired a considerable degree of vigour.
   It may be presumed, that something  more than  mere con-
traction of the cervix uteri  must have taken place in the case
last described; or, it is probable, that the pus  would have made
its way through the  natural opening, instead of the circuitous
mode by adhesion and ulceration.
   During the author's attendance upon some patients, labouring
under enlargement of the uterus, supposed.to  be carcinomatous,
it has been  occasionally remarked, that a sudden discharge has
taken place,-of a small quantity of a fluid, of a yellowish-brown
colour, after which the patient has remained comparatively easy
for some time.  As the appearance of this discharge  could not be
accounted for, it is not improbable that die enlargement of the
uterus  might, in such cases, be owing to a distention of the ca-
vity with pus; the esrape of a small quantity of which from time
to time might, by diminishing the  degree of  distention, relieve
the urgency of the symptoms.
   The author offers  this  merely as a conjecture, which farther
observation  and experience may confirm or destroy; but, if it
be so, the occurrence, not being very unusual, these cases must
exist more frequently than might at first be expected; because
other practitioners, whose attention has been directed to the cure
of the diseases of the female organs, must often have heard simi-
lar remarks  made by their patients.
  The uneasiness attending this disease, the detection of an en-
larged state of the uterus, together.with the increased sensibility
of the part, will naturally lead to the employment of those reme-
dies which are found useful in  removing inflammation: and this
mode of treatment will be equally applicable in  restraining the
progress of carcinoma, as in alleviating or removing the symp-
toms of this disease.  If  the habit of the patient  be plethoric,
twelve  or fourteen ounces of blood  may  be taken  by cupping-
glasses from the  region of the sacrum;  or, under any state of
constitution, ten or fourteen leeches may be applied to the groins,
once in a week or ten days.  The use of the hip-bath will be a
great source of comfort to the patient, whose  hips may be im-
mersed in tepid water for fifteen or twenty minutes every night
and morning;  at which time some warm water may be thrown
into the vagina by a syringe.  Opium may be  exhibited in suffi-
cient quantity to diminish the uneasiness of the patient; to coun-
teract the astringent effect of which, as well as to lessen inflam-
matory action, purgatives  must be occasionally exhibited; unless, 
THE PURULENT  DISCHARGE.
191
indeed, sufficient relief can be procured by the administration of
hyoscyamus or hemlock, which possess the advantage of not in-
ducing constipation. When the uterus has acquired  the  size
which  it is found to possess at the fourth  month of pregnancy,
it is to be presumed that the disease is  not carcinoma, strictly so
called; no tumour of this  character, which the author has seen,
having acquired this size; that is to say, ulceration does not  take
place in such tumours.  A  reference to  a great number of prepa-
rations, illustrative of this disease, demonstrates the truth of this
assertion.
  The rapidity of the enlargement of the uterus in cases of col-
lection of pus  in  the cavity of the uterus, comparatively with
that of fleshy tubercle,  may throw some light upon the nature of
the case; and if there is reason to believe  that the uterus is dis-
tended by pus, it may  be advisable gently  to introduce  the ex-
tremity of a bougie, or of a male catheter,  into the os uteri, and
to pass it onwards, until it has reached  the cavity  of  the uterus.
By such  a mode of proceeding no  harm  can  be done, and an
opportunity may be given  to the patient to be quickly freed of
her disease. 
192          THE PURULENT  DISCHARGE.
 INFLAMMATION OF THE  MUCOUS  MEMBRANE
                  OF THE VAGINA.

  The membrane ofthe vagina is liable to take on inflammato-
ry action from many causes;  and, inflammation being once pro-
duced, the membrane is quickly excited to the secretion of a
puriform fluid. When the very extensive surface of this mem-
brane is considered, it will not  be a matter of surprise that the
quantity of fluid secreted by it,  should be very considerable.  In
the corrugated state of this membrane, the canal is of  small di-
ameter; but, when distended to its greatest degree, a very large
surface is exposed, the whole of which is endowed with a pow-
er of secretion. Inflammation of this part may  be caused by the
application of any of those circumstances, which excite inflam-
mation elsewhere;  but the vagina is  more especially subject to
inflammation in consequence  ofthe performance of those func-
tions, which  succeed  to communication  between the sexes, the
very act of which, in some women, produces the disease.  The
complaint may  also  originate  from  the pressure to which it is
liable in the act of parturition. Inflammation also of this passage
may arise from specific contagion, which form of the disease is
denominated gonorrhoea.  In the greater number of the cases of
inflammation of the vagina, the disease extends to the neighbour-
ing membrane ofthe  urethra, as the  symptoms appear to show.
The disease,  being once excited, is much disposed to continue
in a chronic form;  and after the inflammatory  symptoms have
all subsided, the discharge will continue profuse for a great length,
of time, even under the best management.
  The symptoms attending both common and specific inflam-
mation of this membrane, are not dissimilar. The disease begins
by a sense of heat referred to the orifice of the passage and ex-
tending "up the body*," the uneasiness is sometimes  described
as a burning pain, affecting all the internal parts: an intolerable
degree  of itching  of all  the external organs is not an unusual
concomitant; and the labia themselves become distended, by a
greater determination of blood being  made to them. If the mat-
ter be not carefully washed  from the folds of the part, the sur-
face becomes superficially abraded;  and if it be examined at-
tentively, a number of small  round spots will be found to cover
it. The sexual feelings become stronger during the continuance
ofthe disease; a sense of burning is experienced in the act  of
making water, arising partly from the disease  affecting the  ure-
thra, and  partly from the passage of the urine over the neigh-
* This is the term usually employed by the patient. 
THE PURULENT  DISCHARGE.
193
bouring irritable parts; and the patient is excited very frequent-
ly to void the contents of the bladder, the urine being passed in
small quantities only at a time.
   The interval between  the application  of the cause and the
first appearance of the symptoms in the case of specific conta-
gion, differs in length  in different persons; depending  upon the
irritability ofthe parts concerned, the cleanliness ofthe person,
or perhaps upon the  degree of virulence of  the disease in the
person communicating the infection.
   In the generality of cases, the first notice of the  existence of
disease is given at the end of about eight-and-forty hours; some-
times a little earlier; in other cases much later. If the suspicions
ofthe patient are excited,  the  first symptoms  will  be observed
sooner, than by women whose fears are not alive to the subject.
   Attempts have been made  to discriminate between the ap-
pearances of the matter secreted in common, and in specific in-
flammation; and there are  not wanting practitioners who fancy
that the matter of gonorrhoea produces  a stain upon the linen of
a darker or more green colour than common pus. Such persons,
in all probability, impose upon themselves; and too frequently,
it is to be feared, voluntarily  mislead credulous patients.
   The lymphatic glands in the groin sometimes enlarge, seldom
in common, more  frequently in specific inflammation of the va-
gina;  and in some instances, these glands are found to inflame,
and to suppurate, although this is a rare occurrence. Where ma-
ny glands  inflame  at once,  suppuration  is  less likely to take
place, than when one  gland only takes on  enlargement. The en-
largement of the glands subsides, as the inflammation is removed
from the vagina.
   In simple inflammation  ofthe mucous membrane ofthe  vagi-
na, the purulent discharge  being established  in  large  quantity,
the inflammatory  symptoms frequently subside very  rapidly,
after which a termination  is  put to the secretion;  the parts re-
turning to a state of health,  provided there  be no  acting cause
producing  its  continuance; in which case  the symptoms will
continue until its removal, when they will speedily cease.
   In the case  arising from specific contagion, the duration ofthe
disease is greater;  and the discharge, once established, contin-
ues for weeks, or perhaps for months, although not always ac-
companied by the  other local symptoms.
   It is difficult, if  not impossible, to determine  at  what period
ofthe disease the power of communicating  infection ceases. A
prudent practitioner will be careful to  give no decisive opinion
respecting  the non-existence of this power, as there are no cri-
teria by which its  presence can be ascertained;  and it  may per-
haps be presumed, that no person is  secure from danger who 
194
THE PURULENT  DISCHARGE.
indulges in intercourse with a woman so long as the discharge
continues.
   It is a curious fact, that in young subjects, both male and fe-
male, purulent  discharge from the urethra and from the vagina
takes place in consequence of the existence of irritation in dis-
tant par's; thus, during dentition, whilst the capsule of the tooth,
or the gum covering it, is  violently  pressed upon by the crown
of the tooth,  the  above circumstance is not unusual;  medical
men, therefore, should be  careful to avoid denominating this
symptom venereal; since, were  it actually  so, it would lead to
nothing useful  in  the treatment;  and discussions, highly  de-
structive of the peace of families, might be thereby introduced.
   Histories of cases of gonorrhoea virulenta and  gonorrhoea be-
nigna, by which names inflammation  of the mucous membrane
ofthe vagina has been treated of,  are to'be found in the works
of many excellent writers on surgery, who have  also laid down
the best directions for the management of the different  forms of
the disease. It remains only for the  author to state, that it ap-
pears to him that the  mode  of treating venereal  gonorrhoea dif-
fers little,  if at all,  from that which is  applicable  to the  manage-
ment of the case  depending upon  the  application  of  common
causes.  It is rarely necessary to carry the employment of  anti-
phlogistic remedies to any great extent. Temperance, rest, care
in avoiding general and local  stimulants, mild purgatives, tepid
bathing, constitute, perhaps, almost all the  necessary remedies.
Mucilaginous drinks are generally recommended; and, inasmuch
as the salts  of  the urine  being  abundantly diluted, will be less
likely to stimulate than  when in a state of concentration,  such
diluting drinks may  be  advantageously  employed. Nitiate of
potash is frequently exhibited: the  author has prescribed it, but
perhaps more in  compliance  with  custom,  than for any better
reason.
   Great stress has been  laid by a writer of deserved  celebrity
upon the effects of Peruvian bark,  in  diminishing the irritability
of the urethra in this disease.* Upon  the authority of this writer,
the author has  exhibited  it; but he has not been happy enough
to observe any beneficial effects from it.
   When inflammatory symptoms have subsided, and  when the
purulent discharge appears to continue, either from a relaxation of
the secreting vessels,  or  from what has been termed a habit of
secreting, the exhibition  of  Peruvian bark, of  the resins,  tur-
pentine, and above all, of the true  balsam  of copaiva,  has  been
attended with the  best effects. Astringent injections thrown into
the vagina, will also be found serviceable; and they may be em-
* Dr. George Fordyce. 
THE PURULENT  DISCHARGE.           195
ployed at a much earlier period of the disease, than in the other
sex, in whom it has been thought that a foundation has been laid
by them for the production of strictures in the urethra.
  It is true that such strictures have been frequently  attributed
to the too great strength of the  injection employed; but when it
is considered that the urethra of different persons varies in its
degree of irritability,  that man must acknowledge himself to be
a very nice prescriber, who can  accommodate precisely the
strength of bis injection to the peculiar susceptibility of the  ure-
thra in every individual case.
  Practitioners of deserved celebrity have differed much upon
the subject of gonorrhoea virulenta  being  followed by secondary
symptoms. Few surgeons think it  necessary to subject a patient
to a long continued mercurial course; many direct the employ-
ment of small quantities of mercury only, whilst the majority ne-
glect it altogether.
  The question is of great importance; and the  author declines
to offer an opinion upon the subject. He has certainly seen cop-
per-coloured spots on the bodies of patients, who have laboured
under gonorrhoea virulenta,  removable only by  the oxymuriate
of mercury and sarsaparilla:  but be thinks that he has seen simi-
lar  appearances upon the skin of patients, whose chastity could
not be suspected.
  The author has certainly known several instances of married
women, who have laboured under a purulent discharge,  which
might possibly be the effect of contagion, bringing forih children
prematurely; some of which have been  born dead, and  others
possessing a dark-coloured furfuraceous cuticle in different parts
of their bodies, which  appearances have yielded to  the use of
the milder preparations of mercury. 
196
THE PURULENT DISCHARGE.
             ABSCESS  OF THE VAGINA.

  The labia and the nymphae, but especially the former, are li-
able to take on inflammation, which frequently terminates in the
formation of matter. The symptoms of this disease and its treat-
ment differ so little from those of inflammation in other external
parts of loose structure, that nothing need be said respecting them
in this  place;  but purulent discharges from the vagina occasion-
ally issue from the  cavities of abscesses, which form in  the cel-
lular membrane surrounding  this canal.  Such  cases, not admit-
ting of those modes of cure, which are applicable to other puru-
lent discharges from these parts, some observations will  be here
made upon the subject.
  In the first place, it is to be remarked, that such cases are of
very infrequent occurrence; the common causes of inflammation
being much more apt to produce this action  in the uterus, or in
the  membrane of the vagina, than in the cellular membrane which
surrounds the passage.
  At the commencement of the  disease, there are no  especial
circumstances which point out its existence; the practitioner finds
symptoms present which  denote local inflammatory action, and
treats them accordingly. At length a discharge of matter takes
place, which shortly ceases, and the patient believes that  her
complaint is cured.  After some time  she is again attacked with
uneasiness in the part affected, attended with a sense of fulness
and of pressure; and again a quantity of  pus escapes.  These
circumstances lead to an  examination, when a soft tumour will
be found  behind the vagina; and pressure being made upon it,
pus will escape. After the disease has continued for some time,
the  general health will  be found to  suffer, and occasionally, the
parts in the neighbourhood will  become more  than commonly
irritable.
  In the  few cases of this disease which have fallen under the
care of the author, the  menstruation has been  usually profuse;
which, indeed, might be expected, when it is considered that
inflammatory action is taking place in the  neighbourhood of the
uterus.
  The author has known this disease arise in single women of
lax  fibre,  in whom no cause for its production could be assigned.
Indeed, whenever the  disease  has  occurred, the subjects of it
have been weak  and irritable women. At different  periods of
tijne, the  glands of  the groin become enlarged and  hard, and
sometimes suppurate.
  When a collection of matter has taken place in any part of the 
THE PURULENT  DISCHARGE.
197
 body, the absorbents are disposed,  by their  action, to form a
 communication either with the  surface of the  body, or with an
 internal cavity having an external opening, provided such cavity
 lies adjacent: and, ceteris paribus, the abscess will break where
 the action of the parts is the most considerable, and the tempe-
 rature the highest. For instance, if an abscess takes place in one
 of the labia, a natural opening  will be  more  likely to occur in
 that part which is in contact with the labium of the opposite side,
 than externally.  When abscess  takes place in the cellular mem-
 brane surrounding the rectum,  it will frequently burst  into that
 gut, instead of on the outside of  the anus.  So, in like manner,
 when abscess takes place in the cellular  membrane, surrounding
 the vagina, it will be found to break  more frequently at the up-
 per part, where the action of the vessels of the  parts is the great-
 est, than at the lower part, notwithstanding the pressure made
 upon it by the matter contained; and, out of this circumstance
 arises one of the greatest inconveniences attending the  disease;
 the abscess in this way being seldom emptied of its contents,
 which become, from retention, highly offensive; the supernatant
 quautity escaping out of the mouth of the abscess, when its ca-
 vity can contain no  more.
   Cases of the above description become very unmanageable,
 even when clearly understood.  It is evident that no astringents
 can restrain the discharge, that no stimulant can be thrown into
 the cavity of the  abscess, so as to induce a contraction of it, ad-
 hesion between its sides, or granulations; and  unless the most
 depending part of the abscess should  be situated so low, as to
 be capable of being  brought within sight of the surgeon,  it would
 be hazardous to attempt an operation, so as to expose its cavity,
 or to introduce any extraneous body, such as a seton, to excite
 a  new action within  it.
   In the year 1818, a young lady, recently married, laboured
 under an offensive  purulent discharge, not constant,  but  occa-
 sional, and which always followed communication with her hus-
 band; so that the case was involved in some obscurity.   A ten-
 derness of the surrounding parts  was present,  and  the  general
 health was a good deal impaired.  It was ascertained,  that, al-
 though  some  uneasiness  attended connexion, the patient was
 rendered more comfortable for several days afterwards.
   The  lady (who lived in  the  country) came  to London, and
 placed herself under the care of the author.  Mr. Cline also saw
 the patient two or three times in consultation.  On examination,
 a bag distended with  fluid could  be felt  behind the vagina, and
 the lower part of this being pressed upon, a highly offensive pu-
 rulent discharge of a greenish colour came from the Ujjper part
of the vagina.  The pressure being continued, all the matter es- 
198          THE  PURULENT  DISCHARGE.
caped, and the bag could be no longer felt.  Thus it was satis-
factorily explained why the symptoms were diminished  by the
coition, and how this produced an evacuation of the contents of
the bag.
  It was not judged proper to resort to any chirurgical  opera-
tion:  a plan of treatment was  directed, having for  its intention
the improvement of the health of the  patient, and the prevention
of accumulation in the cavity of the abscess.
  The patient returned into the country; the powers of her con-
stitution were restored; the discharge diminished, and ceased to
be offensive; pregnancy took place, and the patient was deliver-
ed prematurely, in consequence of some exertion which she had
undergone.
  Another case,  not very unlike the preceding, occurred  in a
lady in the country, who fell under the care of Mr.  Dairymple,
of Norwich, and the author. It is hardly worth while to describa
the particular circumstances of this case.  It is to be observed,
however, that it terminated equally favourably with  the former,
in consequence ofthe employment of similar means.
  A young lady was attacked with  pain about the pelvis,  attend-
ed with soreness of the vagina, and she was incapable of bearing
the slightest exercise in a carriage without an  aggravation of all
the symptoms.  A brownish puriforrn discharge, of an offensive
smell, was occasionally voided;  the  functions of the stomach
were disturbed; the powers of the constitution  flagged,  as  well
as those ofthe mind. An examination was made by the author;
but he discovered little, except that, on the removal of the fin-
ger, a purulent  discharge followed.  The uterus was perfectly
healthy.  This case was also  attended  by Mr. Murray Forbes.
The patient employed a variety of different remedies, both local
and general;  and although she gained strength, and her spirits
improved, the author cannot flatter  himself that the means which
he suggested  were of the least service in removing the  disease
itself.
  It is to be observed that  in  all the cases of this  disease, the
discharge  is not constant, as from an  ulcerated surface; but that
the patient is sometimes entirely free from it, whilst at others the
quantity of puriforrn fluid is very considerable. 
THE PURULENT DISCHARGE.           199
 ON  ULCERATION ATTACKING THE  OS UTERI
             AND THE CERVIX UTERI.

  It has been too much the custom with practitioners to consi-
der all  the  different kinds of ulceration, taking  place in these
parts, as terminations of the disease called scirrhus or carcino-
ma. This opinion has been strengthened by the fatal termination
of such  ulcerations.  But there are two varieties of ulceration at-
tacking  these parts, which, although  both  fatal  in their conse-
quences, produce symptoms differing very much from each other.
In the second edition of Dr. Baillie's work on Morbid Anatomy,
a disease called Malignant Ulcer of the Uterus is described, and
Dr. Baillie has the candour to state that, in his  first edition, he
confounded  this  disease with scirrhous enlargement, considering
these  as varieties of the same complaint.
  It has been the custom of the author, during a period of six-
teen years as a teacher, to describe two different kinds of ulce-
ration of the uterus, both of which may be considered as malign;
the one under the denomination ofthe corroding ulcer ofthe os
uteri, the other under the name of carcinomatous ulcer.  These
will be separately considered. 
200
THE PURULENT DISCHARGE.
ON THE CORRODING  ULCER OF THE OS UTERI.

   This complaint usually occurs at that period of life at which
the secretion of the menstruous fluid becomes  naturally inter-
rupted. The age at which this happens, it is well known, varies
in different women.  The author does not recollect having met
with an instance of the disease before  the  age  of forty, and it
commonly takes place between that age and fifty-five.
   It would be expected, a priori, that diseases of increased ac-
tion would be especially likely to arise at this time, in  conse-
quence of the cessation of a  long-continued  secretion.
   Even when no change of  structure lakes place in  the uterus,
that viscus is commonly found of a larger size  than  is usually
met with in the unimpregnated state in  an earlier period of life,
and it is not until the  balance of the constitution  has been re-
stored, that the organ is again  brought  back to its original size.
It is not here meant, that any considerable degree of enlarge-
ment takes place, but just what might be expected to occur in a
part to which the usual determination of blood is made, but from
which the accustomed  secretion has been removed.
   When inflammation attacks a part, if its progress  be not ar-
rested, it sometimes happens, especially in situations where loose
texture prevails,  that abscess takes place. In situations possess-
ing a firmer texture, it more  usually happens that an  extravasa-
tion of coagulating lymph is formed, occasioning a thickening of
the part.   The inflammation  proceeding, ulceration takes place
in the part so thickened. Sometimes, however, this is not the
case, and  the symptoms of inflammation retire when the arteries
have effected this change of structure.
   In other cases, especially  where inflammation attacks mem-
branes, the  morbid  action proceeds to another  stage, in which
the action of the absorbents produces what is termed ulceration,
no intermediate thickening of the parts concerned having been
effected; and this is  the peculiarity of that disease which is called
the corroding ulcer of the os uteri.
   It has been so much the custom with writers to have recourse
to other languages to designate different diseases, that it may be
thought that a better name  might be given to  this  complaint
than that of " the corroding ulcer of the os uteri."  But  as it is
the object of the author to be understood, he prefers  the above
name. If another reason for  employing this  term should  be ex-
pected, it  is briefly this,—that it was employed by the late Dr.
Clarke, whose acuteness and talents  were only equalled by the 
THE  PURULENT  DISCHARGE.
201
simplicity of his manners at the bed-side, and  in the lecture-
room: and who  strove, not to be admired, but to be useful.
   When once ulceration  has produced a breach of surface in a
membrane, il frequently happens that such ulceration extends
itself over continuous parts of such membrane, so as to enlarge
its surface; in other instances the process involves the more deep-
seated parts, causing an excavation, with no enlargement of the
original boundary of the ulcer.
   In the  corroding  ulcer of the os uteri, the  membrane which
covers it first takes on disease,  and very shortly afterwards the
ulcer extends to the whole circumference of the  opening, and to
the parts  immediately beneath  it;  so  that the natural  shape of
the os uteri is destroyed.  Thence the ulceration  proceeds to the
cervix, and consumes it; so that, if the patient should die in this
Stage of the disease, nothing will be  found, after death, but the
body and fundus of the  uterus.  Sometimes the disease does not
stop here, but, before the patient is  destroyed, the  absorbents
employed in the process of ulceration will have taken up nearly
the whole  body  of the uterus, so that very little more than the
fundus will remain.
  In the author's collection,  there are three preparations show-
ing the disease in all of these different stages.
  This does not happen  in the carcinomatous ulcer, by which
the patient is worn out before there is time for such a degree of
absorption to have  happened.  If an  examination be made  per
vaginam, the breach of surface may be readily distinguished^
and the extent ofthe disease  ascertained; but no  hardness ofthe
parts will  be present, no thickening, no deposit of new matter.
  If the body of the patient  be  inspected after death, there  will
appear abundant evidences  of  the destructive process, but no
hardness, no thickening, no deposit of new matter; so that,  dur-
ing life, and after death, there is a tangible and visible difference
between the corroding ulcer, and the ulceration of cancer.—A
manifest distinction between these two diseases will be met with
also in the

                         Symptoms.

  Changes in the temperature of different parts  of the body so
frequently  occur, that but little attention is usually paid to them.
A sense of extraordinary heat in a part may be noticed;  it  may
subside, and be  forgotten: so, in this disease, a sense of warmth
referred to the upper part ofthe vagina, may arrest the attention
of the patient, but may  not excite apprehensions respecting its
cause, until either it has been greatly increased in degree, or ac-
companied by other symptoms.
                  Sc 
202
THE PURULENT  DISCHARGE.
  It is not unusual with women to refer all extraordinary sensa-
tions, arising at the time ofthe cessation ofthe menses, to what
they term "the change of life;" and to consider that, when they
have  thus  accounted for their diseases, they have at the same
time cured them.
  The menstruous secretion, it has been already said, has ceased;
in its stead a  yellowish discharge escapes, perhaps trifling in
quantity, and now and then mixed  with a streak of  blood;  by
degrees the sense of warmth is converted  into a glowing  heat,
affecting the region ofthe uterus;  and  it is by-no means uncom-
mon with patients to state, that  they feel " as if a  hot coal was
within them."
  As this sensation of.heat increases, so the quantity of the dis-
charge increases, the ulceration extending more rapidly.
  The  perpetual drain  necessarily  diminishes  the quantity of
circulating blood; in consequence  of which the countenance be-
comes pallid,  and weakness of the  whole system  is produced.
The effects of weakness upon the muscles, the arteries, the heart,
and the absorbent system, are too well  known to need any de-
scription here.  It will be sufficient to state that the  effects of de-
bility will be visible in the want of  the due  performance of the
functions of these and other parts.
  Supposing  that this disease were carcinomatous  ulceration,
amongst an assemblage of other symptoms the most prominent
would be, the lancinating  pain, which invariably attends  that
complaint.
  In the corroding ulcer, lancinating pain forms no part of the
symptoms. By this assertion, it is not intended  to convey a no-
tion that a disease so formidable as that which has been described
can exist wholly without uneasiness; an ulceration of the leg will
be attended with pain, but by no means comparable with that at-
tendant upon cancerous ulceration of the scrotum or mammae.
  It appears, then, that  pain of an intense and acute kind is not
a character of the corroding ulcer of the os uteri.
  When a finger, introduced into the vagina, is made to pass
over the ulceration, the  patient does not complain  of pain; she
does not suddenly shrink from pressure, as when carcinomatous
ulceration is present:  but  if asked what sensation  she experi-
ences, she will commonly reply, that she has a sense of soreness.
  From what  has been said, the author trusts that  a disease has
been described of a distinct kind, being nevertheless allied to
what has  been called cancer in its termination, possessing  uni-
formly a fatal  tendency, although the  corroding ulcer will last
during a much greater length of time,  unless attended by violent
hemorrhages, which arise sometimes from the exposure of blood-
vessels, the coats of which are destroyed by the ulcerative pro-
cess. 
THE PURULENT  DISCHARGE.          208
                           Treatment.

   In no disease is it more important to attend to the early symp-
 toms, than in inflammation.  By so doing the  most frightful con-
 sequences are frequently prevented, and the safety of many or-
 gans thereby ensured;  as when this process attacks  the brain,
 the eye, the  lungs, &tc.  It is true that the uterus performs  no
 office in the constitution when menstruation  has ceased;  it re-
 mains an inactive, and thenceforward a useless part, liable, how-
 ever, to suffer materially from morbid  changes,  and to  involve
 the constitution at the same  time in  destruction. When once the
 ulcerative process has commenced in  this disease, the part at-
 tacked  by it never, as far as the author's  experience  has gone,
 recovers its healthy structure;  but increased action ofthe blood-
 vessels of the os uteri, which would eventually terminate in ul-
 ceration, may probably  be diminished or controlled, so that no
 ulceration may take place, and, by such a mode of treatment,
 much advantage is gained.
   Whenever, therefore, a patient in whom the menstruous se-
 cretion has recently ceased,  complains  of an increase of  heat in
 the lower part of the back, or  of the abdomen, or in the parts of
 generation themselves, a prudent  practitioner,  foreseeing the
 probable result, will direct the loss of some blood from the neigh-
 bouring parts. The  most precise mode of obtaining this blood
 will be by cupping; although, if the  patient be averse to the ope-
 ration, leeches may  be  applied; but, upon the whole, they do
 not afford the same certain and immediate relief, neither can the
 quantity  of blood removed by  them be so exactly estimated.
   The operation of cupping should be repeated at the termina-
 tion of a fortnight or three weeks; and, if the sense of heat should
 continue, the further loss of blood should be directed.  The only
 disadvantage  which can arise from this practice, will be a tempo-
rary  weakness,—a circumstance of  no importance when com-
pared with the magnitude of the complaint which it is the object
of the treatment  to remove.
   General bleedings from the  system will  afford  little or no re-
lief; and  will, as  is well known, induce a greater degree of de-
bility.
   The immersion of the hips of the patient in warm water twice
 a-day will be found highly serviceable;  and the hip-bath  will be
 the most convenient mode of employing this remedy. The heat of
the water should  be so regulated that it should not exceed ninety-
four degrees;  neither should the temperature be such as to in-
duce  any feeling of chilliness.  Some of the water in which the
patient sits may  be thrown  into the vagina by a female syringe. 
204
THE PURULENT  DISCHARGE.
  If this remedy be useful in the early stage of the complaint, it
is no less so in that in which ulceration has taken place, as by
means of it  the parts will be kept clean, and the  pus  removed
soon after it has been secreted.  When the patient has not the
means of procuring the convenience of  the hip-bath, she may
apply warm water by sponges to the lower part of the abdomen,
and to the external organs of generation; and the use of the sy-
ringe with warm water will be  still more  essential  than when
more perfect modes of ablution can be attended to.
  Saline purgatives,  exhibited  in very small doses, possess not
only the power of allaying inflammation,  by  the watery secre-
tions which they produce from the intestines, but they appear
also  to possess a specific  power of tranquillizing the system,
when in a state of disturbance and increased action, even when
they produce very little sensible effect.
  Twenty, thirty, or forty grains of magnesiae sulphas, or potas-
sa? sulphas,  may be exhibited twice in each twenty-four hours;
and the beneficial effect of these medicines may be  still further
increased  by combining them with very moderate quantities of
extractum conii, or extractum  hyoscyami.
  The neutral  salts  may be made more agreeable by the addi-
tion  of a small quantity of some aromatic  water; and, if nausea
should be produced, four or five drops of tinctura opii  may he
added to each dose,  instead of the other vegetable sedatives.
  There can be no objection to the employment of sarsaparilla,
or of any medicine supposed to produce an alterative effect, pro-
vided that such  medicines are not found  to derange  the func-
tions of the stomach, or in any way to impair the powers of the
constitution.
   There is too much reason to fear that both of these effects are
unintentionally produced, when patients are desired to  swallow
a quart or  three pints of decoctum sarsae in the course  of each
twenty-four hours.
   An abstemious diet should be enjoined; and the food should
be of such a nature as will neither form blood readily, nor stimu-
late the patient, nor oppress the stomach. Fish, puddings, boil-
ed  fruits, and vegetables, will constitute the best kind of nourish-
ment.
   It need  hardly be stated, that  every thing which can excite
die action  of the parts concerned  should be studiously avoided.
   Hitherto it has been supposed, that the disease has  been in its
 infancy; but, let it be allowed that ulceration is proceeding,  and
that the patient is already weakened by the quantity of the pu-
 rulent discharge, what supports that ulceration  but the inflamma-
 tory process? what remedies will be more serviceable than those
 which retard it? so that, even in this second stage of the disease* 
THE  PURULENT  DISCHARGE.           205
the remedies applied to the first stage will be equally proper. At
length, however, it may happen, that the patient may be so much
weakened by the purulent secretion, as to render it probable that
she may sink under its effects.
  Mild astringent  fluids, in the form of injection, may then be
thrown into the vagina, the posture ofthe  patient during the use
of them  being such as to favour their  application to the  seat of
the disease.
  In the progress of the ulceration, hemorrhage may arise; to
restrain  which, some  stronger applications will be necessary,
such as solutions of sulphas aluminae in decoctum corticis grana-
ti; or,  if this should be inefficacious, solutions of cupri sulphas,
or argenti nitras.
  Small doses of  acidum sulphuricum, given in equal  parts of
decoctum cinchonae and infusum  rosae, will sometimes be found
useful auxiliaries;  and both in the early and the latter stage of
the disease, the patient should remain  constantly in  the horizon-
tal posture, if she sets any value upon the continuance  of life;
and the necessity of attending to this  latter direction  should  be
enforced in the strongest manner by the practitioner. 
206
THE PURULENT DISCHARGE.
   ULCERATED CARCINOMA OF THE RECTUM.

   The vicinity  of the  rectum to the uterus, the sympathy be-
 tween these parts, and the effect produced  by  the action of the
 one upon the other, will account for an assemblage of symptoms
 in diseases of both of these organs, of a mixed nature; so that
 without an accurate inquiry and an examination,  it will be diffi-
 cult to determine which part has become affected. Many instan-
 ces have occurred in which a complaint of the rectum  has been
 treated as a disease of the uterus; and even a  greater number,
 where alterations  in  the structure of the uterus  have been re-
 ferred to the rectum.
   In proportion  as the  practitioner is engaged  in treating the
 complaints of one or the other of these parts, he will  be led to
 attribute  the symptoms to that organ to which  his attention  has
 been chiefly directed.
   Whenever, therefore, symptoms of carcinoma in the rectum
 or in the uterus present themselves, it should be first recollected
 that,  as the latter part is more liable to the complaint than the
 former, it is probable  that the uterus is the seat  of the disease.
   In the first volume  of this work, the first stage of carcinoma,
 both  ofthe uterus and ofthe rectum, has been  considered; and
 it now becomes necessary to  record those changes which  take
 place in consequence of the ulcerating process commencing,
 which converts the complaint  into what has  been  familiarly call-
 ed cancer.
  The mucous discharge which  attends the early stage of car-
 cinoma  of the rectum, becomes gradually of a purulent nature,
 and the quantity of pus secreted will be found  to be in propor-
 tion to the length of the intestine included in the disease.
  The appearance of  pus at  the anus may lead  to  a suspicion
 that fistula exists; but an examination  of the parts will shortly
 put this question at rest.
  If the finger of the  practitioner be carried into  the rectum, it
 will be girt by a  constriction of considerable thickness, through
 which it cannot be passed; and if any  attempt is made to  sur-
 mount the difiiculty by violence, the  patient will suffer excruci-
 ating  pain, and a discharge of blood will be  the consequence of
 such  a rude inquiry.
  The surface of the  constricted part, instead of  possessing the
 smoothness of the villous coat of the  intestine, will be sensibly
 abraded; and it will be scarcely possible to  conduct the investi-
 gation without producing some discharge of blood.
  The existence of the disease being once  known, the surgeon
should not be too solicitous to ascertain its extent, as no advan- 
THE PURULENT  DISCHARGE.
207
tage can arise from  such knowledge even when acquired; be-
cause it is not here,  as in the more superficial situations of the
disease, that  it can be removed by operation; previously to de-
termining upon which, it would  of course become necessary to
be acquainted with the boundaries of the disease. The most tri-
fling case of carcinoma existing in  an internal part requires the
same vigilant care,  as one in which the  disease has proceeded
to a much greater extent; and the  same fatal consequences will
be found to ensue from a small carcinomatous thickening of the
intestinal canal, as from a larger portion  being involved in the
disease, the patient being frequently cut off not so  much by the
symptoms arising from the disease itself, as from the effects pro-
duced by such disease upon the functions of the organ which is
the seat of it.
  A large tubercle  of the liver may exist  during many years
without proving fatal; but a small tumour of that organ, situated
so as to compress the  gall ducts,  may destroy the patient in a
much shorter time by producing jaundice, dyspepsia, emaciation,
and dropsy.
  Very little is known respecting the diseases ofthe pancreas;
but a trifling thickening of the head of that viscus pressing upon the
gall ducts may produce irremediable jaundice, dropsy, and death.
  An enlargement of the mesenteric glands may exist to a con-
siderable extent, attended only  by symptoms of  debility; but
such a consolidation of them  may  be  produced as may com-
press the large blood-vessels  at  the posterior part of the cavity
ofthe abdomen, and as to cause convulsions  and death; a pre-
paration of which the author has in his collection.
  In like  manner, carcinoma affecting not more than a  quarter
of an inch of the rectum may, by obstructing the passage of the
foeces, cause  a distention of the whole colon;  and the  patient
may die of inflammation of the  coats of the gut produced by
such distention. If three inches of the intestine had been involved
in the disease, the symptoms would only have been the same;
so that neither will the treatment be improved, nor the prognos-
tic be assisted by the knowledge of the extent ofthe complaint.
  When common ulceration attacks a part, such part is destroy-
ed by it;  but where  the ulceration of carcinoma exists,  the de-
posit of new  matter by the arteries more than  counterbalances
the effect produced  by the action of the absorbents, and the
thickening and the destructive process proceed simultaneously.
  The functions of the rectum, as a reservoir for the foeces, and
as a canal through and by which they are to be ejected, render
it impossible  to maintain this part in a slate of rest; and the con-
stant pain  belonging to  the disease will be materially aggravated
by the disturbance to which the parts will be occasionally subject. 
208
THE PURULENT DISCHARGE.
  If the constipation attendant upon carcinoma of the rectum be
not referred to its true cause, and if the patient be frequently ex-
posed to the action of purgatives,  the symptoms  of the disease
will be increased by the very means employed to alleviate them.
  All the symptoms which attend  the first stage of this disease
will be found to exist in a greater degree in the  second.   The
darting pain will be increased both in frequency and in violence;
the action of the heart will be greatly, and permanently accele-
rated; the functions ofthe stomach will become more and more
impaired;  vomiting will be almost constantly present; temporary
relief will be found only in opium; and permanent  rest only in
the grave.  In the progress of the  ulceration, blood-vessels will
be exposed which will pour out, according to their size, a larger
or smaller quantity of blood; and  ha^py would it be for the pa-
tient if such hemorrhage should prove fatal; but such an event is
hardly to be expected; and,  unless in parts  more  abundantly
supplied with blood than the rectum,  such an occurrence is sel-
dom met with.
  The ravages of carcinoma extend in all directions; most where
the disease is least resisted. Thus it will occasionally happen that
the parts which form the barrier between the rectum and the va-
gina will be destroyed, and a communication will be  formed be-
tween the two cavities; or it may happen  that distention ofthe
upper part of the  rectum by foeces above the seat of the disease
may cause common ulceration  of the  coats ofthe intestine and of
the vagina; and the foeces may from  this cause also  be voided
through the latter passage during the continuance of the patient's
life. From this  point of time, the disease in the rectum proceeds
after the manner of external carcinoma; the part  in which it ex-
ists, having ceased to perform its accustomed functions, becomes
no longer  annoyed by serving the purpose of a canal.
  Great stress has been laid  upon the  fcetor of the discharges
from cancerous sores;  that they are offensive is beyond doubt,
but it is probably in consequence ofthe sloughing  progress which
commonly in some degree exists  in  such  sores, and  not  from
any peculiarity  of the discharges themselves.  Common pus to
which  the access of air is allowed will  become putrid;  and it
will be difficult to wash away the  discharges from the parts, as
soon as they are secreted.                     •
  In those instances where a communication is formed between
the rectum and the vagina, the mixture ofthe contents of the intes-
tinal canal  with the discharges  will give them a fa*culent odour.
   As ulcerated carcinoma of the  rectum, and of the uterus,  re-
quire a  mode of treatment nearly  similar, the  reader is referred
to the observations which will  be  made upon  the subject of  ul-
cerated carcinoma of the  uterus, with regard to that point. 
THE PURULENT DISCHARGE.
209
  ULCERATED  CARCINOMA OF THE UTERUS.

  A carcinomatous tumour ofthe cervix ofthe uterus, or a thick-
ening of that part, may arise between the age of thirty and forty,
and the woman may die of some other disease  during its con-
tinuance;  or she  may live  many years under proper manage-
ment, and provided she  will submit to certain privations.   1 he
treatment  of the first stage of this  disease will be found in the
first volume of this work. Sometimes, however, notwithstanding
all  the means employed on the part of the practitioner, and all
the disposition to submit to the rules laid down, upon  the part
ofthe patient, a  new action will take place upon  the surface of
the tumour, or thickening; namely, absorption, or the ulcerative
process.                                              ..
   In  one  patient, ulceration will be found to attack a small part
only  of the surface of the tumour; in another, the process wiU
commence all at once over a more extended surface.
   In the  former  instance, the disease  will be a longer time be-
fore it proves fatal; in the latter, cateris paribus, the progress of
the disease will  be more rapid.  A great difference is also ob-
servable in the quickness with which the disease proceeds at the
commencement of the  ulcerative  process, and  after it has con-
tinued some  time; and this is attributable to the failing  powers
of the patient, in which case the action of the absorbents being
lessened, the ulcerative change proceeds more slowly.  Practi-
tioners should be well aware of this fact, or they will be led has-
tily to make a false prognostic respecting the  duration of the
 complaint, estimating the future steps of the disease*, by the for-
 mer.                                            . ,  ,
    Thus a number of instances will be found, in which  the pa-
 tient will exist in a state of exreme weakness during many weeks
 or even months, contrary to the expectations of the medical at-
 tendant.  Spontaneous bleedings from the ulcerated surface, pro-
 ducing more sudden debility, will have the same effect in retard-
 ing the progress of the disorder.                  m  #
    At the commencement of the ulcerative process, it is not un-
 usual for the patient to  complain  of a puffy and enlarged  stale
 of the external  organs, which owes its origin  simply to the in-
 creased  action  and distention of the vessels in the neighbour-
 hood.  A great degree of itching  is another frequent attendant,
 and  erisypelas occasionally takes place in the vicinity.
    The   cuticle is  often found to desquamate; a trifling oozing
 ensues, which dries upon the surface, forms furfuraceous scales,
 and constitutes a new source of irritation.  These latter inconve-
                      2d 
210          THE  PURULENT  DISCHARGE.

niences, are by no means confined to the external organs of ge-
neration, as they are usually called; but they extend themselves
towards the groins, and to the inside of the thighs;  the vestibu-
lum becomes irritated by the discharge, which assumes an icho-
rous,  and  shortly afterwards a  purulent appearance.  But the
quantity of the discharge,  is by no means comparable with that
which is  met with in some other diseases of those organs.
  The pus discharged in these  cases, has usually a  foetid odour,
the reason  of which has been before i^iven. The  quantity of the
discharge sometimes greatly diminishes, although  the disease
advances, in consequence ofthe diminished quantity of blood in
the circulation; streaks of blood are occasionally mixed with the
pus which escapes; or small coagula come away; or hemorrhage
may take place in quantity  sufficient to cause syncope, and to
excite great alarm in the mind of the patient.
  If the  bladder and the rectum have not  sympathized with the
disease in its early stage, they will seldom  escape at this period,
not only from the consent which  obtains  between  all  these or-
gans, but also from  the disease  extending itself to these in com-
mon with all the adjacent  parts. Such a degree of thickening of
the meatus urinarius, sometimes takes place, as  to impede the
passage of the urine, and  to require  the  use of the  catheter;
shortly after which  the  urine will gradually and spontaneously
escape, not through the  urinary passage,  but from a communi-
cation formed between the posterior part of the neck ofthe blad-
der and the vagina.  Portions of coagulating lymph will frequent-
ly be washed away from the parts in the passage of the urine.
   When the vicinity of the rectum to the  uterus is considered,
it will  be  expected  that a communication  between the former
part and the vagina would at the  same time take place; but this
is not so, as in many cases where there is a fistula of the blad-
der, there will be found no communication between the intestine
and the vagina.
   Still, however, this circumstance  is  now and  then met with,
and from the moment that it is established, no faeces pass through
the anus; the external parts forming the channel through which
urine from the bladder, faeces  from  the  rectum, and  pus from
the ulceration, are discharged. The stench now becomes intole-
rable, and the hips of the  patient, lying almost always immersed
in  the excreted  matters, the soft parts inflame, and  sloughing
lakes place.
   Whilst these changes  are going on in  the  organs which  are
the seat of the disease, others  no less visible and distressing are
met with elsewhere: the  circulation becomes hurried, and  the
additional  wear and tear, produced  by  this  circumstance, in-
creases  the emaciation always attendant  upon  this complaint. 
THE PURULENT  DISCHARGE.
211
The fat is absorbed in every part of the  body, so as to expose
the shape of the skeleton; the muscles shrink, and  by degrees
the blood-vessels become drained of their contents, the pulse ac-
quiring a character of hardness, from  the  necessarily increased
action ofthe coats of  the arteries upon the diminished quantity
of their contents.  The constitution possesses no power of com-
pensating for this  waste of strength and of substance;  the func-
tions ofthe  stomach fail; little food is received, less  is digested;
and sometimes incessant vomiting takes place, first of ihe  mat-
ters  usually contained in the stomach, and afterwards of  bile,
which regurgitates into the stomach from the violent efforts of
retching.  Small ill-conditioned  sores arise in  the angles of the
mouth, and  teaze  the patient not a little, the  tongue becomes
sore, its surface being sometimes pale, dry, and glossy, and some-
times having a dark red colour.
   The mucous membrane which  lines the mouth  is liable to
small ulcerations, having a languid  base; and these are called
aphthae.  Perhaps none of the mucous membranes  in the  body
are exempt from these appearances, in certain states of weak-
ness produced by long-continued disease. They are occasionally
seen about the margin of the anus, and the author has frequently
noticed them upon the surface ofthe  vestibulum.
   A burning heat of the stomach, and of the intestinal canal, be-
comes  another cause of distress to the patient;  this sensation
may be dependant in part upon  the irritating quality of the flu-
ids of  the stomach, and in part upon  the presence of  aphthae in
the primae viae. Another symptom, by which the patient is much
distressed, is an insatiable thirst, which nothing can  allay.  This
greediness of liquids is not present during the whole of the dis-
ease, but it arises at that part of the complaint at which so little
blood  remains in the blood-vessels as not to furnish fluids for
secretions.  Something like this takes place in hemorrhages when
they become profuse. To sum  up the  patient's misery, to ren-
der her situation  more distressing, she is tortured by a violent,
acute, and darting pain, sometimes resembling a sharp instrument
piercing the pelvis in  different parts; becoming sometimes so in-
tense as to  cause the most patient woman to exclaim; and  de-
 priving her of all quiet by day, and  all repose by night.
   Thus it appears that the situation of a woman labouring under
 ulcerated carcinoma of the uterus is infinitely  more  pitiable than
 that of a woman  who has the disease in her breast; for not only
 are the symptoms more numerous, and  more insufferable, but
 she has not the good fortune to be cut offin the progress  ofthe
 disease  by  accidental symptoms.  In ulcerated carcinoma  oi the
 breast, the  patient is usually destroyed by hydrothoiax; but no
 $uch blessing is afforded to the subject of this disease in the ute- 
212
THE PURULENT  DISCHARGE.
rus, the sufferer being compelled to endure till her frame is ex-
hausted by pain,  by vomiting, by want of sleep,  by discharge,
by an offensive atmosphere, or by gangrene of the integuments.

                         Treatment.

  In considering  the  mode of treating ulcerated  carcinoma of
the uterus, regard must  be had to the  cause of this  disease,
which, although not obeying the laws by which common inflam-
mation is  governed, is nevertheless  controlled by the employ-
ment of those means which subdue that  process when arising
from the application  of common causes.  Whenever a patient,
labouring  under carcinoma of the uterus, has  placed herself un-
der the constant care of a  physician or surgeon, it  will be neces-
sary that he should watch with attention the changes which take
place in her constitution.  If he should find the circulation be-
coming accelerated, the skin more  than usually hot, flabbiness
ofthe integuments, softness and shrinking  of the muscles in dif-
ferent parts of the body,  he may presume  that some important
change has taken  place in the diseased organ.  If, together with
these symptoms, the lancinating pain  has  been rendered more
acute;  if  the sympathies  between  the uterus and the  adjacent
parts, or between that organ and the stomach, have been more
than usually called forth; or if, lastly, the mucous  discharge has
assumed a puriforrn character, there can  be  little doubt that a
breach of surface has taken place, and that the complaint has
acquired its most  frightful  and distressing character.  Sometimes
considerable itching  ushers in this  change: from this  point of
time, all those cautions which were offered to the patient in the
earlier  stages of the disease should  be insisted upon, as circum-
stances essential to her future comfort, and  necessary to  her pre-
servation.  If the  patient  should possess a  vigorous constitution,
and if she has  been in the habit of  living freely, the  pulse being
full, and strong, and hard, it will scarcely  be justifiable to omit
general blood-letting.  Such a practice is,  however, seldom re-
quisite: and the propriety of adopting it must be left  to the judg-
ment of the practitioner,  who must take into consideration this
circumstance, that the disease does not exist in an organ essen-
tial to  life, and that  time  will  be allowed him to repeat local
blood-lettings if he should think them to be more proper.  So
that the treatment should  not only  be  adapted to  the symptoms
themselves, but should have relation  to the  organ  involved in
the disease.
  Some blood having been taken away by the lancet, the prac-
titioner will  determine upon the propriety of a second  blood-
letting, by the  greater or less degree of the inflammatory crust, 
THE PURULENT. DISCHARGE.
213
and by the proportion of the solid to the serous part of this fluid.
By a single general blood-letting, the symptoms may be arrest-
ed, and the ulcerative process may remain  nearly stationary, as
far as it may be judged of  by the subsidence or diminution of
the symptoms.
   When the disease occurs  in less plethoric constitutions, where
general blood-letting would  be contra-indicated, local bleeding
will  be found eminently serviceable;  and,  by a timely use, and
repetition of this remedy, there is reason to believe that essen-
tial benefit is obtained. It has been already observed that, during
the process of ulceration in this disease, the deposit of new mat-
ter continues, so that it is by no means uncommon to find, on
opening the bodies of women who die in the ulcerated forms of
this complaint,  a much greater thickening of the parts than ac-
tually existed many months  previously to death.  Local  blood-
letting, then, diminishes the  action of the arteries, by which new
lymph is effused. The quantity of blood to  be taken by cupping
may vary from  six to twelve ounces, and  the cupping-glasses
should be applied just above the fissure between the nates. It
is not always practicable to procure a sufficient quantity of blood
from the lower part ofthe abdomen; and even  if it were  so, wo-
men are very naturally and  properly averse to the operation be-
ing done at that part.  If, therefore, it should be thought  right to
take away blood from the lower part of the abdomen,  the ob-
ject  must  be effected  by the application  of leeches  scattered
above  the pubis, from one  groin to the other.  From a variety
of circumstances, it becomes impossible to  estimate the precise
quantity of blood taken away by these means; but it may be
presumed that three or four drachms will be  taken by each leech,
including  the quantity which afterwards escapes from the orifice.
In the progress ofthe complaint, leeches may  be applied to the
labia, or even within the vestibulum, by means of which more
relief is sometimes obtained  than by their application to  the pu-
bus. It will not  be sufficient to order local  blood-letting  once or
twice, but it will be desirable to prescribe it once in three werks
or a month, provided the patient should not be much weakened
by it, or exhausted by pain, or by discharge of any kind.
   In  some  instances, a profuse spontaneous bleeding has arisen
from  some vessel exposed by the ulceration, to  the extent of
producing syncope; the result  of  such a circumstance is fre-
quently found to be  favourable to the patient, the progress of
the symptoms being thereby, for the  time, arrested. Even in the
latter stages of  the  disease, when the loss of blood could hardly
be considered  to be warranted, it may, nevertheless, be proper
to recommend  it.  It is a well known fact that -arciiioina ofthe
uterus involves, in its ulcerated stage, all the parts in its  neigh- 
2ll<          THE PURULENT DISCHARGE.

bourhood; but the author is not aware, that the manner in which
this communication is  made has been described by other wri-
ters.  When the process of  ulceration is simply confined to ihe
uterus,  and cellular membrane  surrounding  it, the symptoms
proceed with a degree of regularity and uniformity; but when a
new organ is attacked, new symptoms arise, appertaining to and
characteristic of inflammation in such organ. For instance, when
the rectum is attacked, there is tenesmus, great heat in that part,
increased  distress on voiding the  faeces, exquisite tenderness of
the gut if the finger be carried into it.  So,  in like manner, if the
disease proceeds to the  bladder, shivering  usually comes on,
succeeded by heat, great pain, which is fixed and constant, to-
gether with strangury;  if the disease makes its way, which, how-
ever, is not very  common, into the cavity of the abdomen, symp-
toms of peritoneal inflammation  will  present  themselves; such
as tenderness of the belly, distention of its cavity, and  a small
frequent pulse. Now, if these symptoms are allowed to proceed,
the patient will die,  as she would do if attacked by acute inflam-
mation of the bladder, or of the peritoneum. Thus the presence
of these symptoms, even in a late period of the disease, may call
for the loss of blood, although, under any other circumstances,
it would be improper to direct such a remedy.
  The management ofthe  discharge from carcinomatous sores,
is a  circumstance deserving the best attention ofthe surgeon.
This  discharge appears to have the  power  of converting the
neighbouring parts to which it is  applied, in some instances, into
sores of a  similar character to that by which it was itself secret-
ed; and there is  reason to believe that the  spreading of carcino-
matous ulceration may be greatly retarded by the employment
of those means which absorb or  remove the  ichorous fluid  se-
creted by them.  Common  aphthous sores,  which frequently
arise  in the vestibulum of women who have long laboured under
diseases of the female organs,  may also possibly be  converted
into malignant ulcerations. These observations especially apply
to carcinomatous ulcerations of internal parts, in which  the dis-
charges are more likely to be retained  than where the disease
attacks external surfaces. If it were only that the fcetor attend-
ing such sores, would be removed by  cleanliness,  attention  to
this circumstance would be of great  consequence, inasmuch as
the patient's health, and that of such  persons  as may associate
with  her, will be less likely to suffer than when  constantly breath-
ing an impure atmosphere.
  Of all the modes of applying water to sores at the upper part
ofthe vagina, none  is so effectual as the use ofthe hip-bath; in
the employment  of which, the water is brought into contact with
the sore without any risk of injuring the latter.  By these means 
THE PURULENT  DISCHARGE.
215
the object of maintaining cleanliness is not only obtained, but a
soothing application is made to an irritable surface;  ihe careful
injection of warm water into the vagina, by a syringe, or the agi-
tation of the water by the hand, will render it more likely to re-
move any  portions of coagulating lymph or thickened matter
which may adhere to the inside of the vagina.  The heat of the
water employed should depend upon the feeling of the patient
in some measure; but, generally  speaking, it  may vary from
about 860 to  940. Where the patient is too weak to bear the ex-
ertion of being  placed in a hip-bath, her hips may be brought
over the edge of the bed, and warm water may be carefully in-
jected into the vagina by a female syringe.  The quantity of the
discharge is frequently increased by the means above-mentioned,
but the  comfort which  the  patient will derive from it will abun-
dantly compensate her for any debility which may be  produced
by the remedy; and excruciating attacks of pain are sometimes
rendered very sufferable by a frequent recurrence  to it. Strong
decoction of carrots, sometimes used  for  the same purpose, has
the happiest  effects. Warm water may also be made the vehicle
for a variety of sedative applications,  which are found by expe-
rience to tranquillize all irritable sores; and, in some, to expedite
the healing process. Amongst the different applications for this
purpose, the extractum conii, or extractum hyoscyami,  may be
mentioned, either of which may be employed in the proportion of
about three or four drachms to a pint  of water. Solutions of opi-
um, or of extract of poppy, may also be used; of the former, two
drachms of the latter, half an ounce, may  be dissolved in each
pint of water. Starch,  or mucilage of squince-seed, form good
menstrua  for these applications; their adhesive property ena-
bling them to cling to surfaces to which they are applied. Three
or four  ounces of either of these fluids, impregnated with  seda-
tive substances, may be thrown into the  rectum in those  cases
where relief is not obtained by their application to  the vagina;
but when opium is  used for this purpose, the practitioner should
be very careful to watch over its effects, as it has sometimes hap-
pened that unpleasant consequences have arisen from the appli-
cation of this drug to the rectum, such  as, vomiting,  syncope,
cold extremities, and irregularity  of the circulation. The action
of the absorbents  of the rectum  is,  in  all probability,  in these
cases, increased by the inflammatory process which exists in
the vicinity;  besides which, the  action  of the rectum itself is
temporarily taken off, so that the enema will  probably be re-
tained during a  considerable length of time.  Plasters and lini-
ments,  into the composition of which, opium enters largely,  will
sometimes be found serviceable in allaying pain, and  are useful
auxiliaries in a disease in which all the  resources of the practi-
tioner may be required to  diminish the sufferings of the patient. 
216           THE PURULENT  DISCHARGE.

  There are some applications which produce a sedative, or a
stimulating effect, according to the strength of which they are
used. A very  diluted mixture of acetic acid, or of nitric acid in
water, will form a soothing application to an irritable part, whilst
in different proportions they will become highly irritating. Either
ofthe lotions mentioned beneath may be employed.

       R Acidi acetici, §ss.
          Aquae distillatae, Oi.   M.
fiat injectio.

       R Acidi nitrici, gutt. x.
         Aquae distillatae, Oi.  M.
fiat injectio.

       R Liquoris plumbi acetatis, 3i-
         Acidi acetici, 3ii»
         Sp.  vinosi, $.
          Aquae distillatae, ^xvss.   M.
fiat injectio.

  If the discharge  should become so profuse as to induce great
debility, injections which possess an astringent  power must be
sought for.

       R Decocti corticis granati, Oi.
          Sulphatis aluminas,  ^ss.  M.
fiat injectio.

       R Zinci sulphatis, 3ss.
          Aquae distillatae,  §xv.
         Tinct. kino, §i.   M.
fiat injectio.

  If the discharge should assume  a  sanguineous appearance,  it
should be considered, how far it would be safe to permit its con-
tinuance. If the patient should be in great pain at the time,  it
may be right not to restrain it hastily,  unless the patient's strength
should have been previously much exhausted;  but if it should
appear desirable  to  diminish the hemorrhage, the  astringents
which have been before recommended  may be employed, and
their  strength  may be increased, or the following may be em-
ployed in their stead.

            R  Argenti nitratis, gr.  x.
               Aquae distillatae, Oi. M.

            R Cupri sulphatis, 3ss.
               Decocti cinchonae, Oi. M. 
THE PURULENT  DISCHARGE.          217
  Respecting internal remedies, although no one has as yet dis-
covered any medicine capable of removing the disease, it may
not be too much to state, that there  is scarcely a medicine of
any class, which may not, in some way or other, or at some pe-
riod or other, be useful in this complaint.  Various are the symp-
toms which may arise; various must be the means of obviating
them; and he will be ihe best practitioner, who best understands
the adaptation of these means to their end.  To point them out
here, would be an  endless labour, and a waste of the  reader's
time.
  It may be sufficient to observe, that the patient should be treat-
ed upon  general principles, bearing in mind, on the one  hand,
the hitherto intractable nature of the malady, and on the  other,
the sufferings of humanity,  which call loudly for relief.
  Pain, the great evil of life, is the symptom by which the pa-
tient will be most distressed; and, happily, in the sedative class
of medicines  there are to be found many capable of relieving it.
  It should be  a rule of practice, never to exhibit a sedative of
great power,  when  a milder will produce equal relief;  because
the disease is one of long duration, of increasing  suffering, and
every medicine will at length fail in producing its  effect.
  Hyoscyamus and conium may be amongst the first employed,
and the dose of each may vary from three to eight, or ten grains;
larger  doses have been exhibited; but the object is not  to know
how much of these, or of any other drug can be taken with im-
punity, but how much is necessary to produce the desired effect.
If they are wantonly employed, the  patient will be exposed to
another set of  symptoms, arising from a disturbed state of the
stomach, and of the brain,  as  flatulence,  heartburn,  eructations,
delirium:  the necessity  for the exhibition of these medicines
must regulate, not  only  their  dose, but the frequency of their
exhibition.
  Extractum stramonii,  is another serviceable remedy,  in allay-
ing pain, and it may be  given in doses of a grain.
  The writer is not in the habit of exhibiting Belladonna, hav-
ing once  seen a patient nearly destroyed  by two small  doses of
it. Other practitioners, however, have employed it, it is said, with
advantage. Mr. Brodie  has  informed the writer,  that he has
seen the  happiest effects produced  by a  suppository containing
extracti Belladonna? gr. j. in cases of irritable bladder,  and also
of carcinoma of the rectum.  Perhaps, therefore, in those in-
stances, in which, the administration of other sedatives is una-
vailing, it  may be advisable to administer the  above medicine
in the  form alluded to.
  As the  symptoms become  more pressing, and as the suffer-
ings of the patient increase, still there will remain to the pracli-
                    2 E 
•
218           THE  PURULENT  DISCHARGE.

tioner one resource, and to the patient one solace, in opium, by
means of which, her distresses may be alleviated, and  her pas-
sage from this world to another, rendered less agonizing. It will
not be sufficient simply to prescribe a dose  of  opium, at stated
intervals; that dose must be proportioned to the necessity for its
use; and the skilful combination  of it with other medicines, and
the selection of its different preparations will call forth the  hap-
piest efforts of the  practitioner: in one case opium, in a  solid
form, will be found to agree; in  another, the tinctura opii, of the
Pharmacopoeia will  better answer  the  purpose; in a third, the
preparation  known by the  name of black drop; in a fourth, the
liquor opii sedalivus,  of Mr. Battley, will  quiet the patient, and
at the  same time  produce  the least  disturbance in  the  system;
whilst the  irritable  state  into which some patients fall, will be
most successfully diminished by  the very small quantity of opi-
um which enters  into the  composition of the tinctura camphorae
composita.
   In the greater  number  of painful  diseases which call for the
use of opium, less care is  required; but the sympathy of the sto-
mach is so actively called  forth, when the uterus is the seat of
this disease, that it will  be  capriciously inclined  towards one
medicine, whilst it receives another with great  comfort and ad-
vantage. If, as always happens  towards the close of  ulcerated
carcinoma of the  uterus, vomiting should come  on, the combina-
tion of spices, with opium, will render this medicine more agree-
able to the stomach. The julepum menthae, cinnamon-water, and,
in some cases, weak  brandy and water, will form the best  vehi-
cles for the  different  preparations of opium; sometimes a mix-
ture of confeciio  opiata and spiritus aetheris sulphunci  composi-
tus, given in peppermint-water, in  small doses, at short intervals,
will relieve, in an  expeditious and certain manner, the  vomiting,
singultus, and eructations,  more  effectually than any other  com-
binations of medicines.
   The writer forbears to enter into  speculative discussions, re-
specting the employment of several medicines,  which have been
suggested for the cure of  carcinoma;  and he  does so, because
the profession have not yet had sufficient experience of the ef-
fect of such medicines; or, because he himself has not known
them Used with benefit.
   In thus concluding his work, the writer  can conscientiously
assert, that  he has made no statements which, in his opinion, are
not  founded in fact, and  that he  has withheld nothing which
might in any way tend to the  advantage of the practitioner, or
to the comfort of the patient.
THE END, 
I 
6
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Eng'd by J.Druyton 
EXPLANATION  OF THE PLATES.
                      PLATE  I.

  This plate shows a-portion of hydatids of the uterus. The
quantity voided by the patient would  have filled a gallon mea-
sure. The preparation is suspended in the spirit by a portion of
organized coagulating lymph, from which the  hydatids spring,
being connected with it by means of small filaments ofthe same
substance. The cysts vary in size; some of them contain a fluid,
whilst others have collapsed in consequence  of its escape. 
220
EXPLANATION  OF THE  PLATES.
                       PLATE  II.

  In this plate are two figures of the cauliflower-excrescence of
the uterus.
Fig.  1. Conveys  an exceedingly  good idea of the disease,
          as met with  in the living  body,  the  surface being
          studded with a number of little granules heaped upon
          each  other, forming masses -of an  irregular shape.
          The lines drawn  from  letters A.  and B.  terminate
          in different parts of the mass. The letter A. in a por-
          tion  which has a  granulated appearance;  the  letter
          B. in a small flocculent portion, which, having lost the
          blood originally contained in it, forms a fine light sub-
          stance, which floats in the spirit.
Fig. 2. Shows the uterus of a patient who  died of  the cauli-
          flower-excrescence.  The preparation is  suspended
          by the fallopian tubes.
  A.   Points to the loose flocculent substance always found af-
         ter death in  patients who have laboured under the dis-
         ease. During life the flocculent substances, being vas-
         cular, is filled with blood, and a solid mass is thereby
         formed; but these small vessels emptying themselves,
         nothing remains but their coats, which are seen lightly
         floating in the spirit in which the preparation is placed.
  B.   Shows a part of the os uteri which  remains  perfectly
        healthy. Perhaps this part may be about two-fifths of
        its whole circumference.
  C. C. The  ovaria.
 D.   An incision made through  the parietes of the  uterus,
        which are somewhat thickened. 
PLATE II-
 
222         EXPLANATION OF THE  PLATES.
                       PLATE IV.

             Ulcerated carcinoma of the  uterus.
  This plate, when contrasted with the former, shows the uterus
altogether much thickened, the  cervix of the uterus especially.
  Two lines meet at A.; these diverging, lead to the upper and
lower, or rather to the anterior and posterior parts of the cervix
uteri. All  traces of the os uteri are destroyed.
  The points particularly deserving of notice in these plates are,
ulceration  without thickening  in the corroding ulcer, and ulcera-
tion with great thickening in carcinoma.
  B. The fallopian tube. 
PLATE   4
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