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1852
TREAT
I S E   /
CAUSES, CONSTITUTIONAL EFFECTS,
TREATMENT
UTERINE  DISPLACEMENTS.
BY
   WILLIAM-EDWARD COALE, M.D.
MEMBER OF THE BOSTOS SOC. FOB MEDICAL IMPROVEMEST, ETC. ETC. ETC.
           BOSTON:
PRINTED BY DAVID CLAPP. .184 WASHINGTON STREET
MEDICAL AND SURGICAL JOURXAL OFFICE.
1852.
 
 
■«-S'
 
 
            TREATISE
                  ON THE

    CAUSES, CONSTITUTIONAL EFFECTS
                   AND

          TREATMENT
                   OF                 \

UTERINE  DISPLACEMENTS.
iVw            by
     WILLIAM-EDWARD CpALE, M.D.
  MEMBER OF THE BOSTON SOC. FOR MEDICAL IMPROVEMENT, ETC. ETC. ETC.
            BOSTON:
PRINTED BY DAVID CLAPP.184 WASHINGTON STREET.
          Medical and Surgical Journal Office.
               1852. 
ari/lu rc
   The following is not intended to be a comprehensive treatise on uterine
displacements.   Its object  is to present  to  others certain practical views
of the writer with regard to the  causes of these affections, and the means
of treating them which experience has taught him to be most efficacious.
For neither of these does he claim the merit of originality ;  but he thinks
that where certain of the causes which  he  lays down as important have
been entertained by others, they have not been properly appreciated, and
consequently methods of treatment based upon them have been too much
slighted, if not entirely overlooked.
   It has been  the aim of the writer rather to make these remarks sugges-
tive, and  to avoid  anything like dogmatical  assertion, feeling confident,
from the results which have occurred  under his immediate notice, that
others will, upon fair examination and experiment, not differ very greatly
from him  as far as he goes, and hoping  that by pursuing the same  path
they may  attain to still greater  light  and achieve  further advantages in
the treatment of these important, and now  too common affections.
   To exhibit more  particularly the results just mentioned, it was at first
intended to give cases in illustration  ; it  was found, however, that they
did not differ greatly, even  in  the details,  and they would have added
very materially to the bulk of the treatise.  For the same reason 'reference
to and  quotations from authorities, whether  in support of or in contradic-
tion to the text, have been indulged in to a  very limited extent.
 
TREATISE ON  UTERINE  DISPLACEMENTS.
           ANATOMICAL AND  PHYSIOLOGICAL CONSIDERATIONS.
    An examination into  the  anatomy  of the appendages of the uterus,
 and into the relations of that organ with the  surrounding ones, will  at
 once  relieve us of any surprise that  it should be, of all the various vis-
 cera of the human body, the  one most liable  to displacement.   Itself
 dense  and unyielding, mounted upon the extremity of a thin musculo-
 membranous tube; with nothing solid beneath to sustain it; with no im-
 mediate lateral  attachments to hold it in place ; with the whole contents
 of the abdomen  directly above, gliding so  readily  upon each  other as
 to convert the pressure they exert, for all practical purposes at least, into
 a powerful hydrostatic one—considering the  subject in a purely mechani-
 cal point of view, we would be surprised that a dislodgment of the uterus
 from its  normal  situation,  upon the slightest  assistance given to the
 forces  apparently continually  at work, should not be the rule, and those
 cases  where it  resists these influences  be the exception, in the history
 of woman's health.
    It is true that in descriptions given  of the anatomy of the  organ, it
 has been, from  the earliest periods  down to the present day, described
 as held in its situation by certain ligaments (Meckel J. Fred. Handbook
 of Anat. viii., §241]—as being bound by the peritoneum  [Winslow, Ex-
 position Anatomique, t.  iii., 767]—as  being also defended from pres-
 sure above by that membrane  [Boerhaave, lnstitutiones Medecina, 1720],
 A reference however, to the arrangement and relation of  the parts, will,
 we feel, be convincing that these  ligaments and these peritoneal at-
 tachments can have very little  of the supposed influence in preserving
the organ in its proper site.  Let us,  then, give them an examination, for
we are of opinion  that, even at this  early period of our  investigationsj
we will detect one of the frequent and fundamental errors upon which is 
4
Treatise  on Uterine Displacements.
based much  of the  treatment now  used  in  contending  with uterine
displacements.
  These  ligaments are described as the round ligaments—the lateral or
broad ligaments—the inferior anterior and the inferior posterior ligaments.
Of  each of these there are two in number.
  The  round ligaments  passing  from the  fundus of the uterus, just in
front of the junction of the Fallopian tubes  with the organ, to be ex-
panded  upon the pubis, can surely have  no  influence  in  keeping the
womb from sinking downward into the pelvis, for their  course  practically
considered does not  depart much from  the horizontal plane—evidently
not enough to allow us for a moment  to  think that the uterus is depen-
dent from them.
  The  broad  ligaments,  passing  off laterally  from the  fundus, seem to
lack two essentials for giving the  necessary support—a point d'appui to
which to  attach themselves, and a sufficient tenseness  between their
outer extremity and the uterus.*
  The  anterior and posterior ligaments have scarcely that name allowed
them by  many anatomists, but are often described as simple folds  of the
peritoneum into which it, as any  pliant membrane or cloth thrown over
several  rotund bodies would do, arranges itself in hanging across the de-
pressions between them—from the apex of the one to those of the others.
   It  is true that beneath, or lining the outer side of the peritoneum  and
attaching it to the uterus, there is a  denser and more  resistant layer of
fibres described by Madame Boivin [Memorial de l'Art des  Accouche-
ments, Paris, 1824],  as the " Tunique utero-sous-peritoneale," which un-
doubtedly does exert some  power in protecting the organ from great and
sudden displacement.  But even  this is too  lax—not sufficiently tense
to preserve it perfectly fixed, and certainly  not sufficiently enduring in its
resistance to prevent it submitting in time to any  disturbing influence per-
sistent in its  action.   Any one, who has ever had an opportunity of ex-
periencing the effect of the  patient coughing, when  undergoing the
 touch, upon  the uterus, will, we feel confident, agree with us in the main
 in  the  above  proposition.   In such cases, even, where there is no ten-
dency  to prolapsus,  the  organ,  at  each exertion or spasm  of the dia-
 phragm,  is thrown downwards violently, and to some distance—returning
immediately the exertion  is over, to its proper  situation.
   If then we are called  upon to say what does preserve the uterus  in
 situ—what  enables it to  resist the downward pressure of all the movea-
  * An accidental reference to Astruc gives full confirmation by that author of our views
gards the amount of support furnished to the uterus by the round and the broad ligaments. 
Treatise  on Uterine Displacements.
5
ble contents  of the  abdomen, not only weighty in themselves, but, by
their  mobility and that of the walls that enclose them, in front exerting
a depressing force duplicating several times their weight alone—we must
state, that, in  our belief, it  cannot be  solely the loosely-attached and
tenseless expansions and membranous folds  called the ligaments of the
uterus, but, that  that  force,  termed appropriately (by the  French  first,
we believe) vital tonicity, has a very  great share of the work.  By those
who look at  all the physical forces as purely mechanical, this will seem
a mere fancy  ; but to  others, who  believe that in addition to the  varied
and beautiful  machinery  of the  animal frame there is still  something
more necessary  in  order to preserve that  harmony between its  many
parts, which  must endure to greater or less  degree for some three score
years— to those who  feel that it  is not owing to its main strength and
the toughness of its fibres alone that  the aorta does not burst or the over-
strained muscles  snap, our  proposition, we  are confident, will not seem
 wholly unsupported.
    We  do not, however, introduce this proposition here, merely for the
 sake of  a theory, upon which  to  speculate.   We  believe,  as we
 have just said, that an exclusion of the consideration of, and a  want of
 proper estimate of, the influence of  this vital tonicity, has induced many
 physicians to look upon uterine displacements too much in a simply me-
 chanical point of view, and to shape their remedies accordingly.  The
 consequence  has  been, that  local causes have  been too much insisted
 upon as accounting for  the origin of these  affections, and pessaries and
 abdominal supporters have been  too much relied upon  in the treatment
 of them, to  the  disregard of remedies intended  to  restore  the  health
 generally and to give tone to the system  at large.  But we will speak
 more fully upon this presently.

              THE VARIETIES  OF  UTERINE  DISPLACEMENTS.
    The displacements to which the  uterus is subject, are as follows :—
    Elevation.—An unnaturally high position of the organ, in which its
 tendency is to mount out of the pelvic cavity into the abdominal.
    Prolapsus.  (Synonymes—Pysteroptosis, Exometra, Procidentia uteri,
 Chute de la  matrice, Falling of  the womb.)—As the word  indicates, a
 slipping down of the organ from its  natural position.
    Anteversion.—A turning over of the womb, with its  fundus forward.
    Retroversion.—A  similar turning over, but with the  fundus backward.
    Obliquity of the womb.—An  inclination of the organ to one side or
 to the other  of  the pelvis, the variety being specified  by the position of
 the fundus. 
6
Treatise  on Uterine Displacements.
   The last condition ma)-  accompany either of the two preceding, and
either of the last three may also be attended by either of the first two-
elevation or prolapsus.
   Lastly, the uterus may form the contents  of a hernial  sac, and  thus
be protruded into or beyond the walls of the pelvis or  abdomen at any
of those points at which  protrusions of the contents  of  these  cavities
occur.
                       Elevation  of the Uterus.
   Elevation, of all these  displacements, is the rarest  excepting hernia,
and  indeed never  occurs as an affection of itself, but is always the result
of some other condition or disease  of the uterus or  of some neighboring
organ.  Thus, in  pregnancy during the middle  months, the organ rises
higher than it is habitually at  other times.   For at  an  earlier period its
weight, favored probably by the state of the  system generally, first tends
to settle it  down—but, as it becomes too large for the pelvis, it rises out
of it, and  the os  tineas  is found  further from tbe  os  externum than at
any  other  period.   Again, during the  latter months, the weight of the
foetus presses it down once more.   Thus explained, elevation cannot be
considered a pathological state.
   The morbid condition  that generally accompanies elevation  of  the
uterus is most frequently some tumor, either of the walls of the organ
or attached   firmly to  it.    The  growth of such an  attachment  we
can readily see might raise the uterus with  it mechanically, in finding for
itself a space for increased development above the brim of  the pelvis.
   A striking  instance of this condition we found in a patient, some 45
years of age,  who  had a fulness and hardness at the lower part of the
abdomen,  evidently some morbid growth.   The  only trouble that  it
caused her was, that it would  sometimes  suddenly disappear, and  imme-
diately, as  she expressed it, her lower limbs  would fall asleep  and  re-
quire her  to  sit down.   Very soon she would feel something rise  into
the abdomen  again with a  sudden  jerk, and all would  be right.   Dying
of an acute disease, we made a post-mortem examination of the body.
In addition to the disease that caused death, we found the  uterus, with a
large fibrous tumor attached, riding habitually above the brim of the pel-
vis, far higher than the natural position  of the organ ; but the shape of
the mass was such, that by a slight adjustment it would pass down into
the cavity  below and fill it so compactly as to compress the nerves pass-
ing along its walls, and thus cause  the symptoms  just described.
   This displacement is not characterized by any symptom  peculiar to it,
nor indeed should  we look upon it as an  affection  proper to the organ 
Treatise  on Uterine Displacements.                7
but  only as an  accidental  condition  attending  another  affection.   Of
course, for the reason just mentioned, no special treatment can be adopt-
ed for it, and with this notice we dismiss all further consideration of it.

                           Prolapsus  Uteri.
   As the displacement just mentioned is one  of the  rarest of all  those
to which the uterus is subjected, this,  on the contrary, is by  far  the
most frequent in occurrence.
   Condition of the Parts.—Under  the  general  term prolapsus, we in-
clude  several degrees of descent  of the organ—to each of which  some
writers, unnecessarily we think, give  separate and distinctive names.
   So far as the position  of the organ is  concerned, the disease  exhibits
itself in three well-marked phases or degrees.  In the first, we scarce find
any  great departure from the normal  type.   The os tincae is more readily
reached than commonly, apparently  from a simple shortening of the va-
gina upon itself; and it seems to project a little more than it should into
the extremity of  this tube—the groove or depression  between the  neck
of the uterus and walls of the vagina being slightly exaggerated in depth.
Otherwise the organ is  not appreciably altered in situation, nor  is  it in
size  or other particular.   Astruc asserts  that  this  condition exists  ha-
bitually in women who have borne children, and it is this degree to which
prolapsus may take place in  the earliest months of pregnancy.   The
organ becomes  a little  heavier,  and—not owing to that circumstance
solely, but availing itself of  some want of tone in the general  system,
caused, say, by  the exhausting effects of nausea and vomiting and other
disturbance of the general health incidental to that state—it sinks down
slightly,  and there remains until its increased size causes it to wedge itself
out of the pelvis again,  and support  itself against the brim of that cavity.
   As the effect of this  cause, this  degree of prolapsus cannot be called
a pathological condition, any more than can the elevation existing during
the  middle months of pregnancy.   But even when it is truly a  disease,
for practical purposes it  cannot much interest us, because it is seldom de-
tected—probably never  except accidentally.   There are possibly no at-
tendant symptoms  advising  us  of a departure from the healthy type, or
these are  so slight as not  to attract attention.   It  is therefore more as a
stage of  the disease than as  of importance in its treatment, that this con-
dition is mentioned.
   In  the next degree the peculiarities of the last become  exaggerated.
The  os tinea? approaches  more nearly to the  os  externum.   The  body
of the uterus is situated  entirely, or almost so, within  the vagina, which 
8
Treatise  on Uterine Displacements.
has now become  turned  wrong-side-outward upon itself,  to  permit this
descent into its cavity.   Still  later, the  pear-shaped organ, favored by
its wedge-like configuration, forces itself  downward,  and at last is found
lying almost horizontally upon the floor  of the perineum.   This is the
degree in which the disease first  urges itself upon the  attention of the
patient by the severity of the attendant symptoms, and calls imperatively
for aid from the physician.
   In this  stage an alteration in  the position  of the organ is not the only
morbid condition affecting the parts.   The uterus  itself, if not primarily
so, soon becomes  engorged, tumefied  and hardened, always  tender, and
frequently highly sensitive—conditions often  precursors to a state of chro-
nic inflammation of the organ, attended by unceasing  and severe suffering
—and always  accompanied, as are also  often  the others, with more or
less leucorrhoea.
   The walls of the vagina are also unnaturally lax  and flabby, doubling
before the finger when inserted into it, oftenest bathed with a profuse  flow
of mucus, mingled with  the discharge from  the uterus—but sometimes,
on the other hand, participating in the excited state of the  chief organ,
and  offering a dry rugose surface, highly sensitive to the touch and  of a
deep red color.
   In the last stage, or highest degree of prolapsus, the  uterus  is  pro-
truded from  the external  parts.  It is then, of course, covered with the
walls of the vagina which it has carried  along with it.  These, as  may
be readily conceived,  are at first irritated and inflamed by their unwont-
ed  exposure to the air, and by  contact with the  urine  and with the
neighboring surfaces—and, if not speedily relieved by a  discharge of mu-
cus  so  as  to unload  their distended vessels, become highly tumid and
exquisitely sensitive.   The  displaced  organ participates in this condition
generally, but is,  besides  this,  still further engorged by the obstruction
presented to a return of its venous blood through the vessels now com-
pressed and embarrassed by their unnatural relations  to the parts  behind.
This primary stage passing off, either from the topical application of reme-
dies directed against the  most  urgent symptoms, or from  some  rallying
effort of nature, the exposed mucous membrane thickens, becomes less
sensitive, and assimilates itself to the external integuments, as is the  case
in similar exposures of it  from accidental causes, in other parts of the
system.   The  uterus, too,  though remaining  hardened  and  enlarged,
abates somewhat  of its irritability,  and  measurably  adapts  itself to its
new condition.
   During the  descent of the uterus  from its  normal position, the  con- 
                    Treatise on Uterine Displacements.                9

 tents of the abdomen participate in the change and  assume  new rela-
 tions with regard to  each other.   The urinary  bladder, the caecum and
 the rectum, are too rigidly confined to change in general  very much their
 positions, but the concave dish formed by the peritoneum, as it falls from
 one side to the other of the pelvis, and from the anterior  abdominal walls
 over the  fundus of the bladder and of the uterus, to attach itself to the
 neighborhood of the last  lumbar vertebra, is deepened in its concavity—
 the  rounded elevation  in it, formed hitherto by the fundus of the uterus,
 disappears and gives place to a  depression, which  is sometimes  partly
 filled by  the  posterior  wall of the bladder sinking  backward  for want
 of its usual support, but still more by the rectum  almost habitually dis-
 tended  in  these  cases with retained and hardened faeces.  If these  do
 not suffice, a fold or two  of the  small intestines finds a resting place in
 the  new depression, and  their former situation is filled in  turn by a gene-
 ral subsidence of the abdominal contents.
   These  last particulars may be by some considered  of not sufficient
 importance to receive  mention here;  but  they are, nevertheless, a part
 of the history of the disease, and, as slight as they seem,  we still believe,
 that, to them, at least while  the  affection is recent, most uncomfortable
 symptoms attending it may be attributed.   We say, while the affection
 is recent,  for every practitioner who has had much experience in these
 diseases must have noticed how, apparently  inexplicably,  some of the
 most distressing sensations attending them  often lessen while the  affec-
 tion itself  is not ameliorated.
   Some cases are  on record where the uterus  has not only been pro-
 truded, but actually become dependent—in more than one,  as far as the
 knees.  In these the cavity behind  the organ contained  some of the
 small intestines,  the  Fallopian tubes stretched to their utmost, and even
 the  bladder wrenched,  for the most part, from its  anterior  attachments.
 Such cases are very rare, and cannot be looked  upon so  much as instan-
 ces of prolapsus  uteri,  as of some constitutional  peculiarity or original
 defect in construction, permitting this large hernia through the infra-pelvic
 strait.

   In simple anteversion and retroversion of the uterus, without de-
 scent, there need not necessarily be any marked alteration  Jn the sub-
 stance of  the  organ—nor, indeed, in the condition of the vagina, further
 than, as may be supposed, a distortion of its superior extremity caused
 by the change in the proper relations of the axis of the  uterus with  its
own.   When, however, the  former descends  and is compressed  in  the
                   2 
10
Treatise  on Uterine Displacements.
antero-posterior diameter of the pelvis, it is found to be in the same con-
dition  as in simple prolapsus to  a  corresponding degree;  and this, in
many  instances, is a little  exaggerated from a greater embarrassment of
the circulation, particularly  in the return of the venous blood from the
organ.   The vagina, too, in the last case, exhibits  the same  condition as
has been described above in prolapsus of the same stage and continuance.
   Of  the organs in the neighborhood, the one that  suffers most is the
bladder ; and   this more  in  retro version than in  ante version.    For,
though in  the  latter it  is  rendered  very irritable  by  the  fundus falling
against it, in the former the  neck is compressed, and retention of urine
caused to such  a degree as inevitably, in time, to produce organic changes
in the  organ.
                      Obliquities of the Uterus.
   In obliquities of the uterus, the direction of the  deviation is generally
to the  right, the  fundus  being forced over  by the rectum and  its con-
tents.   The condition  of the parts will, likewise, as  may be supposed,
be varied with  the state of  the organ in other  particulars, assuming on
occasion any  of  the phases  just  described.    As in  anteversion  and
in retroversion, the bladder is also embarrassed more or less in the per-
formance of its functions by an oblique position of the uterus.  An  inter-
esting  case illustrating this is given by Dr. Montault (in the Journal Uni-
versel  et Hebdomaire,  1832).   The  obliquely placed  uterus was five
inches in length, and caused retention of urine  for so long a period and
to such  a  degree that  the ureters were distended, and even disease in-
duced  in the calices of the kidneys.

                        Hernia  of the Uterus.
   Though  very rare, this has  presented itself in some very marked cases.
The pathology of the disease  does  not differ in important essentials from
that of hernia of any of the organs of the abdominal  or pelvic  cavity.
The body of the viscus is forced into an opening in the  surrounding walls,
and  may remain there or may pass entirely through. The points at which
it has found exit have been—at a congenital deficiency in the linea alba;
between the separated  fibres  of the  abdominal  muscles, as  in ordinary
ventral hernia ;  or, through  the inguinal ring, in  contact  with the round
ligament;  or, down the crural canal, as described by  Lallemand and
Chopart.   Cruvelhier  figures, in  the 34th livraison  of his Pathological
Anatomy, a specimen, in which the  uterus, Fallopian tube and ovary
of one side are entirely within the hernial sac, those  of the other side
occupying  the ring. 
Treatise  on Uterine Displacements.               11
  For convenience, to do  away with  the necessity  of mentioning  this
uncommon affection again, we  will dispose of it entirely here under this
statement of  its occasional  existence.
  The causes of uterine hernia, both predisposing and proximate, do not
differ from those  producing hernias of other organs in  that neighborhood ;
laxit)' of the fibres of the abdominal muscles, abnormal or pretematurally
large openings in the walls of  the  abdomen, furnishing the  former ;
some undue exertion or accidental violence, the latter.
  The  recognition of the disease, for want of any  distinguishing cha-
racteristic symptom, must  depend entirely upon the tact of the physi-
cian, and the chance  is not  great that he will have  any opportunity of
exerting this as  long  as  the organ is  in a  state of vacuity.   For, the
immediate effects of hernia upon  the  uterus, from the  scant history we
have of the cases yet known, seem by no means striking.   In a state
of pregnancy, however, we  may imagine  the case to  be different, and
o-rievous accidents to  occur of  vital  influence upon the patient.   Fa-
bricius Hildanus (De nova, rara et admiranda Hernia Uterina—in Opera
Omnia,  Frank.,  1682., page 893), and Sennertus (De Hernia Uterina,
in Op.  Om., Paris,  1641); each  relate such  a case, where the  gravid
uterus went through its gradual development wholly without the abdomi-
nal walls until maturity, when  delivery was  effected  artificially through
the  substance of the  organ.   Another case  is given, however, by Sax-
torph (Bibliotheque Med., t. LXVI1., p.  59), in which the uterus con-
tained in a hernial  tumor in  the inguinal  region,  forced  itself to the
outside  of the abdomen  as the  development  of the  foetus progressed,
yet  delivery  was  accomplished in the natural way.   It is interesting  to
note in these  cases  that  in  the last the mother  lived, whilst in the two
former death  supervened ; in  the first, three days after delivery—in the
second,  within twenty hours.
   With these remarks, we  entirely  dismiss  the consideration  of a dis-
ease, so infrequent, that, up  to the  present time, we have too few cases
on record to permit  us  to lay down  any rules for its  treatment, which
could be called more than theoretical, and which would not readily sug-
gest  themselves  from the meagre facts we  have given or  from general
principles of surgery.   The  most  satisfactory notices of the disease
that  we have yet found, are  by Nauche  (Des Maladies propres aux
Femmes, Paris,  1829, Ire.  part, p.  123), though brief; and  by Murat
 (article  « Hernie," in  the Diet, de Med., in 21 volumes) to whom Nauche
refers. 
12
Treatise  on Uterine Displacements.
                causes of  uterine displacements.
  The causes of elevation of the  uterus we have already given in our
remarks upon that affection.
   Obliquities of the uterus can, we feel, only  be accounted  for, at least
to a  certain extent, theoretically.   Probably a  congenital want of per-
fect accuracy, so to speak, in the placing of the organ, or want of sym-
metry in it or in its appendages, may furnish some causes, and obliquity
in the shape of the pelvis  others.   For right  obliquity  of the womb, a
lax state of  the  parts, possibly common in the case to the  whole sys-
tem,  assisted by a rectum  habitually distended by constipation, would
offer  a  very satisfactory cause.   But while  these causes are theoretical,
they are yet the best  and only ones we can give, and still, we claim  for
them that  they be not  entirely disregarded ; for though not confirmed,
as well as we could wish, by actual examination, they have surely reason
to support  them—and thus we leave  them.
   For anteversion and retroversion  of the  uterus  we  have  even  less
ability to offer a cause  than for lateral obliquities—at least such an one as
would stand the test  of reason and perfectly satisfy the mind.   A lax
fibre, want of  tone  in the general system, afford some  explanation, or,
at least, ground, for one  of  these  affections ;  but this is, of course, only
a  proximate one.  The immediate  one—why  in one  case  the uterus
should be turned over to the  front, and why in another it should be turned
over  backwards—is yet to be supplied.  Possibly, our coming remarks
may furnish  that explanation indirectly, which we do not care to give in
the form of mere speculation or theory, directly.
   In common  with the last two instances, an  attempt to investigate the
cause of prolapsus uteri  is beset  with  many difficulties.   The chief of
these is  the  advanced  stage to which the disease almost invariably arrives
before it comes under the notice of the physician.   Its  inception is pos-
sibly  unsuspected  by  the patient,  as we have said above ;  possibly
there are  no symptoms  advising  her  of a  departure from the  healthy
type, or these are so slight that, even if noticed, they are not  attributed
to so grave an affection.  Both local changes and constitutional troubles
have  therefore already been  greatly  developed before the time at which
the physician has an opportunity of commencing his investigations.  The
consequence of this is, that the disease, being one in most instances of very
gradual progress—at least during its' earlier stages—the difficulty of tracing
back its history is very great, and, still greater, that of unravelling the con-
fusion of symptoms so  as  to  distinctly separate  antecedent from conse- 
Treatise on  Uterine Displacements.
13
quent, and to distinguish clearly simple  post  hoes  from genuine propter
hoes.   In some few instances, it is true, women affected with  prolapsus,
or other  displacement of the  womb,  recollect that the  symptoms came
on  immediately  after a severe fall,  or  a jump  from a height, or some
such  violent succussion,  and  we satisfy ourselves with  attributing the
disease to the violence—a  method  of disposing  of the  rationale of a
case  too often resorted to by physicians, yet, evidently, highly unphilo-
sophical.  The reason why  a jump or some such violence, with which
hundreds of women meet, without harm to themselves, should in one par-
ticular case cause uterine displacement, is too readily shut out from con-
sideration, yet is it not the greater, the most important one ?
   The method we propose for considering the subject, urges itself more
strongly  upon the writer, from  the  fact that he discovers great discre-
pancy between his own personal observations and those of previous au-
thors with regard to certain particulars in the  natural history of the  dis-
ease.  By a reference to former writers, particularly those of forty years
back, we find that uterine displacements are spoken  of as diseases pecu-
liar to persons in advanced life, or  to those broken  down in  health, or
who  have frequently endured the   labors  of a mother.  In the  present
day,  our experience  (and we cannot believe that  it  differs greatly from
that of others) shows us that these  affections are not so peculiar to those
coming  under either of the  above  categories, a  fact we have  already
 strongly insisted  upon in a paper (Boston  Med. and Surg. Jour., Aug.
 1851) to which we shall have occasion to refer again presently.  We
 find now that, earliest  womanhood—that, freedom from the harsher and
 more evidently-exhausting  trials  of  woman's  strength—that, absence of
 all the  more obvious and  familiarly reputed causes of these diseases, do
 not protect from  them very many whom by the old rule we should have ex-
 pected to be the last liable to such affections.   It seems, therefore, highly
 important in our investigations into the  causes of a disease which is now
 so common, and which afflicts so different  a class  from what it was wont
 a half a century ago, that  we should not rest  satisfied with any plausi-
 ble reason given in limine, but that  we should go behind this as far as
 possible, and  try to ascertain whether the accident, the violence,  the
 fall,  the'jump, or whatever  it might have been, that is  so often assign-
 ed as the cause, was not in truth  merely  the crowning incident  to a
 long series  of predisposing  causes.  It is very evident  that, to  do this
 thoroughly and satisfactorily, the care, the  tact, the eclectic ability of the
 physician will have  to be greatly exerted, but the  exertion we  hold to be
 necessary, and the result will, we feel confident, justify it. 
14
Treatise on Uterine Displacements.
   In illustration of our views, let us take an actual case from the many
 before us.   A lady, aged 21, soon after her marriage is placed under our
 care by her husband, who  thinks she is not so well as she ought to be,
 though she  says she is not suffering more than she has done for some  time
 past.  The  symptoms point to uterine displacement, which the touch, the
 only means which can with certainty be relied upon, and without which the
 physician should never be  satisfied with  his  diagnosis, makes her  case
 clear as one of prolapsus.   The  uterus is  enlarged and tender, though
 not hard.   The amount of displacement has not yet arrived at the full ex-
 tent of what we have described as the second degree—the organ does not
 yet lie upon the floor of the perineum.   There is, and  has been for a
 year, more or less leucorrhcea, and, for a  longer  period  than  that, there
 has  been dysmenorrhcea, as well as pain  in  the  back ; a sensation of
 bearing  down  and of weight  around the  hips.   The consequences of
 marriage have slightly aggravated these  last symptoms.  She has now but
 little color, and, though tolerably  full  in  figure, has  the  appearance of
 having lost flesh.   So much for  the present condition  of the patient.
 Upon inquiring into the history of the case, with a view  of finding out as
 accurately as possible the cause of  the  derangement and  of determining
 the point (not important only as  regards  the  natural  history  of the  dis-
 ease, but also as  regards  the treatment of  the  particular case) as to
 whether the uterus is the  offended or  the offending  organ—in making
 this inquiry, the first difficulty we meet with is as to dates.  The various
 symptoms have  existed for some  time—some of them  " ever so long,"
 " certainly more than a year, yes, even two years and more."   Commenc-
 ing,  then, with the biography of the patient as a girl, we find  that when
 she left school, say at 17 or 18, she was  much stouter than she is now,
 had  much more color, and  could endure more exercise  without  fatigue.
 She entered upon a gay life, and at the end of the first year was as well as
 ever, except that she  remembers she used to feel, habitually, somewhat
 tired at the end of the winter, spent in the amusements usual in that  sea-
 son.   In this way we, in  time, draw out  the  facts, that the  symptoms
 now  exhibited in the case, for the most  part, gradually became more
 prominent and constant, until their present urgency was attained—though,
 be it noted,  a certain  fall from a swing at a watering place, by which she
 was  laid up for nearly a  week, and a certain severe  pain  in the back
 with which  she was seized  immediately after dancing a whole evening,
 might, had we not examined more  deeply, have been  considered a fully
sufficient cause  for an affection  which it  is  very evident now was  the
effect not of any sudden accident, but of three years  spent in  violence 
                  Treatise on Uterine  Displacements.                15

to all rules of hygiene—and which have also produced a condition of the
general system which must be greatly altered for the better before we can
make any impression, that will be permanent, upon the uterine affection.
   This is a  case from  one phase of  social life ; those from the other ex-
treme, where workwomen and  house servants are  the subjects, do  not
differ except in the details.   Severe  or prolonged  bodily exertion, irregu-
lar hours  for sleep and food, unwholesome occupations or  close work-
shops,  wearing  out the  vital  energies  and reducing  the  tone of  the
general system, are  to  us  more satisfactory causes for uterine displace-
ment than the fall that one got in going down stairs, or the wrench an-
other gave herself in attempting to  lift a heavy tub.  And yet, having
urged this  view of the  subject so  far,  we  wish distinctly to be  under-
stood that we do not  deny that accidental  violence  may  be inflicted
upon the organ—by a fall, for instance—which might dislodge it from its
normal position and induce  any  of the displacements we have  described.
What we do believe, and what we are anxious to present  here, is, that
these affections occurring in young persons (in so  many of whom they
do occur now-a-days) are more often the effects of radical errors in their
mode of life—nay, even  farther back  than  that,  of errors in their train-
ing during childhood, by which  a  weak and  lax fibre is  entailed upon
them, and the whole system  debarred  from attaining that tone and elas-
ticity, which would  of  itself be the  greatest guard against many of  the
physical evils to which  woman is now so often condemned.
   To expatiate more fully upon this  point in a treatise solely upon uterine
displacements, would scarcely be expected of us, and  might possibly be
thought out of place.   Of  the truth, however, of the above proposition,
we  are more and more convinced the  more we  investigate the subject
—and  its importance  more impresses  us  upon every additional  oppor-
tunity of observation.   If, then, a great predisposing cause  for these af-
fections is a want of tone—an exhausted condition of the  general  sys-
tem—our remarks cannot be thought  wholly  impertinent, nor ourselves
be  accused of unnecessarily parading a hobby into the field, though the
slight consideration that hygiene in  females, as applied to the prevention
of these particular diseases, has hitherto  received,  makes us feel  that
this apology is needed.   The  fact that an English woman  lives half a
century before she begins to wane, while our  females  reach their prime
mostly at  little over half that  age, and that another lustrum finds them
on the decline, ought strongly  to arrest our attention and  induce us  to
examine w hether we are right in attributing all this difference to climate,
and whether we might  not find  in  some error  of habits of  early life, at
least a partial explanation of the disparity. 
16
Treatise on Uterine Displacements.
   To be brief, then, after  this preface—to state  broadly our convictions
—we think that it is a radical  error to make  a difference  between the
physical training of a man-child and of a woman-child before nature has
made a difference in their physical being.   So long as there  are the same
muscles to develope,  the  same organs of digestion and assimilation to be
stimulated, the same apparatus of respiration to be strengthened—so long
should the means of doing this be the same in each sex.  A system of phy-
sical training so planned should, we also hold, only be varied  as new func-
tions come into play, which, in the  further development of the being, may
require special care, and then  we  allow that this training may be modi-
fied—but then only so far and at such times as the  demand of the  last
may be paramount—no longer and no further.   We cannot but believe
that  were the physical  female under 12 years of age looked upon in the
light  in  which  we have  placed her, and that were the course we have
sketched out  pursued in  bringing  her forward  to  the uses of woman-
hood, those uses would be  more  properly performed and  with  far  less
wear and  tear to the general system, than that which it is now the daily
pain of almost every physician to witness, and which indeed often makes
her a  wreck  long before  she  has served  her ultimate physical use—her
crowning  office, as a mother.
   We would go farther, and say that the same error is  made in her
moral training also—and with the close connection in view between the
moral  and  physical  being, this cannot  be  unimportant.   Her moral
training should be such, that while it made her  not less  a woman, it
should enable her to  rise above the hundreds of arbitrary conventionali-
ties that now  in  every way fetter  her—that mould  every  thought  and
control  every judgment—that under  the names of " propriety," " re-
finement,"  " custom,"  " fashion," exert  an absolute tyranny over her
from  the  cradle  to the coffin.   This  tyranny is  broken  through  only in
a few individual  cases, and  then by  a rebellion which for want of the
very moral  training that  originally permitted the oppression, is often so
outre in its aspect as  to expose her to the charge  of unsexing* herself,
and  to  render her, if not repulsive, at least the object of ridicule and
sarcasm.   In  short, we wish  that  woman should be taught to know her
proprium  and to make herself fit to fill it—not as the antagonist in  the
  * We often hear horror expressed at a woman's " unscxing herself," which used very arbi-
trarily generally means doing something independently and differently from the generality of her
sex, by which she is thought to assimilate herself to man.  There is, however no such horror at
women dis-sexing themselves—rendering themselves, by a life spent in utter defiance of the laws
of physical and moral hygiene, of no sex „t all—becoming mothers, if at all, only at the expen-
diture of half their feeble vitality, and wholly unable to nourish their offspring. 
Treatise on  Uterine Displacements.
17
slightest sense, but as the complement of man, the  other half of a beau-
tiful unity.   While  the physical training we urge would never enable
her to sing bass, the moral  training would  never  fit her for  the rostrum,
the pulpit or the hustings ;  but, on  the contrary, it would enable her to
see clearly her unfitness for these, and still further  it would enable her to
see as clearly a hundred duties around her, which are peculiarly hers as a
woman, and the  full and faithful performance of which would save her from
that carking care, that discontent, most often unrecognized by herself,
that listless  aimlessness,  that  now  saps  the moral, and necessarily the
physical vitality of hundreds of her sex—that wears them down in mind
and body—that  brings them  sick headaches, crooked spines, flat chests,
hysterics, premature age, and, as a climax to this list—for our purpose—
uterine displacements.
   Having thus commenced at the distant extremity of a long series of causes
which we believe predispose women to the affections under consideration,
we will take up in succession some more immediate.  In the class to which
we have hitherto confined ourselves, viz*, those acting upon the general sys-
tem, we must enumerate those offences against the laws of physiology which
are often so habitually committed that their flagrancy is not only not sus-
pected, but very difficult to be demonstrated to the offender.
   It would be impossible,  without giving a separate chapter to the sub-
ject, to enter into all the particulars of these—nor,  indeed, unless we were
writing a treatise for the people, would it be  necessary.   We will  there-
fore only enumerate the heads under which such offences are found.
   There are, as the chief ones—diet, exercise, ventilation, thermal condi-
tion, and clothing.
   Upon the first and  second we imagine we can say nothing  that the
reader does not already know, and, indeed, which  is not already thread-
bare from  repeated reiteration in  almost every popular work on health.
In ventilation,  or rather in a want of proper ventilation, we  still find
offences committed  that many practitioners,  grounded theoretically in the
subject,  do not fairly estimate.  Bed-rooms  are,  but in a  very few in-
stances, ventilated as they should be ; even in the largest houses and with
the most intelligent.   With those in humble life, the fault in this particu-
lar is still greater.  The consequence is, that many  are habitually deprived
for one-third of their whole life of the proper amount of pure air  neces-
sary to  renew  and  render nutrient  the  blood, a  deprivation  that must
be powerful in  its  effects  to  break down the tone and elasticity  of the
system,  and which  of itself seems to us  a sufficient cause for  the gaunt
forms  and  white faces so common amongst us.    The same want  of
                  3 
  18               Treatise  on Uterine Displacements.

 ventilation  is found  to  as fully great a degree  in  most  of the work-
 shops of female operatives, at  least  during  the winter time, when dozens
 may be found occupying one room,  of itself far too small, and heated by
 a close stove.
   In the thermal condition in which we keep ourselves, we think the fault
 two-fold.  Houses are heated too highly—and the difference between our
 in-door and out-door garments  is not in any degree proportionate to the
 difference in  temperature.   From  the  first  fault, an unduly rapid yet
 feeble circulation, and a lax fibre of body,  are acquired—two conditions
 highly favorable to engendering the diseases under consideration, particu-
 larly when the individual is, as is  often  the case, exposed  to such influ-
 ences day after  day without  any out-door  exercise ; the  only variation
 being from a sitting room at  80° and over, to a  close and urfventilated
 bed-room.  The change we would  advise, is to keep the  house cooler, to
 dress habitually warmer, to  depend more  upon  natural, and less upon
 artificial heat.  Then, when  out-door exposure is to be endured, meet it
 with a  greater difference of garmont.
   The above fault in our clothing  is one which  applies  equally to each
 sex.  Another which interests  us here more, is peculiar to women—viz.,
 the slight protection offered by  their garments to the lower limbs. Their
 shoes are too thin, and their  stockings, even when of thick material, too
 open  to effectually prevent the  access of cold to a large  portion  of the
 surface of the leg.   The effect  of this is to drive in the blood and induce
 engorgements of the pelvic viscera, more particularly of  the rectum and
 uterus.   That cold applied to the feet and legs does this,  any one who is
 subject to haemorrhoids  can  testify,  from  the readiness with which  thin
 shoes on  a  cold day,  or wet feet, will bring on an acute  attack of the
 disease.   The same mischief is effected with woman ;  though, unless the
 imprudence is committed at the menstrual period, and then does it imme-
 diately by suppressing or at least embarrassing  the flow, the evil conse-
 quences are not perceived until  the damage  is a confirmed one.  Their
 skirts wet by dragging through  the snow or rain, and then hanging about
 their ankles  for hours afterwards, is  another very prolific source of these
 engorgements  in school-girls and work-women.   In both,  we have traced
dysmenorrhcea immediately  to  this  cause, which  it is evident may be,
and is likely to be, repeated with both these  classes of females until the
effects are permanent.
   Even when not produced in the  above  manner, but  as a disease of
itself,  dysmenorrhcea  from a uterine engorgement must, we  think, be
enumerated among the causes of the  other affection.  At least, cases have
been presented to us in which we have had  an opportunity of watching 
Treatise  on Uterine Displacements.
19
the progress of the disease, though unfortunately, from indisposition of the
patient to assist us, without  power to arrest it—where we have found no
other reason for the gradual descent of the womb except  its unnatural
weight and the loss of tone in the parts from the violent perturbations to
which they were subjected at each menstrual period. To this we ask par-
ticular attention, as with the exception  of Lisfranc [Maladies de 1'Uterus,
p. 5:26] we find no author giving congestion the prominence we have been
led to think due to it as a cause of these affections.
 ,  The last of these causes operating only  indirectly, is habitual constipa-
tion—we mean in one method of  its action.   The mass collected at  the
extremity of the colon, and in the rectum, pressing upon the vessels return-
ing blood from the uterus, evidently furnish a frequent source of  engorge-
ment of  that organ, and, if the views just stated  are  correct, a cause of
displacement.
   We have thus  disposed of  those causes, or, at least, of the principal
and sufficient of them, which  in  producing uterine displacements operate
through the  general system.  We will  now take up those that act more
immediately upon the organ itself.
   The  first among these, acting indeed to a certain extent in both ways,
is found  in exertion too soon after child-birth—and we feel  assured that
our readers will agree with us in considering this a very prolific one.  There
is scarcely a more common  error among women than to pride themselves
upon the early period at which  they " get  about" after confinement.
With the young and  hearty—primapares—the general system soon rallies
after child-birth, and they feel  as strong as  ever ; and possibly—even put-
ting aside the stimulus of emulation, so they are—except, locally. The
contents of the pelvis, however, have not fully returned to their previous
condition ; or if they have, they have not yet regained that tenseness of
fibre which is necessary to guard them from the effects of severe strains—
so, that though  the  first bodily exertions  may not immediately be felt,
these do produce an impression which,  if increased, or even kept up, must
result in a most hurtful disturbance of the  organs of that locality, particu-
larly of  the most mobile one—the uterus.
 '  Adding to the above cause the method  in which many women  habitu-
ally support their children—not  against the chest or upon  the lap, but
against the upper part of the abdomen, and, when sitting, with the whole
weight of the infant  directly upon its walls—and we have,  if not of itself
a  new cause,  at least a powerful adjuvant  to the last.
   We have just mentioned the indirect effects of constipation.   It acts,
however, still more  immediately by effecting  displacement mechanically,
a  fact that no one will doubt who has ever examined by touch the uterus 
20                Treatise on Uterine Displacements.

of a  woman  habitually costive.   It will be found wholly  impossible to
produce the slightest effect in attempting to return the organ to its proper
place, while  the rectum  is full.   Another  method in which  this  condi-
tion acts in producing these affections, is, by the great exertions required
to obtain a stool.   The efforts of the abdominal muscles to force out the
hardened and impacted faeces must be felt  almost equally by the  uterus,
and assisted by the still more direct effects of a  loaded rectum upon it—
just spoken of—they cannot but  have great effect in forcing  down that
organ, or in pushing it—already  canted forward—over upon the bladder,
and thus inducing anteversion.
   Another mechanical cause of uterine displacements is one which has as
yet received but little attention, and which, in the paper above alluded to,
we have set forth at length, claiming at the same time to  be the first to
have  so done.  It is in  the weight and in the method of wearing  the
skirts of their dress now adopted by women for some eight or ten years
past.   We  feel that we cannot do  better than to quote  from the  article.
After describing the upper half of the dress now worn, as cut low in the
neck  and receiving no  support from the  shoulders, but held solely by
the strips of whalebone  planted upon and supported by the expansion
of the figure at the hips, we  go on to say :  " To the part below the waist
however, we believe we can look with confidence for a full and satisfac-
tory  explanation of the mischief done.
   " With a view to improving their  shape, the lower part of the dress of
women now  consists of six, eight, or even  more  skirls, made of  various
materials;   cotton—the stiff  woollen material,  intended for  curtains,
called moreen—flannel,  and at times quilted with  cotton-wool—weighing
together, as  ascertained  by  actual  experiment, ten,  twelve, and even
fifteen  pounds.*   Each  of these  is  supported by a string drawn  very
tightly round the body.   We have  seen the marks  of these strings for
days  after the skirts have been removed—we have seen them even after
death.  Here, then, is the first source of evil; the continued pressure and
constraint that these strings  keep up, evidently embarrassing greatly the
organs  within.  When to this, however, we add the  weight of the skirts,
we cannot but at once perceive how great an additional  force we set to
work, particularly if its operation, as exerted upon organs having amongst
 * The higher numbers mentioned here must of course be considered as rare and extreme cases.
The truth of the general statement—which we have often heard denied—we again re-assert  Our
authority is the acknowledgment of women themselves, and still better, actual experiment  In
one case we astonished an incredulous patient, by weighing one of her skirts  in her presence' and
showmg her that she had been carrying five pounds in one garment alone, strung round her'hips
How much the other four weighed, we did not think it necessary to ascertain.              ' 
Treatise on  Uterine Displacements.
21
themselves a mobility almost as great  as  that of fluid, be properly esti-
mated.  To protect the abdominal viscera  against this pressure, remember
there is nothing, in front at least, save a thin partition of woman's soft and
tensionless muscle.   That  these viscera should  be  forced downwards, is
not surprising ; that they must in turn exert an equal force  downward on
the pelvic viscera, is apparent;  and that the uterus,  the most moveable of
the last, and the most obvious by its situation to receive such an impulse,
should give way to the continual assaults  upon it, is what we might most
readily expect  from the  premises.   Here we have  an explanation, full,
and we trust convincing,  of the frequency of a disease in the youngest
and heartiest of the sex, which twenty years since was considered peculiar
to those whose  powers of  life were greatly exhausted by demands upon
them, or were already on the decline from age."
   With reference  to the  insidiousness of this cause, and the blindness
 of the  sufferer to it,  we say: " We look upon the  mischief thus done as
 no whit less than that effected by tight lacing ; but if anything, greater, for
it is more silently done.    Friends  cannot see,  and  do not understand,.
the evil at work, and therefore  can give  no warning word.  The symp-
toms themselves commence so gradually and point so  indirectly to the
 cause, as to excite no alarm in the victim.  Exercise which ought to in-
 vigorate,  soon  fatigues  and becomes  distasteful.   Ascending  a  flight of
 stairs, or  stooping to  lift  a comparatively light weight, instantly loads the
hips with a burden that  can scarcely  be  borne.  The  back, particularly
 at the lower part, feels  sprained, and  memory is taxed in vain for some
 injury to account for it.   Dragging sensations around the hips,  pain down
 the legs, and  weak  knees, are attributed to rheumatism.  The symp-
 toms may now begin to  point more directly to the  real seat of the  trou-
 ble—every  monthly period brings renewed sufferings, from  which the
 system rallies  more and more  slowly—daily and hourly embarrassments
 occur of  nearly all the organs   within  the pelvis—an irritable bladder (a
 very frequent  symptom  in my  experience)—haemorrhoids—unceasing
 pain and continual sensation of bearing down.  The retiring delicacy of
 maidenhood shrinks from telling these, and unless marriage happily brings
 her under the care of a physician, the mischief goes  beyond  hope
 of relief."
    So much, for the present,  upon this  particular  cause, the importance
 of a consideration of which, as we have just said, has forced itself strongly
 upon us; being convinced that even  where  it cannot  be esteemed  the
 sole cause, it  yet plays  such a  part in aggravating  and perpetuating
 the disease, as  to render futile any attempt at relief until it be removed.
    To close this list of  mechanical causes, we add to it all those occupa- 
  ^2                Treatise on Uterine Displacements.

  tions which require strong contractions of the diaphragm and abdominal
  muscles continued for a length of time,  particularly when to  these are
  added a stooping position.   We cannot, of course, specify all  such, but
  among them  we may mention  as  instances washing, ironing, scrubbing
  floors,  some  branches  of the manufacture of cotton and woollen cloths,
  and, indeed, several mechanical trades in  which women engage.   This
  list,  however,  is already sufficient for our purpose.
    We  have thus divided the causes of uterine  displacement into two
  classes—viz.,  those acting upon the general system, and  those acting
  mechanically  upon  the organ  more  or less directly.   In  enumerating
  these, we have given only those  about which there can be no doubt, or
  which  at least were so plausible as to  demand  in  our estimation careful
  consideration,  on account of the immediate practical bearing of them.
    There are  still some  causes of uterine displacement  of a mixed  cha-
 racter, between these  two classes ;  and, also, some which various authors
 have given, but which we think very doubtful,  though still  such as we
 ought not to pass over in silence.
    Among these is  frequent  child-bearing ;  which, however, we cannot
 look  upon, as  some would, in the  light of a cause, necessarily, though
 we do not doubt that the exhaustion of the system attending the frequent
 bringing forth and nursing of children may predispose a woman to descent
 of the  uterus.
    Relaxation of the vagina has. with great plausibility, been  considered
 a frequent cause of prolapsus uteri •;  we do not  think, however, that  this
 tube acts so peculiarly as  a supporter  to  the organ above, that we  can
 very well separate and particularize the effects of a flaccid state of it from
 those of a want of  tone  in the neighboring parts—which, be it noted,
 must  always necessarily be  the result of the same influence that produces
 the other.   In  saying  this, we have in view the success  of the ope-
 ration devised by Girardin  for the relief of prolapsus, by excising a por-
 tion of the  circumference of the vagina, but we  do not think" that it
 weakens our general position.   We  will speak more particularly of  this
 bye-and-bye.
   Prolonged phthisis, and also  chronic bronchitis, are often accompanied
 by prolapsus, which may be the result of the combined influence of  the
 ennervation  of  the system and  of the frequent spasm of  the diaphragm.
 Great emaciation is  also charged with inducing it, and   we  can readily
conceive that an attenuation of all  the  parts  concerned   would favor a
 descent of the uterus, more especially when accompanied,  as it almost al-
 ways must be, by general debility and relaxation.
   There are certain peculiarities of the  person  which are considered as 
Treatise  on Uterine Displacements.
23
 predisposing causes  of  prolapsus.   Those  most so,  are great breadth
 of the  pelvis, and obesity.   As  unvarying  as all traditional assertion is
 in giving these  as causes, we still feel great doubts  as to the facts, and
 wait for further systematic observation  to determine them.  Though we
 cannot as  yet offer a great array numerically, what cases have come un-
 der  our notice  have been such  as  to start the doubt above expressed.
 As another structural cause, Levret mentions preternatural length of the
 ligaments  of the  uterus, which may be congenital or  may be induced.
 Duges  and Boivin  oppose this,  as would any one who took the  view
 above quoted from Astruc as to  the functions of  the  ligaments.   With
 this we close our list of causes of uterine  displacements, confident  that
 we have  fairly  exhibited all that  have any claim  upon our attention,
 either for  their interesting pathological  bearings, or for any practical pur-
 poses in treating the  disease.
 constitutional  effects  and  symptoms  of displacement of the
                               UTERI S.
   As, in estimating the causes of these affections, there was  a difficulty
 in separating the attending conditions of the general system from  those
 which  lead more  or less immediately  to displacement of the uterus, so
 in detailing the symptoms  of these  diseases  we  find  some difficulty in
 separating those sensations proceeding from disorder of the economy, acci-
 dentally attending  the  chief affection, from  those caused  by the  dis-
 placed  organ.  This difficulty  is increased  from there being in fact no
 pathognomonic sign of the disorder—no symptom that of itself can set
 the existence of the disease beyond  all doubt, and still less which  will
 enable us to discriminate in all cases- and accurately between one form of
 displacement and another.
   There is a difficulty, too, in  separating the  constitutional  effects from
 symptoms.  For, if the  former  are very constant,  they of course  could
 properly be classed under the latter.   We have therefore embraced both
 of them under one head, and in detailing them,  for the most part, shall
 leave it entirely  to the reader  to class them as he wishes.
   We should here say that the  absence just spoken of,  of any pathogno-
 monic sign, for all practical purposes does not matter, as  the touch is  an
 infallible test of the existence of the disease ; and, as we have already
 strongly stated, whatever symptoms may lead us  to suspect  uterine  dis-
 placement, and  however strongly  our suspicions may be heightened, no
 practitioner should feel justified  for a moment in  depending upon them,
when so speedy  and so sure a means of removing all trace of doubt and
all possibility of mistake is at  hand. 
 24               Treatise on Uterine Displacements.

   We look, then, upon the symptoms  attendant  upon these diseases as
 only valuable in turning our attention at the outset to  the affected organ,
 and in pointing out what other derangements accompany or are caused by
 the  chief one.
   Omitting any further  consideration  of elevation and of hernia of the
 uterus, we will give  in turn the symptoms of the  other displacements to
 which the organ is subject, and  afterwards those common to all—or the
 constitutional effects, where they have  not been  sufficiently detailed in
 our  previous remarks.
   Anteversion and Retroversion.—In neither of these derangements, when
 existing simply without prolapsus, are the symptoms at all marked, unless
 they produce embarrassment in  the  functions or  the surrounding organs
 by mechanical  pressure.  We  have  had but two cases of anteversion
 and  one of retroversion in our practice ; and this seems, from the statistics
 of others, to be more than our share.   Of course, they cannot of them-
 selves go  far to illustrate the diseases, but  they did exhibit to  a  marked
 degree a difference of symptom  which  we are inclined  to believe  may
 be pretty constant.   It  was  with regard to the  manner in which the
 bladder was annoyed.   In one of the  cases of anteversion, there  was an
 irritability of the bladder—a frequent desire  to urinate ; in that of retro-
 version, there was an inability to vent the urine.   In  the first case, the
 fundus of the uterus having fallen against the body of the  bladder, irri-
 tated it and excited  a desire  to  empty it.   In the second, the mouth of
 the uterus had settled against  the neck of the bladder, and thus created
 the difficuly in urinating.   So far, our observation  from these solitary ex-
 amples is  confirmed by other writers.  Of the  second case of anteversion,
 we will have occasion  to  speak, when we come to treat of the displace-
 ments of  the gravid  uterus.   In retroversion, embarrassment of the rec-
 tum  becomes a very  troublesome accompaniment, the fundus often lying
 directly against  it, and causing an accumulation of faeces.  In antever-
 sion, the bladder is chiefly annoyed.   For the rest, there are no  symp-
 toms of the displacements  which are  not common to both, and  also to
 prolapsus  of the  organ.   Upon examination  with the finger,  there can
scarcely  be any difficulty in recognizing the disease.  Even where  en-
 gorgement has  altered the form  and density of the organ, its orifice can
be reached with the finger, and  thus  prevent its being mistaken for a
tumor, whilst the direction in which the aperture is found  will determine
the particular kind of the displacement.
   In  obliquities, the  embarrassment of the neighboring organs  not
amounting to a very  perceptible  degree, the disease is generally not  sus-
pected until pregnancy, or until the  uterus  is also prolapsed, in  which 
Treatise on Uterine Displacements.               25
case, the symptoms are those  common to a descent of the organ without
obliquity, modified  possibly to a  slight degree by  interference, as in the
above cases, with the neighboring organs.
   Prolapsus Uteri.—The immediate symptoms of prolapsus uteri—that
is, those sensations excited  in the neighborhood by the  mechanical im-
pingement of the organ upon the  neighboring ones—are somewhat antici-
pated in the last  paragraphs.  As  in anteversion^md retroversion, both
bladder and rectum  are liable to be embarrassed,  particularly the latter,
rendering defaecation  difficult.   There is a feeling of weight within the
pelvis, as of a body pressing downwards and exciting efforts at times to
bear down ; accompanying which is a sympathetic  sensation  of weight
all around  the  hips,  and  a  peculiar  dragging pain at times  in the
small of  the  back, where,  indeed,  almost  always, there  is more or
less  pain, though not of so distressing a kind.   With these are also the
general sympathetic sensations as given in the  quotation from our article
on woman's dress ;  altogether, a group, of which, though in particular in-
stances several  may be  wanting,  yet furnishing  a  very characteristic
exhibition of the disease, and one  to  which we can scarcely make an
addition.   One particular symptom is not there included, which we  have
frequently met with.   It is  a feeling of emptiness at the pit of the sto-
mach, sometimes heightened to a sense of gnawing.  We suppose that
this  may be one of those instances where a very trifling cause gives rise
to sensations utterly incommensurate with it—and  that the settling down
of the organ, taking from the small intestines their support, forces them,
also, to take a  lower  place in  the  abdominal cavity,  and  causes this
sensation of vacuity at the upper  part  of it.  It is true that we  have
found this symptom quite a prominent  one where the disease existed to a
slight degree only ;  but this, it may be  here observed, is a  remarkable
peculiarity of the symptoms of uterine displacements, viz., that they are
by no means proportioned in severity to the amount of the disease.  So far
from this, we have found them quite urgent when the displacement could
scarcely be detected by touch ;  and, again, we have found  the uterus
lying on the floor of the  perineum, and yet the  patient perfectly  com-
fortable so far as it was concerned.  Indeed, there seems to be in  some
instances a disposition on the part of nature  to  accommodate  herself to
the new circumstances, and  to submit to them without  producing an-
noyance and trouble.   Thus we have had  patients who at the  onset
of their disease  suffered  much with all  the characteristic symptoms of
uterine displacements,  yet in the course  of time  these disappeared one
by one,  though the affection became  more advanced, until by the  time
the second degree of  prolapsus was confirmed, the- attrioyances had for
              4 
26
Treatise  on Uterine Displacements.
 the most part ceased, or were only such as attention to emptying the rec-
tum would relieve.
  Leucorrhoea is  an almost invariable attendant upon uterine displace-
ment.   But  we look upon it as a symptom common to many diseases of
the organ, and dependent upon a  condition of it which has not neces-
sarily any connection with displacement.  So, with dysmenorrhoea,  an
almost equally constant attendant;  it is the effect, not of the dislocation
of the organ, but  of an  engorgement of it, which  state, however, does
very constantly exist with the other.
   As for the state of the uterus itself, we have  already  mentioned  its
engorged  condition,  which may vary from  a slight tumidity to enlarge-
ment accompanied with great hardness.   In the event of protrusion of
the organ, this state is heightened, and the organ increases much in  size,
offering a firmness and elasticity to the touch.   In color it varies from
a light pink  to  a  dark red,  or brown, taking  the  latter hue when per-
fectly irreducible.  The mucous  membrane covering it, acquires, for the
most part, a thick epithelium, but is exceedingly liable to ulceration, as is
also the organ itself.  These ulcers  are often very deep, always increas-
ing greatly the sufferings of the patient, and lessening the strength by the
perpetual drainage they keep up.   Sometimes they become gangrenous,
and, in more than one case, the whole organ has  sphacelated  and drop-
ped off;  in  one instance,  of  a lady 60  years  old (related by Nauche),
with perfect relief  to the patient.
  With regard to the more distant influences of uterine displacements, as
we  stated at the opening  of the  chapter, it is difficult to say what we
should enumerate as  sympathetic sensations from the displacement of the
organ, and what as  accidental feelings  either  dependent upon another
affection, or due to  a general state of the system of which the  disease
under consideration is an effect, or of which it is an  accidental  attendant.
Thus, a dizziness of the head, coming on irregularly, and in some cases
depriving the individual  of consciousness for  a   moment, is a frequent
accompaniment  of prolapsus, and we consider it a manifestation of the
hysterical condition which is,  so notoriously, often associated with affec-
tions of the uterus.  Pain between  the shoulders occurs sufficiently often
to entitle it to note;  yet we must consider this as merely a result of the
generally debilitated  state  of the system, and one which would, and does,
of course, occur independently of the local affection.
  Be this as it may, it is very certain that except with those blessed with
unusual powers of vital resistance, as the  French  term it__with an im-
perturbability of the nervous system, so  to speak—uterine displacement,
whatever  may be  its origin, and however healthy the subject of it  may 
Treatise on Uterine Displacements.               27
be in all other  respects, soon  brings with it a train of evils, in enumerat-
ing which we can scarce make a limit short of a general derangement of
all  the  vital functions.   This  undermining influence is first felt by the
nervous  system.   The patient, generally irritable, is sometimes  corres-
pondingly depressed in spirits  ; or, at other times, loses control of herself
in paroxysms of  hysteria.   The digestive organs are not long in showing
their subjection to the influence.   Dyspepsia, in one of its many forms,
appears ; and  the functions  of assimilation being  interfered  with, the
blood begins to be less rich, becomes thin and  impoverished, of course
losing its fitness  to nourish the economy.  The heart, now, from feeling
the defects of innervation  and  from want of its  accustomed stimulus of
a rich  circulating  fluid, becomes  irregular in its  action—mostly feeble,
and scarce  sending its contents to  the extremities  of  the system.   At
times it loads the lungs with  a flood which the respiration, hurried to the
last degree, can scarce dispose of.   Of course muscular debility has long
since supervened;  and, to  it, still later,  is added cold  hands and feet,
 pallor and emaciation.  To this description of the general wreck of the
physical, and, in many instances, sad  to  say, of the moral health of the
woman, caused by uterine displacement,  we have to add but  one more
 detail—that is, the sterility  which  most usually attends it.  Of this,
 however, we will have occasion to speak again more at length.

               TREATMENT OF UTERINE  DISPLACEMENTS.
   The first end to be attained in  the  treatment of these  affections, is
 the replacement  of the organ.  When the case is  one of simple  prolap-
 sus, this is  not difficult.   The rectum  should  first  be emptied, the pa-
 tient placed on  the back.  The  forefinger  of the right hand, previously
 well smeared with lard, is then introduced into the vagina,  and  the ex-
 tremity of it placed against the edge of the os uteri.  Gentle efforts must
 then be made to  carry the womb  upward towards its proper situation,
 and, if a little discretion be used in modifying the direction of the thrust,
 it will in most cases obey the  impulse.   When  elevated to  the utmost,
 the left hand  should be  placed  above  the pubis  and  gentle  pressure
 exerted there.   The  result upon  the uterus will soon  be ascertained ;
 and  if it  is found that the  pressure forces it  still  higher,  or retains  it
 firmly in its proper  situation  so that it be not disposed to follow  the
 finger in withdrawing it, we have  at once a powerful assistance given
 us°in our efforts to prevent the  organ  from being  again displaced.   A
 bandage and compress, a belt, or an abdominal supporter, may then be
 put on°  with reasonable hopes of acting  successfully.
   This examination into the effects of pressure over the pubis we hold 
28
Treatise  on Uterine Displacements.
 to be very important, because there are many instances in which the or-
 gan is not pushed high  enough to permit pressure exerted there to act
 beneath it.   The consequence is, that  instead of its  being retained in
 its place or carried upwards by the external force, it  is actually impelled
 downwards again.   In  such cases, of course, the various external me-
 chanical  contrivances intended for the relief or the cure of the  disease,
 so far from being beneficial, are, in fact, just the reverse—hurtful.
   If there is  anteversion or retroversion, replacing the organ is not gene-
 rally so readily accomplished, as it has first to be brought into its natural
 relations with the axes of the pelvis.   In one case of the former affection
 we  had no difficulty in  doing this ;  but, in the other, and in the case of
 retroversion, both accompanied with great prolapsus, we found much dif-
 ficulty in placing the organ in such  a position that  it  could be carried
 upwards.  In the first of these, in fact, we had to introduce a silver ca-
 theter directly under the pubis, and  by this, elevate the  fundus of the
 uterus, while, with the forefinger of the other hand, the neck was brought
 downwards and forwards.
   In many cases,  however, a restoration of the  organ  to its  proper
 situation  is not  immediately possible, on account of its congested, en-
 larged and hardened state; and in most, even where it can be restored at
 once, we have to combat this  condition.   We  must  therefore  now look
 to the means  we have of doing this.
   If it has not gone beyond simple congestion, the uterus feeling slightly
 enlarged and  spongy to  the touch, revulsives to the small of the back
 are in many  cases perfectly sufficient.   We have used dry cupping as
 efficaciously as any other form of these ; and the ingenuity of Dr. Augustus
 Gould, of Boston, has afforded us the most simple and convenient means
 of doing  this.   He suggested, for either wet or dry cupping, cutting in half
 the hollow India-rubber  balls made as playthings for children, and ap-
 plying the cut surface to the spot, emptying at the  moment  the space
 within of air  by pressure upon the outside.   When the pressure is re-
 moved, the elasticity of the  ball creates a vacuum within,  and thus all
 the requisites for  an efficient cupping apparatus are obtained.   We have
 still further increased the power of this little instrument by only cutting
 off a third of the ball, and thus  making the other two thirds  an ex-
 hausted receiver  ; in this way attaining  a larger and more perfect vacu-
 um, and  of course  greater strength  of suction.  The  great advantage
 in these is, that the patient can apply them without any assistance what-
 ever ; and from this circumstance  alone, the remedy  is much more likely
to be used faithfully, or for a sufficient length of time to render it effica-
cious, than if it were repulsive either in itself or from  the  circumstance 
Treatise  on Uterine Displacements.
29
of its requiring  the  interference of others.  Our direction for the use
of these cups generally, is  to  apply them  for fifteen or twenty minutes
before  dressing  in the  morning, and for  the  same  space of time after
undressing at night, using a  little care to slightly shift the spot for appli-
cation  every day, in order to avoid  the chance of making  the skin sore
where  the mouth of the cup bears against it.  We have often found that
so much  relief was given  by these, and  so speedily, that our patients
have enthusiastically persevered in using them three times a-day ; though,
for general  purposes, we think twice a-day sufficient.   The lady, whose
case was  given  in picturing the individual history of uterine displace-
ments, was treated thus, and with the most marked success.
   Where  a  general fulness of the system indicates the  propriety, wet
cups may be used instead of dry ones, but of course not so frequently.
Twice a week is as often as we should care to use them ; but we even pre-
fer to  this, timing their  application  to the menstrual  flux, using them say
once a-day, for the three days immediately preceding that period.  The ad-
vantage of this is, that it lessens the embarrassment of the uterus just at a
moment when it is about to  make an effort to do its duty—an effort, that,
without assistance, would be futile, but which, with it, is often in its effects
a most powerful means of accomplishing the very aim we have in view.
Leeches  have been used  for the same purpose,  but we do not consider
them so convenient.  By some, they are recommended to the organ itself,
and we see  no  reason  why they should  not be  as  eminently useful as
they are  represented to be.  It is very evident,  however, that their ap-
plication must be  very troublesome to the physician—who,  of  course, in
our country  at least, would  have to apply  them  himself;  and  to the pa-
tient, in most  instances, they must, when  used in this way, be repulsive
in the  extreme on several obvious accounts.  The same objections apply
to scarifying the neck of the uterus, which has also been found a very effi-
cient remedy.  Where the organ is  protruded, however, this is very con-
veniently  done, and has an immediate effect in reducing the fulness of its
vessels.
   Where  the condition of the  uterus is a  still  more chronic and confirm-
ed affair—where, for  instance,  a year or more has fixed upon it the con-
dition of congestion and its attendants, the  means just mentioned would
have but  little efficacy.   In such cases we want something which will
act more  steadily—more uniformly—more powerfully—and which can
be continued any length of  time that may be requisite, without losing its
efficacy, or  exacting  too  much  from the patient.  The latter is a  very
important consideration, as everyone who has had much to do  with chro-
nic cases will at once  confess.  In  many such, the disease is submitted 
30
Treatise on Uterine Displacements.
to, the system  gets accustomed to it, and reconciles itself to the annoy-
ance—but not  so to the  remedy.  The  influence of the latter is  slow,
its effects not perceived for some time.   There is nothing, therefore, im-
mediately to cheer and encourage the patient, who in it only finds a new
annoyance.  If, then, this latter be great,  it will  not be  persisted  in
faithfully and hopefully—two important conditions in  any remedy—nor
sufficiently long to attain the end  desired.
  We have found the seton to be such a remedy as  is  wanted—lacking
the objectionable points just mentioned.   Why this  old means of revul-
sion should have gone so much out of use, we have never been able  to
explain to ourselves.  Its  application is far  less painful than  drawing  a
blister, and the  care  required in dressing it also much less than that of a
blister, or of an issue.  It looks, too, much less  repulsive than the last,
and does not leave so large  and  unseemly a scar  when healed.  We
prefer  a  thumb lancet as the instrument with  which to  introduce it.
Gathering  up a fold of the skin we transfix  it, and  while the lancet is
still in, pass between it and the  skin  above, but in the  contrary direc-
tion, a common tape-needle,  armed  with  silk braid.    Performing the
operation in this simple way disarms it  of much that is frightful to the
patient, and the thumb lancet is much  more apt to be very sharp than
the seton needle.   Instead of  the old  way of using a long strip of braid
wound on something, and unwinding a little every day and  drawing  it
through the incision, we prefer, as far more convenient and cleanly, taking
a piece only  six inches  long,  and, after  its  introduction, tying the ends
together in a hard knot, so as to prevent its being accidentally drawn out
again.  The  length of the loop will  readily admit  of its being  drawn
back and forth  an inch or so, and this  should be done daily.   When the
strip has become soiled, it should be cut,  a new piece sewed to the knot-
less end,  and drawn through  as in  the  old  method.   We  have found
this so much more  convenient  and cleanly than  the former way of
managing a seton, that we have thought the time given to describing it
as fully worth the while.
  Thus applied, we have found the seton a most efficacious revulsive  in
cases where the uterus is hardened and enlarged by a long continuance  of
the disease.  And  even, at an  earlier period, it seems to  have a most
wholesome effect in so far relieving the organ as  to permit it to return  to
the more regular  exercise of its menstrual  functions ;  a  thino-  always
greatly to be  desired in such cases, both on  account of the  local  and of
the general effect.
  As an assistant to these  depletives and revulsives, we have used, just at
the menstrual  period, warm hip baths—commencing some three or four 
Treatise on Uterine Displacements.                31
nights before the flow is expected.  They should be taken just before go-
ing to bed, which should be warmed to such a degree as to avoid all pos-
sibility of chilling the patient upon getting into it.  As a means  of taking
the hip bath, a common wash tub does very well.  It should be so large
that the  patient can sit down in it with  the feet over one  side and the
back against  the  other, and so deep that the hips will be well covered.
While taking it, the rest of the person should be well protected from cold,
and a blanket ought to be thrown over the tub, so as to retain the heat,
and make it more uniform to the  parts not submerged.
   There is another local  remedy which, so far as  a  very few cases go,
we have found very efficacious in  mild degrees of uterine engorgement.
This is cauterizing the neck of the organ with nitrate of silver.  It was
first recommended in cases of uterine irritation, and the success  of its ap-
 plication has gotten it very largely into use where that condition exists.
 Finding that  on applying it in cases  where the prolapsed and tumid ute-
 rus was very irritable, not  only the  last symptom, but  also  the tumidity,
 was relieved, we  have since used it successfully for that alone, but. as yet,
 in too few cases to urge it strongly, though these cases were very marked.
 It  is effected through  a speculum,  by a piece  of  nitrate  of silver in a
 porte caustic*   The  frequency of  its use  must be determined by the
 symptoms.   In most instances we have found that four days would give
 time for the eschar to fall off and a fresh surface to  be presented for the
 caustic again.
   Thus far our remedies  have been  directed to the  organic condition  of
 the uterus itself, and to replacing it in  its proper situation. There are other
 symptoms closely associated with it and with the parts in contiguity, which
 require attention.   The most obvious of these  in most instances is the
 leucorrhoea ; and in  combating  this, we think we  have reason to say,
 error is often committed  in addressing the  remedies to it without  suffi-
 ciently considering the condition of the organ whence it proceeds and its
 relation to that condition.   As we  have hinted above, we look  upon it in
 a measure as a sort of provisional drainae from the engorged vessels, con-
 nected undoubtedly  in advanced cases at  last  with  an alteration, to a
 greater or  less degree, of the inner  surface of the organ.    To attempt,
 then, to suppress it, whilst the  condition  on which  it depends, or, to say

   * We have been much inconvenienced in making applications to the os uteri for want of a  pro-
 per instrument to hold the substance applied, whether it be solid caustic or a  sponge, or cotton
 Too d oped into a solution. To remedy this, we have had one made wh.ch wo find answers .dm-
 rablv It consists simply of a rod of whalebone, 3-16 of an inch in thickness and eight mete, long,
 «ed wHh a pair "gill forcepjaws at  one end. It is easily cleansed, and  does not mterfere
 with the sight wtwn u*ing it. 
32
Treatise on Uterine Displacements.
 the least, with which  it is  so  closely associated, still exists, must be an
 error, and we feel that this view will  be confirmed by closer examination
 into the phases of the disease in  its progress  towards removal.  Why it
 has not been more insisted upon  hitherto, is, that in most  cases  two or
 three symptoms are attacked at once, and the opportunity for analyzing
 the relation of the one to the other, is  lost by their successive disappear-
 ance being attributed to the influence of the respective remedies used
 against them.  Thus, the uterus is replaced by manipulation,  and retain-
 ed mechanically in its position ; its congested state attacked by revulsives,
 and the leucorrhcea by astringents.  In  due time each morbid phenomenon
 disappears, and we  attribute the  disappearance to the particular remedy
 used, without having any reason  to suspect that  had the engorgement of
 the organ been relieved, the flow might have ceased of itself.   It has,
 however, more than once happened with us, that the  astringents acted a
 little faster than the revulsives, and an aggravation of the  uterine irritation,
 amounting in one  case to decided  inflammation, was induced, leading  us
 to examine  more  closely into the correctness of the principles on which
 our treatment was planned,  and to come to the conclusions  above stated.
   The same remarks  apply,  though  not with  the same force, to the
 vaginal leucorrhcea.  Here  we  have a vascular  membrane in a state of
 irritation and congestion, pouring out from its surface a  quantity of fluid
 which must have  a very direct effect in relieving the vessels.   To leave
 these vessels in their full condition, and at the same  time essay to prevent
 the drain, would  be bad  philosophy, and the  speedy induction of acute
 vaginitis that we have witnessed  as  the result of such  efforts, has since
 ever made us cautious on this point.  Proceeding upon  the above views,
our course has  been not to concern ourself about the leucorrhcea in the
 commencement of the treatment, but to wait  for the indications of  a re-
 turn to health of the uterus  itself.   In many cases  the other will disap-
 pear.   In some instances, however, the drainage  may be so profuse as of
itself  to be a great obstacle  to the recovery of the patient on account of
the debility it produces.  In such, as in the others, we essay to relieve the
condition causing  the flow, but we do  this by  more direct means.   The
most  efficient of these  we have  found to be  injections of warm water,
made two or three times a day.  Trial by the individual will give the best
indication of the precise temperature to commence with, which in most
cases  it will  be found can be gradually lowered with advantage until the
water used is positively cold.   In other words, as we relieve one symp-
tom, we go on  to attack another—the  want of tone in  the parts__by a
powerful tonic.
   Frequently, even when the original offending condition is  removed, the 
                   Treatise on  Uterine Displacements.               33

 leucorrhoa  is still perpetuated, either  by the  want  of tone just men-
 tioned, or by what  is called, for want of a better term, habit—instances
 of which we often see in chronic  inflammation of any of the  mucous
 membranes.  In  these  cases an interference or assistance is legitimately
 called  for, and  tonic  and  astringent injections become  highly  useful.
 Cold  water is  the simplest  of these, but  not  always  applicable ;  we
 have  had it in one case produce violent neuralgic pains all through  the
 pelvis.  The vegetable and  mineral astringents have both been largely
 used,  and are probably equally extolled ; but what experience we have
 had induces us to give preference to the latter.
    Of the former, oak bark—rhatany, either in  the root or in the extract
 —catechu  and kino, used in the form of decoction or of diluted tincture,
 are all highly recommended, and we have never had reason to think one
 superior to the others.  Of the latter, alum—aromatic sulphuric acid—the
 sulphates of iron, of copper or of zinc and nitrate of silver, are the princi-
 pal ; indeed, all that we can have need of.   In ordinary cases, the astrin-
 gent we commence with is a decoction of an ounce of white oak bark in
 a  pint of water, using it  twice a-day.   To this, as the parts get accus-
 tomed  to it, may be added a drachm of  alum.    As  with  all such reme-
 dies, one should not  be used too long, but  a change should be made  at
 the end of a week  or  ten  days, and some other astringent substituted.
 As we often find, in treating chronic indolent ulcers, that a powerful reme-
 dy in  time loses its efficacy, and a change  even to a much milder one
 is  beneficial  ; so in treating leucorrhoea, we  find that it  is  better to go
 backwards to a  less powerful astringent, than to continue to  use one  too
 long.
    Among the mineral astringents, the aromatic sulphuric acid pleases us
 most.   It  should be diluted until it  is about as acid as ordinary vinegar ;
 but if  on trial it produces  no bad effect, the  strength  may be very gra-
 dually increased—say as far as two or even three drachms to the pint of
 water.   The solution of nitrate  of silver we have only used when there
 was, in addition to  the  leucorrhoea, an irritable or sensitive condition of
 the lining of the  vagina.   We  found  it then, after  prefacing its use for
 a week or ten days with warm water, to be  very  efficacious, while other
 astringents irritated.  The strength  in which it was used was four grains
 to  the ounce of distilled water.   The particular application of the other
 astringents we leave to the judgment of the reader, based on  the well-
 known properties of the  article,  all familiar, and  the  demands of the in-
dividual  case.
  For  injecting fluids into the vagina, many  syringes have been invent-
ed__most of them objectionable.   The  common  female syringe—a cy-
                 5 
31                Treatise on  I lerine  Displacements.
 linder of uniform diameter  and perforated  with holes at  the end to he
 introduced—is faulty  in  size.   If made to hold much, it i^ too large to
 be readily introduced.   The body of the syringe being introduced, it  is
 very inconvenient to push the piston up ;  and when the latter is of glass,
 it  is very apt  to be  broken off.   When the syringe is of glass, it is of
 course fragile, and  it  must be  managed with great care that it  may
 not be broken  while using it.   Pewter ones are  acted upon by mineral
 solutions, and  of course will not answer in using these.  Where it is de-
 sirable to use  a continued  stream, as is often the case with warm or cold
 water, Dr. E.  Kennedy [Dub. Quar. Jour,  of Med.  Sc, Feb., 1S47J
 offers an  instrument which  seems  well contrived for  the purpose.  It is
 in fact nothing more than  the common force-pump injecting instrument
 with  a rose nozzle  fitted  to the  end  of the  elastic  tube, which also
 passes through a piece of India rubber some two and a half inches wide,
 four  long, and a  quarter  of an inch thick, to  apply over  the external
 parts, and retain  the  fluid  a little  longer than otherwise would be possi-
 ble.   As excellent as  this adaptation really is, it would be unnecessarily
 complex  for any but the above-mentioned cases—though  the India-rub-
 ber plate  might be adapted with advantage to any syringe.
   The syringe to  which   we give  the  preference, is  the  India-rubber
 bottle fitted with an  ivory  tube, having a small ball at the  end perfo-
 rated with fine holes.   The bottle  is  filled by compressing it, putting the
 end of the tube into the injection fluid, and suffering the bottle to ex-
 pand  again ; it should therefore be just  so  thick  as to keep its  shape
 when empty.   Thicker than this,  it  is  not  emptied  readily; thinner, it
 does  not  expand and fill itself.   The great  advantages of this injection
 apparatus, are, its perfect  simplicity of construction, the facility  with
 which  it  is used and also kept  clean, its  quality of resisting the  action
 of all fluids, and its  durability—not being  liable to be put out of order
 or to  be  broken.  The only improvement  we could suggest to this is,
 that the ivory  nozzle might be connected with the  bottle by an elastic
 tube,  say six inches in length—and, instead  of the  bottle being fitted
 to this  last by  a screw, the  connection might be made by a short  ivory-
 mouth piece, accurately fitted with  a ring of the same material on the
 tube.   With this, the bottle could be readily  detached and re-charged
 as often as necessary, without  disturbing the nozzle when introduced
 thus having all the  advantages of  the force-pump arrangement just de-
 scribed, but none of its complexity.
  The rectum is another  organ  in the immediate  neighborhood, which
requires a  large share of attention  in the treatment of uterine  displace-
ments.  As we have already mentioned, before any attempt  to reduce 
Treatise on  Uterine Displacements.               35
the displacement it must  be thoroughly emptied.   But  this is only a
beginning.   It must be kept as  empty as is consistent with the general
comfort and  health of the  patient.   This  we have already anticipated
in our mention of the causes of these  affections.   How to effect the de-
sired end  in  this particular, we leave  for the most part  to the reader.
The indication is  a very simple one, and the means should be equally
simple—avoiding of course everything that is unpleasant  in  itself and
therefore liable to be neglected by the patient; and also everything which
might  prove irritating to the parts and thus increase somewhat the trou-
ble already  existing.   With some, we  have found injections of cold wa-
ter answer admirably ; with others, powdered  senna eaten  at bed-time in
a fig suits very well, both  as  regards the method of taking it and the ef-
fect.  Rhubarb root, chewed in such quantities as trial has shown to serve,
is also very convenient.  Whatever the means be, thoroughness and gen-
tleness should be its characteristics.  One formula which we think it well
to offer for  this  purpose, is as follows—R. Pill. Rufi, pulv. rhei, aa.  3 j.
Mix  and make into 24  pills.  The  dose  is from  one to four of these,
taken at bed-time.   The  particular excellence of this compound is that
the aloes it contains is a sufficient quantity to produce a thorough evacua-
tion of the rectum without irritating that organ ; and from the well-known
tonic properties of  the ingredients, the bowels are often strengthened so
as to act without any  aid.   We may  add  that  we have seldom  found
these pills to act at all harshly.
   Having gotten the organ back to its proper place, the next  thing is to
keep it there.  To be sure, the means we have just been recommend-
ing for restoring  it and the neighboring  parts to a healthy condition, all
tend mediately to this, but  we want something more direct.  Position is
of itself in most cases sufficient—keeping the  patient on  the back ;  and
Dr. Godefrey, of Rennes, reports [Lond. and Edin. Monthly  Jour, of
Med. Sc, March, 1842] two cases of anteversion which were cured by
this means alone.   But however excellent  in the abstract, it  is unfortu-
nately greatly  inapplicable in the actual.  The objections to its use are
several.°  The most prominent  one of all, is  the inability  of getting any
woman, born in New England, to belong enough in  bed, unless otherwise
physically incapacitated from getting out of it.   Even if the  disposition
existed, there might be other reasons  why it could not be carried out.
Time  is money  with most ; and besides, there  are certain  duties and
cares of a domestic nature, which must be met personally, and for which
money cannot buy  a substitute.  As efficacious, therefore, as rest is, we
not only cannot use it often to  our advantage, but, on the contrary, we 
36                Treatise on Uterine  Displacements.
 have  to contend  not  solely against  the disease, but also against bodily
 exertion, the result of the habits or of the necessities of  the patient.
    Various mechanical contrivances have been made  for  the purpose of
 retaining the uterus  in  situ.   Some of  these—pessaries—are introduced
 into the vagina.  Others, called  abdominal  supporters,  uterine trusses,
 foe, are worn  externally, acting of course  by pressure through  the ab-
 dominal walls, or on  the perineum.
    Pessaries have  for the last fifty years been greatly  relied  upon  as a
 remedy for uterine  displacements,  particularly  for  prolapsus ; and  to
 adapt them more perfectly to  that use, they have been very much varied
 in  the material  of which  they are composed and in their form.   The
 first conception of a pessary was  that  of a  body  of such a size, that,
 when  introduced into the vagina,  it  would  not only retain its  situation
 there, but do  this with  sufficient  firmness to support upon it the uterus
 tending to  prolapse.   With  this  view  it was  made of some  material
 which could not be affected by the fluids that it might  be  brought into
 contact  with—hard  wood, sponge, ivory, gum  elastic, silver, and, lastly
 —the suggestion,  we  believe, of Dr.   Hopkinson, of Philadelphia—of
 glass.   To dispose of the merits  of these various materials is not  diffi-
 cult, and we will  do  it at once.   Glass is fragile, unless thick and heavy,
 and then should be carefully  annealed, otherwise the shape into which
 it has  to be blown, to serve as a pessary, will dispose  it to break readily.
 The results of such an accident seem likely to be  too severe to run  any
 risk.   Wood, no matter how hard and  dense, will in time be acted on
 by  the fluid, and its surface undergoes a sort  of erosion.   We have  seen
 this in box and lignum  vitae, but have never tried ebony.  We should,
 however, discard all.  Gum elastic serves well as far as its resistance to
 the  action of the  fluid  goes ; but it is difficult to get them made of such
 shape  and size as  may be required, and when once  moulded, they can-
 not be altered in the  slightest  particular.   Sponge  has the advantage of
 being compressed  so as to be introduced readily, but has of course to be
 replaced very frequently, and even then is apt to irritate the parts in con-
 tact with  ,t.  Silver, of all others, is the best, taking material  solely in
 view, particularly  when it  is gilt.   But it is  expensive.   Ivory  in most
 cases, using the pessary as we  do, is perfectly sufficient in its resistance
 to the action of the  secretions.   It has the great advantages of cheap-
 ness and of being very readily shaped in  the lathe or by hand to precisely
 suit any particular case—this latter is very great.
  In shape, with the simple intent above mentioned in  view  the  pes
sary was a  disc with very thick  edges where  it  bore against' the walls 
Treatise on  Uterine Displacements.
37
of the vagina, and having the upper surface concave so as to receive the
lips of the uterus.   It had  also a hole through the bottom of this con-
cavity to give vent to  the  uterine  secretions.   It was oftenest circular ;
though, to meet the views of some, ellipsoid in shape, the antero-posterior
diameter of course being the longest one.  In England, spherical ones were
at one time greatly lauded and used, but with what particular end in view
we cannot imagine.   It is  evident that  the  uterus could not so readily
be sustained upon a  convexity, and  the shape would fit the instrument
to slip down  too readily.   Besides which, unless  drilled in every direc-
tion,  so that whatever portion happened to be uppermost, the fluids could
escape through it, these must collect in some degree behind it.
   This is the pessary contrived with  the single intent above mentioned.
In many instances the pressure  above is  too  great to let it avail  even
when increased in  size to the  utmost, an  increase  which  it  is evident
 must be limited after  a certain point, both on account of the difficulty
 of introducing it, and of the  disturbance a too bulky body might cause
 when introduced.  Besides which, exercising the distension that it  does
 and must do, it only remedies one evil by substituting another, and never
 effects  a cure.  It also sets up  a great deal of irritation, accompanied
 with profuse leucorrhoea, sometimes  with  ulcerations, putrid  discharges
 and fungous  growths.   It is apt, too, to make  the  bladder  irritable, and
 to cause costiveness and embarrass defalcation.
    On account of these obvious objections, several  pessaries  have been
 devised with a view to avoid them.   The  body of the instalment was
 made smaller, and to  keep it in its place it was  mounted on a stem, pass-
 ing down the vagina  and  supported  externally.   The particular form of
 the stem, and the method of attaching it to the disc, have been varied
 with a view  to convenience, fee, but the principle is just as stated.   Re-
 camier invented one  with  an elastic  stem, which he thought would  pre-
 sent an  advantage in yielding to any accidental jar or  motion of the
 body.   Hervey de  Chegoigne,  besides mounting  the pessary upon a
 stem, still further adapted the stem and the upper part of the instrument
 itself to the  form of  the  neighboring organs, so as to embarrass the lat-
 ter as little as possible, and to produce a more equable operation of the
 sustaining force.  For retroversion of the uteais, for instance, he thick-
 ened the posterior edge of the  disc, and  thus more effectually canted
 the organ forwards than could be done by one of more uniform thickness.
 [De quelques deplacemens de la  matrice, et des pessaires le plus convena-
 bles  pour y remedier.   Dans Memoires de l'Acad. Roy. de Med., 1833,
 torn, ii., p. 319.  A  fair abstract of  the paper will  be found in the Ga-
 zette Med. de Paris, Jan., 1833.]   The cases given with the  memoir 
38
Treatise on Uterine Displacements.
are  not only  interesting themselves, but are illustrative of an important
fact, viz., that we cannot  use any pessary  under routine direction.   We
must adapt the instrument in size and  shape to  the "particular case,  and
cases vary so much  as to make it useless  to enter into a  disquisition on
the  advantage of one precise  form over  another.   Each may  suit in
some particular instance—all may be equally  inefficacious in some.  In
other words, in adapting the shape of a pessary, it has to be done by the
requirements of the case in  hand, and the physician has to depend rather
upon his mechanical  tact than  upon  any rule  or direction that can be
given him.   We  therefore  abstain from any further enlargement upon
this part of our subject, although it  has stimulated the inventive talents
of many, and afforded employment to the  pen  of Jules  Cloquet [Diet.
de Med. in 30 vols.], of Gerdy [Traite  des Pansements, 2d edition, 1839
—Des Pessaires,  t. ii., p. 57], of Rognetta  [Remarques Nouvelles sur les
Pessaires en Caoutchouc,  foe. &c, Gaz. Med.  de Paris, Juin, 1834], of
Duges, of Desormeaux, and of a host  of others in advocating the merits
of particular curves, concavities, &c.
   We  must  notice,  before  going further,   the  dispute between Duges
and Hervey de Chegoigne, as to whether the uterus should be supported
by  the lower  extremity, or  whether this, as the  latter insists, is apt to
irritate it, making it more proper  to sustain the organ by contact with
its body.   We have  been unable  to  find anything to support the views
of M. de Chegoigne, and  we must therefore be permitted to pass them
by in spite of the attention  they  received  when  he  first  insisted  upon
them with such urgency in  1833—an  attention  and  an urgency which
made us  hesitate to leave them unmentioned.
  For  anteversion and retroversion, Dr. Simpson, of Edinburgh,  devised
a pessaiy consisting  of a slender  stem of  ivory, two. inches in length,
rising from  the middle of a circular  disc—the whole being mounted
upon a wire supported by a perineal strap.   The ivory stem is  introduced
into the uterus, after getting it into proper position, and by this it is kept
from falling over.  Of the effects of this  pessary, Dr. Ashwell says :—
" Two cases  have recently come  under my care, and I have heard ot
more, where the results arising from the use of this instrument  have been
very serious.   Looking at  it pathologically,  I can  scarcely imagine any-
thing better devised for inducing disease.  According  to this practice, a
piece of ivory two inches long is to be introduced into the uterine cavity,
and its bearing must of necessity be  on some part of the  lining  mem-
brane, a  surface  ill adapted to support the pressure  for two or three
months together of such an instrument.  *   * *    In both, the speculum
showed that abrasion of the os and the ostium vaginae  had  resulted from 
Treatise  on Uterine Displacements.
39
the use of the so-called uterine supporter.   *  *   *  Is there anything
so serious in a retroversion or retroflexion of the unimpregnated uterus, as
to justify a practitioner in running the risk of exciting peritonitis, cellular
inflammation and abscess—injuring  the  structure of the womb—and en-
kindling  desires, or  implanting habits,  which destroy  purity of feeling
and physical health ?   Our own conviction is, that this  supporter will be
found  to create more disease than it cures."   One case, in which we
tried it, supported fully Dr.  A.'s opinion, yet  friends  of ours have seen
cases treated by  Dr. Simpson himself  very  successfully  with  it.   We
should wish, however, better recommendations before using it again.
   Dr. Simpson  [copied into  the Am. Jour, of Med. Sciences, 1849] and
several others have advocated the employment of medicated pessaries, the
first suggestion of which was  probably given by Osiander,  who used to
support the uterus by inserting  into  the vagina  a small bag filled with
chipping*  of  oak or other  astringent  wood.   Undoubtedly,  in  their
 medicinal  influence  these would  be an advantage ; but we think this
 could be, on the whole, more  conveniently obtained  by injections, leav-
 ing for the pessary a more perfect material in other respects.
    We find, both from publications  on the  subject, and from the verbal
 expressions of our friends, that,  latterly, pessaries  are not relied upon as
 they were formerly, either as a curative or a palliative means, nor  resort-
 ed to as frequently in either capacity.   This  distrust in them and disuse
 of them is in perfect accordance with the views to which our own  expe-
 rience has led us.
    In fact, in treating  uterine displacement with a view to cure, we look
 upon the pessary as an assistant during the first periods of the treatment
 to relieve  speedily an urgent and embarrassing  difficulty—the disposi-
 tion of the organ to  descend.  In using them,
 we feel  that  they should not further distend
 the vagina and embarrass the organs  in the
 neighborhood ;  the pessary must  therefore be
 as small  as  possible consistently with its fur-
 nishing  the  proper  amount  of support to the
 organ.   To retain  it  in its place,  as it  lacks
 size for  this, it should be  mounted upon a
 stem and supported by a perineal strap.  This
 is a satisfactory  settlement, in our mind, of the
 question as to what kind of  pessary should be used—one with or without
 a stem.   As to the material, in ordinary cases we use ivory,  of the shape
here <n'Ven in section.   If the case is a peculiar  one, and requires some
particular modification of the instrument, gutta percha offers  an admirable
 
40
Treatise  on Uterine Displacements.
 material, as under hot water it can be readily modelled to any shape de-
 sired.   The stem is a piece of brass wire, having an eye at one end  by
 which  to attach  it  to the perineal  strap, and at the other a semi-circular
 piece of wire by which it  is attached to  the pessary.   The  strap that
 supports it is buckled in front to a belt—is bifurcated in the perineum,
 and each  end passes  up  backward to a  button on the  belt  at each
 hip.  At the bifurcation, a common  button mould should be inserted,
 and to  the  material covering this,  the  end  of the stem  supporting
 the  pessary  is attached.  The material  for the belt and strap is com-
 mon cotton or linen cloth, covered  on the  perineum with oiled silk—al-
 together a most  simple contrivance, that any woman can make for her-
 self.  The pessary  being very small, is readily introduced by  the patient
 in the morning before rising, and removed by her on lying down at night,
 prefacing the insertion  and  following its removal with an  astringent  or
 tonic injection.   This is the  only  pessary we would ever  use, and we
 only use it  until our other remedies can restore tone to the parts con-
 cerned as well  as to the general  system, and enable these to do their
 work.
   The only bad effect  that we have found from the use of this pessary
 is, that the wire stem has in two cases irritated the neck of the bladder
 —though in one of these, there was a  pretematurally irritable  state of it,
 which had already required  treatment.  The fear of this, at the present
 moment, prevents us from  using  it in another case.  Mr. Schofield,  of
 Bradford, Eng., seems to have used one very similar, made of porcelain,
 with great benefit, but we do not know that it would have any advantage
over the one described ; and the pessaires  " a tige " of Hervey de Che-
 goigne and others do not seem to be as simple.
   Abdominal supporters have varied as much in their fashion as pessa-
 ries, though  there are few  principles  concerned  in  their employment.
 Some are belts, buttoned or  laced around the  hips and over the abdomen.
 Others consist of  an adaptation of springs, furnished at particular points
 with pads, some of  which keep the apparatus in  place, whilst one large
 or two smaller ones,  just over the  pubis, are intended to act  upon the
uterus, and by making forcible pressure there, keep that organ  from slip-
 ping down.  Such,  in brief,  is the rationale of the construction of a vari-
ety of contrivances whose name is  now legion.   Some have  spiral spring
pads—others concave pads—others horn ones—and so on ;  but  they all
amount  to the same thing, above sketched.
   These affairs are  now so  generally worn,  that  opportunities of observ-
ing the effects of  them  are very plenty, and  the  result of availing our-
setf of such opportunities has brought us  to the conclusion—possibly 
Treatise on  Uterine Displacements.               41
surprising to others—that in not more than one case out of six does the
supporter retain the uterus in place.  These numbers are not given from
accurately recorded  cases, but  we are certain  that they  cannot be far
from right.  To be sure, in some of the six cases the instrument is not
needed so far  as  the  uterus is  concerned, for in fact  no displacement
of it exists, and  the instrument  is adopted at the recommendation of
some unprofessional friend, in consequence of an error caused by feelings of
debility which  the instrument  does remedy.   In the cases  upon which
we make  this assertion, it had been  used  too short a time to have pro-
duced a cure.   In the  cases remaining, the uterus often remained pro-
lapsed, because, as we  above explained, the line  of pressure was too
high to act beneath the  body of the  organ—yet  the instrument  was a
comfort in sustaining the contents of the abdomen, disposed to sink down
from relaxation of the walls.  In some, we found  the supporter decidedly
hurtful, and its name  a misnomer, for if it  did not actually force the
organ down, it tended to keep it so.
   We  have used supporters in very  few cases with  a view of directly
supporting the uterus, for  we think it will be found  that in very few,
comparatively, can it  be so supported;  but we have found them very
serviceable in  assisting  to restore  tone to the abdominal walls and their
contents, and also sympathetically to the organs within the pelvis.  Using
them in this way, they act in the  same manner as bandages on a feeble
[imb—supporting the muscles and other tissues, until they gain one else-
where, but which  would not be so readily gained without such support.
Having this in view—and  also  an  ever-ruling  principle with us, to sim-
plify everything as much as  possible—we have added ourself to the num-
ber of  contrivers  of abdominal  supporters.   Ours  consists of a  belt of
Dowlas linen, cut bias so as to "give"—three inches wide behind—be-
coming  broader as it passes forwards over the hips—and six inches wide
in front where it laces up.   On  each  hip there is a gore, so as to fit it to
the shape.  In front, the line of it is horizontal above—but cut to the
line  of Poupart's  ligament and  the  pubis below.   From  two  inches
back of the lacing on the upper edge, passing down  to just back of it
at the  lower front corner of the belt, there  is let into it a strip of sheet
brass about half an  inch wide.   This should not be. thick enough to be
heavy, but sufficiently so to keep  its  curve, when once fitted to that of
the abdomen.  This, like the pessary, is as simple as  possible, and any
woman of ordinary ingenuity could fit herself with it.   She  should have
two for a change.
   This  is the belt which we  use in connection with  the  pessary ; as
even where its other offices are not particularly wanted, it sets so well as
               6 
■12                Treatise on Uterine Displacements.

to fully repay  in comfort for the  trouble of making  it.   We have been
much gratified  at  the  number of instances in which we have seen  the
more complicated and expensive supporters thrown aside, and preference,
after trial, given to this simple affair.  It may  be well to add, that if  our
views are  correct,  and  it  is a general supporter  to the  muscles that is
wanted, rather than a  doubtful  sustainer of  the uterus—a broad belt,
like the above described, gives much more equable and uniform support
than any series of  pads could.
  For cases in which cure is out  of the question, and prevention of pro-
trusion is the only object in view, the pressure of a pad  upon the ex-
ternal labia has been found very effectual.  Dr. Hamilton's contrivance
for this was  a simple T 'bandage, or belt  and  perineal  strap, the  latter
supporting the cushion  [Practical Observations, p.  25].  Dr.  Annan,
formerly of Baltimore, used a spring like that  of a truss  around the hips,
and to this was attached another at right angles, passing down in  front
of the pubis  and furnished with  a  pad  at its extremity—[Amer. Jour.
of Med.  Sc,  Aug., 1836].   On general principles, we should prefer
the first.
   Having thus disposed  of mechanical contrivances, we  will now see
what surgery essays to do  for uterine displacements.
   Dr. Hamilton,  in his strong objections to pessaries,  detailed in  his
Practical Observations,  before  advising  the contrivance  just mentioned,
suggests narrowing the  calibre of the vagina.   This he attempted him-
self in one case by introducing into it a ball of " emplastrum ccral,"  and
a second time  a bag  of alum.  Inflammation and sloughing followed,
but no adhesion or  narrowing.   In another  case he got  Mr. Liston to
bring together the walls of the passage by ligature ;  but after much  suf-
fering, no benefit was attained.   Langier made the same attempt with
actual cautery and with nitrate  of mercury,  but was equally unsuccess-
ful—[Sur le  Cauterization du  Vagin au fer rouge—Encyclog. des Sc.
Med., Sept.,  1838].   We are,  however, under the impression, though
we cannot  now recall the authority, that  he did effect his  object with
nitric  acid.
   M. Girardin suggested an  operation like that of Uev and  of Dupuy-
 tren for  prolapsus ani—removing a  strip of  the  vaginal mucous  mem-
 brane by the  knife, and bringing the edges of  the wound  together with
 sutures.   This has now been  frequently performed by different surgeons
 with great success.  They exhibit some slight variation in  the operation.
 Thus, Dieffenbach removed  a strip on  each  side—Marshall  Hall one in
 front. Dr. Ireland [Dub. Jour. Med. Sc, vol. vi., p. 484] has performed
 it twice—in -the first case taking one broad strip from  the side ;  in the last, 
                  Treatise on  Uterine Displacements.               43

one  from  the back  and another from  the front.  The removal should
include nothing but  the mucous  membrane.  The incisions should em-
brace a very acute triangle,  with  the base towards  the  external labia.
Three ligatures generally  suffice.  The  one nearest the os uteri should
be tied first, and the uterus reduced as each is tied in  succession.
   The hemorrhage  is slight, as is  also  the pain except when dissecting
near the labia.  The subsequent inflammation  must be combatted with
the usual antiphlogistic  means, among which cold water  injections  are
very useful, and should  be given three times a-day.   This operation is
termed episionhaphy.   The  only objection to it is, that, in  child-bearing
women, the course of the  incision  might be re-opened during delivery ;
but Dr. Fricke. who has cured three out of four cases by it, says that he
delivered one of these without the slightest accident.   Where  the patient
is beyond  the period,  a modification of the operation has been  used,
having in  view the prevention  of protrusion.  It consists in obtaining an
adhesion between  the external  labia to some  distance within.   This has
been done by Dr.  Geddings,  of South Carolina, with success in several
cases—[Aiuer. Jour, of Med. Sciences].
   As a last resource, surgery, failing in  its highest aim, has removed the
prolapsed organ in one  case where  reduction was impossible.   The ope-
rator was Dr. Toogood, of Bridgewater  in  England.   The patient was
60 years of age.   The result was a great relief  to the sufferer, who bore
the operation  well.   It will  be recollected that we have already men-
tioned a case where  nature resorted to the same  means of relieving pro-
lapsus, and with success.   The number of cases of excision of the uterus
which are now on record, enables us by this time to pronounce upon the
operation.   So far as danger to the patient is concerned, it is not as ob-
jectionable as many others  which are unquestionably among the justifia-
ble efforts of surgery.  It  has  other  bearings, however, which must al-
ways have a strong modifying  influence with the  physician—a control-
ling one against its performance except in a very few, exceptional, cases.
   This comprises all the local treatment for uterine displacements which
we think  merits attention.   It is not, however, all that we can expect
to do for these affections.   A very  important  part  of our care yet re-
mains in that addressed to the general system.
   Much that would otherwise come  under this  head, has already been
anticipated in our  disquisition  upon the  causes  that  lead to the disease.
Of course in our essay  to cure, we  must first remove  any cause that may
still exist, and alter all those circumstances that originally led to the mor-
bid condition—or  that still tend to its continuance.  This  will induce  a
rigid scrutiny as to whether the laws of hygiene  be habitually and strictly 
44
Treatise on Uterine Displacements.
 complied with, more particularly those which we pointed out as so liable
 to be disregarded by the female sex.   Upon  only one  point concerning
 these do we now  think  it  necessary  to say more,  and upon  this but
 little.
   In speaking of dress as a cause, we quoted  largely our  previously
 published  views, and  corroborated them with  the results  of our more
 recent  and fuller  experience.   W7e will  now only add  the  method in
 which we remedy evils from this  source.   When  a case of uterine  dis-
 placement presents  itself to  us, after  insisting upon the free and gentle
 yet thorough evacuation of the bowels once a-day, as an absolute neces-
 sity if cure is desired, we next insist on  a complete alteration of the dress,
 by  which  all its objectionable  peculiarities  are  remedied.   Where the
 disease  is not urgent;  where it has not continued  long, and  the rest of
 the system still preserves its tone, if we cannot go farther, we require that
 a light under jacket shall  be worn, to  which all the skirts shall be but-
 toned, and by thus  sustaining them, relieve the hips and  abdomen al-
 most wholly of their weight.   This is a modification greatly for the bet-
 ter ;  but there is a still  greater one which we enforce where the  disease
 has continued longer, and  where the general system has suffered so much
 from it as to demand in its favor every  advantage, no matter how trifling.
 We urge that warmth and comfort be attained entirely by loose drawers,
 buttoned to the jacket just mentioned ; and  that  over these only one light
 skirt—say a starched cotton  or  a grass cloth one—be worn  beside the
 outer dress.  In other words, that the woman be  dressed just  like a boy
 in jacket  and trowsers—covered after  this with her outer  garments, for
 propriety and  grace.  This is, we  confess,  a  very thorough change, and
 many might call it an unnecessary exaction  ; but we do not think so,  nor
 does one of the many patients who have submitted to it.   On the con-
 trary, they have without exception used the  most  unqualified  terms of
 praise—often approbatory to  an  extravagant degree, in assuring us of the
 comforting effects of it.   It  not only  attains  the immediate end of re-
 lieving the uterus,  but it gives a freedom to the  whole person, ensuring
 more warmth with but half the former weight  of clothing.
  Another point in dress requires, as we have already hinted, attention ;
 the  legs and feet must  be warmly clad.  This  may be effected in the
 way most agreeable to the patient, but we  say with emphasis, it must
be done.
  Having attended  to these more external matters, we still have the want
 of tone, and general debility of the system,  to remedy ; and for this it is
.very difficult to lay down  any general rule.
  We  mentioned among  the effects of these affections  a disposition to 
                  Treatise on Uterine Displacements.                45

gastric derangement, or rather to  atony of the stomach.   This in most
cases  we  treat with ale,  which affords at  once a stimulus, a tonic and
nourishment—relieving the exhaustion of the moment—strengthening the
stomach, and affording an easily assimilated nutriment wherewith  to in-
vigorate the attenuated frame.  We know of no objection to the  use of
this, except some accidental  idiosyncrasy of the individual.  If it be not
advisable, sherry wine  is the best substitute—lacking the nutritive and
the direct tonic effect of the other.   Beyond  this we cannot' specify a
stimulus—for after all, it must be fitted  to the wants of the particular in-
dividual, and  therefore trial must indicate what is best.  Where not only
the immediate stimulus, but also a  more powerful  and continuous tonic is
needed, Peruvian bark, gentian, columbo,  and all  articles of  that class,
will serve us in turn, but of course  it would  be unnecessary and  indeed
impossible for us to attempt to discriminate between them here.   That
must be done by the physician when the individual case is before him.
   We also mentioned as one of the consequences of disorder of the ute-
rus, an attenuation of the blood—an anaemic disposition, exhibited in  pal-
lor of the countenance, waxy aspect  of the  skin, and cold  hands  and
feet.    Iron of course is our remedy for this, and it only remains for us to
indicate the form in which it is  to be administered.   As that form of the
remedy against which, in the largest number of cases, the stomach does
not rebel, we have long used the ammonio-tartrate.  It is very conveni-
ent, too, to administer.  We write for two  drachms, and direct the patient
to dissolve it in sixty teaspoonfuls of water or syrup (say of orange peel,
a home-made article).  The  dose measured by the same teaspoon will
then  contain two grains, which  may be taken  four  times a day.  When
there is  fear  of  this fermenting,  or where  the  stimulus of wine is also
wanted, sherry is a good  menstruum, though  it  takes more of this fluid
than  of water to  serve as a solvent—about  double  the quantity.   The
flavor of neither of these solutions is unpleasant, and we have found but
few cases where  there  was an intolerance of the remedy.  The tincture
of the muriate of iron has been much extolled for leucorrhoea, and  there-
fore  if that accompaniment  is a prominent and  troublesome one, it may
be administered instead of the ammonio-tartrate.   It is very apt, however,
to disagree with  the stomach, and the flavor of it cannot be made very
agreeable.  Care  should be  used that neither be taken into an empty
stomach, or if so, a cracker or something of  the kind  should be eaten
immediately after.   This will prevent an unpleasant gnawing and nausea
that  often  follows  the administration of iron without these precautions.
Where the last remedy is not tolerated, and a  demand for it seems  to ex-
ist we have used  the sulphate of  iron  instead, under the same precau- 
46
Treatise  on Uterine Displacements.
 tions, dissolving  it as we advised for  the ammonio-tartrate, but giving it
 in smaller  doses—say U grain; this  is as much  as in most instances
 will  be borne without  irritating  the stomach  in  the course of the period
 for which we may have to use it.  Frequently, indeed, we have to com-
 mence with a half or  third  of a dose, and gradually increase  it  to  the
 maximum.   This of course  is easily done when  the salt is in solution.
    However admirable may be the effects of the  above-mentioned  tonics,
 there are few cases where  they alone  will suffice to restore the health
 and strength of the patient, and  enable  her to preserve them when reco-
 vered, unless  we bring the  influence of cold water  to  their assistance.
 Indeed, this remedy in  some  form or another is by us  brought very early
 to bear upon the disease, and we should have  introduced a mention of it
 sooner but  for not wishing to  interrupt  the  above continuous series of
 kindred remedies.   Not only, too, do we look upon cold water as a tonic,
 but we consider it a powerful alterative in breaking up that circle of mor-
 bid phenomena,  at  various points of which are found, as we have before
 this detailed—a displaced  uterus—dysmenorrhcea—gastric  irritation—
 hysteria—and the  rest, too familiar by this time  to repeat.   As  soon as
 we have made an estimate of the vital  energies of our patient, we com-
 mence enveloping  her to a degree proportionate to what we consider her
 power of re-action—with  the wet  sheet.   When the energies  are much
 reduced,  this   must be  done very cautiously, and only  very partially.
 Thus, as a first essay, we wrap the hips  in a common  roller towel  about
 twenty inches wide, dipped in water at about 60°.   Over this is wrapped
 a flannel skirt or  some such thing, and the patient lies thus in bed  for an
 hour or hour and a  quarter.  After this  she is  well  rubbed with a crash
 towel, and dressed  if necessary.  If this is readily endured—if the chill
 it causes soon passes off—and particularly if it be replaced by a propor-
 tionate glow, we  may venture further, and envelope  more of the frame in
 it, and use colder water, until we reach the point of wrapping the  whole
 figure, from  the arms down, in a  sheet wet with the  coldest pump water.
 When so wrapped,  the  patient should  be also covered in blankets and
 remain thus for an  hour and a quarter.   If  the  operation  is such as is
 desired, the chill passes off at  the end of ten or fifteen minutes__the
 remaining discomfort of the  cold in twenty more.  Soon a glow is  felt
 which goes on to diaphoresis  (though not profuse), attended with a posi-
 tive feeling of enjoyment and exhilaration.  Used in this way, we claim
 that this means is raised  from all taint of hydropathic quackery to a ra-
 tional and scientific  remedy, and  as such we ask for it  its fair share of
attention.   We are confident that if this be given,  it will be highly valued
in  the light both of  a powerful alterative as above stated, and as a  tonic 
Treatise on  Uterine Displacements.               47
 tolerated and  beneficial, when the stomach refuses others, or where they
' may prove incompatible, as is well known they often do, with some other
 condition of the system.
   The proper  time of the day for using this  remedy is  the forenoon,
 though the particular  hour we do not  deem important;  we permit the
 patient to  choose that which will  best suit her convenience.   The re-ac-
 tion is probably  greater on first  awaking, and, if nothing hinders, we
 should select this time.
   Used in this way, the influence of cold water seems much more deep
 and thorough than  when simply taken in the form of a cold bath.  We
 cannot suppose that a very different  series of phenomena  occurs in one
 than in the other; but, with the wet sheet, each one of the series is pro-
 longed, and in this way possibly the depths, as it were, of the system are
 more  perfectly probed, and the most distant and hidden operations of the
 morbid influence reached.   Thus  in a cold bath the chill  is  endured  at
 the farthest for five  minutes—the  body is then dried, and in another five
 every opportunity given for re-action, which  comes on with  greater or less
 despatch.   With the wet sheet, the  chill is prolonged for  ten or fifteen
 minutes—the rallying effort  to force back to the surface the blood which
 had left it then begins, but  requires from fifteen to twenty-five  minutes
  more.  Still, after this, the surface is excluded  from  the  air, and kept
  bedewed with a fluid now at blood heat, prolonging and heightening the
  duration and violence of the re-action.   This at least seems to  us a ra-
  tional comparison between the two.
    We must  finish  this chapter with some notice of the other alteratives
  which have been at various times advised to break up the morbid  action
  —the congestion,  hardening,  and irritation of the uterus, and  the dis-
  turbed functions  of the neighboring organs accompanying  displacement.
  For  this  purpose the writers of  fifty years since advise  mercurials,  but
  with apparently  no very great precision in  their views as to what was to
  be done.   Later, since the virtues of iodine have  been  recognized and
  appreciated, some of  its  combinations  have been recommended for the
  same purpose, but  apparently scarcely more than on theoretical  grounds,
  even with the few who have made the recommendation.   We have look-
  ed very carefully for any facts that would support the view that  they  are
  beneficial, and we  find none either in  the flood of periodical medical li-
  terature which we now enjoy, or in the experience of our personal  friends
  or ourself.   We do still occasionally use the syrup of ioduret of  iron, but
  it is  rather as a tonic and an appetizer than as  an alterative.
     We thus  conclude our list of remedies, and  the  details of our course
  of treatment of uterine  displacements.   There  are  many suggestions 
48               Treatise on Uterine Displacements.

which have been made, many theories broached, and  many instruments
contrived, of which we have taken no notice.   W e feel, however, that we
have weighed these carefully and without prejudice, and estimating them
not hastilv, have deemed that no benefit  could accrue to the reader from
a mere rehearsal of them and exposition of their failings ; but have thought
that time was better spent in making a full exposition of what reason and
experiment have taught us we can rely upon.

               DISPLACEMENTS OF  THE  GRAVID UTERUS.
   To avoid confusion we have hitherto treated only of displacements of
the unimpregnated  uterus.   When  the impregnated  uterus is displaced,
or w hen the  displaced uterus becomes impregnated, some new features
are presented which require particular notice.
   The chances of impregnation are much lessened  by displacement of
the organ, though  from cases on hand, where the affection existed to a
very great degree, and yet it did take place, we must conclude  that it is
not the simple displacement, but the  condition of the uterus  which ge-
nerally accompanies it, that leads  to sterility.   This  condition  and this
consequence of it seems to have been recognized by  Hippocrates in say-
ing, " When  the  mouth of the uterus is hard, it  is  also  shut "—[54th
Aphorism,  Sec. v.].  And again,  " Women  who have  the  uterus cold
and dense, do not conceive "—[62nd  Aphorism, same Section].
   Impregnation of the prolapsed uterus, when the organ  is reducible, is
readily managed, if, indeed, it require interference.  It should be reduced,
if  it does not readily reduce itself, which, however, is generally the case,
and so retained until  the  fourth month,  when it  will have increased to
such a size as to sustain  itself above  the brim of the pelvis.  This, in-
deed, ministers to the  cure of the disease—provided care  be taken after
confinement to prevent, by all the other means we have above indicated,
a return of the affection.   When a protruded uterus becomes  impreg-
nated, which has happened now in three or  four recorded cases, too
familiar even to quote [Portal gives one,  Mem. de l'Academie de  Chir.
torn iii., p. 369.   Chopart, another, Traite  des Malad. de la Vessie, torn.
ii., p. 73.   Still later, Perfetti,  a third, reported  in  Prov. Medical and
Surgical Journal, Dec. 2nd. 1844.   The last is very  interesting,  because
after  delivery the  organ  was reduced and apparently a cure effected],
the difficulties attending  the condition arise from the size  and weight of
the organ during gestation,  and from the hardness and undilatibility  of the
mouth at delivery.   The  first  is remedied by rest and by mechanical
means which will suggest themselves—suspension in a properly contrived
bandage.  For the last,  the  knife has  been resorted  to—enlarcrinir the 
                  Treatise on Uterine Displacements.                49

opening by a crucial incision.  This was done in three of the cases  re-
corded, and without great complication of the case, or suffering to the
patient.
  The  anteverted  or retroverted  uterus is  not so  liable to become im-
pregnated as  the simply prolapsed one—for besides the condition above
mentioned of the organ itself opposing  it, the  neck of the  uterus  is  so
placed as to increase the difficulty.  When it does, however, become  so,
it is a much more serious thing than with the prolapsed organ—for there
is generally no tendency in it to rise out of the pelvis, as the period of ges-
tation advances.  The consequence is, as the development proceeds, the
organs in the neighborhood, particularly  the bladder and rectum, become
more and more embarrassed, until they are wholly unable to perform their
functions, and  the result of course is fatal unless  effective aid be given.
Should, then, a woman, affected with either of  these displacements, find
herself pregnant, her condition must at once become the care of her phy-
sician.  Every means  must  at once  be used which may tend to rectify
the position of the organ, or at least to raise it out of the pelvis before its  in-
creased size makes this impossible, that its  subsequent development may
cause no such urgent embarrassment in the vital organs, as  those just
mentioned.
  How to effect this elevation of the  uterus, does not require particular
directions, or indeed any, beyond what  are already suggested earlier  in
this essay.   When  retroversion exists, there is  often difficulty in getting
the fundus  out of the  concavity of the sacrum.   We have seen  an  in-
strument contrived for doing this, which consisted of a steel conductor to
be introduced into  the rectum—and upon it, but passing into the vagina,
was a rod armed at the end with an  ivory pad, intended  to  act against
the fundus  of the uterus.  This  would  undoubtedly be  serviceable,
though  we  scarcely think a surgeon  would  need any special  contriv-
ance for the purpose.
  In  anteversion the difficulty  of reduction is  not so  great, and the
fundus is more readily reached and passed behind the pubis.
  When the development of the ovum has increased to such a degree as
to render it impossible  to reduce  the  uterus, and  the grave consequences
above mentioned are  imminent, it becomes of serious  moment to know
what shall be our resort.   Sabatier seemed to think that emptying  the
bladder by puncture would remove its bulk and thus permit reduction ;  but
we can see that the main  difficulty, the size of the uterus, will not thus
be affected.  Hunter advised plunging a trocar into the organ itself, and
reducing its size by giving  exit to the amnios.   There is no  record,
however, of such a course being adopted ; though judging from the  effect
                7
                     <\RMLD  FORCES MEDICAL UBFUFO
                            WASHINGTON, D. C 
I
  50               Treatise on  Uterine Displacements.

  of accidental wounds of the uterus and from other parallel cases, we can-
  not but think it would be unattended with serious  consequences, and it
  surely seems the most rational means suggested.
    With a view of saving the infant as well as the mother, Purcell [Ca-
  puron—Traite des Malad. des  Femmes,  1S17, p. 287], suggested sym-
  physotomy, supposing  that it would effect such  an enlargement of the
  pelvis that the uterus might be  reduced when  otherwise it would be im-
  possible.  Gardien  advocates this strongly, but both are as strongly op-
  posed, and we think with reason.
    In  one of the cases of anteversion quoted above, as occurring in our
 own practice, abortion  took  place  regularly at the end of the fourth
 month—apparently as a resort of nature to get rid of what could be deve-
 loped no further.
                     INVERSION OF  THE  UTERUS.
    This is the term given to  the condition  in which the uterus is turned
 inside outwards.   It may occur suddenly, or by very  slow degrees.   It
 can only take place suddenly immediately after delivery, when  the whole
 organ is a flaccid bag—the body of which may be forced  through the
 mouth, either by pressure behind or by traction through the os, as by the
 cord.   When it  takes place  by degrees,  it is  always the effect of the
 weight of some tumor attached  to the fundus, which  in its development
 forces its way through the os, drawing the fundus after it.  In  this latter
 case it is evident that the tumor is the main difficulty, and that our con-
 test must, be with that—we therefore dispense with any further conside-
 ration of inversion from this cause.
   Symptoms.—A feeling of sinking and utter prostration  comes on im-
 mediately after inversion has occurred, even when  no flooding  accompa-
 nies it.   This is sometimes accompanied by convulsions, but almost  al-
 ways with those  violent,  nervous perturbations so frequently  attending
 uterine trouble.  These symptoms are generally proportioned in violence
 to the degree of inversion.  With them  there  is often  a  most alarming
 hemorrhage,  sometimes destroying life immediately.   When several of
 the above symptoms excite our suspicions of the nature of the mishap, ex-
 amination must be carefully made for  the organ through the walls of the
abdomen, and an inability to detect it  there will at once of itself convert
our suspicions into conviction, especially if,  in  addition, we find the va-
gina filled by a fleshy substance.   Without the  abdominal examination,
the latter alone might  be  taken for another  foetus (breech  presentation,
for instance)—a polypus, or some other tumor.   It  may be well to sug-
gest that a  polypus has comparatively  little sensibility, while the inverted
uterus is highly sensitive. 
Treatise on  Uterine Displacements.
51
  If the;  organ be not  speedily reduced, a contraction and  thickening of
its walls soon render this impossible.  We  should therefore lose no time
in setting about to effect its reduction.   Well oiling the hand, the organ
should be grasped and passed back into the vagina.  Forming the fingers
into a cone, the apex of which is placed against the fundus of the uterus,
pressure  must  be made steadily upwards.   This will at first carry the
whole organ unaltered  further into the pelvis, until the vagina is put upon
the  stretch.   After  this it will commence receding,  and  then with  a
sudden start pass through the os, and it is again in its usual condition.
The hand now must not be withdrawn, but left there  until contractions
are excited, by which it ought to be permitted to  be forced gradually out.
This is to prevent a  return of the accident.
   One point incident to this  operation has excited much discussion—the
removal of the placenta.  Should this be done before the  reduction, or
afterwards ?   On the ground of lessening the bulk of  the mass to be re-
turned, some of the  highest authorities  on the subject advise its removal.
Others of equally high position^with  the  plea,that  the force us^din
separating theVwo will irritate tl|e uterus, and  that'll increase of'.the
hemorrhage ma\ be  induced at foment when evel^drop of  blqod
is important—recommend that the afiei«birth should be earned back and
the case afterwardsS^ated as one of  retained placenta.   It  seems to us
that the  course must  be determined  for  the  individual case, for we can
 conceive of the placenta being  so bulky as to greatly embarrass  if not
 entirely  prevent reduction—and the attachment between it and  the uterus
 may not be so strong  as to require violence and  cause irritation in over-
 coming  it.  Nauche  advises snipping the circular fibres of the os, if they
 seem to threaten strangulation or  to otherwise impede the reduction.
   As we above  said,  the  reduction ought  to  be attempted without any
 delay for everv moment increases the contractions of  the uterus and les-
 sens our ability to turn it back  again through the os.  The  liability of
 this is so great that  even a half dozen hours may put the mishap beyond
 reach of remedy, though  two  cases  are  recorded where  reduction was
 effected after  an  inversion of several weeks standing [one of  these is in
 the Am. Journ.  of  Med.  Sc, vol. xvi., p. 81].
    When permanently unreduced, inversion of the uterus is attended with
 most  painful, harassing and dangerous  symptoms.    The  organ be-
 comes bighlv sensitive, and is affected with a constant feeling of uneasi-
 ness  heightened at times  by severe,  sharp, lancinating pains.  A profuse
 dischargers soon set up from the inner surface, now turned outward and
 is of itself enough to speedily exhaust the vital  powers; but in addition
 to it  frequent hemorrhages still  further increase the danger from this 
52                Treatise on Uterine Displacements.

source.   The os uteri is at all times very much contracted, but occasion-
ally this contraction is greatly increased by inflammation, and strangula-
tion may ensue, causing  sphacelus of the whole organ.   Even where the
circulation  is not interrupted sufficiently for this, the vitality of the organ
may be so  lessened that, as in  protruded uteri,  ugly sloughing  ulcers
form  in its substance, and thus add  another source of suffering, danger
and death to the patient.
  To ameliorate this horrible state of things, various courses  have been
adopted by different practitioners, but apparently without  any guarantee
of success.   The  only resort which holds out promises of restoring the
sufferer to comfort  and health, is one which, considering that the subjects of
this mishap are generally otherwise in the full enjoyment of their woman-
hood, seems dreadful, and which could not be justified and would not be
tolerated, but  for  the perfect  conviction that it is the only resort.   This
is extirpation of the uterus.   The method which has been adopted is by
ligature—first drawing the organ down so  as to get  it as  near  the labia
as possible, and then transfixing the neck just below the os with nee-
dles/armed with string  silk.   The ligapres  are tightene/ very gradu-
ally.  At first the*pain is very severepmd attended by y/iusea and pros-
tration—which,are combatted withjjpiates and stimulants.   In  a  case oth-
erwise favorably  fitted  for  it, there seems  to be  nir peculiarly serious
source of danger in the operation.
  The cases recorded exhibit a gratifying return of strength and health
after the removal of the  cause of exhaustion and disease—and the gene-
ral state of the system does not .seem to  be  greatly altered—indeed, not
even  appreciably  so  in  several  instances.  One patient, Lasserre [En-
cyclop, des Sc. Med., v. xxxvi. p. 179]  tells us, " est restie sensibles aux
voluptes conjugales." 
  ThS^
mended by
of them at t

  January 1, 1853.
     nufacture the fcelt recom-
      i may now be obtained
            ton.   \
JAMES MILLER  & 60. 
 
 
\f/nA\yAn\l/nlv ; 
 
OF MEDICINE
NLN QM14070b
NLM041407067